Early Outcomes of the Pipeline Vantage Flow Diverter : A Multicentre Study

PURPOSE

The recently introduced Pipeline Vantage Embolization Device with Shield Technology is the fourth generation of Pipeline flow diverter devices. Due to the relatively high rate of intraprocedural technical complications, modifications were subsequently made to the device after a limited release of the device in 2020. This study aimed to evaluate the safety and efficacy of the modified version of this device.

METHODS

This was a multicentre retrospective series. The primary efficacy endpoint was aneurysm occlusion in the absence of retreatment. The primary safety endpoint was any neurological morbidity or death. Ruptured and unruptured aneurysms were included in the study.

RESULTS

A total of 52 procedures were performed for 60 target aneurysms. Treatment was performed on 5 patients with ruptured aneurysms. The technical success rate was 98%. The mean clinical follow-up time was 5.5 months. In patients presenting with unruptured aneurysms there were no deaths, 3 (6.4%) major complications and 7 (13%) minor complications. In the five patients presenting with subarachnoid haemorrhage there were 2 (40%) major complications with 1 (20%) of these resulting in death, and 1 (20%) minor complication. Of the patients 29 (56%) had undergone 6‑monthly postprocedural angiographic imaging with a mean time of 6.6 months demonstrating that 83% of patients had achieved adequate occlusion (RROC1/2) of the aneurysm.

CONCLUSIONS

In this non-industry-sponsored study, the occlusion rates and safety outcomes were similar to those seen in previously published studies with flow diverter devices and earlier generation Pipeline devices. Modifications to the device appear to have improved ease of deployment.

Dural arteriovenous fistula causing reversible cognitive impairment

A previously independent 82-year-old woman presented with 5 months of worsening confusion, mobility and cognitive decline, with deficits in orientation, language and executive function. A cerebral dural arteriovenous fistula was identified and successfully embolised, after which her cognitive ability and independence dramatically improved. Although rare, a dural arteriovenous fistula may mimic a rapidly progressive dementia, but its early recognition and treatment can completely reverse the dementia.

A life-threatening dental implant: A case report

BACKGROUND

Intraoral bleeding complications in implant surgery are infrequent; nevertheless, serious and life-threatening complications have been described, generally related to mandibular implants.

PURPOSE

This article presents the exceptional case of a 24-year-old woman who underwent repeated delayed life-threatening episodes of intraoral bleeding following uncovering of a maxillary dental implant. Local measures afforded only temporary control.

RESULTS

The episodes were successfully managed by embolising the greater descending palatine artery, and the patient remains now under close follow-up.

CONCLUSIONS

Early recognition of shock secondary to hemorrhage following intraoral surgery is of paramount importance.

Woven Endobridge (WEB) Device as a Retreatment Strategy After Unsuccessful Surgical Clipping

BACKGROUND

Surgical clipping of intracranial aneurysms is typically robust and durable. However, residual aneurysmal components may be seen after clipping. Furthermore, there may be occasional aneurysmal recurrence. These factors are both clinically relevant because subarachnoid hemorrhage after clipping is a rare but important event. The rationale for any treatment is to substantially decrease the future risk of hemorrhage. Small series have shown coiling as a retreatment strategy after unsuccessful clipping, but none has explored the feasibility of Woven Endobridge (WEB) implantation.

CASE DESCRIPTION

We examined the feasibility of WEB implantation as second-line treatment for wide-necked residual aneurysms after unsuccessful clipping. We also recorded the safety and efficacy in this small series of 6 patients. To determine safety, we measured the modified Rankin Scale score before and after the procedure, and at 2 later time points (mean follow-up, 5 months and 15 months). To determine efficacy, we obtained radiographic aneurysm occlusion outcomes (including WEB Occlusion Scale) at these 2 time points. Four middle cerebral artery and 2 anterior communicating artery complex aneurysms were treated with WEB implantation, showing feasibility in 6/6 cases (100%). Follow-up at 15 months showed no change from preprocedural modified Rankin Scale score and there were no other complications. There was adequate occlusion in 5/6 cases (83%).

CONCLUSIONS

WEB implantation provided a feasible option in this challenging retreatment scenario. This is a small series and prospective data are required to make outcome inferences for this population. Nonetheless, we observed no complications and high adequate occlusion rates.

Outcome Study of the Pipeline Embolization Device with Shield Technology in Unruptured Aneurysms (PEDSU)

BACKGROUND AND PURPOSE

The recently introduced Pipeline Flex Embolization Device with Shield Technology (Pipeline Shield) is the third generation of Pipeline flow-diverter devices. It has a new stent-surface modification, which reduces thrombogenicity. We aimed to evaluate clinical and radiographic (safety and efficacy) outcomes of the Pipeline Shield.

MATERIALS AND METHODS

The 30-day and 1-year mortality and morbidity rates and the 6- and 18-month radiographic aneurysm occlusion outcomes for procedures performed between March 2016 and January 2018 were analyzed. 3D-TOF-MRA was used for follow-up.

RESULTS

Forty-four attempted Pipeline Shield procedures were performed for 41 patients with 44 target aneurysms (total of 52 aneurysms treated). A total of 88.5% of devices were inserted in the anterior circulation, and 11.5%, in the posterior circulation; 49/52 (94.2%) aneurysms were saccular; and 1/52 (1.9%) was fusiform. One (1.9%) aneurysm was an iatrogenic pseudoaneurysm, and 1 (1.9%) was a dissecting aneurysm. Seventy-one percent (35/49) of the saccular aneurysms were wide-neck (neck, >4 mm), 34.6% (18/52) were large (≥10 mm), and 3.8% (2/52) were giant (≥25 mm). The mean aneurysm sac maximal diameter was 9.0 mm, and the mean neck width was 5.0 mm. The cumulative mortality and morbidity rates were 2.3% and 6.8% at 1 year, respectively. The adequate occlusion rate was 78.8% at 6 months and 90.3% at 18 months.

CONCLUSIONS

In this pragmatic and non-industry-sponsored study, the occlusion rates and safety outcomes were similar to those seen in previously published studies with flow-diverter devices and earlier generation Pipeline Embolization Devices.

Facile One-Pot Synthesis of Flower Like Cobalt Oxide Nanostructures on Nickel Plate and Its Supercapacitance Properties

A flower like cobalt oxide nanostructured thin film (Co2O3) on Nickel (Ni) plate as have been successfully developed via alcoholic Seed Layer assisted chemical bath Deposition (SLD) process. Through the controlled alkaline electrolytes, the flower and paddles like Co2O3 nanoarchitectures were formed. The prepared thin film was characterized by X-ray diffraction (XRD), scanning electron microscope with energy dispersive X-ray (SEM and EDX), Atomic Force Microscope (AFM), Raman spectroscopy techniques. Electron micrograph reveals the flower and paddles like nanostructured Co2O3 thin film deposited on Ni plates. The electrochemical characteristics were investigated using cyclic voltammetry (CV), charge-discharge and AC impedance spectroscopy in different aqueous electrolytes such as NaOH, KOH, and LiOH. The maximum specific capacitance of 856 Fg-1 was attained with 2 M KOH electrolyte with 2 mVs-1 of the Co2O3 thin film coated Ni plate at 80 °C using SLD method. The capacitance values obtained with various electrolytes are in the order of KOH > NaOH > LiOH. The results indicate that the present method is economical and the material is ecofriendly with enhanced capacitance property.

IDH1-associated primary glioblastoma in young adults displays differential patterns of tumour and vascular morphology

Glioblastoma is a highly aggressive tumour with marked heterogeneity at the morphological level in both the tumour cells and the associated highly prominent vasculature. As we begin to develop an increased biological insight into the underlying processes driving the disease, fewer attempts have thus far been made to understand these phenotypic differences. We sought to address this by carefully assessing the morphological characteristics of both the tumour cells and the associated vasculature, relating these observations to the IDH1/MGMT status, with a particular focus on the early onset population of young adults who develop primary glioblastoma. 276 primary glioblastoma specimens were classified into their predominant cell morphological type (fibrillary, gemistocytic, giant cell, small cell, oligodendroglial, sarcomatous), and assessed for specific tumour (cellularity, necrosis, palisades) and vascular features (glomeruloid structures, arcades, pericyte proliferation). IDH1 positive glioblastomas were associated with a younger age at diagnosis, better clinical outcome, prominent oligodendroglial and small cell tumour cell morphology, pallisading necrosis and glomeruloid vascular proliferation in the absence of arcade-like structures. These features widen the phenotype of IDH1 mutation-positive primary glioblastoma in young adults and provide correlative evidence for a functional role of mutant IDH1 in the differential nature of neo-angiogenesis in different subtypes of glioblastoma.

Temozolomide responsiveness in aggressive corticotroph tumours: a case report and review of the literature

Pituitary carcinoma occurs in ~0.2% of resected pituitary tumours and carries a poor prognosis (mean survival <4 years), with standard chemotherapy regimens showing limited efficacy. Recent evidence suggests that temozolomide (TMZ), an orally-active alkylating agent used principally in the management of glioblastoma, may also be effective in controlling aggressive/invasive pituitary adenomas/carcinomas. A low level of expression of the DNA-repair enzyme O6-methylguanine-DNA methyltransferase (MGMT) predicts TMZ responsiveness in glioblastomas, and a similar correlation has been observed in the majority of aggressive pituitary adenomas/carcinomas reported to date. Here, we report a case of a silent pituitary corticotroph adenoma, which subsequently re-presented with Cushing's syndrome due to functioning hepatic metastases. The tumour exhibited low immunohistochemical MGMT expression in both primary (pituitary) and secondary (hepatic) lesions. Initial TMZ therapy (200 mg/m² for 5 days every 28 days-seven cycles) resulted in marked clinical, biochemical [>50% fall in adrenocorticotrophic hormone (ACTH)] and radiological [partial RECIST (response evaluation criteria in solid tumors) response] improvements. The patient then underwent bilateral adrenalectomy. However, despite reintroduction of TMZ therapy (further eight cycles) ACTH levels plateaued and no further radiological regression was observed. We review the existing literature reporting TMZ efficacy in pituitary corticotroph tumours, and highlight the pointers/lessons for treating aggressive pituitary neoplasia that can be drawn from experience of susceptibility and evolving resistance to TMZ therapy in glioblastoma. Possible strategies for mitigating resistance developing during TMZ treatment of pituitary adenomas/carcinomas are also considered.

Changing incidence and management of penetrating neck injuries in the South East London trauma centre

INTRODUCTION

A total of 17 cases of penetrating neck injury were managed by the otolaryngology team at King's College Hospital over a 3-year period in the 1980s. In April 2010 King's College Hospital became the major trauma centre for South East London. This prospective cohort study compares the incidence, changing demographic features and treatment outcomes of penetrating neck trauma in South East London over the previous 23 years.

METHODS

Data were collected over a 12-month period (April 2010 to March 2011) and a selective management protocol was introduced to standardise initial investigations and further treatment.

RESULTS

The past 23 years have seen a 550% increase in the incidence of penetrating neck injuries in South East London, with a marked increase in gun crime. Only 38% of cases underwent negative neck exploration in 2011 compared with 65% in 1987. Selective conservative management based on the absence of haemodynamic instability or radiological findings reduces length of hospital stay, lightens surgical workload and cuts costs without affecting morbidity or mortality.

CONCLUSIONS

The increased incidence of penetrating neck injury is a reflection of more interpersonal violence rather than a consequence of the larger South East London trauma centre catchment area. Tackling this problem requires focus on wider issues of community prevention. Sharing of data between the four London trauma centres and the police is needed to help prevent interpersonal violence and develop a universal treatment algorithm for other institutions to follow.

GPU-based streaming architectures for fast cone-beam CT image reconstruction and demons deformable registration

This paper shows how to significantly accelerate cone-beam CT reconstruction and 3D deformable image registration using the stream-processing model. We describe data-parallel designs for the Feldkamp, Davis and Kress (FDK) reconstruction algorithm, and the demons deformable registration algorithm, suitable for use on a commodity graphics processing unit. The streaming versions of these algorithms are implemented using the Brook programming environment and executed on an NVidia 8800 GPU. Performance results using CT data of a preserved swine lung indicate that the GPU-based implementations of the FDK and demons algorithms achieve a substantial speedup--up to 80 times for FDK and 70 times for demons when compared to an optimized reference implementation on a 2.8 GHz Intel processor. In addition, the accuracy of the GPU-based implementations was found to be excellent. Compared with CPU-based implementations, the RMS differences were less than 0.1 Hounsfield unit for reconstruction and less than 0.1 mm for deformable registration.

Milk protein polymorphism in Kangayam cattle

This paper reports the milk protein polymorphism, the allele frequencies of variants and the possible linkages among various combinations of milk protein phenotypes in the Kangayam cattle of south India. Milk samples from 156 Kangayam cows were typed by starch gel and polyacrylamide gel electrophoresis for caseins and whey proteins, respectively. All the four milk protein components studied, alpha(s)1-casein. beta-casein, beta-lactoglobulin and alpha-lactalbumin, exhibited polymorphism with high allele frequencies of 0.9231 +/- 0.0151 for alpha(s)1-casein C, 0.9263 +/- 0.0148 for beta-casein A, 0.9135 +/- 0.0159 for beta-lactoglobulin B and a relatively high frequency of 0.6218 +/- 0.0275 for alpha-lactalbumin A. The mean heterozygosity estimated over all the four milk protein loci was 0.2420. Genetic equilibrium was observed among all the loci studied, except alpha-lactalbumin. Linkage analysis confirmed the non-independence between alpha(s)1- and beta-caseins and between caseins and alpha-lactalbumin phenotypes.

Adult body weight of indigenous and crossbred ewes under semi-arid conditions in India

Data on adult body weight of ewes belonging to Nali, Chokla breeds and their crosses (F1) with Rambouillet and Soviet Merino raised under semi-arid conditions in India were analysed. The ewes belonged to 5 distinct age groups ranging from 16.5 to 64 months. Nali and Chokla were significant lighter than all the 4 crossbred groups. There were no significant differences in body weight between crossbred groups except in the case of Soviet Merino x Chokla group which was the lightest and differed significantly from all other groups. Rambouillet crosses were heavier than Merino crosses but the difference was statistically significant only on Rambouillet x Chokla and Merino x Chokla. The improvement in body weight in crossbreds over native sheep ranged between 9.3 and 21.88%. The increase in live weight was significant only up to 49 months.