摘要:

The value of carotid endarterectomy in asymptomatic patients with high-grade stenosis is controversial. The objective of this study is to compare the immediate and long-term outcome of patients after carotid endarterectomy for asymptomatic carotid stenosis (>75%) with the reported natural history of patients followed nonoperatively to determine whether carotid endarterectomy reduces the subsequent neurological event rate.MethodsThe data from 141 carotid endarterectomies performed in 123 patients between January 1980 and December 1986 were reviewed from the perspective of perioperative results and long-term follow-up to January 1990, providing a follow-up ranging from 3 to 10 years. The mean follow-up was 56.6 months (range 27-117 months).ResultsThere were no perioperative deaths. There were two postoperative strokes: one in the cerebellar distribution and one in the middle cerebral distribution. During the course of follow-up, no patient suffered a stroke in the hemisphere ipsilateral to carotid endarterectomy. One patient developed ipsilateral transient ischemic attacks 24 months after surgery associated with carotid restenosis. A total of three patients developed four recurrent carotid stenoses, for an incidence of 2.8%. All four recurrences were corrected surgically.ConclusionsThese findings are in marked contrast to the reported natural history of patients with >75% stenosis in which the 1-year neurological event rate is 18% and the 1-year stroke rate is 5%. Although final proof of efficacy for prophylactic carotid endarterectomy in asymptomatic patients will await the outcome of randomized trials, until these data are available, prophylactic carotid endarterec-tomy is justified in centers of excellence that can perform the surgery with low perioperative risk.

ISSN:0039-2499    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Silent cerebral infarction is often found on computed tomographic scan in patients with asymptomatic carotid stenosis, but its relation to the arterial stenosis is uncertain.MethodsWe compared computed tomographic scans and carotid Doppler in 115 patients with asymptomatic carotid stenosis, 203 with carotid transient ischemic attacks and carotid stenosis, and 63 with transient ischemic attacks but without carotid stenosis. There was no group with normal carotid arteries for comparison.ResultsLesions seen on CT scan were most common in the transient ischemic attack with carotid stenosis group (47%) compared with the other groups (30%, 19%) (p<0.001). Cerebral infarcts ipsilateral to the carotid stenosis were found in 10% of patients with mild (35-50%) stenosis, 17% in moderate (50-75%) stenosis, and 30% with severe (>75%) carotid stenosis (p>0.001). In patients with asymptom-atic carotid stenosis, 68% of infarcts were ipsilateral to the stenosis; in those with transient ischemic attacks and carotid stenosis, 86% of infarcts were ipsilateral to the stenosis.ConclusionsThe more severe the carotid stenosis, the higher the incidence of cerebral infarction ipsilateral to the stenosis. This finding applied to central infarcts as well as to peripheral infarcts in both symptomatic and asymptomatic patients. Silent cerebral infarction may be an indication for carotid endarterectomy in asymptomatic patients.

ISSN:0039-2499    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Hyperacute cerebral infarction trials require early differentiation of infarction subtype. Our aim was to determine clinical factors predictive of infarction subtype from data collected in the early hours of admission.MethodsUsing the 1,273 patients enrolled in the Stroke Data Bank, stroke risk factors and demographic, clinical, and radiological features were compared between the 246 cardioembolic and 113 large-vessel atherosclerotic cerebral infarcts.ResultsStroke Data Bank definitions ensured more transient ischemic attacks in atherosclerotic infarcts and more cardiac disease in cardioembolic infarcts, but the diagnosis was distinguished further using a logistic regression model. Fractional arm weakness (shoulder different from hand) (odds ratio 3.1, 95% confidence interval [CI] 1.6-5.8), hypertension (odds ratio 2.8, CI 1.4-5.3), diabetes (odds ratio 2.5, CI 1.2-5.1) and male gender (odds ratio=2.2, CI 1.2-4.1) occurred more frequently in patients with atherosclerotic than cardioembolic infarcts. Reduced consciousness (odds ratio=3.2, CI 1.4-7.3) was more frequent in cardioembolism. For a male patient with hypertension, diabetes, and fractional arm weakness, the estimated odds of an atherosclerotic infarction were 47-fold that of a cardioembolic infarction. Patients with atherosclerotic infarcts were more likely to have a fractional arm weakness regardless of infarct size, whereas, for those with cardioembolic infarctions, fractional weakness was more frequent in infarcts less than 20 cc in volume.ConclusionsClinical features that are observed at stroke onset can help distinguish cerebral infarction subtypes and may allow for early stratification in therapeutic trials.

ISSN:0039-2499    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Elevated middle cerebral erythrocyte velocities and tissue hypoperfusion have been correlated with delayed ischemia after subarachnoid hemorrhage, but few studies have compared serial arterial velocities with cerebral blood flow and neurological deficits.MethodsSerial measurements of middle cerebral velocities, using transcranial Doppler ultrasonogra-phy, were performed in 34 patients after subarachnoid hemorrhage and correlated with cerebral blood flow, measured in 20 of the 34 using single-photon emission computed tomography with technetium-99m hexamethylpropylene amine oxime and neurological evidence of delayed ischemia.ResultsIn 16 patients without delayed ischemia, eight had evidence of vasospasm (>120 cm/sec), but only one of seven had hypoperfusion, suggesting that vasospasm might be more common than hypoperfusion in this group (p=0.1). In 10 patients with delayed ischemia and a lateralizing deficit, both asymmetrical middle cerebral vasospasm (eight of nine with vasospasm) and hypoperfusion (six of six studied) were concordant with the clinically ischemic hemisphere (p<0.05). Vasospasm occurred with nonlateralized delayed ischemia in seven of eight patients and with hypoperfusion in five of six, affecting the anterior cerebral territory in three.ConclusionsConcordant vasospasm and hypoperfusion were most often present in patients with delayed ischemia and lateralizing neurological deficits. Discordant results reflect inherent limitations and the different levels of the circulation monitored by the two techniques.

ISSN:0039-2499    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

The relation between electroencephalographic pattern changes and cerebral ischemia during carotid endarterectomy under general anesthesia is well established. Pattern changes seen on somatosensory evoked potentials under the same conditions are reported to be more sensitive indicators of cerebral ischemia. We estimated the sensitivity and specificity of somatosensory evoked potentials relative to electroencephalography for detecting cerebral ischemia during carotid endarterec-tomy under general anesthesia.MethodsWe simultaneously monitored electroencephalographs and somatosensory evoked potentials in 53 carotid endarterectomies performed on 51 patients under general anesthesia, and we determined the extent to which somatosensory evoked potentials detected cerebral ischemia defined by electroencepha-lographic pattern changes at the time of carotid cross-clamp.ResultsTwenty-three of the 53 cases studied had electroencephalographic evidence of ischemia following carotid cross-clamp. Ten of these 23 cases had an increased somatosensory evoked potential latency of 0.1 msec or greater (sensitivity 0.43). One of these 23 patients had a decrease in somatosensory evoked potential amplitude of 50% or greater (sensitivity 0.04). Of the 30 subjects who had no electroencephalographic evidence of ischemia, 13 had either no change or a decrease in somatosensory evoked potential latency (specificity 0.45). None of these 30 cases had a significant decrease in somatosensory evoked potential amplitude (specificity 1.0). If somatosensory evoked potential latencies were a sensitive method for detecting cerebral ischemia (true sensitivity of 0.95 or higher), the probability of only 10 subjects having somatosensory evoked potential latency increases would be less than 0.001. Therefore, our observed sensitivity cannot be attributed to chance.ConclusionsWe conclude that measuring somatosensory evoked potentials is not a sensitive method for detecting cerebral ischemia during carotid endarterectomy.

ISSN:0039-2499    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Computed tomography is now routinely used in many hospitals to investigate cerebrovascular disease. The purpose of our prospective study was to determine whether cranial computed tomography in connection with neurological assessment was useful in prognostic evaluation of survival after acute stroke.MethodsTwo-hundred forty-five consecutive stroke patients were included in the project during a 1-year period. Each had a detailed neurological assessment 24-72 hours after stroke onset and underwent cranial computed tomography without intravenous contrast injection within the first week after admission. The lesions were divided according to neuroanatomic regions. In the statistical analyses we used a multiple logistic regression model with survival/death as the binary variable.ResultsComputed tomography showed 76% of the patients had infarcts, 11% had hemorrhages, and 13% had no acute lesion. Forty-three patients had more than one acute lesion, and 57 had one or more old infarctions. The temporal, parietal, and frontal regions and the basal ganglia were most often affected.ConclusionsWe conclude that age, level of consciousness, and involvement of the temporal lobe on computed tomography were factors of prognostic significance regarding survival in the acute phase.

ISSN:0039-2499    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

We studied 12 patients with unilateral cerebellar hemorrhage to look at its effect on regional cerebral blood flow.MethodsWe used single-photon emission computed tomography by continuous inhalation of xenon-133. The blood flow was quantified in the cerebellum and in nine areas of interest on the slice passing through the basal ganglia.ResultsThe comparison of the blood flow values of the patients and control subjects showed a significant reduction in the contralateral hemisphere of the patients, predominantly in the frontal region and in the lenticular nucleus of the contralateral hemisphere but also in the anterointernal frontal area of the ipsilateral hemisphere. The analysis of the asymmetry indexes revealed in the same way significant differences between patients and control subjects in the frontal cortex and in the lenticular nucleus.ConclusionsThese results provided concordant evidence suggesting a blood flow reduction in the contralateral hemisphere. This phenomenon of “crossed hemispheric diaschisis” is probably related to the interruption of cerebellocortical tracts.

ISSN:0039-2499    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Evaluation of biochemical patterns in cerebrospinal fluid may add diagnostic and prognostic information. We tested to determine whether the concentration of superoxide dismutase in cerebrospinal fluid is a marker of brain tissue damage in acute ischemic stroke.MethodsWe investigated 36 acute ischemic stroke patients for cerebrospinal fluid activity of the enzyme superoxide dismutase on two occasions shortly after symptom onset (average, day 1 and day 4).ResultsIn 75% of the patients, the first of two lumbar punctures revealed the maximal superoxide dismutase value. The amount in the cerebrospinal fluid was significantly correlated with the size of infarction on computed tomographic scan (p<0.001 by analysis of variance) and to functional impairment and stroke-related mortality during initial hospital stay (p<0.002). The correlation of initial superoxide dismutase concentration with the need for long-term institutional care and mortality at 3 months after the stroke was also significant (p<0.03).ConclusionsWe conclude that superoxide dismutase in cerebrospinal fluid is a marker of an acute brain lesion and has some value as a prognostic predictor. This small enzyme leaks rapidly from ischemically injured cells.

ISSN:0039-2499    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

The Early Stroke Trial is a randomized, placebo-controlled, double-masked, multicenter study to assess the safety and efficacy of monosialoganglioside in patients who have suffered an ischemic stroke of the cerebral hemispheres.MethodsOnly patients who could be evaluated and treated within 5 hours after the onset of stroke were considered; within each center, subjects were stratified by age, sex, and clinical severity. Patients were randomly allocated to receive a specified sequence of intravenous and intramuscular doses of either monosialoganglioside or identical-appearing placebo for 21 days. Patients were followed up for 4 months after randomization. Neurological status was measured primarily by using the Canadian Neurological Scale. After assessing the effect of treatment on survival, the principal measure of efficacy will be the change in neurological status between baseline and the 4-month follow-up among survivors.ResultsSixteen clinical centers, I5 in Europe and one in North America, entered a total of 792 eligible patients during a 36-month recruitment period (from May 1987 to April 1990). In our series there were more men than women, and the relative frequency of patients increased with advancing age. The most frequently associated cardiovascular conditions were hypertension, atrial fibrillation, and peripheral vascular disease. Approximately 46% of the patients were admitted to a hospital within 1 hour and 81%, within 2 hours after the onset of stroke. About 22% first received the study treatment within 3 hours and 57%, within 4 hours.ConclusionsThis study demonstrates the feasibility of large-scale trials with the onset of treatment within 5 hours after an ischemic stroke.

ISSN:0039-2499    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

This prospective study was designed to describe different aspects of psychosocial function after stroke and the development of changes over time. A major aim has been to identify mental, functional, and social factors associated with low life satisfaction late after stroke.MethodsSocial network, functional ability, leisure-time activities, experience of ill health, major depression, and life satisfaction were assessed repeatedly over 3 years in a population-based sample of 50 long-term survivors of stroke (mean age 71.4 years).ResultsCompared with a general elderly population, patients 3 years poststroke had more psychiatric symptoms, lower functional ability, and reduced life satisfaction. Contacts with children were maintained over the 3-year follow-up period, whereas contacts with friends and neighbors declined early after stroke and remained lower than in the general elderly population (p<0.05). When time dependency was analyzed, activities of daily living and somatic/neurological symptoms were found to change little after 3 months, while psychiatric symptoms showed changes later. Between 3 and 12 months poststroke, the prevalence of major depression decreased, leisure-time activities and social contacts were partly resumed, and life satisfaction improved (p<0.01). Once good life satisfaction was restored it was maintained, and poor life satisfaction at 1 year remained poor for the entire 3 years.ConclusionsIt is concluded that major depression early after stroke, functional disability, and an impaired social network interact to reduce life satisfaction for the long-term survivors of stroke.

ISSN:0039-2499    

出版商:OVID    

年代:1992

数据来源: OVID