Posterior Circulation Endovascular Thrombectomy for Large-Vessel Occlusion: Predictors of Favorable Clinical Outcome and Analysis of First-Pass Effect.

BACKGROUND AND PURPOSE: Successful vessel recanalization in posterior circulation large-vessel occlusion is considered crucial, though the evidence of clinical usefulness, compared with the anterior circulation, is not still determined. The aim of this study was to evaluate predictors of favorable clinical outcome and to analyze the effect of first-pass thrombectomy. MATERIALS AND METHODS: A retrospective, multicenter, observational study was conducted in 10 high-volume stroke centers in Europe, including the period from January 2016 to July 2019. Only patients with an acute basilar artery occlusion or a single, dominant vertebral artery occlusion ("functional" basilar artery occlusion) who had a 3-month mRS were included. Clinical, procedural, and radiologic data were evaluated, and the association between these parameters and both the functional outcome and the first-pass effect was assessed. RESULTS: A total of 191 patients were included. A lower baseline NIHSS score (adjusted OR, 0.77; 95% CI, 0.61-0.96; P = .025) and higher baseline MR imaging posterior circulation ASPECTS (adjusted OR, 3.01; 95% CI, 1.03-8.76; P = .043) were predictors of better outcomes. The use of large-bore catheters (adjusted OR, 2.25; 95% CI, 1.08-4.67; P = .030) was a positive predictor of successful reperfusion at first-pass, while the use of a combined technique was a negative predictor (adjusted OR, 0.26; 95% CI, 0.09-0.76; P = .014). CONCLUSIONS: The analysis of our retrospective series demonstrates that a lower baseline NIHSS score and a higher MR imaging posterior circulation ASPECTS were predictors of good clinical outcome. The use of large-bore catheters was a positive predictor of first-pass modified TICI 2b/3; the use of a combined technique was a negative predictor.

Functional and radiological outcomes after bridging therapy versus direct thrombectomy in stroke patients with unknown onset: Bridging therapy versus direct thrombectomy in unknown onset stroke patients with 10-point ASPECTS.

BACKGROUND AND PURPOSE: The aim was to assess functional and radiological outcomes after bridging therapy (intravenous thrombolysis plus mechanical thrombectomy) versus direct mechanical thrombectomy (MT) in unknown onset stroke patients. METHODS: A cohort study was conducted on prospectively collected data from unknown onset stroke patients who received endovascular procedures at ≤6 h from symptom recognition or awakening time. RESULTS: Of the 349 patients with a 10-point Alberta Stroke Program Early Computed Tomography Score (ASPECTS), 248 received bridging and 101 received direct MT. Of the 134 patients with 6-9-point ASPECTS, 123 received bridging and 111 received direct MT. Each patient treated with bridging was propensity score matched with a patient treated with direct MT for age, sex, study period, pre-stroke disability, stroke severity, type of stroke onset, symptom recognition to groin time (or awakening to groin time), ASPECTS and procedure time. In the two matched groups with 10-point ASPECTS (n = 73 vs. n = 73), bridging was associated with higher rates of excellent outcome (46.6% vs. 28.8%; odds ratio 2.302, 95% confidence interval 1.010-5.244) and successful recanalization (83.6% vs. 63%; odds ratio 3.028, 95% confidence interval 1.369-6.693) compared with direct MT; no significant association was found between bridging and direct MT with regard to rate of symptomatic intracerebral hemorrhage (0% vs. 1.4%). In the two matched groups with 6-9-point ASPECTS (n = 45 vs. n = 45), no significant associations were found between bridging and direct MT with regard to rates of excellent functional outcome (44.4% vs. 31.1%), successful recanalization (73.3% vs. 76.5%) and symptomatic intracerebral hemorrhage (0% vs. 0%). CONCLUSIONS: Bridging at ≤ 6 h of symptom recognition or awakening time was associated with better functional and radiological outcomes in unknown onset stroke patients with 10-point ASPECTS.

Strategies to implement community guidelines on nutrition and their long-term clinical effects in nursing home residents.

OBJECTIVES: Studies on implementation techniques that focus on nutrition in the setting of elderly care are scarce. The aims of this study were to compare two implementation strategies i.e., external facilitation (EF) and educational outreach visits (EOVs), in order to introduce nutritional guidelines (e.g. screening, food quality and mealtime ambience), into a nursing home (NH) setting and to evaluate the clinical outcomes. DESIGN: A controlled study with baseline and follow-up measurements. SETTING: Four NHs. PARTICIPANTS: A total of 101 NH residents. INTERVENTION: The EF was a one-year, multifaceted intervention that included support, guidance, practice audits, and feedback that were provided to two NHs. The EOVs performed at the other NHs consisted of one session of three hours of lectures about the guidelines. Both interventions targeted a team of the unit manager, the head nurse, and 5-10 of the care staff. MEASUREMENTS: The outcomes were nutritional status (Mini Nutritional Assessment-Short Form, MNA-SF), body mass index (BMI), functional ability (Barthel Index, BI), cognitive function (Short Portable Mental Status Questionnaire, SPMSQ, performed in a subgroup of communicative NH residents), health-related quality of life (EQ-5D), and the levels of certain biochemical markers like for example vitamin D, albumin and insulin-like growth factor 1. RESULTS: After a median of 18 months, nutritional parameters (MNA-SF and BMI) remained unchanged in both groups. While there were no differences in most outcomes between the two groups, the cognitive ability of those in the EOV group deteriorated more than in individuals in the EF group (p=0.008). Multiple linear regression analyses indicated that the intervention group assignment (EF) was independently from other potentially related factors associated with less cognitive decline. CONCLUSION: An extended model of implementation of nutritional guidelines, including guidance and feedback to NH staff, did not affect nutritional status but may be associated with a delayed cognitive decline in communicative NH residents.

Two-year follow-up after microsurgical discectomy and dynamic percutaneous stabilization in degenerate and herniated lumbar disc: clinical and neuroradiological outcome.

AIM: Lumbar disc herniation associated with back pain is often related to disc degeneration. Back pain after microdiscectomy often persists, prejudicing clinical outcome and quality of life. To this day, the evolution of disc degeneration after classical microdiscectomy has never been proven. Percutaneous dynamic stabilization after microdiscectomy has been proposed as a novel surgical strategy for treatment of back pain with herniated disc. However, clinical results are still debated and no evidences about the long-term evolution of back pain and relationships between neuroradiological imaging and clinical outcome have been provided. We report our preliminary observations concerning the clinical and neuroradiological outcome of 11 patients treated with microdiscectomy and dynamic percutaneous lumbo-sacral stabilization, after a long-term follow-up (2-years). METHODS: This was an uncontrolled case series. The study included 11 patients (3 F, 8 M) with L5-S1 discal herniation and degeneration underwent microdiscectomy and percutaneous dynamic stabilization, from December 2008 to November 2009. All the patients were symptomatic with back and leg pain non-responsive to long-term (8-12 months) medical and physical treatments. VAS and Satisfaction Index were used, respectively, for evaluation of clinical outcome and general postoperative patients' satisfaction. Modic and Pfirrmann scores were used for evaluation of neuroradiological outcome. All the patients underwent to microdiscectomy and implantation of the same percutaneous device for dynamic stabilization of the middle vertebral column during the same surgery. Modic, Pfirrmann, VAS and Satisfaction Index scores were collected before surgery and over the follow-up (45 days, 1 and 2 years). MRI and dynamic X-Ray 2 years after surgery were compared to the preoperative imaging. RESULTS: Motion preservation at the functional spinal unit after surgery was demonstrated in all the cases. All patients reported a reduction or complete resolution of back and leg pain, they were satisfied and came back to normal socio-professional life. No modification of the preoperative Pfirrmann was observed, even in those patients who experienced restoration of back pain. No surgical complications nor device failures were reported. CONCLUSION: Percutaneous minimally invasive lumbo-sacral dynamic stabilization after microdiscectomy seems a reliable and effective technique in order to obtain a resolution of back pain and seems to prevent the Pfirrmann worsening, over a long-term follow-up.

Invasive procedure for intractable epistaxis in an old comorbid woman: a case report.

Epistaxis is a condition mainly self-limiting or easily treated conservatively, although in rare cases it could become life-threatening. We discuss the case of a 73 year comorbid old woman with severe and recurrent epistaxis treated with superselective catheterism and embolization of the internal maxillary artery. The possible underlying causes, including drug related issues, are discussed.

Evaluation of acute perihematomal regional apparent diffusion coefficient abnormalities by diffusion-weighted imaging.

In this study, we investigated 40 patients (18 male, 22 female; mean age = 64.5 +/- 11.0; GCS = 9 to 14) with acute supratentorial spontaneous intracerebral hemorrhage (SICH) at admission by using a 1-tesla magnetic resonance imaging (MRI) unit equipped for single-shot echo-planar spin-echo isotropic diffusion-weighted imaging (DWI) sequences. All DWI studies were obtained within 48 hours after symptom onset. Regional apparent diffusion coefficient (rADC) values were measured in 3 different regions of interest (ROIs) drawn freehand on the T2-weighted images at b 0 s/mm2 on every section in which hematoma was visible: 1) the perihematomal hyperintense area; 2) 1 cm of normal appearing brain tissue surrounding the perilesional hyperintense rim; 3) an area mirroring the region including the clot and perihematomal hyperintense area placed in the contralateral hemisphere. rADC mean values were higher in perihematomal hyperintense and in contralateral than in normal appearing areas (p < 0.001), with increased rADC mean levels in all regions examined. Our findings show that rADC values indicative of vasogenic edema were present in the perihematomal area and in normal appearing brain tissue located both ipsilateral and contralateral to the hematoma, with lower levels in non-injured areas located in the T2 hyperintense rim around the clot.

Assessment of acute spontaneous intracerebral hematoma by CT perfusion imaging.

A single-section deconvolution-derived computerized tomographic perfusion imaging was performed in 45 patients (22 male and 23 female; mean age=69.89+/-10.07 years) with acute supratentorial spontaneous intracerebral hemorrhage. Mean rCBF and rCBV were lower in the hemorrhagic core than in the perihematomal low density area (p<0.001), and in the perihematomal low density area than in normal appearing brain parenchyma (p<0.001). Mean rMTT values were higher in perihematomal low density area than in normal appearing area (p<0.01) and in both hemorrhagic and perihematomal area than in controlateral ROI (p<0.001). There were no differences in rMTT mean values between hemorrhagic core and perihematomal area, as well as between normal appearing and controlateral areas. We found a concentric distribution of all CT perfusion parameters characterized by an improvement from the core to the periphery, with low perihematomal rCBF and rCBV values suggesting edema formation.

Home oxygen therapy after preterm birth in Western Australia.

OBJECTIVES: To review our management of infants discharged home receiving supplemental oxygen. Stable preterm infants receive low flow O(2) by nasal cannulae aiming for SaO(2) of > or = 95%. Oxygen-dependent infants must pass an air test (ability to maintain SaO(2) > 80% during 4 h disconnection from oxygen) before discharge home with supplemental oxygen. A sleep study is performed before nocturnal O(2) is ceased. METHODS: Infants less than 33 weeks gestational age (GA) who were admitted January 1999-June 2001 and discharged home with supplemental oxygen were identified through the databases and medical records of the King Edward Memorial/Princess Margaret Hospitals. The data collected were compared with an audit performed a decade earlier. RESULTS: Ninety-three infants were discharged home with supplemental oxygen between 1999 and 2001 (10% neonatal intensive care unit admissions less than 33 weeks GA; median GA 26 weeks (interquartile range 25-28). All infants had an air test before discharge: 63% failed the first air test and 30% at least two air tests. The median delay between the first air test and discharge was 2 weeks. The median postmenstrual age at discharge was 40 weeks gestation (interquartile range 38-41). Ninety infants had a sleep study before nocturnal oxygen was ceased and nine failed the first sleep study. Hospital readmission rate was 60%. More preterm infants (less than 33 weeks) were discharged with supplemental oxygen in 1999-2001 (10%, n = 96 in 1999-2001) than in 1987-1992 (2.5%, n = 53) and this was associated with an earlier discharge (40 vs 44 weeks postmenstrual age), lower oxygen requirements at discharge (60 vs 125 mL/min), earlier discontinuation of daytime and nocturnal oxygen (1 vs 4 months postmenstrual age and 2.5 vs 6 months postmenstrual age) and no increase in readmission rate (64% vs 60%). The incidence of bronchopulmonary dysplasia for these infants has remained stable at 20%. CONCLUSION: Our home oxygen programme, based on an air test predischarge and a sleep study prediscontinuation of nocturnal oxygen, facilitates early discharge home. Our data suggest that over the last decade, bronchopulmonary dysplasia is associated with less impairment in lung function. Further evidence from randomized clinical trials is required to determine optimal target range for oxygen saturation in preterm infants.

Nutritional status according to mini nutritional assessment in an institutionalized elderly population in Sweden.

BACKGROUND: In 1992, local municipalities in Sweden took over full responsibility for the long-term care of elderly. This has led to an increased care burden for the various assisted accommodation services run by the municipalities. OBJECTIVE: Since ageing and chronic diseases are risk factors for protein-energy malnutrition, we evaluated the nutritional status of all individuals in assisted accommodation, i.e., service flats (SF), old people's homes (OPH), group living for the demented (GLD), and nursing homes (NH), in three Swedish municipalities. METHODS: Of 994 eligible subjects, 872 were examined; the average age was 84.5+/-8 years, and 69% were female. The Mini Nutritional Assessment (MNA) scale (0-30 points) was used, consisting of 18 point-weighted questions in four categories, i.e., anthropometry, global and dietary issues, and self-assessment. RESULTS: MNA <17, i.e., malnutrition, was noted in 36% of the study population. Divided according to accommodation type, the MNA scores were <17 in 21% of individuals in SF, 33% of those in OPH, 38% of those in GLD, and 71% of those in NH. The corresponding values for MNA scores 17-23.5 (risk for malnutrition) were 49, 51, 57, and 29%, respectively. Average body mass index (BMI) values were 24.2+/-5 (SF), 23.6+/-5 (OPH), 23.9+/-4 (GLD), and 22.3+/-4 (NH). BMI values < or =20 were found in 18% of those in SF, in 25% of those in OPH, in 19% of those in GLD, and in 33% of those in NH. Both MNA and BMI correlated with upper arm and calf circumference, with r values ranging from 0.4 to 0.7 (p<0.001). MNA and BMI correlated significantly (r = 0.52, p<0.001). Age correlated with MNA and BMI with r values of 0.1 (p<0.01) and 0.14 (p < 0.001), respectively. Subjects with significant help requirements during meals ate fewer whole meals per day than those who could feed themselves. CONCLUSIONS: Based on the MNA, one third of the study subjects living in assisted accommodation, and more than half of those living in NH, appeared to be malnourished. Further studies are necessary to assess to what extent these nutritional disturbances are reversible.

Monitoring by cis-parinaric fluorescence of free radical induced lipid peroxidation in aqueous liposome suspensions.

Cis-parinaric acid is fluorescent when partioned into a lipid environment and its fluorescence is destroyed upon reaction with free radicals. In our study 1-palmitoyl-2-parinoyl-phosphatidylcholine (cis-PnA) has been used to monitor the time-course of liposomal lipid peroxidation, using reverse-phase evaporation vesicles (REV) of different composition exposed to oxidative stress in various conditions. This methodology allowed us to estimate the potential damage produced by two different oxidizing systems, namely hydrogen peroxide (H2O2), a water soluble oxidant, and t-butyl hydroperoxide (t-BHP), a hydrophobic hydroperoxide. Furthermore, we evaluated the protective effects of bilayer-associated antioxidants, namely alpha-tocopherol acetate (alpha-THA), vitamin K1 and beta-carotene, as well as of two antioxidants dissolved in the aqueous bulk solution, that is, biverdin and uric acid. Under our experimental conditions, the results suggest that (i) both oxidizing compounds were able to interact with liposomal PnA leading to decay either of the excitation and of emission spectra of the probe; (ii) hydrogen peroxide seemed to be of most effective among the two stressing agents, when employed at similar concentrations; (iii) the alpha-THA appeared to be a stronger antioxidant than vitamin K1 and beta-carotene, resulting in a decrease of the liposomal membrane stress caused by those two oxidizing agents; (iv) among the water soluble antioxidant compounds, biliverdin displayed a protective effect at least 10 x higher than uric acid; (v) the overall damage, as well as the protection mechanisms, seemed to be dependent either on the lipid composition of the vesicles and on the pH of the liposomal suspension. This relatively easy experimental approach suggests the validity of the use of the bilayer associated fluorescent probe PnA in the monitoring of spontaneous and/or chemically induced liposomal lipid damage.

[The role of muscle scintigraphy with 201Tl in the morphofunctional assessment of obliterative arterial pathology of the lower limbs]. / Ruolo della scintigrafia muscolare con 201Tl nella valutazione morfo-funzionale della patologia arteriosa obliterante degli arti inferiori.

This study was aimed at assessing the role of stress 201Tl leg scintigraphy, compared with digital angiography, in the diagnosis and prognosis of peripheral arterial obstructive disease (PAOD) before and after surgical treatment. Fifty-four patients with known PAOD in Fontaine stages IIb, III or IV submitted to revascularization (36) or lumbar ganglionectomy (18), were examined with both angiography and scintigraphy. A statistical analysis of 360 segments (thighs and calves) was performed; in particular, correlation values were derived from 216 preoperative and 144 postoperative segments (18 patients who underwent lumbar ganglionectomy were not submitted to postoperative angiography). Scintigraphy vs. angiography sensitivity (84%), specificity (80%) and diagnostic accuracy (90%) values obtained in this study are in agreement with those reported in international literature. Scintigraphy yields information on the locoregional perfusion of an angiography-demonstrated anatomic lesion, under physiologic stress, which is particularly useful in symptomatic patients with angiographically unimportant stenoses. At present, 201Tl leg scintigraphy is the only technique yielding semiquantitative data in the assessment of single muscle groups perfusion increase in Fontaine IV patients submitted to lumbar ganglionectomy. The original contribution of this study consists in the evidence of a high predictive value (p < 0.01) of scintigraphy in the calculation of pain-free intervals in the patients with successful revascularization at clinics and angiography. This finding, if confirmed, shows a possible role for 201Tl leg scintigraphy in the diagnosis of peripheral arterial obstructive disease.

[Subrenal coarctation of the aorta. Presentation of a clinical case]. / Coartazione sottorenale dell'aorta. Presentazione di un caso clinico.

Coarctation of abdominal aorta constitutes a rare group of vascular abnormalities, including segmental stenoses and extended hypoplasia below the restriction. Usually hypertension is the only clinical evidence. The natural history of the surgically untreated disease foresees a decline of life expectancy; while surgical operation permit an almost complete "restitutio ad integrum". The Authors report a case of coarctation of the abdominal aorta come to their observation whose particularly was determined by the absence of high blood pressure, the aortic stenoses being located under the renal arteries.