Rita Huber

Symptomatic acute occlusion of the internal carotid artery: Reappraisal of urgent vascular reconstruction based on current stroke imaging

OBJECTIVE We hypothesized that a subgroup of patients with frank stroke due to sudden occlusion of the internal carotid artery could safely undergo surgery to restore carotid patency and to rescue brain tissue not yet irreversibly damaged if current stroke diagnostic methods were applied. METHODS From November 1997 to March 2007, 1810 patients underwent carotid endarterectomy of the internal carotid artery for occlusive disease at our department. Within the same period, 5369 patients were examined at our stroke unit, and 502 from this cohort underwent internal carotid artery reconstruction. A subgroup of 35 patients (28 men, 7 women; mean age, 61 +/- 10 years) underwent urgent surgical revascularization due to an acute internal carotid artery occlusion < or =72 hours (mean 25 +/- 17 hours) after the onset of stroke symptoms and < or =36 hours (mean 16 +/- 10 hours) after admission to our stroke unit. Our diagnostic workup consisted of extracranial intracranial duplex sonography, cerebral computed tomography, digital subtraction angiography, magnetic resonance imaging, and angiography, including diffusion- and perfusion-weighted imaging, to discriminate between viable and irreversibly damaged brain tissue. The study excluded patients who presented an impaired level of consciousness, occlusion of the intracranial internal carotid artery, occlusion of the ipsilateral middle cerebral artery, or infarction more than one-third of the territory perfused by the middle cerebral artery. Imaging showed signs of recent ischemic infarction in all 35 cases. On admission, eight patients (23%) scored 0 to 2 points and 27 (77%) scored 3 to 5 points in Rankin scale. RESULTS Confirmed by postoperative Doppler and duplex sonography at discharge, internal carotid artery patency could be achieved in 30 of 35 cases (86%). Intracranial hemorrhage occurred in two patients (6%) and reinfarction in another two (6%). Two patients died during their hospital stay (30-day mortality, 6%). Compared with the preoperative neurologic status, rates of clinical improvement (> or =1 point in Rankin scale), stability, and deterioration were 57%, 31%, and 6%, respectively. CONCLUSIONS Restoration of blood flow in an acutely occluded internal carotid artery can only be achieved in the acute stage. Our pilot study demonstrated that a thorough diagnostic workup allows selection of patients who may benefit from urgent revascularization of acute internal carotid artery occlusion in the stage of an acute stroke. A prospective randomized multicenter trial comparing surgery with conservative medical treatment is needed.

Gene expression in acute Stanford type A dissection: a comparative microarray study

BackgroundWe compared gene expression profiles in acutely dissected aorta with those in normal control aorta.Materials and methodsAscending aorta specimen from patients with an acute Stanford A-dissection were taken during surgery and compared with those from normal ascending aorta from multiorgan donors using the BD Atlas™ Human1.2 Array I, BD Atlas™ Human Cardiovascular Array and the Affymetrix HG-U133A GeneChip®. For analysis only genes with strong signals of more than 70 percent of the mean signal of all spots on the array were accepted as being expressed. Quantitative real-time polymerase chain reaction (RT-PCR) was used to confirm regulation of expression of a subset of 24 genes known to be involved in aortic structure and function.ResultsAccording to our definition expression profiling of aorta tissue specimens revealed an expression of 19.1% to 23.5% of the genes listed on the arrays. Of those 15.7% to 28.9% were differently expressed in dissected and control aorta specimens. Several genes that encode for extracellular matrix components such as collagen IV α2 and -α5, collagen VI α3, collagen XIV α1, collagen XVIII α1 and elastin were down-regulated in aortic dissection, whereas levels of matrix metalloproteinases-11, -14 and -19 were increased. Some genes coding for cell to cell adhesion, cell to matrix signaling (e.g., polycystin1 and -2), cytoskeleton, as well as several myofibrillar genes (e.g., α-actinin, tropomyosin, gelsolin) were found to be down-regulated. Not surprisingly, some genes associated with chronic inflammation such as interleukin -2, -6 and -8, were up-regulated in dissection.ConclusionOur results demonstrate the complexity of the dissecting process on a molecular level. Genes coding for the integrity and strength of the aortic wall were down-regulated whereas components of inflammatory response were up-regulated. Altered patterns of gene expression indicate a pre-existing structural failure, which is probably a consequence of insufficient remodeling of the aortic wall resulting in further aortic dissection.

Management of patients with renal artery stenosis. Reappraisal of operative treatment

Zusammenfassung.Eine arterielle Hypertonie stellt häufig den ersten diagnostischen Hinweis auf das Vorliegen einer Nierenarterienstenose (NAST) dar. Geeignete Screeningmethoden zur Abklärung einer Hypertonie sind farbkodierte Duplexsonographie und Captoprilszintigraphie. Die Angiographie (intraarterielle digitale Subtraktionsangiographie) stellt den diagnostischen Goldstandard dar und ist Voraussetzung für die Wahl des invasiven Therapieverfahrens. Die Arteriosklerose ist im höheren Lebensalter die häufigste Ursache einer NAST. Bei jüngeren Patienten überwiegt die fibromuskuläre Dysplasie, von der fünf Haupttypen mit unterschiedlichen Prognosen und Therapieindikationen zu unterscheiden sind. Seltene Ursachen einer NAST sind Nierenarteriendissektion, Nierenarterienaneurysma mit kombinierten Stenosen sowie die meist im Kindes- und Jugendalter diagnostizierte „Coarctatio aortae abdominalis“ mit Hypoplasie der Viszeralarterien. Jede NAST, die hämodynamisch wirksam ist und eine renovaskuläre Hypertonie verursacht, sollte behandelt werden, wobei Nutzen und Risiko für den Patienten individuell abzuwägen sind. Ziele der Behandlung sind Besserung der Hypertonie und Erhalt der Nierenfunktion. Operative Verfahren, die nachfolgend erläutert werden, sind u. a. bei allen Patienten mit NAST, bei denen simultan weitere abdominale Gefäßeingriffe erforderlich sind (Bauchaortenaneurysmen, Stenosen oder Aneurysmen der aortoiliakalen oder viszeralen Arterien), indiziert. Bei arteriosklerotischen ostialen und ostiumnahen NAST stellen Angioplastie (PTA) und Operation (in der Regel transaortale Thrombendarteriektomie) derzeit konkurrierende Verfahren dar, wobei aufgrund eigener Erfahrungen die Langzeitergebnisse der operativen Therapie besser sind. Beide Methoden werden derzeit im Rahmen einer randomisierten Studie in unserer Klinik verglichen. Die Ergebnisse der operativen Therapie der Nierenarterien sind durchweg gut, das Operationsrisiko ist insbesondere für isolierte Eingriffe an den Nierenarterien niedrig. Die Resultate der eigenen Klinik werden nachfolgend dargelegt.Abstract.Arterial hypertension is most often the first symptom of renal artery stenosis (RAS). Appropriate screening methods for the diagnostic workup of hypertension are colour-coded duplex ultrasound and captopril scintigraphy. Angiography (intraarterial digital subtraction angiography) represents the diagnostic “gold standard”, which is the prerequisite for the selection of the most suitable therapeutic method. Atherosclerosis is the most common disease in elderly patients presenting with RAS. In younger patients, fibromuscular dysplasia is more frequent. Five main types with different prognosis and therapeutic indications can be classified. Rare causes of RAS are dissection, renal artery aneurysm with combined stenosis, and especially in children and adolescents middle aortic syndrome with hypoplasia of the visceral arteries. Every patient with RAS of hemodynamic relevance in the presence of hypertension should be treated, whereas therapeutic risk and benefit must be weighed up individually. Aims are the improvement of hypertension and the maintenance of renal function. Surgical techniques, which are described subsequently, are indicated in all patients who need further simultaneous treatment of the abdominal vessels (abdominal aortic aneurysm, aortoiliac or visceral artery stenosis or aneurysm, respectively). In atherosclerotic ostial stenoses, angioplasty (PTA) and open surgery (normally transaortic endarterectomy) are concurrent methods. In our experience, the long-term results of surgical reconstruction seem to be superior. Both procedures are subject to an ongoing randomized study in our department. The outcome of surgical treatment for RAS is satisfying, the operative risk especially in isolated renal artery lesions is negligible.

Stellenwert der Revaskularisation eines akuten Karotisverschlusses

BACKGROUND AND PURPOSE We examined indications for emergent revascularisation of acutely occluded internal carotid artery (ICA) using current diagnostic methods. MATERIAL AND METHODS From 1997 to 2006 we prospectively followed 34 consecutive patients undergoing emergency revascularisation due to acute extracranial ICA occlusion and acute ischaemic stroke within 72 h after symptom onset (mean 25) and within 36 h after admission (mean 16). Exclusion criteria were occlusion of the intracranial ICA or ipsilateral middle cerebral artery (MCA), ischaemic infarction of more than one third of the MCA perfusion area, or reduced level of consciousness. All patients underwent duplex sonography, cerebral CT, and/or MRI and angiography (MRA and/or DSA). We performed endarterectomy and thrombectomy of the ICA. RESULTS Confirmed by postoperative duplex sonography at discharge, ICA revascularisation was successful in 30 (88%) of 34 cases. Postoperative intracranial haemorrhage was detected in two patients (6%) and perioperative reinfarction in one (3%). Compared to the preoperative status, 20 patients (59%) showed signs of clinical improvement by at least one point on the Rankin scale, ten patients (29%) remained stable, and two patients (6%) had deteriorated. The 30-day mortality was 6% (two patients). CONCLUSION After careful diagnostic workup, revascularisation of acute extracranial ICA occlusion is feasible with low morbidity and mortality.

Therapie der Nierenarterienstenosen

Zusammenfassung.Eine arterielle Hypertonie stellt häufig den ersten diagnostischen Hinweis auf das Vorliegen einer Nierenarterienstenose (NAST) dar. Geeignete Screeningmethoden zur Abklärung einer Hypertonie sind farbkodierte Duplexsonographie und Captoprilszintigraphie. Die Angiographie (intraarterielle digitale Subtraktionsangiographie) stellt den diagnostischen Goldstandard dar und ist Voraussetzung für die Wahl des invasiven Therapieverfahrens. Die Arteriosklerose ist im höheren Lebensalter die häufigste Ursache einer NAST. Bei jüngeren Patienten überwiegt die fibromuskuläre Dysplasie, von der fünf Haupttypen mit unterschiedlichen Prognosen und Therapieindikationen zu unterscheiden sind. Seltene Ursachen einer NAST sind Nierenarteriendissektion, Nierenarterienaneurysma mit kombinierten Stenosen sowie die meist im Kindes- und Jugendalter diagnostizierte „Coarctatio aortae abdominalis“ mit Hypoplasie der Viszeralarterien. Jede NAST, die hämodynamisch wirksam ist und eine renovaskuläre Hypertonie verursacht, sollte behandelt werden, wobei Nutzen und Risiko für den Patienten individuell abzuwägen sind. Ziele der Behandlung sind Besserung der Hypertonie und Erhalt der Nierenfunktion. Operative Verfahren, die nachfolgend erläutert werden, sind u. a. bei allen Patienten mit NAST, bei denen simultan weitere abdominale Gefäßeingriffe erforderlich sind (Bauchaortenaneurysmen, Stenosen oder Aneurysmen der aortoiliakalen oder viszeralen Arterien), indiziert. Bei arteriosklerotischen ostialen und ostiumnahen NAST stellen Angioplastie (PTA) und Operation (in der Regel transaortale Thrombendarteriektomie) derzeit konkurrierende Verfahren dar, wobei aufgrund eigener Erfahrungen die Langzeitergebnisse der operativen Therapie besser sind. Beide Methoden werden derzeit im Rahmen einer randomisierten Studie in unserer Klinik verglichen. Die Ergebnisse der operativen Therapie der Nierenarterien sind durchweg gut, das Operationsrisiko ist insbesondere für isolierte Eingriffe an den Nierenarterien niedrig. Die Resultate der eigenen Klinik werden nachfolgend dargelegt.Abstract.Arterial hypertension is most often the first symptom of renal artery stenosis (RAS). Appropriate screening methods for the diagnostic workup of hypertension are colour-coded duplex ultrasound and captopril scintigraphy. Angiography (intraarterial digital subtraction angiography) represents the diagnostic “gold standard”, which is the prerequisite for the selection of the most suitable therapeutic method. Atherosclerosis is the most common disease in elderly patients presenting with RAS. In younger patients, fibromuscular dysplasia is more frequent. Five main types with different prognosis and therapeutic indications can be classified. Rare causes of RAS are dissection, renal artery aneurysm with combined stenosis, and especially in children and adolescents middle aortic syndrome with hypoplasia of the visceral arteries. Every patient with RAS of hemodynamic relevance in the presence of hypertension should be treated, whereas therapeutic risk and benefit must be weighed up individually. Aims are the improvement of hypertension and the maintenance of renal function. Surgical techniques, which are described subsequently, are indicated in all patients who need further simultaneous treatment of the abdominal vessels (abdominal aortic aneurysm, aortoiliac or visceral artery stenosis or aneurysm, respectively). In atherosclerotic ostial stenoses, angioplasty (PTA) and open surgery (normally transaortic endarterectomy) are concurrent methods. In our experience, the long-term results of surgical reconstruction seem to be superior. Both procedures are subject to an ongoing randomized study in our department. The outcome of surgical treatment for RAS is satisfying, the operative risk especially in isolated renal artery lesions is negligible.

Ultrasound turbulence index during thromboendarterectomy predicts postoperative cerebral microembolism.

Background: Cerebral microembolic signals (MES) after carotid endarterectomy (CEA) are associated with an increased risk of postoperative stroke. We investigated the relationship of an intraoperatively recorded ultrasound turbulence index (TI) during CEA and the occurrence of MES. Methods: Short-time MES detection was performed on 164 patients (mean age 64 years, 140 males) in the ipsilateral middle cerebral artery within 2 h after CEA. A specialized continuous-wave ultrasound Doppler probe measured the TI within the reconstructed internal carotid artery during surgery. Results: The occurrence of postoperative MES increased significantly with the TI: a TI >26 predicted MES with a sensitivity of 72% and a specificity of 76%. The MES rate and TI were higher in patients operated with the eversion technique than in patients operated with the patch technique (p = 0.005). There was no relationship with preoperative MES, site of surgery or age of patients. Female patients had a higher risk of postoperative MES than males (p = 0.003). Conclusions: Simplified intraoperative Doppler sonography or short-time MES detection after CEA are feasible, and may be helpful for surgical quality control and decision making (e.g. treatment with platelet antagonists).

Indication for emergent revascularisation of acute carotid occlusion

BACKGROUND AND PURPOSE We examined indications for emergent revascularisation of acutely occluded internal carotid artery (ICA) using current diagnostic methods. MATERIAL AND METHODS From 1997 to 2006 we prospectively followed 34 consecutive patients undergoing emergency revascularisation due to acute extracranial ICA occlusion and acute ischaemic stroke within 72 h after symptom onset (mean 25) and within 36 h after admission (mean 16). Exclusion criteria were occlusion of the intracranial ICA or ipsilateral middle cerebral artery (MCA), ischaemic infarction of more than one third of the MCA perfusion area, or reduced level of consciousness. All patients underwent duplex sonography, cerebral CT, and/or MRI and angiography (MRA and/or DSA). We performed endarterectomy and thrombectomy of the ICA. RESULTS Confirmed by postoperative duplex sonography at discharge, ICA revascularisation was successful in 30 (88%) of 34 cases. Postoperative intracranial haemorrhage was detected in two patients (6%) and perioperative reinfarction in one (3%). Compared to the preoperative status, 20 patients (59%) showed signs of clinical improvement by at least one point on the Rankin scale, ten patients (29%) remained stable, and two patients (6%) had deteriorated. The 30-day mortality was 6% (two patients). CONCLUSION After careful diagnostic workup, revascularisation of acute extracranial ICA occlusion is feasible with low morbidity and mortality.

Stellenwert der Revaskularisation eines akuten Karotisverschlusses@@@Indication for emergent revascularisation of acute carotid occlusion

BACKGROUND AND PURPOSE We examined indications for emergent revascularisation of acutely occluded internal carotid artery (ICA) using current diagnostic methods. MATERIAL AND METHODS From 1997 to 2006 we prospectively followed 34 consecutive patients undergoing emergency revascularisation due to acute extracranial ICA occlusion and acute ischaemic stroke within 72 h after symptom onset (mean 25) and within 36 h after admission (mean 16). Exclusion criteria were occlusion of the intracranial ICA or ipsilateral middle cerebral artery (MCA), ischaemic infarction of more than one third of the MCA perfusion area, or reduced level of consciousness. All patients underwent duplex sonography, cerebral CT, and/or MRI and angiography (MRA and/or DSA). We performed endarterectomy and thrombectomy of the ICA. RESULTS Confirmed by postoperative duplex sonography at discharge, ICA revascularisation was successful in 30 (88%) of 34 cases. Postoperative intracranial haemorrhage was detected in two patients (6%) and perioperative reinfarction in one (3%). Compared to the preoperative status, 20 patients (59%) showed signs of clinical improvement by at least one point on the Rankin scale, ten patients (29%) remained stable, and two patients (6%) had deteriorated. The 30-day mortality was 6% (two patients). CONCLUSION After careful diagnostic workup, revascularisation of acute extracranial ICA occlusion is feasible with low morbidity and mortality.

Therapie der Nierenarterienstenosen@@@Management of Patients with Renal Artery Stenosis. Reappraisal of Operative Treatment

Zusammenfassung.Eine arterielle Hypertonie stellt häufig den ersten diagnostischen Hinweis auf das Vorliegen einer Nierenarterienstenose (NAST) dar. Geeignete Screeningmethoden zur Abklärung einer Hypertonie sind farbkodierte Duplexsonographie und Captoprilszintigraphie. Die Angiographie (intraarterielle digitale Subtraktionsangiographie) stellt den diagnostischen Goldstandard dar und ist Voraussetzung für die Wahl des invasiven Therapieverfahrens. Die Arteriosklerose ist im höheren Lebensalter die häufigste Ursache einer NAST. Bei jüngeren Patienten überwiegt die fibromuskuläre Dysplasie, von der fünf Haupttypen mit unterschiedlichen Prognosen und Therapieindikationen zu unterscheiden sind. Seltene Ursachen einer NAST sind Nierenarteriendissektion, Nierenarterienaneurysma mit kombinierten Stenosen sowie die meist im Kindes- und Jugendalter diagnostizierte „Coarctatio aortae abdominalis“ mit Hypoplasie der Viszeralarterien. Jede NAST, die hämodynamisch wirksam ist und eine renovaskuläre Hypertonie verursacht, sollte behandelt werden, wobei Nutzen und Risiko für den Patienten individuell abzuwägen sind. Ziele der Behandlung sind Besserung der Hypertonie und Erhalt der Nierenfunktion. Operative Verfahren, die nachfolgend erläutert werden, sind u. a. bei allen Patienten mit NAST, bei denen simultan weitere abdominale Gefäßeingriffe erforderlich sind (Bauchaortenaneurysmen, Stenosen oder Aneurysmen der aortoiliakalen oder viszeralen Arterien), indiziert. Bei arteriosklerotischen ostialen und ostiumnahen NAST stellen Angioplastie (PTA) und Operation (in der Regel transaortale Thrombendarteriektomie) derzeit konkurrierende Verfahren dar, wobei aufgrund eigener Erfahrungen die Langzeitergebnisse der operativen Therapie besser sind. Beide Methoden werden derzeit im Rahmen einer randomisierten Studie in unserer Klinik verglichen. Die Ergebnisse der operativen Therapie der Nierenarterien sind durchweg gut, das Operationsrisiko ist insbesondere für isolierte Eingriffe an den Nierenarterien niedrig. Die Resultate der eigenen Klinik werden nachfolgend dargelegt.Abstract.Arterial hypertension is most often the first symptom of renal artery stenosis (RAS). Appropriate screening methods for the diagnostic workup of hypertension are colour-coded duplex ultrasound and captopril scintigraphy. Angiography (intraarterial digital subtraction angiography) represents the diagnostic “gold standard”, which is the prerequisite for the selection of the most suitable therapeutic method. Atherosclerosis is the most common disease in elderly patients presenting with RAS. In younger patients, fibromuscular dysplasia is more frequent. Five main types with different prognosis and therapeutic indications can be classified. Rare causes of RAS are dissection, renal artery aneurysm with combined stenosis, and especially in children and adolescents middle aortic syndrome with hypoplasia of the visceral arteries. Every patient with RAS of hemodynamic relevance in the presence of hypertension should be treated, whereas therapeutic risk and benefit must be weighed up individually. Aims are the improvement of hypertension and the maintenance of renal function. Surgical techniques, which are described subsequently, are indicated in all patients who need further simultaneous treatment of the abdominal vessels (abdominal aortic aneurysm, aortoiliac or visceral artery stenosis or aneurysm, respectively). In atherosclerotic ostial stenoses, angioplasty (PTA) and open surgery (normally transaortic endarterectomy) are concurrent methods. In our experience, the long-term results of surgical reconstruction seem to be superior. Both procedures are subject to an ongoing randomized study in our department. The outcome of surgical treatment for RAS is satisfying, the operative risk especially in isolated renal artery lesions is negligible.