Search Results (305)

Background and Aims: Decreased cerebrovascular reactivity (CVR) in patients with significant internal carotid artery stenosis (ICAS ≥ 70%) is an independent risk factor for cerebral infarction. To evaluate CVR, changes in cerebral perfusion pressure and blood flow velocity (BFV) of the middle cerebral artery (MCA) can be estimated by CO₂- (hyperventilation—HV and breath-holding—BH) and pressure–flow-based (Common Carotid Artery Compression—CCC and Valsalva Maneuver—VM) stimuli. We used a multimodal approach to characterize CVR in patients before carotid endarterectomy (CEA). Methods: HV, BH, CCC, and VM tests were performed on 31, 26, and 34 patients. BFV of MCAs was monitored by transcranial Doppler, and continuous arterial blood pressure was registered non-invasively. CVR was compared between the operated significantly stenotic and the contralateral sides. Results: The extent of HV- and BH-induced CVR was similar, but the time to the lowest HV-induced BFV was shorter on the side with significant ICAS. The response to CCC was sensitive to hemodynamic asymmetry in the transient hyperemic response ratio and in the cumulative change in the (mean arterial blood pressure)/(mean BFV) ratio. In VM, the slope of BFV increased in the ascending (2b) phase, and the time to overshoot correlated with the side of the stenosis. Conclusions: These results suggest that in patients with significant ICAS, in addition to CO₂ reactivity measurements, a more complex estimation of CVR, by using hemodynamic tests (CCC and VM), should also be used to better quantify cerebral ischemic risk. Full article

Background and Clinical Significance: Moyamoya disease (MMD) is a progressive intracranial vasculopathy characterized by stenosis or occlusion of the terminal internal carotid arteries and the development of fragile collateral networks. It predisposes patients to ischemic and hemorrhagic strokes. Although both direct and indirect revascularization procedures are recommended to restore cerebral blood flow, recurrent cerebrovascular events may still occur, and delayed hemorrhage following revascularization is particularly uncommon. Case Description: We report the case of a 42-year-old woman who presented with seizure, syncope, and aphasia. Cranial computed tomography (CT) revealed a large left temporal–insular intraparenchymal hematoma with a midline shift. Computed tomography angiography (CTA) demonstrated bilateral internal carotid artery narrowing and collateral vessel proliferation, without aneurysm. Her history indicated a hemorrhagic stroke 15 years earlier, at which time MMD was diagnosed by magnetic resonance angiography (MRA) and managed with multiple burr hole surgeries. She remained free of cerebrovascular events until the current presentation. The patient underwent emergent hematoma evacuation, followed by intensive care management. Postoperatively, she demonstrated neurological improvement, though with residual motor aphasia and right-sided weakness, and was discharged for rehabilitation. Conclusions: This case underscores the rare occurrence of delayed intracerebral hemorrhage 15 years after indirect revascularization in MMD. Although revascularization surgery remains the standard therapeutic approach, this report highlights the importance of sustained long-term surveillance, strict risk factor management, and careful postoperative follow-up. The key point is that late hemorrhagic complications, though uncommon, must be considered in the long-term care of MMD patients following revascularization. Full article

Background: Carotid artery stenting (CAS) is a common revascularization approach for carotid artery stenosis. While its impact on the internal carotid artery (ICA) has been extensively studied, the effects on the external carotid artery (ECA)—a key collateral pathway for cerebral perfusion—remain insufficiently explored. This study aimed to assess structural changes in the ECA following CAS and their clinical significance. Methods: A retrospective observational cohort study of 963 patients treated with CAS between 2018 and 2024 was conducted. Demographic data, comorbidities, and procedural characteristics were collected. Pre- and postprocedural ICA and ECA diameters were measured via angiography. Spearman’s correlation, regression modeling, and receiver operating curver (ROC) analysis were used to identify predictors of ECA narrowing and occlusion and their relationship with neurological outcomes. Results: The median ECA diameter decreased post-CAS (from 4.7 mm to 3.8 mm, p < 0.001). ECA overstenting occurred in 96.4% of cases, with 71.7% exhibiting diameter reduction. De novo ECA occlusion occurred in 2.5% of patients and was associated with a higher incidence of stroke, transient ischemic attack, and in-stent restenosis (ISR). Multivariate analysis identified preoperative ECA diameter (p < 0.001), ICA diameter (p = 0.001), and second-generation stents (p = 0.02) as independent predictors of ECA narrowing. ROC analysis confirmed that a preoperative ECA diameter ≤ 3.05 mm strongly predicted occlusion (Area under the curve (AUC) = 0.93, p < 0.001). Conclusions: CAS frequently leads to ECA remodeling, including occlusion, compromising collateral perfusion and contributing to adverse ischemic incidences and ISR. Preprocedural ECA assessment may aid in optimizing patient selection and procedural planning. Full article

Background: Previous research from our group demonstrated that novel hemodynamic indices can predict 3–5-year mortality risk in myocardial infarction survivors. Building on these findings, we assessed the long-term prognostic value of these markers over a 10-year follow-up period. Methods: We conducted a prospective study involving 569 consecutive acute coronary syndrome (ACS) patients admitted within 12 h of symptom onset, all presenting with >50% coronary artery stenosis. Hemodynamic indices were assessed using echocardiography to measure ejection fraction (EF), global longitudinal peak systolic strain (GLPSS), and ventricular–arterial coupling (VA coupling). Excess aortic pressure (excess_PTI) was evaluated via radial tonometry, while local arterial stiffness was assessed by pulse wave velocity (PWV) through carotid ultrasonography. The primary outcome was all-cause mortality over a 10-year follow-up period. Results: Over a median follow-up of 3249 days, 172 patients reached the primary endpoint (death). Deceased individuals were older and exhibited lower EF, impaired VA coupling, higher excess_PTI, and a lower PWV/GLPSS index compared to survivors. In multivariate Cox proportional hazards analysis, EF, VA coupling, excess_PTI, and PWV/GLPSS index were independently associated with all-cause mortality over a 10-year follow-up period. Conclusions: This study highlights the significant long-term prognostic value of novel hemodynamic indices, including VA coupling, PWV/GLPSS index, and excess_PTI, in predicting 10-year all-cause mortality in ACS patients. Full article

Objectives: While traditionally, carotid plaques with significant stenosis have been considered major embolic sources, recent evidence suggests that even non-stenotic small plaques with a <50% stenosis rate may contribute to cerebral infarction. Herein, we evaluated the relationship between non-stenotic small plaques and embolic stroke of undetermined source (ESUS) using computed tomography angiography (CTA). Materials and Methods: We retrospectively reviewed our single-institutional database of hospitalized patients with stroke between April 2017 and December 2022 and enrolled them with ESUS. We evaluated the presence or absence of non-stenotic carotid artery plaque lesions ipsilateral and contralateral to the cerebral infarction lesion using CTA. A neurologist, blinded to the stroke side and all other clinical information, reviewed each CTA and viewed the axial and sagittal CTA source images. In each image, a line perpendicular to the vessel wall was drawn and the plaque diameter was measured. The largest part was considered as the maximum plaque diameter. Results: A total of 951 patients with stroke were hospitalized during the study period. Among these, 35 patients with unilateral anterior circulation ESUS were enrolled. Plaque prevalence > 3 mm was compared between the carotid artery on the ESUS side and contralateral carotid artery. The prevalences were 31% and 8% on the ESUS and contralateral sides, respectively. Plaques > 3 mm were often found on the ESUS side. Conclusions: Patients with ESUS were more likely to exhibit non-stenotic plaques of ≥3 mm in the infarcted carotid artery than in the contralateral carotid artery. Thus, small non-stenotic plaques may be the embolization source in ESUS, and CT angiography is useful for these evaluations. Full article

Background: Accurate localization of internal carotid artery (ICA) occlusion is critical for optimizing endovascular thrombectomy (EVT) strategies. Conventional multiphase CT angiography (mCTA) often omits the carotid bifurcation in delayed phases, limiting differentiation between true cervical ICA occlusion and pseudo-occlusion. Methods: We retrospectively analyzed 56 acute ischemic stroke patients with ICA occlusion who underwent EVT and extended-range mCTA between 2016 and 2020. The scan range of the second and third arterial phases was modified to include the carotid bifurcation. Imaging patterns were evaluated to distinguish bifurcation stenosis with superimposed occlusion from proximal ICA occlusion, and to infer thrombus location by comparing arterial opacification levels across phases. Results: Extended mCTA significantly improved visualization of ICA enhancement patterns in delayed phases (p < 0.001). Cases with bifurcation stenosis showed consistently lower and stable opacification levels across phases, whereas proximal ICA occlusion demonstrated progressive contrast advancement. Distal occlusion, particularly beyond the ophthalmic artery, showed higher opacification. Including the carotid bifurcation increased scan length by ~10%, with acceptable radiation exposure. Conclusions: Incorporating the carotid bifurcation into delayed mCTA phases enhances the ability to differentiate occlusion subtypes and estimate thrombus location. This refined imaging approach enables better EVT planning, including device selection and procedural timing, thereby improving patient outcomes in acute stroke care. Full article

Background/Objectives: Stroke and arteriosclerotic diseases remain the main challenge for global healthcare. Carotid artery procedures aim to restore blood flow through the carotid arteries to prevent embolic events. The most common techniques include carotid endarterectomy (CEA) and carotid artery stenting (CAS). The choice of intervention depends on the severity of stenosis, the patient’s overall condition and the presence of comorbidities. The personalized approach, which includes sex-related differences, is crucial in optimizing the outcome. Methods: Sex-related differences in atherosclerosis risk factors and early carotid artery stenting treatment outcomes were evaluated in 271 patients. The goal of the study was to asses sex-related differences in early outcome of CAS, including success rate and complications. Results: The only significant difference in classical arteriosclerosis risk factors included a higher occurrence of smoking among males. The technical success rate of carotid artery stenting was high (94.46%). The sex-related differences in CAS involve using smaller sizes of implanted stents in females. There was a high incidence of complications (mostly minor), predominantly among females. They had a significantly higher frequency of bleeding and hypotension. Blood pressure and BMI significantly influenced the odds of complications. Conclusions: Females undergoing CAS have a higher complication risk with a similar success rate. Full article

Background and Objectives: Carotid artery stenosis is an inflammatory vascular disease closely linked to atherosclerosis and associated with inflammatory biomarkers. The neutrophil/albumin ratio (NAR) is a novel promising biomarker in assessing cardiovascular disease severity. This study aimed to evaluate the relationship between NAR and lesion severity in patients with carotid artery stenosis. Materials and Methods: This retrospective, single-center, comparative study included 625 asymptomatic patients who underwent digital subtraction angiography (DSA) for suspected high-grade carotid artery stenosis between 2012 and 2022. Patients were classified into two groups based on stenosis severity: critical carotid artery stenosis (≥70% stenosis) and non-critical carotid artery stenosis (<70%). Only asymptomatic patients were included; patients with symptoms were excluded. NAR was calculated preoperatively as neutrophil count divided by serum albumin. Additional inflammatory markers, such as neutrophil–lymphocyte ratio (NLR) and C-reactive protein (CRP) to albumin ratio (CAR), were also analyzed. Results: Severe carotid artery stenosis was detected in 191 of the patients who underwent DSA. Individuals in the critical carotid artery stenosis group were older and had a higher prevalence of diabetes mellitus and hypertension (51 (45–57) vs. 60 (54–68), p < 0.001; 143 vs. 83, p = 0.025; 193 vs. 104, respectively, p = 0.021), as well as higher neutrophil counts (4.3 (3.2–6.2) vs. 8.1 (4.9–12.5), p < 0.001), NLR (2.2 (1.4–3.2) vs. 4.2 (2.3–8.9), p < 0.001), while CRP (3.8 (1.8–8) vs. 5.7 (3.6–7.6), p = 0.005) and CAR (0.9 (0.5–1.9) vs. 1.6 (0.8–2.1), p < 0.001) values were significantly higher. NAR was higher in patients of the critical carotid artery stenosis group than the non-critical (1.1 (0.8–1.6) vs. 2.1 (1.4–3.2), p < 0.001). Multivariate analysis identified NAR as an independent predictor of carotid artery stenosis (Odds Ratio [OR]: 3.432; 95% Confidence Interval [CI]: 2.116–5.566; p < 0.001). The best cut-off value of NAR for predicting critical carotid artery stenosis was 1.47, which provided 73.8% sensitivity and 70.5% specificity. Conclusions: NAR, which can be easily measured through a simple blood test, demonstrated moderate sensitivity and specificity in predicting critical carotid artery stenosis, suggesting its potential role as a supportive marker in clinical risk assessment. Full article

Background and Objectives: Galectin-3 (Gal-3), a pro-inflammatory cytokine, has been implicated in atherosclerosis and adverse cardiovascular outcomes. While its role in coronary artery disease (CAD) is increasingly recognized, its association with systemic atherosclerosis remains underexplored. Objective: To investigate serum Gal-3 levels in patients with CAD and evaluate correlations between CAD severity and extra-coronary atherosclerotic involvement (carotid, femoral, and radial territories). Materials and Methods: We prospectively enrolled 56 patients with CAD undergoing coronary angiography (42.8% with acute-ACS; 57.2% with chronic coronary syndromes-CCS). Gal-3 levels were measured within 24 h of admission. Atherosclerosis severity was assessed angiographically and through vascular ultrasound of the carotid, femoral, and radial arteries. Patients were stratified by median Gal-3 levels, and clinical follow-up was performed at 1 and 3 months. Results: Gal-3 levels were significantly higher in CAD vs. controls (20.7 vs. 10.1 ng/mL; p < 0.00001) and in ACS vs. CCS (22.18. vs. 17.93 ng/mL; p = 0.019). Gal-3 correlated positively with culprit lesion diameter stenosis (DS) (R = 0.30; p = 0.023) and maximum severity of additional treated lesions (R = 0.62; p = 0.006). Gal-3 also correlated positively with carotid plaque thickness (R = 0.32; p = 0.016), while patients with Gal-3 levels above the median showed increased median values for femoral plaque thickness (32.4 vs. 26.45 mm, p = 0.046). No correlation was found with radial artery calcification. Gal-3 showed moderate discrimination for ACS (AUC = 0.685; cut-off 20.18 ng/mL). On multivariate analysis age, DS, and ACS presentation were independent predictors of Gal-3 above 19.07 ng/mL. Conclusions: Gal-3 levels are elevated in ACS and correlate with atherosclerotic burden, particularly in coronary, carotid, and femoral territories. These findings support Gal-3 as a potential marker of lesion severity and systemic vascular involvement, highlighting its possible role in risk stratification and the monitoring of atherosclerotic disease progression. This study provides integrated insights into the impact of Gal-3 across multiple vascular beds by assessing them concurrently within the same patient cohort. Full article

Objectives: The mechanisms linking vitamin D deficiency to carotid artery stenosis (CAS) remain unclear. Data on cardiovascular outcomes in CAS patients with vitamin D deficiency are limited. We investigated the association of vitamin D deficiency with carotid plaque morphology and patient outcomes in high-grade CAS. Methods: A total of 332 patients undergoing carotid endarterectomy for symptomatic (n = 113, 34%) or asymptomatic (n = 219, 66%) CAS were included. Preoperative vitamin D levels were measured, and duplex sonography was used to assess luminal narrowing. Associations of vitamin D with clinical presentation were analyzed using univariate and multivariate linear regression. For vitamin D deficiency and the prediction of major adverse cardiovascular events (MACE) and all-cause mortality, the Cox proportional hazard regression model was used. Results: The median age was 69 years (interquartile range (IQR) 64–74), and 94 (29.3%) patients were female. Vitamin D deficiency was present in 84 (25%) patients. Symptomatic patients had significantly lower vitamin D levels (41.2 nmol/L, IQR 25.1–63.5) than asymptomatic patients (51.6 nmol/L, IQR 30.5–74.3, p = 0.011). Patients with echolucent (44.9 nmol/L, IQR 27.4–73.7) or mixed plaques (39.2 nmol/L, IQR 22.9–63.5) had lower vitamin D levels than those with echogenic plaques (52.3 nmol/L, IQR 34.1–75.7). Vitamin D deficiency predicted MACE and all-cause mortality with an adjusted HR of 1.6, 95% CI of 1.1–2.6, and p = 0.030 and an HR of 2.2, 95% CI of 1.3–3.6, and p = 0.002, respectively, in a multivariable Cox proportional hazard regression model. Conclusions: A deficiency in vitamin D was correlated with unstable plaque characteristics and symptomatic CAS. Furthermore, vitamin D deficiency was associated with long-term adverse cardiovascular outcomes and mortality, suggesting its potential as a modifiable risk factor for improved risk stratification in patients undergoing carotid endarterectomy. Full article

Background/Objectives: This study aimed to prospectively assess the incidence of retinal embolization and to evaluate the vascular and structural changes in the retina and choroid in 52 patients with asymptomatic severe carotid artery disease who underwent carotid artery revascularization. Methods: In our study, 35 patients underwent carotid endarterectomy (CEA) and 17 underwent carotid artery stenting (CAS). Biomicroscopy, fundoscopy, optical coherence tomography (OCT), and OCT-angiography (OCTA) were performed at baseline and 1 month after revascularization. Results: The subfoveal choroidal thickness (SFCT), peripapillary choroidal thickness inferior to the optic nerve head (ppCTi), total overall average retinal vascular density (rVDtot), and total overall average choriocapillaris vascular density (ccVDtot) of the eyes ipsilateral to the operated carotid artery increased significantly after revascularization, whereas a statistically significant increase was also found in the SFCT, rVDtot, and ccVDtot of the contralateral eyes in the overall cohort. Comparing the two study groups, we found that the SFCT, superior and inferior peripapillary choroidal thicknesses (ppCTs, ppCTi), rVDtot, and ccVDtot increased in both groups after revascularization, but significantly only in the CEA group. Furthermore, the temporal choriocapillaris vascular density (ccVDt) increased significantly after revascularization in both groups to a similar degree. Conclusions: Carotid artery revascularization led to a statistically significant increase in retinal and choroidal vascular densities, which indicates significantly improved ocular perfusion. The analysis of the findings of the two study groups suggests the superiority of CEA in terms of improving ocular perfusion in asymptomatic severe carotid artery disease. The rate of retinal embolization was similar in both surgical groups. Full article

Background: The coexistence of extracranial arterial stenoses and intracranial aneurysms presents a unique clinical dilemma. While staged interventions are traditionally preferred to reduce procedural risks, recent advances have enabled single-stage endovascular treatment. This study evaluates the clinical outcomes, procedural strategies, and predictive factors associated with such combined interventions. Methods: This retrospective study included 47 patients treated with single-stage endovascular procedures for concurrent extracranial stenosis and intracranial aneurysm between 2016 and 2024. Clinical, angiographic, and procedural data were collected. Outcomes were assessed using the mmodified Rankin Scale (mRS), and statistical analyses were performed to identify associations between clinical variables and functional outcomes. Results: Of the 47 patients, 85.1% achieved favorable outcomes (mRS 0–2) at ≥6-month follow-up. The most commonly treated arteries were the internal carotid artery (70.2%) and the middle cerebral artery (34%). Stent-assisted coiling or flow diversion was performed in 93.6% of aneurysm cases, while 91.5% underwent carotid or vertebral stenting. Lesion laterality (left-sided aneurysms, p = 0.019) and stenosis length (p = 0.0469) were significantly associated with outcomes. Smoking was linked to multiple stenoses (p = 0.0191). Two patients experienced major complications: one aneurysmal rebleed after stenting, and one intraoperative rupture. Conclusions: Single-stage endovascular treatment for patients with concurrent extracranial stenosis and intracranial aneurysm is technically feasible and clinically effective in selected cases. Lesion configuration, anatomical considerations, and individualized planning are critical in optimizing outcomes. Full article

Background: Patients with chronic kidney disease (CKD) have a substantially higher risk of developing cognitive impairment (CI) than the general population. Patients with CKD undergoing haemodialysis (HD) treatment also have an elevated risk of developing cerebrovascular and cardiovascular diseases. This study aims to investigate the relationship between the cognitive performance of haemodialysis patients and cerebral and carotid haemodynamic indices. Methods: This study was a non-interventional observational study; the sample consisted of 32 patients (age 65 ± 12 years) undergoing chronic HD treatment. The patients underwent neuropsychological and haemodynamic instrumental investigations, including Supra-Aortic Trunk Echodoppler (SAT) and Transcranial Doppler (TCD). Results: Patients were 17% deficient at Montreal Cognitive Assessment (MoCA), 45% deficient at Frontal Assessment Battery (FAB), 55% deficient at Trail-Making Test-A (TMT-A) and 65% deficient at TMT-B. The TCD investigation detected a decrease in flow (MFV) and an increase in Breath Hold Index (BHI) predominantly in the right cerebral arterial district. The SAT investigation revealed an altered IMT, plaques and the presence of severe carotid stenosis. A strong association between cerebral and carotid indices and cognitive scores was also observed. Correlation analyses reported statistically significant correlations between TMT-A and TMT-B and cerebral flow indices. Conclusions: Among haemodialysis patients, there is a high percentage of cognitive impairment associated and correlated with alterations in cerebral and carotid haemodynamics. Cerebral haemodynamics are a factor to be taken into consideration as a possible pathological mechanism underlying cognitive impairment in haemodialysis. Full article

Background: With an aging population, dementia prevalence is increasing in Korea. Vascular dementia (VaD), often caused by cerebrovascular disease (CVD), is more common in Korea compared to Western countries. Hwanhon decoction, a traditional medicine containing Ephedrae Herba, Armeniacae Semen, and Glycyrrhizae Radix et Rhizoma, is traditionally used for CVD-related loss of consciousness. This study aimed to assess the cognitive improvement and anti-inflammatory effects of Hwanhon decoction extract (HHex) in a mouse model of VaD caused by chronic cerebral hypoperfusion (CCH). Methods: Key pharmacologically active ingredients of Hwanhon decoction were identified using network pharmacology analysis. VaD was induced in C57Bl/6 male mice through bilateral common carotid artery stenosis (BCAS). Mice were divided into sham surgery, BCAS control, low-dose HHex (L-HHex), and high-dose HHex (H-HHex) groups (n = 5/group). After CCH induction, L-HHex or H-HHex was administered thrice weekly for six weeks. Cognitive function, inflammatory markers, and RNA sequencing data were analyzed. Results: HHex administration reduced cognitive impairment and mitigated CCH-induced astrocyte activation. Inflammatory responses mediated by reactive astrocytes were suppressed, and network pharmacology predicted central proteins influencing HHex’s activity. Conclusions: HHex alleviated cognitive dysfunction and reduced inflammation in a VaD mouse model, suggesting its potential as a therapeutic agent for vascular dementia associated with impaired cerebral blood flow. Full article

Background: Histological signs of carotid atheromatous plaque vulnerability, such as hemorrhage, neovascularization, atherothrombosis, and ulceration, develop against an unstable biological background. Declining renal function contributes to atherosclerotic progression and worsens cardiovascular outcomes. Methods: In a single-center prospective cohort study, we studied 41 endarterectomized patients with severe carotid atherosclerosis. The histological samples were stained with H&E to assess morphology and immunohistochemically labeled with antibodies for CRP and MMP-9 proteins. Complete blood count, the presence of serum biomarkers hsCRP, oxLDL, MCP-1, and MMP-9, and the level of eGFR were determined. Results: Twenty-eight patients with complicated plaques had significantly lower eGFR values: 79.5 (24–110) vs. 94 (69–114) (p = 0.004). Patients with eGFR > 90 mL/min/1.73m² had a higher incidence of intraplaque hemorrhage and histologic complications of any cause (p = 0.012 and p = 0.003). Patients with bleeding and ulceration from the carotid plaque had a higher neutrophil/lymphocyte ratio. Significantly lower levels of MCP-1 were found in the serum of patients with massive inflammatory infiltrate of the carotid plaques, while serum levels of biomarkers like hsCRP, MMP-9, and oxLDL did not show differences in cases with plaque vulnerability. Conclusions: Signs of plaque vulnerability are associated with reduced renal function, a higher neutrophil/lymphocyte ratio, and lower serum levels of MCP-1 in advanced carotid artery stenosis disease. Full article