颈动脉狭窄引起短暂性脑缺血的外科治疗

目的 探讨颈动脉内膜剥脱术的适应证及围手术期处理。方法 回顾性总结11例因短暂性脑缺血(TIA)伴有颈动脉硬化狭窄患而行颈动脉内膜剥脱术(CEA)的临床资料。结果 除1例术后第二天发生脑梗塞死亡外，其余患TIA表现消失，4例慢性脑缺血症状也得到明显的改善。术后未出现偏瘫或脑出血等严重的并发症。结论 对于TIA病人，经多普勒超声或动脉血管造影(DSA)或磁共振血管造影(MRA)检查发现一侧或双侧颈总动脉或颈内动脉狭窄大于50％，可以考虑行颈动脉内膜剥脱术。对于双侧颈动脉狭窄，分期手术治疗较为安全。做好围手术期处理。有助于减少手术并发症。     

Carotid endarterectomy for stroke prevention

Minor neurologic signs or transient ischemic attacks (TIAs) precede stroke in 50 percent of patients. In men, antiplatelet therapy decreases the risk of recurrent TIA and stroke. Carotid endarterectomy for TIA is now one of the most commonly performed vascular operations. Preoperatively, the arterial anatomy of the patient must be carefully studied by conventional angiography or digital subtraction angiography. The goal of surgery is to eliminate the atherosclerotic plaque and restore the artery to its normal size with a smooth intima.     

Carotid endarterectomy for unilateral carotid system transient cerebral ischemia

This study involved 151 consecutive patients who had transient focal cerebral ischemia (TIA) in one carotid arterial system and who had carotid endarterectomy on the side corresponding to the ischemic symptoms. Each patient was examined preoperatively by a neurologist, who also judged the postoperative morbidity and mortality. All patients were operated on by one surgeon. A major or minor ischemic stroke occurred in 3% of patients during operation or within 30 days thereafter. The mortality was less than 1% at 1 month. After the first month, ischemic stroke occurred at a rate of 2% per year, and two-thirds of the strokes were ipsilateral to the endarterectomy. Long-term mortality was 3% per year. Long-term stroke morbidity was less than would have been expected for a comparable group of patients with TIA, and the percentage of deaths due to a cardiac cause was greater than expected, owing to a relative shift from stroke mortality to cardiac mortality. No patient who had a cerebral blood flow of 40 ml or greater per 100 g of brain per minute during occlusion for endarterectomy had a stroke during operation or during 4 1/2 years of follow-up.     

Implementation of an Emergency Department–based Transient Ischemic Attack Clinical Pathway: A Pilot Study in Knowledge Translation

Objectives To assess the feasibility of implementing an emergency department (ED)—based transient ischemic attack (TIA) clinical pathway that uses computer-based clinical support, and to evaluate measures of quality, safety, and efficiency.
Methods This was a prospective cohort study of adult patients presenting to a community ED with symptoms consistent with acute TIA. Adherence to the clinical pathway served as a test of feasibility. Compliance with guideline recommendations for antithrombotic therapy and vascular imaging were used as process measures of quality. The 90-day risk of recurrent TIA, stroke, or death provided estimates of safety. Efficiency was assessed by measuring the rate of uneventful hospitalization, defined as a hospital admission that did not result in any major medical event or vascular intervention such as endarterectomy or stent placement.
Results Of the 75 subjects enrolled, physician adherence to the clinical pathway was 85.3%, and 35 patients (46.7%) were discharged home from the ED. Antithrombotic agents were prescribed to 68 (90.7%), and vascular imaging was performed in 70 (93.3%). The 90-day risk of recurrent TIA was seven out of 75 (9.3%; 95% confidence interval [CI] = 4.6% to 18.0%), one patient experienced stroke (1.3%; 95% CI = 0.2% to 7.2%), and three patients died (4.0%; 95% CI = 1.4% to 11.1%). Uneventful hospitalization occurred in 38 of 40 patients (95.0%).
Conclusions Implementation of a clinical pathway for the evaluation and management of TIA using computer-based clinical support is feasible in a community ED setting. This pilot study in knowledge translation provides a design framework for further studies to assess the safety and efficiency of a structured ED-based TIA clinical pathway.     

Guidelines for the management of transient ischemic attacks.

On the basis of a review of the literature on anticoagulant, antiplatelet, and surgical treatment, supplemented by our personal experience, we have developed guidelines for the management of patients with transient ischemic attacks (TIA). 1. The majority of patients with vertebral-basilar TIA are treated medically. 2. If a skilled surgeon and an experienced angiographer are available, patients with typical carotid TIA who are suitable medical risks should have angiography followed by carotid endarterectomy if an appropriate lesion is found. 3. Nonoperated patients with TIA of less than 2 months' duration are treated with 3 months of warfarin therapy (unless contraindicated) before treatment with aspirin is begun. 4. Nonoperated patients with continuing TIA of 2 or more months' duration are treated with aspirin unless there has been a recent increase in the frequency, duration, or severity of TIA. Under these circumstances, warfarin therapy is advised for 3 months before aspirin is started. Aspirin therapy should be continued until the patient has been free of TIA for 1 year. 5. No treatment is advised for nonoperated patients whose last episode of TIA was longer than 12 months ago.     

Prevention of recurrent ischemic stroke.

Treatment after an ischemic stroke or transient ischemic attack (TIA) should target the presumed cause of the initial episode to facilitate focused prophylaxis. In the majority of ischemic strokes, degenerative large- and small-vessel disease is the cause. In these patients, attention to modifiable risk factors is an important priority. However, uncertainty and controversy remain regarding therapy, although issues are gradually being settled. There are now strong scientific data to support the use of carotid endarterectomy in patients with 70% to 99% stenosis and an ipsilateral TIA or nondisabling stroke. Aspirin is accepted as standard preventive therapy and should be used in all patients with a TIA or stroke, including those who undergo endarterectomy. Although the dose most commonly used in clinical trials is 1,300 mg/day, a daily dose of 325 mg is probably equally effective with less gastrotoxicity. Given present evidence, use of dipyridamole (Persantine) is not warranted. The role of ticlopidine hydrochloride (Ticlid) in stroke prophylaxis is not well defined. Its superiority over aspirin demonstrated in one study may make it the drug of first choice despite its expense and side effects. The efficacy of warfarin sodium (Coumadin, Panwarfin, Sofarin) or heparin in ischemic stroke caused by degenerative cerebrovascular disease is not supported by scientific data, but no prospective controlled studies have demonstrated that these agents are ineffective. Therefore, it seems prudent to reserve anticoagulant therapy for situations in which an ongoing thrombotic process is likely (eg, progressing stroke). Heparin therapy in the immediate post-TIA period is not warranted on the basis of current scientific evidence.     

Carotid sonography and transesophageal echocardiography in patients with ischemic stroke or transient ischemic attack in the territory of the carotid artery

PURPOSE: To assess the benefit of combining carotid sonography and transesophageal echocardiography (TEE) for the evaluation of patients with stroke or transient ischemic attack (TIA) in the territory of the carotid artery. METHODS: During a 2-year period in Turku University Hospital, consecutive in patients with stroke or TIA who were candidates for carotid endarterectomy and for oral anticoagulation were evaluated with carotid sonography for symptomatic moderate (50-69%) or severe (>or=70%) internal carotid artery (ICA) stenosis, and with TEE for potential cardiac sources of embolism. RESULTS: In 20% (40/197) of patients, a severe symptomatic ICA stenosis and/or a major risk factor for a cardiac source of embolism were found. In 56% (110/197) of patients, a moderate or severe symptomatic ICA stenosis and/or a potential cardiac source of embolism were found, whereas 11% (21/197) of patients had both a moderate or severe symptomatic ICA stenosis and a potential cardiac source of embolism. CONCLUSIONS: This study suggests that the presence of a moderate or severe symptomatic ICA stenosis does not exclude the presence of a potential cardiac source of embolism and vice versa. Carotid sonography and TEE complement each other and are valuable diagnostic tools that should be recommended in patients with ischemic stroke or TIA in the territory of the carotid artery when they are candidates for carotid endarterectomy and for oral anticoagulation.     

Transient ischaemic attacks: evaluation and management

Transient ischaemic attacks (TIAs) are temporary focal cerebral or retinal deficits that resolve within 24 hours. Attention should be given to the tempo and localisation of the clinical syndrome, as multiple and hemispheric TIAs are associated with the greatest incidence of early stroke. Evaluation of TIAs depends on the clinical symptoms, physical examination and investigations. Attention should be given to clinical evidence of generalised atherosclerotic disease, as death due to the complications of ischaemic heart disease is the commonest outcome in patients with TIA. Early attention should focus on risk factor modification, with emphasis on the treatment of hypertension and smoking cessation. Antiplatelet therapy should be instituted. Aspirin is the first-line treatment but, if not tolerated, clopidogrel is effective in preventing vascular complications. Anticoagulants are generally reserved for patients with atrial fibrillation and are associated with a significant reduction of stroke risk. The use of statins is becoming more widespread, with emerging evidence of their efficacy in reducing stroke risk. The risk of stroke is greatest in the weeks following TIA and patients should be referred for carotid duplex ultrasonography. Carotid endarterectomy for symptomatic internal carotid artery high grade stenosis virtually abolishes stroke risk in that vascular territory over subsequent years. TIAs should be regarded as an emergency requiring early diagnosis and prompt referral.     

3D-ASL与多模态磁共振在诊断短暂性脑缺血发作中的应用研究进展

短暂性脑缺血发作（TIA）被定义为脑、脊髓或视网膜局灶性缺血所致的、不伴急性梗死的短暂性神经功能障碍，判断TIA或急性脑梗死鉴别诊断的唯一依据是有无梗死，与临床症状持续时间无关。临床上TIA常依靠临床症状进行诊断，常规MR检查一般多无阳性发现。三维动脉自旋标记（3D-ASL）是目前比较流行且突出的灌注成像技术，可以产生定量的灌注图像，作为研究大脑功能的一种强有力的临床手段而日益受到重视。临床研究表明3D-ASL可以提供诊断TIA的依据，当联合DWI、MRA或者DSC-PWI检查时，对TIA的诊断、治疗、预后、风险评估等提供可靠依据，且对于不同身体耐受情况的患者可以选择不同的诊断模式。本文将对不同身体耐受情况TIA患者进行3D-ASL与DWI、MRA、DSC-PWI联合诊断的现状进行综述。      

Diagnosis and management of transient ischaemic attacks in accident and emergency.

Stroke is an important cause of morbidity and mortality. Often the first presentation of cerebrovascular disease is a TIA which will present to the A&E department. Patients who have had a TIA are at increased risk of stroke, myocardial infarction, and vascular death. The risk of stroke after a TIA is greatest in the first year (approximately 11.6%) with a risk of approximately 5.9% per year over the first five years. As the risk is highest in the first months following a TIA it is important that the patients are diagnosed accurately, investigated promptly, and referred appropriately for treatment in order that valuable time is not lost. For this reason A&E physicians have a valuable role in the initial assessment and management of the patient. It has been advocated that patients should be seen by a neurologist or physician with an interest in cerebrovascular disease within days of their symptoms and be prepared for surgery within two weeks after a TIA. While it is usually not possible to achieve this ideal, improved cooperation between A&E physicians and these neurologists, general physicians, and geriatricians should lead to the implementation of speedy efficient referral procedures which can only improve patient care. When you next see a patient with a TIA in the A&E department remember what they have to lose. Three questions relating to this article are: (1) How are TIAs subdivided and what clinical features allow this differentation? (2) What are the initial investigations that should be performed in A&E? (3) When are the risks of completed stroke greatest after a TIA? Enumerate these risks. How effective is aspirin at reducting this risks?     

颈内动脉系统TIA患者99Tcm-ECD脑SPECT双嘧达莫负荷显像的研究

目的：初步评价最新的诊断技术＾９９Ｔｃ＾ｍ－ＥＣＤ脑ＳＰＥＣＴ双嘧达莫负荷显像在颈内动脉系统短暂脑缺血发作（ＴＩＡ）患者中的应用价值,并与脑ＳＰＥＣＴ静息显像和头颅ＭＲＩ相比较。方法：对１４例颈内动脉系统ＴＩＡ患者在发作间期进行＾９９Ｔｃ＾ｍ－ＥＣＤ脑ＳＰＥＣＴ静脉和双嘧莫负荷显像及头颅ＭＲＩ检查。结果：脑ＳＰＥＣＴ双嘧达莫负荷显像与静息显像相比较,共有１０例患者在负荷状态下,局部放射性稀疏的程度     

Can the UK guidelines for stroke be effective? Attitudes to the symptoms of a transient ischaemic attack among the general public and doctors

This questionnaire-based study assessed the attitudes of the general public to the symptoms of a transient ischaemic attack (TIA) and determined the current level of knowledge about the management of TIA among doctors. The public chose to wait for symptom recurrence before seeking medical advice for amaurosis (41%) and upper limb (UL) monoparesis (51%), sensory loss (68%), or paraesthesia (95%). However, medical advice would be sought most often for slurred speech alone (89%) or combined with UL monoparesis (99%). Most physicians confirmed that these symptoms could represent a 'carotid TIA' but many considered diverse symptoms as relevant. While most general practitioners would prescribe anti-platelet therapy, 22-40% would not refer first-time TIA patients, depending upon the presenting symptom. In conclusion, the general public does not recognise the importance of TIA symptoms and the need for rapid assessment. This is compounded by deficiencies in the medical management of TIA. Stroke guidelines will remain ineffective without public awareness campaigns and physician education.     

Carotid endarterectomy: nursing care and controversies

Carotid endarterectomy, was first performed in 1951 and has since become one of the most commonly recommended operations. However, it has recently come under scrutiny for being performed too frequently for the wrong indications and at too high a risk for the patient. This article will cover pertinent anatomy and physiology of cerebral blood flow, symptoms of carotid circulation ischemia, indications for surgery along with the expected risks and benefits, and the role neuroscience nurses play in the care of these patients. In order to assist neuroscience nurses in ethical decision making regarding patient advocacy, several controversies surrounding carotid endarterectomy will be addressed.     

Contrast-Enhanced Ultrasound to Assess Carotid Intraplaque Neovascularization

Contrast-enhanced ultrasound (CEUS) is increasingly being used to identify patients with carotid plaques that are vulnerable to rupture, so-called vulnerable atherosclerotic plaques, by assessment of intraplaque neovascularization. A complete overview of the strengths and limitations of carotid CEUS is currently not available. The aim of this systematic review was to provide a complete overview of existing publications on the role of CEUS in assessment of carotid intraplaque neovascularization. The systematic review of the literature yielded 52 studies including a total of 4660 patients (mean age: 66 y, 71% male) who underwent CEUS for the assessment of intraplaque neovascularization. The majority of the patients (76%) were asymptomatic and had no history of transient ischemic attack (TIA) or stroke. The assessment of intraplaque neovascularization was mostly performed using a visual scoring system; several studies used time–intensity curves or dedicated quantification software to optimize analysis. In 17 studies CEUS was performed in patients before carotid surgery (endarterectomy), allowing a comparison of pre-operative CEUS findings with histologic analysis of the tissue sample that is removed from the carotid artery. In a total of 576 patients, the CEUS findings were compared with histopathological analysis of the plaque after surgery. In 16 of the 17 studies, contrast enhancement was found to correlate with the presence and degree of intraplaque neovascularization on histology. Plaques with a larger amount of contrast enhancement had significantly increased density of microvessels in the corresponding region on histology. In conclusion, CEUS is a readily available imaging modality for the assessment of patients with carotid atherosclerosis, providing information on atherosclerotic plaques, such as ulceration and intraplaque neovascularization, which may be clinically relevant. The ultimate clinical goal is the early identification of carotid atherosclerosis to start early preventive therapy and prevent clinical complications such as TIA and stroke.     

短暂性脑缺血发作126例的临床与CT研究

目的：探讨短暂性脑缺血发作（ＴＩＡ）患者脑梗死的发生率及可能相关的因素。方法：对１２６例颈内动脉系统ＴＩＡ的临床与ＣＴ资料进行分析。结果：脑ＣＴ扫描后发现７２例显示梗死灶,占５７．１％。其中：单发新鲜梗死灶３８例,多发新鲜梗死灶１８例,新旧梗死灶并存１６例。以腔隙性梗死灶最为多见（９７．５％）,多数病灶与本次ＴＩＡ症状无关,与本次ＴＩＡ临床症状相对应的责任病灶仅占２６．４％。局限性脑功能障碍持续的     

Comparison of Carotid Artery Stenting and Carotid Endarterectomy in Patients with Symptomatic Carotid Artery Stenosis: A Single Center Study

Introduction

Carotid artery stenting (CAS) is believed to be an alternative to carotid endarterectomy (CEA); however, recent studies have demonstrated an increase of complications with stenting that does not reflect our experience. We thus wanted to compare the periprocedural and 1-year follow-up outcomes of CAS with those of CEA among patients with symptomatic extracranial carotid stenosis in a population from eastern Turkey.

Methods

The hospital records of all patients who underwent carotid artery revascularization were retrospectively reviewed. Patients were divided into two groups based on the type of carotid revascularization performed, namely CEA or CAS. Comparisons were made with respect to 30-day and 1-year outcomes of transient ischemic attack (TIA), myocardial infarction (MI), stroke, and all-cause death rates. Composite endpoints for both groups were also analyzed.

Results

Thirty-two CEA and 33 CAS procedures were performed for symptomatic occlusive carotid disease. Baseline characteristics were similar between both groups except for the incidence of diabetes mellitus. No significant differences were found with respect to 30-day mortality, MI, and neurologic morbidity endpoints for CEA and CAS procedures. In the postprocedural 1-year follow-up, only TIA was observed to be significantly higher in the CAS group; the other endpoints did not differ significantly. One-year composite endpoints did not differ between both groups (log-rank P = 0.300).

Conclusion

In our trial of patients with symptomatic carotid artery stenosis, no significant difference could be shown in periprocedural outcomes, postprocedural outcomes except TIA, and in composite endpoints between the CEA and CAS groups. CAS is a safe and efficacious alternative for the treatment of symptomatic carotid artery stenosis.     

Utility of point of care assessment of platelet reactivity (using the PFA-100®) to aid in diagnosis of stroke

Background

Rapid and accurate diagnosis of patients presenting with symptoms of stroke is needed to facilitate the timely delivery of proven effective treatment for patients with acute ischemic stroke (AIS). The aim of this study was to determine whether early assessment of platelet reactivity in patients presenting with symptoms of AIS was associated with a diagnosis of AIS, transient ischemic attack (TIA), or stroke mimic.

Percutaneous transluminal angioplasty following endarterectomy

Prior to the introduction of percutaneous transluminal angioplasty (PTA), bypass grafting or endarterectomy was the treatment of choice for aortoiliofemoral atherosclerotic occlusive disease. Currently, PTA is a well-established procedure for the treatment of aortoiliofemoral atherosclerotic occlusive disease. PTA is as effective as, and safer than, surgery in these cases. Percutaneous transluminal angioplasty and endarterectomy cause similar trauma to the arterial wall, i.e., intimal denudation, plaque disruption and splitting, and medial disruption, splitting, and overstretching. Both PTA and endarterectomy heal in a similar manner, i.e., neointima formation and scarring. Both PTA and endarterectomy can be repeated. Therefore, PTA can be performed after endarterectomy or vice versa. Several patients with recurrent occlusive disease after endarterectomy have been safely treated with PTA. Our results obtained with PTA in patients who had a prior endarterectomy are comparable to the results obtained in patients who did not have a prior endarterectomy. No complications have been encountered. A previous endarterectomy does not preclude a subsequent PTA, or vice versa, in patients with recurrent occlusive disease.     

小檗碱治疗TIA30例及对血小板聚集率的影响

目的：观察小檗碱（黄连素）对短暂性脑缺血发作（ＴＩＡ）的临床疗效和对血小板聚集水平的影响。方法：口服小檗碱３００ｍｇ,每日３次,于服药前及服药后每隔１０天检测血小板聚集率１次,并设对照组口服羟乙基芦丁（维脑路通）２００ｍｇ,每日３次,对比临床疗效和血小板聚集率的变化。结果：小檗碱治疗３０天,血小板聚集率明显下降,ＴＩＡ发作频率明显降低。结论：小檗碱能降低ＴＩＡ患者血小板聚集率水平,缓解临床症状,是     

颈动脉内膜剥脱术治疗颈动脉狭窄的临床研究

[目的]探讨颈动脉内膜剥脱术治疗颈动脉狭窄的指证与手术技巧.[方法]回顾分析在2007年6月至2009年5月期间20例颈动脉狭窄患者行颈动脉内膜剥脱术并随访的相关资料.[结果]手术均成功,颈动脉内膜剥脱术1例术后第2天出现脑梗死,3例出现局部淤血,其余未出现明显神经功能障碍.术后平均随访15个月,未有一过性脑卒中或脑梗死发生.[结论]颈动脉内膜剥脱术治疗颈动脉狭窄是安全可靠的,但需要严格掌握手术指证并由技术娴熟的专科医师操作,手术的疗效才能得到保证.