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Percutaneous carotid interventions
Published in John Edward Boland, David W. M. Muller, Interventional Cardiology and Cardiac Catheterisation, 2019
Taraneh Amir-Nezami, Anthony Grabs
Incidence of distal cerebral embolisation varies and may be affected by operator experience and patient selection. Advanced patient age and unfavourable or difficult arch anatomy are some of the known predictors for embolic stroke. Options available for treatment of an embolic event include catheter-directed thrombolysis (using urokinase or tissue plasminogen activator), thrombus maceration, aspiration thrombectomy, snare removal, and administration of glycoprotein IIb/IIIa receptor inhibitor (e.g. Abciximb), all with variable results. Presently, prevention remains the best option for avoiding the disastrous consequences of distal cerebral embolisation.32–34
Stroke
Published in Hemanshu Prabhakar, Charu Mahajan, Indu Kapoor, Manual of Neuroanesthesia, 2017
History of preexisting hypertension is significant. It is a major risk factor for stroke. The autoregulation curve is shifted to the right and sudden lowering of the BP may predispose the patient to cerebral ischemia. Autoregulation is impaired in the ischemic areas of the brain. Presence of atrial fibrillation may be a risk factor for embolic stroke. If the patient is on warfarin, an urgent INR must be requested. An INR ≥1.7 is a contraindication for IV tPa therapy.4 A platelet count ≤100,000 is also a contraindication for thrombolytic therapy. Baseline creatinine must be documented. Hypoglycemia may mimic stroke symptoms and must be ruled out. Hyperglycemia has been associated with worse outcomes and must be treated. Diabetes is a risk factor for renal impairment. Contrast-induced nephropathy may occur post procedure. If time of onset of symptoms is between 3 and 4.5 h, some institutions might administer IV tPa. This may also be an indication for intra-arterial tPa for clot lysis, since the total dose of tPa is much lower. Beyond 6 h, interventional therapy includes thrombectomy and clot extraction.
The patient with an acute stroke
Published in Andrew Stewart, Rory Mackinnon, Pocket On Call, 2015
Andrew Stewart, Rory Mackinnon
The onset of symptoms can vary significantly and doesn’t always follow a predictable pattern. In theory, a true embolic stroke will produce a very acute onset of symptoms with maximal neurological deficit seen immediately, whereas an infarct caused by thrombosis in situ tends to develop over minutes to hours.
Procedural embolic protection strategies for carotid artery stenting: current status and future prospects
Published in Expert Review of Medical Devices, 2023
Eligio Miccichè, Francesco Condello, Davide Cao, Alessia Azzano, Anna Maria Ioppolo, Andrea Mangiameli, Alberto Cremonesi
Recently, Foo et al. described a novel method of neuroprotection during CAS, which employs aspects of both proximal and distal embolic protection principles: the CaRotid Artery Filtering Technique (CRAFT) [75]. During CRAFT, an 8 Fr FlowGate balloon guide catheter (Stryker Neurovascular, Fremont, CA, U.S.A.) is advanced proximal to the lesion and then inflated causing an antegrade flow arrest. The Casper stent is flushed with a glycoprotein IIb/IIIa inhibitor prior to loading it on the guidewire in order to reduce the risk of stent occlusion. The stent is then deployed only in its distal third so that, due to its micromesh design, it acts as a filter when the FlowGate balloon is subsequently deflated to restore antegrade flow and to allow the complete deployment of the stent. Among 89 symptomatic patients treated with this novel technique, 6 (6.4%) experienced acute stent occlusion, 1 of which was fatal. Five patients (5.3%) experienced embolic stroke in the middle cerebral artery territory. Six (6.4%) developed intracranial hemorrhage after the procedure. Notwithstanding the relatively high rate of complications, 91.5% of the procedures were performed in an emergency setting, and all patients had symptomatic carotid artery stenosis. The higher risk of stent occlusion with dual-layer stents as compared to first-generation stents in acute setting has been previously described [76]. Studies investigating the role of this hybrid technique in asymptomatic patients are warranted.
Association between CHARGE-AF risk score and LA mechanics: LA reservoir strain can be a single parameter for predicting AF risk
Published in Acta Cardiologica, 2023
Turkan Seda Tan, Kubra Korkmaz, Irem Muge Akbulut, Kaan Akin, Yakup Yunus Yamanturk, Haci Ali Kurklu, Volkan Kozluca, Kerim Esenboga, Irem Dincer
There is robust evidence that cryptogenic ischaemic strokes are mostly thromboembolic [32] caused by several potential embolic sources, including paradoxical embolism and arteriogenic emboli, such as aortic arch atherosclerotic plaques and cerebral artery nonstenotic plaques with ulceration. Notably, covert paroxysmal atrial fibrillation is a potential cause of cryptogenic stroke, which is detected in 10–20% of patients with cardiac rhythm monitoring [33–35]. In addition, an embolic stroke of undetermined source (ESUS) is defined as a nonlacunar brain infarct without proximal arterial stenosis or cardioembolic sources and hence a clear indication for anticoagulation. Many patients with ESUS are diagnosed with paroxysmal or subclinical atrial AF (SCAF) during hospital electrocardiographic monitoring [36]. A diagnosis of SCAF among those with ESUS is essential to make decisions for using oral anticoagulation [37]. However, some patients still have an embolic stroke of undetermined source. They may have atrial myopathy, which is also the cause of atrial stasis and thrombi as was mentioned above.
Acute promyelocytic leukemia presenting as recurrent venous and arterial thrombotic events: a case report and review of the literature
Published in Journal of Community Hospital Internal Medicine Perspectives, 2021
Kira MacDougall, Divya Chukkalore, Maryam Rehan, Meena Kashi, Alexander Bershadskiy
Three months later, the patient presented to the ED for acute onset of dysarthria and expressive aphasia. His National Institutes of Health Stroke Scale score was 2. He admitted to missing several doses of apixaban. Magnetic resonance imaging (MRI) of the head revealed multiple small and punctate acute infarcts within the bilateral cerebellar hemispheres, two small foci of signal abnormality within the right frontal lobe likely reflecting small subacute infarcts, and small rounded focus of signal abnormality within the right occipital lobe, potentially reflecting a subacute infarct. There was no evidence of antiphospholipid syndrome and the panel for hypercoagulable workup was normal, except for heterozygosity for C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene (Table 2). A transthoracic echocardiogram was performed and was negative for a patent foramen oval and no thrombus was seen. The patient was diagnosed with acute embolic stroke of unknown source. His symptoms resolved, and he was discharged home on apixaban 5 mg BID and aspirin 81 mg.