Secondary prevention of ischaemic stroke

In spite of a documented reduction in incidence in high-income countries over the last decades, stroke is still a leading cause of death and disability worldwide. With the ageing of the population stroke-related economic burden is expected to increase, because of residual disability and its complications, such as cognitive impairment, high risk of falls and fractures, depression and epilepsy. Furthermore, because of the substantial rate of early and long-term vascular recurrences after the first event, secondary prevention after cerebral ischaemia is a crucial issue. This is even more important after minor stroke and transient ischaemic attack (TIA), in order to reduce the risk of potentially more severe and disabling events. To accomplish this aim, acute long-term medical and surgical treatments as well as lifestyle modifications are strongly recommended. However, apart from the well-established indications to thrombolysis, studies in acute phase after a first stroke or TIA are scarce and evidence is lacking. More trials are available for long-term secondary prevention with different classes of drugs, including antithrombotic medications for ischaemic events of arterial and cardiac origin, especially related to atrial fibrillation (antiplatelets and anticoagulants, respectively), lipid lowering agents (mainly statins), blood pressure lowering drugs, surgical and endovascular revascularization procedures.     

Cerebral revascularization by endovascular techniques

The minimally invasive approach to managing patients with ischemic and hemorrhagic stroke by endovascular intervention has made tremendous progress over the past years. Early recognition of stroke, improved ability to accurately diagnose the site of pathological abnormality with advanced imaging techniques and advances in treatment alternatives have led to better patient outcomes. Endovascular techniques for cerebral revascularization, a leading new therapeutic approach in the treatment of cerebrovascular disease, play a major role in both the management of acute stroke and secondary prevention. Selective intra-arterial thrombolysis for acute stroke has been performed for more than two decades with increasing success. Neurovascular therapies for secondary prevention include angioplasty of extracranial and intracranial vessels, as well as procedures for arterial reconstruction.     

Late cerebrovascular complications of cardiac transplantation

The occurrence of stroke after the post-operative period of cardiac transplantation is a rare event, and the role of the cardiac transplant in these patients, who often have various vascular risk factors, is unclear. We reviewed the clinical records of 303 consecutive patients with orthotopic cardiac transplantation performed from March 1985 to December 1996 and selected those who developed a stroke over the first 2 months postoperatively, in order to evaluate the frequency and the mechanisms of late cerebrovascular complications. Four patients had presented cerebral infarct and two intracranial hemorrhage. The overall risk of late cerebrovascular complications was 2.6p.100 at 5 years. Ischemic stroke was related to cardiac embolus in one patient, lacunar infarction in another, and was of undetermined etiology in two cases. In addition to vascular risk factors prior to transplantation and the development of intracardiac thrombus, immunosuppressive therapy, the surgical procedure and cardiac rejection may play a role in the occurrence of stroke in such patients.     

Stenting for coarctation of the aorta precipitating migraine with aura

The case of a 16-year-old girl with hypertension and coarctation of the aorta is presented. She underwent endovascular balloon dilation and stenting of the coarctation. Two days after this uncomplicated procedure, she started suffering from migraine with aura. Initially, the diagnosis of transient ischemic attacks was briefly considered, but extensive further assessment revealed no abnormalities. It is known that endovascular procedures, such as cerebral angiography or embolization of an intracranial vascular malformation, can induce migraine. To our knowledge, this is the first report of migraine with aura precipitated by an extracranial endovascular procedure: stenting for coarctation of the aorta. Series on both short-term results and long-term outcome of endovascular management of aortic coarctation have never reported migraine as a complication. Although the mechanism responsible for the onset of migraine in our patient remains unclear, it is conceivable that there was a relative intracranial hypertension before and a relative hypotension leading to hypoperfusion after dilation of the aorta. This acute disturbance of the cerebral hemodynamic balance may have set off the neurovascular mechanism leading to migraine attacks with aura.     

Future of extracranial-intracranial bypass

Total occlusion of internal carotid artery in the cervical region is an end result of progressive occlusive vascular disease. A small proportion of these patients will have symptoms of cerebral ischemia due to cerebral hypoperfusion in a delayed fashion. Identification of those individuals who are at risk of developing symptoms and prophylactically treating with a revascularization procedure will prevent such catastrophic events. With the co-operative study for bypass not supporting the bypass procedure and trial being questioned for its design and conclusions, a new trial of extracranial-intracranial bypass, The Carotid Occlusion Surgery Study, using the currently available technology will be undertaken to verify that the bypass will decrease the future stroke rate by at least 40% in patients with total carotid occlusion. A subset of patients with skull base pathology including tumors and aneurysms who may have to undergo carotid sacrifice as part of the surgical procedure are at risk of peri-operative and delayed stroke. Identification of these patients at risk by pre-operative tests may allow performance of extracranial-intracranial bypass prior to undertaking complex skull base procedures. The new imaging technology will guide management of these patients at risk and help identify patients who may need a bypass procedure.     

Extracranial-intracranial arterial bypass for treatment of occlusion of the internal carotid artery

Extracranial-intracranial arterial bypass was frequently utilized in the 1970s and early 1980s to treat patients with atherosclerotic occlusive carotid arterial lesions not amenable to extracranial arterial revascularization procedures. After a large randomized trial reported in 1985 that there was no benefit of surgery in these patients, the procedure was generally abandoned as a treatment for symptomatic atherosclerotic cerebrovascular disease. In the past two decades, multiple studies have shown that patients with impaired cerebral hemodynamics distal to an occlusive cerebrovascular lesion have a significantly increased risk of subsequent stroke. Two new randomized, controlled clinical trials of extracranial-intracranial arterial bypass in patients with symptomatic atherosclerotic occlusive cerebrovascular disease that are using cerebral hemodynamic criteria for patient selection are currently in progress. At the present time, extracranial-intracranial arterial bypass should not be performed on these patients outside of a clinical trial.     

Malformation vasculaire cérébrale découverte dans le bilan pré-thrombolyse d’un infarctus cérébral. Impact sur la décision thérapeutique

Intravenous recombinant tissue plasminogen activator for acute ischemic stroke is contraindicated in patients harboring an asymptomatic intracranial vascular malformation, whether it is incidentally discovered at the time of the initial cerebral imaging or previously known. Because thrombolysis is associated with a risk of serious intracerebral hemorrhage, it is theoretically possible that this treatment increases the risk of bleeding or rupture of these malformations. However, this risk seems very low in clinical practice. We report two cases, one with a probable brainstem cavernous malformation treated with alteplase for a supratentorial ischemic stroke who developed just after treatment a fatal brainstem hemorrhage, and another one with asymptomatic dural arteriovenous fistula, treated by endovascular thrombectomy solely. This approach was safe and effective, and the patient had an endovascular embolization of the fistula one month later as it became symptomatic. Based on the literature, we discuss the bleeding risk of asymptomatic intracranial vascular malformations in acute ischemic stroke patients treated with alteplase, depending on the type of malformation (intracranial aneurysm, arteriovenous and cavernous malformation or fistula), and the alternative therapeutic options.     

Current issues in endovascular surgical neuroradiology

Endovascular surgical neuroradiology is a newly recognized specialty within the American Medical Association. Remarkable advances in the specialty with regard to stroke prevention and therapy as well as the treatment of ruptured and unruptured cerebral aneurysms have provided patients and their treating physicians with novel treatment options that complement existing therapy. The issues surrounding the efficacy of endovascular treatment of intracranial atherosclerosis and cerebral aneurysms will be reviewed using a case-based learning format.     

血管内机械性开通治疗颅外动脉闭塞性脑梗死

目的探讨血管内机械性开通治疗颅外动脉闭塞性脑梗死的临床效果。方法对经全脑数字减影血管造影(DSA)检查证实的3例颅外动脉闭塞的脑梗死患者(2例为颈内动脉起始部至岩骨段闭塞,1例为左椎动脉起始部至近椎间孔段末端闭塞)给予血管内机械性开通术治疗;术前、术后3 d时对患者进行美国国立卫生研究院卒中量表(NHISS)评分;支架植入后复查DSA观察闭塞血管开通状况。结果 3例患者接受血管内介入治疗,术后即刻DSA检查示闭塞血管均完全开通;术后患者的症状均明显改善,2例术后NHISS评分(4分,1分)比术前(7分,3分)明显下降。结论血管内机械性开通治疗可以较好地改善颅外动脉闭塞脑梗死患者的神经功能缺损症状。     

进展性脑梗死与完全性脑梗死危险因素对照分析

目的对照分析进展性脑梗死与完全性脑梗死的危险因素。方法选取进展性脑梗死与完全性脑梗死患者各100例,分组比较患者的血压、血糖、血管评价结果、血脂、凝血状态等指标,所得数据经统计学分别处理。结果进展性脑梗死患者血压、血糖、血管评价结果、血脂、凝血状态等指标均较完全性脑梗死组患者平均水平差,其中颈动脉与脑部大血管狭窄与斑块检出率差异有统计学意义(P<0.05)。结论进展性脑梗死与完全性脑梗死患者有较多相同的临床危险因素,进展性脑梗死患者各项指标的平均值均较完全性脑梗死患者表现差。     

静脉溶栓桥接动脉取栓成功治疗左房黏液瘤所致急性脑梗死一例

心房黏液瘤作为心脏最常见的良性肿瘤,常由肿瘤或肿瘤表面血栓引起栓塞,黏液瘤所致脑梗死的治疗目前仍是一个临床和技术挑战。惠州市第三人民医院收治了1例61岁左侧大脑中动脉栓塞的男性患者,NIHSS评分16分,发病1 h后接受静脉溶栓并桥接动脉取栓,取出栓子病理提示黏液瘤,术后没有颅内出血,进一步检查发现了左心房肿瘤,3周后手术切除心脏肿瘤,病理报告为心房黏液瘤。在术后1个月的随访中,患者NIHSS评分为1分,改良Rankin量表评分为0分,术后未再出现栓塞发作。推测对心房黏液瘤所致脑梗死进行静脉溶栓并桥接动脉取栓是安全有效的,而尽早的心房黏液瘤切除能有效避免脑梗死复发。     

进程崎岖,前途广阔-颅内外血管搭桥术治疗非烟雾病性慢性脑缺血的研究现状及展望

颅内外血管搭桥术是公认的治疗成人烟雾病患者的主要方法,然而,颅内外血管搭桥术治疗非烟雾病性慢性脑缺血的疗效目前尚未完全阐明,其涉及到脑血流自主调节、脑代谢、认知功能、高级神经活动等一系列脑科学相关领域。因此,本文回顾国内外采用颅内外血管搭桥术治疗非烟雾病性慢性脑缺血的相关研究,以期提高临床工作者的认识,更好地促进颅内外血管搭桥术的应用和推广。     

Current strategies for ischemic stroke prevention: role of multimodal combination therapies

Stroke remains a global leading cause of death and long-term disability, highlighting the need for more effective treatment approaches. The majority of strokes are of ischemic origin, often caused by large- or small-artery atherothrombosis, or cardioembolism. Considering the systemic nature of the atherothrombotic disease process, stroke patients are at increased risk for ischemic events in several vascular territories: cerebral, coronary and peripheral. Due to the limited options for acute stroke therapies, stroke prevention is an important therapeutic approach. In addition to the management of modifiable risk factors such as hypertension, dyslipidemia and smoking through pharmacotherapy or lifestyle adjustments, anticoagulants, surgical and perhaps endovascular approaches are indicated in certain patients. Antiplatelet therapies using various agents are a cornerstone of secondary stroke prevention. To ensure the appropriate continuum of care after hospitalization for ischemic stroke, some interventions for the prevention of recurrent ischemic stroke should be initiated during the acute hospitalization setting and maintained in the out-patient setting.     

Pseudoaneurysmen der extrakraniellen A. carotis interna

Pseudoaneurysms of the extracranial internal carotid artery (ICA) can be caused by external injury or may be due to spontaneous dissection. Pseudoaneurysms bear an increased risk of arterio-arterial embolism. Treatment of pseudoaneurysms is influenced by the location and the type of injury, associated injuries, collaterals to the ipsilateral hemisphere, neurological signs and symptoms, growth of the lesion and patient age. Potential treatment regimen include conservative and medical approaches with anticoagulation and antiplatelet therapy, extra-intracranial bypass, resection of the pseudoaneurysm with vessel reconstruction, ligation or endovascular balloon occlusion of the ICA. Pseudoaneurysms of the ICA adjacent to the skull base require a major surgical procedure. If there are contra-indications for vessel occlusion conservative or medical treatment used to be the only therapeutic alternatives. We report the treatment of two patients with extracranial ICA pseudoaneurysms after blunt injury with stent placement (in one case combined with coil embolization) as a further treatment option.     

Traumatic vascular injuries and their management

Traumatic vascular injury to the intracranial and extracranial circulation can be sequelae of blunt, penetrating, or iatrogenic insults to the head, face, or neck. Treatment options include conservative medical management, or more invasive surgical or endovascular therapy. The appropriate treatment depends on the risk-benefit ratio of each option considering the natural history of each. Injuries include mild intimal irregularities, intimal flaps, pseudoaneurysms, fistulas, and occlusions. Need for treatment is partly determined by the collateral circulation to the brain, and the degree to which the lesion is thrombogenic. Advances in endovascular devices and techniques provide us with less invasive alternatives to surgery intervention or allow the interventionalist to treat lesions not treatable by any other modality.     

Extracranial carotid and vertebral artery stenting

The proof that carotid endarterectomy (CEA) is beneficial for the prevention of stroke in patients with atherosclerotic plaques of the carotid artery has been met with wide acceptance and liberal application in clinical practice. However, the procedure is most useful when performed by highly skilled surgeons in a low-risk population of patients. Thus, the search for alternative methods of treatment for patients whose situation involves less than optimal surgical circumstances has helped fuel the interest for carotid artery stenting (CAS). The latter, a technique that dates less than a decade, has quickly become a competitive procedure, one that is about to be tested in prospective randomized clinical trials. Clearly, for patients who are not surgical candidates, CAS may be the only available solution to their clinical condition. More importantly, atherosclerotic narrowing of the extracranial vertebral artery lends itself ideal for endovascular therapy, particularly because there is little evidence that surgical intervention is appropriate treatment for these patients. The present is a summary of the current technique and experience with stenting of the extracranial portions of the carotid and vertebral arteries.     

Therapeutisch induzierte Arteriogenese im Gehirn

Stroke is the leading cause of disability and a major cause of death in Germany and the western world. Ischemic stroke involves different pathophysiologic mechanisms such as thromboembolic vascular occlusion, cerebral micro- or macroangiopathy, extracranial arterial stenosis, and cardiac embolism. Experimental and clinical studies have shown that arteriogenesis, the adaptive growth of pre-existing collateral arteries, can be therapeutically enhanced in peripheral circulation and the heart. We examined the consequences to time course and hemodynamics of brain arteriogenesis in a chronic hypoperfusion model following systemic administration of the hemopoietic growth factor called granulocyte macrophage colony stimulating factor (GM-CSF). Treatment with GM-CSF led to the growth of intracranial collateral arteries, which improved the cerebral hemodynamic reserve and significantly reduced energy failure when brains were additionally challenged by hypotension. Therapeutically induced arteriogenesis may be of considerable interest for preventing infarction in patients with uncompensated cerebrovascular disease.     

血管内支架成形材料在脑供血动脉狭窄治疗中的应用

目的：总结近年来血管内支架成形材料在脑供血动脉狭窄治疗中的应用情况。 方法：由作者应用计算机检索维普数据库中与血管内支架置入治疗脑供血动脉狭窄有关的文章,检索时限2000-01/2010-10。检索关键词：血管内支架成形术;脑供血动脉狭窄;缺血性脑卒中;并发症。纳入标准：血管内支架置入治疗脑供血动脉狭窄的文章。排除标准：重复研究或较陈旧文献。 结果：金属内支架进入临床治疗后取得了令人瞩目的效果,但具有一定的致血栓形成性、永久性存留体内、再狭窄仍较高、金属表面难以附载药物等缺点。针对以上不足,近些年对支架材料、构形设计、制作工艺等均作了不少改进,更引人注目的是20世纪80年代末和90年代初覆膜支架的出现和生物学支架概念的提出,使血管内支架又进入了一个新的阶段。 结论：随着血管内技术的发展,脑保护装置下血管内支架置入已成为治疗颅内外动脉狭窄的主要方法之一,支架技术的安全性和有效性已显著提高,但仍存在如血栓形成、脑出血、再狭窄以及过度灌注等问题。 关键词：血管内支架成形术;脑供血动脉狭窄;缺血性脑卒中;并发症;生物材料 doi:10.3969/j.issn.1673-8225.2011.08.037     

Racial differences in ischemic cerebrovascular disease.

Purpose: To evaluate racial differences in extracranial carotid atherosclerosis and vascular risk factors in patients with symptomatic cerebrovascular disease. Background: There are conflicting data on racial differences in certain vascular risk factors and prevalence of large-vessel versus small-vessel disease in patients with stroke. Methods: We prospectively studied 211 consecutive patients admitted to our stroke service. There were 71 African-American, 114 Caucasian, 20 Hispanic, and 6 other patients. Extracranial vascular stenosis was assessed with a carotid duplex (CD) scan. Risk factors monitored included race, age, history of hypertension (HTN), diabetes mellitus (DM), prior stroke, hyperlipidemia, smoking, cardiac disease (congestive heart failure, atrial fibrillation), and family history of stroke. Cholesterol and triglyceride blood levels, and computed tomography/magnetic resonance imaging results were obtained in most cases. Results: Significant differences were found between Caucasians and African-Americans in several variables. Caucasians had more frequent hypertriglyceridemia and a higher rate of cardiac disease. African-Americans had more frequent lacunar infarcts. There was a trend toward decreased risk of CD scan abnormality, and more HTN and prior stroke in African-Americans. There were no differences in the presence of DM, both HTN and DM, abnormal cholesterol (including high- and low-density lipoprotein) values, and smoking history. Except for the difference in lacunar infarction, there were no differences in the type of stroke. Conclusions: Our data indicate a greater risk of cardiac disease and hypertriglyceridemia in Caucasians with cerebrovascular disease. There was a trend for Caucasians to have more extracranial carotid disease, and a trend for African-Americans to have more hypertension and prior stroke, although the difference did not reach significance. Consistent with prior racial studies, we found African-Americans to have more lacunar strokes than Caucasians.     

动脉硬化性大脑中动脉狭窄的治疗进展

动脉硬化性大脑中动脉狭窄发病率不高,但它极易引起脑缺血和卒中。目前内科治疗还是其主要的治疗方式,但是部分患者还需要采用血管内介入或外科手术进行治疗。本文在回顾大脑中动脉狭窄的自然病程、病理生理变化和内科治疗疗效的基础上,重点介绍血管内介入和外科手术的治疗原则、方法及疗效。