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Fibrilación Atrial , Ablación por Catéter , Embolia Aérea , Fístula Esofágica , Oxigenoterapia Hiperbárica , Embolia Intracraneal , Humanos , Fibrilación Atrial/cirugía , Fibrilación Atrial/terapia , Embolia Aérea/etiología , Embolia Aérea/terapia , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodos , Fístula Esofágica/etiología , Oxigenoterapia Hiperbárica/métodos , Embolia Intracraneal/etiología , Masculino , Atrios Cardíacos/diagnóstico por imagen , Fístula/etiología , Persona de Mediana EdadRESUMEN
BACKGROUND: Prompt diagnosis and treatment of vertebral artery dissection (VAD) is critical for preventing stroke. The use of emboli detection studies (EDS) using Doppler ultrasonography is an emerging method that has been proposed to predict stroke risk and guide subsequent treatment. Limited data exists on the predictive value of this emerging modality in the posterior circulation. This study aims to assess the predictive value of emboli detection studies (EDS) in forecasting inpatient stroke in VAD patients and identify associated risk factors. Patients were recruited between January 2009 and January 2018. METHODS: We performed a retrospective analysis of 104 consecutive patients with VAD who underwent EDS at our institution. Patients underwent transcranial ultrasonography for detection of microemboli and were followed clinically and radiographically thereafter for evidence of stroke. RESULTS: A total of 104 patients with spontaneous (58 %), traumatic (39 %) or iatrogenic (4 %) VAD were included in our analysis. Stroke occurred more frequently in patients with spontaneous VAD compared to traumatic VAD (p < 0.001). Microemboli were detected in 17 patients (16 %), including 18.3 % of spontaneous VAD, 12.5 % of traumatic VAD, and 25 % of iatrogenic VAD. 61 patients (59 %) suffered a posterior circulation stroke, however there was no significant association between detection of microemboli and stroke events (60 % of patients without microemboli vs. 53 % of patients with ≥ 1 HITS during EDS; p = 0.6). Similarly, no microemboli were detected in any of the patients who went on to develop a delayed stroke. CONCLUSIONS: In our single-institution retrospective analysis of patients with VAD, the detection of microemboli on EDS was not associated with stroke nor was it predictive of delayed stroke. Additionally, patients with spontaneous VAD may be at higher risk for stroke compared to traumatic VAD.
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Ultrasonografía Doppler Transcraneal , Disección de la Arteria Vertebral , Humanos , Masculino , Femenino , Persona de Mediana Edad , Estudios Retrospectivos , Disección de la Arteria Vertebral/epidemiología , Disección de la Arteria Vertebral/diagnóstico por imagen , Disección de la Arteria Vertebral/complicaciones , Adulto , Ultrasonografía Doppler Transcraneal/métodos , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/diagnóstico por imagen , Anciano , Factores de Riesgo , Pacientes Internos/estadística & datos numéricos , Embolia Intracraneal/epidemiología , Embolia Intracraneal/diagnóstico por imagen , Embolia Intracraneal/etiologíaRESUMEN
Cerebral air embolism after removal of central venous catheter (CVC) is a rare complication but can lead to fatal outcomes. We report a rare case of both cerebral venous and arterial embolism occurring in a patient with underlying scleroderma-related interstitial lung disease (SSc-ILD) and pulmonary hypertension following removal of percutaneous introducer sheath for pulmonary artery catheterization. We discuss the mechanisms, pathophysiology, management and prevention of cerebral air embolism.
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Embolia Aérea , Embolia Intracraneal , Humanos , Embolia Aérea/etiología , Embolia Aérea/diagnóstico , Embolia Intracraneal/etiología , Embolia Intracraneal/diagnóstico , Remoción de Dispositivos/métodos , Remoción de Dispositivos/efectos adversos , Persona de Mediana Edad , Masculino , Femenino , Enfermedades Pulmonares Intersticiales/etiología , Enfermedades Pulmonares Intersticiales/diagnóstico , Enfermedades Pulmonares Intersticiales/terapia , Cateterismo de Swan-Ganz/efectos adversos , Cateterismo de Swan-Ganz/instrumentaciónRESUMEN
OBJECTIVES: This study aimed to analyse the impact of preoperative septic cerebral embolism on early and late postoperative outcomes in patients with infective endocarditis undergoing valve surgery. METHODS: Retrospective multicentric study based on the Clinical Multicentric Project for Analysis of Infective Endocarditis in Germany (CAMPAIGN) registry comprising patients with infective endocarditis who underwent valve surgery between 1994 and 2018 at 6 German centres. Patients were divided into 2 groups for statistical comparison according to the presence or absence of preoperative septic cerebral embolism. Propensity score matching was performed for adjusted comparisons of postoperative outcomes. Primary outcomes were 30-day mortality and estimated 5-year survival. RESULTS: A total of 4917 patients were included in the analysis, 3909 (79.5%) patients without and 1008 (20.5%) patients with preoperative septic cerebral embolism. Patients with preoperative septic cerebral embolism had more baseline comorbidities. Mitral valve endocarditis (44.1% vs 33.0% P < 0.001), large vegetations >10 mm (43.1% vs 30.0%, P < 0.001), and Staphylococcus species infection (42.3% vs 21.3%, P < 0.001) were more frequent in the cerebral embolism group. Among patients with preoperative cerebral embolism, 286 (28.4%) patients had no stroke signs (silent stroke). After matching (1008 matched pairs), there was no statistically significant difference in 30-day mortality (20.1% vs 22.8%; P = 0.14) and 5-year survival (47.8% vs 49.1%; stratified log-rank P = 0.77) in patients with and without preoperative cerebral embolism, respectively. CONCLUSIONS: Preoperative septic cerebral embolism in patients with infective endocarditis requiring valve surgery does not negatively affect early or late mortality; therefore, it should not play a major role in deciding if surgery is to be performed.
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Embolia Intracraneal , Humanos , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Embolia Intracraneal/mortalidad , Embolia Intracraneal/epidemiología , Anciano , Endocarditis/cirugía , Endocarditis/mortalidad , Endocarditis/complicaciones , Alemania/epidemiología , Complicaciones Posoperatorias/epidemiología , Resultado del Tratamiento , Sistema de Registros , Endocarditis Bacteriana/cirugía , Endocarditis Bacteriana/mortalidad , Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/epidemiología , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Válvulas Cardíacas/cirugía , Factores de RiesgoRESUMEN
BACKGROUND: Despite impressive improvements in the safety profile of Transcatheter aortic valve replacement (TAVR), the risk for peri-procedural stroke after TAVR has not declined substantially. In an effort to reduce periprocedural stroke, cerebral embolic protection (CEP) devices have been utilized but have yet to demonstrate benefit in all-comers. There is a paucity of data supporting the utilization of CEP in TAVR patients with an anticipated high risk for peri-procedural stroke. METHODS: The Transcatheter Aortic Valve Replacement In-Hospital Stroke (TASK) score is a clinical risk tool for predicting the in-hospital stroke risk of patients undergoing transfemoral TAVR. This score was used to identify high-risk patients and calculate the expected in-hospital stroke risk. This was a single-centre cohort study in all consecutive TAVR patients who had placement of CEP. The observed versus expected ratio for peri-procedural stroke was calculated. To obtain 95% credible intervals, we used 1000 bootstrapped samples of the original cohort sample size without replacement and recalculated the TASK predicted scores. RESULTS: The study included 103 patients. The median age was 83 (IQR 78,89). 63 were male (61.1%) and 45 (43.69%) had a history of previous Stroke or TIA. Two patients had an in-hospital stroke after TAVR (1.94%). The expected risk of in-hospital stroke based on the TASK score was 3.39% (95% CI 3.07-3.73). The observed versus expected ratio was 0.57 (95% CI 0.52-0.64). CONCLUSION: In this single-center study, we found that in patients undergoing TAVR with high stroke risk, CEP reduced the in-hospital stroke risk by 43% when compared with the risk-score predicted rate. CLINICAL TRIAL NUMBER: N/A.
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Dispositivos de Protección Embólica , Accidente Cerebrovascular , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Masculino , Femenino , Anciano , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Factores de Riesgo , Medición de Riesgo , Anciano de 80 o más Años , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/epidemiología , Resultado del Tratamiento , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/fisiopatología , Factores de Tiempo , Embolia Intracraneal/prevención & control , Embolia Intracraneal/etiología , Embolia Intracraneal/epidemiología , Embolia Intracraneal/diagnóstico , Estudios Retrospectivos , Técnicas de Apoyo para la Decisión , Valor Predictivo de las PruebasRESUMEN
OBJECTIVES: Cerebral microemboli can be detected by transcranial Doppler monitoring (TCDM) and may elucidate stroke etiology, the effect of preventive therapy, and the risk of stroke recurrence. Microemboli detection is usually performed for up to 60 minutes, but due to temporal variability, microembolization may be missed if the monitoring time is too short. We aimed to assess the time course of microembolization in acute ischemic stroke and explore the utility of prolonged and repeated microemboli detection. MATERIALS AND METHODS: Patients with suspected ischemic stroke and symptom onset within 24 hours were examined with bilateral, stationary TCDM for one hour followed by unilateral, ambulatory TCDM for two hours. Unilateral TCDM was repeated for the following two days and after three months. RESULTS: We included 47 patients, of which 41 had ischemic stroke, five had transient ischemic attack, and one had amaurosis fugax. Microemboli were detected in 60 % of patients. The occurrence was highest within 24 hours after onset and significantly lower at three months. Prolonged and repeated microemboli detection yielded only one additional microemboli-positive patient. Hence, patients who initially were microemboli negative tended to remain negative. We could not demonstrate an association between microemboli occurrence and clinical outcome or stroke recurrence. CONCLUSIONS: Microembolic signals are frequent within 24 hours after ischemic stroke onset, but prolonged and repeated microemboli detection did not increase the yield of MES positive patients. CLINICAL TRIAL REGISTRATION-URL: http://www. CLINICALTRIALS: gov. Unique identifier: NCT03543319.
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Embolia Intracraneal , Accidente Cerebrovascular Isquémico , Valor Predictivo de las Pruebas , Ultrasonografía Doppler Transcraneal , Humanos , Masculino , Femenino , Anciano , Accidente Cerebrovascular Isquémico/etiología , Accidente Cerebrovascular Isquémico/terapia , Accidente Cerebrovascular Isquémico/diagnóstico , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Factores de Tiempo , Persona de Mediana Edad , Embolia Intracraneal/diagnóstico por imagen , Embolia Intracraneal/etiología , Embolia Intracraneal/diagnóstico , Anciano de 80 o más Años , Noruega/epidemiología , Estudios Prospectivos , Factores de Riesgo , Recurrencia , Ataque Isquémico Transitorio/diagnóstico , Ataque Isquémico Transitorio/etiología , Ataque Isquémico Transitorio/diagnóstico por imagen , Ataque Isquémico Transitorio/terapiaAsunto(s)
Fibrilación Atrial , Ablación por Catéter , Criocirugía , Embolia Intracraneal , Humanos , Fibrilación Atrial/cirugía , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Criocirugía/efectos adversos , Ablación por Catéter/efectos adversos , Estudios Prospectivos , Incidencia , Embolia Intracraneal/etiología , Embolia Intracraneal/epidemiología , Resultado del Tratamiento , Masculino , Femenino , Factores de Riesgo , Persona de Mediana Edad , Anciano , Factores de TiempoAsunto(s)
Embolia Intracraneal , Válvula Mitral , Humanos , Válvula Mitral/cirugía , Válvula Mitral/fisiopatología , Válvula Mitral/diagnóstico por imagen , Embolia Intracraneal/prevención & control , Embolia Intracraneal/etiología , Embolia Intracraneal/diagnóstico por imagen , Prótesis Valvulares Cardíacas , Resultado del Tratamiento , Cateterismo Cardíaco/instrumentación , Cateterismo Cardíaco/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Dispositivos de Protección Embólica , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/fisiopatologíaAsunto(s)
Cateterismo Cardíaco , Prótesis Valvulares Cardíacas , Embolia Intracraneal , Válvula Mitral , Humanos , Válvula Mitral/cirugía , Válvula Mitral/fisiopatología , Válvula Mitral/diagnóstico por imagen , Embolia Intracraneal/prevención & control , Embolia Intracraneal/etiología , Embolia Intracraneal/diagnóstico por imagen , Cateterismo Cardíaco/instrumentación , Cateterismo Cardíaco/efectos adversos , Resultado del Tratamiento , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Dispositivos de Protección Embólica , Falla de Prótesis , Factores de Riesgo , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/fisiopatología , Diseño de PrótesisRESUMEN
INTRODUCTION: Cerebral Embolic Protection Device (CEPD) captures emboli during Transcatheter Aortic Valve Replacement (TAVR). With recently published pivotal trials and multiple cohort studies reporting new data, there is a need to re-calibrate available statistical evidence. METHODS: A systematic literature search was conducted across databases from inception till February 2023. Dichotomous outcomes were pooled using Odds Ratio (OR), while continuous outcomes were pooled using Standardized Mean Difference (SMD) along with 95% corresponding intervals (95% CIs). RESULTS: Data was included from 17 studies (7 RCTs, 10 cohorts, n = 155,829). Use of CEPD was associated with significantly reduced odds of stroke (OR = 0.60, 95% CI = 0.43-0.85, p = 0.003). There was no significant difference in disabling stroke (p = 0.25), non-disabling stroke (p = 0.72), and 30-day mortality (p = 0.10) between the two groups. There were no significant differences between the two groups for Diffusion-Weighted Magnetic Resonance Imaging (DW-MRI) findings, acute kidney injury, risk of pacemaker implantation life-threatening bleed, major bleed, minor bleed, worsening National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and vascular complications (p > 0.05). CONCLUSIONS: The use of CEPD during TAVR reduced the incidence of all-stroke (p = 0.003); however, there were no significant differences in any of the other pooled outcomes (p > 0.05). REGISTRATION: The protocol of this meta-analysis was registered with the Open Science framework [https://doi.org/10.17605/OSF.IO/7W564] before data acquisition was started.
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Estenosis de la Válvula Aórtica , Dispositivos de Protección Embólica , Embolia Intracraneal , Accidente Cerebrovascular , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Embolia Intracraneal/prevención & control , Embolia Intracraneal/etiología , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/etiología , Estenosis de la Válvula Aórtica/cirugía , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: This study aimed to clarify the characteristics and survival prediction value of transcranial Doppler microembolic signals (MES) in patients with acute cerebral infarction and active cancer. METHODS AND RESULTS: Between 2017 and 2022, 1089 cases of acute cerebral infarction were recorded within 7 days of disease onset. Among them, transcranial Doppler was successful in 33 patients who had active cancer, and these data were analyzed in this study. The primary outcomes were stroke recurrence and mortality at 3 months. The study population had the following characteristics [median (interquartile range)]: age, 70 years (63-78); body mass index, 21.6 (20-24), National Institutes of Health Stroke Scale 3 (1-6), and modified Rankin Scale score at discharge 1 (1-4). The most common cancer types were lung (24%), pancreatic (24%), and intestinal (18%). MES was present in 16 of 33 patients (48.5%). The presence and number of MES were significantly associated with the levels of D-dimer (P <0.001) and C-reactive protein (P=0.012). Moreover, the presence of MES was associated with multiple ischemic lesions and the 3-territory sign on magnetic resonance imaging. Of the 33 patients, 9 died at 3 months, and 1 had stroke recurrence. On Cox multivariate analysis, using the MES-negative group as a reference, the presence of MES was significantly associated with all-cause death (adjusted hazard ratio, 12.19 [95% CI, 1.45-216.85]; P=0.020). CONCLUSIONS: In patients with acute ischemic stroke and active cancer, the presence of MES was associated with D-dimer and C-reactive protein levels and multiple and 3-territory ischemic lesions, and was predictive of short-term survival.
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Embolia Intracraneal , Accidente Cerebrovascular Isquémico , Neoplasias , Ultrasonografía Doppler Transcraneal , Humanos , Masculino , Femenino , Anciano , Ultrasonografía Doppler Transcraneal/métodos , Persona de Mediana Edad , Accidente Cerebrovascular Isquémico/mortalidad , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Neoplasias/mortalidad , Neoplasias/complicaciones , Neoplasias/diagnóstico por imagen , Embolia Intracraneal/mortalidad , Embolia Intracraneal/diagnóstico por imagen , Embolia Intracraneal/etiología , Factores de Tiempo , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Factores de Riesgo , Pronóstico , Medición de Riesgo , RecurrenciaRESUMEN
BACKGROUND: Stent-assisted carotid artery revascularization employing surgical cutdown for transcervical access and dynamic flow reversal (TCAR) is gaining popularity. TCAR, despite maximized intra-procedural cerebral protection, shows a marked excess of 30-day neurologic complications in symptomatic vs. asymptomatic stenoses. The TCAR conventional single-layer stent (free-cell area 5.89mm2) inability to seal embologenic lesions may be particularly relevant after the flow reversal neuroprotection is terminated. METHODS: We evaluated peri-procedural and 30-day major adverse cerebral and cardiac events (MACCE) of TCAR (ENROUTE, SilkRoad Medical) paired with MicroNET-covered neuroprotective stent (CGuard, InspireMD) in consecutive patients at elevated risk of complications with transfemoral/transradial filter-protected stenting (increased lesion-related and/or access-related risk). CGuard (MicroNET free cell area ≈0.02-0.03 mm2) has level-1 evidence for reducing intra- and abolishing post-procedural lesion-related cerebral embolism. RESULTS: One hundred and six increased-risk patients (age 72 [61-76] years, median [Q1-Q3]; 60.4% symptomatic, 49.1% diabetic, 36.8% women, 61.3% left-sided index lesion) were enrolled in three vascular surgery centers. Angiographic stenosis severity was 81 (75-91)%, lesion length 21 (15-26)mm, increased-risk lesional characteristics 87.7%. Study stent use was 100% (no other stent types). 74.5% lesions were predilated; post-dilatation rate was 90.6%. Flow reversal duration was 8 (5-11)min. One stroke (0.9%) occurred in an asymptomatic patient prior to establishing neuroprotection (index lesion disruption with the sheath insertion wire); there were no other peri-procedural MACCE. No further adverse events occurred by 30-days. 30-day stent patency was 100% with normal velocities and absence of any in-stent material by Duplex Doppler. CONCLUSIONS: Despite a high proportion of increased-risk lesions and clinically symptomatic patients in this study, TCAR employing the MicroNET-covered anti-embolic stent showed 30-day MACCE rate <1%. This suggests a clinical role for combining maximized intra-procedural prevention of cerebral embolism by dynamic flow reversal with anti-embolic stent prevention of peri- and post-procedural cerebral embolism (TOPGUARD NCT04547387).
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Estenosis Carotídea , Dispositivos de Protección Embólica , Embolia Intracraneal , Diseño de Prótesis , Stents , Humanos , Anciano , Femenino , Masculino , Estenosis Carotídea/cirugía , Estenosis Carotídea/fisiopatología , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/complicaciones , Persona de Mediana Edad , Resultado del Tratamiento , Embolia Intracraneal/prevención & control , Embolia Intracraneal/etiología , Factores de Tiempo , Factores de Riesgo , Circulación Cerebrovascular , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/efectos adversos , Estudios Prospectivos , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/etiologíaRESUMEN
BACKGROUND: The study aims to evaluate the association of proximal flow-inversion cerebral protection and MicroNet-covered CGuard stents in reducing early and late embolic events in carotid artery stenting procedures. METHODS: From 2018 to 2023, we performed 204 procedures in 180 patients with flow inversion cerebral protection and CGuard stents at the Vascular Surgery Unit of Sant'Eugenio Hospital in Rome. Cerebral protection was achieved with a Flow-Gate2 catheter connected to a peripheral vein. The tip balloon is inflated in the CCA to obtain an effective endoclamping, the pressure difference between the carotid bifurcation and the venous compartment ensures a constant back flow with wash-out in the venous compartment. Inclusion criteria were: life expectancy of >12 months, target lesions indicating treatment according to ESVS Guidelines, increased surgical risk due to comorbidities or anatomic issues. ECD follow-up was performed immediately postoperatively, at 30 days, 6 and 12 months, and subsequently annually. RESULTS: The treatment protocol was successfully implemented in 99% of cases. No major strokes occurred, while one minor stroke (0.5%) occurred within 8 hours of the procedure, regressing in the following months. One perioperative death (0.5%) due to cerebral hemorrhage occurred three hours after the procedure. All patients remained asymptomatic, with no short or medium-term neurological score deterioration. One hemodynamically significant restenosis (0.5%) was detected at the 6-month follow-up. All patients completed the 6 months follow-up, though 6 (3%) were lost at the 12-month appointment. CONCLUSIONS: Our prospective monocentric study has demonstrated the effectiveness and safety of the FlowGate2 flow inversion cerebral protection system in association with MicroNet covered CGuard stent.
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Estenosis Carotídea , Dispositivos de Protección Embólica , Diseño de Prótesis , Stents , Humanos , Femenino , Masculino , Anciano , Estenosis Carotídea/complicaciones , Estenosis Carotídea/fisiopatología , Estenosis Carotídea/cirugía , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/terapia , Resultado del Tratamiento , Factores de Tiempo , Circulación Cerebrovascular , Persona de Mediana Edad , Anciano de 80 o más Años , Factores de Riesgo , Ciudad de Roma , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/instrumentación , Embolia Intracraneal/prevención & control , Embolia Intracraneal/etiología , Estudios ProspectivosRESUMEN
BACKGROUND: Recent randomized controlled trials (RCTs) have demonstrated similar outcomes in terms of ischemic stroke incidence after carotid endarterectomy (CEA) or carotid artery stenting (CAS) in asymptomatic carotid disease, while CEA seems to be the first option for symptomatic carotid disease. The aim of this meta-analysis is to assess the incidence of silent cerebral microembolization detected by magnetic resonance imaging (MRI) following these procedures. METHODS: A systematic search was conducted using PubMed, Scopus, and Cochrane databases, including comparative studies involving symptomatic or asymptomatic patients undergoing either CEA or CAS and reporting on new cerebral ischemic lesions in postoperative MRI. The primary outcome was the newly detected cerebral ischemic lesions. Pooled effect estimates for all outcomes were calculated using the random-effects model. Prespecified random effects metaregression and subgroup analysis were conducted to examine the impact of moderator variables on the presence of new cerebral ischemic lesions. RESULTS: 25 studies reporting on a total of 1827 CEA and 1500 CAS interventions fulfilled the eligibility criteria. The incidence of new cerebral ischemic lesions was significantly lower after CEA compared to CAS, regardless of the time of MRI assessment (first 24 hours; OR: 0.33, 95% CI: 0.17-0.64, P < 0.001), (the first 72 hours, OR: 0.25, 95% CI 0.18-0.36, P < 0.001), (generally within a week after the operation; OR: 0.24, 95% CI: 0.17-0.34, P < 0.001). Also, the rate of stroke (OR: 0.38, 95% CI: 0.23-0.63, P < 0.001) and the presence of contralateral new cerebral ischemic lesions (OR: 0.16, 95% CI 0.08-0.32, P < 0.001) were less frequent after CEA. Subgroup analysis based on the study design and the use of embolic protection device during CAS showed consistently lower rates of new lesions after CEA. CONCLUSIONS: CEA demonstrates significant lower rates of new silent cerebral microembolization, as detected by MRI in postoperative period compared with CAS.
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Endarterectomía Carotidea , Procedimientos Endovasculares , Imagen por Resonancia Magnética , Valor Predictivo de las Pruebas , Stents , Humanos , Endarterectomía Carotidea/efectos adversos , Resultado del Tratamiento , Factores de Riesgo , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Factores de Tiempo , Anciano , Femenino , Masculino , Isquemia Encefálica/etiología , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/prevención & control , Incidencia , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/terapia , Estenosis Carotídea/cirugía , Persona de Mediana Edad , Medición de Riesgo , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/cirugía , Enfermedades de las Arterias Carótidas/terapia , Embolia Intracraneal/etiología , Embolia Intracraneal/diagnóstico por imagen , Embolia Intracraneal/prevención & control , Enfermedades AsintomáticasRESUMEN
Introduction: Cerebral gas embolism is an unusual but extremely serious condition that occurs when air is introduced into the arterial or venous circulation of the brain. Although rare, it can lead to significant neurological deficits and even the death of the patient. Clinical Case: 76-year-old patient with pre-existing diffuse interstitial lung disease, who experienced a massive stroke due to spontaneous pneumomediastinum. Her presentation included confusion, seizures, and motor weakness. Imaging tests revealed air bubbles in the cerebral sulci and hypodense areas in the cerebellum and parietooccipitals. In addition, pneumothorax and air in the upper mediastinum were noted on chest radiographs and chest CT scan. Despite therapeutic measures such as hyperbaric oxygen, the patient unfortunately died due to multiple organ failure. Discussion: The diagnosis of cerebral gas embolism generally involves performing a cerebral computed tomography, which is highly sensitive for detecting the presence of air in the cerebral vessels. Management includes monitoring of vital and neurological signs, as well as specific measures such as airway closure, venous catheter aspiration, Trendelenburg positioning, and hyperbaric oxygen. Conclusion: Cerebral gas embolism is a potentially fatal condition that requires a brain computed tomography for diagnosis and it is vitally important to know the prevention measures to avoid the appearance of this complication and also to know the general measures to adopt when it occurs.
Introducción: La embolia gaseosa cerebral es una afección inusual pero extremadamente grave que se produce cuando se introduce aire en la circulación arterial o venosa del cerebro. Aunque poco común, puede derivar en déficits neurológicos significativos e incluso la muerte del paciente. Caso Clínico: Paciente de 76 años con una enfermedad pulmonar intersticial difusa preexistente, que experimentó un ictus masivo debido a un neumomediastino espontáneo. Su presentación incluyó confusión, convulsiones y debilidad motora. Las pruebas de imagen revelaron burbujas de aire en los surcos cerebrales y áreas hipodensas en el cerebelo y parietooccipitales. Además, se observó neumotórax y aire en el mediastino superior en las radiografías de tórax y la tomografía torácica. A pesar de las medidas terapéuticas como el oxígeno hiperbárico, la paciente lamentablemente falleció debido al fallo multiorgánico. Discusión: El diagnóstico de embolia gaseosa cerebral generalmente implica la realización de una tomografía computarizada cerebral, que es altamente sensible para detectar la presencia de aire en los vasos cerebrales. El manejo incluye el control de las constantes vitales y neurológicas, así como medidas específicas como cierre de la entrada de aire, aspiración de catéteres venosos, posicionamiento de Trendelenburg y oxígeno hiperbárico. Conclusión: La embolia gaseosa cerebral es una afección potencialmente mortal que requiere una tomografía computarizada cerebral para el diagnóstico y de vital importancia conocer las medidas de prevención para evitar la aparición de esta complicación y así mismo conocer las medidas generales a adoptar cuando ésta se presenta.
Asunto(s)
Embolia Aérea , Embolia Intracraneal , Enfermedades Pulmonares Intersticiales , Humanos , Masculino , Embolia Aérea/etiología , Embolia Aérea/diagnóstico por imagen , Embolia Aérea/terapia , Anciano , Resultado Fatal , Enfermedades Pulmonares Intersticiales/diagnóstico por imagen , Enfermedades Pulmonares Intersticiales/etiología , Enfermedades Pulmonares Intersticiales/complicaciones , Embolia Intracraneal/etiología , Embolia Intracraneal/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Oxigenoterapia HiperbáricaRESUMEN
BACKGROUND: Surgery or fibrinolysis is the currently available evidence-based treatment for obstructive mechanical valve thrombus. We reported the feasibility and short-term outcomes of percutaneous transcatheter therapy with cerebral embolic protection. Mid- and long-term outcomes remain unknown. METHODS: From 2020 to 2023, 24 patients underwent percutaneous transcatheter release of stuck leaflets with cerebral embolic protection for obstructive mitral mechanical valve thrombus. The indications for the transcatheter therapy were failed fibrinolysis, contraindications for fibrinolysis, not willing for fibrinolysis, or high risk for surgery. The study participants were followed up for a median period of 344.50 (65.00-953.75) days. RESULTS: Technical success was achieved in 91.67% (n=22) of procedures. During the follow-up, 12.50% (n=3) all-cause death, 4.17% (n=1) stroke, and 16.67% (n=4) recurrence were seen. The mean survival time free from death was 1101.48 (95% CI, 929.49-1273.47) days, stroke was 1211.38 (95% CI, 1110.40-1312.35) days, and recurrence was 907.71 (95% CI, 760.20-1055.21) days. CONCLUSIONS: Transcatheter release of the stuck mitral mechanical valve with cerebral embolic protection is an alternative therapy with promising mid-term outcomes where surgery or fibrinolysis is not possible or in failed fibrinolysis subsets.
Asunto(s)
Cateterismo Cardíaco , Dispositivos de Protección Embólica , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Embolia Intracraneal , Válvula Mitral , Humanos , Masculino , Femenino , Válvula Mitral/cirugía , Válvula Mitral/fisiopatología , Válvula Mitral/diagnóstico por imagen , Anciano , Embolia Intracraneal/prevención & control , Embolia Intracraneal/etiología , Embolia Intracraneal/mortalidad , Embolia Intracraneal/diagnóstico por imagen , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/instrumentación , Cateterismo Cardíaco/mortalidad , Persona de Mediana Edad , Factores de Tiempo , Factores de Riesgo , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Resultado del Tratamiento , Estudios Retrospectivos , Anciano de 80 o más Años , Recurrencia , Diseño de Prótesis , Trombosis/prevención & control , Trombosis/etiología , Trombosis/mortalidad , Trombosis/diagnóstico por imagen , Estudios de Factibilidad , Falla de Prótesis , Medición de RiesgoRESUMEN
BACKGROUND: Cerebral embolic protection devices (EPDs) were developed to mitigate the risk of stroke during transcatheter aortic valve replacement (TAVR), but their benefit remains unproven. In the PROTECTED-TAVR trial (Stroke Protection With Sentinel During Transcatheter), EPD use did not reduce periprocedural stroke (primary study outcome) but led to a 62% reduction in the secondary end point of disabling stroke. Given these results, the impact of EPDs during TAVR remains unclear. METHODS: We used STS/ACC TVT registry data to examine the association between EPD use and a proxy for disabling stroke among transfemoral TAVR patients between January 2018 and June 2023. The primary outcome was in-hospital disabling stroke-defined as stroke associated with either in-hospital death or discharge to a nonhome location. We evaluated the association between EPD use and disabling stroke using instrumental variable analysis with a site-level preference for EPD use as the instrument-a quasi-experimental approach that can support causal inference. In addition, we performed a propensity score-based comparison using overlap weighting as a secondary analysis. RESULTS: The study population consisted of 414â 649 patients of whom 53â 389 (12.9%) received an EPD. The unadjusted rate of in-hospital disabling stroke was 0.7% among the EPD group and 0.9% in the no-EPD group. EPD use was associated with a reduction in disabling stroke in both instrumental variable analysis (relative risk, 0.87 [95% CI, 0.73-1.00]) and propensity-weighted analysis (odds ratio, 0.79 [95% CI, 0.70-0.90]) but was not associated with a reduction in nondisabling stroke. In subgroup analyses, the benefit of EPD was greater among those with versus without prior stroke (Pinteraction<0.05 for both instrumental variable and propensity-weighted analyses). CONCLUSIONS: In the largest study to date, among patients undergoing TAVR, EPD use was associated with a small, borderline significant reduction in stroke associated with death or discharge to a nonhome location (a proxy for disabling stroke) that is likely to be causal in nature. Taken together with previous mechanistic and clinical studies, these findings provide credible evidence that EPDs benefit patients undergoing TAVR.