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Journal of Clinical Neuroscience :... Jun 2024Aneurysms of the posterior cerebral circulation constitute a burdensome condition with high mortality and morbidity. In the modern era, there has been a trend toward...
When microsurgery becomes the only lifesaving resource: An institutional experience treating patients from low-income backgrounds affected by posterior circulation brain aneurysms.
BACKGROUND AND OBJECTIVE
Aneurysms of the posterior cerebral circulation constitute a burdensome condition with high mortality and morbidity. In the modern era, there has been a trend toward favoring an endovascular approach over microsurgery for aneurysm cases. Nevertheless, this transition has yet to be mirrored in low-to-middle-income countries where endovascular therapy may not be widely available. Herein, we aim to illustrate our experience treating these challenging conditions in patients from low-income backgrounds and discuss the relevance of the clinical setting in the treatment decision.
METHODS
The authors conducted a retrospective review of the health records of patients who received microsurgical treatment for aneurysms in the posterior circulation, including the basilar artery (BA), posterior cerebral artery (PCA), and posterior inferior cerebellar artery (PICA) in an institution providing treatment to people of low-income backgrounds. Epidemiological data, microsurgical technique, and neurological function were retrieved and analyzed.
RESULTS
Surgical clipping was employed for 12 patients (75% female) harboring 15 aneurysms (87% in the posterior circulation and 62% ruptured at presentation). Aneurysms were predominately located in the BA (69%), followed by the PCA (15%) and PICA (15%). Among neurological complications, 25% of patients developed oculomotor nerve palsy. The mortality rate was 17% owing to complications such as cerebral vasospasm, infarction, and severe intracranial hypertension. At the 6-month follow-up, 90% of patients had a good clinical outcome (modified Rankin scale scores of 0-2).
CONCLUSION
The present case series illustrates the manifest role of microsurgical techniques for posterior circulation aneurysms, particularly in a scenario where endovascular techniques are not easily accessible. Importantly, this clinical setting pressure could exhort trainees to strive for microsurgical mastery and gain a competitive advantage.
PubMed: 38943907
DOI: 10.1016/j.jocn.2024.06.014 -
Alternative Therapies in Health and... Jun 2024Cerebral aneurysm can rupture a blood vessel and cause bleeding in the brain. Microsurgical clipping of the tumor neck has been reported to be effective in treating...
Clinical Efficacy of Early Microsurgical Clipping of Tumor Neck in the Treatment of Cerebral Aneurysm Rupture and Bleeding and Its Impact on Oxidative Stress Response and Prognosis of Patients.
BACKGROUND
Cerebral aneurysm can rupture a blood vessel and cause bleeding in the brain. Microsurgical clipping of the tumor neck has been reported to be effective in treating cerebral aneurysm rupture and bleeding.
OBJECTIVE
This research attempted to clarify the clinical efficacy of early microsurgical clipping of tumor neck for treating cerebral aneurysm rupture and bleeding, and its impact on prognosis of patients.
DESIGN
This was a retrospective study.
SETTING
This study was carried out in the Department of Neurosurgery, The Yancheng School of Clinical Medicine of Nanjing Medical University, Yancheng Third People's Hospital.
UNLABELLED
One hundred patients with cerebral aneurysm rupture and bleeding patients aged from 23 to 70 years old, and diagnosed with CA rupture and bleeding through imaging examinations such as CT angiography (CTA) and digital subtraction angiography (DSA), and there was spontaneous subarachnoid hemorrhage treated in our hospital from November 2020 to November 2022 were selected and divided into an experimental group (n=25) and a control group (n=25) according to surgical time.
INTERVENTIONS
All patients underwent microsurgical clipping of the tumor neck for therapy. Under microscope monitoring, the temporal and frontal lobes of the patient were separated, and the tumor body was selected in the internal carotid artery and cerebral artery. After the tumor neck of the patient was exposed, the artery supplying blood was clipped and appropriate tumor clips were selected. The control group chose to undergo surgery 72 h after the onset of cerebral aneurysm rupture and bleeding, while the experimental group chose to undergo complete surgery within 72 h after the onset of cerebral aneurysm rupture and bleeding. After surgery, targeted treatment were given to patients in 2 groups based on their physical condition, such as dehydration to reduce intracranial pressure, anti-vasospasm, anti-infection, monitoring of neurological changes, and monitoring of vital signs. Cerebral angiography should also be performed for reexamination.
PRIMARY OUTCOME MEASURES
(1) incidence of complications (2) cognitive function scores assessed by Montreal Cognitive Assessment (MoCA) (3) prognosis assessed by Glasgow Outcome Scale (GOS) (4) surgical indicators (5) oxidative stress response and (6) quality of life assessed by short form 36 health survey questionnaire (SF-36).
RESULTS
Compared to the control group, the incidence of complications in the experimental group exhibited depletion (24.0% vs 8.0%) (P < .05), the prognosis in the experimental group exhibited elevation [(2.23±0.45) points vs (4.12±0.3) points] (P < .05), the hospitalization time in the experimental group exhibited depletion [(15.69±1.21) d vs (11.31±0.65) d] (P < .05), the nomination, abstraction, language, orientation, attention, delayed recall and visual and executive function scores and total scores in experimental group exhibited elevation [(2.69±0.52 points, 2.07±0.63 points, 3.02±0.44 points, 2.45±0.51 points, 3.12±0.36 points, 2.14±0.75 points, 3.15±0.64 points and 17.24±2.15 points) vs (4.25±0.65 points, 3.88±1.08 points, 5.03±0.73 points, 3.34±0.72 points, 4.05±0.66 points, 3.85±0.33 points, 5.02±1.04 points and 26.89±1.33 points)] (P < .05), serum levels of oxidative stress-related indicators in the experimental group exhibited depletion [(462.14±48.47 ng/mL, 281.14±36.44 ng/mL and 1.62±0.12 nmol/mL) vs (365.58±44.56 ng/mL, 201.51±34.47 ng/mL and 1.15±0.1 nmol/mL)](P < .05) and the quality of life in experimental group exhibited elevation [(73.65±7.43 points, 72.24±7.23 points, 73.25±7.36 points, 70.24±7.05 points and 72.16±7.25 points) vs (81.25±8.14 points, 80.87±8.09 points, 81.43±8.15 points, 80.57±8.07 points and 81.32±8.14 points)] (P < .05).
CONCLUSION
Early microsurgical clipping of the tumor neck can downregulate risk of complications and cognitive impairment of cerebral aneurysm rupture and bleeding patients, which is worthy for clinical application.
PubMed: 38940784
DOI: No ID Found -
Scientific Reports Jun 2024Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid haemorrhage (aSAH) is a singular pathological entity necessitating early diagnostic approaches and both...
Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid haemorrhage (aSAH) is a singular pathological entity necessitating early diagnostic approaches and both prophylactic and curative interventions. This retrospective before-after study investigates the effects of a management strategy integrating perfusion computed tomography (CTP), vigilant clinical monitoring and standardized systemic administration of milrinone on the occurrence of delayed cerebral infarction (DCIn). The period included 277 patients, and the one 453. There was a higher prevalence of Modified Fisher score III/IV and more frequent diagnosis of vasospasm in the period. Conversely, the occurrence of DCIn was reduced with the management strategy (adjusted OR 0.48, 95% CI [0.26; 0.84]). Notably, delayed ischemic neurologic deficits were less prevalent at the time of vasospasm diagnosis (24 vs 11%, ), suggesting that CTP facilitated early detection. In patients diagnosed with vasospasm, intravenous milrinone was more frequently administered (80 vs 54%, ) and associated with superior hemodynamics. The present study from a large cohort of aSAH patients suggests, for one part, the interest of CTP in early diagnosis of vasospasm and DCI, and for the other the efficacy of CT perfusion-guided systemic administration of milrinone in both preventing and treating DCIn.
Topics: Humans; Subarachnoid Hemorrhage; Milrinone; Male; Female; Middle Aged; Cerebral Infarction; Retrospective Studies; Tomography, X-Ray Computed; Aged; Vasospasm, Intracranial; Adult; Administration, Intravenous
PubMed: 38937568
DOI: 10.1038/s41598-024-65706-w -
Neurologic Clinics Aug 2024Major advances in neurocritical care and the modalities used to treat aneurysms have led to improvement in the outlook of patients with aneurysmal subarachnoid... (Review)
Review
Major advances in neurocritical care and the modalities used to treat aneurysms have led to improvement in the outlook of patients with aneurysmal subarachnoid hemorrhage. Yet, several knowledge gaps remain widely open. Variability in practices stems from the lack of solid evidence to guide management, which recent guidelines from professional organizations aim to mitigate. In this article, the authors review some of these gaps in knowledge, highlight important messages from recent management guidelines, emphasize aspects of our practice that we consider particularly useful to optimize patient outcomes, and suggest future areas of research.
Topics: Subarachnoid Hemorrhage; Humans; Disease Management
PubMed: 38937037
DOI: 10.1016/j.ncl.2024.03.005 -
Biomacromolecules Jun 2024Microvascular surgery plays a crucial role in reconnecting micrometer-scale vessel ends. Suturing remains the gold standard technique for small vessels; however,...
Microvascular surgery plays a crucial role in reconnecting micrometer-scale vessel ends. Suturing remains the gold standard technique for small vessels; however, suturing the collapsed lumen of microvessels is challenging and time-consuming, with the risk of misplaced sutures leading to failure. Although multiple solutions have been reported, the emphasis has predominantly been on resolving challenges related to arteries rather than veins, and none has proven superior. In this study, we introduce an innovative solution to address these challenges through the development of an injectable lidocaine-loaded pectin hydrogel by using computational and experimental methods. To understand the extent of interactions between the drug and the pectin chain, molecular dynamics (MD) simulations and quantum mechanics (QM) calculations were conducted in the first step of the research. Then, a series of experimental studies were designed to prepare lidocaine-loaded injectable pectin-based hydrogels, and their characterization was performed by using Fourier transform infrared spectroscopy (FT-IR), scanning electron microscopy (SEM), and rheological analysis. After all the results were evaluated, the drug-loaded pectin-based hydrogel exhibiting self-healing properties was selected as a potential candidate for studies to determine its performance during operation. In this context, the hydrogel was injected into the divided vessel ends and perivascular area, allowing for direct suturing through the gel matrix. While our hydrogel effectively prevented vasospasm and facilitated micro- and supermicro-vascular anastomoses, it was noted that it did not cause significant changes in late-stage imaging and histopathological analysis up to 6 months. We strongly believe that pectin-based hydrogel potentially enhanced microlevel arterial, lymphatic, and particularly venous anastomoses.
PubMed: 38934558
DOI: 10.1021/acs.biomac.4c00102 -
European Heart Journal. Case Reports Jun 2024Type I variant Kounis syndrome is characterized by coronary spasm following an allergic or anaphylactic reaction. Coronary spasm is also recognized as a contributing...
An unusual case of two acute coronary syndrome episodes caused by allergic and non-allergic coronary artery dissection with potential coronary vasospasm association: a case report.
BACKGROUND
Type I variant Kounis syndrome is characterized by coronary spasm following an allergic or anaphylactic reaction. Coronary spasm is also recognized as a contributing factor in spontaneous coronary artery dissection (SCAD).
CASE SUMMARY
A 46-year-old woman presented to the emergency room with a chief complaint of chest discomfort following the ingestion of a steamed bun. A marked decrease in systolic blood pressure and a prominent rash on her forearms and groin suggested anaphylactic shock. Upon stabilization of vital signs, acute coronary syndrome (ACS) was suspected based on electrocardiogram findings and symptoms, prompting an emergency coronary angiography (CAG). The CAG revealed severe stenosis with coronary artery dissection in the right coronary artery (RCA), and a stent implantation was performed. Given the suspicion of type I variant Kounis syndrome, a spasm provocation test was performed, yielding a positive result. Six years later, she experienced chest discomfort while sleeping and was admitted to our emergency department. An electrocardiogram showed ST-segment elevation in leads II, III, and aVF. An emergency CAG identified a severely stenotic lesion with coronary artery dissection in the RCA, leading to a diagnosis of SCAD. Direct stenting was performed at the stenotic site. The patient was discharged following intensification of medication.
DISCUSSION
This report describes a rare case of a middle-aged woman with two episodes of ACS caused by both allergic and non-allergic coronary artery dissection. These episodes suggest that a shared underlying coronary vasospasm in both conditions may be a common trigger for coronary artery dissection.
PubMed: 38933366
DOI: 10.1093/ehjcr/ytae288 -
Internal Medicine (Tokyo, Japan) Jun 2024
PubMed: 38925970
DOI: 10.2169/internalmedicine.3886-24 -
Journal of Clinical Neuroscience :... Jun 2024Aneurysmal subarachnoid hemorrhage (aSAH) is a severe event often complicated by cerebral vasospasm (CV). This study aimed to assess the efficacy and safety of... (Review)
Review
BACKGROUND
Aneurysmal subarachnoid hemorrhage (aSAH) is a severe event often complicated by cerebral vasospasm (CV). This study aimed to assess the efficacy and safety of clazosentan, an endothelin receptor antagonist, in reducing CV, delayed cerebral ischemia (DCI), and the need for rescue therapy in aSAH patients, while evaluating its impact on functional outcomes and mortality.
METHODS
We conducted a literature search across multiple databases to identify relevant studies evaluating the effects of clazosentan in aSAH patients. Both cohort studies and randomized controlled trials (RCTs) were included. The primary outcomes were vasospasm incidence, moderate to severe vasospasm, DCI, and the need for rescue therapy. Secondary outcomes included functional outcomes, mortality, and adverse events. The data were pooled as Risk ratios (R/R) with 95 % confidence intervals (CI) using RevMan 5.4 software.
RESULTS
A total of 11 studies, including 10 published and one unpublished, comprising 8,469 patients were included in the meta-analysis. Clazosentan significantly reduced the incidence of vasospasm (R/R = 0.49: 0.34-0.70), moderate to severe vasospasm (R/R = 0.53: 0.46-0.61), DCI (R/R = 0.70: 0.59-0.82), and the need for rescue therapy (R/R = 0.65: 0.52-0.83) compared to placebo. However, no significant improvement in functional outcomes or mortality rates was observed. Clazosentan was associated with increased rates of pulmonary adverse events (R/R = 1.89: 1.64-2.18), hypotension (R/R = 2.47: 1.79-3.42), and anemia (R/R = 1.49: 1.23-1.79) but no increased risk of hepatobiliary adverse events or cerebral hemorrhage.
CONCLUSIONS
Clazosentan demonstrates efficacy in reducing vasospasm, moderate to severe vasospasm, DCI, and the need for rescue therapy in aSAH patients, but does not significantly improve functional outcomes or mortality rates. While associated with specific adverse events, clazosentan may be a valuable adjunctive therapy in the management of aSAH, particularly in a high-risk population for vasospasm.
PubMed: 38924824
DOI: 10.1016/j.jocn.2024.06.019 -
Journal of Clinical Pharmacology Jun 2024Subarachnoid hemorrhage (SAH) is a devastating type of stroke, leading to high mortality and morbidity rates. Cerebral vasospasm and delayed cerebral ischemia (DCI) are...
Subarachnoid hemorrhage (SAH) is a devastating type of stroke, leading to high mortality and morbidity rates. Cerebral vasospasm and delayed cerebral ischemia (DCI) are common complications following SAH that contribute significantly to the poor outcomes observed in these patients. Intrathecal (IT) nicardipine delivered via an existing external ventricular drain is an off-label intervention that has been shown to be correlated with reduced DCI and improved patient outcomes. The current study aims to characterize the population pharmacokinetic (popPK) properties of intermittent IT nicardipine. Following informed consent, serial cerebrospinal fluid (CSF) samples were obtained from 16 SAH patients (50.4 ± 9.3 years old; 13 females) treated with IT nicardipine every 6 h (q6h, n = 8) or every 8 h (q8h, n = 8) for an average of 72 ± 21 doses. High-performance liquid chromatography was used to quantify CSF concentration from each sample. Our popPK analysis showed that the CSF pharmacokinetics of IT nicardipine in the cohort was adequately described by a two-compartment model with a lag time. Model parameter estimates were reliable (relative standard error <50%). Intracranial pressure influenced both the total clearance and the central volume of nicardipine (i.e., negative correlation, P <-.001). Calculated PK parameters were similar between q6h and q8h dosing regimens. Despite a small cohort of SAH patients, we successfully developed a popPK model to describe the nicardipine disposition kinetics in the CSF following IT administration. These findings may help inform future clinical trials designed to examine the optimal dosing of IT nicardipine.
PubMed: 38923537
DOI: 10.1002/jcph.2488 -
Cureus Jun 2024Takotsubo cardiomyopathy (TC) mimics myocardial infarction with symptoms like chest pain, electrocardiogram (EKG) changes, and elevated troponin levels, although it...
Case Report and Literature Review of an Anomalous Course of the Left Main Coronary Artery (LMCA) Arising From the Right Sinus of Valsalva (RSV) Presenting as Takotsubo Cardiomyopathy.
Takotsubo cardiomyopathy (TC) mimics myocardial infarction with symptoms like chest pain, electrocardiogram (EKG) changes, and elevated troponin levels, although it typically features normal coronary arteries upon angiography. While often asymptomatic, coronary artery anomalies (CAAs) can cause intermittent vasospasm and endothelial dysfunction, potentially inducing TC. We report the case of a 74-year-old female with a history of hypertension, hyperlipidemia, and peripheral artery disease, who presented with sudden onset chest pain. Initial EKG and elevated troponin suggested myocardial infarction. However, coronary angiography revealed an anomalous left main coronary artery (LMCA) originating from the right coronary artery (RCA), with no significant stenosis. Subsequent transthoracic echocardiography indicated TC, with the left ventricular ejection fraction improving from 35-40% to 60-65% within days. Cardiac computed tomography angiography (CCTA) revealed that the anomalous LMCA originated from the common trunk at the right sinus of Valsalva (RSV), which further continued as a large, dominant RCA. The LMCA branched into a small to moderate left anterior descending artery (LAD) and a non-dominant left circumflex artery (LCx). The LMCA followed a prepulmonic/anterior course, while the LCx took an interarterial course between the aorta and pulmonary artery. The patient was referred for further surgical evaluation. We conclude that the CAA was an incidental finding and was not related to underlying TC. Although rare, this case suggests a possible correlation between CAAs and a predisposition to stress-induced cardiomyopathy, warranting further investigation.
PubMed: 38919862
DOI: 10.7759/cureus.63028