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A series of 44 cases is presented of patients who received surgical treatment for unruptured aneurysms in the anterior circulation, and which were associated with ischemic cerebrovascular disease (CVD). The age of patients varied from 34 to 76 (mean 62.8) years old. The associated ischemic CVD was transient ischemic attack (TIA) in ten, minor completed stroke in 23, and major completed stroke in 11 cases. Thirty five patients recovered fully. However, there were three deaths due to new cerebral infarction or delayed intracranial hemorrhage within 30 days after surgery (mortality 6.8%). Transient morbidity occurred in four patients (9.1%), and permanent morbidity in two patients (4.5%). In six cases, new ischemic events occurred after the surgery. In contrast, all 40 patients whose unruptured aneurysms were not associated with CVD fully recovered from the surgery they underwent. The authors indicate three risk factors which might lead to complication; diabetes mellitus, aneurysms located in the middle cerebral artery, and those larger than 6mm in diameter. Another three life-threatening factors are; elderly patients (> 65 year-old), male, aneurysms larger than 7mm in diameter. Direct surgery for unruptured aneurysms in ischemic CVD patients should be considered in cases free of risk factors indicated above. Eight cases in this series had extracranial carotid artery stenosis on the same side as the aneurysm. Carotid endoarterectomy (CEA) was performed prior to aneurysmal clipping in six patients, and their postoperative courses were excellent. In two patients, clipping was performed prior to CEA, and transient morbidity occurred in one of them.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:[Surgical indication for unruptured cerebral aneurysm in patients with ischemic cerebrovascular disease]. 809 Feb 62

Carotid duplex ultrasonography is the noninvasive procedure of choice for evaluating ECAD. However, carotid angiography should be performed before doing carotid endarterectomy. Multivariate logistic regression analysis showed that significant prognostic variables for ECAD in an elderly population are (1) cigarette smoking, (2) serum total cholesterol, (3) serum HDL cholesterol (inverse association), (4) diabetes mellitus, and (5) prior CAD. Patients with 80-100% ECAD develop a higher incidence of ABI and TIA than patients with 40-80% ECAD. Patients with 40-80% ECAD develop a higher incidence of ABI and TIA than patients with 0-40% ECAD. Patients with ECAD have a higher prevalence of prior CAD and develop a higher incidence of new coronary events than patients without ECAD. In patients with ECAD, significant prognostic variables for new coronary events are (1) silent ischemia, (2) prior CAD, (3) serum HDL cholesterol (inverse association), and (4) cigarette smoking. Risk factors for ECAD and CAD should be treated in patients with ECAD. Cigarette smoking must be stopped. Hypertension, dyslipidemia, and diabetes mellitus should be treated. Aspirin, 325 mg/d, should be administered to patients with ECAD. Ticlopidine hydrochloride, 250 mg two times per day should be considered in patients with ECAD who are unable to tolerate aspirin or who develop cerebrovascular events on aspirin. Carotid endarterectomy should be considered in symptomatic patients with 70-99% ECAD.
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PMID:Extracranial carotid arterial disease. 818 62

The specificity and sensitivity of the questionnaire method, whether through direct contact or via mail, in collecting information on thrombosis, embolism and bleeding after heart valve replacement were assessed by a critical analysis of methods currently in clinical use. The 16 questions contained in the standard questionnaire of the Albert Einstein College of Medicine searching for transient events were put to 1000 apparently healthy individuals. Additional questions related to risk factors such as previous heart valve replacement, any existing heart disease, hypertension, diabetes or current anticoagulant treatment for any reason were also asked. The male/female ratio was 54.9/45.1, and the mean age was 36.3 years with a range of 14-97 years. Eighty-five persons had one or more risk factors, 915 had none. A positive answer to at least one of the questions searching for TIA (transient ischemic attack) was given by 69.4% (n = 59) of those with, and by 54.8% (n = 501) without any risk factors. The total number of reported 'events' was 164 (1.93/person) for those with, and 1331 (1.45/person) for those without any risk factors. Four different follow up methods were applied to each of 123 patients after heart valve replacement: (a) regular follow up at an out-patient clinic, questionnaires sent at (b) six, (c) 18 and (d) 36 months after the start of the study. 57% of the transient and reversible events reported at the out-patient clinic were forgotten and not mentioned by the same patients in the 36 month questionnaire. One of the three permanent disabilities was also 'forgotten'.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Potential flaws in the assessment of minor cerebrovascular events after heart valve replacement. 826 21

A community-based, prospective study was carried out in the Lehigh Valley to determine how 5 selected risk factors and their control affected the frequency of stroke recurrence and death after an initial stroke. The initial stroke was verified clinically and by computerized tomography. Between 1987 and 1989, 662 patients with an initial stroke were enrolled and followed regularly every 4-6 months for up to 7 visits. The average follow-up period was 2 years. The risk factors selected included hypertension, myocardial infarction, cardiac arrhythmia, diabetes mellitus and transient ischemic attacks. Interim death and its cause were noted. Surviving patients were interviewed and examined to determine whether a second stroke has occurred. At enrollment, 51.4% of the cohort was male. The average age of men was 69.6, while women were older, averaging 74.3 years. Stroke types were thrombosis, 14%; embolus, 23%; lacune, 9%; nonspecific infarct, 48%, and intracerebral hemorrhage, 6%. There were 138 deaths (21%) and 81 second strokes (12%) during follow-up. The frequency of risk factors at enrollment was as follows; hypertension, 59%; myocardial infarction, 25%, cardiac arrhythmia, 47% (of which 16% had atrial fibrillation); diabetes mellitus, 29%, and transient ischemic attack, 18%. Of course many patients had multiple risk factors. We analyzed whether the presence of a risk factor at enrollment and its quality of control during follow-up affected stroke recurrence frequency and the mortality rates. These results will be reported in future papers.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:The Lehigh Valley Recurrent Stroke Study: description of design and methods. 827 84

The current study was undertaken to determine prospectively the risk of cerebral thromboembolism and the prognostic significance of left ventricular thrombus in ambulatory patients with chronic congestive heart failure. A total of 264 ambulatory patients (mean age 62 years, mean left ventricular ejection fraction 27%) were followed prospectively for 24 +/- 9 months to determine the incidence of nonhemorrhagic stroke, transient ischemic attack, and mortality. Two-dimensional echocardiographic studies, performed for clinical indications other than previous systemic thromboembolism in 109 patients, were analyzed to relate the presence of left ventricular thrombus to subsequent outcome. Nine cerebral thromboembolic events occurred in 264 patients during the two-year mean follow-up period, yielding a rate of 1.7 thromboembolic events per 100 patient-years of follow-up. Known risk factors for stroke (hypertension, diabetes mellitus, and/or atrial fibrillation) were present in all nine patients with cerebral thromboembolic events. The 109 patients with echocardiographic studies had more severe heart failure than patients without echocardiographic studies (functional class 2.6 vs 2.1, p < 0.01), greater risk of a thromboembolic event (2.4 vs 1.4 events/100 patient-years of follow-up, p < 0.01), and higher mortality (21.3 vs 5.5 deaths/100 patient-years, p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Low incidence of stroke in ambulatory patients with heart failure: a prospective study. 832 56

To be consistent with a diagnosis of TIA or stroke, a focal neurologic deficit must have occurred suddenly. The differential diagnosis of TIA includes migraine aura (possibly without a headache), a hypotensive episode, radiculopathy, and an unusual seizure. Vascular risk factors (eg, hypertension, diabetes, smoking) and the extent of their control should be determined. Cardiac examination and ECG may provide important clues, as atrial fibrillation and valvular heart disorders are well recognized potential sources of emboli. During an acute stroke, CT is the best test to reliably distinguish between ischemic and hemorrhagic stroke. Other tests that may be indicated on an individual basis include MRI,, echocardiography, carotid duplex ultrasound, and arteriography.
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PMID:Ischemic stroke, Part 1: Early, accurate diagnosis. 844 19

Patients with AF have a mortality rate about twice that of age-and sex-matched individuals without AF, and a stroke rate that is about fivefold greater. Patients less than 60 years of age with lone AF have an extremely low risk of stroke. Patients less than 65 years of age who do not have diabetes, a history of hypertension, a previous TIA or stroke, or heart failure have an annual risk of stroke of about 1% per year. Unfortunately, patients older than 65 or younger patients with any of the four risk factors have an annual risk of stroke of 4% or greater. Transthoracic and transesophageal echocardiography may be able to refine the risk stratification further, but additional studies are needed to establish their role.
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PMID:Prognosis of individuals with atrial fibrillation. 859 95

There is a demonstrated statistical association between atrial fibrillation, rheumatic valvular disease, and embolic stroke. This article assesses the results of 6 major clinical trials (AFASAK, BAATAF, SPINAF, SPAF [parts I and II], CAFA and EAFTA--see text for trial names). Multivariate analysis revealed 4 independent clinical features that identified patients with atrial fibrillation at an increased risk for stroke: hypertension, increasing age, previous transient ischemic attack, and diabetes mellitus. Without anticoagulation therapy, patients with any of these risk factors had a 4% annual risk of stroke. Patients with cardiac disorders such as congestive heart failure and coronary artery disease have a stroke rate 3 times higher than patients without any risk factors; patients with atrial fibrillation but no concomitant risk factors or structural heart disease seemed to have little concomitant risk for stroke. Meta-analysis revealed a 64% reduction of risk for stroke in patients treated with warfarin, as compared with placebo. The value of warfarin therapy in patients > 75 years old is less clear because of a high risk of hemorrhagic complications.
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PMID:Atrial fibrillation, anticoagulation, and stroke. 860 90

A total of 167 carotid endarterectomies by the eversion technique were completed in 158 patients at a teaching hospital during the 6-year period ending July 1995. The average patient age was 66 years with a range of 39 to 89 years, and 99 (63%) were male. General anesthesia was employed routinely, and temporary indwelling shunts, were not used. Indications for endarterectomy included hemispheric transient ischemic attack (43), amaurosis fugax (20), stroke (41), and asymptomatic stenosis (63). Associated patient risk factors were not significantly different for men and women, and included diabetes mellitus (22%), tobacco abuse (72%), hypertension (69%), hypercholesterolemia (76%), cardiac disease (54%), and renal disease (21%). One (0.6%) permanent operative stroke and two (1%) 30-day hospital deaths occurred. Vascular laboratory follow-up was accomplished by duplex scanning with a documented sensitivity of 98 per cent in detecting a > or = 40 per cent stenosis. Eighty-nine per cent (148) of the 167 endarterectomies were tested at least once postoperatively. Overall laboratory follow-up averaged 17 months and ranged from one to 69 months. Residual stenosis, included perioperative thrombosis, occurred in 8 (5%) arteries. Recurrent stenosis was detected in four (2%) cases at 9, 24, 54, and 66 months after endarterectomy. Statistical analyses failed to implicate any specific patient risk factor, age, sex, or operative indication relevant to recurrent stenosis. Residual stenosis was correlated with younger patient age (P = 0.002), female gender (P = 0.12), and endarterectomy on the right side (P = 0.008). Carotid eversion endarterectomy appears to be a universally applicable, safe, and durable operative technique.
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PMID:Technical results from the eversion technique of carotid endarterectomy. 861 62

A prospective case-control study was carried out to clarify associations of cerebral transient ischemic attacks (TIAs) and other stroke risk factors with progression and exacerbation of cardiovascular and cerebrovascular disorders; 243 neurologically normal controls and 123 TIA patients without prior history of stroke were followed up for a mean interval of 4.4 years of TIA patients, 26 (21%) developed other events (excluding recurrent TIAs); 10 died of vascular causes (8.1%). Of controls, 44 (18%) developed events; 13 died of vascular causes (5.4%) and 3 from cancer. TIA patients were at 2.3 times greater risk than normal controls for stroke or death from vascular causes. They were predominantly male with significantly higher associations of risk factors for stroke, including hypertension, heart disease, diabetes mellitus, smoking, hyperlipidemia, alcohol consumption, and limited education. Controls developing vascular events compared with controls who did not were older, more frequently male, and with greater incidences of heart disease. TIA patients had lower rates of cerebral perfusion compared with controls that persisted throughout the study, with similar rates of decline related to aging among both groups. Among TIA patients, stroke risk factors were more prevalent than among controls. The longer their duration, the greater the incidence and the more rapid the rate of severe, often fatal cardiovascular complications.
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PMID:Prospective study of vascular events and cerebral perfusional changes following transient ischemic attacks. 863 63


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