8 results found in Carotid & Acute Stroke
Masseter Muscle Index as a Diagnostic Predictor of Prolonged Hospitalization in Carotid Endarterectomy
By: Othman Alabdullah
Background: Carotid endarterectomy (CEA) is critical for stroke prevention, but as-sessing a patient's preoperative physiological reserve remains challenging. This study aimed to evaluate the impact of sarcopenia and preoperative albumin on postoperative management outcomes and resource utilization in CEA patients with a high prevalence of metabolic comorbidities. Methods: This retrospective cohort study evaluated 67 pa-tients who underwent elective or urgent CEA between January 2015 and June 2025. Sarcopenia was quantified using the masseter muscle index (MMI) derived from rou-tine preoperative head and neck computed tomography (CT) scans. Multivariable re-gression models were used to assess the relationships between MMI, serum albumin levels, and surgical outcomes. Results: The cohort had a mean age of 66.8 years and demonstrated a significant metabolic burden, with a high prevalence of diabetes (71.6%) and an average body mass index (BMI) of 28.15 kg/m². Despite this predomi-nantly overweight demographic, MMI revealed underlying frailty and showed a strong inverse relationship with hospital resource utilization. A one-unit increase in MMI significantly reduced total hospital length of stay (LOS) by 14.40 days (p=0.001) and ICU LOS by 6.91 days (p<0.001). Emergency surgery was the only independent pre-dictor of mortality (OR 16.61, p=0.047), while neither MMI nor albumin significantly predicted short-term adverse clinical events. Conclusion: In a patient population where higher BMI may mask underlying frailty, opportunistic screening for sarcopenia using routine preoperative CT scans provides important prognostic value. In this cohort study, lower MMI was independently associated with prolonged hospital and ICU stays. While it did not independently predict short-term mortality, its utility in fore-casting resource utilization warrants further investigation in larger, prospective co-horts.
Carotid & Acute StrokeEndovascular Repair of Left Subclavian Artery Transection Using Fusion Roadmap Technology in a Young Athlete, Case report and literature review
By: Abubakr Ali
Background: Blunt subclavian artery trauma is a rare yet critical vascular injury, typically resulting from high- energy trauma such as blunt or penetrating chest injuries. The subclavian artery is protected by several anatomical structures, including the clavicle, ribs, and surrounding ligaments, making these injuries uncommon but often severe. Due to the risk of rapid hemorrhage and the frequent association with other significant injuries, subclavian artery trauma carries high morbidity and mortality. Early and accurate diagnosis via computed tomography angiography is essential for injury grading and treatment planning. Recent advancements in endovascular techniques, particularly image fusion technology, have shifted the management of subclavian artery injuries from traditional open repair to minimally invasive procedures, especially for Grade 2–3 injuries, as recommended by the 2025 European Society for Vascular Surgery (ESVS) guidelines. Case Presentation: We present the case of a 19-year-old male horse racing athlete who sustained blunt polytrauma after a high-speed fall from a horse, resulting in complete transection of the left subclavian artery with left upper limb ischemia, and a proximal left common carotid artery dissection. Upon arrival, the patient exhibited signs of airway injury, respiratory distress, and ischemic left limb. Imaging revealed a complete subclavian artery transection and a dissection of the left common carotid artery. Urgent endovascular repair was performed using Fusion Roadmap Technology, which facilitated precise stent graft placement through brachial artery access. This intervention successfully restored blood flow to the left subclavian artery and perfusion to the left upper limb. The carotid artery dissection, being non-flow-limiting, was managed conservatively. The patient’s treatment also included multidisciplinary care for associated thoracic injuries and airway edema. Conclusion: This case demonstrates the effectiveness of endovascular stent grafting guided by Fusion Roadmap Technology in managing traumatic subclavian artery injuries. The advantages of this technique include reduced operative time, decreased contrast use, lower fluoroscopy exposure, minimized blood loss, and enhanced procedural accuracy. Our experience supports the growing role of minimally invasive endovascular approaches in complex vascular trauma. This case highlights the importance of early diagnosis, advanced imaging, and access to hybrid operating rooms for optimal outcomes.
Carotid & Acute StrokeAn Audit of Blood Pressure Control in Patients Admitted for Carotid Surgery in 2024
By: Emily Tsang
To assess achievement of risk-based blood pressure (BP) targets in patients admitted for carotid surgery at Colchester General Hospital in 2024.
Carotid & Acute StrokeImpact of Shunting and Preoperative TFCA on New Brain Lesions After Carotid Endarterectomy
By: DEOKBI HWANG
Background: Carotid stenosis is a major cause of ischemic stroke, generally attributed to reduced cerebral perfusion or distal embolic events. A recent 2022 Cochrane review on the use of shunts during carotid endarterectomy (CEA) concluded that there is still insufficient evidence to support or refute the routine or selective use of shunts under general anesthesia. Assuming that new brain lesions (NBLs) are caused by distal embolization, we aimed to assess the safety of routine shunting during CEA. Methods: Between July 2007 and June 2023, 472 consecutive patients diagnosed with internal carotid artery stenosis who underwent CEA were enrolled in a vascular registry at a tertiary hospital in South Korea. We evaluated the occurrence of postoperative NBLs on MRI and stroke events according to shunt usage and preoperative TFCA (conventional angiography), and analyzed the risk factors for NBL or late stroke. Results: The use of a shunt did not affect the occurrence of ipsilateral NBL, whereas performing TFCA was significantly associated with the development of NBL. Conclusion: Shunts may be used when necessary during CEA, but diagnostic TFCA should be avoided unless intracerebral intra-arterial treatment or other therapeutic procedures are required.
Carotid & Acute StrokeCan you Differentiate a Carotid Body tumour from a Vagal Paraganglioma – A Radiological Dilemma
By: Nathaniel Fernandes
Aim To evaluate whether a structured radiological imaging approach enhances the ability of clinicians to distinguish carotid body tumours (CBT) from a Neck nerve paragangliomas (eg Vagal paragangliomas). Methods Ninety healthcare professionals with varying levels of expertise, ranging from junior surgical trainees to consultant surgeons, reviewed ten anonymized imaging studies of neck paragangliomas , comprising of five CBTs and five nerve associated paragangliomas. The participants were initially asked to identify the tumour type. Following initial assessment, four key distinguishing imaging features were then outlined, and participants reassessed the same image set. Diagnostic accuracy was analyzed by tumour type, reviewer professional role, imaging modality (CT versus MRI), and image orientation (transverse versus longitudinal planes) Results Initial diagnostic accuracy across all participants was 65%. Binary Logistic regression suggested a significantly higher accuracy among consultant-level reviewers and when using CT imaging (p<0.01). No significant difference was observed based on tumour type. Awareness of key distinguishing imaging features improved overall diagnostic accuracy to 81%, particularly better for CBTs (p<0.05). MRI imaging and non-consultant reviewers were consistently associated with lower diagnostic confidence. Conclusion Preoperative identification of neck paraganglioma subtype remains diagnostically challenging across healthcare professionals of all experience levels. However, knowledge of key imaging features significantly improves diagnostic accuracy, particularly for carotid body tumours. These findings have immediate clinical implications for surgical planning, perioperative risk stratification, and comprehensive preoperative patient counselling, potentially improving surgical outcomes, and reducing procedure-related morbidity.
Carotid & Acute StrokeThe impact of Carotid Artery Stenosis resolution on Cognitive Function in relation to Cerebral Blood Flow volume.
By: Joanna Kaszczewska
Aims: The aim of this study is to evaluate whether carotid revascularization leads to changes in cognitive function (CF) in correlation with cerebral blood flow (CBF) following surgical treatment of symptomatic internal carotid artery (ICA) stenosis exceeding 70%. Methods: The study group consisted of 50 patients (17 women, 33 men) who were qualified for carotid revascularization due to symptomatic internal carotid artery (ICA) stenosis greater than 70%. 37 underwent carotid endarterectomy (CEA) and 13 underwent carotid artery stenting (CAS). All patients underwent preoperative and postoperative evaluations (2–3 days after surgery), including the Rey Auditory Verbal Learning Test (RAVLT; memorization and repetition of 15 words over five trials), the Maze Test (MT), and the Montreal Cognitive Assessment (MoCA). Cerebral blood flow (CBF) was assessed using Doppler Ultrasonography, as the sum of flow volumes in the Internal Carotid Arteries (ICAs), External Carotid Arteries (ECAs), and Vertebral Arteries (VAs). Patients were categorized based on preoperative CBF values: those with CBF below the reference range [1] were classified as having no compensation (NC), those within the reference range as mild compensation (MC), and those above the reference range as significant compensation (SC). Results: Reference values for cerebral blood flow (CBF) were as follows: 898.5 ± 119.1 ml/min for ages 65–69 years, 838.5 ± 148.9 ml/min for ages 70–74 years, 805.1 ± 99.3 ml/min for ages 75–79 years, and 685.7 ± 112.3 ml/min for patients aged ≥ 80 years [1]. Preoperatively, 28 patients were classified as no compensation (NC), 18 as mild compensation (MC), and 4 as significant compensation (SC). In NC group the average increase in CBF of 183,64 ml/min (from 637,64 to 821,29; p=0,000005) was accompanied by significant increase in RAVLT of 8,86 words (from 34,86 to 43,71; p=0,001). In MC patients CBF increase of 105,39 ml/min (from 801,44 to 906,83; p=0,03) was accompanied with non-significant increase in RAVLT of 5,28 words (from 33,94 to 39,22; p=0,18). In the whole study group (WSG) several changes were observed. The MT decreased significantly of 34,25 seconds in test time (from 95,11 to 60,86; p=0,02), however there were no significant difference between subgroups. CBF and RAVLT increased significantly by 154,46 (from 711,88 to 866,34; p=0,000001), RAVLT 6,76 (from 34,18 to 40,94; p=0,003) approximately. No significant differences were observed between preoperative and postoperative MoCA scores in any of the subgroups. The results are presented in Figure 1. No statistically significant differences were observed between the CEA and CAS groups. Conclusions: Carotid stenosis treatment leads to increased cerebral blood flow (CBF) and enhanced cognitive function. The benefits are more pronounced in patients with lower preoperative CBF values. No statistically significant differences were found between the two operative techniques.
Carotid & Acute StrokeThe Impact of High-Flow Haemodialysis Access on Cerebral Blood Flow: A Duplex Ultrasound Pilot Study
By: Premjithlal Bhaskaran
The Impact of High-Flow Haemodialysis Access on Cerebral Blood Flow: A Duplex Ultrasound Pilot Study Premjithlal Bhaskaran1, Julie Low1, Jeremy Crane2, and Mohammed Aslam2 1National Heart and Lung Institute, 2Department of Surgery and Cancer, Imperial College London, United Kingdom Background High flow arteriovenous fistula (AVF) in haemodialysis access significantly alters systemic haemodynamics, particularly affecting cardiac and cerebral circulation. While the cardiac consequences are well-documented, the effects on cerebral blood flow (CBF) remain less documented. The altered CBF patients in end-stage renal disease (ESRD) reports neurological symptoms such as dizziness, confusion, and cognitive decline. The aim of the study is to investigate the relationship between high-flow haemodialysis access and cerebral circulation using duplex ultrasound imaging. Methods This is prospective study included 30 ESRD patients. This study classified as brachial artery volume flow (VF) into a control group with flow <1000 ml/min and a high-flow group with flow ≥1000 ml/min in right sided upper limb AVFs. B-mode ultrasound and spectral Doppler ultrasound were used to image bilateral common carotid arteries (CCA) and brachial arteries. Lumen diameter, peak systolic velocity and volume flow were the parameters measured. All measurements were repeated three times and averaged to minimise observer variability, Statistical analysis was performed using paired t-tests and Pearson’s correlation coefficient, with significance defined as p<0.05. Results This cohort study consists of equal number male and female patients, 15 each were included with a mean age of 54.5 ± 12.9 years with most prevalent comorbidities of hypertension (73.3%) and diabetes mellitus (50%). Seventeen patients (56.7%) of the participants had high-flow AVFs, predominantly on the right arm (73.3%). The mean right CCA VF and the left CCA VF were as 428.5 ± 141 ml/min and 471.3 ± 171 ml/min respectively with mean difference of 9.1% and p<0.05. The VF was significantly lower in right compared to the left CCA. The right CCA flow was 11.6% and 7.2% respectively in control and high flow rates. This disproportionateness was consistently lower than the left. The analysis confirmed the access laterality, the right sided AVFs demonstrated a significant reduction in reduction in ipsilateral CCA flow (13.8%) compared to left-sided access (6.4%). Peak systolic velocity was substantial increase in the left CCA (87 ± 34 cm/s) in relation with the right (78 ± 19 cm/s, p<0.05), while lumen diameters were similar (right 7.9 ± 0.97 mm; left 7.8 ± 1.01 mm). Conclusion This study demonstrates that right upper limb haemodialysis AVFs is related with a constant reduction in ipsilateral CCA flow, whether the access is classified as high-flow or normal-flow. The confirmed asymmetry between right and left carotid circulation may be attributed to the unique anatomical configuration of the brachiocephalic trunk and its influence on cerebral perfusion. The high-flow AVFs could possibly change cerebral haemodynamics and require further investigation into their long-term neurological and cardiovascular consequences. Duplex ultrasound and spectral Doppler ultrasound are valuable non-invasive tools for monitoring such haemodynamic changes. This helps in identifying patients at risk of cerebral hypoperfusion secondary to high-flow AVFs related to poor brain perfusion.
Carotid & Acute StrokeTranscarotid artery revascularization: Ready for Europe? Early Experience with an Off-the-Shelf Technique
By: Wojciech Haratym
Aim Carotid endarterectomy (CEA) is currently the standard for treatment of symptomatic and asymptomatic carotid artery disease. Transfemoral carotid artery stenting (TFCAS), an alternative in selected cases, carries higher perioperative stroke risk due to manipulation of the aortic arch and embolization during lesion crossing 1,2 . Transcarotid artery revascularization (TCAR) elimiates the manipulation of the aortic arch by direct acess to the common carotid artery (CCA). Effective cerebral protection is established through flow reversal (FR). Data from the Vascular Quality Initiative (VQI) show perioperative outcomes comparable to CEA and superior to TFCAS, with lower stroke rates, fewer cranial nerve injuries, and fewer myocardial infarctions 3 . Despite data from VQI, TCAR is not yet established in Europe, mainly due to unavailability of the US- device on the European market. However, early European experiences confirm that TCAR can be performed with an off-the-shelf approach, with high technical success and complication rates comparable to CEA without the need for a specific TCAR device 4 . These data support need for adoption of TCAR in existing carotid revascularization strategies. Methods We conducted a retrospective analysis of eight consecutive patients undergoing TCAR at our institution. All procedures were performed with direct carotid access under regional anesthesia using FR for neuroprotection. An off-the-shelf technique was applied, using two 8F sheaths—one inserted into the CCA and the other into the ipsilateral internal jugular vein (IJV)—interconnected with a male-to-male connector for FR. The IJV was used to shorten the arterial–venous distance, reducing resistance, and facilitating more efficient FR. All procedures were performed with a micro-mesh stent, enhancing procedural safety by encapsulating the plaque and preventing emboli. Primary endpoints were technical success and perioperative complications. Results Eight patients (7 male, mean age 74.1 years; 2 symptomatic, 6 asymptomatic) underwent TCAR. Technical success was 100%. No perioperative stroke, myocardial infarction or death occurred. Stenosis severity was mean 88.8% NASCET. Complex anatomy was common: mean carotid depth was 4.0 cm, stenosis length 24 mm and two patients (25%) had distal stenosis extension >3 cm from the bifurcation. One patient presented with tandem stenosis, (75%) had soft plaque morphology. Clinical comorbidities included CAD (12.5%), COPD (12.5%), reduced EF< 30% (25%), and AF (12.5%). Conclusion TCAR can be safely performed in Europe using an off-the-shelf approach. Outcomes were excellent, with no perioperative stroke, myocardial infarction, or mortality and a 100% technical success rate. These findings suggest that TCAR provides outcomes similar to CEA and superior to TFCAS. The off- the-shelf technique achieved the same safety profile as the commercially available system in the US. Moreover, the use of micro-mesh stent technology combined with flow reversal may further enhance procedural safety compared with the standard U.S. device and technique. In Europe, broader adoption of TCAR has been prevented by the absence of the device on the european market, a traditionally strong notion towards CEA and the absence of clear recommendations in European guidelines. Furthermore the off-the-shelf technique is also considerably more cost-effective than the commercially available U.S. system, which further supports its potential value for European practice. 1. Morris DR, Ayabe K, Inoue T, Sakai N, Bulbulia R, Halliday A, Goto S. Evidence-Based Carotid Interventions for Stroke Prevention: State-of-the-art Review. J Atheroscler Thromb. 2017 Apr 3;24(4):373-387. doi: 10.5551/jat.38745. Epub 2017 Mar 4. PMID: 28260723; PMCID: PMC5392474. 2. Association of carotid revascularization approach with perioperative outcomes based on symptom status and degree of stenosis among octogenarians Kibrik, Pavel et al. Journal of Vascular Surgery, Volume 76, Issue 3, 769 - 777.e2 3. Schermerhorn ML, Liang P, Dakour-Aridi H, Kashyap VS, Wang GJ, Nolan BW, Cronenwett JL, Eldrup-Jorgensen J, Malas MB. In-hospital outcomes of transcarotid artery revascularization and carotid endarterectomy in the Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg. 2020 Jan;71(1):87-95. doi: 10.1016/j.jvs.2018.11.029. Epub 2019 Jun 18. PMID: 31227410; PMCID: PMC6918010. 4. Lamarca MP, Flores Á, Martín A, Peinado J, Estébanez S, Arriola M, Llergo B, García E, Tique J, Torralbas F, Millán E, Rigolin M, Lobato P, Segundo JC, Morín M, Jamilena Á, Moreno R, Orgaz A. Prospective evaluation of acute cerebral injury by DW-MRI following transcarotid artery revascularization using a double-layer micromesh stent. J Cardiovasc Surg (Torino). 2023 Dec;64(6):583-590. doi: 10.23736/S0021-9509.23.12764-9. Epub 2023 Dec 11. PMID: 38078708.
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