Manual thromboaspiration technique as a first approach for endovascular stroke treatment: A single-center experience

BACKGROUND

For intracranial large vessel occlusion in acute ischemic stroke (AIS), a high degree of revascularization in the minimal amount of time predicts good outcomes. Recently, different studies have shown that the direct aspiration first pass technique (ADAPT technique) for AIS obtains high recanalization rates, fast interventions and low costs when it works as first attempt. This study retrospectively describes revascularization efficacy, duration of procedure, intra and post-procedural complications, early and after 90-days clinical outcome in a group of patients who underwent ADAPT as the primary endovascular approach, eventually followed by stent retriever thrombectomy, for recanalization of large vessels in the anterior circulation.

MATERIALS AND METHODS

We analyzed clinical and procedural data of patients treated from April 2014 to August 2015. Recanalization was assessed according to the Thrombolysis in Cerebral Infarction score. Clinical outcome was evaluated at discharge and after 3 months (modified Rankin Scale, mRS).

RESULTS

Overall, 71 patients (mean age of 69.7 years) were treated. Sites of occlusion were anterior circulation (including seven tandem extracranial-intracranial occlusions). In 39 patients i.v. rtPA was attempted. Recanalization of the target vessel was obtained in 87.3% of cases whereas direct aspiration alone was successful in 46/71cases (64.8%) with an average puncture-to-revascularization time of 43.1 minutes. Symptomatic intracranial hemorrhage occurred in 7.8% and embolization to new territories in 5.6%. In total, 38 patients (53.5%) had a good outcome at 90 days follow-up.

CONCLUSIONS

In our series, the manual thromboaspiration technique has been shown as fast and safe, with good rates of vessel revascularization in 87.3% of patients and neurological outcome <3 mRS in 53.5% of patients.

Hemodynamic and Anatomic Variations Require an Adaptable Approach during Intra-Arterial Chemotherapy for Intraocular Retinoblastoma: Alternative Routes, Strategies, and Follow-Up

BACKGROUND AND PURPOSE

Intra-arterial chemotherapy for retinoblastoma is not always a straightforward procedure, and it may require an adaptable approach. This study illustrates strategies used when the ophthalmic artery is difficult to catheterize or not visible, and it ascertains the effectiveness and safety of these strategies.

MATERIALS AND METHODS

A retrospective study was performed on a series of 108 eyes affected by intraocular retinoblastoma and selected for intra-arterial chemotherapy (follow-up range, 6-82 months). We recognized 3 different patterns of drug delivery: a fixed pattern through the ophthalmic artery, a fixed pattern through branches of the external carotid artery, and a variable pattern through either the ophthalmic or the external carotid artery.

RESULTS

We performed 448 sessions of intra-arterial chemotherapy, 83.70% of them through the ophthalmic artery and 16.29% via the external carotid artery. In 24.52% of eyes, the procedure was performed at least once through branches of the external carotid artery. In 73 eyes, the pattern of drug delivery was fixed through the ophthalmic artery; for 9 eyes, it was fixed through branches of the external carotid artery; and for 17 eyes, the pattern was variable. Statistical analysis did not show any significant difference in the clinical outcome of the eyes (remission versus enucleation) treated with different patterns of drug delivery. Adverse events could not be correlated with any particular pattern.

CONCLUSIONS

Alternative routes of intra-arterial chemotherapy for intraocular retinoblastoma appear in the short term as effective and safe as the traditional drug infusion through the ophthalmic artery.

[Neuroimaging and definition of transient ischemic attack]

AIM

Transient ischemic attack (TIA) has to be considered an "alarm bell" of a more or less severe organic or systemic vasculopathy. Positive findings at neuroimaging means tissue damage. The purpose of this retrospective study was to assess the role of neuroimaging in the management of patients presenting with TIA, and to consider the relative implications.

METHODS

In a consecutive series of 82 patients (53 males, 29 females, mean age: 65.9±13.1 years) admitted for TIA, it was possible to review the history and the clinical data of 66 patients, including ABCD2 score, laboratory including plasmatic D-dimer, and neuroimaging data including computed tomography (CT) and magnetic resonance imaging including diffusion-weighted with apparent diffusion coefficient measure (DWI-ADC) obtained at diagnosis and by a week later (16 by CT, and 50 by DWI-ADC). Thirty-three patients underwent DWI-ADC within 24 hours from symptoms onset. Statistical analysis has been performed by non-parametric tests (χ2 and Mann-Whitney), and logistic regression by a commercially available software.

RESULTS

CT and/or DWI-ADC showed signs of acute ischemic lesions in 23/66 (35%) patients. 12 out of the 35 patients with a 24-hour DWI-ADC follow-up were positive. Statistical analysis showed that positive neuroimaging was significantly associated only with familial history of cardiovascular diseases (P<0.012) and previous TIA/stroke (P<0.046).

CONCLUSION

In this patients series, at least 35% of patients with TIA had a positive neuroimaging, especially DWI-ADC. Positive neuroimaging seems an independent factor. Patients with TIA need an early assessment by neuroimaging including DWI-ADC, in order to obtain a correct classification and prognosis.

Benign orbital pseudolymphoma. Case report

Orbital pseudolymphomas are uncommon benign tumors composed of reactive lymphocytes. The typical clinical presentation is painless onset of ptosis, proptosis, diplopia, or eyelid swelling. Virtually any adnexal structure can be affected, but lacrimal gland, orbital soft tissue, or extraocular muscles are the usual sites of involvement. Historically, treatment has been with oral corticosteroids or localized radiotherapy. We present a case of benign orbital pseudolymphoma.

Endovascular treatment of a cavernous sinus dural arteriovenous fistula by transvenous embolisation through the superior ophthalmic vein via cannulation of a frontal vein

We describe a new approach for transvenous embolisation of cavernous sinus dural arteriovenous fistulae through the superior ophthalmic vein (SOV), i.e., via percutaneous cannulation of a frontal vein. Modern neurointerventional angiographic materials make it possible to reach the SOV in this way without puncturing it in the orbit or a surgical exposure. Orbital phlebography should still be in the repertoire of interventional neuroradiology units in large centres.

Coats disease: smaller volume of the affected globe

PURPOSE

To determine whether a significant smaller volume of the affected globe, compared with that of the normal globe, is an additional feature of Coats disease.

MATERIALS AND METHODS

Ocular globe volume was assessed in 13 children (11 boys, two girls; age range, 0.6-14 years; mean age, 4.1 years) with Coats disease and in 18 (eight boys, 10 girls; age range, 0.5-12 years; mean age, 3.6 years) with unilateral retinoblastoma. Orbital computed tomographic scans were available for all children; magnetic resonance images were available for 11 children-seven with Coats disease and four with retinoblastoma. For volume estimation, anteroposterior and equatorial diameters of ocular globes were measured. Statistical analysis was conducted with univariate and multivariate methods.

RESULTS

In children with Coats disease, the mean volume of the affected globe was 4,877.03 mm(3) (range, 2,951.47-6,284.70 mm(3)) and that of the normal globe, 6,018.00 mm(3) (range, 4,062.32-7,509.26 mm(3)). In children with retinoblastoma, the mean volume of the affected globe was 4,557.06 mm(3) (range, 1,612.01-7,463.00 mm(3)) and that of the normal globe, 4,402.11 mm(3) (range, 1,360.46- 7,463.00 mm(3)). The Coats disease population had a significantly smaller volume of the affected globe (z = -3.1009; P =.002); the retinoblastoma population did not have a statistically significant trend toward a bigger affected globe volume (z = -1.7064; P =.088). The difference between the affected globe volume and the normal globe volume in children with Coats disease was the only significant independent variable (P =.005).

CONCLUSION

A significantly smaller volume of the affected globe is an additional feature of Coats disease.

gamma-Glutamyltransferase isoenzyme pattern in workers exposed to tetrachloroethylene

In compliance with the mandatory medical surveillance of workers exposed to tetrachloroethylene (PCE) in Italy, isoenzyme fractioning of serum gamma-glutamyltransferase (GGT) was performed on 141 workers of both sexes and on 130 control subjects. None of the workers showed any clinical symptoms of liver disease and their enzymatic profiles, including AST, ALT, 5'-NU, ALP, and GGT, were within the normal reference limits. A statistically significant increase in total GGT serum level was found in the exposed subjects, which was associated with an increase in one of the two fractions normally present in healthy individuals (GGT-2), as well as with the appearance and progressive increase of the level of a fraction (GGT-4) considered to be an expression of hepato-biliary impairment. Further research is ongoing among these workers, which will clarify whether or not electrophoretic GGT tests may be useful in detecting liver function changes due to occupational exposure to PCE.

Influence of cigarette smoking on pituitary and sex hormone balance in healthy premenopausal women

Plasma gonadotropin FSH and LH, PRL, sex steroids (17-beta E2, E1, and P), SBP binding capacity, and urine estrogens (E1, E2, and E3) were measured in 485 premenopausal healthy women, subdivided according to smoking habits. The aim of the study was to verify if cigarette smoking influences sex hormone balance. Baseline PRL levels were significantly lower (P less than 0.002) in smoker (n = 174) than in nonsmoker (n = 311) women. No difference was found in the other parameters of the two groups, particularly in plasma and urine estrogenic pattern. Our data suggest that smoking directly affects PRL levels by involving the hypothalamic mechanism that regulates PRL secretion.

[Electromyography of those exposed to vibration]

Electrophysiological findings in the median and ulnar nerves of a group of ten workers who operate hand-held vibrating power tools are described. Motor conduction velocities, motor latencies and amplitude of evoked compound muscle action potentials were measured. We have observed statistically significant changes in the distal latencies and in the amplitude of evoked compound muscle action potentials of median nerves in all the subjects examined, whereas the motor conduction velocities were normal in both median and ulnar nerve. These findings are compatible with functional changes without a clinically manifest neuropathy and they are suggestive of a compression damage such as carpal tunnel syndrome: the possible pathogenic mechanism of these damages are discussed. It's necessary to emphasize the importance of further studies in order to estimate the type and entity of the exposure to vibrations to show a cause-effect relationship.

[Assessment of exposure to perchloroethylene in dry-cleaning shops]

The occupational work-risk by PCE was evaluated in a group of 143 workers in 47 laundries, where perchloroethylene (PCE) was the only solvent used. Airborne measurements of PCE showed mean concentration values below the TLV-TWA, and a number of instant concentration values superior to TLV-STEL. Trichloracetic acid (TCA) values in the urine of exposed workers was superior to the limit established by our institute (29% of workers).

[Possible risk of liver diseases from exposure to bitumen]

The influence of exposure to bitumen on hepatic enzymatic induction was examined. Measurement of serum GT in a group of exposed workers and a control group produced statistically significant results, indicating that exposure to bitumen causes enzymatic induction.

[Behavior of blood gamma glutamyltransferase in workers exposed to hepatotoxic agents]

The behaviour of serum GT is evaluated as an indicator of exposure to enzymatic inductors that are potentially hepatotoxic. Serum GT was measured in 437 exposed workers and 149 controls. The statistically significant variation observed in the exposed group probably indicates enzymatic induction.

[Endoscopy findings in gastroduodenal pathology in a group of welders]

Fourteen welders were examined with the purpose to evaluate the incidence and the type of pathologic changes of the gastrointestinal tract due to the exposure to welding fumes. The medical examination was followed by endoscopic and bioptic study of gastric and duodenal mucosa. The results show the presence of pathologic changes, mainly of flogistic type, in all the microscopic investigations, although the appearance of the mucosa was generally normal. Moreover, the results of this investigation suggest that pathologic changes of gastrointestinal tract could precede those of the respiratory tract.

[Food poisoning with marine animal toxins of invertebrate origin]

The consumption of seafood is increasing and hence the risk of poisoning. For this reason, the study of food poisoning caused by zootoxins from marine invertebrates has become of signal importance. These toxins come from bivalve molluscs and other species. Depending on the type of toxin concerned, poisoning attributable to molluscs may give rise to paralysis, caused by saxitossin, neurotoxic effects (gimbretoxin), or haemolysis (venerupin). Poisoning caused by coelenterates, echinoderms, cephalopods, Neptunea, abalone, crabs and lobsters is less common, and its clinical pictures and pathogenesis have not been fully established. In some instances, toxins presented in the phytoplankton ingested by these animals appear to be responsible, whereas in others its would seem that they themselves elaborate the active principles directly.

[Toxic occupational liver diseases. Therapeutic effects of silymarin]

We considered two groups, one of 35 and the other of 20 patients, with occupational toxic hepatopathy caused by various toxic substances (mostly solvents, paints and glues). The patients were mostly suffering from chronic or subacute forms. We considered the work conditions in the anamnesis, the period of exposure and most important laboratory parameters of hepatic function checked before and after treatment with Silymarin (420 mg/die/os) for the first group and with "placebo" for the second group. Five patients of the first group were diagnosed by biopsy. The treatment with Silymarin has shown slight variations in some parameters. The therapeutic effect is probably not dependent upon the kind of pathogen noxa; it seems instead to be more evident when the exposure period is shorter. The group "placebo" does not show significant variations.

[Echocardiographic study of the left ventricle in chronic alcoholism]

Echocardiographyc has been used to study clinical signs of cardiopathy in 25 chronic alcoholics. Compared to normal control subjects, the alcoholics presented an increase in the left ventricular wall and an increase in the cross section and volume of the left myocardium. The left ventricular cavity was also increased. On the other hand, echocardiographic indices of myocardial contractility, represented by the ejection fraction, rate of circumferential shortening and rate of increase of the thickness of the left ventricular wall from telediastole to telesystole, were within normal limits.

[Functional respiratory and blood gas analytical studies of the effects of fenspiride, in oral and intramuscular administration, in chronic bronchopneumopathic subjects]

A group of 20 chronic bronchopneumopathics was treated for 15 days with fenspiride orally and i.m. The behaviour of a set of functional respiratory and haemogasanalytic parameters was monitored at various times (basic, 5th, 10th and 15th days). Progressive, significant improvements in VC, FEV1, RV and in related parameters were observed. These were attributed to the drug's anti-inflammatory effect in the respiratory ways as well as to its direct antibronchospastic action. Stress is laid on the excellent clinical tolerance of fenspiride following its oral and i.m. administration.

[Histologic patterns of liver damage in chronic poisoning from tri-ortho-cresyl phosphate (author's transl)]

Six subjects, affected with TOCP polyneuritis, were submitted to liver biopsy by means of Menghini's technique. By means of both optic and electron microscopy, histologic and ultrastructural findings of liver damage were evaluated, whose genesis is believed to be due to the toxic effect of TOCP. The hepatocytes showed changes, mainly represented by cloud-vacuolar swelling of the cytoplasm, with abnormalities of nuclear membrane and lipofuscin pigment accumulation. The above mentioned patterns were found in all the examined needle biopsies, which possibly account for their toxic nature.