Can we predict complications after elective carotid artery angioplasty and stenting with a simple Valsalva test?

Objectives. Arterial baroreflex plays a key role in short-term blood pressure balancing. It can also be quantified noninvasively with baroreceptor sensitivity during Valsalva manoeuver. The aim of the study was to evaluate the role of Valsalva manoeuver as a potential marker of possible autonomic dysfunction in patients after carotid artery angioplasty and stenting. Materials and methods. We evaluated dynamic changes of blood pressure during Valsalva manoeuver (Valsalva ratio, adrenergic baroreceptor sensitivity) in 22 patients (11 male; 63.2 ± 6.7 years) with symptomatic, unilateral internal carotid artery stenosis, and compared results with age and sex matched control subjects. Results. Valsalva ratio between baseline and post-procedural day (1.26 ± 0.13 vs 1.46 ± 0.31; p=0.002) was the only statistically significant parameter. All other tests (also between the study and the control group), cardiovagal and adrenergic, revealed no significant differences. Conclusion. We were not able to show that Valsalva manoeuver, as a simple, non-invasive and easy to perform test, could reliably confirm patients who are at a risk for postprocedural complications. It seems that most of the compensatory mechanisms, occurring after a revascularisation procedure, remain largely unclarified

Minor stroke due to large artery occlusion. When is intravenous thrombolysis not enough? Results from the SITS International Stroke Thrombolysis Register

Purpose: Beyond intravenous thrombolysis, evidence is lacking on acute treatment of minor stroke caused by large artery occlusion. To identify candidates for additional endovascular therapy, we aimed to determine the frequency of non-haemorrhagic early neurological deterioration in patients with intravenous thrombolysis-treated minor stroke caused by occlusion of large proximal and distal cerebral arteries. Secondary aims were to establish risk factors for non-haemorrhagic early neurological deterioration and report three-month outcomes in patients with and without non-haemorrhagic early neurological deterioration. Method: We analysed data from the SITS International Stroke Thrombolysis Register on 2553 patients with intravenous thrombolysis-treated minor stroke (NIH Stroke Scale scores 0–5) and available arterial occlusion data. Non-haemorrhagic early neurological deterioration was defined as an increase in NIH Stroke Scale score ≥4 at 24 h, without parenchymal hematoma on follow-up imaging within 22–36 h. Findings: The highest frequency of non-haemorrhagic early neurological deterioration was seen in 30% of patients with terminal internal carotid artery or tandem occlusions (internal carotid artery + middle cerebral artery) (adjusted odds ratio: 10.3 (95% CI 4.3–24.9), p < 0.001) and 17% in extracranial carotid occlusions (adjusted odds ratio 4.3 (2.5–7.7), p < 0.001) versus 3.1% in those with no occlusion. Proximal middle cerebral artery-M1 occlusions had non-haemorrhagic early neurological deterioration in 9% (adjusted odds ratio 2.1 (0.97–4.4), p = 0.06). Among patients with any occlusion and non-haemorrhagic early neurological deterioration, 77% were dead or dependent at three months. Conclusions: Patients with minor stroke caused by internal carotid artery occlusion, with or without tandem middle cerebral artery involvement, are at high risk of disabling deterioration, despite intravenous thrombolysis treatment. Acute vessel imaging contributes usefully even in minor stroke to identify and consider endovascular treatment, or intensive monitoring at a comprehensive stroke centre, for patients at high risk of neurological deterioration

Can we predict complications after elective carotid artery angioplasty and stenting with a simple Valsalva test?

Objectives. Arterial baroreflex plays a key role in short-term blood pressure balancing. It can also be quantified noninvasively with baroreceptor sensitivity during Valsalva manoeuver. The aim of the study was to evaluate the role of Valsalva manoeuver as a potential marker of possible autonomic dysfunction in patients after carotid artery angioplasty and stenting. Materials and methods. We evaluated dynamic changes of blood pressure during Valsalva manoeuver (Valsalva ratio, adrenergic baroreceptor sensitivity) in 22 patients (11 male; 63.2 ± 6.7 years) with symptomatic, unilateral internal carotid artery stenosis, and compared results with age and sex matched control subjects. Results. Valsalva ratio between baseline and post-procedural day (1.26 ± 0.13 vs 1.46 ± 0.31; p=0.002) was the only statistically significant parameter. All other tests (also between the study and the control group), cardiovagal and adrenergic, revealed no significant differences. Conclusion. We were not able to show that Valsalva manoeuver, as a simple, non-invasive and easy to perform test, could reliably confirm patients who are at a risk for postprocedural complications. It seems that most of the compensatory mechanisms, occurring after a revascularisation procedure, remain largely unclarified

Long-term Cognitive Deficits in Patients with Good Outcomes after Aneurysmal Subarachnoid Hemorrhage from Anterior Communicating Artery

Aim: To evaluate long-term cognitive consequences of subarachnoid hemorrhage with good outcome and the opinion of patients and their relatives about these consequences. Methods: The study included 10 patients surgically treated for subarachnoid hemorrhage due to the rupture of aneurysm of the anterior communicating artery 2 or more years earlier, and 10 age- and sex-matched healthy controls. The preoperative and postoperative course in the patients was uneventful. Clinical and psychosocial factors and cognitive status of the patients were assessed by use of checklists and neuropsychological tests for executive functions, attention, and memory, and event-related potential recordings (waves P3a and P3b) with tree-stimulus auditory oddball paradigm, which was also performed in healthy controls. Results: The number of reported cognitive problems negatively correlated with the patients’ level of community integration (ρ range, -0.22 to -0.75). The average neuropsychological results ranged between the 12th and 46th percentile. Impaired results were found in 7 patients across different tests and were most frequent for visual memory, followed by verbal memory and executive functions. A clear decline in cognitive functioning was observed in 3 patients. Neither P3a nor P3b wave could be found in 3 patients. In comparison with controls, patients had significantly longer P3b wave latencies (364 vs 334 ms; Mann-Whitney U test, P = 0.025). We found statistically non-significant, but still prominent negative correlations between the sustained attention results and latencies of P3a (ρ = -0.58; P = 0.172) and P3b (ρ = -0.58; P = 0.172) waves. Conclusion: Despite good outcome after subarachnoid hemorrhage, persistent cognitive consequences were still manifest, limiting the patients\u27 psychosocial functioning. The correlation between neuropsychological and neurophysiological measures indicated frontal lobe damage, which in some patients persisted for years after the hemorrhage

Safety of Statin Pretreatment in Intravenous Thrombolysis for Acute Ischemic Stroke

Background and Purpose-A recent meta-analysis investigating the association between statins and early outcomes in acute ischemic stroke (AIS) patients treated with intravenous thrombolysis (IVT) indicated that prestroke statin treatment was associated with increased risk of 90-day mortality and symptomatic intracranial hemorrhage. We investigated the potential association of statin pretreatment with early outcomes in a large, international registry of AIS patients treated with IVT