Treatment of a fusiform vertebral aneurysm with double stent placement. A technical case report and review of the literature

A 34-year-old man admitted to another hospital presented with sudden onset of headache. The CT scan was unremarkable, but magnetic resonance angiography revealed a fusiform aneurysm in the left vertebral artery. Six days later, the patient was sent to our institution for further diagnosis and treatment. Cerebral angiography confirmed a fusiform aneurysm located in the right vertebral artery. At first, we placed a neuroform-3 stent and could see contrast medium stasis in the aneurysm, so we did not fill coils into the aneurysm. Four months later, the patient was admitted for rechecking. DSA showed the aneurysm remained and we placed a LEO stent in the lumen of the Neuroform stent. A control DSA eight months later showed the aneurysm had almost healed. Overlapping stents may induce spontaneous thrombosis of vertebral artery aneurysms and facilitate parent artery reconstruction through flow remodeling and stent endothelialization. This technique may be an option in treating dissecting or fusiform intracranial aneurysms that are not amenable to open surgical treatment or endovascular coil embolization.

Genomic structure and characterization of mRNA expression pattern of porcine interferon gamma receptor 1 gene

Interferon gamma receptor (IFNGR) plays an important role in the biological effects of IFN-γ. In this study, porcine IFNGR1 cDNA was cloned and two transcripts both having a coding region of 1413 bp were identified. Porcine IFNGR1 cDNA shares 62.95%, 63.73%, 72.90% and 81.10% identity in nucleotide sequence; and 45.64%, 46.69%, 58.04% and 72.55% homology in amino acid sequence to those of rat, mouse, human and cattle, respectively. The porcine IFNGR1 genomic structure consists of seven exons and six introns and is located on porcine chromosome 1. The mRNA expression of porcine IFNGR1 gene is detected in all tissues examined, with strong expression in spleen and liver tissues and weak expression in cerebrum, cerebellum and uterus tissues, respectively. A different developmental pattern in IFNGR1 mRNA expression between Laiwu and Duroc breeds was revealed by real-time quantitative RT-PCR: in Duroc pigs, a significantly higher expression was found in the tissues of heart (P<0.05), liver (P<0.01), kidney (P<0.01) and skeletal muscle (P<0.05) of adult pigs compared to piglets. In porcine reproductive and respiratory syndrome virus (PRRSV)-infected Dapulian pigs, compared to the uninfected ones, the expression level of IFNGR1 mRNA in spleen was significantly up-regulated (P<0.05), whereas its expression in the lymph node was significantly down-regulated (P<0.05); in PRRSV-infected Duroc × Yorkshire × Landrace commercial pigs, however, the differences both in spleen and lymph node tissues were not significant.

A p1 aneurysm and diabetes insipidus caused by traumatic brain injury

We describe a patient with a P1 aneurysm of the posterior cerebral artery (PCA) with diabetes insipidus (DI) caused by traumatic brain injury. A 21-year-old woman presented with epidural hematoma, left temporal contusion and subarachnoid hemorrhage caused by head trauma. DI occurred with normal anterior hypophyseal function on the second day after admission and cerebral angiography demonstrated an aneurysm at the right P1 portion after one month. DI was treated with administration of desmopressin and the aneurysm and P1 portion of the right PCA were occluded completely. After three months, her DI recovered and decompressin was discontinued. The six month follow-up angiogram confirmed cure of the P1 aneurysm. P1 aneurysm and DI can be caused by traumatic brain injury. Cranial DI caused by head injury with perturbations in water balance may be transitory and resolve.

Endovascular treatment for cerebral aneurysms using stents

Endovascular stent placement combined with coil embolization is an established procedure for the treatment of intracranial aneurysms. We describe lesion outcome using stents for the treatment of intracranial aneurysms. Sixty-nine patients (30 females and 39 males; age range 12-78 years) treated with stent placement at Beijing Tiantan Hospital over a six-year period. Seventy- six cerebral aneurysms were encountered and 74 lesions were treated with 79 stents. Outcome was evaluated using the Glasgow Outcome Scale (GOS) score during a mean follow-up period of 32 months. Of the 74 stented aneurysms, 34 (45.9%) were located in the anterior circulation and 40 (54.1%) in the posterior circulation. Forty-eight (64.9%) aneurysms were small and 26 (35.1%) were large or giant. In 67 (90.5%) aneurysms embolization was completed by packing the aneurysm sac with platinum coils. In five small fusiform and four saccular aneurysms, the stent was used alone. Six procedure-related complications were observed and a cause of death in 7.2% of the patients. Follow-up angiography obtained at three months to one year in 68 (91.9%) aneurysms demonstrated complete occlusion in 43 aneurysms with a progressive thrombosis rate of 19.4% (six out of 31 aneurysms). Aneurysm recurrence occurred in four (5.8%) patients, three were treated with coil embolization and one with placement of another stent. Overall long-term outcome was good (GOS Score 4 or 5) in 92.8%, and fatal (GOS Score 1) in 7.2% of the patients. Intracranial stents can be a useful addition to coil embolization for complex broad-based aneurysms. Favorable overall long-term outcome can be achieved in 92.8% of patients when using endovascular stent placement techniques.

Giant vertebrobasilar aneurysm treated with bilateral vertebral artery occlusion. Two case reports

Giant vertebrobasilar aneurysms constitute a relatively uncommon subgroup of aneurysms with a high mortality rate. These aneurysms are often difficult to treat with conventional clipping or coiling because of their location and their morphology. Here we describe two patients with giant vertebrobasilar aneurysms, both of which were successfully treated with bilateral vertebral artery occlusion. This approach is suggested as a definitive treatment for vertebrobasilar aneurysms in appropriate circumstances.

Endovascular treatment for complex intracranial aneurysms: lessons learnt in five patients

We describe our experience in five cases of endovascular treatment for complex intracranial aneurysms. The senior author (ZW) has clinical experience with more than 6000 cases of brain aneurysms treated with endovascular techniques. Multiple endovascular therapies, such as treatment with Onyx, parent vessel occlusion, stent-assisted coiling, covered stent, can be used in an attempt to provide a solution to various clinical dilemmas associated with the management of these difficult lesions. Here, we focus on the latest five patients and lessons learnt in endovascular techniques for complex intracranial aneurysms.On the basis of the knowledge obtained over the years, multimodality endovascular techniques should be re-evaluated to improve patient outcomes.

Transarterial and transvenous embolization for cavernous sinus dural arteriovenous fistulae

We report on the safety and efficacy of trans-arterial and transvenous Onyx embolization in the treatment of dural arteriovenous fistulae (DAVFs) of the cavernous sinus. We reviewed the findings from a retrospectively database for 22 patients with cavernous sinus DAVFs who were treated with either transarterial Onyx embolization alone (n = 8) or transarterial and transvenous Onyx embolization (n = 14) over a four year period. The mean follow-up period after endovascular treatment was 21.6 months (range 3-42 mths). Total number of embolizations was 27 for 22 patients. Two patients were treated transvenously after transarterial embolization. All 22 patients (100%) experienced improvement of their clinical symptoms. All 22 patients (100%) experienced total obliteration of their DAVFs, as documented by angiography performed at a mean follow-up of 5.8 months after the last treatment. No patient experienced a recurrence of symptoms after angiography showed DAVF obliteration. One patient exhibited temporary deterioration of ocular symptoms secondary to venous hypertension after near total obliteration; one had transient V cranial nerve deficit related to transarterial embolization, and two patients exhibited transient III and VI cranial nerve weakness related to transvenous embolization. Two patients experienced recurrent symptoms after incomplete transarterial embolization and underwent transvenous embolization at three and four months. Both patients achieved clinical and angiographic cures. Transarterial and transvenous embolization with Onyx, whenever possible, proved to be a safe and effective management for patients with cavernous sinus DAVFs.

Role of neurocrine somatostatin on sphincter of Oddi contractility and intestinal ischemia reperfusion-induced acute pancreatitis in macaques

BACKGROUND

Intestinal ischemia-reperfusion (IIR) is implicated in the pathogenesis of severe acute pancreatitis (SAP). This study investigates the impact of neurocrine somatostatin (SST) on the contraction of sphincter of Oddi (SO) during IIR.

METHODS

Intestinal ischemia-reperfusion model in macaques was induced by occluding the superior mesenteric artery. Pancreatitis was confirmed by pancreatic histology and serum levels of amylase and lipase. SST and its receptors (SSTRs) in SO were visualized by immunohistochemistry. Effects of SST on the contraction of the isolated SO were recorded in vitro.

KEY RESULTS

Inflammatory scores of the pancreas and serum levels of amylase or lipase in the macaques that underwent IIR were significantly higher than those in the control group. The frequency and amplitude of phasic contraction of the circular muscle in SO was increased by SST in a concentration-dependent manner. Compared with the control group, SST innervation or SSTR2 expression in SO of macaques treated with IIR was increased 5.2 fold or 5.6 fold respectively. Prophylactic infusion of SST before IIR significantly reduced SST immunoreactive fibers in SO as compared to those in the IIR group and remarkably alleviated the pathophysiologic changes due to IIR.

CONCLUSIONS & INFERENCES

Increased SST innervation in SO during the early phase of IIR associated with the contraction of circular muscle of SO, which might be one of the promoting factors associated with the development of SAP. Prevention of IIR or intervention of SO contraction after occurrence of acute pancreatitis might be beneficial for preventing SAP.

Clinical outcomes of ruptured and unruptured vertebral artery-posterior inferior cerebellar artery complex dissecting aneurysms after endovascular embolization

BACKGROUND AND PURPOSE

Surgical treatment of VA-PICA dissecting aneurysms is difficult and complication of LCNP is common. These lesions can be approached easily with endovascular technique, but complete obliteration can only be achieved in a small number of cases. Our aim was to report the clinical outcomes of VA-PICA dissecting aneurysms treated by endovascular embolization.

MATERIALS AND METHODS

Between 2001 and 2007, the authors treated 22 consecutive patients (15 men and 7 women; ranging in age from 12 to 59 years; mean age, 43 years) with VA-PICA dissecting aneurysms. Diagnosis of VA-PICA dissecting aneurysm was based on clinical, MR imaging, and cerebral angiography studies.

RESULTS

Of the 22 patients, 6 had unruptured aneurysms. One patient presented with headaches, whereas the remaining 5 patients showed brain stem ischemia. Four were treated with stent-only or stent-coil embolization, and 2 were treated with unilateral VA occlusion. Among 16 patients presenting with SAH, 10 were treated with stent-only or stent-coil embolization. The other 6 patients with SAH were treated by using unilateral endovascular VA occlusion. One patient could not return to his previous daily activities.

CONCLUSIONS

VA-PICA aneurysms are rare lesions associated with significant morbidity, and endovascular treatment strategies for these lesions were stent deployment with or without coil embolization and VA occlusion. Favorable clinical outcomes can be achieved with endovascular techniques.

A systematic comparison between collagen-induced arthritis and pristane-induced arthritis in Dark Agouti rats

OBJECTIVES

Both collagen-induced arthritis (CIA) and pristane-induced arthritis (PIA) are commonly used rat models of rheumatoid arthritis (RA). The aim of this study was systematically to compare the differences between CIA and PIA in Dark Agouti (DA) rats.

METHODS

The CIA was induced by immunising DA rats intradermally with collagen type (C) and PIA was induced by injecting subcutaneously with pristane. The arthritis was evaluated macroscopically and microscopically. Nitric oxide (NO) level of plasma was determined by Griess reaction method. Plasma autoimmune antibodies, including C specific IgG antibody (anti-C IgG), cyclic citrullinated peptide specific IgG antibody (anti-CCP IgG), IgM and IgG rheumatoid factors (IgM RF and IgG RF), were detected by the enzyme-linked immunosorbent assay.

RESULTS

The onset of PIA rats was earlier than that of CIA rats. The involved sites of PIA rats were mostly wrist/ankle and metacarpophalangeal/metatarsophalangeal (MCP/MTP) joints while those of CIA rats were primarily distal interphalangeal (DIP) joints. NO level of plasma was increased in PIA rats, as anti-C IgG, anti-CCP IgG, IgM RF and IgG RF levels of plasma were increased in CIA rats. The kidney hyaline casts were more frequent in CIA rats than in control rats, with 9/12 in PIA group, 8/8 in CIA, and 4/8 in control, respectively.

CONCLUSIONS

PIA mainly affected wrist/ankle joints and MCP/MTP joints, had more severe inflammation and hardly involved other organs; while CIA mostly influenced DIP joints, had more autoimmune antibodies in plasma, and always showed hyaline casts in kidney. These findings will be useful to select the animal model of RA.

Diversity of soil actinomycetes in yunnan, china

Since 1978, about 4,200 soil samples have been collected from 22 selected areas of various vegetational and climatic types throughout the province of Yunnan. Actinomycetes of 29 genera were isolated by the methods employed. The correlations between diversity and climate were grouped into tropical, subtropical plateau, cool temperate mountain, and snowy mountain types. Actinomycete populations of the first two types were more complex than were the other ones. Correlations between actinomycete diversity and vegetation were also attempted. Six types of vegetation were compared. The diversity of actinomycetes was greatest in soil samples of a primeval forest, with an average of 9.0 genera isolated, followed by secondary forest and vegetable farmland samples, with averages of 6.7 and 6.5 genera isolated, respectively. The upper limit for the occurrence of thermophilic actinomycetes is about 3,500 m above sea level in Yunnan. Psychrophilic actinomycetes were isolated at up to the same altitude. In addition, the drier and poorer the soil was and the cooler the climate was, the lower the count of actinomycetes was and the higher the percentage of streptomycetes observed was. The genus Streptomyces appears to be the most important in ecological function. It represents up to 90% of all soil actinomycete diversity in Yunnan and is likely an important characteristic of the soil actinomycete population.

Diversity of aquatic actinomycetes in lakes of the middle plateau, yunnan, china

A total of 749 sediment and water samples were collected from 12 lakes of the Middle Plateau of Yunnan from 1983 to 1993. The diversity and biological characteristics of the aquatic actinomycetes in these lakes were studied. Sixteen genera of actinomycetes were isolated from these samples. Micromonospores assumed a notable dominance (from 39 to 89%) in the actinomycete populations of these lake sediments. Streptomycetes were the second most abundant organisms. The diversity and counts of actinomycetes varied with the season. Thermophilic actinomycetes have a wide distribution in these lakes, but their counts were smaller. The cell wall compositions of certain Micromonospora and Streptomyces strains from an alkaline lake revealed an unusual combination of glycine and isomers of diaminopimelic acid. It seems that aquatic actinomycetes play a significant role in the decomposition of organic substances, including some toxic compounds such as phenol, in these lakes. It also appears that aquatic actinomycetes are one of the important resources for screening useful enzymes and metabolites.

Endovascular embolization for deep Basal Ganglia arteriovenous malformations

We report our experience with basal ganglia AVM embolization and clinical outcomes after embolization. We retrospectively evaluated consecutive 15 patients with AVMs in the basal ganglia with respect to the endovascular treatment of these lesions. Treatment consisted of embolization and radiosurgery in combination. The angiographic follow-up after the last management was 24-36 months (mean 27 months). Clinical follow-up monitoring (range, 24-120 months, mean 76 months) was measured by the Modified Rankin Scale (mRS). The 15 patients studied had a mean age of 25.1 years at diagnosis, and 33.3% were male. Intracranial hemorrhage (ICH) was the event leading to clinical detection in eight patients (53.3%), and 85.5% of these patients were left with hemiparesis. At presentation, eight (53.3%) patients bled a total of 11 times. Twenty-four embolization procedures (16 pedicles embolized) were performed in 15 patients with embolization as the adjunct to radiosurgery. There were three clinically significant complications. Excellent or good outcomes (mRS≤2) were observed in 13 (86.7%) patients. Unfavorable outcomes (mRS≤2) were 13.3% at follow-up, without mortality. Seven (46.7%) patients had complete AVM obliteration at follow-up. The risk of incurring a neurological deficit with basal ganglia AVM is high. Treatment of these patients is endovascular embolization with a combination of radiosurgery to prevent neurological injury from a spontaneous ICH.

Endovascular treatment accounts for a change in brain arteriovenous malformation natural history risk

This study estimated the risk and rates of intracranial hemorrhage (ICH) in patients harbor-ing brain arteriovenous malformation (BAVM) after endovascular embolization. One hundred and forty-four consecutive patients with BAVM treated with endovascular embolization between 1998 and 2003 were retrospectively reviewed. The risk of ICH subsequent to endovascular embolization was studied using Kaplan-Meier curves. We reviewed 144 patients with BAVM treated with endovascular embolization. Two hundred and sixty-nine procedures were performed, 69 were performed with silk sutures, 18 with coils, 137 with NBCA and 36 with Onyx18. Twenty-three (16.0%) patients were treated with additional gamma-knife radiosurgery and one (0.7%) with additional surgical AVM excision. Complete obliteration of BAVMs was achieved in 20 patients (13.9%). During a mean follow-up of 5.9 years for the ICH group and 6.9 years for the non-ICH group, hemorrhages occurred in 11 (17.7%) of the ICH patients and in nine (11%) of the non-ICH group (p>0.1). The annual risk of hemorrhage was 3.0% and 1.6%, respectively. In the multivariate regression model, the adjusted relative risk (RR) for hemorrhage at initial presentation was 1.6 (95% CI 1.2-3.2; p>0.1). Deep venous drainage, male sex, age or AVM size were not significantly associated with subsequent hemorrhage. ICH and non-ICH groups did not differ in progression to subsequent ICH after endovascular embolization (log-rank X (2) =1.339, p>0.1) in survival analyses. The overall annual hemorrhage risk for all patients after endovascular embolization was 2.1%. Endovascular embolization alone or combined with gamma-knife radiosurgery or surgical treatment are able to decrease ICH occurrence compared to abstention.

Periprocedural bleeding complications of brain AVM embolization with Onyx

The advent of Onyx has provided a new method for neurointerventional therapists to treat brain AVMs. Although some retrospective studies have reported complications for AVM embolization with Onyx, periprocedural bleeding complications with Onyx embolization have not yet been described in detail. The aim of this retrospective study was to analyze the factors of Onyx-related bleeding complications and to find a way to avoid and manage these complications.From January 2003, patients with AVMs recruited in our institution started to be treated by Onyx embolization. From January 2007 to July 2009, 143 consecutive interventions were performed in 126 patients using flow-independent microcatheters and Onyx as embolic agents. Seven patients encountered bleeding complications (5.4% per patients and 4.7% per procedures) during or after the endovascular procedures. Among them, five bleeding episodes occurred during procedures, the other two after procedures. Details of the seven patients' clinical presentations, imaging presentations, speculative reasons and management of these complications were recorded. Follow-up data, including postoperative course, clinical symptoms and duration of follow-up were documented. The five active bleedings discovered in procedures were managed in time, and the patients recovered without any new neurological symptoms compared with preoperation. However, of the two bleeding episodes that occurred after interventional procedures, one was detected half an hour later: the patient was remained comatose two months later after resection of right occipital hematoma; the other who encountered intraventricular and midbrain hemorrhage was treated conservatively and suffered Parinaud syndrome and hemianesthesia.

CONCLUSION

Periprocedural bleeding of AVMs embolization is considered a severe and devastating complication. The clinical course and prognosis of bleeding mostly depends on prompt detection and management. Interventional embolization is an effective method to manage bleeding during procedures, and the detection of risk factors and imaging signs of bleeding is extremely important.

Delayed thrombosis of the basilar artery after stenting for a basilar trunk dissection aneurysm. A case report and review of the literature

A 30-year-old man was referred in our department for treatment of a midbasilar trunk aneurysm. His presenting symptoms included headache and dizziness. A CT scan at another hospital showed no significant findings whereas a digital subtraction angiogram disclosed a dissecting aneurysm in the midbasilar trunk, and there was severe stenosis in the basilar artery. After discussion, we planned to use stent-assisted-coil embolization technique. During the procedure, a LEO stent (Balt, Montmorency, France) was implanted into the basilar artery across the aneurysm neck, but fearing acute basilar artery occlusion because of stent collapse or thrombus we did not fill coils into the aneurysm. After the procedure, the completion angiography demonstrated considerably decreased flow into the aneurysm, with stasis persisting into the venous phase of angiography. The patient awoke from general anaesthesia after the procedure and had no additional neurological symptoms, he was discharged three days later and used clopidogrel and aspirin for antiplatelet therapy. Six months later when he was admitted for a recheck, a DSA showed the basilar artery was occluded completely and the aneurysm had disappeared even though the patient remained neurologically normal.

The incidence of trigeminocardiac reflex in endovascular treatment of dural arteriovenous fistula with onyx

This paper reports the incidence of tri-geminocardiac reflex (TCR) in endovascular treatment of dural arteriovenous fistulas (DAVFs) with Onyx. The consecutive case histories of 45 patients with DAVFs, treated with Onyx transarterially and transvenously, from February 2005 to February 2008 at Beijing Tiantan Hospital, China, were retrospectively reviewed. The time period was limited as the anesthetic and intravascular procedure was performed under the same standardized anesthetic protocol and by the same team. The TCR rate was subsequently calculated. Of the 45 patients, five showed evidence of TCR during transarterial Onyx injection and transvenous DMSO injection. Their HR fell 50% during intravascular procedures compared with levels immediately before the stimulus. However, blood pressure values were stable in all cases. The TCR rate for all patients was 11.1% (95% CI, 4 to 24%), 7.7% (95% CI, 2 to 21%) in patients treated intraarterially and 33.3% (4 to 78%) in patients treated intravenously. Once HR has fallen, intravenous atropine is indicated to block the depressor response and prevention further TCR episodes. TCR may occur due to chemical stimulus of DMSO and Onyx cast formation under a standardized anesthetic protocol and should be blunted by atropine.