Complete Infarction Research Articles

Effectiveness of Elective Unilateral Uterine Artery Embolization: A Case-control Study

Purpose To evaluate the effectiveness of elective unilateral uterine artery embolization (UAE) in limited fibroid disease. Materials and Methods A review of 1,431 UAE recipients at a single institution identified 76 who underwent unilateral embolization, most in the setting of anatomic variants or technical failure. A total of 28 had intentional unilateral UAE because of unilateral disease on magnetic resonance (MR) imaging with supply from only the ipsilateral uterine artery on angiography. These 28 case-group patients were compared with a control group of 28 patients who underwent bilateral UAE contemporaneously. Outcome measures included a chief symptom resolution score, fluoroscopy time, tumor infarction rate, patient satisfaction, analgesia requirements, and maximum pain score. Baseline characteristics and outcome measures were compared with t tests, Pearson χ 2 tests, analyses of variance, and nonparametric tests. Results Three-month clinical follow-up and postprocedure MR imaging were available for 25 of the case-group patients. The unilateral UAE group had fewer analgesia doses demanded (28.8 vs 57.5; P = .049), lower total analgesia dose (22.8 mg vs 34.5 mg; P = .029), shorter fluoroscopy time (10.9 min vs 13.4 min; P = .013), and lower maximum pain score (3.7 vs 5.7; P = .003). There were no differences in chief symptom resolution score (2.1 vs 1.9; P = .27), satisfaction score (4.0 vs 4.0; P = .72), or complete tumor infarction (92% vs 88%; P = .64). Conclusions Unilateral UAE in appropriately selected patients has similar clinical results as standard bilateral UAE and is associated with reduced fluoroscopy time and postprocedural pain.

Gangrena intestinal aguda masiva.

Acute mesenteric ischemia is a life-threatening vascular emergency that has a mortality rate between 70 and 80%. To improve the survival of these patients it requires a high indes of suspicion, early and aggresive resuscitation manuevers. Regardless of etiology, the acute interruption of perfusion of the small intestine and proximal colon progresses from potentially reversible physiologic alterations in tissue integrity to complete transmural infarction with hemorrhagic necrosis

Another Score to Predict Ischemic Stroke Mortality?

An 84-year-old man with a history of atrial fibrillation, congestive heart failure, and chronic renal insufficiency has a moderate to severe right middle cerebral artery infarct. He was not a candidate for intravenous or intra-arterial thrombolytics because of symptom onset on awakening and a completed infarct with no appreciable penumbra on computed tomography angiography or computed tomography perfusion. Following acute stabilization of patients like this man, the primary goals of care are to prevent complications and to begin rehabilitation. In addition, discussions with family regarding code status, end-of-life care preferences, and prognosis occur soon after admission. Clinicians generally rely on their anecdotal experience when these discussions occur, and these predictions have been shown to be relatively good. In one study of ischemic stroke patients, 90% of patients predicted to do poorly were dead or dependent at 6 months.1 However, clinicians tend to overestimate the likelihood of good outcome in stroke patients. In the same study, only 65% of ischemic and hemorrhagic stroke patients predicted by clinicians to survive 1 year and be independent were actually independent (defined as modified Rankin Score ≤2).1 Having a quantitative estimate of mortality or outcome in a patient such as this gentleman can help guide family discussions, since reliance solely on clinical prediction is insufficient. Article see p 739 Multiple prognostic models for mortality and functional status in stroke patients have been developed and validated. Simple models that include only age and National Institutes of Health Stroke Scale within the first 6 hours of symptom onset were shown to predict mortality up to 150 days poststroke.2 In this stroke population, mortality was predicted better by the models than by the treating physicians' …

Early Decompressive Hemicraniectomy in Older Patients With Nondominant Hemispheric Infarction Improves Outcome

### The Case: A 70 year-old right-handed woman with a massive right MCA infarction and 3 mm midline shift is seen within 17 hours of onset. ### The Questions: ### The Controversy: Early decompressive hemicraniectomy in older patients with non-dominant hemispheric infarction improves outcome. To answer the questions regarding the efficacy of hemicraniectomy in older patients with malignant middle cerebral artery infarctions, several facts and open questions must be considered. First, the natural course of complete middle cerebral artery infarctions is associated with early death in 70% to 80% of cases. This “malignant” and deadly course can also be seen in older patients. Second, in case of survival, recovery with a complete functional independent outcome is almost impossible.1 Third, there is no proven standard medical or conservative critical care management. Standard care is largely ineffective and probably not better than palliative care.1,2 Osmotherapy, hyperventilation, buffers, barbiturates, and hypothermia are unproven, ineffective, or even detrimental.2 Fourth, the efficacy …

Complete versus culprit only revascularization in acute ST elevation myocardial infarction: A meta‐analysis

Current guidelines recommend against the revascularization of noninfarct related artery (complete revascularization [CR]) in patients with ST elevation myocardial infarction (STEMI) and no hemodynamic compromise, though level of evidence is C. Our aim was to examine the available evidence to determine any advantage of CR over culprit only revascularization (COR). We systematically searched medline using key words-"culprit coronary revascularization," "complete revascularization myocardial infarction," and "multivessel STEMI" for studies reporting outcomes after COR versus CR during primary procedure or index hospitalization published in English language and indexed before February 2010. A random effect or fixed effect meta-analysis, as applicable, was performed using RevMan 5 (Cochrane Center, Denmark). Nine eligible nonrandomized studies amounting to 4,530 patients in CR and 27,323 patients in COR group were included. In addition, two small randomized trials were reviewed and included in secondary analysis. Majority of patients were hemodynamically stable. Major adverse cardiovascular events (Odds ratio [OR] = 0.95, 95% CI 0.47-1.90) and long term mortality (OR = 1.10, 95% CI 0.76-1.59) were similar. The marginal increased odds of in-hospital mortality was derived from a single study with no difference found after sensitivity and cumulative analysis (OR = 1.21 95% CI 0.85-1.73). Current analysis of heterogeneous studies did not reveal any benefit of CR over COR in patients with STEMI. However, also provide no conclusive evidence of increased in hospital mortality after CR. A randomized trial is needed to confirm these findings and recognize any subgroup which might benefit from CR.

Bilateral In Utero Cerebellar Infarction

We report a case of complete bilateral cerebellar infarction diagnosed in utero by routine prenatal ultrasound and magnetic resonance imaging in a 26-week-old fetus. This posterior fossa ischemic stroke with secondary hemorrhage caused transient obstructive hydrocephalus and likely occurred subsequent to vertebrobasilar artery thrombosis. Such posterior fossa ischemic insults diagnosed in utero are rare with scarce clinical reports. The serial imaging characteristics, clinical, and developmental implications of this case are reviewed.

脳梗塞急性期における拡散強調画像での高信号領域の可逆的信号強度に関する研究

The high signal intensity (SI) of diffusion weighted image (DWI) is well correlated with complete brain infarction. High SI of DWI includes reversible and/or irreversible ischemia, and the borderline between them has not been confirmed clearly yet. In this report, we elucidate the clinical borderline of ischemic condition of reversibility concerned with SI of DWI at the acute ischemic stage. MRI data were collected in 15 patients with acute stroke who achieved recanalization within 6 hours from onset. SI was investigated with correlation to the apparent diffusion coefficient (ADC) and ratio to normal location as standard. An inversed correlation was demonstrated between signal intensity of DWI and ADC. The irreversible borderline was less than 0.56 (10-3 mm2/s) in ADC and it was equal to a signal intensity of more than 175 in DWI. The signal ratio effectively divided infarct and retained when the basic standard site was anatomical contralateral point. The irreversible borderline of the signal ratio was more than 1.4 to the contralateral portion in DWI. This study suggests SI in DWI can be a criterion for ischemic reversibility.

Embolization of Uterine Leiomyomas with Polyzene F–coated Hydrogel Microspheres: Initial Experience

To evaluate effectiveness and safety of Polyzene F-coated hydrogel microspheres for uterine artery embolization (UAE) in women with symptomatic uterine leiomyomas. Between August 2006 and August 2008, 86 nonconsecutive premenopausal women (mean age, 43.9 years; median, 44 y; range, 28-54 y) were treated with UAE. Calibrated microspheres of 500, 700, and 900 μm, alone or in combination, were used as embolic agents. Change in uterine and tumor volume and tumor infarction rate during follow-up were assessed with magnetic resonance imaging. Clinical follow-up was evaluated by the Uterine Fibroid Severity and Quality Of Life (UFS-QOL) questionnaire at baseline, 3 months, and last follow-up in November 2008. At 3 months, mean volume reductions of the dominant leiomyoma and uterus were 45% and 42%, respectively, and complete infarction of the dominant leiomyoma was achieved in 69 patients (80%). Complete infarction of the overall tumor burden was achieved in 52 patients (60%). Infarction rates of the dominant tumor and overall tumor burden were more than 90% in 81 patients (94%) and 79 patients (91%), respectively. During follow-up, permanent amenorrhea developed in seven women (8.1%). Four women (4.7%) had additional therapy after UAE; three had a hysterectomy and one had a second embolization. The UFS-QOL showed significant improvement in symptom severity and quality of life after 3 months that continued to improve at last follow-up (mean, 12.8 months). In this preliminary study, Polyzene F-coated hydrogel microspheres for UAE resulted in good dominant and overall tumor infarction in most patients, with corresponding improvement of symptoms. Determining optimal sizing of the material and comparing outcomes versus those of other embolic agents requires additional study.

Upstream tirofiban reduces reperfusion cardiac arrhythmias in patients of acute ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

“Open the artery in time” has become the dogma in treating ST-elevation myocardial infarction (STEMI) since the 1990s. It has been a consensus that the more patent the infarct-related artery (IRA), the better the clinical outcomes [ 1 Simes R.J. Topol E.J. Holmes Jr., D.R. et al. Link between the angiographic substudy and mortality outcomes in a large randomized trial of myocardial reperfusion. Importance of early and complete infarct artery reperfusion. GUSTO-I Investigators. Circulation. 1995; 91: 1923-1928 Crossref PubMed Scopus (463) Google Scholar , 2 Anderson J.L. Karagounis L.A. Califf R.M. Meta-analysis of five reported studies on the relation of early coronary patency grades with mortality and outcomes after acute myocardial infarction. Am J Cardiol. 1996; 78: 1-8 Abstract Full Text PDF PubMed Scopus (160) Google Scholar ]. In addition, the strategies of reperfusion, referring to intravenous thrombolytics and primary percutaneous coronary interventions (pPCI), have been proved to differ among themselves in acute success of reperfusion and long-term outcomes. The pPCI is better in restoring the coronary blood flow and renders less complications than thrombolytic therapy [ 3 Zijlstra F. de Boer M.J. Hoorntje J.C.A. Reiffers S. Reiber J.H. Suryapranata H. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med. 1993; 328: 680-684 Crossref PubMed Scopus (1177) Google Scholar , 4 Zeymer U. Schroder R. Machnig T. Neuhaus K.L. Primary percutaneous transluminal coronary angioplasty accelerates early myocardial reperfusion compared to thrombolytic therapy in patients with acute myocardial infarction. Am Heart J. 2003; 146: 686-691 Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar ]. As the platelet plays the central role in triggering the acute thrombotic mechanism in STEMI, the complete inhibition of the platelet function, from adhesion, activation to aggregation, has been the focus of current optimal anti-platelet therapy. The standard dual anti-platelet therapy (DAT), consisting of aspirin and clopidogrel, exerts its function to counteract the platelet activation. The inadequacy and negligence to inhibiting platelet aggregation at the time of pPCI were proved to result in more major adverse cardiovascular events (MACE), especially in patients of clopidogrel resistance [ [5] Matetzky S. Shenkman B. Guetta V. et al. Clopidogrel resistance is associated with increased risk of recurrent atherothrombotic events in patients with acute myocardial infarction. Circulation. 2004; 109: 3171-3175 Crossref PubMed Scopus (1282) Google Scholar ]. It is also said “the lower the platelet reactivity, the less the myocardial necrosis and the better the clinical outcomes [ [6] Campo G. Valgimigli M. Gemmati D. et al. Value of platelet reactivity in predicting response to treatment and clinical outcome in patients undergoing primary coronary intervention. Insights into the STRATEGY Study. J Am Coll Cardiol. 2006; 48: 2178-2185 Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar ].” In order to further block the platelet aggregation, adding a glycoprotein IIb/IIIa (GP IIb/IIIa) antagonist, thus formulating the triple anti-platelet therapy, has been recommended for high risk non-ST-elevation acute coronary syndromes (NSTEACS) [ [7] Bassand J.P. Hamm C.W. Ardissino D. et al. Task force for diagnosis and treatment of non ST elevation acute coronary syndromes. Eur Heart J. 2007; 28: 1598-1660 Crossref PubMed Scopus (49) Google Scholar ]. GP IIb/IIIa antagonist, especially tirofiban, could be adopted as one of the background therapy in dealing with NSTEACS [ [8] Hsin H.T. Li A.H. Yeih D.F. et al. Two-year follow-up of tirofiban-based management of non-ST-elevation acute coronary syndrome — a single center study. Acta Cardiol Sin. 2010; 26: 19-27 Google Scholar ]. On the other hand, peri-PCI abciximab has been demonstrated to significantly improve reperfusion in the infarct region and clinical outcomes of patients with STEMI undergoing pPCI, which has been regarded as class IIa recommendation since 2004 [ 9 Van de Werf F. Ardissino D. Betriu A. et al. Management of acute myocardial infarction in patients presenting with ST-segment elevation. The Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J. 2003; 24: 28-66 Crossref PubMed Scopus (1491) Google Scholar , 10 Antman E.M. Anbe D.T. Armstrong P.W. et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004; 44: E1-E211 Abstract Full Text PDF PubMed Google Scholar ]. However, the role of tirofiban is rather obscure. The efficacy and timing to administer tirofiban in STEMI are still on debate.

White Matter Hyperintensity Burden and Susceptibility to Cerebral Ischemia

White matter hyperintensity (WMH) burden increases risk of ischemic stroke; furthermore, it predicts infarct growth in acute cerebral ischemia. We hypothesized that WMH would be less severe in patients with TIA as compared to those with acute ischemic stroke and completed infarct. Cases (TIA, n = 30) and controls (acute ischemic stroke, n = 120) were selected from an ongoing longitudinal cohort study of patients with stroke and matched for age, gender, and race/ethnicity. All subjects had brain MRI within 48 hours of presentation to evaluate for evidence of acute cerebral ischemia. WMH burden on MRI was quantified using a validated computer-assisted program with high inter-rater reliability. Median WMH volume in individuals with TIA was 3.7 cm³ (interquartile range, 1.5 - 8.33 cm³) compared to 6.9 cm³ (interquartile range, 3.1-11.9 cm³) in acute ischemic stroke (P < 0.04). In multivariable analysis, the odds of completed infarct were higher (OR, 2.19; 95% CI, 1.27-3.77; P < 0.005) in subjects with larger volumes of WMH. WMH burden was significantly less in subjects with TIA as opposed to those with ischemic stroke. These data provide further evidence to support a detrimental role of WMH burden on the capacity of cerebral tissue to survive acute ischemia.

Brain choline concentration

Better prediction of tissue prognosis in acute stroke might improve treatment decisions. We hypothesized that there are metabolic ischemic disturbances measurable noninvasively by proton magnetic resonance spectroscopy ((1)H MRS) that occur earlier than any structural changes visible on diffusion-tensor imaging (DTI), which may therefore serve for territorial identification of tissue at risk. We performed multivoxel (1)H MRS plus DTI within a maximum of 26 hours, and DTI at 3-7 days, after ischemic stroke. We compared choline, lactate, N-acetylaspartate, and creatine concentrations in normal-appearing voxels that became infarcted (infarct expansion) with normal-appearing voxels around the infarct that remained "healthy" (nonexpansion) on follow-up DTI. Each infarct expansion voxel was additionally classified as either complete infarct expansion (infarcted tissue on follow-up DTI covered > or =50% of the voxel) or partial infarct expansion (<50% of voxel). In 31 patients (NIH Stroke Scale score 0-28), there were 108 infarct nonexpansion voxels and 113 infarct expansion voxels (of which 80 were complete expansion and 33 partial expansion voxels). Brain choline concentration increased for each change in expansion category from nonexpansion, via partial expansion to complete expansion (2,423, 3,843, 4,158 IU; p < 0.05). Changes in lactate, N-acetylaspartate, and creatine concentrations in expansion category were insignificant although for lactate there was a tendency to such association. Choline concentration measurable with (1)H MRS was elevated in peri-ischemic normal-appearing brain that became infarcted by 3-7 days. The degree of elevation was associated with the amount of infarct expansion. (1)H MRS might identify DTI-normal-appearing tissue at risk of conversion to infarction in early stroke.

Effect of Uterine Artery Embolization on Uterine and Leiomyoma Perfusion: Evidence of Transient Myometrial Ischemia on Magnetic Resonance Imaging

To document immediate and short-term changes in uterine perfusion after uterine artery embolization (UAE). Fifteen patients (median age, 42 years) underwent UAE with tris-acryl gelatin microspheres and a limited embolization protocol. Contrast-enhanced magnetic resonance imaging was performed before therapy and 1 hour (immediate), 48-72 hours (subacute), and a median of 5 months (short-term follow-up) after UAE to determine uterine and leiomyoma perfusion. Leiomyomas with a minimum diameter of 10 mm were included. Changes in regional (ie, fundus/body/cervix), zonal (ie, endometrium/inner/middle and outer myometrial layer), and leiomyoma perfusion were documented. UAE was technically successful in all patients. Immediate contrast-enhanced MR imaging revealed ischemia of the uterine body and fundus. The endometrium and inner myometrial layer was involved in all 15 patients; the middle layer was also involved in 13. Ischemic defects were seen in the outer layer in one patient but never in the cervix. Subacute follow-up showed reperfusion of the myometrium in 73% of patients. Ischemic defects occurred in the endometrial and junctional zone in four patients and in the middle zone in one. Five-month follow-up showed perfusion of all uterine layers in all patients. Ten patients had complete infarction of all leiomyomas; five presented with 11 partially perfused leiomyomas. Limited bilateral UAE leads to transient uterine ischemia, particularly involving the endometrium and inner and middle zone of the myometrium of the uterine body and fundus. The cervix and subserosal layer are spared. Complete reperfusion of myometrial tissue is observed within 48-72 hours in most cases, whereas ischemic leiomyomas undergo irreversible infarction.

Uterine Artery Embolization for Leiomyomas: Percentage of Infarction Predicts Clinical Outcome

To determine the effect of partial versus complete leiomyoma infarction on relief of leiomyoma-related symptoms and freedom from invasive reinterventions and to assess if patient age, location of the dominant leiomyoma, number of leiomyomas, or baseline uterine and dominant leiomyoma volume were associated with clinical failure. Study protocol was approved by the institutional review board, and informed consent was obtained. One hundred fifteen consecutive women (median age, 42 years; range, 34-61 years) with symptomatic uterine leiomyomas underwent contrast material-enhanced magnetic resonance (MR) imaging at baseline and 24-72 hours after uterine artery embolization (UAE) to determine the percentage of infarction of leiomyoma tissue (complete = 100%, almost complete = 90%-99%, and partial = 0%-89%). Clinical outcome and frequency of reinterventions were compared for up to 36 months. One hundred thirteen patients completed at least one clinical follow-up. Twenty-four months after UAE, 50% +/- 15.2 (standard error) of the patients with partial infarction and 80% +/- 13.4 (standard error) of patients with almost complete infarction had undergone no reintervention. No patient with complete infarction needed a second treatment (P < .001). The hazard ratios for reintervention between the complete infarction group and the almost complete and partial infarction groups were 15.88 (95% confidence interval [CI]: 1.22, 2225.54; P = .034) and 73.08 (95% CI: 8.33, 9636.35; P < .001), respectively. There were significant differences in hazard ratios between patients with partial and those with complete infarction for persistence or recurrence of menorrhagia (hazard ratio, 7.45; 95% CI: 2.08, 28.31; P = .002) and bulk-related symptoms (hazard ratio, 5.90; 95% CI: 1.66, 21.92; P = .007). There was no significant correlation between patient age, number of leiomyomas, location of the dominant leiomyoma, or baseline uterine and dominant leiomyoma volume and clinical failure. Women with leiomyoma infarction above 90% on contrast-enhanced MR images after UAE show significantly better symptom control and fewer reinterventions than do patients with a lower infarction rate.

Retained placental tissue: role of MRI findings in diagnosis and clinical assessment

To assess the role of MRI in diagnosis and predicting clinical outcome in women with retained placental tissue. Eleven patients with pathologically proven RPT were retrospectively studied. All underwent MRI. The following MRI parameters of RPT were studied: size, signal intensity on T1- and T2-weighted images, enhancement pattern on dynamic study, extent of attachment to the uterine myometrium, and myometrial thickness at the attachment site. Clinical reports were reviewed and MRI findings were compared with respect to outcome. RPT diameter varied from 30 to 102 mm. On T2-weighted images, 10 cases showed high intensity, while on T1-weighted images, seven cases showed high intensity. Nine cases were hypervascular. The myometrium was thinner at the attachment side than at the opposite side. All five cases in which RPT was delivered spontaneously showed an attachment area of less than a semicircle, hence broad attachment appears to impede detachment and necessitate additional therapy. After uterine arterial embolization, two patients showed complete infarction of RPT on enhanced MRI. MRI is useful for diagnosis and follow-up of RPT. The evaluation of extent of RPT attachment to the myometrium and vascularity on MRI can help the clinical assessment.

CT and MR imaging of primary cerebrovascular complications in pediatric head trauma

The incidence of severe traumatic head injury in children has constantly increased over the last years. Diagnostic imaging has become an unrenounceable tool for the documentation and follow-up of intracranial lesions. The use of magnetic resonance imaging (MRI) in the early posttraumatic phase has led to a more thorough understanding of intracranial injuries. We retrospectively analyzed the cranial computed tomography (CCT) and magnetic resonance (MR)-studies of patients with traumatic head injuries for primary cerebrovascular complications. In 64 children (45 male, 19 female) with traumatic head injuries, CCT and MR examinations were available for analysis. The children's age ranged from 3 months to 15 years with a median age of 7 years. All patients had initial CCT on admission to the hospital with follow-up examinations depending on clinical state and initial imaging findings. All patients had at least one MR examination between 0 to 120 days after the trauma with a median time interval of 17 days. In five of 64 (7.8%) patients, cerebrovascular complications were found on imaging studies. Initial imaging within the first 24 h after the trauma detected a complete middle cerebral artery infarction in one patient and extensive sinus thrombosis after a complex skull fracture in another. In two patients, thrombosis of the transverse sinus appeared on MRI 4 to 6 days after the trauma. In another patient with open-skull injury, a posttraumatic aneurysm of the pericallosal artery was diagnosed on MRI 30 days after the trauma. Our study shows that, although primary cerebrovascular lesions after traumatic head injuries in children are rare, the radiologist should be aware of the characteristic injury patterns and the time appearance of imaging findings on CT and MRI.

Incomplete Brain Infarction

We present a 70-year-old man who suffered two attacks of possible incomplete infarction. At the first attack, the responsible lesion was unclear on MRI including DWI, but demonstrated a high uptake of (99m)Tc-ECD SPECT during the acute phase; thereafter the lesion became atrophic with a low uptake on SPECT during the chronic phase. At the second attack, the responsible lesion revealed weakly hyperintense changes on DWI without marked changes on conventional modalities, but had a high uptake on SPECT and capillary blush on angiography during the acute phase. It is suggested that incomplete infarction can solely result in a massive and clinically critical lesion without an accompanying complete infarction.

Impact of distal embolization on myocardial perfusion and survival among patients undergoing primary angioplasty with glycoprotein IIb–IIIa inhibitors: insights from the EGYPT cooperation

Even though primary angioplasty is able to obtain TIMI 3 flow in the vast majority of STEMI patients, epicardial recanalization does not guarantee optimal myocardial perfusion, that remain suboptimal in a relatively large proportion of patients. Large interest has been focused in recent years on the role of distal embolization as major determinant of impaired reperfusion. The aim of the current study was to investigate in a large cohort of STEMI undergoing primary angioplasty with Gp IIb-IIIa inhibitors the impact of distal embolization on myocardial perfusion and survival. Our population is represented by patients undergoing primary angioplasty for STEMI included in the EGYPT database. Distal embolization was defined as an abrupt ''cutoff'' in the main vessel or one of the coronary branches of the infarct-related artery, distal to the angioplasty site. Myocardial perfusion was evaluated by angiography or ST-segment resolution, whereas infarct size was estimated by using peak CK and CK-MB. Follow-up data were collected between 30 days and 1 year after primary angioplasty. Data on distal embolization were available in a total of 1182 patients (71% of total population). Distal embolization was observed in 132 patients (11.1%). Patients with distal embolization were older (P < 0.001), with larger prevalence of diabetes (P = 0.01), previous MI (P = 0.048) and advanced Killip class at presentation (P = 0.018), abciximab administration (P < 0.001), with a lower prevalence of smoking (P = 0.04). Patients with distal embolization had more often poor preprocedural recanalization (P = 0.061), less often postprocedural TIMI 3 flow (P < 0.001), postprocedural MBG 2-3 (P < 0.001), complete ST-segment resolution (P = 0.021) and larger infarct size (CK-MB: 328 +/- 356 U/l vs. 259 +/- 226 U/l, P = 0.012). The impact of distal embolization on myocardial perfusion was confirmed after correction for baseline confounding factors as evaluated by MBG 2-3 (adjusted OR [95% CI] = 3.14 [2.06-4.77], P < 0.0001) but not complete ST-segment resolution (adjusted OR [95% CI] = 1.23 [0.84-1.92], P = 0.26). At 208 +/- 160 days follow-up, distal embolization was associated with a significantly higher mortality (9.2% vs. 2.7%, HR [95% CI] = 3.41 [1.73-6.71], P < 0.0001), that was confirmed after correction for baseline confounding factors (adjusted HR [95% CI] = 2.23 [1.1-4.7], P = 0.026). This study showed among STEMI patients treated with Gp IIb-IIIa inhibitors, that distal embolization is independently associated with impaired myocardial perfusion and survival.

Beneficial Effects of Electrical Vagal Stimulation on Heart Failure Progression May Involve Central Mechanism

We have shown that electrical vagal nerve stimulation prevented cardiac remodeling and improved survival in rats with completed myocardial infarction and subsequent development of chronic heart failure. To make some insights into the mechanism, we examined the effect of coadministration of beta-adrenergic blockers, and the effect on salt intake and plasma arginine vasopressin in 8-week male SD rats after extensive myocardial infarction. Vagal stimulation was similarly effective for anti-remodeling either with or without metoprolol, or either with or without salt restriction.

Uterine Artery Embolization versus Laparoscopic Occlusion of Uterine Arteries for Leiomyomas: Long-term Results of a Randomized Comparative Trial

To compare long-term symptom recurrence and 6-month magnetic resonance (MR) imaging results after two different treatments for uterine leiomyomas. Sixty-six women with uterine leiomyomas were randomized to undergo uterine artery embolization (UAE) or laparoscopic bilateral occlusion of uterine arteries. Contrast-enhanced MR imaging was performed before treatment and after 6 months. Fifty-eight patients received treatment. Median follow-up time was 48 months (range, 8-73 months). Clinical failure and symptom recurrence occurred in 14 patients after laparoscopy (48%) and in five after UAE (17%; P = .02, log-rank test). Hysterectomy was performed in two patients after UAE (7%) and in eight after laparoscopy (28%; P = .041). Six-month MR imaging results were available for 26 patients treated with UAE and 22 treated with laparoscopy. The mean uterine volume was reduced by 51% (range, 16%-86%) after UAE treatment, compared with 33% (range, 6%-77%) after laparoscopy (P = .001). Complete leiomyoma infarction was seen in all 26 patients in the UAE group and in only five patients in the laparoscopy group (P < .001). Eleven patients experienced symptom recurrence later than 6 months. Uterine volume reduction at 6 months was 24% in this group, compared with 48% in the 37 patients with no recurrence (P = .004). Incomplete infarction of leiomyomas was seen in eight of the 11 cases of recurrence (73%) versus nine of 37 cases without recurrence (24%; P = .009). Recurrence rate was significantly lower after UAE than after laparoscopic treatment. Larger volume reduction and more complete devascularization of leiomyomas were found after UAE treatment and among patients with no recurrence.

Neuronal Circuit Remodeling in the Contralateral Cortical Hemisphere during Functional Recovery from Cerebral Infarction

Recent advances in functional imaging of human brain activity in stroke patients, e.g., functional magnetic resonance imaging, have revealed that cortical hemisphere contralateral to the infarction plays an important role in the recovery process. However, underlying mechanisms occurring in contralateral hemisphere during functional recovery have not been elucidated. We experimentally induced a complete infarction of somatosensory cortex in right hemisphere of mice and examined the neuronal changes in contralateral (left) somatosensory cortex during recovery. Both basal and ipsilateral somatosensory stimuli-evoked neuronal activity in left (intact) hemisphere transiently increased 2 d after stroke, followed by an increase in the turnover rate of usually stable mushroom-type synaptic spines at 1 week, observed by using two-photon imaging in vivo. At 4 weeks after stroke, when functional recovery had occurred, a new pattern of electrical circuit activity in response to somatosensory stimuli was established in intact ipsilateral hemisphere. Thus, the left somatosensory cortex can compensate for the loss of the right somatosensory cortex by remodeling neuronal circuits and establishing new sensory processing. This finding could contribute to establish the effective clinical treatments targeted on the intact hemisphere for the recovery of impaired functions and to achieve better quality of life of patients.