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Biomedical subjects

Vincent Larrue

Publications and source records attributed to Vincent Larrue.

10 recordsLinked to original sources
PubMed2006

Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis.

BACKGROUND: Carotid stenting is less invasive than endarterectomy, but it is unclear whether it is as safe in patients with symptomatic carotid-artery stenosis. METHODS: We conducted a multicenter, randomized, noninferiority trial to compare stenting with endarterectomy in patients with a symptomatic carotid stenosis of at least 60%. The primary end point was the incidence of any stroke or death within 30 days after treatment. RESULTS: The trial was stopped prematurely after the inclusion of 527 patients for reasons of both safety and futility. The 30-day incidence of any stroke or death was 3.9% after endarterectomy (95% confidence interval [CI], 2.0 to 7.2) and 9.6% after stenting (95% CI, 6.4 to 14.0); the relative risk of any stroke or death after stenting as compared with endarterectomy was 2.5 (95% CI, 1.2 to 5.1). The 30-day incidence of disabling stroke or death was 1.5% after endarterectomy (95% CI, 0.5 to 4.2) and 3.4% after stenting (95% CI, 1.7 to 6.7); the relative risk was 2.2 (95% CI, 0.7 to 7.2). At 6 months, the incidence of any stroke or death was 6.1% after endarterectomy and 11.7% after stenting (P=0.02). There were more major local complications after stenting and more systemic complications (mainly pulmonary) after endarterectomy, but the differences were not significant. Cranial-nerve injury was more common after endarterectomy than after stenting. CONCLUSIONS: In this study of patients with symptomatic carotid stenosis of 60% or more, the rates of death and stroke at 1 and 6 months were lower with endarterectomy than with stenting. (ClinicalTrials.gov number, NCT00190398 [ClinicalTrials.gov].).

Aged↗
PubMed2006

[Acute ischemic stroke: time is brain!].

Care of patients with acute ischemic stroke in dedicated stroke units reduces the rates of death and disability independently from any specific treatment. The only validated treatment for acute ischemic stroke is thrombolysis with intravenous alteplase. Its efficacy is strongly time-dependent. It is currently demonstrated for an administration up to 3 hours after symptom onset. Intravenous fibrinolysis for acute ischemic stroke is associated with an increased risk of symptomatic intracerebral haemorrhage. This can be reduced by rigorous application of recommendations for drug prescription. The efficacy of intravenous alteplase is relatively weak in patients with large artery occlusion. Combined therapies, using transcranial ultrasound, intraarterial thrombolysis, or clot retrieval devices are being evaluated to improve the efficacy of thrombolysis.

Acute Disease↗
PubMed2006

The use of embolic signal detection in multicenter trials to evaluate antiplatelet efficacy: signal analysis and quality control mechanisms in the CARESS (Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic carotid Stenosis) trial.

BACKGROUND AND PURPOSE: The CARESS (Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic carotid Stenosis) trial proved the effectiveness of the combination of clopidogrel and aspirin compared with aspirin alone in reducing presence and number of microembolic signals (MES) in patients with recently symptomatic carotid stenosis. The present study aimed at installing primary and secondary quality control measures in CARESS because MES evaluation relies on subjective judgment by human experts. METHODS: As primary quality control, centers participating in CARESS evaluated a reference digital audio tape (DAT) before the study containing both MES and artifacts. Interobserver agreement of classifying signals as MES was expressed as proportions of specific agreement of positive ratings (ps+/-values). For all DATs included in CARESS (n=300), online number of MES and off-line number of MES read by the central reader were compared using correlation coefficients. As secondary control, a sample of 16 of 300 DATs was cross-validated by another independent reader (post-trial validator). RESULTS: For the reference tape, the cumulative ps+/-value was 0.894 based on 12 of 14 observers. Two observers with very different results improved after a training procedure. Agreement between post-trial validator and central reader was ps+=0.805, indicating very good agreement. Correlation between online evaluation and off-line evaluation of DATs was very good overall (cumulative rho=0.84; P<0.001). CONCLUSIONS: Multicenter studies using MES as outcome parameter are feasible. However, primary and secondary quality control procedures are important.

Aspirin↗
PubMed2005

Baroreflex sensitivity is impaired in bilateral carotid atherosclerosis.

BACKGROUND AND PURPOSE: The arterial baroreflex is an important determinant of the short-term regulation of blood pressure and cardiovascular variability. The purpose of our study was to determine whether baroreflex sensitivity (BRS) and heart rate (HR) variability are altered in patients with carotid atherosclerosis (CA) and to assess the impact of characteristics of CA on BRS. METHODS: BRS and HR variability were prospectively evaluated in 75 consecutive patients undergoing carotid duplex examination in our neurosonology unit. Resting BRS was measured with the sequence method. HR variability was evaluated using spectral analysis. RESULTS: BRS was significantly reduced in patients with bilateral CA compared with patients without CA (P=0.015) and patients with unilateral CA (P=0.045). BRS was unaltered in patients with unilateral CA compared with patients with no CA. BRS was already reduced in mild (stenosis <50%), bilateral CA and was not further impaired in more severe CA. The association of BRS impairment with bilateral CA remained significant after adjustment for age, hypertension, and a history of stroke or transient ischemic attack. The study of HR variability demonstrated a reduction in the power of high-frequency band in patients with bilateral CA compared with patients with unilateral CA or without CA (P=0.015). CONCLUSIONS: Bilateral CA is associated with an impairment of BRS and a shift of the sympathovagal balance toward a relative decrease of the parasympathetic component of HR variability. These changes are already present in mild, bilateral CA.

Adult↗
PubMed2005

Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using doppler embolic signal detection: the Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (CARESS) trial.

BACKGROUND: Evidence for efficacy of dual antiplatelet therapy in stroke is limited. Symptomatic carotid stenosis patients are at high risk of early recurrent stroke. In this group, asymptomatic microembolic signals (MES), detected by transcranial Doppler ultrasound (TCD), are markers of future stroke and transient ischemic attack (TIA) risk. They offer a surrogate marker to evaluate antiplatelet therapy, but no multicenter study has evaluated the feasibility of this approach. METHODS AND RESULTS: Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (CARESS) is a randomized, double-blind study in subjects with recently symptomatic > or =50% carotid stenosis. Patients were screened with TCD, and if MES were detected, they were randomized to clopidogrel and aspirin or aspirin monotherapy. Repeated TCD recordings were made on days 2 and 7. MES were detected in 110 of 230 patients by online analysis at baseline, of whom 107 were randomized. Intention-to-treat analysis revealed a significant reduction in the primary end point: 43.8% of dual-therapy patients were MES positive on day 7, as compared with 72.7% of monotherapy patients (relative risk reduction 39.8%; 95% CI, 13.8 to 58.0; P=0.0046). The secondary end point of MES frequency per hour was reduced (compared with baseline) by 61.4% (95% CI, 31.6 to 78.2; P=0.0013) in the dual-therapy group at day 7 and by 61.6% (95% CI, 34.9 to 77.4; P=0.0005) on day 2. There were 4 recurrent strokes and 7 TIAs in the monotherapy group versus no stroke and 4 TIAs in the dual-therapy group that were treatment emergent and ipsilateral to the qualifying carotid stenosis; 2 additional ipsilateral TIAs occurred before treatment started. MES frequency was greater in the 17 patients with recurrent ipsilateral events compared with the 90 without (mean+/-SD: 24.4+/-27.7 versus 8.9+/-11.5 per hour; P=0.0003). CONCLUSIONS: In patients with recently symptomatic carotid stenosis, combination therapy with clopidogrel and aspirin is more effective than aspirin alone in reducing asymptomatic embolization. Doppler MES detection is a feasible method to evaluate the efficacy of antiplatelet therapy in multicenter studies.

Aged↗
PubMed2005

Continuous monitoring of middle cerebral artery recanalization with transcranial color-coded sonography and Levovist.

BACKGROUND AND PURPOSE: Treatment of acute ischemic stroke with intravenous recombinant tissue plasminogen activator (rtPA) is relatively ineffective in patients with large vessel occlusion. Numerous experimental studies have demonstrated that ultrasound (US) can accelerate enzymatic fibrinolysis and acceleration of lysis by US is enhanced in the presence of microbubbles used as echo-contrast agents. The purpose of this study was to evaluate the feasibility of continuous monitoring of middle cerebral artery (MCA) recanalization using transcranial color-coded sonography (TCCS) and intravenously administered microbubbles. METHODS: Recanalization of middle cerebral artery (MCA) mainstem occlusion was assessed using continuous monitoring with TCCS and intravenously administered galactose-based microbubbles (Levovist) in 8 consecutive patients with acute ischemic stroke treated with intravenous rt-PA within 3 hours of symptom onset. RESULTS: Recanalization at one hour occurred in 4 of 8 patients. The median NIHSS score was 21 (range 10 to 28) at baseline, 15 (range 0 to 24) at 1 h, and 11 (range 0 to 22) at 24 h. Asymptomatic hemorrhagic transformation (HT) was demonstrated on brain imaging in 6 patients. CONCLUSION: This study demonstrates the feasibility of continuous monitoring of MCA recanalization using TCCS and Levovist, in acute stroke patients. The findings suggest a high rate of asymptomatic HT in monitored patients. Although all HTs were asymptomatic and did not preclude early clinical improvement, particular attention should be given to the incidence and clinical significance of HT in future studies using these methods.

Angioplasty, Balloon↗
PubMed2005

Intravenous alteplase for acute ischaemic stroke.

Thrombolysis with intravenous alteplase is the only validated and approved treatment for acute ischaemic stroke. It is currently licensed for use within 3 h of stroke onset. This treatment improves functional outcome without increasing mortality, although it can initially cause a devastating intracerebral haemorrhage. Risk factors for this complication have been identified and postmarketing studies have shown an acceptable safety profile when the guidelines for drug prescription and administration are rigorously applied. Intravenous alteplase is weakly effective in recanalising major intracranial artery occlusions and more potent strategies of reperfusion are needed. Ongoing clinical trials are evaluating alteplase combined with transcranial ultrasound and intravenous microbubbles, alteplase at reduced doses combined with intravenous glycoprotein IIb/IIIa inhibitors and intravenous alteplase at a reduced dose followed by intra-arterial recanalisation.

Brain Ischemia↗
PubMed2002

Dynamics of cerebral blood flow autoregulation in hypertensive patients.

In hypertensive patients, the upper and lower limits of cerebral autoregulation are shifted to higher levels. However, the dynamics of cerebral autoregulation in hypertensive patients are less well known. We compared the dynamics of cerebral autoregulation in 21 treated hypertensive patients (13 men and 8 women; mean age: 48.9+/-13.6 years) and in 21 normotensive subjects (13 men and 8 women; mean age: 51+/-14.5 years) by transcranial Doppler (TCD) of the middle cerebral artery (MCA) during the acute decrease in blood pressure induced by standing up after 2 min in squatting position. MCA maximal outline blood flow velocity (FV), blood pressure (Finapres) and end-tidal PCO2 were continuously monitored and computerised. A cerebral vascular resistance index (CR) was calculated as follows: mean arterial BP/MCA mean FV with normalised changes in CR per second during the blood pressure decrease (CR slope). The CR slope reflecting the rate of cerebral autoregulation did not differ between the two groups and within the hypertensive patients [well controlled (8 patients) and not controlled (13 patients)]. The time to maximum decrease of CR (T1) and the time to full recovery of CR after the initial drop (T2) were also similar in the two groups (controls T1: 11.3+/-3.1 s, T2: 12+/-5.9 s; hypertensive T1: 11.7+/-2.5 s, T2: 10.7+/-4.5 s) and within hypertensive patients. These findings suggest that the dynamics of cerebral autoregulation are well preserved in hypertensive patients, with no difference according to the efficiency of treatment of hypertension.

Adult↗
PubMed2002

High rate of recanalization of middle cerebral artery occlusion during 2-MHz transcranial color-coded Doppler continuous monitoring without thrombolytic drug.

BACKGROUND AND PURPOSE: Experimental evidence indicates that ultrasound can accelerate thrombolysis. We report our findings on early recanalization during transcranial color-coded Doppler (TCCD) continuous monitoring in acute stroke patients with middle cerebral artery (MCA) main stem occlusion. METHODS: We performed continuous TCCD monitorings in 6 consecutive patients with acute MCA main stem occlusion using a 2-MHz transducer. Patients were not treated with recombinant tissue plasminogen activator. RESULTS: Partial recanalization, defined as blunted waveforms, occurred during monitoring in 5 patients (83%). The mean time to beginning of recanalization was 17.2+/-9.6 minutes. Complete recanalization at 24 hours occurred in only 1 patient. The mean National Institutes of Health Stroke Scale score in the patients who recanalized during monitoring was 21.2+/-4.1 at baseline, 19.2+/-5 at 2 hours, and 15.6+/-3.4 at 24 hours (P=0.1). CONCLUSIONS: In this short series of patients with acute MCA main stem occlusion, not treated with recombinant tissue plasminogen activator, we found a high rate of early partial recanalization during continuous exposure to 2-MHz ultrasound.

Aspirin↗