Effect of different shunt strategies on cerebral infarction after carotid endarterectomy / 北京大学学报(医学版)

OBJECTIVE@#The key point of anesthesia management in carotid endarterectomy (CEA) is to maintain adequate cerebral perfusion during carotid artery occlusion. Placement of shunt is one of the common surgical methods. This study analyzed the effects of different shunt strategies on cerebral infarction after carotid endarterectomy.@*METHODS@#A total of 443 patients who underwent CEA under general anesthesia within 2 years were divided into imaging group (based on preoperative imaging data as the basis for shunt) and stump pressure group (based on intraoperative stump pressure as the basis for shunt). The preoperative demographic data, past medical history, degree of cervical vascular stenosis, blood pressure at each time point during the perioperative period, vascular blocking time, whether to place the shunt, postoperative hospital stay, cerebral infarction during hospitalization, and other adverse events were collected and compared between the two groups. On this basis, the preoperative and intraoperative conditions with significant differences were matched with propensity scores, and the influence of different shunt strategies on postoperative cerebral infarction was analyzed.@*RESULTS@#In the study, 268 patients in the imaging group and 175 patients in the stump pressure group underwent CEA under general anesthesia. There were statistically significant differences in basic conditions and blood pressure at each time point between the two groups. After matching the propensity scores, 105 patients in each of the two groups were matched. The basic conditions of the patients before surgery and the difference in blood pressure of the two groups at each time point were not statistically significant. There was no significant diffe-rence in the incidence of postoperative cerebral infarction between the two groups (1.9% vs. 1.0%, P>0.999). The intraoperative shunt rate in the imaging group was lower than that in the stump pressure group (0 vs. 22.9%, P < 0.001). The postoperative hospital stay in the imaging group was 8 (7, 8) days, which was longer than the stump pressure group 5 (4, 6) days (P < 0.001).@*CONCLUSION@#The rate of the shunt was lower according to preoperative imaging examination than that according to the residual pressure in our hospital. There is no significant difference in the incidence of cerebral infarction during the postoperative hospital stay. The effect of different shunt strategies on cerebral infarction needs further study.

Effects of the prophylactic use of escitalopram on the prognosis and the plasma copeptin level in patients with acute cerebral infarction

This study aimed to investigate whether the routine administration of escitalopram for three months would improve the prognosis of patients with ischemic stroke and decrease the plasma copeptin level. A total of 97 patients with acute cerebral infarction were randomly allocated to receive escitalopram (5-10 mg once per day, orally; n=49) or not to receive escitalopram (control group; n=48) for 12 weeks starting at 2-7 days after the onset of stroke. Both groups received conventional treatments, including physiotherapy and secondary prevention of stroke. The National Institutes of Health Stroke Scale (NIHSS) score was used to evaluate the disability of patients at the initial evaluation and at the monthly follow-up visits for three months. Impairment in the daily activities was assessed using the Barthel Index (BI), while cognitive impairment was assessed using Mini-Mental State Examination (MMSE) score. The psychiatric assessment included the administration of the Present State Examination modified to identify Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) symptoms of depression. The severity of depression was measured using the 17-item Hamilton Rating Scale for Depression (HAMD). During the 3-month follow-up period, 95 patients were included in the analysis (two patients withdrew from the escitalopram group). NIHSS and BI improvement at the 90th day were significantly greater in the escitalopram group (P<0.05), while HAMD and plasma copeptin levels significantly decreased, compared to the control group (P<0.01). In patients with acute ischemic stroke, the earlier administration of escitalopram for three months may improve neurological functional prognosis and decrease copeptin level.

A forced running wheel system with a microcontroller that provides high-intensity exercise training in an animal ischemic stroke model

We developed a forced non-electric-shock running wheel (FNESRW) system that provides rats with high-intensity exercise training using automatic exercise training patterns that are controlled by a microcontroller. The proposed system successfully makes a breakthrough in the traditional motorized running wheel to allow rats to perform high-intensity training and to enable comparisons with the treadmill at the same exercise intensity without any electric shock. A polyvinyl chloride runway with a rough rubber surface was coated on the periphery of the wheel so as to permit automatic acceleration training, and which allowed the rats to run consistently at high speeds (30 m/min for 1 h). An animal ischemic stroke model was used to validate the proposed system. FNESRW, treadmill, control, and sham groups were studied. The FNESRW and treadmill groups underwent 3 weeks of endurance running training. After 3 weeks, the experiments of middle cerebral artery occlusion, the modified neurological severity score (mNSS), an inclined plane test, and triphenyltetrazolium chloride were performed to evaluate the effectiveness of the proposed platform. The proposed platform showed that enhancement of motor function, mNSS, and infarct volumes was significantly stronger in the FNESRW group than the control group (P<0.05) and similar to the treadmill group. The experimental data demonstrated that the proposed platform can be applied to test the benefit of exercise-preconditioning-induced neuroprotection using the animal stroke model. Additional advantages of the FNESRW system include stand-alone capability, independence of subjective human adjustment, and ease of use.

El tratamiento quirúrgico de la enfermedad carotidea / Surgical treatment of carotid artery disease

La endarterectomía carotidea es una técnica estandarizada para la remoción de placas de ateromas obstructivos en la carótida interna. Es una de las intervenciones quirúrgicas más extensamente estudiadas a través de estudios multicéntricos para evaluar su rol en el tratamiento y la prevención de síntomas isquémicos cerebrales. Los estudios de ECST y ACAS en enfermos con estenosis carotidea y síntomas pertinentes, demostraron que la cirugía es beneficiosa para pacientes con 70 y 99 por ciento de estenosis y se ha convertido en una indicación ampliamente aceptada. El estudio de ACAS en enfermos con estenosis asintomática, demostró un beneficio marginal de la cirugía respecto al tratamiento médico y que se invalidaba si la morbi-mortalidad del procedimiento superaba el 3 por ciento. Por estas razones la indicación de remover la placa en forma preventiva en enfermos asintomáticos, debe ser juiciosamente indicada, de acuerdo a la experiencia del centro.

Carotid endarterectomy is a standardized technique for removing obstructive plaques in the internal carotid arteries. It is one of the surgical procedures more extensively studied through multicentric randomized trials to find its place in prevention and treatment of cerebral ischemic symptoms. ECST and NASCET trials in patients with symptomatic carotid stenosis clearly showed a benefit from surgery in patients with 70 to 99 percent stenosis. ACAS trial, designed to study asymptomatic patients with carotid stenosis, showed only marginal benefit from surgery compared to medical treatment and this benefit was abolished if combined surgical morbidity and mortality exceeded 3 percent. Thus the indications for surgical removal of a carotid plaque in asymptomatic patients must be carefully judged according to the results in a specific centre.

Effect of chlorophyll and aqueous extracts of Bacopa monniera and Valeriana wallichii on ischaemia and reperfusion-induced cerebral injury in mice.

Bilateral carotid artery occlusion followed by reperfusion produced significant cerebral infarction and impaired short-term memory, motor co-ordination and lateral push response. Individual pretreatments with chlorophyll and aqueous extracts of B. monniera and V. wallichii markedly attenuated ischaemia-reperfusion induced cerebral injury in terms of decreased infarct size, increase in short-term memory, motor in coordination and lateral push response. The results suggest that chlorophyll and aqueous extracts of B. monniera and V. wallichii prevent ischaemia-reperfusion induced cerebral injury with comparable potency.

Reversal of severe SPECT asymmetry after venous extra-intracranial high flow bypass in a patient submitted to therapeutic internal carotid occlusion: case report

Therapeutic occlusion of the internal carotid artery is the main option for the treatment of the symptomatic intracavernous internal carotid artery aneurysms, but the issue of the best way of doing the balloon test occlusion (BTO) regarding prediction of future ischemic events remains debatable. Single photon emission computerized tomography (SPECT) has been offered as one of the best option of monitoring regional cerebral blood flow (rCBF) during the BTO, where severe asymmetry is predictive of delayed ischemia. We describe a case of important SPECT asymmetry during BTO clinically negative and its complete reversal with carotid occlusion after extra-intracranial bypass with high flow safenous vein bypass between the cervical carotid artery and the middle cerebral artery

Effectiveness of propofol pretreatment on the extent of deranged cerebral mitochondrial oxidative enzyme system after incomplete forebrain ischemia/reperfusion in rats

It has been suggested that propofol has the protective effect on cerebral ischemia-reperfusion injury. The aim of this study is to evaluate the effect of propofol pretreatment on incomplete forebrain ischemia-reperfusion injury in rats. Thirty Sprague-Dawley rats were anesthetized with isoflurane in oxygen and randomly allocated into propofol group (n=13) and saline group (n=17). In propofol group, propofol was pretreated in a step-down scheme before inducing forebrain ischemia by occlusion of both common carotid arteries and arterial hypotension. After ischemia (20 min) and reperfusion (30 min), rats were decapitated. Brain was sliced to obtain coronal slices of 4-12 mm from frontal pole, which were reacted with 2% 2,3,5-triphenyl-2H-tetrazolium chloride (TTC) for 10 min to differentiate the damaged tissues from normal tissues. Median (interquartile range) values of the average percent infarct area were 0.0 (8.6)% and 20.1 (41.2)% in propofol and saline groups, respectively. There was significant difference between the groups. In conclusion, propofol may have a protective effect on incomplete forebrain ischemia-reperfusion injury.

Antiagregantes plaquetarios en la prevención de la enfermedad vascular cerebral / Antiplatelates cerebral infartion prevention

Los mecanismos productores de isquemia cerebral son múltiples; sin embargo, el tromboembolismo explica una gran proporción de los casos de isquemia cerebral. El papel de los antiagregantes plaquetarios en la prevención secundaria del infarto cerebral esta bien definido. La presente revisión analiza los mecanismos de acción y la eficacia de las tres únicas drogas antiagregantes plaquetarias con efectividad demostrada en la prevención del infarto cerebral. Se analizan las relaciones riesgo-beneficio en cada uno de los agentes farmacológicos, así como también se discuten aspectos en cuanto a la dosis "ideal" de aspirina para esta indicación

Tratamiento quirúrgico de las lesiones carotídeas / Surgical treatment for carotid lesions

Se presenta una serie de 98 cirugías carotídeas, 93 endarterectomías y cinco resecciones de tumores del cuerpo carotídeo. La serie de 93 endarterectomías se comparó con dos informes recientes de la literatura; se analizaron 16 variables y se obtuvo una correlación estadística mediante la t de Student en cada una de ellas. Se encontraron diferencias estadísticamente significativas en: número de enfermos y tipo de seguimiento, indicaciones quirúrgicas (en nuestra serie más de 90 por ciento de las operaciones se efectuaron en enfermos con lesiones sintomáticas, en comparación con lo informado, en donde hubo 40 por ciento de enfermos con lesiones asintomáticas). En nuestra serie se utilizó una derivación, selectiva. Las cifras de morbimortalidad y los resultados a largo plazo fueron similares con otros estudios revisados. En la discusión se analiza la literatura reciente al respecto. Los tumores del cuerpo carotídeo, aunque poco frecuentes, constituyen un reto para su tratamiento. Se discute la técnica quirúrgica utilizada (resección subadventicia), ya que ésta simplifica su resección y disminuye el porcentaje de complicaciones

Arterioesclerosis obliterante / Obliterant arteriosclerosis

Una de las tres grandes manifestaciones de la arterioesclerosis obliterante es el infarto cerebral. Este se puede prevenir en un 50%o más de los casos, si se logran reconocer sus primeros síntomas y signos, como es la correlación entre soplo carotídeo y accidente isquémico transitorio. En el presente artículo, se revisan brevemente aspectos clínicos así como de prevención y tratamiento de la arterioesclerosis obliterante cerebral

Revisión retrospectiva de 278 casos de accidentes cerebrovasculares en mujeres internadas en el Hospital General Nacional Arzobispo Loayza / A retrospective review of 278 cases of strokes in internal women in the Hospital General Nacional Arzobispo Loayza (Lima-Perú)

El presente estudio es una revisión retrospectiva de 278 casos de accidentes cerebrovasculares en mujeres internas en el Hospital General Nacional Arzobispo Loayza entre los años 1983-1988. Tiene como objetivo el incentivar el interés de los médicos en general, y no sólo de los neurólogos, en el conocimiento de los accidentes cerebrovasculares, patología de manejo frecuente en nuestro ambiente hospitalario. En nuestro trabajo hemos hallado una incidencia hospitalaria de accidentes cerebrovasculares de 6/1000 casos en población femenina. El 79.5 por ciento de los diagnósticados fue clínico. El 64.4 por ciento de las pacientes presentó complicaciones médicas durante su hospitalización. las más frecuentes fueron las infecciones del tracto urinario (37.1 por ciento), las neumonías aspirativas (29.1 por ciento) y las sepsis (13.3 por ciento). La letalidad general hospitalaria fue de 34.9 por ciento. El 59.6 por ciento de los cuáles falleció durante la primera semana de hospitalización. Clínicamente el enclavamiento por hipertensión endocraneana (40.2 por ciento) y la sepsis (34.0 por ciento) fueron las 2 causas de muerte más frecuentes. El 44.2 por ciento de los pacientes que sobrevivieron fue dado de alta con algún déficit neurológico. Los más frecuentes fueron los motores puros (19.9 por ciento) y los combinados con disartria (13.8 por ciento)