Intracranial arterial stenosis (ICAS) is a common cause of stroke, and the risk of ischemic stroke from a stenotic intracranial artery remains high despite best medical therapy (BMT). As a result, clinicians have increasingly turned to percutaneous transluminal angioplasty and stenting (PTAS) over the last decade as an alternative therapy in high-risk patients with symptomatic ICAS. In this review, we will critically analyze multiple clinical trials to assess the safety and efficacy of PTAS with BMT versus BMT alone. The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial reported a higher rate of stroke or death within 30 days in the PTAS plus BMT group (14.7%) than the BMT only group (5.8%, p = 0.002). The rate of any stroke during the follow-up period (mean = 32 months) was higher in the PTAS plus BMT group (22.3%) than the BMT only group (14.1%, p = 0.03). The Vitesse Intracranial Stent Study for Ischemic Stroke Therapy (VISSIT) trial reported a higher rate of stroke or death within 30 days in the PTAS plus BMT cohort (24.1%) than the BMT only cohort (9.4%, p = 0.05). There was also a higher rate of hard transient ischemic attack (TIA) or stroke within one year in the PTAS plus BMT group (36.2%) than the BMT only group (15.1%, p = 0.02). The Vertebral Artery Ischaemia Stenting (VIST) trial reported the rate of any stroke during the follow-up period to be two events in 50 person-years in the PTAS plus BMT cohort versus four events in 45 person-years in the BMT only cohort, with a calculated hazard ratio of 0.47 (p = 0.39). Vertebral Artery Stenting Trial (VAST) reported a higher incidence of stroke, MI, or vascular death in the PTAS with BMT cohort (22%) than the BMT only cohort (0%). Tang et al. reported no significant difference in the incidence of vascular events at one year and three years between the PTAS plus BMT and BMT only cohorts. However, the distribution of vascular events was more concentrated in the first postoperative week in the PTAS plus BMT cohort (75% of all vascular events) versus the BMT only cohort (17%). Feng et al. reported a lower periprocedural complication rate (9.1%) with the Enterprise stent in comparison to the Wingspan and balloon-expandable stents used in the SAMMPRIS and VISSIT trials. We conclude that PTAS should not be employed as first-line treatment in patients with symptomatic ICAS. However, PTAS should be considered in symptomatic ICAS patients that are hemodynamically unstable or have repeatedly failed BMT, especially at sites with lower rates of perioperative complications than those reported here.
Spinocerebellar ataxia 3 (SCA3), also known as Machado–Joseph disease (MJD) is an autosomal dominant, progressive neurodegenerative disorder. Patients present with cerebellar ataxia, dystonia, rigidity, and neuropathy that worsen with time. On a molecular level, it occurs due to a CAG trinucleotide repeat expansion in the ATXN3 gene. Due to the risk of pulmonary aspiration, hypoventilation, autonomic and thermoregulatory dysfunction, vocal cord paralysis, progressive paraplegia, parkinsonian symptoms, and chronic pain, it has significant anesthesia implications. Rarely, case reports occur in the literature describing regional anesthetic management of patients with SCA3, but none that describe general anesthesia specifically with MJD. We therefore describe a case of a patient with SCA3 who successfully underwent general anesthesia and considerations for perioperative management of this patient population.
Purpose: To examine whether pre-HTN is a risk factor for CV structural and functional abnormalities. METHODS: We screened 2233 asymptomatic subjects, age 23-80, for CVD risk using Early CVD Risk Score (ECVDRS). ECVDRS consists of 10 tests: large (C1) and small (C2) artery stiffness, BP at rest and post mild exercise (PME), Carotid Intima Media Thickness (CIMT), abdominal aorta and left ventricle ultrasound, retinal photography, microalbuminuria, ECG, and pro-BNP. Pre-HTN and normotension (NT) was defined according to the JNC VII criteria. Results: Among the subjects screened, 38% (855 of 2233) were NT; 70% (596 of 855) were not taking CV medication. 42% (942 of 2233) of subjects were pre-HTN; 55% (521 of 942) were not taking CV medication. The untreated, NT group was split into Group A 82% (491 of 596) with norm. BP rise PME and Group B 18% (105 of 596) with abn. BP rise PME. The untreated, pre-HTN group was split into Group C 61% (318 of 521) with norm. BP rise PME and Group D 39% (203 of 521) with abn. BP rise PME. The presence of structural abnormalities in the groups is shown on Table 1. Conclusions: Based on our data, pre-HTN is a prevalent disease (42%), exceeding NT (38%) in the subjects screened. Pre-HTN is associated with greater functional and structural abnormalities than the NT group. The structural abnormalities, particularly CIMT (statistically significant p value of <0.0016), may be accounted for by the greater abn. BP rise PME in the pre-HTN group (39%). Based on our data, pre-HTN justifies ECVDRS screening for appropriate risk stratification and treatment. These findings may warrant lowering the bar for the definitions of HTN and pre-HTN in future guidelines.
There have been over 80 documented cases of swallow syncope-a rare form of reflex or neurally mediated syncope-with most cases associated with an underlying esophageal disorder. Here, we describe the first reported case of swallow syncope or presyncope caused by an infectious esophagitis. Our 65-year-old patient initially developed dysphagia, odynophagia, and presyncope with swallowing. This lead to nutrition and medication avoidance behavior, which was followed by the development of diabetic ketoacidosis. The diagnosis of swallow presyncope was confirmed with a provocative swallow study demonstrating 8 s sinus arrest, and an underlying cause of Candida esophagitis was found by upper endoscopy. Symptoms completely resolved after treatment with micafungin.
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