A horse, a horse, my kingdom for a horse. Saddle thrombosis of carotid bifurcation in acute stroke

Background: Saddle thrombosis is less frequently detected in carotid arteries than in peripheral arterial embolism. The clot and the distal vessel patency have to be promptly recognized in these cases, because if the carotid vessel is open distally, chances may arise for successful emergent surgical procedures to remove the thrombus. At conventional static imaging, mobile floating thrombi may be difficult to differentiate from thrombosis on carotid complicated lesions of atherosclerotic origin. High-resolution ultrasound (US), with its unique capability of real-time imaging, adds fundamental data for interpretation of the findings. Methods: Carotid ultrasound has been performed in acute stroke patients with high-resolution probes. Real-time clips are analyzed and imaging is presented. Results: Saddle carotid bifurcation thrombosis of cardiac origin has been identified in 2 patients with acute homolateral ischemic stroke, with prompt successful surgical removal in one case. Moreover, an example of a thrombus attached on the ruptured surface of a complicated atherosclerotic plaque in an acute symptomatic stroke patient that was successfully operated in emergency is presented. Conclusions: Early high-resolution ultrasound with real-time imaging can easily identify peculiar characteristics of carotid vulnerable diseases in acute stroke phase. Different clinical implications result from the early identification of these different conditions, modifying the therapeutical strategies. © 2012 Elsevier GmbH

La dislipidemia aterogenica e il rischio residuo cardiovascolare nella patologia cerebrovascolare

Background: Treatment with statins reduces the rate of cardiovascular events in high-risk patients, but residual risk persists. At least part of that risk may be attributable to atherogenic dyslipidemia (AD) characterized by low high-density lipoprotein cholesterol (HDL-C) and high triglycerides. Methods and results: We studied subjects with stroke or TIA in the PERFORM (n=19,100) and SPARCL (n=4,731) trials who were treated with a statin and who had AD (HDL-C ≤40 mg/dL and triglycerides ≥150 mg/dL) 3-months after randomization (n=10,498 and 2,900 respectively). The primary outcome measure for this exploratory analysis was the occurrence of major cardiovascular events (MVEs; nonfatal myocardial infarction, nonfatal stroke or cardiovascular death). We also performed a time-varying analysis to account for all available HDL-C and triglyceride measures. 11% of subjects in PERFORM and 9% in SPARCL had AD after at least 3 months on statin therapy. After a follow-up of 2.3-years (PERFORM) and 4.9-years (SPARCL), a MVE occurred in 1,123 and 485 patients in the two trials, respectively. The risk of MVEs was higher in subjects with versus those without AD in both PERFORM (hazard ratio [HR]=1.36, 95% confidence interval [CI]=1.14-1.63) and SPARCL (HR=1.40, 95%CI=1.06-1.85). The association was attenuated after multivariable adjustment (HR=1.23, 95%CI=1.03-1.48 in PERFORM; HR=1.24; 95%CI= 0.93-1.65 in SPARCL). Time-varying analysis confirmed these findings. Conclusions: The presence of atherogenic dyslipidemia was associated with higher residual cardiovascular risk in PERFORM and SPARCL subjects with stroke or TIA receiving statin therapy. Specific therapeutic interventions should now be trialed to address this residual risk

Prévention de l’AVC chez les patients avec une fibrillation auriculaire

Oral anticoagulation with vitamin K antagonists (VKA) was the cornerstone of stroke prevention in atrial fibrillation (AF). This review article presents the state of the art, with regard to the treatment options developed over the past few years, the new oral anticoagulants (NOAC). A search in PubMed for relevant published studies has been performed. Dabigatran and apixaban were superior to warfarin to reduce stroke risk or systemic embolism ; dabigatran, rivaroxaban and edoxaban were non-inferior. All NOAC are globally non-inferior to warfarin for stroke prevention in non-valvular AF and they have a superior safety profile, with a reduced intracranial bleeding risk. They are now the first choice for treatment

Bilateral spontaneous internal carotid artery dissection with both early and very late recanalization: A case report

Spontaneous bilateral internal carotid artery dissection has frequently been described in the literature as a cause of stroke. In more than half of the patients with internal carotid artery dissection, recanalization occurs early after the event and is unusual later than 6 months after onset of the dissection. We describe a patient with ischemic stroke due to left internal carotid artery occlusion in the extracranial segment. The patient was treated with anticoagulants and early vessel recanalization did not occur. Ten months later, he developed contralateral internal carotid occlusion in the intracranial tract, which was followed by early complete recanalization. Anticoagulation therapy was continued and, 16 months after the initial event, the left internal carotid artery unexpectedly also reopened. (C) 2010 Wiley Periodicals, Inc. J Clin Ultrasound 39:48-53, 2011; Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jcu.2071

Embolic Stroke of Undetermined Source and Patent Foramen Ovale Risk of Paradoxical Embolism Score Validation and Atrial Fibrillation Prediction

Background and Purpose: The Risk of Paradoxical Embolism (RoPE) score stratifies patients with stroke according to the probability of having a patent foramen ovale (PFO), which (through Bayes theorem and simple assumptions) can be used to estimate the probability that a PFO is pathogenic in a given subgroup of patients with specific features (ie, a given RoPE score value): a higher PFO prevalence corresponds to a higher probability that a PFO is pathogenic. Among alternative mechanisms in embolic stroke of undetermined source (ESUS), the actual stroke cause may be covert atrial fibrillation. We aimed to validate the RoPE score in a large ESUS population and investigate the rate of stroke recurrence and new incident atrial fibrillation during follow-up according to PFO status and RoPE score. Methods: We pooled data of consecutive patients with ESUS from 3 prospective stroke registries. We assessed RoPE score’s calibration and discrimination for the presence of PFO (and consequently for the probability that it is pathogenic). Multivariate logistic regression analysis was performed to identify factors associated with PFO. Results: Among 455 patients with ESUS (median age 59 years), 184 (40%) had PFO. The RoPE score’s area under the receiver operating characteristic curve was 0.75. In addition to RoPE score variables, absence of left ventricular hypertrophy, absence of atherosclerosis, and infratentorial lesions were independently associated with PFO. In patients with PFO and RoPE 7 to 10, PFO and RoPE 0 to 6, and without PFO, new incident atrial fibrillation rate was 3.1%, 20.5%, and 31.8%, respectively (log-rank test=6.28, P=0.04). Stroke recurrences in patients with likely pathogenic PFO were not statistically different from other patients. Conclusions: This multicenter study validates the RoPE score to predict the presence/absence of PFO in patients with ESUS, which strongly suggests that RoPE score is helpful in identifying patients with ESUS with pathogenic versus incidental PFOs. Left ventricular hypertrophy, atherosclerosis, and infratentorial stroke may further improve the score. Low RoPE scores were associated with more incidental atrial fibrillation during 10-year follow-up

Effects of a Single Mannitol Bolus on Cerebral Hemodynamics in Intracerebral Hemorrhage: A Transcranial Doppler Study

Background: Mannitol infusion is widely used in clinical practice to reduce perilesional edema in intracerebral hemorrhage (ICH), though no controlled studies have yet provided evidence of its effects on clinical outcome or on cerebral blood flow impairment following the event. The aim of our study was to evaluate blood flow velocity changes in the middle cerebral arteries (MCA) after a mannitol bolus in patients with ICH. Methods: Transcranial Doppler bilateral monitoring was performed for 90 min in 20 patients with ICH, during 100 ml mannitol bolus i.v. administration. The MCA mean flow velocities (MFVs) and pulsatility index (PI) were recorded. Results: When the 'healthy' and the 'affected' hemispheres were compared, we observed higher MCA MFV and lower PI on the affected side than on the contralateral side, both at baseline and during the experiment. After the mannitol bolus, we observed a significant MFV increase, starting at the end of the infusion and lasting longer than 60 min in the MCA on the affected side alone. The PI increased after mannitol administration on the healthy side alone. Conclusions: A single bolus of mannitol modified cerebral hemodynamics in our patients with ICH, increasing flow velocities on the affected MCA. This effect may be a consequence of reduced edema in the perilesional areas. The increased PI on the unaffected side may be indicative of preserved pulsatility in the healthy hemisphere. Copyright (C) 2011 S. Karger AG, Base

Threedimensional imaging of carotid arteries: Advantages and pitfalls of ultrasound investigations

Summary Objectives To describe normal and pathological findings with three-dimensional (3D) ultrasound of the carotid bifurcation. Methods Patients admitted to our ultrasound laboratory for vascular screening were submitted to standard carotid duplex and to 3D ultrasound reconstruction of the carotid bifurcation. Volume 3D scans were performed manually, on the axial plane, and the software presented the volume rendering from the inward blood flow signal detected with the Power Color Mode. Results Forty normal subjects, 7 patients with caliber alterations (4 carotid bulb ectasia and 3 internal carotid lumen narrowing), 45 patients with course variations (tortuosities and kinkings) and 35 patients with internal carotid artery stenosis of various degrees have been investigated. Conclusions 3D ultrasound is a feasible technique. It can improve carotid axis general imaging through a global image presentation "at a glance", visualizing caliber variations and vessels course. Imaging of stenosis from inward flow can be provided, but complete stenosis characterization requires the assessment of plaque morphology and vessel wall