Visualization of Lenticulostriate Arteries on CT Angiography Using Ultra-High-Resolution CT Compared with Conventional-Detector CT.

BACKGROUND AND PURPOSE: The newly developed ultra-high-resolution CT is equipped with a 0.25-mm detector, which has one-half the conventional section thickness, one-half the in-plane detector element width, and one-half the reconstructed pixel width compared with conventional-detector CT. Thus, the ultra-high-resolution CT scanner should provide better image quality for microvasculature than the conventional-detector CT scanners. This study aimed to determine whether ultra-high-resolution CT produces superior-quality images of the lenticulostriate arteries compared with conventional-detector CT. MATERIALS AND METHODS: From February 2017 to June 2017, thirteen patients with aneurysms (4 men, 9 women; mean age, 61.2 years) who underwent head CTA with both ultra-high-resolution CT and conventional-detector CT were enrolled. Two board-certified radiologists determined the number of all lenticulostriate arteries on the CTA coronal images of the MCA M1 segment reconstructed from 512 matrixes on conventional-detector CT and 1024 matrixes on ultra-high-resolution CT. RESULTS: There were statistically more lenticulostriate arteries identified on ultra-high-resolution CT (average, 2.85 ± 0.83; 95% CI, 2.509-3.183) than on conventional-detector CT (average, 2.17 ± 0.76; 95% CI, 1.866-2.480) (P = .009) in 16 of the total 26 MCA M1 segments. CONCLUSIONS: Improvements in lenticulostriate artery visualization were the result of the combined package of the ultra-high-resolution CT scanner plus the ultra-high-resolution scanning protocol, which includes higher radiation doses with lower than the national diagnostic reference levels and stronger adaptive iterative dose-reduction processing. This package for ultra-high-resolution CT is a simple, noninvasive, and easily accessible method to evaluate microvasculature such as the lenticulostriate arteries.

The maze-making and solving technique for coil embolization of large and giant aneurysms.

BACKGROUND AND PURPOSE: Despite major progress in treating aneurysms by coil embolization, the complete occlusion of aneurysms of >10 mm in diameter (large/giant aneurysms) remains challenging. We present a novel endovascular treatment method for large and giant cerebral aneurysms called the "maze-making and solving" technique and compare the short-term follow-up results of this technique with those of conventional coil embolization. MATERIALS AND METHODS: Eight patients (65 ± 11.5 years of age, 7 women) with large/giant unruptured nonthrombosed cerebral aneurysm (mean largest aneurysm dimension, 19 ± 4.4 mm) were treated by the maze-making and solving technique, a combination of the double-catheter technique and various assisted techniques. The coil-packing attenuation, postoperative courses, and recurrence rate of this maze group were compared with 30 previous cases (conventional group, 65.4 ± 13.0 years of age; 22 women; mean largest aneurysm dimension, 13.4 ± 3.8 mm). RESULTS: Four maze group cases were Raymond class 1; and 4 were class 2 as indicated by immediate postsurgical angiography. No perioperative deaths or major strokes occurred. Mean packing attenuation of the maze group was significantly higher than that of the conventional group (37.4 ± 5.9% versus 26.2 ± 5.6%). Follow-up angiography performed at 11.3 ± 5.4 months revealed no recurrence in the maze group compared with 39.2% in the conventional group. CONCLUSIONS: The maze-making and solving technique achieves high coil-packing attenuation for efficient embolization of large and giant cerebral aneurysms with a low risk of recurrence.

Three-dimensional morphology and bony range of movement in hip joints in patients with hip dysplasia.

To confirm whether developmental dysplasia of the hip has a risk of hip impingement, we analysed maximum ranges of movement to the point of bony impingement, and impingement location using three-dimensional (3D) surface models of the pelvis and femur in combination with 3D morphology of the hip joint using computer-assisted methods. Results of computed tomography were examined for 52 hip joints with DDH and 73 normal healthy hip joints. DDH shows larger maximum extension (p = 0.001) and internal rotation at 90° flexion (p < 0.001). Similar maximum flexion (p = 0.835) and external rotation (p = 0.713) were observed between groups, while high rates of extra-articular impingement were noticed in these directions in DDH (p < 0.001). Smaller cranial acetabular anteversion (p = 0.048), centre-edge angles (p < 0.001), a circumferentially shallower acetabulum, larger femoral neck anteversion (p < 0.001), and larger alpha angle were identified in DDH. Risk of anterior impingement in retroverted DDH hips is similar to that in retroverted normal hips in excessive adduction but minimal in less adduction. These findings might be borne in mind when considering the possibility of extra-articular posterior impingement in DDH being a source of pain, particularly for patients with a highly anteverted femoral neck.

Near-infrared spectroscopy in carotid artery stenting predicts cerebral hyperperfusion syndrome.

OBJECTIVE: Cerebral hyperperfusion syndrome (CHS) following carotid artery stenting (CAS) or carotid endarterectomy (CEA) is rare but often fatal once intracranial hemorrhage has occurred. In particular, CHS occurs significantly earlier after CAS than after CEA. Thus a monitoring method for early detection of CHS is required. Near-infrared spectroscopy (NIRS) provides a noninvasive monitoring technique for assessing regional cerebral oxygen saturation (rSO2). This study evaluated the usefulness of transcranial NIRS during CAS for prediction of CHS. METHODS: Periprocedural rSO2 was monitored in 64 cases of CAS (52 men, 12 women; 71 +/- 6.6 years). The average degree of carotid stenosis was 76.8 +/- 11.3% by North American Symptomatic Carotid Endarterectomy Trial criteria. Bifrontal rSO2 was monitored during the procedure using NIRS. Seventeen patients were symptomatic and 47 were asymptomatic. CHS was diagnosed by increased cerebral blood flow by SPECT performed on the day after treatment with deterioration of neurologic symptoms. RESULTS: CHS was observed in two cases (3.1%). In the CHS group, post-reperfusion rSO2 values increased >24% from baseline until 3 minutes after reperfusion. In the non-CHS group, the normal upper limit (NUL) of the rSO2 change was set at 10.0% at 3 minutes after reperfusion. In the CHS group, rSO2 at 3 minutes after reperfusion was markedly higher than the NUL. In patients showing an rSO2 at 3 minutes after reperfusion increased by more than 10.0%, CHS following CAS could be predicted. CONCLUSION: Periprocedural increases in regional cerebral oxygen saturation measured by near- infrared spectroscopy can be an excellent predictor of cerebral hyperperfusion syndrome after carotid artery stenting.

Percutaneous angioplasty and stenting of subclavian arteries before surgical coronary revascularization in a patient with an aberrant right subclavian artery.

An aberrant right subclavian artery occurs in less than 2% of the population. An associated stenosis of the subclavian artery carries a risk of subclavian-coronary steal in patients who undergo coronary revascularization. We report on the case of a 54-year-old man admitted to our hospital for a coronary artery bypass graft (CABG). Angiographic examination revealed bilateral subclavian-artery stenosis with an aberrant right subclavian artery, anomalous origin of the right vertebral artery from the right common carotid artery, and left vertebral-artery occlusion. The patient underwent successful bilateral subclavian angioplasty and stenting.

Result of neck clipping and coil embolization as a treatment for unruptured aneurysm.

SUMMARY: The report of the International Subarachnoid Aneurysm Trial (ISAT) study showed that coil embolization was superior to neck clipping as a treatment for subarachnoid hemorrhage (SAH) (1). Recently, some results of treatments for unruptured aneurysm via coil embolization and neck clipping have been reported (2,3).We compared the results of coil embolization and neck clipping in our institute. Generally better outcomes were obtained by endovascular surgery than by neck clipping. Postoperative ischemic strokes occurred in one case (1.8%) as a major stroke and in three cases (5.6% ) as a minor stroke among coil-treated cases, and in two cases(2.6%) as a major stroke, and in seven cases(9.0%) as a minor stroke among neck clipping cases. Other complications after these treatments were six cases of subdural effusion/hematoma, four cases of infection, two cases of epidural hematoma, one abducens nerve palsy, one hydrocephalus, and one acute myocardial infarction among 78 neck clipping cases, and two subcutaneous hematoma, one pseudoaneurysm at the puncture points, one direct carotid-cavernous fistula among 54 coil-treated cases. Four coil-treated cases, in which introduction of microcatheters to the aneurysm was impossible, were treated completely by neck clipping after endovascular treatments. In terms of modified Rankin Scale(mRS) three months after treatments, while mRS 3 was noted in only one case in the endovascular treatment group, there were one case of mRS 3, two cases of mRS 4, and two cases of mRS 5 in the neck clipping group. Duration of hospitalization averaged 11.9 days in the endovascular group and 24.1 days in the neck clipping group. The results of endosaccular enbolizations as treatment of the unruptured aneurysm seems to be better than neck clipping. However, not all cases of unruptured aneurysms can be treated by coil embolization due to the width of aneurysmal neck and relation of the aneurysm to parent arteries. Therefore, surgeons should also be able to perform neck clipping as an alternative modality.

Result of neck clipping and coil embolization as a treatment for subarachnoid haemorrhage.

SUMMARY: The report of the International Subarachnoid Aneurysm Trial (ISAT) study showed that coil embolization was superior to neck clipping as a treatment for subarachnoid haemorrhage (SAH) (1). We compared the results of coil embolization and neck clipping in our institute. Generally better outcomes were obtained by endovascular surgery than neck clipping. Symptomatic vasospasm and symptomatic hydrocephalus occurred less frequently in coil embolization than neck clipping. Because not all cases of SAH can be treated by coil embolization due to the width of aneurysmal neck and relation of the aneurysm to parent arteries, we should also be able to perform neck clipping as another modality.

[Osteoma originating in the dura: a case report].

We report a case of intracranial osteoma attached to the dura. The patient, a 35-year-old man, had suffered several episodes of vertigo over the previous two years. Physical and neurological findings on admission were unremarkable. A plain craniogram showed a dense calcified mass in the right frontal area, and CT revealed a homogeneous high-density mass without significant enhancement. MRI confirmed the dural origin of the lesion, which showed hyperintensity in the T1-weighted image and low intensity in the T2-weighted image. The mass was 5 cm in diameter and 2 cm in thickness. Total resection was performed under a preoperative diagnosis of calcified meningioma. Histopathology revealed the mass to be an osteoma. Osteomas are common benign bone tumors that usually arise from long bones of the extremities. Intracranial osteomas are extremely rare lesions. The literature on intracranial osteoma of dural origin is reviewed.

[Combined endovascular stent implantation and coil embolization for the treatment of a vertebro-basilar fusiform aneurysm: technical case report].

We describe a case of the combined application of endovascular stent implantation and Guglielmi detachable coil packing for the treatment of a vertebro-basilar fusiform aneurysm and review the literature on stent placement to treat cerebral aneurysms. A 70-year-old female presented with an acute headache from subarachnoid hemorrhage. A fusiform aneurysm with a broad-based neck and dome, measuring 15 mm, involving the union of the vertebral arteries and the proximal basilar artery was demonstrated on cerebral angiography. The aneurysm was judged to be inoperable and treated conservatively. Twelve days later the patient was transferred to our hospital for endovascular therapy. An intravascular stent (MultiLink) was placed across the base of the aneurysm through the right vertebral artery. After this, coil placement in the aneurysm around the stent was performed via a microcatheter guided from the left vertebral artery. After that a microcatheter was guided from the right vertebral artery through the interstices of the stent into the aneurysm, and additional coils were placed. Final angiography showed subtotal occlusion of the aneurysm and excellent blood flow of the parent artery through the stent. There were no new neurological deficits. Neither rerupture nor ischemic event has occurred. The use of stents provides another treatment for managing the difficult entity of intracranial aneurysms.

Important role of the hepatic vagus nerve in glucose uptake and production by the liver.

We examined the role of the hepatic vagus nerve in hepatic and peripheral glucose metabolism. To assess endogenous glucose production (EGP), hepatic uptake of first-pass glucose infused intraportally (HGU), and the metabolic clearance rate of glucose (MCR), rats were subjected to hepatic vagotomy (HV, n = 7) or sham operation (SH, n = 8), after 10 days, they were then subjected to a euglycemic-hyperinsulinemic clamp together with a portal glucose load in the 24-hour fasting state. Metabolic parameters were determined by the dual-tracer method using stable isotopes. During the experiment, [6,6-2H2]glucose was continuously infused into the peripheral vein. To maintain euglycemia (4.5 mmol/L), insulin (54 pmol x kg(-1) x min(-1)) and glucose were infused peripherally after the 90-minute tracer equilibration and 30-minute basal periods, and glucose containing 5% enriched [U-13C]glucose was infused intraportally (50 micromol x kg(-1) x min(-1)) for 120 minutes (clamp period). EGP was significantly higher in HV rats versus SH rats during the basal period (64.3 +/- 7.6 v 43.6 +/- 5.3 micromol x kg(-1) x min(-1), P < .005)) and was comparable to EGP in SH rats during the clamp period (9.3 +/- 21.5 v 1.1 +/- 11.7 micromol x kg(-1) x min(-1)). HGU was reduced in HV rats compared with SH rats during portal glucose infusion (5.9 +/- 2.4 v 10.1 +/- 3.2 micromol x kg(-1) x min(-1)). The MCR in HV rats was significantly higher than in SH rats in the basal period (11.0 +/- 2.0 v 7.9 +/- 0.8 mL x kg(-1) x min(-1), P < .01)) and was comparable to the MCR in SH rats during the clamp period (41.9 +/- 10.0 and 36.6 +/- 5.7 mL x kg(-1) x min(-1)). We conclude that innervation of the hepatic vagus nerve is important for the regulation of hepatic glucose production in the postabsorptive state and HGU in the postprandial state.

A grading system for intracranial arteriovenous malformations applicable to endovascular procedures.

SUMMARY: A grading system was designed by the first author (B.S.) specifically to predict the difficulty of endovascular obliteration of an intracranial arteriovenous malformation based on the feeding arterial characteristics, and the venous drainage system. We have retrospectively reviewed our cases of intracranial arteriovenous malformation, with special interest in those underwent endovascular embolization. The grading of the AVM was by either our new proposed system or by a surgically oriented grading system. Both systems were compared from the endovascular point of view.Using the present proposed grading system intracranial arteriovenous malformation may range from grade I to grade V. The difficulty of the endovascular embolization correlated well with the new grading system, while in most cases it did not reflect the degree of difficulty of the procedure when a pure surgical grading system was used. This newly designed grading system has a better prediction value to the difficulty of performing endovascular embolization than does other grading systems.

Embolic Complications of Endovascular Surgery for Cerebrovascular Diseases. Evaluation with Diffusion-Weighted MR Imaging.

SUMMARY: The purpose of this study was to evaluate asymptomatic embolisms during cerebral endovascular surgery for cerebrovascular diseases with diffusion-weighted magnetic resonance imaging (DWI) which allowed sensitive and early detection of cerebral ischemic lesions. 71 patients who underwent a total of 74 cerebral endovascular procedures were subjected to DWI screening study. MR imaging was performed on a 1.5T system by using single-shot SE echo-planar imaging (EPI) with b value of 1100 seconds per mm(2) in pre- and post-treatment periods (between day 2 and 5 after procedures). In 38 (51.3%) of 74 procedures, new high intensity lesions, as recent infarctions related to procedures, were detected on post-procedural DWI. In 18 Of the patients (47.4%), symptomatic infarctions occurred and resulted in TIAs (n = 4), RINDs (n = 8), minor strokes (n = 6) and no major strokes and no death. 20 (52.6%) of the recent infarctions detected by DWI were asymptomatic lesions.Most of the asymptomatic ischemic lesions were likely to be distributed in watershed border areas. On the other hand, symptomatic lesions tended to be distributed in cortical and/or perforator regions and to be multiple. Thus, DWI is a useful method that can detect neurologically silent and asymptomatic ischemic lesions. It can be used to help to evaluate the safety and efficacy of neurovascular intervention.

Combination of intraischemic and postischemic hypothermia provides potent and persistent neuroprotection against temporary focal ischemia in rats.

BACKGROUND AND PURPOSE: It is not known whether a combination of intraischemic and postischemic mild hypothermia provides extra neuroprotection and if so, whether the neuroprotection is persistent. METHODS: Sixty-eight Sprague-Dawley rats were used. In group 1, ischemia and reperfusion were performed under normothermic (N) conditions (control, N-N). In group 2, ischemia was induced and maintained under hypothermic conditions (33 degrees C for 2 hours) and reperfusion was performed under normothermic conditions, H-N. In group 3, both ischemia and reperfusion were performed under hypothermic conditions for an additional 21 hours after the surgery, H-22H. In group 4, ischemia was induced and maintained under hypothermic conditions and reperfusion was performed under hypothermic conditions only for the initial 3 hours (H-3H). In group 5, ischemia was induced and maintained under normothermic conditions and reperfusion was performed under hypothermic conditions (33 degrees C) (N-22H). All rats were perfused 48 hours after the induction of ischemia. In addition, the normothermic or hypothermic therapy used for groups 1, 3, and 4 was performed again, and these rats were killed 30 days after the induction of ischemia. Furthermore, neurological deficits were monitored in groups N-N and H-22H for 4 weeks. RESULTS: In the H-3H and H-22H groups, the total infarct volume was significantly reduced by 41% or 66%, respectively, assessed 48 hours after ischemia. The significant reduction in group H-22H was again confirmed 30 days after ischemia, ie, 50% reduction was observed. In contrast, the reduction in group H-3H (31%) was not significant. The neurological deficits were significantly more severe in the N-N group than in the H-22H group during week 4. CONCLUSIONS: The neuroprotective effects against temporary focal ischemia evaluated by infarct volume and neurological functions by the combination therapy with intraischemic and prolonged postischemic mild hypothermia were persistent in rats. Appropriate design of mild hypothermia therapy extending into the late reperfusion period is important to maximize the neuroprotective effects of hypothermia.

[Endovascular surgery for untreated ruptured aneurysm with symptomatic vasospasm].

It is difficult to treat ruptured aneurysms with symptomatic vasospasm. Although direct surgery for such cases is associated with poor outcomes, conservative therapy has the risk of both rerupture and infarction. In two cases of ruptured aneurysms with symptomatic vasospasm, we performed aneurysmal coil embolization with Guglielmi electrodetatchable coils (GDC). At the same time we performed percutaneous transluminal angioplasty (PTA) with papaverine infusion. In both cases, rerupture did not occur and PTA was effective angiographically. A good outcome was achieved in case 1. However, broad cerebral infarction occurred in case 2, in which the patient had shown severe symptomatic vasospasm on admission. In advanced cases, such as in case 2, the outcome is poor. The aneurysm may not be able to be approached before PTA because of severe vasospasm. In such cases, PTA must be performed carefully to avoid aneurysmal rerupture. Intraarterial papaverine infusion is safer than PTA for severe spasm in distal vessels. However the efficacy of papaverine is known to be transient in many cases. It is often difficult to determine the exact relationship between branches and the aneurysm in the presence of vasospasm. In such cases, we recommend that the rupture point be packed and that the aneurysmal neck remain unpacked. After vasospasm is cured and good general condition has been recovered, direct surgery can be performed. In summary, endovascular surgery is an effective option for treatment of ruptured aneurysm with symptomatic vasospasm.

Prevention of neointimal formation by a serine protease inhibitor, FUT-175, after carotid balloon injury in rats.

BACKGROUND AND PURPOSE: In vivo and vitro studies revealed the activation of thrombin and the complement system in vascular lesion formation during the process of atherosclerosis, along with pathological proliferation of smooth muscle cells. We examined the effect of the synthetic serine protease inhibitor FUT-175 (developed as a potent inhibitor of thrombin and the complement system) on vascular lesions using balloon dilatation-induced neointimal formation in the carotid artery of rats. METHODS: Sprague-Dawley (SD) rats underwent balloon dilatation injury of the left carotid artery to induce neointimal formation. Three groups of these rats (n=8, each) were treated with daily intraperitoneal injections of 1 of the following doses of FUT-175: 0.5, 1.0, or 2.0 mg/d in 1 mL of saline for 7 consecutive days. The control group (n=8) was similarly treated with 1 mL of saline for 7 days. The injections were started immediately after balloon injury. Two weeks after the injury, the left carotid arteries were perfusion-fixed, and the areas of the neointimal and medial layer were analyzed under a microscope. RESULTS: A morphometric analysis revealed that there were significant differences in the intima-media ratio between the 4 groups treated with vehicle (saline) or a low, medium, or high dose of FUT-175 (1.45+/-0.11, 1.08+/-0.06, 0.71+/-0.04, or 0.32+/-0.04, respectively). This suppression was achieved in a dose-dependent manner by the administration of FUT-175 after balloon injury. In the histological study, it was demonstrated that FUT-175 suppresses the production of platelet-derived growth factor (PDGF)-BB in the neointima and the medial smooth muscle cell layer. CONCLUSIONS: After balloon injury activated proteases that were inhibited by FUT-175 were demonstrated to have an essential role in the development of the pathological thickening of the arterial wall.

Endovascular treatment of aneurysms on the feeding arteries of intracranial arteriovenous malformations.

The association between intracranial aneurysms and arteriovenous malformations (AVMs) is well documented. Recent advances in the understanding of the haemodynamics of this association encourage an aggressive approach to these aneurysms. However, the pathophysiology of these aneurysms is not fully understood and a strategy for their management has not been established. We describe seven patients, with eight aneurysms, on the feeding arteries of AVMs. The aneurysms could be divided into those located 1. proximally on the superficial feeding artery (type I; 4 aneurysms); 2. distally on the superficial feeding artery (type II; 3 aneurysms); and 3. on the deep feeding artery (type III; 1 aneurysm). All aneurysms were treated by the endovascular procedure prior to, or simultaneously with, treatment of the AVM, using detachable coils or liquid embolic material. All aneurysms were obliterated successfully, with no adverse events. Each patient further received treatment of the AVM. None of the patients suffered intracranial haemorrhage after treatment for the aneurysms. Based on our experiences, we discuss the indications for this approach for each type of aneurysm. We believe endovascular treatment could be an important alternative for treatment of aneurysms associated with AVMs, thus reducing the risk of haemorrhage.

Delayed thrombus propagation after parent artery clipping for giant fusiform aneurysms of the circle of Willis.

BACKGROUND: Obliteration of a giant fusiform aneurysm without significant therapeutic morbidity is extremely difficult. Ischemic complications have been often reported. METHODS: Two patients with giant fusiform aneurysms of the circle of Willis are presented. Both patients underwent proximal parent artery clipping after a bypass procedure. Balloon occlusion tests confirmed both patients' ability to tolerate flow reduction after proximal clipping. RESULTS: Although both patients awoke from anesthesia without neurologic deficit, they developed contralateral hemiparesis several hours after the operation as a result of a small infarct in the basal ganglia. These ischemic events might be attributed to the delayed thrombosis involving the orifice of the distal perforating arteries. CONCLUSIONS: In the treatment for giant fusiform aneurysms of the circle of Willis, special attention should be paid not only to flow reduction, but also to delayed thrombus propagation that may not be predicted by preoperative balloon occlusion testing.

High plasma free fatty acids decrease splanchnic glucose uptake in patients with non-insulin-dependent diabetes mellitus.

It has been proposed that high plasma free fatty acid (FFA) levels observed in patients with non-insulin dependent diabetes mellitus (NIDDM) contribute to the development of their insulin resistance. We examined patients with NIDDM to find whether maintaining plasma FFA levels in the fasting range with a euglycemic hyperinsulinemic clamp combined with an oral glucose load (clamp OGL) would affect insulin-mediated peripheral glucose uptake (PGU) and splanchnic glucose uptake (SGU). Nine NIDDM subjects (age, 55 +/- 3 years; duration of diabetes, 11 +/- 2 years; body mass index, 21.0 +/- 0.4 kg/m2; hemoglobin A1c, 9.0 +/- 0.3%; fasting plasma glucose, 9.4 +/- 3.0 mmol/l, means +/- SEM) were hospitalized and treated with diet, oral hypoglycemic agents or insulin for at least 2 weeks to maintain fasting plasma glucose < 8 mmol/l. All the patients were subjected to two different protocols in a random order. On one protocol, under the hyperinsulinemic condition, FFAs were maintained at the their fasting levels (1.19 +/- 0.08) by triglyceride emulsion infusion (Lipid infusion study, L), and on the other protocol, FFAs were made to fall (0.26 +/- 0.06 mmol/l) with saline instead of triglyceride emulsion infusion (Saline infusion study, S). During euglycemic (L, 5.4 +/- 0.2; S, 5.1 +/- 0.2 mmol/l) hyperinsulinemic (L, 1377 +/- 108; S, 1328 +/- 67 pmol/l) clamp, high FFA levels significantly reduced PGU (L, 26.7 +/- 3.6; S, 32.1 +/- 3.4 mumol.kg-1.min-1, P < 0.05) and SGU (L, 12.1 +/- 4.2; S, 27.5 +/- 5.6%, P < 0.05). In conclusion, high FFA levels in patients with NIDDM impaired insulin-mediated glucose uptake in the splanchnic as well as peripheral tissues.