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Drexler R, Sauvigny T, Pantel TF, Ricklefs FL, Catapano JS, Wanebo JE, Lawton MT, Sanchin A, Hecht N, Vajkoczy P, Raygor K, Tonetti D, Abla A, El Naamani K, Tjoumakaris SI, Jabbour P, Jankowitz BT, Salem MM, Burkhardt JK, Wagner A, Wostrack M, Gempt J, Meyer B, Gaub M, Mascitelli JR, Dodier P, Bavinzski G, Roessler K, Stroh N, Gmeiner M, Gruber A, Figueiredo EG, da Silva Coelho ACS, Bervitskiy AV, Anisimov ED, Rzaev JA, Krenzlin H, Keric N, Ringel F, Park D, Kim MC, Marcati E, Cenzato M, Westphal M, Dührsen L. Global Outcomes for Microsurgical Clipping of Unruptured Intracranial Aneurysms: A Benchmark Analysis of 2245 Cases. Neurosurgery 2024; 94:369-378. [PMID: 37732745 PMCID: PMC10766286 DOI: 10.1227/neu.0000000000002689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/27/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Benchmarks represent the best possible outcome and help to improve outcomes for surgical procedures. However, global thresholds mirroring an optimal and reachable outcome for microsurgical clipping of unruptured intracranial aneurysms (UIA) are not available. This study aimed to define standardized outcome benchmarks in patients who underwent clipping of UIA. METHODS A total of 2245 microsurgically treated UIA from 15 centers were analyzed. Patients were categorized into low- ("benchmark") and high-risk ("nonbenchmark") patients based on known factors affecting outcome. The benchmark was defined as the 75th percentile of all centers' median scores for a given outcome. Benchmark outcomes included intraoperative (eg, duration of surgery, blood transfusion), postoperative (eg, reoperation, neurological status), and aneurysm-related factors (eg, aneurysm occlusion). Benchmark cutoffs for aneurysms of the anterior communicating/anterior cerebral artery, middle cerebral artery, and posterior communicating artery were determined separately. RESULTS Of the 2245 cases, 852 (37.9%) patients formed the benchmark cohort. Most operations were performed for middle cerebral artery aneurysms (53.6%), followed by anterior communicating and anterior cerebral artery aneurysms (25.2%). Based on the results of the benchmark cohort, the following benchmark cutoffs were established: favorable neurological outcome (modified Rankin scale ≤2) ≥95.9%, postoperative complication rate ≤20.7%, length of postoperative stay ≤7.7 days, asymptomatic stroke ≤3.6%, surgical site infection ≤2.7%, cerebral vasospasm ≤2.5%, new motor deficit ≤5.9%, aneurysm closure rate ≥97.1%, and at 1-year follow-up: aneurysm closure rate ≥98.0%. At 24 months, benchmark patients had a better score on the modified Rankin scale than nonbenchmark patients. CONCLUSION This study presents internationally applicable benchmarks for clinically relevant outcomes after microsurgical clipping of UIA. These benchmark cutoffs can serve as reference values for other centers, patient registries, and for comparing the benefit of other interventions or novel surgical techniques.
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Affiliation(s)
- Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias F. Pantel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L. Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joshua S. Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - John E. Wanebo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Aminaa Sanchin
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kunal Raygor
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Daniel Tonetti
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Adib Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula I. Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Brian T. Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Pennsylvania Medicine, Philadelphia, Pennsylvania, USA
| | - Mohamed M. Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Pennsylvania Medicine, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Pennsylvania Medicine, Philadelphia, Pennsylvania, USA
| | - Arthur Wagner
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Michael Gaub
- Department of Neurosurgery, University of Texas Health and Science Center at San Antonio, San Antonio, Texas, USA
| | - Justin R. Mascitelli
- Department of Neurosurgery, University of Texas Health and Science Center at San Antonio, San Antonio, Texas, USA
| | - Philippe Dodier
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Karl Roessler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Nico Stroh
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Matthias Gmeiner
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Eberval G. Figueiredo
- Division of Neurological Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | | | - Harald Krenzlin
- Department of Neurosurgery, University Hospital Mainz, Mainz, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Hospital Mainz, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Hospital Mainz, Mainz, Germany
| | - Dougho Park
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Korea
| | - Mun-Chul Kim
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Korea
| | - Eleonora Marcati
- Department of Neurosurgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Cenzato
- Department of Neurosurgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Sauvigny J, Drexler R, Pantel TF, Ricklefs FL, Catapano JS, Wanebo JE, Lawton MT, Sanchin A, Hecht N, Vajkoczy P, Raygor K, Tonetti D, Abla A, El Naamani K, Tjoumakaris SI, Jabbour P, Jankowitz BT, Salem MM, Burkhardt JK, Wagner A, Wostrack M, Gempt J, Meyer B, Gaub M, Mascitelli JR, Dodier P, Bavinzski G, Roessler K, Stroh N, Gmeiner M, Gruber A, Figueiredo EG, Coelho ACSDS, Bervitskiy AV, Anisimov ED, Rzaev JA, Krenzlin H, Keric N, Ringel F, Park D, Kim MC, Marcati E, Cenzato M, Krause L, Westphal M, Dührsen L, Sauvigny T. Microsurgical Clipping of Unruptured Anterior Circulation Aneurysms-A Global Multicenter Investigation of Perioperative Outcomes. Neurosurgery 2024:00006123-990000000-01023. [PMID: 38240568 DOI: 10.1227/neu.0000000000002829] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/13/2023] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Microsurgical aneurysm repair by clipping continues to be highly important despite increasing endovascular treatment options, especially because of inferior occlusion rates. This study aimed to present current global microsurgical treatment practices and to identify risk factors for complications and neurological deterioration after clipping of unruptured anterior circulation aneurysms. METHODS Fifteen centers from 4 continents participated in this retrospective cohort study. Consecutive patients who underwent elective microsurgical clipping of untreated unruptured intracranial aneurysm between January 2016 and December 2020 were included. Posterior circulation aneurysms were excluded. Outcome parameters were postsurgical complications and neurological deterioration (defined as decline on the modified Rankin Scale) at discharge and during follow-up. Multivariate regression analyses were performed adjusting for all described patient characteristics. RESULTS Among a total of 2192 patients with anterior circulation aneurysm, complete occlusion of the treated aneurysm was achieved in 2089 (95.3%) patients at discharge. The occlusion rate remained stable (94.7%) during follow-up. Regression analysis identified hypertension (P < .02), aneurysm diameter (P < .001), neck diameter (P < .05), calcification (P < .01), and morphology (P = .002) as preexisting risk factors for postsurgical complications and neurological deterioration at discharge. Furthermore, intraoperative aneurysm rupture (odds ratio 2.863 [CI 1.606-5.104]; P < .01) and simultaneous clipping of more than 1 aneurysm (odds ratio 1.738 [CI 1.186-2.545]; P < .01) were shown to be associated with an increased risk of postsurgical complications. Yet, none of the surgical-related parameters had an impact on neurological deterioration. Analyzing volume-outcome relationship revealed comparable complication rates (P = .61) among all 15 participating centers. CONCLUSION Our international, multicenter analysis presents current microsurgical treatment practices in patients with anterior circulation aneurysms and identifies preexisting and surgery-related risk factors for postoperative complications and neurological deterioration. These findings may assist in decision-making for the optimal therapeutic regimen of unruptured anterior circulation aneurysms.
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Affiliation(s)
- Jennifer Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias F Pantel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - John E Wanebo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Aminaa Sanchin
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kunal Raygor
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Daniel Tonetti
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Adib Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Arthur Wagner
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Michael Gaub
- Department of Neurosurgery, University of Texas Health and Science Center at San Antonio, San Antonio, Texas, USA
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health and Science Center at San Antonio, San Antonio, Texas, USA
| | - Philippe Dodier
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Karl Roessler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Nico Stroh
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Matthias Gmeiner
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Eberval G Figueiredo
- Division of Neurological Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | | | - Harald Krenzlin
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| | - Dougho Park
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Korea
| | - Mun-Chul Kim
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Korea
| | - Eleonora Marcati
- Department of Neurosurgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Cenzato
- Department of Neurosurgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Linda Krause
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Baig AA, Manion C, Khawar WI, Donnelly BM, Raygor K, Turner R, Holmes DR, Iyer VS, Hopkins LN, Davies JM, Levy EI, Siddiqui AH. Cerebral emboli detection and autonomous neuromonitoring using robotic transcranial Doppler with artificial intelligence for transcatheter aortic valve replacement with and without embolic protection devices: a pilot study. J Neurointerv Surg 2023:jnis-2023-020812. [PMID: 37940386 DOI: 10.1136/jnis-2023-020812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/26/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Periprocedural ischemic stroke remains a serious complication in patients undergoing transcatheter aortic valve replacement (TAVR). We used a novel robotic transcranial Doppler (TCD) system equipped with artificial intelligence (AI) for real-time continuous intraoperative neuromonitoring during TAVR to establish the safety and potential validity of this tool in detecting cerebral emboli, report the quantity and distribution of high intensity transient signals (HITS) with and without cerebral protection, and correlate HITS occurrence with various procedural steps. METHODS Consecutive patients undergoing TAVR procedures during which the robotic system was used between October 2021 and May 2022 were prospectively enrolled in this pilot study. The robotic TCD system included autonomous adjustment of the TCD probes and AI-assisted post-processing of HITS and other cerebral flow parameters. Basic demographics and procedural details were recorded. Continuous variables were analyzed by a two-sample Mann-Whitney t-test and categorical variables by a χ2 or Fisher test. RESULTS Thirty-one patients were prospectively enrolled (mean age 79.9±7.6 years; 16 men (51.6%)). Mean aortic valve stenotic area was 0.7 cm2 and mean aortic-ventricular gradient was 43 mmHg (IQR 31.5-50 mmHg). Cerebral protection was used in 16 cases (51.6%). Significantly fewer emboli were observed in the protection group than in the non-protection group (mean 470.38 vs 693.33; p=0.01). Emboli counts during valve positioning and implantation were significantly different in the protection and non-protection groups (mean 249.92 and 387.5, respectively; p=0.01). One (4%) transient ischemic attack occurred post-procedurally in the non-protection group. CONCLUSION We describe a novel real-time intraoperative neuromonitoring tool used in patients undergoing TAVR. Significantly fewer HITS were detected with protection. Valve positioning-implantation was the most significant stage for intraprocedural HITS.
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Affiliation(s)
- Ammad A Baig
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | | | - Wasiq I Khawar
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Brianna M Donnelly
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Kunal Raygor
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Ryan Turner
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - David R Holmes
- Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Vijay S Iyer
- Cardiology, Gates Vascular Institute, Buffalo, New York, USA
| | - L Nelson Hopkins
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
| | - Jason M Davies
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
- Neurosurgery and Bioinformatics and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Elad I Levy
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
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4
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Huang L, Cheng F, Zhang X, Zielonka J, Nystoriak MA, Xiang W, Raygor K, Wang S, Lakshmanan A, Jiang W, Yuan S, Hou KS, Zhang J, Wang X, Syed AU, Juric M, Takahashi T, Navedo MF, Wang RA. Nitric oxide synthase and reduced arterial tone contribute to arteriovenous malformation. Sci Adv 2023; 9:eade7280. [PMID: 37235659 PMCID: PMC10219588 DOI: 10.1126/sciadv.ade7280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 04/20/2023] [Indexed: 05/28/2023]
Abstract
Mechanisms underlying arteriovenous malformations (AVMs) are poorly understood. Using mice with endothelial cell (EC) expression of constitutively active Notch4 (Notch4*EC), we show decreased arteriolar tone in vivo during brain AVM initiation. Reduced vascular tone is a primary effect of Notch4*EC, as isolated pial arteries from asymptomatic mice exhibited reduced pressure-induced arterial tone ex vivo. The nitric oxide (NO) synthase (NOS) inhibitor NG-nitro-l-arginine (L-NNA) corrected vascular tone defects in both assays. L-NNA treatment or endothelial NOS (eNOS) gene deletion, either globally or specifically in ECs, attenuated AVM initiation, assessed by decreased AVM diameter and delayed time to moribund. Administering nitroxide antioxidant 4-hydroxy-2,2,6,6-tetramethylpiperidine-1-oxyl also attenuated AVM initiation. Increased NOS-dependent production of hydrogen peroxide, but not NO, superoxide, or peroxynitrite was detected in isolated Notch4*EC brain vessels during AVM initiation. Our data suggest that eNOS is involved in Notch4*EC-mediated AVM formation by up-regulating hydrogen peroxide and reducing vascular tone, thereby permitting AVM initiation and progression.
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Affiliation(s)
- Lawrence Huang
- Laboratory for Accelerated Vascular Research, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Feng Cheng
- Laboratory for Accelerated Vascular Research, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Xuetao Zhang
- Laboratory for Accelerated Vascular Research, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Jacek Zielonka
- Free Radical Research Laboratory, Department of Biophysics, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Matthew A. Nystoriak
- Department of Pharmacology, University of California, Davis, Davis, CA 95616, USA
| | - Weiwei Xiang
- Laboratory for Accelerated Vascular Research, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Kunal Raygor
- Laboratory for Accelerated Vascular Research, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Shaoxun Wang
- Laboratory for Accelerated Vascular Research, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Aditya Lakshmanan
- Laboratory for Accelerated Vascular Research, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Weiya Jiang
- Laboratory for Accelerated Vascular Research, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Sai Yuan
- Laboratory for Accelerated Vascular Research, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Kevin S. Hou
- Laboratory for Accelerated Vascular Research, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Jiayi Zhang
- Laboratory for Accelerated Vascular Research, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Xitao Wang
- Laboratory for Accelerated Vascular Research, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Arsalan U. Syed
- Department of Pharmacology, University of California, Davis, Davis, CA 95616, USA
| | - Matea Juric
- Free Radical Research Laboratory, Department of Biophysics, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Takamune Takahashi
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Manuel F. Navedo
- Department of Pharmacology, University of California, Davis, Davis, CA 95616, USA
| | - Rong A. Wang
- Laboratory for Accelerated Vascular Research, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA
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5
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Bouslama M, Kuo CC, Monteiro A, Lim J, Turner R, Raygor K, Lai PMR, Baig AA, Davies JM, Snyder KV, Levy EI, Siddiqui AH. Mechanical thrombectomy versus medical management for acute basilar artery occlusions: A meta-analysis of randomized trials. Interv Neuroradiol 2023:15910199231157924. [PMID: 37005965 DOI: 10.1177/15910199231157924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Basilar artery occlusion (BAO) stroke is a catastrophic clinical event that results in significant morbidity and mortality. Whether MT is superior in improving outcomes remains largely inconclusive. We performed a meta-analysis of randomized controlled trials (RCTs) to better understand the efficacy and safety of MT in treating BAO compared to medical management (MM). METHODS PubMed and EMBASE were searched to identify RCTs that directly compared the safety and efficacy of MT versus MM for patients with BAO. The primary outcome was modified Rankin scale (mRS) 0-3 at 3 months, and secondary outcome variables included National Institutes of Health Stroke Scale (NIHSS) at 24 hours, mRS 0-2 at 3 months, symptomatic intracranial hemorrhage (sICH), and 90-day mortality. RESULTS Four RCTs with 988 patients (432 in the MM arm and 556 in the MT arm), were included. Patients receiving MT had significantly higher rate of mRS 0-2 (OR = 1.994, 95% CI: 1.319-3.012) and mRS 0-3 (OR = 2.259, 95% CI: 1.166-4.374) at 3 months in comparison to patients receiving MM. Mortality was also significantly reduced in the MT group (OR = 0.640, 95% CI: 0.493-0.831). However, increased odds of sICH were found in the MT group compared to the MM group (OR = 8.193, 95% CI: 2.451-27.389). No difference was observed in terms of NIHSS at 24 hours between the two arms. CONCLUSIONS Despite the higher risk of sICH, MT was associated with superior functional outcomes and reduced mortality compared to MM in BAO patients. A revision of current guidelines for treatment of acute ischemic stroke from basilar artery occlusion should be considered.
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Affiliation(s)
- Mehdi Bouslama
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Ryan Turner
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Kunal Raygor
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Pui Man Rosalind Lai
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
- Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
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6
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Nielsen CM, Zhang X, Raygor K, Wang S, Bollen AW, Wang RA. Endothelial Rbpj deletion normalizes Notch4-induced brain arteriovenous malformation in mice. J Exp Med 2022; 220:213722. [PMID: 36441145 PMCID: PMC9700524 DOI: 10.1084/jem.20211390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 10/10/2022] [Accepted: 11/09/2022] [Indexed: 11/29/2022] Open
Abstract
Upregulation of Notch signaling is associated with brain arteriovenous malformation (bAVM), a disease that lacks pharmacological treatments. Tetracycline (tet)-regulatable endothelial expression of constitutively active Notch4 (Notch4*tetEC) from birth induced bAVMs in 100% of mice by P16. To test whether targeting downstream signaling, while sustaining the causal Notch4*tetEC expression, induces AVM normalization, we deleted Rbpj, a mediator of Notch signaling, in endothelium from P16, by combining tet-repressible Notch4*tetEC with tamoxifen-inducible Rbpj deletion. Established pathologies, including AV connection diameter, AV shunting, vessel tortuosity, intracerebral hemorrhage, tissue hypoxia, life expectancy, and arterial marker expression were improved, compared with Notch4*tetEC mice without Rbpj deletion. Similarly, Rbpj deletion from P21 induced advanced bAVM regression. After complete AVM normalization induced by repression of Notch4*tetEC, virtually no bAVM relapsed, despite Notch4*tetEC re-expression in adults. Thus, inhibition of endothelial Rbpj halted Notch4*tetEC bAVM progression, normalized bAVM abnormalities, and restored microcirculation, providing proof of concept for targeting a downstream mediator to treat AVM pathologies despite a sustained causal molecular lesion.
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Affiliation(s)
- Corinne M. Nielsen
- Laboratory for Accelerated Vascular Research, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Xuetao Zhang
- Laboratory for Accelerated Vascular Research, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Kunal Raygor
- Laboratory for Accelerated Vascular Research, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Shaoxun Wang
- Laboratory for Accelerated Vascular Research, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Andrew W. Bollen
- Department of Pathology, University of California, San Francisco, San Francisco, CA
| | - Rong A. Wang
- Laboratory for Accelerated Vascular Research, Department of Surgery, University of California, San Francisco, San Francisco, CA,Correspondence to Rong A. Wang:
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7
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Budohoski KP, Raygor K, Tonetti DA, Narsinh KH, Winkler EA, Dowd C, Abla AA. Intraoperative Angiogram Using C-Arm Fluoroscopy and Direct Common Carotid Artery Puncture During Surgical Treatment of Paraclinoid Aneurysms. World Neurosurg 2022; 165:95-99. [PMID: 35779758 DOI: 10.1016/j.wneu.2022.06.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/22/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Intraoperative angiography (IOA) has been shown to be a useful adjunct in surgical treatment of cerebral aneurysms. However, its use can be limited by hybrid operating room availability. On the other hand, the use of C-arm fluoroscopy can add challenges to IOA during navigation of the aortic arch and selection of the great vessels. We aimed to describe a simple method of IOA that can be applied during surgery of paraclinoid aneurysms and can be performed in a normal operating room without the need to navigate the aortic arch. METHODS In patients undergoing surgery for paraclinoid aneurysms with need for cervical carotid artery exposure, IOA was performed using a single plane C-arm fluoroscopy unit after direct puncture of the carotid artery. RESULTS Five patients were included: 2 with subarachnoid hemorrhage, 2 with unruptured aneurysm and history of subarachnoid hemorrhage, and 1 with unruptured aneurysm. There were 2 internal carotid blister aneurysms, 2 ophthalmic artery aneurysms, and 1 superior hypophyseal artery aneurysm. IOA was performed using direct carotid puncture through the neck incision required for proximal control. In all cases, intraoperative images were of sufficient quality to determine the completeness of aneurysm occlusion as well as parent and branching vessel patency. There were no postoperative infarctions and no complications related to IOA. CONCLUSIONS IOA using direct carotid puncture can be performed in a standard operating room with the use of a C-arm, eliminating the need to catheterize the great vessels of the aortic arch.
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Affiliation(s)
- Karol P Budohoski
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA; Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA.
| | - Kunal Raygor
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Kazim H Narsinh
- Department of Radiology, University of California San Francisco, San Francisco, California, USA
| | - Ethan A Winkler
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Christopher Dowd
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Adib A Abla
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
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8
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Budohoski KP, Raygor K, Cook D, Henrich T, Abla AA. Rapid sequential development and rupture of mycotic aneurysms within a period of days in a patient with graft-versus-host disease and angiotropic Scedosporium apiospermum infection. Surg Neurol Int 2022; 13:242. [PMID: 35855168 PMCID: PMC9282729 DOI: 10.25259/sni_970_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 05/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Fungal origin mycotic aneurysms are rare and carry a high mortality rate. Scedosporium apiospermum is an ubiquitous fungus which has been described to cause devastating infections in immunocompromised hosts. Case Description: We report a case of a 23-year-old patient with Burkitt’s lymphoma and graft-versus-host disease admitted with intracerebral hemorrhage and sequential development of 12 anterior circulation aneurysms from disseminated Scedosporium infection. Despite aggressive surgical and antimicrobial treatment, the patient died 6 months later from multiorgan failure. The notable feature of this case is the rapid angioinvasiveness of the infection with new aneurysm formation within days of clear angiographic imaging despite the apparent lack of skull base osteomyelitis. Conclusion: We highlight the difficulties in treating fungal mycotic aneurysms and the associated high mortality. While a less aggressive approach might have been appropriate given the known poor outcomes, the age of the patients as well as the family wishes dictated the treatment decisions.
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Affiliation(s)
- Karol P. Budohoski
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, Unites States
| | - Kunal Raygor
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, Unites States
| | - Dan Cook
- Department of Radiology, University of California San Francisco, San Francisco, California, Unites States
| | - Timothy Henrich
- Department of Medicine, Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, California, Unites States
| | - Adib A. Abla
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, Unites States
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9
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Baker A, Raygor K, Caton MT, Narsinh KH, Smith E, Dowd CF, Cooke DL, Higashida RT, Amans MR, Abla AA, Hetts SW. Pharyngo-tympano-stapedial middle meningeal artery variant supply to a falcotentorial dural arteriovenous fistula. J Neurointerv Surg 2022; 14:neurintsurg-2022-018817. [PMID: 35545428 DOI: 10.1136/neurintsurg-2022-018817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/29/2022] [Indexed: 11/03/2022]
Abstract
The pharyngo-tympano-stapedial middle meningeal artery (PTS-MMA) variant has been described in one case report and never in the setting of arterial supply to a dural arteriovenous fistula, to our knowledge. We report the case of a middle-aged patient with severe, daily headache who presented to our institution for angiography and treatment. CT angiography and MRI demonstrated an enlarged left middle meningeal artery coursing to a large venous varix in the falcotentorial region. Dural arteriovenous fistula was confirmed by subsequent cerebral angiography. Endovascular treatment was performed but without complete obliteration of the fistula. Follow-up angiography demonstrated parasitized arterial supply from a right middle meningeal artery arising from the proximal cervical internal carotid artery coursing through the middle ear consistent with a PTS-MMA variant. The fistula was then treated surgically without recurrence at the 6-month follow-up.
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Affiliation(s)
- Amanda Baker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Kunal Raygor
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - M Travis Caton
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Kazim H Narsinh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Eric Smith
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Christopher F Dowd
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Randall T Higashida
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Matthew R Amans
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
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10
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Winkler EA, Kim CN, Ross JM, Garcia JH, Gil E, Oh I, Chen LQ, Wu D, Catapano JS, Raygor K, Narsinh K, Kim H, Weinsheimer S, Cooke DL, Walcott BP, Lawton MT, Gupta N, Zlokovic BV, Chang EF, Abla AA, Lim DA, Nowakowski TJ. A single-cell atlas of the normal and malformed human brain vasculature. Science 2022; 375:eabi7377. [PMID: 35084939 DOI: 10.1126/science.abi7377] [Citation(s) in RCA: 105] [Impact Index Per Article: 52.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cerebrovascular diseases are a leading cause of death and neurologic disability. Further understanding of disease mechanisms and therapeutic strategies requires a deeper knowledge of cerebrovascular cells in humans. We profiled transcriptomes of 181,388 cells to define a cell atlas of the adult human cerebrovasculature, including endothelial cell molecular signatures with arteriovenous segmentation and expanded perivascular cell diversity. By leveraging this reference, we investigated cellular and molecular perturbations in brain arteriovenous malformations, a leading cause of stroke in young people, and identified pathologic endothelial transformations with abnormal vascular patterning and the ontology of vascularly derived inflammation. Here, we illustrate the interplay between vascular and immune cells that contributes to brain hemorrhage and catalog opportunities for targeting angiogenic and inflammatory programs in vascular malformations.
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Affiliation(s)
- Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA, USA.,Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.,Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Chang N Kim
- Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA, USA.,Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.,Department of Anatomy, University of California, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - Jayden M Ross
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA, USA.,Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.,Department of Anatomy, University of California, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - Joseph H Garcia
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Eugene Gil
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA, USA
| | - Irene Oh
- Rebus Biosystems, Santa Clara, CA, USA
| | | | - David Wu
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Kunal Raygor
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Kazim Narsinh
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Shantel Weinsheimer
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Daniel L Cooke
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.,Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Brian P Walcott
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Nalin Gupta
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Berislav V Zlokovic
- Department of Physiology and Neuroscience, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Edward F Chang
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Daniel A Lim
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA, USA.,Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Tomasz J Nowakowski
- Department of Neurological Surgery, University of California, San Francisco, CA, USA.,Eli and Edythe Broad Center for Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA, USA.,Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.,Department of Anatomy, University of California, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA.,Chan Zuckerberg Biohub, San Francisco, CA, USA
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11
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Winkler EA, Raygor K, Caleb Rutledge W, Lu AP, Phelps RRL, Lien BV, Rubio RR, Abla AA. Local in situ fibrinolysis for recanalization of an occluded extracranial-intracranial bypass: Technical note. J Clin Neurosci 2019; 64:287-291. [PMID: 30885594 DOI: 10.1016/j.jocn.2019.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/08/2019] [Indexed: 11/29/2022]
Abstract
Extracranial-intracranial (EC-IC) bypass is a versatile technique to augment or preserve blood flow when treating cerebrovascular pathologies to prevent ischemic complications. Technical success and good patient outcomes rely on the successful establishment and maintenance of a patent bypass graft. Multiple modalities have been developed to confirm intraoperative graft patency. However, techniques and strategies to manage an occluded bypass are sparsely reported. The authors describe a novel technique for the in situ fibrinolysis utilizing recombinant tissue plasminogen activator (r-tPA) to recanalize an occluded EC-IC bypass following thrombus formation. This technique is feasible and effective in restoring long term EC-IC graft patency without requirement of additional vessel harvest or added ischemia time which may be tailored for use with other pharmacologic agents based on the acuity of an in-graft thrombosis.
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Affiliation(s)
- Ethan A Winkler
- University of California San Francisco, Department of Neurological Surgery, San Francisco, CA, USA
| | - Kunal Raygor
- University of California San Francisco, Department of Neurological Surgery, San Francisco, CA, USA
| | - W Caleb Rutledge
- University of California San Francisco, Department of Neurological Surgery, San Francisco, CA, USA
| | - Alex P Lu
- University of California San Francisco, Department of Neurological Surgery, San Francisco, CA, USA
| | - Ryan R L Phelps
- University of California San Francisco, Department of Neurological Surgery, San Francisco, CA, USA
| | - Brian V Lien
- University of California San Francisco, Department of Neurological Surgery, San Francisco, CA, USA
| | - Roberto Rodriguez Rubio
- University of California San Francisco, Department of Neurological Surgery, San Francisco, CA, USA
| | - Adib A Abla
- University of California San Francisco, Department of Neurological Surgery, San Francisco, CA, USA.
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12
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Li A, Zhou C, Moore J, Zhang P, Tsai TH, Lee HC, Romano DM, McKee ML, Schoenfeld DA, Serra MJ, Raygor K, Cantiello HF, Fujimoto JG, Tanzi RE. Changes in the expression of the Alzheimer’s disease-associated presenilin gene in drosophila heart leads to cardiac dysfunction. Curr Alzheimer Res 2011; 8:313-22. [PMID: 21524270 DOI: 10.2174/156720511795563746] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Accepted: 10/15/2010] [Indexed: 12/22/2022]
Abstract
Mutations in the presenilin genes cause the majority of early-onset familial Alzheimer’s disease. Recently, presenilin mutations have been identified in patients with dilated cardiomyopathy (DCM), a common cause of heart failure and the most prevalent diagnosis in cardiac transplantation patients. However, the molecular mechanisms, by which presenilin mutations lead to either AD or DCM, are not yet understood. We have employed transgenic Drosophila models and optical coherence tomography imaging technology to analyze cardiac function in live adult Drosophila. Silencing of Drosophila ortholog of presenilins (dPsn) led to significantly reduced heart rate and remarkably age-dependent increase in end-diastolic vertical dimensions. In contrast, overexpression of dPsn increased heart rate. Either overexpression or silencing of dPsn resulted in irregular heartbeat rhythms accompanied by cardiomyofibril defects and mitochondrial impairment. The calcium channel receptor activities in cardiac cells were quantitatively determined via real-time RT-PCR. Silencing of dPsn elevated dIP3R expression, and reduced dSERCA expression; overexprerssion of dPsn led to reduced dRyR expression. Moreover, overexpression of dPsn in wing disc resulted in loss of wing phenotype and reduced expression of wingless. Our data provide novel evidence that changes in presenilin level leads to cardiac dysfunction, owing to aberrant calcium channel receptor activities and disrupted Wnt signaling transduction, indicating a pathogenic role for presenilin mutations in DCM pathogenesis.
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Affiliation(s)
- A Li
- Genetics and Aging Research Unit, Department of Neurology, MassGeneral Institute for Neurodegenerative Diseases, Massachusetts General Hospital and Harvard Medical School, USA
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13
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Gianni D, Li A, Tesco G, McKay KM, Moore J, Raygor K, Rota M, Gwathmey JK, Dec GW, Aretz T, Leri A, Semigran MJ, Anversa P, Macgillivray TE, Tanzi RE, del Monte F. Protein aggregates and novel presenilin gene variants in idiopathic dilated cardiomyopathy. Circulation 2010; 121:1216-26. [PMID: 20194882 DOI: 10.1161/circulationaha.109.879510] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Heart failure is a debilitating condition resulting in severe disability and death. In a subset of cases, clustered as idiopathic dilated cardiomyopathy (iDCM), the origin of heart failure is unknown. In the brain of patients with dementia, proteinaceous aggregates and abnormal oligomeric assemblies of beta-amyloid impair cell function and lead to cell death. METHODS AND RESULTS We have similarly characterized fibrillar and oligomeric assemblies in the hearts of iDCM patients, pointing to abnormal protein aggregation as a determinant of iDCM. We also showed that oligomers alter myocyte Ca(2+) homeostasis. Additionally, we have identified 2 new sequence variants in the presenilin-1 (PSEN1) gene promoter leading to reduced gene and protein expression. We also show that presenilin-1 coimmunoprecipitates with SERCA2a. CONCLUSIONS On the basis of these findings, we propose that 2 mechanisms may link protein aggregation and cardiac function: oligomer-induced changes on Ca(2+) handling and a direct effect of PSEN1 sequence variants on excitation-contraction coupling protein function.
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Affiliation(s)
- Davide Gianni
- Cardiovascular Institute, Beth Israel Deaconess Medical Center, Boston, MA 02125, USA
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