Impact of immediate postrecanalization cooling on outcome in acute ischemic stroke patients with a large ischemic core: prospective cohort study.

BACKGROUND: Patients with large acute ischemic strokes (AIS) often have a poor prognosis despite successful recanalization due to multiple factors including reperfusion injury. The authors aim to describe our preliminary experience of endovascular cooling in patients with a large AIS after recanalization. METHODS: From January 2021 to July 2022, AIS patients presenting with large infarcts (defined as ASPECTS ≤5 on noncontrast CT or ischemic core ≥50 ml on CT perfusion) who achieved successful recanalization after endovascular treatment were analyzed in a prospective registry. Patients were divided into targeted temperature management (TTM) and non-TTM group. Patients in the TTM group received systemic cooling with a targeted core temperature of 33° for at least 48 h. The primary outcome is 90-day favorable outcome [modified Rankin Scale (mRS) 0-2]. The secondary outcomes are 90-day good outcome (mRS 0-3), mortality, intracranial hemorrhage and malignant cerebral edema within 7 days or at discharge. RESULTS: Forty-four AIS patients were recruited (15 cases in the TTM group and 29 cases in the non-TTM group). The median Alberta Stroke Program Early CT Score (ASPECTS) was 3 (2-5). The median time for hypothermia duration was 84 (71.5-147.6) h. The TTM group had a numerically higher proportion of 90-day favorable outcomes than the non-TTM group (46.7 vs. 27.6%, P=0.210), and no significant difference were found regarding secondary outcomes (all P>0.05). The TTM group had a numerically higher rates of pneumonia (66.7 vs. 58.6%, P=0.604) and deep vein thrombosis (33.3 vs. 13.8%, P=0.138). Shivering occurred in 4/15 (26.7%) of the TTM patients and in none of the non-TTM patients (P=0.009). CONCLUSIONS: Postrecanalization cooling is feasible in patients with a large ischemic core. Future randomized clinical trials are warranted to validate its efficacy.

Safety and efficacy of glibenclamide on cerebral oedema following aneurysmal subarachnoid haemorrhage: a randomised, double-blind, placebo-controlled clinical trial.

BACKGROUND: Glibenclamide has garnered attention due to its multifaceted neuroprotective effects in cases of acute central nervous system injury. We initiated a trial to explore the effectiveness and safety of a high dose of glibenclamide in the management of cerebral oedema following aneurysmal subarachnoid haemorrhage (aSAH). METHODS: This trial constituted a single-centre, randomised clinical study. Half of the 56 patients assigned to the glibenclamide group received 15 mg of glibenclamide tablets daily for 10 days (5 mg, three times/day). The primary outcome was the proportion of patients achieving the subarachnoid haemorrhage early brain oedema score dichotomy (defined as Subarachnoid Haemorrhage Early Brain Oedema Score 0-2) at the 10-day postmedication. The secondary outcome of cerebral oedema was the concentration of sulfonylurea receptor 1-transient receptor potential melastatin 4 (SUR1-TRPM4) in the plasma and cerebrospinal fluid. RESULTS: We enrolled 56 patients diagnosed with aSAH, who were admitted to the neurosurgery intensive care unit between 22 August 2021 and 25 April 2023. The primary outcome revealed that the glibenclamide group exhibited a notably higher proportion of mild cerebral oedema in comparison to the placebo group (60.7% vs 42.9%, adjusted OR: 4.66, 95% CI 1.14 to 19.10, p=0.032). Furthermore, the concentration of SUR1-TRPM4 in the cerebrospinal fluid of the glibenclamide group was significantly higher than the placebo group (p=0.0002; p=0.026), while the plasma TRPM4 concentration in the glibenclamide group was significantly lower than the placebo group (p=0.001). CONCLUSION: Oral administration of high-dose glibenclamide notably reduced radiological assessment of cerebral oedema after 10 days of medication. Significant alterations were also observed in the concentration of SUR1-TRPM4 in plasma and cerebrospinal fluid. However, it is worth noting that glibenclamide was associated with a higher incidence of hypoglycaemia. Larger trials are warranted to evaluate the potential benefits of glibenclamide in mitigating swelling and then improving neurological function. TRIAL REGISTRATION NUMBER: ChiCTR2100049908.

Role of Decompressive Craniectomy in the Treatment of Malignant Cerebral Venous Sinus Thrombosis: A Single Center Consecutive Case Series Study in China.

OBJECTIVE: Patients with cerebral venous sinus thrombosis (CVST) may die during the acute phase due to increased intracranial pressure and cerebral herniation. The purpose of this study was to assess the role of decompressive craniectomy in the treatment of patients with malignant CVST. METHODS: Patients who underwent decompressive craniectomy and were consequently admitted to the Critical Care Unit, Department of Neurosurgery, at Capital Medical University Xuanwu Hospital from March 2010 to January 2021 were retrospectively examined with follow-up data at 12 months. RESULTS: In total, 14 cases were reviewed, including 9 female and 5 male patients, aged 23-63 years (42.7 ± 12.3 years). Prior to surgery, all patients had a GCS score <9. 6 patients had a unilateral dilated pupil, while 4 patients had bilateral dilated pupils. According to the head computed tomography (CT), all patients had hemorrhagic infarction, and the median midline shift was 9.5 mm before surgery. Thirteen patients underwent unilateral decompressive craniectomy, and 1 patient underwent bilateral decompressive craniectomy, among whom, 9 patients underwent hematoma evacuation. Within 3 weeks of surgery, 3 cases (21.43%) resulted in death, with 2 patients dying from progressive intracranial hypertension and 1 from acute respiratory distress syndrome (ARDS). Eleven patients (78.57%) survived after surgery, of whom 4 (28.57%) patients recovered without disability at 12-month follow-up (mRS 0-1), 2 (14.29%) patients had moderate disability (mRS 2-3), and 5 (35.71%) patients had severe disability (mRS 4-5). CONCLUSIONS: Emergent decompressive craniectomy may provide a chance for survival and enable patients with malignant CVST to achieve an acceptable quality of life (QOL).

Related Factors and a Threshold of the Maximum Neuron-Specific Enolase Value Affecting the Prognosis of Patients with Aneurysmal Subarachnoid Hemorrhage.

Background: The prognosis of patients with subarachnoid hemorrhage is influenced by many factors. Neuron-specific enolase (NSE) is a biological marker of neurological damage. This study aimed to determine the related prognostic factors and whether or not the maximum NSE value (NSEmax) has a threshold between good and poor prognosis in aneurysmal subarachnoid hemorrhage (aSAH). Methods: A total of 259 patients admitted following aSAH were treated by appropriate methods. Initial neurological severity was evaluated by using the initial Glasgow coma scale and Hunt-Hess grades. NSE plasma concentration was measured during the patient's stay in the neurosurgical intensive care unit, and NSEmax was selected for further study. The primary endpoint of the study was Glasgow outcome score (GOS), which was dichotomized as poor outcome (GOS 1-3) or good outcome (GOS 4-5) at discharge. Results: A poor outcome of patients with aSAH at discharge was associated with mild hypothermia treatment, Hunt-Hess grade, rehemorrhagia, neurogenic pulmonary edema, and pneumonia, which were independent risk factors affecting the prognosis of patients. The best threshold of the maximum value of NSE for poor or good prognosis was 26.255 µg/L (specificity 0.908). Conclusions: Poor neurological score, pulmonary complications, aneurysm rerupture, and mild hypothermia indicate a poor prognosis. NSEmax>26.255 µg/L is an independent predicting factor of poor neurological outcome at discharge after aSAH. This threshold value could help clinicians make the appropriate decision and prognosis.

Targeted temperature management at 33 degrees Celsius in patients with high-grade aneurysmal subarachnoid hemorrhage: a protocol for a multicenter randomized controlled study.

BACKGROUND: Studies on the use of therapeutic hypothermia (TH) to improve the outcome of high-grade aneurysmal subarachnoid hemorrhage (aSAH), show promising, though conflicting results because of the lack of high-quality trials. The aim of this study is to evaluate the safety and efficacy of TH (maintaining bladder temperature at 33 °C for ≥72 h) to treat patients with high-grade aSAH (Hunt-Hess grade IV-V). METHODS: A multicenter, randomized, controlled clinical trial will be conducted for October 2020 to September 2024 involving 10 clinics. Patients who meet the inclusion criteria will be randomized 1:1 to a TH group and a normothermia group. The trial will enroll 96 participants in TH group and normothermia one, respectively. The trial was registered with ClinicalTrials.gov (NCT03442608) on February 22, 2018. Following conventional treatment for aSAH, patients will undergo either TH for at least 72 h or normothermia. The primary endpoint is the Glasgow outcome scale at 6 months after bleeding. The secondary endpoints are: (I) mortality at 6 months after bleeding; (II) intracranial pressure; (III) intensive care unit stay; and (IV) hospital stay. The safety endpoints include neurological, infectious, intestinal, circulatory, coagulation, and bleeding complications, electrolyte disorders, and other complications. DISCUSSION: If the study hypothesis is confirmed, TH at 33 °C in patients with high-grade aSAH may become a promising treatment strategy for improving 6-month outcome. TRIAL REGISTRATION: The trial has been registered at ClinicalTrials.gov (ID: NCT03442608).

Risk Factors for Prognosis in Elderly Patients with Severe Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study.

INTRODUCTION: To investigate the risk factors affecting the prognosis of elderly patients with severe aneurysmal subarachnoid hemorrhage (aSAH). METHODS: Forty-nine elderly patients with severe aSAH (Hunt and Hess [H-H] grade III-V) were enrolled in this retrospective study. Follow-up was conducted with patients 30 days after discharge using the Glasgow Outcome Scale (GOS), on which scores of 1-3 indicated a poor outcome (n = 32) and scores of 4-5 indicated a good outcome (n = 17). The patients' general information (gender, age, presence of hypertension, diabetes, or coronary atherosclerotic heart disease, location of ruptured aneurysm, and H-H grade) and complications (cerebral vasospasm, new cerebral infarction, pulmonary infection, liver dysfunction, hypoalbuminemia, anemia, and electrolyte disturbance) were recorded, and comparison between the different outcome groups was undertaken. Univariate analysis was used to analyze the factors associated with different outcomes, and multivariate logistic regression analysis was used to determine the factors that lead to poor outcomes. RESULTS: The incidence of all complications increased in patients with higher H-H grades, but without statistical significance (P > 0.05). There was no statistically significant difference between the two outcome (poor and good) groups in general information and complications (all P > 0.05), with the exception of different H-H grades (P < 0.05). H-H grade was a statistically significant risk factor for poor outcomes in elderly patients with severe aSAH (OR 11.627, 95% CI 2.475-55.556, P = 0.002). CONCLUSION: H-H grade is an independent factor related to the prognosis of elderly patients with severe aSAH.

Effect of Remote Ischemic Conditioning in Patients With Takotsubo Syndrome After Acute Stroke: Study Protocol for a Randomized Controlled Trial.

Introduction: Takotsubo syndrome (TTS) is an acute heart failure syndrome which is preceded by a variety of emotional or physical triggers, with central nervous system conditions being an important trigger. Remote ischemic conditioning (RIC) is a promising interventional treatment based on the probability that both TTS and acute coronary syndrome may respond similarly to interventions. The heart protection effect of RIC has been repeatedly confirmed in animal models and observational clinical trials; however, it has never been studied in patients with TTS after acute stroke in randomized clinical trials with a higher level of evidence. The present study will be a proof-of-concept study to determine whether RIC can reduce cardiac injury and eventually improve the heart function and clinical outcomes of TTS patients after acute stroke. Methods and Analysis: A single-center, outcome-assessor-blinded, randomized controlled trial (RCT) will be conducted to evaluate the effect of RIC in TTS patients after acute stroke. Major eligibility criteria include TTS patients diagnosed with acute stroke, which can be confirmed on computed tomography or magnetic resonance imaging; patients aged 18-75 years; patients admitted to a hospital within 48 h after the onset of acute stroke; and patients diagnosed with Takotsubo cardiomyopathy with an InterTAK diagnostic score ≥50. A total of 60 eligible patients will be randomly allocated into either the RIC or the control group. The primary endpoint is a composite of death from any cause and major adverse cardiac and cerebrovascular events during the in-hospital period and at the 1- and 6-month follow-up. Ethics and dissemination: This study has been approved by the Medical Ethics Committee of Xuanwu Hospital, Capital Medical University ([2017] 072). The study findings will be presented at international conferences and published in a peer-reviewed journal. Trial registration: This study has been prospectively registered in the Chinese Clinical Trial Registry on September 10, 2018 (ChiCTR1800018290).

The effect of remote ischemic conditioning on blood coagulation function and cerebral blood flow in patients with aneurysmal subarachnoid hemorrhage.

OBJECTIVE: To explore the effect of remote ischemic conditioning (RIC) on blood coagulation function and cerebral blood flow in patients with aneurysmal subarachnoid hemorrhage. PATIENTS AND METHODS: According to inclusion and exclusion standards, from October 2017 to June 2018, 30 consecutive patients of aneurysmal subarachnoid hemorrhage admitted to Intensive Care Unit, Department of Neurosurgery at Xuanwu Hospital, were given remote ischemic conditioning 5 times intervention to each patient within 7 days, and blood coagulation function testing, including prothrombin activity (PTA), prothrombin time (PT), activated partial prothrombin time (APTT), fibrinogen (Fib), D-dimer, and thromboelastogram (TEG, including R, K, Angle, MA, EPL, LY30, A, CI, G, and A30) were performed for each patient before and after the RIC intervention, as well as venous ultrasound monitoring before and after the RIC intervention for detection of deep vein thrombosis (DVT). Transcranial Doppler evaluation (TCD), including cerebral blood flow of bilateral ACA, MCA, PCA and intracranial segments of VA, as well as BA and the ratios of MCA cerebral blood flow/terminal segment of ipsilateral ICA cerebral blood flow, was performed before and after RIC intervention; and fresh infarction was evaluated by head CT or MRI recheck after RIC intervention. Thirty cases without RIC intervention of matched age, gender, and Hunt Hess grade with aneurysmal subarachnoid hemorrhage were selected to compare coagulation function and cerebral blood flow using TCD with RIC group. RESULTS: (1) Comparing the data before and after the RIC intervention, there was no significant difference for APTT, Fib, and D-dimer (P > 0.05), while PTA decreased and PT increased slightly after intervention as well as INR (P < 0.05) but all still in normal reference values. (2) Comparing the data before and after the RIC intervention, within TEG parameters, only the R value increased with significant difference (P < 0.05) but still in normal reference value, while K, Angle, MA, EPL, LY30, A, CI, G, and A30 had no significant difference (P > 0.05). (3) Comparing the data before and after the RIC intervention, DVT was not detected on the pressurized limbs of patients. (4) Comparing the data before and after the RIC intervention, the cerebral blood flow of bilateral MCA, L-ACA, L-VA, and BA increased (P < 0.05), while the elevation ranges were all in 25%, and the other parameters showed no significant difference. (5) Head CT or MRI showed no fresh cerebral infarction after the RIC intervention. (6) Compared with the group without RIC intervention, the coagulation function and the cerebral blood flow evaluated by TCD of the RIC group showed no statistical difference (P > 0.05) except APTT and D-dimer decreased after RIC but still in normal reference values. CONCLUSION: RIC showed no obvious effect on blood coagulation function and cerebral blood flow in patients with aneurysmal subarachnoid hemorrhage both after the intervention and compared with the non-intervention group. DVT was not detected on the pressurized limbs of patients and no fresh cerebral infarction was detected. This preliminary study confirmed the safety of RIC on blood coagulation function and cerebral blood flow in patients with aneurysmal subarachnoid hemorrhage, and the application of RIC on patients with aneurysmal subarachnoid hemorrhage needs further study to confirm and validate the safety and effectiveness.

Nitrogen Addition Increases the Sensitivity of Photosynthesis to Drought and Re-watering Differentially in C3 Versus C4 Grass Species.

Global change factors, such as variation in precipitation regimes and nitrogen (N) deposition, are likely to occur simultaneously and may have profound impacts on the relative abundance of grasses differing in functional traits, such as C3 and C4 species. We conducted an extreme drought and re-watering experiment to understand differences in the resistance and recovery abilities of C3 and C4 grasses under different N deposition scenarios. A C3 perennial grass (Leymus chinensis) and two C4 grasses (annual species Chloris virgata and perennial species Hemarthria altissima) that co-occur in Northeast China were selected as experimental plants. For both C3 and C4 grasses, N addition caused a strong increase in biomass and resulted in more severe drought stress, leading to a change in the dominant photosynthetic limitation during the drought periods. Although N addition increased antioxidant enzyme activities and protective solute concentrations, the carbon fixing capacity did not fully recover to pre-drought levels by the end of the re-watering period. N addition resulted in lower resilience under the drought conditions and lower resistance at the end of the re-watering. However, N addition led to faster recovery of photosynthesis, especially in the C3 grass, which indicate that the effect of N addition on photosynthesis during drought was asymmetric, especially in the plants with different photosynthetic nitrogen use efficiency (PNUE). These findings demonstrated that nitrogen deposition may significant alter the susceptibility of C3 and C4 grass species to drought stress and re-watering, highlighting the asymmetry between resistance and resilience and to improve our understanding about plant responses to climate change.

Exosomes from adipose-derived mesenchymal stem cells prevent cardiomyocyte apoptosis induced by oxidative stress.

Exosomes from bone marrow stem cells or cardiac progenitor cells can reduce apoptosis in myocardial cells after ischemia and reperfusion injury. However, there is little known about the effects of exosomes from adipose-derived stem cells (ADSCs), which are more abundant and have a lower risk of side effects. The aim of this study was to characterize exosomes from ADSCs and evaluate their cardioprotective actions against ischemia reperfusion injury. The exosomes were isolated from ADSCs and analyzed by protein marker expression, transmission electron microscopy, and nanoparticle tracking analysis. The ADSC-exosomes were then used for ex vivo investigation of the cardioprotective effects on cardiomyocytes after exposure to oxidative stress. Exosomes from ADSCs exhibited a diameter of 150 nm and expressed the marker proteins, CD9 and CD29. ADSC-exosomes had no effect on proliferation of untreated cardiomyocytes. In contrast, ADSC-derived exosomes reduced apoptosis in myocardial cells subjected to oxidative stress. This study confirms that exosomes originating from ADSCs can protect cardiomyocytes from oxidative stress.

A wearable mixed-reality holographic computer for guiding external ventricular drain insertion at the bedside.

OBJECTIVE: The goal of this study was to explore the feasibility and accuracy of using a wearable mixed-reality holographic computer to guide external ventricular drain (EVD) insertion and thus improve on the accuracy of the classic freehand insertion method for EVD insertion. The authors also sought to provide a clinically applicable workflow demonstration. METHODS: Pre- and postoperative CT scanning were performed routinely by the authors for every patient who needed EVD insertion. Hologram-guided EVD placement was prospectively applied in 15 patients between August and November 2017. During surgical planning, model reconstruction and trajectory calculation for each patient were completed using preoperative CT. By wearing a Microsoft HoloLens, the neurosurgeon was able to visualize the preoperative CT-generated holograms of the surgical plan and perform EVD placement by keeping the catheter aligned with the holographic trajectory. Fifteen patients who had undergone classic freehand EVD insertion were retrospectively included as controls. The feasibility and accuracy of the hologram-guided technique were evaluated by comparing the time required, number of passes, and target deviation for hologram-guided EVD placement with those for classic freehand EVD insertion. RESULTS: Surgical planning and hologram visualization were performed in all 15 cases in which EVD insertion involved holographic guidance. No adverse events related to the hologram-guided procedures were observed. The mean ± SD additional time before the surgical part of the procedure began was 40.20 ± 10.74 minutes. The average number of passes was 1.07 ± 0.258 in the holographic guidance group, compared with 2.33 ± 0.98 in the control group (p < 0.01). The mean target deviation was 4.34 ± 1.63 mm in the holographic guidance group and 11.26 ± 4.83 mm in the control group (p < 0.01). CONCLUSIONS: This study demonstrates the use of a head-mounted mixed-reality holographic computer to successfully perform hologram-assisted bedside EVD insertion. A full set of clinically applicable workflow images is presented to show how medical imaging data can be used by the neurosurgeon to visualize patient-specific holograms that can intuitively guide hands-on operation. The authors also provide preliminary confirmation of the feasibility and accuracy of this hologram-guided EVD insertion technique.

[An interpretation of an evidence-based guideline from the American Neuro-critical Care Society about the implementation of targeted temperature management].

OBJECTIVE: Targeted temperature management (TTM) is often used in neuro-critical care to minimize secondary neurologic injury and improve outcomes. Evidence-based implementation guideline of TTM was generated from clinical questions relevant to TTM implementation for neuro-critical care by experts recruited by the American Neuro-critical Care Society. Interpretation of this guideline would help the readers to understand the implementation of TTM, bring benefits to standardization of TTM application, and contribute to the solving of specific issues related to TTM implementation.

Diagnosis and treatment of severe neurosurgical patients with pyogenic ventriculitis caused by gram-negative bacteria.

The aim of the study is to explore the experiences in diagnosis and treatment of severe neurosurgical patients with pyogenic ventriculitis caused by gram-negative bacteria (G-). Nineteen patients with pyogenic ventriculitis were reviewed for their treatment. The bacterial testing results of cerebrospinal fluid (CSF), the clinical intervention, and the patients' prognosis were evaluated. The bacterial smears of ventricular drainage from all the cases were G- bacteria. Head CT and MRI scans confirmed that they were intraventricular empyema. Eighteen cases of CSF bacterial test were positive, including 12 cases of Acinetobacter baumannii positive, 2 of Klebsiella pneumonia positive, 2 of Serratia marcescens positive, 1 of Pseudomonas maltophila positive, and 1 case of Escherichia coli positive. One case of the bacterial culture was negative. All patients were treated by using intraventricular lavage in combination with intravenous and intraventricular antibiotics in accordance with the clinical conditions. After treatment for 2 to 8 weeks, 14 patients were cured (74%) and 5 were died (26%). Eight patients who were cured had received ventriculoperitoneal shunt due to hydrocephalus at 2 to 6 weeks after infection controlled, and none of them had any reinfection. Twelve of the 14 cured cases came to consciousness, but 2 were persistent in vegetative state starting before the infection; they did not show any improving consciousness after infection had been cured. Suppurative ventriculitis in severe neurosurgical patients is mainly infected by G- with a higher mortality. Early diagnosis, especially in identifying pathogen types, timely ventricular irrigation, and ventricular drainage together with intravenous and intraventricular antibiotic treatment, should improve prognosis.

Drought Sensitivity of the Carbon Isotope Composition of Leaf Dark-Respired CO2 in C3 (Leymus chinensis) and C4 (Chloris virgata and Hemarthria altissima) Grasses in Northeast China.

Whether photosynthetic pathway differences exist in the amplitude of nighttime variations in the carbon isotope composition of leaf dark-respired CO2 (δ13Cl) and respiratory apparent isotope fractionation relative to biomass (ΔR,biomass) in response to drought stress is unclear. These differences, if present, would be important for the partitioning of C3-C4 mixed ecosystem C fluxes. We measured δ13Cl, the δ13C of biomass and of potential respiratory substrates and leaf gas exchange in one C3 (Leymus chinensis) and two C4 (Chloris virgata and Hemarthria altissima) grasses during a manipulated drought period. For all studied grasses, δ13Cl decreased from 21:00 to 03:00 h. The magnitude of the nighttime shift in δ13Cl decreased with increasing drought stress. The δ13Cl values were correlated with the δ13C of respiratory substrates, whereas the magnitude of the nighttime shift in δ13Cl strongly depended on the daytime carbon assimilation rate and the range of nighttime variations in the respiratory substrate content. The ΔR,biomass in the C3 and C4 grasses varied in opposite directions with the intensification of the drought stress. The contribution of C4 plant-associated carbon flux is likely to be overestimated if carbon isotope signatures are used for the partitioning of ecosystem carbon exchange and the δ13C of biomass is used as a substitute for leaf dark-respired CO2. The detected drought sensitivities in δ13Cl and differences in respiratory apparent isotope fractionation between C3 and C4 grasses have marked implications for isotope partitioning studies at the ecosystem level.

Efficacy of high intensity atorvastatin versus moderate intensity atorvastatin for acute coronary syndrome patients with diabetes mellitus.

OBJECTIVE: To investigate whether more benefits can be achieved through high intensity atorvastatin compared with moderate intensity atorvastatin in acute coronary syndrome (ACS) patients with diabetes mellitus (DM). METHODS: This was a randomized controlled trail. Total 591 ACS patients with DM who underwent percutaneous coronary intervention were enrolled, 297 in high intensity atorvastatin group (40mg/day) and 294 in moderate intensity atorvastatin group (20mg/day). The primary end point was one-year incidence of major adverse cardiovascular events (MACE, including cardiovascular death, spontaneous myocardial infarction, unplanned revascularization). Cox proportional hazard regression models were used to analyze the association between clinical endpoints and atorvastatin treatment. RESULTS: At the end of one-year, low-density lipoprotein cholesterol level was lower in high intensity group than in moderate group (1.6±0.6 vs 1.8±0.6, p=0.041). MACE in high intensity group decreased 44.5% than moderate group (8.4% vs. 14.6%, p=0.018). The adjusted hazard ratio (HR) for MACE in patients with atorvastatin 40mg/d was lower compared to patients with atorvastatin 20mg/d (HR [95% CI] 0.61 [0.36 to 0.91], p=0.026). The rates of adverse events were no significantly different between the two groups. CONCLUSIONS: For ACS patients with DM, high intensity atorvastatin induced better long-term outcomes compared with moderate intensity.

Xe-CT and transcranial doppler in symptomatic vasospasm subarachnoid hemorrhage patients under euvolemic treatment without sedation.

BACKGROUND: Delayed cerebral ischemia from cerebral arterial vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) is associated with significant morbidity and mortality. Early recognition of the cerebral arterial vasospasm and institution of appropriate treatment can reduce the consequences. AIM: We investigated the association of transcranial Doppler (TCD) and Xe-CT with the characteristics of symptomatic vasospasm secondary to aneurysmal subarachnoid hemorrhage (SAH) in patients who underwent euvolemic treatment without sedation. MATERIALS AND METHODS: Data collected prospectively in patients with aSAH admitted to a neurocritical care unit in a regional hospital were retrospectively analyzed. Out of the 98 consecutive patients with aSAH, 30 patients underwent paired Xe-CT (not sedated) and TCD studies. Correlation between cortical cerebral blood flow (CBF) and mean blood flow velocity in middle cerebral artery (MCA) territories was analyzed. The lowest cortical regional CBF and MCA velocity were compared between patients with and without symptomatic vasospasm. RESULTS: Symptomatic vasospasm occurred in 12 patients. No correlation was found between CBF and mean blood flow velocity of the MCA territory. The differences between MCA velocity and lowest cortical CBF in patients with symptomatic vasospasm were significantly different from patients without symptoms. CONCLUSION: TCD does not help to predict regional CBF in the MCA territory in patients with aSAH on euvolemic treatment.

Early nonischemic oxidative metabolic dysfunction leads to chronic brain atrophy in traumatic brain injury.

Chronic brain atrophy after traumatic brain injury (TBI) is a well-known phenomenon, the causes of which are unknown. Early nonischemic reduction in oxidative metabolism is regionally associated with chronic brain atrophy after TBI. A total of 32 patients with moderate-to-severe TBI prospectively underwent positron emission tomography (PET) and volumetric magnetic resonance imaging (MRI) within the first week and at 6 months after injury. Regional lobar assessments comprised oxidative metabolism and glucose metabolism. Acute MRI showed a preponderance of hemorrhagic lesions with few irreversible ischemic lesions. Global and regional chronic brain atrophy occurred in all patients by 6 months, with the temporal and frontal lobes exhibiting the most atrophy compared with the occipital lobe. Global and regional reduction in cerebral metabolic rate of oxygen (CMRO(2)), cerebral blood flow (CBF), oxygen extraction fraction (OEF), and cerebral metabolic rate of glucose were observed. The extent of metabolic dysfunction was correlated with the total hemorrhage burden on initial MRI (r=0.62, P=0.01). The extent of regional brain atrophy correlated best with CMRO(2) and CBF. Lobar values of OEF were not in the ischemic range and did not correlate with chronic brain atrophy. Chronic brain atrophy is regionally specific and associated with regional reductions in oxidative brain metabolism in the absence of irreversible ischemia.