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Annals of Vascular Surgery Oct 2023To measure the impact of the COVID-19 pandemic on the management of patients with carotid artery stenosis.
BACKGROUND
To measure the impact of the COVID-19 pandemic on the management of patients with carotid artery stenosis.
METHODS
We prospectively collected data from 25 centers (19 centers in the United States and 6 centers internationally) on postponed carotid artery operations between March 2020 and January 2022. We describe the characteristics of these patients and their planned operations, along with outcomes including mortality and neurological deterioration during the period of operative delay due to the COVID-19 pandemic.
RESULTS
A total of 1,220 vascular operations were postponed during the pandemic, of them 96 patients presented with significant carotid stenosis (median stenosis of 71%; interquartile range; 70-80) and 80% of them were planned for carotid endarterectomy. Most patients were asymptomatic (69%), and 31% of patients were symptomatic (16% of patients had a stroke, 15% of patients had a transient ischemic attack, and 1% of patients experienced amaurosis fugax). The median length of surgical delay was 71 days (interquartile range: 45.5, 115.5). At the data entry time, 62% of patients had their carotid operations postponed and successfully completed. Most postponements (72%) were due to institutional policies aimed at resource conservation. During the delay, no patient decompensated or required an urgent operation. A total of 5 patients (5%) with carotid stenosis died while awaiting operations due to COVID-19.
CONCLUSIONS
Our study of a cohort of patients with carotid artery stenosis who underwent a median delay of 71 days during the COVID-19 pandemic showed a disparate operation delay between US regions and internationally, most postponements were due to hospital policy, and none of the patients deteriorated or required an emergency surgery during the delay.
Topics: Humans; Carotid Stenosis; Pandemics; Treatment Outcome; COVID-19; Ischemic Attack, Transient; Endarterectomy, Carotid; Stroke; Carotid Arteries
PubMed: 37355018
DOI: 10.1016/j.avsg.2023.05.041 -
Cephalalgia : An International Journal... Dec 2023Retinal migraine is a diagnosis of exclusion and is characterized by repeated episodes of transient monocular blindness associated with migraine. We report a case of...
BACKGROUND
Retinal migraine is a diagnosis of exclusion and is characterized by repeated episodes of transient monocular blindness associated with migraine. We report a case of systemic lupus erythematosus with acute episodes mimicking retinal migraines.
CASE REPORT
A 46-year-old woman with a history of migraine with aura since her 20s and Evans syndrome presented with episodic transient monocular blindness. Retinal migraine was considered as the cause, and migraine prophylaxis initially reduced its frequency. After 5 months, the frequency increased, with chilblain-like lupus lesions on her extremities. Laboratory testing revealed lymphopenia and hypocomplementemia, fulfilling the diagnostic criteria for systemic lupus erythematosus, which may have caused Evans syndrome and transient monocular blindness, mimicking retinal migraines. After intravenous methylprednisolone and rituximab therapy, the transient monocular blindness episodes did not recur.
CONCLUSION
Given the clinical presentation, systemic lupus erythematosus should be considered as a cause of transient monocular blindness and should be distinguished from retinal migraine.
Topics: Humans; Female; Middle Aged; Amaurosis Fugax; Lupus Erythematosus, Systemic; Vision Disorders; Migraine Disorders
PubMed: 38069834
DOI: 10.1177/03331024231219477 -
Journal of Neuro-ophthalmology : the... Dec 2023
Topics: Humans; Amaurosis Fugax; Constriction, Pathologic; Posterior Cerebral Artery; Carotid Artery, Internal; Carotid Stenosis; Cerebrovascular Disorders; Blindness
PubMed: 35439227
DOI: 10.1097/WNO.0000000000001566 -
Journal of Vascular Surgery Feb 2024The aim of this study was to investigate the natural history of internal carotid artery (ICA) stenosis progression.
OBJECTIVE
The aim of this study was to investigate the natural history of internal carotid artery (ICA) stenosis progression.
METHODS
This single-institution retrospective cohort study analyzed patients diagnosed with ICA stenosis of 50% or greater on duplex ultrasound from 2015 to 2022. Subjects were drawn from our institutional Intersocietal Accreditation Commission-accredited noninterventional vascular laboratory database. Primary outcomes were incidences of disease progression, and stroke or revascularization after index study. Progression was defined as an increase in stenosis classification category. Imaging, demographic, and clinical data was obtained from our institutional electronic medical record via a database mining query. Cases were analyzed at the patient and artery levels, with severity corresponding to the greatest degree of ICA stenosis on index and follow-up studies.
RESULTS
Of 577 arteries in 467 patients, mean cohort age was 73.5 ± 8.9 years at the time of the index study, and 45.0% (n = 210) were female. Patients were followed with duplex ultrasound for a mean of 42.2 ± 22.7 months. Of 577 arteries, 65.5% (n = 378) at the index imaging study had moderate (50%-69%) stenosis, 23.7% (n = 137) had severe (70%-99%) stenosis, and 10.7% (n = 62) were occluded. These three groups had significant differences in age, hypertension, hyperlipidemia prevalence, and proportion on best medical therapy. Of the 467-patient cohort, 56.5% (n = 264) were on best medical therapy, defined as smoking cessation, treatment with an antiplatelet agent, statin, and antihypertensive and glycemic agents as indicated. Mean time to progression for affected arteries was 28.0 ± 20.5 months. Of those arteries with nonocclusive disease at diagnosis, 21.3% (n = 123) progressed in their level of stenosis. Older age, diabetes, and a history of vasculitis were associated with stenosis progression, whereas antiplatelet agent use trended towards decreased progression rates. Of the 467 patients, 5.6% (n = 26) developed symptoms; of those, 38.5% (n = 10) had ischemic strokes, 26.9% (n = 7) had hemispheric transient ischemic attacks, 11.5% (n = 3) had amaurosis fugax, and 23.1% (n = 6) had other symptoms. A history of head and neck cancer was positively associated with symptom development. Of 577 affected arteries, 16.6% (n = 96) underwent intervention; 81% (n = 78) of interventions were for asymptomatic disease and 19% (n = 18) were for symptomatic disease. No patient-level factors were associated with risk of intervention.
CONCLUSIONS
A significant number of carotid stenosis patients experience progression of disease. Physicians should consider long-term surveillance on all patients with carotid disease, with increased attention paid to those with risk factors for progression, particularly those with diabetes and a history of vasculitis.
Topics: Humans; Female; Middle Aged; Aged; Aged, 80 and over; Male; Carotid Stenosis; Retrospective Studies; Constriction, Pathologic; Platelet Aggregation Inhibitors; Carotid Artery, Internal; Disease Progression; Ultrasonography, Doppler, Duplex; Risk Factors; Diabetes Mellitus; Vasculitis
PubMed: 37925038
DOI: 10.1016/j.jvs.2023.10.059 -
Journal of Vascular Surgery Jun 2024Plaque ulceration in carotid artery stenosis is a risk factor for cerebral ischemic events; however, the characteristics that determine plaque vulnerability are not...
OBJECTIVE
Plaque ulceration in carotid artery stenosis is a risk factor for cerebral ischemic events; however, the characteristics that determine plaque vulnerability are not fully understood. We thus assessed the association between plaque ulceration sites and cerebrovascular ischemic attack.
METHODS
We retrospectively collected the clinical data of 72 consecutive patients diagnosed with carotid artery stenosis with plaque ulcers. After excluding patients with pseudo-occlusion, a history of previous carotid endarterectomy (CEA) or carotid artery stenting (CAS) before the ulcer was first discovered, follow-up data of less than 1 month, or CEA or CAS performed within 1 month after the ulcer was first discovered, 60 patients were ultimately included. Patients were divided into proximal and distal groups based on the ulcer location relative to the most stenotic point. The primary endpoints were ipsilateral cerebrovascular ischemic events ("ischemic events"), such as amaurosis fugax, transient ischemic attack, or ischemic stroke due to carotid artery stenosis with plaque ulceration. The association between ulcer location and ischemic events was also assessed.
RESULTS
In the patients with plaque ulcer, more patients had proximal than distal plaque ulcers (39 vs. 21, p=0.028). The median follow-up duration was 3.8 (interquartile range: 1.5-6.2) years. Nineteen patients (32%) experienced ischemic event. Ischemic events occurred more frequently in the distal than in the proximal group (18% vs. 59%; p=0.005). Kaplan-Meier curves demonstrated a significantly shorter event-free time in the distal group (log-rank p=0.021). In univariate analysis, distal ulcer location was associated with ischemic events (odds ratio [OR]: 2.94, 95% confidence interval [CI]: 1.13-7.65, p=0.03). Multivariate analysis using two different models also showed that distal ulcer location was independently associated with ischemic events (Model 1, OR: 3.85, 95%CI: 1.26-11.78, p=0.03; Model 2, OR: 4.31, 95%CI: 1.49-12.49, p=0.009).
CONCLUSIONS
Patients with carotid artery stenosis and plaque ulcers located distal to the most stenotic point are more likely to experience cerebrovascular ischemic attacks. Therefore, carotid plaques with ulcers located distal to the most stenotic point may be a potential indication for surgical treatment.
PubMed: 38852894
DOI: 10.1016/j.jvs.2024.06.004 -
Diagnosis and Treatment of Ophthalmic Artery Stenosis Causing Recurrent Ipsilateral Amaurosis Fugax.Journal of Neuro-ophthalmology : the... Apr 2024
PubMed: 38578705
DOI: 10.1097/WNO.0000000000002141 -
Romanian Journal of Internal Medicine =... Mar 2024Optic perineuritis is the inflammation of the optic nerve sheath. This affliction can lead to visual field impairment and other signs and symptoms related to the orbital... (Review)
Review
Optic perineuritis is the inflammation of the optic nerve sheath. This affliction can lead to visual field impairment and other signs and symptoms related to the orbital space, such as pain, disc edema, ophthalmoplegia, proptosis. However, not all patients present with such suggestive symptoms, requiring a thorough assessment. We report the case of a young male admitted to our hospital for recurrent episodes of monocular blindness. Amaurosis fugax is a well-known presentation of transient ischemic attacks (TIA) and it was ruled out. Gadolinium-enhanced MRI revealed a typical aspect of optic perineuritis. It was mandatory to consider all possible causes of secondary optic perineuritis as they all represent serious clinical conditions, even if the idiopathic form is more frequent. The clinical and paraclinical evaluation of the patient excluded an underlying disease and primary optic perineuritis was diagnosed. Corticosteroid therapy is usually curative and a course of methylprednisolone was initiated for our patient with good outcome. However, response to treatment is not diagnostic as both primary and secondary optic perineuritis are normally responsive, hence thorough differential diagnosis is necessary.
Topics: Humans; Male; Amaurosis Fugax; Gadolinium; Methylprednisolone; Inflammation; Magnetic Resonance Imaging
PubMed: 37906620
DOI: 10.2478/rjim-2023-0026 -
Cureus Aug 2023In this case report, we highlight a case of a 24-year-old primigravida who suffered a sudden and painless loss of vision and headache in the immediate postpartum period....
In this case report, we highlight a case of a 24-year-old primigravida who suffered a sudden and painless loss of vision and headache in the immediate postpartum period. Vision loss was transient and remarkable. Her brain magnetic resonance imaging revealed vasogenic edema in parieto-occipital white matter, suggestive of posterior reversible encephalopathy syndrome. Posterior reversible encephalopathy syndrome is a clinical-radiological entity, having hemodynamic catastrophe also known as reversible posterior cerebral edema syndrome. It tends to occur during pregnancy complicated by eclampsia. Hypertension and a hypercoagulable tendency tend to engulf the entire homeostasis into its deadly clutches sending the autoregulation into a frizzy. It presents with a gamut of red flags like headache, seizures, encephalopathy, amaurosis fugax, cortical visual disturbances, and even blindness. Clinical improvement was seen with supportive treatment in this patient. Thus, timely diagnosis and intervention help reverse the dire consequences.
PubMed: 37727199
DOI: 10.7759/cureus.43703 -
Cureus Nov 2023Introduction Carotid endarterectomy (CEA) is the gold standard intervention for patients experiencing transient ischemic attacks (TIAs) or embolic strokes with >50%...
Introduction Carotid endarterectomy (CEA) is the gold standard intervention for patients experiencing transient ischemic attacks (TIAs) or embolic strokes with >50% internal carotid artery (ICA) stenosis supplying index hemispheric territory. The recommended period for CEA is 14 days post-index event; this period carries a heightened risk for second ischemic events. However, implementation of this stringent timeline often encounters delays stemming from multifaceted factors. The centralization of vascular services, designed to enhance patient care, introduces a paradigm shift. Centralization's efficacy in improving patient outcomes, particularly in the CEA pathway, is a subject of ongoing investigation. Our study aims to discern the impact of centralized services on the timeliness of CEA for symptomatic carotid artery stenosis, shedding light on this complex interplay of factors. Methods This retrospective study analyzed CEA data at the Bedfordshire, Luton, and Milton Keynes Vascular Network between January 2021 and June 2023. Eligible patients exhibited symptomatic carotid artery stenosis, with asymptomatic cases; those unfit for surgery or receiving best medical therapy only were excluded. Patients were categorized by their primary referral location: Hub, Spoke-1, or Spoke-2. Demographic and referral data were collected, and timelines from symptom onset to surgery were recorded. Continuous variables were expressed as means and standard deviations, and categorical variables as counts and percentages. Box plots illustrated the relationship between referral origin and surgery timing, and the Classification and Regression Tree (CART) assessed second events. Statistical significance was determined using Fisher's exact and chi-square tests, with p<0.05 indicating significance. Results A total of 148 patients underwent CEA after implementing exclusion criteria. 35.5% (n=53) of patients were referred from the Hub, while 45.6% (n=67) and 18.8% (n=28) were from Spoke-1 and Spoke-2, respectively. 40% (n=59) received CEA within the recommended timeframe, and 15.4% (n=23) experienced a second ischemic event pre-surgery. Time from TIA clinic review to referral was 5.5±8 days and 16.4±20 days from vascular referral to surgery. Patterns of delays were observed, with Spoke-2 exhibiting the most significant delays. Notably, amaurosis fugax and embolic stroke correlated with recurrent ischemic events, emphasizing the importance of timely care in CEA. Conclusion Our study underscores the significant benefits and challenges of the Hub and Spoke model in vascular surgery. The growing referral delays from Spoke sites are concerning, emphasizing the need for a multi-disciplinary team approach within Spoke sites to ensure efficient and standardized care delivery.
PubMed: 38050531
DOI: 10.7759/cureus.49726 -
Retinal Cases & Brief Reports Sep 2023To describe a case of paracentral acute middle maculopathy and ocular ischemic syndrome after intranasal steroid injection. (Review)
Review
PURPOSE
To describe a case of paracentral acute middle maculopathy and ocular ischemic syndrome after intranasal steroid injection.
METHODS
Case report.
RESULTS
Following an intranasal steroid injection, the patient experienced an episode of amaurosis fugax in her right eye lasting several minutes. Afterward, her visual acuity returned to baseline, but she noted a persistent central scotoma. Optical coherence tomography demonstrated paracentral acute middle maculopathy and fluorescein angiography showed staining and leakage to peripheral vessels concerning for diffuse ischemia.
CONCLUSION
Steroid injections to the face and nasopharynx may result in ischemic and vaso-occlusive events in the retina. Ophthalmologists and other physicians performing these procedures need to be aware of this potential adverse outcome.
Topics: Female; Humans; Retinal Diseases; Acute Disease; Vascular Diseases; Ischemia; Retina; Macular Degeneration; Steroids
PubMed: 35199649
DOI: 10.1097/ICB.0000000000001262