Learning Curve Effect of Combined Technique Thrombectomy as First-Line Attempt for Acute Ischemic Stroke: A Single-Center Retrospective Study.

OBJECTIVES: We retrospectively examined the initial experience and learning curve after the introduction of thrombectomy with the combined technique using an aspiration catheter and a stent retriever as first-line attempt for acute ischemic stroke. METHODS: Consecutive patients undergoing thrombectomy for acute ischemic stroke at our institution between January 2020 and December 2022 were divided into 3 groups according to the year of thrombectomy. Patient characteristics and procedural, safety, and clinical outcomes were compared between the three year periods to determine predictors of favorable clinical outcome. RESULTS: In 2020, 2021, and 2022, the numbers of patients were 74, 70, and 90, respectively, with similar patient characteristics across the three years; successful recanalization rates were 79.7%, 97.1%, and 93.3%, respectively (P < 0.01 for the first 2 years); median procedure times were 67, 43, and 32 minutes, respectively (P < 0.01 for the first 2 years and P = 0.018 for the last 2 years); first pass effect rates were 20.3%, 41.4%, and 44.4%, respectively (P < 0.01 for the first 2 years); symptomatic intracranial hemorrhage rates were 14.9%, 2.9%, and 1.1%, respectively (P = 0.018 for the first 2 years); and percentages of modified Rankin Scale score 0-2 at 90 days were 24.3%, 42.9%, and 41.1%, respectively (P = 0.022 for the first 2 years). Procedure time (P = 0.038) and successful recanalization (P = 0.041) were independent predictors of favorable clinical outcome. CONCLUSIONS: The learning curve effect of the combined technique may be associated with better clinical outcome due to increased successful recanalization rates, shortened procedure time, and reduced symptomatic intracranial hemorrhage.

Basilar artery occlusion due to vertebral artery injury treated with thrombectomy and distal vertebral artery embolization through the unaffected side.

Background: There is no established opinion regarding embolization of asymptomatic traumatic vertebral artery injuries that do not require cervical spine repair and fixation. Case Description: A 78-year-old man fell backward from a height of about 1 m and was rushed to his previous hospital. He had a fracture of the left transverse process of the 6th cervical vertebra. Six hours after the trauma, he became unconscious; magnetic resonance angiography showed occlusion of the left vertebral and basilar arteries, and he was transferred to our hospital. The basilar artery was completely recanalized 430 min after the onset of unconsciousness. Due to the presence of thrombi in the distal vertebral artery at the level of the 6th cervical vertebra and collateral blood flow from the deep cervical artery, the distal vertebral artery was occluded to prevent embolism. Postoperative diffusion-weighted imaging showed extensive infarction in the posterior circulation, and the patient died two days after surgery. Conclusion: In the case of vertebral artery injury, preparation for early occlusion of the basilar artery is necessary. If a thrombus and collateral blood flow are present distal to the vertebral artery injury, distal vertebral artery embolization may be necessary to prevent embolism.

Factors for failure of ultrasound-guided compression repair for femoral pseudoaneurysms after neuroendovascular therapy.

OBJECTIVE: Pseudoaneurysms are a serious complication of neuroendovascular therapy with femoral artery puncture, for which ultrasound-guided compression repair (UGCR) is often the first choice of radical therapy. We sought to retrospectively investigate the factors for failure of UGCR for pseudoaneurysm at the femoral artery puncture site. METHODS: Among patients undergoing neuroendovascular therapy with femoral artery puncture at our hospital between January 2018 and April 2021, those who received a diagnosis of pseudoaneurysm and underwent UGCR were enrolled. They were classified into two groups according to whether UGCR was successful (UGCR group) or was converted to surgical repair (SR group). Patient and procedural characteristics were compared between the two groups. RESULTS: During the study period, 577 patients underwent neuroendovascular therapy with femoral artery puncture, 10 of whom (1.7%) received a diagnosis of pseudoaneurysm and underwent UGCR. There were seven patients in the UGCR group and three patients in the SR group. The sheath diameter tended to be larger in the SR group than in the UGCR group (p = 0.16). The modified Rankin scale score when a diagnosis of pseudoaneurysm was made was significantly lower in the SR group than in the UGCR group (1 [0-2] vs. 3 [2-5], p = 0.037). CONCLUSIONS: Physical activity may be associated with failure of UGCR. In patients with high physical activity, the use of sedatives and analgesics to keep them at rest during puncture site compression after UGCR may lead to successful UGCR.

White Embolus-induced Basilar Artery Occlusion Due to Pulmonary Vein Invasion of a Metastasis of a Malignant Melanoma.

An 80-year-old woman presented with impaired consciousness after malignant melanoma resection. Magnetic resonance angiography showed basilar artery occlusion, which was subjected to mechanical thrombectomy for recanalization. A pathological analysis of the retrieved embolus revealed that it was derived from a metastasis of malignant melanoma. Contrast-enhanced chest computed tomography showed multiple pulmonary metastases, one of which was in the right upper lobe and invaded the pulmonary vein. To our knowledge, this is the first case of white embolus-induced cerebral embolism due to pulmonary vein invasion of a metastasis of a pathologically diagnosed malignant melanoma.

Short-term aneurysm formation and rupture due to septic embolism diagnosed with a thrombus retrieved from another occluded artery.

Background: In rare cases, septic embolism is diagnosed on the basis of pathological findings of retrieved thrombi. Infected aneurysms can rapidly form and rupture after septic embolism, leading to a poor prognosis. We report a case of subcortical hemorrhage due to an infected aneurysm forming shortly after septic embolism in the left anterior cerebral artery. Case Description: In this case, the diagnosis of septic embolism was made on the basis of pathological findings of a thrombus retrieved from the simultaneously occluded left middle cerebral artery, and endovascular embolization of the infected aneurysm was performed. Conclusion: The pathological findings of a retrieved thrombus were useful for making a diagnosis of septic embolism. The possibility of short-term formation and rupture of an infected aneurysm after septic embolism should be noted. Endovascular embolization of occluded vessels due to septic embolism may prevent aneurysm formation and subsequent bleeding.

Inferior Epigastric Artery Injury due to Femoral Venipuncture for Neuroendovascular Intervention: Two Cases Requiring Transcatheter Arterial Embolization.

Objective: Injury to the inferior epigastric artery (IEA) caused by femoral puncture may lead to retroperitoneal hematoma. We report on two cases of IEA injury due to femoral venipuncture for neuroendovascular intervention that resulted in hemorrhagic shock and required transcatheter arterial embolization. Case Presentations: A 67-year-old woman and a 71-year-old man receiving dual antiplatelet therapy sustained injury to a branch of the IEA in the process of right femoral venipuncture for neuroendovascular intervention. In both cases, stent placement in the intracranial artery was accomplished as intended with systemic heparinization throughout the procedure; however, the patients became hypotensive during the procedure, and contrast-enhanced CT scans taken after the stenting revealed extravasation of contrast from the IEA and retroperitoneal hematoma. Transcatheter arterial embolization of the bleeding branch of the IEA was performed with the left femoral approach, and subsequent angiography confirmed the disappearance of the extravasation of contrast. Conclusion: Femoral venipuncture for neuroendovascular intervention in patients receiving antithrombotic agents may cause IEA injury requiring transcatheter arterial embolization. The risk of IEA injury may be reduced by using the femoral head as a reference, performing ultrasound-guided puncture, and confirming the course of the IEA by femoral angiography before venipuncture.

Low-profile visualized intraluminal support Blue stenting within a Neuroform Atlas stent for a large wide-necked aneurysm: A case report and a bench-top experiment.

Low-profile visualized intraluminal support deployment in an Enterprise has been reported; however, that in an Atlas has yet to be in detail. Enterprise has a closed-cell design, while Atlas has an open-cell design. We detail here a case of a large wide-necked aneurysm treated by coil embolization with low-profile visualized intraluminal support Blue deployment within a Neuroform Atlas and a bench-top experiment using a silicon tube to test low-profile visualized intraluminal support, Atlas, Enterprise, and their combinations. A better low-profile visualized intraluminal support expansion was achieved by simultaneously pushing the wire and the system within the Atlas placed at the aneurysm neck, which resulted in an increased metal coverage of the aneurysm neck and a shorter transition zone with low metal coverage at both ends of the aneurysm neck. This technique may enable a high metal coverage by low-profile visualized intraluminal support expansion without restriction by the Atlas and contribute to aneurysm occlusion by increasing the flow-diverting effect.

Novel approach to determining the absolute configurations at the C3-positions of various types of sterols based on an induced circular dichroism.

Circular dichroism (CD) spectra of the 2,2'-binaphthyl ester derived from Δ(5)-sterols showed not bisignate CD but diagnostic CD bands at around 210 and 240 nm. These bands might be attributable to an interaction between an olefinic chromophore and a binaphthyl one. Various types of unsaturated sterols were thus derivatized followed by complete hydrogenation, to give saturated sterols. As a result, CD spectra of the binaphthyl derivatives of the saturated sterols showed bisignate curves centered at 240 nm (3S(ß): positive chirality; 3R(α): negative one). This suggested a straightforward and practical method for discriminating the absolute stereogenic center at the C-3 positions of sterols based on an induced CD. This finding should contribute significantly to the analysis of metabolites of various types of sterols.

Straightforward approach to the discrimination of (4R)- and (4S)-beta-isocryptoxanthin from a conformationally insensitive CD band.

A straightforward strategy is reported for chiral discrimination in a specified carotenoid using a CD band, which is insensitive to conformational changes, computed by quantum chemical calculation.

Managing prenatally diagnosed asymptomatic congenital cystic adenomatoid malformation.

AIM: To review our cases of congenital cystic adenomatoid malformation (CCAM) with special emphasis on the management of prenatally diagnosed asymptomatic CCAM (PDA-CCAM). METHODS: A total of 42 consecutive CCAM patients treated between 1990 and 2008 at our institution and affiliated hospitals were divided into four groups, according to whether prenatal diagnosis was made [PD (+) or (-)], whether patients were symptomatic [S (+) or (-)], whether there was any increase in size observed radiologically [R (+) or (-)], and whether surgical resection was performed [X (+) or (-)], to give a symptomatic early surgery group diagnosed prenatally (group A; n = 15): PD (+), S (+), R (+), X (+); an asymptomatic early surgery group diagnosed prenatally (group B; n = 8): PD (+), S (-), R (-), X (+); a conservative observation group diagnosed prenatally (group C; n = 6): PD (+), S (-), R (-), X (-); and a symptomatic surgery group diagnosed postnatally (group D; n = 13): PD (-), S (+), R (unknown), X (+). Patient demographics, effects of surgical stress, histopathology, and outcome were compared between the four groups. RESULTS: Groups A and B had surgery as neonates and mean duration of post-operative follow-up has been 15.7 months for group A and 63.3 months for group B. Group C has been under observation for a mean of 21.6 months (range: 10-40 months) with no incidence of infection. In group D, four had surgery as neonates after developing respiratory distress, and nine had surgery later (mean age: 4.1 years) after developing pneumonia (late onset group). Mean duration of follow-up for group D has been 48.0 months. In the late-onset group, pneumonia was successfully treated medically, and all nine had elective surgery with no intra- or post-operative complications. However, compared with group B (asymptomatic early surgery group diagnosed prenatally) the late-onset group had significantly longer duration of surgery (P < 0.05), significantly greater intraoperative blood loss (P < 0.01), and significantly higher peak post-operative C-reactive protein (P < 0.01), although there were no statistical differences for increase in white blood cell count ratios or length of hospitalization. Malignancy has not developed to date in any subject. CONCLUSION: Our data suggest that patients with PDA-CCAM may be observed safely until they become symptomatic or changes in size are observed radiologically.

Effects of glutamic acid and taurine on total parenteral nutrition.

BACKGROUND: The objective of the present study was to ascertain whether simultaneous administration of glutamic acid (Glu) and taurine (Tau) to patients on total parenteral nutrition (TPN) could improve intestinal mucosal atrophy and suppress bacterial translocation. METHODS: A 5-day TPN study was conducted in 5-week-old Sprague-Dawley rats. Commercially available Glu was used for TPN in group G and was enhanced with Tau (500 mg kg(-1) day(-1)) in group GT. Oral nutrition was provided in group C controls. At 5 days, amino acid and cytokine levels in plasma and endotoxin levels in portal blood were measured. The histology of the small intestine, liver, and lung were analyzed. RESULTS: Mucosal thickness and villus height in the small intestine were lower for group G than for groups C and GT. Taurine level in group GT was higher than in group G. Arginine and citrulline levels in groups G and GT were lower than in group C. Taurine level in the small intestine was greater in group GT than in group G. Citrulline concentration was lower in group G than in groups GT and C. Endotoxin level in portal blood and cytokine (tumor necrosis factor alpha, interleukin-1beta, and interleukin-6) levels in blood tended to be lower for group GT than for group G, but no significant differences were noted. Immunostaining showed strong positive reactions to vascular cell adhesion molecule-1 in the liver and lung for group G, and milder reactions for group GT. CONCLUSIONS: Simultaneous administration of Glu and Tau improved small intestinal mucosal thickness and villus height during TPN. Levels of Tau in the small intestine and plasma increased, and the level of citrulline in the small intestine improved. Decreased expression of adhesion molecules in the liver and lung and improved microcirculation in the liver were also confirmed.

Synthesis of (-)-epibatidine and its derivatives from chiral allene-1,3-dicarboxylate esters.

(-)-Epibatidine, an excellent candidate of non-opioidal anesthesia, was formally synthesized in short steps from di-(l)-menthyl (R)-allene-1,3-dicarboxylate that was facilely prepared as a single isomer by means of crystallization-induced asymmetric transformation from a diastereomer mixture of (R)- and (S)-allene-1,3-dicarboxylates. Taking advantage of the chiral synthesis, derivatives of (-)-epibatidine were also prepared for targeting diagnostic agents that could bind nicotinic acetylcholine receptors (nAChRs) in the mammalian central nerve system.

Unusual onset of chronic graft-versus-host disease after adult living-related liver transplantation from a homozygous donor.

Graft-versus-host disease (GVHD) is a rare complication that occurs after living-related liver transplantation (LRLT). This condition usually occurs early after transplantation and is fatal. Although one-way matching between a human leukocyte antigen (HLA)-homozygous donor and a haploidentical recipient has been shown to be a significant risk factor for the development of acute GVHD, chronic GVHD has not been clarified. A 50-year-old woman underwent LRLT for primary biliary cirrhosis with her 32-year-old HLA-homozygous son as the donor. The patient developed chronic GVHD 114 days posttransplant, presenting with a skin rash only. Her atypical onset included neither fever nor gastrointestinal symptoms. The patient responded to corticosteroid therapy and is now doing well at home. Careful donor selection and HLA matching before LRLT should be performed to prevent GVHD. However, the risks associated with grafts from homozygous donors may be unavoidable at present because of the shortage of cadaveric donors in Japan.