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Journal of Vascular Surgery Jan 2020Carotid endarterectomy (CEA) is a well-established procedure with prospective randomized data demonstrating the benefit of stroke prevention. With the aging of the...
OBJECTIVE
Carotid endarterectomy (CEA) is a well-established procedure with prospective randomized data demonstrating the benefit of stroke prevention. With the aging of the population, there are limited data published for nonagenarians, especially for asymptomatic stenosis. This study investigated 30-day morbidity and mortality as well as late survival in symptomatic and asymptomatic nonagenarians with severe carotid stenosis undergoing CEA.
METHODS
A retrospective review was conducted of a single vascular surgery group's registry involving multiple hospitals between November 1994 and June 2017 for all primary CEAs of patients ≥90 years old at the time of surgery. The exclusion criterion was redo surgery or bilateral CEAs. Demographic data, sex, symptoms, risk factors, and postoperative complications were analyzed. Survival analysis was conducted using SPSS software (IBM Corp, Armonk, NY) for the specific end point 30-day morbidity or mortality and late survival.
RESULTS
There were 77 patients (44 male [57%]) who underwent CEA for symptomatic (44 [57%]) and asymptomatic (33 [43%]) internal carotid artery stenosis with a median age of 92 years; 23 women were symptomatic compared with 21 men, and 23 men were asymptomatic compared with 10 women. Symptomatic patients included amaurosis fugax (n = 3), stroke (n = 16), and transient ischemic attack (n = 25). CEAs were performed using the eversion technique under cervical block with selective shunting. The 30-day morbidity included one (2.3%) nonfatal myocardial infarction and one (2.3%) ischemic stroke in the symptomatic group compared with one (3%) patient having a nonfatal myocardial infarction and none with ischemic stroke in the asymptomatic group. One patient of the symptomatic group required return to the operating room for hematoma evacuation. The 30-day mortality was 2.3% in the symptomatic group compared with 6.1% in the asymptomatic group. There was no statistical difference in survival based on sex (P = .444). The symptomatic and asymptomatic groups had similar median survival of 27.7 months and 29.4 months (P = .987), respectively.
CONCLUSIONS
The aging population adds increasing difficulty in decision-making for surgical intervention on carotid stenosis. CEA in nonagenarians is associated with reasonably low 30-day rates of ischemic stroke and myocardial infarction in our small study. However, enthusiasm for asymptomatic CEA in this population must be tempered by low survival rates.
Topics: Age Factors; Aged, 80 and over; Asymptomatic Diseases; Brain Ischemia; Carotid Stenosis; Clinical Decision-Making; Endarterectomy, Carotid; Female; Humans; Male; Myocardial Infarction; Patient Selection; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Stroke; Time Factors; Treatment Outcome
PubMed: 31611107
DOI: 10.1016/j.jvs.2019.07.083 -
Journal of Clinical Medicine Aug 2022To determine the associations among carotid stenosis, stroke, and myocardial infarction (MI) in patients with amaurosis fugax (AF).
BACKGROUND
To determine the associations among carotid stenosis, stroke, and myocardial infarction (MI) in patients with amaurosis fugax (AF).
METHODS
We retrospectively reviewed the records of patients diagnosed as having AF between January 2000 and December 2019. Among 14,857 patients with AF initially reviewed in the database, only 173 were ultimately enrolled, after excluding patients with wrong diagnosis, insufficient medical records, or loss of follow-up.
RESULTS
Of the 173 patients with AF, 61 (35.3%) had carotid stenosis, and among them, 18 (10.4%) had severe stenosis. In multivariate regression analysis, carotid stenosis was significantly associated with age ( = 0.009), male sex ( = 0.006), and ischemic heart disease ( = 0.039). Sixteen (9.2%) patients experienced a stroke after AF diagnosis (mean time to stroke: 23.1 ± 31.1 months, range: 1 day~85 month), 11 (68.8%) of whom had carotid artery stenosis ( = 0.003). Three (1.7%) patients had MI after AF (mean time to MI: 24.8 ± 35.9 months, range: 12 days~66 months), none of whom had carotid artery stenosis ( = 0.553). Four (2.3%) patients had central retinal artery occlusion (CRAO) after AF, all of whom had carotid artery stenosis ( = 0.034).
CONCLUSIONS
A high incidence of internal carotid artery stenosis was observed after AF attack and was significantly associated with stroke. The incidence of MI and CRAO after AF was low. Among them, only CRAO was associated with carotid artery stenosis.
PubMed: 36079019
DOI: 10.3390/jcm11175088 -
Neurological Research and Practice May 2024Retinal artery occlusions lead to sudden, painless vision loss, affecting millions globally. Despite their significance, treatment strategies remain unestablished,...
BACKGROUND
Retinal artery occlusions lead to sudden, painless vision loss, affecting millions globally. Despite their significance, treatment strategies remain unestablished, contrasting with acute ischemic stroke (AIS), where IVT has proven efficacy. Similar to AIS, retinal artery occlusions demand urgent evaluation and treatment, reflecting the principle "time is retina". Even for patients with transient monocular vision loss, also known as amaurosis fugax (AF), pertinent guidelines meanwhile recommend immediate emergency assessment in a specialized facility. However, data on the clinical benefit and comparability with persistent occlusions are missing. This study aimed to compare the results of a comprehensive stroke-workup among patients with persistent retinal artery occlusions (RAO), including both central retinal (CRAO) and branch retinal artery occlusion (BRAO) and those with AF.
METHODS
Conducted at the University Hospital Giessen, Germany, this exploratory cross-sectional study enrolled patients with transient or permanent unilateral vision loss of non-arteritic origin. The primary outcome were differences between the two groups RAO and AF with regard to cardiovascular risk profiles and comorbidities, vascular and pharmacological interventions and clinical neurological and ophthalmological outcomes. Secondary outcome was a sub-group analysis of patients receiving IVT.
RESULTS
Out of 166 patients assessed, 76 with RAO and 40 with AF met the inclusion criteria. Both groups exhibited comparable age, gender distribution, and cardiovascular risk profiles. Notably, RAO patients did not show significantly more severe vascular comorbidities than AF patients. However, AF patients received vascular interventions more frequently. Pharmacological intervention rates were similar across groups. RAO patients had slightly worse neurological outcomes, and IVT did not yield favorable ophthalmological outcomes within any observed patients.
CONCLUSION
The study found similar vascular burden and risk factors in patients with RAO and AF, with implications for clinical workflows. IVT for RAO may only be effective in very early treatment windows. This emphasizes the need for public awareness and collaborative protocols between ophthalmologists and neurologists to improve outcomes.
PubMed: 38750601
DOI: 10.1186/s42466-024-00326-3 -
Cureus Jun 2022There are many causes of amaurosis fugax, including polycythemia. Polycythemia is associated with elevated hematocrit levels and hyperviscosity, which can lead to ocular...
There are many causes of amaurosis fugax, including polycythemia. Polycythemia is associated with elevated hematocrit levels and hyperviscosity, which can lead to ocular manifestations. We report a polycythemia patient with amaurosis fugax, who had resolution of ocular symptoms following venesection. A 29-year-old gentleman presented with a six-month history of episodic bilateral transient loss of vision (amaurosis fugax), followed by slow recovery back to normal after 15-20 minutes. The symptoms worsened with fatigue. He also had an unsteady gait for the preceding one year. Ocular examination was unremarkable. His visual acuity was 20/20 OU. Neurological examination revealed gait ataxia and dysdiadochokinesia. Computed tomography (CT) angiogram showed an old cerebellar infarct. Blood investigations showed persistent elevated hemoglobin and hematocrit with positive JAK-2 V617F mutation. Infective and connective tissue workups were all negative. A diagnosis of polycythemia was made by the haematology team. In addition to oral aspirin given by the neurology team, he underwent venesection with improvement in ocular symptoms following each episode of venesection. The frequency of amaurosis fugax reduced from 2-3 episodes a week to once a month, then resolved completely after five venesections. Systemically, his cerebellar symptoms also resolved and there were no neurological deficits. Polycythemia is a rare disease that can cause amaurosis fugax and thrombotic events in young patients. Better knowledge and accurate diagnosis are important, as early treatment may improve the symptoms and long-term morbidity.
PubMed: 35812629
DOI: 10.7759/cureus.25752 -
Ophthalmology and Therapy Jun 2024Transient monocular visual loss (TMVL), also known as transient monocular blindness or amaurosis fugax ("fleeting blindness"), is a temporary loss of vision often due to... (Review)
Review
Transient monocular visual loss (TMVL), also known as transient monocular blindness or amaurosis fugax ("fleeting blindness"), is a temporary loss of vision often due to ischemia to the retina. While acute TMVL should be considered an emergency that further requires exhaustive investigation, there are some cases in which TMVL arises secondary to benign causes. Age has a major impact in the diagnosis of ischemia and although the differential diagnosis of TMVL can be broad, timely and appropriate history, examination, diagnostic testing, and treatment can be vision- or life-saving. We review the causes of TMVL and the impact of age on the differential diagnoses and management.
PubMed: 38587773
DOI: 10.1007/s40123-024-00932-z -
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 Vascular Surgery May 2021The current recommendations are to perform carotid endarterectomy within 2 weeks of symptoms for maximum long-term stroke prevention, although urgent carotid... (Comparative Study)
Comparative Study
OBJECTIVE
The current recommendations are to perform carotid endarterectomy within 2 weeks of symptoms for maximum long-term stroke prevention, although urgent carotid endarterectomy within 48 hours has been associated with increased perioperative stroke. With the development and rapid adoption of transcarotid artery revascularization (TCAR), we decided to study the effect of timing on the outcomes after TCAR.
METHODS
The Vascular Quality Initiative database was searched for symptomatic patients who had undergone TCAR from September 2016 to November 2019. These patients were stratified by the interval to TCAR after symptom onset: urgent, within 48 hours; early, 3 to 14 days; and late, >14 days. The primary outcome was the in-hospital rate of combined stroke and death (stroke/death), evaluated using logistic regression analysis. The secondary outcome was the 1-year rate of recurrent ipsilateral stroke and mortality, evaluated using Kaplan-Meier survival analysis.
RESULTS
A total of 2608 symptomatic patients who had undergone TCAR were included. The timing was urgent for 144 patients (5.52%), early for 928 patients (35.58%), and late for 1536 patients (58.90%). Patients undergoing urgent intervention had an increased risk of in-hospital stroke/death, which was driven primarily by an increased risk of stroke. No differences were seen for in-hospital death. On adjusted analysis, urgent intervention resulted in a threefold increased risk of stroke (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.3-6.2; P = .01) and a threefold increased risk of stroke/death (OR, 2.9; 95% CI, 1.3-6.4; P = .01) compared with late intervention. Patients undergoing early intervention had comparable risks of stroke (OR, 1.3; 95% CI, 0.7-2.3; P = .40) and stroke/death (OR, 1.2; 95% CI, 0.7-2.1; P = .48) compared with late intervention. On subset analysis, the type of presenting symptoms was an effect modifier. Patients presenting with stroke and those presenting with transient ischemic attack or amaurosis fugax both had an increased risk of stroke/death when undergoing urgent compared with late TCAR (OR, 2.7; 95% CI, 1.1-6.6; P = .04; and OR, 4.1; 95% CI, 1.1-15.0; P = .03, respectively). However only patients presenting with transient ischemic attack or amaurosis fugax had experienced an increased risk of stroke with urgent compared with late TCAR (OR, 5.0; 95% CI, 1.4-17.5; P < .01). At 1 year of follow-up, no differences were seen in the incidence of recurrent ipsilateral stroke (urgent, 0.7%; early, 0.2%; late, 0.1%; P = .13) or postdischarge mortality (urgent, 0.7%; early, 1.6%; late, 1.8%; P = .71).
CONCLUSIONS
We found that TCAR had a reduced incidence of stroke when performed 48 hours after symptom onset. Urgent TCAR within 48 hours of the onset of stroke was associated with a threefold increased risk of in-hospital stroke/death, with no added benefit for ≤1 year after intervention. Further studies are needed on long-term outcomes of TCAR stratified by the timing of the procedure.
Topics: Aged; Aged, 80 and over; Carotid Artery Diseases; Databases, Factual; Endovascular Procedures; Female; Hospital Mortality; Humans; Incidence; Male; Middle Aged; Myocardial Infarction; Retrospective Studies; Risk Assessment; Risk Factors; Stents; Stroke; Time Factors; Time-to-Treatment; Treatment Outcome
PubMed: 33038481
DOI: 10.1016/j.jvs.2020.08.148 -
Radiology Oct 2022Background MRI and fluorine 18-labeled sodium fluoride (F-NaF) PET can be used to identify features of plaque instability, rupture, and disease activity, but large... (Observational Study)
Observational Study
Background MRI and fluorine 18-labeled sodium fluoride (F-NaF) PET can be used to identify features of plaque instability, rupture, and disease activity, but large studies have not been performed. Purpose To evaluate the association between F-NaF activity and culprit carotid plaque in acute neurovascular syndrome. Materials and Methods In this prospective observational cohort study (October 2017 to January 2020), participants underwent F-NaF PET/MRI. An experienced clinician determined the culprit carotid artery based on symptoms and record review. F-NaF uptake was quantified using standardized uptake values and tissue-to-background ratios. Statistical significance was assessed with the Welch, χ, Wilcoxon, or Fisher test. Multivariable models were used to evaluate the relationship between the imaging markers and the culprit versus nonculprit vessel. Results A total of 110 participants were evaluated (mean age, 68 years ± 10 [SD]; 70 men and 40 women). Of the 110, 34 (32%) had prior cerebrovascular disease, and 26 (24%) presented with amaurosis fugax, 54 (49%) with transient ischemic attack, and 30 (27%) with stroke. Compared with nonculprit carotids, culprit carotids had greater stenoses (≥50% stenosis: 30% vs 15% [ = .02]; ≥70% stenosis: 25% vs 4.5% [ < .001]) and had increased prevalence of MRI-derived adverse plaque features, including intraplaque hemorrhage (42% vs 23%; = .004), necrotic core (36% vs 18%; = .004), thrombus (7.3% vs 0%; = .01), ulceration (18% vs 3.6%; = .001), and higher F-NaF uptake (maximum tissue-to-background ratio, 1.38 [IQR, 1.12-1.82] vs 1.26 [IQR, 0.99-1.66], respectively; = .04). Higher F-NaF uptake was positively associated with necrosis, intraplaque hemorrhage, ulceration, and calcification and inversely associated with fibrosis ( = .04 to < .001). In multivariable analysis, carotid stenosis at or over 70% (odds ratio, 5.72 [95% CI: 2.2, 18]) and MRI-derived adverse plaque characteristics (odds ratio, 2.16 [95% CI: 1.2, 3.9]) were both associated with the culprit versus nonculprit carotid vessel. Conclusion Fluorine 18-labeled sodium fluoride PET/MRI characteristics were associated with the culprit carotid vessel in study participants with acute neurovascular syndrome. Clinical trial registration no. NCT03215550 and NCT03215563 © RSNA, 2022
Topics: Aged; Carotid Arteries; Constriction, Pathologic; Female; Fluorine; Fluorine Radioisotopes; Humans; Magnetic Resonance Imaging; Male; Plaque, Atherosclerotic; Positron-Emission Tomography; Prospective Studies; Sodium Fluoride
PubMed: 35670715
DOI: 10.1148/radiol.212283