Multicenter study of the safety and effectiveness of intracranial aneurysm treatment with the p64MW-HPC flow modulation device.

BACKGROUND AND PURPOSE: The new p64 flow diverter with hydrophilic polymer coating (HPC) was designed to reduce thrombogenicity. To date, it is unclear how antithrombogenic surface modifications affect neoendothelialization and thrombus formation in patients with unruptured intracranial aneurysms. The purpose of this study was to evaluate the safety and effectiveness of the p64MW-HPC in the treatment of unruptured aneurysms of small to giant size and of both the anterior and posterior circulation. MATERIALS AND METHODS: Between March 2020 and October 2022 all patients with unruptured intracranial aneurysms treated with the p64MW-HPC were included at five neurovascular centers. Demographic data, aneurysm characteristics, antiplatelet therapy, procedural complications, and clinical and angiographic outcomes were recorded. RESULTS: A total of 100 patients with 100 unruptured intracranial aneurysms met the inclusion criteria. Eighty-three aneurysms were classified as saccular, 12 aneurysms were fusiform, 4 aneurysms dissecting, and 1 aneurysm was blister-like. Dual antiplatelet therapy with Clopidogrel and Aspirin was given in 68 cases, and with Ticagrelor and Aspirin in 24 cases. Technical issues with deployment were encountered in 14 cases (torsion (n = 3), foreshortening (n = 8), and incomplete opening (n = 3)). Ischemic stroke occurred in a total of seven cases. In one patient a wire perforation and subsequent severe ICH occurred. Complete aneurysm occlusion at angiographic follow-up (mean time = 7 months) was seen in 73% and adequate occlusion in 93%. CONCLUSION: This study is the largest multicenter study to date documenting the safety and effectiveness of the new antithrombogenic p64MW-HPC in the treatment of unruptured intracranial aneurysms of the anterior and posterior circulation.

Psychological coping in female breast cancer patients from a Metropolitan Lima hospital. / Afrontamiento psicológico en pacientes mujeres con cáncer de mama de un hospital de Lima Metropolitana.

OBJECTIVE.: Motivation for the study: it is important to identify the coping strategies used by women with breast cancer, in order to contribute to their physical and emotional well-being. Main findings: strategies related to the emotional sphere are used to a greater extent, and also lead to progressive acceptance of the disease. Cognitive and behavioral distractions are necessary to balance patients' daily activities. Implications: understanding how women face this disease allows the development of primary care strategies to improve their wellbeing. To understand the psychological coping strategies in female patients with breast cancer from a hospital in Metropolitan Lima. MATERIALS AND METHODS.: This was a qualitative research with a reflexive thematic analysis design. Sixteen women with breast cancer between 35 and 65 years of age were interviewed. Data was analyzed with the ATLAS.ti 22 software. RESULTS.: Three psychological coping strategies were described: emotional coping, which was found more frequently, includes the support of important people, religious coping, and focusing on positive consequences, which leads to a positive reinterpretation and progressive acceptance of the disease; active coping, characterized by diligent action, following indications, and seeking professional support. Finally, avoidance coping, which focuses on negative elements, postponement of the coping process and cognitive and behavioral distractions, the latter being of utmost relevance to balance the activities in the patients' daily lives. CONCLUSIONS.: Participants used emotional coping strategies more frequently, since they tried to increase positive emotions, accompanied by religious and environmental support. In addition, they also used active coping strategies, since they focused their actions to receive medical attention and treatment, leaving aside other activities; in spite of this, they used strategies to take their focus off the condition and thus detach themselves from their worries.

OBJETIVOS.: Motivación para realizar el estudio: es importante conocer el empleo de estrategias de afrontamiento que utilizan las mujeres que tienen cáncer de mama, con la finalidad de contribuir a su bienestar físico y emocional. Principales hallazgos: las estrategias relacionadas al ámbito emocional son utilizadas con mayor intensidad, asimismo, conllevan a una aceptación progresiva de la enfermedad. La distracción cognitiva y conductual resultan necesarias para equilibrar las actividades cotidianas de las pacientes. Implicancias: el comprender cómo las mujeres afrontan su enfermedad, permite la generación de estrategias desde la atención primaria para la mejora de su bienestar. Comprender el afrontamiento psicológico en pacientes mujeres con cáncer de mama de un hospital de Lima Metropolitana. MATERIALES Y MÉTODOS.: La investigación siguió un enfoque cualitativo con un diseño de análisis temático reflexivo. Se entrevistó a 16 mujeres con cáncer de mama entre los 35 y 65 años. El análisis de datos se realizó con apoyo del software ATLAS.ti 22. RESULTADOS.: Se presentaron tres estrategias de afrontamiento psicológico: afrontamiento emocional, el cual se encontró con mayor intensidad, y comprende el apoyo de personas significativas, el afrontamiento religioso y la concentración en las consecuencias positivas, generando una reinterpretación positiva y la aceptación progresiva de la enfermedad; el afrontamiento resolutivo, caracterizado por la acción diligente, con seguimiento a las indicaciones, y la búsqueda de apoyo profesional. Finalmente, el afrontamiento evasivo, se centró en los elementos negativos, el aplazamiento del afrontamiento y la distracción cognitiva y conductual, siendo este último de suma relevancia para equilibrar las actividades en la vida cotidiana de las pacientes. CONCLUSIONES.: Las mujeres emplearon con mayor frecuencia estrategias del estilo emocional, ya que intentan incrementar las emociones positivas, acompañado del apoyo religioso y del entorno; además, utilizaron estrategias relacionadas al estilo resolutivo, puesto que centraron sus acciones para recibir la atención y tratamiento médico, dejando de lado otras actividades; pese a ello, emplearon estrategias para desenfocarse del padecimiento y así desligarse de sus preocupaciones.

Aneurysm Treatment in Acute SAH with Hydrophilic-Coated Flow Diverters under Single-Antiplatelet Therapy: A 3-Center Experience.

BACKGROUND AND PURPOSE: In certain clinical circumstances, dual-antiplatelet therapy can be problematic in patients with acute SAH. In some aneurysms, however, flow-diverting stents are the ideal therapeutic option. We report our experience with ruptured intracranial aneurysms treated with flow diverters with hydrophilic coating (p48 MW HPC and p64 MW HPC) under single-antiplatelet therapy. MATERIALS AND METHODS: Patients were treated with either flow-diverter placement alone or a flow diverter and additional coiling. Due to the severity of the hemorrhage, the potential for periprocedural rehemorrhage, and the potential for additional surgical interventions, a single-antiplatelet regimen was used in all patients. RESULTS: Thirteen aneurysms were treated in 10 patients. The median age was 62 years; 5 patients were male. All had acute SAH due to aneurysm rupture. Four blood-blister, 2 dissecting, and 7 berrylike aneurysms were treated. Seven aneurysms were adjunctively coiled. Eight of the 10 patients received a single-antiplatelet protocol of aspirin, 1 patient was treated with prasugrel only, and 1 patient was treated with tirofiban first and then switched to the aspirin single-antiplatelet protocol. One device-related complication occurred, a thrombosis of an overstented branch. All stents, however, remained open at DSA, CTA, or MRA follow-up. CONCLUSIONS: The implantation of flow diverters with reduced thrombogenicity due to hydrophilic surface coating under single-antiplatelet therapy seems to be an option in carefully selected cases of SAH due to aneurysm rupture.

Role of PCA3 and SelectMDx in the optimization of active surveillance in prostate cancer.

INTRODUCTION & OBJECTIVES: A not negligible percentage of patients included in active surveillance (AS) for low and very low risk prostate cancer (PCa) are reclassified in the confirmatory biopsy or have disease progression during follow-up. Our aim is to evaluate the role of PCA3 and SelectMDx, in an individual and combined way, in the prediction of pathological progression (PP) in a standard AS program. MATERIALS & METHODS: Prospective and observational study comprised of 86 patients enrolled in an AS program from 2009 to 2019, with results for PCA3 and SelectMDx previous to PCa diagnosis or during their confirmatory period. Univariate and multivariate analysis were performed to correlate PCA3 and SelectMDx scores as well as clinical and pathological variables with PP-free survival (PPFS). The most reliable cut-offs for both biomarkers in the context of AS were defined. RESULTS: SelectMDx showed statistically significant differences related to PPFS (HR 1.035, 95%CI: 1.012-1.057) (p = 0.002) with a C-index of 0.670 (95%CI: 0.529-0.810) and AUC of 0.714 (95%CI: 0.603-0.825) at 5 years. In our series, the most reliable cut-off point for SelectMDx was 5, with a sensitivity and specificity for PP of 69.8% and 67.4%, respectively. Same figure for PCA3 was 65, with a sensitivity and specificity for PP of 51.16% and 74.42%, respectively. The combination of both biomarkers did not improve the prediction of PP, C-index 0.630 (95%CI: 0.455-0.805). CONCLUSIONS: In the context of low or very low risk PCa, SelectMDx > 5 predicted 5 years PP free survival with a moderate discrimination ability outperforming PCA3. The combination of both tests did not improved outcomes.

Does Increasing Packing Density Using Larger Caliber Coils Improve Angiographic Results of Embolization of Intracranial Aneurysms at 1 Year: A Randomized Trial.

BACKGROUND AND PURPOSE: The impact of increased aneurysm packing density on angiographic outcomes has not been studied in a randomized trial. We sought to determine the potential for larger caliber coils to achieve higher packing densities and to improve the angiographic results of embolization of intracranial aneurysms at 1 year. MATERIALS AND METHODS: Does Embolization with Larger Coils Lead to Better Treatment of Aneurysms (DELTA) was an investigator-initiated multicenter prospective, parallel, randomized, controlled clinical trial. Patients had 4- to 12-mm unruptured aneurysms. Treatment allocation to either 15- (experimental) or 10-caliber coils (control group) was randomized 1:1 using a Web-based platform. The primary efficacy outcome was a major recurrence or a residual aneurysm at follow-up angiography at 12 ± 2 months adjudicated by an independent core lab blinded to the treatment allocation. Secondary outcomes included indices of treatment success and standard safety outcomes. Recruitment of 564 patients was judged necessary to show a decrease in poor outcomes from 33% to 20% with 15-caliber coils. RESULTS: Funding was interrupted and the trial was stopped after 210 patients were recruited between November 2013 and June 2017. On an intent-to-treat analysis, the primary outcome was reached in 37 patients allocated to 15-caliber coils and 36 patients allocated to 10-caliber coils (OR = 0.931; 95% CI, 0.528-1.644; P = .885). Safety and other clinical outcomes were similar. The 15-caliber coil group had a higher mean packing density (37.0% versus 26.9%, P = .0001). Packing density had no effect on the primary outcome when adjusted for initial angiographic results (OR = 1.001; 95% CI, 0.981-1.022; P = .879). CONCLUSIONS: Coiling of aneurysms randomized to 15-caliber coils achieved higher packing densities compared with 10-caliber coils, but this had no impact on the angiographic outcomes at 1 year, which were primarily driven by aneurysm size and initial angiographic results.

[Cerebral embolism during commercial flight: case report]. / Embolismo cerebral durante vuelo comercial: reporte de caso.

We present the case of a 25-year old man with a history of marijuana and tobacco consumption who, during a commercial flight to Cusco, presented dyspnea, loss of consciousness, and epileptic condition. He arrived in this city presenting arterial hypotension, abolished pulmonary murmur, with no recovery of consciousness. The thorax tomography revealed lung bullae and the tomography showed pneumocephalus. He was diagnosed with cerebral gas embolism. Hypoxemia associated with seizures and loss of consciousness in a young person during a flight is not a common event. Loss of cabin pressure during climb appears to be the triggering event in patients with lung disease.

Presentamos el caso de un varón de 25 años con antecedentes de consumo de marihuana y tabaco, que durante viaje en vuelo comercial a Cusco presentó disnea, pérdida de conciencia y estado epiléptico. Arribó a esta ciudad presentando hipotensión arterial, murmullo pulmonar abolido, sin recuperación de conciencia. La tomografía de tórax reveló bullas pulmonares y la tomografía mostró neumoencéfalo, diagnosticándose embolia gaseosa cerebral. La hipoxemia asociada a convulsiones y pérdida de conciencia en una persona joven durante el vuelo no es un evento común. La pérdida de la presión en la cabina durante el ascenso parece ser el evento desencadenante en pacientes con enfermedad pulmonar.

Curative cerebrovascular reconstruction with the Pipeline embolization device: the emergence of definitive endovascular therapy for intracranial aneurysms.

Endovascular, endosaccular, coil embolization has emerged as an established therapy for both ruptured and unruptured cerebral aneurysms. However, many aneurysms are not cured using conventional endovascular techniques. Coil embolization often results in incomplete aneurysm occlusion or recanalization in the ensuing months after treatment. The Pipeline embolization device (PED; Chestnut Medical) represents a new generation endoluminal implant which is designed to treat aneurysms by reconstructing the diseased parent artery. Immediately after implantation, the PED functions to divert flow from the aneurysm, creating an environment conducive to thrombosis. With time, the PED is incorporated into the vessel wall as neointimal-endothelial overgrowth occurs along the construct. Ultimately, this process results in the durable complete exclusion of the aneurysm from the cerebrovasculature and a definitive endoluminal reconstruction of the diseased parent artery.

Noninvasive imaging of treated cerebral aneurysms, part I: MR angiographic follow-up of coiled aneurysms.

MRA is emerging as an alternative to conventional catheter based angiography for the assessment of aneurysms after endovascular treatment. Short TE and contrast enhanced MRA techniques can be applied to optimize image quality. We review the available data regarding the application of MR for the assessment of cerebral aneurysms after endovascular therapy.

Noninvasive imaging of treated cerebral aneurysms, Part II: CT angiographic follow-up of surgically clipped aneurysms.

Although not useful for the evaluation of coiled aneurysms, CT angiography (CTA) is far superior to MR angiography (MRA) for the evaluation of aneurysms after surgical clipping. Using the latest multidetector row scanners and optimized imaging parameters, CTA can often effectively depict and follow small aneurysm remnants; demonstrate patency, stenosis, or vasospasm in the adjacent parent vessels; and provide surveillance of the entire cerebrovasculature for de novo aneurysms after surgical clipping. Despite these advances, conventional angiography remains the gold standard for the evaluation of surgically treated aneurysms and should be liberally used to resolve any cases of diagnostic uncertainty on noninvasive imaging.

Marginal sinus arteriovenous fistulas mimicking carotid cavernous fistulas: diagnostic and therapeutic considerations.

Marginal sinus fistulas (MSFs) are uncommon vascular anomalies. Occasionally, the dominant venous drainage is forced retrograde up the inferior petrosal sinus and into the cavernous sinus, causing chemosis, proptosis, and ocular hypertension, mimicking a carotid cavernous fistula. This atypical clinical presentation may lead to misdiagnosis and inappropriate hazardous treatment of an MSF. Identifying the site of the fistula and understanding the anatomy of the venous drainage are critical in providing appropriate, safe, and efficacious endovascular treatment.

CT angiographic appearance of in-stent restenosis of intracranial arteries treated with the Wingspan stent.

Four patients underwent angioplasty and stenting of medically refractory symptomatic intracranial atherosclerosis with the new Wingspan stent system. In all 4 patients, CT angiography (CTA) showed an abnormality within the stented segment that was suggestive of nonocclusive in-stent thrombus. However, subsequent conventional angiography findings were typical for in-stent restenosis. The CTA imaging features of in-stent restenosis are important to recognize, and the misinterpretation of in-stent restenosis as in-stent thrombus may result in inappropriate management.

Self-expanding stents for recanalization of acute cerebrovascular occlusions.

BACKGROUND AND PURPOSE: Stent-assisted revascularization increases prevailing recanalization rates ( congruent with 50%-69%) for vessel occlusions recalcitrant to thrombolytics. Although balloon-mounted coronary stents can displace thrombus (via angioplasty) and retain clot along vessel walls, intracranial self-expanding stents are more flexible and exert less radial outward force during deployment, increasing deliverability and safety. To understand the effectiveness of self-expanding stents for recanalization of acute cerebrovascular occlusions, we retrospectively reviewed our preliminary experience with these stents. MATERIALS AND METHODS: Eighteen patients (19 lesions) presenting with a clinical diagnosis of acute stroke underwent catheter-based angiography documenting focal occlusion of an intracranial artery. A self-expanding stent was delivered to the occlusion and deployed. Stent placement was the initial mechanical maneuver in 6 cases; others involved a combination of pharmacologic and/or mechanical maneuvers prestenting. GP IIb/IIIa inhibitors were administered in 10 cases intraprocedurally or immediately postprocedurally to avoid acute in-stent thrombosis. RESULTS: Stent deployment at the target occlusion (technical success) was achieved in all cases. Thrombolysis in Cerebral Ischemia (TICI)/Thrombolysis in Myocardial Ischemia (TIMI) 2/3 recanalization (angiographic success) was achieved in 15 of 19 lesions (79%). All single-vessel lesions (n=8) were recanalized, but only 7 of 11 combination internal carotid artery and middle cerebral artery lesions were recanalized. No intraprocedural complications occurred. Seven in-hospital deaths occurred: stroke progression, 4; intracranial hemorrhage, 2; respiratory failure, 1. Seven patients had >or=4-point National Institutes of Health Stroke Scale improvement within 24 hours after the procedure, 6 had modified Rankin Score (mRS)

Afrontamiento psicológico en pacientes mujeres con cáncer de mama de un hospital de Lima Metropolitana / Psychological coping in female breast cancer patients from a Metropolitan Lima hospital

Objetivos. Comprender el afrontamiento psicológico en pacientes mujeres con cáncer de mama de un hospital de Lima Metropolitana. Materiales y métodos. La investigación siguió un enfoque cualitativo con un diseño de análisis temático reflexivo. Se entrevistó a 16 mujeres con cáncer de mama entre los 35 y 65 años. El análisis de datos se realizó con apoyo del software ATLAS.ti 22. Resultados. Se presentaron tres estrategias de afrontamiento psicológico: afrontamiento emocional, el cual se encontró con mayor intensidad, y comprende el apoyo de personas significativas, el afrontamiento religioso y la concentración en las consecuencias positivas, generando una reinterpretación positiva y la aceptación progresiva de la enfermedad; el afrontamiento resolutivo, caracterizado por la acción diligente, con seguimiento a las indicaciones, y la búsqueda de apoyo profesional. Finalmente, el afrontamiento evasivo, se centró en los elementos negativos, el aplazamiento del afrontamiento y la distracción cognitiva y conductual, siendo este último de suma relevancia para equilibrar las actividades en la vida cotidiana de las pacientes. Conclusiones. Las mujeres emplearon con mayor frecuencia estrategias del estilo emocional, ya que intentan incrementar las emociones positivas, acompañado del apoyo religioso y del entorno; además, utilizaron estrategias relacionadas al estilo resolutivo, puesto que centraron sus acciones para recibir la atención y tratamiento médico, dejando de lado otras actividades; pese a ello, emplearon estrategias para desenfocarse del padecimiento y así desligarse de sus preocupaciones.

Objective. To understand the psychological coping strategies in female patients with breast cancer from a hospital in Metropolitan Lima. Materials and methods. This was a qualitative research with a reflexive thematic analysis design. Sixteen women with breast cancer between 35 and 65 years of age were interviewed. Data was analyzed with the ATLAS.ti 22 software. Results. Three psychological coping strategies were described: emotional coping, which was found more frequently, includes the support of important people, religious coping, and focusing on positive consequences, which leads to a positive reinterpretation and progressive acceptance of the disease; active coping, characterized by diligent action, following indications, and seeking professional support. Finally, avoidance coping, which focuses on negative elements, postponement of the coping process and cognitive and behavioral distractions, the latter being of utmost relevance to balance the activities in the patients' daily lives. Conclusions. Participants used emotional coping strategies more frequently, since they tried to increase positive emotions, accompanied by religious and environmental support. In addition, they also used active coping strategies, since they focused their actions to receive medical attention and treatment, leaving aside other activities; in spite of this, they used strategies to take their focus off the condition and thus detach themselves from their worries.

Lack of Association between Statin Use and Angiographic and Clinical Outcomes after Pipeline Embolization for Intracranial Aneurysms.

BACKGROUND AND PURPOSE: Use of statin medications has been demonstrated to improve clinical and angiographic outcomes in patients receiving endovascular stent placement for coronary, peripheral, carotid, and intracranial stenoses. We studied the impact of statin use on long-term angiographic and clinical outcomes after flow-diverter treatment of intracranial aneurysms. MATERIALS AND METHODS: We performed a post hoc analysis from pooled patient-level datasets from 3 Pipeline Embolization Device studies: the International Retrospective Study of the Pipeline Embolization Device, the Pipeline for Uncoilable or Failed Aneurysms Study, and the Aneurysm Study of Pipeline in an Observational Registry. We analyzed data comparing 2 subgroups: 1) patients on statin medication, and 2) patients not on statin medication at the time of the procedure and follow-up. Angiographic and clinical outcomes were compared by using the χ2 test, Fisher exact test, or Wilcoxon rank sum test. RESULTS: We studied 1092 patients with 1221 aneurysms. At baseline, 226 patients were on statin medications and 866 patients were not on statin medications. The mean length of clinical and angiographic follow-up was 22.1 ± 15.1 months and 28.3 ± 23.7 months, respectively. There were no differences observed in angiographic outcomes at any time point between groups. Rates of complete occlusion were 82.8% (24/29) versus 86.4% (70/81) at 1-year (P = .759) and 93.3% (14/15) versus 95.7% (45/47) at 5-year (P = 1.000) follow-up for statin-versus-nonstatin-use groups, respectively. There were no differences in any complication rates between groups, including major morbidity and neurologic mortality (7.5% versus 7.1%, P = .77). CONCLUSIONS: Our study found no association between statin use and angiographic or clinical outcomes among patients treated with the Pipeline Embolization Device.

Hydrogel versus Bare Platinum Coils in Patients with Large or Recurrent Aneurysms Prone to Recurrence after Endovascular Treatment: A Randomized Controlled Trial.

BACKGROUND AND PURPOSE: Some patients are at high risk of aneurysm recurrence after endovascular treatment: patients with large aneurysms (Patients Prone to Recurrence After Endovascular Treatment PRET-1) or with aneurysms that have previously recurred after coiling (PRET-2). We aimed to establish whether the use of hydrogel coils improved efficacy outcomes compared with bare platinum coils. MATERIALS AND METHODS: PRET was an investigator-led, pragmatic, multicenter, parallel, randomized (1:1) trial. Randomized allocation was performed separately for patients in PRET-1 and PRET-2, by using a Web-based platform ensuring concealed allocation. The primary outcome was a composite of a residual/recurrent aneurysm, adjudicated by a blinded core laboratory, or retreatment, intracranial bleeding, or mass effect during the 18-month follow-up. Secondary outcomes included adverse events, mortality, and morbidity (mRS > 2). The hypothesis was that hydrogel would decrease the primary outcome from 50% to 30% at 18 months, necessitating 125 patients per group (500 for PRET-1 and PRET-2). RESULTS: The trial was stopped once 250 patients in PRET-1 and 197 in PRET-2 had been recruited because of slow accrual. A poor primary outcome occurred in 44.4% (95% CI, 35.5%-53.2%) of those in PRET-1 allocated to platinum compared with 52.5% (95% CI, 43.4%-61.6%) of patients allocated to hydrogel (OR, 1.387; 95% CI, 0.838-2.295; P = .20) and in 49.0% (95% CI, 38.8%-59.1%) in PRET-2 allocated to platinum compared with 42.1% (95% CI, 32.0%-52.2%) allocated to hydrogel (OR, 0.959; 95% CI, 0.428-1.342; P = .34). Adverse events and morbidity were similar. There were 3.6% deaths (1.4% platinum, 5.9% hydrogel; P = .011). CONCLUSIONS: Coiling of large and recurrent aneurysms is safe but often poorly effective according to angiographic results. Hydrogel coiling was not shown to be better than platinum.

Risk Factors for Ischemic Complications following Pipeline Embolization Device Treatment of Intracranial Aneurysms: Results from the IntrePED Study.

BACKGROUND AND PURPOSE: Risk factors for acute ischemic stroke following flow-diverter treatment of intracranial aneurysms are poorly understood. Using the International Retrospective Study of Pipeline Embolization Device (IntrePED) registry, we studied demographic, aneurysm, and procedural characteristics associated with postoperative acute ischemic stroke following Pipeline Embolization Device (PED) treatment. MATERIALS AND METHODS: We identified patients in the IntrePED registry with post-PED-treatment acute ischemic stroke. The rate of postoperative acute ischemic stroke was determined by demographics, comorbidities, aneurysm characteristics, and procedure characteristics (including anticoagulation use, platelet testing, number of devices used, sheaths, and so forth). Categoric variables were compared with χ(2) testing, and continuous variables were compared with the Student t test. Odds ratios and 95% confidence intervals were obtained by using univariate logistic regression. Multivariate logistic regression analysis was used to determine which factors were independently associated with postoperative stroke. RESULTS: Of 793 patients with 906 aneurysms, 36 (4.5%) patients had acute ischemic stroke. Twenty-six (72.2%) strokes occurred within 30 days of treatment (median, 3.5 days; range, 0-397 days). Ten patients died, and the remaining 26 had major neurologic morbidity. Variables associated with higher odds of acute ischemic stroke on univariate analysis included male sex, hypertension, treatment of MCA aneurysms, treatment of fusiform aneurysms, treatment of giant aneurysms, and use of multiple PEDs. However, on multivariate analysis, the only one of these variables independently associated with stroke was treatment of fusiform aneurysms (OR, 2.74; 95% CI, 1.11-6.75; P = .03). Fusiform aneurysms that were associated with stroke were significantly larger than those not associated with stroke (mean, 24.5 ± 12.5 mm versus 13.6 ± 6.8 mm; P < .001). CONCLUSIONS: Ischemic stroke following PED treatment is an uncommon-but-devastating complication. Fusiform aneurysms were the only variable independently associated with postoperative stroke.

International retrospective study of the pipeline embolization device: a multicenter aneurysm treatment study.

BACKGROUND AND PURPOSE: Flow diverters are increasingly used in the endovascular treatment of intracranial aneurysms. Our aim was to determine neurologic complication rates following Pipeline Embolization Device placement for intracranial aneurysm treatment in a real-world setting. MATERIALS AND METHODS: We retrospectively evaluated all patients with intracranial aneurysms treated with the Pipeline Embolization Device between July 2008 and February 2013 in 17 centers worldwide. We defined 4 subgroups: internal carotid artery aneurysms of ≥10 mm, ICA aneurysms of <10 mm, other anterior circulation aneurysms, and posterior circulation aneurysms. Neurologic complications included spontaneous rupture, intracranial hemorrhage, ischemic stroke, permanent cranial neuropathy, and mortality. Comparisons were made with t tests or ANOVAs for continuous variables and the Pearson χ(2) or Fisher exact test for categoric variables. RESULTS: In total, 793 patients with 906 aneurysms were included. The neurologic morbidity and mortality rate was 8.4% (67/793), highest in the posterior circulation group (16.4%, 9/55) and lowest in the ICA <10-mm group (4.8%, 14/294) (P = .01). The spontaneous rupture rate was 0.6% (5/793). The intracranial hemorrhage rate was 2.4% (19/793). Ischemic stroke rates were 4.7% (37/793), highest in patients with posterior circulation aneurysms (7.3%, 4/55) and lowest in the ICA <10-mm group (2.7%, 8/294) (P = .16). Neurologic mortality was 3.8% (30/793), highest in the posterior circulation group (10.9%, 6/55) and lowest in the anterior circulation ICA <10-mm group (1.4%, 4/294) (P < .01). CONCLUSIONS: Aneurysm treatment with the Pipeline Embolization Device is associated with the lowest complication rates when used to treat small ICA aneurysms. Procedure-related morbidity and mortality are higher in the treatment of posterior circulation and giant aneurysms.

The interactions of typical and atypical antipsychotics with the (-)2, 5,-dimethoxy-4-methamphetamine (DOM) discriminative stimulus.

The present study was designed to test the hypothesis that atypical, but not typical, antipsychotics produce a functional in vivo blockade of 5-HT2A receptors. The magnitude of functional in vivo 5-HT2A receptor blockade elicited by representative compounds from each of the six major structural classes of typical antipsychotics, and the representative atypical antipsychotics clozapine and risperidone, was indicated by their respective abilities to block the stimulus effects of the phenylalkylamine hallucinogen (-)DOM in the rat. Chlorpromazine, thioridazine, fluphenazine, thiothixene and haloperidol did not produce a significant antagonism of the (-)DOM stimulus. The benzoxapine, loxapine (60%), and the atypical dibenzodiazepine, clozapine (62%), partially blocked and risperidone fully blocked (100%) the (-)DOM stimulus. None of these agents elicited significant levels of (-)DOM-appropriate responding when administered alone. These results indicate that the typical antipsychotics, with the exception of lozapine, fail to produce effective in vivo antagonism of 5-HT2A receptors at doses compatible with the preservation of operant behavior. In contrast, the atypical antipsychotics clozapine and risperidone elicit effective in vivo antagonism of 5-HT2A receptors without severe behavioral disruption. Thus, these data are supportive of the hypothesis that the mechanism of action of atypical, but not typical, antipsychotics involves the antagonism of 5-HT2A receptors in vivo.

Further investigations of the interactions of antipsychotics with the (-)2,5-dimethoxy-4-methylamphetamine (DOM) discriminative stimulus.

Stimulus control induced by (-)-2,5-dimethoxy-4-methylamphetamine (DOM) is believed to be mediated by agonism at 5-HT2A receptors. We hypothesized that blockade of (-) DOM-induced stimulus control may thus prove useful in the pre-clinical characterization of novel antipsychotic agents by providing an in vivo index of antagonism at that receptor. A previous study (Fiorella et al., 1995a) observed no antagonism by typical agents such as haloperidol and thioridazine, partial antagonism by the atypical agent, clozapine, and full antagonism by risperidone, a second atypical antipsychotic. The present investigation extends these observations to include seven additional drugs: SCH 23390, sulpiride, amperozide, melperone, octoclothepin, tiospirone and ritanserin. Of the drugs tested in rats in which (-) DOM-induced stimulus control had reliably been established, only tiospirone and ritanserin produced complete antagonism of the (-) DOM stimulus. Intermediate levels of antagonism were observed following treatment with amperozide, melperone, and octoclothepin. Finally, SCH 23390 and sulpiride yielded no evidence of antagonistic activity in (-) DOM-trained animals. Because clozapine and risperidone are both classified as atypical antipsychotics yet yield different degrees of antagonism of (-) DOM-induced stimulus control, we tested the substitution of risperidone for clozapine in rats trained with clozapine as a discriminative stimulus. No significant substitution was observed. In conclusion it appears that complete or partial antagonism of the (-) DOM stimulus serves as an effective pre-clinical means of identifying antipsychotics with significant 5-HT2A antagonist properties. However, the failure of risperidone to substitute for clozapine in pigeons (Hoenicke et al., 1992) and in rats (present study) suggests that despite their shared 5-HT2A antagonist properties, clozapine and risperidone differ with respect to their stimulus effects.