Clinical Impact of Routine Cardiology Consultation Prior to Elective Carotid Endarterectomy in Neurologically Asymptomatic Patients.

OBJECTIVE: The aim was to determine the clinical impact of routine cardiology consultation before carotid endarterectomy (CEA) in neurologically asymptomatic patients, in terms of early and long term cardiovascular events. METHODS: A single centre retrospective review of consecutive patients receiving CEA from 2007 to 2017 for asymptomatic carotid stenosis was performed. Two groups were compared: patients operated on from 2007 to 2012 received a pre-operative cardiology consultation only in selected cases (group A); from 2012 to 2017 patients received a routine pre-operative cardiology consultation (group B). In hospital death, myocardial infarction (MI), heart failure, dysrhythmias, and stroke were compared. A multiple logistic regression was performed to identify predictors of peri-operative complications. Long term overall survival and freedom from fatal cardiovascular events were compared. RESULTS: In total, 878 CEAs were performed in group A and 1094 in group B. Patients in group B were more likely to have had a previous coronary intervention (0.5% vs. 5.1%; p < .001), and to be on dual antiplatelet (4.6% vs. 9.5%; p = .001), statin therapy (60.3% vs. 72.4%; p < .001), and a higher number of cardiac drugs (1.77 ± 1.22 vs. 1.92 ± 1.23; p = .01) at the time of CEA. In hospital mortality was 0.1% for both groups (p = 1.0), and there were no significant differences regarding neurological complications (0.8% vs. 0.3%; p = .20); group B had a significant reduction in overall cardiac complications (3.4% vs. 1.9%; p = .05) and MI (1.6% vs. 0.6%; p = .05). Multivariable analysis confirmed that routine cardiology consultation was an independent predictor of MI (odds [OR] ratio 0.61; p = .04) and overall reduction in cardiac complications (OR 0.28; p = .01). At five years, overall survival was similar (84.2% vs. 82.4%; p = .72), but patients in group B had a significantly lower mortality from cardiovascular events (92.0% vs. 95.8%; p = .04). CONCLUSION: Routine cardiology consultation before elective CEA in patients with asymptomatic carotid stenosis reduced peri-operative cardiac complications and long term fatal cardiovascular events. This approach may be considered to maximise the risk/benefit ratio of CEA in asymptomatic patients.

Influencia de la manipulación osteopática cervical sobre el flujo arterial / No disponible

Introducción: La medicina osteopática es uno de los medios de tratamiento más empleados en las dolencias de la columna cervical. Debemos conocer con precisión la relación entre manipulación cervical y valores hemodinámicos arteriales carotideos y vertebrales. Objetivos: Revisar el cuerpo de conocimientos que la literatura científica recoge sobre la relación entre la manipulación cervical osteopática y los posibles cambios en el flujo arterial carotideo. Material y Métodos: Realizamos una revisión bibliográfica en las bases de datos Pubmed, Web of Science y la plataforma EBSCOhost con los términos «spinal», «vertebral», «cervical manipulation», «carotid», «vertebral», «blood flow», «carotid», «vertebral», «blood velocity». Resultados: Obtenemos inicialmente una muestra de 232 estudios (n=232). Tras excluir los estudios que no cumplen los criterios establecidos, obtenemos una muestra de 12 estudios de lectura completa, de los que 5 (n=5) se incluyen en la revisión. Conclusiones: Hay escasa evidencia científica de los efectos postmanipualtivos sobre la circulación arterial cervical (AU)

No disponible

One, two and three-dimensional ultrasound measurements of carotid atherosclerosis before and after cardiac rehabilitation: preliminary results of a randomized controlled trial.

BACKGROUND: It is still not known how patients who are post-transient ischemic attack (TIA) or post-stroke might benefit from prospectively planned comprehensive cardiac rehabilitation (CCR). In this pilot evaluation of a larger ongoing randomized-controlled-trial, we evaluated ultrasound (US) measurements of carotid atherosclerosis in subjects following TIA or mild non-disabling stroke and their relationship with risk factors before and after 6-months of CCR. METHODS: Carotid ultrasound (US) measurements of one-dimensional intima-media-thickness (IMT), two-dimensional total-plaque-area (TPA), three-dimensional total-plaque-volume (TPV) and vessel-wall-volume (VWV) were acquired before and after 6-months CCR for 39 subjects who had previously experienced a TIA and provided written informed consent to participate in this randomized controlled trial. We maintained blinding for this ongoing study by representing treatment and control groups as A or B, although we did not identify which of A or B was treatment or control. Carotid IMT, TPA, TPV and VWV were measured before and after CCR as were changes in body mass index (BMI), total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TG), systolic blood pressure (SBP) and diastolic blood pressure (DBP). RESULTS: There were no significant differences in US measurements or risk factors between groups A and B. There was no significant change in carotid ultrasound measurements for group A (IMT, p = .728; TPA, p = .629; TPV, p = .674; VWV, p = .507) or B (IMT, p = .054; TPA, p = .567; TPV, p = .773; VWV, p = .431) at the end of CCR. There were significant but weak-to-moderate correlations between IMT and VWV (r = 0.25, p = .01), IMT and TPV (r = 0.21, p = .01), TPV and TPA (r = 0.60, p < .0001) and VWV and TPV (r = 0.22, p = .02). Subjects with improved TC/HDL ratios showed improved carotid VWV although, this was not statistically significant. CONCLUSION: In this preliminary evaluation, there were no significant differences in carotid US measurements in the control or CCR group; a larger sample size and/or longer duration is required to detect significant changes in US or other risk factor measurements.

Neural substrates of spoken language rehabilitation in an aphasic patient: an fMRI study.

Little is known about the neural counterparts of speech therapy in aphasic patients. An fMRI experiment was performed before and after a specific and intensive speech output therapy in RC, a patient with long-lasting speech output deficit following a left-sided ischemic lesion. Overt picture naming and picture/word rhyming were used as activation tasks in RC and 6 control subjects. The naming task concerned the output lexicon deficit to be rehabilitated while rhyming referred to preserved levels of processing and was used to control for repetition effect. The speech therapy program improved naming performance. By comparison to the pattern observed before therapy, the naming task after therapy induced a pattern of activation close to that observed in control subjects, involving left-sided language areas surrounding the lesion. Speech therapy effect was associated with activations in Broca's area and the left supra-marginal gyrus, which might reflect a therapy-induced phonological compensatory strategy for naming.

Síndrome de Eagle: relato de caso / Eagle's syndrome: report of a case

A síndrome de Eagle é caracterizada pela calcificação do ligamento estilohioídeo, causando limitação dos movimentos cervicais e dores intensas na região. Normalmente é confundida clinicamente com distúrbios de outra ordem, tais como as alterações das articulações temporomandibulares. O diagnóstico dessa entidade é basicamente clínico e radiográfico. Neste trabalho, relatamos um caso da síndrome, bem como uma breve revisão da literatura, ressaltando a importância do diagnóstico dessa entidade incomum, com o objetivo de fornecer aos profissionais maiores informações no que diz respeito ao diagnóstico diferencial e, conseqüentemente ao tratamento correto das dores orofaciais

Silent myocardial ischemia during rehabilitation for cerebrovascular disease.

In asymptomatic patients the importance of silent ischemic ST-T wave changes on Holter monitoring is known to be a significant predictive variable for one-year mortality of postmyocardial infarction patients. This case report represents the uses of ambulatory ECG to detect ischemic ST changes in patients who have had recent strokes. The cases reported here of silent myocardiac ischemia in stroke patients reflect previous reports in which 70% of the ischemic episodes in patients with symptomatic coronary artery disease are not associated with angina and in which approximately 10% to 15% of acute myocardial infarctions are silent. We now believe that the incidence of "silent" ischemia may be precipitated in poststroke patients during their rehabilitation program. This belief is supported by two main factors. First, a high level of personally relevant mental stress exists which activates the sympathoadrenal system, which may lead to myocardial ischemia. Second, some stroke patients become aphasic and are unable to communicate adequately even if they experience angina symptoms. We have found that poststroke, most patients could not undergo exercise treadmill testing secondary to a variety of factors: inability to coordinate limbs, poor endurance, inability to follow directions, and/or lack of attention. We now propose that 24-hour monitoring for ST-T wave changes poststroke should be considered as part of a vigorous investigation for myocardial ischemia during the rehabilitation of these patients because they have an increased risk of cardiac morbidity.