Long-term survival and stroke-free survival after eversion carotid endarterectomy for asymptomatic severe carotid stenosis

BackgroundLevel 1 evidence supports carotid endarterectomy (CEA) as the standard treatment for severe (>70% lumen reduction) carotid stenosis in asymptomatic patients, though its safety and efficacy in high-risk patients remain controversial. Long-term survival and stroke-free survival after CEA may guide decisions concerning this procedure for asymptomatic patients, but this outcome has only been considered in few reports outside the large randomized trial setting. This study analyzed long-term survival and stroke-free survival after CEA and the impact of risk factors in a consecutive series of asymptomatic patients, including those with medical comorbidities and particular anatomical features believed to increase the perioperative morbidity and mortality of CEA.MethodsFor over 10 years, data were prospectively collected for all patients who underwent CEA for asymptomatic severe carotid disease at our institution. All CEAs performed by the same surgeon involved eversion technique, with patients under deep general anesthesia and continuous perioperative electroencephalographic (EEG) monitoring for selective shunting. All patients had neurological follow-up and duplex ultrasound at 1, 6, and 12 months, and yearly thereafter. A complete follow-up (mean, 6.1 years; range, 0.1 to 10.6 years) was obtained in 348 patients (93%) with an overall 365 CEAs (93%). Survival analyses were performed using Kaplan-Meier life tables.ResultsAmong 374 patients undergoing 391 CEAs, there were no perioperative deaths or strokes. There were 17 (4.8%) late deaths, mainly cardiac-related (70%), and 2 (0.5%) non-fatal strokes. At 5 and 10 years, survival was 96.3% and 85.7%, and stroke-free survival was 95.6% and 84.8%, respectively. At multivariate analysis, diabetes mellitus (P = .002) and cardiac disease (P = .005) were independent predictors of a shorter long-term survival.ConclusionsEversion CEA proved safe and effective in a series of patients with asymptomatic severe carotid disease representing the typical population of daily clinical practice. Although long-term results were extremely favorable, excellent stroke-free survival was not translated into a longer patient survival

Symptomatic intracranial stenosis: A university hospital-based ultrasound study

Summary Introduction Stenosis of intracranial arteries are responsible for 30–50% of strokes in Orientals, 11% in Hispanics, 6% in Blacks and only 1% in Caucasians. However, the clinical importance of intracranial stenosis in Whites may have been underestimated. Subjects and methods We examined our database registry of all TIA/ischemic stroke Caucasian patients over a two-year period, from January 1st 2009 to December 31st 2010. All patients underwent a complete cervical and intracranial ultrasound assessment, MRA and/or CTA and/or DSA. Results Among 292 patients (males 79.7%; mean age, 71.0 ± 12.8 years), we found 59 (20.2%) subjects harboring at least one intracranial stenosis and 20 (33.9%) patients with 2 stenosis; the total number of intracranial stenosis was 95. Regarding risk factors, hypertension was present in 67.8% of patients, diabetes in 27.1%, smoking in 30.5%, obesity in 10.2%, hypercholesterolemia in 37.3%, previous TIA/stroke in 23.7%, heart disease in 18.6%. Forty-six (77.9%) patients presented with stroke, while 13 (22.1%) with TIA. Concerning the site of stenosis, 50 (52.6%) were located in the anterior circulation [MCA 46 (48.4%), ACA 4 (4.2%)], 45 (47.4%) in the posterior circulation: [PCA 28 (29.5%), BA 11(11.6%), VA 6(6.5%)]; 46 (54.8%) on the right hemisphere, 38 (45.2%) on the left hemisphere. Conclusions In this university hospital-based study among Caucasian patients with acute cerebral ischemia, ultrasound disclosed a higher prevalence of intracranial stenosis than previously thought, suggesting the clinical importance of this condition in White European TIA/stroke patients

Primary stroke prevention for sickle cell disease in north-east Italy: the role of ethnic issues in establishing a Transcranial Doppler screening program

<p>Abstract</p> <p>Background</p> <p>Stroke is a serious complication of sickle cell disease (SCD) in children. Transcranic Doppler (TCD) is a well-established predictor of future cerebrovascular symptoms: a blood flow velocity >200 cm/sec in the Middle Cerebral Artery (MCA) correlates with a high risk of stroke in cohorts of African-american HbS/HbS patients. In North-East Italy the recent increase in SCD patients is mainly due to immigration from Africa. A comprehensive care program for children with SCD was established in our Center since 2004, but a wide and routine screening for Primary stroke prevention needs to be developed.</p> <p>Methods</p> <p>In order to verify the feasibility of TCD and Transcranial color coded Sonography (TCCS) screening in our setting and the applicability of international reference values of blood velocities to our population of African immigrants with HbS/HbS SCD, we performed TCD and TCCD in 12 HbS/HbS African children and two groups of age-matched controls of Caucasian and African origin respectively. TCD and TCCS were performed on the same day of the scheduled routine hematologic visit after parental education.</p> <p>Results</p> <p>All parents accepted to perform the sonography to their children. TCD and TCCD were performed in all patients and an adequate temporal window could be obtained in all of them. Pulsatility index and depth values in both the MCA and the Basilar Artery (BA) were similar at TCD and TCCS evaluation in the three groups while time-average maximum velocities (TAMM), peak systolic velocity and diastolic velocity in the MCA and BA were higher in the patients' group on both TCD and TCCS evaluation. African and Caucasian healthy controls had similar lower values.</p> <p>Conclusion</p> <p>Our preliminary data set the base to further evaluate the implementation of a primary stroke prevention program in our setting of HbS/HbS African immigrants and HbS/beta thalassemia Italians. Parental education-preferably in the native language- on stroke risk and prevention in SCD increases compliance and should be a necessary part of the program. Ethnic background does not seem to influence TCD velocity and internationally accepted reference values already validated in African-American SCD pediatric patients can be used, but long prospective trials are needed to verify their efficacy in defining stroke risk in our setting.</p

Early and long-term outcomes of carotid endarterectomy in the very elderly: An 18-year single-center study

ObjectiveTo evaluate the perioperative (30-day) and long-term outcomes of carotid endarterectomy (CEA) in elderly patients with severe symptomatic and asymptomatic carotid disease. Although the efficacy of CEA in preventing stroke in selected patients has been clearly demonstrated, concern has been expressed about the role of CEA in people over 80 years old.MethodsAn analysis was conducted on a prospectively compiled computerized database of all primary CEAs performed at our institution from 1990 to 2007. Descriptive demographic data, risk factors, surgical details, perioperative strokes and deaths, and other complications were recorded. All patients underwent postoperative duplex ultrasound scanning and clinical follow-up at one, six, and 12 months, and yearly thereafter. Survival analyses were performed using Kaplan-Meier life-tables. Long-term relative survival after CEA was assessed against age- and gender-matched controls.ResultsIn all, 1769 CEAs were performed in 1562 patients, 193 of them (207 CEAs; group I) were ≥ 80 years old and 1371 were younger (1562 CEAs; group II). All CEA procedures were performed with patients under deep general anesthesia with continuous perioperative EEG monitoring for selective shunting. No strokes or deaths occurred in group I, whereas there were 11 perioperative strokes and three deaths in group II (1%). A complete follow-up (median, 5.2 years) was obtained in 185 elderly patients: no late occlusions or restenoses were detected, while the seven-year freedom from stroke and death were 96.6% and 52.4%, respectively. The relative seven-year survival rate was 99.8%.ConclusionsCEA in elderly patients proved safe and effective, with an excellent long-term durability. The long-term relative survival after CEA in elderly patients was better than in an age-and gender-matched population, so the likelihood of living long enough to benefit from CEA is not jeopardized by being very elderly

Relaxation of natural selection in the evolution of the giant lungfish genomes

Nonadaptive hypotheses on the evolution of eukaryotic genome size predict an expansion when the process of purifying selection becomes weak. Accordingly, species with huge genomes, such as lungfish, are expected to show a genome-wide relaxation signature of selection compared with other organisms. However, few studies have empirically tested this prediction using genomic data in a comparative framework. Here, we show that 1) the newly assembled transcriptome of the Australian lungfish, Neoceratodus forsteri, is characterized by an excess of pervasive transcription, or transcriptional leakage, possibly due to suboptimal transcriptional control, and 2) a significant relaxation signature in coding genes in lungfish species compared with other vertebrates. Based on these observations, we propose that the largest known animal genomes evolved in a nearly neutral scenario where genome expansion is less efficiently constraine

Genetic and environmental factors on heart rate, mean arterial pressure and carotid intima–media thickness: A longitudinal twin study

Background: Heart rate (HR), mean arterial pressure (MAP) and carotid intima–media thickness (cIMT) are moderately heritable cardiovascular traits, but the environmental effects on the longitudinal change of their heritability have never been investigated. Methods: 368 Italian and Hungarian twins (107 monozygotic, 77 dizygotic) underwent oscillometric measurement and B-mode sonography of bilateral carotid arteries in 2009/2010 and 2014. Within- -individual/cross-study wave, cross-twin/within-study wave and cross-twin/cross-study wave correlations were estimated, and bivariate Cholesky models were fitted to decompose the total variance at each wave and covariance between study waves into additive genetic, shared and unique environmental components. Results: For each trait, a moderate longitudinal stability was observed, with within-individual/crosswave correlations of 0.42 (95% CI: 0.33–0.51) for HR, 0.34 (95% CI: 0.24–0.43) for MAP, and 0.23 (95% CI: 0.12–0.33) for cIMT. Cross-twin/cross-wave correlations in monozygotic pairs were all significant and substantially higher than the corresponding dizygotic correlations. Genetic continuity was the main source of longitudinal stability, with across-time genetic correlations of 0.52 (95% CI: 0.29–0.71) for HR, 0.56 (95% CI: 0.31–0.81) for MAP, and 0.36 (95% CI: 0.07–0.64) for cIMT. Overlapping genetic factors explained respectively 57%, 77%, and 68% of the longitudinal covariance of the HR, MAP and cIMT traits. Conclusions: Genetic factors have a substantial role in the longitudinal change of HR, MAP and cIMT; however, the influence of unique environmental factors remains relevant. Further studies should better elucidate whether epigenetic mechanisms have a role in influencing the stability of the investigated traits over time

Heritability of the dimensions, compliance and distensibility of the human internal jugular vein wall

AIMS: The elasticity of the internal jugular vein (IJV) is a major determinant of cerebral venous drainage and right atrium venous return. However, the level of genetic determination of IJV dimensions, compliance and distensibility has not been studied yet. METHODS: 170 adult Caucasian twins (43 monozygotic [MZ] and 42 dizygotic [DZ] pairs) were involved from the Italian twin registry. Anteroposterior and mediolateral diameters of the IJV were measured bilaterally by ultrasonography. Measurements were made both in the sitting and supine positions, with or without Valsalva maneuver. Univariate quantitative genetic modeling was performed. RESULTS: Genetic factors are responsible for 30-70% of the measured properties of IJV at higher venous pressure even after adjustment for age and gender. The highest level of inheritance was found in the supine position regarding compliance (62%) and venous diameter during Valsalva (69%). Environmental and measurement-related factors instead are more important in the sitting position, when the venous pressure is low and the venous lumen is almost collapsed. The range of capacity changes between the lowest and highest intraluminal venous pressure (full distension range) are mainly determined by genetic factors (58%). CONCLUSIONS: Our study has shown substantial heritability of IJV biomechanics at higher venous pressures even after adjustment for age and gender. These findings yield an important insight to what degree the geometric and elastic properties of the vascular wall are formed by genetic and by environmental factors in humans

genetic and environmental factors on heart rate mean arterial pressure and carotid intima media thickness a longitudinal twin study

Background: Heart rate (HR), mean arterial pressure (MAP) and carotid intima-media thickness (cIMT) are moderately heritable cardiovascular traits, but the environmental effects on the longitudinal change of their heritability have never been investigated. Methods: 368 Italian and Hungarian twins (107 monozygotic, 77 dizygotic) underwent oscillometric measurement and B-mode sonography of bilateral carotid arteries in 2009/10 and 2014. Within-individual/cross-study wave, cross-twin/within-study wave and cross-twin/cross-study wave correlations were estimated, and bivariate Cholesky models were fitted to decompose the total variance at each wave and covariance between study waves into additive genetic, shared and unique environmental components. Results: For each trait, a moderate longitudinal stability was observed, with within-individual/cross-wave correlations of 0.42 (95% CI: 0.33–0.51) for HR, 0.34 (95% CI: 0.24–0.43) for MAP, and 0.23 (95% CI: 0.12–0.33) for cIMT. Cross-twin/cross-wave correlations in monozygotic pairs were all significant and substantially higher than the corresponding dizygotic correlations. Genetic continuity was the main source of longitudinal stability, with across-time genetic correlations of 0.52 (95% CI: 0.29–0.71) for HR, 0.56 (95% CI: 0.31–0.81) for MAP, and 0.36 (95% CI: 0.07–0.64) for cIMT. Overlapping genetic factors explained respectively 57%, 77%, and 68% of the longitudinal covariance of the HR, MAP and cIMT traits. Conclusions: Genetic factors have a substantial role in the longitudinal change of HR, MAP and cIMT; however, the influence of unique environmental factors remains relevant. Further studies should better elucidate whether epigenetic mechanisms have a role in influencing the stability of the investigated traits over time

Euclid: Identifying the reddest high-redshift galaxies in the Euclid Deep Fields with gradient-boosted trees

Context. ALMA observations show that dusty, distant, massive (M* &amp; 1011 M ) galaxies usually have a remarkable star-formation activity, contributing of the order of 25% of the cosmic star-formation rate density at z 3 5, and up to 30% at z ∼ 7. Nonetheless, they are elusive in classical optical surveys, and current near-IR surveys are able to detect them only in very small sky areas. Since these objects have low space densities, deep and wide surveys are necessary to obtain statistically relevant results about them. Euclid will potentially be capable of delivering the required information, but, given the lack of spectroscopic features at these distances within its bands, it is still unclear if Euclid will be able to identify and characterise these objects. Aims. The goal of this work is to assess the capability of Euclid, together with ancillary optical and near-IR data, to identify these distant, dusty, and massive galaxies based on broadband photometry. Methods. We used a gradient-boosting algorithm to predict both the redshift and spectral type of objects at high z. To perform such an analysis, we made use of simulated photometric observations that mimic the Euclid Deep Survey, derived using the state-of-the-art Spectro-Photometric Realizations of Infrared-selected Targets at all-z (SPRITZ) software. Results. The gradient-boosting algorithm was found to be accurate in predicting both the redshift and spectral type of objects within the simulated Euclid Deep Survey catalogue at z &gt; 2, while drastically decreasing the runtime with respect to spectral-energy-distribution-fitting methods. In particular, we studied the analogue of HIEROs (i.e. sources selected on the basis of a red H - [4:5] &gt; 2:25), combining Euclid and Spitzer data at the depth of the Deep Fields. These sources include the bulk of obscured and massive galaxies in a broad redshift range, 3 &lt; z &lt; 7. We find that the dusty population at 3 . z . 7 is well identified, with a redshift root mean squared error and catastrophic outlier fraction of only 0:55 and 8:5% (HE = 26), respectively. Our findings suggest that with Euclid we will obtain meaningful insights into the impact of massive and dusty galaxies on the cosmic star-formation rate over time