Condroma pulmonar y paraganglioma carotídeo como manifestaciones de la tríada de Carney: reporte de un caso / Pulmonary chondroma and carotid paraganglioma as expressions of Carney's triad: report of a case

Resumen Objetivos: Presentar caso clínico y revisión de la literatura sobre asociación de tumores poco frecuentes compatibles con diagnóstico de tríada de Carney. Paciente y Métodos: Revisión de ficha clínica de paciente de sexo femenino de 39 años de edad con antecedentes de asma, quien acude a servicio de urgencias por síntomas respiratorios. En estudio con imágenes se evidencia masa pulmonar en lóbulo superior derecho probablemente hamartoma y masa en la bifurcación carotídea izquierda compatible con posible paraganglioma. Se completó el estudio con endoscopia digestiva alta sin evidencia de tumor gástrico y PET-CT (tomografía de emisión de positrones-tomografía computarizada) que descartó otras lesiones. Resultados: La paciente fue sometida a resección quirúrgica de ambos tumores (pulmonar y carotídeo). En estudio histopatológico diferido, se plantean los diagnósticos de paraganglioma carotideo y hamartoma pulmonar, el cual, luego de una segunda revisión histopatológica, es corregido a condroma pulmonar. Discusión: La tríada de Carney se compone por la asociación de al menos 2 de 3 tumores: tumor estromal gastrointestinal (GIST), paraganglioma extra-adrenal y condroma pulmonar. Su expresión es variable, coexistiendo en forma completa en solo el 22% de los casos. Conclusión: Los pacientes con sospecha de tríada de Carney deben recibir evaluación multidisciplinaria, estudio completo en búsqueda de tumores asociados y seguimiento a largo plazo por posibles recurrencias o metástasis.

Objective: To present a clinical case and review of the literature on the infrequent association of pulmonary and extra thoracic tumors compatible with Carney's triad. Patient and Methods: Review of clinical records of a 39 years-old female patient with history of asthma who presented in the emergency department with respiratory symptoms. An imaging study showed a pulmonary mass in the right upper lobe with the aspect of hamartoma and a mass in the left carotid artery bifurcation compatible with a possible paraganglioma. Upper gastrointestinal endoscopy showed no evidence of gastric tumor and a PET-CT (Positron Emission Tomography - Computed Tomography) excluded other lesions. Results: Patient underwent surgical resection of both tumors (pulmonary and carotid). Diagnosis of carotid paraganglioma and pulmonary hamartoma were stated by histopathology. However, lung tumor after a second pathological analysis was confirmed to be a pulmonary chondroma. Discussion: Carney's triad is defined by the association of at least 2 of 3 tumors: Gastrointestinal Stromal Tumor (GIST), extraadrenal paraganglioma and pulmonary chondroma. Its expression is variable, coexisting completely in only 22% of cases. Conclusion: Patients with suspected Carney's triad should receive a multidisciplinary assessment, a complete study searching associated tumors and long-term follow-up for recurrences or metastases.

Lesão transfixante de carótida por espinha de peixe - relato de caso / Carotid artery perforation by fish bone - a case report

Abstract Accidental fish bone ingestion is a common complaint at emergency departments. The majority of cases have a benign course. However, serious complications such as esophagus perforation, cervical vessel injury and cervical abscess can occur in 7.4% of cases. Mortality rates can be as high as 50% when mediastinitis occurs. We report a case of an esophageal perforation caused by a fish bone with a lesion to the right common carotid artery after 20 days of evolution. Surgical exploration occurred with corrections of the lesion in the right common carotid and esophagus. Early identification of this kind of injury is paramount to prevent potentially fatal complications.

Abstract Accidental fish bone ingestion is a common complaint at emergency departments. The majority of cases have a benign course. However, serious complications such as esophagus perforation, cervical vessel injury and cervical abscess can occur in 7.4% of cases. Mortality rates can be as high as 50% when mediastinitis occurs. We report a case of an esophageal perforation caused by a fish bone with a lesion to the right common carotid artery after 20 days of evolution. Surgical exploration occurred with corrections of the lesion in the right common carotid and esophagus. Early identification of this kind of injury is paramount to prevent potentially fatal complications.

Carotid artery stenting has similar outcomes in men and women / Implante de stent na artéria carótida tem desfechos semelhantes em homens e mulheres

Abstract Background The aim of carotid interventions is to prevent cerebrovascular events. Endovascular treatment (carotid-artery-stenting/CAS) has become established as an alternative to open surgery in some cases. Historically, female sex has been considered as a perioperative risk factor, however, there are few studies regarding this hypothesis when it comes to CAS. Objectives To analyze the CAS results in our center adjusted by sex. Methods A retrospective cohort study was designed, including patients with carotid atheromatosis operated at a single center from January 2016 to June 2019. Our objective was to compare cardiovascular risk, including myocardial infarction, stroke, and mortality, by sex. Follow-up rates of stent patency, restenosis, stroke, myocardial infarction, and death were reported. Results 71 interventions were performed in 50 men (70.42%) and 21 women (29.57%). Mean age was 70.50 ± 10.72 years for men and 73.62 ± 11.78 years for women. Cardiovascular risk factors did not differ significantly between sexes. Mean follow-up was 11.28 ± 11.28 months. There were no significant differences in neurological events during follow-up. No adverse cardiological events were detected at any time. Regarding the mortality rate, during medium-term follow up there were 2 neurological related deaths with no significant differences between sexes (p=0.8432). Neither sex had higher rated of restenosis during long term follow-up (5.63% vs. 1.41%, p = 0.9693) or reoperation (1.41% vs. 1.41%, p = 0.4971). All procedures remained patent (<50% restenosis). Conclusions Despite the limitations of our study, CAS is a therapeutic option that is as effective and safe in women as in men. No sex differences were observed.

Resumo Contexto As intervenções carotídeas visam prevenir eventos cerebrovasculares. O tratamento endovascular (implante de stent na artéria carótida) se estabeleceu como uma alternativa à cirurgia aberta em alguns casos. Historicamente, o sexo feminino é considerado um fator de risco perioperatório, mas há poucos estudos abordando essa hipótese em casos de stent de carótida. Objetivos Analisar os resultados do CAS em nosso centro ajustados por sexo. Métodos Este estudo de coorte retrospectivo incluiu pacientes com ateromatose carotídea operados em um centro de janeiro de 2016 a junho de 2019. Nosso objetivo foi comparar o risco cardiovascular, incluindo infarto do miocárdio, acidente vascular cerebral e mortalidade, de acordo com o sexo. No seguimento, foram descritos patência do stent, reestenose, acidente vascular cerebral, infarto do miocárdio e morte. Resultados Setenta e uma intervenções foram realizadas: 50 homens (70,42%) e 21 mulheres (29,57%). A média de idade foi de 70,50 ± 10,72 anos nos homens e 73,62 ± 11,78 anos nas mulheres. Os fatores de risco cardiovascular não diferiram significativamente entre os sexos. A média de seguimento foi de 11,28 ± 11,28 meses. Durante o seguimento, não houve diferenças significativas nos eventos neurológicos. Nenhum evento cardiológico adverso foi detectado. Quanto à taxa de mortalidade, durante o seguimento de médio prazo ocorreram 2 óbitos neurológicos sem diferenças significativas entre os sexos (p = 0,8432). Não foi observada maior taxa de reestenose no seguimento de longo prazo (5,63% vs. 1,41%, p = 0,9693) ou de reoperação (1,41% vs. 1,41%, p = 0,4971) ao comparar os dois sexos. Todos os procedimentos permaneceram pérvios (< 50% de reestenose). Conclusões Apesar das limitações deste estudo, o stent de carótida em mulheres é uma opção terapêutica tão eficaz e segura quanto em homens. Nenhuma diferença foi observada entre os sexos.

Correção cirúrgica de fístula carotídeo-jugular traumática / Surgical repair of a traumatic carotid-jugular arteriovenous fistula

Resumo Traumatismos cervicais penetrantes podem ser potencialmente fatais. Em cerca de 25% dos casos, há lesão vascular associada, que pode evoluir para fístulas arteriovenosas. Os autores apresentam um caso de correção tardia, por cirurgia aberta, de uma fístula carotídeo-jugular e fazem uma breve revisão sobre o diagnóstico e opções de tratamento dessa condição.

Abstract Penetrating neck injuries can be life threatening. In about 25% of cases there are vascular injuries, which can progress to formation of arteriovenous fistulas. The authors present a case of delayed open surgery to repair a carotid-jugular fistula and briefly review the diagnosis and treatment options for this condition.

Impact of metabolic syndrome on short-term outcome of carotid revascularization: a large sample size study in Chinese population / 中华医学杂志(英文版)

BACKGROUND@#Metabolic syndrome (MetS) is relatively common worldwide and an important risk factor for cardiovascular diseases. It is closely linked to arterial stiffness of the carotid artery. However, the association of MetS with the safety of carotid revascularization has been rarely studied. The aim of this study was to observe the current status of MetS and its components in Chinese carotid revascularized patients, and investigate the impact on major adverse clinical events (MACEs) after carotid endarterectomy (CEA) or carotid artery stenting (CAS).@*METHODS@#From January 2013 to December 2017, patients undergoing CEA or CAS in the Neurosurgery Department of Xuanwu Hospital were retrospectively recruited. The changes in prevalence of MetS and each component with time were investigated. The primary outcome was 30-day post-operative MACEs. Univariable and multivariable analyses were performed to identify the impact of MetS on CEA or CAS.@*RESULTS@#A total of 2068 patients who underwent CEA (766 cases) or CAS (1302 cases) were included. The rate of MetS was 17.9%; the prevalence rate of MetS increased with time. The occurrence rate of MACEs in CEA was 3.4% (26 cases) and in CAS, 3.1% (40 cases). There was no statistical difference between the two groups (3.4% vs. 3.1%, P = 0.600). For CEA patients, univariate analysis showed that the MACE (+) group had increased diabetes history (53.8% vs. 30.9%, P = 0.014) and MetS (34.6% vs. 15.8%, P = 0.023). For CAS patients, univariate analysis showed that the MACE (+) group had increased coronary artery disease history (40.0% vs. 21.6%, P = 0.006) and internal carotid artery tortuosity (67.5%% vs. 37.6%, P < 0.001). Furthermore, the MACE (+) group had higher systolic blood pressure (143.38 ± 22.74 vs. 135.42 ± 17.17 mmHg, P = 0.004). Multivariable analysis showed that the influencing factors for MACEs in CEA included history of diabetes (odds ratio [OR] = 2.345; 95% confidence interval [CI] = 1.057-5.205; P = 0.036) and MetS (OR = 2.476; 95% CI = 1.065-5.757; P = 0.035). The influencing factors for MACEs in CAS included systolic blood pressure (OR = 1.023; 95% CI = 1.005-1.040; P = 0.010), coronary artery disease (OR = 2.382; 95% CI = 1.237-4.587; P = 0.009) and internal carotid artery tortuosity (OR = 3.221; 95% CI = 1.637-6.337; P = 0.001).@*CONCLUSIONS@#The prevalence rate of MetS increased with time in carotid revascularized patients. MetS is a risk for short-term MACEs after CEA, but not CAS.

Risk-Benefit Assessment of Carotid Revascularization / Avaliação do Risco-Benefício da Revascularização Carotídea

Abstract Severe carotid atherosclerotic disease is responsible for 14% of all strokes, which result in a high rate of morbidity and mortality. In recent years, advances in clinical treatment of cardiovascular diseases have resulted in a significant decrease in mortality due to these causes. To review the main studies on carotid revascularization, evaluating the relationship between risks and benefits of this procedure. The data reviewed show that, for a net benefit, carotid intervention should only be performed in cases of a periprocedural risk of less than 6% in symptomatic patients. The medical therapy significantly reduced the revascularization net benefit ratio for stroke prevention in asymptomatic patients. Real life registries indicate that carotid stenting is associated with a greater periprocedural risk. The operator annual procedure volume and patient age has an important influence in the rate of stroke and death after carotid stenting. Symptomatic patients have a higher incidence of death and stroke after the procedure. Revascularization has the greatest benefit in the first weeks of the event. There is a discrepancy in the scientific literature about carotid revascularization and/or clinical treatment, both in primary and secondary prevention of patients with carotid artery injury. The identification of patients who will really benefit is a dynamic process subject to constant review.

Resumo A doença aterosclerótica carotídea grave é responsável por 14% de todos os acidentes vasculares cerebrais (AVC), que refletem em uma alta taxa de morbimortalidade. Nos últimos anos, os avanços no tratamento clínico das doenças cardiovasculares geraram um decréscimo importante na mortalidade por estas causas. Revisar principais estudos que dizem respeito à revascularização carotídea avaliando a relação entre risco e beneficio deste procedimento. Os dados encontrados indicam que o procedimento só deve ser realizado se houver um risco periprocedimento menor que 6% em pacientes sintomáticos para que haja beneficio líquido na intervenção carotídea. O tratamento clínico reduziu significativamente o benefício líquido da revascularização na prevenção de AVC em pacientes assintomáticos. Registros que refletem a prática diária demonstram que a angioplastia carotídea esta associada a um risco periprocedimento mais elevado. O volume anual de procedimentos por operador e a idade dos pacientes têm uma importante influência nas taxas de AVC e morte pós angioplastia. Pacientes sintomáticos têm uma maior incidência de AVC e morte após procedimento. A revascularização tem o maior benefício nas primeiras semanas do evento. Existem discrepâncias na literatura científica com relação à revascularização carotídea e/ou tratamento clínico, tanto na prevenção primária quanto secundária de pacientes com lesão carotídea. A identificação do paciente que realmente será beneficiado é um processo dinâmico sujeito a constante revisão.

Caracterización de las variantes quirúrgicas realizadas en dos años a pacientes con enfermedad cerebrovascular extracraneal / Characterization of surgical varians performed in patients with extracranial cerebrovascular diseases in two years

Objetivo: Caracterizar las variantes quirúrgicas realizadas a los pacientes ingresados con enfermedad cerebrovascular extracraneal en un período de dos años. Métodos: Estudio descriptivo prospectivo en 27 pacientes, sin distinción de edad y sexo, operados por enfermedad cerebrovascular de origen extracraneal. Se tuvieron en cuenta los criterios de cirugía, además del estadio clínico, enfermedad cerebrovascular extracraneal que motivó la operación, localización de la lesión carotidea, variantes quirúrgicas realizadas, la permeabilidad de estas y las complicaciones poscirugía. Los pacientes fueron seguidos en consulta externa por dos años. Resultados: Se encontró que el 44,4 por ciento tuvo un ataque transitorio isquémico. Fueron más frecuentes las lesiones unilaterales (85,2 por ciento) y las de la carótida derecha (48,1 por ciento). Se halló una asociación significativa entre el sexo masculino con el estadio clínico y la localización de las lesiones carotideas. La endarterectomía por eversión fue la variante quirúrgica más realizada (44,4 por ciento). El 96,3 por ciento de las intervenciones se mantuvo permeable hasta los 18 meses poscirugía, mientras que tres pacientes presentaron reestenosis a los 24 meses. El 40,7 por ciento no desarrolló complicaciones, y entre estas el sangrado fue la de mayor frecuencia (33 por ciento). Conclusiones: Las variantes quirúrgicas realizadas se caracterizaron por altos porcentajes de permeabilidad durante el tiempo de estudio, con un mínimo de complicaciones posquirúrgicas(AU)

Objective: To characterize the surgical variants performed in hospitalized patients with extracranial cerebrovascular diseases in two years. Methods: Prospective and descriptive study of 27 patients, regardless of age and sex, who had been operated on from cerebrovascular disease of extracranial origin. Surgical criteria, clinical condition, extracranial cerebrovascular disease that required surgery, location of the carotid lesion, surgical variants, their permeability and the post-surgery complications were all taken into account. The patients were followed-up in the outpatient service during two years. Results: It was found that 44.4 percent of patients had had a transient ischemic attack. Unilateral lesions (85.2 percent) and right carotid lesions (48.1 percent) were the most common. Significant association was found between the male sex and the clinical staging and the location of carotid lesions. Eversion endarterectomy was the most performed surgical technique (44.4 percent). In the study, 96.3 percent of operations were kept permeable up to 18 months after the surgery whereas three patients presented with re-stenosis after 24 months. In the study group, 40.7 percent did not develop complications, being bleeding the most frequent one (33 percent). Conclusions: The surgical variants performed in the study time were characterized by high percentages of permeability and minimal postsurgical complications(AU)

Experimental study of histological changes in vascular loops according to the duration of the postoperative period: Application in reconstructive microsurgery

OBJECTIVES: To analyze the histological changes observed in venous grafts subjected to arterial blood flow as a function of the duration of the postoperative period to optimize their use in free flap reconstructions. METHOD: Twenty-five rats (7 females and 18 males) underwent surgery. Surgeries were performed on one animal per week. Five weeks after the first surgery, the same five animals were subjected to an additional surgery to assess the presence or absence of blood flow through the vascular loop, and samples were collected for histological analysis. This cycle was performed five times. RESULTS: Of the rats euthanized four to five weeks after the first surgery, no blood flow was observed through the graft in 80% of the cases. In the group euthanized three weeks after the first surgery, no blood flow was observed in 20% of the cases. In the groups euthanized one to two weeks after the first surgery, blood flow through the vascular loop was observed in all animals. Moreover, intimal proliferation tended to increase with the duration of the postoperative period. Two weeks after surgery, intimal proliferation increased slightly, whereas strong intimal proliferation was observed in all rats evaluated five weeks after surgery. CONCLUSION: Intimal proliferation was the most significant change noted in venous grafts as a function of the duration of the postoperative period and was directly correlated with graft occlusion. In cases in which vascular loops are required during free flap reconstruction, both procedures should preferably be performed during the same surgery.

Trombo móvel na carótida interna: planejamento cirúrgico definido pela ultrassonografia vascular / Floating thrombus in the internal carotid artery: surgical planning defined by vascular ultrasound / Trombo Móvil en la Carótida Interna: Planeamiento Quirúrgico Definido por la Ultrasonografía Vascular

Os principais objetivos para o relato deste caso foram: Enfatizar a importância do diagnóstico ultrassonográfico de um trombo móvel na carótida interna, responsável pelo acidente vascular de um paciente atendido no setor de emergência e descrever uma nova técnica de imagem futurística, denominada Caracterização Tecidual Ultrassonográfica (CATUS). A CATUS tem a finalidade de avaliar e estimar a composição do trombo, a sua aderência na parede arterial e o risco de embolização relacionado em potencial com a gravidade de sintomas cerebrovasculares. A demonstração ultrassonográfica do trombo móvel foi o fator determinante para o planejamento cirúrgico e a endarterectomia confirmou a presença do material trombótico.

The objectives of this case report were: to emphasize the importance of the ultrasonographic diagnosis of a floating thrombus in the internal carotid artery, linked to a stroke on a pacient seen in the emergency room, and to describe a new visionary imaging technique, ultrasonographic tissue characterization (USTC), designed toevaluate and estimate the thrombus composition, it’s adherence to the vascular walland embolization risk. Ultrasonographic demonstration of a embolus was determinant factor for surgical planning. Presence of the thombus was confirmed during carotidendarterectomy.

Los principales objetivos para el relato de este caso fueron: Enfatizar la importancia del diagnóstico ultrasonográfico de un trombo móvil en la carótida interna, responsable por el accidente vascular de un paciente atendido en el sector de emergencia y describir una nueva técnica de imagen futurista, denominada Caracterización del Tejido Ultrasonográfica (CATUS). La CATUS tiene la finalidad de evaluar y calcular la composición del trombo, su adherencia en la pared arterial y el riesgo de embolización relacionado en potencia con la gravedad de síntomas cerebrovasculares. La demostración ultrasonográfica del trombo móvil fue el factor determinante para la planificación quirúrgica y la endarterectomía confirmó la presencia del material trombótico.

Implante percutâneo de stent em artérias carótidas e vertebrais: dados do REMAT (Registro Madre Teresa) / Carotid and vertebral artery stenting: REMAT data (Madre Teresa Registry)

INTRODUÇÃO: O acidente vascular encefálico (AVE) é a principal causa de morbidade e mortalidade no Brasil. Entre 10% e 30% dos AVEs estão associados à doença carotídea e 8%, à artéria vertebral. O tratamento endovascular das lesões extracrania­nas é alternativa à endarterectomia. Analisamos os resultados e avaliamos os preditores de eventos adversos em pacientes submetidos a angioplastia carotídea e vertebral com implante de stents. MÉTODOS: Incluídos assintomáticos com lesão > 70% ou sintomáticos com lesão > 50% em artérias carótidas e sintomáticos com lesão > 70% em artérias vertebrais. Avaliamos desfecho primário, definido como a incidência combinada de morte relacionada ou não ao procedimento, AVE maior, AVE menor ou infarto agudo do miocárdio (IAM). RESULTADOS: Realizadas 224 intervenções com implante de stents em 199 pacientes consecutivos, com predomínio do sexo masculino (73,9%), idade de 69,8 ± 9,9 anos e 37,7% eram diabéticos. Pacientes sintomáticos representaram cerca de dois terços dos casos e as lesões mais tratadas foram as lesões de novo (96,4%). As artérias carótidas internas esquerda (46%) e direita (44,6%) foram os vasos mais abordados. Desfecho combinado primário ocorreu em 5%, mortalidade relacionada ao procedimento em 1%, mortalidade não-relacionada ao procedimento em 1%, AVE menor em 1,5% e IAM em 1,5%. Pacientes com antecedente de doença arterial coronária mostraram chance de apresentar desfecho primário 4 vezes maior [odds ratio (OR) 4,32, intervalo de confiança de 95% (IC 95%) 1,09-17,21; P = 0,038]. CONCLUSÕES: Em nosso estudo obtivemos alto índice de sucesso e baixa ocorrência de eventos adversos, que demonstram a segurança e a eficácia do implante percutâneo de stent em artérias carótidas e vertebrais.

BACKGROUND: Stroke remains the leading cause of morbidity and mortality in Brazil. Epidemiological data suggest that 10% to 30% of all strokes are due to atherosclerotic carotid artery disease and 8% due to vertebral artery disease. Endovascular treatment of extracranial lesions is an alternative to endarterectomy. We evaluated the results and predictors of adverse events in patients undergoing carotid and vertebral artery stenting. METHODS: Asymptomatic patients with lesion > 70% or symptomatic patients with lesions > 50% in carotid arteries and symptomatic patients with lesion > 70% in vertebral arteries were included. We evaluated the primary endpoint, defined as the composite incidence of death (procedural or non-procedural), major stroke, minor stroke or myocardial infarction (MI). RESULTS: Two hundred and twenty-four interventions with stenting were performed in 199 consecutive patients with a prevalence of males (73.9%), 69.8 ± 9.9 years of age and 37.7% were diabetics. Symptomatic patients represented about two thirds of the cases and the most commonly treated lesions were de novo lesions (96.4%). The left (46%) and right (44.6%) internal carotid arteries were the most commonly approached vessels. Composite primary endpoint was observed in 5% of the patients, procedure-related mortality in 1%, non-procedure related mortality in 1%, minor stroke in 1.5% and MI in 1.5%. Patients with a history of coronary artery disease had a 4-fold probability of presenting the primary endpoint [odds ratio (OR) 4.32, 95% confidence interval (CI 95%) 1.09-17.21); P = 0.038]. CONCLUSIONS: In our study we obtained a high success rate and had a low rate of adverse events, demonstrating the safety and efficacy of percutaneous stent implantation in the carotid and vertebral arteries.

Paraganglioma de corpo carotídeo com abaulamento de orofaringe: relato de caso / Carotid body paraganglioma with bulging oropharynx: case report

Os paragangliomas são tumores altamente vascularizados frequentemente benignos e unilaterais. Localizados no corpo carotídeo, predominam no espaço parafaríngeo. O objetivo deste relato é apresentar um caso de paraganglioma de corpo carotídeo unilateral com extensão ao espaço parafaríngeo. Paciente feminina, 66 anos, observou a presença de assimetria na região amigdalina à direita há aproximadamente um ano sem outros sintomas. A oroscopia e a videotelelaringoscopia evidenciaram assimetria da loja amigdalina direita com suspeita de massa expansiva que projetava a amígdala e pilar posterior para a linha média estendendo-se inferiormente até a vertente externa do seio piriforme. No exame do pescoço apresentava à direita extensão da massa para a região júgulo-carotídea (nível II) de consistência aumentada. A suspeita clínica de glomus foi confirmada por estudo tomográfico computadorizado contrastado do pescoço, ressonância nuclear magnética e angiorressonância de vasos cervicais que definiram uma lesão ovalada com 5X4X6 cm, na topografia do espaço carotídeo direito, deslocando a artéria carótida externa e interna na região do bulbo carotídeo, hipervascularizada, com extensão ao espaço parafaríngeo e sugestiva de paraganglioma carotídeo. O tratamento indicado foi a ressecção cirúrgica sem a realização de embolização prévia. O paraganglioma carotídeo é um tumor raro e de crescimento lento que acomete a região júgulo-carotídea. A extensão parafaríngea é rara e deve estar no diagnóstico diferencial das patologias do espaço parafaríngeo (AU)

Paragangliomas are highly vascularized tumors often benign and unilaterais. Located in the carotid body, they predominate within parafaringeo space. The aim of tyhis repor was to describe a case of unilateral carotid body paraganglioma extending into space parafaríngeo. A female, 66 years-old patient noted the presence of asymmetry in the tonsillar region right about 1 year without other symptoms symptoms. Oroscopy and videotelelaryngoscopy showed asymmetry in right tonsillar store with suspected expansive mass that projected the amygdala and posterior pillar to the middle line extending inferiorly to the lateral aspect of the piriform sinus. On examination of the neck showed right extension of mass for jugular-carotid region (level II) consistency increased. A clinical suspicion of glomus was confirmed by computerized tomography scan study contrasted neck, magnetic resonance imaging and Magnetic resonance angiography of the cervical vessels that defined an injury with oval 5X4X6cm, the topography of the right carotid space shifting the external carotid artery and the internal carotid bulb hypervascular region, extending to the parapharyngeal space and suggestive of carotid paraganglioma. The treatment indication was surgical resection without performing previous embolization. The carotid paraganglioma is a rare tumor and growth slow that affects the jugular-carotid region. The parapharyngeal extension is rare and should be in the differential diagnosis of parapharyngeal space (AU)

The Influence of Anti-Platelet Resistance on the Development of Cerebral Ischemic Lesion after Carotid Artery Stenting

PURPOSE: Cerebral ischemic lesions are frequently observed after carotid artery stenting (CAS), and anti-platelet agents are used to prevent stent thrombosis and peri-procedural complications. However, despite the premedication, cerebral ischemic lesions are observed, suggesting that they may rather be related to anti-platelet resistance. We, therefore, investigated the effects of anti-platelet resistance on the development of cerebral ischemic lesions after CAS. MATERIALS AND METHODS: We retrospectively reviewed patients who received CAS and selected patients for whom brain MRI was performed within 24 hours after CAS and for whom anti-platelet resistance was checked. Anti-platelet resistance was examined by the VerifyNow system. We analyzed the correlation between anti-platelet resistance and cerebral ischemic lesions detected on follow-up MRI. RESULTS: Among 76 patients, 45 (59.2%) developed new ischemic lesions after CAS. Twelve (15.8%) patients showed aspirin resistance and 50 (65.8%) patients showed clopidogrel resistance. Patients with a new ischemic lesion demonstrated a significantly greater frequency of clopidogrel resistance than those who had no new ischemic lesion (82.2% versus 41.9%, p=0.001). The frequency of aspirin resistance was not significantly different between the groups of patients with and without new ischemic lesions (20.0% versus 9.7%, p=0.340). In multivariate analysis, clopidogrel resistance was a significant risk factor for post-procedural cerebral ischemia. CONCLUSION: Anti-platelet resistance can be used to predict new ischemic lesions after CAS. Anti-platelet resistance should be evaluated in all patients prior to CAS to prevent ischemic complications related to CAS.

Hemodynamic Instability during Carotid Angioplasty and Stenting-Relationship of Calcified Plaque and Its Characteristics

PURPOSE: During carotid angioplasty and stenting (CAS), hemodynamic instability (HDI) can occur, possibly causing post-procedural ischemic complications. The goal of this study was to investigate the risk factors of HDI focusing on characteristics of plaque. MATERIALS AND METHODS: Thirty nine CAS patients were retrospectively evaluated for HDI. Prolonged HDI that lasted over 30 minutes was analyzed in relation to characteristics of calcified plaque. RESULTS: Nineteen (48.7%) patients had HDI. Ten of the 19 had both bradycardia and hypotension, and nine had only bradycardia. All bradycardia was treated well with a transcutaneous temporary cardiac pacemaker. But eight patients presented with prolonged hypotension in spite of recovery of bradycardia. Calcified plaque was a related factor associated with HDI (odds ratio, 8.571; 95% confidence interval, 1.321-55.62; p=0.024). Extensive and eccentric type calcified plaques were associated with prolonged hypotension (p=0.04, and p=0.028, respectively). CONCLUSION: The calcification of plaque is a predictable factor of HDI during CAS, and its extensive and eccentric calcified plaques may be related to prolonged HDI.

Colocación de stents vs. endarterectomía para enfermedades carotídeas. Resultados del Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) / Stenting vs. endarterectomy for carotid disease. Results of the carotid revascularization endarterectomy vs. stenting trial (CREST) / Colocação de stent vs. Endarterectomia para doença arterial carotídea. Resultados do carotid revascularization endarterectomy vs. Stenting trial (crest)

Antecedentes y objetivos: La estenosis de la arteria carótida causa hasta el 10% de todos los ataques cerebrovasculares isquémicos. La endarterectomía carotídea (CEA) se presentó como tratamiento para prevenir los ataques cerebrovasculares en los comienzos de 1950. La colocación del stent carotídeo (CAS) fue presentada como tratamiento para prevenir el ataque cerebrovascularen 1994. Métodos: CREST es un estudio randomizado con adjudicación completamente ciega. Tanto los pacientes sintomáticos como los asintomáticos fueron randomizados a CAS o CEA. El objetivo final primario fue la combinación de cualquier accidente cerebrovascular, de infarto de miocardioo bien de fallecimiento durante el período periprocedimiento y de accidente cerebrovascular ipsilateral después de 4 años. Resultados: No existió una diferencia significativa en los promedios del objetivo final entre CASy CEA (7.2% vs. 6.8%; HR=1.11; 95% CI, 0.81-1.51; P=0.51). Tanto el estado sintomático como el sexo de los pacientes no modificaron el efecto del tratamiento, pero si se detectó una interacción entre la edad y el tratamiento. Los resultados fueron levemente mejores con CAS, en aquellos pacientes menores de 70 años, mientras que para los pacientes mayores a 70 años fue mejor para aquellos pacientes con CEA. El objetivo final periprocedimiento no difería entre CAS y CEA, pero existían diferencias en los componentes CAS vs. CEA (ataques cerebrovasculares 4.1% vs. 2.3%, P=0.012; y el infarto de miocardio 1.1% vs. 2.3%, P=0.032). Conclusiones: En el CREST, el objetivo final primario tanto en CAS como en CREST, tuvo similares síntomas a corto como a largo plazo. Durante el período periprocedimiento, existía mayor riesgo de ataque cerebrovascular con CAS mientras que con CEA existía un riesgo mayor de infarto de miocardio.

Antecedentes e objetivos: A estenose arterial carotídea é causa de aproximadamente 10% de todos os acidentes cerebrovasculares isquêmicos. A endarterectomia carotídea (CEA) se apresentou como tratamento para prevenir os acidentes cerebrovasculares no início dos anos 50. A colocação do stent carotídeo (CAS) foi apresentada como um tratamento para prevenir o acidente cerebrovascular em 1994. Métodos: O estudo CREST foi um ensaio clínico randomizado completamente cego. Tantoos pacientes sintomáticos quanto os assintomáticos foram randomizados CAS ou randomizados CEA. O objetivo final primário foi a combinação de qualquer acidente cerebrovascular, de infarto do miocárdio ou inclusive de óbito durante o período periprocedimento e de acidente cerebrovascular ipsilateral depois de 4 anos. Resultados: Não foi demonstrada uma diferença significativa nas médias do objetivo final entre CAS e CEA (7.2% vs. 6.8%; HR=1.11; 95% CI, 0.81-1.51; P=0.51). Tanto o estado sintomático quanto o sexo dos pacientes não modificaram o efeito do tratamento, porém, detectou-se uma interação entre a idade e o tratamento. Os resultados foram levemente melhores com CAS nos pacientes menores de 70 anos, enquanto que para os pacientes maiores de 70 anos foi melhor com CEA. O objetivo final periprocedimento não diferia entre CAS e CEA, mas existiam diferenças nos componentes CAS vs. CEA (acidentes cerebrovasculares 4.1% vs. 2.3%, P=0.012; e o infarto do miocárdio 1.1% vs. 2.3%, P=0.032). Conclusões: No estudo CREST, o objetivo final primário tanto em CAS quanto em CREST, apresentou similares sintomas tanto a curto como a longo prazo. Durante o período periprocedimento, existia maior risco de acidente cerebrovascular com CAS enquanto que com CEA existia um risco maior de infarto do miocárdio.

Background and purpose: Carotid artery stenosis causes 10% of all ischemic cerebrovascular attacks. Carotid endarterectomy (CEA) was introduced as the treatment to prevent strokes in the beginning of the 50´s. The placement of a carotid stents (CAS) was introduced as a treatment to prevent strokes in 1994. Method: CREST is a randomized study with complete blind randomization. Both symptomatic and asymptomatic patients were randomized to CAS or CEA. The primary outcome was the combination of the prevention of stroke, myocardial infarction or death during the periprocedural period or ipsilateral stroke after 4 years. Results: There were no significant differences in the mean final outcome between CAS andCEA (7.2% vs. 6.8%; HR=1.11; 95% CI, 0.81-1.51; P=0.51). Both being symptomatic as well as the gender of the patients did not modify the treatment effect, but there was a relationship between age and treatment. The results were slightly better with CAS in patients under 70 years old, while in patients over 70 years old the results were better with CEA. The final peri-procedural outcome did not differ between CAS and CEA but there were differences in the CAS vs CEA components (stroke 4.1% vs. 2.3%, P=0.012; and myocardial infarction 1.1% vs. 2.3%, P=0.032). Conclusions: In the CREST study, with regards to the primary end point both CAS and CEA had similar short-term symptoms. During the peri-procedural period in patients undergoing CAS there was a higher risk of stroke while patients undergoing CEA presented a higher risk of myocardial infarction.

Protective Effect of Hypoxic Preconditioning on Hypoxic-Ischemic Injured Newborn Rats

Brief episodes of cerebral hypoxia-ischemia cause transient ischemic tolerance to subsequent ischemic events that are otherwise lethal. This study was conducted to evaluate the protective effect of hypoxic preconditioning on hypoxic-ischemic injury in the neonatal rat and the persistence of a protective window after hypoxic preconditioning. The rats were preconditioned with hypoxia (8% oxygen, 92% nitrogen) for three hours, subjected to ischemia using ligation of the right common carotid artery, and then exposed to another three hours of hypoxia. Using proton magnetic resonance spectroscopy, terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling (TUNEL) staining, and morphologic scores, this study shows that hypoxic preconditioning 6-hr to 1-day before hypoxic-ischemic injury increases survival rates and has neuroprotective effects against subsequent hypoxic-ischemic injury. The mechanism of the protective effects of hypoxic preconditioning in the newborn rat brain may involve downregulation of apoptotic cell death.

El género femenino como factor predictivo en los resultados de la endarterectomía carotídea / Female gender as a predictive factor in the outcome of carotid endarterectomy

Introducción: Existe evidencia contradictoria acerca del beneficio de la endarterectomía carotídea (EC) en la mujer. Objetivo: Evaluar si el género femenino afecta los resultados inmediatos y alejados de la EC. Material y método: Estudio retrospectivo de 346 EC realizadas entre Enero de 1990 y Julio de 2008 en el Hospital Guillermo Grant Benavente de Concepción. Del total, 137 EC fueron realizadas en mujeres. Como grupo control se consideró a los hombres operados en el mismo período, quienes presentaron características demográficas y otras variables potencialmente adversas en proporción similar a las mujeres. Todas las variables se analizaron en un estudio bivariado y multivariado. Se comparó la morbimortalidad operatoria AVC/muerte), la sobrevida global a 5 y 10 años, el intervalo libre de eventos neurológicos y de reestenosis a 5 años. Se utilizó el método de Kapplan-Meier para la sobrevida actuarial, el Test de Log Rank y Chi Cuadrado para la significación estadística y la regresión logística (Backward Stepwise) para el análisis multivariado. Los resultados alejados se expresan en sobrevida promedio + error estándar. Resultados: El género femenino no mostró ser una variable independiente negativa para los resultados de la EC. La incidencia de AVC/muerte en las mujeres fue 1,5 por ciento.(hombres: 1,4 por ciento) (p= NS). La sobrevida global a 5 y 10 años fue 82,5 por ciento +/- 4,1 y 49,7 por ciento +/- 9,7, respectivamente (hombres: 73,5por ciento + 4,0 y 45 por ciento +/- 7,8) (p= NS). A 5 años, el intervalo libre de eventos neurológicos fue 97 por ciento +/- 1,8 (hombres: 98,3 por ciento +/- 1,0) (p= NS) y el de reestenosis fue 93,9 por ciento +/- 3,6 (hombres: 98,5 por ciento +/- 1,1) (p= NS). Conclusión: El género femenino no afecta los resultados de la EC por lo que no se debe considerar un factor predictivo adverso.

Background: The benefits of carotid endarterectomy (CE) in women have been questioned Aim: to evaluate whether female gender influences the results of CE Methods: 346 procedures of CE performed between January 1990 and July 2008 at Hospital Guillermo Grant Benavente in Concepcion were restrospectively analyzed. 137 CE were performed in women. Demographic characteristics were similar between males and females. A university and multi variate analysis including other adverse factors influencing the results of surgery was performed. Operative morbidity and mortality, global survival, neurologic events free survival and the re stenosis rate at 5 years were analyzed. Actuarial survival was analyzed by the Kapplan-Meir procedure using the Log-rank and Chi square tests; Backward stepwise logistic regression was used in multivariate analysis. Results: Female gender was not found to be an independent risk factor for poorer outcomes of CE. Stroke plus total death in woman was 1,5 percent, versus 1,4 percent in man (P=NS). Survival in woman at 5 and 10 years was 82,5 percent +/- 4,1 and 49,7 percent +/- 9,7, respectively, whereas in man it was 73,5 percent +/- 4,0 and 45 percent +/- 7,8) (p NS). At 5 years follow-up 97 percent +/- 1,8 of woman versus 98,3 percent +/- 1,0 of men were free of neurological events; free of having restenosis were 93,9 percent +/- 3,6 of woman versus 98,5 percent +/- 1,1 of man (p= NS). Conclusion: female gender did not result in poorer results following CE and, therefore, should not be considered an adverse predictive factor for this surgical procedure.