Ultra-distal access of the M1 segment with the 5†Fr Navien distal access catheter in acute (anterior circulation) stroke: is it safe and efficient?

BACKGROUND AND AIM: The importance of mechanical thrombectomy in acute stroke treatment has grown over recent years. Mechanical thrombectomy comprises many different techniques. Technical improvements in the catheter material have led to the development of large-bore distal access catheters which can enter tortuous intracranial vessels. This has promising applications for endovascular stroke treatment. This study evaluated the safety and success rate of ultra-distal access of the middle cerebral artery (MCA) M1 segment with the 5 Fr Navien 58 distal access catheter in the treatment of acute stroke in combination with stent retrievers. METHODS: We retrospectively analyzed 81 patients with an acute stroke of the anterior circulation in whom ultra-distal access to the M1 segment was carried out using the Navien 58 catheter with an anchoring technique with a stent retriever for mechanical thrombectomy. Technical complications, success rates of catheter placement, success rates of thrombectomy using the modified Thrombolysis In Cerebral Infarction (mTICI) score, and the procedure times were evaluated. RESULTS: Ultra-distal access with the Navien 58 was successful in 75% (61/81) of cases. Recanalization success with a mTICI score of 2b and better was achieved in 83% overall (67/81), in 90% (55/61) of cases with successful ultra-distal access and in 60% (12/20) of cases without ultra-distal access. No severe adverse effects such as dissections or perforations occurred as a result of the ultra-distal catheter placement in the M1 segment. In 4% (3/81) of the cases a reversible MCA vasospasm occurred. CONCLUSIONS: Ultra-distal placement of the Navien 58 distal access catheter into the M1 segment in acute anterior circulation stroke can be achieved consistently, is safe in practice, and results in good recanalization success rates.

General Anesthesia Versus Conscious Sedation in Acute Stroke Treatment: The Importance of Head Immobilization.

PURPOSE: While today mechanical thrombectomy is an established treatment option for main branch occlusions in anterior circulation stroke, there is still an ongoing debate on the kind of anesthesia to be preferred. Introducing a simple method for head stabilization, we analyzed safety and duration of endovascular recanalization procedures under general anesthesia (GA) and conscious sedation (CS). METHODS: We retrospectively identified 84 consecutive patients who underwent mechanical thrombectomy owing to acute anterior circulation stroke. Fifty-three were treated under GA and 31 under CS equipped with a standard cervical collar to reduce head movement. We evaluated recanalization results, in-house time to start recanalization, procedure times, technical and clinical complication rates, and conversion rates from CS to GA. RESULTS: Recanalization of mTICI ≥2b was achieved in 80 % under CS and in 81 % under GA. Median in-house time to start recanalization for CS was 60 min (IQR 28; 44-72) and 77 min (IQR 23; 68-91) for GA (P = 0.001). Median procedure time under CS was 35 min (IQR 43; 69-25) and 41 min (IQR 43; 66-23) for GA (P = 0.9). No major complications such as ICH occurred in either group, and no conversions from CS to GA were necessary. CONCLUSION: Mechanical thrombectomy can be performed faster and safely under CS in combination with simple head immobilization using a standard cervical collar.

Prediction of Stent-Retriever Thrombectomy Outcomes by Dynamic Multidetector CT Angiography in Patients with Acute Carotid T or MCA Occlusions.

BACKGROUND AND PURPOSE: The selection of patients for endovascular therapy is an important issue in stroke imaging. The aim of this study was to determine the predictive value of 3 different dynamic CT angiography parameters, occlusion length, collateralization extent, and time delay to maximum enhancement, for latest generation of stent retriever thrombectomy recanalization outcomes in patients with acute ischemic stroke. MATERIALS AND METHODS: In this study, subjects were selected from an initial cohort of 2059 consecutive patients who had undergone multiparametric CT, including whole-brain CT perfusion. We included all patients with a complete occlusion of the M1 segment of the MCA or the carotid T and subsequent intra-arterial stent retriever thrombectomy. Dynamic CT angiography was reconstructed from whole-brain CT perfusion raw datasets. Angiographic outcome was scored by using the modified TICI scale; and clinical outcome, by using the modified Rankin Scale. Logistic regression analyses were performed to determine independent predictors of a favorable angiographic (mTICI = 3) and clinical outcome (mRS ≤2). RESULTS: Sixty-nine patients (mean age, 68 ± 14 years; 46% men) were included for statistical analysis. In the regression analysis, a short occlusion length was an independent predictor of favorable angiographic outcome (OR, 0.41; P < .05). Both collateralization grade (OR, 1.00; P > .05) and time delay to peak enhancement (OR, 0.90; P > .05) failed to predict a favorable angiographic outcome. None of the dynamic CT angiography predictors were significantly associated with clinical outcome on discharge (OR, 0.664-1.011; P = .330-.953) or at 90 days (OR, 0.779-1.016; P = .130-.845). CONCLUSIONS: A short occlusion length as determined by dynamic CT angiography is an independent predictor of a favorable angiographic outcome of stent retriever thrombectomy in patients with ischemic stroke.

Diffusion tensor imaging of the trigeminal nerve in patients with trigeminal neuralgia due to multiple sclerosis.

INTRODUCTION: Neurovascular compression (NVC) is the most common cause of trigeminal neuralgia (TN), leading to microstructural changes in the affected nerve detectable using diffusion tensor imaging (DTI). But TN may also emerge as a symptom of multiple sclerosis (MS). The aim of this study was to evaluate if patients with MS-related TN feature the same DTI characteristics as patients with TN caused by NVC. METHODS: Twelve patients with MS-related TN, 12 age-matched patients with NVC-related TN, and 12 healthy controls were included. Using 3T-DTI, mean fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were calculated for each affected and contralateral trigeminal nerve in patients with MS and NVC-related TN as well as healthy controls. Furthermore, presence of NVC was evaluated for patients with TN. RESULTS: There was no significant difference concerning FA or ADC when comparing the affected and the non-affected sides in patients with MS. FA was significantly lower and ADC higher in patients with MS on the TN affected as well as on the non-affected side compared to the non-affected side of patients with idiopathic TN or healthy controls. Likewise, FA was significantly lower on the affected side compared to the non-affected side in patients with idiopathic TN or healthy controls. NVC was evident in 41.7/0% on the affected/contralateral side in MS patients and 100/8% in the patients with NVC-related TN. CONCLUSION: In patients with MS-related TN, DTI reveals microstructural changes within the trigeminal nerve not only on the affected side but also on the clinically non-affected side.

Neuroinfectious diseases at a European neurological tertiary care center: one-third of patients require treatment in the neurological intensive care unit.

BACKGROUND AND PURPOSE: Studies on the impact of infectious diseases affecting the nervous system are sparse. METHODS: All patients with neuroinfectious diseases (NIDs) who were treated at our Department of Neurology from 2005 until 2009 were retrospectively analyzed. RESULTS: Patients with NIDs required treatment at the intensive care unit in 34.8%. The mortality rate of patients with NIDs was significantly higher than that of other inpatients with neurological diseases (5.1% vs. 3.0%, respectively, P = 0.018). CONCLUSION: In summary, this study shows that patients with NIDs are severely ill and mortality is high.

[Migration of a retained intra-abdominal foreign body into the colon]. / Migration eines intraoperativ belassenen Bauchtuches in das Kolon.

Even in the era of correct precautions and risk management culture adverse and preventable adverse events, such as intraoperatively residual foreign bodies remain a hot topic. Due to legal considerations and possible image loss many cases may remain unpublished leading to an underestimation of the real incidence in literature. The following casuistic is an example for a rarely documented and in this case a partial migration of a retained surgical sponge into the colon. The causes for the delayed foreign body detection, accounting for the relative good health even during chemoradiotherapy are analyzed in order to sharpen the awareness of such serious complications.

EUROMET supplementary comparisons for photon and beta radiation--actual state and first results.

In January 2004, two EUROMET supplementary comparisons started, coordinated by Physikalisch-Technische Bundesanstalt (PTB): one for the radiation protection quantity 'personal dose equivalent' Hp(10) using X-radiation, and one for the quantity 'absorbed dose in tissue' Dt(0.07) using beta reference fields. The focus of both comparisons lies on calibrations using radiation qualities at which the dissemination of the quantities considered here is difficult. Within the scope of the two comparisons, an ionisation chamber shall be calibrated. Together with a transfer chamber optimised to measure Hp(10) and Dt(0.07), respectively, for each comparison a complete electronic measuring system is circulated. These transfer devices, as well as, a specially developed test procedure, which has to be carried out by each participant to check the instruments, are described. For both comparisons, the results of those participants who had finished their measurements and delivered the measuring protocol until February 2005 were evaluated. As the comparisons are still running these first results are shown in an anonymous form. A first assessment of the data will be given.

UV-damage-mediated induction of homologous recombination in Arabidopsis is dependent on photosynthetically active radiation.

Plants are continuously subjected to UV-B radiation (UV-B; 280-320 nm) as a component of sunlight causing damage to the genome. For elimination of DNA damage, a set of repair mechanisms, mainly photoreactivation, excision, and recombination repair, has evolved. Whereas photoreactivation and excision repair have been intensely studied during the last few years, recombination repair, its regulation, and its interrelationship with photoreactivation in response to UV-B-induced DNA damage is still poorly understood. In this study, we analyzed somatic homologous recombination in a transgenic Arabidopsis line carrying a beta-glucuronidase gene as a recombination marker and in offsprings of crosses of this line with a photolyase deficient uvr2-1 mutant. UV-B radiation stimulated recombination frequencies in a dose-dependent manner correlating linearly with cyclobutane pyrimidine dimer (CPD) levels. Genetic deficiency for CPD-specific photoreactivation resulted in a drastic increase of recombination events, indicating that homologous recombination might be directly involved in eliminating CPD damage. UV-B irradiation stimulated recombination mainly in the presence of photosynthetic active radiation (400-700 nm) irrespective of photolyase activities. Our results suggest that UV-B-induced recombination processes may depend on energy supply derived from photosynthesis.

Assay of DNA photolyase activity in spinach leaves in relation to cell compartmentation-evidence for lack of DNA photolyase in chloroplasts.

Spinach cyclobutane pyrimidine dimer (CPD)-specific DNA photolyase was successfully detected in leaf extracts by an assay system for plant photolyase using an improved enzyme-linked immunosorbent assay (ELISA) which was newly introduced by novel horseradish peroxidase (HRP)-linked CPD specific monoclonal antibodies. The assay system includes two main steps: a photorepair reaction of CPD introduced in substrate DNA and measurement of CPD remained after the photorepair by the improved ELISA. When CPD- induced salmon sperm DNA was used as a substrate, high CPD-photolyase activities were observed in the enzyme fraction prepared from whole spinach leaf extracts, but not from chloroplast extracts. This strongly suggests that spinach CPD-specific photolyases are localized in cell compartments other than chloroplasts.

Efficiency of hospital cholera treatment in Ecuador.

This study analyzed the efficiency of cholera treatment in three hospitals representative of the Ecuadorian public health system in order to provide hospital directors and administrators and health service policy-makers with information to plan responses to future epidemics and to reduce the costs of cholera treatment in general. For the study, total and excess cholera treatment costs were calculated using hospital files and statistics and an in-hospital surveillance system of the cholera cases. The type and quantity of each input used for each treatment were analyzed, as well as the number of days hospitalized, according to the severity of the illness. With this process, excess costs were determined in relation to a "treatment norm" that would have been appropriate for each patient. The researchers found that 45% of the cholera treatment costs were excessive. The most important contributor was excess recurrent costs (90%), including extended hospital stays, disproportionate use of intravenous rehydration solutions, and unnecessary laboratory tests. Excess capital costs, from land, buildings, and hospital equipment, represented 10% of the total excess treatment costs. No significant relationship was found between treatment costs and the severity of the illness, nor between costs and a patient's age. A patient's sex appeared to be an important variable, with the cost of treating women being notably higher than for men. An inverse relationship was found between treatment costs and the complexity of the hospital. The researchers concluded there was an inefficient use of resources in the treatment of cholera in the three hospitals where the research was performed.

Open label tissue plasminogen activator for stroke: the Oregon experience.

BACKGROUND: Tissue plasminogen activator (t-PA) is the first effective treatment for stroke. This study sought to explore the outcome of patients treated with t-PA in the community after approval of its use in the treatment of stroke in June, 1996. METHODS: All patients with acute stroke within the 6-hospital Oregon Stroke Center network were screened for potential t-PA treatment. Baseline and 24-hour outcome assessments were performed with the use of the National Institutes of Health Stroke Scale (NIHSS) and computed tomography (CT); 3-month outcome was evaluated by using the Modified Rankin scale. RESULTS: Thirty-three patients who met the criteria for t-PA therapy were treated within 3 hours of symptom onset. All but 2 strokes were in the anterior circulation; 48.5% were cardioembolic. The NIHSS scores at 24 hours after administration of t-PA (mean, 14.7) showed modest gains from baseline NIHSS scores (mean, 16.6). Twelve patients (36%) had minimal or no deficits at 3 months. Three patients (9%), all of whom had baseline NIHSS scores of 20 or more, had symptomatic intracranial hemorrhages, 2 of which were fatal (6%). CONCLUSION: This study shows the feasibility of treating acute stroke with t-PA in the community. The percentage of fully recovered patients at 3 months mirrored those in the National Institute of Neurologic Disorders and Stroke (NINDS) trial.

Monitoring experimental alcelaphine herpesvirus-1 infection in cattle by nucleic-acid hybridization and PCR.

The DNA probe SW15 derived from the laboratory-attenuated Alcelaphine Herpesvirus-1 (AHV-1) strain WC11 as well as from the polymerase chain-reaction test (Hsu, Shih, Castro & Zee 1990), was used to detect viral DNA of malignant catarrhal fever (MCF) in six experimentally infected cattle. Heparinized blood samples were collected and tested at least three times a week over a period of up to 142 d. Results of hybridization and PCR tests were compared with the results of clinical examinations, and on various occasions with those of viral isolation and serum-neutralization assays as well as with those of pathology. Three animals developed clinical signs and lesions typical of MCF, while the other three animals remained clinically healthy. All cattle seroconverted, and viral nucleic acid was detected by DNA hybridization and PCR at various intervals during the observation period. Virus isolation was successful in two of the clinical cases and all cattle seroconverted. Storage of blood samples at 4 degrees C for up to 10 d did not influence the hybridization and DNA-amplification results.

Ultraviolet Light Inhibition of Phytochrome-Induced Flavonoid Biosynthesis and DNA Photolyase Formation in Mustard Cotyledons (Sinapis alba L.).

In cotyledons of etiolated mustard (Sinapis alba L.) seedlings, phytochrome-far-red-absorbing form-induced flavonoid biosynthesis was found to be inhibited by short-term ultraviolet (UV) irradiations. UV inhibition was shown for the synthesis of quercetin, anthocyanin, and also for the accumulation of the mRNA for chalcone synthase, the key enzyme of this pathway. The UV effect was more pronounced on flavonoid biosynthesis, a process that selectively occurs in the epidermal layers, than on the synthesis of mRNA for chlorophyll a/b-binding protein localized in the mesophyll tissue. These UV inhibitory effects were accompanied by cyclobutane pyrimidine dimer (CPD) formation showing a linear fluence-response relationship. CPD formation and UV inhibition of flavonoid biosynthesis was found to be partially reversible by blue/UV-A light via DNA photolyase (PRE), allowing photoreactivation of the DNA by splitting of CPDs, which are the cause of the UV effect. Like flavonoid formation PRE was also induced by the far-red-absorbing form of phytochrome and induction was inhibited by UV. A potential risk of inhibition, in response to solar UV-B irradiation, was shown for anthocyanin formation. This inhibition, however, occurred only if photoreactivation was experimentally reduced. The PRE activity present in the etiolated seedlings (further increasing about 5-fold during light acclimatization) appears to be sufficient to prevent the persistence of CPDs even under conditions of high solar irradiation.

[Atypical facial neuralgia or depressive facial pain. Diagnostic aspects of a well-demarcated form of masked depression]. / "Atypische Gesichtsneuralgie" oder depressiver Gesichtsschmerz? Diagnostische Aspekte einer gut abgrenzbaren Form der larvierten Depression.

In three paradigmatical cases the problem of the diagnosis "atypical face pain" is discussed. On clinical inpatients can be demonstrated, that behind an "atypical face pain" a chronic depressive illness can be hidden. The symptom "facial pain" in these cases is part of an oligosymptomatic depressive disorder. A special antidepressant therapy is necessary in the clinical management of these "masked depressions". Therefore it is necessary to be reserved on diagnosing an "atypical face pain". The exact analysis of psychopathological disturbances can prevent these patients who in reality suffer from depressive face pain from therapies in maxillary surgery or in dentistry etc. that are far from useful.

[Light-and electron microscopic appearances of the orbicularis oculi muscle in patients with chronic progressive ocular muscular dystrophy and in normal persons (author's transl)]. / Licht-und elektronenmikroskopische Befunde des M. orbicularis oculi bei chronisch progressiver okulärer Muskeldystrophie und bei Normalpersonen.

In 8 patients with chronic progressive ocular muscular dystrophy, of whom some showed a weakness of lid closure, and in 3 normal persons (aged 62 to 69 years) biopsies of the orbicularis oculi muscle were investigated with the light- and electron microscopes. We tried to find out if the histopathological investigation alone of the orbicularis oculi muscle can establish the diagnosis of ocular muscular dystrophy or not. Both groups of investigated persons showed myopathic changes in the orbicularis oculi muscle. These changes were explained as followings of catabiosis (so called "secondary myopathic reaction") in the normal persons. The changes of the patients with myopathies, however, were explained as primarily myopathic, especially with regard to the anomalies of structure, and the pathological inclusions of the mitochondria. The findings showed that there occurred similar histopathological phenomena seen by light microscope in both groups of investigated persons; the muscle cell changes of the myopathy patients, however, were more prominent in the examination of the ultrastructure.

[Studies on the determination of optimal insemination time using electrometric resistance measurements in heifers and young cows after estrus synchronization]. / Untersuchungen zur Ermittlung des optimalen Besamungszeitpunktes mittels elektrometrischer Widerstandsmessungen bei Färsen und Jungkühen nach der Brunstsynchronisation.

Studies were conducted on how to use under the conditions of industrialised production in the GDR an electrometric method proposed by Soviet scientists to determine oestrus and ovulation date in oestric-synchronised heifers and cows. "Oestrometer-2", an instrument developed in the USSR, was used for 4,818 measurements of electric resistance in 700 oestric-synchronised heifers and 39 oestric-synchronised cows. The typical course of the resistence curve was confirmed by the results. Individual data variation together with unsatisfactory data reliability of the instrument, when applied to measurement at vaginovestibular mucosa, were likely to suggest that the method could not be used with good effect for high-accuracy determination of the ovulation date and therefore, was not useful in helping to save semen pellets after oestric synchronisation.