RESUMEN
BACKGROUND: Accumulating evidence suggests that cardiac findings after stroke are an important, yet understudied, manifestation of brain-heart interactions. Our aim was to investigate and compare cardiac findings after different cerebrovascular events (acute ischemic stroke, transient ischemic attack, and hemorrhagic stroke). METHODS AND RESULTS: There were 7113 patients screened who were treated between December 2013 and December 2020 at the University Hospital Zurich for ischemic stroke, transient ischemic attack, and hemorrhagic stroke. Seven hundred twenty-one patients without evidence of previous cardiac disease or presumed cardioembolic origin of their cerebrovascular disease and with at least 1 cardiac checkup were included. Clinical reports from the year following disease onset were screened for new cardiac findings, which were categorized as arrhythmia/electrocardiographic changes, myocardial alterations, valvular abnormalities, and coronary perfusion insufficiency. Differences in proportions of findings among groups were analyzed using the Pearson χ2 test or Fisher exact test. ECG changes were observed in 81.7% (n=474) of patients with ischemic stroke, 71.4% (n=70) of patients with transient ischemic attack, and 55.8% (n=24) of patients with hemorrhagic stroke (P<0.001). Myocardial alterations occurred often in all 3 groups (60.9% ischemic stroke [n=353], 59.2% transient ischemic attack [n=58], 44.2% hemorrhagic stroke [n=19]; P=0.396). CONCLUSIONS: Cardiac findings are frequent in patients with cerebrovascular disease, even without prior cardiac problems or suspected cardiac cause. Similarities, especially between patients with ischemic stroke and transient ischemic attack, were observed. Our data suggest that all patients with acute cerebrovascular events should receive thorough workup searching for cardiac manifestations.
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Accidente Cerebrovascular Hemorrágico , Ataque Isquémico Transitorio , Accidente Cerebrovascular Isquémico , Humanos , Masculino , Femenino , Anciano , Persona de Mediana Edad , Accidente Cerebrovascular Isquémico/etiología , Accidente Cerebrovascular Isquémico/fisiopatología , Accidente Cerebrovascular Isquémico/diagnóstico , Ataque Isquémico Transitorio/fisiopatología , Ataque Isquémico Transitorio/etiología , Ataque Isquémico Transitorio/diagnóstico , Accidente Cerebrovascular Hemorrágico/epidemiología , Accidente Cerebrovascular Hemorrágico/diagnóstico , Electrocardiografía , Cardiopatías/fisiopatología , Cardiopatías/etiología , Cardiopatías/diagnóstico , Estudios Retrospectivos , Anciano de 80 o más Años , Suiza/epidemiología , Factores de Riesgo , Trastornos Cerebrovasculares/fisiopatología , Trastornos Cerebrovasculares/etiología , Trastornos Cerebrovasculares/diagnósticoRESUMEN
The foramen ovale plays a vital role in sustaining life in-utero; however, a patent foramen ovale (PFO) after birth has been associated with pathologic sequelae in the systemic circulation including stroke/transient ischemic attack (TIA), migraine, high altitude pulmonary edema, decompression illness, platypnea-orthodeoxia syndrome (POS) and worsened severity of obstructive sleep apnea. Importantly, each of these conditions is most commonly observed among specific age groups: migraine in the 20 to 40s, stroke/TIA in the 30-50s and POS in patients >50 years of age. The common and central pathophysiologic mechanism in each of these conditions is PFO-mediated shunting of blood and its contents from the right to the left atrium. PFO-associated pathologies can therefore be divided into (1) paradoxical systemic embolization and (2) right to left shunting (RLS) of blood through the PFO. Missing in the extensive literature on these clinical syndromes are mechanistic explanations for the occurrence of RLS, including timing and the volume of blood shunted, the impact of age on RLS, and the specific anatomical pathway that blood takes from the venous system to the left atrium. Visualization of the flow pattern graphically illustrates the underlying RLS and provides a greater understanding of the critical flow dynamics that determine the frequency, volume, and pathway of flow. In the present review, we describe the important role of foramen ovale in in-utero physiology, flow visualization in patients with PFO, as well as contributing factors that work in concert with PFO to result in the diverse pathophysiological sequelae.
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Foramen Oval Permeable , Humanos , Foramen Oval Permeable/fisiopatología , Foramen Oval Permeable/complicaciones , Trastornos Migrañosos/fisiopatología , Trastornos Migrañosos/etiología , Ataque Isquémico Transitorio/fisiopatología , Ataque Isquémico Transitorio/etiología , Apnea Obstructiva del Sueño/fisiopatología , Apnea Obstructiva del Sueño/complicaciones , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/fisiopatología , Enfermedad de Descompresión/fisiopatología , Enfermedad de Descompresión/complicaciones , Edema Pulmonar/etiología , Edema Pulmonar/fisiopatología , Embolia Paradójica/fisiopatología , Embolia Paradójica/etiologíaRESUMEN
BACKGROUND: Elevated blood viscosity (BV), a critical determinant in blood rheology, is a contributing factor in cerebrovascular diseases. The specific influence of BV on small vessel disease burden remains unexplored. This study aims to examine the relationship between BV and regional white matter hyperintensity (WMH) volume in patients with acute ischemic stroke. METHODS AND RESULTS: We enrolled a cohort of 302 patients with acute ischemic stroke or transient ischemic attack who were admitted to a hospital within 7 days of symptom onset in this study. We measured whole BV using a scanning capillary-tube viscometer and categorized systolic blood viscosity into 3 groups based on established references. We quantified and normalized WMH volumes using automated localization and segmentation software by NEUROPHET Inc. We performed multivariable logistic regression analysis to assess the correlation between systolic BV and WMH. The mean subject age was 66.7±13.4 years, and 38.7% (n=117) of the participants were female. Among a total of 302 patients, patients with higher deep WMH volume (T3) were typically older and had an atrial fibrillation, strokes of cardioembolic or undetermined cause, elevated levels of C-reactive protein, diastolic blood viscosity and systolic BV. A multivariable adjustment revealed a significant association between high systolic BV and increased deep-WMH volume (odds ratio [OR], 2.636 [95% CI, 1.225-5.673]). CONCLUSIONS: Elevated systolic BV is more likely to be associated with deep WMH volume in patients with acute ischemic stroke or transient ischemic attack. These findings reveal novel therapeutic strategies focusing on blood rheology to enhance cerebral microcirculation in stroke management.
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Viscosidad Sanguínea , Accidente Cerebrovascular Isquémico , Sustancia Blanca , Humanos , Femenino , Masculino , Anciano , Accidente Cerebrovascular Isquémico/sangre , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Accidente Cerebrovascular Isquémico/fisiopatología , Persona de Mediana Edad , Sustancia Blanca/diagnóstico por imagen , Sustancia Blanca/patología , Imagen por Resonancia Magnética , Leucoencefalopatías/sangre , Leucoencefalopatías/diagnóstico por imagen , Leucoencefalopatías/fisiopatología , Leucoencefalopatías/etiología , Sístole , Factores de Riesgo , Anciano de 80 o más Años , Ataque Isquémico Transitorio/sangre , Ataque Isquémico Transitorio/fisiopatologíaRESUMEN
Transient ischemic attack (TIA) is an early warning sign of stroke and death, necessitating suitable animal models due to the associated clinical diagnostic challenges. In this study, we developed a TIA model using flexible spatially targeted photothrombosis combined with real-time blood flow imaging feedback. By modulating the excitation light using wavefront technology, we precisely created a square light spot (50 × 250 µm), targeted at the distal middle cerebral artery (dMCA). The use of laser speckle contrast imaging (LSCI) provided real-time feedback on the ischemia, while the excitation light was ceased upon reaching complete occlusion. Our results demonstrated that the photothrombus formed in the dMCA and spontaneously recanalized within 10 min (416.8 ± 96.4 s), with no sensorimotor deficits or infarction 24 h post-TIA. During the acute phase, ischemic spreading depression occurred in the ipsilateral dorsal cortex, leading to more severe ischemia and collateral circulation establishment synchronized with the onset of dMCA narrowing. Post-reperfusion, the thrombi were primarily in the sensorimotor and visual cortex, disappearing within 24 h. The blood flow changes in the dMCA were more indicative of cortical ischemic conditions than diameter changes. Our method successfully establishes a photochemical TIA model based on the dMCA, allowing for the dynamic observation and control of thrombus formation and recanalization and enabling real-time monitoring of the impacts on cerebral blood flow during the acute phase of TIA.
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Circulación Cerebrovascular , Modelos Animales de Enfermedad , Ataque Isquémico Transitorio , Ataque Isquémico Transitorio/diagnóstico por imagen , Ataque Isquémico Transitorio/fisiopatología , Animales , Masculino , Trombosis/diagnóstico por imagen , Ratones , Imágenes de Contraste de Punto Láser/métodos , Arteria Cerebral Media/diagnóstico por imagenRESUMEN
BACKGROUND AND AIM: Cerebral Vasomotor Reactivity (VMR) is a property of cerebral hemodynamics that protects from cerebrovascular disease. We aimed to explore the VMR longitudinal changes in patients with acute non-disabling stroke/Transient Ischemic Attack (TIA) to understand its implication in stroke ethiopatogenesis. METHODS: VMR by Transcranial Doppler Breath Holding test was performed at 48-72 h from stroke onset (T1) and after 6 months (T2) on MCA of the non-affected hemisphere and PCA of the affected hemisphere. RESULTS: We consecutively enrolled 124 patients with a median age of 66.0 (IQR 54.75-74.25) years with a median NIHSS 2 (IQR 1-3). Both MCA (1.38 %/s SD 0.58) and PCA (1.35 %/s SD 0.75) BHI at T1 did not differ among different stroke subtypes (p=0.067 and p=0.350; N=124). MCA and PCA BHI decreased from T1 to T2 (respectively 1.39 %/s SD 0.56 vs 1.18%/s SD 0.44 and 1.30 %/s SD 0.69 vs 1.20 %/s SD 0.51; N=109) regardless of ethiopatogenesis (respectively p<0.0001 and p=0.111). CONCLUSION: The VMR is higher in acute phase than at 6 months in patients with non-disabling stroke/TIA, regardless of etiopathogenesis. The higher VMR in acute phase could be sustained by an increased Cerebral Blood Flow due to collateral circulation activation supporting the ischemic zone.
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Contencion de la Respiración , Circulación Cerebrovascular , Ataque Isquémico Transitorio , Ultrasonografía Doppler Transcraneal , Humanos , Masculino , Femenino , Persona de Mediana Edad , Estudios Prospectivos , Anciano , Ataque Isquémico Transitorio/fisiopatología , Ataque Isquémico Transitorio/diagnóstico , Factores de Tiempo , Arteria Cerebral Media/fisiopatología , Arteria Cerebral Media/diagnóstico por imagen , Accidente Cerebrovascular/fisiopatología , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular Isquémico/fisiopatología , Accidente Cerebrovascular Isquémico/diagnóstico , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Evaluación de la Discapacidad , Velocidad del Flujo Sanguíneo , Arteria Cerebral Posterior/fisiopatología , Arteria Cerebral Posterior/diagnóstico por imagenAsunto(s)
Cognición , Ataque Isquémico Transitorio , Entrenamiento de Fuerza , Rehabilitación de Accidente Cerebrovascular , Accidente Cerebrovascular , Humanos , Ataque Isquémico Transitorio/fisiopatología , Ataque Isquémico Transitorio/terapia , Ataque Isquémico Transitorio/diagnóstico , Ataque Isquémico Transitorio/psicología , Accidente Cerebrovascular/terapia , Accidente Cerebrovascular/fisiopatología , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/complicaciones , Resultado del Tratamiento , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Tiempo , Terapia por Ejercicio , Recuperación de la Función , Masculino , Femenino , AncianoAsunto(s)
Cognición , Ataque Isquémico Transitorio , Ensayos Clínicos Controlados Aleatorios como Asunto , Entrenamiento de Fuerza , Rehabilitación de Accidente Cerebrovascular , Accidente Cerebrovascular , Humanos , Ataque Isquémico Transitorio/fisiopatología , Ataque Isquémico Transitorio/terapia , Ataque Isquémico Transitorio/diagnóstico , Accidente Cerebrovascular/terapia , Accidente Cerebrovascular/fisiopatología , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/complicaciones , Resultado del Tratamiento , Factores de Tiempo , Terapia por Ejercicio , Recuperación de la FunciónRESUMEN
OBJECTIVES: Web-based interventions may assist in post-discharge stroke care. However, strategies for maximising uptake and engagement are needed. AIMS: To determine the: (1) effectiveness of a discharge support intervention (EnableMe web-based portal and strategies to encourage use) in improving quality of life and reducing depression (primary outcome); anxiety and unmet needs of survivors of stroke and transient ischemic attack (TIA); and (2) EnableMe use and acceptability. MATERIALS AND METHODS: An open, parallel-group, multi-centre randomised controlled trial (RCT) of the intervention compared to usual care for survivors of stroke/TIA and their support persons. Participants recruited from eight hospitals completed questionnaires at baseline, 3 and 6 months. Outcomes included quality of life, depression, anxiety and unmet needs. RESULTS: 98 survivors (n=52 intervention, n=47 control) and 30 support persons (n=11 intervention, n=19 control) enrolled in the RCT. Bayesian analyses showed substantial evidence of an intervention effect on survivors' quality of life scores at 3 months. There was moderate-to-strong evidence of a treatment effect on depression scores and strong evidence that intervention participants had fewer unmet needs at 3 and 6 months. 45 % of intervention group survivors and 63 % of support persons self-reported using EnableMe. 64 % of survivors and 84 % of support persons found it helpful. CONCLUSION: Substantial evidence for the discharge support intervention was found, with a difference between groups in survivor quality of life, depression, and unmet needs. Acceptability was demonstrated with largely positive attitudes towards EnableMe. Future research should explore different engagement strategies to improve uptake of online stroke resources.
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Ansiedad , Depresión , Ataque Isquémico Transitorio , Alta del Paciente , Calidad de Vida , Accidente Cerebrovascular , Humanos , Ataque Isquémico Transitorio/terapia , Ataque Isquémico Transitorio/psicología , Ataque Isquémico Transitorio/diagnóstico , Ataque Isquémico Transitorio/fisiopatología , Femenino , Masculino , Anciano , Persona de Mediana Edad , Resultado del Tratamiento , Depresión/terapia , Depresión/psicología , Depresión/diagnóstico , Accidente Cerebrovascular/terapia , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/fisiopatología , Accidente Cerebrovascular/psicología , Factores de Tiempo , Ansiedad/terapia , Ansiedad/psicología , Ansiedad/diagnóstico , Portales del Paciente , Intervención basada en la Internet , Anciano de 80 o más Años , Conocimientos, Actitudes y Práctica en Salud , Rehabilitación de Accidente Cerebrovascular/métodosRESUMEN
Background and Objectives. Neurogenesis is an integral process in post-stroke recovery, involving the recruitment of proliferating neuroblasts from neurogenic niches of the mammal brain. However, the role of neurogenesis in the long-term restoration following ischemic stroke is fragmented. Post-stroke motor dysfunction includes challenges in the proper, coordinated use of hands and is present in roughly two-thirds of human patients. In this study, we investigated chronic behavioral and biochemical alterations after transient cerebral ischemia in adult male mice. Materials and Methods: Twelve-week-old C57BL/6N male mice were used, and fMCAo lasting 60 min was induced. At multiple timepoints after fMCAo induction, a single pellet reaching task was performed. Six months after the procedure, we immunohistochemically determined the number of proliferating neuroblasts (BrdU and DCX-positive) and the number of differentiated astrocytes (GFAP-positive) in both brain hemispheres. Results: The reaching ability of fMCAo mice was impaired from one month to six months after the induction of ischemia. Neuroblast proliferation was increased in the ipsilateral SVZ, whereas GFAP+ cell count was elevated in the hippocampal DG of both hemispheres of the fMCAo group mice. Conclusions: Our current report demonstrates the long-term effects of transient cerebral ischemia on mice functional parameters and neurogenesis progression. Our data demonstrate that transient cerebral ischemia promotes a long-lasting regenerative response in the ipsilateral brain hemisphere, specifically in the neurogenic SVZ and DG regions.
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Astrocitos , Proteína Doblecortina , Ratones Endogámicos C57BL , Destreza Motora , Neurogénesis , Animales , Neurogénesis/fisiología , Ratones , Masculino , Astrocitos/fisiología , Destreza Motora/fisiología , Modelos Animales de Enfermedad , Ataque Isquémico Transitorio/fisiopatología , Ataque Isquémico Transitorio/complicacionesRESUMEN
BACKGROUND AND AIM: Asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA) have been proposed as mediators of endothelial dysfunction. In this study, we aimed to investigate the diagnostic and prognostic role of ADMA and SDMA in acute cerebrovascular disease. METHODS AND RESULTS: A prospective case-control study was performed, enrolling 48 patients affected by ischemic stroke with no cardioembolic origin, 20 patients affected by TIA, 40 subjects at high cardiovascular risk and 68 healthy subjects. ADMA levels were significantly lower in high-risk subjects (18.85 [11.78-22.83] µmol/L) than in patients with brain ischemic event, both transient (25.70 [13.15-40.20] µmol/L; p = 0.032) and permanent (24.50 [18.0-41.33] µmol/L; p = 0.001). SDMA levels were different not only between high-risk subjects and ischemic patients, but also between TIA and stroke patients, reaching higher levels in TIA group and lower levels in stroke group (1.15 [0.90-2.0] vs 0.68 [0.30-1.07] µmol/L; p < 0.001). SDMA was also correlated with short-term prognosis, with lower levels in case of adverse clinical course, evaluated by type of discharge (p = 0.009) and need of prolonged rehabilitation (p = 0.042). CONCLUSIONS: The present study highlights the relationship between l-arginine, ADMA, SDMA and acute cerebrovascular events. Therefore, our results suggested a potential role of SDMA as a specific marker of transient ischemic damage and as a short-term positive prognostic marker.
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Arginina , Biomarcadores , Endotelio Vascular , Ataque Isquémico Transitorio , Accidente Cerebrovascular Isquémico , Valor Predictivo de las Pruebas , Humanos , Arginina/análogos & derivados , Arginina/sangre , Masculino , Estudios Prospectivos , Femenino , Biomarcadores/sangre , Anciano , Persona de Mediana Edad , Ataque Isquémico Transitorio/sangre , Ataque Isquémico Transitorio/diagnóstico , Ataque Isquémico Transitorio/fisiopatología , Endotelio Vascular/fisiopatología , Pronóstico , Estudios de Casos y Controles , Accidente Cerebrovascular Isquémico/sangre , Accidente Cerebrovascular Isquémico/diagnóstico , Accidente Cerebrovascular Isquémico/fisiopatología , Medición de Riesgo , Factores de RiesgoRESUMEN
INTRODUCTION: Cerebral blood flow (CBF) declines with age and abnormalities in CBF are associated with age-related cerebrovascular disease and neurodegeneration. Women have higher CBF than men, although this sex-difference diminishes to some extent with age in healthy subjects. The physiological drivers of these age/sex differences are uncertain, but might be secondary to age and sex-differences in haemoglobin (Hb) level. Hb levels are inversely correlated with CBF, are lower in women, and decline with age in men, but the interrelations between these factors have not been explored systematically either in healthy subjects or across the full age-range in patients with vascular risk factors. We aimed to determine the age-specific interrelations between sex, Hb, and CBF velocity in a large cohort of patients with cerebrovascular disease. PATIENTS AND METHODS: In patients with a recent transient ischaemic attack or minor stroke (Oxford Vascular Study) and no ipsilateral or contralateral stenosis of the carotid or intracranial arteries, we related peak-systolic velocity (PSV) and other parameters on transcranial Doppler ultrasound (TCD) of the middle cerebral artery to sex, age, Hb and vascular risk factors. RESULTS: Of 958 eligible subjects (mean age/SD = 68.04/14.26, 53.2% male), younger women (age < 55 years) had higher CBF velocities than men (mean sex difference in PSV at age < 55 years = 16.31 cm/s; p < 0.001), but this difference declined with age (interaction p < 0.001), such that it was no longer significant at age 75-84 (∆PSV = 3.26 cm/s; p = 0.12) and was reversed at age ⩾ 85 (∆PSV = -7.42 cm/s; p = 0.05). These changes mirrored trends in levels of Hb, which were higher in men at age < 55 (∆Hb = 1.92 g/dL; p < 0.001), but steadily decreased with age in men but not in women (interaction p < 0.001), with no residual sex-difference at age ⩾ 85 (∆Hb = 0.12 g/dL; p = 0.70). There was an inverse correlation between Hb and PSV in both women and men (both p ⩽ 0.01), and the sex-difference in PSV at age < 55 was substantially diminished after adjustment for Hb (∆PSV = 6.92; p = 0.036; ∆PSV = 5.92, p = 0.13 with further adjustment for end-tidal CO2). In contrast, the sex difference in PSV was unaffected by adjustment for systolic and diastolic blood pressure, heart rate, and vascular risk factors (history of hypertension, diabetes, hyperlipidaemia and smoking). DISCUSSION: CBF velocity is strongly correlated with Hb level at all ages, and sex-differences in CBF velocity appear to be explained in major part by age-related sex-differences in Hb.
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Circulación Cerebrovascular , Hemoglobinas , Ultrasonografía Doppler Transcraneal , Humanos , Masculino , Femenino , Circulación Cerebrovascular/fisiología , Persona de Mediana Edad , Hemoglobinas/análisis , Hemoglobinas/metabolismo , Anciano , Velocidad del Flujo Sanguíneo/fisiología , Ultrasonografía Doppler Transcraneal/métodos , Factores de Edad , Caracteres Sexuales , Factores Sexuales , Anciano de 80 o más Años , Factores de Riesgo , Accidente Cerebrovascular/sangre , Accidente Cerebrovascular/fisiopatología , Accidente Cerebrovascular/diagnóstico por imagen , Adulto , Ataque Isquémico Transitorio/sangre , Ataque Isquémico Transitorio/fisiopatología , Arteria Cerebral Media/diagnóstico por imagen , Arteria Cerebral Media/fisiopatologíaRESUMEN
AIM: To explore whether LPA5 was involved in the inflammatory responses in CI/R injury by regulation of NLRC4. METHOD: The cerebral I/R model in rats was constructed with ischemia of 2h and different time points of reperfusion. After that, western blot was used to determine protein expression (LPA5, NLRC4, AIM2, caspase-1, cleaved-caspase-1, mature IL-1ß, and precursor IL-1ß). And LPA5 and NLRC4 expression were also detected by using immunofluorescence experiment. Afterward, two sequence of LPA5-siRNA were injected into rats via intracerebroventricular administration. TTC staining and HE staining were performed. RESULT: As the reperfusion time was prolonged, LPA5 content was continuously increased, and the highest expression of NLRC4 was found at 4h of reperfusion. And protein expression of AIM2, cleaved-caspase-1, and mature IL-1ß was also at highest level at 4h. And after reperfusion of 4h, LPA5 siRNA1# or 2# was injected into lateral ventricles. LPA5 silence markedly reduced the infract volume and improved the histological change of ischemic zone. And LPA5 silence significantly downregulated NLRC4, AIM2, and the ratio of cleaved-caspase-1/caspase-1 and mature IL-1ß/precursor IL-1ß. And compared with LPA5-siRNA2#, LPA5-siRNA1# exerted a more significant effect. CONCLUSION: Low expression of LPA5 can protect against the inflammatory responses in CI/R model of rats through inhibiting NLRC4 inflammasomes.
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Encéfalo/efectos de los fármacos , Inflamasomas/efectos de los fármacos , Ataque Isquémico Transitorio/tratamiento farmacológico , Ataque Isquémico Transitorio/fisiopatología , Proteína con Dominio Pirina 3 de la Familia NLR/efectos de los fármacos , Receptores del Ácido Lisofosfatídico/metabolismo , Receptores del Ácido Lisofosfatídico/uso terapéutico , Animales , Encéfalo/metabolismo , Modelos Animales de Enfermedad , Humanos , Masculino , Ratas , Daño por Reperfusión/metabolismo , Daño por Reperfusión/fisiopatologíaRESUMEN
BACKGROUND AND PURPOSE: Poststroke/transient ischemic attack obstructive sleep apnea (OSA) is prevalent, linked with numerous unfavorable health consequences, but remains underdiagnosed. Reasons include patient inconvenience and costs associated with use of in-laboratory polysomnography (iPSG), the current standard tool. Fortunately, home sleep apnea testing (HSAT) can accurately diagnose OSA and is potentially more convenient and cost-effective compared with iPSG. Our objective was to assess whether screening for OSA in patients with stroke/transient ischemic attack using HSAT, compared with standard of care using iPSG, increased diagnosis and treatment of OSA, improved clinical outcomes and patient experiences with sleep testing, and was a cost-effective approach. METHODS: We consecutively recruited 250 patients who had sustained a stroke/transient ischemic attack within the past 6 months. Patients were randomized (1:1) to use of (1) HSAT versus (2) iPSG. Patients completed assessments and questionnaires at baseline and 6-month follow-up appointments. Patients diagnosed with OSA were offered continuous positive airway pressure. The primary outcome was compared between study arms via an intention-to-treat analysis. RESULTS: At 6 months, 94 patients completed HSAT and 71 patients completed iPSG. A significantly greater proportion of patients in the HSAT arm were diagnosed with OSA (48.8% versus 35.2%, P=0.04) compared with the iPSG arm. Furthermore, patients assigned to HSAT, compared with iPSG, were more likely to be prescribed continuous positive airway pressure (40.0% versus 27.2%), report significantly reduced sleepiness, and a greater ability to perform daily activities. Moreover, a significantly greater proportion of patients reported a positive experience with sleep testing in the HSAT arm compared with the iPSG arm (89.4% versus 31.1%). Finally, a cost-effectiveness analysis revealed that HSAT was economically attractive for the detection of OSA compared with iPSG. CONCLUSIONS: In patients with stroke/transient ischemic attack, use of HSAT compared with iPSG increases the rate of OSA diagnosis and treatment, reduces daytime sleepiness, improves functional outcomes and experiences with sleep testing, and could be an economically attractive approach. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02454023.
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Ataque Isquémico Transitorio , Polisomnografía , Apnea Obstructiva del Sueño , Accidente Cerebrovascular , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Ataque Isquémico Transitorio/diagnóstico , Ataque Isquémico Transitorio/etiología , Ataque Isquémico Transitorio/fisiopatología , Masculino , Persona de Mediana Edad , Apnea Obstructiva del Sueño/complicaciones , Apnea Obstructiva del Sueño/diagnóstico , Apnea Obstructiva del Sueño/fisiopatología , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/fisiopatologíaRESUMEN
Capillary density rarefaction and endothelial dysfunction contribute to chronic hypoperfusion and cerebral small vessel disease. Previous animal experiments revealed spatiotemporal microvascular remodeling directing post-stroke brain reorganization. We hypothesized that microcirculatory changes during acute cerebrovascular events could be reflected systemically and visualized sublingually. In a prospective observational trial in vivo sublingual sidestream darkfield videomicroscopy was performed in twenty-one patients with either acute stroke (n = 13 ischemic, n = 1 ischemic with hemorrhagic transformation and n = 2 hemorrhagic stroke) or transitory ischemic attacks (n = 5) within 24 h after hospital admission and compared to an age- and sex-matched control group. Repetitive measurements were performed on the third day and after one week. Functional and perfused total capillary density was rarefied in the overall patient group (3060 vs 3717 µm/mm2, p = 0.001 and 5263 vs 6550 µm/mm2, p = 0.002, respectively) and in patients with ischemic strokes (2897 vs. 3717 µm/mm2, p < 0.001 and 5263 vs. 6550 µm/mm2, p = 0.006, respectively) when compared to healthy controls. The perfused boundary region (PBR), which was measured as an inverse indicator of glycocalyx thickness, was markedly related to red blood cell (RBC) filling percentage (regarded as an estimate of microvessel perfusion) in the overall patient group (r = -0.843, p < 0.001), in patients with ischemic strokes (r = -0.82, p = 0.001) as well as in healthy volunteers (r = -0.845, p < 0.001). In addition, there were significant associations between platelet count or platelet aggregation values (as measured by whole blood impedance aggregometry) and microvascular parameters in the overall patient collective, as well as in patients with ischemic strokes. In conclusion, cerebrovascular events are associated with altered systemic microvascular perfusion.
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Capilares/patología , Accidente Cerebrovascular Hemorrágico/patología , Ataque Isquémico Transitorio/patología , Accidente Cerebrovascular Isquémico/patología , Rarefacción Microvascular , Suelo de la Boca/irrigación sanguínea , Anciano , Anciano de 80 o más Años , Capilares/fisiopatología , Femenino , Accidente Cerebrovascular Hemorrágico/diagnóstico por imagen , Accidente Cerebrovascular Hemorrágico/fisiopatología , Humanos , Ataque Isquémico Transitorio/diagnóstico por imagen , Ataque Isquémico Transitorio/fisiopatología , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Accidente Cerebrovascular Isquémico/fisiopatología , Masculino , Microcirculación , Microscopía por Video , Persona de Mediana Edad , Agregación Plaquetaria , Estudios ProspectivosRESUMEN
OBJECTIVE: Blood pressure (BP) management is a vital aspect of stroke prevention and post-stroke care. Different surgical carotid endarterectomy (CEA) techniques may impact on BP control post-operatively. Specifically, the carotid sinus nerve, which innervates the carotid baroreceptors and carotid body, is commonly left intact during conventional CEA but is routinely transected as part of eversion CEA. The aim of this study was to assess long term BP control after eversion and conventional CEA. METHODS: Patients from the International Carotid Stenting Study (ICSS cohort) and a personal series of patients from the Stroke Clinical Trials Unit at University College London (UCL cohort) were separately analysed and divided into eversion and conventional CEA groups. Mixed effect linear models were fitted and adjusted for baseline demographic data and antihypertensive treatment to test for changes in BP from baseline over a three year follow up period after the respective procedures. RESULTS: There were no differences in changes in baseline BP readings and follow up readings between eversion and conventional CEA in the ICSS or UCL cohorts. In the ICSS cohort a mild but significant systolic (-8.6 mmHg; 95% confidence interval [CI] -10.6 - -6.6) and diastolic (-4.9 mmHg; 95% CI -6.0 - -3.8) BP lowering effect was evident at discharge in the conventional group but not in the eversion CEA group. BP monitoring during follow up did not reveal any consistent BP changes with either conventional or eversion CEA vs. baseline levels. CONCLUSION: Neither conventional nor eversion CEA seem to result in clinically significant long term BP changes. Potential concerns related to either short or long term alterations in BP levels with transection of the carotid sinus nerve during eversion CEA could not be substantiated.
Asunto(s)
Presión Sanguínea , Estenosis Carotídea/cirugía , Endarterectomía Carotidea/métodos , Anciano , Antihipertensivos/uso terapéutico , Seno Carotídeo/inervación , Estenosis Carotídea/complicaciones , Endarterectomía Carotidea/efectos adversos , Femenino , Estudios de Seguimiento , Humanos , Ataque Isquémico Transitorio/etiología , Ataque Isquémico Transitorio/fisiopatología , Ataque Isquémico Transitorio/cirugía , Masculino , Prevención Secundaria , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/fisiopatología , Accidente Cerebrovascular/cirugía , Sistema Nervioso Simpático/fisiología , Resultado del TratamientoRESUMEN
Recent work has highlighted that people who have had TIA may have abnormal motor and cognitive function. We aimed to quantify deficits in a cohort of individuals who had TIA and measured changes in their abilities to perform behavioural tasks over 1 year of follow-up using the Kinarm Exoskeleton robot. We additionally considered performance and change over time in an active control cohort of migraineurs. Individuals who had TIA or migraine completed 8 behavioural tasks that assessed cognition as well as motor and sensory functionality in the arm. Participants in the TIA cohort were assessed at 2, 6, 12, and 52 weeks after symptom resolution. Migraineurs were assessed at 2 and 52 weeks after symptom resolution. We measured overall performance on each task using an aggregate metric called Task Score and quantified any significant change in performance including the potential influence of learning. We recruited 48 individuals to the TIA cohort and 28 individuals to the migraine cohort. Individuals in both groups displayed impairments on robotic tasks within 2 weeks of symptom cessation and also at approximately 1 year after symptom cessation, most commonly in tests of cognitive-motor integration. Up to 51.3% of people in the TIA cohort demonstrated an impairment on a given task within 2-weeks of symptom resolution, and up to 27.3% had an impairment after 1 year. In the migraine group, these numbers were 37.5% and 31.6%, respectively. We identified that up to 18% of participants in the TIA group, and up to 10% in the migraine group, displayed impairments that persisted for up to 1 year after symptom resolution. Finally, we determined that a subset of both cohorts (25-30%) experienced statistically significant deteriorations in performance after 1 year. People who have experienced transient neurological symptoms, such as those that arise from TIA or migraine, may continue to experience lasting neurological impairments. Most individuals had relatively stable task performance over time, with some impairments persisting for up to 1 year. However, some individuals demonstrated substantial changes in performance, which highlights the heterogeneity of these neurological disorders. These findings demonstrate the need to consider factors that contribute to lasting neurological impairment, approaches that could be developed to alleviate the lasting effects of TIA or migraine, and the need to consider individual neurological status, even following transient neurological symptoms.
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Cognición/fisiología , Ataque Isquémico Transitorio/fisiopatología , Destreza Motora/fisiología , Robótica , Anciano , Estudios de Cohortes , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Trastornos Migrañosos/fisiopatología , Análisis y Desempeño de TareasRESUMEN
Background Emerging yet contrasting evidence from animal and human studies associates ischemic preconditioning with improvement of subsequent stroke severity, although long-term outcome remains unclear. The purpose of this study was to analyze how preceding cerebral ischemic events influence subsequent stroke severity and outcome. Methods and Results Data for this retrospective cohort study were extracted from ASTRAL (Acute Stroke Registry and Analysis of Lausanne). This registry includes a sample of all consecutive patients with acute ischemic strokes admitted to the stroke unit and/or intensive care unit of the Lausanne University Hospital, Switzerland. We investigated associations between preceding ischemic events (transient ischemic attacks or ischemic strokes) and the impact on subsequent stroke severity and clinical improvement within 24 hours, measured through National Institute of Health Stroke Scale, as well as 3-month outcome, determined through a shift in the modified Rankin Scale. Of 3530 consecutive patients with ischemic stroke (43% women, median age 73 years), 1001 (28%) had ≥1 preceding cerebral ischemic events (45% transient ischemic attack, 55% ischemic stroke; 31% multiple events). After adjusting for multiple prehospital, clinical, and laboratory confounders, admission stroke severity was significantly lower in patients preconditioned through a preceding ischemic event, but 24-hour improvement was not significant and 3-month outcome was unfavorable. Conclusions Preceding ischemic events were independently associated with a significant reduction in subsequent stroke severity but worsened long-term clinical outcome. These results, if confirmed by future randomized studies, may help design neuroprotective strategies. The unfavorable effect on stroke outcome is probably a consequence of the cumulative disability burden after multiple ischemic events.
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Circulación Cerebrovascular , Ataque Isquémico Transitorio/fisiopatología , Accidente Cerebrovascular Isquémico/fisiopatología , Anciano , Evaluación de la Discapacidad , Femenino , Estado Funcional , Humanos , Ataque Isquémico Transitorio/diagnóstico , Ataque Isquémico Transitorio/terapia , Accidente Cerebrovascular Isquémico/diagnóstico , Accidente Cerebrovascular Isquémico/terapia , Masculino , Recuperación de la Función , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Suiza , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: The role of shunting during carotid endarterectomy (CEA) in symptomatic patients is unclear. The aim was to evaluate early outcomes of CEA with routine "delayed" shunt insertion, for patients with symptomatic carotid stenosis. METHODS: We conducted a single-center retrospective study of symptomatic patients undergoing CEA (2009-2020). All CEAs were performed under general anesthesia using a standardized technique, based on delayed routine shunt insertion after plaque removal. Primary endpoints were 30-days mortality and stroke. A logistic regression was performed to identify clinical and procedural factors associated with postoperative stroke. RESULTS: Two-hundred-sixty-three CEAs were performed for TIA (N.=178, 47%) or acute ischemic stroke (N.=85, 32%). Mean delay of surgery was 6±19 days, and early CEA (<48 hours) was performed in 98 cases (37%). Conventional CEA was performed in 171 patients (67%), eversion CEA in 83 (33%). Early (30-days) mortality was 0.3%. Stroke/death rate was 2.3%. Female sex (OR=5.14, 95% CI: 1.32-24.93; P=0.023), use of anticoagulants (OR=10.57, 95% CI: 2.67-51.86; P=0.001), preoperative stroke (OR=5.34, 95% CI: 1.62-69.21; P=0.006), and the presence of preoperative CT/MRI cerebral ischemic lesions (OR=5.96, 95% CI: 1.52-28.59; P=0.013) were associated with early neurological complications. Statin medication (OR=0.18, 95% CI: 0.04-0.71; P=0.019) and CEA timing <2 days (OR=0.14, 95% CI: 0.03-0.55; P=0.005) were protective from postoperative stroke. CEA outcomes were independent from time period (P=0.201) and operator's volume (P=0.768). A literature systematic review identified other four studies describing the CEA outcomes with routine shunting in symptomatic patients, with a large variability in the selection of patients, surgical technique, and description of the results. CONCLUSIONS: Routine delayed shunting after plaque removal seems to be a safe and effective technique, that contributed to maintain a low complication rate in neurologically symptomatic patients. Statin use and expedited timing were associated with improved outcomes using this technique.
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Estenosis Carotídea/cirugía , Circulación Cerebrovascular , Endarterectomía Carotidea , Ataque Isquémico Transitorio/etiología , Accidente Cerebrovascular/etiología , Tiempo de Tratamiento , Anciano , Anciano de 80 o más Años , Estenosis Carotídea/complicaciones , Estenosis Carotídea/mortalidad , Estenosis Carotídea/fisiopatología , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/mortalidad , Femenino , Humanos , Ataque Isquémico Transitorio/mortalidad , Ataque Isquémico Transitorio/fisiopatología , Masculino , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/fisiopatología , Factores de Tiempo , Resultado del TratamientoRESUMEN
For patients with symptomatic unilateral internal carotid artery (ICA) occlusion, impaired cerebrovascular reactivity (CVR) indicates increased stroke risk. Here, the role of collateral activation remains a matter of debate, whereas angio-anatomical collateral abundancy does not necessarily imply sufficient compensatory flow provided. We aimed to further elucidate the role of collateral activation in the presence of impaired CVR. From a prospective database, 62 patients with symptomatic unilateral ICA occlusion underwent blood oxygenation-level dependent (BOLD) fMRI CVR imaging and a transcranial Doppler (TCD) investigation for primary and secondary collateral activation. Descriptive statistic and multivariate analysis were used to evaluate the relationship between BOLD-CVR values and collateral activation. Patients with activated secondary collaterals exhibited more impaired BOLD-CVR values of the ipsilateral hemisphere (p = 0.02). Specifically, activation of leptomeningeal collaterals showed severely impaired ipsilateral hemisphere BOLD-CVR values when compared to activation of ophthalmic collaterals (0.05 ± 0.09 vs. 0.12 ± 0.04, p = 0.005). Moreover, the prediction analysis showed leptomeningeal collateral activation as a strong independent predictor for ipsilateral hemispheric BOLD-CVR. In our study, ipsilateral leptomeningeal collateral activation is the sole collateral pathway associated with severely impaired BOLD-CVR in patients with symptomatic unilateral ICA occlusion.
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Arteria Carótida Interna/patología , Trastornos Cerebrovasculares/diagnóstico por imagen , Circulación Colateral/fisiología , Imagen por Resonancia Magnética/métodos , Meninges/irrigación sanguínea , Anciano , Circulación Cerebrovascular/fisiología , Femenino , Humanos , Ataque Isquémico Transitorio/diagnóstico , Ataque Isquémico Transitorio/fisiopatología , Accidente Cerebrovascular Isquémico/diagnóstico , Accidente Cerebrovascular Isquémico/fisiopatología , Masculino , Meninges/diagnóstico por imagen , Persona de Mediana Edad , Análisis Multivariante , Saturación de Oxígeno/fisiología , Estudios Prospectivos , Ultrasonografía Doppler Transcraneal/métodosRESUMEN
In specific cases of moyamoya disease (MMD), posterior cerebral artery (PCA) stenosis can develop after treatment of the anterior circulation and require additional revascularization. Here, we report two cases that underwent additional posterior indirect revascularization with multiple burr holes for PCA involvement after bilateral revascularization treatment of the anterior circulation. They presented with transient ischemic attack even after bilateral superficial temporal artery-middle cerebral artery bypass, and magnetic resonance angiography (MRA) showed that PCA stenosis had worsened. Indirect revascularization with multiple burr holes using Benz-marked skin incisions was performed. After surgery, the symptoms improved without perioperative complications, and cerebral angiography showed collateral circulation via the burr hole. Indirect revascularization for MMD is often combined with direct revascularization, and there are only a few reports on the use of multiple burr hole surgery alone. In addition, there are few reports of posterior circulation, despite the emphasis on the importance of PCA involvement in MMD. Indirect revascularization with multiple burr holes alone can be performed in multiple areas and applied to patients who cannot undergo direct revascularization using the occipital artery. The procedure is simple and less invasive than traditional direct revascularization procedures. Therefore, it can be effective, especially in pediatric cases of MMD with PCA involvement.