Common Carotid Artery Flow Research Articles

Impact of Suturing Techniques on Microvascular Anastomosis Maturation.

INTRODUCTION Microvascular anastomosis using interrupted suture is a widely accepted standard technique. Continuous suture is less common due to the presumption that its firmness can negatively affect anastomosis maturation. The purpose of this study was to determine whether the use of continuous suture allows maturation of the microanastomosis site. MATERIAL AND METHODS A rat common carotid artery (CCA) end-to-end microanastomosis model was utilized, with 19 Long-Evans rats in the interrupted sutures group and 13 in the continuous suture group. Immediate blood flow of the operated and contralateral intact CCAs was compared before clamping, at the completion of the anastomosis and after 14 days. Quantitative transit time flowmetry measurement and histological examination were employed. RESULTS Initial blood flow in both intact CCAs was similar across all animals (p = .004). In the interrupted suture group, median anastomosis blood flow was 88.9% of the contralateral CCA blod flow, with a median suture time of 46 minutes. After two weeks, blood flow increased to 96.1%. In the continuous suture group, median anastomosis blood flow was 88.3% of the contralateral CCA blood flow, with a median suture time of 30 minutes. After two weeks, blood flow increased to 100.0%. The reduction in suture time achieved with continuous suture was 34.8% (p < .001). Histological examination confirmed scar maturity. CONCLUSIONS The maturation rates of continuous and interrupted suture microanastomosis were comparable in our study, implying that concerns about the suture restricting maturation may be unwarranted. Additional finding is the potential for a reduction in microanastomosis time when using the continuous suture technique.

Flow Characteristics on Carotid Artery Bifurcation of Different Aneurysmal Morphology

Aneurysm is a vascular disorder characterized by abnormal focal dilation of an artery which is considered as a serious and potentially life-threatening condition. An estimated 2%–5% of the general population is affected by intracranial aneurysms. Through computational fluid dynamic (CFD) investigation, this study aims to learn the flow characteristic on aneurysm afflicted common carotid artery (CCA). This study focused on the velocity, wall shear stress (WSS) and sensitivity of blood viscosity of the CCA flow. CFD method was done to 3 simplified model of CCA which were normal, saccular aneurysm, fusiform aneurysm CCA model. The simulation was done with different blood viscosity model which were Newtonian and non-Newtonian. The high velocity area of blood flow has corresponding effect to the increase of the WSS distribution to the wall of the geometry. The results also showed at certain value of low velocity area, WSS distribution for different blood viscosity model was deviated significantly.

Plasma 24-hydroxycholesterol is associated with narrower common carotid artery and greater flow velocities in relapsing multiple sclerosis

Background: Multiple sclerosis (MS) studies suggest greater cardiovascular disease burden and disturbances in the cholesterol pathways1,2 The potential impact of oxidized cholesterol molecules (oxysterols) on MS is emerging (Figure 1).3&#x0D; Objective: To determine the relationship between multiple oxysterol molecules and atherosclerosis burden in MS patients.&#x0D; Materials and methods: A total of 99 MS patients (61 relapsing-remitting MS (RRMS) and 38 progressive MS (PMS)) patients and 38 healthy controls (HCs) underwent magnetic resonance angiography (MRA) and the cross-sectional area (CSA) of the common carotid artery (CCA) was determined at three different levels before the bifurcation (C7, C6 and C5). Additionally, an echo-color Doppler ultrasound was performed and measures of blood flow velocities were derived. Blood samples acquired at the time of the imaging examinations were analyzed and 24-, 25-, 27-hydroxycholesterol (24HC, 25HC, 27HC) and 7-ketocholesterol (7KC) were quantified in ng/mL.&#x0D; Results: In the MS patients, higher levels of 24HC were significantly associated with smaller CCA CSA measured at all three cervical levels (r=-0.201, p=0.046; r=-0.228, p=0.023, and r=-0.215, p=0.032, for C7, C6 and C5, respectively). These associations were driven by the RRMS group only (r=-0.407, p=0.002 for C7; r=-0.414, p=0.002, for C6; and r=-0.368, p=0.006 for C5). No associations were seen in the HCs. Despite adjusting for the significant age effect (B=0.445, p=0.004), higher 24HC levels were independently associated with smaller CCA CSA (B=-0.20, p=0.045). 24HC was additionally associated with greater time-averaged and peak diastolic CCA velocities. RRMS patients treated with potent anti-inflammatory therapies had lower oxysterol levels (p=0.019). RRMS patients in the lower 24HC quartiles had significantly higher expanded disability status scale (EDSS) scores when compared to RRMS patients in the higher two 24HC quartiles (2.5 (IQR 1.9-3.1) vs 2.0 (1.5-2.5), p=0.038).&#x0D; Conclusions: Greater 24HC levels are associated with smaller CSA CCA and greater flow velocities in RRMS patients. The higher inflammatory activity in RRMS patients may contribute to the production of highly reactive oxysterols and worsen the atherosclerotic burden in the MS population. Potent anti-inflammatory medications can significantly decrease oxysterol levels.

Plasma 24-hydroxycholesterol is associated with narrower common carotid artery and greater flow velocities in relapsing multiple sclerosis

BackgroundMultiple sclerosis (MS) studies suggest greater cardiovascular disease burden and disturbances in the cholesterol pathways. The potential impact of oxidized cholesterol molecules on MS is emerging. ObjectiveTo determine the relationship between multiple oxysterol molecules and atherosclerosis burden in MS patients. Materials and MethodsA total of 99 MS patients (61 relapsing-remitting MS(RRMS) and 38 progressive MS (PMS)) patients and 38 healthy controls (HCs) underwent magnetic resonance angiography (MRA) and the cross-sectional area (CSA) of the common carotid artery (CCA) was determined at three different levels before the bifurcation (C7, C6 and C5). Additionally, an echo-color Doppler ultrasound was performed and measures of blood flow velocities were derived. Blood samples acquired at the time of the imaging examinations were analyzed and 24-, 25-, 27-hydroxycholesterol (24HC, 25HC, 27HC) and 7-ketocholesterol (7KC) were quantified in ng/mL ResultsIn the MS patients, higher levels of 24HC were significantly associated with smaller CCA CSA measured at all three cervical levels (r=-0.201, p = 0.046; r=-0.228, p = 0.023, and r=-0.215, p = 0.032, for C7, C6 and C5, respectively). These associations were driven by the RRMS group only (r=-0.407, p = 0.002 for C7; r=-0.414, p = 0.002, for C6; and r=-0.368, p = 0.006 for C5). No associations were seen in the HCs. Despite adjusting for the significant age effect (B = 0.445, p = 0.004), higher 24HC levels were independently associated with smaller CCA CSA (B=-0.20, p = 0.045). 24HC was additionally associated with greater time-averaged and peak diastolic CCA velocities. RRMS patients treated with potent anti-inflammatory therapies had lower oxysterol levels (p = 0.019). ConclusionGreater 24HC levels are associated with smaller CSA CCA and greater flow velocities in RRMS patients.

Ambient Temperature Is Correlated With the Severity of Neonatal Hypoxic-Ischemic Brain Injury via Microglial Accumulation in Mice.

BackgroundThe pathophysiology of neonatal hypoxic-ischemic encephalopathy (HIE) has been studied in several rodent models to develop novel treatments. Although it is well known that high ambient temperature results in severe HIE, the effect of subtle changes in ambient temperature during a hypoxic-ischemic (HI) insult has not been studied. Therefore, in order to clarify the difference of pathophysiological change among the HIE models due to the influence of small changes in chamber temperature, three-step gradual change of 0.5°C each were prepared in ambient temperature during hypoxic exposure.MethodsBlood flow in the left common carotid artery (CCA) of neonatal mice was interrupted using bipolar electronic forceps under general and local anesthesia. The mice were subsequently subjected to 10% hypoxic exposure for 50 min at 36.0, 36.5, or 37.0°C. A control group was also included in the study. The size of the striatum and hippocampus and the volume reduction rate of the hemisphere in the section containing them on the ischemic side were evaluated using microtubule associated protein 2 (MAP2) immunostaining. The accumulation of Iba1-positive cells was investigated to assess inflammation. Additionally, rotarod and open-field tests were performed 2 weeks after HI insult to assess its effect on physiological conditions.ResultsMAP2 staining revealed that the higher the temperature during hypoxia, the more severe the volume reduction rate in the hemisphere, striatum, and hippocampus. The number of Iba1-positive cells in the ipsilateral lesion gradually increased with increasing temperature, and there was a significant difference in motor function in the 36.5 and 37.0°C groups compared with the sham group. In the open-field tests, there was a significant decrease in performance in the 37.0°C groups compared with the 36.0°C and sham groups.ConclusionsEven a small gradual change of 0.5°C produced a significant difference in pathological and behavioral changes and contributed to the accumulation of Iba1-positive cells. The arrangement of ambient temperature is useful for creating a rodent model with the appropriate severity of the targeted neuropsychological symptoms to establish a novel therapy for HIE.

Common Carotid Artery Flow Parameters Predict the Incidence of Hypertension.

[Figure: see text].

Open or closed: Changes in ductus arteriosus flow patterns at birth using 4D flow MRI in newborn piglets.

The ductus arteriosus (DA) functionally closes during the transition from fetal to postnatal life because of lung aeration and corresponding cardiovascular changes. The thorough and explicit measurement and visualization of the right and left heart output during this transition has not been previously accomplished. We combined 4D flow MRI (dynamic volumetric blood flow measurements) and T2 relaxometry (oxygen delivery quantification) in surgically instrumented newborn piglets to assess the DA. This was performed in Large White‐Landrace‐Duroc piglets (n = 34) spanning four age groups: term‐9 days, term‐3, term+1, and term+5. Subject's DA status was classified using 4D flow: closed DA, forward DA flow, reversed DA flow, and bidirectional DA flow. Over all states, vessel diameters and flows normalized to body weight increased with age (for example in the ascending aorta flow—term‐9: 126.6 ± 45.4; term+5: 260.2 ± 80.0 ml/min per kg; p = 0.0005; ascending aorta diameter—term‐9: 5.2 ± 0.8; term+5: 7.7 ± 0.4 mm; p = 0.0004). In subjects with reversed DA blood flow there was lower common carotid artery blood flow (forward: 37.5 ± 9.0; reversed: 20.0 ± 7.4 ml/min per kg; p = 0.032). Linear regression revealed that as net DA flow decreases, common carotid artery flow decreases (R2 = 0.32, p = 0.004), and left (R2 = 0.33, p = 0.003) and right (R2 = 0.34, p = 0.003) pulmonary artery flow increases. Bidirectional DA blood flow changed oxygen saturation as determined by MRI between the ascending and descending aorta (ascending aorta: 90.1% ± 8.4%; descending aorta: 75.6% ± 14.2%; p < 0.05). Expanded use of these techniques in preterm animal models will aid in providing new understandings of normal versus abnormal DA transition, as well as to test the effectiveness of related clinical interventions.

右腋窩動脈送血開始後に左総頸動脈血流が消失し大腿動脈送血に切り替え手術を完遂し得たStanford A型急性大動脈解離の1例

右腋窩動脈送血開始後に左総頸動脈血流が消失し大腿動脈送血に切り替え手術を完遂し得たStanford A型急性大動脈解離の1例

Postoperative Stroke after Spinal Anesthesia and Responses of Carotid or Cerebral Blood Flow and Baroreflex Functionality to Spinal Bupivacaine in Rats.

Simple SummarySpinal anesthesia (application of local anesthetic into the subarachnoid space of spinal cord where cerebrospinal fluid circulates) is generally considered a simple, effective and safe procedure. Three rare incidents of patients who developed stroke after surgery under spinal anesthesia with bupivacaine prompted us to report these infrequent clinical cases. Their shared pathology of stenosis (abnormal narrowing of a blood vessel) or atheromatosis (abnormal accumulation of material in an artery) in the carotid or middle cerebral artery (key blood supply to brain), revealed postoperatively, formed the impetus to assess in a companion animal study whether spinal bupivacaine may compromise blood supply to the brain. We found in two-thirds of the rats studied that on application of bupivacaine into the subarachnoid space, blood pressure, blood flow in common carotid artery and baroreflex (responsible for maintained blood pressure) remained stable after a transient drop. However, the other third exhibited a secondary hypotension, depressed baroreflex, declined heart rate, reduced carotid blood flow and waning blood supply to and oxygen level in the cerebral cortex. Our animal study confirmed that blood supply to the brain can indeed be compromised (cause of stroke) after spinal anesthesia, and an impaired baroreflex, which leads to hypotension, plays a contributory role.Spinal anesthesia is generally accepted as an effective and safe practice. Three rare incidents of postoperative cerebral infarction after surgery under spinal anesthesia prompted us to assess whether spinal bupivacaine may compromise carotid or cerebral blood flow. Postoperative examination after the stroke incident revealed that all three patients shared a common pathology of stenosis or atheromatosis in the carotid or middle cerebral artery. In a companion study using 69 Sprague-Dawley rats, subarachnoid application of bupivacaine elicited an initial (Phase I) reduction in the mean arterial pressure, carotid blood flow (CBF) and baroreflex-mediated sympathetic vasomotor tone, all of which subsequently returned to baseline (Phase II). Whereas heart rate (HR) exhibited sustained reduction, cardiac vagal baroreflex, baroreflex efficiency index (BEI) and tissue perfusion and oxygen in the cerebral cortex remained unaltered. However, in one-third of the rats studied, Phase II gave way to Phase III characterized by secondary hypotension and depressed baroreflex-mediated sympathetic vasomotor tone, along with declined HR, sustained cardiac vagal baroreflex, decreased BEI, reduced CBF and waning tissue perfusion or oxygen in the cerebral cortex. We concluded that carotid and cerebral blood flow can indeed be compromised after spinal anesthesia, and an impaired baroreflex-mediated sympathetic vasomotor tone, which leads to hypotension, plays a contributory role.

Hemodynamic effects of high frequency oscillatory ventilation with volume guarantee in a piglet model of respiratory distress syndrome.

Respiratory failure is a common condition faced by critically ill neonates with respiratory distress syndrome (RDS). High frequency oscillatory ventilation (HFOV) is often used for neonates with refractory respiratory failure related to RDS. Volume guarantee (VG) mode has been added to some HFOV ventilators for providing consistent tidal volume. We sought to examine the impact of adding the VG mode during HFOV on systemic and cerebral hemodynamics, which has not been studied to date. A neonatal piglet model of moderate to severe RDS was induced by saline lavage. Piglets (full term, age 1-3 days, weight 1.5-2.4 kg) were randomized to have RDS induced and receive either HFOV or HFOV+VG (n = 8/group) or sham-operation (n = 6) without RDS. Cardiac function measured by a Millar® catheter placed in the left ventricle as well as systemic and carotid hemodynamic and oxygen tissue saturation parameters were collected over 240 min of ventilation. Mean airway pressure, alveolar-arterial oxygen difference and left ventricular cardiac index of piglets on HFOV vs. HFOV+VG were not significantly different during the experimental period. Right common carotid artery flow index by in-situ ultrasonic flow measurement and cerebral tissue oxygen saturation (near-infrared spectroscopy) significantly decreased in HFOV+VG at 240 min compared to HFOV (14 vs. 31 ml/kg/min, and 30% vs. 43%, respectively; p<0.05). There were no significant differences in lung, brain and heart tissue markers of oxidative stress, ischemia and inflammation. HFOV+VG compared to HFOV was associated with similar left ventricular function, however HFOV+VG had a negative effect on cerebral blood flow and oxygenation.

Ventilatory response to hypercapnia is increased after 4\xa0h of head down bed rest

Head-down bed rest (HDBR) has previously been shown to alter cerebrovascular and autonomic control. Previous work found that sustained HDBR (≥ 20 days) attenuates the hypercapnic ventilatory response (HCVR); however, little is known about shorter-term effects of HDBR nor the influence of HDBR on the hypoxic ventilatory response (HVR). We investigated the effect of 4-h HDBR on HCVR and HVR and hypothesized attenuated ventilatory responses due to greater carotid and brain blood flow. Cardiorespiratory responses of young men (n = 11) and women (n = 3) to 5% CO2 or 10% O2 before and after 4-h HDBR were examined. HDBR resulted in lower HR, lower cardiac output index, lower common carotid artery flow, higher SpO2, and higher pulse wave velocity. After HDBR, tidal volume and ventilation responses to 5% CO2 were enhanced (all P < 0.05), yet no other changes in cardiorespiratory variables were evident. There was no influence of HDBR on the cardiorespiratory responses to hypoxia (all P > 0.05). Short-duration HDBR does not alter the HVR, yet enhances the HCVR, which we hypothesize is a consequence of cephalic CO2 accumulation from cerebral congestion.

Carotid Beta Stiffness Association with Thyroid Function

Background: Thyroid hormone modulation of cardiovascular function has been associated with cardiovascular disease. Recent evidence suggests that free thyroxine (FT4) levels are associated with an increase in systemic arterial stiffness, but little is known about the effects of FT4 at the local level of the common carotid artery. β-stiffness index is a local elastic parameter usually determined by carotid ultrasound imaging. Methods: We conducted a cross-sectional analysis in the ProgeNIA cohort, including 4846 subjects across a broad age range. For the purpose of this study, we excluded subjects with increased thyrotropin (TSH) levels and those treated with levothyroxine or thyrostatic. We assessed β stiffness, strain, wall–lumen ratio, carotid cross-sectional area (CSA), and stress and flow in the right common carotid artery. We tested whether FT4, heart rate, and their interactions were associated with carotid parameters. Results: FT4 was positively and independently associated with β stiffness index (β = 0.026, p = 0.041), and had a negative association with strain (β = −0.025, p = 0.009). After adding heart rate and the interaction between FT4 and heart rate to the model, FT4 was still associated with the β stiffness index (β = 0.186, p = 0.06), heart rate was positively associated with the stiffness index (β = 0.389, p < 0.001) as well as their interaction (β = 0.271, p = 0.007). Conclusion: This study suggests that higher FT4 levels increase arterial stiffness at the common carotid level, consistent with a detrimental effect on elastic arteries. The effect of FT4 is likely to be primarily attributable to its effect on heart rate.

Common carotid artery blood flow volume in extremely preterm infants.

The aim of this study was to determine carotid blood flow volume, a surrogate for cerebral blood flow, using Doppler ultrasound in extremely preterm infants. In infants <29weeks, right common carotid artery flow volume (RCCAF) was calculated from vessel diameter and intensity-weighted mean velocity measured using Doppler ultrasound on days 1 and 3. In addition, left ventricular output (LVO), ductus arteriosus characteristics and invasive mean arterial blood pressure (MABP) were obtained. Sixty infants with mean gestation of 25.8weeks were studied. The median RCCAF increased from 12 (IQR 9-15) mL/kg/min on day 1, to 14 (IQR 12-18) mL/kg/min on day 3 (p=0.007). RCCAF was positively correlated with invasive MABP on days 1 and 3. RCCAF significantly correlated with LVO in infants with closing or closed ductus arteriosus on day 1. Using multiple regression analysis, RCCAF was significantly associated with invasive MABP on day 1 and to inotropic treatment on day 3. Doppler ultrasound can be used to measure RCCAF in extremely preterm infants receiving intensive care. RCCAF increased during the first three days and was positively related to invasive MABP on day 1. Values were lower than previously described in more mature infants. ISRCTN 83507686.

Common carotid artery true lumen flow impairment in patients with type A aortic dissection.

Our aim was to evaluate clinical and neurological effects of common carotid artery (CCA) true lumen flow impairment or occlusion in patients with type A aortic dissection. Characteristics and imaging data of patients with dissected CCA secondary to acute type A aortic dissection from 3 institutions were analysed. We defined true lumen blood flow as unimpaired when the maximum true lumen diameter exceeded 50% of the complete CCA diameter, as impaired when the true lumen was compressed to ˃50% of the complete lumen, or as occluded. Out of 440 patients, 207 presented unimpaired CCA flow, 172 impaired CCA flow and CCA occlusion was present in 61 patients. Preoperative shock (P = 0.045) or a neurological deficit (P < 0.001) were least common in patients with unimpaired CCA flow and most common in those with CCA occlusion. Non-cerebral, other-organ malperfusion was common in 37% of all patients, but the incidence was similar (P = 0.69). In patients with CCA occlusion, postoperative stroke (P < 0.001) and in-hospital mortality (0.011) were significantly higher, while the incidences were similar between patients with unimpaired and impaired CCA flow. Mixed-effects logistic regression models showed that CCA flow impairment (P = 0.23) or occlusion (P = 0.55) was not predictive for in-hospital mortality, but CCA occlusion was predictive for in-hospital stroke (odds ratio 2.166, P = 0.023). Shock and non-cerebral, other-organ malperfusion are common in patients with CCA dissection. While there is a high risk for stroke in patients with CCA occlusion, CCA flow impairment and occlusion were not predictive for in-hospital mortality. Surgery should not be denied to patients with CCA flow impairment or occlusion.

Head and neck CT angiography to assess the internal carotid artery stealing pathway

BackgroundCommon carotid artery occlusive disease (CCAOD) could form internal carotid artery steal pathways. Based on the diagnostic results of digital subtraction angiography (DSA), head and neck computed tomography angiography (CTA) was used to find the internal carotid artery stealing pathway after CCAOD.Methods: The clinical and imaging data of 18 patients with CCAOD were retrospectively analyzed. DSA and CTA was used to evaluate internal carotid artery steal pathways.ResultsOf the 18 patients with CCAOD, 10 patients found internal carotid artery steal pathways. There were 7 males and 3 females. Vascular ultrasound examination of all patients: The affected side had no blood flow in common carotid artery (CCA), and had retrograde blood flow in the external carotid artery (ECA). The blood flow of the affected side was decreased in the internal carotid artery (ICA), but it was antegrade. DSA diagnosed 10 cases of CCA occlusion and CTA diagnosed 10 cases of CCA occlusion. DSA and CTA found 6 internal carotid artery blood stealing pathways: ① Vertebral artery → occipital artery → external carotid artery → internal carotid artery (6 cases); ② Thyrocervical trunk → ascending cervical artery → occipital artery → external carotid artery → internal carotid artery (7 cases); ③ Costocervical trunk → deep cervical artery → occipital artery → external carotid artery → internal carotid artery (6 cases); ④ Affected side thyroid neck trunk → inferior thyroid artery → superior thyroid artery → external carotid artery → internal carotid artery (2 cases); ⑤ Contralateral external carotid artery → contralateral superior thyroid artery → affected superior thyroid artery → external carotid artery → neck Internal artery (2 cases); ⑥ Parathyroid neck → superficial cervical artery → occipital artery → external carotid artery → internal carotid artery (1 case).ConclusionsThe patients with CCAOD can find the internal carotid artery blood stealing pathway through CTA.

Venous and Arterial Responses to Partial Gravity.

Introduction: Chronic exposure to the weightlessness-induced cephalad fluid shift is hypothesized to be a primary contributor to the development of spaceflight-associated neuro-ocular syndrome (SANS) and may be associated with an increased risk of venous thrombosis in the jugular vein. This study characterized the relationship between gravitational level (Gz-level) and acute vascular changes.Methods: Internal jugular vein (IJV) cross-sectional area, inferior vena cava (IVC) diameter, and common carotid artery (CCA) flow were measured using ultrasound in nine subjects (5F, 4M) while seated when exposed to 1.00-Gz, 0.75-Gz, 0.50-Gz, and 0.25-Gz during parabolic flight and while supine before flight (0-G analog). Additionally, IJV flow patterns were characterized.Results: IJV cross-sectional area progressively increased from 12 (95% CI: 9–16) mm2 during 1.00-Gz seated to 24 (13–35), 34 (21–46), 68 (40–97), and 103 (75–131) mm2 during 0.75-Gz, 0.50-Gz, and 0.25-Gz seated and 1.00-Gz supine, respectively. Also, IJV flow pattern shifted from the continuous forward flow observed during 1.00-Gz and 0.75-Gz seated to pulsatile flow during 0.50-Gz seated, 0.25-Gz seated, and 1.00-Gz supine. In contrast, we were unable to detect differences in IVC diameter measured during 1.00-G seated and any level of partial gravity or during 1.00-Gz supine. CCA blood flow during 1.00-G seated was significantly less than 0.75-Gz and 1.00-Gz supine but differences were not detected at partial gravity levels 0.50-Gz and 0.25-Gz.Conclusions: Acute exposure to decreasing Gz-levels is associated with an expansion of the IJV and flow patterns that become similar to those observed in supine subjects and in astronauts during spaceflight. These data suggest that Gz-levels greater than 0.50-Gz may be required to reduce the weightlessness-induced headward fluid shift that may contribute to the risks of SANS and venous thrombosis during spaceflight.

Abstract 114: Diverse Patients Show Physiologic Benefit From Refined Sphenopalatine Ganglion Electrode Placement and Stimulation Level Selection to Augment Blood Flow and Neurologic Function in Acute Ischemic Stroke (The IMPACT-24M Trial)

Background: Two large RCTs have indicated sphenopalatine ganglion (SPG) stimulation reduces 3m disability in acute ischemic stroke patients with confirmed cortical involvement. The current trial evaluated two refinements in SPG stimulation technique: 1) SPG electrode placement with real-time optical tracking guidance; and 2) stimulation intensity comfortable tolerance level (CTL) selection using non-noxious facial physiologic markers. Methods: Single, active arm trial at 4 centers, enrolling patients with anterior circulation ischemic stroke &lt;24h, NIHSS 1-6, not receiving recanalization therapies. Stimulation level was based on ipsilateral facial tingling sensation or lacrimation. SPG stimulation effects were assessed by volumetric blood flow in the ipsilateral common carotid artery (ultrasound) and affected hand grasp and pinch strength before and during stimulation, and by NIHSS change by day 7. Results: Among 50 enrolled patients, age was median 66y (IQR 60-74), 44% female, NIHSS median 5 (IQR 4-5), and median onset-to-screening time 18h (IQR 9-20). Median implantation skin-to-skin time was 4 minutes (IQR 3-7) and all 50 implants were placed correctly. CTL was found based on physiological biomarkers in 96% of patients, including 86% in the optimal, low-medium intensity range. SPG stimulation significantly increased common carotid artery peak systolic and end diastolic blood flow (up 44%, p&lt;0.0001; and up 52%, p&lt;0.0001) and improved pinch strength (up 42%, p&lt;0.0001) and grasp strength (up 26%, p&lt;0.0001). Degree of NIHSS recovery by day 7 was greater than in matched historic controls, median 75% vs 50%, p=0.0003. Forest plot analysis showed benefits were homogenous across the subgroups of: sex, age, time from onset, stroke side, NIHSS, and ASPECTS score. Conclusion: SPG stimulator placement with real-time optical tracking guidance was fast and accurate, and selection of optimal stimulation intensity levels based on non-noxious facial tingling and lacrimation was feasible in nearly all patients. SPG activation led to cranial blood flow augmentation and improved hand motor function during stimulation, and neurologic deficit reduction at 1 week, consistently across broad patient subsets of age, sex, side, severity, and time to treatment.

Comparison of cardiac output measured by carotid artery Doppler ultrasound and echocardiography in patients admitted to Golestan and Imam Khomeyni Hospitalsl in Ahvaz.

Introduction:Ultrasound is highly effective, safe, and cost-effective for monitoring the hemodynamics and measuring the cardiac output of patients. This study aims to investigate the value of cardiac output by the measurement of common carotid artery flow, which is an inexpensive, simple, and accessible method.Method:Doppler ultrasound of the carotid artery at thyroid level was obtained from the patients admitted to Golestan and Imam Khomeyni Hospitals in Ahvaz (the result is recorded medially from the bilateral outputs unless otherwise prescribed on one side due to a problem such as a catheter or specific position). A transthoracic echocardiography was also recorded using a portable device to measure the left ventricular outlet of diameter 0.5 cm below the aortic valve in the left parasternal with a long axis view.Results:Of the 94 patients studied between the ages of 25 to 87 years, 53 (56.4%) were males and 41 (43.6%) females with a mean age of 53.61 with a standard deviation of 14.56. There was a direct and significant relationship between age and cardiac output using both echocardiography and color Doppler carotid ultrasound (P < 0.001).Discussion:The results of this study showed that the measurement of cardiac output using color Doppler ultrasound in the case of inaccessible emergency echocardiography is a cheap, simple, and accessible method for the hemodynamic evaluation of patients.

Thoracic Endovascular Aortic Repair Using Combined the Najuta Fenestrated Stent Graft Plus the Distal Ctag Stent Graft for Aortic Arch Aneurysm

Introduction - The Najuta fenestrated stent graft extend the proximal sealing zone during thoracic endovascular aortic repair (TEVAR). On the other hand, the CTAG stent graft has good conformability in the inner curvature of the aortic arch and has a less spring-back force of the stent graft. Based on these strength, we used the Najuta fenestrated graft for proximal fixation while the CTAG was used for distal landing for TEVAR of aortic arch in high-risk patients. We report the early results of this combined strategy. Methods - From January 2015 to March 2018, 117 TEVARs were performed in our facility. 16 patients (94% male; mean age 75 years) treated with combined the Najuta plus the CTAG stent graft. Results -TAA were fusiform in 7 cases, saccular in 4, dissecting in 4, and 1 patient was treated for proximal type 1 endoleak after previous TEVAR. The stent graft was landed in zone 0 in 13 cases, in zone 1 in 3 cases. The Najuta custom made fenestration was designed to preserve flow in the left common carotid artery in 11 patients, in the left subclavian artery in 2. There were 10 cases (63%) in which we could avoid the debranching bypass. No proximal type 1 endoleak occurred and proximal sealing was achieved in all cases. Technical success was 100% with no 30-day mortality. Mean operative time was 185 minutes. All targeted vessels were patent. One stroke occurred with TEVAR landing in zone 0 with an overall stroke rate of 6%. No paraplegia and retrograde dissection were encountered. During a mean follow up of 12 months, no conversion to open surgical repair and no aortic rupture occurred. Conclusion - Combined proximal Najuta and distal CTAG stent grafting appears to be a safe and effective treatment. This strategy also decreases the need for debranching bypass procedures.

Refined Sphenopalatine Ganglion Stimulator Placement and Intensity Setting to Augment Blood Flow and Neurologic Function.

Background and Purpose- Two large, randomized trials indicated that sphenopalatine ganglion (SPG) stimulation improves final disability outcome in acute anterior circulation patients with ischemic stroke with confirmed cortical involvement. This study evaluated 2 refinements in SPG stimulation treatment technique: (1) SPG electrode placement with real-time optical tracking guidance; and (2) stimulation intensity comfortable tolerance level selection using non-noxious facial physiological markers. Methods- This study was a single, active arm trial at 4 centers, enrolling patients with anterior circulation ischemic stroke, National Institutes of Health Stroke Scale 1 to 6 including arm weakness subitem score ≥1, not receiving recanalization therapies, and within 24 hours of onset. Stimulation level was set based on ipsilateral facial tingling sensation or lacrimation. SPG stimulation effects were assessed by measuring volumetric blood flow in the ipsilateral common carotid artery by ultrasound and grasp and pinch strength in the affected hand before and during stimulation, and by change in National Institutes of Health Stroke Scale from day 1 to 7. Results- Among 50 enrolled patients, age was median 66 years (interquartile range, 60-74), 44% were female, National Institutes of Health Stroke Scale median was 5 (interquartile range, 4-5), and median onset-to-screening time was 18 hours (interquartile range, 9-20). Median implantation skin-to-skin time was 4 minutes (interquartile range, 3-7), and all 50 implants were placed correctly. Comfortable tolerance level was found based on physiological biomarkers in 96% of patients, including 86% in the optimal, low-medium intensity range. SPG stimulation significantly increased common carotid artery peak systolic and end-diastolic blood flow (44%, P<0.0001; and 52%, P<0.0001) and improved pinch strength (42%, P<0.0001) and grasp strength (26%, P<0.0001). Degree of National Institutes of Health Stroke Scale recovery by day 7 was greater than in matched historic controls, median 75% versus 50%, P=0.0003. Conclusions- SPG stimulator placement with real-time optical tracking guidance was fast and accurate, and selection of stimulation intensity levels based on non-noxious facial tingling and lacrimation was feasible in nearly all patients. SPG stimulation led to cervico-cranial blood flow augmentation and improved hand motor function. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT03551093.