P450ome of the white rot fungus Phanerochaete chrysosporium: structure, evolution and regulation of expression of genomic P450 clusters

The model white rot fungus Phanerochaete chrysosporium has the extraordinary ability to degrade (to CO2) lignin and detoxify a variety of chemical pollutants. Whole genome sequencing of this fungus has revealed the presence of the largest P450ome in fungi comprising approx. 150 P450 genes, most of which have unknown function. On the basis of our genome-wide structural and evolutionary analysis, these P450 genes could be classified into 12 families and 23 subfamilies and under 11 fungal P450 clans. The analysis further revealed an extensive gene clustering with a total of 16 P450 clusters constituted of up to 11 members per cluster. In particular, evidence and role of gene duplications and horizontal gene transfer in the evolution of these P450 clusters have been discussed using two of the P450 families [CYP63 and CYP505 (where CYP is cytochrome P450)] as examples. In addition, the observed differential transcriptional induction of the clustered members of the CYP63 gene family, in response to different xenobiotic chemicals and carbon sources, indicated functional divergence within the P450 clusters, of this basidiomycete fungus.

Microarray-based global differential expression profiling of P450 monooxygenases and regulatory proteins for signal transduction pathways in the white rot fungus Phanerochaete chrysosporium

Whole genome sequencing of the model white rot basidiomycete Phanerochaete chrysosporium has revealed the largest P450 contingent known to date in fungi, along with related phase I and phase II metabolic genes and signaling cascade genes. As a part of their functional characterization, genome-wide expression profiling under physiologically distinct conditions, nutrient-limited (ligninolytic) and nutrient-rich (non-ligninolytic), was investigated using a custom-designed 70-mer oligonucleotide microarray developed based on 190 target genes and 23 control genes. All 150 P450 genes were found to be expressible under the test conditions, with 27 genes showing differential expression based on a >twofold arbitrary cut-off limit. Of these, 23 P450 genes were upregulated (twofold to ninefold) in defined high-nitrogen cultures whereas four genes were upregulated (twofold to twentyfold) in defined low-nitrogen cultures. Furthermore, tandem P450 member genes in ten of the 16 P450 genomic clusters showed nonassortative regulation of expression reflecting their functional diversity. Full-length cDNAs for two of the high-nitrogen upregulated genes pc-hn1 (CYP5035A1) and pc-hn2 (CYP5036A1) and partial cDNA for a low-nitrogen upregulated gene pc-ln1 (CYP5037A1) were cloned and characterized. The study provided first molecular evidence for the presence of active components of the cAMP- and MAP kinase-signaling pathways in a white rot fungus; four of these components (cpka and ste-12 of cAMP pathway and two MAP kinases, mps1 and sps1) were significantly upregulated (fourfold to eightfold) under nutrient-limited conditions, implying their likely role in the regulation of gene expression involved in secondary metabolism and biodegradation processes under these conditions.

Anti-tubercular agents. Part 3. Benzothiadiazine as a novel scaffold for anti-Mycobacterium activity

In an effort to develop new and more effective therapies to treat tuberculosis, a series of benzothiadiazine 1,1-dioxide derivatives were synthesized and their in vitro activity against Mycobacterium tuberculosis, Mycobacterium avium and Mycobacterium intracellulare was evaluated. One of the compounds, 8c, exhibited potent anti-tubercular activity, particularly for the resistant strains and thus prompted us to investigate its in vivo profile. However, the in vivo testing in a mouse model of tuberculosis infection did not show significant anti-tubercular activity, probably because of its poor bioavailability.

Antitubercular agents. Part 2: New thiolactomycin analogues active against Mycobacterium tuberculosis

Structurally modified analogues of naturally occurring antibiotic thiolactomycin, substituted at 4-position of the thiolactone ring have been prepared and evaluated for their antitubercular activity. Some of the compounds have exhibited potential activity against Mycobacterium tuberculosis.

Antitubercular agents. Part 1: Synthesis of phthalimido- and naphthalimido-linked phenazines as new prototype antitubercular agents

The preparation and antitubercular properties of a series of phthalimido- and naphthalimido-linked phenazines are described. Some of these new compounds inhibited the growth of Mycobacterium tuberculosis ATCC 27294, Mycobacterium avium ATCC 49601, Mycobacterium intracellulare ATCC 13950 and some clinical isolates.

First example of ring expansion of activated quinolines and isoquinolines: novel benzoazepinesElectronic supplementary information (ESI) available: experimental section. See http://www.rsc.org/suppdata/cc/b4/b405100a/

Activated quinoline and isoquinoline undergo unexpected ring expansion by diazocarbonyl compounds via C-C insertion in the presence of 5 mol% of copper triflate to produce ethyl 1H-benzo[b]azepine-1-carboxylate and ethyl 3H-benzo[d]azepine-3-carboxylate, respectively, in excellent yields with a high degree of selectivity

Green protocol for conjugate addition of thiols to alpha,beta-unsaturated ketones using a [bmim]PF6/H2O system

Alpha,beta-unsaturated ketones undergo conjugate addition rapidly with thiols in a hydrophobic ionic liquid [bmim]PF(6)/H(2)O solvent system (2:1) in the absence of any acid catalyst to afford the corresponding Michael adducts in high to quantitative yields with excellent 1,4-selectivity under mild and neutral conditions. The enones show enhanced reactivity in ionic liquids, thereby reducing reaction times and improving the yields significantly. The use of ionic liquids helps to avoid the use of either acid or base catalysts for this conversion. The recovered ionic liquid was reused four to five times with consistent activity.

[Bmim]PF(6): a novel and recyclable ionic liquid for conversion of oxiranes to thiiranes in aqueous media

A variety of epoxides respond rapidly with potassium thiocyanate in [bmim]PF(6)-H(2)O (2:1) solvent system at room temperature under mild and convenient conditions to produce the corresponding thiiranes in high to quantitative yields. Enhanced rates, improved yields, and recyclability of ionic liquids are the remarkable features observed in ionic liquids (ILs). The use of ionic liquids for this transformation avoids the use of heavy metal halides as promoters and chlorinated hydrocarbons as solvents. The ionic liquid was recycled in five to six subsequent runs with gradual decrease in activity.

Solid-phase synthesis of isoxazolines

The polymer-supported synthesis of isoxazolines is described via nitrile oxide intermediates, starting from primary nitroalkanes in a one-pot process.

Optimization of fermentation conditions for production of glycopeptide antibiotic vancomycin by Amycolatopsis orientalis

Glycopeptides produced by Streptomyces species are the drugs used against beta-lactam drug-resistant staphylococcal infections, and vancomycin is important among them. Increased prevalence of resistant strains increased the usage of vancomycin worldwide and also promoted attempts for indigenous production. The optimum process conditions pH, temperature, inoculum size, agitation, and aeration for vancomycin production by Amycolatopsis orientalis were evaluated, statistically analyzed, and the response surface curves were constructed. The optimum process conditions were a pH of 7.6, a temperature of 29 degrees C, an inoculum size of 4.5%, an agitation of 255 rpm, and an aeration of less than 1:10 medium-to-air ratio.

Biotransformation of linear alkylbenzene sulfonate (LAS) by Phanerochaete chrysosporium: oxidation of alkyl side-chain

The white rot fungus Phanerochaete chrysosporium, which generally mineralizes substituted aromatics to CO2, transformed linear alkylbenzene sulfonate (LAS) surfactants mainly at their alkyl side chain. Degradation of LAS was evidenced by a zone of clearing on LAS-containing agar plates and colorimetric analysis of liquid cultures. Disappearance of LAS was virtually complete within 10 days in low nitrogen (2.4 mM N), high nitrogen (24 mM N) and malt extract (ME) liquid media. After 5 days of incubation in ME medium, transformation of LAS was complete at concentrations < or = 4 mg l(-1), but decreased at higher concentrations. The LAS degradation was not dependent on lignin peroxidases (LiPs) and manganese-dependent peroxidases (MnPs). Mineralization of 14C-ring-LAS to 14CO2 by P. chrysosporium was < 1% regardless of the culture conditions used. Thin layer chromatography and mass spectral analyses indicated that P. chrysosporium transformed LAS to sulfophenyl carboxylates (SPCs) through oxidative shortening of the alkyl side-chains. While LAS disappearance in the cultures was not dependent on LiPs and MnPs, transformation of the parent LAS moieties to SPCs was more extensive in low N medium that favors expression of these enzymes. The SPCs produced in LN cultures were shorter in chain- length than those produced in ME cultures. Also there was a notable shift in the relative abundance of odd and even chain length metabolites compared to the starting LAS particularly in the low N cultures suggesting the possible involvement of processes other than or in addition to beta-oxidation in the chain-shortening process.

Efficient enantioselective reduction of ketones with Daucus carota root

A novel and efficient reduction of various prochiral ketones such as acetopehones, alpha-azido aryl ketones, beta-ketoesters, and aliphatic acyclic and cyclic ketones to the corresponding optically acive secondary alcohols with moderate to excellent chemical yield was achieved by using Daucus carota, root plant cells under extremely mild and environmentally benign conditions in aqueous medium, has been described. Many of these optically active alcohols are the potential chiral building blocks for the synthesis of pharmaceutically important molecules and asymmetric chiral ligands. Hence, this biocatalytic approach is found to be the most suitable for the preparation of a wide range of chiral alcohols and gave inspiration for the development of a new biotechnological process.

Cerium(III) chloride promoted highly regioselective ring opening of epoxides and aziridines using NaN(3) in acetonitrile: a facile synthesis of 1,2-azidoalcohols and 1,2-azidoamines

A convenient and efficient synthesis of 1,2-azidoalcohols and 1,2-azidoamines has been achieved by ring opening of epoxides and aziridines using cerium(III) chloride and sodium azide in acetonitrile. The reaction is highly regioselective and afforded the corresponding products in good to excellent yields under mild and neutral reaction conditions. The method is very rapid and equally compatible for both epoxides and aziridines.

Cytogenetic damage in plastic industry workers exposed to polyvinyl chloride

Cytogenetic investigations on peripheral blood lymphocytes of 40 workers exposed to polyvinyl chloride in the plastic industry were undertaken. These were compared with an equal number of occupationally unexposed and matched controls in relation to age, sex and smoking habits. The mitotic index (MI), chromosomal aberrations (CA), sister chromatid exchanges (SCE) and satellite associations (SA) were analysed. All the parameters showed a significant increase (p <0.01) in the exposed sample compared with the controls, viz MI, 3.64-6.30, CA 1.02-3.77, SCE 3.40-7.83 and SA 5.57-12.05. The occurrence of the DG type of satellite association B was highest and that of 3D type lowest. The frequencies of all the parameters increased with the duration of exposure, but MI declined after 15 years of exposure.

Asymmetric synthesis of (+)-allo-quercitol and (+)-talo-quercitol via free radical cycloisomerization of an enantiomerically pure alkyne-tethered aldehyde derived from a carbohydrate

We describe for the first time the free radical cyclization of enantiomerically pure alkyne-tethered aldehydes obtained from a carbohydrate (6, 7). The synthesis of compounds 6 and 7 obtained from a derivative of D-ribose is reported. These radical precursors have been submitted to cyclization with tributyltin hydride plus azobisisobutyronitrile to yield, after ring closure, two carbocycles, respectively. These carbocycles have been obtained as mixtures of E and Z vinyltin isomers, but with excellent diastereoselection at the new stereocenter formed during the ring closure. After protodestannylation, only one diastereomer was detected and isolated. The absolute configuration at the new stereocenter formed during the carbocyclization has been established by detailed (1)H NMR analysis. The specific transformation of 7-methoxymethoxy-2,2-dimethyl-4-methylene-5-tert-butyldimethylsilyloxy-(3aR,5S,7S,7aS)-perhydrobenzo[d][1,3]dioxole into optically pure (+)-allo-quercitol and (+)-talo-quercitol is described. From these results, we conclude that under an appropriate choice of radical precursors and conditions, the synthesis of highly functionalized cyclohexane derivatives of biological interest is now available.

Dual antiplatelet therapy with clopidogrel and aspirin after carotid artery stenting

BACKGROUND

Carotid artery stenting is being used as an alternative to carotid endarterectomy, both within the context of clinical trials and in non-surgical candidates. Though stenting is known to activate platelets, the role of antithrombotic therapy in carotid stenting has not been fully characterized.

METHODS AND RESULTS

Consecutive patients (n = 162) were followed in a single-center carotid stent registry. The cumulative rate of 30-day death, stroke, transient ischemic attack and myocardial infarction in those patients receiving a thienopyridine was determined, as were rates of stent thrombosis and intracranial hemorrhage. The mean age of the patients was 70.3 years and there was an extremely high prevalence of cardiovascular comorbidities, including 40% with unstable angina. The carotid lesion was symptomatic in 59% of patients. The average pre-treatment stenosis was 83%. The cumulative 30-day rate of death, stroke, transient ischemic attack and myocardial infarction was 5.6%. Specifically, in the patients who received ticlopidine (n = 23), the rate was 13%, versus 4.3% in the patients who received clopidogrel (n = 139) (p = 0.01). In this series, there were no cases of stent thrombosis and 1 intracranial hemorrhage.

CONCLUSION

Dual antiplatelet therapy with clopidogrel plus aspirin in patients receiving carotid artery stents is associated with a low rate of ischemic events. Furthermore, clopidogrel appears superior to ticlopidine. Thus, our findings lend support to the dual antiplatelet strategy of clopidogrel plus aspirin for patients undergoing carotid artery stenting.

Prevention of distal embolization during coronary angioplasty in saphenous vein grafts and native vessels using porous filter protection

BACKGROUND

Although distal embolization and the "no-reflow" phenomenon are well described in saphenous vein graft (SVG) interventions, the frequency, magnitude, and characterization of embolized debris have not been evaluated in routine coronary interventions. A unique embolus protection device described herein provides a means of containing and retrieving plaque material dislodged during percutaneous coronary interventions. This report details the first clinical experience of the effectiveness and safety of an emboli protection system in 11 SVG lesions and 15 native coronary artery lesions.

METHODS AND RESULTS

The AngioGuard Emboli Capture Guidewire (Cordis) consists of a PTCA wire with an expandable filter at the distal tip. The porous membrane permits normal distal blood flow, while trapping potential emboli by filtration. After crossing the lesion, the filter is expanded, and routine angioplasty is performed over the same wire. Emboli retrieval is achieved by collapsing the filter and retracting the emboli capture wire (ECW). In 26 patients, standard angioplasty was performed over the ECW; 20 of these 26 patients received a stent. Collected debris was sent for histopathological analysis. Plaque debris was retrieved after native coronary and SVG interventions in all cases. The ECW was positioned and retrieved without complications. No major adverse events occurred. Myocardial infarctions and no-reflow were not observed.

CONCLUSIONS

The embolization of plaque fragments frequently occurs during coronary and SVG intervention. Distal embolization leading to microvascular obstruction and no-reflow could be successfully minimized by using the ECW.

Self-expanding stents for carotid interventions: comparison of nitinol versus stainless-steel stents

BACKGROUND

Angioplasty and stenting are becoming increasingly accepted techniques for the treatment of carotid stenosis. However, the optimal stent for carotid intervention is not known.

METHODS

We compared the short- and intermediate-term results of carotid stenting using either nitinol or stainless-steel self-expanding stents in 178 high surgical risk patients undergoing carotid stenting at our institution. Of these 178 patients, eighty-nine received stainless-steel stents and 89 received nitinol stents. The groups were similar with respect to age, gender, diabetes, hypertension, left ventricular function, and symptom status. There were more patients with contralateral carotid occlusion in the nitinol stent group. Independent neurological evaluation was performed in all patients pre- and post-carotid stenting.

RESULTS

At 6 months, there was a similar incidence of stroke (3.3% versus 2.2%) in the stainless-steel group and nitinol stent group, respectively. There was higher 6-month mortality noted in the stainless-steel stent group, but there were no neurological deaths in either group.

CONCLUSIONS

In a single-center patient cohort with similar baseline characteristics, patients receiving nitinol stents and stainless-steel stents had similar neurological outcomes.

Initial experience of platelet glycoprotein IIb/IIIa inhibition with abciximab during carotid stenting: a safe and effective adjunctive therapy

BACKGROUND AND PURPOSE

Abciximab has been shown to decrease periprocedural ischemic complications after coronary intervention. However, the adjunctive use of abciximab in carotid stenting has not been adequately studied. We sought to determine the efficacy and safety of abciximab in carotid stenting.

METHODS

Carotid stenting was performed in 151 consecutive patients determined to be at high surgical risk by a vascular surgeon. Of these, 128 consecutive patients received adjuvant therapy with abciximab (0.25 mg/kg bolus before the lesion was crossed with guidewire and 0.125 micro. kg(-1). min(-1) infusion for 12 hours.). A heparin bolus of 50 U/kg was given, and activated clotting time was maintained between 250 to 300 seconds. All patients received aspirin and thienopyridine. Procedural and 30-day outcomes were compared between the control (n=23) and abciximab (n=128) groups.

RESULTS

The 2 groups had similar baseline characteristics. Procedural events were more frequent in the control group (8%; 1 major stroke and 1 neurological death) compared with the abciximab group (1.6%; 1 minor stroke and 1 retinal infarction; P=0.05). On 30-day follow-up, 1 patient presented with delayed intracranial hemorrhage in the abciximab group. There were no other major bleeding complications.

CONCLUSIONS

Adjunctive use of abciximab for carotid stenting is safe with no increase in the risk of intracranial hemorrhage. This adjunctive therapy with potent glycoprotein IIb/IIIa inhibition may help to reduce periprocedural adverse events in patients undergoing carotid stenting.

Update on peripheral vascular diseases: from smoking cessation to stenting

Newer pharmacologic agents including gene therapy hold promise for the treatment of atherosclerotic peripheral vascular disease (PVD), as do advances in endovascular revascularization techniques. Nonetheless, the two most important treatments remain the same: stopping smoking and starting a walking program.

Management practices in carotid stenting

Carotid endarterectomy can be regarded as the standard of care for low-risk patients with severe carotid stenosis; however, this technique is less appropriate for certain patient groups. For high-risk patients, carotid stenting currently represents a suitable alternative to endarterectomy. The major cause of morbidity and mortality linked to carotid intervention is release of plaque material, which leads to microembolic obstruction of distal intracranial branch vessels and arterioles. Emboli retrieval devices are in development to help prevent distal occlusion, and effective antiplatelet therapy has a role in mitigating the clinical consequences of microembolization. Initial experience has shown that antiplatelet therapy with the adenosine diphosphate receptor antagonist clopidogrel plus aspirin (+/- abciximab) is associated with a very low risk of procedural stroke or stent thrombosis and does not appear to increase the risk of intracranial haemorrhage. The availability of potent antiplatelet regimens, emboli prevention devices and nitinol stents will greatly expand the spectrum of carotid disease that can be safely treated with endovascular therapy.

LiBF4-mediated C-glycosylation of glycals with allyltrimethylsilane: a facile synthesis of allyl C-glycosylic compounds

The treatment of glycals with allyltrimethylsilane in the presence of lithium tetrafluoroborate in acetonitrile gave the corresponding allyl 2,3-unsaturated C-glycosylic compounds in excellent yields with high anomeric selectivity.

Percutaneous intervention for symptomatic vertebral artery stenosis using coronary stents

BACKGROUND

There is very limited experience with percutaneous treatment of symptomatic vertebral artery disease. Angioplasty and stenting for vertebral artery stenosis are still evolving and have generally been performed for asymptomatic disease. We performed vertebral artery stenting in 12 patients with vertebrobasilar transient ischemic attacks and present our short- and intermediate-term results.

METHODS

A total of 12 lesions affecting the vertebral artery were treated by coronary stent placement. The mean age was 72 +/- 8 years and 83% were males (10 males, 2 females). Baseline characteristics included hypertension (11/12); hypercholesterolemia (8/12); coronary artery disease (8/12); and diabetes (5/12). Mean lesion length was 8.6 +/- 2.7 mm, mean calipered stenosis was 78 +/- 8%, and mean arterial diameter was 4.1 +/- 0.3 mm. All patients were symptomatic, fulfilling our criteria for vertebral artery angioplasty. All patients were followed for at least 6 months after treatment.

RESULTS

All 12 lesions were successfully stented, with a mean residual stenosis of 11 +/- 6%. Clinical follow-up showed resolution or improvement of symptoms in all patients. One patient had symptomatic restenosis seven months after the initial procedure requiring repeat angioplasty.

CONCLUSIONS

Stent placement for symptomatic stenosis involving the vertebral artery is safe and effective for alleviating symptoms of vertebrobasilar ischemia. Coronary stents appear to be well suited to treat atherosclerotic lesions of the vertebral artery.

Preprocedural risk stratification: identifying an appropriate population for carotid stenting

PURPOSE

Given the uncertainties associated with carotid angioplasty and stenting, the initial assessment of the procedure may be best undertaken in a subgroup of patients at increased risk for complications with standard carotid surgery. In an effort to characterize such a subgroup, we reviewed the results of carotid endarterectomy in patients with and without significant medical comorbidity.

METHODS

During a 10-year period 3061 carotid endarterectomies were performed at a single institution and entered prospectively into a registry. A high-risk patient subgroup was identified, defined by the presence of severe coronary artery disease, chronic obstructive lung disease, or renal insufficiency. The outcome of carotid endarterectomy was assessed with respect to perioperative stroke, myocardial infarction, or death, as well as the combined end point of one or more of the end points.

RESULTS

The rate of the composite end point stroke/myocardial infarction/death was 3.8% in the total group of 3061 patients who underwent endarterectomy. As individual end points, the rate of stroke was 2.1%, myocardial infarction 1.2%, and death 1.1%. Among the high-risk subset, the composite end point stroke/myocardial infarction/death occurred in 7.4%. This rate was significantly greater than the corresponding rate of 2.9% in the low-risk subset (P <.0005). Similarly, the rate of stroke (3.5% vs 1.7%, P =.008) or death (4.4% vs 0.3%, P <.001) as solitary events was significantly greater in high-risk patients.

CONCLUSIONS

Although carotid endarterectomy is an extremely safe procedure in most patients, results are not as favorable in a high-risk subset with severe coronary, pulmonary, or renal disease. The initial clinical evaluation of carotid stenting might best be undertaken in such a high-risk population, one that comprises patients for whom standard therapy is associated with a high rate of complications.

Clinical application of procedural platelet monitoring during percutaneous coronary intervention among patients at increased bleeding risk

The goal of platelet function testing in the catheterization laboratory is to provide information about the platelet contributions to the risk of thrombotic or hemorrhagic events and optimization of anti-platelet therapy for percutaneous interventions. We present several illustrative cases in which platelet monitoring with the Rapid Platelet Function Assay (RPFA, Accumetrics) was used to guide dosing of a glycoprotein (GP) IIb/IIIa inhibitor for coronary and peripheral intervention among patients at increased bleeding risk.

A Highly Efficient, Mild, and Selective Cleavage of β-Methoxyethoxymethyl (MEM) Ethers by Cerium(III) Chloride in Acetonitrile

[structure: see text]. A highly selective cleavage of MEM ethers has been achieved in high yields using CeCl3.7H2O in refluxing acetonitrile under mild and neutral reaction conditions. The method is very rapid and compatible with other hydroxyl protecting groups such as Bn, TBDPS, Ac, Me, Tr, PMB, benzylidene, THP, MOM, BOM, and NHAc present in the substrate.

Interventional advances in long-term stroke prevention

Endovascular angioplasty and stent placement are rapidly emerging therapeutic modalities for selected patients with carotid arterial occlusive disease. Prospective analyses of several large studies have shown that although carotid endarterectomy is the standard of care for most patients, it is associated with significant morbidity and mortality in high-risk patients. When carotid endarterectomy is not feasible in patients with conditions such as contralateral occlusions, recurrent stenosis, and pre-existing cranial palsies, carotid stenting is the treatment of choice. Adjunctive administration of potent antiplatelet agents such as clopidogrel and aspirin appears to reduce the risk of stroke. Currently available embolization-prevention devices and nitinol stents greatly reduce the mortality and morbidity because of embolization during carotid stenting. The spectrum of carotid diseases that can be safely treated with endovascular intervention will increase as new and safer options become available.

Update on clinical trials of antiplatelet therapy for cerebrovascular diseases

Antiplatelet medications are an important part of the therapy of cerebrovascular diseases. Oral agents such as aspirin have an established role in the secondary prevention of stroke. An aspirin and dipyridamole combination has recently been approved. Ticlopidine has been proven to be more effective than aspirin, but its potentially serious side effect profile makes long-term use hazardous. Clopidogrel has been demonstrated to be both more effective than and at least as safe as aspirin. The combination of clopidogrel plus aspirin represents the likely future therapy for high-risk patients. The role of oral antiplatelet therapy in the acute treatment of stroke is beginning to be clarified. Aspirin treatment appears to be strongly indicated. Intravenous antiplatelet therapy with glycoprotein IIb/IIIa inhibitors for acute stroke and as an adjunct to carotid artery stenting appears promising.