Intracranial angioplasty and stenting: long-term results from a single center.

BACKGROUND AND PURPOSE: Large-vessel intracranial atherosclerotic stenosis carries a proved stroke risk of 8%-22% per year with "best medical therapy." The long-term clinical neurologic and angiographic outcomes of angioplasty and/or stent placement for intracranial atherosclerosis in a consecutive series of patients are presented. METHODS: The demographics, procedural details, procedural outcome, and long-term neurologic follow-up in 60 consecutive patients with 71 lesions, undergoing a total of 84 procedures, were analyzed. RESULTS: Angioplasty alone was performed in 62 procedures; 22 procedures involved stent placement. The periprocedural stroke+death rate was 4.8%. The overall complication-free success rate was 90.5%. Restenosis occurred in 23 lesions at a mean of 4.6 months; 13 were re-treated without complication. There were 4 strokes and 4 non-neurologic deaths during 224 patient-years of follow-up. The annualized stroke rate was 1.8%, and the annualized stroke+all-cause death rate was 3.0%. CONCLUSIONS: The stroke and death rates in this consecutive series of patients with severe intracranial atherosclerotic stenosis treated with optimal endovascular therapy are considerably less than those associated with the natural history of intracranial atherosclerosis treated with maximal medical therapy. Intracranial angioplasty with conditional stent placement is technically feasible and clinically effective with a substantial reduction in long-term stroke and death.

Transcatheter interventions for the treatment of peripheral atherosclerotic lesions: part II.

Transcatheter endovascular procedures are increasingly used to treat symptomatic peripheral atherosclerosis. This second part of a two-part review assesses the existing supportive evidence for the application of recently introduced transcatheter treatments for lesions that cause cerebrovascular ischemia and stroke. Studies were identified via MEDLINE (January 1993 through April 1999) and reference lists of identified articles. When multicenter prospective randomized trials or other high-quality studies were unavailable, studies with at least 50 patients per treated group and a minimum follow-up duration of 6 months were included. For each application, the authors assessed the quality of evidence (efficacy, safety, and, where available, cost-effectiveness) and made recommendations with appropriate caveats. Although recommendations based on proven efficacy and cost-effectiveness cannot be made in general, the use of transcatheter therapies can be supported in specific circumstances based on expected reduction in procedure-related morbidity and/or mortality. It is hoped that the identification of deficiencies in the literature will inform and inspire critically needed research in this area.

Percutaneous transluminal angioplasty for intracranial atherosclerotic lesions: evolution of technique and short-term results.

OBJECT: A retrospective analysis of a 9-year experience with balloon angioplasty for intracranial atherosclerotic stenosis was undertaken with the goals of illustrating development of a safe technique for treatment of intracranial atherosclerotic disease and reporting the immediate results in this series of patients. METHODS: Three distinct periods are defined, based on the technique used. In the early period, in which eight patients were treated, the angioplasty balloon size approximated the vessel size, but was always smaller. Angioplasty was moderately rapid and brief (15-30 seconds). Clinical improvement occurred in seven (87.5%) of eight patients, dissection without consequence occurred in four (50%) of eight, and residual stenosis greater than 50% was found in three (37.5%) of eight. No neurological complications occurred. In the middle period, in which 12 patients were treated, the balloon size approximated the vessel size, but oversizing by up to 0.25 mm was permitted. Angioplasty was extremely rapid and brief. Angiographically visible dissection occurred in nine (75%) of 12 patients, necessitating urokinase infusion in five (41.7%) of 12 and producing abrupt occlusion in one (8.3%) of 12, resulting in death. Occlusion secondary to the recrossing of the lesion occurred in one (8.3%) of 12, resulting in stroke. Good outcome was eventually achieved in 10 (83.3%) of 12. In the current period, in which 50 patients have been treated, the balloon is always undersized and inflation is extremely slow (several minutes). Dissection occurred in seven (14%) of 50 patients, necessitating fibrinolysis in two of 50 (4%, both uneventful) and producing no abrupt occlusion or stroke. Residual stenosis greater than 50% occurred in eight (16%) of 50, with no stenosis greater than 70%. Late restenosis occurred in four (9%) of 44 and successful repeated angioplasty was performed in all four. One guidewire vessel perforation occurred (2%), resulting in the patient's death. Good angiographic and short-term clinical outcome was achieved in the other 49 patients (98%). CONCLUSIONS: Extremely slow balloon inflation combined with balloon undersizing results in decreased intimal damage, decreased acute platelet/thrombus deposition, and decreased acute closure. This technique sometimes yields suboptimal angiographic results but achieves the clinical goal safely. Intracranial angioplasty can be safely performed using this technique and modern equipment.

Emergency endovascular treatment of stroke.

The key to treating arterial or venous vascular occlusive process is to remove the occluding thrombus. We review the available thrombolytic agents and their potential benefits and complications. The results of recent clinical trials are discussed along with strategies for treating intracranial arterial occlusion and venous sinus thrombosis.

Outcomes of ultrasound diagnosis of ectopic pregnancy. Dependence on observer experience.

BACKGROUND: The effect of examiner experience on the detection of ultrasound findings in ectopic pregnancy was assessed in a retrospective study. METHODS: Records and examinations of 267 consecutive patients with surgically proven ectopic pregnancy were reviewed. Patients were divided into two groups: (1) those who were examined by faculty during the day (182 examinations) and (2) those who were examined by resident physicians at night (85 examinations). RESULTS: A statistical difference was found in the incidence of adnexal mass, free fluid, sac within the mass, and corpus luteum cyst. CONCLUSION: Examiner experience has a strong effect on the diagnostic accuracy of ultrasound examination. Adnexal abnormalities may be difficult to identify because of confusion with loops of bowel or other pelvic structures. Faculty follow-up and review are important in patient management.

Ruptured pelvic appendix diagnosed by transvaginal sonography.

BACKGROUND: Appendicitis in a pelvic appendix can be difficult to diagnose. Transvaginal sonography may help to visualize an inflamed pelvic appendix. CASE: A 31-year-old woman presented to the hospital with symptoms suggestive of pelvic inflammatory disease. Transabdominal ultrasound, useful in the diagnosis of appendicitis, showed a mass between the uterus and the right ovary. Transvaginal ultrasound clarified the finding as a bulbous fluid-filled structure extending into the cul-de-sac. The structure was diagnosed as an inflamed appendix. Laparoscopic appendectomy was performed, and the patient had an uneventful recovery. CONCLUSION: To our knowledge, this is the first case of appendicitis diagnosed with transvaginal sonography. Transvaginal sonography can delineate the features of an inflamed pelvic appendix and help to narrow the diagnostic possibilities in symptomatic women of childbearing age.

Basilar artery occlusion in rats.

The basilar artery is one of the three major sources of blood supply to the circle of Willis. To investigate the effects of basilar artery occlusion, we surgically exposed and coagulated the basilar artery in 25 rats. Basilar artery occlusion at any single point between the foramen magnum and the circle of Willis in 11 rats did not produce histologically detectable infarcts in the brain at 12-24 hours. Two-point occlusions of the basilar artery in 12 rats produced variable infarcts between the occlusion sites but no ischemic lesions elsewhere. After either single- or double-point occlusions, the proximal basilar artery refilled within 2-3 minutes. When the basilar artery was occluded above and below the origins of the anterior inferior cerebellar arteries, the artery segments between the occlusion points initially collapsed but refilled within 2-3 minutes in two rats. Basilar artery occlusions invariably suppressed cortical somatosensory evoked potentials by greater than 50%. Regardless of whether a brain stem infarct developed, somatosensory evoked potential amplitudes recovered to greater than baseline levels by 4 hours in seven of 17 rats and returned to baseline levels by 24 hours in every rat tested. We conclude that the occluded basilar artery receives extensive retrograde collateral blood flow and that somatosensory evoked potentials are exquisitely sensitive to basilar artery occlusion but are insensitive to whether brain stem infarcts develop.

Primary neuroendocrine (Merkel cell) carcinoma presenting in the calvarium: case report.

A case of a primary neuroendocrine carcinoma arising in the calvarium and involving the bone, dura, and underlying brain is presented. The histopathology and immunohistochemical staining characteristics of tumor were consistent with those of Merkel cell tumor. The natural history and histopathology of this tumor are discussed, along with the possible explanation for the origin of this tumor in the calvarium.

Extracellular potassium activity and axonal conduction in spinal cord of the myelin-deficient mutant rat.

We recorded somatosensory evoked potentials SEPs), extracellular K+ ionic activity ([K+]e), and K+ clearance rates in the spinal cords of 14 myelin-deficient mutant rats and 16 normal male littermates at 16-41 days after birth. Tested under pentobarbital anesthesia (25 mg/kg ip) and hypothermic conditions (32-34 degrees C), myelin-deficient rats had longer cortical SEP latencies (67 +/- 20 ms) compared to those in normal siblings (48 +/- 15 ms; P less than 0.05). Mean baseline [K+]e levels were 2.6 +/- 0.5 mM in myelin-deficient rats and 2.6 +/- 0.8 mM in normal siblings. Clearance times of KCl solutions injected into the spinal cord were biphasic and exponential. The mean initial and secondary exponential half-times were 1.0 +/- 0.5 and 2.7 +/- 1.7 min for myelin-deficient rats and 0.8 +/- 0.4 and 3.8 +/- 3.2 min for normal siblings. Repetitive sciatic nerve stimulation (2-20 Hz, 2- to 6-s trains) produced 1-3 mM transient [K+]e rises in thoracic and lumbar cords of myelin-deficient rats. The [K+]e rises were largest in the dorsal spinal cord at 200-500 microns depth. The normal siblings had smaller or no stimulus-induced [K+]e rises. In myelin-deficient rats, injection of 1 mM 4-aminopyridine (4-AP) solution into the thoracic spinal cord completely suppressed the stimulus-induced [K+]e and markedly increased spinal and cortical SEP amplitudes for several hours. In the normal siblings, the 4-AP injections transiently blocked spinal conduction for 20-30 min but thereafter enhanced cortical SEP amplitudes for 2-3 h. We conclude that sciatic nerve stimulation produces spinal cord [K+]e rises in myelin-deficient rat larger than those in the normal siblings, that the [K+]e transients represent increased K+ release rather than impaired K+ clearance, and that the K+ ions come from 4-AP blockable sources.

21-Aminosteroid reduces ion shifts and edema in the rat middle cerebral artery occlusion model of regional ischemia.

U74006F is a member of a new family of steroid drugs called 21-aminosteroids, which are potent inhibitors of lipid peroxidation with little or no glucocorticoid or mineralocorticoid activity. We investigated the effects of U74006F on the early ionic edema produced by middle cerebral artery occlusion in rats. Intravenous doses of 3 mg/kg U74006F were given 10 minutes and 3 hours after occlusion. Tissue concentrations of Na+, K+, and water at and around the infarct site were measured by atomic absorption spectroscopy and by wet-dry weight measurements 24 hours after occlusion. Compared with vehicle treatment, U74006F treatment reduced brain water entry, Na+ accumulation, K+ loss, and net ion shift by 25-50% in most brain areas sampled in the frontal and parietal cortex. However, reductions of ionic edema were most prominent and reached significance (p less than 0.005, unpaired two-tailed t test) mostly in the frontoparietal and parietal cortex areas adjacent to the infarct site. Our findings suggest that a steroid drug without glucocorticoid or mineralocorticoid activity can reduce edema in cerebral ischemia but that the effects are largely limited to tissues in which collateral blood flow may be present.

Intracranial hemorrhage and cocaine use.

Cocaine use has increased rapidly over the past few years. This has led to an increase in the number and variety of cocaine-related conditions for which medical attention is sought. Among these have been several cases of intracranial hemorrhage. Four cases reported in the literature and 6 from our own institution are presented here. They represent different diagnoses including hemorrhage from aneurysms and arteriovenous malformations, hemorrhage into a tumor, and spontaneous hemorrhage with no underlying lesion with and without preexisting hypertension. Analysis of these cases suggests that the hypertension induced by cocaine secondary to sympathetic stimulation may be the common factor. Cocaine may also cause arterial spasm. Although the pathophysiology has not been entirely resolved, the clinical significance of this association is clear. Intracranial hemorrhage should be considered in the differential diagnosis whenever a patient presents with an acute alteration in neurologic examination associated with cocaine use.