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

Before 1981, the neurologic morbidity and mortality associated with carotid endarterectomy (CEA) in the Los Angeles County/USC Medical Center public teaching institution was 20 per cent, similar to results from other hospitals. In 1981, a standardized protocol was adopted in an attempt to improve surgical outcome following CEA. Between 1981 through 1990, 89 patients with a mean age of 60.9 years (range 38 to 80 yrs) had 100 consecutive CEAs. Atherosclerotic risk factors included hypertension in 57 patients (61.8%), tobacco use in 57 (64.0%), and diabetes mellitus in 28 (31.5%). Forty-nine patients had a history of ischemic heart disease. Indications for CEA were stroke in 40 cases, transient ischemic attack in 33 cases, and asymptomatic, high-grade stenosis of the internal carotid artery (greater than 85 per cent) in 19. Perioperative and surgical management are detailed in the authors' protocol. Intraluminal shunts were routinely used (99 cases) and 24 arteriotomies were patched. Completion arteriograms were performed in 99 cases, four of which were revised because of arteriographic abnormalities. Three patients sustained postoperative ipsilateral neurologic events. Ten patients had cranial nerve palsies, six of which were transient. Two patients had nonfatal postoperative myocardial infarctions. There were no deaths. The combined stroke and transient ischemic attack (TIA) mortality rate was 3 per cent. In conclusion, the audit and quality assurance process identified unacceptable results following CEA. A protocol was developed that addressed pre, intra, and postoperative details of patient selection, operative technique, and postoperative care. By adhering to the protocol, the major neurologic morbidity and mortality rate has been reduced to 3 per cent.
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PMID:A review of carotid endarterectomy at a large teaching hospital. 174 89

To evaluate the perioperative outcomes and the immediate increases in size after patch closure, 140 carotid endarterectomies were randomized into one of three groups: direct no-patch closure, saphenous vein patch closure, and polytetrafluoroethylene patch closure. Seven patients (4.4%) experienced signs of cerebral ischemia in the immediate postoperative period. In three cases this was transient and reversible. In the other four reexploration was undertaken and carotid thrombosis was corrected by thrombectomy. The condition of one of these patients deteriorated to a permanent stroke, whereas the other patients made a complete recovery. Neurologic complications were more frequent in the no-patch group, but the differences between the groups were not significant. The incidence of perioperative internal carotid stenosis, aneurysmal dilatation, and other morphologic abnormalities was assessed in 131 intravenous digital subtraction angiograms taken before the patient was discharged from the hospital. Eight (17.0%) of the endarterectomies in the no-patch group were narrowed by 30% to 50% diameter stenosis, whereas none of the patched arteries had more than 30% stenosis. In contrast, dilatation of the common or internal carotid artery to more than twice the measured diameter was absent in non-patched arteries but was present in seven (17.0%) saphenous patch closures and four (9.23%) polytetrafluoroethylene patch closures. We conclude that patch closure after carotid endarterectomy is less likely to cause stenosis in the perioperative period. Poly-tetrafluoroethylene patches resist dilatation better than do saphenous vein patches and are less likely to become aneurysmal.
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PMID:Comparison of saphenous vein patch, polytetrafluoroethylene patch, and direct arteriotomy closure after carotid endarterectomy. Part I. Perioperative results. 270 21

The hypothesis that saphenous vein patch angioplasty protects against early postoperative restenosis and thrombosis-occlusion was tested by comparing the clinical outcome and carotid artery status of 100 carotid endarterectomies with and 100 without saphenous vein patch angioplasty performed by a single surgeon over a 30-month period. The patient population, selection, perioperative management, and the technical aspects of the operation, except for the vein patch, were essentially identical in both groups. Carotid artery status was assessed by direct continuous wave Doppler and Gee OPG at three to six months and again at one year postoperatively. There were two hospital deaths, both in the nonpatched group, one cardiac and the other neurologic due to internal carotid thrombosis. Two reversible neurological deficits due to thrombosis and one due to restenosis occurred in the non-patched group. Asymptomatic greater than 50% diameter restenosis occurred in four and asymptomatic occlusion in one non-patched carotids. There were no restenosis, no occlusions and no neurologic symptoms in the patched group. Morbidity, mortality, restenosis or thrombosis-occlusion occurred in 10/100 (10%) non-patched and 0/100 (0%) patched arteries (p less than 0.01 by Chi Square). Restenosis or thrombosis-occlusion occurred in 9/100 (9%) of non-patched and 0/100 (0%) patched arteries (p less than 0.01). These results support the use of saphenous vein patch angioplasty reconstruction of carotid endarterectomy to protect against early restenosis and thrombosis-occlusion.
Stroke
PMID:Prevention of early restenosis and thrombosis-occlusion after carotid endarterectomy by saphenous vein patch angioplasty. 376 62

A prospective study was undertaken to determine the efficacy of performing carotid endarterectomy without an intraluminal shunt. During a two-year period, 240 patients, ranging in age from 36 to 89 years, underwent 309 consecutive carotid endarterectomies. The indication for operation was transient ischemic attacks in 151 (63%) patients, asymptomatic carotid bruit in 67 (28%), and previous stroke in 22 (9%). Internal shunts were not used in any patients and all arteriotomies were patched with a preclotted knitted Dacron velor patch. Systemic heparinization was used during the procedure. The early postoperative mortality was 0.64% (2/309). Both deaths were caused by myocardial infarction. The incidence of stroke after operation was 1.29% (4/309). Neither carotid clamp time nor the presence of contralateral disease correlated with the occurrence of postoperative stroke. According to results of angiography, 22 patients had total occlusion of the contralateral internal carotid artery with satisfactory intracranial circulation. No postoperative strokes occurred in this subgroup. Results of this study revealed that equally good or superior results may be obtained without a temporary shunt in performing carotid endarterectomy.
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PMID:Carotid endarterectomy without temporary intraluminal shunt. Study of 309 consecutive operations. 738 32

A randomized controlled trial was performed to evaluate patch angioplasty for patients undergoing carotid endarterectomy. There were 213 patient episodes affecting 148 men and 65 women, with 109 allocated to patch angioplasty. Following surgery six patients suffered transient ischaemic attacks but these did not delay discharge from hospital. Six individuals (four patched operations, two not patched) required re-exploration for postoperative haemorrhage and eight (two patched procedures, six not) had potentially serious neurological problems after operation. Of these eight patients, four (none receiving patch angioplasty) underwent re-exploration and in each case a clot was removed and a patch inserted; three of the four made a good long-term recovery. The other four patients suffered completed strokes from which one died. Two further patients (one patched procedure, one not) died after operation from myocardial events, giving an overall 30-day stroke or mortality rate of 2.8 per cent. Objective follow-up assessment with duplex scanning at 1 year was completed by 94.8 per cent of patients; significantly more vessel restenoses and occlusions were observed in those not receiving patches (P < 0.01). Patch angioplasty reduces the number of immediate postoperative complications, and significantly lowers vessel restenosis and occlusion rates at 1 year after operation.
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PMID:Randomized controlled trial of patch angioplasty for carotid endarterectomy. The Joint Vascular Research Group. 829 16

The role of carotid endarterectomy (CEA) in stroke prevention is now better defined. However, its role in patients older than 79 years of age is controversial. This group of patients has been excluded in most clinical trials. In this study the authors reviewed their experience with CEA patients >79 years old. The records of all patients older than 79 years of age who underwent a CEA in a recent time period from January 1988 to December 1996 were retrospectively reviewed. Forty-one patients (31 men, 10 women) were identified by computer search. The indication for operation included transient ischemic attack in 12 (29.3%), amaurosis fugax in nine (22%), stroke in two (4.9%), and nonhemispheric symptoms in three (7.3%). Fifteen patients (36.6%) were asymptomatic. Medical risk factors included coronary artery disease in 26 (63.4%), hypertension in 22 (53.7%), and smoking in 12 (29.3%). The procedure was performed under EEG monitoring in all patients. General anesthesia was administered in 37 (90%) and regional anesthesia in four (10%). Shunts were used in four (10%) patients. The internal carotid artery was patched in 16 patients (39%). One patient (2.4%) developed a perioperative stroke and only one patient developed perioperative myocardial infarction (MI). None of the patients died within 30 days of surgery. In addition to the one MI case, five patients developed minor complications. The average length of time for stay after CEA was 3.4 days. Patients were followed up for an average of 20.7 months. Six patients died during follow-up. Four of those died from an MI and two from a stroke. The authors conclude that with proper selection of patients, CEA is safe in the octogenarian. Age alone should not be a contraindication for CEA.
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PMID:Entering the ninth decade is not a contraindication for carotid endarterectomy. 955 30

BACKGROUND: There has been increasing interest in audit of outcome following surgery. A previous study reported a significant difference in clinical outcome between consultant and trainees but there is no information on technical factors. Duplex ultrasonography before wound closure was used to compare clinical and technical outcome for consultant and trainees. METHODS: Patients underwent endarterectomy (89 by consultant, 60 by six trainees). In the consultant group nine vessels were patched and 36 patients underwent shunting compared with seven and 31 respectively for trainees. RESULTS: In the consultant group there were two deaths, one stroke, one transient ischaemic attack (TIA) and two cranial nerve injuries. The neurological event rate was 2 per cent, and overall stroke and death rate 3 per cent. There were ten residual flaps (11 per cent) (three re-explored) and eight kinks (9 per cent). The residual stenosis rate was 10 per cent (nine of 89) and following re-exploration this reduced to 7 per cent. In the trainee group there was one death, two strokes, one TIA and one cranial nerve injury. The neurological event rate was 5 per cent, and the overall stroke and death rate 3 per cent. There were nine flaps (15 per cent) (four re-explored) and 13 kinks (22 per cent). The residual stenosis rate was 22 per cent (13 of 60) which reduced to 15 per cent (nine of 60) following re-exploration. There was no significant difference in clinical outcome between consultant and trainees but there was an increased incidence of technical problems among the trainees (t = 2.12, P < 0.05). CONCLUSION: Intraoperative duplex ultrasonography is a valuable method for assessing surgical technique; it gives immediate feedback to the surgeon, enables corrective measures to be taken and may facilitate training.
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PMID:Vascular surgical society of great britain and ireland: audit of surgical technique during carotid endarterectomy by intraoperative duplex ultrasonography: trainees compared with consultant 1036 12

A 74-year-old man with a previously placed ascending aortic graft was admitted to our hospital with a pulsating sternal mass, 2 days after an episode of severe coughing. Six months earlier, computed tomographic scanning had shown an intact aortic graft and no sternal wire fracture, but the wires had cut through the sternum. Computed tomographic scans at the current admission showed the patient to have 2 perforations of the ascending aortic graft, which led to 2 pseudoaneurysms and a large subcutaneous hematoma. In another view, a fractured sternal wire could be seen leading to one of the pseudoaneurysms. We performed emergent surgery and found sternal separation, as well as 2 holes in the graft that coincided with the location of the fractured sternal wires. We successfully patched the graft; however, the patient had a cerebral ischemic stroke and died 2 weeks postoperatively. This case emphasizes the importance of early removal of loosening sternal wires.
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PMID:Aortic graft pseudoaneurysm secondary to fracture of sternal wires. 1295 12

Visual perceptual distortion (i.e., elongation) has been demonstrated in a single case study after several months of cortical deprivation after a stroke. Here we asked whether similar perceptual elongation can be observed in healthy participants after deprivation and, crucially, how soon after deprivation this elongation occurs. To answer this question, we patched one eye, thus noninvasively and reversibly depriving bottom-up input to the region of primary visual cortex (V1) corresponding to the blind spot (BS) in the unpatched eye, and tested whether and how quickly elongation occurs after the onset of deprivation. Within seconds of eye patching, participants perceived rectangles adjacent to the BS to be elongated toward the BS. We attribute this perceptual elongation to rapid receptive field expansion within the deprived V1 as reported in electrophysiological studies after retinal lesions and refer to it as "referred visual sensations" (RVS). This RVS is too fast to be the result of structural changes in the cortex (e.g., the growth of new connections), instead implicating unmasking of preexisting connections as the underlying neural mechanism. These findings may shed light on other reported perceptual distortions, as well as the phenomena of "filling-in."
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PMID:"Referred visual sensations": rapid perceptual elongation after visual cortical deprivation. 1960 33

Right half-field eye-patched glasses intervention was performed in two chronic stroke patients with unilateral spatial neglect. Eye movement on the neglect side, the center of gravity as an index of the internal midline bias, neglect sign tests, and the regional cerebral blood flow (rCBF) were measured before and after intervention. The improvement of eye movement was not shown clearly after intervention. The center of gravity shifted significantly to the right and backward. Letter and star cancellation tests were improved in both the cases. Line bisection test showed improvement in one patient. However, line cancellation and line bisection tests were worsened in the other. The rCBF was not changed after intervention. This case study suggests that right half-field eye patching might not be an effective intervention.
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PMID:Right half-field eye patching may not be an effective approach for chronic hemispatial neglect--a two-case investigation. 2461 55


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