Actualización sobre el síndrome de Eagle y sus complicaciones neurocardiológicas: casos clínicos / An update on Eagle´s syndrome and its neuro-cardiological complications: clinical cases

El síndrome de Eagle o síndrome estilohioideo o sín-drome de la arteria carótida es un trastorno que se origina por la mineralización y elongación del pro-ceso estiloides. Factores traumáticos agudos y cró-nicos, así como otras teorías, han sido propuestos para explicar la etiología y patogenia de esta altera-ción. El conjunto de síntomas puede incluir: dolor fa-ríngeo, odinofagia, disfagia, cefalea, con irradiación a oreja y zona cervical. Si bien existen varias clasifi-caciones, de manera universal se acepta que existen principalmente dos formas de presentación de esta patología: el tipo I o clásico, generalmente asociado a un trauma faríngeo y acompañado de dolor en la zona faríngea y cervical, y el tipo II o carotídeo, que sue-le presentar molestia cervical, cefalea y alteración de la presión arterial, con riesgo de daño de la ac-tividad cardíaca. La identificación de este síndrome suele ser confusa dada la similitud de los síntomas con otras afecciones. El diagnóstico debe realizarse en base a los síntomas y a los estudios por imágenes específicos. El tratamiento puede ser conservador y actuar simplemente sobre los síntomas, o bien, qui-rúrgico. El objetivo del presente trabajo es realizar una revisión actualizada de la literatura sobre el sín-drome de Eagle y presentar tres casos clínicos con distintas manifestaciones (AU)

Eagle's syndrome or styloid syndrome or stylo-carotid artery syndrome is a disease caused by mineralization and elongation of the styloid process. Acute and chronic traumatic factors, along with other hypothesis, have been proposed to explain the aetiology and pathogenesis of this condition. Symptoms can include: pharynx pain, odynophagia, dysphagia, headache, with radiating pain to the ear and neck. Despite there are several classifications, it is universally accepted that this pathology can present in two forms: the type I or classic, generally associated to tonsillar trauma and characterized by pharyngeal and neck pain, and the type II or carotid artery type, which frequently presents with neck pain, headache, blood pressure variation, with risk of damage to cardiac function. Identifying of Eagle's syndrome is often confusing because some symptoms are shared with other pathologies. Diagnosis must be made on the basis of symptoms and imaging studies. Treatment can be conservative, acting only on symptoms, or surgical. The aim of this paper is to provide an updated review of the literature on Eagle syndrome and to present three clinical cases with different manifestations (AU)

Manifestações oftalmológicas em paciente com aneurisma gigante de carótida interna / Ophthalmological manifestation in patient with gigantic aneurysm of the internal carotid

RESUMO Os aneurismas intracranianos são dilatações em segmentos arteriais que irrigam o sistema nervoso central. Acometem 2% da população e as alterações oftalmológicas podem ser as primeiras manifestações do quadro. O objetivo deste relato foi descrever um caso de aneurisma de artéria carótida interna que cursou com restrição da movimentação ocular, alteração do reflexo fotomotor, ptose palpebral, dor facial e cervical. O diagnóstico foi confirmado pela identificação do aneurisma por meio do exame de angiografia cerebral. Foi realizado teste de oclusão por balão, cujo resultado positivo possibilitou a oclusão total da artéria carótida interna por meio de ligadura cirúrgica, procedimento este realizado com sucesso.

ABSTRACT Intracranial aneurysms are dilations in segments of the arteries that irrigate the central nervous system. They affect 2% of the population and the ophthalmologic disorders may be the first evidence in the clinical examination. The aim of the report is to describe a case of an internal carotid artery aneurysm that showed restrictions of ocular movements, change of pupillary light reflex, palpebral ptosis, facial, and cervical pain. This diagnosis was confirmed by the identification of the aneurysm through angiography. A balloon occlusion test was performed, and its positive result made a complete occlusion of the Internal Carotid Artery possible through surgery ligation, procedure that was successful.

Prevalencia de lesiones ateroscleróticas carotídeas en radiografía panorámica y su relación con factores de riesgo cardiovascular en brasileños / Prevalence of atherosclerotic carotid lesions on panoramic radiography and relationship with cardiovascular risk factors in Brazilians

RESUMEN: Aunque la radiografía panorámica no es una prueba de diagnóstico inicial para detectar la aterosclerosis carotídea, no podemos ignorar su valor al ver estas lesiones como hallazgos incidentales que pueden ser grandes aliados en el diagnóstico temprano y la prevención de eventos vasculares graves. El objetivo de este estudio fue evaluar la prevalencia de calcificaciones en la bifurcación de la arteria carótida en las radiografías panorámicas de rutina como principio diagnóstico, así como su relación con los factores de riesgo cardiovascular en individuos brasileños. Se analizaron 449 exámenes de radiografía panorámica de la base de datos del Departamento de Radiología de la Facultad de Odontología de Piracicaba, UNICAMP, São Paulo, Brasil. Después de obtener mediciones de la presión arterial e información sobre el tabaquismo y las enfermedades sistémicas, fue buscado en la radiografía panorámica la presencia o ausencia de la masa radiopaca en las regiones de las vértebras cervicales C3-C4. En el caso de una imagen sugestiva de ateroma, se realizó una radiografía anteroposterior para confirmar el diagnóstico. Aplicamos la prueba estadística de Chi-cuadrado con distribución normal y muestras independientes y aleatorias con un intervalo de confianza del 95 %. La confirmación de calcificaciones carotideas se produjo en el 8,5 % de la población de estudio (38 casos). No encontramos ninguna relación entre la presencia de calcificaciones con el tabaquismo, con el sexo o con datos previos de antecedentes familiares. Sin embargo 49,1 % de los casos estaban por encima de sesenta años y tenía asociación significativa con la hipertensión (P = 0,006). El mayor riesgo se presenta en pacientes ancianos hipertensos y, por lo tanto, hacemos hincapié en la importancia de una observación minuciosa de las radiografías panorámicas en la búsqueda de cualquier alteración de la anatomía normal y si es así, proceder con la derivación lo antes posible para un diagnóstico concluyente por parte de un especialista, pudiendo así ayudar en la prevención de episodios vasculares graves.

SUMMARY: Although panoramic radiography is not an initial diagnostic test for detecting carotid atherosclerosis, we cannot ignore its value in viewing these lesions as incidental findings that can be great allies in early diagnosis and prevention of serious vascular events. The aim was to evaluate the prevalence of calcifications in the bifurcation of the carotid artery on routine panoramic radiographs as a diagnostic principle, as well as its relationship with cardiovascular risk factors in Brazilians. We analyzed 449 panoramic radiography exams from the database of the Department of Radiology of the Faculty of Dentistry of Piracicaba, UNICAMP, São Paulo, Brazil. After obtaining blood pressure measurements and information on smoking and systemic diseases, the researcher observed on the panoramic radiograph, the presence or absence of the radiopaque mass in the regions of the cervical vertebrae C3-C4. In the case of a suggestive image of atheroma, an anteroposterior radiography was performed to confirm the diagnosis. The Chi-square test of normal distribution for independent and random samples with a 95 % confidence interval was applied to the data. Confirmation of carotid calcifications occurred in 8.5 % of the study population (38 cases). We did not find any relationship between the presence of calcifications with smoking, sex or previous family history. However, 49.1 % of cases occurred above sixty years old and there was a significant relationship with hypertension (P = 0.006). The greatest risk was presented in elderly and hypertensive patients, so we highlight the importance of a thorough observation by the dentist of panoramic radiographs to detect any alteration of the normal anatomy and in the positive case, proceed with the referral as soon as possible for a conclusive diagnosis by a specialist, being able to thus assist in the prevention of severe vascular episodes.

Carotid plaque is a predictor of major adverse cardiac and cerebrovascular events in patients undergoing coronary angiography / La presencia de placa carotídea es predictor de eventos adversos cardiacos y cerebrovasculares en sujetos sometidos a coronariografía

Abstract Introduction: Carotid disease, measured as carotid intima-media thickness (CIMT) and carotid plaque (CP), is associated with major adverse cardiac and cerebrovascular events (MACCE) in people without the previous atherosclerotic disease; however, there are few published data in patients undergoing coronary angiography. The aim of the study is to determinate if the carotid disease is associated with MACCE after coronary angiography. Methods: A total of 390 consecutive patients underwent coronary angiography after exercise echocardiography and carotid ultrasonography between 2002 and 2013. MACCE was defined as stroke, myocardial infarction due to atherosclerosis progression or death due to a stroke or cardiac event. Results: Two patients were lost (0.5%). During a mean follow-up of 6.0 years (standard deviation of 2.9), 52 patients (13.4%) suffered MACCE. 1, 5, and 10 years, event-free survival was 96.4% (1.0), 88.7% (1.7), and 81.4% (2.8), respectively. Event rates at 10 years were higher in the CP group (23.2% vs. 10.2%, p = 0.013) and in the CIMT > 0.9 mm group (25.9% vs. 13.3%, p = 0.023). Multivariate analysis showed smoking habit (hazard ratio [HR] 2.51, 95% confidence interval [CI] 1.36-4.62, p = 0.003), glomerular filtration rate (HR 0.98, 95% CI 0.98-0.99), aortic stenosis (HR 2.99, 95% CI 1.24-7.21, p = 0.014), incomplete/no coronary revascularization (HR 1.97, 95% CI 1.06-3.67, p = 0.033), insulin treatment (HR 2.63, 95% CI 1.30-5.31, p = 0.006), and CP (HR 2.36, 95% CI 1.02-5.44, p = 0.044) as predictors of MACCE. Conclusions: CP is an independent predictor of MACCE in patients undergoing coronary angiography.

Resumen La enfermedad carotídea, definida como grosor de íntima media (GIMC) y placa (PC), se asocia con eventos adversos cardiacos y cerebrovasculares (EACC) en sujetos sin aterosclerosis previa; sin embargo hay pocos datos en pacientes sometidos a coronariografía. El objetivo del estudio es determinar si la enfermedad carotídea se asocia a EACC en pacientes remitidos a coronariografía Métodos: Entre 2002 y 2013 390 pacientes fueron sometidos a coronariografía tras ecocardiograma de esfuerzo y ecografía carotídea. Se definió EACC como accidente cerebrovascular, infarto de miocardio por progresión aterosclerótica o muerte por accidente cerebrovascular o causa cardiaca. Resultados: Durante un seguimiento medio de 6 años (desviación estándar 2, 9) se registraron 2 pérdidas y 52 eventos (13,4%). La supervivencia media libre de eventos a uno, cinco y diez años fue 96.4% (1.0), 88.7% (1.7) y 81.4% (2.8). Hubo mayor número de eventos a 10 años en el grupo de PC (23.2% frente 10.2%, p = 0.013) y GIMC > 0.9 mm (25,9% frente 13.3%, p = 0.023). En el análisis multivariado los predictores de EACC fueron tabaquismo (hazard ratio [HR] 2.51, intervalo de confianza [IC] al 95% 1.36-4.62, p = 0.003), filtrado glomerular renal (HR 0.98 IC95% 0.98-0.99), estenosis aórtica (HR 2.99, IC 95% 1.24-7.21, p = 0.014), revascularización incompleta/no revascularización (HR 1.97, IC 95% 1.06-3.67, p = 0.033), tratamiento con insulina (HR 2.63, IC 95% 1.30-5.31, p = 0.006) y PC (HR 2.36, 95%CI 1.02-5.44, p = 0.044). Conclusiones: La PC es un predictor independiente de EACC en pacientes sometidos a coronariografía.

Correlação entre aterosclerose carotídea e disfunção ventricular esquerda ao ecocardiograma / Correlation between carotid atherosclerosis and left ventricular dysfunction at echocardiography

As doenças cardiovasculares são a maior causa de morbimortalidade no mundo. A prevenção primária, por meio do diagnóstico precoce, é necessária para possibilitar o tratamento adequado e controlar a evolução da doença, reduzindo a mortalidade e os gastos em saúde pública. Correlacionar aterosclerose em artéria carótida (avaliada pelo Eco Doppler) e disfunção ventricular esquerda (avaliada pelo ecocardiograma), além de correlacionar tais achados com o risco cardiovascular dos pacientes estudados. Método: Foram analisados 286 prontuários de pacientes que realizaram os exames Eco Doppler carotídeo e ecocardiograma transtorácico. Os dados analisados foram: presença de placa aterosclerótica e grau de estenose, fração de ejeção do ventrículo esquerdo e presença de alterações contráteis difusas ou segmentares do ventrículo esquerdo. Resultados: Dos 238 laudos de Eco Doppler carotídeo, 18 tinham estenose maior que 70% em artéria carótida e 14 destes apresentavam alteração contrátil do ventrículo esquerdo (p = 0,045). Dos pacientes que tinham risco cardiovascular muito alto, 61 apresentavam estenose em artéria carótida (p < 0,001); 51 pacientes com risco cardiovascular muito alto apresentavam alteração contrátil (p < 0,001). Dos 266 laudos de ecocardiograma, 37 registravam fração de ejeção do ventrículo esquerdo reduzida. Desses, 25 tinham risco cardiovascular muito alto (p < 0,001). Conclusão: Houve relação positiva entre estenose de artéria carótida, redução da fração de ejeção do ventrículo esquerdo e alteração contrátil do ventrículo esquerdo (difusa ou segmentar) com risco cardiovascular muito alto. Também foi possível correlacionar a estenose carotídea com alteração contrátil, apesar deste estudo não demonstrar correlação entre estenose carotídea e redução da fração de ejeção do ventrículo esquerdo

Cardiovascular diseases are the leading cause of morbidity and mortality worldwide. Primary prevention, through early diagnosis, is necessary to enable proper treatment and control disease progression, reducing mortality and public health expenditures. Objective: Correlate carotid artery atherosclerosis (evaluated by Doppler echocardiography) and left ventricular dysfunction (evaluated by echocardiography) and to correlate the findings with the patients' cardiovascular risk. Method: A total of 286 medical records of patients who underwent carotid Doppler echocardiography and transthoracic echocardiography were analyzed. The data analyzed were: presence of atherosclerotic plaque and degree of stenosis, left ventricular ejection fraction and presence of diffuse or segmental left ventricular contractile disorders. Results: Of the 238 reports of carotid Doppler echocardiography, 18 had stenosis greater than 70% in the carotid artery and 14 of those had left ventricular contractile disorders (p = 0.045). Of the patients with very high cardiovascular risk, 61 had carotid artery stenosis (p < 0.001); 51 patients with very high cardiovascular risk had contractile disorders (p < 0.001). Of the 266 echocardiography reports, 37 had reduced left ventricular ejection fraction. Of these, 25 had very high cardiovascular risk (p < 0.001). Conclusion: There was a positive relationship between carotid artery stenosis, reduced left ventricular ejection fraction and left ventricular (diffuse or segmental) contractile disorder with very high cardiovascular risk. It was also possible to correlate carotid stenosis with contractile disorder, although this study did not demonstrate any correlation between carotid stenosis and reduced left ventricular ejection fraction

Carotid intima-media thickness and plaques in internal carotid artery as surrogate markers of lower limb arterial lesions in Chinese patients with diabetic foot

Peripheral arterial disease (PAD) can impair healing of diabetic foot (DF) in patients with diabetes mellitus. To determine whether carotid intima-media thickness (CIMT) can predict lower limb arterial lesions in patients with DF, this cross-sectional study enrolled patients with DF at West China Hospital (China) between January 2012 and December 2015. Ultrasonography was used to measure CIMT, assess the internal carotid arteries (ICA) for plaques, and evaluate lower limb segmental arteries for stenosis. The optimal CIMT cutoff for detecting lower limb PAD was determined by receiver operating characteristic (ROC) curve analysis. Factors associated with PAD were identified by logistic regression analyses. A total of 167 patients (mean age: 69.7±10.3 years; 102 men) were included. Patients with PAD were older and had higher levels of total cholesterol and low-density lipoprotein than patients without PAD (P<0.05). The area under the ROC curve was 0.747 (P<0.001). At the optimal CIMT cutoff of 0.71 mm, the sensitivity, specificity, positive predictive value, and negative predictive value were 79.65, 61.11, 81.08, and 58.93%, respectively. Compared with those without PAD, more patients with PAD had CIMT ≥0.71 mm (79.65 vs 38.89%; P<0.001) and ICA plaques (66.37vs 11.11%; P<0.001). Multivariate logistic regression revealed that age (odds ratio [OR]: 1.118; 95% confidence interval [95%CI]: 1.056-1.183; P<0.001), ICA plaques (OR: 13.452; 95%CI: 4.450-40.662; P<0.001), and CIMT ≥0.71 mm (OR: 2.802; 95%CI: 1.092-7.188; P=0.032) were associated with PAD.CIMT may be a surrogate marker of PAD in patients with DF.

Subluxação da mandíbula para abordagem de bifurcação carotídea alta em paciente com parotidite por contraste iodado: relato de caso e revisão de literatura / Subluxation of the mandible for access to figh carotid bifurcation in a patient with iodinated contrast induced parotitis: care report and literature review

A doença aterosclerótica das carótidas extracranianas pode resultar em complicações com alta morbidade e mortalidade. A avaliação pré-operatória com exames contrastados de imagem é associada a complicações como a parotidite, além das já bem conhecidas reações alérgicas e da disfunção renal. A bifurcação carotídea alta e a doença aterosclerótica de extensão cranial costumam ser fatores limitantes para o tratamento cirúrgico convencional. Entretanto, quando há contraindicação ao uso de contraste iodado ou impossibilidade do tratamento endovascular, há a necessidade do conhecimento de técnicas cirúrgicas que permitam a realização da endarterectomia com segurança. A subluxação da mandíbula se mostrou uma técnica adjuvante segura e efetiva, de fácil execução e reprodutibilidade, possibilitando o acesso a bifurcações carotídeas altas com boa exposição do campo cirúrgico e permitindo a realização da endarterectomia conforme a técnica padrão. Apresentamos o caso de uma paciente com bifurcação carotídea alta e com limitações para uso do contraste iodado que foi submetida a endarterectomia carotídea após subluxação de mandíbula

Atherosclerotic disease of the extracranial carotid arteries can cause complications with high morbidity and mortality rates. The contrast imaging examinations used in preoperative evaluation are associated with complications such as parotitis, in addition to well-known allergic reactions and renal dysfunction. A high carotid bifurcation or atherosclerotic disease that extends distally are often limiting factors for conventional surgical treatment. However, when iodinated contrast is contraindicated or endovascular treatment is not feasible, knowledge of surgical techniques that allow safe endarterectomy is required. Subluxation of the mandible has proven to be a safe and effective adjuvant technique that is easy to perform and reproducible, providing access to high carotid bifurcations with good exposure of the surgical field and allowing endarterectomy to be performed with a standard technique. We present the case of a patient with a high carotid bifurcation and limitations for use of iodinated contrast who underwent carotid endarterectomy after subluxation of the mandible

The association of the circle of Willis anomaly and risk of stroke in patients with carotid artery disease / A associação de anomalia de Círculo de Willis e o risco de AVC em pacientes com doença carotídea

ABSTRACT The circle of Willis is an important collateral system that maintains perfusion to the stenotic area from the contralateral carotid and basilar artery to the region of reduced brain perfusion. The aim of the present study was to compare the circle of Willis anomaly in patients with unilateral symptomatic and asymptomatic carotid artery disease. Results In this retrospective study, we analyzed 175 patients who presented at our outpatient stroke clinic between January, 2013 and June, 2015 with either unilateral symptomatic or asymptomatic carotid artery disease, and who had had CT angiography imaging performed. Demographic properties, carotid artery stenosis and the anomaly of the circle of Willis was recorded. Conclusion There was no statistically significant difference in patients with symptomatic and asymptomatic carotid artery disease in terms of the anomaly of the circle of Willis.

RESUMO O Círculo de Willis é um importante sistema colateral que mantém a perfusão à área estenótica da carótida contralateral e da artéria basilar para a região de perfusão cerebral reduzida. O objetivo do presente estudo foi comparar a anomalia do Círculo de Willis em pacientes com doença carotídea assintomática e sintomática unilateral. Resultados Neste estudo retrospectivo, foram analisados 175 pacientes que foram à nossa clínica ambulatorial de AVC, entre janeiro de 2013 e junho de 2015, com doença carotídea assintomática ou sintomática unilateral, e que fizeram angiografia por tomografia computadorizada. Propriedades demográficas, estenose da artéria carótida e anomalia do Círculo de Willis foram registradas. Conclusão Não houve diferença estatisticamente significativa em pacientes com doença carotídea sintomática e assintomática em termos de anomalia do Círculo de Willis.

Endoscopic endonasal management of cerebrospinal fluid rhinorrhea after anterior clinoidectomy for aneurysm surgery: changing the paradigm of complication management / Endoscopia endonasal no tratamento da fístula liquórica após clinoidectomia anterior na cirurgia de aneurisma: mudando o paradigma no manejo desta complicação

ABSTRACT Resection of the anterior clinoid process results in the creation of the clinoid space, an important surgical step in the exposure and clipping of clinoidal and supraclinoidal internal carotid artery aneurysms. Cerebrospinal fluid rhinorrhea is an undesired and potentially serious complication. Conservative measures may be unsuccesful, and there is no consensus on the most appropriate surgical treatment. Two patients with persistent transclinoidal CSF rhinorrhea after aneurysm surgery were successfully treated with a combined endoscopic transnasal/transeptal binostril approach using a fat graft and ipsilateral mucosal nasal septal flap. Anatomical considerations and details of the surgical technique employed are discussed, and a management plan is proposed.

RESUMO A ressecção da clinóide anterior resulta na criação do espaço clinoideo, um passo cirúrgico importante na exposição e clipagem de aneurismas dos segmentos clinoideo e supraclinoideo da artéria carótida interna. Fístula liquórica é uma das complicaçoes mais indesejadas e é potencialmente grave. O manejo com medidas conservadoras pode ser bem sucedido, e não há consenso sobre o tratamento cirúrgico mais adequado. Dois pacientes com rinorréia persistente secundária a fistula liquórica transclinoidal após cirurgia de aneurisma foram tratados com sucesso por uma abordagem endoscópica combinada transnasal/transseptal binostril usando um enxerto de gordura e retalho de mucosa naso-septal ipsilateral. Considerações anatômicas e detalhes da técnica cirúrgica empregada são discutidos, e um plano de manejo destes tipo de fistula líquorica é proposto.

Ateroesclerosis subclínica en población de riesgo cardiovascular bajo y moderado por Framingham chileno / Subclinical atherosclerosis among Chilean subjects classified as having a low cardiovascular Framingham risk

Background: Framingham risk score (FRS) has limitations and can underestimate risk. Carotid ultrasound to measure intima media thickness or plaques is recommended for cardiovascular risk assessment. Aim: To determine the prevalence of subclinical atherosclerosis in asymptomatic subjects classified as low and intermediate risk. Material and Methods: Cross-sectional study performed in subjects without cardiovascular disease. Cardiovascular risk was estimated using the Chilean FRS and the General Cardiovascular Disease FRS. Carotid ultrasound was performed in all subjects. We defined subclinical atherosclerosis as the presence of carotid plaque or intima media thickness greater than 75th percentile by gender and age. Results: We studied 203 subjects aged 47.2 ± 9.6 years (54% males). Mean intima media thickness was 0.62 ± 0.1 mm. An abnormal value was detected in 68 subjects (33%) and carotid plaques in 32 subjects (15.7%). Based on Chilean FRS, 96% were considered at low risk, 4% at intermediate, and none at high risk. In the low risk group the prevalence of abnormal intima media thickness and plaques was 40 and 14% respectively. Presence of plaques was more common in women than men (23 and 7% respectively, p < 0.01). According to the General Cardiovascular Disease FRS, 23% were at low, 39% at low intermediate and 28% at high intermediate risk. In the low risk group the prevalence of an abnormal intima media thickness was 34% and no subject had plaques. Conclusions: Carotid plaques were detected in Chilean subjects classified as having a low FRS risk. The underestimation of risk was higher in Chilean women.

Predictive value of CHADS2 score for cardiovascular events in patients with acute coronary syndrome and documented coronary artery disease

BACKGROUND/AIMS: The CHADS2 score, used to predict the risk of ischemic stroke in atrial fibrillation (AF) patients, has been reported recently to predict ischemic stroke in patients with coronary heart disease, regardless of the presence of AF. However, little data are available regarding the relationship between the CHADS2 score and cardiovascular outcomes. METHODS: This was a retrospective study on 104 patients admitted for acute coronary syndrome (ACS) who underwent coronary angiography, carotid ultrasound, and transthoracic echocardiography. RESULTS: The mean age of the subjects was 60.1 +/- 12.6 years. The CHADS2 score was as follows: 0 in 46 patients (44.2%), 1 in 31 (29.8%), 2 in 18 (17.3%), and > or = 3 in 9 patients (8.7%). The left atrial volume index (LAVi) showed a positive correlation with the CHADS2 score (20.8 +/- 5.9 for 0; 23.2 +/- 6.7 for 1; 26.6 +/- 10.8 for 2; and 30.3 +/- 8.3 mL/m2 for > or =3; p = 0.001). The average carotid total plaque area was significantly increased with CHADS2 scores > or = 2 (4.97 +/- 7.17 mm2 vs. 15.52 +/- 14.61 mm2; p = 0.002). Eight patients experienced cardiovascular or cerebrovascular (CCV) events during a mean evaluation period of 662 days. A CHADS2 score > or = 3 was related to an increase in the risk of CCV events (hazard ratio, 14.31; 95% confidence interval, 3.53 to 58.06). Furthermore, LAVi and the severity of coronary artery obstructive disease were also associated with an increased risk of CCV events. CONCLUSIONS: The CHADS2 score may be a useful prognostic tool for predicting CCV events in ACS patients with documented coronary artery disease.

A giant carotid aneurysm with intrasellar extension: a rare cause of panhypopituitarism

No abstract available.

Periodontal disease and atherosclerosis / Doença periodontal e aterosclerose

Atherosclerotic disease (AD) is one of the most important causes of morbidity and mortality in the world. It expresses inflammatory markers such as C-reactive protein (CRP) and can provoke arterial wall thickening, which can be evaluated using Doppler ultrasound. Risk factors associated with AD include diabetes mellitus, systemic arterial hypertension, dyslipidemia and smoking. More recently, periodontal disease (PD) has been identified as a factor related to AD. Periodontal disease has a high prevalence in the global population and the inflammatory process and bacterial activity at the periodontium appear to increase the risk of AD. Encouraging good oral hygiene can reduce expression of inflammatory markers of AD. A review of literature on PD, AD and inflammatory markers and the interrelationships between the two diseases was conducted using data published in articles indexed on the PUBMED, SCIELO and BIREME databases...

A doença aterosclerótica (DA) constitui uma das principais causas de morbimortalidade no mundo. A sua expressão laboral pode ser através de marcadores inflamatórios, como a proteína C reativa (PCR) e/ou o espessamento da parede arterial, que pode ser analisado pela ultrassonografia com Doppler colorido. Os fatores de risco associados à DA são o diabetes mellitus, a hipertensão arterial sistêmica, a dislipidemia e o tabagismo. Mais recentemente, a doença periodontal (DP), que tem uma elevada prevalência na população mundial, tem sido considerada um fator relacionado ao desenvolvimento da DA, em que o processo inflamatório e a atividade bacteriana no periodonto parecem aumentar o risco para a DA. A motivação da higiene oral pode diminuir a expressão dos marcadores inflamatórios da DA. Com base em dados publicados em revistas eletrônicas e indexados pelos mecanismos de busca PUBMED, SCIELO e BIREME, foi realizada uma revisão de literatura sobre a DP e a DA, além dos marcadores inflamatórios expressos em ambas as doenças e suas possíveis inter-relações...

Progressão atípica de perda visual em paciente com glaucoma primário de ângulo aberto / Atypical progression of visual loss in a patient with primary open-angle glaucoma

A dolicoectasia da artéria carótida interna (ACI) é uma condição rara que pode ser acompanhada de manifestações neuro-oftalmológicas, como perda da acuidade e alteração do campo visual decorrente da compressão do nervo óptico (NO). O objetivo é relatar um caso de paciente do sexo masculino, 67 anos, portador de glaucoma primário de ângulo aberto (GPAA) com evolução atípica, assimetria de escavação, palidez da rima do NO à esquerda, devido à neuropatia óptica compressiva à esquerda, por segmento dolicoectásico da ACI. O diagnóstico foi baseado na história clínica, aspecto do NO e exames de neuroimagem.

Dolichoectasia of the internal carotid artery (ICA) is a rare condition that may be associated with neuro-ophthalmic manifestations, such as loss of visual acuity and visual field resulting from compression of the optic nerve (ON). The aim is to report a 67-year-old male patient with primary open-angle glaucoma (POAG) with atypical evolution, asymmetry of cupping and increased pallor of the rim of the left ON, due to compressive optic neuropathy by the dolichoectatic segment. The diagnosis was based on clinical history, appearance of the ON and neuroimaging.

Gender Differences in the Association between Depressive Symptoms and Carotid Atherosclerosis among Middle-Aged and Older Koreans: The Namwon Study

We investigated the association of depressive symptoms with carotid intima-media thickness (IMT) and plaques in the general Korean population. A total of 7,554 Korean males and females aged 45-74 yr who were free from cardiovascular diseases were included in the analyses. Depressive symptoms were assessed by the Center for Epidemiologic Studies Depression Scale (CES-D). Subjects with a score of > or =16 were classified as having clinically significant depressive symptoms. Carotid ultrasonography was used to measure mean carotid IMT (C-IMT) and to determine the presence of plaques. A significant association between depressive symptoms and C-IMT was observed only in females. After adjustment for established cardiovascular risk factors, females with depressive symptoms had significantly greater C-IMT than females without depressive symptoms (mean difference 0.011+/-0.004 mm; 95% confidence interval, 0.003-0.019 mm). Compared with controls, the fully adjusted risk of females with depressive symptoms for abnormal C-IMT (> or =1.0 mm) was significant (odds ratio, 1.63; 95% confidence interval, 1.16-2.30). No significant association between depressive symptoms and carotid plaques was observed in either gender. This study shows a significant association between depressive symptoms and C-IMT in middle-aged and older females.

Assessment of the co-incidence between non alcoholic fatty liver disease and carotid atherosclerosis

Non-alcoholic fatty liver disease [NAFLD] is currently the most common cause of abnormal liver biochemistry and cryptogenic cirrhosis. Those with NAFLD have a higher prevalence of atherosclerosis, as shown by increased carotid artery intimal media thickness [CIMT]. The aim of this study is to assess the co-incidence and prevalence between NAFLD and carotid atherosclerosis. In this study seventy-two subjects were categorized into 2 groups. QL 52 patients diagnosed as NAFLD with diabetes mellitus type 2 or obesity or hyperlipedemia. Gil: 20 diseased controls diagnosed as NAFLD without other predisposing factor. CIMT and plaque prevalence were estimated by carotid ultrasonography as a single trained operator who was blind to clinical characteristics of participants. The results showed that CIMT by carotid duplex ultrasonography was significantly higher in group A than group B but CIMT did not reveal any significant difference as regards to the etiology of NAFLD. CIMT was significantly higher in cases with bright liver than those with homogenous liver [by abdominal US] in group I and II. CIMT was significantly higher in those with moderate steatosis than those with mild steatosis [in GI and Gil]

Função vestibular no acidente vascular cerebral do território carotídeo / Vestibular function in carotid territory stroke patients

Pacientes após Acidente Vascular Cerebral (AVC) podem apresentar sintomas otoneurológicos. OBJETIVO: Avaliar a função vestibular de pacientes com antecedente pessoal de AVC no território carotídeo. Desenho científico: estudo de coorte histórica com corte transversal. MÉTODO: Quarenta pacientes foram submetidos à anamnese, exame otorrinolaringológico, Dizziness Handicap Inventory e vectoeletronistagmografia. RESULTADOS: Anormalidades discretas dos movimentos sacádicos foram encontradas em 20 pacientes (50,0%); nove referiram desequilíbrio e um tontura. O ganho do rastreio pendular foi anormal em 17 casos (42,5%); seis referiram desequilíbrio e um tontura. Preponderância direcional anormal do nistagmoperrotatório ocorreu em dois casos (5,0%), que referiram desequilíbrio. A prova calórica identificou três casos (7,5%) com predomínio labiríntico anormal e dois (5,0%) com preponderância direcional anormal do nistagmo; os cinco casos relataram desequilíbrio. Dos 11 pacientes que não referiram manifestações de alteração do equilíbrio corporal, 10 apresentaram alterações nos movimentos sacádicos e no rastreio pendular e um apresentou exame vestibular normal. CONCLUSÃO: Pacientes com antecedente pessoal de AVC no território carotídeo podem apresentar tontura ou desequilíbrio corporal e sinais de comprometimento da motilidade ocular e da função vestibular.

Stroke patients may present otoneurological symptoms. OBJECTIVE: To assess the vestibular function of subjects with a history of carotid territory stroke. METHOD: This historical cohort cross sectional study enrolled 40 patients; subjects answered the Dizziness Handicap Inventory, were interviewed and submitted to ENT examination and vectorelectronystagmography. RESULTS: Mild saccadic movement anomalies were seen in 20 patients (50.0%); nine complained of imbalance and dizziness. Abnormal smooth pursuit gain was seen in 17 cases (42.5%); six subjects reported imbalance and one complained of dizziness. Abnormal directional preponderance during rotational nystagmus was seen in two cases (5.0%), who also reported imbalance. Three patients (7.5%) and two subjects (5.0%) were found to have abnormal labyrinthine predominance and abnormal nystagmus directional preponderance respectively; all five individuals reported imbalance. Ten of the 11 patients without complaints of disordered balance had altered saccadic and smooth pursuit eye movements, while one had unaltered vestibular function. CONCLUSION: Patients with a history of carotid territory stroke may suffer from dizziness or imbalance and present signs of compromised eye motility and vestibular function.

Avaliação da espessura do complexo mediointimal das carótidas em idosos portadores de esclerose valvar aórtica / Evaluation of the carotid intima-media complex thickness in elderly patients with aortic valve sclerosis

Objetivo: Avaliar a medida da ECMIC em idosos portadores de EVAo, de forma a tentar estabelecer uma relação entre a EVAo e a Aterosclerose de Carótidas. Método: Estudo seccional observacional baseado na demanda espontânea do Serviço de Ecocardiografia do Centro Clínico Vingt-un Rosado, município de Mossoró-RN, no período de novembro de 2.009 a junho de 2.010. Foram excluídos com história de evento e/ou doença cardiovascular prévios. Foram considerados portadores de aumento da ECMIC, aqueles que tiveram uma medida da ECMIC ≥ 10mm. A análise estatística foi realizada pelo método do Teste Exato de Fisher, considerando significância estatística para um p < 0,05. Resultados: Foram avaliados 105 pacientes, dos quais 37 preenchiam os critérios de exclusão do estudo. Entre os 68 pacientes analisados, foram 18 (26,4%) homens e 50 mulheres (73,5%), com média de idade de 71,9 anos. 56 pacientes (82,3%) tinham EVAo, sendo 16 do sexo masculino (28,5%) e 40 do sexo feminino (71,4%); e 40 apresentavam aumento da ECMI, com prevalência significativamente maior nos pacientes portadores de EVAo (p < 00,5). Conclusão: Os resultados sugerem que idosos portadores de EVAo devem ser mais bem avaliados para detecção de ateromatose subclínica.

Efeito da terapia antirretroviral e dos níveis de carga viral no complexo médio-intimal e no índice tornozelo-braço em pacientes infectados pelo HIV / Antirretroviral therapy effect in the intima-medio complex and ankle-brachial index in patients infected by HIV

OBJETIVOS: Identificar precocemente a prevalência de aterosclerose, por causa do espessamento do complexo médio-intimal das carótidas comuns e do índice tornozelo-braço. Essas medidas foram relacionadas com os fatores de risco clássicos de aterosclerose e os específicos dos infectados pelo HIV (tempo de doença, tempo de tratamento, tipo de tratamento, tipo de terapia antirretroviral utilizada, CD4 e carga viral). MÉTODOS: Setenta casos infectados com o HIV foram avaliados pela medida automática do complexo médio-intimal nas carótidas e do índice tornozelo-braço. Consideraram-se os fatores de risco clássicos de aterosclerose (idade, sexo, hipertensão arterial sistêmica, tabagismo, hipercolesterolemia, hipertrigliceridemia, obesidade e história familiar de evento cardiovascular), as medidas antropométricas e as variáveis relacionadas ao HIV. O nível de significância assumido foi de 5%. RESULTADOS: O tempo médio de diagnóstico do HIV foi de 104,9 meses e de tratamento foi de 97,9 meses. Quanto ao tipo de tratamento, 47 (67,1%) fizeram uso de inibidor de protease por mais de seis meses e 36 (51,4%) estão em uso atualmente. O índice tornozelo-braço estava aumentado em um único paciente (0,7%) e não se evidenciou espessamento do complexo médio-intimal em nenhum indivíduo. Não existiu associação significante da medida do complexo médio-intimal da carótida comum direita com nenhuma das variáveis analisadas. CONCLUSÕES: Indivíduos jovens, sob o uso de terapia antirretroviral por cinco anos ou mais, não apresentaram espessamento do complexo médio-intimal ou aumento do índice tornozelo-braço. Não houve diferença do espessamento do complexo médio-intimal associada ao tipo de esquema antirretroviral utilizado ou nível de carga viral.

OBJECTIVES: To precociously identify the prevalence of atherosclerosis caused by thickening of the intima-media complex of the common carotid arteries and of the ankle brachial index. These measurements were associated with the classical risk factors of atherosclerosis and the specific factors of those infected by HIV (duration of disease, length of treatment, kind of treatment, kind of antiretroviral therapy used, CD4 and viral load). METHODS: Seventy cases infected by HIV were assessed by automatic measurement of the intima-media complex in the carotids and of the ankle brachial index. The classical risk factors of atherosclerosis (age, gender, systemic arterial hypertension, smoking, hypercholesterolemia, hypertriglyceridemia, obesity, and family history of cardiovascular events), anthropometric measurements and the variables related to HIV were taken into consideration. The adopted level of significance was 5%. RESULTS: The mean time of HIV diagnosis was 104.9 months, mean duration of treatment was 97.9 months. As regard to the type of treatment, 47 (67.1%) used protease inhibitor for more than six months and 36 (51.4%) are using it recently. The ankle brachial index was increased in one patient (0.7%), and the intima-media complex was not thickened in any individual. There was no significant association of the measurement of the intima-media complex of the right common carotid with any of the variables analyzed. CONCLUSIONS: Young individuals under the use of antiretroviral therapy for five years or more did not show increase in thickness of the intima-media complex or increase in the ankle brachial index, and there was no difference in the intima-media complex thickness associated with the therapeutical scheme of antiretroviral used or the viral load level.