Background and Purpose —Percutaneous angioplasty of the intracranial arteries still carries the risk of dissection, with acute closure and embolization. Stenting has been shown to improve the safety and durability of angioplasty in every... more
Background and Purpose —Percutaneous angioplasty of the intracranial arteries still carries the risk of dissection, with acute closure and embolization. Stenting has been shown to improve the safety and durability of angioplasty in every circulatory bed in which it has been applied. However, stenting of the intracranial arteries has been limited by the availability of stents that can be reliably deployed intracranially. Methods —Twelve patients underwent elective stenting of the basilar artery after episodes of vertebrobasilar ischemia. In all patients, either medical therapy had failed or the patient had a contraindication for long-term anticoagulation. Information from independent neurological examinations, quantitative angiography, and clinical follow-up was collected. Differences between pretreatment and posttreatment degree of stenoses were subjected to 1-way ANOVA for repeated measures. Results —There were 10 men and 2 women, all white, aged 40 to 82 years (mean age, 62.6 year...
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The results of the A Randomized Trial of Unruptured Brain Arteriovenous (ARUBA) study, indicating that conservative medical management of unruptured brain arteriovenous malformations (UBAVM) is superior to interventional therapy, have... more
The results of the A Randomized Trial of Unruptured Brain Arteriovenous (ARUBA) study, indicating that conservative medical management of unruptured brain arteriovenous malformations (UBAVM) is superior to interventional therapy, have generated debates that have hampered their application into clinical practice. Irrespectively of study conclusions, it seems reasonable to explore how much better interventional therapy would have to be to become competitive with conservative medical management. We conducted an exploratory analysis to replicate the original data from ARUBA. The functional form of the replicated ARUBA data, according to their Weibull distribution, allowed estimation of parameters. We carried out Monte Carlo simulations while introducing theoretical reductions of interventional risk, and the results were used to construct theoretical and example Kaplan-Meier curves from simulations. The "ARUBA Replication" analysis showed results nearly identical to those publi...
Research Interests: Treatment Outcome, Risk assessment, Clinical Decision Making, Humans, Computer Simulation, and 13 moreRisk factors, Clinical Sciences, Theoretical Models, Time Factors, Risk Factors, Risk Assessment, Intracranial Arteriovenous Malformations, Neurosciences, Monte Carlo Method, Conservative treatment, Endovascular Procedures, Randomized Controlled Trials as Topic, and Patient selection
El presente texto tiene como objeto realizar la descripción del estado actual de la investigación respecto del daño antijurídico imputable al Estado y de la conciliación como método de solución de conflictos en los litigios contra... more
El presente texto tiene como objeto realizar la descripción del estado actual de la investigación respecto del daño antijurídico imputable al Estado y de la conciliación como método de solución de conflictos en los litigios contra el Estado. En él se exponen los distintos estudios, y se resumen los aportes en materia de diagnóstico de la situación y de recomendaciones respecto de los temas de estudio.
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The aim of this study was to verify if the use of intraoperative transesophageal echocardiography (TEE), by detecting mitral insufficiency or residual stenosis during surgery, may improve medium term results in patients with severe mitral... more
The aim of this study was to verify if the use of intraoperative transesophageal echocardiography (TEE), by detecting mitral insufficiency or residual stenosis during surgery, may improve medium term results in patients with severe mitral stenosis who undergo open heart valvuloplasty. This prospective study included twenty-two patients (20 women and 2 men) with a mean age of 49+/-13 years with severe mitral stenosis. Mean follow-up was 32 months (range 12-55 months). All the patients underwent transthoracic echocardiography (TrE) before surgery and intraoperative TEE. Before surgery the mean transmitral gradient was 11+/-6.8 mmHg, the mean pressure half time (PHT) area was 0.89+/-0.19 cm2, the mean echo score was 8.9+/-2.2. Intraoperative TEE before the repair showed a mean echo score of 7.9+/-1.8. Two patients with unsatisfactory repair at TEE underwent immediate valve replacement. In the remaining patients, mean transmitral gradient and PHT valve area before discharge was 5.2+/-3 ...
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Sinus arrest is a rare complication of metoclopramide administration. A 51-year-old woman developed Guillain-Barre syndrome and severe dysautonomia. Metoclopramide was administered for the treatment of gastroparesis. Sinus arrest followed... more
Sinus arrest is a rare complication of metoclopramide administration. A 51-year-old woman developed Guillain-Barre syndrome and severe dysautonomia. Metoclopramide was administered for the treatment of gastroparesis. Sinus arrest followed drug administration on several occasions and on rechallenge. After reviewing the literature and discussing possible etiologies for this unusual adverse drug reaction in this setting, we recommend that metoclopramide be used with caution in patients prone to develop bradyarrythmias, particularly those with dysautonomias and Guillain-Barre syndrome.
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... 5 One had transient ischemic attacks that abated on resumption of heparin; the other had bilateralstent thrombosis when heparin was stopped before Coumadin treatment reached therapeutic levels. ... Walter L. Biffl, MD. Ernest E.... more
... 5 One had transient ischemic attacks that abated on resumption of heparin; the other had bilateralstent thrombosis when heparin was stopped before Coumadin treatment reached therapeutic levels. ... Walter L. Biffl, MD. Ernest E. Moore, MD. Charles Ray, MD. J. Paul Elliott, MD. ...
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The risk of perioperative strokes has been demonstrated to be very low in general surgical procedures, and somewhat higher in cardiac and carotid artery procedures. We describe 5 patients who underwent major head and neck procedures not... more
The risk of perioperative strokes has been demonstrated to be very low in general surgical procedures, and somewhat higher in cardiac and carotid artery procedures. We describe 5 patients who underwent major head and neck procedures not requiring carotid ligation and who postoperatively suffered strokes. These occurred between the first and ninth postoperative days. Four of the patients were thought to have had emboli, 3 to the cerebral hemispheres (2 ipsilateral and 1 contralateral to the neck dissections), and another to the lower brain stem. Hypoperfusion was thought to have caused the stroke in the fifth patient. All patients had risk factors for stroke. The cases in our series were difficult to diagnose because of the delayed onset and subtle nature of symptoms, as well as masking of speech and communication due to the operative involved. Thrombogenesis within the internal carotid and vertebral artery systems due to patient positioning and intraoperative cervical manipulation may be an important etiologic factor in this form of stroke.
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Cardiac hypertrophy is a relatively common complication seen in patients with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD). Moreover, cardiac hypertrophy is even more frequently seen in patients with ESRD who... more
Cardiac hypertrophy is a relatively common complication seen in patients with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD). Moreover, cardiac hypertrophy is even more frequently seen in patients with ESRD who have an arteriovenous (AV) access. There has been substantial evidence pertaining to the effects of AV access creation on the heart structure and function. Similarly, there is increasing evidence on the effects of AV access closure, flow reduction, transplantation, and immunosuppressive medication on both endpoints. In this review, we present the evidence available in the literature on these topics and open the dialog for further research in this interesting field.
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The term "top of the basilar" has been used in reference to a group of signs and symptoms of midbrain, diencephalic, and posteroinferior hemispheric dysfunction. It has... more
The term "top of the basilar" has been used in reference to a group of signs and symptoms of midbrain, diencephalic, and posteroinferior hemispheric dysfunction. It has been attributed to ischemia in the territory of second- and third-order vessels that arise from the uppermost portion of the basilar artery. We report our experience with four patients who had alteration of consciousness, confusion, and vertical gaze paresis accompanied by other physical abnormalities. Extensive evaluation did not help in documenting the lesions or in understanding their pathogenesis. The top of the basilar syndrome is a not uncommon form of stroke and carries a variable prognosis. Treatment by anticoagulation may prevent further infarction in selected patients who are seen early.
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Technetium Tc 99m DTPA single photon emission computerized tomography (SPECT) brain scans of 20 patients with acute ischemic stroke were reviewed retrospectively and compared with clinical and radiologic (CT) data. Fourteen of the... more
Technetium Tc 99m DTPA single photon emission computerized tomography (SPECT) brain scans of 20 patients with acute ischemic stroke were reviewed retrospectively and compared with clinical and radiologic (CT) data. Fourteen of the patients had abnormal SPECT studies. The abnormal findings were demonstrated by static views in eight patients, by the flow study in one patient, and by both sets of images in the other five patients. All abnormalities correlated with the clinical syndrome of presentation, and only two of the patients had no corresponding lesions on CT. Of the six patients with normal SPECT scans, two had abnormal CT studies, and in the other four, no lesions were shown at all. The ability of 99mTc DTPA SPECT to display cerebral infarctions appears to be, at best, comparable to that of CT. SPECT also provides qualitative information regarding flow dynamics in the affected hemisphere of some patients (6/20 in our review). This, we believe, represents the objective demonstration of the preexisting insufficient collateral flow in the hemisphere at risk for ischemic stroke.
Research Interests: Cardiovascular disease, Humans, Beta decay, Female, Male, and 15 moreCentral Nervous System, Ischemic Stroke, Aged, Middle Aged, Single Photon Emission Computed Tomography, Adult, Blood Flow, Retrospective Studies, Technetium, Computerized tomography, Organometallic Compounds, Cerebrovascular Disorders, Acute Ischemic Stroke, Cerebral Infarction, and Medical and Health Sciences
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Object The use of intracranial stents in stent-assisted coil embolization is now a current neurosurgical practice worldwide. The clinical utility of these stents in the sole stenting (SS) technique, however, has not been thoroughly... more
Object The use of intracranial stents in stent-assisted coil embolization is now a current neurosurgical practice worldwide. The clinical utility of these stents in the sole stenting (SS) technique, however, has not been thoroughly described, and the published reports of this experience are scarce. This study was designed to evaluate SS treatment of dissecting and nondissecting aneurysms of the posterior circulation. Methods This prospective and descriptive study was conducted in 20 consecutive patients who harbored single aneurysms of the posterior circulation and who were treated using the SS approach in the last 3 years. The clinical and radiological assessment and follow-up of the patients were evaluated using the modified Rankin scale as well as with computed tomography angiography and digital subtraction angiography at discharge and at 1, 3, 6, and 12 months. Results Eleven of the 20 patients had subarachnoid hemorrhages, 3 presented with ischemia, 1 presented with brainstem c...
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To present the results of a multicenter registry established to collect data on carotid stent procedures in patients with restenosis following carotid endarterectomy. The procedural details, outcomes, and late follow-up results were... more
To present the results of a multicenter registry established to collect data on carotid stent procedures in patients with restenosis following carotid endarterectomy. The procedural details, outcomes, and late follow-up results were collected from 14 centers in the United States. Thirty-day and late stroke and death rates were analyzed. Three hundred and thirty-eight patients (201 men; 71 +/- 8 years) underwent carotid stenting in 358 arteries. The average duration from carotid endarterectomy was 5.5 +/- 7.3 years. Sixty-one percent of the patients were asymptomatic. The overall 30-day stroke and death rate was 3.7%. The minor stroke rate was 1.7% (6/358), and the major nonfatal stroke rate was 0.8% (3/358). The fatal stroke rate was 0.3% (1/358), and the nonstroke-related death rate was 0.9% (3/338). There was 1 (0.3%) fatal and 1 (0.3%) nonfatal stroke during the follow-up period. The overall 3-year rate of freedom from all fatal and nonfatal strokes was 96% +/- 1% (+/- SE). Carotid artery stenting can be performed in patients with restenosis following carotid endarterectomy with 30-day complication rates comparable to those of most published studies on repeat carotid endarterectomy. Results of late follow-up suggest that this technique is durable and efficacious.
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To examine the impact of age upon the development of neurological and major systemic complications during or after carotid artery stenting. We reviewed the complications that occurred in patients undergoing elective carotid stent... more
To examine the impact of age upon the development of neurological and major systemic complications during or after carotid artery stenting. We reviewed the complications that occurred in patients undergoing elective carotid stent implantation between September 1994 and August 1996. The study population was then divided into 3 groups according to age: > or = 80 (group A), 75 to 79 (group B), and < or = 74 (group C) years. The rates of death, major and minor stroke, and myocardial infarction were compared among the groups, as well as with the rates reported by the major carotid endarterectomy (CEA) trials. During the study period, 182 patients (216 vessels) were treated with carotid stenting. There were 19 (10.4%) complications: 1 (0.5%) death, 2 (1.1%) major strokes, 15 (8.2%) minor strokes, and 1 (0.5%) myocardial infarction. Neurological complications were clearly related to increased age with rates of 25.0% in group A versus 8.6% in group C (p = 0.042). The overall per patient rate of death or major stroke was 1.6% (1.4% per vessel). Increasing age has a negative impact on the rate of complications in carotid stent patients. However, the majority of those complications are minor. The relative roles of medical therapy, stenting, and CEA in patients > 80 years of age must await the results of randomized trials.
Research Interests: Treatment Outcome, Stents, Endovascular Therapy, Electrocardiography, Stroke, and 15 moreHumans, Female, Male, Incidence, Clinical Sciences, Aged, Myocardial Infarction, Survival Rate, Retrospective Studies, Age Factors, Endovascular Surgery, Carotid Stenosis, Carotid Artery Stenting, Cerebral Angiography, and Postoperative Complications
To examine the usefulness of a novel method for neurological monitoring during carotid artery stenting (CAS). The records of patients who underwent elective CAS between June 1996 and October 1998 were reviewed to identify those who had... more
To examine the usefulness of a novel method for neurological monitoring during carotid artery stenting (CAS). The records of patients who underwent elective CAS between June 1996 and October 1998 were reviewed to identify those who had neurological changes during the procedure. We examined whether the neurological change had been detected by a change in the ability of the patient to respond to predetermined commands involving a small rubber duck placed in the contralateral hand. hundred seventy patients (320 vessels) underwent monitoring using the Duck Squeezing Test; 10 suffered neurological events during the procedure. Four of these were transient and temporally related to balloon inflation. Another 6 were tentatively ascribed to distal embolism. All instances were accompanied by a change in the patient's ability to perform the Duck Squeezing Test, which allowed the identification of the abnormal clinical situation. In addition, there were 4 false-positive tests secondary to the patient accidentally dropping the rubber duck. The Duck Squeezing Test is a sensitive and specific method for monitoring patients during elective CAS. Its practical applicability is based on sound neurophysiological concepts, which underscore the clinical importance of the test.
Research Interests: Web Design, Stents, Endovascular Therapy, Humans, Female, and 15 moreMale, Rubber, Clinical Sciences, Angiography, Aged, Middle Aged, Adult, ALOGORITHM DESIGN, Retrospective Studies, Sensitivity and Specificity, Endovascular Surgery, Cerebrovascular Disorders, Carotid Stenosis, Carotid Artery Stenting, and Psychomotor Performance
... events Camilo Gómez*, Jessica Buriticá and Mauricio Sánchez-Silva ... systems. Jessica Buriticá is an Electronics Engineer from Universidad de los Andes (2010) and is currently engaged in his Masters degree at the same university. ...
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Is it a seizure? This question can be difficult for a clinician to answer, and it may be more critical if the possible seizure lasts... more
Is it a seizure? This question can be difficult for a clinician to answer, and it may be more critical if the possible seizure lasts >30 min. Long-duration questionable seizure activity changes the question to, "Is it status epilepticus?" Status epilepticus (SE) can be divided into convulsive and nonconvulsive types. Convulsive SE is the most easily recognized, whereas nonconvulsive SE is more clinically variable and controversial. The term nonconvulsive SE is more often applied to patients who are severely obtunded or comatose with minimal or no motor movements, or in a stupor of altered consciousness reflecting generalized ictal activity. Nonconvulsive SE also can be caused by focal seizure activity, sometimes restricted to deep small volumes of brain in which scalp EEG may not be diagnostic. We present the case of a patient who had dominant limbic hippocampal SE, but in whom the diagnosis could not be confirmed until a modified novel use of the sodium amytal test was performed.
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ABSTRACT This study represents another example of the usefulness of transesophageal echocardiography in the assessment of stenosis involving the proximal, mid, and distal coronary arteries in stroke patients referred for exclusion of a... more
ABSTRACT This study represents another example of the usefulness of transesophageal echocardiography in the assessment of stenosis involving the proximal, mid, and distal coronary arteries in stroke patients referred for exclusion of a cardiac source of embolism.
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Percutaneous revascularization techniques have dramatically altered traditional approaches to the management of both coronary and peripheral vascular disease. Their major advantage is that they are less invasive than conventional surgical... more
Percutaneous revascularization techniques have dramatically altered traditional approaches to the management of both coronary and peripheral vascular disease. Their major advantage is that they are less invasive than conventional surgical procedures, offering revascularization without the risk of general anesthesia and with lesser procedural morbidity and mortality, shorter hospital stay, and lower cost. In patients with comorbidities that increase their risk of surgical complications, percutaneous revascularization techniques are the procedures of choice. The Achilles heel of balloon angioplasty, the higher risk of lesion recurrence, restenosis, has been markedly reduced with the use of endovascular stents. Over the past 20 years, percutaneous angioplasty and stenting have become accepted alternatives to surgical revascularization of aortoiliac, renal, femoropopliteal, subclavian, brachiocephalic, and dialysis access lesions. The most recent application of percutaneous intervention has been to explore its clinical utility and safety for stroke prevention in stenotic extracranial carotid arteries. Cathet. Cardiovasc. Intervent. 51:339-346, 2000.
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Archives of Neurology, a monthly professional medical journal published by the American Medical Association, publishes original, peer-reviewed scientific research on the nervous system.
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Información del artículo La tutoría educativa en acción: valoración de diferentes agentes educativos y de sus destinatarios.