Search Results (11)

Background: Adult moyamoya disease (MMD) is a progressive steno-occlusive cerebrovascular disorder for which surgical revascularization is the primary treatment. The standard direct superficial temporal artery–middle cerebral artery (STA-MCA) bypass uses the frontal and/or parietal branch of the STA as the donor. However, in some patients, conventional STA-MCA bypass may be suboptimal because of a large mismatch in caliber between the STA branch and the recipient artery, increasing the risk of cerebral hyperperfusion. This study aimed to investigate the impact of a modified STA-MCA bypass on MMD treatment. Methods: We retrospectively reviewed adult cases of MMD at our institution (2012–2025) for patients who underwent modified direct STA-MCA bypass using a small side branch of the STA as the donor artery. Surgical techniques and clinical outcomes of these cases were analyzed descriptively. Results: Five cases (five hemispheres in four patients) underwent side-branch STA-MCA bypass. All procedures were completed successfully, with 100% graft patency confirmed by intraoperative indocyanine green angiography, and a mild increase in cerebral blood flow confirmed by postoperative single-photon emission computed tomography. No patients developed postoperative cerebral hyperperfusion syndrome or wound healing complications. Clinically, all patients experienced a stable or improved neurological status, with no reported new ischemic or hemorrhagic events during follow-up. Conclusions: In this small feasibility series, the side-branch STA–MCA bypass was technically feasible and safe, with no cerebral hyperperfusion syndrome observed. Any risk-mitigating effect on hyperperfusion remains theoretical and requires confirmation in comparative studies. Full article

Background: Seizures are a rare but potentially serious complication following carotid endarterectomy (CEA). Understanding their prevalence and associated factors is crucial for optimizing perioperative care and improving patient outcomes. This meta-analysis aimed to estimate the pooled prevalence of seizures following CEA and explore clinical and procedural factors contributing to their occurrence. Methods: We conducted a systematic review and meta-analysis of studies reporting on seizures following CEA. A systematic search of PubMed, Embase, and Cochrane CENTRAL databases was performed, following PRISMA and MOOSE guidelines. Random-effects meta-analysis was used to calculate the pooled prevalence of postoperative seizures. Heterogeneity was assessed using the I² statistic. A total of 20 studies, encompassing 69,479 patients, were included. Results: The overall pooled prevalence of seizures following CEA was 1% (95% CI: 0–2%; p < 0.001), with significant heterogeneity (I² = 93.52%). Prospective studies reported a higher pooled prevalence (2%, 95% CI 0–4%; I² = 76.34%) compared to retrospective studies (0%, 95% CI 0–1%; I² = 91.51%). Male predominance was noted among patients who experienced seizures, and hypertension was the most common comorbidity. Cerebral hyperperfusion syndrome was identified as a key contributing factor to postoperative seizures. Data on long-term outcomes, including the development of epilepsy, were insufficient for further analysis. The methodological quality of the included studies varied, with most studies demonstrating a moderate risk of bias. Conclusions: Seizures occur in approximately 1% of patients following CEA, with higher rates observed in prospective studies. Cerebral hyperperfusion syndrome is an important contributor to this rare complication. We provide evidence-based specific recommendations for seizure management and introduce the SMART-CEA Checklist, a practical framework to guide perioperative care and reduce complications. Future research should focus on long-term outcomes, including epilepsy, and incorporate standardized methodologies to improve data reliability and guide clinical practice. Full article

Cerebral hyperperfusion syndrome (CHS) is a serious post-procedural complication of carotid artery stenting (CAS). The pathophysiological mechanisms of CHS in the absence of arterial hypertension (AH) remain only partially understood. We performed a systematic literature search of the PubMed database using the terms »cerebral hyperperfusion syndrome«, »hypotension«, »hyperperfusion«, »stroke«, »intracranial hemorrhages«, »risk factors«, »carotid revascularization«, »carotid stenting«, »carotid endarterectomy«, »blood-brain barrier«, »endothelium«, »contrast encephalopathy«, and combinations. We present a case of a normotensive female patient who developed CHS post-CAS for symptomatic carotid stenosis while being hypotensive with complete recovery. We identified 393 papers, among which 65 were deemed relevant to the topic. The weighted average prevalence of CHS after CAS is 1.2% [0.0–37.7%] with that of intracranial hemorrhage (ICH) being 0.51% [0–9.3%]. Recently symptomatic carotid stenosis or contralateral carotid revascularization, urgent intervention, acute carotid occlusion, contralateral ≥70% stenosis, and the presence of leptomeningeal collaterals were associated with CHS. A prolonged hemodynamic instability after CAS conveys a higher risk for CHS. However, none of the articles mentioned isolated hypotension as a risk factor for CHS. Whereas mortality after ICH post-CAS ranges from 40 to 75%, in the absence of ICH, CHS generally carries a good prognosis. AH is not obligatory in CHS development. Even though impaired cerebral autoregulation and post-revascularization changes in cerebral hemodynamics seem to play a pivotal role in CHS pathophysiology, our case highlights the complexity of CHS, involving factors like endothelial dysfunction and sudden reperfusion. Further research is needed to refine diagnostic and management approaches for this condition. Full article

Background: Carotid endarterectomy is a recognized method for preventing stroke for both symptomatic and asymptomatic hemodynamically carotid artery stenosis. Hemodynamic depression is more frequently associated with carotid artery stenting, while postoperative hypertension and cerebral hyperperfusion syndrome are known frequent complications after carotid endarterectomy. Severe hypotension after carotid revascularization is associated with a higher risk of perioperative stroke, myocardial infarction, and death, with limited data existing regarding risk factors. This study aims to investigate intraoperative risk factors for severe hypotension after carotid endarterectomy. Methods: A total of 160 patients who underwent carotid endarterectomy were included in this study. Patients with other cardiac conditions that required concomitant cardiac surgery, patients with incomplete medical records, and patients considered high risk for surgery were excluded. Results: The incidence of severe hypotension was 30.6%. Patients with severe hypotension after carotid endarterectomy had a higher incidence of diabetes, moderate mitral valve regurgitation, a history of percutaneous coronary intervention, and higher operative times. Using logistic regression, temporary shunt insertion was independently associated with severe postoperative hypotension (OR = 2.26, 95% CI = 1.09–4.71, p = 0.029). Conclusions: This result favors the selective shunting strategy when performing carotid endarterectomies, especially for those patients with comorbidities predisposing to postoperative complications. Full article

Multiple strategies for tandem severe carotid artery stenosis are reported: bilateral carotid artery endarterectomy (CEA), bilateral carotid artery stenting (CAS), and hybrid procedures (CEA and CAS). The management is controversial, considering the reported high risk of periprocedural stroke, hemodynamic distress, and cerebral hyperperfusion syndrome. We present the case of a 64-year-old patient with severe symptomatic bilateral internal carotid artery stenosis (95% stenosis on the left internal carotid artery with recent ipsilateral watershed anterior cerebral artery–medial cerebral artery (ACA-MCA) and medial cerebral artery–posterior cerebral artery (MCA-PCA) ischemic strokes and 90% stenosis on the right internal carotid artery with chronic ipsilateral frontal ischemic stroke) managed successfully with staged CEA within a 3-day interval. The patient had a history of coronary angioplasty and stenting. Strategies for brain protection included shunt placement after the evaluation of carotid stump pressure, internal carotid backflow, and near-infrared spectroscopy. A collagen and silver-coated polyester patch was used to complete the endarterectomy using a 6.0 polypropylene continuous suture in both instances. Management also included neurological consults after extubation, dual antiplatelet therapy, head CT between the two surgeries, myocardial ischemia monitoring, and general anesthesia. Staged CEA with a small time interval between surgeries can be an option to treat tandem symptomatic carotid artery stenosis in highly selected patients. The decision should be tailored according to the patient’s characteristics and should also be made by a cardiology specialist, a neurology specialist, and an anesthesia and intensive care physician. Full article

Aims: To describe through emblematic images rare but clinically relevant carotid artery stenting complications that occurred at two high-volume centres for carotid artery stenting (CAS). Background: CAS is an alternative to carotid endarterectomy (CEA) for the treatment of carotid artery stenosis in patients judged to be at high risk for CEA. CAS complications range between 1 and 9% and are higher in older patients complaining of neurological symptoms at the time of presentation. Besides periprocedural or early-after-procedure stroke, which remains the true Achilles’ heel of CAS, other dramatic complications might compromise the clinical outcomes of this procedure. Methods: Five infrequent complications, out of more than 1000 CAS performed in the years 2016–2021, have been described. Results: Among CAS complications, acute carotid stent thrombosis, rescue retrieval of a disconnected distal cerebral embolic protection device, plaque prolapse after carotid stenting, cerebral hyperperfusion syndrome (CHS), and radial artery long sheath entrapment requiring surgical intervention were found to account for 0.3% of the total number of procedures performed by operators with high CAS volume. Conclusions: Unusual CAS complications may infrequently occur, even in hands of expert operators. To know how to deal with such complications might help interventionalists to improve CAS performance. Full article

Non-atherosclerotic aortic arch pathologies (NA-AAPs) and anatomical variants are characterized as rare cardiovascular diseases with a low incidence rate, below 1 case per 2000 population, but enormous heterogeneity in terms of anatomical variants, i.e., Takayasu disease (TAK) and fibromuscular dysplasia (FMD). In specific clinical scenarios, NA-AAPs constitute life-threatening disorders. Methods: In this study, 82 (1.07%) consecutive patients with NA-AAPs (including 38 TAKs, 26 FMDs, and 18 other AAPs) out of 7645 patients who underwent endovascular treatment (EVT) for the aortic arch and its side-branch diseases at a single institution between 2002 and 2022 were retrospectively reviewed. The recorded demographic, biochemical, diagnostic, operative, and postoperative factors were reviewed, and the functional outcomes were determined during follow-up. A systematic review of the literature was also performed. Results: The study group comprised 65 (79.3%) female and 17 (21.7%) male subjects with a mean age of 46.1 ± 14.9 years. Overall, 62 (75.6%) patients were diagnosed with either cerebral ischemia symptoms or aortic arch dissection on admission. The EVT was feasible in 59 (72%) patients, whereas 23 (28%) patients were referred for medical treatment. In EVT patients, severe periprocedural complications occurred in two (3.39%) patients, including one periprocedural death and one cerebral hyperperfusion syndrome. During a median follow-up period of 64 months, cardiovascular events occurred in 24 (29.6%) patients (5 deaths, 13 ISs, and 6 myocardial infarctions). Repeated EVT for the index lesion was performed in 21/59 (35.6%) patients, including 19/33 (57.6%) in TAK and 2/13 (15.4%) in FMD. In the AAP group, one patient required additional stent-graft implantation for progressing dissection to the iliac arteries at 12 months. A baseline white blood count (odds ratio [HR]: 1.25, 95% confidence interval [CI]: 1.11–1.39; p < 0.001) was the only independent prognostic factor for recurrent stenosis, while a baseline hemoglobin level (HR: 0.73, 95%CI: 0.59–0.89; p = 0.002) and coronary involvement (HR: 4.11, 95%CI: 1.74–9.71; p = 0.001) were independently associated with a risk of major cardiac and cerebral events according to the multivariate Cox proportional hazards regression analysis. Conclusions: This study showed that AAPs should not be neglected in clinical settings, as it can be a life-threatening condition requiring a multidisciplinary approach. The knowledge of prognostic risk factors for adverse outcomes may improve surveillance in this group of patients. Full article

Objective. The search for methods by which to predict the risks of cerebral hyperperfusion syn-drome (CHS) in adults with moyamoya disease (MMD), including those utilizing new biomarkers, still deserves further research. The objective of this study was to investigate the association between the hemodynamics of parasylvian cortical arteries (PSCAs) and postoperative CHS. Methods. A consecutive number of adults with MMD who had undergone direct bypass between September 2020 and December 2022 were recruited. Intraoperative microvascular doppler ultrasonography (MDU) was performed to evaluate the hemodynamics of PSCAs. The intraoperative flow direction, mean value of velocity (MVV) of recipient artery (RA) and bypass graft were recorded. According to flow direction after bypass, RA was divided into entering sylvian (RA.ES) and leaving sylvian (RA.LS) subtypes. Univariate, multivariate, and ROC analyses of the risk factors for postoperative CHS were performed. Results. A total of 16 (15.09%) cases in 106 consecutive hemispheres (101 patients) sat-isfied the postoperative CHS criteria. According to univariate analysis, advanced Suzuki stage, MVV of RA before bypass, and fold increase of MVV in RA.ES after bypass were significantly associated with postoperative CHS (p < 0.05). Multivariate analysis indicated that left-operated hemisphere (OR (95%CI), 4.58 (1.05–19.97), p = 0.043), advanced Suzuki stage (OR (95%CI), 5.47 (1.99–15.05), p = 0.017), and fold increase of MVV in RA.ES (OR (95%CI), 1.17 (1.06–1.30), p = 0.003) were statistically significantly associated with the occurrence of CHS. The cut-off value of fold increase of MVV in RA.ES was 2.7-fold (p < 0.05). Conclusions. Left-operated hemisphere, advanced Suzuki stage, and postoperative fold increase of MVV in RA.ES were potential risk factors for postoperative CHS. Intraoperative MDU was useful for evaluating hemodynamics and predicting CHS. Full article

Kleine–Levin syndrome (KLS) is characterized by episodes of hypersomnia. Additionally, these patients can present with hyperphagia, hypersexuality, abnormal behavior, and cognitive dysfunction. Functional neuroimaging studies such as fMRI-BOLD, Positron Emission Tomography (PET) or SPECT help us understand the neuropathological bases of different disorders. We conducted a systematic review to investigate the neuroimaging features of KLS patients and their clinical correlations. This systematic review was conducted by following the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) and PRISMA protocol reporting guidelines. We aim to investigate the clinical correlation with neuroimaging among patients with KLS. We included only studies written in the English language in the last 20 years, conducted on humans; 10 studies were included. We excluded systematic reviews, metanalysis, and case reports. We found that there are changes in functional imaging studies during the symptomatic and asymptomatic periods as well as in between episodes in patients with K.L.S. The areas most reported as affected were the hypothalamic and thalamic regions, which showed hypoperfusion and, in a few cases, hyperperfusion; areas such as the frontal, parietal, occipital and the prefrontal cortex all showed alterations in cerebral perfusion. These changes in cerebral blood flow and regions vary according to the imaging (SPECT, PET SCAN, or fMRI) and the task performed while imaging was performed. We encountered conflicting data between studies. Hyper insomnia, the main feature of this disease during the symptomatic periods, was associated with decreased thalamic activity. Other features of K.L.S., such as apathy, hypersexuality, and depersonalization, were also correlated with functional imaging changes. There were also findings that correlated with working memory deficits seen in this stage during the asymptomatic periods. Hyperactivity of the thalamus and hypothalamus were the main features shown during the asymptomatic period. Additionally, functional imaging tends to improve with a longer course of the disease, which suggests that K.L.S. patients outgrow the disease. These findings should caution physicians when analyzing and correlating neuroimaging findings with the disease. Full article

Background: Carotid artery stenting (CAS) is a minimally invasive and proven percutaneous procedure that is widely used to treat patients with symptomatic and asymptomatic carotid artery stenosis. The purpose of this study was to characterize the in-hospital outcomes of symptomatic and asymptomatic patients undergoing CAS at a single neurovascular center. Methods: The study was conducted as a retrospective analysis of 1158 patients (asymptomatic, n = 636; symptomatic, n = 522; male, n = 816; median age, 71 years; NASCET method, 70–99% stenosis, n = 830) who underwent CAS between May 2009 and December 2020. In-hospital neurological outcomes, adverse reactions to iodinated contrast media, acute myocardial infarction, intraprocedural complications, and access-site issues were evaluated. The primary endpoints were disabling stroke (including disabling cerebral hyperperfusion syndrome [CHS]) and all in-hospital deaths. Results: A carotid stent could not be deployed in one patient due to calcified plaques (technical failure rate of 0.09%). Four patients (0.3%) experienced in-hospital, stroke-associated death, while five patients (0.4%) died from non-stroke-related causes. All stroke-associated deaths occurred in the symptomatic group and were due to CHS. The disabling stroke rate was 0.9% overall (n = 10; 0.5% versus 1.3% in asymptomatic versus symptomatic patients, respectively). Nineteen patients (1.6%) reached the in-hospital primary endpoint. More patients in the symptomatic group achieved this endpoint than in the asymptomatic group (2.5% versus 0.9%, respectively; p = 0.060). Conclusions: An evaluation was conducted on the in-hospital outcomes of 1158 patients at a single center who underwent CAS and was performed by trained physicians who were supervised by a senior neurovascular interventionist with over 20 years of experience, confirming the excellent safety profile of this procedure with a low rate of complications. Full article

Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis is the most commonly used treatment for Moyamoya disease. During the perioperative period, however, these patients are vulnerable to ischemic injury or hyperperfusion syndrome. This study investigated the ability of combined remote ischemic pre-conditioning (RIPC) and remote ischemic post-conditioning (RIPostC) to reduce the occurrence of major neurologic complications in Moyamoya patients undergoing STA-MCA anastomosis. The 108 patients were randomly assigned to a RIPC with RIPostC group (n = 54) or a control group (n = 54). Patients in the RIPC with RIPostC group were treated with four cycles of 5-min ischemia and 5-min reperfusion before craniotomy and after STA-MCA anastomosis (RIPostC). The incidence of postoperative neurologic complications and the duration of hospital stay were determined. The overall incidence of neurologic complication was significantly higher in the control group than in the RIPC with RIPostC group (13 vs. 3, p = 0.013). The duration of hospital stay was significantly longer in the control group than in the RIPC with RIPostC group (17.8 (11.3) vs. 13.8 (5.9) days, p = 0.023). Combined remote ischemic pre- and post-conditioning can be effective in reducing neurologic complications and the duration of hospitalization in Moyamoya patients undergoing STA-MCA anastomosis. Full article