ABSTRACT
INTRODUCTION: A rare but significant cause for stroke is sub-intimal carotid dissection and this mechanism accounts for approximately 2.5% of all strokes.(1) Dissection of the carotid artery is often caused by trauma to the face or neck.(2) Under 45 years old, it is the second leading cause of stroke.(3) Neurological symptoms can be lacking or subtle, therefore the condition may be overlooked but the pathological processed is believed to be attributed to thromboembolism.(4) Microemboli in the middle cerebral artery, are known as a risk factor for ischaemic stroke following a transient ischaemic attack (TIA) and can be detected by transcranial Doppler examination (TCD).(5) The established treatment regime is antiplatelet therapy, anticoagulation or both along with supportive therapy.(6) Current evidence suggests managing microemboli in both crescendo TIA's and post carotid endarterectomy improves outcome.(7) We have found the use of Tirofiban, a potent intravenous antiplatelet agent currently licensed for use in acute coronary syndrome, effective in the treatment of microemboli in this manner.(7) CASE PRESENTATION: We report a case of symptomatic carotid artery dissection post radical neck dissection, causing TCD detected microemboli and successfully treated with Tirofiban. CONCLUSION: We believe further study into the use of Tirofiban in the treatment of microemboli after carotid dissection is indicated.
Subject(s)
Cardiovascular Diseases/prevention & control , Intermittent Claudication/drug therapy , Peripheral Vascular Diseases/drug therapy , Platelet Aggregation Inhibitors/therapeutic use , Ankle Brachial Index , Cardiovascular Diseases/etiology , Cardiovascular Diseases/mortality , Evidence-Based Medicine , Humans , Intermittent Claudication/diagnosis , Intermittent Claudication/etiology , Intermittent Claudication/mortality , Peripheral Vascular Diseases/complications , Peripheral Vascular Diseases/diagnosis , Peripheral Vascular Diseases/mortality , Practice Guidelines as Topic , Randomized Controlled Trials as Topic , Risk Assessment , Risk Factors , Treatment OutcomeABSTRACT
Abdominal aortic aneurysm (AAA) is a life-threatening condition with an overall mortality of 80%. It predominantly affects men 65-74 years of age and is caused by focal distension of the main blood vessel in the abdomen. Most patients go undetected until their aneurysm ruptures. Controversy surrounds the most appropriate form of screening for AAA. Currently, screening is only carried out selectively in patients with peripheral vascular disease. Some patients have their AAA detected incidentally, whilst ultrasound examination of the abdomen is carried out for other indications. These patients have the opportunity to undergo surveillance or elective surgery. The mortality rate of emergency surgical intervention following rupture (50%) is far worse in comparison to that of patients undergoing planned intervention under specialist vascular surgeons (5%). Despite improvements in outcomes from elective intervention for AAA as a result of specialisation, the overall mortality from this condition remains very high (80%) as the commonest presentation of an AAA is rupture. Screening all men aged 65-74 years is considered too costly in the current economic climate. However the cost difference between elective repair and emergency repair of AAA must be considered given that the outcome from elective AAA repair is far superior to that following ruptured AAA repair. Our objective was to retrospectively collect costs and outcomes of elective and emergency AAA repair in order to carry out a cost-effectiveness analysis. Four multiprofessional teams in accident and emergency, operation theatres, intensive care, and surgical wards at the Kent and Canterbury Hospital were selected from health-care professionals including doctors, managers, nurses, and clerical staff with the purpose of obtaining costs. Detailed cost data collection sheets were prepared to calculate costs, which included staff costs, consumables including drugs, intravenous fluids, equipment, investigations, laundry, catering, and stationery. An inventory of costs per item was obtained, and the total cost was calculated from the number of items used. Outcomes were measured in terms of survival. The total costs of emergency AAA repair were pounds sterling 96,700.69, with a cost per life saved of pounds sterling 24,175.17. The total cost of elective AAA repair was pounds sterling 76,583.22, with a cost per life saved of pounds sterling 5,470.23. Emergency intervention for AAA was found to cost five times more than a planned intervention per life saved per year.
