Zsuzsanna Járányi

Impairment of blood-brain barrier integrity during carotid surgery as assessed by serum S-100B protein concentrations

Abstract During carotid endarterectomy (CEA) the internal carotid artery is cross-clamped for a period of several minutes. This maneuver may cause cerebral hypoperfusion and/or impairment of the blood-brain barrier (BBB) even in cases where clinical signs are absent. The aim of the present study was to examine whether such alterations could be detected by monitoring the cerebral marker S-100B protein concentrations during and after CEA in the serum. Twentyfive consecutive patients (17 M/8 F, mean age: 64.2 years, range 47-79 years) undergoing elective CEA at our department were studied. All of these patients were without perioperative neurological deficit. Intraoperative samples were collected from internal jugular and peripheral venous blood: 1) before carotid cross-clamping; 2) immediately before declamping; 3) after clamp release. Postoperative samples were taken from peripheral blood at 6 and 24 h, respectively. S-100B was assayed in sera using an immunoluminometric technique. During carotid crossclamping, S-100B protein concentrations in the ipsilateral jugular serum significantly (p < 0.02) increased to pre-clamp values. After declamping, however, S-100B returned to the baseline level. No differences were seen between the responses of hypertensive and normotensive patients. There was no correlation between carotid occlusion time and S-100B protein concentrations. In the peripheral venous serum no significant changes in S-100B concentrations were detected during or after CEA. We presume that the elevation of S-100B protein concentration during CEA in patients with no neurological deficits indicates the transient opening of the BBB elicited by carotid cross-clamping. Clin Chem Lab Med 2003; 41(10):13201322

Echolucent or predominantly echolucent femoral plaques predict early restenosis after eversion carotid endarterectomy

OBJECTIVE Although the association between vulnerable lesions and cardiovascular events is well established, little is known about their relationship to postsurgery restenosis. To address this issue, we initiated a prospective, nonrandomized study to examine the femoral plaques on both sides in patients who were undergoing eversion carotid endarterectomy (CEA) and were longitudinally followed-up for early restenosis development. METHODS The final analysis enrolled 321 patients (189 women) with a median age of 67.0 years (interquartile range, 59.0-73.0 years), who underwent eversion CEA (2005 to 2007). Using duplex ultrasound scanning, we evaluated 321 common femoral atherosclerotic lesions on the day before CEA. A quantitative scale was used to grade the size of plaques as grade 1, one or more small plaques (<20 mm2); grade 2, moderate to large plaques; and grade 3, plaques giving flow disturbances. The plaque morphology in terms of echogenicity was graded as echolucent, 1; predominantly echolucent, 2; predominantly echogenic, 3; echogenic 4; or calcified, 5. The plaque surface was categorized as smooth, irregular, or ulcerated. The patients underwent carotid duplex ultrasound imaging at 6 weeks and at 6, 12, and 24 months after CEA. Mann-Whitney U test, chi2 test, and multivariate logistic regression were used for statistical evaluation. RESULTS Internal carotid artery restenosis of > or = 50% was detected in 33 patients (10.28%) in the operated region. Neither the size (grade 1, P = .793; grade 2, P = .540; grade 3, P = .395) nor the surface characteristics of the femoral plaques (smooth, P = .278; irregular, P = .281; ulcerated, P = .934) were significantly different between the patients with and without carotid restenosis. Echolucent-predominantly echolucent femoral lesions were an independent predictor of recurrent carotid stenosis (adjusted odds ratio, 5.63; 95% confidence interval, 2.14-10.89; P < .001). CONCLUSION Ultrasound evaluation of femoral plaque morphology before CEA can be useful for identifying patients at higher risk for carotid restenosis.

Asymptomatic free-floating thrombus of the internal carotid artery

Abstract Free-floating thrombus (FFT) of the internal carotid artery, which is almost always symptomatic and is usually discovered by ultrasound or angiography performed after a transient cerebrovascular event, is a highly uncommon diagnosis. Here, we report a case of an asymptomatic freefloating internal carotid artery thrombus most probably caused by an atherosclerotic plaque rupture. It was detected by carotid ultrasound and was treated with eversion endarterectomy without any neurologic complications. Six weeks after surgery, the patient is doing well.

Mycotic Aneurysms of the Thoracic and Thoracoabdominal Aorta

We report seven mycotic aneurysms. In five cases the thoracoabdominal aorta, including visceral and renal tributaries, was affected; in one the distal aortic arch was involved; and in one the descending thoracic aorta was affected. The sources of infection were enteritis, chest trauma, peritonitis, pyelitis, pneumonia, and gunshot and splinter injuries. In four cases the septic origin was first detected during surgery. Klebsiella, coagulase-negative Staphylococcus (m = 2), and Salmonella and Escherichia coli were found in cultures; no organism had been recognized in three emergency cases at the time of surgery and the identification remained obscure in one. Debridement, disinfection, and in situ replacement involving side branches were done in four cases; direct suture and patchplasty were performed in the others. Two patients died within 36 h, one 40 days following rupture of the sutures. One patient died after 6 months owing to septic hemorrhage; graft explantation and homograft implantation could not prevent the fatal outcome. Three patients survived, one of whom, a young boy, has been doing well for 10 years. Another patient who had had aggressive antibiotic pretreatment has survived 5 years without signs of recurrence. The third patient underwent aortic replacement 5 months ago and so far has been doing well. Septic aneurysms have a poor prognosis, although antibiotic pretreatment may reduce the risk. If the mycotic aneurysm ruptures or main tributaries are involved, surgery has little chance to prevent a fatal outcome.

Atypical Thoracoabdominal Aortic Coarctation

Atypical aortic coarctation accounts for approximately 2% of all coarctations. The pathological background is supposedly congenital, but the role of Takayasu or autoimmune aortitis has been emphasized in recent studies. During 1980–1999 we registered 23 patients (8 females, 15 males) with atypical aortic coarctation. The age ranged between 2 and 50 years (mean 22 years). Morphology varied from short stenosis to involvement of the entire thoracoabdominal aorta. Clinical manifestations were hypertension (n = 22), claudication (n = 4), and malabsorption (n = 2). Excessive hypertension led to cardiac failure in four patients. Epigastric bruit was a typical sign. Digital Subtraction angiography provided the diagnosis. Localization was thoracic in 5 cases, thoracoabdominal in 6, suprarenal in 11, and infrarenal in 1. Surgery included patchplasty in 17, aortoaortic bypass in 4 (with reimplantation of visceral and renal arteries in 2), splenorenal bypass in 2, and splenohepatorenal bypass in 1. There was no early morbidity. The follow-up period ranged between 3 and 20 years (mean 8 years). An aortoenteric fistula developed in one patient but healed but after removal of the infrarenal patch. Two patients required repeated surgery 8 and 4 years, respectively, after primary repair (following growth). All patients ultimately became normotensive. We concluded that atypical aortic coarctation may be found in the background in hypertensive children or in young adults. Surgical repair provides good results, but normal growth may necessitate repeated surgery.