Reocclusion after successful endovascular treatment in acute ischemic stroke: systematic review and meta-analysis.

BACKGROUND: Endovascular treatment (EVT) is the standard of care for selected patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). OBJECTIVE: To systematically review the available data on: (1) incidence, predictors, and outcomes of patients with reocclusion after successful EVT for AIS and, (2) the characteristics, complications, and outcomes of patients with reocclusion treated with repeated EVT (rEVT) within 30 days of the first procedure. METHODS: PubMed was searched (between January 2012 and April 2021) to identify studies reporting reocclusion following successful EVT (Thrombolysis in Cerebral Infarction ≥2b) in patients with AIS due to LVO. Pooled incidence of reocclusion per 100 patients with successful recanalization following EVT was calculated using a random-effects model with Freeman-Tukey double arcsine transformation. Extracted incidences of reocclusion according to etiology and use of intravenous thrombolysis were pooled using random-effects meta-analytic models. RESULTS: A total of 840 studies was identified and seven studies qualified for the quantitative analysis, which described 91 same-vessel reocclusions occurring within the first 7 days after treatment among 2067 patients (4.9%; 95% CI 3% to 7%, I2=70.2%). Large vessel atherosclerosis was associated with an increased risk of reocclusion (OR=3.44, 95% CI 1.12 to 10.61, I2=50%). We identified 90 patients treated with rEVT for recurrent LVO, described in five studies. The rates of procedural complications, mortality, and unfavorable functional outcome at 3 months were 18.0%, 18.9%, and 60.3%, respectively. CONCLUSION: In cohorts of patients with AIS due to LVO, 5% of patients experienced reocclusion within 7 days after successful EVT. Repeated EVT can be a safe and effective treatment for selected patients with reocclusion.

Matrix Metalloproteinase-9 Levels are Associated with Brain Lesion and Persistent Venous Occlusion in Patients with Cerebral Venous Thrombosis.

BACKGROUND: Elucidating mechanisms of brain damage in cerebral venous thrombosis (CVT) would be instrumental to develop targeted therapies and improve prognosis prediction. Matrix metalloproteinase-9 (MMP-9), a gelatinase that degrades major components of the basal lamina, has been associated to blood-brain barrier disruption. We aimed to assess, in patients with CVT, the temporal change in serum concentrations of MMP-9 and its association with key imaging and clinical outcomes. METHODS: Pathophysiology of Venous Infarction-PRediction of InfarctiOn and RecanalIzaTion in CVT (PRIORITy-CVT) was a multicenter prospective cohort study of patients with newly diagnosed CVT. Serial collection of peripheral blood samples performed on day 1, 3, and 8, and standardized magnetic resonance imaging on day 1, 8, and 90. MMP-9 was quantified using enzyme-linked immunosorbent assay in 59 patients and 22 healthy controls. Primary outcomes were parenchymal brain lesion, early evolution of brain lesion, early recanalization, and functional outcome on day 90. RESULTS: CVT patients with parenchymal brain lesion had higher baseline concentrations of MMP-9 compared with controls (adjusted p = 0.001). The area under receiver operating characteristic curve value for MMP-9 for predicting brain lesion was 0.71 (95% confidence interval [CI]: 0.57-0.85, p = 0.009). Patients with venous recanalization showed early decline of circulating MMP-9 and significantly lower levels on day 8 (p = 0.021). Higher MMP-9 on day 8 was associated with persistent venous occlusion (odds ratio: 1.20 [per 20 ng/mL], 95% CI: 1.02-1.43, p = 0.030). CONCLUSION: We report a novel relationship among MMP-9, parenchymal brain damage, and early venous recanalization, suggesting that circulating MMP-9 is a dynamic marker of brain tissue damage in patients with CVT.

Long-term Neuropsychiatric and Neuropsychological Sequelae of Endovascularly Treated Aneurysmal Subarachnoid Hemorrhage.

INTRODUCTION: There is limited evidence regarding long-term outcomes of aneurysmal subarachnoid hemorrhage survivors. Most follow-up programs are relatively short and focused on physical functions. Endovascular aneurysmal embolization enables recovery of normal vascular architecture. However, there is growing evidence that neuropsychological and behavior sequelae can significantly impact the lives of these patients, even when treatment is successful. In this study, we reviewed cognition, psychiatric and neuropsychological symptoms, global functionality, and health-related quality of life 10 to 12 years after an aneurysmal subarachnoid hemorrhage. MATERIAL AND METHODS: A cross-sectional observational study was carried out in a university hospital. All cases of aneurysmal subarachnoid hemorrhage admitted between January 2004 and December 2006 and endovascularly treated were reviewed. Participants underwent a neuropsychological evaluation and a clinical interview with a psychiatrist. RESULTS: Fourteen patients participated in the study. Almost 70% (n = 10) showed cognitive impairment; in more than 40% (n = 6) of the subjects, significant symptoms of anxiety were identified, and 35% (n = 5) were classified as having clinical depression. Relevant posttraumatic symptoms were reported by more than 70% (n = 10) of patients, and almost 30% (n = 4) showed other moderate neuropsychiatric symptoms. Overall, health-related quality of life was impaired, and personality changes were frequently reported by the participants and their relatives. DISCUSSION: A significant prevalence of ongoing deficits in high-level functioning and reduced health-related quality of life were observed in a sample of young and professionally active individuals that were successfully treated and discharged from follow-up consultations. CONCLUSION: There is a need for better follow-up strategies, targeting more subtle deficits and psychological symptoms after aneurysmal subarachnoid hemorrhage.

Introdução: As evidências sobre a evolução a longo prazo dos sobreviventes de uma hemorragia subaracnoideia aneurismática são relativamente limitadas. A maioria dos programas de follow-up têm uma curta duração e são focados principalmente nas funções motoras. Apesar da embolização aneurismática endovascular permitir uma recuperação da arquitetura vascular normal, há evidências crescentes de que certas sequelas neuropsicológicas e comportamentais podem afetar significativamente a vida desses pacientes, a longo prazo, mesmo quando o tratamento é bem-sucedido. Neste estudo, analisamos os sintomas cognitivos, psiquiátricos e neuropsicológicos, a funcionalidade global e a qualidade de vida relacionada com a saúde, 10 a 12 anos após uma hemorragia subaracnoideia aneurismática. Material e Métodos: Um estudo observacional, transversal, foi realizado num hospital universitário. Todos os casos de hemorragia subaracnoideia aneurismática, admitidos entre janeiro de 2004 e dezembro de 2006, tratados endovascularmente, foram revistos. Os participantes foram sujeitos a uma avaliação neuropsicológicas e a uma entrevista clínica com um psiquiatra. Resultados: Participaram no estudo 14 doentes. Cerca de 70% (n = 10) apresentavam compromisso cognitivo; em mais de 40% (n = 6) foram identificados sintomas significativos de ansiedade e 35% (n = 5) foram classificados como tendo depressão clínica. Sintomas de stress pós-traumático relevantes foram relatados por mais de 70% (n = 10) e quase 30% (n = 4) apresentavam sintomas neuropsiquiátricos moderados. Em geral, a qualidade de vida relacionada com o estado de saúde encontrava-se reduzida e relatos de alterações de personalidade foram frequentemente feitos pelos participantes e seus familiares. Discussão: Uma prevalência significativa de défices em altos níveis de funcionamento e uma redução da qualidade de vida relacionada com a saúde foi observada numa amostra de indivíduos jovens e profissionalmente ativos, que foram tratados com sucesso e tiveram alta das consultas de seguimento. Conclusão: São necessárias melhores estratégias de follow-up, visando défices cognitivos e sintomas psicológicos mais subtis, após uma hemorragia subaracnoideia aneurismática.

Bioengineered Temporomandibular Joint Disk Implants: Study Protocol for a Two-Phase Exploratory Randomized Preclinical Pilot Trial in 18 Black Merino Sheep (TEMPOJIMS).

BACKGROUND: Preclinical trials are essential to test efficacious options to substitute the temporomandibular joint (TMJ) disk. The contemporary absence of an ideal treatment for patients with severe TMJ disorders can be related to difficulties concerning the appropriate study design to conduct preclinical trials in the TMJ field. These difficulties can be associated with the use of heterogeneous animal models, the use of the contralateral TMJ as control, the absence of rigorous randomized controlled preclinical trials with blinded outcomes assessors, and difficulties involving multidisciplinary teams. OBJECTIVE: This study aims to develop a new, reproducible, and effective study design for preclinical research in the TMJ domain, obtaining rigorous data related to (1) identify the impact of bilateral discectomy in black Merino sheep, (2) identify the impact of bilateral discopexy in black Merino sheep, and (3) identify the impact of three different bioengineering TMJ discs in black Merino sheep. METHODS: A two-phase exploratory randomized controlled preclinical trial with blinded outcomes is proposed. In the first phase, nine sheep are randomized into three different surgical bilateral procedures: bilateral discectomy, bilateral discopexy, and sham surgery. In the second phase, nine sheep are randomized to bilaterally test three different TMJ bioengineering disk implants. The primary outcome is the histological gradation of TMJ. Secondary outcomes are imaging changes, absolute masticatory time, ruminant time per cycle, ruminant kinetics, ruminant area, and sheep weight. RESULTS: Previous preclinical studies in this field have used the contralateral unoperated side as a control, different animal models ranging from mice to a canine model, with nonrandomized, nonblinded and uncontrolled study designs and limited outcomes measures. The main goal of this exploratory preclinical protocol is to set a new standard for future preclinical trials in oromaxillofacial surgery, particularly in the TMJ field, by proposing a rigorous design in black Merino sheep. The authors also intend to test the feasibility of pilot outcomes. The authors expect to increase the quality of further studies in this field and to progress in future treatment options for patients undergoing surgery for TMJ disk replacement. CONCLUSIONS: The study has commenced, but it is too early to provide results or conclusions.

Delayed leukoencephalopathy after acute carbon monoxide intoxication.

Delayed leukoencephalopathy is an uncommon complication of hypoxic-ischemic events of different etiologies, including carbon monoxide intoxication. We present a case of a 40-year-old male patient who was admitted with rapidly progressive neurocognitive and behavioral deficits. There was a history of accidental carbon monoxide intoxication one month before, presenting with loss of consciousness and short hospitalization, followed by a complete clinical recovery. The imaging studies in the delayed phase depicted confluent, symmetric supra-tentorial white matter lesions in keeping with diffuse demyelinization. Restricted diffusion and metabolite abnormalities in magnetic resonance proton spectroscopy were also seen. The diagnosis of CO-mediated delayed post-hypoxic leukoencephalopathy was assumed after exclusion of other mimickers. Hyperbaric oxygen therapy was tentatively performed and the patient had a favorable clinical and radiological evolution.

The human nucleus accumbens: where is it? A stereotactic, anatomical and magnetic resonance imaging study.

Objectives. Identification, delimitation, and stereotactic localization of the human nucleus accumbens (Acc) in order to allow its accurate definition and three-dimensional targeting on magnetic resonance imaging (MRI) enabling its use for deep brain stimulation. Methods. Magnetic resonance imaging and anatomical coronal serial cuts were performed on 24 Acc from human cadaver brains perpendicular to the anterior commissure-posterior commissure line; identification, localization, and determination of its dimensions and three-dimensional stereotactic coordinates. Results. Twenty Acc were studied anatomically, 14 by MRI and 12 by both methods. The contours of the Acc were traced and the dimensions measured; mean values: length 10.5 mm, width 14.5 mm and height 7.0 mm. The stereotactic coordinates were obtained every millimeter along its length. Conclusion. It was possible to identify well the human Acc, define its limits and establish its three-dimensional coordinates as potential MRI-guided stereotactic target.