Initial Conservative Treatment Research Articles

Outcome after conservative management or surgical treatment for new-onset epilepsy in cerebral cavernous malformation.

OBJECTIVE The aim of this study was to determine seizure outcome, functional outcome, and the withdrawal of antiepileptic drugs (AEDs) after conservative or surgical treatment of patients with new-onset cavernoma-related epilepsy (CRE). METHODS The authors conducted a retrospective comparative observational study of 79 consecutive patients, each with a single sporadic cerebral cavernous malformation (CCM) and new-onset CRE. RESULTS Forty-one patients underwent initial surgery (IS), and 38 patients underwent initial conservative (IC) treatment. Of those in the latter group, 19 underwent delayed surgical (DS) treatment. At the last follow-up, 88%, 32%, and 79% of patients in the respective groups had been seizure free for at least 2 years (International League Against Epilepsy [ILAE] Class 1; IS vs IC, p < 0.0001) and 78%, 8%, and 58%, respectively, had been off AEDs (IS vs IC, p < 0.0001). The cumulative probability of staying seizure free (ILAE Class 1) during a 5-year period was 73% (mean seizure-free follow-up 49.8 ± 2.7 months, 95% CI 44.4-55.1 months) for the IS group, 22% (mean 31.8 ± 3.6 months, 95% CI 24.8-38.8 months) for the IC group, and 68% (mean 48.6 ± 4.3 months, 95% CI 40.1-57.1 months) for the DS group (IS vs IC p < 0.001). Long-term operative morbidity was 3%, and long-term morbidity in the conservatively treated group was also 3%. CONCLUSIONS Patients with CCM and new-onset CRE who underwent IS treatment showed better results in seizure control and the discontinuation of AEDs than the conservatively treated patients. Operative morbidity was comparable to the morbidity from symptomatic CCM hemorrhage in the conservative group. Half of the patients who started with conservative treatment underwent subsequent surgical treatment; however, a longer duration of epilepsy prior to surgery did not worsen postoperative seizure outcome.

Complicated pneumothorax and congenital lung cystic malformation

Congenital cystic adenomatoid malformation, also named congenital pulmonary airway malformation (CPAM), is a congenital lung abnormality which is uncommon in adults. The usual radiological appearance of CPAM is a cystic space-occupying lesion. We present one case of CPAM with unusual clinical and radiological findings, a complicated spontaneous pneumothorax with intracystic haemorrhage with successful conservative initial treatment, despite acute haemodynamic instability.

Laparoscopic cholecystectomy for acute cholecystitis: early or delayed?: Evidence from a systematic review of discordant meta-analyses.

The laparoscopic cholecystectomy (LC) is an important approach of treating acute cholecystitis and the timing of performing this given treatment is associated with clinical outcomes. Although several meta-analyses have been done to investigate the optimal timing of implementing this treatment, the conflicting findings from these meta-analyses still confuse decision-making. And thus, we performed this systematic review to assess discordant meta-analyses and generate conclusive findings to facilitate informed decision-making in clinical context eventually. We electronically searched the PubMed, Cochrane Library, and EMBASE to include meta-analysis comparing early (within 7 days of the onset of symptoms) with delayed LC (at least 1 week after initial conservative treatment) for acute cholecystitis through August 2015. Two independent investigators completed all tasks including scanning and appraising eligibility, abstracting essential information using prespecified extraction form, assessing methodological quality using Oxford Levels of Evidence and Assessment of Multiple Systematic Reviews (AMSTAR) tool, and assessing the reporting quality using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), as well as implementing Jadad algorithm in each step for the whole process. A heterogeneity degree of ≤50% is accepted. Seven eligible meta-analyses were included eventually. Only one was Level I of evidence and remaining studies were Level II of evidence. The AMSTAR scores varied from 8 to 11 with a median of 9. The PRISMA scores varied from 19 to 26. The most heterogeneity level fell into the desired criteria. After implementing Jadad algorithm, 2 meta-analyses with more eligible RCTs were selected based on search strategies and implication of selection. The best available evidence indicated a nonsignificant difference in mortality, bile duct injury, bile leakage, overall complications, and conversion to open surgery, but a significant reduction in wound infection, hospitalization, and operation duration and improvement of the quality of life when compared early LC with delayed LC. However, number of work days lost, hospital costs, and patient satisfaction are warranted to be assessed further. With the best available evidence, we recommend early LC to be as the standard treatment option in treating acute cholecystitis.

Diagnosis of Abdominal Tuberculosis Needs Attention.

Dear Editor, We read with keen interest the article titled BStudy of surgical emergencies of tubercular abdomen in developing countries^ by Wani et al. published in the May–June 2015 issue of the Indian Journal of Surgery. The authors have presented 50 patients of tubercular abdomen. The inclusion criteria for patient selection and the diagnostic criteria used to label the patient as a case of abdominal tuberculosis (AT) has not been specified. The authors mentioned rates of positivity of PCR and IgM ELISA for blood and ascitic fluid and its sensitivity. The details of test-kit used for IgM ELISA have not been mentioned. Absolute number of tests on ascitic fluid is not mentioned; ascites was present in a small proportion of patients (n=8). It is not mentioned what gold standard was used for calculating sensitivity for these tests. The authors have not taken into consideration the specificity of these tests for diagnosis of AT. Histopathology test was reported to confirm the diagnosis in 97.8 % patients; however, the histopathological criteria for diagnosing AT have not been mentioned. The proportion of patients who required surgery on failure of initial conservative antituberculosis treatment (ATT) has not been mentioned. Clarification on these points will enhance the value of the observations. A number of tests are being used for confirming the clinical diagnosis of AT. AT being an infective disease, the demonstration of Mycobacterium tuberculosis (MT) from the abdominal lesions would be an ideal criterion for diagnosis; however, the yield ofMTon tissue sections is poor [1]. The demonstration of AFB on Ziehl-Nielsen staining or demonstration of caseating granulomas in abdominal specimen is the next acceptable level of evidence for diagnosis for AT. Diagnosis on the basis of nonspecific granulomas would be a matter of conjecture as several other diseases—notably Crohn’s disease, Ulcerative colitis, Salmonella, Yersinea, Histoplasma capsulatum, and Mycobacteriun capsulatum infection—can produce granulomas in the intestine, lymph nodes, and/or peritoneum. It is difficult to establish evidence-based diagnosis of AT due to difficulty in obtaining specimen for testing and low positivity of accepted criteria. The CT scan is a valuable adjunct in diagnosing ATas it can document typical lesions in intestine, lymph nodes, and omentum, and collections of exudates in abdomen. CT facilitates image guided FNAC and aspiration to collect specimen for cytological / microbiological tests . Demonstration of MT, AFB, caseating granulomas in specimens from other organ/systems like sputum, urine, and FNAC from extra-abdominal lymph nodes, and biopsy from endometrium may corroborate the CT and increase the level of confidence of the diagnosis of AT. Laparoscopy has an important role in demonstrating the typical abdominal lesions and facilitating collection of exudates/tissue specimen for testing. Commercial serological tests provide inconsistent and imprecise findings resulting in highly variable values for sensitivity and specificity. WHO has strongly recommended that these tests not be used for the diagnosis of pulmonary and extrapulmonary TB [2]. Reported high positivity of PCR from blood (72%) is an interesting finding, and its value in diagnosis of AT needs further evaluation. Empirical treatment with ATT should be prescribed only after due diligence, based on available * Bhupendra Kumar Jain bhupendrakjain@gmail.com

Extensor Carpi Ulnaris Instability in Athletes - Diagnosis and Treatment

This article specifically focuses on extensor carpi ulnaris (ECU) tendon instability in athletes. ECU instability occurs when insufficiency of the fibro-osseous subsheath allows the ECU tendon to subluxate out of the distal ulnar groove, which may result in painful snapping of the tendon at the ulnar side of the wrist. Etiologies commonly include acute traumatic rupture of the subsheath or chronic degeneration of the subsheath. Injuries are often seen in stick, racquet, and club athletes (ie, hockey, baseball, golf, and tennis). A careful patient history and a physical examination are the keys to diagnosis, but advanced imaging can play a role, especially in the assessment of concomitant ulnocarpal compartment pathologies as causes of ulnar-sided wrist pain. Acute and chronic subsheath injuries comprise a spectrum of presentations including pain and apprehension with provocation of ECU instability, frank instability and painful ECU snapping, and a chronically incompetent subsheath with ECU tendinopathic changes and extensor tenosynovitis. Initial conservative treatment consists of forearm immobilization in pronation with the wrist immobilized in a position of extension and radial deviation. For persistent painful snapping of the ECU, in-season management may include the use of cortisone injection to attempt to achieve painless snapping until repair or reconstruction can be performed in the off-season. Surgical treatment is indicated in refractory cases and may consist of repair of the torn edge of the ECU subsheath or more frequently reconstruction of the extensor retinaculum to create a stabilizing sling for the tendon.

The recurrence risk of placenta accreta following uterine conserving management.

Placenta accreta is a condition of abnormal placental attachment that was usually treated by hysterectomy. Techniques to conserve the uterus are now commonly used and series of subsequent pregnancy outcomes have been reported. The recurrence risk of placenta accreta is now a relevant detail and is currently not known. This work was performed to calculate the recurrence risk by reviewing the published literature. A literature search using the terms "placenta accreta", "placenta percreta", "placenta increta", "abnormal placental attachment" and "placental attachment disorder" followed by hand-searching identified 6 papers that contained data concerning recurrence of placenta accreta in subsequent pregnancies following initial conservative treatment. Overall 407 pregnancies were recorded and 85.7% of women reported achieved a subsequent pregnancy following conservative treatment. The risk of recurrence of placental attachment disorder in a subsequent pregnancy was 19.9% (weighted mean, 95% CI 12.2-27.7). The recurrence risk of placental attachment disorder following uterine conservation treatments is 20% . This risk should be discussed with women with an antenatal diagnosis of a placental attachment disorder who may be considering uterine conservation in order to retain the option of a future pregnancy.

Active Surveillance versus Surgery of Nonfunctioning Pancreatic Neuroendocrine Neoplasms ≤2 cm in MEN1 Patients

Background: The aim of this study was to evaluate the efficacy of conservative treatment for nonfunctioning pancreatic neuroendocrine neoplasms (NF-PNEN) ≤2 cm in multiple endocrine neoplasia type 1 (MEN1)-affected patients compared with surgical treatment. Methods: The databases of 4 tertiary referral institutions (San Raffaele Scientific Institute, Milan; Philipps-Universität Marburg, Marburg; University of Padua, Padua; Royal Free Hospital, London) were analyzed. A comparison of conservative management and surgery at initial diagnosis of NF-PNEN ≤2 cm between 1997 and 2013 was performed. Results: Overall, 27 patients (45%) underwent up-front surgery and 33 patients (55%) were followed up after the initial diagnosis. A higher proportion of patients in the surgery group were female (70 vs. 33%, p = 0.004). Patients were mainly operated on in the period 1997-2007 as compared with the period 2008-2013 (n = 17; 63 vs. 37%; p = 0.040). The rate of multifocal tumors was higher in the surgery group (n = 24; 89%) than in the ‘no surgery' group (n = 22; 67%; p = 0.043). After a median follow-up of 126 months, 1 patient deceased due to postoperative complications within 30 days after surgery. The 5-, 10-, and 15-year progression-free survival (PFS) rates were 63, 39, and 10%, respectively. The median PFS was similar in the two groups. Overall, 13 patients (32.5%) were operated on after initial surgical or conservative treatment. The majority of the surgically treated patients had stage 1 (77.5%), T1 (77.5%), and G1 (85%) tumors. Conclusions: NF-PNEN ≤2 cm in MEN1 patients are indolent neoplasms posing a low oncological risk. Surgical treatment of these tumors at initial diagnosis is rarely justified in favor of conservative treatment.

Advances in minimally invasive treatment of hemorrhagic and ischemic stroke.

Advances in minimally invasive treatment of hemorrhagic and ischemic stroke.

Early laparoscopic cholecystectomy in acute cholecystitis: safety and advantages

Background: Cholecystectomy is a widely performed procedure all over world though popularized late in India. Today, Laparoscopic cholecystectomy is the method of choice to remove gall bladder. A concern exists in the minds of surgeons when it comes to immediate removal of an acutely inflammed gall bladder, laparoscopically. To analyze this hesitation, statistically, this study has been carried out.Methods: A prospective and randomized study was conducted among 66 patients from March 2013 to February 2016. Thirty three patients presenting with acute calculous cholecystitis were subjected to delayed laparoscopic cholecystectomy (Group A) after an initial conservative treatment and gap of 6-8 weeks. Another group of 33 patients presenting with acute calculous cholecystitis were taken up for laparoscopic cholecystectomy within 72 hours of onset of symptoms (Group B). Results obtained, in both the groups, under different headings were compared and analyzed.Results: Time taken for early laparoscopic cholecystectomy was significantly higher than that for delayed laparoscopic cholecystectomy. Cost of treatment and total hospital stay in delayed group was significantly high as compared to early group. No significant difference was found in incidence of conversion rate, common bile duct (CBD) and gastrointestinal tract (GIT) injury, requirement of drain, postoperative pain and analgesia requirement and port related complications.Conclusions: Early cholecystectomy in acute cholecystitis is feasible, safe, cheaper and requires shorter hospital stay, if, performed within 72 hours of onset of symptoms.

Review of evidence-based modern treatment for chylothorax

Chylothorax is a multi-factorial complication, frequently of an operation or an accident, but rarely of a tumour. In the absence of prospective or randomised studies evidence-based treatment is normally based on personal experience, ideally in the possession of retrospective analyses using the "best practice" method. The aim of the authors was the review the up-to-date chylothorax treatments. They performed the PubMed database's "chylothorax" keyword search of the publications reported in the last ten years. They put emphasis on articles that included a comparative analysis of the various treatment options. During the critical analysis of the methods and recommendations, the authors relied on their own joint experience amounting to 39 years. The results showed that the success of the initial conservative treatment indicates a significant deviation depending on the etiology (3-90%). The success rate of non-invasive or semi-invasive interventions is between 50-100%, again depending on the etiology. The standard surgical treatment following an unsuccessful conservative treatment of an operable patient includes the fitting of a (thoracoscopic) knot to the ductus thoracicus, pleurodesis, insertion of a permanent chest drain or a pleuroperitoneal shunt. The success rate of these interventions is between 64-100%, with a morbidity index and mortality index exceeding 25%. Conservative treatment should be the first step, which should then be followed by a gradually increased aggressive therapy, during which the decisions should be made according to the patient's condition and the drain volume. Interventional radiology procedures are safe, successful and they can be offered concurrently with conservative or operative treatment, although they are available only in a few centres.

Isolated lesions of the lower subscapularis tendon: diagnosis and management.

Isolated lesions of the caudal portion of the subscapularis (SSC) tendon are rare and have not been subject of major attention in the literature yet. However, these lesions can lead to tremendous impairment of shoulder function. The purpose of the present study was to raise clinician's awareness for these "hidden lesions" and to present the crucial steps for diagnosis and management. Five patients (three men, two women; mean age 40) with traumatic isolated caudal SSC lesion were enrolled in the present study. After clinical and radiological examination, all patients underwent diagnostic arthroscopy and open inferior SSC repair. The results of the clinical and radiological examination were documented along with the intraoperative findings. Post-operative pain level and shoulder function were assessed. In all patients the SSC lesion could be detected clinically. In two patients the caudal SSC tear was diagnosed delayed after initial conservative treatment. Preoperatively, all patients showed restricted active movement of the shoulder with positive clinical tests for the SSC. All SSC lesions could be detected on MR images and identified arthroscopically. After a mean follow-up of 12months, all clinical SSC tests were negative, and the patients have almost regained preinjury shoulder function. The mean post-operative pain score (VAS) was 1 (range 0-1), and the mean ASES score was 93.3 (range 91.6-95). Arthroscopic visualization of the SSC tendon is incomplete rendering caudal SSC tears difficult to detect and easy to overlook. Clinicians' awareness of this pathology along with accurate clinical and radiological examination leads to the correct diagnosis. Open caudal SSC repair provides pain relief and reliable shoulder function after short-term follow-up. IV.

Clinical Evaluation and Preoperative Planning of Articular Cartilage Lesions of the Knee.

Articular cartilage injuries are quite common. Most studies and review articles on cartilage repair and restoration focus on the different techniques available to treat cartilage defects; however, few thoroughly discuss the initial evaluation of patients with these defects. Outcomes are intimately associated with appropriate patient selection and indications for treatment; therefore, understanding the initial evaluation and conservative treatment of cartilage defects is essential to achieving excellent outcomes after surgical intervention, regardless of the chosen procedure. In patients with cartilage injury, a careful history, physical examination, and imaging are required before treating the lesion to ensure the patient's symptoms are actually related to the defect. To address any special considerations, other factors must be considered to improve patient outcomes, including the status of the meniscus, assessing and treating malalignment or off-loading the patellofemoral compartment, and reconstructing any ligamentous deficiencies. It is important for medical providers to understand what cartilage lesions may be symptomatic and when to refer these patients to surgeons who manage cartilage injury.

Changes in Prolapse and Urinary Symptoms After Successful Fitting of a Ring Pessary With Support in Women With Advanced Pelvic Organ Prolapse: A Prospective Study

To estimate the percentage of improvement in prolapse and urinary symptoms and adverse effects in women with advanced pelvic organ prolapse (POP) after 3 months of use of a ring pessary with support. In this prospective study, 109 consecutive women with advanced POP were fitted with a ring pessary with support; 73 (73/109, 67.0%) of the women had a successful 3-month pessary fitting trial. Prolapse symptoms, urinary symptoms, and urinary flow parameters were assessed at baseline and at 3 months. Adverse effects were assessed within 3 months. McNemar's test and paired-sample t tests were performed. Prolapse and urinary symptoms improved from baseline to 3 months, including bulging (90.4% to 23.3%; P <.001) and pressure (64.4% to 13.7%; P <.001). Voiding difficulty improved in 97.8% of the women (45/46; P <.001), splinting improved in 100% (19/19; P <.001), urge urinary incontinence improved in 76.9% (30/39; P <.001), and stress urinary incontinence improved in 58.1% (18/31; P = .025) after 3 months. After pessary treatment, the differences in maximum flow rate, mean flow rate, void volume, and postvoid residual at baseline and 3 months were statistically significant (P <.05). Vaginal discharge (32/73, 43.8%) was the most common adverse event. Vaginal ulcers developed in 7 (7/73, 9.6%) of the women. The ring pessary with support was successfully fitted in patients with advanced POP with a high success rate and few complications. The pessary could resolve more than half of the prolapse and urinary symptoms. Therefore, initial conservative treatment with a ring pessary with support in advanced POP is worthwhile.

Predictive factors for conservative treatment failure in grade IV pediatric blunt renal trauma

Most children with grade IV renal injury are treated using a conservative approach with a high success rate. However, a small minority of patients with grade IV renal injury require urological intervention because of symptomatic urinomas. The challenge lies in predicting which of the patients receiving initial conservative treatment may require delayed interventional management because of urological complications. To identify clinical factors and radiological features associated with the need for urological intervention in grade IV pediatric, blunt renal trauma patients who were initially treated with a conservative approach. The medical records of consecutive 26 children presenting to our center between 1996 and 2014 with grade IV renal injury, were retrospectively reviewed. Clinical factors, radiological features on computed tomography (CT), use of urological intervention, and patient outcomes were analyzed. The population algorithm of this study is shown in the figure. The patients who required urological intervention had a higher transfusion rate and larger perinephric hematomas (>2.2cm) than those who did not require intervention. The main laceration was located in the antero-medial portion of the kidney, and intravascular contrast extravasation was observed more often in patients who underwent urological intervention compared with patients with successful conservative management. The authors recommend the use of cautious observation and timely imaging studies for unresolved or expanding urinomas in children with grade IV renal trauma with predictive factors. Moreover, most patients received urological intervention 4-8 days after the trauma. Therefore, it is suggested that a follow-up image study for early detection of urological complications should be conducted 4-5 days after trauma in grade IV renal trauma children with predictive factors. If none of these factors are observed on the initial CT or during the clinical course, follow-up imaging study may be avoided during hospitalization. The need for transfusion, and the presence of specific image features on initial CT, such as the main laceration location in the antero-medial portion of kidney, intravascular contrast extravasation, and a large perinephric hematoma, served as useful predictive factors for urological intervention in grade IV pediatric blunt renal trauma patients who were initially treated with a conservative approach. The findings indicate that early detection and appropriate intervention should be considered a priority in the conservative treatment of grade IV pediatric renal trauma with predictive factors.

Clinical outcomes of mesh exposure/extrusion: presentation, timing and management.

The Food and Drug Administration has recently highlighted an increase in reported complications associated with the use of transvaginal mesh. To describe the clinical outcomes, presentation, timing and management of mesh exposure/extrusion Retrospective study from December 2006 to March 2012. A total of 40 women had vaginal mesh exposure/extrusion secondary to prior transvaginal mesh (TVM) surgery. Descriptive statistics were used for demographics and pre-operative data. Paired-samples t-test was applied for comparison of pre- and postoperation. A P value of <0.05 was considered statistically significant. The mesh exposure/extrusion rate was noted to be 2.64% (17/642). Vaginal bleeding in 29 of 40 (72.5%) and hispareunia in 12 of 13 (92.3%) were identified as the most common symptoms for mesh exposure/extrusion. The onset of complications occurred in two peaks: between 3 and 4 months and after 1-year of follow-up. Initial conservative treatment was given for 12.5% (5/40) of women, while 87.5% (35/40) had undergone repair for mesh exposure/extrusion (21 outpatient and 14 inpatient cases). Among those who had conservative treatment, 80% (4/5) had persistent mesh exposure. Persistent or new-onset abnormal vaginal bleeding and hispareunia after TVM surgery should be considered as 'red flag' symptoms for mesh exposure/extrusion. Frequent follow-up from the first 3-4 months up to 1 year postoperative may identify complications. Utilisation of mesh excision or trimming as the initial means of treatment may yield a better outcome.

Management of Acute Upper Extremity Ischemia: Treatment Strategies and Outcome

The aim of the study was to evaluate etiology, type of procedure, limb salvages attempted, and outcomes in acute upper limb ischemia (AULI). Patients from January 2013 to December 2014 with AULI (excluding trauma, iatrogenic) admitted at our hospital (Jain Institute of Vascular Sciences, Bengaluru, India) were included in the study. The analysis included 43 patients (53% males), mean age of 51 ± 12 years. Three patients presented ≤6 hours, and 32 presented >24 hours. Left upper limb (UL) was involved in 34 patients (79%). Of the 43 patients, 12 (27%) had cardiac source of embolus; 23 (53%) had unprovoked thrombosis, and 7 (17%) had other etiologies. Twenty-nine of 43 underwent surgery (transbrachial embolectomy), and the rest (34%) were managed conservatively (anticoagulation, prostacyclin infusion). Four required cervical rib excision, including two subclavian aneurysm repair, and three underwent proximal subclavian stenting of 29 surgical patients. Failure to revascularize was observed in 2 patients, 4 patients had rethrombosis in the operating room, and 1 patient underwent primary amputation. Seven had reocclusion in immediate postoperative period, requiring intervention. Three had amputation. The mortality rate was 4.6% due to cardiac complications. At the end of 1 month, 69% had patent flow, with a total limb salvage rate of 89% after surgery. AULI constitutes ∼12% of acute extremities ischemia. Unprovoked thrombosis is the most common etiology in comparison with Western populations. Choice of initial treatment of patients with AULI may be based on the severity of the ischemia, and those patients with less severe acute ischemia benefit from initial conservative treatment. Late surgical intervention resulted in higher morbidity and lower limb salvage, as observed in our study.

Multicenter Randomized Clinical Trial of Four Different Devices for Endovascular Aneurysm Repair: Design of the LEOPARD Trial

Results: The analysis included 43 patients (53% males), mean age of 51 6 12 years. Three patients presented #6 hours, and 32 presented >24 hours. Left upper limb (UL) was involved in 34 patients (79%). Of the 43 patients, 12 (27%) had cardiac source of embolus; 23 (53%) had unprovoked thrombosis, and 7 (17%) had other etiologies. Twenty-nine of 43 underwent surgery (transbrachial embolectomy), and the rest (34%) were managed conservatively (anticoagulation, prostacyclin infusion). Four required cervical rib excision, including two subclavian aneurysm repair, and three underwent proximal subclavian stenting of 29 surgical patients. Failure to revascularize was observed in 2 patients, 4 patients had rethrombosis in the operating room, and 1 patient underwent primary amputation. Seven had reocclusion in immediate postoperative period, requiring intervention. Three had amputation. The mortality rate was 4.6% due to cardiac complications. At the end of 1 month, 69% had patent flow, with a total limb salvage rate of 89% after surgery. Conclusions: AULI constitutes w12% of acute extremities ischemia. Unprovoked thrombosis is the most common etiology in comparison with Western populations. Choice of initial treatment of patients with AULI may be based on the severity of the ischemia, and those patients with less severe acute ischemia benefit from initial conservative treatment. Late surgical intervention resulted in higher morbidity and lower limb salvage, as observed in our study.

Rethinking the roles of inflammation in the intracerebral hemorrhage.

Blood in the vessels bleeds into the brain parenchyma resulting in the intracerebral hemorrhage (ICH) [1]. The direct mass effect of the rapidly formed hematoma causes the brain damage, which leads to neurologic deficit. Thus, clearing the hematoma may be beneficial to the patient with ICH. However, the Surgical Trial in Intracerebral Hemorrhage (STICH) trial showed no overall benefit from early hematoma evacuation compared to initial conservative treatment [2]. Therefore, the secondary brain injury caused by the metabolic products or the components of hematoma attracted more researchers’ attention [3]. Converging evidence shows that both central and peripheral inflammation play critical roles in the ICH-induced secondary brain injury [3–8]. Previously, most studies concentrated on the downstream inflammatory events, such as proinflammatory cytokines, showed that inflammatory responses contribute to the secondary brain injury after ICH, while no direct clinical effects on targeting these downstream events have been achieved [7]. Hence, it is worth thinking about why this kind of therapeutic strategies has no direct clinical effects and rethinking the roles of inflammation in the ICH.

Evaluation and management of symptomatic isolated spontaneous celiac trunk dissection.

The purpose of this study is to describe 10 cases of symptomatic isolated spontaneous celiac trunk dissection (ISCTD) in order to evaluate the initial clinical presentation, diagnosis, treatment modalities and outcomes. A retrospective search was performed from 2009 to 2014 and 10 patients with ISCTD were included in the study. Patients with associated aortic and/or other visceral artery dissection were excluded. The following information was collected from each case: sex, age, associated risk factors, symptoms, diagnostic method, anatomic dissection pattern, treatment modality and outcome. Most patients were male (90%), with an average age of 44.8 years, and the most common symptom was abdominal pain (100%). Hypertension and vasculitis (polyarteritis nodosa) were the most frequent risk factors (40% and 30%, respectively). Diagnosis was made in all patients with computed tomography. Dissection was limited to the celiac trunk in three patients and extended to celiac branches in the other seven. Initial conservative treatment was attempted in every case and was successful in nine patients. In one case, initial conservative treatment was unsuccessful and arterial stenting with coil embolization of the false lumen was performed. After successful initial treatment, late progression of the dissection to aneurysmal dilatation was observed in two patients and it was decided to perform endovascular treatment. Mean follow-up was 19 months, ranging from 2 to 59 months. In conclusion, initial conservative treatment seems adequate for most patients with ISCTD. Long-term follow-up is mandatory, owing to the risk of later progression to aneurysm.

Effect of Intravenous Thrombolysis on the Time Course of the Apparent Diffusion Coefficient in Acute Middle Cerebral Artery Infarction

To examine the possible effects of intravenous thrombolysis on the time course of the apparent diffusion coefficient in the patients with acute middle cerebral artery infarct. Serial MRI data with all in all 190 MR examinations including diffusion-weighted imaging (DWI), apparent diffusion coefficient map (ADC map) and T2 -weighted imaging (T2 w) of 74 patients with initial intravenous thrombolysis (study group; N = 37) or conservative stroke treatment (control group; N = 37) were retrospectively analyzed. A trend function was fitted to the relative values (rADC, rDWI, rT2 w) to model an objective, general time course. Relative apparent diffusion coefficient (rADC) decreased in both groups to a minimum about 15 hours after symptom onset. Afterwards rADC increased faster in the study group and reached pseudonormalization 5 ± 2 days after symptom onset. In the control group pseudonormalization was determined later at 7 ± 6 days after symptom onset. After pseudonormalization rADC continued to increase in both groups. rADC pseudonormalization occurred by trend earlier in the study group. Therefore, intravenous thrombolysis seems to have an effect on the time course of ADC, which is likely to be due to earlier cerebral reperfusion after thrombolysis. In addition, initial stroke treatment as thrombolysis should be considered in radiological rating of stroke MRI time course.