Predictors of intracranial cerebral artery stenosis in patients before cardiac surgery and its impact on perioperative and long-term stroke risk

Background The aim of this prospective study was to determine the prevalence of stenosis within intracranial and extracranial arteries in patients before coronary artery bypass surgery (CABG), to evaluate the influence of intracranial artery stenosis on neurological outcome and to identify preoperative risk factors for these patients. Methods One hundred and seventy-five patients (71% males, mean age=66.1) scheduled for CABG were enrolled for extracranial Doppler duplex sonography, transcranial color-coded duplex sonography (TCCS) and transcranial Doppler (TCD) examination. Results Twenty-six patients (14.7%) had extracranial stenosis or occlusion and 13 patients (7.3%) intracranial vascular disease. Six patients (3.5%) had both extra- and intracranial artery disease. The presence of peripheral artery disease and diabetes mellitus was a strong risk factor for extracranial artery stenosis but not for intracranial artery stenosis, which occurred independently also of typical atherosclerotic risk factors like age >70, male sex, hypertension, hyperlipidemia, hyperhomocysteinemia, smoking habit, obesity (BMI>30) and waist to hip ratio >1. Functional neurological outcome of the patients with intracranial arterial disease evaluated 7 days after CABG was the same as the patients without extra- and intracranial stenosis. However, 12-months neurological follow-up revealed significantly more ischemic strokes in patients with intracranial artery stenosis compared to patients without intracranial stenosis (p=0.015). Conclusion The occurrence of intracranial artery stenosis in CABG patients cannot be predicted by well-known atherosclerotic risk factors and seems not to be associated with perioperative stroke

Effectiveness and safety of ICA stenting in conjunction with mechanical thrombectomy (antegrade approach) in acute ischaemic stroke patients due to tandem occlusion

Aim of study. We investigated the effectiveness and safety of an antegrade approach consisting of emergency ICA stenting in conjunction with mechanical thrombectomy (MT) in a one-stage procedure as a treatment for Tandem Occlusion (TO).Clinical rationale for study. We here describe our experience in the treatment of TO with an antegrade approach with long-term results. We also discuss the advantages and drawbacks of this treatment modality with special attention to possible haemorrhagic complications that can be encountered in patients with ischaemic stroke who receive antiplatelet treatment. We believe that our study adds to the limited number of reports on this topic.Materials and methods. We selected 34 patients diagnosed with acute ischaemic stroke due to ICA and ipsilateral intracranial occlusion treated with ICA stenting in conjunction with MT. We analysed the short- and long-term results as well as investigating complications with special regard to haemorrhagic transformationassociated with the need for antiplatelet treatment after stent implantation in patients after acute ischaemic stroke treatment.Results. A favourable angiographic outcome was defined as mTICI 2b–3. This was achieved in 33/34 patients (97%). On average, NIHSS at 24 hours after the procedure was 8.5 ± 7, which indicates a significant clinical improvement. Four cases of symptomatic ICH were observed (11.8%). One re-occlusion in stent was noted. At three-month follow-up, mRS scores were 0 in 11 (34.3%), 1 in 5 (16%), 2 in 1 (3%), 3 in 3 (9.3%), 4 in 3 (9.3%), and 5 in 2 (6%) patients. Seven patients did not survive (22%). Overall, a favourable outcome (mRS 0–2) was achieved in 17/34 patients (50%). The final mortality rate was 26.5% (9/34 patients).Conclusions and clinical implications. We conclude that an antegrade approach is a feasible and effective method for treating acute TO stroke, giving the patient the chance to regain his or her full independence in everyday life, with low overall complication and final mortality rates

Single nucleotide polymorphisms as predictors of treatment efficacy and adverse effects of morphine in palliative medicine — a literature review

Introduction: Pain has a significant negative impact on the quality of life of cancer patients and implies numerous clinical consequences. Moderate to severe pain is common in patients receiving palliative care. A major issue is the individual variability resulting in different degrees of response to the analgesic effects of opioids, including morphine, and to the occurrence of their adverse effects. According to one of the theories of pharmacogenomics, single nucleotide polymorphisms (SNPs) are associated with opioid metabolism. Material and methods: A literature review of the PubMed database identified 18 scientific articles concerning SNPs that affect the analgesic effects and adverse effects of morphine or other opioids, per morphine equivalent, from which additional 22 scientific articles were retrieved. Results: The review identified SNPs in the genes OPRM1 A118G, COMT rs4680, ABCB1 C3435T, IL-6, IL-8, TNF-⍺, TAOK3, HTR3B, UGT1A1/UGT1A8 and OPRM1 Arg181Cys, which were found to affect both the occurrence of potential adverse effects and the different demand in palliative care patients for a dose of morphine that will effectively relieve pain. SNPs were found to significantly affect morphine metabolism; the determination of this effect is individual-based. Most studies were conducted in small groups of individuals from ethnically diverse populations, which, if mutations are present, may significantly affect the efficacy of opioid-related SNP assays and the response of patients to the analgesic treatment administered. Conclusions: Findings raise the prospect of the use of SNPs in clinical practice as part of personalised medicine in the future.Ból nowotworowy ma poważny wpływ na jakość życia chorych i implikuje liczne kliniczne konsekwencje. Ból w stopniu od umiarkowanego do ciężkiego doświadcza większość pacjentów medycyny paliatywnej. Problem stanowi zmienność osobnicza powodująca różny stopień odpowiedzi na działanie przeciwbólowe opioidów, w tym morfiny i na wystąpienie ich efektów ubocznych. Jedną z teorii farmakogenomicznych mających na celu wyjaśnienie zmienności są polimorfizmy pojedynczych nukleotydów (SNP – single nucleotide polymorphisms) związane z metabolizmem opioidów. Przegląd literatury przeprowadzony w bazie PubMed zidentyfikował 16 artykułów naukowych dotyczących SNP wpływających na działanie przeciwbólowe i działania niepożądane morfiny bądź innych opioidów z przeliczeniem na ekwiwalent morfiny, z których dodatkowo pozyskano 22 istotne dla przeglądu artykuły naukowe. W przeglądzie zidentyfikowano SNP w genach OPRM1 A118G, COMT rs4680, ABCB1 C3435T, IL-6, IL-8, TNF⍺, TAOK3, HTR3B, UGT1A1/UGT1A8, a także OPRM1 Arg181Cys, które wykazały wpływ na zróżnicowane zapotrzebowanie pacjentów paliatywnych na dawkę morfiny skutecznie kontrolującej ból oraz na wystąpienie potencjalnych działań niepożądanych. Wykazano, że SNP istotnie wpływa na metabolizm morfiny. Określenie tego wpływu jest zależne osobniczo. W przeprowadzonej analizie większość badań opierała się na niewielkich liczebnie grupach pacjentów z różnorodnych etnicznie populacji, co w przypadku występowania mutacji może mieć istotny wpływ na skuteczność oznaczania SNP związanych z opioidami i na odpowiedź pacjentów na zastosowane leczenie przeciwbólowe. Liczba dostępnych dowodów naukowych w literaturze daje nadzieję na wykorzystanie SNP w praktyce klinicznej w przyszłości jako element medycyny spersonalizowanej

External quality monitoring facilitates improvement in already well-performing stroke units: insights from RES-Q Poland

Introduction. The Registry of Stroke Care Quality (RES-Q) is used in Poland for quality monitoring by numerous hospitals participating in the Angels Initiative. Our aim was to assess the degree of improvement in highly stroke-oriented centres that report cases to the RES-Q each year. Material and methods. This retrospective analysis included Polish stroke units that from January 2017 to December 2020 contributed to the RES-Q at least 25 patients annually. Results. Seventeen out of 180 Polish stroke units reported patients each year (2017, n = 1,691; 2018, n = 2,986; 2019, n = 3,750; 2020, n = 3,975). The percentage of ischaemic stroke patients treated with alteplase remained stable (26%, 29%, 30% and 28%, respectively). The door-to-needle time progressively decreased, from a median 49 minutes to 32 minutes. The percentage of patients treated ≤ 60 minutes and ≤ 45 minutes significantly increased (from 68% to 86% and from 43% to 70%, respectively), with no change observed between 2019 and 2020. Despite a general improvement in dysphagia screening (81%, 91%, 98% and 99%), screening performed within the first 24h from admission became less frequent (78%, 76%, 69% and 65%). In-hospital mortality significantly increased (11%, 11%, 13% and 15%), while the proportion of patients discharged home remained stable. Conclusions. Quality-oriented projects facilitate the improvement of stroke care, even in centres demonstrating good baseline performance. Polish stroke units that consistently reported cases to the RES-Q demonstrated improvement in terms of door-to- -needle time and dysphagia screening. However, there is still a need to shorten the time to dysphagia screening, and carefully monitor stroke unit mortality following the COVID-19 pandemic

Mechanical thrombectomy in acute stroke – Five years of experience in Poland

Objectives Mechanical thrombectomy (MT) is not reimbursed by the Polish public health system. We present a description of 5 years of experience with MT in acute stroke in Comprehensive Stroke Centers (CSCs) in Poland. Methods and results We retrospectively analyzed the results of a structured questionnaire from 23 out of 25 identified CSCs and 22 data sets that include 61 clinical, radiological and outcome measures. Results Most of the CSCs (74%) were founded at University Hospitals and most (65.2%) work round the clock. In 78.3% of them, the working teams are composed of neurologists and neuro-radiologists. All CSCs perform CT and angio-CT before MT. In total 586 patients were subjected to MT and data from 531 of them were analyzed. Mean time laps from stroke onset to groin puncture was 250±99min. 90.3% of the studied patients had MT within 6h from stroke onset; 59.3% of them were treated with IV rt-PA prior to MT; 15.1% had IA rt-PA during MT and 4.7% – emergent stenting of a large vessel. M1 of MCA was occluded in 47.8% of cases. The Solitaire device was used in 53% of cases. Successful recanalization (TICI2b–TICI3) was achieved in 64.6% of cases and 53.4% of patients did not experience hemorrhagic transformation. Clinical improvement on discharge was noticed in 53.7% of cases, futile recanalization – in 30.7%, mRS of 0–2 – in 31.4% and mRS of 6 in 22% of cases. Conclusion Our results can help harmonize standards for MT in Poland according to international guidelines

Standards in neurosonology. Part I

The paper presents standards related to ultrasound imaging of the cerebral vasculature and structures. The aim of this paper is to standardize both the performance and description of ultrasound imaging of the extracranial and intracranial cerebral arteries as well as a study of a specifi c brain structure, i.e. substantia nigra hyperechogenicity. The following aspects are included in the description of standards for each ultrasonographic method: equipment requirements, patient preparation, study technique and documentation as well as the required elements of ultrasound description. Practical criteria for the diagnosis of certain pathologies in accordance with the latest literature were also presented. Furthermore, additional comments were included in some of the sections. Part I discusses standards for the performance, documentation and description of different ultrasound methods (Duplex, Doppler). Part II and III are devoted to standards for specifi c clinical situations (vasospasm, monitoring after the acute stage of stroke, detection of a right-toleft shunts, confi rmation of the arrest of the cerebral circulation, an assessment of the functional effi ciency of circle of Willis, an assessment of the cerebrovascular vasomotor reserve as well as the measurement of substantia nigra hyperechogenicity)

Standards in neurosonology. Part II

The paper presents standards related to ultrasound imaging of the cerebral vasculature and structures. The aim of this paper is to standardize both the performance and description of ultrasound imaging of the extracranial and intracranial cerebral arteries as well as a study of a specific brain structure, i.e. substantia nigra hyperechogenicity. The following aspects are included in the description of standards for each ultrasonographic method: equipment requirements, patient preparation, study technique and documentation as well as the required elements of ultrasound description. Practical criteria for the diagnosis of certain pathologies in accordance with the latest literature were also presented. Furthermore, additional comments were included in some of the sections. Part I discusses standards for the performance, documentation and description of different ultrasound methods (Duplex, Doppler). Part II and III are devoted to standards for specific clinical situations (vasospasm, monitoring after the acute stage of stroke, detection of a right-toleft shunts, confirmation of the arrest of the cerebral circulation, an assessment of the functional efficiency of circle of Willis, an assessment of the cerebrovascular vasomotor reserve as well as the measurement of substantia nigra hyperechogenicity)

Standardy badań ultrasonograficznych. Neurosonologia. Część I

The paper presents standards related to ultrasound imaging of the cerebral vasculature and structures. The aim of this paper is to standardize both the performance and description of ultrasound imaging of the extracranial and intracranial cerebral arteries as well as a study of a specific brain structure, i.e. substantia nigra hyperechogenicity. The following aspects are included in the description of standards for each ultrasonographic method: equipment requirements, patient preparation, study technique and documentation as well as the required elements of ultrasound description. Practical criteria for the diagnosis of certain pathologies in accordance with the latest literature were also presented. Furthermore, additional comments were included in some of the sections. Part I discusses standards for the performance, documentation and description of different ultrasound methods (Duplex, Doppler). Part II and III are devoted to standards for specific clinical situations (vasospasm, monitoring after the acute stage of stroke, detection of a right-toleft shunts, confirmation of the arrest of the cerebral circulation, an assessment of the functional efficiency of circle of Willis, an assessment of the cerebrovascular vasomotor reserve as well as the measurement of substantia nigra hyperechogenicity).W artykule przedstawiono podstawowe standardy dotyczące badania układu naczyniowego i struktur mózgu metodą ultrasonograficzną. Celem opracowania jest ujednolicenie wykonywania i opisu badań ultrasonograficznych tętnic domózgowych zewnątrz- i wewnątrzczaszkowych oraz specyficznego badania struktur mózgowia – hiperechogeniczności istoty czarnej. Opis standardu badania każdą z metod ultrasonograficznych obejmuje: wymagania aparaturowe, przygotowanie do badania, technikę wykonania badania, dokumentację badania oraz obowiązkowe elementy opisu badania. Przedstawiono także praktyczne kryteria rozpoznania poszczególnych patologii, z uwzględnieniem najnowszego piśmiennictwa. W niektórych podrozdziałach zawarto również uwagi uzupełniające. W części I omówiono standardy wykonania, dokumentacji i opisu badań poszczególnymi metodami ultrasonograficznymi (badanie dupleksowe, badanie dopplerowskie). W części II opisano standardy dotyczące poszczególnych sytuacji klinicznych (skurcz naczyniowy, monitorowanie ostrego okresu udaru mózgu, wykrywanie bezpośredniego przecieku z krążenia małego – prawego do dużego – lewego, potwierdzanie zatrzymania krążenia mózgowego, ocena wydolności koła tętniczego mózgu, badanie rezerwy wazomotorycznej naczyń mózgowych i badanie hiperechogeniczności istoty czarnej)

Standardy badań ultrasonograficznych. Neurosonologia. Część III

The paper presents standards related to ultrasound imaging of the cerebral vasculature and structures. The aim of this paper is to standardize both the performance and description of ultrasound imaging of the extracranial and intracranial cerebral arteries as well as a study of a specific brain structure, i.e. substantia nigra hyperechogenicity. The following aspects are included in the description of standards for each ultrasonographic method: equipment requirements, patient preparation, study technique and documentation as well as the required elements of ultrasound description. Practical criteria for the diagnosis of certain pathologies in accordance with the latest literature were also presented. Furthermore, additional comments were included in some of the sections. Part I discusses standards for the performance, documentation and description of different ultrasound methods (Duplex, Doppler). Part II and III are devoted to standards for specific clinical situations (vasospasm, monitoring after the acute stage of stroke, detection of a right-to-left shunts, confirmation of the arrest of the cerebral circulation, an assessment of the functional efficiency of circle of Willis, an assessment of the cerebrovascular vasomotor reserve as well as the measurement of substantia nigra hyperechogenicity).W artykule przedstawiono podstawowe standardy dotyczące badania układu naczyniowego i struktur mózgu metodą ultrasonograficzną. Celem opracowania jest ujednolicenie wykonywania i opisu badań ultrasonograficznych tętnic domózgowych zewnątrz- i wewnątrzczaszkowych oraz specyficznego badania struktur mózgowia – hiperechogeniczności istoty czarnej. Opis standardu badania każdą z metod ultrasonograficznych obejmuje: wymagania aparaturowe, przygotowanie do badania, technikę wykonania badania, dokumentację badania oraz obowiązkowe elementy opisu badania. Przedstawiono także praktyczne kryteria rozpoznania poszczególnych patologii, z uwzględnieniem najnowszego piśmiennictwa. W niektórych podrozdziałach zawarto również uwagi uzupełniające. W części I omówiono standardy wykonania, dokumentacji i opisu badań poszczególnymi metodami ultrasonograficznymi (badanie dupleksowe, badanie dopplerowskie). W części II i III opisano standardy dotyczące poszczególnych sytuacji klinicznych (skurcz naczyniowy, monitorowanie ostrego okresu udaru mózgu, wykrywanie bezpośredniego przecieku z krążenia małego – prawego do dużego – lewego, potwierdzanie zatrzymania krążenia mózgowego, ocena wydolności koła tętniczego mózgu, badanie rezerwy wazomotorycznej naczyń mózgowych i badanie hiperechogeniczności istoty czarnej)