Academic literature on the topic 'Extracranial carotid arterie'

L'endoarteriectomia, come confermano i risultati degli studi multicentrici NASCET (North American Symptomatic Carotid Endarterectomy Trial), ECST (European Carotid Surgery Trial) ed ACAS (Asymptomatic Carotid Atherosclerosis Study), rappresenta il trattamento di elezione delle stenosi aterosclerotiche interessanti il distretto extracranico dell'arteria carotide, sia nei pazienti sintomatici (stenosi > 70%) che asintomatici (stenosi > 60%). L'intervento chirurgico è gravato da un rischio cumulativo di morbilità-mortalità (stroke/morte) che il NASCET, l'ECST e l'ACAS segnalano, rispettivamente, nel 5,8%, 7,5% e 2,3%, insieme ad altre possibili complicanze: infarto miocardico (0,9%), paralisi di nervi cranici (7,6%), ematoma del collo (5,5%), infezioni (3,4%). Qualora, per ragioni cliniche od anatomiche, il rischio chirurgico sia troppo elevato, come nei pazienti cardiopatici, diabetici, con insufficienza polmonare o renale, con restenosi, con stenosi post-attiniche o fibrodisplastiche, con stenosi carotidee prossimali o distali, con lesioni «tandem», l'angioplastica transluminale percutanea (PTA) e/o lo Stenting carotideo possono rappresentare una valida alternativa terapeutica all'endoarteriectomia. In questo articolo presentiamo la nostra casistica relativa a 41 procedure (36 PTA; 5 Stenting), eseguite su 33 pazienti negli ultimi due anni. I trattamenti sono stati rivolti a 28 arterie carotidi interne, 4 arterie carotidi esterne, 2 arterie carotidi comuni, 2 tronchi anonimi; gli stents sono stati rilasciati in 4 arterie carotidi interne e in 1 arteria carotide comune. Le procedure regolarmente portate a termine sono state 37 (32 PTA; 5 Stents), con un ottimo risultato anatomico in 36 casi. Nei controlli a 6 mesi abbiamo riscontrato una ristenosi (< 60%), asintomatica. In questo articolo illustriamo il nostro protocollo, gli insuccessi tecnici, i risultati e le complicanze.

Carotid duplex ultrasound (CDU) is a commonly performed vascular exam for the detection of carotid disease. In most cases, the exam is performed to detect hemodynamically significant changes that could cause a cerebrovascular accident. Ultrasound is accurate in the detection of >70% stenosis. CDU exams are often used to detect a potentially harmful atherosclerotic process before it embolizes. In some cases, the atherosclerotic formation will be so great that it will occlude the extracranial vessels. The true incidence of carotid occlusion is not well known as it may be asymptomatic. CDU can show where the occlusion is located and if the bifurcation is patent which can reveal treatment options for the patient. Carotid occlusions can be medically managed or may require surgery to restore flow to the cerebrovasculature.

The aim of the study was to trace the presence of the internal carotid artery in the system of cerebral arteries of the domestic cat and to determine the role of this artery in supplying blood to the brain in ontogenesis. The available publications provide ambiguous or even contradictory information. The authors of some studies claim that there is no extracranial segment in the domestic cat’s internal carotid artery. Other authors reported the internal carotid artery in the arterial pattern of the encephalon base. The study was conducted on sixty-one domestic cats: fifteen foetuses, sixteen juvenile cats, and thirty adult cats were analysed. The internal carotid artery – a vessel with a relatively large lumen – was fully preserved in all the foetuses and most of the juvenile animals. This artery was not complete with regard to the adults and some juvenile individuals, because it had lost the extracranial segment as a result of the obliteration process. A precise description of this area is not only of biological, but also of clinical, significance. The knowledge of the anatomical structure of cerebral vessels is particularly important to correctly interpret images obtained during diagnostic tests and to conduct surgical procedures correctly.

A 56-year-old male with arterial hypertension sought for medical help for a sudden unilateral swelling of the oral tongue and changed quality of speech. An ENT examination revealed a lesion of the left hypoglossal nerve. Neurological examinations including brain imaging showed negative results. The MRI of the neck only suggested, the angiography confirmed internal carotid aneurysm in the extracranial portion causing pressure on the hypoglossal nerve. The aneurysm was treated with a flow diverter, which reroutes the blood flow and thus embolises the aneurysm. The aneurysm shrunk, its mass effect disappeared and the function of the nerve fully recovered. Keywords: case report – hypoglossal nerve – a. carotis interna – sudden appeared lesion

Aim. Evaluation of histological structure of an atherosclerotic plaque of the carotids received during carotid endarterectomy and its comparison to the data obtained at ultrasonography of carotids.Methods. 36 patients with the history of cerebral circulatory disorders aged from 50 to 75 years (24 males and 12 females) were examined. 22 patients (14 males and 8 females) had ischemic focus at CAT scan, 7 patients had recurrent ischemic stroke and the rest had transient ischemic attacks. We performed color duplex scanning of extracranial vessels. In addition to ultrasonography contrast intensifying was performed. Sulfur hexafluoride stabilized by phospholipid shell was used as a contrast. Transcranial Doppler with functional assays was carried out as well. Pathomorphological study of the plaques removed at carotid endarterectomy was conducted.Results. According to the results of ultrasonography conducted before the surgery and histological results, 28 plaques received during carotid endarterectomy were unstable. 60 to 90% stenoses of carotid bifurcation and internal carotids were revealed. Heterogeneous structure, disturbance of fibrous cap and ulcerations, presence of hypoechoic zones of various sizes were observed.Conclusions. The results of ultrasonography are in accordance with histological conclusion; this method is a reliable tool that provides new opportunities for prediction of embolic complications risk and proves the necessity for carotid endarterectomy.

Objective: To determine the bilaterally asymmetrical associations between extracranial carotid artery atherosclerosis and ipsilateral middle cerebral artery (MCA) stenosis in symptomatic patients using magnetic resonance vessel wall imaging. Approach and Results: Patients with symptomatic carotid artery atherosclerosis were recruited from the Chinese Atherosclerosis Risk Evaluation, a multicenter study. All subjects underwent intracranial magnetic resonance angiography and extracranial carotid artery magnetic resonance imaging. Severe stenosis (stenosis ≥50%) of MCA, carotid moderate-to-severe stenosis (stenosis ≥50%), plaque compositions, and high-risk plaque on symptomatic side were evaluated in all subjects. Associations between ipsilateral MCA stenosis and extracranial carotid plaque features were evaluated. A total of 363 patients (mean age: 61.2±10.4 years old; 254 males) were included. In the left symptomatic cerebrovascular group (n=186), carotid moderate-to-severe stenosis (odds ratio [OR], 3.00 [95% CI, 1.03–8.79]; P =0.045), intraplaque hemorrhage (OR, 3.68 [95% CI, 1.21–11.19]; P =0.021), fibrous cap rupture (OR, 5.70 [95% CI, 1.60–20.31]; P =0.007), and high-risk plaque (OR, 2.95 [95% CI, 1.19–7.35]; P =0.020) were significantly associated with ipsilateral severe MCA stenosis, after adjusting for confounding factors. In the right symptomatic cerebrovascular group (n=177), severe MCA stenosis was significantly associated with ipsilateral carotid moderate-to-severe stenosis (OR, 3.98 [95% CI, 1.54–10.32]; P =0.004) but not with other extracranial carotid plaque features (all P >0.05), after adjusting for confounding factors. Conclusions: In the symptomatic arteries, vulnerable plaque features are independently associated with ipsilateral severe MCA stenosis on the left side, but this association is not found on the right side, indicating the associations of atherosclerotic disease between intracranial and extracranial carotid arteries are asymmetrical.

Purpose The objective of the study was to evaluate the frequency and severity of atherosclerotic lesions in extracranial sections of carotid arteries and to determine the level of the correlation between these lesions and symptoms of cerebral ischemia. Secondly, to identify the most common risk factors of ischaemic stroke occurrence in population of patients of vascular outpatient clinic. Material and Methods Prospective study was conducted on a group of 1,000 people (217 women and 783 men), aged 50 to 86 years, the average age was 62 years (± 9.95). Results Atherosclerotic lesions of carotid arteries were observed in 670 examined people (67%). In 63 cases (6.3%) carotid artery occlusion was revealed. Patients with symptomatic carotid artery stenosis more frequently were addicted to cigarettes and suffered from hypertension in comparison to asymptomatic group. A statistically significant correlation between the TIA or ischemic stroke and smoking were noticed, as well as between TIA/ischemic stroke and hypertension Conclusions Among patients with atherosclerosis of peripheral arteries atherosclerotic lesions in the extracranial carotid sections occur with a high frequency. Statistically significant differences in the incidence and severity of atherosclerotic lesions in the carotid arteries were observed in this group. A statistically significant correlation was revealed between the prevalence and severity of atherosclerosis in the carotid arteries in symptomatic patients and smoking and hypertension. Performing screening in patients with atherosclerosis of the abdominal aorta and/or lower limb arteries may detect significant carotid artery stenosis, requiring surgical intervention.

Contesto e scopo: La proproteina convertasi subtilisina/kexina di tipo 9 (PCSK9), uno dei principali regolatori del metabolismo del recettore delle LDL, è stata associata allo sviluppo di aterosclerosi. Diversi studi hanno confermato tale associazione attraverso vie lipidiche e non lipidiche. Tuttavia, le relazioni dirette tra PCSK9 circolante e marcatori di aterosclerosi subclinica e clinica sono ancora da chiarire. Pertanto, abbiamo valutato le relazioni tra i livelli plasmatici di PCSK9 ed alcuni indici di aterosclerosi subclinica (marcatori di imaging) e clinica (eventi vascolari; EV). Un altro obiettivo è stato l'identificazione dei determinanti indipendenti di PCSK9, con particolare attenzione ai lipidi e ai biomarcatori infiammatori. Infine, abbiamo anche valutato la relazione tra alcuni marcatori di imaging e quattro SNPs del gene PCSK9, noti per essere associati alla presenza di bassi livelli di colesterolo LDL. Per validare i risultati ottenuti in quest’ultima parte, le analisi genetiche sono state replicate in una coorte indipendente reclutata nel Regno Unito (UK). Metodi: Lo studio è stato realizzato sfruttando le banche dati, biobanche e la banca di immagini dello studio IMPROVE. 3,703 soggetti europei (54-79 anni; 48% uomini), privi di EV al basale e definiti ad alto rischio per la presenza di almeno tre fattori di rischio vascolare, sono stati reclutati e seguiti per 36 mesi. PCSK9 è stata misurata tramite ELISA e trasformata in logaritmo prima delle analisi. I marcatori di imaging convenzionali [spessore medio-intimale carotideo (cIMT, dall’inglese intima-media thickness) e dimensione della placca carotidea] ed emergenti [cambiamento di cIMT nel tempo, ecolucenza dello spessore del complesso medio intimale della carotide comune misurato in zone libere da placca (PF CC-IMTmean), ecolucenza della placca più grande rilevata in tutto l'albero carotideo e punteggio di calcio carotideo (cCS, dall’inglese carotid calcium score)] sono stati misurati su scansioni ultrasonografiche conservate nella banca di immagini. In particolare, l'ecolucenza è stata misurata in termini di mediana della scala dei grigi (GSM, dall’inglese grey scale median) della distribuzione dei pixel di una specifica regione d’interesse, mentre il cCS è stato calcolato come somma delle lunghezze dei coni d’ombra acustici generati dal calcio all'interno delle placche carotidee. I lipidi sono stati misurati con metodi enzimatici (ad eccezione del colesterolo LDL che è stato calcolato con la formula di Friedewald). Tra i marcatori infiammatori, la proteina C reattiva ad alta sensibilità (hs-PCR) è stata misurata con la turbidimetria, mentre il conteggio dei globuli bianchi (WBC, dall’inglese white blood cells) e la formula leucocitaria sono stati misurati localmente. Tutti i soggetti dello studio IMPROVE e della coorte UK (n=22,179; 48 % uomini) sono stati genotipizzati. Risultati: Nell'analisi univariata, PCSK9 correlava positivamente con colesterolo totale, LDL e HDL e con trigliceridi e basofili (tutte le p <0.0001), mentre correlava negativamente con neutrofili ed eosinofili (entrambe le p=0.04). Le correlazioni positive osservate con hs-PCR e con il conteggio dei WBC erano solo vicine alla significatività statistica (p=0.060 e 0.064, rispettivamente). Le terapie con fibrati o statine (positivamente; entrambe le p <0.0001), così come sesso maschile e storia familiare di diabete (negativamente; entrambe le p <0.05) erano i predittori indipendenti più forti dei livelli plasmatici di PCSK9. Nell'analisi non aggiustata, si osservava una correlazione negativa tra PCSK9 e variabili basali di cIMT (IMTmean, IMTmax, IMTmean-max, e PF CC-IMTmean), una correlazione negativa tra PCSK9 e la variazione di cIMT nel tempo (Fastest-IMTmax-progr) e cCS (tutte le p ≤0.01), mentre si osservava un trend positivo tra PCSK9 e GSM sia del PF CC-IMTmean che della placca carotidea (entrambe le p ≤0.0001). Il cCS (positivamente) e il GSM del PF CC-IMTmean (positivamente) erano associati significativamente (o vicini alla significatività) a PCSK9 in diversi modelli multivariati (tutte le p ≤0.064). Tutte le correlazioni osservate all’analisi univariata tra PCSK9 e le variabili basali di cIMT, Fastest-IMTmax-progr e GSM della placca carotidea perdevano la significatività statistica dopo aggiustamento delle stesse per età, sesso, latitudine ed altri potenziali confondenti. Durante il follow-up [mediana (intervallo interquartile): 3.01 (2.98; 3.12) anni], sono stati registrati 215 EV: 125 coronarici, 73 cerebrali e 17 EV periferici. Tra questi, 37 erano eventi hard (infarto miocardico, morte improvvisa ed ictus). Nell'analisi non aggiustata, PCSK9 era associata positivamente ad eventi combinati e coronarici (entrambe le p <0.01), ma non ad eventi cerebrovascolari. Anche in questo caso, tuttavia, tutte le associazioni osservate perdevano la significatività statistica dopo aggiustamento delle analisi per età, sesso e stratificazione per latitudine. La mancanza di associazione con EV era confermata anche nel modello aggiustato per tutti i fattori confondenti considerati e nelle analisi focalizzate sugli eventi hard. Per quanto riguarda il ruolo delle varianti genetiche, nessuno dei quattro SNPs considerati correlava con cIMT (IMTmean, IMTmax, IMTmean-max) quando l'analisi era effettuata nei soggetti reclutati nello studio IMPROVE. La variante rs11591147, invece, correlava negativamente con l’IMTmax misurato nella popolazione UK (p=0.002). Combinando le quattro varianti genetiche in uno score, la relazione con cIMT era non significativa nello studio IMPROVE, mentre era negativa e significativa nella popolazione UK (tutte le p <0.01). Conclusioni: I livelli plasmatici di PCSK9 non sono associati a EV. Per quanto riguarda i marcatori dell'aterosclerosi subclinica, i livelli plasmatici di PCSK9 non sono associati né alla dimensione della lesione, né all'ecolucenza della placca carotidea, ma sono associati all'ecolucenza dello spessore della parete carotidea e al carotid calcium score. Ulteriori studi sono pertanto necessari per comprendere meglio il ruolo di tale proproteina nell'ecolucenza dello spessore della parete carotidea e nel carotid calcium score. La terapia con fibrati o statine, così come il sesso maschile e la storia familiare di diabete sono i predittori indipendenti più forti di PCSK9 circolante. È stata inoltre confermata l'associazione, precedentemente osservata, tra PCSK9 circolante e alcuni marcatori lipidici ed infiammatori. La relazione tra i livelli plasmatici di PCSK9 ed altri marcatori infiammatori (neutrofili, basofili ed eosinofili) merita ulteriori indagini, così come merita ulteriori indagini l’associazione tra le quattro varianti genetiche di PCSK9 selezionate e il cIMT nella coorte britannica, in quanto lascia intravvedere un possibile ruolo di SNPs o polimorfismi genici di PCSK9 nell’aterosclerosi e nelle strategie della sua prevenzione.
Background and purpose: Proprotein convertase subtilisin/kexin type 9 (PCSK9), one of the main regulators of LDL receptor metabolism, has been associated with atherosclerosis development. Several studies have confirmed such association through both lipid and non-lipid pathways. However, the direct relationships between circulating PCSK9 and markers of subclinical and clinical atherosclerosis are still matter of debate. Therefore, we investigated the relationships between plasma PCSK9 levels and some indexes of subclinical (imaging markers) and clinical (vascular events; VEs) atherosclerosis. Another objective was the identification of the independent determinants of PCSK9, with particular attention to lipids and inflammatory biomarkers. Finally, we also assessed the relationship between some imaging markers and four SNPs of the PCSK9 gene, known to be associated with the presence of low levels of LDL-cholesterol. In order to validate the results obtained in this last part, the genetic analyses were replicated in an independent cohort recruited in the United Kingdom (UK). Methods: The study was carried out taking advantage of databases, biobanks and imaging-bank of the IMPROVE study. 3,703 European subjects (54-79 years; 48% men), free of VEs at baseline and defined at high risk for the presence of at least three vascular risk factors, were recruited and followed-up for 36 months. PCSK9 was measured by ELISA and log-transformed prior to analyses. Conventional imaging markers [carotid intima-media thickness (cIMT) and carotid plaque-size], and emerging imaging markers [cIMT change over time, echolucency of the intima-media thickess of common carotid measured in plaque free areas (PF CC-IMTmean), echolucency of the biggest plaque detected in the whole carotid tree, and carotid calcium score (cCS)] were measured on ultrasonographic scans stored in the imaging-bank. In particular, echolucency was measured in terms of grey scale median (GSM) of pixels distribution of a specific region of interest, whereas cCS was calculated as sum of lengths of acoustic shadow cones generated by calcium within carotid plaques. Lipids were measured with enzymatic methods (except for LDL-cholesterol, which was calculated by Friedewald's formula). Among inflammatory markers, high-sensitivity C-reactive protein (hs-CRP) was measured by turbidimetry, whereas white blood cells (WBC) count and the leukocyte formula had already been measured locally. All the IMPROVE study and UK (n=22,179; 48% men) subjects have been genotyped. Results: In the univariate analysis, PCSK9 was positively correlated with total, LDL-, and HDL-cholesterol, and with triglycerides and basophils (all p <0.0001), whereas was negatively correlated with neutrophils and eosinophils (both p=0.04). The positive correlations observed with hs-CRP and WBC count were just close to the statistical significance (p=0.060 and 0.064, respectively). Fibrates or statins therapies (positively; both p <0.0001), as well as male sex and family history of diabetes (negatively; both p <0.05) were the strongest independent predictors of plasma PCSK9 levels. In the unadjusted analysis, a negative correlation was observed between PCSK9 levels and basal cIMT variables (i.e. carotid IMTmean, IMTmax, IMTmean-max, and PF CC-IMTmean), a negative correlation between PCSK9 and cIMT change over time (Fastest-IMTmax-progr) and cCS (all p ≤0.01), whereas a positive trend was observed between PCSK9 and GSM of both PF CC-IMTmean and carotid plaque (both p ≤0.0001). The cCS (positively) and the GSM of PF CC-IMTmean (positively) were significantly (or almost significantly) associated with PCSK9 in several multivariate models (all p ≤0.064). All correlations observed in the univariate analysis between PCSK9 and basal cIMT variables, Fastest-IMTmax-progr and GSM of carotid plaque lost the statistical significance after adjustment for age, sex, latitude, and other potential confounders. During the follow-up [median (interquartile range): 3.01 (2.98; 3.12) years], 215 VEs were recorded: 125 coronary, 73 cerebral and 17 peripheral VEs. Among these, 37 were hard events (i.e. myocardial infarction, sudden death and stroke). In the unadjusted analysis, PCSK9 was positively associated with combined and coronary events (both p <0.01), but not with cerebrovascular events. Also in this case, however, all the associations observed lost the statistical significance after adjustment of the analyses for age, sex, and stratification for latitude. The lack of association with VEs was confirmed also in the model adjusted for all confounding factors considered, and in the analyses focused on hard events. With regard to the role of genetic variants, none of the four SNPs considered was correlated with cIMT (i.e. IMTmean, IMTmax, IMTmean-max) when the analysis was performed in the subjects recruited in the IMPROVE study. The rs11591147 variant, by contrast, was negatively correlated with IMTmax measured in the UK population (p=0.002). By combining the four genetic variants in a score, the relationship with cIMT was not significant in the IMPROVE study, whereas was negative and significant in the UK population (all p <0.01). Conclusions: Plasma PCSK9 levels are not associated with VEs. Regarding markers of subclinical atherosclerosis, PCSK9 levels are associated neither with lesion size, nor with carotid plaque echolucency, but are associated with echolucency of carotid wall thickness and with carotid calcium score. Therefore, further studies are needed to better understand the role of such circulating proprotein in carotid wall thickness echolucency and in carotid calcium score. Fibrates or statins therapies, as well as male sex and family history of diabetes are the strongest independent predictors of PCSK9 levels. The associations, previously observed, between circulating PCSK9 and some lipid and inflammatory markers have been confirmed. The relationship between plasma levels of PCSK9 and other inflammatory markers (neutrophils, basophils and eosinophils) deserves further investigation, as does the association between the four selected PCSK9 variants and cIMT in the UK cohort, as it suggests a possible role of PCSK9 SNPs or gene polymorphisms in atherosclerosis and in its preventive strategies.

Thesis submitted in fulfilment of the requirements for the degree Master of Technology: Radiography in the Faculty of Health and Wellness Sciences at the Cape Peninsula University of Technology Supervisor: Ms. Ferial Isaacs Co-supervisor: Prof. Susan J. Van Rensburg Bellville September 2013
Multiple Sclerosis (MS) is characterised by demyelination within the central nervous system (CNS), which may result in neurological disabilities over time, causing considerable hardship to patients and their families, in addition to being costly to treat. Recent studies have linked MS to impaired cerebral blood flow, called chronic cerebrospinal venous insufficiency (CCSVI). Anecdotal evidence has suggested that surgical correction thereof results in improvement of symptoms experienced by MS patients. To my knowledge, no information is available in the literature on carotid artery disease in MS. The USA National MS Society has therefore called for more research to be done in this area. This cross-sectional observational sub-study will determine, by ultrasound (B-Mode, Colour and Pulsed-wave Doppler), the prevalence of chronic venous insufficiency (CCSVI) and carotid artery disease in the selected sample of MS patients within the region of the Western Cape, South Africa. Biochemical data; lifestyle factors such as physical activity and smoking; and nutritional status of MS patients were determined from the main study entitled: “The development of a comprehensive gene-based, pathology supported intervention program for improved quality of life in patients diagnosed with multiple sclerosis” (Division of Chemical Pathology, NHLS, Tygerberg Hospital, and University of Stellenbosch). Twenty-nine (29) patients were aged between 28-64years and they suffered from MS for 0.83-27years. A larger proximal and mid cross-sectional diameter (CSD) of the right IJV compared to the left (differences significant, P= 0.026 and P=0.023) was demonstrated. Increased intima media thickness (IMT) was present in 13.33% of the non-smoking MS group and 20% in the smoking MS group. IJV reflux was evident in 13.33% of the MS group. A significant reduction of cross-sectional diameters of the IJV’s was evident in smoking MS patients; suggesting that smoking is not only a risk factor for atherosclerotic disease but could also be related to narrowing of the major neck veins. This study also supports findings of other studies viz that there’s no significant correlation between extracranial venous abnormalities and MS. Early carotid artery disease was noted in smoking and non-smoking MS patients, however the findings were non-significant.

Introducción: El tratamiento endovascular de las lesiones de la arteria carótida interna (ACI) extracraneal en el contexto de una oclusión en tándem constituye uno de los principales retos terapéuticos actuales. Además de su escasa respuesta al tratamiento fibrinolítico endovenoso, cosa que implica un peor pronóstico funcional a largo plazo, en su planteamiento terapéutico compiten dos conceptos que requieren un manejo prácticamente opuesto: por un lado, establecer y mantener la permeabilidad de la ACI y, por el otro, evitar la transformación hemorrágica cerebral, una de las principales causas de deterioro neurológico precoz y de mal pronóstico funcional. Métodos: Estudio observacional prospectivo en el que se incluyeron pacientes consecutivos diagnosticados en el Servicio de Urgencias del Hospital Universitari Vall d’Hebron de un ictus isquémico secundario a una oclusión en tándem y que fueron sometidos a tratamiento endovascular hiperagudo con acción directa sobre la ACI extracraneal mediante stenting (con stent balón-expandible [BX] o auto-expandible [SX] en función del periodo de estudio) o angioplastia con balón. El objetivo principal del estudio fue una variable combinada positiva compuesta por ausencia de reoclusión o restenosis de alto grado de la ACI (eficacia) y ausencia de transformación hemorrágica (seguridad) a las 24 horas del procedimiento endovascular. Los objetivos secundarios incluyeron eficacia, seguridad, variables de evolución clínica y mal pronóstico funcional (puntuación en la modified Rankin Scale >2) a los 90 días tras el ictus. Se realizó un sub-análisis preespecificado para valorar diferencias entre los stents BX y SX. Resultados: Se incluyeron 113 pacientes en el estudio. Aquellos pacientes a los que se les realizó stenting durante el procedimiento endovascular hiperagudo presentaron una mayor frecuencia de la variable combinada positiva (65’3% frente a 19’5%, P< 0’001) y una menor tasa de reoclusión o restenosis de la ACI extracraneal a las 24 horas (22’2% frente a 80’5%, P< 0.001) que aquellos tratados con angioplastia con balón. Sin embargo, la frecuencia de transformación hemorrágica, transformación hemorrágica sintomática, mejoría neurológica precoz, deterioro neurológico precoz y mal pronóstico funcional fueron similares entre ambos grupos. La reoclusión o restenosis de alto grado de la ACI extracraneal a las 24 horas del procedimiento endovascular es un predictor independiente de mal pronóstico funcional (OR 5’76, IC al 95% 1’10-14’22). En el grupo de stents BX, los pacientes tuvieron una tasa menor de deterioro neurológico precoz, (3’4% frente a 23’3%, P=0’041) y una tendencia a presentar una menor frecuencia de transformación hemorrágica sintomática (3’4% frente a 16’3%, P=0’069) respecto a los pacientes tratados con stents SX. Conclusiones: Los pacientes tratados mediante stenting hiperagudo de la ACI extracraneal en contexto de una oclusión en tándem, presentan una mayor frecuencia de la variable combinada positiva de eficacia y seguridad en comparación con los tratados con angioplastia con balón únicamente. Los stents BX podrían plantearse como una alternativa los stents SX en este contexto, dado que presentan iguales tasas de reoclusión o restenosis de alto grado de la ACI extracraneal, una menor frecuencia de deterioro neurológico precoz y una tendencia a presentar menor transformación hemorrágica sintomática. La reoclusión o restenosis de la ACI extracraneal a las 24 horas del procedimiento endovascular es un predictor de mal pronóstico funcional.
Introduction: Endovascular treatment of extracranial internal carotid artery (ICA) lesion in the setting of tandem occlusions (TIO) is a therapeutic challenge. On the one hand, recanalization rate with fibrinolytic agents is lower compared to isolate intracranial occlusions. On the other hand, there are two competing rationales: to establish and maintain extracranial ICA patency, and to avoid hemorrhagic transformation, one of the leading causes of early neurological worsening and poor functional outcome. Methods: Prospective observational study of consecutive patients admitted to the Emergency Room of Vall d’Hebron University Hospital with TIO undergoing EVT. Extracranial ICA lesion was treated with stenting (balloon-expandable [BX] or self-expandable [SX], depending on the study period) or angioplasty alone. Primary outcome was a combined positive outcome composed by absence of extracranial ICA high-grade restenosis or reocclusion (efficacy) and absence of hemorrhagic transformation (HT) (safety) at 24 hours. Secondary outcomes included efficacy, safety, and clinical and functional outcomes. A pre-specified subanalysis was performed to assess differences between BX and SX stents. Results: One-hundred thirteen patients fulfilled the inclusion criteria. Patients undergoing stenting presented more frequently the combined positive outcome (65.3% vs. 19.5%, P< 0.001) and less frequently extracranial ICA high-grade restenosis or reocclusion (22.2% vs. 80.5%, P< 0.001) than angioplasty alone patients. Similar rates of hemorrhagic transformation, symptomatic hemorrhagic transformation, clinical, and poor functional outcomes were found between groups. Extracranial ICA high-grade restenosis or reocclusion was independently related to poor functional outcome (OR 11 5.76, 95% CI 1.10-14.22). BX-stenting presented less frequently early neurological worsening (3.4% vs. 23.3%, P= 0.041) and tended to present a lower frequency of symptomatic HT (3.4% vs. 16.3%, P=0.069) than SX-stenting. Conclusions: Hyperacute extracranial ICA stenting in the setting of TIO presents more frequently the combined positive outcome of efficacy and safety than AA. BX stents are a promising alternative to SX stents in this particular scenario, due to the similar rate of extracranial ICA reocclusion or high-grade restenosis, a lower frequency of early neurological worsening, and a tendency to present less cases of symptomatic hemorrhagic transformation. Extracranial ICA reocclusion or high-grade restenosis predicts poor functional outcome.

Cerebrovascular disease continues to be responsible for significant morbidity and mortality. There is a pressing need to better understand the biomechanics of both intracranial arteries and the extracranial arteries that feed these vessels. Histology and immunohistochemistry were performed on basilar and carotid arteries and elucidated their structural differences. Nonlinear optical microscopy (NLOM) provided collagen fiber orientation and distribution, which offered motivation for a more microstructrually-based model. Biaxial testing was performed on acute basilar and carotid arteries and cultured basilar arteries. We used a validated 2D, four fiber family constitutive relation to model passive biaxial stress-stretch behaviors of basilar and common carotid arteries, and we developed a new relation to model their active biaxial responses. Residual stress information from opening angles and collagen fiber orientation were used to create a 3D fiber distribution constitutive relation. Passive biaxial stress-stretch behavior of basilar arteries was modeled with the 3D fiber distribution constitutive relation and was combined with our new active relation to model the active response of basilar arteries. These data and 2D, four fiber family and active constitutive relation allow the first full comparison of circumferential and axial biomechanical behaviors between a muscular (basilar) and an elastic (carotid) artery from the same species. Our active model describes the responses by both types of vessels to four doses of the vasoconstrictor endothelin-1 (10^-10, 10^-9, 10^-8, 10^-7 M) and predicts levels of smooth muscle activation associated with basal tone under specific in vitro testing conditions. Cultured arteries revealed smooth muscle tone is necessary for vascular remodeling. Our 3D model allowed for the calculation of stress through the wall in passive basilar arteries. These results advance our understanding of the biomechanics of intracranial and extracranial arteries, which is needed to understand better their differential responses to similar perturbations in hemodynamic loading.

In the secondary prevention of stroke chapter the case is made for preventing recurrent stroke by targeted evidence-based intervention based on the aetiological cause of stroke. Lifestyle measures such as smoking cessation as well as pharmacological prevention strategies are discussed. Blood pressure treatment, lipid lowering, and antiplatelet therapy are all examined. Since the last edition there has been a major advance in the stroke prevention treatment of atrial fibrillation with the licensing of new anticoagulant agents and the evidence for their use is reviewed. Surgical and endovascular interventions for extracranial and intracranial stenosis are also outlined, including carotid endarterectomy, carotid stenting, extracranial-intracranial bypass, and intervention for vertebral artery disease.

Introduction: TIAs are ischemia, caused by stenosis of the carotid and vertebral arteries. Those who have a TIA are at risk of ischemic stroke and myocardial infarction, with carotid endarterectomy being an intervention. Objective: To analyze the benefits of carotid endarterectomy using drugs. Methods: Literature review, in bases such as PUBMED, MEDLINE, descriptors: “Endarterectomy”, “Ischemic Attack”, with operator “AND” and “OR”. Those with two descriptors were selected in the summary and date between 2010-2020, English / Portuguese language, resulting in: 17 articles. Results: The internal carotid artery (ICA) is located in the neck as a branch of the common carotid artery, being one of its branches the middle cerebral artery (MCA), the main artery affected in strokes and TIAs. Thus, ACI ischemia causes a risk of thrombosis in MCA, the treatment of carotid stenosis requires drugs to prevent atheroma, as well as antiplatelet drugs to reduce embolic events¹. In some cases, carotid endarterectomy or carotid stent implantation is complementary. Therefore, patients with TIA or stroke, who have “transient, fluctuating or persistent unilateral motor weakness or speech disorder or eye symptoms”, should undergo endarterectomy if they have moderate-severe stenosis of the extracranial internal carotid artery in the first days of presentation². Thus, endarterectomy is the treatment of choice and stenting should only be offered to symptomatic patients. Conclusion: Therefore, endarterectomy has been shown to be safe for patients with internal carotid artery stenosis, indicating the prevalence in relation to the stent.

Context: Stroke is a considerable cause of morbidity and mortality nowadays. It is known the incidence, risk factors and etiology in mid-adults differ notably from older patients. When are young stroke patients, should investigate, besides traditional risk factors, a congenital heart disease, inflammatory and infectious causes, and the use of drugs to prevent new events. Case report: A 29-year-old woman, white, with hypothyroidism and history of surgical resection of retinoblastoma at 3 years of age, with sequelae of bilateral amaurosis, admitted with a history of neurological deficit in the left hemibody, with progression in 14 days until complete left hemiparesis provided. The cranial tomography showed infarction in the territory of the right middle cerebral artery and arteriography showed occlusion of the right internal carotid and dissection of the supraclinoid portion of this artery. Conclusions: While much is known about risk factors, pathophysiology and prognosis of extracranial arterial dissection, data are rare when it comes to the dissection of the intracranial portion of the internal carotid, no case was found that evidenced internal carotid artery occlusion of one side and contralateral dissection. The importance of knowing about the internal carotid dissection is the fact that this etiology is suspected when diagnosis young stroke patients.

Stroke is the third leading cause of death and a major cause of disability in the United States. Extracranial carotid artery disease is a major risk factor for stroke. Local hemodynamic forces are important in the development and progression of atherogenesis with areas of low and oscillatory wall shear stress (WSS) such as those occurring in the carotid bifurcation being more prone to atheroma development. Despite the importance of WSS in atherosclerosis, there is currently no practical means of measuring this variable clinically. Computational fluid dynamics (CFD) simulations of patient-specific models built from imaging data may provide a clinically relevant solution [1]. For CFD results to be clinically applicable, they need to replicate hemodynamic and imaging measurements to provide physiologic WSS values and the simulation and quantification process must be conducted in a time-frame consistent with the short duration needed for plaque and intima-media thickness assessment. LaDisa, Migrino and colleagues recently reported on a rapid and practical means of generating WSS maps associated with carotid atherosclerosis using patient-specific CFD models derived from 2D and Doppler ultrasound for flow information and MRI for 3D structure before and after 6 months of statin treatment [2]. Although these results were achieved after 17±8 hours/patient instead of days or weeks for prior models, model construction, quantification of results and simulation time were the most time consuming portions of the simulation process with CFD model construction being the most user-intensive portion of the process.