Hospitalized COVID-19 Patients Were Five Times More Likely to Suffer From Total Sleep Deprivation Compared to Non-COVID-19 Patients; an Observational Comparative Study.

Objectives: Sleeping disorders are a common complaint in patients who suffer from an acute COVID-19 infection. Nonetheless, little is known about the severity of sleep disturbances in hospitalized COVID-19 patients, and whether these are caused by disease related symptoms, hospitalization, or the SARS-CoV-2 virus itself. Therefore, the aim of this study was to compare the quality and quantity of sleep in hospitalized patients with and without COVID-19, and to determine the main reasons for sleep disruption. Methods: This was an observational comparative study conducted between October 1, 2020 and February 1, 2021 at the pulmonary ward of an academic hospital in the Netherlands. This ward contained both COVID-19-positive and -negative tested patients. The sleep quality was assessed using the PROMIS-Sleep Disturbance Short Form and sleep quantity using the Consensus Sleep Diary. Patient-reported sleep disturbing factors were summarized. Results: A total of 79 COVID-19 patients (mean age 63.0, male 59.5%) and 50 non-COVID-19 patients (mean age 59.5, male 54.0%) participated in this study. A significantly larger proportion of patients with COVID-19 reported not to have slept at all (19% vs. 4% of non-COVID-19 patients, p = 0.011). The Sleep quality (PROMIS total score) and quantity (Total Sleep Time) did not significantly differ between both groups ((median PROMIS total score COVID-19; 26 [IQR 17-35], non-COVID-19; 23 [IQR 18-29], p = 0.104), (Mean Total Sleep Time COVID-19; 5 h 5 min, non-COVID-19 mean; 5 h 32 min, p = 0.405)). The most frequently reported disturbing factors by COVID-19 patients were; 'dyspnea', 'concerns about the disease', 'anxiety' and 'noises of other patients, medical staff and medical devices'. Conclusion: This study showed that both patients with and without an acute COVID-19 infection experienced poor quality and quantity of sleep at the hospital. Although the mean scores did not significantly differ between groups, total sleep deprivation was reported five times more often by COVID-19 patients. With one in five COVID-19 patients reporting a complete absence of night sleep, poor sleep seems to be a serious problem. Sleep improving interventions should focus on physical and psychological comfort and noise reduction in the hospital environment.

Initial Experience With Hand-Assisted Laparoscopic Living Donor Nephrectomy: Training and Clinical Practice as a General Surgeon.

BACKGROUND: To analyze our initial results of hand-assisted laparoscopic living donor nephrectomy, executed by a skilled gastrointestinal surgeon. METHODS: A total of 22 consecutive patients underwent the hand-assisted laparoscopic living donor nephrectomy between December 2014 and January 2017. We retrospectively analyze the patient's perioperative clinical data, which were collected prospectively. RESULTS: The right kidney was harvested in 12 patients. The mean operative time and intraoperative blood loss was 241.0 ± 43.4 minutes (range, 140-310 min) and 293.2 ± 203.1 mL (range, 50-700 mL), respectively. The mean warm ischemic time was 288.4 ± 103.4 seconds (range, 179-610 s). Postoperative complications included chyle leakage in 2 patients who were left kidney donors and oliguria in 1 patient who was a right kidney donor. All patients recovered with conservative care, and the mean hospital stay was 7.5 ± 1.7 days. The mean creatinine level was 0.7 ± 0.2 mg/dL before surgery, 1.1 ± 0.3 mg/dL at postoperative day (POD) 1, and 1.0 ± 0.2 mg/dL after discharge. The mean glomerular filtration rate was 97.9 ± 18.2 mL/min/1.73 m2 before surgery, 60.7 ± 10.4 at POD 1, and 67.3 ± 11.1 after discharge. Operation time was not associated with patient body mass index and case number. No significant differences, other than postoperative complications, were found in the perioperative data for the side of kidney donation. CONCLUSION: A skilled surgeon with experience in laparoscopic abdominal surgery (such as gastrectomy or colectomy) might safely perform hand-assisted donor nephrectomy. However, we could not identify a clear case number to complete the learning curve.

An OLTAM system for analysis of brown/beige fat thermogenic activity.

BACKGROUND/OBJECTIVES: Thermogenic fat is present in humans and emerging evidence indicates that increasing the content and activity of these adipocytes may lead to weight loss and improved metabolic health. Multiple reporter systems have been developed to assay thermogenic fat activity based on the transcriptional and translational activation of Ucp1, the key molecule that mediates nonshivering thermogenesis. Our study aims to develop a much-needed tool to monitor thermogenic fat activity through a mechanism independent of Ucp1 regulation, therefore effectively assaying not only canonical ß-adrenergic activation but also various non-UCP1-mediated thermogenic pathways that have been increasingly appreciated. METHODS: We detected increased luciferase activity upon thermogenic activation in interscapular brown and inguinal subcutaneous fat in ODD-Luc mice, a hypoxia reporter mouse model. We then developed an OLTAM (ODD-Luc based Thermogenic Activity Measurement) system to assay thermogenic fat cell activity. RESULTS: In both primary murine and human adipocytes and an immortalized adipose cell line that were transduced with the OLTAM system, luciferase activity can be readily measured and visualized by bioluminescence imaging in response to a variety of stimuli, including UCP1-independent thermogenic signaling. This system can offer a convenient method to assay thermogenic activity for both basic and translational research. CONCLUSIONS: The OLTAM system offers a convenient way to measure the activation of thermogenic fat and presents opportunities to discover novel signaling pathways and unknown compounds targeting metabolically active adipocytes to counteract human obesity.

Blood profile and meat quality of Holstein-Friesian steers finished on total mixed ration or flaxseed oil-supplemented pellet mixed with reed canary grass haylage.

Holstein-Friesian steer beef production is renowned globally as a secondary product of the milk industry. Grass feeding is a common practice in raising Holstein steers because of its low cost. Furthermore, grass feeding is an alternative way to produce beef with a balanced n-6 to n-3 fatty acids (FAs) ratio. However, the performance and meat quality of Holstein-Friesian cattle is more likely to depend on a high-quality diet. The aim of this study was to observe whether feeding two mixed diets; a corn-based total mixed ration (TMR) with winter ryegrass (Lolium perenne) or flaxseed oil-supplemented pellets with reed canary grass haylage (n-3 mix) provided benefits on carcass weight, meat quality and FA composition compared with cattle fed with reed canary grass (Phalaris arundinacea) haylage alone. In all, 15 21-month-old Holstein-Friesian steers were randomly assigned to three group pens, were allowed free access to water and were fed different experimental diets for 150 days. Blood samples were taken a week before slaughter. Carcass weight and meat quality were evaluated after slaughter. Plasma lipid levels and aspartate aminotransferase (AST), γ-glutamyl transpeptidase (GGT), creatine kinase (CK) and alkaline phosphatase (ALP) activities were determined. Diet did not affect plasma triglyceride levels and GGT activity. Plasma cholesterol levels, including low-density and high-density lipoproteins, were higher in both mixed-diet groups than in the haylae group. The highest activities of plasma AST, CK and ALP were observed in the haylage group, followed by n-3 mix and TMR groups, respectively. Carcass weight was lower in the haylage group than in the other groups and no differences were found between the TMR and n-3 mix groups. Although the n-3 mix-fed and haylage-fed beef provided lower n-6 to n-3 FAs ratio than TMR-fed beef, the roasted beef obtained from the TMR group was more acceptable with better overall meat physicochemical properties and sensory scores. According to daily cost, carcass weight and n-6 to n-3 FAs ratio, the finishing diet containing flaxseed oil-supplemented pellets and reed canary grass haylage at the as-fed ratio of 40 : 60 could be beneficial for the production of n-3-enriched beef.

Bilateral Extracranial Carotid Artery Aneurysms Treated by Staged Surgical Repair.

INTRODUCTION: Bilateral extracranial carotid artery aneurysms (ECAAs) are very rare. The case of a patient with bilateral ECAA who underwent staged surgical repair is reported. REPORT: A 35 year old man was referred with a slow growing pulsatile neck mass causing mild discomfort. Computed tomography and duplex ultrasound showed a right ECAA, with a 3.0 cm diameter 5 cm long true aneurysm, and a left ECAA, with 2.1 cm diameter 4.5 cm long true aneurysm. In two stages, both aneurysms were excised and bypassed with an interposition graft using saphenous vein. DISCUSSION: ECAAs are rare with an incidence of about 4% of all peripheral aneurysms. Selection of treatment options is largely dependent on the aneurysm anatomy, including size and length. During open repair, it is important to avoid nerve injury.

Glycerol-3-phosphate acyltransferase-1 upregulation by O-GlcNAcylation of Sp1 protects against hypoxia-induced mouse embryonic stem cell apoptosis via mTOR activation.

Oxygen signaling is critical for stem cell regulation, and oxidative stress-induced stem cell apoptosis decreases the efficiency of stem cell therapy. Hypoxia activates O-linked ß-N-acetyl glucosaminylation (O-GlcNAcylation) of stem cells, which contributes to regulation of cellular metabolism, as well as cell fate. Our study investigated the role of O-GlcNAcylation via glucosamine in the protection of hypoxia-induced apoptosis of mouse embryonic stem cells (mESCs). Hypoxia increased mESCs apoptosis in a time-dependent manner. Moreover, hypoxia also slightly increased the O-GlcNAc level. Glucosamine treatment further enhanced the O-GlcNAc level and prevented hypoxia-induced mESC apoptosis, which was suppressed by O-GlcNAc transferase inhibitors. In addition, hypoxia regulated several lipid metabolic enzymes, whereas glucosamine increased expression of glycerol-3-phosphate acyltransferase-1 (GPAT1), a lipid metabolic enzyme producing lysophosphatidic acid (LPA). In addition, glucosamine-increased O-GlcNAcylation of Sp1, which subsequently leads to Sp1 nuclear translocation and GPAT1 expression. Silencing of GPAT1 by gpat1 siRNA transfection reduced glucosamine-mediated anti-apoptosis in mESCs and reduced mammalian target of rapamycin (mTOR) phosphorylation. Indeed, LPA prevented mESCs from undergoing hypoxia-induced apoptosis and increased phosphorylation of mTOR and its substrates (S6K1 and 4EBP1). Moreover, mTOR inactivation by rapamycin (mTOR inhibitor) increased pro-apoptotic proteins expressions and mESC apoptosis. Furthermore, transplantation of non-targeting siRNA and glucosamine-treated mESCs increased cell survival and inhibited flap necrosis in mouse skin flap model. Conversely, silencing of GPAT1 expression reversed those glucosamine effects. In conclusion, enhancing O-GlcNAcylation of Sp1 by glucosamine stimulates GPAT1 expression, which leads to inhibition of hypoxia-induced mESC apoptosis via mTOR activation.

Combination of Multicatheter Plus Stent or Balloon for Treatment of Complex Aneurysms.

BACKGROUND AND PURPOSE: Coiling of complex aneurysms is still difficult even with current adjuvant techniques. This study sought to evaluate the safety and effectiveness of a combination of multicatheter plus stent or balloon for the treatment of complex aneurysms. MATERIALS AND METHODS: All complex aneurysms that underwent coiling with the combination technique were identified from prospectively maintained neurointerventional data bases. "Complex aneurysm" was defined as a wide-neck aneurysm with branch incorporation into or a deep lobulation of the sac. The clinical and angiographic outcomes were retrospectively analyzed. RESULTS: Sixty-two complex aneurysms (12 ruptured, 50 unruptured) in 62 patients (mean age, 57 years; male/female ratio, 12:50) were treated with a combination technique by using a multicatheter plus stent (n = 42, 3 ruptured) or balloon (n = 20, 9 ruptured). Treatment-related morbidity (grade 3 hemiparesis) occurred in 1 patient (1.6%). Except for 1 patient who had treatment-related morbidity, none of the other patients with unruptured aneurysms developed new neurologic symptoms at discharge. Nine of the 12 patients with ruptured aneurysms had good outcomes (Glasgow Outcome Score, 4 or 5) at the latest follow-up (mean, 32 months; range, 6-72 months), and 1 patient died from an initial SAH. Posttreatment control angiograms revealed complete occlusion in 27, neck remnant in 34, and incomplete occlusion in 1 aneurysm. At least 1 follow-up catheter or MR angiogram was available in 80.6% (n = 50) (mean, 21 months; range, 6-65 months). There were 4 minor and 3 major recurrences (14.0%). CONCLUSIONS: In this case series, the combination technique by using multicatheter plus stent or balloon seemed safe and effective for the treatment of complex aneurysms.

NLRP3 inflammasome activation by mitochondrial ROS in bronchial epithelial cells is required for allergic inflammation.

Abnormality in mitochondria has been suggested to be associated with development of allergic airway disorders. In this study, to evaluate the relationship between mitochondrial reactive oxygen species (ROS) and NLRP3 inflammasome activation in allergic asthma, we used a newly developed mitochondrial ROS inhibitor, NecroX-5. NecroX-5 reduced the increase of mitochondrial ROS generation in airway inflammatory cells, as well as bronchial epithelial cells, NLRP3 inflammasome activation, the nuclear translocation of nuclear factor-κB, increased expression of various inflammatory mediators and pathophysiological features of allergic asthma in mice. Finally, blockade of IL-1ß substantially reduced airway inflammation and hyperresponsiveness in the asthmatic mice. These findings suggest that mitochondrial ROS have a critical role in the pathogenesis of allergic airway inflammation through the modulation of NLRP3 inflammasome activation, providing a novel role of airway epithelial cells expressing NLRP3 inflammasome as an immune responder.

A six-week motor-driven functional electronic stimulation rowing program improves muscle strength and body composition in people with spinal cord injury: a pilot study.

STUDY DESIGN: Preclinical and postclinical intervention and outcomes measure design. OBJECTIVE: To investigate the efficacy of six weeks of motor-driven functional electronic stimulation (FES) rowing exercise intervention on cardiopulmonary fitness, upper body strength and body composition in people with spinal cord injury (SCI). SETTING: The National Rehabilitation Center in Korea. METHODS: A total of 12 people with SCI (ten males, two females) participated in 42.5-minute training sessions on motor-driven FES rowing machine, 5 days a week for 6 weeks. Peak oxygen consumption, body mass index, percent body fat, waist circumference, shoulder abduction and adduction, shoulder flexion and extension and elbow flexion and extension were measured at baseline and after the intervention. RESULTS: The six weeks of training with a motor-driven FES rowing machine significantly decreased percent body fat (Pre: 23.9±8.5 vs. Post: 20.4±7.9, P=0.028) and increased lean body mass (Pre: 50.4±9.4 vs. Post: 53.3±10.0, P=0.001), muscular strength of the shoulder flexors (Pre: 147.5±68.5 vs. Post: 180.9±71.8, P=0.002), extensors (Pre: 132.7±51.8 vs. Post: 160.6±67.9, P=0.010), abductors (Pre: 126.1±52.6 vs. Post: 163.7±77.8, P=0.002) and adductors (Pre: 172.3±69.0 vs. Post: 215.2±95.7, P=0.003), as well as elbow flexors (Pre: 212.7±66.6 vs. Post: 256.6±76.1, P=0.004) and extensors (Pre: 190.6±65.0 vs. Post: 221.9±63.9, P=0.002). CONCLUSIONS: Exercise using a motor-driven FES rowing machine may be used as a new exercise modality to improve body composition and upper body muscle strength in people with SCI. SPONSORSHIP: This research was supported by a grant (code# 08-B-03, #10-B-01) from the National Rehabilitation Research Institute.

Treatment of multiple intracranial aneurysms with 1-stage coiling.

BACKGROUND AND PURPOSE: Although multiple intracranial aneurysms are frequent, determining treatment strategy and methods for them is often complicated. The aim of this study was to evaluate the safety and effectiveness of 1-stage coiling for multiple intracranial aneurysms. MATERIALS AND METHODS: All patients who underwent 1-stage coiling for ≥2 aneurysms were identified from a prospectively registered neurointerventional data base during 10 years. The patient characteristics and clinical and angiographic outcomes at discharge and follow-up were retrospectively evaluated. RESULTS: One hundred sixty-seven patients (male/female ratio, 30:137; mean age, 58 years) with multiple aneurysms (418 aneurysms; mean, 2.5 aneurysms/patient) underwent attempted 1-stage coiling for ≥2 aneurysms (359 aneurysms; mean, 2.1 aneurysms/patient). In 131 patients (78.4%), all detected aneurysms were treated with coiling only. Treatment-related morbidity and mortality at discharge were 1.8% and 0.6% per patient, respectively. Of the 132 patients without subarachnoid hemorrhage, 129 (97.7%) had favorable outcomes (mRS 0-2) at discharge; of the 35 patients with SAH, 27 (77.1%) had favorable outcomes at discharge. Of the 162 patients (97%) for whom clinical follow-up was available (mean, 35.8 months), 154 patients (95.1%) had favorable outcomes. Immediate posttreatment angiography showed complete occlusion in 186 (51.8%) aneurysms, neck remnants in 134 (37.3%), sac remnants in 33 (9.2%), and failure in 6 (1.7%). Of the 262 (73.9%) aneurysms that underwent follow-up imaging (mean, 24.8 months), 244 (93.1%) showed a stable or improved state, with 12 (4.6%) minor and 6 (2.3%) major recurrences. CONCLUSIONS: One-stage coiling of multiple aneurysms seems to be safe and effective, with low morbidity and mortality.

Comparison of outcomes between endovascular treatment and bypass surgery in Takayasu arteritis.

OBJECTIVES: There is currently a lack of evidence regarding the optimal revascularization method for Takayasu arteritis (TA). This study compares outcomes between endovascular treatment and surgical therapy in TA patients requiring revascularization. METHOD: From September 1994 to January 2011, 235 patients were diagnosed with TA according to the diagnostic criteria of the 1990 American College of Rheumatology, and of these, arterial revascularizations were performed in 65 (27.7%). Symptomatic or angiographic recurrence and peri-operative use of immunosuppressive drugs were investigated by retrospectively reviewing medical records. RESULTS: A total of 111 arterial lesions in the 65 (27.7%) patients were revascularized during the follow-up period (median 3.2 years, range 0.01-12.7 years). At the 2-year follow-up, the symptomatic recurrence rate was significantly higher in the endovascular treatment group (32.3% vs. 11.5%, p = 0.016), as was the incidence of angiographic recurrence (32.1% vs. 11.1%, p = 0.026). The symptomatic recurrence rate was not influenced by the need for peri-operative immunosuppressive drugs (20% vs. 34.1%, p = 0.34). CONCLUSIONS: In TA patients, surgical revascularization seems to be superior to endovascular treatment with regard to patency. Further investigation to identify novel and optimal arterial revascularization methods for TA patients should be undertaken.

Clinical and angiographic characteristics of multiple dural arteriovenous shunts.

BACKGROUND AND PURPOSE: The pathogenesis and characteristics of multiple DAVSs are not well-known. The purpose of this study was to evaluate the angiographic and clinical characteristics of patients with multiple DAVSs with an emphasis on the pathomechanism. MATERIALS AND METHODS: One hundred seventy-nine patients with DAVS were reviewed. Patients with ≥ 2 fistulas at anatomically separate sites were included. Multiple DAVSs were categorized into synchronous (simultaneous multiplicity) or metachronous (temporal sequential development of multiplicity) types. The angiographic and clinical characteristics of these lesions were analyzed. RESULTS: Fourteen patients were diagnosed with multiple DAVSs (7.8%; synchronous, n = 7; metachronous, n = 7). Thirteen of the 14 patients showed CVR (93%, Borden type II/III). Multiple DAVSs were frequently associated with dural sinus thrombosis (71.4%, n = 10). Synchronous DAVSs developed in association with an occluded sinus (n = 5). De novo metachronous lesions developed in association with thrombosis of a previously patent dural sinus (n = 3) or reopening of an occluded sinus (n = 2). Multiplicity was associated with aggressive initial symptoms in 64.3% (n = 9). The newly developed lesions in the metachronous types were accompanied by hemorrhage (n = 1), neurologic deficit (n = 1), worsening of the initial benign symptoms (n = 2), and incidental detection (n = 3). The mean time interval between the initial diagnosis and de novo lesion detection was 31.3 ± 29.8 months (range, 12-92 months). CONCLUSIONS: Multiplicity of DAVSs is associated with poor angiographic and clinical prognosis, requiring an aggressive treatment and management strategy. Sinus thrombosis has a prominent role in the pathomechanism of DAVSs.

Reconstructive endovascular treatment of fusiform or ultrawide-neck circumferential aneurysms with multiple overlapping enterprise stents and coiling.

BACKGROUND AND PURPOSE: Fusiform aneurysms and ultrawide-neck circumferential aneurysms are still some of the most challenging lesions. The aim of this study was to investigate the efficacy and feasibility of the use of multiple overlapping Enterprise stents with coiling for the treatment of fusiform or ultrawide-neck circumferential aneurysms. MATERIALS AND METHODS: Twelve consecutive patients (9 men and 3 women; mean age, 56 years) with fusiform (n = 5) or ultrawide-neck circumferential (n = 7) aneurysms were treated with 2-3 overlapping Enterprise stents and coiling. The feasibility of this procedure and the clinical and angiographic outcomes of this technique were retrospectively evaluated. RESULTS: All patients were successfully treated by using this technique without any complications. Posttreatment angiographic results revealed grade 4 occlusion of the aneurysm in 6, grade 3 in 4, and grade 2 in 2 patients. Clinical follow-up was performed in all patients (mean, 16 months; range, 5-24 months). Nine patients had an mRS score of 0. Two had an mRS score of 1, one of whom had an initial mRS score of 2 due to the mass effect of a giant aneurysm; the other had a recurrent aneurysm presenting with SAH 5 years after clipping. Angiographic follow-up was performed in 10 patients at 6-20 months posttreatment. Nine had stable or improved occlusion, while 1 had a minor recurrence. CONCLUSIONS: In this small series, multiple overlapping Enterprise stents with coiling were a feasible and effective option for the treatment of fusiform and ultrawide-neck circumferential aneurysms. Further experience and follow-up are required to document the long-term efficacy of this treatment.

Stem-cell therapy for peripheral arterial occlusive disease.

OBJECTIVE: The aims of our study were to confirm the effectiveness via animal study and safety through clinical trials of using human cord blood-mononuclear cells (HCB-MNCs). DESIGN: We performed a dose-response animal study (HCB-MNCs: 4 × 106, 4 × 107 and 4 × 108) using a limb ischaemia model in dogs to assess angiogenic responses. Safety assessment in humans in terms of graft-versus-host-disease was also done by observing an uncontrolled case series. MATERIALS AND METHODS: Twelve animal ischaemic limbs and seven patients with thromboangiitis obliterans were treated with HCB-MNCs. These cells (4 × 108) were injected into the ischaemic limb muscle of patients. The results were analysed at 8 weeks for the animal study and at 6 months for patients. RESULTS: In the animal ischaemic models, the number of capillaries, angiogenic gene expression and the angiogenic factors were increased after HCB-MNC injection. In the clinical study, the seven patients experienced no graft-versus-host-disease or cardiac/cerebral complications during the follow-up period. CONCLUSION: This preliminary study suggests that HCB-MNC might be a safe source of stem cells for treating ischaemic limbs. However, further clinical studies are needed to establish the long-term safety and the clinical efficacy of HCB-MNC transplantation in patients with ischaemic limbs.

Outcomes and prognostic factors of intracranial unruptured vertebrobasilar artery dissection.

OBJECTIVE: We aimed to evaluate the long-term clinical outcomes and prognostic factors of symptomatic intracranial unruptured vertebrobasilar artery dissection (siu-VBD). METHODS: A total of 191 patients (M:F = 127:64; median age, 46 years) with siu-VBD were treated between January 2001 and December 2008. Presentations, treatments, outcomes, and prognostic factors were retrospectively analyzed. RESULTS: Clinical manifestations were ischemic symptoms with headache (n = 97) or without headache (n = 13) and headache without ischemic symptoms (n = 81). Forty-six patients (24.1%) underwent endovascular treatment. The remaining 145 patients (75.9%) were medically treated with anticoagulants (n = 49), antiplatelets (n = 48), or analgesics alone (n = 48). Clinical follow-up data were available in 178 patients (102 ischemic and 76 nonischemic) at 15 to 102 months (mean, 46 months). None of the siu-VBD hemorrhaged. All 76 patients without ischemic presentation had favorable outcomes (modified Rankin Scale, 0-1). Of the 102 patients with ischemic presentation, outcomes were favorable in 92 and unfavorable in 10 patients. Four patients died; 3 died of causes unrelated to VBD, and one died as a result of basilar artery (BA) dissection. Old age (odds ratio [OR] 1.099; 95% confidence interval [CI] 1.103-1.204; p = 0.042) and BA involvement (OR 11.886; 95% CI 1.416-99.794; p = 0.023) were independent predictors of unfavorable outcomes in siu-VBD with ischemic presentation. CONCLUSIONS: Clinical outcomes for siu-VBD were favorable in all patients without ischemic symptoms and in most patients with ischemic presentation. None of the siu-VBD caused subarachnoid hemorrhage. Old age and BA involvement were independent predictors of unfavorable outcome in siu-VBD with ischemic presentation.

Management of anterior inferior cerebellar artery aneurysms: endovascular treatment and clinical outcome.

BACKGROUND AND PURPOSE: AICA aneurysms are rare and a challenge to treat surgically. We present our experience of the angiographic results and the clinical outcomes for 9 AICA aneurysms treated by EVT. MATERIALS AND METHODS: Between 1997 and 2009, EVT was attempted for 9 AICA aneurysms. Six patients presented with SAH, and 3 aneurysms were found incidentally. The location of the aneurysms was the proximal AICA in 7 and the distal AICA in 2. Five aneurysms originated from an AICA-PICA variant. Clinical outcomes and procedural complications were evaluated, and angiography was performed 6, 12, and 24 months after embolization to confirm recanalization of the coiled aneurysm. RESULTS: EVT was technically successful in 7 patients (78%). Surgical trapping was performed in 1 patient after failure of EVT, and another aneurysm occluded spontaneously, along with the parent artery during EVT. In 7 patients, the AICAs had good patency on postoperative angiography. Stent-assisted coiling was performed in 3 patients. Follow-up angiographies were performed in 7 patients and showed no evidence of recanalization or progressive occlusion with further thrombosis except in 1 patient. There was no evidence of aneurysm rupture during the follow-up period, and 8 patients were able to perform all usual activities (mRS score, 0-1). CONCLUSIONS: EVT may provide a feasible and safe option as an alternative, though a microsurgical option is initially considered for the management of AICA aneurysms. Further follow-up and more experience are also necessary.

Emergent self-expanding stent placement for acute intracranial or extracranial internal carotid artery dissection with significant hemodynamic insufficiency.

BACKGROUND AND PURPOSE: ICAD with hemodynamic insufficiency may present with either fulminant infarct or with progressive neurologic deterioration. The purpose of this study was to evaluate the safety and efficacy of emergent self-expanding stent placement for acute intracranial or extracranial ICAD with significant hemodynamic insufficiency. MATERIALS AND METHODS: Eight patients (7 men and 1 woman; age range, 20-55 years; NIHSS score, 5-21) underwent emergent self-expanding stent placement for treatment of significant hemodynamic insufficiency due to acute ICAD. The safety and efficacy of emergent self-expanding stent placement were retrospectively evaluated. RESULTS: All patients presented with progressive (n = 6) or fluctuating (n = 2) neurologic deficits and revealed markedly decreased perfusion on CT or MR perfusion studies. Conventional angiography revealed acute occlusion (n = 2) or critical stenosis (n = 6) in intracranial (n = 3) or extracranial (n = 5) carotid arteries with a lack of sufficient collaterals. Stent placement was successful in all patients without any procedure-related complications. In all patients, hemodynamic insufficiency was corrected immediately after stent placement, and neurologic symptoms were completely resolved during several days. Mean improvement of the NIHSS score between baseline and discharge was 11.6 (range, 5-21). All patients remained neurologically intact (mRS, 0) during clinical follow-up for a mean of 21 months (range, 8-50 months). Angiographic follow-up was available for 6 patients at 3-12 months. None of the 6 patients revealed residual or in-stent restenosis. CONCLUSIONS: Self-expanding stent placement is a safe and effective option for selected patients with significant hemodynamic insufficiency due to acute intracranial or extracranial ICAD.

Self-expanding stent for recanalization of acute embolic or dissecting intracranial artery occlusion.

BACKGROUND AND PURPOSE: Stent placement may be an effective and last resort method for recanalization of recalcitrant intracranial artery occlusion. The purpose of this study was to evaluate the safety and efficacy of a self-expanding stent for the recanalization of acute embolic or dissecting intracranial artery occlusion. MATERIALS AND METHODS: Nine patients (mean age, 66 years; NIHSS score, 10-23) with acute embolic (n = 8) or dissecting occlusion (n = 1) of the intracranial arteries (ICA terminus in 5, MCA in 3, and BA in 1) were treated with a recapturable self-expanding stent. The safety and efficacy of the stent for recanalization were evaluated retrospectively. RESULTS: The emboli were entrapped against the vessel wall by the stent, resulting in immediate recanalization (TIMI 2) in all embolic occlusions. The dissecting occlusion was recanalized completely (TIMI 3). Adjunctive thrombolytics (n = 8, urokinase, 100,000-300,000 U) and/or GP IIb/IIIa antagonist (n = 7, tirofiban, 0.5-1 mg) were administered intra-arterially, and the degree of recanalization further improved in 4 embolic occlusions (TIMI 3). Acute in-stent thrombosis occurred in 2 patients, who received only urokinase without GP IIb/IIIa antagonist. Both of the reoccluded arteries were reopened, by stent recapture in 1 and by intra-arterial administration of GP IIb/IIIa antagonist in the other. Recapture was attempted in 7 cases, of which there were 3 successful outcomes. There was 1 asymptomatic hemorrhagic conversion at the infarction site. The mean improvement of the NIHSS score between baseline and discharge was 12.3 (range, 3-22). CONCLUSIONS: Preliminary results of this study suggest that a self-expanding stent may be safe and efficient for recanalization of acute embolic or dissecting intracranial artery occlusion.

Endovascular coil embolization of aneurysms with a branch incorporated into the sac.

BACKGROUND AND PURPOSE: Because of the concern for occlusion of the incorporated branch artery, an aneurysm with a branch incorporated into the sac has been regarded as a contraindication for coiling. The aim of this study is to evaluate the feasibility, techniques, and clinical and angiographic outcomes of coiling for aneurysms with a branch incorporated into the sac. MATERIALS AND METHODS: The medical records and radiologic studies of 69 patients with 79 aneurysms having a branch incorporated into the sac (26 ruptured, 53 unruptured) were retrospectively reviewed and evaluated. RESULTS: Coiling was accomplished in 78 aneurysms in 68 patients but was suspended in 1 due to incorporated branch occlusion. The aneurysms were treated by using the following techniques: single-catheter (n = 37), multicatheter (n = 22), balloon-remodeling (n = 7), stent-assisted coiling (n = 6), and combined (n = 7). Postembolization angiography revealed the following: near-complete occlusion in 71 (89.8%), remnant neck in 4 (5.1%), and incomplete occlusion in 4 (5.1%) aneurysms. Procedure-related permanent morbidity and mortality rates were 5.8% (4/69) and 0%, respectively. All patients with unruptured aneurysms had a modified Rankin Scale (mRS) score of 0, except for 1 patient who had an mRS score of 3. Of the 26 patients with ruptured aneurysms, 18 had favorable outcome (mRS 0-2) but 8 had poor outcome (mRS 3-6). Follow-up angiography was available at least once at 6-50 months (mean, 15 months) in 55 aneurysms (69.6%), of which 45 showed stable or improved occlusion; 4, minor recurrences; and 6, major recurrences. All 6 major recurrent aneurysms were retreated without complication by using a single-catheter (n = 1), multicatheter (n = 2), or balloon-assisted technique (n = 3). CONCLUSIONS: With appropriate techniques, most aneurysms with a branch incorporated into the sac could be safely treated by coiling, with acceptable outcomes.

Reconstructive endovascular treatment of intracranial fusiform aneurysms: a 1-stage procedure with stent and balloon.

BACKGROUND AND PURPOSE: Intracranial fusiform aneurysms, which incorporate the branch vessel and require salvaging of the parent vessel, are difficult to manage. The goal of this study was to evaluate the efficacy of reconstructive endovascular treatment of intracranial fusiform aneurysms by using a 1-stage procedure with a stent and balloon. MATERIALS AND METHODS: During a 3-year period, 20 patients with 20 intracranial fusiform aneurysms were treated by using a 1-stage procedure involving a balloon and stent. Subarachnoid hemorrhage was present in 15 patients. Five aneurysms were located in the anterior circulation and 15, in the posterior circulation. Clinical outcomes and periprocedural complications were evaluated in all patients. The extent of coil packing was evaluated by control angiography after embolization and classified as either complete occlusion or partial occlusion. Angiography was performed 6, 12, and 24 months after embolization to evaluate stent patency and coil packing. RESULTS: The 1-stage procedure by using a combination of balloon and stent was technically successful in all patients. There were no complications related to the procedure, complete occlusion was obtained in 16 patients, and partial occlusion, in 4 patients. All patients recovered well except for 2 who died due to causes unrelated to the procedure. Clinical follow-up was performed in all surviving patients at a mean of 12.3 months (range, 7-24 months), and angiography showed that the patent parent arteries were free of aneurysm recanalization or in-stent stenosis. CONCLUSIONS: This 1-stage procedure may provide a feasible and safe treatment strategy for the management of intracranial fusiform aneurysms that are not amenable to deconstructive embolization.