Standardized approach to direct first pass aspiration technique for endovascular thrombectomy: Description and initial experience with CANADAPT

BACKGROUND

Endovascular thrombectomy (EVT) is standard of care for acute ischemic stroke. Stent assisted EVT with aspiration (SOLUMBRA) technique has remained a mainstay approach. There is growing evidence that A Direct Aspiration First Pass Technique (ADAPT) is a safe, efficient and effective approach for EVT, offering several advantages. This study describes and reports initial institutional experience in the use of a standardized scientific based aspiration only technique: CANADAPT.

METHODS

Single center prospective cohort study was performed on consecutive patients treated for large/medium vessel ischemic stroke with CANADAPT. Intravenous thrombolytics were administered according to routine practice, independent of the decision to proceed with EVT. A sequential stepwise aspiration only technique was then applied, CANADAPT, consisting of three maneuvers, A, B and C. The reperfusion success rate, number of passes, use of rescue technique, complication rate and procedural cost were determined.

RESULTS

Twenty-two patients were included in this case series representing M1 (17, 77%), M1/2 (2, 9%), carotid-T (2, 9%) and basilar (1, 5%) occlusions. First pass recanalization was achieved in 11 (50%) of patients. A further four patients had successful reperfusion with a second pass of CANADAPT (total 68% success rate). Only one patient had successful reperfusion with the aspiration catheter at the clot interface (CANADAPT A). All others required some withdrawal of the aspiration catheter for reperfusion (CANADAPT B and C). Seven patients had SOLUMBRA rescue. Of these, five patients (22% of total patients) had further successful reperfusion. Overall median procedural time was 23 min for first recanalization and 30 min for final recanalization. The cost per procedure was $6630 ± 1069 for CANADAPT, and $13,530 ± 2706 for SOLUMBRA techniques.

CONCLUSIONS

CANADAPT represents a standardized scientific-based approach to aspiration only thrombectomy intervention. This initial study demonstrates the safety, efficiency and efficacy of this technique for use in EVT.

Early detection of cerebral glucose uptake changes in the 5XFAD mouse

Brain glucose hypometabolism has been observed in Alzheimer’s disease (AD) patients, and is detected with ¹⁸F radiolabelled glucose, using positron emission tomography. A pathological hallmark of AD is deposition of brain β-amyloid plaques that may influence cerebral glucose metabolism. The five times familial AD (5XFAD) mouse is a model of brain amyloidosis exhibiting AD-like phenotypes. This study examines brain β-amyloid plaque deposition and ¹⁸FDG uptake, to search for an early biomarker distinguishing 5XFAD from wild-type mice. Thus, brain ¹⁸FDG uptake and plaque deposition was studied in these mice at age 2, 5 and 13 months. The 5XFAD mice demonstrated significantly reduced brain ¹⁸FDG uptake at 13 months relative to wild-type controls but not in younger mice, despite substantial β-amyloid plaque deposition. However, by comparing the ratio of uptake values for glucose in different regions in the same brain, 5XFAD mice could be distinguished from controls at age 2 months. This method of measuring altered glucose metabolism may represent an early biomarker for the progression of amyloid deposition in the brain. We conclude that brain ¹⁸FDG uptake can be a sensitive biomarker for early detection of abnormal metabolism in the 5XFAD mouse when alternative relative uptake values are utilized.

Chemosynthetic Mussels at a Brine-Filled Pockmark in the Northern Gulf of Mexico

A large (540 square meters) bed of Bathymodiolus n. sp. (Mytilidae: Bivalvia) rings a pool of hypersaline (121.35 practical salinity units) brine at a water depth of 650 meters on the continental slope south of Louisiana. The anoxic brine (dissolved oxygen </=0.17 milliliters per liter) contains high concentrations of methane, which nourishes methanotrophic symbionts in the mussels. The brine, which originates from a salt-cored diapir that penetrates to within 500 meters ofthe sea floor, fills a depression that was evidently excavated by escaping gas. The spatial continuity of the mussel bed indicates that the brine level has remained fairly constant; however, demographic differences between the inner and outer parts of the bed record small fluctuations.

New light on the cholodny-went theory

The existence of different auxin sensitivities in epidermal and subepidermal tissues (KV Thimann, CL Schneider 1938 Plant Physiol 25: 627-641) suggests a refinement to the Cholodny-Went theory which overcomes some of the difficulties associated with it. A model is presented to account for the inverse tropic responses of shoots and roots through differences in the respective locations of the auxin-sensitive tissues.

A Kinetic Analysis of Phytochrome Controlled Mesocotyl Growth in Zea mays Seedlings

Mesocotyl elongation in 4 day old etiolated seedlings immediately following 3 hours of white light (3 h W) is reversibly controlled by phytochrome. Time-lapse video measurements were made of the 5 millimeter zone just below the coleoptile which is the main growth region of the mesocotyl. The growth kinetics were determined for five contiguous 1 millimeter zones subtending the coleoptile node for nonirradiated seedlings, for seedlings given 3 h W, and 3 h W followed by terminal far-red (FR) or red subsequent to the far-red (FR/R) irradiation. Each zone in nonirradiated seedlings exhibits exponential elongation kinetics during the early stages of elongation. This finding suggests that during elongation, a growth limiting factor is also exponentially increasing. Following 3 h W differences in the kinetic responses were found for each zone. In all zones, the inhibitory effect following the 3 h W is totally FR reversible. The effect of FR is reversed by R. The upper zone exhibits the fastest response and is the most plastic in its growth response. The three upper zones all exhibit spontaneous and sharp recoveries with time. It is suggested that the control by phytochrome is not inductive but rather continuous, the controlling factor being either the level of the far red-absorbing form of phytochrome (Pfr) or the ratio Pfr to total phytochrome.

The role of the apex in normal and tropic growth of sunflower hypocotyls

Regional growth in vertical and horizontal etiolated sunflower hypocotyls from which the apical hook tissue had been either partly or wholly excised, was measured 24 h later, the regions having been demarcated with resin beads. Removal of the cotyledons (an excision which included the distal end of the shoot apex) had little effect on growth during this period but excision of the apical hook significantly reduced growth. In vertically orientated seedlings, removal of half of the hook severely reduced growth in all other growing regions and removal of the entire hook totally inhibited growth. This inhibition of growth was not a consequence of the removal of the region of growth but a consequence of the removal of a region on which growth was dependent. In horizontal seedlings, the situation was more complex inasmuch as a horizontal orientation itself induced growth in previously non-growing regions. This new growth was localised in its extent and was not as severely affected by progressive excision of the hook as was growth in vertical seedlings. The results are discussed in terms of overall growth co-ordination in the hypocotyl.

Image Analysis of Geo-Induced Inhibition, Compression, and Promotion of Growth in an Inverted Helianthus annuus L. Seedling

The growth responses of a sunflower seedling (Helianthus annuus L.), subjected to repeated inversion, were characterized by time-lapse recording in conjunction with video image analysis. The investigation revealed a characteristic response pattern and established that the directional movement of the seedling is achieved by both inhibition and stimulation of growth in the normal growing regions. The complex growth changes in contiguous regions of the hypocotyl are such as seem to be inexplicable in terms of an environmentally imposed gradient of a single growth substance.

Is there a role for the apex in shoot geotropism?

Experiments with horizontal etiolated sunflower (Helianthus annuus L.) seedlings supported centrally such that both apical and basal ends are free to react to geostimulus, revealed that the apical end commences curvature 1 to 2 hours earlier than the basal end. The later curvature in the basal region is a consequence of the absence of growth in the initial period rather than merely slower growth. A comparison of zonal growth rates in a vertical and a horizontal seedling confirmed that geostimulus induces a renewal of growth in a region where growth had ceased. Removing the apical half of the hypocotyl showed that the curvature resulting from this growth initiation in the basal region is dependent on attachment to the apical region. Evidence that this dependence is unlikely to be due to energy deficiency is adduced. The prior response of the apical end to geostimulus and the apically dependent later initiation of new growth in the basal region are compatible with the delay inherent in message transport from apex to base and are considered as evidence for apical involvement in the totality of the seedling's georesponse.

The positive hook: the role of gravity in the formation and opening of the apical hook

Photographic observations on germinating seedlings of Lepidium sativum L., Cucumis sativus L., and Helianthus annuus L. showed that the hypocotyl hook is not present in the seed but forms during the early stages of growth. Evidence that gravity plays a major role in inducing curvature of the hypocotyl, and in maintaining the hook once it has been formed, was obtained from clinostat experiments, from the use of morphactin to remove geotropic sensitivity and from inversion of seedlings to change the direction of the geostimulus. In L. sativum and H. annuus gravity perception seemed to be the only mechanism responsible for hook formation. In C. sativus hook formation was additionally aided by the mode of emergence of the cotyledons from the seed coat but gravity played an indirect role in regulating such emergence. Further evidence that hook formation is linked to a georesponse was derived from a comparison of hypocotyl development in wild-type Arabidopsis thaliana seedlings with that of an ageotropic mutant, hook formation being found to occur only in the wild type. Hook formation and maintenance is discussed in terms of contrasting geosensitivity between the apical and basal ends of the hypocotyl and it is suggested that light-induced hook opening is a reversal to a condition of uniformly negative georesponse throughout the hypocotyl.

Energy Supply and Light-enhanced Chloride Uptake in Wheat Laminae

The light-supported component of (36)Cl uptake from 5 mM K(36)Cl by green laminae, either chopped or vacuum-infiltrated, of Triticum aestivum L. seedlings has been determined by subtraction of dark uptake values from light uptake values and the energy sources for the uptake elucidated on the basis of the effects of 3-(3,4-dichlorophenyl)-1,1 dimethylurea (DCMU), carbonyl cyanide p-trifluoromethoxy-phenylhydrazone (FCCP), antimycin A(1) (AA), and N(2) on light and dark uptake. The light-supported Cl(-1) uptake is shown to be partially inhibited by DCMU or AA but unaffected or stimulated by FCCP or N(2). There is no additive effect on inhibition caused by DCMU + N(2) or FCCP + AA but there is an added inhibition caused by DCMU + AA, DCMU + FCCP, and by FCCP or AA in anaerobic conditions. The effect of these inhibitors on photosynthetic gas exchange of chopped tissue has also been determined. On the basis of the results it is concluded that the uptake of Cl(-), supported in the dark by oxidative phosphorylation, is enhanced by light and may be supported by cyclic and non-cyclic electron-flow energy. Uptake is not obligatorily linked to any one energetic pathway and there may be switching from one source to another.

Effect of vacuum infiltration on photosynthetic gas exchange in leaf tissue

Using a manometric method, photosynthetic oxygen evolution and (14)CO(2) fixation have been determined for leaf tissue of Triticum aestivum L., Hordeum vulgare L., Phaseolus vulgaris L., and Lemna minor L. Approximately similar values in the range 0.2 to 0.4 millimoles grams fresh weight(-1) hour(-1) were obtained for both gases. In tissue subjected to vacuum infiltration, O(2) evolution and (14)CO(2) fixation were barely measurable. It is considered that the elimination of photosynthetic gas exchange results from a decreased supply of CO(2) to the chloroplasts. Chopping wheat laminae also leads to a reduction in photosynthetic gas exchange, slices 1 millimeter or less giving only 10 to 20% of the value for whole tissue. Respiration is unaffected by either treatment. Carbonic anhydrase did not improve photosynthetic gas exchange in infiltrated tissue. The use of sliced or vacuum-infiltrated leaf tissue in photosynthetic studies is discussed.

Light-enhanced Chloride Uptake by Wheat Laminae: A Comparison of Chopped and Vacuum-infiltrated Tissue

The time course of (36)Cl(-) uptake from 5 mm KCl by 1.5-mm leaf segments of Triticum aestivum L. seedlings has been determined over 24 hours both in the light and in the dark. A light-enhanced uptake of Cl(-) develops after a few hours. Using whole laminae which have been water-injected by vacuum infiltration, a light-enhanced uptake is apparent from zero time. Uptake values achieved in the light by the two types of tissue are similar but in the dark there is a restricted uptake by the whole infiltrated laminae. It is considered that the slower uptake by whole laminae relative to chopped tissue in the dark is due to cuticular resistance to solute penetration, whereas in the light the impediment is overcome by stomatal opening. A light-enhanced uptake unrelated to stomatal opening is discernible in both tissues. Its energetic basis has not been defined but may be related to substrate exhaustion. The absorption mechanism is not impaired by vacuum infiltration.

Anion absorption by etiolated wheat leaves after vacuum infiltration

Chloride and phosphate uptake by leaf segments of green and etiolated 7-day-old seedlings of Triticum aestivum L. cultivar Capelle is enhanced by light. In the range from 1.0 to 10 millimolar KCl, maximal rates of uptake were obtained with 1.5-millimeter segments. Above 1.5 millimeters, ion diffusion through the cut edge was the rate-limiting factor, uptake being proportional to the amount of cut edge, but vacuum infiltration of the tissue overcame this limitation, allowing uptake to be independent of segment length. No deleterious effects of vacuum infiltration were observed, and it is suggested that the technique offers a convenient alternative to existing methods in the study of foliar absorption.

Specificity of cycloheximide in higher plant systems

Although cycloheximide is extremely inhibitory to protein synthesis in vivo in higher plants, the reported insensitivity of some plant ribosomes suggests that it may not invariably act at the ribosomal level. This suggestion is reinforced by results obtained with red beet storage tissue disks, the respiration of which is stimulated by cycloheximide at 1 microgram per milliliter. Inorganic ion uptake by these disks is inhibited by cycloheximide at 1 microgram per milliliter while the uptake of organic compounds, by comparison, is unaffected. Ion uptake by all nongreen tissues tested is inhibited by cycloheximide, but leaf tissue is unaffected, indicating that the ion absorption mechanism in the leaf may differ fundamentally from that in the root. It is concluded that cycloheximide can affect cellular metabolism other than by inhibiting protein synthesis and that the inhibition of ion uptake may be due to disruption of the energy supply.

Characterisation of amino acid incorporation by subcellular fractions from sterile beet disks

The optimum concentrations of leucine, ATP, GTP and Mg(2+) ion for the incorporation of leucine into protein by the microsomal fraction isolated from sterile disks of red beetroot are 0.06 mM, 5 mM, 0.5 mM, and 12 mM respectively. Incorporated (14)C-leucine does not exchange with an excess of soluble-(12)C-leucine. Incorporation into protein is partly dependent on the addition of a high speed supernatant fraction which incorporates leucine into a product with the properties of aminoacyl RNA. Addition of polyuridylic acid to microsomes isolated from fresh disks stimulates the incorporation of phenylalanine into protein nine-fold but has no effect on leucine incorporation. Polyuridylic acid - stimulated incorporation is not inhibited by chloramphenicol. Preincubation of fresh microsomes with trypsin does not increase their activity. These results suggest that the low activity of fresh microsomes may be due to a lack of messenger RNA. The mitochondrial fraction shows a rise and fall in leucine-incorporating ability during aging similar to that shown by the microsomal fraction. Studies with inhibitors suggest that about 25% of this incorporation is due to the mitochondria themselves, the rest being attributable to large microsomes. Fractions isolated from disks aged under non-sterile conditions show large incorporations of leucine which are not dependent on an added energy source. This result confirms the importance of using aseptic techniques when studying the aging of storage tissue disks.

Further evidence of oxygen diffusion as the determining factor in the relation between disk thickness and respiration of potato tissue

The effect of oxygen tension above atmospheric pO(2) on the development of respiratory capacity in potato disks has been examined. Raising the oxygen tension of the aqueous environment to 40% during the aging of 2.0 mm or 3.0 mm thick disks at 25 degrees progressively increased the respiration rate of the tissue as shown by subsequent assay in 100% oxygen. Disks 3.0 mm thick showed a greater response to increased pO(2) than did 2.0 mm disks. A comparison of center 1.0 mm sections excised from 3.0 mm disks after aging, showed that the respiration rate of internal tissue from disks aged in high pO(2) was approximately 40% greater than such tissue aged with atmospheric pO(2). The characteristic inverse relationship between respiration rate and thickness in aged disks can be modified from a concave-downwards curve to a convex-downwards curve by pretreating the tissue with increased pO(2), thus indicating that raising the pO(2) during aging can increase the thickness threshold at which the transition from tissue manifesting the respiratory characteristics of thin disks to that manifesting the characteristics of thick disks, occurs. Similarly increased pO(2) during aging can modify the hyperbolic relationship obtaining between pretreatment temperature in the range 10 degrees to 25 degrees and respiratory capacity of aged 3.0 mm disks, to approximate to the linear relationship observed with 0.75 mm disks. It is concluded that the development of respiratory capacity in disks between 0.75 mm and 3.0 mm thick is restricted by oxygen dificiency and that the characteristic inverse relationship between respiration rate and thickness in aged disks is largely attributable to this factor, the influence of which is discernible both on the development of respiratory capacity and on its subsequent assay.

Activation of protein synthesis by microsomes from aging beet disks

Microsomal fractions isolated from sterile, aged disks of red beetroot incorporate leucine into protein when supplemented with the supernatant fraction, ATP, GTP, and KCl; the incorporation is sensitive to RNase and is not due to bacteria. The microsomal activity is inhibited by puromycin and cycloheximide but is virtually insensitive to both d-threo and l-threo-chloramphenicol, as predicted from physiological studies.Microsomes isolated from fresh disks have much lower incorporating ability than those from disks aged for 1 or 2 days; maximal activity occurs when the rate of protein synthesis by the intact disks is highest. The low activity of fractions from fresh disks is attributable to a deficiency in the microsomal fraction and not to the supernatant fraction; it is not due to a dissociable inhibitor. The RNA content of the microsomal fraction increases with aging and so the increase in incorporating ability may be due to a synthesis of messenger RNA induced by slicing, rather than to an activation of pre-existing messenger. These results support the view that the aging phenomenon involves a derepression of gene activity.

Oxygen tension a determining factor in the respiration of potato disks of varying thickness

The effect of temperature on the respiration rate of potato tuber slices has been analyzed in terms of the Arrhenius equation. Freshly cut disks, irrespective of thickness, show a linear response to increasing temperature up to 30 degrees with an activation energy (E) of approximately 12.0 Kcal. Aged disks less than 1.0 mm thick also give a linear response with E similar to that of fresh disks. With aged disks above 1.0 mm thick there is a loss of linearity above 20 degrees and E falls to about 4.0 Kcal indicating that respiration becomes rate-limited by a diffusion process. This departure from linearity can be corrected by raising the oxygen tension or by subdivision of thick disks to give thin slices. It is concluded that the respiration of aged disks is rate-limited by oxygen deficiency and that the inverse relationship between respiration rate and disk thickness is in large part attributable to this factor.