Frequency-domain optical coherence tomography assessment of very late vascular response after carotid stent implantation.

Intravascular optical coherence tomography is a high-resolution invasive imaging modality that allows the evaluation of vascular responses after stent implantation in a micron-scale level. We describe for the first time two patients with very late vascular response after carotid artery stenting that exhibit two different patterns of low-signal intensity (LSI), "ill-appearing" neointima: the first patient shows layered LSI neointima leading to stent restenosis, coupled with the presence of intraluminal thrombus, whereas the second patient demonstrates another pattern of non-restenotic LSI stent strut coverage, suggestive of lipid laden neointima (ie, "neoatherosclerosis"), recently associated with stent failure in coronary arteries.

Acute cerebral rescue during carotid artery stenting: a stroke of good fortune?

Major stroke is a potentially devastating complication of carotid artery revascularization. Carotid artery stenting, unlike endarterectomy, offers the opportunity to attenuate this complication by allowing for the instantaneous detection and early endovascular treatment of neurologic defects complicating the procedure. We report a case that highlights the utility of aggressive endovascular cerebral rescue during a carotid artery stent procedure.

Optical coherence tomography of the intracranial vasculature and Wingspan stent in a patient.

A 67-year-old man with medically refractory vertebrobasilar insufficiency and short segment occlusions of the intracranial vertebral arteries was treated with angioplasty and stent placement. Fifteen hours after the procedure the patient developed symptoms of posterior fossa ischemia and repeat angiography showed thrombus formation within the stent which was treated with thrombolytic and aggressive antiplatelet therapy. Angiography revealed lysis of the clot, but concerns regarding the mechanism of the thrombotic phenomenon prompted frequency-domain optical coherence tomography (FDOCT) assessment. FDOCT provided excellent visualization of the stent and vessel wall interactions, as well as excluding residual flow-limiting stenosis, obviating the need for further intervention. The potential utility of FDOCT in the evaluation of intracranial atherosclerotic disease and additional intracranial applications are discussed.

Carotid angioplasty and stenting versus carotid endarterectomy for treatment of asymptomatic carotid stenosis: a randomized trial in a community hospital.

OBJECTIVE: Carotid endarterectomy (CEA) is effective in reducing the risk of stroke in individuals with more than 60% carotid stenosis. Carotid angioplasty and stenting (CAS) has been proffered as effective and used in treating individuals with asymptomatic carotid stenosis despite the absence of proven clinical equivalency. This randomized trial was designed to explore the hypothesis that CAS is equivalent to CEA for treating asymptomatic carotid stenosis. METHODS: A total of 85 individuals presenting with asymptomatic carotid stenosis of more than 80% were selected randomly for CAS or CEA and followed up for 48 months. RESULTS: Stenosis decreased to an average of 5% after CAS. The patency of the reconstructed artery remained satisfactory regardless of the technique, as determined by carotid ultrasonography. No major complications such as cerebral ischemia or death occurred. Procedural complications associated with CAS (n = 5) were hypotension and/or bradycardia; those concomitant with CEA (n = 3) were cervical nerve injury or complications related to general anesthesia (n = 4). Both procedures were well tolerated in the context of pain and discomfort. Hospital stay was similar in the two groups (mean, 1.1 versus 1.2 d). The occurrence of complications associated with CAS or CEA prolonged hospitalization by 3 days (mean, 4.0 versus 4.5 d). Return to full activity was achieved within 1 week by more than 85% of patients; all returned to their usual lifestyle by 2 weeks. Although hospital charges were slightly higher for CAS, costs were similar. CONCLUSION: CAS and CEA may be equally effective and safe in treating individuals with asymptomatic carotid stenosis.

Hip status in cerebral palsy after one year of continuous intrathecal baclofen infusion.

The purpose of this study was to assess whether reduction of muscle tone by continuous intrathecal baclofen infusion affects the progression of hip subluxation in persons with cerebral palsy. This prospective, open-label, case series was conducted at multiple specialty referral centers. There were 33 subjects, ages 4 to 31 years. All had a pretreatment lower extremity Ashworth score of >/=3; all subjects had a significant reduction in tone after a bolus injection of intrathecal baclofen and received an implanted pump for continuous delivery of intrathecal baclofen. Subjects had hip x-rays before and 1 year after pump implantation. The primary outcome measure was change in absolute hip migration percentage. One third of the hips had an increase of absolute migration percentage of 5% or more; 12% of the hips had a decrease of migration percentage of 5% or more. Change of migration percentage class was used as a second outcome criterion. 90.9% of hips manifested no deterioration or had improvement of their migration percentage class during the year of intrathecal baclofen therapy. The observed changes were not associated with the subject's age or the severity of cerebral palsy.

Carotid angioplasty with stenting versus endarterectomy: 10-year randomized trial in a community hospital.

OBJECTIVES: This single-center, randomized, clinical trial was designed to determine the 10-year comparative efficacy and durability of carotid angioplasty and stenting (CAS) versus carotid endarterectomy (CEA) in preventing ipsilateral ischemic stroke in symptomatic and asymptomatic patients with high-grade carotid artery stenosis. BACKGROUND: Modern clinical trials with short-term follow-up indicate CAS and CEA are equivalent in reducing the risk for ipsilateral ischemic stroke secondary to carotid stenosis. A paucity of data exists regarding long-term outcomes. METHODS: Patients of all surgical risks with symptomatic and asymptomatic carotid stenosis (>70%) were randomly selected for CEA or CAS and followed a minimum of 10 years. RESULTS: Long-term follow-up was achieved in 173 patients (91%). Eighty-seven (50.2%) died within this period, most commonly of nonvascular causes. No difference in the risk of stroke ipsilateral to the treated artery was noted among treatment groups (p > 0.05). Restenosis determined by sequential ultrasound was assessed only in the CAS group (3.3%) and remained asymptomatic. The combined risk of fatal or nonfatal heart attack over the 10-year period was highest in individuals with symptomatic versus asymptomatic stenosis (27.5% vs. 11.0%; hazard ratio [HR]: 2.32, 95% confidence interval [CI]: 1.298 to 4.146, p = 0.005) and was higher in all patients treated with CEA (HR: 2.27, 95% CI: 1.35 to 3.816, p = 0.002). CONCLUSIONS: Long-term protection against ipsilateral stroke provided by CAS and CEA did not differ in this trial. The 10-year risk of fatal/nonfatal myocardial infarction was highest in all patients harboring symptomatic carotid stenosis at enrollment. The risk of fatal/nonfatal heart attack was significantly more prevalent in those symptomatic or asymptomatic patients randomized to CEA.

Optical coherence tomography of the intracranial vasculature and Wingspan stent in a patient.

A 67-year-old man with medically refractory vertebrobasilar insufficiency and short segment occlusions of the intracranial vertebral arteries was treated with angioplasty and stent placement. Fifteen hours after the procedure the patient developed symptoms of posterior fossa ischemia and repeat angiography showed thrombus formation within the stent which was treated with thrombolytic and aggressive antiplatelet therapy. Angiography revealed lysis of the clot, but concerns regarding the mechanism of the thrombotic phenomenon prompted frequency-domain optical coherence tomography (FDOCT) assessment. FDOCT provided excellent visualization of the stent and vessel wall interactions, as well as excluding residual flow-limiting stenosis, obviating the need for further intervention. The potential utility of FDOCT in the evaluation of intracranial atherosclerotic disease and additional intracranial applications are discussed.

Intravascular frequency-domain optical coherence tomography assessment of carotid artery disease in symptomatic and asymptomatic patients.

OBJECTIVES: The goal of this study was to investigate carotid plaque characteristics in symptomatic versus asymptomatic patients with the use of nonocclusive optical coherence tomography (OCT). BACKGROUND: The identification of asymptomatic patients with carotid disease who are at risk of stroke remains a challenge. There is an increasing awareness that plaque characteristics may best risk-stratify this population. We hypothesized that OCT, a new high-resolution (∼ 10 µm) imaging modality, might be useful for the identification of low-risk versus high-risk carotid plaque features and help us to understand the relationship between carotid diameter stenosis and plaque morphology to ischemic stroke. METHODS: Fifty-three patients undergoing diagnostic carotid angiography were studied with OCT. Data analysis was carried out by imaging experts who were unaware of the clinical characteristics of the study population. RESULTS: Plaque with American Heart Association type VI complicated features was more common in symptomatic than asymptomatic patients (74.1% vs. 36.4%, p = 0.02). This was largely driven by differences in the incidence of thin-cap fibroatheroma with rupture (40.7% vs. 13.6%, p = 0.056) and thrombus (67.7% vs. 36.4%, p = 0.034). Conversely, non-type VI plaques were more common in asymptomatic than symptomatic patients (63.6% vs. 25.9%, p = 0.02). No association between the degree of stenosis and plaque morphology was identified. CONCLUSIONS: This retrospective analysis of carotid OCT data supports the hypothesis that the evaluation of carotid plaque characteristics with this high-resolution imaging technique has the potential to alter the understanding and treatment of carotid artery disease.

Subcellular mobility of the calpain/calpastatin network: an organelle transient.

Calpain (Cp) is a calcium (Ca(2+))-dependent cysteine protease. Activation of the major isoforms of Cp, CpI and CpII, are required for a number of important cellular processes including adherence, shape change and migration. The current concept that cytoplasmic Cp locates and associates with its regulatory subunit (Rs) and substrates as well as translocates throughout the cell via random diffusion is not compatible with the spatial and temporal constraints of cellular metabolism. The novel finding that Cp and Rs function relies upon tenacious hydrophobic interactions with organelle membranes offers a unifying explanation for the paradoxical and puzzling features of Cp activation and regulation such as how nM concentrations of intracellular Ca(2+) can activate Cp molecules requiring muM to mM concentrations of Ca(2+) for in vitro activation, and how this protease can spatially and temporally locate specific substrates and translocate throughout the cell. We hypothesize that Cp and its regulatory moieties associate with organelles to facilitate the activation of this protease resulting in the cleavage of substrates and aid in its translocation throughout the cell.

GMFM 1 year after continuous intrathecal baclofen infusion.

The purpose of this study was to assess whether there is an improvement in motor function in persons with cerebral palsy (CP) who have had a reduction of muscle tone by continuous intrathecal baclofen infusion. This was a prospective, open label, non-blinded case series without a control group, conducted at multiple centres. There were 31 subjects, aged 4-29 years. All had a pre-treatment mean lower extremity Ashworth scores of >or= 3 and a significant reduction in tone after a bolus injection of intrathecal baclofen (ITB) and received an implanted pump for continuous delivery of ITB. Motor function was assessed by the Gross Motor Function Measure (GMFM) prior to and 1 year following pump implantation. Significant improvement (p < 0.05) in mean GMFM scores was seen in subjects < 8 years (mean change 4.1) and in those from 8-18 years (mean change 3.7) and in subjects with CP Classes 2 and 5 (mean changes 6.2 and 2.9). There was a statistically significant decrease (p < 0.05) in Ashworth scores in CP classes 2-5. Subjects or their caregivers that completed a survey about perceived changes stated that motor control, positioning and endurance improved.

Differential compartmentalization of the calpain/calpastatin network with the endoplasmic reticulum and Golgi apparatus.

Calpain, a calcium-activated cysteine protease, is involved in modulating a variety of cell activities such as shape change, mobility, and apoptosis. The two ubiquitous isoforms of this protease, calpain I and II, are considered to be cytosolic proteins that can translocate to various sites in the cell. The activity of calpain is modulated by two regulatory proteins, calpastatin, the specific endogenous inhibitor of calpain, and the 28-kDa regulatory subunit. Using velocity gradient centrifugation, the results of this study confirm and greatly expand upon our previous finding that the calpain/calpastatin network is associated with the endoplasmic reticulum and Golgi apparatus in cells. Moreover, confocal microscopy demonstrates that calpain II colocalizes with specific proteins found in these organelles. Additional experiments reveal that hydrophobic rather than electrostatic interactions are responsible for the association of the calpain/calpastatin network with these organelles. Treatment of the organelles with Na2CO3 or deoxycholate reveal that calpain I, 78-kDa calpain II, and the regulatory subunit are "embedded" within the organelle membranes similar to integral membrane proteins. Proteinase K treatment of the organelles shows that calpain I and II, calpastatin, and the regulatory subunit localize to the cytosolic surface of the organelle membranes, and a subset of calpain II and the regulatory subunit are also found within the lumen of these organelles. These results provide a new and novel explanation for how the calpain/calpastatin network is organized in the cell.

Association of the calpain/calpastatin network with subcellular organelles.

The calcium-activated cysteine protease calpain is intimately involved in modulating cell adhesion and migration. The two ubiquitous isoforms of this protease, calpain I and II, are considered to be cytosolic proteins that can translocate to both focal complexes/adhesions or the plasma membrane. Using confocal microscopy and isopycnic density centrifugation, the results demonstrate that calpain I and II, the 30kDa regulatory subunit, and calpastatin associate with the endoplasmic reticulum and Golgi apparatus. Confocal microscopy reveals that calpain II colocalizes with the subcellular proteins calnexin and Rab6 in cells bound to laminin. To further verify this association, cell lysates prepared from laminin stimulated and unstimulated cells were subjected to isopycnic density centrifugation. The results reveal an increased association of calpain I, II, calpastatin, and the 30kDa regulatory subunit with the endoplasmic reticulum and Golgi apparatus as evidenced by their position in the gradient relative to calnexin, Rab6, caveolin, and beta1 integrin after laminin stimulation. This correlates with the accumulation of inducible calpain activity at the endoplasmic reticulum-Golgi apparatus interface. Further experiments established that calpain II colocalizes with phosphatidylinositol 4,5-bisphosphate. Finally, calpain II associates with membrane lipid rafts. These results provide new insights into how the calpain/calpastatin network is spatially and temporally regulated in cells binding to the extracellular matrix.

Calpain II colocalizes with detergent-insoluble rafts on human and Jurkat T-cells.

Calpain, a calcium-dependent cysteine protease, is known to associate with the T-cell plasma membrane and subsequently cleave a number of cytoskeletal-associated proteins. In this study, we report the novel observation that calpain II, but not calpain I, associates with membrane lipid rafts on human peripheral blood T-cells and Jurkat cells. Raft-associated calpain activity is enhanced with exogenous calcium and inhibited with calpeptin, a specific inhibitor of calpain activity. In addition, we demonstrate that calpain cleaves the cytoskeletal-associated protein, talin, during the first 30-min after cell stimulation. We propose that lipid raft associated-calpain II could function in early TCR signaling to facilitate immune synapse formation through cytoskeletal remodeling mechanisms. Hence, we demonstrate that the positioning of calpain II within T-cell lipid rafts strategically places it in close proximity to known calpain substrates that are cleaved during Ag-specific T-cell signaling and immune synapse formation.