Thrombectomy using Zoom Reperfusion System in pediatric acute ischemic strokes: Case series and literature review.

INTRODUCTION: Zoom reperfusion system (Imperative Care, CA) has proven to be promising for use in adult mechanical thrombectomies (MTs) but has not been described in pediatrics. We present two cases of a 14-year-old with acute right middle cerebral artery (MCA) syndrome and a 10-year old with acute left MCA syndrome who underwent MT using Zoom Reperfusion System safely with TICI 2B and TICI 3 recanalization, respectively. METHOD: Case report and literature review. RESULTS: A 14-year-old healthy boy with right supraclinoid internal carotid artery (ICA) occlusion (case 1) and a 10-year-old boy with left hypoplastic heart syndrome and left ICA terminus occlusion (case 2) were taken for MT after receiving alteplase at our institution. Through femoral access, an 8-French sheath was introduced into the right femoral artery through which a Zoom 88 catheter was introduced and parked at the right petrous ICA segment in case 1 and left ophthalmic ICA segment in case 2. Angiogram demonstrated complete ICA occlusion just past the ophthalmic artery origin in case 1 and at the ICA terminus in case 2. Zoom system (88 and 71) was then navigated to the face of clot with vacuum manifold engaged with the clot. TICI 2B (with the help of Trevo stent retriever [Stryker]) and TICI 3 recanalization were achieved in cases 1 and 2, respectively. CONCLUSION: The use of Zoom reperfusion system could potentially be feasible for use in pediatric age group. Larger pediatric patient population is needed to establish its safety.

Gaseous ozone treatment of chickpea grains: Effect on functional groups, thermal behavior, pasting properties, morphological features, and phytochemicals.

The applicability of ozone has been increased to include pulse grains because of their increased production and significance as plant-based protein source. In many developed countries, there is a growing demand for products made from chickpeas grains. Whole chickpea grains were treated with ozone gas (500-1000 ppm) for 20-30 min. The structural, thermal, pasting properties, and phytochemicals of the ozone-treated, as well as control samples, were evaluated. Minor structural changes in the functional groups in the protein and starch molecules were observed in the treated sample. Ozonation caused significant changes in the pasting properties such as peak viscosity, trough viscosity, breakdown viscosity, final viscosity, setback viscosity, and peak temperature values. Microstructure revealed a reduction in the particle sizes of chickpea powders with the severity of ozone treatment. The total flavonoids (41.35-48.94 mg QE), alkaloids (1120.24-1453.57µg/g), and xanthoprotein (0.995-1.387 µg/g) increased significantly (p < 0.05) with ozone treatment. Commercially, chickpea grains can be ozone treated for achieving desired functional characteristics in a target product. PRACTICAL APPLICATION: Before consuming grain that has been treated with gaseous ozone, it is vitally important for all consumers to have a solid understanding of the facts presented here regarding variations in the chickpea nutritional profile. The impact of ozone treatment on functional groups, thermal behavior, pasting properties, and morphological features in chickpeas reveals vital information regarding changes occurred on macromolecules such as starch, proteins, and bioactive compounds. Since ozonation aids in extraction of health-beneficial bioactive compounds and brings about change in the starch and protein morphology, making them more digestible, it can be highly useful in preparation of health foods.

Predicting Functional Outcome After Decompressive Craniectomy for Malignant Hemispheric Infarction: Clinical and Novel Imaging Factors.

OBJECTIVE: Decompressive craniectomy (DC) is an established optional treatment for malignant hemispheric infarction (MHI). We analyzed relevant clinical factors and computed tomography (CT) measurements in patients with DC for MHI to identify predictors of functional outcome 3-6 months after stroke. METHODS: This study was performed at 2 comprehensive stroke centers. The inclusion criteria required DC for MHI, no additional intraoperative procedures (strokectomy or cerebral ventricular drain placement), and documented functional status 3-6 months after the stroke. We classified functional outcome as acceptable if the modified Rankin Scale score was <5, or as unacceptable if it was 5 or 6 (bedbound and totally dependent on others or death). Multiple logistic regression analyzed relevant clinical factors and multiple perioperative CT measurements to identify predictors of acceptable functional outcome. RESULTS: Of 87 identified consecutive patients, 66 met the inclusion criteria. Acceptable functional outcome occurred in 35 of 66 (53%) patients. Likelihood of acceptable functional outcome decreased significantly with increasing age (OR 0.92, 95% CI 0.82-0.97, P = 0.004) and with increasing post-DC midline brain shift (OR 0.78, 95% CI 0.64-0.96, P = 0.016), and decreased non-significantly with left-sided stroke (OR 0.30, 95% CI 0.08-1.10, P = 0.069) and with increasing craniectomy barrier thickness (OR 0.92, 95% CI 0.85-1.01, P = 0.076). CONCLUSIONS: Patient age and the post-DC midline shift may be useful in prognosticating functional outcome after DC for MHI. Stroke side and craniectomy barrier thickness merit further ideally prospective outcome prediction testing.

Limiting Brain Shift in Malignant Hemispheric Infarction by Decompressive Craniectomy.

OBJECTIVE: Decompressive craniectomy (DC) improves functional outcomes in selected patients with malignant hemispheric infarction (MHI), but variability in the surgical technique and occasional complications may be limiting the effectiveness of this procedure. Our aim was to evaluate predefined perioperative CT measurements for association with post-DC midline brain shift in patients with MHI. METHODS: At two medical centers we identified 87 consecutive patients with MHI and DC between January 2007 and December 2019. We used our previously tested methods to measure the craniectomy surface area, extent of transcalvarial brain herniation, thickness of tissues overlying the craniectomy, diameter of the cerebral ventricle atrium contralateral to the stroke, extension of infarction beyond the craniectomy edges, and the pre and post-DC midline brain shifts. To avoid potential confounding from medical treatments and additional surgical procedures, we excluded patients with the first CT delayed >30 hours post-DC, resection of infarcted brain, or insertion of an external ventricular drain during DC. The primary outcome in multiple linear regression analysis was the postoperative midline brain shift. RESULTS: We analyzed 72 qualified patients. The average midline brain shift decreased from 8.7 mm pre-DC to 5.4 post-DC. The only factors significantly associated with post-DC midline brain shift at the p<0.01 level were preoperative midline shift (coefficient 0.32, standard error 0.10, p=0.002) and extent of transcalvarial brain herniation (coefficient -0.20, standard error 0.05, p <0.001). CONCLUSIONS: In patients with MHI and DC, smaller post-DC midline shift is associated with smaller pre-DC midline brain shift and greater transcalvarial brain herniation. This knowledge may prove helpful in assessing DC candidacy and surgical success. Additional studies to enhance the surgical success of DC are warranted.

New CT measurements to assess decompression after hemicraniectomy: A two-center reliability study.

OBJECTIVES: To test the reliability of three simplified measurements made after decompressive hemicraniectomy (DHC) for malignant hemispheric infarction on computed tomography (CT) scan. PATIENTS AND METHODS: We defined new simple methods to measure the thickness of the soft tissues overlying the craniectomy defect and the extent of infarction beyond the anterior and posterior craniectomy edges on post-DHC CT. Multiple raters independently made the three new CT measurements in 49 patients from two institutions. The Intraclass Correlation Coefficient (ICC) compared the raters for interrater agreements (reliability). RESULTS: Between two raters at Augusta University Medical Center, each measuring 21 CT scans, the ICC coefficient point estimates were good to excellent (0.83 - 0.92). Among four raters at University of Virginia Medical Center, with three raters measuring each of 28 CT scans, the ICC coefficient point estimates were good to excellent (0.87 - 0.95). CONCLUSIONS: The proposed simple methods to obtain three additional CT measurements after DHC in malignant hemispheric infarction have good to excellent reliability in two independent patient samples. The clinical usefulness of these measurements should be investigated.

Comparative efficacy of ropivacaine and levobupivacaine in combined femoral and lateral femoral cutaneous nerve block with adjuvant magnesium for post-operative analgesia.

BACKGROUND AND AIMS: Patients with burns may require multiple surgeries, but poor general condition and underlying protein energy malnutrition make them unsuitable candidates for general or spinal anaesthesia. This study evaluated the role of magnesium sulphate as an adjuvant with levobupivacaine and ropivacaine used in combined femoral and lateral femoral cutaneous nerve (LFCN) blocks in burn patients with relative sparing of thigh portion. METHODS: This prospective, randomised, double-blind study included 54 adult patients of 18-65 years age, undergoing split-thickness skin graft harvest from the thigh, allotted to three equal groups of 18 each. Group L patients received femoral nerve (FN) block with 15 mL of 0.5% levobupivacaine and 8 mL for LFCN block; Group LM patients received 14 mL of 0.5% levobupivacaine along with 1.0 mL of 15% magnesium sulphate for FN block, 7.5 mL of 0.5% levobupivacaine with 0.5 mL of 15% of magnesium sulphate to LFCN block and Group R patients received 15 mL of 0.5% ropivacaine for FN block and 8 mL of 0.5% ropivacaine for LFCN block. Time to block onset and complete surgical block, duration of analgesia, total analgesic dose and the overall analgesia satisfaction score were measured in the first 24 h post-operatively. Quantitative data were analysed with ANOVA and qualitative data subjected to Chi-square tests. Intergroup comparison was performed with independent t-test. RESULTS: The duration of post-operative analgesia did not differ with the addition of magnesium (P = 0.610). Time to onset of the block was significantly decreased with the addition of magnesium (P = 0.0341), but time to complete surgical block onset was similar across the groups. CONCLUSION: Both ropivacaine and levobupivacaine have good perioperative analgesic efficacy. Magnesium as an analgesia adjuvant with levobupivacaine does not prolong the duration of post-operative analgesia.

Cost analysis of three techniques of administering sevoflurane.

Background. This study aimed to evaluate and compare total cost of sevoflurane and propofol for 1.0 MAC-hour of anaesthesia, employing three anaesthetic techniques. Methods. Adult patients scheduled for surgical procedures under general anaesthesia anticipated to last approximately an hour were randomized into three groups (n = 15 each), to receive anaesthesia using one of the following techniques: low flow technique involving induction with propofol, followed by sevoflurane delivered using initial fresh gas flows of 6 L/min till MAC reached 1.0 and then reduced to 0.5 L/min; alternate method of low flow entailing only a difference in fresh gas flow rates being maintained at 1 L/min throughout; the third technique involving use of sevoflurane for both induction and maintenance of anaesthesia. Results. Cost of sevoflurane to maintain 1 MAC-hour of anaesthesia was clinically least with low flow anaesthesia, though statistically similar amongst the three techniques. Once the cost of propofol used for induction in two of the three groups was added to that of sevoflurane, cost incurred was least with the technique using sevoflurane both for induction and maintenance of anaesthesia, as compared to low flow and alternative low flow techniques, a 26% and 32% cost saving, respectively (P < 0.05).