Headache after carotid endarterectomy.

Forty-eight hours after undergoing a successful right carotid endarectomy a patient complained of headache in and behind the right eye radiating to the temple and forehead. The onset of headache was sudden, and the pain was severe and throbbing. After three weeks of regular four- to eight-hour attacks each day the headaches gradually became less frequent. Two months after operation they had disappeared completely. Headache as a complication of endarterectomy is rare, but typically it is vascular and subsides spontaneously in one to six months. If a predisposition to migraine were a precipitating factor many more cases would be expected. No possible explanation for for headache after carotid prearterectomy can account adequately for its apparent rarity.     

The appropriate use of carotid endarterectomy

FOR THE FIRST 30 YEARS AFTER CAROTID ENDARTERECTOMY WAS FIRST DEVELOPED, anecdotal evidence was used to identify patients with internal carotid artery disease for whom this procedure would be appropriate. More recently, the appropriateness of carotid endarterectomy for symptomatic patients and asymptomatic subjects has emerged from 7 randomized trials. Risk of stroke and benefit from the procedure are greatest for symptomatic patients with at least 70% stenosis of the internal carotid artery. Within this group, carotid endarterectomy is most beneficial for the following patients: otherwise healthy elderly patients, those with hemispheric transient ischemic attack, those with tandem extracranial and intracranial lesions and those without evidence of collateral vessels. Risk of perioperative stroke and death is higher in the following groups, although they still benefit: patients with widespread leukoaraiosis, those with occlusion of the contralateral internal carotid artery and those with intraluminal thrombus. Patients with 50% to 69% stenosis experience lesser benefit, and some other groups may even be harmed by carotid endarterectomy, including women and patients with transient monocular blindness only. The procedure is indicated for patients presenting with lacunar stroke and for those with a nearly occluded internal carotid artery, but the benefit is muted. Patients with less than 50% stenosis do not benefit. In the largest randomized trial of asymptomatic subjects, the perioperative risk of stroke and death was very low (1.5%), but the results indicated that a prohibitively high number of subjects (83) must be treated to prevent one stroke in 2 years. The subsequent literature reported higher perioperative risks (2.8% to 5.6%). In asymptomatic individuals nearly half of the strokes that occur may be due to heart and small-vessel disease. These limitations counter any potential benefit. Another trial is in progress and may identify subgroups of asymptomatic subjects who would benefit. Meanwhile, most individuals without symptoms fare better with medical care.The prevention of ischemic stroke by surgical means goes back half a century. After initial endorsement of carotid endarterectomy, confusion arose as to the appropriate selection of patients and the allowable risk from the procedure. In the past 2 decades large randomized trials have been used to evaluate the benefit of the procedure for patients with symptomatic and asymptomatic disease of the internal carotid artery. Sufficient time has now passed since the publication of these trials to analyze their impact on practice and to make recommendations about the application of carotid endarterectomy. There is strong evidence of benefit in some symptomatic patients, whereas other patients will not benefit and may even face harm. There is weak statistical and weaker clinical evidence that asymptomatic subjects will survive longer without experiencing stroke if they undergo endarterectomy than if they do not. The evidence supporting carotid angioplasty and stenting remains anecdotal and conflicting.The purpose of the present report is to provide a clinical roadmap to which symptomatic patients and asymptomatic subjects with carotid stenosis are candidates for endarterectomy. The risks and complications of endarterectomy are also reported. The outlook and benefit for symptomatic patients and asymptomatic subjects are so different that the evidence supporting appropriate use of endarterectomy in these 2 groups will be presented separately.     

Cerebral function before and after carotid endarterectomy.

Twenty men had their cerebral function measured preoperatively and three months after carotid endarterectomy using the Halstead-Reitan neuropsychological test battery. Thirteen patients were cerebrally impaired preoperatively, but 12 of them improved appreciably after surgery. Changes in internal carotid arterial blood flow measured preoperatively showed no significant correlation with the improvement in neuropsychological status. We think that carotid endarterectomy carries an even better prophylaxis for the brain as a whole than had been thought.     

Long-term outcome after coronary stenting

The present review assesses the data on long-term outcome after coronary stenting. Histological, angiographical and intravascular imaging data have shown that the insertion of stents constitutes only a transient stimulus to lumen renarrowing, that this process is almost complete at 6 months and that a certain degree of neointima regression is also possible after this time. Clinical data have confirmed the sustained benefit of stenting in the long term. Careful selection of optimal stent designs and application of the recent advances in adjunctive pharmacological therapy are currently effective strategies to improve both short-and long-term results with coronary stenting. However, further efforts are needed and are ongoing to combat restenosis, a process that counters the excellent short-term results of stenting in the long term.     

Cardiac autonomic control during balloon carotid angioplasty and stenting

Hemodynamic alterations during balloon carotid angioplasty (BCA) and stenting have been ascribed to the consequences of direct carotid baroreceptor stimulation during balloon inflation. BCA with stenting in patients with carotid atheromatous stenoses offers a unique opportunity for elucidating the cardiovascular autonomic response to direct transient intravascular stimulation of the baroreceptors. We analysed the consequences of BCA on the autonomic control of heart rate and on breathing components in nine patients with atheromatous stenoses involving the bifurcation and the internal carotid. A time-frequency domain method, the smoothed pseudo-Wigner-Ville transform (SPWVT), was used to evaluate the spectral parameters (i.e., the instantaneous amplitude and centre frequency (ICF) of the cardiovascular and respiratory oscillations). Those parameters and their dynamics (8 and 24 h later) were evaluated during and after the procedure. BCA stimulates baroreceptors in all patients, which markedly reduces heart rate and blood pressure. Vagal baroreflex activation altered the respiratory sinus arrhythmia in terms of amplitude and frequency (ICF HF RR shifted from 0.27 +/- 0.03 to 0.23 +/- 0.04 Hz pre-BCA vs. BCA, respectively; p < 0.01). Both the high- and low-frequency amplitudes of heart rate oscillations were altered during carotid baroreceptor stimulation, strongly supporting a contribution of the baroreflex to the generation of both oscillations of heart rate. Carotid baroreceptors stimulation increased the inspiratory time (Ti) (1.5 +/- 0.5 to 2.3 +/- 0.6 s pre-BCA vs. BCA, respectively; p < 0.01). In awake patients, BCA with stenting of atheromatous stenosis involving the bifurcation and internal carotid causes marked changes in the cardiac autonomic and respiratory control systems.     

颈动脉窦部支架置入术中血压和心率的精细化管理

目的:探讨颈动脉窦部支架置入术中血压、心率的精细化管理,以减少心血管并发症,提高手术成功率.方法:对2009年6月-2010年3月间行颈动脉窦部狭窄支架置入术的59例患者,通过制定精细化的护理措施,从认知、心理、行为等方面进行护理干预,充分作好预见性准备,建立血压、心率波动曲线图,及时发现术中心率、血压的变化,把握给药时机,有效预防和控制心血管并发症.结果:通过良好的精细化管理措施,术中有心率减慢6例、血压降低4例、血压升高2例,因发现及时,给予对症处理后恢复正常,其余患者顺利完成介入治疗,无严重并发症发生.结论:加强窦部支架置入术中心率、血压的精细化管理,是保证病人安全的有力措施,对手术的顺利进行具有重要的指导意义.     

Comparison of early conceptus mobility between mares and jennies

The caracteristics of early intrauterine mobility of the conceptus were compared between ponies (n = 9) and donkeys (n = 9). The extensive mobility of the early conceptus, previously reported for ponies and horses, was found in donkeys as well. There were no significant differences between donkeys and ponies in the characteristics or patterns of mobility. However, the mean day of fixation was approximately one day later (P<0.05) in donkeys (Day 15.6 +/- 0.3) than in ponies (Day 14.7 +/- 0.2).     

Comparison of endothelial function in the carotid artery between normal and short-term hypercholesterolemic rabbits

The present study was undertaken to investigate and compare the vascular function in carotid arteries isolated from normal short-term hypercholesterolemic rabbits. Rabbits were fed normal or 0.5% cholesterol chow for 5 weeks. The tension of isolated carotid artery rings was measured isometrically. Serum lipid levels were measured and morphometric analysis was performed. And content of nitrate/nitrite in the carotid artery was also determined. In the carotid artery precontracted by phenylephrine, the cholesterol chow diet administered for 5 weeks decreased acetylcholine-induced relaxation at only middle concentrations, though it significantly increased the content of nitrate/nitrite, the sum of stable nitric oxide metabolites, in the carotid artery. Cholesterol chow for 5 weeks had no influence on sodium nitroprusside-induced relaxation in the carotid artery. The N(G)-nitro-L-arginine- and indomethacin-resistant endothelium-dependent relaxation induced by acetylcholine was significantly decreased in rabbits receiving the cholesterol chow as compared to rabbits receiving the control diet. The resistant part of acetylcholine-induced relaxation was significantly inhibited when the carotid artery was treated with glibenclamide, a selective inhibitor of ATP-sensitive K(+) channels, 4-aminopyridine, an inhibitor of voltage-dependent K(+) channels, or charybdotoxin, an inhibitor of large and intermediate conductance Ca(2+)-activated K(+) channels, and it was significantly inhibited by tetraethylammonium, a non-selective inhibitor of Ca(2+)-activated K(+) channels and N,N-di-ethylaminoethyl-2,2-diphenylvalerate hydrochloride (SKF 525a), a nonselective cytochrome P-450 monooxygenase (CYP) inhibitor, or ketoconazole, a selective CYP3A inhibitor in only normal rabbits. These results suggest that short-term hypercholesterolemia decreased EDHF-induced relaxation mediated through K(+) channels in rabbit carotid artery and that it may be due partially to the inhibition of CYP3A system in the carotid artery at an early stage of hypercholesterolemia.