Safety and effectiveness of selective carotid angioplasty prior to cardiac surgery: a single-centre matched case-control study.

OBJECTIVES: Reducing the rate of postoperative stroke after cardiac surgery remains challenging, especially in patients with occlusive cerebrovascular disease. Angioplasty in all patients with high-grade carotid artery stenosis has not been shown to be effective in reducing the post-surgical stroke rate. In this study, we present the initial results of a different approach using selective carotid angioplasty only in patients with poor intracranial collaterals. METHODS: We conducted a single-centre study to assess the safety of this procedure. The postangioplasty complication rate of the study group was compared to that of patients who were scheduled for symptomatic carotid artery angioplasty. To determine the effectiveness of this procedure, the post-cardiac surgery complication rate of the study group was compared with that of the matched case controls. RESULTS: Twenty-two patients were treated with selective carotid angioplasty without developing persistent major neurological complications. All patients except 1 patient subsequently underwent surgery without developing persistent major neurological disabilities. Two patients died of cardiogenic shock within 30 days. CONCLUSIONS: Selective carotid angioplasty prior to cardiac surgery in patients with a presumed high risk of stroke was relatively safe and effective in this study group. Although this strategy does not prevent stroke in these high-risk patients, data suggest that this approach shifts the postoperative type of stroke from a severe haemodynamic stroke towards a minor embolic stroke with favourable neurological outcomes. Larger studies are needed to determine whether this strategy can effectively eliminate the occurrence of haemodynamic stroke after cardiac surgery.

Impact of the Haga Braincare Strategy on the burden of haemodynamic and embolic strokes related to cardiac surgery.

OBJECTIVES: This study prospectively evaluates the impact of the Haga Braincare Strategy (HBS) on the occurrence of haemodynamic and embolic stroke in a cohort of patients who underwent coronay artery bypass grafting (CABG), valve replacement of a combination of both types of surgery between 2012 and 2015 at the Haga Teaching Hospitals. METHODS: The HBS is a dual strategy based on a preoperative vascular work-up of the cerebral circulation by transcranial Doppler and a perioperative monitoring of the cerebral circulation by cerebral oximetry. Duplex of the carotid arteries and/or computed tomography angiography prior to surgery was performed in high-risk patients. Patients with severe carotid artery stenosis were scheduled for carotid angioplasty prior to surgery or waived from surgery. RESULTS: A total of 1065 patients were included. Poor cerebral haemodynamics were identified by transcranial Doppler in 2.1% of patients (n = 22). Based on the HBS, 3 patients were waived from surgery, 4 received preoperative carotid angioplasty followed by cardiac surgery and the remaining patients were operated while being monitored with bilateral cerebral oximetry sensors. In all, 2.2% of the study group experienced a stroke (n = 23), of which none were classified as haemodynamic. Most of the remaining presumed embolic strokes showed a minor to moderate stroke severity. CONCLUSIONS: In this single-centre prospective follow-up study, surveillance of cerebral perfusion by the HBS eliminated the occurrence of haemodynamic stroke while most of the residual strokes had a good to favourable prognosis.

Parafalcine empyema, a tricky infectious cause of headache: a case report.

Headache caused by subdural empyema is usually associated with fever and symptoms and/or clinical signs of meningeal irritation and increased intracranial pressure. We describe a patient with headache with absence of these signs or symptoms of meningeal irritation or intracranial pressure, who turned out to have a parafalcine subduralempyema. A 28-year-old man had headache for 2 weeks, which had started with visual symptoms with duration of 5 minutes. Two days later, he developed fever. During these 2 weeks, he had recurrence of visual symptoms for 4 times, with duration of several minutes.Neurologic examination at presentation on the emergency department showed no meningeal irritation or papilledema. However, on closer examination, a limited homonymous hemianopsia on the left side and a drift of the left leg were found. Magnetic resonance imaging showed parafalcine subdural empyema on the right side of the falx and a small brain abscess right occipitally. Neuronavigated craniotomy was performed, which confirmed the presence of empyema and allowed culture of the specimens. Streptococcus milleri group was cultured,which allowed narrowing of the antibiotic therapy to Benzylpenicillin12 million entities per 24 hours. Headache and subdural empyema diminished during treatment, and at follow-up 12 weeks after start of treatment, patient had no remaining complaints. Parafalcine-located subdural empyema can present without presence of clear localizing symptoms or signs like meningeal irritation and increased intracranial pressure. When headache is accompanied with fever, one should extensively question neurologic symptoms, and a thorough neurologic examination should be done.

Trigeminal autonomic headaches caused by a multinodular goiter--a case report.

BACKGROUND: Though thyroid growths are considered to be a frequent cause of Horner's syndrome, concurrent headache attacks are not commonly seen. CASE: A 63-year-old woman presented with severe, daily occurring, unilateral headache attacks with ipsilateral Horner's syndrome. Magnetic resonance imaging arteriography showed a multinodular goiter displacing the left common carotid artery. CONCLUSION: This case exemplifies the combination of headache attacks and Horner's syndrome due to mechanical pressure of an enlarged thyroid, mimicking the symptoms both of carotid dissection as well as trigeminal autonomic cephalgias like paroxysmal hemicrania.

Successful intra-arterial thrombolysis beyond the accepted 6-hour time window in two young patients.

Two young women with ischemic stroke successfully underwent intra-arterial thrombolysis (IAT) 10 and 11h, respectively after stroke onset. A 23-year-old (case 1) and a 22-year-old woman (case 2) who developed severe neurological deficits (NIHSS 20 and 13, respectively) were presented to our hospital 9h after onset of the symptoms. In case 1 a CT angiography (CTA) revealed an occlusion of the left middle cerebral artery (MCA) and in case 2 CTA showed a large embolus at the left carotid bifurcation, almost entirely occluding the internal carotid artery. We decided to apply IAT beyond the generally accepted 6-hour time window. Case 1 was treated with 2mg rtPA administered locally in the occluded MCA followed by 70 mg rtPA (1 mg/min) and case 2 was treated with 100,000 IU urokinase in the left common carotid artery followed by 200,000 IU during 2h and 10mg abciximab. In case 1 IAT resulted in complete recanalisation of the MCA within 3h and complete resolution of symptoms in the following six weeks. In case 2 IAT resulted in an initial 50% reduction of the thrombus. After nine days CTA showed complete lysis and the patient had completely recovered. Both patients suffered from Anti-Phospholipid-Syndrome. The results show that IAT may be beneficial to young patients with a severe stroke, even beyond the 6-hour time window.

Climate change effects on plant disease: genomes to ecosystems.

Research in the effects of climate change on plant disease continues to be limited, but some striking progress has been made. At the genomic level, advances in technologies for the high-throughput analysis of gene expression have made it possible to begin discriminating responses to different biotic and abiotic stressors and potential trade-offs in responses. At the scale of the individual plant, enough experiments have been performed to begin synthesizing the effects of climate variables on infection rates, though pathosystem-specific characteristics make synthesis challenging. Models of plant disease have now been developed to incorporate more sophisticated climate predictions. At the population level, the adaptive potential of plant and pathogen populations may prove to be one of the most important predictors of the magnitude of climate change effects. Ecosystem ecologists are now addressing the role of plant disease in ecosystem processes and the challenge of scaling up from individual infection probabilities to epidemics and broader impacts.