Moyamoya disease is a rare neurological condition that affects children and adults of all ages. It is characterized by chronic, progressive stenosis of the circle of Willis that ultimately leads to the development of extensive collateral vessels. Presenting symptoms are usually due to cerebral ischemia or hemorrhage. The Japanese term moyamoya (meaning puffy or obscure) was coined to describe the characteristic ‘smoke in the air’ appearance of these vessels on cerebral angiography. Moyamoya has the highest recorded incidence in Japan (0.28 per 100,000). In the west it is an extremely rare condition with an overall incidence of (0.086 per 100,000) in the Western United States. Etiology for the most part is unknown; however, genetic susceptibility related to RNF213 gene on chromosome 17q25.3 has been suggested. Moyamoya is being diagnosed more frequently in all races with varying clinical manifestations. Moyamoya disease is a rare progressive neurologic condition characterized by occlusion of the cerebral circulation with extensive collaterals recruitment in children and adults. Distinguished radiological findings confirm the diagnosis. Early recognition and swift institution of therapy is vital in order to minimize neurological deficits. We present the case of a 19-year-old African American female who presented with left-sided parastheia, weakness, and headache for 2 days duration.
Protease-activated receptor (PAR)-1 inhibitors have recently become popular in the use of atherosclerosis among clinicians. Atherosclerosis can cause cardiovascular and cerebrovascular events leading to one of the major causes of mortality worldwide. Thrombin-mediated platelets can cause atherosclerotic plaques, and these platelets are activated by thrombin through the PAR-1. Vorapaxar and atopaxar are novel antiplatelet drugs that inhibit the thrombin-induced platelet activation by antagonizing the PAR-1. The objective of this article is to review the mechanism of action of vorapaxar and atopaxar and explain the rationale for using them in atherothrombosis patients including myocardial infarction, peripheral arterial disease, and stroke.
This study aims to characterizes the clinical hemodynamic response patterns in patients with intermediate submassive pulmonary embolism (SM-PE) treated with catheter directed thrombolytic therapy (CDT) versus standard anticoagulation (SAC) with intravenous heparin. Hemodynamic compromise in SM-PE is reflected in the magnitude of tachycardia. The clinical data regarding more rapid clinical recovery with CDT versus SAC has not been fully delineated. METHODS: We retrospectively assessed for "Rapid Clinical Responders" (RCR, defined as heart rate (HR) reduction >25% at 24 hours) in patients with intermediate SM-PE (defined as RV strain indicated by RV/LV ratio > 1) in 75 patients treated with CDT versus 75 patients treated with SAC. RESULTS: Results showed a greater percentage of "Rapid Clinical Responders" in CDT group vs SAC group (72% vs 27%, p ¼ <0.0001). There was a greater HR reduction over 24 hours in CDT group with mean 105 bpm to 79 bpm, delta change 26 bpm, p<0.0001 vs SAC group with mean 95 bpm to 84 bpm, delta change 11bpm, p<0.001). Post therapy HR reduction achieved a statistically lower HR in the CDT group versus the SAC group (CDT mean 79 bpm vs SAC mean 84 bpm, p<0.007). CDT led to a significant reduction in tachypnea, which was not seen in the SAC group (CDT mean RR 24 þ/-2 to 18 þ/-1, p<0.0001 vs SAC mean 20þ/-1 to 19 þ/-1, p¼ 0.37). In hospital mortality rates were low in both groups (3.2% for CDT and 3% for SAC, respectively). Of note, length of stay was increased by 3þ/-1.5 days in the CDT group, which likely represents the severity of illness within this population in addition to increased complication rates such as bleeding (noted to be 9%). CONCLUSIONS: These findings demonstrates greater percentage of "Rapid Clinical Responders" in CDT group versus SAC group, with improved hemodynamic outcomes manifest as statistically significant reduction in tachycardia and tachypnea. CLINICAL IMPLICATIONS: These findings may have clinical implications regarding further optimization of care strategies to achieve improved hemodynamic outcomes in SM-PE.
BACKGROUND The percutaneous treatment of the coronary saphenous bypass grafts (SVG) remains a challenge in interventional cardiology. Treatment of degenerated SVG still involves a high risk of immediate embolic complications, high incidence of target lesion revascularization and progression of the disease on adjacent segments and often difficulty in the evaluation of the caliber and discrepancy in size in presence of aneurysm.AIM to evaluate if the use of self-expandable stents may offer an advantage compared to balloon-expandable stents. Self-expandable stents may solve the problem of the discrepancy in size, they can be used in presence of aneurysms or of widespread disease implying a lower risk of malapposition, with less acute thrombosis. They don't require a heavy post-dilatation implying a lower risk of thromboembolism and parietal damage and leading to a reduced risk of in-stent restenosis, edge-restenosis and deterioration of adjacent segments. We called this technique "Soft touch technique" consisting in direct stenting (if possible) and post dilatation limited to the most stenotic portion of the graft using undersized balloons). Self expandable stents increase in diameter in the days following the procedure, this may reduce the incidence of plaque rupture and distal embolization. RESULTSBetween October 2012 and October 2014 we treated 20 patients. 13 with acute coronary syndrome. Mean age of the grafts: 12 years. In 8 cases we used a distal embolic protection filter. 5 patients had aneurysmatic dilatation of the graft. No major complications occurred. In one case we implanted a balloon expandable stent at distal edge of self-expandable stent for distal dissection of the vessel with a good final result. In one case we implanted a balloon expandable stent to treat one ostial instent restenosis due to distortion of the stent struts caused by the guiding catheter. Good angiographic result in all cases (final TIMI flow III). CT angiography performed after 3 months confirmed the patency of the stents. All patients remained asymptomatic during follow-up.CONCLUSIONS The treatment of degenerated SVG with self-expandable stents and "soft touch technique" may reduce the risk of distal embolization and of periprocedural infarction. This technique, implying a minor parietal trauma, may also reduce the incidence of restenosis and solve the problem of mismatch of caliber and widespread disease. Larger and appropriate studies are needed to determine differences, optimize clinical practice and validate our hypothesis.BACKGROUND Though drug-eluting stents (DES) have shown better outcomes when compared to bare metal stents (BMS) in patients with native coronary lesions, their efficacy in saphenous vein graft (SVG) disease is not clear.
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