Disrupted interoception in Military Service Members and Veterans with a history of suicidality.

INTRODUCTION: This project tested whether Service Members (SM) and Veterans with current suicidal ideation or a history of suicide attempt had greater interoceptive dysfunction than SM and Veterans with past or no suicidal ideation. METHOD: Participants (N = 195; 69% male) were SM (62%) and Veterans (38%) who completed measures of suicidal thoughts and behaviors and subjective and objective interoceptive dysfunction. Participants were split into the following suicide groups: no suicidality, lifetime ideation, current ideation, and past attempt. Planned orthogonal contrasts tested for differences. RESULTS: The combined suicidality group (lifetime ideation, current ideation, or past attempt) had worse body trust relative to the no suicidality group, and the current ideation group had worse body trust relative to those with lifetime ideation. Those with a history of suicide attempt had worse body appreciation than the combined group of ideators, and those with current ideation had worse body appreciation relative to those with lifetime ideation. The groups did not differ on objective interoception. CONCLUSION: Interoception is disrupted among individuals with suicidality histories within a predominantly male-identified military sample. Individuals with current suicidal ideation had both worse body trust and appreciation relative to those with past ideation. Suicide risk assessments may benefit from including questions related to body trust.

When, How, & Where Tobacco Initiation and Relapse Occur During U.S. Air Force Technical Training.

INTRODUCTION: Military personnel are at high risk for tobacco use, particularly during the first year of military service. Technical Training follows an 8½ week tobacco ban during basic military training and is a vulnerable time for personnel to both reinitiate and initiate tobacco use. Thus, this can be a crucial time to promote tobacco policies and interventions. However, there is limited research examining when, how, and where personnel access tobacco during the first year of service, particularly among users of newer products (eg, electronic cigarettes[e-cigarettes]). Thus, the purpose of the current study is to explore the timing, source, and location of tobacco use during Technical Training across all types of products. Furthermore, this study will examine differences in demographic characteristics and prior tobacco history in relationship to these tobacco behaviors. MATERIALS AND METHODS: Participants were U.S. Air Force recruits completing Technical Training (2017-2018). Protocol was approved by the Institutional Review Board at the 59th Medical Wing of the U.S. Air Force. During the first week of Technical Training, Airmen were consented to participate in the study and completed a questionnaire about demographics and tobacco use history. Next, Airmen were randomized to receive one of three tobacco prevention interventions as part of military training. At a 3-month follow-up, during the last week of Technical Training, consented participants completed a questionnaire about current tobacco use. Airmen reported when (ie, first month vs. after), how (ie, "bummed" from another airman, bought on or off base, received from the internet or event), and where (ie, designated smoking areas on base, off base, bar or club, friend's house, cigar lounge, hookah bar, or vape shop) they used tobacco during Technical Training. Descriptive statistics were used to examine these behaviors across all tobacco products. Additionally, Wilcoxon-Mann-Whitney and Kruskal-Wallis tests compared differences in demographic characteristics and baseline tobacco use in relationship to these tobacco behaviors. RESULTS: No significant differences were found when comparing prior users and first-time users in relationship to tobacco behaviors during Technical Training; however, significant differences in educational background and age were found in regard to the source and location of tobacco use. Additionally, how and where Airmen first used tobacco during Technical Training differed across products. Cigarettes and smokeless tobacco were equally likely to be bought on or off base and most commonly first used at a designated smoking area on base. However, e-cigarettes, cigarillos/little cigars, and hookah were more likely to be bought off base, and first used at a specialty store (ie, vape shop, hookah bar, or cigar lounge). CONCLUSIONS: Tobacco use behaviors during Technical Training differed depending on the type of product. Specifically, new and emerging products were more likely to be bought off base and first used at a specialty store. Thus, military polices regulating on base tobacco pricing might not reduce the growing prevalence of e-cigarettes. Future policies might consider addressing the density of off-base tobacco retailers to reduce the high rates of tobacco use in this population.

Endovascular treatment of 346 middle cerebral artery aneurysms: results of a 16-year single-center experience.

BACKGROUND: The endovascular treatment of middle cerebral artery (MCA) aneurysms has been controversial because of the frequency of complex anatomy and the relative ease of surgical clipping in this location. OBJECTIVE: To present a large single-center experience with the endovascular treatment of MCA aneurysms. METHODS: The neurointerventional database at our institution was reviewed for all endovascular treatments of MCA aneurysms. Demographics, aneurysm characteristics, treatment modality, intraprocedural hemorrhagic and thromboembolic events, 30-day neurological events, and follow-up angiographic studies were recorded. RESULTS: From December 1996 to April 2013, 292 patients underwent endovascular treatment of 346 MCA aneurysms. Of these, 341 (98.6%) were successfully completed. Balloon neck remodeling was used in 230 procedures (66.5%). Ninety-five procedures (27.4%) were for ruptured aneurysms. The rate of intraprocedural hemorrhage was 2.6% (9 of 346). The overall rate of intraprocedural thromboembolic events was 13.6% (47 of 346), significantly more common in patients with acute subarachnoid hemorrhage (27.4%; P < .001). The 30-day major (modified Rankin Scale score > 2) neurological event rate was 2.9% (10 of 346), significantly more common in patients with subarachnoid hemorrhage (8.4%) compared with those without (0.8%; P < .001). The rate of complete or near-complete aneurysm occlusion at was 90.6% ≥ 6 months and 91.8% at ≥ 2 years, with an average of 24 months of follow-up available for 247 procedures. CONCLUSION: Endovascular treatment of MCA aneurysms can be safe and effective. However, it is associated with a high asymptomatic thromboembolic event rate that is more frequent in the setting of acute subarachnoid hemorrhage.

Successful endovascular treatment of three fusiform cerebral aneurysms with the Pipeline Embolization Device in a patient with dilating HIV vasculopathy.

Dilating HIV vasculopathy can be a cause of ischemic and hemorrhagic stroke in patients with HIV. Although first identified in children, this condition is increasingly being recognized in adults and has a dismal natural history under medical or expectant management. Vessel wall invasion by varicella zoster virus, HIV or Mycobacterium avium intracellulare complex (MAI) has been postulated as a possible etiology. We present a case of an adult patient with HIV and chronic disseminated MAI infection who presented with ischemic stroke and three fusiform cerebral aneurysms that were successfully treated with the pipeline embolization device (PED). Flow diversion may be a viable treatment option for patients presenting with this serious neurovascular condition when aneurysm location precludes parent vessel sacrifice or surgical bypass. In addition, platelet function testing with VerifyNow may be valuable in selecting the appropriate P2Y12 receptor antagonist to be used in order to prevent PED thrombosis, since some of the antiretroviral drugs may inhibit clopidogrel or prasugrel metabolism.

Diagnostic yield of delayed neurovascular imaging in patients with subarachnoid hemorrhage, negative initial CT and catheter angiograms, and a negative 7 day repeat catheter angiogram.

PURPOSE: The yield of delayed neurovascular imaging in patients with subarachnoid hemorrhage (SAH), negative initial CT and catheter angiograms (CT angiography (CTA), DSA), and negative 7 day repeat DSA is not well understood. Our aim was to determine the yield of delayed neurovascular imaging for the detection of causative vascular lesions in this clinical scenario. METHODS: We retrospectively examined the yield of delayed CTA and DSA for the detection of causative vascular lesions in patients presenting to our institution with SAH, negative initial CTA and DSA examinations, and a negative 7 day repeat DSA during a 6.5 year period. Two neuroradiologists evaluated the non-contrast CTs to determine the SAH pattern, and the delayed CTAs and DSAs to assess for the presence of a causative vascular lesion. RESULTS: 39 patients were included: 23 men (59%) and 16 women (41%), mean age 55.5 years (range 33-75). 25 patients had diffuse SAH (64.1%), 12 had perimesencephalic SAH (30.8%), and two had peripheral sulcal SAH (5.1%). The delayed neurovascular examination was CTA in 30 patients (76.9%) and DSA in nine patients (23.1%). Mean time to delayed CTA or DSA was 34.9 days (median 34, range 14-69 days). Delayed CTA demonstrated a causative vascular lesion in two patients (5.1%, one small internal carotid artery aneurysm and one small pontine arteriovenous malformation), both with diffuse SAH (yield 8%). CONCLUSIONS: Delayed neurovascular imaging is valuable in the evaluation of patients with diffuse SAH who have negative initial CTA and DSA examinations and a negative 7 day repeat DSA, demonstrating a causative vascular lesion in 8% of patients.

Variability in initial response to standard clopidogrel therapy, delayed conversion to clopidogrel hyper-response, and associated thromboembolic and hemorrhagic complications in patients undergoing endovascular treatment of unruptured cerebral aneurysms.

BACKGROUND AND PURPOSE: Variability in response to clopidogrel therapy is increasingly being recognized as an important factor in thromboembolic and hemorrhagic complications encountered after neurointerventional procedures. This study aims to determine the variability in response to clopidogrel therapy and associated complications in patients undergoing endovascular treatment of unruptured cerebral aneurysms. METHODS: We recorded baseline patient characteristics, co-administered medications, P2Y12 reaction units (PRU) values with VerifyNow, clopidogrel dosing, and thromboembolic and hemorrhagic complications in patients undergoing endovascular treatment of unruptured cerebral aneurysms at our institution during a 19 month period. RESULTS: 100 patients were included in the study, 76 women and 24 men, mean age 57.3 years. 15 patients exhibited an initial clopidogrel hypo-response (PRU >240) and 21 patients an initial clopidogrel hyper-response (PRU <60). 36 patients had a follow-up VerifyNow test performed without changes to the standard 75 mg daily clopidogrel dose, which demonstrated that 59% of patients who had initially been within the target 60-240 PRU range exhibited a delayed conversion to clopidogrel hyper-response. In our cohort, a clopidogrel hypo-response was associated with a significantly increased risk of thromboembolic complications in patients undergoing cerebral aneurysm treatment with stent assistance or the pipeline embolization device (60%, p=0.003), while a clopidogrel hyper-response was associated with a significantly increased risk of major hemorrhagic complications in all patients undergoing endovascular treatment of cerebral aneurysms (11%, p=0.016). CONCLUSIONS: We found wide and dynamic variability in response to clopidogrel therapy in patients undergoing endovascular treatment of unruptured cerebral aneurysms, which was significantly associated with thromboembolic and major hemorrhagic complications in our cohort.

Concurrent basilar artery double fenestration with aneurysm and vertebral artery dissection: case report and literature review of rare cerebrovascular abnormalities.

Many disorders can cause aneurysm and/or dissection of the cerebral arteries, including fibromuscular dysplasia (FMD), connective tissue disorders, cerebral vasculitis, infection, and vascular malformations. Arterial fenestration is a rare congenital finding that can also cause aneurysms, and can rarely dissect and bleed. Treatment of aneurysm and dissection with subarachnoid hemorrhage can be very complicated, and requires case-by-case analysis of the risks and benefits of antithrombotic therapy. To the authors' knowledge, no case of double fenestration of the basilar artery has been reported. This report presents a case of concurring vertebral artery dissection and double fenestration of the basilar artery with aneurysm. The fenestration and FMD are considered possible main contributing causes of this presentation. A literature review of cerebrovascular fenestration and FMD is provided and the relationship between the 2 is considered. Lastly, the use of antithrombotic therapy in the setting of subarachnoid hemorrhage, dissection, and stent placement is discussed.

Successful endovascular treatment of three fusiform cerebral aneurysms with the Pipeline Embolization Device in a patient with dilating HIV vasculopathy.

Dilating HIV vasculopathy can be a cause of ischemic and hemorrhagic stroke in patients with HIV. Although first identified in children, this condition is increasingly being recognized in adults and has a dismal natural history under medical or expectant management. Vessel wall invasion by varicella zoster virus, HIV or Mycobacterium avium intracellulare complex (MAI) has been postulated as a possible etiology. We present a case of an adult patient with HIV and chronic disseminated MAI infection who presented with ischemic stroke and three fusiform cerebral aneurysms that were successfully treated with the pipeline embolization device (PED). Flow diversion may be a viable treatment option for patients presenting with this serious neurovascular condition when aneurysm location precludes parent vessel sacrifice or surgical bypass. In addition, platelet function testing with VerifyNow may be valuable in selecting the appropriate P2Y12 receptor antagonist to be used in order to prevent PED thrombosis, since some of the antiretroviral drugs may inhibit clopidogrel or prasugrel metabolism.

Pre-procedure P2Y12 reaction units value predicts perioperative thromboembolic and hemorrhagic complications in patients with cerebral aneurysms treated with the Pipeline Embolization Device.

BACKGROUND: There is wide variability in the reported incidence of perioperative thromboembolic (0-14%) and hemorrhagic (0-11%) complications after Pipeline Embolization Device (PED) procedures for cerebral aneurysm treatment, which could be partly due to differences in patient response to the P2Y12 receptor antagonist administered while the PED endothelializes. This study aims to identify an optimal pre-procedure P2Y12 reaction units (PRU) value range and determine the independent predictors of perioperative thromboembolic and hemorrhagic complications after PED procedures. METHODS: We recorded patient and aneurysm characteristics, P2Y12 receptor antagonist administered, pre-procedure PRU value with VerifyNow, procedural variables and perioperative thromboembolic and hemorrhagic complications up to postoperative day 30 after PED procedures at our institution during an 8-month period. Perioperative complications were considered major if they caused a permanent disabling neurological deficit or death. Multivariate regression analysis was performed to identify independent predictors of perioperative complications in our cohort. RESULTS: Forty-four patients underwent 48 PED procedures at our institution during the study period. There were eight thromboembolic and hemorrhagic perioperative complications in our cohort (16.7%), four of which were major (8.3%). A pre-procedure PRU value of <60 or >240 (p=0.02) and a technically difficult procedure (p=0.04) were independent predictors of all perioperative complications. A pre-procedure PRU value of <60 or >240 (p=0.004) and a history of hypertension (p=0.03) were independent predictors of major perioperative complications. CONCLUSIONS: In our cohort, a pre-procedure PRU value of <60 or >240 was the strongest independent predictor of all and major perioperative thromboembolic and hemorrhagic complications after PED procedures.

Complicated cerebral venous sinus thrombosis with intracranial hemorrhage and mastoiditis.

Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke, occurring when a blood clot forms in any of the brain venous sinuses. Symptoms include neurological deficits, headache, seizures, and coma. There are many predisposing factors for CVST including prothrombotic conditions, oral contraceptives, pregnancy/puerperium, malignancy, infection, and head injury. Cerebral venous sinus thrombosis has no identifiable underlying etiology in about 12.5% to 33% of the cases. Diagnosis has become easier with newer imaging techniques, such as magnetic resonance venography. The treatment options for CVST include symptomatic treatment, anticoagulation (AC), thrombolysis, and thrombectomy. Controversy exists over the efficacy and safety of AC in patients with CVST with concurrent intracranial hemorrhage (ICH). We present a complex case of CVST with ICH and mastoiditis as well as provide a literature review about CVST.