Observer agreement regarding the necessity of retreatment of previously coiled recurrent cerebral aneurysms.

BACKGROUND AND PURPOSE: The decision regarding whether or not to retreat a previously treated aneurysm not only directly impacts patient care but also serves as a primary outcome measure in numerous, leading randomized controlled trials of modified coils. Our aim was to determine the degree of interobserver variability regarding the need and type of treatment for recurrent aneurysms following coil embolization. MATERIALS AND METHODS: Twenty-seven previously treated recurrent aneurysms were identified. Five independent readers rated each aneurysm on a 5-point scale: 1, definitely do not retreat; 2, probably do not retreat; 3, unsure; 4, probably retreat; and 5, definitely retreat. The readers noted, in grades 2-5, the type of retreatment preferred, including simple coiling, balloon- or stent-assist coiling, or surgical clipping. Intraobserver agreement κ was calculated. Retreatment recommendations were evaluated between observers by using a Wilcoxon signed rank comparison. Descriptive statistics were performed for categoric treatment-type comparisons. RESULTS: At least 2- or 3-point differences between 2 readers were present in 17 (63%) and 11 (41%) of 27 cases, respectively. The median κ was 0.27 (range, 0.04-0.43), which indicates fair agreement. Differences between readers varied, with readers 4 and 5 more often recommending retreatment compared with reviewers 1-3 (P < .05). Wide variation was noted in treatment approach, with recommendations for surgical clipping ranging from 2 (7%) to 18 (67%) of 27 cases between readers 1 and 5. CONCLUSIONS: The current study demonstrates substantial variability among observers not only in whether to retreat a recurrent aneurysm but also how to treat it. These findings suggest that patient management varies widely across treating physicians and also calls into question the use of "retreatment" as an objective end point in clinical trials.

Rescue retrieval of AngioGuard embolic capture system after failure of capture sheath retrieval in carotid angioplasty and stenting.

This report describes the cases of 2 patients with failed retrieval of an AngioGuard distal protection device after carotid stent placement with rescue retrieval by use of a vertebral catheter. An AngioGuard was deployed before carotid angioplasty and stent placement. Attempted removal of the device with the provided recapture sheath was unsuccessful. A 5F 120-cm vertebral catheter was used to recapture and remove the AngioGuard. This technique is a simple and readily available solution for the retrieval of failed removal of a protection device.

Arterial hyperoxia in severe head injury: a useful or harmful option?

There is mounting evidence both from experimental and clinical studies that traumatic brain injury (TBI) is associated with a reduction of aerobic metabolism. This results from a variable combination of impaired substrate delivery and mitochondrial failure. Mitochondria, which are responsible for the production of 95% of cell adenosine triphosphate (ATP), may become compromised after TBI. On the other hand, in the very early period after the primary injury, oxygen delivery may be impaired due to arterial hypoxia and/or to a reduction of cerebral blood flow (CBF). As a consequence, 80-90% of patients who die of head injury show ischemia on histo-pathological examination of the brain tissue. In the absence of an appropriate treatment for TBI, these observations favored the hypothesis that manipulation of brain oxygen delivery could be a therapeutic tool to improve aerobic metabolism. Several strategies were developed, including the increase of cerebral perfusion pressure (CPP) using amines or the increase of arterial partial pressure of oxygen (PaO(2)) through hyperbaric oxygen (HBO) or normobaric hyperoxia. Several experimental and clinical studies, using normobaric hyperoxia, demonstrated an increase in brain tissue oxygen tension and a reduction of brain extracellular lactate levels, but there is no consensus about the biological meaning of these findings. For some authors, they translate an improvement of brain oxidative metabolism, while for others they represent only biological epiphenomena. The current review addresses the rational behind normobaric hyperoxia as a therapeutic application and discusses the experimental and clinical results achieved so far.

Further studies on the activation of rat median raphe serotonergic neurons by inescapable sound stress.

Previous studies, using a biochemical measure of serotonergic neuronal function, show that inescapable, randomly presented sound pulses activate serotonergic neurons in the rat median raphe but not dorsal raphe nucleus. The present study reveals that this activation also occurs in serotonin projection areas, in hippocampus, nucleus accumbens and cortex but not in caudate nucleus. The selectivity of this response is examined by comparing the response to sound stress with that produced by morphine, a treatment known to selectively activate dorsal raphe but not median raphe serotonergic neurons. Two approaches are used in Sprague-Dawley rat to measure the activation of serotonergic neurons: (1) determination ex vivo of accumulation of 5-hydroxytryptophan (5-HTP) in tissue from the dorsal and median raphe nuclei, hippocampus, cortex, caudate nucleus, and nucleus accumbens following in vivo inhibition of aromatic amino acid decarboxylase; and (2) measurement of extracellular serotonin levels in hippocampus, caudate nucleus, and nucleus accumbens. Sound stress increases 5-HTP accumulation in median raphe nucleus, hippocampus, cortex, and nucleus accumbens, but not dorsal raphe nucleus or caudate nucleus. Sound stress also enhances extracellular serotonin levels in hippocampus and nucleus accumbens, but not caudate nucleus. In contrast, the morphine treatment enhances 5-HTP accumulation in dorsal raphe nucleus, cortex and caudate nucleus, but not in median raphe nucleus, hippocampus or nucleus accumbens. Furthermore, it increases extracellular serotonin levels in only the caudate nucleus. The combined effects of sound stress and morphine on 5-HTP accumulation are identical to those obtained by each treatment individually. These findings provide further support for the presence of serotonergic neurons within the median raphe nucleus that have a unique response profile. These neurons may have an important role in responses or adaptations to stress.