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Query: UMLS:C0038454 (stroke)
 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Although carotid endarterectomy is one of the most frequently performed operations in this country, recent evidence casts doubt on its advisability, particularly for patients with ocular manifestations of cerebral ischemia. The following evidence is that: the risk of future stroke in untreated patients with amaurosis fugax, retinal plaques, and infarcts is less than 3% per year, far lower than that expected for cerebral (hemispheric) transient ischemic attacks (TIAs); the perioperative risk of stroke and death after endarterectomy may be much higher than previously suspected; and aspirin is a comparatively risk-free and moderately effective alternative to endarterectomy. Because of the questions raised about the risk-to-benefit ratio of endarterectomy, patients with ocular manifestations of cerebral ischemia should be considered for this operation only as part of a proposed randomized collaborative study.
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PMID:Carotid endarterectomy. Who needs it? 362 23

Amaurosis fugax is considered an ocular transient ischemic attack with an ominous prognosis. One hundred twenty-eight patients with amaurosis fugax as the presenting symptom underwent carotid endarterectomy at the University of California, San Diego (UCSD) and Scripps Clinic between 1970 and 1985 with one death (0.8%) and one postoperative permanent stroke (0.8%). Subsequently, these patients were followed up for 6 to 160 months (mean 45.3 months). Only two subsequent late strokes were documented (at 2 and 5 years after operation). These results were significantly better (p less than 0.01) by life-table analysis than the late stroke rate after carotid endarterectomy performed to treat anterior motor transient ischemic attacks at both UCSD and Scripps Clinic, as well as the reported late follow-up for all transient ischemic attacks after carotid endarterectomy in the literature (1.8% per year, 17 publications, 1980 operations). Thus amaurosis fugax appears to be a particularly favorable indication for carotid endarterectomy. Left untreated, this event carries a high risk of stroke; after carotid endarterectomy, which has a low operative risk, there is a very low postoperative stroke rate (two strokes in 448 patient-years of follow-up).
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PMID:Late results after carotid endarterectomy for amaurosis fugax. 365 82

Eighty-five patients with retinal emboli, visible ophthalmoscopically, were studied retrospectively. All the patients had presented with transient or permanent visual loss. Follow up from the time of presentation was one year to 12 years with a mean of 4.5 years. Life expectancy in the 58 medically treated patients who presented with cholesterol emboli was significantly reduced (p = 0.028). Stroke was the commonest cause of death and was significantly more frequent than in the general population (p less than 0.001); there was also an increased total incidence of cerebrovascular disease (fatal and non-fatal) compared with the Oxfordshire Stroke Project (p less than 0.001). The mortality from ischaemic heart disease was not significantly increased. We report a series of 85 patients with retinal emboli, 69 of whom had cholesterol emboli (70 fundi), 15 calcific emboli and one platelet-fibrin embolus. The natural history of medically treated patients with cholesterol emboli is compared both with an age and sex matched population and with patients with amaurosis fugax but no visible retinal emboli.
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PMID:Prognosis of patients with retinal embolism. 366 64

To try and improve the interobserver agreement for the diagnosis of TIA, we used a checklist in which the symptoms were recorded in plain language, instead of in abstract diagnostic terms such as amaurosis fugax. Criteria for a diagnosis of TIA were similarly phrased and recommended to all observers. Eight senior neurologists and ten neurology residents interviewed 72 patients in random pairs. In 64 cases the observers agreed on the diagnosis (kappa value = 0.77). After a short discussion between the two observers the agreement increased to a maximum (kappa = 1.0). However, in 29 of the 144 interviews the diagnosis would have been different, had the recommended criteria been fully applied. In 28 of these the observer had diagnosed TIA on insufficient evidence. Six "misinterpretations" led to disagreement for the diagnosis and only these were corrected by the observers during their discussion. The present design has led to a maximal agreement for the diagnosis of TIA between two observers, but the agreement between such a pair and the common diagnostic criteria was not yet ideal. The precision of the diagnosis could be improved if details of the required symptoms are discussed in general as well as for each patient.
Stroke
PMID:Diagnosis of transient ischemic attacks: improvement of interobserver agreement by a check-list in ordinary language. 373 56

The presence of a bruit after carotid endarterectomy may indicate a persistent or recurrent lesion. The authors noninvasively evaluated, by Duplex scanning, 18 asymptomatic postoperative patients who underwent a total of 23 carotid endarterectomies and who developed a postoperative bruit to determine the significance of the bruit. Eleven men and seven women were studied from 6 weeks to 2 years postsurgery. Ages ranged from 49 to 75 years (63.6 +/- 8.0 years). Indications for endarterectomy were: transient ischemic attacks (including amaurosis fugax), 17 vessels; completed stroke with significant functional recovery and residual carotid disease, 3 vessels; and asymptomatic bruit with hemodynamically significant carotid stenosis, 3 vessels. Each patient had a Duplex scan performed to noninvasively evaluate the carotid artery. All scans were independently reviewed by two observers. Real-time B images were interpreted as normal in 14 vessels, mild thickening in eight vessels, and moderate thickening in only one vessel. Doppler recordings demonstrated a spectral range of 15-40 cm/sec (26 +/- 8 cm/sec). Ratio of velocity in the internal carotid artery to common carotid artery (VIC/VCC) ranged from 0.389 to 1.281 (0.779 +/- 0.250). This study demonstrates that the presence of a postoperative carotid bruit does not necessarily signify the presence of residual carotid disease or a hemodynamically significant lesion.
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PMID:The post endarterectomy carotid bruit. Evaluation by Duplex scan. 390 47

One hundred patients with asymptomatic carotid bruit or transient ischemic attack (TIA) underwent continuous-wave Doppler (CWD) and real time ultrasound (RTU) testing of their cervical carotid arteries. After ultrasonic studies, 51 patients also underwent bilateral carotid angiography. There was 95% agreement between CWD and angiography for the diagnosis of a significant (greater than 50%) stenosis. The RTU diagnosis of a normal or occluded vessel was correct in 100% of cases. Seven plaques appreciated on RTU may not have been large enough for detection by angiography. In this small series, ulceration confirmed pathologically was more reliably predicted by RTU than by cerebral angiography. Significant ipsilateral carotid plaques occurred more often in patients with amaurosis fugax than in patients with hemispheric TIAs. Ipsilateral plaque ulceration occurred in 50% of symptomatic carotid bruits, but in only 10% of asymptomatic carotid bruits. Plasma concentrations of total cholesterol were significantly higher in TIA patients with carotid stenosis than in controls.
Stroke
PMID:Asymptomatic bruit, carotid and vertebrobasilar transient ischemic attacks--a clinical and ultrasonic correlation. 394 86

A 68 year-old woman presented with a two-week history of amaurosis fugax, ipsilateral fronto-temporal headache and jaw claudication suggesting carotid giant cell arteritis. However, this syndrome proved to be due to atherosclerosis causing complete occlusion of the external carotid artery at its origin and narrowing of the internal carotid artery. Combined external and internal carotid endarterectomy relieved the symptoms. The symptom complex of temporal arteritis may be rarely mimicked by carotid atherosclerotic occlusive disease.
Stroke
PMID:Temporal arteritis-like presentation of carotid atherosclerosis. 396 42

Seven patients with occlusion of internal carotid arteries (ICAs) were prospectively followed during a mean period of 14 months. Prior to demonstration of occlusions, four patients suffered a mild stroke, and three isolated transient ischemic attacks (TIAs) or amaurosis fugax. All patients remained alive and with an unchanged functional ability. During follow-up, one patient suffered amaurosis fugax and TIAs followed by a mild stroke, three suffered isolated TIAs or amaurosis fugax, two suffered reversible cerebro-retinal ischemia of more than 24 hours, and one remained symptom free. In three cases, delayed cerebro-retinal ischemia distal to one of the occluded ICAs was systematically triggered by orthostatic, cardiogenic or iatrogenic hypotension, and resolved after adequate medical treatment or restoration of a functional collateral circulation by endarterectomy of a tightly stenosed ipsilateral external carotid artery (ECA), suggesting hemodynamic phenomena. In three cases, micro-emboli originating from a stump or an ulcerated ipsilateral common carotid artery and migrating through well-developed ECA collateral channels explained delayed episodes of ipsilateral TIAs or amaurosis fugax, which disappeared in two cases after adequate anticoagulant therapy was introduced. Bilateral occlusion of ICA may be a relatively benign condition, if the patients are carefully controlled and treated.
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PMID:Cerebro-retinal ischemia after bilateral occlusion of internal carotid artery. A study with prospective follow-up. 401 Sep 24

Twenty-one patients who underwent 22 external carotid artery reconstructions for cerebral ischemia were reviewed. Ten patients had amaurosis fugax, 9 had hemispheric ischemia, and 2 were asymptomatic. With the exception of one patient, all had ipsilateral internal carotid artery occlusion and either external carotid stenosis or a cul-de-sac of the occluded internal carotid artery. Six patients had ipsilateral common carotid occlusions. The operative technique has been presented. There were no operative strokes or new neurologic deficits. All patients were relieved of symptoms. Patients were followed a mean of 32 months. During follow-up, 3 ipsilateral transient ischemic attacks occurred during the first 3 months. Four strokes occurred (one ipsilateral and three contralateral) from 4 to 33 months postoperatively. Ipsilateral stroke rate by life table analysis was 1 percent per year. These data suggest that external carotid artery reconstruction is a safe, effective, and durable therapeutic alternative for management of patients with cerebral ischemia and an ipsilateral occluded internal carotid artery. External carotid endarterectomy eliminates a potential source of emboli and increases cerebral perfusion. Because of the increase in cerebral blood flow, subsequent extracranial-to-intracranial bypass may be unnecessary.
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PMID:External carotid artery reconstruction: its role in the treatment of cerebral ischemia. 401 72

From December 1976 through March 1982, 188 patients entered an open non-random study carried out on hospitalized patients with a history of transient ischemic attacks or amaurosis fugax. Ninety-two patients received peroral anticoagulants usually combined with heparin treatment during the first days of treatment, and 96 patients enteric-coated acetylsalicylic acid 0,5 g twice daily plus dipyridamole 75 mg twice daily. The patients were followed up to March 1983, irrespective of whether treatment was changed or not. Recurrent transient ischemic attack or amaurosis fugax occurred more frequently (P less than 0.01) from 2 months of follow-up and throughout the observation period in the antiplatelet-treated group. There were no statistically significant differences between the 2 groups on the originally given treatment for endpoints such as stroke (6 patients on anticoagulants, 12 patients on antiplatelet therapy) or stroke or death (11 patients on anticoagulants, 17 patients on antiplatelet therapy). The findings from this trial suggest that anticoagulant treatment is superior to antiplatelet therapy given in the prevention of ischemic attacks and that this difference mainly exists during the first one to 2 months after onset of transient ischemic attacks or amaurosis fugax.
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PMID:Enteric-coated acetylsalicylic acid plus dipyridamole compared with anticoagulants in the prevention of ischemic events in patients with transient ischemic attacks. 402 60


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