Non-dermatologic isolated intracranial necrobiotic xanthogranuloma

Necrobiotic xanthogranuloma is a condition that was first identified in 1980 based on its characteristic histological identity, and it has been known since then as a dermatologic manifestation of an underlying systemic dysproteinemia. Intracranial manifestation is a rare presentation of this condition and has been reported only once in its more than 40 years of existence. Herein and to our knowledge, we report the second observation of an intracranial manifestation and, surprisingly, the first case without the expected dermatologic and systemic dysproteinemia associations. This case identifies an existing knowledge gap in our understanding of necrobiotic xanthogranuloma and emphasises the need for further research into understanding the presentation, comorbidities and management of this condition.

Stroke thrombectomy volume, rather than stroke center accreditation status of hospitals, is associated with mortality and discharge disposition

BACKGROUND

Few studies have explored the association between stroke thrombectomy (ST) volume and hospital accreditation with clinical outcomes.

OBJECTIVE

To assess the association of ST case volume and accreditation status with in-hospital mortality and home discharge disposition using the national Medicare Provider Analysis and Review (MEDPAR) database.

METHODS

Rates of hospital mortality, home discharge disposition, and hospital stay were compared between accredited and non-accredited hospitals using 2017-2018 MEDPAR data. The association of annual ST case volume with mortality and home disposition was determined using Pearson's correlation. Median rate of mortality and number of ST cases at hospitals within the central quartiles were estimated.

RESULTS

A total of 29 355 cases were performed over 2 years at 847 US centers. Of these, 354 were accredited. There were no significant differences between accredited and non-accredited centers for hospital mortality (14.8% vs 14.5%, p=0.34) and home discharge (12.1% vs 12.0%, p=0.78). A significant positive correlation was observed between thrombectomy volume and home discharge (r=0.88; 95% CI 0.58 to 0.97, p=0.001). A significant negative relationship was found between thrombectomy volume and mortality (r=-0.86; 95% CI -0.97 to -0.49, p=0.002). Within the central quartiles, the median number of ST cases at hospitals with mortality was 24/year, and the median number of ST cases at hospitals with home discharge rate was 23/year.

CONCLUSION

A higher volume of ST cases was associated with lower mortality and higher home discharge rate. No significant differences in mortality and discharge disposition were found between accredited and non-accredited hospitals.

[68Ga]Ga-DOTA-TATE uptake in subacute stroke following craniotomy for meningioma: a diagnostic tool for stroke?

Gallium 68 (68Ga) 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid labelled octreotate ([68Ga]Ga-DOTA-TATE) positron emission tomography (PET) is an established imaging technique for identifying tumours of neuroendocrine origin and meningiomas; the radiotracer binds to somatostatin receptor type 2 (SSTR2), which is richly expressed by these malignancies. Here, we present a rare case hinting at novel ischaemic stroke detection by [68Ga]Ga-DOTA-TATE PET scan. The scan was performed 14 days post resection of an atypical meningioma with the intention to assess the extent of residual tumour for radiosurgical treatment of the operative cavity. Surprisingly, the [68Ga]Ga-DOTA-TATE PET-avid region corresponded to an area of perioperative subacute ischaemic stroke detected by MRI. This case corroborates the two previously reported cases of incidental detection of ischaemic stroke during routine [68Ga]Ga-DOTA-TATE PET imaging, collectively suggesting the need for caution when interpreting the imaging findings. A possible underlying mechanism for [68Ga]Ga-DOTA-TATE uptake in stroke is increased SSTR2 expression by macrophages recruited into infarcted tissue.

Walrus Balloon Guide Catheter for Stroke Intervention: Technical Considerations and Clinical Outcomes

BACKGROUND

The use of balloon guide catheters (BGCs) for proximal flow arrest during neurointerventional procedures has been limited owing to the incompatibility of BGCs with large-bore aspiration catheters and difficulty in device navigation. The objective of our study was to describe the use of the Walrus catheter (Q'Apel Medical, Fremont, California, USA), a new 8F BGC, with a variety of aspiration catheters and procedures requiring flow arrest.

METHODS

Consecutive cases using Walrus BGCs for proximal flow arrest during mechanical thrombectomy for acute stroke cases were recorded. The procedure indication, vessel occlusion site, technique, first-pass effect (modified thrombolysis in cerebral infarction score of 2C or 3 after the first recanalization attempt), and complications were recorded and evaluated statistically.

RESULTS

Our study included 57 patients who had undergone mechanical thrombectomy. In addition to mechanical thrombectomy, the Walrus BGC was used in conjunction with the following techniques: stent retrieval in 2 patients (3.5%), stent retrieval followed by aspiration (Solumbra technique) in 41 (71.9%), and aspiration followed by stent retrieval in 14 patients (24.6%). Eight different aspiration catheters were used in 56 of these 57 procedures. The first-pass effect (modified thrombolysis in cerebral infarction score of 2C and 3) was achieved in 36 (63.2%) of 57 procedures. Two patients (3.5%) had experienced intraoperative complications (symptomatic intracerebral hemorrhage) and one patient (1.8%) had died in-hospital.

CONCLUSIONS

Our results have demonstrated that the Walrus BGC is a highly navigable 8F guide catheter compatible with most available aspiration catheters. Owing to its compatibility with most available aspiration catheters and ease of use, the Walrus BGC is a valuable addition to the tools available for mechanical thrombectomy.

Endovascular management of radial artery loop for neuroangiography: Case series

Background

Radial loops are rare congenital radial artery anomalies that may pose a significant challenge to successful transradial neuroangiography. In this case series, we describe the anatomy and frequency of radial artery loops and provide a technique for successful navigation of this anatomic anomaly.

Methods

We reviewed our database of radial diagnostic or interventional neuroangiographic procedures to identify cases in which a radial loop was encountered during the procedure. The loop pattern, the presence of an associated recurrent radial artery branch, navigation technique, and procedure-related complications were recorded. A descriptive analysis was performed.

Results

A total of 997 transradial approach procedures were performed over a 9-month period. A radial loop was identified in 10 (1.0%) patients. The average age was 68.6 ± 14.3 years. A microcatheter advanced over a microwire was used to navigate the loop and avoid entry into the recurrent branch. A diagnostic neuroangiographic procedure was performed successfully in 8 cases and an intervention was performed successfully in 1 case. A 360° loop was present in 2 of these cases. In each case, transradial access was performed successfully. In 1 other diagnostic case, transradial access was aborted, and the femoral artery was accessed to perform the procedure.

Conclusions

A radial loop was present in 1% of the cases in this series. Our technical results suggest that this anomaly should not be considered a contraindication to transradial neuroangiography because the procedure was successfully performed in most (9 of 10) cases using a microcatheter system to navigate the loop.

Safety and feasibility of ulnar artery access for neuroangiography and neurointervention: a case series

BACKGROUND

Radial access has become popular among neurointerventionalists because it has favorable risk profiles compared with femoral access. Difficulties in accessing or navigating the radial artery have been viewed as a reason to convert to femoral access, but ulnar artery access may prevent complications associated with transfemoral procedures.

OBJECTIVE

To evaluate the safety and feasibility of ulnar access for neurointerventions and diagnostic neuroangiographic procedures.

METHODS

Consecutive patients who underwent diagnostic angiography or neurointerventional procedures via ulnar access between July 1, 2019 and April 15, 2020 were included. Data recorded were demographics, procedure indication, devices, technique, and complications. Descriptive analysis was performed.

RESULTS

Ulnar artery access was obtained for 21 procedures in 18 patients (mean age 70.3±7.8 years; nine men). Procedures included 13 diagnostic angiograms and eight neurointerventions (3 left middle meningeal artery embolization, 1 of which was aborted; 2 carotid artery stenting; 2 angioplasty; 1 mechanical thrombectomy for in-stent thrombosis). A right-sided approach with ultrasound guidance was used for all cases except one. Indications included small caliber radial artery (n=9), radial artery occlusion (n=10), and radial artery preservation for potential bypass (n=2). A 5-French slender sheath was used for diagnostic angiography; a 6-French slender sheath was used for neurointerventions. No case required conversion to femoral access. Two patients had minor hematomas after the procedure; one other had ulnar artery occlusion on 30-day ultrasonography.

CONCLUSION

Ulnar access is safe and feasible for diagnostic and interventional neuroangiographic procedures. It provides a useful alternative to radial access, potentially avoiding complications associated with femoral access.

Brief and extended abstinence from chronic oral methylphenidate treatment produces reversible behavioral and physiological effects

Methylphenidate (MP) is a commonly prescribed psychostimulant to individuals with Attention Deficit Hyperactivity Disorder, and is often used illicitly among healthy individuals with intermittent breaks to coincide with breaks from school. This study examined how intermittent abstinence periods impact the physiological and behavioral effects of chronic oral MP self-administration in rats, and whether these effects persist following prolonged abstinence from the drug. Rats were treated orally with water, low-dose (LD), or high-dose (HD) MP, beginning at PND 28. This daily access continued for three consecutive weeks followed by a 1-week abstinence; after three repeats of this cycle, there was a 5-week abstinence period. Throughout the study, we examined body weight, food intake, locomotor activity, and anxiety- and depressive-like behaviors. During the treatment phase, HD MP decreased body weight, food intake, and depressive- and anxiety-like behaviors, while it increased locomotor activity. During intermittent abstinence, the effects of MP on locomotor activity were eliminated. During prolonged abstinence, most of the effects of HD MP were ameliorated to control levels, with the exception of weight loss and anxiolytic effects. These findings suggest that intermittent exposure to chronic MP causes physiological and behavioral effects that are mostly reversible following prolonged abstinence.

Weekday-only chronic oral methylphenidate self-administration in male rats: Reversibility of the behavioral and physiological effects

Methylphenidate (MP) is a commonly prescribed psychostimulant for Attention Deficit Hyperactivity Disorder (ADHD). We recently reported behavioral and developmental effects of chronic MP use in healthy rats. The current study investigated how interrupting chronic MP treatment with weekend abstinence altered the behavioral and physiological consequences of chronic MP treatment, and if prolonged abstinence would reverse the observed effects. Male Sprague Dawley rats were assigned to one of three treatment groups: water (W); low dose (LD) MP; and high dose (HD) MP. For 13 weeks, rats had access to drink from a bottle containing 4 mg/kg MP (LD), 30 mg/kg MP (HD) or water (W) for 1 h, and 10 mg/kg MP (LD), 60 mg/kg MP (HD) or water (W) for the next 7 h, each week day. During weekends, all animals received only water as well as throughout the 5-week-long abstinence phase, which immediately followed the treatment phase. Throughout the treatment phase, regardless of weekend abstinence, chronic MP resulted in significant decreased food and fluid intake and body weight. Also, HD MP exposure resulted in the following behavioral effects: increased open field and circadian locomotor activity; increased latency to immobility and decreased time spent immobile in the forced swim test; increased center activity in the open field and percent of time spent in an open arm of the elevated-plus-maze; and increased social affiliation and memory in the Crawley's three chamber sociability test. During the prolonged (5-week) abstinence phase, all these effects were reversed while HD treated rats increased their fluid intake. These results indicated that intermittent brief abstinence periods (weekend's off-treatment) produced the same behavioral and developmental effects as those previously reported with chronic (7 days/week) MP treatment, but were reversible following a prolonged abstinence period (5 weeks).

Recovery from behavior and developmental effects of chronic oral methylphenidate following an abstinence period

Chronic oral methylphenidate (MP) exposure in rats is associated with numerous developmental and behavioral consequences. The present study investigated the persistence of the effects of chronic oral MP exposure after abstinence from MP use. Male and female rats were exposed to daily orally self-administered water, low dose MP (LD), or high dose (HD) MP for 13 weeks, followed by a 4-week abstinence period. Fluid, food consumption and bodyweights were monitored and animals were tested for locomotor activity, anxiety- and depressive-like symptoms, learning and memory, and social behavior during both the treatment and abstinence phases of the experiment. During treatment, MP attenuated bodyweight regardless of sex, but increased food and fluid consumption in females and males by 20.7% and 30.1%, respectively. MP also increased locomotor activity in both males and females observed as increased distance travelled in an open field. (59.1% and 95.9%, respectively) and increased locomotor activity in the home cage over a 24-hour circadian cycle (45.5% and 63.0%). Additionally, MP exerted an anxiolytic effect observed as increased time spent in the open arms of an elevated plus maze (31.1% in HD males, 59.2% in HD females), and an increased latency to immobility in a forced swim test (330% in HD males, 418% in HD females). The effects of MP (bodyweight, consumption, locomotion, anxiolytic, and anti-depressive) were, almost without exception, eliminated during the abstinence period. MP had no impact on learning and memory performance as measured by a T-maze, or social behavior during treatment. These findings suggest that the behavioral consequences of chronic oral MP treatment in our preclinical model are reversible in rats following an abstinence period from use of the drug.

Assessing the risk of birth defects associated with exposure to highly active anti-retroviral therapy during organogenesis in rats

The use of anti-retroviral drugs during pregnancy has increased since the demonstration of reduction of mother-to-child transmission of HIV with highly active antiretroviral therapy (HAART). The risk of HAART cannot be ruled out; data are generally limited or varied. This study intends to thoroughly assess the teratogenic effect of HAART on the organogenesis stage of fetal development using animal model. Pregnant rats were divided into 13 groups with 12 animals per group. The therapeutic doses of drug administration were done to simulate the treatment pattern in APIN HIV/AIDS Clinic of the University of Lagos Teaching Hospital, Nigeria (find detailed treatment groups in methodology). Six rats in each group were randomly selected and sacrificed on day 20 by cervical dislocation prior to day 21 of gestation and the foetuses were harvested through abdominal incision for physical examination. Blood samples were collected from the 1st filial rats of the remaining six animals for biochemical and haematological examination. The liver, kidney, heart and brain of all the sacrificed animals were used for histopathological examination. There were significant (P ≤ 0.05) low birth weights of the foetuses of the animals that were treated with HAART. Results also revealed a reduction (P ≤ 0.05) in the platelets counts, WBC and RBC of most treatment groups at the first filial generation. Significant (P ≤ 0.05) elevations in the levels of AST and UA in the foetuses of the animals treated with HAART were also observed. It can be concluded that administration of single and combined antiretrovirals have potential teratogenic effect.

Small bowel obstruction: review of nine years of experience

Strong evidence in the literature suggests that improvements in the management and outcome of small bowel obstruction result from early diagnosis, better fluid and electrolyte replacement, use of antibiotics, and early surgical intervention. This paper reviews the outcomes of 49 male and 31 female patients who were operated on for small bowel obstruction. The average age was 38 years (range, 3 to 87 years); the average hospital stay was 13 days. There was one death. The causes of obstruction included postoperative adhesions (78 percent), strangulated external hernia (11 percent), gangrenous bowel (4 percent), intussusception (2.5 percent), appendiceal mass (3.5 percent), and Meckel's diverticulum (1 percent). The outcome was worse with late presentation, perforation or gangrene of the bowel, and delayed surgery.

Traumatic pancreatic pseudocysts

At the Martin Luther King, Jr, General Hospital in Los Angeles, during the period from June 1972 to April 1981, seven patients underwent surgery for traumatic pancreatic pseudocysts. The overall average age was 28 and the average hospital stay was 31 days. Ultrasound was the most useful test for diagnosis and follow-up. Preoperatively, serum amylases were not consistently elevated. Overall recurrences and complications totaled 57 percent. There were no deaths. The authors consider a large cystogastrostomy the treatment of choice for mature cysts that are satisfactorily adherent to the stomach. The second preference is a Roux-en-Y cystojejunostomy. External drainage was employed for acute cysts that required drainage. A distal pancreatectomy was performed for patients with small pancreatic tail pseudocysts. Patients who underwent acute drainage were usually drained externally and had a poorer outcome than patients who were operated on later with internal drainage. When compared with another group of 15 alcoholic patients who were operated on for pancreatic pseudocysts, patients with traumatic pseudocysts had a poorer outcome.