Microsurgical clipping versus newer endovascular techniques in treatment of unruptured anterior communicating artery-complex aneurysms: a meta-analysis and systematic review

The aim of this study is to compare occlusion rate, complication rate, and clinical outcome of microsurgical clipping (MC) and advanced endovascular techniques (EVT) in unruptured anterior communicating artery-complex aneurysms (ACoCAs). We reviewed the scientific literature reporting occlusion rate, time of occlusion assessment, and clinical outcome of MC and EVT in patients with unruptured ACoCAs, from January 2009 to December 2019. We included in our analysis 25 studies and 872 patients with unruptured ACoCAs (434 treated with endovascular techniques and 438 with MC). Ninety-three (10.7%), 320 (36.7%), 21 (2.4%), and 438 (50.2%) were treated with flow diverter (FD), stent-assisted coiling (SAC), endosaccular devices (ES), and microsurgical clipping (MC) respectively. FD, SAC, ES, and MC subgroups presented minor complications in 11.8%, 3.8%, 14.3%, and 7.1% of cases (p=.016), and major complications in 3.2%, 4.4%, 0%, and 7.1% (p=.136) of patients. A total occlusion rate post-treatment has been achieved in 4.3%, 87.1%, 47.6%, and 98.2% of cases (p=.000), while at 12 months' follow-up in 50%, 66%, 83.3%, and 80% of patients (p=.001). FD, SAC, ES, and MC subgroups had a good clinical outcome at 12 months in 93.5%, 90.5%, 100%, and 67.8% of cases. MC is associated with higher post-treatment total occlusion rate, but higher complication and lower good clinical outcome rates. EVT are promising in treating unruptured anterior cerebral artery aneurysms with high margin of safety and good clinical outcome, despite the lower total occlusion rate.

Trans-Radial Approach: technical and clinical outcomes in neurovascular procedures

Background

To evaluate efficacy and safety of Trans-Radial Approach (TRA) in cerebral angiography for diagnostic and therapeutic purpose.

Methods

We retrospectively included consecutive patients eligible for TRA cerebral angiography at our Institution between September 2019 and January 2020. Cerebral DSA was classified in diagnostic (one-vessel imaging) or therapeutic (emergency/elective). Technical and clinical outcome were recorded for each group.

Results

A total of 61 TRA angiographies were evaluated. Right-sided TRA was obtained in 85,2% of all cases. Interventional procedures included 11 strokes, 2 ruptured aneurysms, 2 unrupted aneurysms, 1 DAVF and 3 symptomatic atheromatous intracranial stenosis. Successful TRA angiographies were obtained in 97,6% and 94,7% for diagnostic and therapeutic group, respectively. No major radial artery complications were recorded. Mean puncture-to-final angiogram was 11 and 62 min for diagnostic and therapeutic groups, respectively. Mean radial compression maintenance was 4 h, allowing patients discharge within 6 h in all cases undergone diagnostic angiography.

Conclusions

TRA could be a valid technique in terms of efficacy and safety both for diagnostic and therapeutic cerebral angiographies, with low complication rate.

A comparison of acute vascular damage caused by ADAPT versus a stent retriever device after thrombectomy in acute ischemic stroke: a histological and ultrastructural study in an animal model

Background

It has been amply demonstrated that endovascular procedures can be successful treatment for stroke, both in terms of revascularization and clinical outcome. There is not, however, a published comparison of any histological or ultrastructural damage to the vessels that may be caused by a direct aspiration first pass technique (ADAPT) or stent retrievers (SR) used in these procedures. This study analyses and compares acute damage to the arterial wall caused by ADAPT or SR.

Material and methods

Damage to the walls of swine extracranial arteries was evaluated after ADAPT with the Penumbra system or thrombectomy with an SR (Solitaire 6×30). The procedures were performed after injecting thrombi into the selected arteries (arteries with diameters similar to those of the human internal carotid artery and first segment of the middle cerebral artery). After the procedures, the animal was euthanized and 12 arterial samples were obtained for analysis by optical and electronic microscopy.

Results

Tissue samples from the vessels treated with SR showed almost complete loss of endothelium, thickening of the internal elastic lamina, and degeneration of the elastic fibers of the bordering lamina media and adventitia. In contrast, tissue samples of the vessels treated with ADAPT had a clear integral internal elastic lamina and uninterrupted endothelial lining, although cell alignment was altered and there were surface lacerations due to manipulation of the samples.

Conclusions

Both techniques caused acute damage to the vessel walls, however, thrombectomy with SR appeared to be more harmful to all layers of the arterial wall, particularly the endothelium.

New therapeutic strategies regarding endovascular treatment of glioblastoma, the role of the blood-brain barrier and new ways to bypass it

The treatment protocols for glioblastoma multiforme (GBM) involve a combination of surgery, radiotherapy and adjuvant chemotherapy. Despite this multimodal approach, the prognosis of patients with GBM remains poor and there is an urgent need to develop novel strategies to improve quality of life and survival in this population. In an effort to improve outcomes, intra-arterial drug delivery has been used in many recent clinical trials; however, their results have been conflicting. The blood-brain barrier (BBB) is the major obstacle preventing adequate concentrations of chemotherapy agents being reached in tumor tissue, regardless of the method of delivering the drugs. Therapeutic failures have often been attributed to an inability of drugs to cross the BBB. However, during the last decade, a better understanding of BBB physiology along with the development of new technologies has led to innovative methods to circumvent this barrier. This paper focuses on strategies and techniques used to bypass the BBB already tested in clinical trials in humans and also those in their preclinical stage. We also discuss future therapeutic scenarios, including endovascular treatment combined with BBB disruption techniques, for patients with GBM.

[The activation of the phosphotyrosine phosphatase eta is responsible for the somatostatin inhibition of PCCl3 thyroid cell proliferation]

BACKGROUND

This study was aimed to identify possible intracellular effectors of the somatostatin (SST) antiproliferative activity, in PCCl3 thyroid cells.

METHODS

To prove the involvement of r-PTPeta in SST's effect, we studied th proliferative activity of subclones of PCCl3 cells that do or do not express this PTP.

RESULTS

SST inhibited PCCl3 TSH+insulin-dependent cell proliferation through the induction of a phosphotyrosine phosphatase (PTP) activity, detected using the synthetic substrate pNPP (+150%, p<0.01). Conversely, PCCl3 cells stably expressing the v-mos oncogene (PCmos) were completely insensitive to SST antiproliferative effects due to the incapability of SST to increase PTP activity, that correlated with the abolishment of the expression of the receptor-like PTP, r-PTPeta. In the cells in which r-PTPeta was transfected (PCmos/ PTPeta) SST inhibited cell proliferation showing a dose-dependence similar to that observed in PCCl3 cells. Conversely, the transfection of a catalytically inactive mutant of r-PTPeta did not restore the responsivity to SST. Also in PCmos/PTPeta cells SST, treatment increased membrane PTP activity.

CONCLUSIONS

SST inhibition of PCC13 cell proliferation requires the activation of r-PTPeta.

A link between apoptosis and degree of phosphorylation of high mobility group A1a protein in leukemic cells

Nuclear phosphoprotein HMGA1a, high mobility group A1a, (previously HMGI) has been investigated during apoptosis. A change in the degree of phosphorylation of HMGA1a has been observed during apoptosis induced in four leukemic cell lines (HL60, K562, NB4, and U937) by drugs (etoposide, camptothecin) or herpes simplex virus type-1. Both hyper-phosphorylation and de-phosphorylation of HMGA1a have been ascertained by liquid chromatography-mass spectrometry. Hyper-phosphorylation (at least five phosphate groups/HMGA1a molecule) occurs at the early apoptotic stages and is probably related to HMGA1a displacement from DNA and chromatin release from the nuclear scaffold. De-phosphorylation (one phosphate or no phosphate groups/HMGA1a molecule) accompanies the later formation of highly condensed chromatin in the apoptotic bodies. We report for the first time a direct link between the degree of phosphorylation of HMGA1a protein and apoptosis according to a process that involves the entire amount of HMGA1a present in the cells and, consequently, whole chromatin. At the same time we report that variously phosphorylated forms of HMGA1a protein are also mono-methylated.

Relationship between antral lymphocyte density and basal gastrin levels in patients with Helicobacter pylori infection

BACKGROUND

The mechanism by which Helicobacter pylori causes hypergastrinaemia is not completely understood.

AIM

To evaluate whether antral lymphocyte density could play a role in this alteration.

METHODS

A total of 12 patients with active duodenal ulcer and 10 with non-ulcer dyspepsia were enrolled upon detection of Helicobacter pylori infection at endoscopy Enrolled as controls were 7 matched dyspeptic patients without Helicobacter pylori infection. Biopsy specimens were collected for Helicobacter pylori and histological assessments, and for antral lymphocyte density assessment by a histomorphometric method. A blood sample was obtained from each patient to determine basal gastrin levels. All patients were controlled by a further endoscopy 4 weeks after the end of Helicobacter pylori treatment.

RESULTS

Antral lymphocyte density (5,464 +/- 1,328 and 5,635 +/- 1,186 vs 2,267 +/- 557 lymphocytes/mm2; p<0.001 and p<0.001, respectively) and gastrin levels (66.7 +/- 14.1 and 60.4 +/- 21.7 vs 40.7 +/- 7.8 pg/dl; p=0.004 and p=0.02, respectively) were higher in duodenal ulcer and non-ulcer dyspepsia patients than in controls, while no significant differences emerged between duodenal ulcer and non-ulcer dyspepsia patients. There was a significant direct correlation between antral lymphocyte density and gastrin levels both in duodenal ulcer (r=0.77; p=0.003) and in non-ulcer dyspepsia (r=0.75; p=0.03) patients, while no correlation was found in controls [r=0.12; p=0.8). After treatment, this correlation persisted in 10 eradication failure patients (r=0.68; p=0.027), but disappeared in those successfully cured.

CONCLUSIONS

These data suggest that lymphocyte density in the antral mucosa could play a role in the impaired gastrin production occurring in patients with Helicobacter pylori infection.

Ascorbic acid and intestinal metaplasia in the stomach: a prospective, randomized study

BACKGROUND

Intestinal type metaplasia plays a role in intestinal type gastric carcinoma development. Ascorbic acid demonstrates a protective effect against gastric carcinogenesis, due to its ability to inactivate oxygen free-radicals as well as its nitrite-scavenging effects.

AIM

To assess whether long-term ascorbic acid administration following Helicobacter pylori eradication could affect intestinal metaplasia regression in the stomach.

METHODS

Sixty-five patients were included in the study. The inclusion criterion was the presence of intestinal metaplasia on the gastric mucosa after H. pylori eradication. An upper gastrointestinal endoscopy was performed and 3 biopsy specimens were taken in the antrum, 3 in the gastric body, and 2 in the incisura angularis. Patients were randomized to receive 500 mg of ascorbic acid o.d., after lunch (32 patients) for 6 months or no treatment (33 patients). All patients underwent to endoscopic control at the end of the 6 months.

RESULTS

H. pylori infection recurrence was detected in 6 (9.4%) patients (three from each group), and these patients were excluded from further analysis. We were unable to find evidence of intestinal metaplasia in any biopsied site of the gastric mucosa in 9/29 (31%) patients from the ascorbic acid group and in 1/29 (3.4%) of the patients from the control group (P=0.006). Moreover, a further six (20.7%) patients from the ascorbic acid group presenting chronic inactive pangastritis with widespread intestinal metaplasia at entry, showed less extensive antritis with intestinal metaplasia at control, whilst a similar finding was only seen in one patient from the control group (P=0.051).

CONCLUSION

The administration of ascorbic acid significantly helps to resolve intestinal metaplasia of the gastric mucosa following H. pylori eradication, and its use as a chemoprevention treatment should be considered.

HMGI(Y) and HMGI-C genes are expressed in neuroblastoma cell lines and tumors and affect retinoic acid responsiveness

HMGI-C and HMGI(Y) are architectural DNA-binding proteins that participate in the conformational regulation of active chromatin. Their pattern of expression in embryonal and adult tissues, the analysis of the "pygmy" phenotype induced by the inactivation of the HMGI-C gene, and their frequent qualitative or quantitative alteration in experimental and human tumors indicate their pivotal role in the control of cell growth, differentiation, and tumorigenesis in several tissues representative of the epithelial, mesenchymal, and hematopoietic lineages. In contrast, very little information is available on their expression and function in neural cells. Here, we investigated the expression of the HMGI(Y) and HMGI-C genes in neuroblastoma (NB), a tumor arising from an alteration of the normal differentiation of neural crest-derived cells and in embryonal and adult adrenal tissue. Although HMGI(Y) is constitutively expressed in the embryonal and adult adrenal gland and in all of the NB cell lines and ex vivo tumors examined, its regulation appears to be associated to growth inhibition and differentiation because we observed that HMGI(Y) expression is reduced by retinoic acid (RA) in several NB cell lines that are induced to differentiate into postmitotic neurons, whereas it is up-regulated by RA in cells that fail to differentiate. Furthermore, the decrease of HMGI(Y) expression observed in RA-induced growth arrest and differentiation is abrogated in cells that have been made insensitive to this drug by NMYC overexpression. In contrast, HMGI-C expression is down-regulated during the development of the adrenal gland, completely absent in the adult individual, and only detectable in a subset of ex vivo NB tumors and in RA-resistant NB cell lines. We provide evidence of a causal link between HMGI-C expression and resistance to the growth arrest induced by RA in NB cell lines because exogenous HMGI-C expression in HMGI-C-negative and RA-sensitive cells is sufficient to convert them into RA-resistant cells. Therefore, we suggest that HMGI-C and HMGI(Y) may participate in growth- and differentiation-related tumor progression events of neuroectodermal derivatives.

Helicobacter pylori infection in dyspeptic cirrhotic patients

BACKGROUND/AIMS

To date, few studies have focused on the role of Helicobacter pylori (H. pylori) in cirrhotic patients with gastroduodenal disease and reported results are conflicting. The aim of this study was to assess the H. pylori infection rate in dyspeptic cirrhotic patients with or without gastroduodenal lesions at endoscopy.

METHODOLOGY

In a prospective study, 226 consecutive dyspeptic cirrhotic patients were enrolled in the study upon assessment of H. pylori infection. Two-hundred dyspeptic non-cirrhotic patients were also included as controls. The presence of H. pylori was detected by rapid urease test and histology (Giemsa staining) in 3 biopsy specimens from the antrum and 3 from the gastric body.

RESULTS

H. pylori infection was found in 135 (59.7%) cirrhotics and in 121 (60.5%) controls (p = NS). The prevalence of gastric ulcer was higher in cirrhotics than in controls (16% vs. 2.5%, p = 0.0001), while the prevalence of duodenal ulcer was similar (11% vs. 12%, respectively). The H. pylori infection rate was similar between cirrhotics and controls, both with gastric (83% vs. 80%) and with duodenal (88% vs. 96%) ulcers. Moreover, in our study, a H. pylori-related peptic lesion was the cause of previous gastroduodenal bleeding in 6 of 50 (12%) cirrhotic patients.

CONCLUSIONS

Our results indicated that H. pylori infection is implicated in the pathogenesis of peptic ulcer in cirrhotic patients, similar to findings in non-cirrhotic patients.

Whole body and regional body composition analysis by dual-energy X-ray absorptiometry in cirrhotic patients

OBJECTIVES

To compare whole body and regional (arms, legs and trunk) fat mass, fat-free mineral-free mass bone mineral content and bone mineral density, measured by DXA, in cirrhotic patients and age, sex and BMI matched healthy volunteers.

DESIGN

Cross-sectional study.

SETTING

Two medical research institutions.

SUBJECTS

Twenty-two non ascitic cirrhotic patients and 16 age, sex and BMI matched healthy volunteers.

INTERVENTIONS

The Lunar DPX whole-body X-ray densitometer with Lunar software version 3.6z (Lunar Radiation Corp., Madison WI, USA) was used. Regional analysis was performed on the arms, legs, trunk and head.

RESULTS

Compared to controls, cirrhotic patients showed a significant reduction in percentage body fat. When differentiated by gender, however, the reduction in percentage body fat was evident in female cirrhotics only, particularly in the trunk. In male cirrhotic patients fat-free mineral-free mass was reduced in absolute terms in the whole body and the limbs. For both genders and in each body segment bone mineral content and density were reduced in cirrhotics compared to controls. In cirrhotic patients bone mineral density was significantly correlated to both fat-free, mineral-free mass (r = 0.85; P < 0.001) and to the Physical Activity Index (r = 0.52; P < 0.01).

CONCLUSIONS

Two different patterns of soft tissue loss may be found in cirrhotic patients: in women lean tissue is maintained while fat stores are reduced, as in early starvation; in men lean tissue is reduced, as seen under conditions of stress. Moreover, factors influencing lean body mass, such as nutritional depletion and physical inactivity, may contribute to the reduction of bone density frequently observed in cirrhotic patients.

Omeprazole plus clarithromycin and either tinidazole or tetracycline for Helicobacter pylori infection: a randomized prospective study

OBJECTIVE

Helicobacter pylori has begun to show resistance to imidazoles and could result in the low efficacy of short-term triple therapy. The aim of this study was to assess whether administration of tetracycline instead of tinidazole in short-term low-dose triple therapy could increase the H. pylori eradication rate.

METHODS

In a prospective study, 113 patients with peptic ulcer (n = 36) or non-ulcer dyspepsia (n = 77) were randomized to receive 1-wk treatment, composed of omeprazole 20 mg b.i.d., clarithromycin 250 mg b.i.d., and either tinidazole 500 mg b.i.d. (n = 57) or tetracycline 500 mg b.i.d. (n = 56), upon detection of H. pylori infection at endoscopy.

RESULTS

H. pylori eradication, defined as a negative bacterial finding in a rapid urease test and upon histologic assessment at least 4 wk after cessation of therapy, was achieved in 86% (49 of 57; 95% confidence interval = 76.9-95) of patients in the first group and in 71.4% (40 of 56; 95% confidence interval = 59.6-83.3) in the second group (p = not significant). Side effects occurred in 28% of patients from the tinidazole-based group and in 12.5% from the tetracycline group (p = not significant). Two patients in the tinidazole group discontinued therapy at 5 and 6 days because of side effects.

CONCLUSIONS

The administration of tetracycline instead of tinidazole in short-term triple therapy yielded disappointing results in H. pylori eradication.

The management of failed dual or triple therapy for Helicobacter pylori eradication

BACKGROUND

After each treatment for Helicobacter pylori infection there is an eradication failure rate ranging from 5 to 50%. Thus, the best therapy schedule and treatment regimen sequence have still to be identified.

METHODS

Patients with H. pylori infection were randomized to receive either a 1-week triple therapy of omeprazole 20 mg b.d., clarithromycin 250 mg b.d. and tetracycline 500 mg b.d. (OCT; 78 patients) or a 2-week dual therapy of omeprazole 20 mg b.d. and amoxycillin 1 g b.d. (OA; 75 patients). H. pylori infection at entry and eradication 4-6 weeks after therapy had ended were assessed by rapid urease test and histology on biopsies from the antrum and the corpus. When eradication did not occur with either the OCT or OA regimens, patients were switched over to the OA or OCT therapy, respectively. Eradication in these patients was assessed 4-6 weeks after conclusion of treatment by a further endoscopy.

RESULTS

H. pylori eradication was achieved in 67.9% (95% CI = 57.6-78.3%) of patients treated with the OCT regimen and in 75.7% (95% CI = 65.9-85.5%) of patients treated with the OA therapy (chi 2 = 1.11; P = 0.29). Moreover, H. pylori eradication was achieved in 39.1% (95% CI = 19.2-59.1%) of patients re-treated with the OA regimen and in 88.9% (95% CI = 74.4-100%) of patients re-treated with the OCT therapy (chi 2 = 8.52; P = 0.003). Thus, the overall success rate 'per protocol' analysis in our study was 81.6% (95% CI = 72.9-90.3%) for the triple and dual therapy sequence and 97.3% (95% CI = 93.6-100%) for dual followed by triple therapy (chi 2 = 8.14; P = 0.004).

CONCLUSIONS

Our data found that H. pylori eradication with OA therapy after OCT therapy failure was poor, while that obtained with OCT after OA therapy was good.

Implication of laparoscopy and peritoneal cytology in the staging of early pancreatic cancer

Staging of pancreatic cancer still represents a challenge for surgeons involved in this field. Diagnostic methods of radiological imaging used routinely (CT, NMR, angiography) may understage this neoplasm. In fact, the presence of peritoneal or subglissonian hepatic micrometastases (< 2 cm) is a frequent surprise at laparotomy and forces the surgeon to use a palliative procedure. Actually this policy has not to be followed because the possibility to perform non-surgical palliation of jaundice or pain respectively by percutaneous radiological stent insertion and celiac alcoholization. In this viewpoint, preoperative staging has acquired an important role for a correct treatment, be it surgical or medical. Laparoscopy allows it to overcome the understaging produced by the more common diagnostic means, with the possibility to view directly the celomatic space and the surface of the abdominal viscera; moreover, during this procedure it is possible to perform a peritoneal washing to obtain other information about the cancer stage. In our experience, 56 patients were judged as resectable by radiologic methods; 31 were excluded from surgery by laparoscopy; 10 of the remaining 25 cases were submitted to radical resection. The operative resectability rate resulted in 40%, against 18% in cases where we submitted to surgery all the patients. Seven patients underwent peritoneal washing, always with a negative result; all were submitted to surgery and radically resected. In our opinion, laparoscopy and peritoneal washing represent useful tools in the staging of patients affected by pancreatic cancer.

Pancreatic cancer and retroperitoneal neural tissue invasion. Its implication for survival following radical surgery

To analyze the implication of retroperitoneal perineural lymphatic infiltration (rpli) for the survival of patients affected by exocrine pancreatic cancer, we considered 17 cases which underwent radical resection at our Institute from 1980 to 1993. Histology of specimens showed an rpli in 15 cases, without any correlation between this anatomopathologic aspect and the neoplasm size or the presence of lymph node metastases. The 2 patients without rpli are both alive and have been free from disease during a follow-up period of more than 5 years. In the group of 15 patients with positive rpli, 3 (21.4%) have remained free from disease (2 alive and 1 dead for other reason). Eleven remained with disease (1 is alive and 10 have died). One died in the postoperative period and could not be included in the evaluation. These observations have led the surgeon to consider the necessity, during resection, of an accurate dissection not only of the regional lymph nodes but also of the retropancreatic tissue and the neural structures present in this area. This approach may lead to a more correct staging of the neoplasia, a better radical surgery and perhaps a longer survival. Moreover it may represent an important marker for an adjuvant protocol of chemotherapy and/or radiotherapy.

[Comparative evaluation of propofol and thiopentone for induction of general anesthesia in dentistry]

For dental and stomatologic operations of short duration the Authors can consider "propofol" as the best hypnotic, because it is gifted with hypnotic inducing properties, which have a remarkable speed of recuperation, characterised by the subject's sensation of well-being, and, with modest respiratory depression and maintenance of cardiovascular values.

[The L.A.I. test and tumor markers (Ca 19-9 and TPA) in the diagnosis of pancreatic carcinoma]

A particular cell-mediated immune response is tested in this work: the leukocyte adherence inhibition (L.A.I.) in the presence of organ tumor antigens. Forty-two patients suspected of having pancreatic cancer were submitted to the L.A.I. test and Ca 19.9 and TPA determination. The diagnosis of pancreatic cancer was eventually surgically confirmed and staged in 30 patients. The most important features of the L.A.I. test were good specificity (94%) and the ability to diagnose stage I cancers (3/4 cases, 75%), while the other markers are more likely to diagnose more advanced stages. The L.A.I. test seems to be also useful during the follow-up period since its positivity may even be some months previous to the clinical symptoms. During follow-up the L.A.I. test proved useful in supervising the neoplastic disease course from the moment of relapse to advanced clinical symptoms.

Differential pulse polarographic determination of clorazepate monopotassium and dipotassium

Polarographic investigation of clorazepate monopotassium and dipotassium showed two cathodic waves at about -1.28 and -1.66 v. The cathodic wave associated with clorazepate monopotassium or dipotassium at about -1.66 v was a pH-independent, diffusion-controlled wave. This wave was used to develop a specific stability-indicating procedure for clorazepate monopotassium and dipotassium in the presence of their degradation products, namely, nordiazepam, 2-amino-5-chlorobenzophenone, and glycine. The method involves a 10(-2) M LiOH-10(-1) M LiCl extraction of the active ingredient from the formulation, filtration, dilution with the same supporting electrolyte, and then use of the standard addition technique for drug quantitation in capsules. Typical fomulation excipients did not interfere with the analysis. Accuracy and precision of the procedure were 99.55 +/- 0.68%.