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SUMMARY: This study aimed to compare the clinical value of carotid ultrasound and digital subtraction angiography (DSA) for carotid artery stenosis in patients with cerebral infarction. Sixty patients with cerebral infarction underwent carotid ultrasound and DSA. Carotid artery stenosis, degree of stenosis (mild, moderate, severe, and occlusion), and carotid artery plaques were recorded and compared. Carotid stenosis rate was 96.67 % (58/60) and 91.67 % (55/60) on DSA and carotid ultrasound, respectively, and the difference was not statistically significant. Mild, moderate, and severe carotid artery stenosis and occlusion were diagnosed in 35, 28, 20, and 17 arteries, respectively, with DSA, and in 39, 25, 10, and 9 arteries, respectively, with carotid ultrasound. There was a statistically significant difference in the degree of carotid stenosis between the two methods (p<0.05). The kappa value of carotid plaques detected by carotid ultrasound and DSA was 0.776, indicating good consistency. Both carotid ultrasound and DSA are effective for screening carotid artery stenosis and carotid atherosclerotic plaques. While carotid ultrasound is faster and more convenient, DSA can more accurately detect the degree of stenosis and presence of occlusion. Thus, our recommendation is a combination of carotid ultrasound and DSA in clinical settings to improve the convenience and accuracy of diagnosis.

Este estudio tuvo como objetivo comparar el valor clínico de la ecografía carotídea y la angiografía por sustracción digital (DSA) para la estenosis de la arteria carótida en pacientes con infarto cerebral. Sesenta pacientes con infarto cerebral fueron sometidos a ecografía carotídea y DSA. Se registraron y compararon la estenosis de la arteria carótida, el grado de estenosis (leve, moderada, grave y oclusión) y las placas de la arteria carótida. La tasa de estenosis carotídea fue del 96,67 % (58/60) y del 91,67 % (55/60) en DSA y ecografía carotídea, respectivamente, y la diferencia no fue estadísticamente significativa. Se diagnosticaron estenosis y oclusión de la arteria carótida leve, moderada y grave en 35, 28, 20 y 17 arterias, respectivamente, con DSA, y en 39, 25, 10 y 9 arterias, respectivamente, con ecografía carotídea. Hubo una diferencia estadísticamente significativa en el grado de estenosis carotídea entre los dos métodos (p<0,05). El valor kappa de las placas carotídeas detectadas por ecografía carotídea y DSA fue de 0,776, lo que indica una buena consistencia. Tanto la ecografía carotídea como la DSA son eficaces para detectar la estenosis de la arteria carótida y las placas ateroscleróticas carotídeas. Si bien la ecografía carotídea es más rápida y conveniente, la DSA puede detectar con mayor precisión el grado de estenosis y la presencia de oclusión. Por lo tanto, nuestra recomendación es una combinación de ecografía carotídea y DSA en entornos clínicos para mejorar la conveniencia y precisión del diagnóstico.

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Carotid artery stenosis (CAS) is a common vascular disease with long-term consequences for the brain. Although CAS is strongly associated with impaired cerebral hemodynamics and neurodegeneration, the mechanisms underlying hemodynamic impairment in the microvasculature remain unknown. In this work, we employed functional near-infrared spectroscopy (fNIRS) to introduce a methodological approach for quantifying the temporal delay of the evoked hemodynamic response. The method was validated during a vasodilatory task (breath-holding) in 50 CAS patients and 20 controls. Our results suggest that the hemodynamic response to breath-holding can be delayed by up to 6 s in the most severe patients, a significant increase from the median 4 s measured for the control group (p = 0.01). In addition, the fraction of brain regions that responded to the task decreased as the CAS severity increased, from a median of 90% in controls to 73% in the most severe CAS group (p = 0.04). The presence of collateral circulation increases the response to breath-holding and decreases the average time delays across the brain, although the number of communicating arteries alone cannot predict these fNIRS-based hemodynamic variables (p > 0.09). Overall, this work proposes a method to quantitatively assess impaired cerebral hemodynamics in CAS patients.

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OBJECTIVES: The primary aims of the study to evaluate the efficacy of carotid screening tests to identify asymptomatic carotid artery stenosis among high-risk patients and early prevention of stroke. BACKGROUND: The estimated prevalence of asymptomatic severe carotid stenosis (≥70%) in the general adult population ranges up to 3.1%. However, the prevalence is higher in comorbid individuals. This makes it important to perform screening testing for early diagnosis and treatment in predetermined high-risk patients. MATERIAL AND METHODS: In this prospective study, 3000 selected patients screened during March 2017 and September 2018 at the most populated family health center. Participants selected among registered individuals who have at least one of the risk factors such as hypertension, hyperlipidemia, diabetes mellitus, obesity, and smoking. All the participants were asymptomatic and above the age of 55. Bilateral carotid artery screening performed by Duplex Ultrasonography (DUSG) at the first call and one year later. Patients with severe carotid and/or coronary artery stenosis treated by surgical revascularization or stent implantation in the light of the latest guidelines. CONCLUSION: Carotid screening among high-risk asymptomatic individuals is of great importance to identify severe carotid artery as well as coronary artery stenosis. Patient education during screening may play a crucial role in preventing the disease.

OBJETIVOS: Los objetivos principales del estudio fueron evaluar la eficacia de las pruebas de detección de carótidas para identificar la estenosis asintomática de la arteria carótida en pacientes de alto riesgo y la prevención temprana del accidente cerebrovascular. ANTECEDENTES: La prevalencia estimada de estenosis carotídea grave asintomática (≥70%) en la población adulta general varía hasta el 3,1%. Sin embargo, la prevalencia es mayor en individuos comórbidos. Esto hace que sea importante realizar pruebas de detección para el diagnóstico y el tratamiento tempranos en pacientes predeterminados de alto riesgo. MATERIAL Y MÉTODOS: En este estudio prospectivo, 3000 pacientes seleccionados fueron evaluados durante marzo de 2017 y septiembre de 2018 en el centro de salud familiar más poblado. Participantes seleccionados entre individuos registrados que tienen al menos uno de los factores de riesgo como hipertensión, hiperlipidemia, diabetes mellitus, obesidad y tabaquismo. Todos los participantes estaban asintomáticos y tenían más de 55 años. Cribado bilateral de la arteria carótida realizado por ecografía dúplex (DUSG) en la primera llamada y un año después. Pacientes con estenosis severa de carótidas y/o arterias coronarias tratados mediante revascularización quirúrgica o implantación de stents a la luz de las últimas guías. CONCLUSIÓN: El cribado carotídeo en individuos asintomáticos de alto riesgo es de gran importancia para identificar la estenosis grave de la arteria carótida y la arteria coronaria. La educación del paciente durante el cribado puede desempeñar un papel fundamental en la prevención de la enfermedad.

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Background: Severe carotid artery stenosis (sCAS) is frequently discovered at the time of evaluation for coronary arterial revascularization. However, there has been controversy regarding the optimal management of sCAS. This study evaluated the potential effects of untreated sCAS at time of coronary artery bypass grafting (CABG) in contemporary practice. Methods: This was a retrospective study from a multihospital healthcare system including patients undergoing isolated CABG between 2011 and 2018. Patients were stratified by the presence of sCAS (≥80% stenosis) in at least 1 carotid artery. Perioperative and 5-year stroke were compared, and multivariable analysis was used to identify risk-adjusted predictors of stroke and mortality. Results: A total of 5475 patients were included, 459 (8.4%) with sCAS and 5016 (91.6%) without sCAS. Patients with sCAS experienced more frequent perioperative stroke (4.4% vs 1.2%; P < .001), with most attributable to ischemic or embolic etiologies. The median duration of follow-up was 4.6 years (interquartile range, 3.0-6.5 years). One-year and 5-year survival were both lower in patients with sCAS (P < .001). In multivariable analysis, sCAS was associated with increased risk-adjusted hazard for both mortality (hazard ratio [HR], 1.28; 95% confidence interval [CI], 1.02-1.60; P = .030) and stroke (HR, 1.76; 95% CI, 1.20-2.59; P = .004). The strongest risk-adjusted predictor for stroke was a previous history of stroke (HR, 2.51; 95% CI, 1.77-3.55; P < .001). Conclusions: This contemporary analysis of CABG procedures reveals that concurrent sCAS continues to confer a significant stroke risk, especially in those with history of previous stroke. Although whether sCAS lesions are responsible for most strokes is unclear, they likely serve as a surrogate for other stroke risk factors.

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BACKGROUND: In this study, the risk factors for stroke after coronary artery bypass grafting (CABG) were examined. In particular, the role of asymptomatic carotid artery stenosis (both unilateral and bilateral) as a predictor of in-hospital postoperative stroke was investigated. Finally, the trends surrounding in-hospital postoperative stroke from 1999 to 2011 also were examined. The purpose of the study was to appropriately identify patients at high risk for stroke after CABG and spark discussion about the perioperative management of such patients. MATERIALS AND METHODS: Data from the Nationwide Inpatient Sample from 1999 to 2011 were analyzed retrospectively. The study cohort was identified using the International Classification of Diseases, Ninth Revision, Clinical Modification and Projection Clinical Classification Software codes. Exploratory statistics, univariate analyses, and multivariable regression were used for this study. RESULTS: The analysis demonstrated that both asymptomatic unilateral and bilateral carotid stenoses were independent risk factors for in-hospital postoperative stroke. In addition, increasing age, female sex, increasing van Walraven score, paralysis, neurologic disorders, history of infective endocarditis, asymptomatic basilar stenosis, and cerebral occlusion all were demonstrated to be statistically significant predictors of stroke. Patients with carotid stenosis and a van Walraven score >14 were found to be particularly vulnerable to in-hospital postoperative stroke. Lastly, predictors of carotid stenosis were examined, and increasing age, female sex, and increasing van Walraven score all were found to be significant predictors of asymptomatic carotid stenosis. CONCLUSIONS: This study examined risk factors for stroke after CABG in a large, longitudinal, and population-based database. The study found that both unilateral and bilateral asymptomatic carotid stenoses are indeed risk factors for in-hospital postoperative stroke. In addition, a number of other predictors were identified. These results can be used to identify patients at high risk for perioperative stroke and hopefully decrease the rate of a devastating complication of CABG.

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ABSTRACT Mechanical thrombectomy as an adjunctive to intravenous thrombolysis is now the standard treatment for acute ischemic stroke (AIS) due to large vessel occlusions. However, the best management of acute carotid tandem occlusions (CTO) remains controversial. Method Twenty patients underwent endovascular treatment of acute CTO. The primary endpoint was the composite rate of complete or partial recanalization without a symptomatic intracranial hemorrhage (sICH). Secondary endpoints were recanalization times, procedure times, and clinical outcomes at three months. Results The primary endpoint was reached in 17 (85%) patients. Recanalization rate was reached in 90% of patients (19/20) and sICH rate was 5% (1/20). At the 3-month follow-up we obtained a mRS ≤ 2 rate of 35% (7/20) and a mortality rate of 20% (4/20). Conclusion Carotid angioplasty stenting and endovascular treatment of AIS due to CTO appears effective with an acceptable rate of sICH.

RESUMO Trombectomia mecânica com stentrievers associada a trombólise endovenosa com rTPA é o tratamento padrão-ouro do acidente vascular cerebral isquêmico agudo (AVCi) devido à oclusões de grandes vasos. No entanto, a melhor estratégia terapêutica para oclusões carotídeas combinadas ainda permanece controversa. Método Vinte paciente receberam tratamento endovascular. O desfecho primário foi a taxa de recanalização completa sem sangramento intracraniano sintomático. Os desfechos secundários foram os tempos de recanalização, duração dos procedimentos e desfechos clínicos em 3 meses. Resultados O desfecho primário foi alcançado em 17 (85%) pacientes. A taxa de recanalização foi de 90% (19/20) e a taxa de HIS foi de 5% (1/20). Em três meses, foi obtido bom desfecho neurológico em 35% (7/20) dos pacientes e a mortalidade foi de 20% (4/20). Conclusão A angioplastia com stent de carotída associada ao tratamento endovascular para oclusões combinadas agudas de carótida parece ser efetiva sem um aumento de HIS.

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PURPOSE: The purpose of the study is to analyze the results obtained using stents for the treatment of neurovascular diseases in pediatric patients. METHODS: A retrospective study of 6-year period was undertaken evaluating clinical charts and imaging studies of patients treated with stents because of neurovascular diseases. RESULTS: Nine patients were managed with 10 stents. Seven children were females. The median age was 11 years. There were four cases of broad neck cerebral aneurysms, a pseudoaneurysm of the cervical internal carotid artery, a vertebro-jugular fistula, two patients with internal carotid artery (ICA) stenosis affecting the cervical and supraclinoid segment, and a vertebral artery dissection. The only complication was a silent posterior communicating artery (PCoA) thrombosis in a PCoA aneurysm treated with two stents. Dual antiplatelet therapy was given after the procedure to avoid in stent thrombosis. CONCLUSION: Stents are safe and effective for treatment of neurovascular diseases in children, but studies are needed in order to protocolize the use of antiplatelet drugs in children.

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INTRODUCTION: Early carotid revascularization (≤ 14 days) is recommended for symptomatic carotid stenosis. Carotid artery stenting (CAS) has become an alternative to carotid endarterectomy (CEA); however, safety data on early CAS is controversial. The study aims to compare early versus late CAS, when CAS is performed as a first intention revascularization strategy. METHODS: A retrospective analysis of all symptomatic patients admitted to our stroke unit who underwent CAS was conducted. Patients were divided between two groups: patients who had undergone CAS within 14 days after symptoms and those who had undergone CAS later. Primary endpoints were ipsilateral ischemic stroke or ipsilateral parenchymal hemorrhage (iPH) at 30 days. The secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE) at the 30-day and at the 12-month follow-up. RESULTS: One hundred twenty-seven consecutive patients were evaluated. Primary endpoints obtained in the early and late CAS groups were, respectively, ipsilateral stroke (2.0% vs. 2.6%, P = 1.00) and iPH (2.0% vs. 0.0%, P = 0.40). The rates of MACCE between the early and the late CAS groups were, respectively, (7.8% vs. 2.6%, P = 0.21) at the 30-day follow-up, and (12.2% vs. 10.5%, P = 0.77) at the 12-month follow-up. CONCLUSIONS: In this study, CAS seems to be safe when used as first intention revascularization treatment within 2 weeks of symptoms, if infarcted area is less than one third of the middle cerebral artery territory. Our results need to be confirmed by larger studies.

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OBJECTIVES: Carotid artery stenting is an emerging revascularization alternative to carotid endarterectomy. However, guidelines have recommended carotid artery stenting only if the rate of periprocedural stroke or death is < 6% among symptomatic patients and < 3% among asymptomatic patients. The aim of this study is to evaluate and compare clinical outcomes of symptomatic and asymptomatic patients who had undergone carotid artery stenting as a first-intention treatment. METHOD: A retrospective analysis of patients who underwent carotid artery stenting by our interventional neuroradiology team was conducted. Patients were divided into two groups: symptomatic and asymptomatic patients. The primary endpoints were ipsilateral ischemic stroke, ipsilateral parenchymal hemorrhage and major adverse cardiac and cerebrovascular events at 30 days. The secondary endpoints included ipsilateral ischemic stroke, ipsilateral parenchymal hemorrhage, ipsilateral transient ischemic attack and major adverse cardiac and cerebrovascular events between the 1- and 12-month follow-ups. RESULTS: A total of 200 consecutive patients were evaluated. The primary endpoints obtained in the symptomatic vs. asymptomatic groups were ipsilateral stroke (2.4% vs. 2.7%, p = 1.00), ipsilateral parenchymal hemorrhage (0.8% vs. 0.0%, p = 1.00) and major adverse cardiac and cerebrovascular events (4.7% vs. 2.7%, p = 0.71). The secondary endpoints obtained in the symptomatic vs. asymptomatic groups were ipsilateral ischemic stroke (0.0% vs. 0.0%), ipsilateral parenchymal hemorrhage (0.0% vs. 0.0%), ipsilateral TIA (0.0% vs. 0.0%, p = 1.00) and major adverse cardiac and cerebrovascular events (11.2% vs. 4.1%, p = 0.11). CONCLUSIONS: In this retrospective study, carotid artery stenting was similarly safe and effective when performed as a first-intention treatment in both symptomatic and asymptomatic patients. The ...

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Para el tratamiento de la enfermedad carotídea se recomienda como primera elección la endarterectomía, reservándose la angioplastia stent para pacientes con riesgo quirúrgico, por sus comorbilidades o por la localización de la estenosis. Objetivo: Evaluar la morbimortalidad y los beneficios de la terapia endovascular: angioplastia y stent, para el tratamiento de la estenosis carotídea en pacientes tratados, durante un período de 12 años. Materiales y métodos: Entre septiembre de 1996 y mayo de 2008 se realizaron 174 angioplastias e implantación de stent en 148 pacientes (26 de los cuales fueron tratados por estenosis bilateral). Resultados y discusión: Los resultados mostraron una morbimortalidad de 2% que es menor o igual a lo reportado en la literatura mundial.

For the treatment of the carotid disease the endarterectomy is recommended as the first election, saving the angioplasty stent for patients with surgical risk, due to comorbidities or the location of the stenosis. Objetive: To evaluate the morbidity, mortality and benefits of endovascular therapy: angioplasty and stenting for the treatment of carotid stenosis in patients treated during a period of 12 years. Materials and methods: Between september 1996 and may 2008, 174 angioplasties and implantation of stent were realized in 148 patients (26 of which were treated for bilateral stenosis). Results and discussion: The results showed a mortality of 2 % that is less or equal to the reported in the world literature.

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OBJECTIVES: A duplex ultrasound study was performed to investigate morphological and hemodynamic patterns of carotid stenoses treated by endarterectomy with patch closure versus stenting. MATERIALS AND METHOD: Twenty-nine carotid stenoses were treated with stenting and 65 with patch closure. Duplex ultrasound parameters (luminal diameter, mm; peak systolic velocity and end-diastolic velocity, cm/s) were measured 24 hours after the procedures and also at 12 months post-procedure. Residual stenoses (immediately postprocedure) and restenoses (within 12 months of procedure) were defined as narrowings of >50 percent on duplex ultrasound examination. RESULTS: In stented patients, the luminal diameter of the proximal internal carotid artery increased in the interval between the 24-hour and 12-month post-procedure studies, while in the patch closure patients, the diameter decreased. Carotid hemodynamics normalized immediately after both patching and stenting and remained relatively stable thereafter up to 12 months. No statistically elevated flow velocities (in the absence of residual stenosis or restenosis) were observed in the patched or stented carotid arteries. No significant differences in residual stenosis rates were observed between the stenting group (3 cases, 10.34 percent) and the patch closure group (1 case, 1.53 percent, P = 0.08). At 12 months, 2 stenting patients (6.88 percent) and 2 patch closure patients (3.07 percent) had $50 percent restenosis (P = 0.58). One case of late stroke due to restenosis was observed in the stenting group; the patient died 12 months postoperatively, before receiving new intervention. CONCLUSION: Measurements over time in luminal diameter signalized differences in arterial remodeling mechanisms between patched and stented carotids. Both stenting and patch closure were associated with carotid patency and flow restoration. This study does not support a general approach to new velocity criteria indiscriminately applied to stented or patched carotids.

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