scholarly journals Risk of subsequent stroke, with or without extracranial-intracranial bypass surgery: a nationwide, retrospective, population-based study

2019 ◽  
Vol 130 (6) ◽  
pp. 1906-1913 ◽  
Author(s):  
XianXiu Chen ◽  
Cheng-Li Lin ◽  
Yuan-Chih Su ◽  
Kuan-Fei Chen ◽  
Shih-Wei Lai ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
High Risk ◽  
Carotid Artery ◽  
Bypass Surgery ◽  
Hemorrhagic Stroke ◽  
Population Based ◽  
Imaging Data ◽  
Cardiac Events ◽  
Ischemic Brain ◽  
Bypass Group

OBJECTIVEAlthough no benefits of extracranial-intracranial (EC-IC) bypass surgery in preventing secondary stroke have been identified previously, the outcomes of initial symptomatic ischemic stroke and stenosis and/or occlusion among the Asian population in patients with or without bypass intervention have yet to be discussed. The authors aimed to evaluate the subsequent risk of secondary vascular disease and cardiac events in patients with and without a history of this intervention.METHODSThis retrospective nationwide population-based Taiwanese registry study included 205,991 patients with initial symptomatic ischemic stroke and stenosis and/or occlusion, with imaging data obtained between 2001 and 2010. Patients who underwent EC-IC bypass (bypass group) were compared with those who had not undergone EC-IC bypass, carotid artery stenting, or carotid artery endarterectomy (nonbypass group). Patients with any previous diagnosis of ischemic or hemorrhagic stroke, moyamoya disease, cancer, or trauma were all excluded.RESULTSThe risk of subsequent ischemic stroke events decreased by 41% in the bypass group (adjusted hazard ratio [HR] 0.59, 95% CI 0.46–0.76, p < 0.001) compared with the nonbypass group. The risk of subsequent hemorrhagic stroke events increased in the bypass group (adjusted HR 2.47, 95% CI 1.67–3.64, p < 0.001) compared with the nonbypass group.CONCLUSIONSBypass surgery does play an important role in revascularization of the ischemic brain, while also increasing the risk of hemorrhage in the early postoperative period. This study highlights the fact that the high risk of bypass surgery obscures the true benefit of revascularization of the ischemic brain and also emphasizes the importance of developing improved surgical technique to treat these high-risk patients.

Abstract 2771: Incidence of High Risk Atherosclerotic Lesions in Intracranial and Extracranial Carotid Arteries in Patients with Acute Ischemic Stroke: A 3.0T Magnetic Resonance Imaging Study

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Xihai Zhao ◽  
Huilin Zhao ◽  
Feiyu Li ◽  
Jie Sun ◽  
Ye Cao ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
High Risk ◽  
Carotid Artery ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Carotid Arteries ◽  
Atherosclerotic Plaques ◽  
Slice Thickness ◽  
Atherosclerotic Lesions ◽  
Vascular Beds

Introduction Rupture of vulnerable atherosclerotic plaques in the intracranial and extracranial carotid arteries could trigger ischemic stroke. However, the incidence of high risk atherosclerotic lesions in these vascular beds is not well known. This study sought to investigate the incidence of high risk atherosclerotic lesions in intracranial and extracranial carotid arteries in stroke patients using magnetic resonance (MR) imaging. Methods Seventy-five patients (mean age 62.7 years, 56 males) with acute ischemic stroke underwent MR imaging for index carotid arteries, assigned as the same side as the brain lesions, with a Philips 3.0T MR scanner. Intracranial carotid MR angiography was performed using 3D TOF sequence with FOV of 23 × 23 cm 2 , matrix of 256 × 256, and a slice thickness of 1mm. The multi-contrast vessel wall images (3D TOF, T1W, T2W, and MP-RAGE) were acquired for extracranial carotid arteries with FOV of 14 × 14 cm 2 , matrix of 256 × 256, and slice thickness of 2 mm. The intracranial artery includes middle cerebral artery (MCA), anterior cerebral artery (ACA), and posterior cerebral artery (PCA). The extracranial carotid artery was divided into internal carotid artery (ICA), bulb, and common carotid artery (CCA). Luminal stenosis for each intracranial and extracranial carotid segment was measured and graded (normal or mild = 0-29%, moderate =30-69%, severe=70-99%). Normalized wall index (NWI = wall area/total vessel area × 100%), and presence/absence of calcification, lipid-rich necrotic core (LRNC), and intraplaque hemorrhage (IPH) and/or fibrous cap rupture in each extracranial carotid segment were determined. Results MCAs developed more severe stenotic lesions (24.6%), followed by extracranial carotids (16.5%), PCAs (5.4%), and ACAs (4.1%) in stroke patients ( Figure 1 A). For extracranial carotid arteries, ICAs showed the largest plaque burden as measured by NWI (44.3%±13.1%), followed by bulbs (39.4%±13%), and CCAs (37%±6.8%). Compared to CCAs, ICAs and bulb regions had more LRNCs (38.4% and 49.3% for ICA and bulb respectively) and IPH and/or rupture (11% and 9.6% for ICA and bulb respectively) ( Figure 1 B). Conclusions In patients with acute ischemic stroke, high risk atherosclerotic plaques can be found in both intracranial and extracranial carotid arteries, particularly in the MCA, ICA and bulb regions. Compared to extracranial carotid arteries, intracranial arteries develop more high risk lesions. The findings of this study suggest the necessity for early screening to detect high risk atherosclerotic lesions in these carotid vascular beds prior to cerebravascular events.

Early versus Delayed Extracranial-Intracranial Bypass Surgery in Symptomatic Atherosclerotic Occlusion

Neurosurgery ◽  
2018 ◽  
Vol 85 (5) ◽  
pp. 656-663 ◽  
Author(s):  
Cory J Rice ◽  
Sung-Min Cho ◽  
Ather Taqui ◽  
Nina Z Moore ◽  
Alex M Witek ◽  
...  
Keyword(s):  
Bypass Surgery ◽  
Hemorrhagic Stroke ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Inclusion Criteria ◽  
Short Term ◽  
Ischemic Event ◽  
Perioperative Stroke ◽  
Tertiary Referral Center ◽  
Bypass Group

Abstract Background Clinical trials of extracranial-intracranial (EC-IC) bypass surgery studied patients in subacute and chronic stage after ischemic event. OBJECTIVE To investigate the short-term outcomes of EC-IC bypass in progressive acute ischemic stroke or recent transient ischemic attacks. Methods The study was a retrospective review at a single tertiary referral center from 2008 to 2015. Inclusion criteria consisted of EC-IC bypass within 1 yr of last ischemic symptoms ipsilateral to atherosclerotic occlusion of internal carotid or middle cerebral artery. Early bypass group who underwent surgery within 7 d of last ischemic symptoms were compared to late bypass group who underwent surgery >7 d from last ischemic symptom. The primary endpoint was perioperative ischemic or hemorrhagic stroke or intracranial hemorrhage within 7 d of surgery. Results Of 126 patients who underwent EC-IC bypass during the period, 81 patients met inclusion criteria, 69 (85%) persons had carotid artery occlusion, 7 (9%) had proximal MCA occlusion, and 5 (6%) had both. Early surgery had a 31% (9/29) perioperative stroke rate compared to 11.5% (6/52) of patients undergoing late bypass (P = .04). Of patients with acute stroke within 7 d of surgery, 41% (7/17) had perioperative stroke within 7 d (P = .07). Six of nine patients (67%) with blood pressure dependent fluctuation of neurologic symptoms had perioperative stroke (P = .049). Conclusion EC-IC bypass in setting of acute symptomatic stroke within 1 wk may confer higher risk of perioperative stroke. Patients undergoing expedited or urgent bypass for unstable or fluctuating stroke symptoms might be at highest risk for perioperative stroke.

scholarly journals Clinical significance of cerebral microbleeds on MRI: A comprehensive meta-analysis of risk of intracerebral hemorrhage, ischemic stroke, mortality, and dementia in cohort studies (v1)

2018 ◽  
Vol 13 (5) ◽  
pp. 454-468 ◽  
Author(s):  
Andreas Charidimou ◽  
Sara Shams ◽  
Jose R Romero ◽  
Jie Ding ◽  
Roland Veltkamp ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
High Risk ◽  
Intracerebral Hemorrhage ◽  
Meta Analysis ◽  
Population Based ◽  
Cerebral Microbleeds ◽  
Clinical Settings ◽  
Memory Clinic ◽  
Increased Risk ◽  
Stroke Death

Background Cerebral microbleeds can confer a high risk of intracerebral hemorrhage, ischemic stroke, death and dementia, but estimated risks remain imprecise and often conflicting. We investigated the association between cerebral microbleeds presence and these outcomes in a large meta-analysis of all published cohorts including: ischemic stroke/TIA, memory clinic, “high risk” elderly populations, and healthy individuals in population-based studies. Methods Cohorts (with > 100 participants) that assessed cerebral microbleeds presence on MRI, with subsequent follow-up (≥3 months) were identified. The association between cerebral microbleeds and each of the outcomes (ischemic stroke, intracerebral hemorrhage, death, and dementia) was quantified using random effects models of (a) unadjusted crude odds ratios and (b) covariate-adjusted hazard rations. Results We identified 31 cohorts ( n = 20,368): 19 ischemic stroke/TIA ( n = 7672), 4 memory clinic ( n = 1957), 3 high risk elderly ( n = 1458) and 5 population-based cohorts ( n = 11,722). Cerebral microbleeds were associated with an increased risk of ischemic stroke (OR: 2.14; 95% CI: 1.58–2.89 and adj-HR: 2.09; 95% CI: 1.71–2.57), but the relative increase in future intracerebral hemorrhage risk was greater (OR: 4.65; 95% CI: 2.68–8.08 and adj-HR: 3.93; 95% CI: 2.71–5.69). Cerebral microbleeds were an independent predictor of all-cause mortality (adj-HR: 1.36; 95% CI: 1.24–1.48). In three population-based studies, cerebral microbleeds were independently associated with incident dementia (adj-HR: 1.35; 95% CI: 1.00–1.82). Results were overall consistent in analyses stratified by different populations, but with different degrees of heterogeneity. Conclusions Our meta-analysis shows that cerebral microbleeds predict an increased risk of stroke, death, and dementia and provides up-to-date effect sizes across different clinical settings. These pooled estimates can inform clinical decisions and trials, further supporting cerebral microbleeds role as biomarkers of underlying subclinical brain pathology in research and clinical settings.

Symptomatic Carotid Stenosis: Stroke and Transient Ischemic Attack

2019 ◽  
Author(s):  
Kenneth R. Ziegler ◽  
Thomas C. Naslund
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Ct Scan ◽  
Hemorrhagic Stroke ◽  
Fibromuscular Dysplasia ◽  
The United States ◽  
Carotid Artery Dissection ◽  
Artery Dissection ◽  
Ct Angiogram ◽  
Ischemic Attack

Nearly 800,000 strokes are reported in the United States annually, with an economic impact upward of $33 billion. Carotid artery disease, familiar to all vascular surgeons, accounts for just over one fifth of these strokes. However, these cases reflect an opportunity for the surgeon to intervene and mitigate the substantial burden of stroke. This review includes the epidemiology of stroke in the United States and the carotid artery and noncarotid etiologies of stroke, including atherosclerotic disease, fibromuscular dysplasia, carotid artery dissection, and cardioembolism. The clinical presentations of ischemic and hemorrhagic stroke and transient ischemia attacks are examined, as are the major findings expected in the patient history and physical examination. Strategies for further evaluation of the patient are discussed, including the use of sonographic imaging of the carotid artery and the relative advantages and disadvantages among the dominant modes of brain imaging. New updates to the review include interventional approaches toward the treatment of acute ischemic stroke, as well as the latest strategies regarding the timing of carotid endarterectomy after stroke and the utility of carotid artery stenting in these patients, with active areas of current research highlighted. Figures show a computed tomographic (CT) angiogram of fibromuscular dysplasia of an internal carotid artery, a CT angiogram of an internal carotid artery dissection showing a defect in the dissection, a CT scan demonstrating hemorrhagic conversion of cardioembolic stroke, a CT scan of acute thalamic hemorrhage, a CT scan of evolving ischemic stroke, a T2-weighted image demonstrating acute left frontal stroke and remote right frontal stroke, T1- and T2-weighted images of right parietal ischemic stroke, and M1 occlusion of a middle cerebral artery treated successfully with transcatheter thrombectomy. Tables list Society of Radiologists in Ultrasound and University of Washington criteria for duplex ultrasound diagnosis of carotid artery stenosis.   This review contains 8 figures, 8 tables, and 68 references. Keywords: Carotid stenosis, ischemic stroke, transient ischemic attack, endovascular therapy, thrombolysis, infarct, hemorrhagic stroke, atherosclerosis, embolism

High-Flow Extracranial-to-Intracranial Excimer Laser–Assisted Nonocclusive Anastomosis Bypass for Symptomatic Carotid Artery Occlusion

Neurosurgery ◽  
2011 ◽  
Vol 68 (6) ◽  
pp. 1687-1694 ◽  
Author(s):  
Tristan P.C. van Doormaal ◽  
Catharina J.M. Klijn ◽  
Perry T.C. van Doormaal ◽  
L. Jaap Kappelle ◽  
Luca Regli ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Bypass Surgery ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
High Flow ◽  
Transient Ischemic Attacks ◽  
Mean Flow ◽  
Symptomatic Carotid

Abstract BACKGROUND: A high-flow bypass is theoretically more effective than a conventional low-flow bypass in preventing strokes in patients with symptomatic carotid artery occlusion and a compromised hemodynamic state of the brain. OBJECTIVE: To study the results of excimer laser-assisted nonocclusive anastomosis (ELANA) high-flow extracranial-to-intracranial (EC-IC) bypass surgery in these patients. METHODS: Between August 1998 and May 2008, 24 patients underwent ELANA EC-IC bypass surgery because of transient ischemic attacks or minor ischemic stroke associated with carotid artery occlusion. We retrospectively collected information. Follow-up data were updated by structured telephone interviews between May and September 2008. RESULTS: In all patients, the ELANA EC-IC bypass was patent at the end of surgery with a mean flow of 106 ± 41 mL/min. Within 30 days after the operation, 22 patients (92%) had no major complication, whereas 2 patients (8%) had a fatal intracerebral hemorrhage. During follow-up of a mean 4.4 ± 2.4 years, the bypass remained patent in 18 of the 22 surviving patients (82%) with a mean flow of 141 ± 59 mL/min. All patients with a patent bypass remained free of transient ischemic attacks and ischemic stroke. In 4 patients, the bypass occluded, accompanied by ipsilateral transient ischemic attacks in 2 patients, ipsilateral ischemic stroke in 1 patient, and contralateral ischemic stroke in another patient. CONCLUSION: ELANA EC-IC bypass surgery in patients with carotid artery occlusion is technically feasible and results in cessation of ongoing transient ischemic attacks and minor ischemic strokes, but carries a risk of postoperative hemorrhage.

scholarly journals Association of Neovascular Glaucoma with Risk of Stroke: A Population-Based Cohort Study

2017 ◽  
Vol 2017 ◽  
pp. 1-7 ◽  
Author(s):  
Cheng-Wen Su ◽  
Yue-Cune Chang ◽  
Cheng-Li Lin ◽  
Hsin-Yi Chen
Keyword(s):  
Ischemic Stroke ◽  
Hemorrhagic Stroke ◽  
Cox Regression ◽  
Neovascular Glaucoma ◽  
Population Based ◽  
Incidence Density ◽  
Cerebrovascular Accidents ◽  
Nationally Representative ◽  
And Control ◽  
The Relationship

Neovascular glaucoma (NVG), caused by ocular ischemia, is a serious ocular disease complicated by intractably increased intraocular pressure. Cerebrovascular accidents are classified into ischemic and hemorrhagic stroke. Based on the similar pathogenic mechanisms of NVG and ischemic stroke, we investigated the relationship between NVG and stroke by using a nationally representative sample. This study included 416 NVG patients and 4160 controls. Medical comorbidities were also evaluated. The cumulative incidence of ischemic stroke was 15.6% higher in the NVG cohort than in the control cohort (p<0.001); the incidence density rates of stroke were 3.80 and 1.19 per 10,000 person-years in the NVG and control cohorts, respectively. According to the multivariable Cox regression results, the estimated adjusted hazard ratio (aHR) of stroke was 2.07 (95% confidence interval (CI) = 1.41–3.02) for the NVG cohort. Furthermore, the NVG cohort was 2.24-fold more likely to develop ischemic stroke (95% CI = 1.51–3.32). The risk of ischemic stroke was higher in patients with hypertension (aHR = 2.09, 95% CI = 1.55–2.82) and in patients with diabetic retinopathy (aHR = 1.69, 95% CI = 1.05–2.72). Notably, patients with NVG have a higher risk of ischemic stroke, but not hemorrhagic stroke.

Symptomatic Carotid Stenosis: Stroke and Transient Ischemic Attack

2020 ◽  
Author(s):  
Kenneth R. Ziegler ◽  
Thomas C. Naslund
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Ct Scan ◽  
Hemorrhagic Stroke ◽  
Fibromuscular Dysplasia ◽  
The United States ◽  
Carotid Artery Dissection ◽  
Artery Dissection ◽  
Ct Angiogram ◽  
Ischemic Attack

Nearly 800,000 strokes are reported in the United States annually, with an economic impact upward of $33 billion. Carotid artery disease, familiar to all vascular surgeons, accounts for just over one fifth of these strokes. However, these cases reflect an opportunity for the surgeon to intervene and mitigate the substantial burden of stroke. This review includes the epidemiology of stroke in the United States and the carotid artery and noncarotid etiologies of stroke, including atherosclerotic disease, fibromuscular dysplasia, carotid artery dissection, and cardioembolism. The clinical presentations of ischemic and hemorrhagic stroke and transient ischemia attacks are examined, as are the major findings expected in the patient history and physical examination. Strategies for further evaluation of the patient are discussed, including the use of sonographic imaging of the carotid artery and the relative advantages and disadvantages among the dominant modes of brain imaging. New updates to the review include interventional approaches toward the treatment of acute ischemic stroke, as well as the latest strategies regarding the timing of carotid endarterectomy after stroke and the utility of carotid artery stenting in these patients, with active areas of current research highlighted. Figures show a computed tomographic (CT) angiogram of fibromuscular dysplasia of an internal carotid artery, a CT angiogram of an internal carotid artery dissection showing a defect in the dissection, a CT scan demonstrating hemorrhagic conversion of cardioembolic stroke, a CT scan of acute thalamic hemorrhage, a CT scan of evolving ischemic stroke, a T2-weighted image demonstrating acute left frontal stroke and remote right frontal stroke, T1- and T2-weighted images of right parietal ischemic stroke, and M1 occlusion of a middle cerebral artery treated successfully with transcatheter thrombectomy. Tables list Society of Radiologists in Ultrasound and University of Washington criteria for duplex ultrasound diagnosis of carotid artery stenosis.   This review contains 8 figures, 8 tables, and 68 references. Keywords: Carotid stenosis, ischemic stroke, transient ischemic attack, endovascular therapy, thrombolysis, infarct, hemorrhagic stroke, atherosclerosis, embolism

Symptomatic Carotid Stenosis: Stroke and Transient Ischemic Attack

2020 ◽  
Author(s):  
Kenneth R. Ziegler ◽  
Thomas C. Naslund
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Ct Scan ◽  
Hemorrhagic Stroke ◽  
Fibromuscular Dysplasia ◽  
The United States ◽  
Carotid Artery Dissection ◽  
Artery Dissection ◽  
Ct Angiogram ◽  
Ischemic Attack

Nearly 800,000 strokes are reported in the United States annually, with an economic impact upward of $33 billion. Carotid artery disease, familiar to all vascular surgeons, accounts for just over one fifth of these strokes. However, these cases reflect an opportunity for the surgeon to intervene and mitigate the substantial burden of stroke. This review includes the epidemiology of stroke in the United States and the carotid artery and noncarotid etiologies of stroke, including atherosclerotic disease, fibromuscular dysplasia, carotid artery dissection, and cardioembolism. The clinical presentations of ischemic and hemorrhagic stroke and transient ischemia attacks are examined, as are the major findings expected in the patient history and physical examination. Strategies for further evaluation of the patient are discussed, including the use of sonographic imaging of the carotid artery and the relative advantages and disadvantages among the dominant modes of brain imaging. New updates to the review include interventional approaches toward the treatment of acute ischemic stroke, as well as the latest strategies regarding the timing of carotid endarterectomy after stroke and the utility of carotid artery stenting in these patients, with active areas of current research highlighted. Figures show a computed tomographic (CT) angiogram of fibromuscular dysplasia of an internal carotid artery, a CT angiogram of an internal carotid artery dissection showing a defect in the dissection, a CT scan demonstrating hemorrhagic conversion of cardioembolic stroke, a CT scan of acute thalamic hemorrhage, a CT scan of evolving ischemic stroke, a T2-weighted image demonstrating acute left frontal stroke and remote right frontal stroke, T1- and T2-weighted images of right parietal ischemic stroke, and M1 occlusion of a middle cerebral artery treated successfully with transcatheter thrombectomy. Tables list Society of Radiologists in Ultrasound and University of Washington criteria for duplex ultrasound diagnosis of carotid artery stenosis.   This review contains 8 figures, 8 tables, and 68 references. Keywords: Carotid stenosis, ischemic stroke, transient ischemic attack, endovascular therapy, thrombolysis, infarct, hemorrhagic stroke, atherosclerosis, embolism

scholarly journals Accuracy of identifying incident stroke cases from linked health care data in UK Biobank

Neurology ◽  
2020 ◽  
Vol 95 (6) ◽  
pp. e697-e707 ◽  
Author(s):  
Kristiina Rannikmäe ◽  
Kenneth Ngoh ◽  
Kathryn Bush ◽  
Rustam Al-Shahi Salman ◽  
Fergus Doubal ◽  
...  
Keyword(s):  
Primary Care ◽  
Ischemic Stroke ◽  
Hospital Admission ◽  
Hemorrhagic Stroke ◽  
Large Population ◽  
Population Based ◽  
Uk Biobank ◽  
Electronic Patient Records ◽  
Death Record ◽  
Stroke Type

ObjectiveIn UK Biobank (UKB), a large population-based prospective study, cases of many diseases are ascertained through linkage to routinely collected, coded national health datasets. We assessed the accuracy of these for identifying incident strokes.MethodsIn a regional UKB subpopulation (n = 17,249), we identified all participants with ≥1 code signifying a first stroke after recruitment (incident stroke-coded cases) in linked hospital admission, primary care, or death record data. Stroke physicians reviewed their full electronic patient records (EPRs) and generated reference standard diagnoses. We evaluated the number and proportion of cases that were true-positives (i.e., positive predictive value [PPV]) for all codes combined and by code source and type.ResultsOf 232 incident stroke-coded cases, 97% had EPR information available. Data sources were 30% hospital admission only, 39% primary care only, 28% hospital and primary care, and 3% death records only. While 42% of cases were coded as unspecified stroke type, review of EPRs enabled a pathologic type to be assigned in >99%. PPVs (95% confidence intervals) were 79% (73%–84%) for any stroke (89% for hospital admission codes, 80% for primary care codes) and 83% (74%–90%) for ischemic stroke. PPVs for small numbers of death record and hemorrhagic stroke codes were low but imprecise.ConclusionsStroke and ischemic stroke cases in UKB can be ascertained through linked health datasets with sufficient accuracy for many research studies. Further work is needed to understand the accuracy of death record and hemorrhagic stroke codes and to develop scalable approaches for better identifying stroke types.

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