Early CEA within 6 weeks after a carotid-related ischemic stroke can be performed with a perioperative stroke or mortality rate comparable with the results reported in the European Carotid Surgery Trial and the North American Symptomatic Carotid Endarterectomy Trial. The risk of parenchymatous bleeding is low. ASA grades III and IV and decreasing age were predictive of an increased perioperative risk, especially if CEA was performed within the first 3 weeks. Patients at low risk can undergo operation safely within the first 3 weeks. Individual patient selection in an interdisciplinary approach between neurologists, anesthesiologists, and vascular surgeons remains mandatory in these patients.
operative procedures at time of graduation for matriculating general surgery chief residents been impacted (P ¼ .56). Comments: The concern that specialty-specific training programs (vascular surgery from our perspective) would degrade the general surgery training experience has not materialized. This may be particularly true for vascular surgery programs since the shift in general surgery to laparoscopic techniques and ours to endovascular techniques have really taken us down different roads, which continues to evolve and differentiate. It should be noted that these results were potentially impacted by introducing offsite experience that marginally increased volume during this study. The latter is a good example of being a good steward of the opportunities available and could suggest steps open to other institutions facing similar conditions of training.
This article covers three major topics of acute stroke therapy: extension of the time window for thrombolysis with desmoteplase, decompressive surgery after malignant middle cerebral artery infarction, and the effect of hemostatic therapy with recombinant activated factor VII (rFVIIa) in patients with spontaneous primary intracerebral hemorrhage. Thrombolytic therapy with recombinant tissue or tissue-type plasminogen activator is still the only approved acute stroke therapy within a 3-h time window. Imaging-based patient selection seems to help extending this time window. After promising results of two phase II trials with the thrombolytic agent desmoteplase in an extended time window after acute ischemic stroke, the DIAS-II study was reconducted in Europe, North America, and Australia as a phase III trial. First results of the included 186 patients are shown. Surprisingly, patients treated with desmoteplase had no better outcome than placebo-treated patients, and there was increased mortality in the high-dose group. Among all stroke subtypes, space-occupying malignant middle cerebral artery is one with the poorest prognosis. Most patients die within a few days due to the development of massive brain edema, despite maximum intensive care. Decompressive hemicraniectomy represents a much more effective therapy for the treatment of local brain swelling. However, until recently this method was highly controversial. Here we present the results of the randomized trials published in 2007 and discuss their relevance for acute therapy. Hematoma growth occurs within 4 h in one third of patients who suffer from intracerebral hemorrhage. Prospective, placebo-controlled, multicenter trials have shown that intravenous application of rFVIIa reduces volume increase. We present preliminary results of the latest phase III trial (FAST: recombinant factor VIIa in acute hemorrhagic stroke), which tried to find whether the hemostatic effect will translate into clinical effect.
A standardized postacute inpatient rehabilitation program (Anschlussheilbehandlung) after stroke is well established in Germany. Yet the needs of patients being admitted to an Anschlussheilbehandlung (AHB) are not completely known. Therefore sociodemographic data, handicap, impairment and neuropsychologic deficits in 200 stroke patients were evaluated before admission to an AHB with different scores (Barthel, modified Rankin Score, NIHSS, HAWIE-R, Wilde, etc.). About half of the patients were still working prestroke. Most patients suffered from several vascular risk factors, which were insufficiently treated, and about a third of the patients had cerebrovascular disease prior to this stroke. At admission to the rehabilitation program the group of patients with severe neurological deficits was small. In average the disability was rather moderate (Rankin = 2.6). Mainly gait and finger dexterity were handicapped. Functional impairment was outweighed by neuropsychological deficits.
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