Assessment of language lateralization in epilepsy patients using the super-selective Wada test.

BACKGROUND: The classical Wada test (cWada), performed by injecting a short-acting anesthetic through the intracarotid route, helps determine language dominance. In the cWada, adverse effects are observed in 10-30% of trials, hindering accurate assessments. In this study, we assessed the effectiveness of the super-selective Wada test (ssWada), a more selective approach for anesthetic infusion into the middle cerebral artery (MCA). METHODS: We retrospectively examined the data of 17 patients with epilepsy who underwent ssWada via anesthetic injection into one M1 segment of the MCA and at least one contralateral trial. RESULTS: The ssWada identified 12 patients with left language dominance, 3 with right language dominance, and 2 with bilateral language distribution. Nine trials on the language dominant side resulted in global aphasia for patients with left- or right language dominance. Of the 13 trials conducted on the non-dominant language side, 12 revealed intact language function and one resulted in confusion. Among these, the outcomes of global aphasia or no language impairment were confirmed in the contralateral trials. Among the 22 trials of unilateral M1 injections in patients with unilateral language dominance, 21 (95.5%) showed either global aphasia or no language impairment, indicating language dominance. CONCLUSIONS: The ssWada yields clear results, with a high rate of over 90% in determining the language dominant hemisphere with few side effects.

Number of intra-operative cyclic knee motion required to achieve stable graft tension in anterior cruciate ligament reconstruction; a prospective clinical study.

BACKGROUND: Applying pretension by cyclic knee motion immediately before graft fixation in anterior cruciate ligament (ACL) reconstruction surgery decreases graft elongation during the postoperative course. However, the expected change in graft tension caused by cyclic knee motion remains unclear. We measured graft tension changes caused by cyclic knee motion during double-bundle ACL reconstruction. METHODS: We included 39 patients undergoing primary anatomical double-bundle ACL reconstruction with autologous hamstrings as graft sources, at multiple centers between February 2021 and August 2022. After securing the anteromedial (AM) and posterolateral (PL) bundle grafts to the femoral cortex, they were initially tensioned to 40 N per bundle. After 10 cycles of knee extension and flexion motion, ranging from 0 to 90-110°, tension was re-measured and re-tensioned to 40 N if the graft tension had decreased. This was repeated thrice for 10 cycles on each graft. Every 10 cycles, we recorded graft tension changes (ΔGT) and compared the mean ΔGT in the AM and PL bundles. Furthermore, we assessed relationships between total ΔGT in each bundle, age, sex, and graft diameter. RESULTS: Twenty-five women and 14 men with a mean age of 27.4 ± 12.4 years were included. The mean ΔGT in AM and PL bundles after every 10 cycles were 6.6 ± 3.7 N, 3.0 ± 2.3 N, 1.4 ± 1.5 N, and 9.9 ± 3.8 N, 4.9 ± 2.6 N, and 2.5 ± 1.9 N, respectively. There were significant differences in ΔGT in both bundles after every 10 cycles (p < 0.01). ΔGT in the AM bundle was significantly lower than in the PM bundle at the same number of cycles (p < 0.01). No correlation was observed between ΔGT in either bundle and age, sex, or graft diameter. CONCLUSIONS: The initially applied graft tension decreased by intra-operative cyclic knee movement, and the changes in graft tension decreased after retention and repeated cycles. Three sets of 10 cycles knee motion may avoid initial tension loss of the hamstring autograft in the early phase after double-bundle ACL reconstruction.

Nuclear receptor subfamily 1 group D member 1 in the pathology of obesity-induced osteoarthritis progression.

Mechanical overload and chemical factors are both related to obesity-induced progression of knee osteoarthritis. The circadian rhythm is related to the development of metabolic syndrome and the progression of osteoarthritis, and the core clock genes nuclear receptor subfamily 1 group D member 1 (NR1D1) and brain and muscle arnt-like protein 1 (BMAL1) are dysregulated in cartilage from patients with osteoarthritis. Here, we focused on NR1D1 and investigated osteoarthritis-related changes and gene expression in a mouse model of diet-induced obesity. A high-fat diet was provided to C57BL6/J mice, and changes in body weight, blood lipids, and gene expression were investigated. Destabilization of the medial meniscus or sham surgery was performed on mice fed a high-fat diet or normal diet, and histological osteoarthritis-related changes and NR1D1 expression were investigated. The effects of the NR1D1 agonist SR9009 were also assessed. Mice fed a high-fat diet developed significant obesity and dyslipidemia. Nr1d1 and Bmal1 gene expression levels decreased in the liver and knee joints. Moreover, increased osteoarthritis progression and decreased NR1D1 protein expression were observed in high-fat diet-fed mice after surgical osteoarthritis induction. SR9009 decreased the progression of obesity, dyslipidemia, and osteoarthritis. Overall, obesity and dyslipidemia induced by the high-fat diet led to osteoarthritis progression and decreased NR1D1 expression. Thus, NR1D1 may play an important role in obesity-induced osteoarthritis.

Foot morphology and correlation with lower extremity pain in Japanese children: A cross-sectional study of the foot posture Index-6.

BACKGROUND: Abnormal foot morphology in children and adolescents is a possible risk factor for lower extremity pain. Foot posture index-6 (FPI-6) is a valid and reliable tool to assess foot morphology. However, the normative data on the age distribution for FPI-6 in Asian children and adolescents are still minimal. Further, the correlation of FPI-6 with lower extremity pain is poorly understood. We aimed to investigate the normative distribution for FPI-6 and the relationship between FPI-6 scores and knee and heel pain in Japanese children. METHODS: We included 2569 Japanese children, aged 9-15 years, at a single school from 2016 to 2018. We summarized the age distribution of children and their mean bilateral FPI-6 scores. Additionally, we assessed the tenderness at the apophysis or tendon insertions at the knee and heel. We performed a cross-sectional analysis to investigate the correlations between FPI-6 scores and sex, age, and knee and heel pain for the data obtained each year. RESULTS: The mean FPI-6 score was 3.1 ± 2.4, 3.4 ± 2.0, and 3.2 ± 1.9 for the left foot and 3.0 ± 2.4, 3.2 ± 1.9, and 3.1 ± 1.9 for the right foot in 2016, 2017, and 2018, respectively. Boys tended to have higher scores than girls, and the FPI-6 score of the left foot was significantly higher than that of the right foot (p < 0.05). There was no correlation between FPI-6 scores and knee and heel pain. CONCLUSION: Children and adolescents between 9 and 15 years of age have neutral to slightly pronated foot morphology and an average FPI-6 score of 3.0-3.4. In addition, there was no relationship between foot morphology and knee and heel pain. This normative distribution for FPI-6 in Japanese children could serve as a reference value for future research and clinical evaluation.

Differences in the expression of myelopathy in a rat model of chronic spinal cord compression.

CONTEXT/OBJECTIVE: The degree of spinal cord compression does not always parallel neurological symptoms. We considered that some compensatory neuroprotective mechanism underlies the expression of this neurological phenotype. Oxygen-regulated-protein 150 (ORP150) is neuroprotective and expressed in neurons in response to neuronal ischemia. We sought to elucidate whether ORP150 expression is associated with the severity and variation of neurological recovery in our rat model of chronic spinal cord compression. METHODS: We made a rat model of chronic spinal cord compression inserting an expandable water-absorbing polyurethane sheet. A neurological behavioral assessment of the severity of paralysis was performed for 10 weeks postoperatively. The rat model was defined as two groups: a myelopathy group with decreased locomotor function and an asymptomatic group. At 10 weeks postoperatively, the spinal cord of the cervical segment was resected for histology and qPCR. RESULTS: Slowly progressive paralysis appeared at 5-10 weeks postoperatively in 53% of the rats with spinal cord compression. The asymptomatic group had no histological changes indicative of myelopathy. Histology and qPCR showed increased expression of ORP150 in the asymptomatic group, but the ratio of ORP150-positive neuron in the two groups was not significantly different. CONCLUSION: The expression of ORP150 in neurons associated with spinal cord compression suggested that the spinal cord was under ischemic stress due to compression, but relation to the development of myelopathy was unclear. The results suggested that some other compensatory mechanisms may exist in response to spinal cord compression in asymptomatic rats.

Determination of language areas in patients with epilepsy using the super-selective Wada test.

The Wada test is the gold standard for determining language-dominant hemisphere. However, the precise determination of language areas in each patient requires more invasive methods, such as electrocortical stimulation. Some studies have reported the use of anesthetic injection into selective cerebral arteries to predict postoperative function. To assess the function of the anterior and posterior language areas separately, we developed an advanced test named the "super-selective Wada test" (ssWada). The ssWada procedure is as follows: an endovascular neurosurgeon identifies the arterial branches of the middle cerebral artery (MCA) perfusing the anterior language area of the inferior frontal gyrus and the posterior language area of the posterior part of the superior temporal gyrus using angiography. Behavioral neurologists assess language symptoms before and after propofol administration using a microcatheter tip in the selected arterial branch. From 30 serial patients with epilepsy who underwent ssWada test at Tohoku University Hospital, we retrospectively reviewed patients in whom multiple areas in the bilateral MCA region was examined. Eight cases were identified in this study. All eight cases had been considered for resection of the area overlapping the classical language area. Three of the eight cases were left-dominant, and the within-hemisphere distribution was also considered typical. One case was determined to be left-dominant but atypical in the intra-hemispheric functional distribution. Two cases were right-dominant, and the intra-hemispheric functional distribution was considered a mirror image of the typical pattern. The remaining two cases were considered atypical, not only in terms of bilateral language function, but also in terms of anterior-posterior functional distribution. This case series demonstrates the potential utility of ssWada in revealing separate function of the anterior and posterior language areas. The ssWada allows simulation of local surgical brain resection and detailed investigation of language function, which potentially contributes to planning the resection area. Although indications for ssWada are quite limited, it could play a complementary role to noninvasive testing because it provides information related to resection using a different approach.

Influence of Age on Signal Intensity of Magnetic Resonance Imaging and Clinical Outcomes in Double-Bundle Anterior Cruciate Ligament Reconstruction: Comparisons Among Different Age Groups.

BACKGROUND: Thus far, the clinical results of anterior cruciate ligament (ACL) reconstruction have been observed to be comparable between young and older patients. In contrast, age-related changes in the structural and mechanical properties of tendons used for autografts have been described. However, age-related changes associated with graft maturation remain poorly understood. HYPOTHESES: The hypotheses of this study were that (1) clinical outcomes after ACL reconstruction would be comparable between younger and relatively older patients and (2) younger patients would show lower signal intensity changes on magnetic resonance imaging scans indicative of graft maturation that would be better than that in relatively older patients. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We retrospectively evaluated 236 patients who underwent double-bundle ACL reconstruction via the outside-in technique using hamstring autograft between January 2012 and December 2015. The patients were categorized by age into 3 groups: <20 years old, 20 to 39 years old, and ≥40 years old. Clinical outcomes were evaluated using the subjective International Knee Documentation Committee (IKDC) score, Tegner activity scale, Lysholm score, and objective assessment of joint laxity 24 months after surgery. In addition, graft maturation was evaluated using magnetic resonance imaging-derived measures of the signal intensity ratio (SIR) at 3, 6, 12, and 24 months postoperatively. Clinical outcomes and graft maturation were compared among the 3 groups. RESULTS: The SIR of both bundles increased from 3 months to 12 months and decreased by 24 months, showing the same tendency in all groups. No significant difference was found in the SIR among the 3 groups at any time point (P > .05). The IKDC score was significantly lower in the ≥40-year group than in the <20-year group (P < .01). In contrast, no significant differences were noted in other clinical outcomes. CONCLUSION: Patients aged ≥40 years exhibited lower IKDC scores compared with younger patients, although the results of graft maturation were comparable.

Effect of Systemic Administration of Granulocyte Colony-Stimulating Factor on a Chronic Partial-Thickness Cartilage Defect in a Rabbit Knee Joint.

OBJECTIVE: Cartilage lesions in the knee joint can lead to joint mechanics changes and cause knee pain. Bone marrow stimulation (BMS) promotes cartilage regeneration by perforating the subchondral bone just below the injury and inducing bone marrow cells. This study aimed to investigate whether systemic administration of granulocyte colony-stimulating factor (G-CSF) with BMS improves repair of chronic partial-thickness cartilage defects (PTCDs). DESIGN: Eighteen 6-month-old New Zealand white rabbits were divided into 3 groups: control (C, n = 6), BMS alone (n = 6), and BMS + G-CSF (n = 6). Partial cartilage defects with 5 mm diameter were created in the trochlear region of both knees; after 4 weeks, the BMS alone and BMS + G-CSF groups underwent BMS; G-CSF (50 µg/kg) or saline was administered subcutaneously for 5 days starting from 3 days before BMS. At 8 and 16 weeks after cartilage defect creation, the area of cartilage defects was macroscopically and histologically evaluated. RESULTS: International Cartilage Repair Society (ICRS) grades for macroscopic assessment were 0, 0.7, and 0.7 at 8 weeks and 0, 1.2, and 1.3 at 16 weeks in the C, BMS, and BMS + G-CSF groups, respectively. Wakitani scores for histological assessment were 9.8, 8.7, and 8.2 at 8 weeks and 9.5, 9, and 8.2 at 16 weeks in the C, BMS, and BMS + G-CSF groups, respectively. The BMS + G-CSF group showed significantly more repair than the C group, but there was no difference from the BMS group. CONCLUSIONS: The effect of BMS and G-CSF on chronic PTCDs in mature rabbit knees was limited.

Facial memory ability and self-awareness in patients with temporal lobe epilepsy after anterior temporal lobectomy.

Anterior temporal lobectomy (ATL) is the most common surgical treatment for drug-resistant temporal lobe epilepsy (TLE). Right ATL has been reported to reduce facial memory ability in patients with TLE, as indicated by poor performance on the Warrington Recognition Memory Test for Faces (RMF), which is commonly used to evaluate visual memory in these patients. However, little is known about whether patients with TLE exhibit difficulties in identifying faces in daily life after ATL. The aim of this study was to investigate facial memory ability and self-awareness of face identification difficulties in patients with TLE after ATL. Sixteen patients with TLE after right ATL, 14 patients with TLE after left ATL, and 29 healthy controls were enrolled in this study. We developed the multiview face recognition test (MFRT), which comprises a learning phase (one or three frontal face images without external facial feature information) and a recognition phase (frontal, oblique, or noise-masked face images). Facial memory abilities were examined in all participants using the MFRT and RMF, and self-awareness of difficulties in face identification was evaluated using the 20-item prosopagnosia index (PI20), which has been widely used to assess developmental prosopagnosia. The MFRT performance in patients with TLE after ATL was significantly worse than that in healthy controls regardless of the resected side, whereas the RMF scores in patients with TLE were significantly worse than those in healthy controls only after right ATL. The MFRT performance in patients with TLE after both left and right ATL was more influenced by working memory load than that in healthy controls. The PI20 scores revealed that patients with TLE after left ATL were aware of their difficulties in identifying faces. These findings suggest that patients with TLE not only after right ATL but also after left ATL might have difficulties in face identification.

Conscious Hemiasomatognosia with No Somatosensory Disturbance Other Than a Unique Problem in Tactile Localization.

Conscious hemiasomatognosia is a disorder of the bodily self, involving subjective symptom where patients feel as if their whole body or part of one side has disappeared. Somatosensory disturbance is considered an essential component of conscious hemiasomatognosia. We herein report a 64-year-old man with conscious hemiasomatognosia of the right arm that developed after a left parietotemporal infarction, without any somatosensory disturbance except for a unique tactile localization problem. His response to the tactile localization test suggested impaired recognition of the positional relationship of his right arm relative to the entire body but normal recognition of positional relationships within the arm.

Do Patients With Parkinson's Disease Exhibit Reduced Cheating Behavior? A Neuropsychological Study.

Parkinson's disease (PD) is a common neurodegenerative disorder characterized by loss of dopamine neurons. Since a seminal report was published in the early twentieth century, a growing body of literature has suggested that patients with PD display characteristic personality traits, such as cautiousness and inflexibility. Notably, PD patients have also been described as "honest," indicating that they have a remarkable tendency to avoid behaving dishonestly. In this study, we predicted that PD patients show reduced cheating behavior in opportunities for dishonest gain due to dysfunction of the dopaminergic reward system. Thirty-two PD patients without dementia and 20 healthy controls (HC) completed an incentivized prediction task where participants were rewarded based on their self-reported accuracy, affording them the opportunity to behave dishonestly. Compared with HC, PD patients showed significantly lower accuracy in the prediction task. Furthermore, the mean accuracy of PD patients was virtually equivalent to the chance level. These results indicate that PD patients exhibit reduced cheating behavior when confronted with opportunities for dishonest gain.

Clinical features of emergency electrocardiography in patients with acute myocardial infarction caused by left main trunk obstruction.

BACKGROUND: To diagnose left main trunk (LMT) infarction by 12-lead standard electrocardiogram (ECG) is an important emergency technique, but the features in LMT infarctions have not been clarified. METHODS AND RESULTS: The study enrolled 140 subjects who were divided into 4 groups according to the location of the culprit artery: 35 with LMT, 35 with left anterior descending artery (LAD), 35 with right coronary artery and 35 with left circumflex artery. Various parameters obtained from the ECGs were analyzed. Average QTc interval (0.51 +/- 0.06 s) in LMT group was markedly longer than that in the 3 other groups. Average QRS axis (-10 +/- 77 degrees) in LMT infarction showed a remarkable left deviation. ST-segment elevation in lead aVR occurred in 28 patients (80.0%) in the LMT group. The ECG features of the LMT group could be classified into 2 main groups: right bundle branch block (RBBB) with a marked left axis deviation (RBBB + LADEV type) and ST-segment elevation in leads V2-5, I and aVL without abnormal axis deviation (LAD type). CONCLUSION: Either ST-segment elevation in lead aVR and marked prolongation of both the QRS width and QTc interval with a prominent abnormal axis deviation or ST-segment elevation in the broad anterior precordial lead with a normal QRS axis strongly suggests LMT infarction.

Mechanisms of acute lumen gain following cutting balloon angioplasty in calcified and noncalcified lesions: an intravascular ultrasound study.

Several studies have shown that mechanisms for lumen enlargement following conventional balloon angioplasty (BA) consist of plaque reduction and vessel expansion. To assess the mechanisms of lumen enlargement after Cutting Balloon (CB) angioplasty, intravascular ultrasound images were analyzed in 180 lesions (89 CB and 91 BA). External elastic membrane (EEM) cross-sectional area (CSA), lumen CSA, and plaque plus media (P+M) CSA were measured before and after angioplasty. In the CB group, lower balloon pressure was utilized (P < 0.0001). DeltaP+M CSA was significantly larger (P = 0.02) and deltalumen CSA showed a trend toward being larger (P = 0.07) compared to BA group. For noncalcified lesions, CB resulted in a larger deltaP+M CSA (P < 0.05) and a smaller deltaEEM CSA (P = 0.10) than BA. For calcified lesions, deltalumen CSA was significantly larger in the CB group (P < 0.05) without significant differences in deltaEEM CSA and deltaP+M CSA. Dissections complicated with calcified lesions were associated with larger deltalumen CSA for the CB group. In conclusion, for noncalcified lesions, CB achieves similar luminal dimensions with larger plaque reduction and less vessel expansion compared to BA. On the other hand, for calcified lesions, the CB achieves larger lumen gain, especially in lesions with evidence of dissections.

Usefulness of the Symphony Nitinol Stent for arteriosclerosis obliterans.

The Symphony Peripheral Stent is a self-expanding stent made of thermal memory Nitinol wire. Stents were implanted in 39 lesions of 32 patients (26 men, 6 women) with atherosclerosis obliterans (ASO). The ankle-arm index (AAI), and vessel diameters evaluated by quantitative angiography were compared before and 6 months after treatment. Symphony Peripheral Stent implantation significantly improved the AAI from 0.50+/-0.4 to 0.9+/-0.2 (p<0.01), the minimum lumen diameter (MLD) from 2+/-1.5 to 5+/-1.4 mm (p<0.01) and percent diameter stenosis (% DS) from 69+/-20% to 16.5+/-8% (p<0.01). Re-evaluation of 33 of the 39 lesions 6 months after treatment revealed a low restenosis rate of 15%, an AAI of 0.8+/-0.3, MLD of 4.5+/-2 mm and %DS of 30+/-22%, so the Symphony Peripheral Stent is thus a promising choice for patients with ASO.

Coronary disease morphology and distribution determined by quantitative angiography and intravascular ultrasound--re-evaluation in a cooperative multicenter intravascular ultrasound study (COMIUS).

Although previous studies have demonstrated that even quantitative coronary angiography (QCA) can not provide accurate disease morphology, there has not been a systematic comparison of disease morphology determined by QCA and intravascular ultrasound (IVUS), particularly in Japanese patients. Therefore, the present study prospectively examined patients in a multicenter cooperative study. A total of 491 coronary sites from 562 patients (446 men, 116 women; mean age, 64+/-11 years) who underwent coronary interventions were enrolled. The target lesions (>50% diameter stenosis) were evaluated pre-operatively by both QCA and IVUS operating at 30-40 MHz and the percent area stenosis, eccentricity index (EI) and lesion length were determined. The minimal (min) and maximal (max) distances from the center of the stenotic lesion to the outline of the vessel wall were measured, and the EI was calculated by the formula: [(max - min)/max]. By QCA, lesion length was determined by measuring the distance between the proximal and distal shoulders of the lesion. When the lesions were observed by IVUS with a motorized pull-back system, the length was calculated by multiplying the time for observation of the disease and 0.5 or 1 mm/s. Although the severity of the stenosis determined by QCA (86+/-10%, mean +/- SD) did not differ from that by IVUS (83+/-13%), there was no correlation between them (r=0.32, y=0.25x+65) and the correlation did not improve when lesions with remodeling, enlargement (n=176) or shrinkage (n=79) were omitted from the calculation. The EIs by QCA and IVUS were 0.51+/-0.26 and 0.52+/-0.22, respectively (NS), and there was no correlation between them (r=0.30, y=0.36x+33). However, when the lesions with remodeling were excluded, the correlation greatly improved (r=0.80, y=0.84x+10.6, p<0.05). Lesion length determined by QCA (12.4+/-6.1 mm) was significantly shorter than that by IVUS (16.3+/-8.9 mm, p<0.01). These results demonstrate that coronary angiography significantly misinterprets disease morphology in terms of severity, eccentricity and length, in part because of vessel remodeling that can be accurately determined only by IVUS.

Comparison of dilatation mechanism and long-term vessel remodeling between directional coronary atherectomy and balloon angioplasty assessed by volumetric intravascular ultrasound.

Although acute and late outcomes of coronary interventions have been determined by coronary angiography, this method cannot determine changes in vessel and plaque volume. Volumetric intravascular analysis has the potential to evaluate the morphology and redistribution of plaque after coronary intervention as well as longitudinal vessel remodeling. We used 3-dimensional intravascular ultrasound (3-D IVUS) to delineate the mechanism of coronary dilatation and long-term (> 1 year) remodeling in 25 patients. Ten patients underwent directional coronary atherectomy (DCA), and 15 underwent balloon angioplasty (POBA). No patients exhibited restenosis at 6-month angiographic follow-up. Validated Netra 3-D IVUS was performed pre- and post-intervention, at 6-months and at > 1-year. There were some differences in mechanism of dilatation and time course of change in vessel size between DCA and POBA patients. The principal mechanism was vessel stretching and longitudinal plaque redistribution in the POBA group and plaque debulking in the DCA group. In the POBA group, vessel volume increased just after the procedure; this increase was maintained at 6 months and at > 1-year. However, in the DCA group, vessel volume increased initially 6 months after the procedure. 3-D IVUS revealed a difference in mechanism of dilatation between POBA and DCA; this difference might affect late-term vessel remodeling even in patients without restenosis.

Early and late clinical outcomes following coronary perforation in patients undergoing percutaneous coronary intervention.

Coronary perforation is a rare but serious complication that occurs during percutaneous coronary intervention (PCI). This study examines the frequency of coronary perforation during PCI, evaluates the management strategies used to treat perforations, and describes the long-term prognosis of patients who have developed coronary perforation during PCI. Coronary perforations were found in 69 (0.93%) of 7,443 consecutive PCI procedures, occurring more often after use of a new device (0.86%) than after use of balloon angioplasty (0.41%) (p<0.05). Coronary perforation was attributable solely to the coronary guidewire in 27 (0.36%) cases. Coronary perforations were divided into 2 types: (1) Those with epicardial staining without ajet of contrast extravasation (type I, n=51), and (2) those with a jet of contrast extravasation (type II, n= 18). Patients with type I and type II perforations were managed by observation only (35% and 0%, respectively), reversal of anticoagulation (57% and 94%), pericardiocentesis and drainage (27% and 61%), and prolonged perfusion balloon angioplasty (16% and 100%). Two patients with type II perforations required emergency coronary artery bypass surgery. There were no in-hospital deaths. Late pseudoaneurysms developed in 18 (28.6%) patients during the 13.4 +/- 11.3 months' follow-up period, and were more common in patients with type II perforations (72.2% vs 11.1% with type I perforations; p<0.001). During the follow-up period, no patient had evidence of coronary rupture. The results suggest that coronary perforation is uncommon after PCI, and can be managed without cardiac surgery in the majority of cases. Late pseudoaneurysms developed in some patients, particularly in patients with type II perforations, but there were no late consequences of coronary perforation after PCI.

Effect of local delivery of L-arginine on in-stent restenosis in humans.

To determine whether intramural administration of L-arginine reduces intimal thickening after optimal Palmaz-Schatz stent deployment in humans, 50 patients with native coronary artery disease who received a single Palmaz-Schatz stent were enrolled in this pilot study. Patients were randomized into 2 treatment groups: an L-arginine group (n = 25) and a saline group (n = 25). After stent deployment, L-arginine (600 mg/6 ml) or saline (6 ml) was locally delivered via the Dispatch catheter (Scimed) over 15 minutes. Serial angiography and intravascular ultrasound examinations (motorized pull-back at 0.5 mm/s) were performed before and after the procedure, and at 6-month follow-up. Measurements of stent area, lumen area, and neointimal area were computed within the stents at 1-mm intervals, by technicians who were blinded to the treatment assignment. Using Simpson's rule, stent, plaque, and lumen volumes, neointimal volume within the stent, and percent neointimal volume were measured before and after the procedure, and at 6-month follow-up. The 6-month volume data in quantitative coronary ultrasound showed that neointimal volume in the L-arginine group was significantly less than in the saline group (25 vs 39 mm(3); p = 0.049). Similarly, percent neointimal volume was significantly less in the L-arginine group at 6-month follow-up (17 +/- 13% vs 27 +/- 21%; p = 0.048). Thus, these results showed that local delivery of L-arginine reduces in-stent neointimal hyperplasia in humans, indicating that this approach may be a novel strategy to prevent in-stent restenosis.

Neointima in coronary stent does not increase during over 1-year in non-restenosed lesion at 6 months follow-up: serial volumetric intravascular ultrasound study.

The long-term outcomes of coronary artery stenting have been determined by coronary angiography only with has the limitation of determining stent expansion and neointimal proliferation at long-term follow-up. Volumetric intravascular analysis has the potential to evaluate the morphology and distribution of neointima longitudinally after coronary artery stenting. We used three-dimensional intravascular ultrasound (3-D IVUS) to evaluate serial changes in stent and neointimal volumes for over 1-year in 9 patients who did not exhibit angiographic restenosis at 6-month follow-up. Volumetric analysis by a validated Netra 3-D IVUS system was performed pre- and post-intervention, at 6-month follow-up (FU1), and at over one-year follow-up (FU2). Lumen volume in the stented lesions increased significantly after intervention, and the increase persisted until FU2. There were no significant changes in stent volume between just after stent implantation and at FU2. Neointimal volume within the stents did not change from FUI to FU2 (FU1; 38.4 +/- 9.0 mm3 vs FU2; 33.8 +/- 10.3 mm3). In 33% (3/9) of all lesions, neointimal volume increased between from 6-months to over 1-year after stent implantation. Neointimal distribution after stenting seemed to be almost equal and unrelated to the plaque burden at pre-intervention. Neointimal volume within the stents did not increase and stent volume did not change over the 1st-year in patients who did not exhibit angiographic restenosis at 6-months.