Abstract 15: Differential Impact of Comprehensive Stroke Care Capacity on in-Hospital Mortality After Stroke-j-aspect Study

Background: The effectiveness of comprehensive stroke center (CSC) capacities on stroke mortality remains uncertain. We examined whether specific CSC capacities influenced in-hospital mortality of patients with ischemic and hemorrhagic stroke in a nationwide study.

Methods and Results: Of 749 certified training institutions in Japan responded to a questionnaire survey regarding CSC capacities, specifically regarding the availability of personnel, diagnostic techniques, specific expertise, infrastructure, and educational components recommended for CSCs, 265 institutions agreed to participate in this study. Data on patients hospitalized for stroke between April 1, 2010 and March 31, 2011 were obtained from the Japanese Diagnosis Procedure Combination database. In-hospital mortality was analyzed using hierarchical logistic regression analysis adjusted for age, sex, level of consciousness on admission, and 25 fulfilled CSC items in each component. Data from 265 institutions and 53,170 emergency-hospitalized patients were analyzed. Mortality rates were 7.8% for patients with ischemic stroke, 16.8% for patients with intracerebral hemorrhage (ICH), and 28.1% for patients with subarachnoid hemorrhage (SAH). Mortality adjusted for age, sex, and level of consciousness was significantly correlated with different items in the five components recommended for CSC depending on stroke types (Table 1 and 2).

Conclusions: CSC capacities were associated with reduced in-hospital mortality rates, and relevant aspects of care were found to be dependent on the type of stroke.

Abstract T P85: Restenosis after Carotid Endarterectomy and Preoperative Carotid Plaque Imaging

Introduction: The incidence of restenosis after carotid endarterectomy (CEA) and carotid artery stenting (CAS) was reported to be approximately 6% at two years after the procedure in the CREST study. Restenosis after CEA, rather than CAS, was more likely to be related to a recurrence of stroke. The correlation between the plaque composition and restenosis after CEA has been investigated in previous reports, but the relationship between restenosis after CEA and preoperative plaque imaging is still unclear.

Objective: We investigated the relationship between restenosis after CEA based on the preoperative plaque imaging.

Methods: One-hundred and eighty-four CEAs were performed from November 2005 to March 2009 in our institution. In this study cohort, we included the 41 cases (40 patients, 37 males, mean age ± SD, 70.7±6.3) who underwent 18F-FDG positron emission tomography (PET) and magnetic resonance (MR) imaging using 3D inversion-recovery -based T1-weighted imaging (magnetization-prepared rapid acquisition gradient-echo [MPRAGE]) before CEA. The signal intensity of the carotid artery plaque on MPRAGE sequences was classified as “high” when the intensity was more than 200% the value of the adjacent muscle. The PET findings were evaluated by the maximum standard uptake value (max SUV) and a high max SUV was defined as >1.74. We included patients who had undergone serial imaging studies (CT angiography; n=36, and/or ultrasonography; n=36) postoperatively. Restenosis was defined as >50% stenosis on a CT angiogram or a >200 cm/sec peak systolic velocity (PSV) on ultrasonography at the treated site.

Results: Overall, restenosis occurred in three cases (7.3%). A MPRAGE high signal was recognized in 31 cases (76%) and a high maxSUV was noted in 23 cases (56%). All three patients with restenosis had both high MPRAGE and high maxSUV values.

The group with MPRAGE high/maxSUV high (n=18) had a significantly higher incidence of restenosis after CEA than did the other groups (P=0.0420).

Conclusions: The incidence of restenosis after CEA is suspected to be higher when the plaque consists of a rich necrotic core/intraplaque hemorrhage and a high degree of inflammation.

Abstract W P104: Comparison of Carotid Endarterectomy and Stenting for Carotid Artery Stenosis with Coronary Artery Disease

Objective: Coronary artery disease (CAD) is a major comorbidity usually developing in patients with carotid artery stenosis and increases the risk of revascularization in these patients. We retrospectively evaluated the impact of CAD on the outcomes of carotid endarterectomy (CEA) and carotid artery stenting (CAS) at a single center.

Methods: We reviewed data of 643 lesions (451 CEA and 192 CAS) in 599 patients who underwent carotid revascularization at our institute between 1998 and 2011. We defined a history of myocardial infarction (MI), coronary artery bypass surgery, or percutaneous coronary intervention as previous CAD and >75% stenosis in more than 2 coronary artery areas as multivessel CAD. Periprocedural stroke, MI, or death from any cause and ipsilateral stroke, MI, or death within a year after treatment were recorded.

Results: Of the 643 lesions, 123 (19.1%) were categorized as “previous CAD” and 73 (11.4%) as “multivessel CAD.” The number of cases of multivessel CAD was significantly higher in the CAS group than the CEA group (14.5% vs. 9.9%, p = 0.009). Of the 102 cases indicated for coronary intervention at a preoperative period, 85 were treated for CAD before carotid revascularization. No periprocedural MI was observed in both the groups, and only 1 case showed MI within a year after CEA (0.2%). The CEA group showed no significant relationship between previous or multivessel CAD and any periprocedural or 1-year postoperative event. In the CAS group, multivessel CAD was identified as an independent risk factor for periprocedural stroke (odds ratio [OR]: 11.23; 95% confidence interval [CI]: 2.96-48.91; p = 0.0004) and ipsilateral stroke and death within a year of treatment (OR: 6.76; 95% CI: 2.09-22.38; p = 0.001).

Conclusion: Previous or multivessel CAD did not increase the risk of MI or death within 1 year after revascularization of carotid artery stenosis, but multivessel CAD was an independent risk factor for stroke after CAS. Thus, the option of CAS should be carefully considered in cases of carotid artery stenosis with multivessel CAD.

Abstract T MP32: T1-Weighted Magnetic Resonance Imaging Evaluation of Carotid Artery Outward Remodeling in Carotid Endarterectomy and Stenting

Objective: We evaluated carotid artery outward remodeling and plaque relative signal intensity (rSI) in patients undergoing carotid endarterectomy (CEA) or carotid artery stenting (CAS) by T1-weighted Magnetic Resonance Imaging (T1-MRI), in order to define their clinical significance in carotid revascularization.

Methods: Eighty-eight lesions (51 CEA and 37 CAS; symptomatic at 54.9 and 45.7%, respectively) from 93 patients who underwent carotid revascularization at our institute were retrospectively considered. We evaluated the carotid artery remodeling parameter of luminal stenosis, which is determined by a ratio of external cross-sectional vessel area (CSVA) at maximum stenosis, and reference CSVA at the distal portion of the ICA (carotid remodeling index, CRI), and MR intensities of atherosclerotic plaque (rSI) using T1 MRI (magnetization-prepared rapid acquisition with gradient-echo [MPRAGE]), preoperatively. We divided carotid lesions into 4 groups using median CRI and rSI: L/L (CRI < 1.8, rSI < 2.5), L/H (CRI < 1.8, rSI ≥ 2.5), H/L (CRI ≥ , and rSI < 2.5), and H/H (CRI ≥ 1.8, rSI ≥ 2.5). The endpoint was defined as the detection of acute ipsilateral ischemia on diffusion-weighted imaging (DWI) within 72 h of treatment.

Results: A significant correlation was found between CRI and rSI (r = 0.359, p = 0.0006). Mean CRI and rSI were significantly higher in lesions treated with CEA than with CAS. Small abnormalities were observed on DWI in 4 cases (7.8%) in CEA, and 10 (27.0%) in CAS (p = 0.01). In the CAS group, the observed frequency of DWI abnormalities in group L/L, L/H, H/L, H/H were 5.5%, 40.0%, 40.0%, and 55.5%, respectively (p = 0.03). In multivariate analysis, rate of stenosis (Odds Ratio [OR]: 1.19; 95% confidence interval [CI]: 1.04-1.48; p = 0.0082), and non-L/L lesions (OR: 29.65; 95% CI: 2.97-555.12; p = 0.002) were independent risk factors for cerebral embolism. In the CEA group, no significant relationship was observed between plaque parameters and DWI lesions.

Conclusion: CRI and rSI are complementary parameters to predict a high-risk plaque for CAS, but not for CEA. Preoperative evaluation with T1 MRI is useful to make decisions about treatment strategy for carotid artery stenosis.

Abstract TP161: Evaluation Of On-treatment Platelet Reactivity During Carotid Artery Stenting Using The VerifyNow System

OBJECTIVE: We evaluated the correlation between point-of-care measurement of on-treatment platelet reactivity and postoperative thromboembolic events in patients undergoing carotid artery stenting (CAS) for atherosclerotic carotid artery stenosis.

METHODS: Thirty patients receiving dual antiplatelet treatment, including clopidogrel, before CAS were prospectively enrolled. On-treatment platelet reactivity was measured within 24 h before CAS using both the VerifyNow P2Y12 and aspirin assays and light transmittance aggregometry (LTA) with ADP (LTA-ADP) and collagen (LTA-collagen) as the agonists. The endpoint was defined as the detection of acute ipsilateral ischemia on diffusion-weighted imaging (DWI) within 72 h after CAS. Cut-off values for high on-treatment platelet reactivity were established by receiver operating characteristic curve analysis.

RESULTS: A significant correlation was observed between VerifyNow P2Y12 reaction units (PRUs) and LTA-ADP and between VerifyNow aspirin reaction units (ARUs) and LTA-collagen. Small abnormalities were observed on DWI in 9 patients (30.0%), and transient ischemic attack was found in 2 (6.67%). Patients with ischemic events had significantly higher mean pre-CAS PRU values (286.42 ± 85.95 vs. 195.28 ± 90.05; p = 0.027) and lower mean pre-CAS PRU percent inhibition (11.71 ± 12.40 vs. 41.52 ± 22.51; p = 0.0027) than those without ischemic events. In the univariate analysis of the endpoint, 4th quartile PRU values (risk ratio [RR]: 3.0; 95% confidence interval [CI]: 1.00-8.92; p = 0.0533), 1st quartile PRU percent inhibition (RR: 6.33; 95% CI: 1.57-25.42; p = 0.0021), and 4th quartile LTA-ADP (RR: 3.06; 95% CI: 1.17-8.00; p = 0.0341) were found to increase the risk of abnormality detection on postprocedural DWI. The optimal cut-offs for high on-treatment platelet reactivity were 264 for pre-CAS PRU values (area under the curve [AUC]: 0.82; 95% CI: 0.65-0.99), 29 for PRU percent inhibition (AUC: 0.89; 95% CI: 0.77-1.01), and 38 for LTA-ADP (AUC: 0.80, 95% CI: 0.67-0.98).

CONCLUSION: This study indicates that the new point-of-care VerifyNow P2Y12 assay might help identify patients who are at higher risk for thromboembolic events after CAS.

Effect of lidocaine on dynamic changes in cortical reduced nicotinamide adenine dinucleotide fluorescence during transient focal cerebral ischemia in rats

Rats were subjected to 90min of focal ischemia by occluding the left middle cerebral and both common carotid arteries. The dynamic changes in the formation of brain ischemic areas were analyzed by measuring the direct current (DC) potential and reduced nicotinamide adenine dinucleotide (NADH) fluorescence with ultraviolet irradiation. In the lidocaine group (n=10), 30min before ischemia, an intravenous bolus (1.5mg/kg) of lidocaine was administered, followed by a continuous infusion (2mg/kg/h) for 150min. In the control group (n=10), an equivalent amount of saline was administered. Following the initiation of ischemia, an area of high-intensity NADH fluorescence rapidly developed in the middle cerebral artery territory in both groups and the DC potential in this area showed ischemic depolarization. An increase in NADH fluorescence closely correlated with the DC depolarization. The blood flow in the marginal zone of both groups showed a similar decrease. Five minutes after the onset of ischemia, the area of high-intensity NADH fluorescence was significantly smaller in the lidocaine group (67% of the control; P=0.01). This was likely due to the suppression of ischemic depolarization by blockage of voltage-dependent sodium channels with lidocaine. Although lidocaine administration did not attenuate the number of peri-infarct depolarizations during ischemia, the high-intensity area and infarct volume were significantly smaller in the lidocaine group both at the end of ischemia (78% of the control; P=0.046) and 24h later (P=0.02). A logistic regression analysis demonstrated a relationship between the duration of ischemic depolarization and histologic damage and revealed that lidocaine administration did not attenuate neuronal damage when the duration of depolarization was identical. These findings indicate that the mechanism by which lidocaine decreases infarct volume is primarily through a reduction of the brain area undergoing NADH fluorescence increases which closely correlates with depolarization.

Long-term outcome of single institutional experience with conservative and surgical management for renal artery aneurysm

BACKGROUND

Spontaneous rupture risk of a renal artery aneurysm (RAA) is extremely low. Indications for surgical repair of RAA remain uncertain.

OBJECTIVE

Long-term outcomes of conservative therapy and surgical repair were evaluated.

PATIENTS

The study included 58 patients (17 males, 41 females) who were diagnosed with RAA during the last 21 years. Median age at the time of diagnosis was 62 (19-85) years, and the median follow-up 69 months (range 3-216).

METHODS

The patients were divided into two groups, conservative group (n = 30) who had been followed with blood pressure control, and treatment group (n = 29), who underwent an intervention.

RESULTS

Multiple efferent aneurysmal branches were observed in seven conservative and 16 treatment cases (P = .002). The median maximum diameter of the aneurysm was lower in the conservative than the treatment group (15 versus 25 mm, P = .005). Two conservative group cases showed increases in aneurysm size during follow-up. The hypertensive state showed essentially no change in either group during the follow-up. Renal function decreased with age similarly both in conservative and treatment groups.

CONCLUSIONS

Our conservative management criteria for RAA are justifiable and even too strict.

Clinical practice at a multi-dimensional treatment centre for individuals with early psychosis in Japan

Early intervention for psychosis in Japan has lagged behind that in western countries, but has rapidly begun to attract attention in recent years. As part of a worldwide trend, a multi-dimensional treatment centre for early psychosis consisting of a Youth Clinic, which specialises in young individuals with an at-risk mental state for psychosis, and Il Bosco, a special day-care service for individuals with early psychosis, was initiated at the Toho University Omori Medical Center in Japan in 2007. The treatment centre aims to provide early intervention to prevent the development of full-blown psychosis in patients with an at-risk mental state and intensive rehabilitation to enable first-episode schizophrenia patients to return to the community. We presently provide the same programmes for both groups at Il Bosco. However, different approaches may need to be considered for patients with an at-risk mental state and for those with first-episode schizophrenia. More phase-specific and need-specific services will be indispensable for early psychiatric interventions in the future.

Successful kidney transplantation ameliorates arterial stiffness in end-stage renal disease patients

PURPOSE

Successful kidney transplantation (KTx) can ameliorate bodily damage caused by end-stage renal disease (ESRD). Arterial stiffness (AS) is one of the critical factors that shorten the survival of patients due to cardiovascular events. KTx may reduce AS as well; however, this has not been investigated well. We therefore conducted a retrospective study using noninvasive pulse wave velocity (PWV), which is a useful index of aortic damage.

PATIENTS AND METHODS

Fifty-eight consecutive kidney recipients (34 men, 24 women) were enrolled in this study. Mean age at transplantation was 40.5 ± 12.3 years and the dialysis period was 73.1 ± 95.8 months. The brachial-ankle PWV was measured preoperatively and 6 months postoperatively. First, we investigated the relationship between the PWV and the other parameters related to AS. Second, we studied the pre- to posttransplant change in PWV to evaluate the amelioration of AS after successful KTx.

RESULTS

PWV showed significant positive correlations with age, systolic blood pressure (BP), diastolic BP, and abdominal aortic calcification index. After successful KTx, PWV significantly decreased (P < .01). In addition, systolic and diastolic BP significantly decreased (P < .01 and P < .05, respectively).

CONCLUSION

Successful KTx ameliorates AS in ESRD patients. This might explain the improved cardiovascular prognosis of ESRD patients who undergo KTx.

Impact of human T cell leukemia virus type 1 in living donor liver transplantation

Human T cell leukemia virus type 1 (HTLV-1) is an endemic retrovirus in southwestern Japan, which causes adult T cell leukemia (ATL) or HTLV-1 associated myelopathy in a minority of carriers. Here, we investigated the impact of HTLV-1 status in living donor liver transplantation (LDLT). Twenty-six of 329 (7.9%) HTLV-1 carriers underwent primary LDLT. One recipient negative for HTLV-1 before LDLT received a graft from an HTLV-1 positive donor. Eight donors were HTLV-1 positive. Twenty-seven recipients (13 male and 14 female; mean age 52.5 years) were reviewed retrospectively. ATL developed in four recipients who ultimately died. The intervals between LDLT and ATL development ranged from 181 to 1315 days. Of the four ATL recipients, two received grafts from HTLV-1 positive donors and two from negative donors. The 1-, 3- and 5-year HTLV-1 carrier survival rates were 91.3%, 78.3% and 66.3%, respectively. Fulminant hepatic failure as a pretransplant diagnosis and a pretransplant MELD score ≥ 15 was identified as risk factors for ATL development in this study (p = 0.001 and p = 0.041, respectively). In conclusion, LDLT can be performed for HTLV-1 positive recipients. However, when fulminant hepatic failure is diagnosed, LDLT should not be performed until further studies have revealed the mechanisms of ATL development.

Comparison of 3D FLAIR, 2D FLAIR, and 2D T2-weighted MR imaging of brain stem anatomy

BACKGROUND AND PURPOSE

Although 3D FLAIR imaging visualizes detailed structures of the brain stem, it has not been used to evaluate its normal anatomy. The purpose of this study was to evaluate whether 3D FLAIR images can provide more detailed anatomic information of the brain stem than 2D FLAIR and 2D T2WI.

MATERIALS AND METHODS

We prospectively evaluated MR images in 10 healthy volunteers. 3D and 2D FLAIR images, 2D T2WI, and DTI were obtained on a 3T MR imaging scanner. A VISTA technique was used for 3D FLAIR imaging. White matter tracts and nuclei of the brain stem were determined on 3D and 2D FLAIR images and 2D T2WI by referring to anatomic atlases and DTI color maps. The subjective assessment of the visibility by using a 4-point grading system and the contrast ratio of the structures on 3D and 2D FLAIR images and 2D T2WI were evaluated.

RESULTS

The visibility of the SCP and MCP, DSCP, CST, and CTT was higher on 3D FLAIR images than on 2D T2WI and 2D FLAIR images. The contrast ratio for the CST, SCP, MCP, DSCP, and CTT was significantly different on 3D FLAIR images and 2D T2WI and on 3D FLAIR and 2D FLAIR images; there was no significant difference in contrast ratio for the SCP at the pons on 3D FLAIR and 2D T2WI.

CONCLUSIONS

3D FLAIR images provide detailed anatomic information of the brain stem that cannot be obtained on 2D T2WI and 2D FLAIR images.

Genetic structure and diversity of Japanese kokanee Oncorhynchus nerka stocks as revealed by microsatellite and mitochondrial DNA markers

Genetic structure and diversity of nine Japanese kokanee (landlocked) Oncorhynchus nerka stocks and anadromous O. nerka from the North Pacific and the Canadian Lake Cultus population were examined using microsatellite and mitochondrial DNA. Sequence analyses of the cytochrome b region of mtDNA for Japanese kokanee O. nerka stocks on Honshu and Hokkaido islands revealed that most Japanese stocks were monomorphic of one major haplotype, which was also dominant in the Lake Cultus population and anadromous O. nerka in the North Pacific. Assignment tests using microsatellite DNA revealed that there was no clear-cut population structure in Japanese kokanee O. nerka stocks.

[Pleomorphic carcinoma of the lung; report of a case]

A 83-year-old male was referred to our hospital for further examination of abnormal shadow on chest radiography. Chest computed tomography (CT) showed a tumor mass in his right lung. Bronchoscopy brushing cytology revealed non-small cell lung carcinoma and right middle lobectomy was performed. Histological findings showed large cell carcinoma comprised of spindle cell component, finally diagnosing as pleomorphic carcinoma of the lung. Although he was diagnosed as pT2N0M0 (stage IA) after the operation, massive liver metastasis was found 7 months later. We report this case with references to the literatures on pleomorphic carcinoma of the lung.