Trombosis venosa cerebral y anticonceptivos orales: estudio de 1 caso / Cerebral venous thrombosis and oral contraceptives: a case study

La enfermedad cerebrovascular es la tercera causa de muerte en el mundo occidental y una de las que tienen mayor morbilidad. Aunque generalmente predomina en grupos de edad avanzada, en los últimos años está creciendo la incidencia de trombosis vascular cerebral en las mujeres menores de 45 años, en muchos casos asociada con el uso de anticonceptivos orales (ACO).La Agencia Española del Medicamento estima el riesgo de tromboembolia venosa en mujeres sanas entre 15 y 44 años de edad que no toman ACO en 5-10 casos por 100.000 mujeres/año. Sin embargo, en las mujeres de ese grupo de edad que toman ACO que contienen al menos 20 µg de etinilestradiol en combinación con desogestrel o gestodeno, este riesgo aumenta hasta cifras de 30-40 casos por 100.000 mujeres/año. Presentamos el caso de una paciente de 26 años de edad que fue diagnosticada de trombosis cerebral del seno sigmoideo con hipertensión intracraneal, en la que el único factor de riesgo encontrado fue el inicio en la toma de ACO (AU)

Long-term follow-up of morbidity and mortality after aortic valve replacement with a mechanical valve prosthesis.

AIMS: The aim of this study was to determine the incidence of valve-related complications in patients with a mechanical aortic valve prosthesis and to identify risk factors for an adverse outcome. METHODS AND RESULTS: In the 424 patients, event-free survival rates 5 and 10 years after aortic valve replacement were 62% and 37%, respectively. The linearized incidence of thromboembolic events was 4.4% per patient-year, and of anticoagulant-related haemorrhage 8.5% per patient-year. Advanced NYHA functional class, atrial fibrillation, pure aortic regurgitation and thromboembolism prior to surgery decreased event-free survival. A history of pre-operative thromboembolism increased the risk for a first embolic event after aortic valve replacement (relative hazard [RH] 3.2), but was even more strongly associated with the risk for repeated events (> or =2 events, RH 5.4). After each thromboembolic episode that occurred, the risk for a subsequent one was increased. The risk for at least one, and up to three or more haemorrhages was increased in patients with a pre-operative history of bleeding (RH 3.3-5.1) and of atrial fibrillation (RH 1.8-3.9). The risk for a subsequent event was increased by a history of repeated haemorrhages, a short interval since previous bleeding, and high age. CONCLUSIONS: There were few factors strongly related to valve related morbidity. However, previous bleedings and previous thromboembolism were powerful risk factors for repeated events.

Craniocerebral trauma induces hemorheological disturbances.

Several mechanisms are involved in the development of secondary ischemic brain damage, including microthrombi formation, which is thought to play a prominent role. Ninety-four autopsy cases were macro- and microscopically examined by specific staining for fibrin, 74 of which showed cortical contusion after a craniocerebral trauma. Twenty cases with no neurological pathology were used as controls. Traumatic cases comprised 52 males and 22 females, with a mean age of 48 years; most cases died in the first 48 h. The total number of fibrinous microthrombi in a slice of each hemisphere was determined. The mean number of microthrombi found in contused hemisphere was 152 (37-283), with 88 in the contralateral hemisphere (21-139) as compared to 13 (0-27) in control cases. Differences were statistically significant. Globular microthrombi or "shock bodies" (2-60 micro diameter) were present in five cases. Enhanced presence of microthrombi in contused brain areas, higher incidence in young people, an increase in the amount of microthrombi up to the 9th day after injury and involvement of the contralateral hemisphere free of contusion foci were all demonstrated. Microthrombi would therefore seem to be one of the central secondary events after brain trauma to bear in mind when designing treatment strategies.

Puerperal cerebral venous thrombosis: therapeutic benefit of low dose heparin.

Advances in imageology have improved the diagnostic yield of cerebral venous/sinus thrombosis (CVT). However, its management remains a challenge. The present study was carried out to study the role of heparin in CVT. Therapeutic outcome of 150 patients of puerperal CVT manifesting within one month of delivery or abortion, was analyzed. The diagnosis was supported by cranial computed tomography and/or angiography whenever required. Seventy three patients, 46 with non-haemorrhagic infarction and 27 with haemorrhagic infarction, received 2500 units of subcutaneous heparin, three times a day within 24 hours of hospitalization till 30th post partum day or symptomatic relief. Seventy seven patients during the same period, 50 with non-haemorrhagic infarction and 27 with haemorrhagic infarction, who did not receive heparin formed the control group. Repeat CT scans were done when indicated. Among the heparin group, 34 patients made full recovery. There were eight deaths, all among the patients with haemorrhagic lesion. In control group, only 14 patients recovered completely (P=<0.001) and 18 died (P=<0.001). There were no adverse effects of heparin. Low dose heparin is safe and efficacious in puerperal CVT, even in patients with haemorrhagic infarction.

Transcranial Doppler directed dextran therapy in the prevention of carotid thrombosis: three hour monitoring is as effective as six hours.

BACKGROUND: Six hours' monitoring by transcranial Doppler (TCD) has been successful in directing Dextran therapy in patients at high risk of thrombotic stroke after carotid endarterectomy (CEA). OBJECTIVES: Is 3 h of routine monitoring as effective as 6 h in the prevention of early postoperative thrombotic stroke? DESIGN: Prospective, consecutive study in all patients with an accessible cranial window. METHODS: One hundred and sixty-six patients undergoing CEA underwent 3 h of postoperative monitoring by TCD. Any patient with > 25 emboli detected in any 10 min period or those with emboli that distorted the arterial waveform were commenced on an incremental infusion of dextran 40. RESULTS: The majority of patients destined to embolise will do so within the first 2 postoperative hours. Dextran therapy was instituted in nine patients (5%) and rapidly controlled this phase of embolisation although the dose had to be increased in three (33%). No patient suffered a postoperative carotid thrombosis but one suffered a minor stroke on day 5 and was found to have profuse embolisation on TCD; high dose dextran therapy was again instituted, the embolus count rate fell rapidly and he made a good recovery thereafter. Overall, the death and disabling stroke rate was 1.2% and the death/any stroke rate was 2.4%. CONCLUSION: Three hours of postoperative TCD monitoring is as effective as 6 h in the prevention of postoperative carotid thrombosis.

Complete thromboendarterectomy of the calcified ascending aorta and aortic arch.

BACKGROUND: Arteriosclerotic plaques of the ascending aorta and transverse arch increase the operative risk of cardiac operations and are strong predictors for late cerebrovascular events. METHODS: Twenty-two patients, mean age 68 +/- 6 years (range, 55 to 77 years), with grade IV + V plaques of the ascending aorta and transverse arch underwent coronary artery bypass grafting (n = 21) and aortic valve replacement (n = 8). Cerebrovascular emboli from unknown sources were found preoperatively in 8 patients (36%). All were in sinus rhythm. Complete thromboendarterectomy of the ascending aorta and transverse arch was performed during hypothermic circulatory arrest. After 21 +/- 12 months (range, 4 to 44 months), magnetic resonance imaging and transthoracic echocardiography of endarterectomized vessels was performed. RESULTS: There was one perioperative death (4.5%), one early (4.5%), and one late (4.7%) adverse neurologic event. Follow-up examinations revealed normal diameters of the endarterectomized aorta. CONCLUSIONS: For patients with grade IV + V plaques, thromboendarterectomy of the ascending aorta and transverse arch can be performed with an acceptable surgical risk and a low recurrence rate for cerebrovascular events. Dilatation of the endarterectomized aorta was not observed.

Stroke incidence and survival among middle-aged adults: 9-year follow-up of the Atherosclerosis Risk in Communities (ARIC) cohort.

BACKGROUND AND PURPOSE: Although stroke mortality rates in the United States are well documented, assessment of incidence rates and case fatality are less well studied. METHODS: A cohort of 15 792 men and women aged 45 to 64 years from a population sample of households in 4 US communities was followed from 1987 to 1995, an average of 7. 2 years. Incident strokes were identified through annual phone contacts and hospital record searching and were then validated. RESULTS: Of the 267 incident definite or probable strokes, 83% (n=221) were categorized as ischemic strokes, 10% (n=27) were intracerebral hemorrhages, and 7% (n=19) were subarachnoid hemorrhages. The age-adjusted incidence rate (per 1000 person-years) of total strokes was highest among black men (4.44), followed by black women (3.10), white men (1.78), and white women (1.24). The black versus white age-adjusted rate ratio (RR) for ischemic stroke was 2.41 (95% CI, 1.85 to 3.15), which was attenuated to 1.38 (95% CI, 1.01 to 1.89) after adjustment for baseline hypertension, diabetes, education level, smoking status, and prevalent coronary heart disease. There was a tendency for the adjusted case fatality rates to be higher among blacks and men, although none of the case fatality comparisons across sex or race was statistically significant. CONCLUSIONS: After accounting for established baseline risk factors, blacks still had a 38% greater risk of incident ischemic stroke compared with whites. Identification of new individual and community-level risk factors accounting for the elevated incidence of stroke requires further investigation and incorporation into intervention planning.

[Systemic thrombolysis with plasminogen activator in chronic stroke patients]. / Systemische Thrombolyse mit Plasminogenaktivator bei alten Schlaganfallpatienten.

Following the study protocol, we stratified the 615 patients of ECASS I according age (< or =/-70 years) and analysed the response to intravenous rt-PA in both subgroups. The older patients (248) suffered from the same stroke severity as the younger patients (367) experienced, however, a more severy clinical course (placebo group after 3 months after stroke: Barthel Index 50 vs. 85, mortality 24% vs. 11%). Treatment with rt-PA increased the proportion of undisabled patients at 3 months after stroke onset significantly only in the younger patients. The risk for brain parenchymal hemorrhage was increased by the factor of 4.7 and 4.6 in both age groups. It is obviously harder to achieve an undisabled state by systemic thrombolysis in the elderly. Facing the risk of brain hemorrhage associated with rt-PA, the risk-benefit-ratio may be less favourable in patients over 70 years.

Collateral circulation and outcome after basilar artery thrombolysis.

BACKGROUND AND PURPOSE: This study was undertaken to examine the relationship between collateral flow and outcome after local intraarterial thrombolytic treatment for basilar artery thrombosis. METHODS: Twenty-four patients with symptomatic basilar thrombosis were treated with intraarterial urokinase. Angiograms at the time of treatment were analyzed to characterize collateral flow. The number of posterior communicating arteries (PCoAs) and the degree of collateral filling of the basilar artery were then compared with symptom duration before treatment, with Glasgow Coma Scale (GCS) score at the time of treatment, with 90-day modified Rankin score, and with 90-day survival status. RESULTS: Of the 20 patients who had carotid artery injections at the time of the thrombolytic procedure, two had no PCoA, eight had one PCoA, and 10 had two PCoAs. Nine had no collateral opacification of the basilar artery, six had collateral opacification of the distal basilar artery, and five had collateral opacification of the distal and proximal basilar artery. Ninety-day survival was 38%; 25% of patients had good neurologic outcomes. No correlation was found between the number of PCoAs and symptom duration, pretreatment GCS score, survival, or neurologic outcome. Duration of symptoms before treatment was longer in patients with collateral flow to the basilar artery. Basilar artery collateral flow did not correlate with survival, but it did correlate with neurologic outcome for the 12 patients with middle or distal basilar artery thrombus in whom collateral flow to the basilar artery was assessed (83% with collateral flow had good neurologic outcomes, but only 17% without collateral flow had good outcomes). All six patients with proximal basilar artery thrombus in whom collateral flow was assessed died, independent of the collateral flow observed. CONCLUSION: In symptomatic acute basilar artery thrombosis, neurologic outcome was better after intraarterial thrombolysis in patients who had collateral filling of the basilar artery, except in cases of proximal basilar thrombosis. Patients with collateral filling of the basilar artery also tolerated longer symptom duration.

[Cerebrovascular disease in young adults. A study of its course in 167 patients]. / Enfermedad vascular cerebral en el adulto joven. Estudio evolutivo en 167 pacientes.

INTRODUCTION: Few studies have been made of the prognosis of ictus in the young adult. The objective of this paper is to study the short term evolution of 167 patients, aged between 15 and 45 years, with cerebral vascular disease. MATERIAL AND METHODS: Since 1986 a protocolized study has been made of all patients aged between 15 and 45 who were admitted to the Neurology Department of the Hospital General Universitario in Valencia for a cerebral vascular incident. The results obtained up to 1993 have been recorded in a data base. In this paper the demographic data and information as to intrahospital evolution have been used with the Canadian, modified Rankin and Barthel Scales in the various ictus groups. RESULTS: 28.7% of the patients were AIT and 71.3% were diagnosed as established ictus, of whom 38.8% were haemorrhagic and 61.2% were ischaemic. 29.8% of the HIP, 33.3% of the embolic infarcts and 18.2% of the atherothrombotic infarcts were severely disabled on discharge from hospital. Mortality was 4.2% when AIT were excluded. DISCUSSION: Most studies are basically aetiopathological and much fewer include evaluation of prognosis. In our series, the patients had a satisfactory clinical course and low short-term mortality. As in the other series, the two groups with the worst prognosis were the HIP and the cardioembolic infarcts. Patients with HSA and HIV made outstandingly good progress.

Outcome after local intra-arterial fibrinolysis compared with the natural course of patients with a dense middle cerebral artery on early CT.

Our purpose was to relate the outcome after local intra-arterial fibrinolysis (LIF) to the natural course in middle cerebral artery (MCA) occlusion. We retrospectively studied 40 patients with a dense middle cerebral artery on early CT; 20 were treated with LIF within 6 h of onset of symptoms, 20 received "conventional" stroke therapy. The dense middle cerebral artery, which is regarded as a highly specific indicator of thromboembolic MCA occlusion, was chosen as inclusion criterion since patients with "conventional" stroke therapy were not exposed to cerebral angiography. Patients treated with LIF had a significantly better outcome using the Barthel index (P = 0.025): there was a 30% increase in the proportion of patients with minimal or no disability. Mortality, however, did not differ significantly (P = 0.7). Two fatal haemorrhages occurred in the LIF group, and one haemorrhagic transformation in the "conventional" group. Leptomeningeal collateralisation correlated significantly with outcome in the LIF group (P = 0.04). Although the relation between outcome and interval from onset of symptoms to LIF was not significant (P = 0.74), all patients treated within 3 h had an excellent outcome.

Basilar artery embolism. Clinical syndrome and neuroradiologic patterns in patients without permanent occlusion of the basilar artery.

The objective of this study was to clarify the clinical and radiologic features, risk factors, and prognosis of basilar embolism without permanent basilar artery occlusion. Forty-five patients (mean age, 59 years) with basilar artery embolism participated in the study. Patients with basilar artery occlusion were excluded. The Glasgow Coma Scale (GCS) score on admission was < 7 in five patients, 7 to 12 in 11 patients, and > 12 in 29 patients. Etiologic factors were cardiac arrhythmia (17 patients), vertebral artery occlusion (12 patients), cervical spine trauma (4 patients), embolism following angiography (2 patients), and surgery (1 patient). MRI was performed in 17 patients and CT in 39 patients. Radiologic examinations were initially normal in 14 patients and remained normal in three patients. Final infarct localization was the thalamus (36 patients), cerebellum (20 patients), posterior cerebral artery territory (21 patients), midbrain (12 patients), and pons (8 patients). Eight to 12 weeks after stroke 12 patients were without clinical signs (Glasgow Outcome Scale [GOS] 1), 15 patients had minor neurologic deficits (GOS 2), 10 were severely disabled (GOS 3), and eight patients had died (GOS 5). Outcome correlated with GCS on admission (p < 0.0001) and with the number of ischemic lesions (p = 0.0001). The typical syndrome is an acute loss of consciousness followed by multiple brainstem symptoms. Usually, clinical symptoms improve rapidly and, in some patients, completely. Compared with basilar occlusion, basilar embolism has a relatively low mortality and outcome is frequently excellent.

Relationship between clot location and outcome after basilar artery thrombolysis.

PURPOSE: To identify factors that predict survival and good neurologic outcome in patients undergoing basilar artery thrombolysis. METHODS: Over a 42-month period, 20 of 22 consecutive patients with angiographic proof of basilar artery thrombosis were treated with local intraarterial urokinase. Brain CT scans, neurologic examinations, symptom duration, clot location, and degree of recanalization were analyzed retrospectively. RESULTS: Overall survival was 35% at 3 months. Survival in patients with only distal basilar clot was 71%, while survival in patients with proximal or midbasilar clot was only 15%. At 3 months, 29% of patients with distal basilar clot and 15% of patients with proximal or midbasilar clot had good neurologic outcomes (modified Rankin score of 0 to 2 and Barthel index of 95 to 100). Complete recanalization was achieved in 50% of patients; 60% of those survived and 30% had good neurologic outcomes. Of patients with less than complete recanalization, only 10% survived. Neither duration of symptoms before treatment (range, 1 to 79 hours), age (range, 12 to 83 years), nor neurologic status at the initiation of treatment (Glasgow Coma Scale score range, 3 to 15) predicted outcome. Pretreatment CT findings (positive or negative for related ischemic changes) did not predict outcome or hemorrhagic transformation. CONCLUSION: The single best predictor of survival after basilar thrombosis and intraarterial thrombolysis was distal clot location. Complete recanalization favored survival. Radiologically evident related infarctions, advanced age, delayed diagnosis, and poor pretreatment neurologic status did not predict poor outcome and therefore should not be considered absolute contraindications for intraarterial thrombolysis in patients with basilar artery thrombosis.

Incidence and prognosis of embolic events and metastatic infections in infective endocarditis.

AIMS: In infective endocarditis, the true incidence of embolic events and metastatic infections remains unknown probably because a large number of events are asymptomatic. The consequences of the prognosis of such events have never been evaluated by a prospective follow-up. This study aimed to assess the incidence of symptomatic or asymptomatic embolic events and metastatic infections in definite infective endocarditis and to determine whether these events carry a risk of mortality. METHODS AND RESULTS: From January 1991 to December 1993, 102 patients with suspected or known infective endocarditis were referred to our institution. Among them, we selected 68 patients (50 males, 18 females, mean age = 52.7 years) exhibiting definite infective endocarditis according to the Duke University criteria. Blood cultures were positive in 49 cases (72%). Echocardiography revealed valvular vegetations in 55 cases (81%). Irrespective of the clinical presentation, patients were examined radiologically by cerebral computed tomography scanning (n = 60), magnetic resonance imaging (n = 3), abdominal computed tomography scanning (n = 32) or abdominal echocardiography (n = 20). Depending on the symptoms, thoracic computed tomography scanning (n = 22), pulmonary angiography (n = 2), ventilation-perfusion scintigraphy (n = 4), or gallium citrate radionuclide scanning (n = 7) were also performed. All patients were prospectively followed-up for a mean period of 21.4 +/- 17.5 months. In 35 patients (51%), 51 embolic or metastatic events were revealed, involving the central nervous system (n = 23), spleen (n = 7), kidney (n = 5), lung (n = 5), liver (n = 4), bone and joint (n = 4), iliac (n = 2) or mesenteric (n = 1) arteries. During the hospital stay, the mortality rate was higher in patients exhibiting embolic or metastatic events (20 vs 12%), but the difference did not reach statistical significance. Kaplan-Meier analysis demonstrated no difference in long-term follow-up. CONCLUSION: Our data suggest that embolic or metastatic events had a high incidence (51%) during infective endocarditis, but were not associated with significant attributable mortality.

Anticardiolipin antibodies and the risk of recurrent thrombo-occlusive events and death. The Antiphospholipid Antibodies and Stroke Study Group (APASS).

We tested the hypothesis that an anticardiolipin antibody (aCL) titer of > or = 10 IgG phospholipid (GPL) at the time of an index ischemic stroke is associated with an increased risk of subsequent thrombo-occlusive events or death. First-time ischemic stroke patients from the Antiphospholipid Antibodies and Stroke Study Group's Prevalence Study were followed prospectively for a median time of 24 months for any thrombo-occlusive event or death. There was no significant difference for the endpoint of stroke, death, myocardial infarction, transient ischemic attack, deep venous thrombosis, pulmonary embolus, or arterial embolus between the aCL positive and negative patients. Although a single aCL value of > or = 10 GPL at the time of an initial ischemic stroke is a significant independent risk factor for stroke, when adjusted for other stroke risk factors in our study population, aCL positivity did not confer a significantly increased risk for subsequent thrombo-occlusive events or death.

[Thrombolytic therapy in ischemic infarct]. / Thrombolytische Therapie beim ischämischen Insult.

Thrombolytic therapy in acute ischemic stroke is safe and effective in a defined subgroup of stroke patients. Until now, different fibrinolytic substances including urokinase, streptokinase and recombinant tissue plasminogen activator (rt-PA) have been tested regarding safety, efficacy, dosage and economic parameters in patients suffering from both carotid and basilar artery territory strokes. Recently, two large multicenter placebo-controlled intravenous rt-PA studies were published. The results show that thrombolysis of acute carotid territory strokes (European Cooperative Acute Stroke Study) and of strokes with a deficit measurable on the NIH Stroke Scale (National Institute of Neurological Disorders and Stroke rt-PA Stroke Study) improves clinical and economic outcome parameters in patients who were treated within 6 hours of the onset of symptoms and had that no signs of extended early infarction on the initial CT-scan. The occurrence of intracranial hemorrhages is more frequent after thombolytic therapy, but the majority of bleeding complications referred to petechial or more confluent hemorrhage limited to the infarcted tissue, without clinical deterioration. However, the identification of the appropriate patients is difficult and depends on the level of clinical and diagnostic experience. In vertebrobasilar artery territory stroke, local intraarterial thrombolysis with urokinase or streptokinase is performed in most cases. Thrombolytic treatment within twelve hours of the onset of symptoms was associated with significantly better results concerning both survival and neurological recovery.

[Embolic complications in bacterial endocarditis]. / Embolische Komplikationen bei bakterieller Endokarditis.

Embolic complications are a major prognostic determinant in the clinical course of infective endocarditis (IE) with an incidence of about 30-50%. In order to analyze risk factors leading to embolism in native (NVE) and prosthetic valve endocarditis (PVE), we reviewed 177 consecutive patients; 43% were female, 57% male, PVE occurred in 24% of all patients all left-sided, among the NVE were 11% right-sided IE. Major embolic complications occurred in 40% of all patients. In NVE, a higher rate of embolic events (45% vs. 26%; p < 0.05), and a larger vegetation size compared to PVE was observed (14 +/- 6 mm vs. 11 +/- 5 mm; p < 0.05). The most important risk factor for embolic complications in NVE was Staphylococcus aureus (odds ratio 6.4). Furthermore, double valve endocarditis, fever, and mitral valve endocarditis were associated with the risk for embolism. In case of severe regurgitation the rate of embolic complications was reduced (54% vs. 77%; p < 0.05). In PVE, fever was a risk factor for embolic events. Staphylococcus aureus was also a frequent microorganism in embolism (45% vs. 22%). The in-hospital mortality was significantly increased in case of embolism (NVE 40% vs. 11%; p < 0.001; PVE 36% vs. 9% p < 0.05). About 50% of all embolic events occurred before admission. In NVE, due to high in-hospital mortality, the rate of patients with embolism undergoing surgery was lower (57% vs. 72%; p < 0.05); whereas in PVE no significant difference was observed. In patients with NVE, aspirin therapy because of coronary artery disease appeared to reduce the rate of embolic complications (11% vs. 47%). However, the low number of patients on aspirin (9%) does not allow recommendations regarding a potential benefit. In conclusion, identification of risk factors leading to embolism in IE may be useful in considering early surgical therapy. However, the high rate of embolic complications before hospital admission indicates a need for improving the diagnostic delay in the prehospital phase.

Intraarterial thrombolysis in vertebrobasilar occlusion.

PURPOSE: To report our experience using intraarterial thrombolysis in the treatment of vertebrobasilar occlusion. METHODS: Twelve patients with 13 angiographically proved thromboses of the vertebrobasilar system underwent local intraarterial thrombolysis with urokinase. Angiographic and clinical outcomes were analyzed with respect to clinical examination at presentation, arterial occlusion patterns, and time to recanalization. RESULTS: The overall mortality was 75%. Recanalization could not be achieved in 3 of 13 treatments; all patients in whom recanalization failed died. The mortality rate was 60% in those patients in whom recanalization was successful. Coma or quadriparesis at the time of therapy uniformly predicted death. There were two cases each of bilateral proximal vertebral occlusions and midbasilar occlusions and nine cases of bilateral distal vertebral occlusions. There were three cases of fatal rethrombosis after initial successful thrombolysis. The mortality rate in the recanalized group before rethrombosis was 30%. There were two fatal hemorrhages of the central nervous system. CONCLUSION: Recanalization of the vertebrobasilar system is necessary but not sufficient for effective treatment of vertebrobasilar occlusive disease. The site of occlusion may help predict angiographic and clinical outcome. Time to initiation of thrombolysis is not an invariable correlate of survival, although clinical condition at presentation may be. Rethrombosis and hemorrhage are significant problems affecting mortality after successful thrombolysis.

Predictive factors for postoperative cerebral complications in patients with thoracic aortic aneurysm.

OBJECTIVE: Perioperative factors affecting the outcomes of postoperative brain function in patients with thoracic aortic aneurysm were demonstrated. PATIENTS AND METHODS: From December 1977 to September 1994, 745 patients with thoracic aortic aneurysm underwent 846 operations. The mean age at surgery was 57.1 +/- 14.2 years old. Four hundred seventy-four patients had true aneurysm and 372 had aortic dissection. Two hundred forty-four patients underwent repair in the ascending aorta, 189 arch repair, 242 repair in the descending aorta. 79 replacement of the thoracoabdominal aorta, and 92 extra-anatomical bypass or thrombo-exclusion of the aorta. Conventional cardiopulmonary bypass was used in 297 patients, partial cardiopulmonary bypass through femoral access in 167, selective cerebral perfusion in 253, deep hypothermic circulatory arrest and retrograde cerebral perfusion in 50, temporary shunt in 29, and no circulatory support was applied in 50. Postoperative cerebral complications were divided into permanent cerebral dysfunction. RESULTS: The early mortality rate was 15.5% (131 patients). Incremental risk factors for hospital mortality were non-preexisting cardiac lesions, ruptured aneurysm, postoperative cerebral complications, sepsis, bleeding, low output syndrome and renal failure. Cerebral complications occurred in 81 patients (9.6%), involving 47 permanent and 34 transient sequelae. The early mortality rate in patients with postoperative brain damage was 42.0%. The etiologies of the brain damage diagnosed by computed tomography were embolism in 41 patients, cerebral hypoperfusion in 16 and unknown in 24. Incremental risk factors for postoperative cerebral complications were: operation early in the series advanced age at surgery, preoperative renal failure, aortic arch lesions, atherosclerotic aneurysm, aortic arch procedures and clamping of the aortic arch. CONCLUSIONS: Although there was an increased incidence of advanced age and complex lesions in patients with aortic aneurysm, an improvement in surgical results has recently been achieved using advanced diagnostic and surgical techniques.

Association of silent myocardial ischemia with new atherothrombotic brain infarction in older patients with extracranial internal or common carotid arterial disease with and without previous atherothrombotic brain infarction.

OBJECTIVE: To correlate silent myocardial ischemia with the incidence of new atherothrombotic brain infarction (ABI) in older patients with 40 to 100% extracranial carotid arterial disease (ECAD) with and without prior ABI. DESIGN: In a prospective study of 208 older patients with 40 to 100% ECAD diagnosed by carotid duplex ultrasonography, 24-hour ambulatory electrocardiograms were obtained to detect silent myocardial ischemia. At 42-month mean follow-up, silent myocardial ischemia was correlated with the incidence of new ABI in patients with and without prior ABI. SETTING: A large long-term health care facility where 208 older patients with 40 to 100% ECAD and technically adequate 24-hour ambulatory electrocardiograms for detecting silent myocardial ischemia were studied. PATIENTS: The 208 patients included 68 men and 140 women, mean age 81 +/- 8 years (range 60 to 100). One-hundred three (50%) of the patients had prior ABI. MEASUREMENTS AND MAIN RESULTS: Sixty-nine (33%) of the 208 patients had silent myocardial ischemia. Mean follow-up was 42 +/- 25 months (range 3 to 101 months). At follow-up, the incidence of new ABI was 64% in patients with prior ABI and 32% in patients with no prior ABI (P < .0001). At follow-up, the incidence of new ABI was 65% in patients with silent ischemia and 40% in patients with no silent ischemia (P = .0005). The multivariate Cox regression model showed that patients with prior ABI have a 2.5 times higher chance of developing new ABI than those without prior ABI after controlling other prognostic variables. Patients with silent ischemia have a 2.1 times higher probability of developing new ABI than those without silent ischemia after controlling other prognostic variables. CONCLUSIONS: Prior ABI and silent ischemia are independent risk factors for the development of new ABI in patients with 40 to 100% ECAD. This probably reflects that silent ischemia is a marker for more advanced or more significant atherosclerotic disease rather than a causal factor for ABI.