Consumption of a Branched-Chain Amino Acid (BCAA) during Days 2-10 of Pregnancy Causes Abnormal Fetal and Placental Growth: Implications for BCAA Supplementation in Humans.

A relatively large branched-chain amino acid (BCAA) supplement, consumed for more than 10 days, appears to be especially effective at alleviating muscle damage and soreness during intense human training. However, perturbations in amino acid and protein consumption could have unwanted transgenerational effects on male and female reproduction. This paper hypothesizes that isoleucine consumption by female mice from days 2 to 10 of pregnancy will alter fetal and placental growth later in gestation. Mice that had received 118 mM isoleucine in their drinking water delivered pups on day 19 of pregnancy that were 9% larger than normal, whereas the reverse was true for pups born on day 20. Moreover, the inverse correlation between birth weight and litter size was lost in mice that previously consumed excess isoleucine. Similarly, the normal correlations between fetal and placental weights were lost by day 18 of pregnancy in mice that had consumed excess isoleucine. Mice that consumed excess isoleucine had placentas smaller than, and fetuses larger than normal on day 18 of pregnancy, but the reverse was true on day 15. Other unintended and unexpected effects of BCAA consumption should be studied more thoroughly due to the increasing use of BCAAs to alleviate muscle damage and soreness in athletes.

Acquired Spinal Arteriovenous Fistula Presenting as Brown-Séquard Syndrome and Endovascular Treatment Outcome.

BACKGROUND: Brown-Séquard syndrome is typically caused by penetrating trauma to the cervical spinal cord; however, other compressive and vascular occlusive etiologies have been previously described. It is extremely uncommon to have a delayed presentation as an extramedullary compressive lesion from the venous varix of an acquired spinal arteriovenous fistula. CASE DESCRIPTION: We present a case of a patient in the fifth decade of life, with a remote history of gunshot wound to the left thorax with progressive left-sided weakness and contralateral pain and temperature sensory loss secondary to cord compression from an acquired spinal arteriovenous fistula. CONCLUSIONS: Subsequent treatment occurred with coil embolization with good outcome.

Outcome of mechanical thrombectomy in the very elderly for the treatment of acute ischemic stroke: the real world experience.

BACKGROUND: Although initial studies of neuroendovascular intervention did not review benefit over intravenous thrombolytics (iv r-tPA), recent studies have suggested otherwise. Elderly patients (age ≥80 years) are typically excluded from clinical trials. PURPOSE: To examine the utility of mechanical thrombectomy based on patient outcomes. MATERIAL AND METHODS: All stroke-alert activations at our health system from January 2011 to June 2014 were examined. All patients aged ≥80 years who had undergone mechanical thrombectomy were identified. Clinical characteristics included physiologic imaging findings, use of intravenous thrombolytics, baseline and postoperative National Institute of Health Stroke Scale (NIHSS), thrombolysis in cerebral infarction scores (TICI), and discharge destination. RESULTS: Mean NIHSS on presentation was 18.2 (range, 6-31), and 13.3 (range, 3-30) post thrombectomy. Three (16.6%) patients received iv r-tPA, two (11.1%) had symptomatic intracranial hemorrhage. Eight (44.4%) died, eight (44.4%) were discharged to nursing homes, and two (11.7%) were discharged to inpatient rehab and subsequently home. Favorable outcome was achieved in five (27.7%) patients. Fourteen (77.7%) patients had physiologic imaging prior to intervention. Three (75%) of four patients who did not have physiologic imaging prior to thrombectomy died. Thirteen (66.6%) patients had TICI 3 recanalization. CONCLUSION: Our study showed that although there remains a role of mechanical thrombectomy in the treatment of acute ischemic stroke in very elderly patients, it is associated with significant higher morbidity and mortality compared to younger patients, but should remain a very viable treatment option when quality of life is the most important consideration.

Desmoplastic infantile ganglioglioma with associated giant aneurysm­case report.

Desmoplastic infantile ganglioglioma (DIG) and supratentorial giant cerebral aneurysm are each extremely rare entities in infants. Here, we present the case of an 8-day old boy who had both of these conditions concurrently. To our knowledge, there is no previous case reported of a patient with coexisting DIG and giant aneurysm.

An innovative, multidisciplinary, process-driven approach to acute stroke in a community health system network.

Stroke is one of the major causes of death and disability in the United States, yet it is undertreated by many major medical centers across the country. Timely recognition and treatment of acute ischemic stroke remains a challenge due to confusing clinical presentations, hospital logistics, communication barriers among providers, and lack of standardized treatment algorithms. By creating a system-wide Code Stroke protocol, St. John Providence Health System improved documentation, increased intravenous tissue plasminogen activator delivery, reduced specialist call-back times, improved door-to-computer tomography scan and door-to-needle time, and identified appropriate patients for endovascular therapy.

Intravenous thrombolysis in acute ischemic stroke patients with negative CT perfusion: a case series.

BACKGROUND: Computed tomography perfusion (CTP) is a commonly used modality of neurophysiologic imaging to aid the selection of acute ischemic stroke patients for neuroendovascular intervention by identifying the presence of penumbra versus infarcted brain tissue. However many patients present with evidence of cerebral ischemia with normal CTP, and in that case, should intravenous thrombolytics be given? PURPOSE: To demonstrate if tissue-type plasminogen activator (tPA)-eligible stroke patients without perfusion defects demonstrated on CTP would benefit from administration of intravenous thrombolytics. MATERIAL AND METHODS: We retrospectively identified patients presenting with acute ischemic symptoms who received intravenous tPA (IV-tPA) from January to June 2012 without a perfusion defect on CTP. Clinical and radiographic findings including the NIHSS at presentation, 24 h, and at discharge, symptomatic and asymptomatic hemorrhagic transformation, and the modified Rankin score at 30 days were collected. A reduction of NIHSS of greater than 4 points or resolution of symptoms was considered significant. RESULTS: Seventeen patients were identified with a mean NIHSS of 8.2 prior to administration of intravenous thrombolytics, 3.5 after 24 h, and 2.5 at discharge. Among them, 13 patients had significant improvement of NIHSS with a mean reduction of 6.15 points at 24 h. One patient initially improved but had delayed hemorrhagic transformation and died. Two patients had improvement in NIHSS but were not significant and two patients had increased in NIHSS at 24 h, although one eventually improved at discharge. There was no asymptomatic hemorrhagic transformation. Mean mRS at 3 months is 1.76. CONCLUSION: The failure to identify a perfusion deficit by CTP should not be used as a contraindication for intravenous thrombolytics. Criteria for administration of intravenous thrombolytics should still be based on time from symptom onset as previously published by NINDS.

Epidural spinal cord compression in a patient with blue rubber bleb nevus syndrome.

Blue rubber bleb nevus syndrome (BRBNS) can present with vascular malformations throughout the body, especially in the gastrointestinal tract. Spinal cord compression from these lesions is rare, particularly in the pediatric population. The authors report a case of BRBNS involving an 18-year-old female patient who presented with back pain and an epidural thoracic mass with cord compression. She underwent an uncomplicated thoracic laminectomy and decompression, with removal of what appeared to be a venous malformation. Postoperatively her pain improved, and imaging revealed resolution of cord compression. Pathological analysis highlighted dilated venous channels with myxoid degeneration in the wall with clot, characteristic of BRBNS. The early age of presentation and location are unique based on the literature search of BRBNS. The present report highlights the multiplicity of venous malformations in BRBNS, and the management of this case.

Solitaire Flow Restoration thrombectomy for acute ischemic stroke: retrospective multicenter analysis of early postmarket experience after FDA approval.

BACKGROUND: The promising results of the Solitaire Flow Restoration (FR) With the Intention for Thrombectomy (SWIFT) trial recently led to Food and Drug Administration (FDA) approval of the Solitaire FR stent retriever device for recanalization of cerebral vessels in patients with acute ischemic stroke. OBJECTIVE: To report the early postmarket experience with this device since its FDA approval in the United States, which has not been previously described. METHODS: We conducted a retrospective analysis of consecutive acute ischemic strokes cases treated between March 2012 and July 2012 at 10 United States centers where the Solitaire FR was used as a single device or in conjunction with other intraarterial endovascular approaches. RESULTS: A total of 101 patients were identified (mean age, 64.7 years; mean admission National Institutes of Health Stroke Scale [NIHSS] score, 17.6). Intravenous thrombolysis was administered in 39% of cases; other endovascular techniques were utilized in conjunction with the Solitaire FR in 52%. Successful recanalization (Thrombolysis in Myocardial Infarction 2/3) was achieved in 88%. The rate of symptomatic intracranial hemorrhage within the first 24 hours was 15%. In-hospital mortality was 26%. At 30 days, 38% of patients had favorable functional outcome (modified Rankin scale score ≤2). Severity of NIHSS score on admission was a strong predictor of poor outcome. CONCLUSION: Our study shows that a variety of other endovascular approaches are used in conjunction with Solitaire FR in actual practice in the United States. Early postmarket results suggest that Solitaire FR is an effective tool for endovascular treatment of acute ischemic stroke.

Treatment of acute cervical internal carotid artery dissection using the Solitaire FR revascularization device.

During treatment of a right internal carotid artery terminus aneurysm, an acute iatrogenic flow limiting dissection was caused in the cervical internal carotid. The true lumen was catheterized using a Mirage 0.008 microwire over an Excelsior SL-10 microcatheter, which was exchanged for a Marksman microcatheter. A 6 mm × 30 mm Solitaire FR revascularization device was then deployed across the dissection as a salvage technique.

Treatment of acute cervical internal carotid artery dissection using the Solitaire FR revascularization device.

During treatment of a right internal carotid artery terminus aneurysm, an acute iatrogenic flow limiting dissection was caused in the cervical internal carotid. The true lumen was catheterized using a Mirage 0.008 microwire over an Excelsior SL-10 microcatheter, which was exchanged for a Marksman microcatheter. A 6 mm×30 mm Solitaire FR revascularization device was then deployed across the dissection as a salvage technique.