Rice anther tapetum: a vital reproductive cell layer for sporopollenin biosynthesis and pollen exine patterning

The tapetum is the innermost layer of the four layers of the rice anther that provides protection and essential nutrients to pollen grain development and delivers precursors for pollen exine formation. The tapetum has a key role in the normal development of pollen grains and tapetal programmed cell death (PCD) that is linked with sporopollenin biosynthesis and transport. Recently, many genes have been identified that are involved in tapetum formation in rice and Arabidopsis. Genetic mutation in PCD-associated genes could affect normal tapetal PCD, which finally leads to aborted pollen grains and male sterility in rice. In this review, we discuss the most recent research on rice tapetum development, including genomic, transcriptomic and proteomic studies. Furthermore, tapetal PCD, sporopollenin biosynthesis, ROS activity for tapetum function and its role in male reproductive development are discussed in detail. This will improve our understanding of the role of the tapetum in male fertility using rice as a model system, and provide information that can be applied in rice hybridization and that of other major crops.

The level and distribution of selected organochlorine pesticides in water of River Satluj Pakistan

The study was aimed to identify different environmental factors (selected organochlorine pesticides) affecting the river water of Satluj. River Sutlej is about 1400 kilometers long and its water is extensively used for irrigation in Punjab, located both in India and Pakistan, which was also a reason of dispute between both countries for its water share. The study area was divided into four zones, Sulemanki Zone, Islam Zone, Mailsi Syphone Zone and Panjnad Zone. Liquid Liquid Extraction (LLE) technique was used for the collected water samples followed by high performance liquid chromatography (HPLC) UV-Visible detector The current finding revealed that aldrin was not detected during summer period in water samples of SZ-1 (Sulemanki Barrage), SZ-2 and SZ-3 (Maisli Siphon) of the study area. Lindane and DDE were found more in the samples of sediments from the study area at SZ-4 ranging from 2.238-8.226 ppb and 4.234-6.876 ppb, respectively. Heaptachlor (in sediments) was found to be0.032-234 ppb only at SZ-4.Endosulfan concentrations in water (winter) at SZ-3 was 0.06 ppb and at SZ-4,it was 0.05 ppb; dieldrin in water (winter) at SZ-4 was 0.0314 ppb and heptachlor was detected at SZ-1 (0.0315 ppb) and SZ-2 (0.0310 ppb) in water during winter season, were reaching to the Maximum Concentrations Limits (MCL), while all other residues investigated were found below the MCLin all the compartments of the study area set by various agencies like WHO/FAO- Codex Alimenterious. Present findings revealed that although the organochlorine pesticides are banned for agricultural use in many countries, including Pakistan, their presence in various samples might be due to illegal use of these pesticides in the study area and its neighboring regions. The overall study area comprises of mainly urban, suburban and agricultural land being the largest cotton growing area of the country. There is a need to take serious steps to minimize water pollution caused by pesticides to achieve a healthy lifestyle.

Presence of selected organochlorine pesticides (OCPs) in sediments and biota of River Satluj, Pakistan: first report

Abstract In the developed countries, the use of OCPs (organochlorine pesticides) has been banned. However, in South Asia several of them are still in use. In Pakistan and India a constant addition of OCPs into the atmosphere has been indicated by various researchers. In this study levels of selected organochlorine pesticide residues were assessed in sediment and biota collected from four (4) water reservoirs (3 Barrages & 1 Siphon) on the River Satluj Pakistan, along 231 miles (372 km) of River stretch which was further divided into 12 sampling sites. It was aimed to find out the levels of organochlorine pesticide (OCPs) residues in sediments and from selected fish species (Labeo rohita, Wallagu attu, Cyprinus carpio) of the River Satluj Pakistan. The Organochlorine residues (seven pesticides) present in samples of sediments and biota were investigated through multi residue method, using Gas Chromatograph (GC-ECD).In the current study, the concentration of DDT, was investigated in Wallago attu (0.786-3.987 ppb), Labeo rohita (0.779-4.355 ppb) and Cyprinus carpio (1.234-5.654 ppb). DDE was also found in Cyprinus carpio (1.244-6.322 ppb), Wallag attu (0.877-4.221 ppb) and Labeo rohita (2.112-5.897 ppb). Aldrin was not observed in Labeo rohita and Wallago attu. Currently, lindane and DDE was found predominately high in the sediments of study area at SZ-4 (Panjnad Barrage) ranging (2.238-8.226 ppb) and (4.234-6.876 ppb), respectively. Heaptachlor was found only at SZ-4 (Panjnad Barrage) from the sediments with concentration ranging (0.032-234 ppb). In short all other residues investigated were found below the MCL (maximum concentration level) in all the compartments of the study area set by various agencies like WHO/FAO- Codex Alimenterious.

Trans-nasal high-flow dehumidified air in acute migraine headaches: A randomized controlled trial

BACKGROUND

Intranasal high flow of dehumidified (dry) air results in evaporative cooling of nasal passages. In this randomized clinical trial, we investigated the effect of dry gas induced nasal cooling on migraine headaches.

METHODS

In this single-blind study, acute migraineurs were randomized to either nasal high-flow dry oxygen, dry air, humidified oxygen or humidified air (control) at 15 L/min for 15 min. All gases were delivered at 37°C. Severity of headache and other migraine associated symptoms (International Classification for Headache Disorders, 3rd edition criteria) were recorded before and after therapy. The primary endpoint was change in pain scores, while changes in nausea, photosensitivity and sound sensitivity scores served as secondary endpoints. A linear regression model was employed to estimate the impact of individual treatment components and their individual interactions.

RESULTS

Fifty-one patients (48 ± 15 years of age, 82% women) were enrolled. When compared to the control arm (humidified air), all therapeutic arms showed a significantly greater reduction in pain scores (primary endpoint) at 2 h of therapy with dry oxygen (-1.6 [95% CI -2.3, -0.9]), dry air (-1.7 [95% CI -2.6, -0.7)]), and humidified oxygen (-2.3 [95% CI -3.5, -1.1]). A significantly greater reduction in 2-h photosensitivity scores was also noted in all therapeutic arms (-1.8 [95% CI -3.2, -0.4], dry oxygen; -1.7 [95% CI -2.9, -0.4], dry air; (-2.1 [95% CI -3.6, -0.6], humidified oxygen) as compared to controls. The presence of oxygen and dryness were independently associated with significant reductions in pain and photosensitivity scores. No adverse events were reported.

CONCLUSION

Trans-nasal high-flow dry gas therapy may have a role in reducing migraine associated pain.Clinical Trial registration: NCT04129567.

"Optimization of Surgical Resident Safety and Education During the COVID-19 Pandemic - Lessons Learned"

The COVID-19 pandemic has engendered rapid and significant changes in patient care. Within the realm of surgical training, the resultant reduction in clinical exposure and case volume jeopardizes the quality of surgical training. Thus, our general surgery residency program proceeded to develop a tailored approach to training that mitigates impact on resident surgical education and optimizes clinical exposure without compromising safety. Residents were engaged directly in planning efforts to craft a response to the pandemic. Following the elimination of elective cases, the in-house resident complement was effectively decreased to reduce unnecessary exposure, with a back-up pool to address unanticipated absences and needs. Personal protective equipment availability and supply, the greatest concern to residents, has remained adequate, while being utilized according to current guidelines. Interested residents were given the opportunity to work in designated COVID ICUs on a volunteer basis. With the decrease in operative volume and clinical duties, we shifted our educational focus to an intensive didactic schedule using a teleconferencing platform and targeted areas of weakness on prior in-service exams. We also highlighted critical COVID-19 literature in a weekly journal club to better understand this novel disease and its effect on surgical practice. The long-term impact of the COVID-19 pandemic on resident education remains to be seen. Success may be achieved with commitment to constant needs assessment in the changing landscape of healthcare with the goal of producing a skilled surgical workforce for public service.

The Post-Pipeline Headache: New Headaches Following Flow Diversion for Intracranial Aneurysm

OBJECTIVE

Flow diversion using devices such as the "pipeline" stent is now a common treatment for unruptured intracranial aneurysms. Though much is known about the efficacy of the device, less is reported regarding potential side effects. In this study, we report the frequency and characteristics of the "post-pipeline headache."

METHODS

We prospectively enrolled a cohort of 222 patients who underwent pipeline stenting for the treatment of intracranial aneurysm between 2015 and 2018. A follow-up telephone survey was conducted with a mean 21.6 months postprocedure evaluating postprocedure headaches and previous headache history. A post-pipeline headache was defined as a new headache or pain distinct from their prior headache syndrome. Information was collected regarding patient demographics, headache characteristics, headache history, and whether symptoms were ongoing. Logistic regression was used to determine factors associated with post-pipeline headache and the risk of long-term headache persistence.

RESULTS

Eighty-eight individuals were reached by phone for follow-up; 48 (55%) of whom reported a new headache postprocedure. Patients experiencing post-pipeline headache were more likely to be young (OR 0.9; 95% CI: 0.85-0.94) and have a history of prior headaches (OR 2.4, 95% CI: 1.02-5.81). Associated motor (OR 6.1; 95% CI: 1.19-31.47), cognitive (OR 7.0; 95% CI: 081-60.33), visual (OR 5.4; 95% CI: 1.05-27.89), and vestibular (OR 4.8; 95% CI: 1.14-20.23) symptoms were associated with ongoing headache.

CONCLUSIONS

Post-pipeline headache is common, particularly in younger individuals with prior headache history, and has distinctive features. Symptoms can remit over time; however, two-thirds experience ongoing headaches, particularly those with associated migrainous features.

Telemedicine in neurology

Purpose

While there is strong evidence supporting the importance of telemedicine in stroke, its role in other areas of neurology is not as clear. The goal of this review is to provide an overview of evidence-based data on the role of teleneurology in the care of patients with neurologic disorders other than stroke.

Recent findings

Studies across multiple specialties report noninferiority of evaluations by telemedicine compared with traditional, in-person evaluations in terms of patient and caregiver satisfaction. Evidence reports benefits in expediting care, increasing access, reducing cost, and improving diagnostic accuracy and health outcomes. However, many studies are limited, and gaps in knowledge remain.

Summary

Telemedicine use is expanding across the vast array of neurologic disorders. More studies are needed to validate and support its use.

Short Term Oral Methylergonovine Maleate Prophylaxis for Status Migrainosus. Case Series and Review of Literature

Background: Intravenous dihydroergotamine (DHE) is frequently used during inpatient hospitalizations or outpatient infusion therapies for 3-5 days in order to break the continuous cycle of status migrainosus. We tried a short term 7 days prophylaxis of oral methylergonovine after discharge in order to prevent status migrainosus relapse and extend the therapeutic benefit from IV DHE. Methods: Patients were diagnosed with status migrainosus in clinic setting based on the ICHD-III criteria. They received 1 mg IV DHE every 8 h along with metoclopramide for 3-5 days followed by methylergonovine maleate oral tablets as prophylaxis for 7 days post discharge. They were asked to maintain their headache diaries which included data on headache frequency and intensity. A post discharge follow up at 1 and 68 weeks was planned. Clinical improvement was defined as >50% decrease in frequency and intensity of headaches. Intensity was graded on verbal numerical rating scale (VNRS) with 10 being the worst possible pain. The institutes IRB and ethics committee exempted this study from review given that it had only 3 patients. Results: A total of 3 patients 25-45 years of age who benefited from IV DHE, consented to trial of Methylergonovine Maleate 0.4 mg oral tablets three times a day prophylaxis on the day of discharge for a period of 7 days. At 1 week post discharge, all of the 3 patients had reported sustained improvement with severity dropping from an average of 8/10 intensity to 3/10 on VNRS. The headaches frequency had dropped from daily to episodic in 2 of the 3 patients. At an average of 7 weeks post discharge, 2 out of the 3 patients had reported sustained benefit. The third patient relapsed to the pre-admission status migrainosus severity. One patient reported mild diarrhea and nausea but was still able to continue the drug for a week. Conclusion: Methylergonovine maleate after 3-5 days of IV DHE infusions may be a feasible treatment strategy for status migrainosus. This approach has the potential to prolonged the benefit of IV DHE and prevent relapse in to status migrainosus.

Expert Consensus on the Management of Adverse Events from EGFR Tyrosine Kinase Inhibitors in the UK

Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) such as gefitinib, erlotinib, and afatinib are standard-of-care for first-line treatment of EGFR-mutant advanced non-small cell lung cancer (NSCLC). These drugs have a proven benefit in terms of higher response rate, delaying progression and improvement of quality of life over palliative platinum-based chemotherapy. The most common adverse events (AEs) are gastrointestinal (GI) (diarrhoea and stomatitis/mucositis) and cutaneous (rash, dry skin and paronychia). These are usually mild, but if they become moderate or severe, they can have a negative impact on the patient’s quality of life (QOL) and lead to dose modifications or drug discontinuation. Appropriate management of AEs, including prophylactic measures, supportive medications, treatment delays and dose reductions, is essential. A consensus meeting of a UK-based multidisciplinary panel composed of medical and clinical oncologists with a special interest in lung cancer, dermatologists, gastroenterologists, lung cancer nurse specialists and oncology pharmacists was held to develop guidelines on prevention and management of cutaneous (rash, dry skin and paronychia) and GI (diarrhoea, stomatitis and mucositis) AEs associated with the administration of EGFR-TKIs. These guidelines detail supportive measures, treatment delays and dose reductions for EGFR-TKIs. Although the focus of the guidelines is to support healthcare professionals in UK clinical practice, it is anticipated that the management strategies proposed will also be applicable in non-UK settings.

Patent Foramen Ovale and Migraine: Closing the Debate--A Review

BACKGROUND

A link between patent foramen ovale (PFO) and migraine as well as the utility of closure of PFO and its effect on migraine have been subjects of debate. The present review is an effort to gather the available evidence on this topic and formulate recommendations.

METHODS

A systematic search of electronic databases (Medline, Embase, Cochrane Library) was performed. A separate search in associated reference lists of identified studies was done. Observational studies and clinical trials published in English using the International Headache Society criteria for diagnosis of migraine were included in the analysis. The search was performed in 3 categories: prevalence of migraine in patients with PFO, prevalence of PFO in migraine patients, and effect of PFO closure and its effect on migraine. The quality of evidence and strength of recommendations during review of these studies was analyzed.

RESULTS

About 14 observational studies with 2602 subjects who had PFO were identified. Migraine prevalence ranged from 16% to 64%. Another 20 studies reported 2444 patients with migraine; the prevalence of PFO ranged from 15% to 90%. About 20 observational studies (1194 patients) that examined the effect of PFO closure on migraine were identified. Resolution of migraine was reported in 10% to 83% of patients, improvement in 14% to 83%, no change in 1% to 54%, and worsening in 4% to 8%. The overall quality of these observational studies was poor. Finally, 3 randomized clinical trials included a total of 238 patients who underwent PFO closure compared with 234 patients in the control groups. All 3 trials failed to meet their primary end points defined as migraine resolution and greater than 50% reduction in migraine days at 1 year. In 2 of the clinical trials, there was some benefit noted in a small subset of migraine patients with aura, but the numbers were too small to extrapolate the findings to the general migraine population.

CONCLUSIONS

There is no good quality evidence to support a link between migraine and PFO. Closure of PFO for migraine prevention does not significantly reduce the intensity and severity of migraine. We do not recommend the routine use of this procedure in current practice.

Increased brain volume among good grade patients with intracerebral hemorrhage. Results from the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) study

BACKGROUND

We ascertained the occurrence of global cerebral edema manifesting as increased brain volume in subjects with intracerebral hemorrhage (ICH) and explored the relationship between subject characteristics and three month outcomes.

METHODS

A post-hoc analysis of a multicenter prospective study that recruited patients with ICH, elevated SBP ≥170 mm Hg, and Glasgow Coma Scale (GCS) score ≥8, who presented within 6 h of symptom onset was performed. Computed tomographic (CT) scans at baseline and 24 h, submitted to a core image laboratory, were analyzed to measure total brain, hematoma, and perihematoma edema volumes from baseline and 24-h CT scans using image analysis software. The increased brain volume was determined by subtracting the hematoma and perihematomal edema volumes from the total brain volume.

RESULTS

A total of 18 (44 %) of 41 subjects had increased brain volume that developed between initial CT scan and 24-h CT scan. The median increase in brain volume among the 18 subjects was 35 cc ranging from 0.12 to 296 cc. The median baseline GCS score was 15 in both groups of subjects who experienced increased brain volume and those who did not, and the median hematoma volume was 10.18 and 6.73, respectively. Three of the 18 subjects with increased brain volume underwent concurrent neurological deterioration and one subject died during hospitalization.

CONCLUSIONS

We found preliminary evidence of increased cerebral brain volume in subjects with good grade and small ICHs, which may be suggestive of global cerebral edema.

The natural history of "contrast stasis" within aneurysm after embolization

OBJECTIVE

Contrast stasis within residual aneurysm sac is sometimes seen after embolization of intracranial aneurysms and is thought to represent sluggish flow prone to thrombosis. We report the short- and intermediate-term angiographic outcomes of intra-aneurysmal contrast stasis following predominantly bioactive coil embolization procedures.

DESIGN/METHODS

Contrast stasis was identified by retrospective review of 153 consecutive patients treated at two centers with endovascular embolizations for intracranial aneurysms. Contrast stasis was defined by persistent opacification despite clearance of contrast from parent artery assessed during angiography at 3-5 frames/second. The contrast stasis were classified based on relative area and location visualized on dynamic angiographic images as small (5-15% of the total aneurysm), large (> 15%), or occurring only in the aneurysm neck by an independent reviewer.

RESULTS

There were 44 patients (23 women: mean age 54.3±12.5 years) who had contrast stasis; 36 patients had small and 8 had contrast stasis in the neck of the aneurysm. There were no patients with large contrast stasis. Of these 44 patients, 33 patients had a mean follow up angiogram in 269.5 days; 10 patients had no follow up. In 21 patients, (18 were small and 3 were in the neck) the area of contrast stasis had spontaneously thrombosed while in 7 patients there was no change in the contrast stasis. The remaining 5 patients had increase in area of contrast stasis and required re-embolization. Size of the contrast stasis (p= 0.02) was the only statistically significant factor although there was a trend dome to neck ratio > 2 (p= 0.16) and washout on the initial angiogram (p= 0.16) affecting the thrombosis of contrast stasis.

CONCLUSIONS

Most small contrast stasis following coil embolization procedures spontaneously thrombose and do not require further treatment. A small proportion of patients had increase in the area of intra-aneurysmal contrast stasis and required further treatment.

ABBREVIATIONS

MRAmagnetic resonance angiographyDSAdigital subtraction angiography.

Abstract TP422: Prevalence and Outcome of Post-Admission Global Brain Edema in Patients with Subarachnoid Hemorrhage

Introduction: Global cerebral edema (GCE) has been recognized in patients with aneurysmal subarachnoid hemorrhage (SAH). The pathophysiology and time course of GCE is not fully understood due to difficulties in quantitating GCE.

Objective: To quantitate GCE using advanced image analysis software on serial computed tomographic (CT) scans and to determine the temporal evolution in patients with SAH.

Methods: Thirty two consecutive SAH patients were identified and all the brain CT scans (n=96) which had been performed during the first week of admission were collected. Using Analyze software (AnalyzeDirect, Overland Park, KS), total brain volume was calculated in each CT scan after subtracting ventricular, gyral, and blood volumes. The difference of total brain volume between follow up and baseline CT scans calculated as GCE. The associations between GCE and patients’ demographic and clinical characteristics and hospital outcome were analyzed.

Results: A total of 12 (38%) of 32 patients had GCE at 24 hour CT scan. The number increased to 14 (44%) and 17 (53%) in 48 hour and one week follow up CT scans, respectively. Mean volume of GCE was 30 ml (95% CI: 0.9-59), 39 ml (95% CI: 24-54), and 33 ml (95% CI: 22-44) in 24 hour, 48 hour, and one week follow up CT scans, respectively. Although the mean age of patients with GCE at 24 hours was higher than patients without edema, the difference was not statistically significant (56 versus 49; p=0.2). Gender, race, Fisher, Hunt and Hess scores, and in-hospital mortality were not different between patients who developed or did not develop GCE. Patients with favorable outcome (modified Rankin Scale<3) had significantly higher volume of GCE in 24 hour follow up CT scan in comparison to patients with poor outcome (mean; 95% CI: 15.6 ml; -15.6-46.8 versus 7.5 ml; 1.7-13.3, p<.0001). The volumes of GCE in 48 hour and one week follow up were also higher in patients with favorable outcomes but the difference was not significant.

Conclusions: Our study demonstrated that GCE can occur in more than 50% of SAH patient during the first week with the rate of occurrence depending upon the time interval elapsed from admission.

Abstract WP308: Global Cerebral Edema Among Good Grade Patients with Intracerebral Hemorrhage. Results from the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) Study

INTRODUCTION: There is some evidence that injury and blood brain barrier disruption can be seen in regions distant from the hematoma in patients with intracerebral hemorrhage (ICH).

Objective: To ascertain the occurrence of global brain edema in patients with ICH and to explore the relationship between patient characteristics and three month outcomes.

Design: A post-hoc analysis of a traditional Phase I dose escalation multicenter prospective study recruited patients with ICH, elevated SBP≥170 mmHg, and Glasgow Coma Scale score ≥8, who presented within 6 hours of symptom onset. Computed tomographic (CT) scans at baseline, 24 hours, and any performed at later intervals were submitted to a core image laboratory. We were able to ascertain the presence and magnitude of global brain edema in 41 of 60 subjects with adequate CT scan resolution.

Settings: Emergency departments and intensive care units.

Primary Outcomes: We determined the total brain, hematoma, and perihematoma edema volumes from baseline, 24 hour, and 48 hour (if available) CT scans using image analysis software. The global brain edema volume was determined by subtracting the hematoma and perihematomal edema volumes from the total brain volume.

Results: A total of 18 (44%) of 41 patients had global cerebral edema that developed between initial CT scan and 24 hour CT scan. The median increase in brain volume among the 18 subjects was 35 cc ranging from 0.12 cc to 296 cc. The baseline GCS score (median 15 versus 15) and hematoma volume (mean±SD; 11.5±10.3 versus 13.9±17) were similar between subjects who experienced global cerebral edema and those who did not. The initial serum glucose was higher among subjects with global cerebral edema (150.5±74.3 mg/dl verus 119.7±34.6 mg/dl). Of the 18 patients who underwent a CT scan at 48 hours, 5 had either new or worsening global cerebral edema. Three of the 18 patients with global cerebral edema underwent neurological deterioration and 1 patient died during hospitalization.

Conclusions: Global cerebral edema can occur even in subjects with mild ICH. The pathophysiological basis and prognostic significance needs to be studied in future trials.

Abstract TP16: Occurrence Of Femoral Nerve Injury Among Patients Undergoing Transfemoral Percutaneous Catheterization Procedures In United States

Background: The proximity of femoral nerve to femoral artery renders it vulnerable to injury during transfemoral percutaneous catheterization procedures.

Objective: To determine the incidence of femoral nerve injury in patients undergoing cardiac catheterization in a nationally representative inpatient database.

Methods: We analyzed the data from Nationwide Inpatient Sample release annually. We pooled the data from 2002 through 2010 and identified patients using the ICD 9 CM procedures codes who underwent transfemoral percutaneous catheterization procedures. We subsequently identified occurrence of femoral nerve injury in this cohort of patients. Baseline characteristics, co-morbid conditions, in hospital complications and discharge outcomes (mortality, minimal disability, and moderate to severe disability) were compared between the two groups.

Results: Of the 14255031 patients who underwent percutaneous catheterization procedures, 508 (3 per 1000 procedures) developed femoral nerve injury. The incidence of femoral nerve injury was higher in women: 57% vs 39%%, p<0.004. Patients with coexisting congestive cardiac failure or coagulopathy had a non-significantly increased incidence of femoral nerve injury. There was no in-hospital mortality among patients who developed femoral nerve injury; however, the rate of discharge to nursing facility was higher in patients with femoral nerve injury: 19% vs 10%, p<0.001. After adjusting for age, gender , presence of congestive cardiac failure and coagulopathy femoral nerve injury during percutaneous catheterization procedures was independently associated with moderate to severe disability at discharge (Odds ratio, 2.3; 95% confidence interval, 1.4-3.8, p<0.001)

Conclusion: Femoral nerve injury is a rare complication during percutaneous catheterization procedures which may increase the likelihood of moderate to severe disability at discharge.

Abstract WP82: Effect Of Ultra-early Endovascular Intracranial Aneurysm Treatment On Rebleeding And Outcomes In Patients With Subarachnoid Hemorrhage

Background: The American Heart Association (AHA) recommends early aneurysm treatment without specifying any specific time intervals in patients with subarachnoid hemorrhage [SAH] [Bederson JB, et al.Stroke. 2009;40:994-1025].The AHA further requires documentation of proportion of SAH patients treated within 36 hours after admission as a Quality of Care metrics in Comprehensive Stroke Centers. [Leifer D, et al. Stroke. 2011; 42: 849-877]However, the definition of early treatment remains controversial.

Objective: To determine the rates of outcomes associated with ultra-early (<12 hours) and delayed (≥12 hours) intracranial aneurysm treatment after admission in patients with SAH.

Methods: We analyzed the data from 144 consecutive SAH patients from two academic centers who underwent endovascular treatment of ruptured intracranial aneurysms over a period of 4 years. Pre procedure rebleeding was defined by an acute neurological deterioration associated with new hemorrhage apparent on a computed tomographic (CT) scan or an increase in hemorrhage burden on a repeat CT scan. Favorable outcome was defined as modified Rankin score of ≤2 at discharge. Baseline characteristics and outcomes were compared between ultra-early (<12 hours) and delayed (≥12 hours) treatment using univariate analysis and by multivariate analysis after adjustment for confounders.

Results: Of the 144 SAH patients (mean age 54±SD: 13). Ninety nine ( 68% ) were women who underwent endovascular intracranial aneurysm treatment, (58%) underwent ultra-early aneurysm treatment. After adjusting for age, Hunt and Hess and Fisher grades, there was no significant difference in rates of favorable outcomes (odd ratio [OR] 0.6, 95% confidence interval [CI](0.2-1.3) or in-hospital mortality (OR 0.8, 95% CI (0.3-2.3) between the two groups. Pre procedure rebleeding was less likely to occur in the ultra-early treatment group (OR 0.1; 95% CI 0.02-0.4, p<0.002).

Conclusions: Ultra-early aneurysm treatment is possible due to the availability of endovascular treatment and appears to significantly reduce the pre-procedural rebleeding rates in patients with SAH.

Abstract WP65: Outcomes Of Thrombolytic Treatment For Acute Ischemic Stroke In Dialysis Dependant Patients In The United States

Objective: To determine the outcomes of dialysis dependant patients who suffered from ischemic stroke and were treated with IV thrombolytics in United States

Methods: We analyzed the data from Nationwide Inpatient Sample (NIS 2005-2008) for all thrombolytic treated patients presenting with acute ischemic stroke with or without dialysis dependence. Patients were identified using the ICD 9 CM codes. Baseline characteristics, inhospital complications including secondary intracerebral hemorrhage (ICH), DVT, UTI, sepsis, pneumonia, sepsis, pulmonary embolism and discharge outcomes (mortality, minimal disability, and moderate to severe disability) were compared between the groups.

Results: Of the 82142 patients with ischemic stroke who receive thrombolytic treatment, 1072 (1.3%) was dialysis dependent. Out of 4215004 patients with ischemic stroke who did not receive thrombolytic treatment, 61400 (1.4%) were dialyses dependent. Baseline characteristics were mainly age, sex, race, medical comorbidities including hypertension, diabetes mellitus, presence of congestive heart failure and chronic lung diseases. The ICH rates did not differ significantly between patients with ischemic stroke with or without dialysis who received thrombolytics (5.2% vs 6.1%)The in-hospital mortality rate was higher in dialysis dependent patients treated with thrombolytics. (22% vs 11%) (P <.0001). After adjusting for age and sex, and co morbidities, dialysis dependence was associated with higher rates of in-hospital mortality in patients treated with thrombolytics (odds ratio [OR], 2.47; 95% CI, 1.80-3.38 vs. odds ratio [OR], 3.06; 95% CI, 2.86-3.26).

Conclusions: The three fold higher odds of in-hospital mortality associated with administration of IV thrombolytics in dialysis dependant patients who present with acute ischemic stroke warrants a careful assessment of risk benefit ratio in this population.

Mandibular reconstruction using osteocutaneous radial forearm flap

OBJECTIVE

To describe the use of radial forearm osteocutaneous free flap in complex mandibular reconstruction.

STUDY DESIGN

A case series.

PLACE AND DURATION OF STUDY

Combined Military Hospital, Rawalpindi, from January 1998 to January 2008.

METHODOLOGY

Patients having a small bony component and a large soft tissue mandibular defect requiring reconstruction were selected. These defects include composite through-and-through defects of the cheek in the retromolar trigone, small lateral bony defects with large intra and extra oral soft tissue defects and small central bony defects with large extra oral tissue loss. Radial forearm osteocutaneous free flap was employed. Complications and graft acceptance were determined at follow-up.

RESULTS

Patients were followed-up for an average period of 28 months. Complications occurred in 8 patients. Wound infection and partial wound dehiscence were the most common complication observed in 3 patients. Non-union at recipient site was seen in 2 patients. Flap donor site healed uneventfully in all patients with no fractures at the donor site.

CONCLUSION

The radial forearm osteocutaneous flap covers oromandibular defects with large intra-oral and extra oral soft tissue losses. Lateral and anterior mandibular defects were reconstructed satisfactorily in our series.

Systolic blood pressure reduction and risk of acute renal injury in patients with intracerebral hemorrhage

BACKGROUND

Aggressive systolic blood pressure reduction may precipitate acute renal injury because of underlying hypertensive nephropathy in patients with intracerebral hemorrhage. The study's objective was to determine the rate and determinants of acute renal injury during acute hospitalization among subjects with intracerebral hemorrhage using a post hoc analysis of a multicenter prospective study.

METHODS

Subjects with intracerebral hemorrhage and elevated systolic blood pressure of 170 mm Hg or greater who presented within 6 hours of symptom onset and underwent treatment of acute hypertensive response and fluid management as per study and local protocols, respectively. Acute renal injury was defined post hoc using the criteria used in Acute Kidney Injury Network classifications within 72 hours of admission. Descriptive statistics and standard statistical tests were used to characterize and evaluate the effect of systolic blood pressure reduction parameters (relative to initial systolic blood pressure) and average maximum hourly dose of nicardipine on the occurrence of acute renal injury.

RESULTS

A total of 60 subjects were recruited (57% were men; mean age of 62.0 ± 15.1 years). Five subjects (9%) had stage I acute renal injury according to the Acute Kidney Injury Network criteria. None of the subjects had stage II or III acute renal injury. The serum creatinine course for the first 3 days suggested that the peak elevation of creatinine was seen at 18, 30, 57, 58, and 71 hours after baseline measurements in these 5 subjects, all of which except for the first one were beyond the protocol-specified treatment period. The incidences of neurologic deterioration and symptomatic hematoma expansion were significantly greater in the subjects with stage I renal impairment. The systolic blood pressure reduction parameters (in particular, the area under the curve depicting the 24-hour systolic blood pressure summary statistic) and the higher average maximum hourly nicardipine dose were strongly associated with stage I renal impairment.

CONCLUSIONS

Although acute renal injury is infrequent and mild among subjects with intracerebral hemorrhage undergoing systolic blood pressure reduction, a trend in association between systolic blood pressure reduction and renal impairment was observed in this small study. Therefore, it is important to carefully monitor the renal function when administering treatment to reduce systolic blood pressure in patients with intracerebral hemorrhage.

Association of serum glucose concentrations during acute hospitalization with hematoma expansion, perihematomal edema, and three month outcome among patients with intracerebral hemorrhage

BACKGROUND

There is some evidence that hyperglycemia increases the rate of poor outcomes in patients with intracerebral hemorrhage (ICH). We explored the relationship between various parameters of serum glucose concentrations measured during acute hospitalization and hematoma expansion, perihematomal edema, and three month outcome among subjects with ICH.

METHODS

A post-hoc analysis of a multicenter prospective study recruiting subjects with ICH and elevated systolic blood pressure (SBP) ≥170 mmHg who presented within 6 h of symptom onset was performed. The serum glucose concentration was measured repeatedly up to 5 times over 3 days after admission and change over time was characterized using a summary statistic by fitting the linear regression model for each subject. The admission glucose, glucose change between admission and 24 hour glucose concentration, and estimated parameters (slope and intercept) were entered in the logistic regression model separately to predict the functional outcome as measured by modified Rankin scale (mRS) at 90 days (0-3 vs. 4-6); hematoma expansion at 24 h (≤33 vs. >33%); and relative perihematomal edema expansion at 24 h (≤40 vs. >40%).

RESULTS

A total of 60 subjects were recruited (aged 62.0 ±15.1 years; 56.7% men). The mean of initial glucose concentration (±standard deviation) was 136.7 mg/dl (±58.1). Thirty-five out of 60 (58%) subjects had a declining glucose over time (negative slope). The risk of poor outcome (mRS 4-6) in those with increasing serum glucose levels was over two-fold relative to those who had declining serum glucose levels (RR = 2.64, 95% confidence interval [CI]: 1.03, 6.75). The RRs were 2.59 (95% CI: 1.27, 5.30) for hematoma expansion >33%; and 1.25 (95% CI: 0.73, 2.13) for relative edema expansion >40%.

CONCLUSIONS

Decline in serum glucose concentration correlated with reduction in proportion of subjects with hematoma expansion and poor clinical outcome. These results provide a justification for a randomized controlled clinical trial to evaluate the efficacy of aggressive serum glucose reduction in reducing death and disability among patients with ICH.

Comparison between angioplasty using compliant and noncompliant balloons for treatment of cerebral vasospasm associated with subarachnoid hemorrhage

BACKGROUND

Considerable controversy exists regarding the choice of balloon used for performing angioplasty as treatment of cerebral vasospasm associated with subarachnoid hemorrhage.

OBJECTIVE

To determine the impact of compliant and noncompliant balloons on angiographic and clinical outcomes among patients with subarachnoid hemorrhage-related cerebral vasospasm.

METHODS

Consecutive patients with cerebral vasospasm who underwent balloon angioplasty were included. Patient characteristics, rate of angiographic recurrence, and occurrence of cerebral infarcts in the affected vessel distribution were compared between arteries treated using different balloons.

RESULTS

A total of 30 patients underwent a first-time angioplasty using compliant (n = 34) or noncompliant (n = 51) balloons. At admission, patients were classified Hunt and Hess grade I to III (n = 20) and Hunt and Hess grade IV to V (n = 10). Fisher grades in patients were I (n = 1), II (n = 3), III (n = 20), and IV (n = 6). No significant differences in the rate of angiographic recurrence (32% vs 53%; P = .14), need for repeat angioplasty (21% vs 20%; P = .97), and occurrence of cerebral infarcts in the affected arterial distribution (21% vs 10% P = .39) were observed with compliant and noncompliant balloons, respectively. Independent of the balloon type, a significant reduction in the need for repeat angioplasty was observed when the initial angioplasty resulted in a normal or supranormal diameter compared with a subnormal diameter (63.5% vs 36.5%; P = .01).

CONCLUSION

No clear difference was observed between compliant and noncompliant balloons for therapeutic angioplasty in preventing angiographic recurrence or the need for repeat angioplasty in patients with subarachnoid hemorrhage-related cerebral vasospasm. An immediate normal or supranormal vessel diameter after the first-time angioplasty resulted in a significant reduction in the need for repeat angioplasty.

Abstract 3326: Reliability Of Hematoma Volume Calculation At Local Sites In The Setting Of A Multicenter Intracerebral Hemorrhage Clinical Trial

Background: In the clinical trials evaluating new therapies for acute management of intracerebral hemorrhage (ICH), rapid hematoma volume (HV) measurements from computed tomographic (CT) scan using previously described ‘ABC/2’ method at study sites is frequently required for either determining eligibility or stratification. However, the accuracy of this method by multiple observers using variable visual display modes is not known.

Method: We performed a post hoc analysis of a multicenter clinical trial that recruited ICH patients within 6 hours of symptom onset at ten sites in the United States. HV was measured by local site investigators to determine eligibility for enrollment (<60 cc) into the trial using the ABC/2 method (manual method) on the initial CT scan. CT scan images were subsequently sent to the core imaging laboratory for blinded computer based analysis of HV using ‘Medical Image Processing, Analysis, and Visualization (MIPAV)’ software (computer method). Paired t-test was used to identify any differences between the manual and the computer methods of HV measurements. Spearman’s correlation was used to study the agreement between the two methods.

Results: HV measurements by both the manual and the computer methods were available in 51 patients enrolled in the trial (mean±standard deviation [SD] age 62±15 years; 26 were women.) The mean±SD HV using as calculated by he computer method (14.6±15.3 mL) was not statistically different from the values calculated by the manual method (16.5±15 mL; p=0.6). Using Spearman’s correlation, there was a significant correlation between the two methods (rho 75%, p<0.01). Manual calculation under estimated the HV by an average of 1.5 mL in the lower 50 percentile of computer-calculated HV (<9.4 ml), while overestimated the HV in the upper 50 percentile by an average of 3.1 mL. None of these differences were statistically significant.

Conclusion: Rapid measurements at study sites for either determining eligibility or stratification provides reliable HV measurements despite measurements by multiple observers using variable visual CT scan display modes.

Abstract 3158: Presence of Underlying Metastatic Malignancy Increases the Risk of Intracerebal Hemorrhage after Endovascular Treatment of Acute Ischemic Stroke

Background: The effect of pre-existing malignancy with or without metastasis on angiographic and clinical success of endovascular treatment in acute ischemic stroke patients has not been previously studied. The procoagulant states in patients with pre-existing malignancy may lead to suboptimal results after endovascular treatment.

Objective: To determine the effect of underlying malignancy with or without metastasis on angiographic recanalization and clinical outcomes among acute ischemic stroke patients undergoing endovascular treatment.

Methods: We reviewed consecutive acute ischemic stroke patients treated with endovascular treatment over a 5-year period. Demographics characteristics, NIHSS score before and after the procedure, and discharge modified Rankin scale (mRS) were collected. An improvement of 1 point or more on the Qureshi grading scale was used to define angiographic recanallization. Primary malignancy and evidence of metastasis was obtained by individual chart review. We analyzed whether the presence of malignancy with or without metastasis was associated with angiographic recanalization, favorable clinical outcome, intra-cerebral hemorrhage (ICH), and length of stay (LOS) after age and NIHSS score adjustment.

Results: We analyzed 186 patients undergoing endovascular treatment, mean age + SD: 65+16 years, 100(54%) men, and mean admission NIHSS score ± SD: 15.3+8. Of these, 34 patients (18%) had underlying malignancy [20 were men] with 16 patients with documented metastatic disease. The mean age was higher in the malignancy group (72 versus 64 years, p=0.014). LOS was similar (11 days versus 9, p=NS). Adjusting for age and admission NIHSS score, regression analysis showed no impact from malignancy with or without metastatic disease on recanalization rate (odds ratio [OR]=0.5, p=NS) or discharge mRS (p=NS). A total of 37 patients developed ICH after endovascular therapy (38% and 18% in patients with or without underlying malignant disease, respectively). The presence of malignancy wih or without metastatic disease was associated with significantly higher ICH rates (OR=3, p=0.05) after endovascular treatment.

Conclusion: Underlying malignancy with or without metastasis in patients undergoing endovascular procedure for acute ischemic stroke is not associated with lower rates of angiographic recanalization or poor outcomes but increases the rates of post-procedural ICH by 3 fold.

Abstract 3688: Factors Associated with Individual Variations in Systolic Blood Pressure Responsive to Intravenous Antihypertensive Medication. Results from the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) Study

Introduction: There is considerable variation in blood pressure response to intravenous antihypertensive medication within patients with intracerebral hemorrhage (ICH).

Objective: To study the variation in systolic blood pressure (SBP) responsiveness to IV nicardipine infusion and effect of various baseline factors on such responsiveness. We also studied the effect of SBP responsiveness on hematoma expansion, perihematomal edema, and three month outcome among subjects with ICH.

Material and Methods: A post-hoc analysis of a multicenter prospective study recruiting subjects with ICH and elevated systolic blood pressure (SBP)≥170 mm Hg who presented within 6 hours of symptom onset was performed. Baseline SBP was calculated using the average of maximum and minimum SBP recorded prior to initiation of treatment. The SBP responsiveness was defined by the ratio between maximum change in SBP (difference between initial SBP and minimum SBP within the first hour) and maximum dose of nicardipine used in the first hour. This value was dichotomized at the median of 8.0, and we defined those with higher values to be responders and lower to be non-responders. We evaluated the effect of SBP reduction (relative to initial SBP) on: (1) hematoma expansion, defined as an increase in the volume of intraparenchymal hemorrhage of >33% measured on the 24-hour computed tomographic (CT) scan compared with the baseline CT scan; (2) relative edema expansion, defined as increase of >40% in edema volume to hematoma volume ratio between baseline and 24-hour CT scan; and (3) poor outcome defined by modified Rankin scale (mRS) of 4-6 at 3 months following treatment.

Results: A total of 56 subjects were treated with IV nicardipine (aged 62 ±15 years; 57% men). The initial mean serum glucose was higher, although not statistically significant, among the 29 responders compared with 27 poor responders (148±72 versus 125±41). There were no clinically meaningful differences in the patient’s age, initial hematoma volume, initial Glasgow Coma Scale score, serum creatinine, or previous use of antihypertensive medication between responders and poor responders. The mean maximum dose of IV nicardipine used was 6.9 (±4.2) mg/hr and mean maximum reduction of SBP of 55.4 (±32.0) mm Hg within the first hour. The risk of poor outcome (mRS 4-6) in the responder was 10% less relative to the non-responders (relative risk [RR]=0.90, 95% confidence interval [CI]: 0.48, 1.69; n=50). The RRs were 0.81 (95% CI: 0.34, 1.93; n=54) for hematoma expansion >33%; and 0.89 (95% CI: 0.52, 1.53; n=51) for relative edema expansion >40%.

Conclusions: There is considerable variation in blood pressure responsiveness to intravenous antihypertensive medication with potential prognostic implications. The variation in responsiveness does not appear to be influenced by other patient related factors that are known to influence functional outcome from ICH.

Abstract 3691: High Resolution Imaging of Brain Vessels at 7 Tesla

Introduction: Brain vessel wall MRI has the potentiality to visualize abnormal thickness and/or structure in intracranial vessel wall and could provide critical biomarkers to diagnose atherosclerosis.This, however, is a challenging task with MR images, given the small size of the vessels, variability in directions and their localization deep in the brain. A human 7T system was chosen to benefit from expected gains in Signal to Noise Ratio (SNR) and tissue contrast. Brain vessel wall MRI at 7T has been demonstrated, but the spatial resolution utilized so far (0.8mm isotropic) makes it difficult to assess the size of the brain vessel walls.

Methods: We describe the preliminary results of a multi modality approach that investigates both ex-vivo and in-vivo achievable cerebral vessel MR limits at 7 Tesla. Samples are imaged with the same sequence and on the same system used for in-vivo studies, facilitating sequence and parameter transfer. Both ex vivo and in vivo studies are conducted on a human 7T MR scanner, facilitating sequences and parameters transfer. Samples of circle of Willis (CW), excised from human cadaver brains were immersed in a perfluoropolyether fluid (no signal in proton MRI) and imaged with a 3D turbo spin echo sequence with TR/TE= 1500/13 ms, an acquisition time of 1h 30 min and 0.16 mm isotropic resolution. In vivo, healthy subjects were scanned with TR/TE/TI= 3000/22/1100 ms, acquisition time of 13min and a 0.64 mm isotropic resolution.

Results: Ex-vivo MR images of CW at high-resolution allow for clear distinction of vessel boundaries. The same sequence was used to acquire in vivo images at high resolution, imaging the brain vessel walls with the additional difficulty to suppress the CSF signal surrounding the brain vessels.

Conclusion: Preliminary results show the potentiality of this multi modality study to image brain vessel walls at 7T. Our goal is to ultimately provide rationales to optimize contrast and spatial resolution tradeoff in clinical protocols aiming at imaging intracerebral arteries within limits of scanning time acceptable for neurological patients. The next step will be to directly compare histopathology with ex-vivo MR images to accurately measure the wall thickness.

Abstract 3898: Predictors Of Admissions In Patients Presenting To Emergency Department With Transient Ischemic Attacks In United States- A National Survey

Background: The estimates of patients who present with transient ischemic attacks (TIA) in the emergency departments (ED) of United states and their disposition including factors that determine hospital admission are not well understood.

Objective: We used a nationally representative database to determine the rate and predictors of admission in TIA patients presenting to the ED.

Methods: We analyzed the data from National Emergency Department Sample (NEDS 2006-2007) for all patients presenting with primary diagnosis of TIAs in the United States. Samples were weighted to provide national estimates of TIA hospitalizations and identify factors that increase the odds of hospital admission including age, sex, type of insurance, hospital type (urban teaching, urban nonteaching and non urban). Multivariate logistic regression analysis was used to identify predictors of hospital admission.

Results: Of the total of 631750 patients presenting with TIA to the EDs in a period of two years in US, 41, 9447 (66.4%) were admitted to the hospital. In the multivariate analysis, independent factors associated with hospital admissions were women (odds ratio[OR] 1.042, 95% confidence interval [CI] 1.014-1.071, p =0.003) , Medicare insurance type (OR 0.82, 95% CI 0.88-0.93, p<0.0001), and urban non-teaching hospital ED (OR 0.825, 95% CI 0.778-0.875, p<0.0001).

Conclusion: Approximately 70% of all patients presenting with TIAs to the EDs within United States are admitted. Factors unrelated to patients condition such as insurance status and ED affiliated hospital type play an important role in the decision to admit TIA patients to the hospitals.

Short- and intermediate-term angiographic and clinical outcomes of patients with various grades of coil protrusions following embolization of intracranial aneurysms

BACKGROUND AND PURPOSE

An infrequent occurrence during endovascular treatment is protusion of detachable coils into the parent lumen with a subsequent thrombosis within in the parent vessel or embolic events. We report the short- and intermediate-term angiographic and clinical outcomes of patients who experience coil or loop protrusions and are managed with medical or additional endovascular treatments.

MATERIALS AND METHODS

The coil protrusions were identified by retrospective review of 256 consecutive patients treated at 3 centers with endovascular embolizations for intracranial aneurysms and subsequently categorized as grade I when a single loop or coil protruded into the parent vessel lumen less than half the parent artery diameter; grades II and III were assigned when a single coil or loop protruded more than half the parent artery diameter, respectively.

RESULTS

There were 19 patients with grade I (n = 9), grade II (n = 4), or grade III (n = 6) coil protrusions. Patients with active hemodynamic compromise (n = 6) had intracranial stents placed in addition to aspirin (indefinitely) and clopidogrel (range, 1-12 months; mean, 4.5 months) treatment. The remaining patients were placed on aspirin indefinitely. Complete aneurysm obliteration was achieved in all patients except in 3 in whom near-complete obliteration was achieved. Two patients had intraprocedural aneurysm ruptures, both of whom survived hospitalization. There were 4 deaths (4-21 days), all due to major strokes in different vascular distributions related to vasospasm (unrelated to the coil protrusion).

CONCLUSIONS

Management of coil protrusions with antiplatelet therapy and placement of stents (in selected patients) appears efficacious in preventing vessel thrombosis.

Aspirin treatment failure and the risk of recurrent stroke and death among patients with ischemic stroke

BACKGROUND

The prognostic value of occurrence of ischemic stroke in a patient despite aspirin treatment (aspirin treatment failure) is not known. Our objective was to determine if aspirin treatment failure predicts recurrent ischemic stroke and/or death.

METHODS

We performed a post-hoc analysis of data from the National Institute of Neurological Disorders and Stroke (NINDS) intravenous recombinant tissue plasminogen activator (rt-PA) trial and the Trial of ORG 10172 in Acute Stroke Treatment (TOAST). Multivariate analysis was used to calculate the odds ratio (OR) of recurrent stroke and recurrent stroke or death for aspirin treatment failure patients for the duration of available follow-up (3 months for TOAST patients; 12 months for NINDS rt-PA trial patients).

RESULTS

The rate of aspirin treatment failure was 40% and 35% among 1275 patients and 624 patients recruited in the TOAST and NINDS rt-PA trials, respectively. The risk of stroke and death at 3 months and 1 year was not higher among patients classified as aspirin treatment failures among the TOAST (OR 1.1; 95% confidence interval [CI] 0.8-1.6; P = .7) or NINDS rt-PA trial patients (OR 0.8; 95% CI 0.6-1.3; P = .4), respectively. In subgroup analysis, aspirin treatment failure was not found to be associated with recurrent stroke or with the combined endpoint of stroke and death among categories defined by etiologic subtype, including those with large artery atherosclerosis.

CONCLUSIONS

In a post-hoc analysis of 2 randomized ischemic stroke trials, aspirin treatment failure was not found to be associated with an increased risk of recurrent stroke or death.

Comparison of single versus multiple spontaneous extra- and/or intracranial arterial dissection

BACKGROUND

Anecdotal data suggest that approximately 20% of patients with a spontaneous extra- and/or intracranial arterial dissection have multiple arterial involvement. Limited data exist regarding the clinical and angiographic characteristics of patients with multiple arterial dissections. We compared the clinical and angiographic features of patients with spontaneous multiple extra- and/or intracranial arterial dissections with those who have a single arterial dissection.

METHODS

A retrospective chart review of the consecutive ischemic stroke database over a 7-year period, maintained at 2 institutions, was conducted to identify patients with spontaneous extra- and/or intracranial arterial dissection. The patients' clinical characteristics and angiographic features (including the artery affected, presence of pseudoaneurysm, fibromuscular dysplasia, and degree of stenosis) were analyzed.

RESULTS

A total of 76 patients were admitted with spontaneous extra- and/or intracranial arterial dissection; 46 dissections were confirmed with 4-vessel cerebral angiography. Multiple arterial dissections were found in a total of 10 (22%) patients. Involvement of multiple arteries was more prevalent in the young, when compared to a single spontaneous arterial dissection (7 [70%] in patients <45 years of age v 11 [31%]; P = .03). Patients with multiple arterial dissections had a higher proportion of pseudoaneurysms (9 [90%] v 11 [31%]; P = .001), a higher prevalence of underlying fibromuscular dysplasia (3 [30%] v 3 [8%]; P = .11), and were more likely to involve the posterior circulation (P < .0001).

CONCLUSIONS

The presence of multiple, simultaneous spontaneous extra- and/or intracranial arterial dissections must be considered when a single spontaneous arterial dissection is identified.

Clinical outcome of patients with acute posterior circulation stroke and bilateral vertebral artery occlusion

BACKGROUND AND INTRODUCTION

Patients presenting with posterior circulation acute ischemic events are occasionally noted to have occlusion of bilateral vertebral arteries with basilar artery blood flow entirely dependent from the anterior circulation. There is limited data about prognosis of such patients in literature.

METHODS

Patients with acute posterior circulation ischemic stroke and bilateral vertebral artery occlusion (including contra-lateral hypoplastic vertebral artery without contribution to the basilar artery system) were identified prospectively from two academic centers. Data including clinical presentation, medical management, angiographic findings, recurrent events and outcome were collected and reported.

RESULTS

A total of 4 patients presenting with acute ischemic events in the posterior circulation were identified to have bilateral vertebral artery occlusion at our center. One additional patient had a vertebral artery occlusion and a contra-lateral hypoplastic vertebral artery. In the functional evaluation of the blood flow with catheter angiography, the basilar artery was filling from the anterior circulation, with no antegrade flow from bilateral vertebral arteries injection in all 5 patients. Patients were treated with anti-platelets (n=4) or started on anti-coagulation after failing anti-platelet therapy (n=2). All patients had recurrent ischemic stroke with new ischemic lesions proven by diffusion weighted images on MRI within 2 to 70 days after the initial event.

CONCLUSION

Patients with acute posterior circulation ischemic stroke and bilateral vertebral artery occlusion are at high risk of having early recurrent ischemic events. Reestablishment of the antegrade vertebro-basilar blood flow through endovascular re-canalization might be an option to decrease stroke recurrence in selected patients with acute posterior circulation stroke and bilateral vertebral artery occlusion.

High Risk of Recurrent Ischemic Events Among Patients With Deferred Intracranial Angioplasty and Stent Placement for Symptomatic Intracranial Atherosclerosis

BACKGROUND:

Intracranial angioplasty with or without stent placement has been performed to treat patients with recurrent cerebral ischemic events despite best medical therapy or those with high-grade stenosis.

OBJECTIVE:

To evaluate early recurrent stroke/transient ischemic attack rates in a cohort of patients with symptomatic &gt;50% intracranial stenosis in whom intracranial angioplasty and stent placement was initially deferred.

METHODS:

All patients presenting to 2 academic hospitals with symptomatic intracranial disease between 2006 and 2008 who underwent catheter angiography were identified. Patients with complete intracranial occlusion or stenosis less than 50% stenosis were excluded (n = 14).

RESULTS:

Thirty-one patients met the study criteria. Sixteen (52%) patients were on antiplatelet medications at the time of the initial event, and 2 patients were also on anticoagulant medications. Six patients (19%) underwent intracranial angioplasty and/or stent placement with their initial diagnostic angiogram. Twenty-five patients (81%) had endovascular treatment deferred for best medical treatment in the interim period. Among the 25 patients who were kept on medical management, 14 (56%) were readmitted with recurrent ischemic events in the distribution of the target artery within a median of 28 days (range, 1-243 days). Recurrent events occurred within 1 week in 8 (57%) patients, between 7 days and 1 month in 4 (29%) patients, 1 to 3 months in 1 (7%) patient, and after 3 months in 1 (7%) patient. Recurrent ischemic events were observed in all 5 patients with basilar artery stenosis and in 13 of 17 patients with severity of stenosis ≥70%.

CONCLUSION:

A high rate of recurrent ischemic events was observed among patients in whom endovascular treatment was deferred, particularly those with basilar artery stenosis and those with high-grade stenosis. This information would be beneficial in decision making for timing of the endovascular treatment among patients with symptomatic intracranial stenosis.

Impact of International Subarachnoid Aneurysm Trial results on treatment of ruptured intracranial aneurysms in the United States

Object

The utilization of endovascular treatment for ruptured intracranial aneurysms is expected to change since the publication of the International Subarachnoid Aneurysm Trial (ISAT) in 2002. The authors performed this analysis to determine the impact of ISAT results on treatment selection for ruptured intracranial aneurysms and associated in-hospital outcomes using nationally representative data.

Methods

We determined the national estimates of treatments used for ruptured intracranial aneurysms and associated in-hospital outcomes, length of stay, mortality, and cost incurred using the Nationwide Inpatient Survey (NIS) data. The NIS is the largest all-payer inpatient care database in the US and contains data from 986 hospitals approximating a 20% stratified sample of US hospitals. All the variables pertaining to hospitalization were compared between 2000–2002 and 2004–2006, and in-hospital outcomes were analyzed using multivariate analysis.

Results

In the 3-year periods prior to and after the ISAT, there were 70,637 and 77,352 admissions for ruptured intracranial aneurysms, respectively. There was a significant increase in endovascular treatment after publication of the ISAT (trend test, p < 0.0001) The in-hospital mortality for ruptured intracranial aneurysm admissions decreased from 27% to 24% (odds ratio [OR] 0.89, 95% CI 0.83–0.96, p = 0.003) after the publication of the ISAT. The cost of hospitalization after adjusting for procedures practices was not significantly higher after the publication of the ISAT ($21,437 vs $22,817, p < 0.89), but cost of hospitalization was higher in the post-ISAT period for patients undergoing endovascular procedure.

Conclusions

The results of the ISAT have been associated with a prominent change in practice patterns related to the treatment of ruptured aneurysms. The cost of hospitalization has increased and the mortality has decreased, presumably due to a larger proportion of patients receiving any treatment and endovascular treatment.

Intracranial angioplasty and/or stent placement in octogenarians is associated with a threefold greater risk of periprocedural stroke or death

PURPOSE

To compare the clinical and angiographic outcomes of endovascular treatment of symptomatic intracranial stenosis between octogenarian and younger patients.

METHODS

Data for 244 consecutive patients (173 men; mean age 61.6 years) who underwent angioplasty and/or stenting for intracranial atherosclerotic disease at 5 specialized centers were pooled. Baseline, 30-day, and follow-up clinical and angiographic information were collected. Rates of clinical and angiographic endpoints were compared between patients >or=80 years old versus those <80 years.

RESULTS

Patients >or=80 years (n = 15) were more likely to be hypertensive (87% versus 69%) and have underlying coronary artery disease (73% versus 36%, p<0.05) compared to younger patients (n = 229). The rate of periprocedural stroke and/or death was 3-fold higher among patients aged >or=80 years compared with those <80 years (20% versus 7%, p = 0.11). No recurrent stroke or death (excluding periprocedural events) was observed during follow-up in the octogenarian group. In patients who had follow-up angiography, a similar rate of >or=50% restenosis was observed among patients aged >or=80 years and those aged <80 years (25% versus 29%, p>0.1).

CONCLUSION

The 3-fold higher periprocedural death and/or stroke rate suggests cautious use of intracranial angioplasty and/or stent placement in octogenarians.

Low patient enrollment sites in multicenter randomized clinical trials of cerebrovascular diseases: associated factors and impact on trial outcomes

Wide variability in patient enrollment among participating sites is a common phenomenon in multicenter trials. We examined stroke trial-related factors associated with the proportion of sites with low patient enrollment and the effect of these low-enrollment sites on trial outcome. We identified efficacy clinical trials enrolling patients with cerebrovascular diseases between 1980 and 2008 using an electronic database. The trials included in our analyses were multicenter randomized controlled trials (RCTs) comparing efficacy endpoints between two or more treatment groups and having >5 sites. Sites enrolling <10 patients or <2% of total trial patients were defined as low- enrollment sites. Trials were classified into tertiles based on the proportion of low-enrollment sites. Factors associated with trials that could be ascertained through a systematic review of published data were identified and examined. The association between low enrollment and a conclusive trial designation (defined by the ability to reject the primary null hypothesis either at or before target enrollment or demonstrate equivalence/noninferiority with adequate statistical power, depending on the initial design) was assessed using a multivariate logistic regression model. We identified 51 trials that met the inclusion criteria and provided information regarding patients enrolled per center. A total of 3059 participating centers enrolled a total of 53,742 trial participants; 78% of the participating sites enrolled <2% of trial participants. Trials enrolling acute stroke patients (within 24 hours of symptom onset) or those evaluating endovascular/surgical intervention had a higher proportion of low-enrollment sites (<10 patients per site). Studies with a higher proportion of low-enrollment sites were more likely to target acute stroke patients and less likely to randomize ≥1000 patients, use general efficacy endpoints, and stratify by site. There was no association between the studies with a higher proportion of low-enrollment sites and designation as a conclusive trial. A better understanding of factors associated with low-enrollment sites in clinical trials and the impact on a trial's ability to demonstrate conclusive outcomes may lead to strategies to make trial enrollments more efficient and cost-effective.