Absence Of Hemorrhage Research Articles

Hemodynamic effects of the Abdominal Aortic and Junctional Tourniquet in a hemorrhagic swine model

BackgroundTorso hemorrhage constitutes a leading cause of battlefield mortality. The Abdominal Aortic and Junctional Tourniquet (AAJT) uses a pneumatic bladder to compress the aorta reducing pelvic and lower extremity perfusion; however, concern exists over the risk of caval compression exacerbating hypotension after application. MethodsMale swine (70-90 kg) were randomized into four groups of 10: presence or absence of hemorrhage and AAJT placement. After a 40% hemorrhage, a 15-min period of hypovolemia was observed before the AAJT application. All animals received two 500 mL boluses of Hextend separated by 30 min. Cardiovascular, pulmonary, and oxygenation values were compared among groups. ResultsThe AAJT was effective in reducing blood flow to the femoral arteries in both hemorrhaged and nonhemorrhaged animals (P < 0.001 for both groups). Hemorrhage resulted in significant decrease in mean arterial pressure compared with sham controls (23.5 ± 2.4 versus 61.6 ± 7.8 mm Hg, respectively, P < 0.001). AAJT application, compared with untreated controls, resulted in a significant increase in mean arterial pressure and systemic vascular resistance but not in cardiac output, oxygenation, and central venous pressure. Furthermore, no indication of overresuscitation injury was present as evidenced by pulmonary artery pressure and pulmonary histology. ConclusionsAAJT application in an animal model of severe shock results in a favorable hemodynamic profile because of afterload support. The present study did not demonstrate any adverse consequences because of caval compression, bowel injury, or pulmonary dysfunction. In addition, there does not appear to be any particular intravenous fluid economy achieved by AAJT application.

Minocycline prevents cerebral malaria, confers neuroprotection and increases survivability of mice during Plasmodium berghei ANKA infection

Cerebral malaria (CM) is a neurological complication arising due to Plasmodium falciparum or Plasmodium vivax infection. Minocycline, a semi-synthetic tetracycline, has been earlier reported to have a neuroprotective role in several neurodegenerative diseases. In this study, we investigated the effect of minocycline treatment on the survivability of mice during experimental cerebral malaria (ECM). The currently accepted mouse model, C57BL/6 mice infected with Plasmodium berghei ANKA, was used for the study. Infected mice were treated with an intra-peritoneal dose of minocycline hydrochloride, 45mg/kg daily for ten days that led to parasite clearance in blood, brain, liver and spleen on 7th day post-infection; and the mice survived until experiment ended (90days) without parasite recrudescence. Evans blue extravasation assay showed that blood-brain barrier integrity was maintained by minocycline. The tumor necrosis factor-alpha protein level and caspase activity, which is related to CM pathogenesis, was significantly reduced in the minocycline-treated group. Fluoro-Jade® C and hematoxylin-eosin staining of the brains of minocycline group revealed a decrease in degenerating neurons and absence of hemorrhages respectively. Minocycline treatment led to decrease in gene expressions of inflammatory mediators like interferon-gamma, CXCL10, CCL5, CCL2; receptors CXCR3 and CCR2; and hence decrease in T-cell-mediated cerebral inflammation. We also proved that this reduction in gene expressions is irrespective of the anti-parasitic property of minocycline. The distinct ability of minocycline to modulate gene expressions of CXCL10 and CXCR3 makes it effective than doxycycline, a tetracycline used as chemoprophylaxis. Our study shows that minocycline is highly effective in conferring neuroprotection during ECM.

ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOR NEOVASCULAR AGE-RELATED MACULAR DEGENERATION

To assess the effect of anti-vascular endothelial growth factor treatment on visual acuity outcome in patients with neovascular age-related macular degeneration presenting with very low vision. Retrospective analysis of electronic patient care record of 420 eyes treated with ranibizumab between March 2010 and June 2013. The authors classified the extracted sample into 3 categories based on the initial best-corrected visual acuity (BCVA) as measured on the Early Treatment Diabetic Retinopathy Study charts: 0 to 35 letters, 36 to 69 letters, and ≥ 70 letters. Best BCVA achieved in Year 1, and average BCVA over 36 months was computed. The neovascular lesion type, area of lesion, the presence or absence of hemorrhage, retinal pigment epithelium tear, and atrophy were systematically graded as was extent of fibrosis on a categorical scale of 0 to 4. Regression analysis was performed with the best BCVA achieved in Year 1 as the outcome variable and initial BCVA, person, and lesion characteristics as explanatory variables. The mean change in BCVA from the initial visit to the best-attained BCVA during Year 1 was highly statistically significant with an improvement of 9.95 letters. The improvement from initial BCVA to average BCVA over 36 months was 4.01 letters. Regression analysis identified atrophy and fibrosis as predictors of best BCVA, with the model having an r of 0.71. Our study supports the use of anti-vascular endothelial growth factor agents even in eyes with low visual acuity particularly when fibrosis and atrophy are absent and suggests algorithms to predict outcome for combinations of visual acuity and lesion characteristics across the full visual acuity range.

Third ventricular cavernoma: Report of two cases.

Sir/Madam, Cerebral parenchyma is the most common site for a cavernoma in the nervous system. Intraventricular cavernomas are rare and constitute 2.5-10.8% of cerebral cavernomas.[1] Third ventricular cavernomas are even rare, only 25 cases have been reported in the literature.[2] We report two more cases of third ventricular cavernomas. The first patient was a 54-year-old man, who presented with acute headache and vomiting. He was unconscious on arrival in casualty. CT scan showed third ventricular hemorrhage [Figure 1a]. He underwent external ventricular drainage, followed by ventriculo-peritoneal (VP) shunt later. An MRI done at 10 days after ictus showed a mixed density lesion with hemorrhagic component occupying the third ventricle with broad base on the floor [Figure 1b]. He underwent tranacallosal-interhemispheric approach and total excision of the lesion. The tumor was arising from the floor of the third ventricle. Histopathology was cavernoma. After surgery the patient developed diabetes insipidus, which was managed with desmopressin. Figure 1 (a) CT scan showing hemorrhage in third ventricle. (b) MRI showing a heterogeneous lesion in the third ventricle with bleed The second patient was a 6-year-old girl who presented with headache and vomiting for 2 months. CT scan showed a calcified in third ventricle with hydrocephalus [Figure 2a]. MRI showed a heterogeneous lesion occupying the entire third ventricle [Figure 2b]. There was no evidence of recent hemorrhage. She underwent VP shunt followed by subfrontal approach, and only partial excision of the lesion as the lesion was densely adherent to the floor of the third ventricle. Histopathology was cavernoma. After surgery she developed transient hyponatremia, which was managed medically. Figure 2 (a) CT scan showing calcified tumor in third ventricle. (b) MRI showing a heterogeneous lesion in the third ventricle Third ventricular cavernomas can present with signs and symptoms of any third ventricular tumors, however they usually present with symptoms of hydrocephalus.[2] Presentation as intraventriuclar hemorrhage is uncommon, and only three cases have been reported.[2] Our first patient presented with hemorrhage, and second with hydrocephalus. They can arise from the suprachiasmatic region, foramen of Monroe, lateral wall or floor of third ventricle.[3] Both of our patients had cavernomas arising from floor of third ventricle. The imaging appearance is that of typical cavernomas. The close differential diagnosis in the absence of hemorrhage is third ventricular craniopharyngioma. The natural history of intraventricular cavernoma is not known. There is a risk of hemorrhage and acute hydrocephalus if the lesion is not excised completely. However, there is risk of hypothalamic damage in case of complete resection of lesion arising from floor of third ventricle, as it happened in our first case. It may be worthwhile doing only a VP shunt for hydrocephalus if the lesion is arising from the floor of the third ventricle.[4]

Protective role of ellagitannins from Eucalyptus citriodora against ethanol-induced gastric ulcer in rats: Impact on oxidative stress, inflammation and calcitonin-gene related peptide

The gastroprotective activity of an ellagitannin-rich fraction obtained from Eucalyptus citriodora (ECF) was investigated against ethanol-induced gastric ulceration in rats. The rats were pretreated with ECF (25, 50 and 100mg/kg) 1h before the administration of absolute ethanol to induce acute gastric ulceration. The gastric lesions were significantly reduced by all doses of ECF. Notably, pre-treatment with ECF (100mg/kg) conferred 99.6% gastroprotection, which is significantly higher than that produced by omeprazole. Moreover, ECF administration markedly increased the mucin content in a dose-dependent manner. The potent gastroprotective effect of ECF could be partly mediated by attenuating ethanol-induced oxidative stress. ECF-pre-treatment markedly increased the depleted GSH and SOD levels in a dose-dependent manner. Moreover, ECF significantly decreased the elevated MDA tissue levels induced by ethanol administration. The results demonstrated that ECF administration exerted a powerful anti-inflammatory activity as evidenced by the reduction in the pro-inflammatory markers; IL-1β, TNF-α, 5-LO and COX-2. Additionally, the caspase-3 tissue levels were significantly reduced in the groups pre-treated with ECF. These results suggest that ECF could exert a beneficial gastroprotective effect through their antioxidant, anti-inflammatory and anti-apoptotic properties. Furthermore, ECF pre-treatment significantly attenuated the ethanol-induced decrease in CGRP expression, which has a protective role against gastric ulceration. Histopathological examination revealed intact mucosal layer, absence of hemorrhage and necrosis in groups treated with ECF. Ellagitannins were identified as the major active constituents responsible for the marked antioxidant and gastroprotective properties of ECF. The HPLC–PDA–ESI/MS/MS technique was employed to identify the ellagitannins of E. citriodora.

Double inversion recovery MR sequence for the detection of subacute subarachnoid hemorrhage.

The diagnosis of subacute subarachnoid hemorrhage is important because rebleeding may occur with subsequent life-threatening hemorrhage. Our aim was to determine the sensitivity of the 3D double inversion recovery sequence compared with CT, 2D and 3D FLAIR, 2D T2*, and 3D SWI sequences for the detection of subacute SAH. This prospective study included 25 patients with a CT-proved acute SAH. Brain imaging was repeated between days 14 and 16 (mean, 14.75 days) after clinical onset and included MR imaging (2D and 3D FLAIR, 2D T2*, SWI, and 3D double inversion recovery) after CT (median delay, 3 hours; range, 2-5 hours). A control group of 20 healthy volunteers was used for comparison. MR images and CT scans were analyzed independently in a randomized order by 3 blinded readers. For each subject, the presence or absence of hemorrhage was assessed in 4 subarachnoid areas (basal cisterns, Sylvian fissures, interhemispheric fissure, and convexity) and in brain ventricles. The diagnosis of subacute SAH was defined by the presence of at least 1 subarachnoid area with hemorrhage. For the diagnosis of subacute SAH, the double inversion recovery sequence had a higher sensitivity compared with CT (P < .001), 2D FLAIR (P = .005), T2* (P = .02), SWI, and 3D FLAIR (P = .03) sequences. Hemorrhage was present for all patients in the interhemispheric fissure on double inversion recovery images, while no signal abnormality was noted in healthy volunteers. Interobserver agreement was excellent with double inversion recovery. Our study showed that the double inversion recovery sequence has a higher sensitivity for the detection of subacute SAH than CT, 2D or 3D FLAIR, 2D T2*, and SWI.

Predictive Value for Malignancy of the Thyroid Nodule Macroscopically

Introduction The fine needle aspiration (FNA) is a method of high accuracy in the preoperative diagnosis of thyroid nodules, but the “follicular” remains a factor of failure. Furthermore, the usefulness of intraoperative examination of freezing is controversial. Macroscopic aspects of thyroid nodules may increase the diagnostic accuracy of preoperative and intraoperative FNA biopsy and freezing. Objective To evaluate the macroscopic aspects of the surgical specimen in the decision facing the nodular disease of thyroid gland. Methods During 2007, 85 patients underwent surgical treatment for thyroid nodular diseases were evaluated by prospective and macroscopic aspects of 125 nodules were compared with histopathological findings. Results We found that the pattern of recent growth, the presence of adhesions of the thyroid, absence of hemorrhage, necrosis and poor demarcation of the nodule had statistical significance in the outcome of malignant disease. Conclusion Pattern of growth, thyroid adhesions, necrosis and poor demarcation of the nodule are predictors of malignancy, while the presence of hemorrhage is a protective factor.

Abstract T P26: Predictors of Clinical and Angiographic Outcomes in Acute Stroke Treatment: Subgroup Analysis From the Star Study

Endovascular acute stroke treatment (AIS) has changed dramatically last years. Stent retrievers are progressively substituting other devices and old practices like intra-arterial thrombolysis. We present the subgroup analysis of the largest prospective multicentre study using stent retrievers on the treatment of AIS. The study was realized in 14 high volume and experienced stroke centres in Europe, Canada and Australia. 202 patients harbouring anterior circulation occlusions were included within 8 hours after onset. All procedures were performed with balloon guiding catheter. We observed that the occlusion location did not change the successful (TICI 2b or 3) recanalization rates (ICA - 76.5% and MCA - 86.4%: p=0.187) or good clinical outcomes (mRS 0-2) (ICA - 47.2% and MCA - 61.3%: p=0.137). However, it was significant when we considered excellent (mRS 0-1) outcomes only (ICA - 25% and MCA - 47.5%: p=0.016). There were no differences concerning the previous use of rtPA on the angiographic (TICI scores) (p=1.0) or clinical (mRS) (p=0.564) outcomes. The anaesthetic management also did not influence the revascularization (p=0.7) or patient’s status (p=0.343). Angiographic collateral status determined using the ASITN/SIR grading system was significantly correlated to good clinical outcomes (Grades 0-2 and Grades3-4, p=0.034). Also the time from the stroke onset to groin puncture influence clinical progress (0-3h, 3-4.5h, over 4.5h: p=0.002). Multivariate regression analysis on prediction of good outcomes was significant for age (OR-0.93 (0.89, 0.97)), baseline NIHSS (OR-0.87(0.79, 0.96)), absence of haemorrhage (OR-5.01 (1.65, 15.16)), time to treatment (OR-0.62(0.45-0.83)) procedure performed under conscious sedation (OR4.83(1.78,13.11)) and successful recanalization (OR-3.37(1.12,10.14)). Early and efficient revascularization is ideal situation for AIS. Conscious sedation can save time for endovascular procedure using a stent retriever in experienced centers.

Use of Plasma in the Management of Central Nervous System Bleeding: Evidence-Based Consensus Recommendations

Central nervous system (CNS) hemorrhage is a potentially life-threatening condition, especially in patients with acquired coagulopathy. In this setting, treatment of CNS bleeding includes hemostatic therapy to replenish coagulation factors. There is currently a debate over the hemostatic efficacy of plasma in many clinical settings, alongside increasing concern about transfusion-associated adverse events. Despite these concerns, plasma is widely used. Moreover, plasma transfusion practice is variable and there is currently no uniform approach to treatment of traumatic, surgical or spontaneous CNS hemorrhage. This study addresses the need for guidance on the indications and potential risks of plasma transfusion in these settings. An Expert Consensus Panel was convened to develop recommendations guiding the use of plasma to treat bleeding and/or coagulopathy associated with CNS hemorrhage. The panel did not advise on the best treatment available but rather proposed recommendations to be used in the formulation of local procedures to support emergency physicians in their decision-making process. Evidence was systematically gathered from the literature and rated using methods established by the Scottish Intercollegiate Guidelines Network. The evidence was used to develop graded consensus recommendations, which are presented along with the evidence-based rationale for each in this report. Sixty-five articles were identified covering both vitamin K antagonist-anticoagulation reversal and treatment of bleeding/coagulopathy in non-anticoagulated patients. Recommendations were then developed in four clinical scenarios within each area, and agreed on unanimously by all members of the panel. The Panel considered plasma to be reasonable therapy for CNS hemorrhage requiring urgent correction of coagulopathy, although physicians should be prepared for potential cardiopulmonary complications, and evidence suggests that alternative therapies have superior risk-benefit profiles. Plasma could not be recommended in the absence of hemorrhage or coagulopathy. Consideration of the absolute risks and benefits of plasma therapy before transfusion is imperative.

Utility of MRI Features in Differentiation of Central Renal Cell Carcinoma and Renal Pelvic Urothelial Carcinoma

The purpose of this article is to evaluate the utility of various morphologic and quantitative MRI features in differentiating central renal cell carcinoma (RCC) from renal pelvic urothelial carcinoma. Sixty patients (39 men and 21 women; mean [± SD] age, 65 ± 14 years; 48 with central RCC and 12 with renal pelvic urothelial carcinoma) who underwent MRI, including diffusion-weighted imaging (b values, 0, 400, and 800 s/mm(2)) and dynamic contrast-enhanced imaging, before histopathologic confirmation were included. Tumor T2 signal intensity and apparent diffusion coefficients (ADCs) were measured and normalized to muscle and CSF (hereafter referred to as normalized T2 signal and normalized ADC, respectively) and then were compared using receiver operating characteristic analysis. Also, two blinded radiologists independently assessed all tumors for various qualitative features, which were compared with the Fisher exact test and unpaired Student t test. Urothelial carcinoma exhibited significantly lower normalized ADC than did RCC (p = 0.008), but no significant difference was seen in ADC or normalized T2 signal intensity (p = 0.247-0.773). Normalized ADC had the highest area under the curve (0.757); normalized ADC below an optimal threshold of 0.451 was associated with sensitivity of 83% and specificity of 71% for diagnosing urothelial carcinoma. Features that were significantly more prevalent in urothelial carcinoma included global impression of urothelial carcinoma, location centered within the collecting system, collecting system defect, extension to the ureteropelvic junction, preserved renal shape, absence of cystic or necrotic areas, absence of hemorrhage, homogeneous enhancement, and hypovascularity (all p < 0.033). Increased T1 signal intensity suggestive of hemorrhage was significantly more prevalent in RCC (p = 0.02). Interreader agreement for the subjective features ranged from 61.7% to 98.3%. In addition to various qualitative MRI parameters, normalized ADC has utility in differentiating central RCC from renal pelvic urothelial carcinoma. Such differentiation may assist decisions regarding possible biopsy and treatment planning.

Intentional Overdose With Tinzaparin: Management Dilemmas

BackgroundLow-molecular-weight heparin (LMWH) is increasingly being prescribed for prophylaxis and treatment of thromboembolic diseases. Despite the fact that its therapeutic use is considered to be safe, it can be complicated by major hemorrhage and, in contrast to unfractionated heparin, it can only partially be neutralized by protamine. Recent reports of LMWH overdose illustrate the need for a consensus on its management. ObjectivesTo describe a case of self-poisoning with a very large dose of tinzaparin and discuss management options in patients with LMWH overdose. Case ReportA 69-year-old woman was brought to the Emergency Department 2 h after injecting herself with 280,000 IU of tinzaparin subcutaneously in an attempt to commit suicide. Despite an unrecordable activated partial thromboplastin time (APTT > 180 s) and prolonged prothrombin time, there was no evidence of active bleeding. She was given an intravenous infusion of 100 mg protamine sulfate and was admitted to the intensive care unit, where further infusions of protamine were administered. Normalization of the APTT occurred 40–50 h post admission, reflecting normal tinzaparin clearance rather than neutralization by protamine. No hemorrhagic complications occurred during her hospitalization except for prolonged bleeding from venipuncture sites. ConclusionIn this case of massive tinzaparin overdose, conventional doses of protamine failed to rapidly normalize the deranged coagulation parameters. The favorable clinical outcome suggests that, regardless of the LMWH amount injected, no active treatment is needed in the absence of hemorrhage. This is in accordance with the limited published data concerning cases of overdose with other LMWHs.

Manual removal of the placenta: Evaluation of some risk factors and management outcome in a tertiary maternity unit. A case controlled study

Objective: Lack of consensus on when to diagnose and manage retained placenta in the absence of hemorrhage in the 3rd stage of labor, has often subjected Manual removal of placenta (MROP) to the discretion of the accoucher. This study aimed to appraise the practice of manual removal of placenta in a tertiary institution in Nigeria with a view to evaluating risk factors for the procedure and advance probable guidelines to enhance standardization of diagnosis of retained placenta. Design: Case controlled study. Setting: Tertiary maternity center in South west Nigeria. Participants: Data from the hospital records of 92 parturients who had MROP from January to December 2009 were compared with 91 immediate next parturients without MROP matched for age and parity. Variables such as the past obstetric and gynecological history, status of accoucher, gestational age at delivery, duration of 3rd stage, estimated blood loss, quantum of blood transfused and length of hospitalization were extracted and subjected to statistical analysis using the SPSS package. Results: There were 4613 deliveries of which 92 parturients had MROP, an incidence of 1.99%. The mean duration of 3rd stage in the study group was 35.6 ± 18.8 minutes compared to 21.6 ± 6.28 minutes in the control. Doctors were the accoucher in 96.8% of cases while midwives took the deliveries in 84.4% in the control group. Previous scarring of the pregnant uterus such as dilatation and curettage and caesarean section predisposed to MROP compared to the control group (P rd stage of labor with definite criteria for diagnosis of retained placenta to reduce the probable risk of unnecessary MROP.

Intravenous Tissue Plasminogen Activator Therapy for Ischemic Stroke Patients who Caused Car Accidents

Stroke can cause car accidents. In our hospital, intravenous tissue plasminogen activator (t-PA) therapy was given to three ischemic stroke patients who had caused car accidents. Since stroke was suspected based on clinical manifestations on arrival, head examinations, as well as detailed examinations of the whole body, were performed immediately. After confirming the absence of hemorrhage from traumatic injuries, the patients were treated with intravenous t-PA. No patients had adverse events including hemorrhage. With extensive examinations, thrombolytic therapy can be safely given to ischemic stroke patients involved in traffic accidents.

Peritoneal inclusion cysts: clinical characteristics and imaging features

To investigate the frequency of patient characteristics, causative factors and imaging features associated with pathology-proven peritoneal inclusion cysts (PICs). From a retrospective search of all available hospital records-dating back 19 years-we identified 228 patients with pathology-proven PICs. Descriptive statistics were calculated for patients' demographic and clinical characteristics. Imaging features of pathology-proven PICs were recorded on a total of 77 computed tomography (CT), magnetic resonance imaging (MRI) and/or ultrasound (US) studies from patients who underwent imaging before surgery. PICs occurred over a wide age range (18-89 years); 82.5 % of patients were women and 17.5 % were men. A history of prior insult to the peritoneum was identified in 70.6 % of patients. Imaging appearances of PICs ranged from loculated, simple fluid collections to complex, multi-septated lesions. In the absence of haemorrhage or debris, PICs were never found to have thick walls. The presence of nodularity, papillary excrescences or other solid components also excluded a diagnosis of PIC, as did the presence of more than a physiological amount of ascites, provided the ascites had no alternate explanation. PICs are more common than suggested by previously published reports. Knowledge of patient characteristics and typical PIC imaging appearances may prevent unnecessary or unnecessarily aggressive therapy.

Large-Scale Automated Assessment of Radiologist Adherence to the Physician Quality Reporting System for Stroke

Physician Quality Reporting System (PQRS) measure 10 assesses the percentage of radiology reports for possible stroke that document the presence or absence of hemorrhage, mass, and acute infarction. Although it is an important report quality metric, determining adherence to this measure is often laborious, limiting its practical use. The aim of this study was to assess adherence to PQRS measure 10 using an automated approach to facilitate continuous measurement. A secondary goal was to identify explanatory variables that may affect adherence. To determine measure adherence, a computerized algorithm was built, validated, and executed on 4,045 reports from CT and MRI examinations performed between January 2008 and October 2010 in patients with suspected stroke. Radiologist adherence was measured, accounting for differences in imaging modality, the presence of abnormalities, and trainee participation in report creation. Of 4,045 reports, 58.1% met the PQRS requirement, documenting all 3 components. Although the presence of infarct increased the chance of PQRS adherence (P < .001), the existence of hemorrhage had the opposite effect (P < .001). Reports that had trainee participation were more likely to be in accordance with PQRS standards (62% vs 47%, P < .001). After controlling for pertinent variables, more than 2-fold variation in individual PQRS adherence (27%-68%) remained (P < .001). A considerable portion of eligible radiology reports do not include all components proposed by PQRS measure 10. An important contributor to performance gaps resides in individual physician variability. By automating measurement and monitoring of radiologist PQRS performance, informatics tools may enable targeted interventions to improve report quality.

Bright-Blood T 2 -Weighted MRI Has High Diagnostic Accuracy for Myocardial Hemorrhage in Myocardial Infarction

Background— Myocardial hemorrhage after myocardial infarction (MI) usually goes undetected. We investigated the diagnostic accuracy of bright-blood T 2 -weighted cardiac MRI for myocardial hemorrhage in experimental MI. Methods and Results— MI was created in swine by occluding the left anterior descending (n=10) or circumflex (n=5) coronary arteries for 90 minutes followed by reperfusion for ≤3 days (n=2), 10 days (n=7), or 60 days (n=6). MRI was performed at 1.5 T, using bright-blood T 2 -prepared steady-state free-precession, T 2 * and early (1 minute) and late (10–15 minutes) gadolinium enhancement (EGE, LGE, respectively) MRI. Left ventricular sections and histology were assessed for hemorrhage by an experienced cardiac pathologist blinded to the MRI data. Hypointense regions on T 2 -weighted and contrast-enhanced MRI were independently determined by 3 cardiologists experienced in MRI who were also blinded to the pathology results. Eighty ventricular pathological sections were matched with MRI (n=68 for EGE MRI). All sections with evidence of MI (n=63, 79%) also exhibited hyperintense zones consistent with edema on T 2 -weighted MRI and infarct on LGE MRI. Myocardial hemorrhage occurred in 49 left ventricular sections (61%) and corresponded with signal voids on 48 T 2 -weighted (98%) and 26 LGE-MRI (53%). Alternatively, signal voids occurred in the absence of hemorrhage in 3 T 2 -weighted (90% specificity) and 5 LGE MRI (84% specificity). On EGE MRI, 27 of 43 cases of early microvascular obstruction corresponded with hemorrhage (63% sensitivity), whereas 5 of 25 defects occurred in the absence of hemorrhage (80% specificity). The positive and negative predictive values for pathological evidence of hemorrhage were 94% and 96% for T 2 -weighted, 84% and 55% for LGE MRI, and 85% and 56% for EGE MRI. Conclusions— Bright-blood T 2 -weighted MRI has high diagnostic accuracy for myocardial hemorrhage.

Inhaled Nitric Oxide for the Prevention of Impaired Arterial Oxygenation during Myocardial Revascularization with Extracorporeal Circulation

Objective: to study the efficacy of inhaled nitric oxide used intraoperatively to prevent lung oxygenating dysfunction in patients with coronary heart disease after myocardial revascularization under extracorporeal circulation (EC). Subjects and methods. Thirty-two patients aged 55.0±2.0 years were examined. The inclusion criteria were the standard course of surgical intervention (the absence of hemorrhage, acute cardiovascular insufficiency, perioperative myocardial infarction, etc.), a pulmonary artery wedge pressure of less than 15 &#8211; mm Hg throughout the study, and the baseline arterial partial oxygen tension/inspired mixture oxygen fraction (PaO2/FiO2) ratio of at least 350 mm Hg. There was a control group (n=21; Group 1) that used no special measures to prevent and/or to correct lung oxygenating dysfunction and Group 2 (n=11) that received inhaled nitric oxide. Ihe administration of inhaled nitric oxide at a concentration of 10 ppm was initiated after water anesthesia, stopped during EC, and resumed in the postperfusion period. Results. At the end, PaO2/FiO2 and intrapulmonary shunt fraction did not differ between the groups (p&gt;0.05). Before EC, the patients receiving inhaled nitric oxide had a lower intrapulmonary blood shunting (8.9±0.7 and 11.7±1.0%; p&lt;0.05). There were no intergroup differences in the values of PaO2/FiO2 at this stage. In the earliest postperfusion period, PaO2/FiO2 was higher in Group 2 than that in Group 1. At the end of operations, Groups 1 and 2 had a PaO2/FiO2 of 336.0±16.8 and 409.0±24.3 mm Hg, respectively (p&lt;0.05) and an intrapulmonary shunt fraction of 14.5±1.0 and 10.4±1.0% (p&lt;0.05). At the end of surgery, the rate of a reduction in PaO2/FiO2 to the level below 350 mm Hg was 52.4±11.1% in Group 1 and 18.2±11.6% in Group 2 (p&lt;0.05). Six hours after surgery, PaO2/FiO2 values less than 300 mm Hg were diagnosed in 61.9±10.5% of Group 1 patients and in 27.3±13.4% of Group 2 ones (p&lt;0.05). Conclusion. The prescription of inhaled nitric oxide at a concentration of 10 ppm to patients with the baseline normal level of PaO2/FiO2 ensured the prevention of lung oxygenating dysfunction in the postperfusion and early postoperative period. The preventive effect of inhaled nitric oxide was steady-state: 6 hours following myocardial revascularization under EC, the patients intraoperatively receiving inhaled nitric oxide showed a 2.3-fold lower rate of lung oxygenating dysfunction (PaO2/FiO2 less than 300 mm Hg) than the controls. Key words: lung oxygenating function, inhaled nitric oxide, operations under extracorporeal circulation, lung ischemia-reperfusion.

Trends over time in the management of 2253 patients with cerebral aneurysms: A single practice experience

Background:To better understand the longitudinal trend in the proportion of techniques employed for cerebral aneurysm treatment, we reviewed our experience with 2253 patients over the last 11 years.Methods:We reviewed data in our prospective aneurysm database for all consecutive patients treated from January 1998 through December 2009. Data regarding age, sex, aneurysm location, presence or absence of hemorrhage, Fisher grade, clinical grade, treatment methods, length of hospitalization, and mortality rates by the time of discharge were retrieved and retrospectively analyzed. The most common aneurysm types were subsequently classified and analyzed separately.Results:The patient population included 663 males (29%) and 1590 females (71%). A total of 2253 patients presented with 3413 aneurysms; 1523 (63%) of the aneurysms were diagnosed as aneurysmal subarachnoid hemorrhage. A total of 2411 (71%) aneurysms were treated. Overall, 645 (27%) of the 2411 aneurysms underwent endosaccular coiling and 1766 (73%) underwent clip ligation; 69 (3%) of these aneurysms required both treatment modalities. The percentage of all aneurysms treated by endosaccular coiling increased from 8% (21) in 1998 to 28% (87) in 2009. There was no statistical difference between the average length of hospitalization for patients who underwent endosaccular coiling and clip ligation for their ruptured (P = 0.19) and unruptured (P = 0.80) aneurysms during this time period.Conclusions:In our practice, endovascular treatment has continued to be more frequently employed to treat cerebral aneurysms. This technique has had the greatest proportional increase in the treatment of posterior circulation aneurysms.

CLINICAL, PATHOLOGIC, AND MAGNETIC RESONANCE IMAGING CHARACTERISTICS OF CANINE DISC EXTRUSION ACCOMPANIED BY EPIDURAL HEMORRHAGE OR INFLAMMATION

Our aim was to characterize the magnetic resonance (MR) imaging features of canine disc extrusion accompanied by epidural hemorrhage or inflammation. We correlated the imaging characteristics of this type of disc extrusion in 46 dogs and compared these features with clinical signs and pathologic findings. Data from 50 control dogs with MR imaging features of a disc extrusion with no associated hemorrhage or inflammation, characterized by a T2-hypointense extradural mass, were used for comparison of the relative location of the two types of lesions and prognosis. Disc extrusion causing epidural hemorrhage or inflammation is more common in the caudal aspect of the lumbar spine than disc extrusions that do not cause signs of hemorrhage or inflammation (P < 0.05) in MR images. In dogs with disc extrusion and associated epidural hemorrhage or inflammation, there was no association between MR imaging features and signalment, the presence or absence of hemorrhage, or pathologic findings. The appearance of the lesion created by disc extrusion with epidural hemorrhage and inflammation encompasses a wide variety of imaging features, likely related to the duration of the hemorrhage and associated inflammatory changes. In 10 of 46 dogs these secondary changes masked identification of the disc extrusion itself in the MR images. An awareness of the variety of MR imaging features of disc extrusion accompanied by extradural hemorrhage or inflammation is important to avoid making an incorrect diagnosis and to facilitate a proper surgical approach. The prognosis of dogs with disc extrusion accompanied by hemorrhage or inflammation does not appear to be different than for dogs with disc extrusion and without imaging signs of epidural hemorrhage or inflammation.

Interventions for treating brain arteriovenous malformations in adults.

Brain arteriovenous malformations (AVMs) are the single most common cause of intracerebral haemorrhage in young adults. Brain AVMs also cause seizure(s) and focal neurological deficits (in the absence of haemorrhage, migraine or an epileptic seizure); approximately one fifth are incidental discoveries. Various interventions are used in an attempt to eradicate brain AVMs: neurosurgical excision, stereotactic radiotherapy/'radiosurgery' (using gamma knife, linear accelerator, proton beam, or 'Cyber Knife'), endovascular embolisation (using glues, particles, fibres, coils, or balloons), and staged combinations of these interventions. This is an update of a Cochrane review first published in 2006. To assess the clinical effects of interventions to treat brain AVMs in adults (with the aim of either partial obliteration or total eradication), using data published in randomised controlled trials (RCTs). We searched the Cochrane Stroke Group Trials Register (last searched November 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2009), MEDLINE (1966 to November 2009) and EMBASE (1980 to November 2009). We searched international registers of clinical trials, the contents pages of relevant journals, and bibliographies of relevant articles (November 2009). We also contacted manufacturers of interventional treatments for brain AVMs (March 2005). We sought randomised trials of any or all of the interventions for brain AVMs, compared against each other or against usual medical therapy, with relevant clinical outcome measures. Two authors independently applied the inclusion criteria and reviewed the relevant studies. One ongoing RCT fulfils the selection criteria for this review: A Randomized trial of Unruptured Brain Arteriovenous malformations (ARUBA, www.arubastudy.org), comparing interventional treatment versus medical management for brain AVMs that have never bled. We also found two RCTs which tested the equivalence of two embolic agents for the pre-operative embolisation of brain AVMs (one published, one unpublished), but none of the primary or secondary outcome measures in these trials met our desired criteria. We also excluded a third RCT which studied three different blood pressure lowering treatments to induce deliberate hypotension during surgical resection of brain AVMs because the intervention was not the focus of this review. There is no evidence from randomised trials with clear clinical outcomes comparing different interventional treatments for brain AVMs against each other or against usual medical therapy to guide the interventional treatment of brain AVMs in adults. One such trial (ARUBA) is ongoing.