Microsurgical Exclusion Research Articles

P-107 MICROFLUIDIC SPERM SEXING: An XLD (X-linked Disorder) model for preventing genetic disorders in newborns

Abstract Study question Can sperm sexing based on unique surface membrane markers – enable genotypic sperm sorting by allosomal content to prevent certain X-linked disorders in newborns? Summary answer In an X-Linked-Disorder prevention model, we utilized a microfluidic device functionalized with H-Y monoclonal antibodies attached to magnetic beads to enrich Y-chromosome bearing sperm sorts. What is known already About 4% of newborns are at risk of being born with an X-linked disease such as Fragile X Syndrome. The current clinically approved mitigation plan for preventing such genetic disorders is to consider Preimplantation Genetic Testing for Monogenetic diseases (PGT-M) which involves an invasive microsurgical procedure on fragile embryos. To minimize this invasiveness, we proposed a less invasive microsurgical exclusion approach to prevent such genetic disorders by genotypically sorting sperm cells that can be used for IUI/IVF/ICSI – with microfluidics – using their allosomal characteristics. Study design, size, duration Semen samples purchased from FairFax Cryobank from anonymous donors were used in immuno-magnetic microfluidic sorting protocols with the use of phycoerythrin (PE) binding Tetrameric Antibody Complexes (TAC) coupled with magnetic beads to tag H-Y monoclonal antibody (mab) binding activities on the sperm surface membrane. Participants/materials, setting, methods Immuno-magnetic sorting was conducted with specially fabricated microfluidic-sperm-sorting (MSS) chips. Sort yield and purities of positively selected sperm populations were assessed by flow-cytometry, immunofluorescence, fluorescent-in-situ-hybridization (FISH) and by quantitative-PCR (qPCR – Cq & Tm). Quantitative experiments were run in triplicates and the results were expressed as absolute means for comparison between paired variables. Statistical analyses were performed using Student’s t-test and a p-value of less than 0.05 was considered to be statistically significant. Main results and the role of chance For the assessment of H-Y sperm sorts, our preliminary data showed that flow cytometry was able to confirm the positive sperm selection (which were mostly Y-chromosome bearing sperm cells) in a sperm genotyping protocol – initially utilizing immuno-magnetic sort tubes prior to flowing through microfluidic chips. Both immuno-magnetic sort tubes and the microfluidic chips were able to optimally confirm from qPCR-Cq means – the negative selection – being the X-chromosome bearing sperm that may have been largely unselected by the H-Y-mab. Values for Cq means compared under H-Y-qPCR data sets were statistically significant with a p value of 0.000023 (p values is significant at < 0.05). Our study was able to elucidate a potential less invasive clinical application of genotypically sorting sperm cells with mab-functionalized microfluidic chips for an XLD-model. Molecular down stream applications like flow cytometry may therefore be utilized to experimentally confirm sort purities of positively selected sperm populations (with H-Y markers) – based on the utility of the SMCX and SMCY gene in the X and Y sperm chromosome bearing sperm cells respectively. Limitations, reasons for caution Physiological effect of magnetic fields of varying tesla or gauss strengths on sperm selected with immuno-magnetic beads may warrant further safety studies prior to actual clinical applications. Optimal selection results may be achieved with the use of freshly collected normospermic rather than frozen-thawed samples. Wider implications of the findings Although we had de-emphasized the clinical application of the microfluidic sperm sexing protocol for legitimate use in sex selection and gender balancing, this study design was solely focused on adapting a less invasive method of preventing X-linked genetic disorders with the potential exclusion of microsurgical procedures leading to PGT-M. Trial registration number NA

Multimodal management of ruptured cerebral micro-arteriovenous malformations: A retrospective series of 19 cases and a review of the literature

BackgroundMicro-arteriovenous malformations (micro-AVMs) are defined as AVMs just visible on angiography with a nidus size between 0.5 and 1cm. Their principal manifestation is intracranial hemorrhage and their diagnosis and therapeutic management are still unclear. MethodsThe aim of our work was to show the clinical presentation, treatment and outcome of ruptured cerebral micro-AVMs in a retrospective cohort study of 19 patients and a systematic review of the literature. ResultsWe obtained a total of 20 micro-AVMs in 19 patients. The mean age was 47.3 years. Clinical presentation was acute bleeding. The mean volume of hematoma was 12.9 mm3 (0 - 60.4), with topographic distribution as follows: 64% cortical with supratentorial bleeding, 26% deep, and 10% in the posterior fossa. Among the 20 micro-AVMs of the series, 11 (55%) had endovascular management, 6 (30%) had surgical treatment and 3 (15%) had GK radiosurgery alone. All of our patients have been cured at the end of the follow up without re-permeabilization. In our series, clinical outcome showed good recovery with a mean score of 4.6 on Glasgow Outcome Scale (GOS). In the literature, 88% of patients had a GOS of 4 or 5. DiscussionIntracerebral hematoma (ICH) was the main clinical manifestation. In the case of negative initial angiographic assessment, patients must have supraselective angiographic exploration. In the case of conservative treatment of hematoma, endovascular obliteration and microsurgical exclusion seems to be reasonable therapeutic options, according to our observations.

Functional outcome 1 year after aneurysmal subarachnoid hemorrhage due to ruptured intracranial aneurysm in elderly patients

BackgroundPopulation aging raises questions about extending treatment indications in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). We therefore assessed functional status 1 year after treatment. MethodsThis study involved 310 patients, aged over 70 years, with ruptured brain aneurysm, enrolled between 2008 and 2014 in a prospective multicentre trial (FASHE study: NCT00692744) but considered unsuitable for randomisation and therefore analysed in the observational arms of the study: endovascular occlusion (EV), microsurgical exclusion (MS) and conservative treatment. The aims were to assess independence, cognition, autonomy and quality of life (QOL) at 1 year post-treatment, using questionnaires (MMSE, ADLI, IADL, EORTC-QLQ-C30) filled in by independent nurses after discharge. ResultsThe 310 patients received the following treatments: 208 underwent EV (67.1%), 54 MS (17.4%) and 48 were conservatively managed (15.5%). At 1 year, independence rates for patients admitted with good clinical status (WFNS I-III) were, according to the aneurysm exclusion procedure (EV, MS or conservative), 58.9%, 50% and 12.1% respectively. MMSE score was pathological in 26 of the 112 EV patients (23.2%), 10 of the 25 MS patients (40%) and 4 of the 9 patients treated conservatively (44%), without any statistically significant difference [Pearson's Chi2 test, F ratio=4.29; P=0.11]. Regarding QoL, overall score was similar between the EV and MS cohorts, but significantly lower with conservative treatment. ConclusionElderly patients in good clinical condition with aSAH should be treated regardless of associated comorbidities. Curative treatment (EV or MS) reduced mortality without increasing dependence, in comparison with conservative treatment.

Results of microsurgical treatment of arterial brain aneurysms in the acute rupture period

Objective – to find out the causes of adverse effects of microsurgical exclusion of arterial aneurysms during the acute rupture period.Materials and methods. The results of 41 microsurgical exclusions of arterial aneurysms in the first two days after the rupture were analyzed. There were 17 men and 24 women. The age of patients was from 32 to 78 years, the average age was 50 years. Neurological status, the severity of the Hunt–Hess condition, and the level of consciousness on the Glasgow com scale were assessed. The Glasgow Scale was used to evaluate the quality of life of surviving patients.Results. After surgery, 12 (29.2 %) patients died. A statistically significant dependence of mortality have been established by the Hunt–Hess scale, the level of consciousness on the Glasgow scale, the prevalence of angiospasm according to cerebral angiography and the presence of ischemia according to spiral computed tomography. The severity of subarachnoid hemorrhage according to Fisher and angiospasm according to transcranial dopplerography, although they affect the mortality and outcome of surgery, but not statistically significant.Conclusion. Given the high mortality rate after microsurgical operations in the acute period of arterial aneurysms rupture the indications for their conduct should be more balanced. It should be taken into account the presence of adverse predictors.

Protective STA-MCA bypass to prevent brain ischemia during high-flow bypass surgery: case series of 10 patients

High-flow extracranial-intracranial bypass is associated with a significant risk of ischemic stroke. The goal of this study is to evaluate the effectiveness of STA-MCA bypass preceding a high-flow bypass as a means of protecting the brain from ischemia during the high-flow bypass anastomosis in patients with otherwise untreatable aneurysms. This prospective study included 10 consecutive patients treated for complex/giant aneurysm using a previous combined STA-MCA bypass and high-flow EC-IC bypass between June 2016 and January 2018 when classical endovascular or microsurgical exclusion was estimated too risky. Early cranial Doppler, MRI, CT scan, and conventional angiography were performed in each patient to confirm patency of bypasses, measure flow in the anastomoses, detect any ischemic lesions, and evaluate exclusion of the aneurysm. The mean age at treatment was 55years (range 34 to 67). The mean time of microsurgical procedure was 11h (range 9 to 12). In all patients, the high-flow bypass was patent intraoperatively and complete occlusion of aneurysm was obtained. No ischemic lesions were noted on early MRI. One patient died from a large hemispheric infarction related to a common carotid artery dissection 10days after the microsurgical procedure and immediate postoperative epidural hematoma was noted in one other patient. In this study, we described the use of a protective STA-MCA bypass, performed prior to the high-flow bypass, in order to reduce the risk of perioperative ischemic lesions without increasing the morbidity of the surgical procedure. This treatment paradigm was feasible in all ten patients without complications related to the STA-MCA anastomosis.

Surgical management of spinal dural arteriovenous fistulas

Spinal dural arteriovenous fistulas are the most common type of spinal arteriovenous malformations. Treatment options consist of microsurgical exclusion and/or endovascular embolization. We retrospectively identified all patients who benefited from surgical treatment at our tertiary center between January 2001 and December 2008. Clinical and imaging data were collected from patient files, including pre- and post-operative formal neurological examination, complete spine MRI and spinal digital subtraction angiography. Of our 30 patients, 25 were men and five were women with a median age of 62years (range 24–76). The average delay between symptom onset and clinical diagnosis was 27months (range 1–90). Complete cure of the fistula was obtained in all patients in a single surgical session with no procedural complications and no surgical morbidity. After a mean follow-up period of 32months (range 14–128), 25 patients (83%) had improved, four were stable and one worsened. Despite recent advances in endovascular techniques and materials, there is a subgroup of patients for which surgery remains the best treatment option. Careful patient selection, a multidisciplinary approach and standardized surgical techniques can lead to excellent results with virtually no complications.

Investigation of the cytokine status in patients during the acute period of intracranial arterial aneurysm rupture

Objective: Analyze the changes of -1β, -4, -6 interleukin indices in blood serum of patients during the acute period of intracranial arterial aneurysm (AA) rupture.Materials and methods: Levels of -1β, -4, -6 interleukins in the serum were analyzed in 37 patients during the acute period of intracranial arterial aneurysm (AA) rupture with the help of immune-enzyme analysis: in 27 patients on the 1–4th day since the manifestation of the disease; in 22 patients — on the 7–10th day after the haemorrhage (in 10 — recurrent). Clinical and instrumental examination of all the patients included brain CCT, cerebral angiography, ultrasonography; microsurgical exclusion of aneurysm was carried out according to indications.Results: The interleukin indices in the serum of patients with SAH were higher than those in the control group mainly on the 7–10th day after the SAH episode.The interleukin-6 level was 20–30 times higher compared to the average index of the control group. There was a reliable increase of its level in patients with cerebral vasospasm (VS) compared to those without VS (p<0,05). The interleukins-1β and -4 indices were moderately (2–5 times) increased in comparison with those in the control group, they did not differ significantly in patients with VS and without it. In patients likely to have grave incapacitation or fatal outcome interleukin-6 levels were significantly higher both during the first 4 days of the disease (p<0,05), and on the 7–10th day.Conclusions: The increased levels of -1β, -4 та -6 interleukins during the first 10 days after AA rupture indicate that there exist active inflammatory processes in this period of the disease, which gives grounds for the use of antiinflammatory therapy. A connection established between the increase of interleukin-6 level, presence of cerebral VS, as well as severity of the disease may be evidence of this cytokine’s significance in SAH.

Usefulness of multislice computerized tomographic angiography in the postoperative evaluation of patients with clipped aneurysms

The aim of our study was to evaluate the diagnostic efficacy of multislice computed tomographic angiography (MSCTA) regarding exclusion quality after aneurysm clipping. Sixty patients (74 aneurysms) underwent microsurgical exclusion using titanium clips. The presence of aneurysm remnants on MSCTA was compared by a neuroradiologist to 2D digital subtraction angiography (DSA), which was considered as a reference examination. The contribution of 3D DSA was assessed in a subpopulation of 29 patients (35 aneurysms). With 2D DSA, six aneurysm remnants (8%) were diagnosed, and only five (7%) by MSCTA. The specificity and sensitivity were 98.5 and 83%, respectively. MSCTA failed to demonstrate one large remnant (>2 mm) because of clip artifacts (six clips). With 3D DSA six supplementary remnants were diagnosed. Two were large remnants blinded by vessel overlaps and clip artifacts. Four were small "dog-eared" remnants (< or =2 mm). No additional treatment was required for small remnants. In the postoperative period, MSCTA was considered a useful tool to evaluate the large remnants as well as a non-invasive ulterior examination for suspected bifurcation. Nevertheless, 3D DSA is still required for an accurate evaluation of aneurysms treated by more than three clips.

Anévrisme intracrânien non rompu et exclusion microchirurgicale : justification d’une étude randomisée chirurgie versus histoire naturelle

Although unruptured intracranial aneurysm (UIA) is becoming a more common finding nowadays, determining the optimal treatment strategy is difficult because the risk of rupture is poorly understood and surgery is not without its own hazards. As the mortality rate after rupture is estimated to range from 56 to 83%, the final therapeutic decision is the result of an analysis of rupture risk and the risks related to surgical exclusion, which may be determined by consideration of the risk factors. We considered the UIA to have a high risk of rupture if it was located on the vertebrobasilar arterial system (RR: 4.4; CI 95%, 2.7-6.8), between 7 and 12 mm in size (RR: 3.3; CI 95%, 1.3-8.2) or larger (RR: 17; CI 95%, 8-36.1), multilobular and had a ratio of depth to width greater than 3.4 (risk x 20). A family history of UIA would constitute a major rupture risk (two to seven times that of spontaneous UIA). Other factors related to UIA rupture include arterial hypertension (RR: 1.46; CI 95%, 1.01-2.11) and smoking (RR: 3.04; CI 95%, 1.21-7.66). After microsurgical exclusion, the morbidity and mortality rates were calculated as 9 and 1.5%, respectively. Microsurgical risk factors were age (32% > 65 years), and factors related to the UIA itself and surgery, such as size (14% > 15 mm), location, presence of atherosclerosis and difficulty of surgical clip application. The incidence of rupture after microsurgical exclusion was estimated to be 0.2% per year, and complete microsurgical exclusion was achieved in 90% of patients. A randomised study of microsurgical exclusion of UIA would offer further proof of our therapeutic hypotheses.

Anévrismes intracrâniens non rompus : que proposer ?

Intracranial unruptured aneurysm (ICUA) has become a common condition for patient consultation. The mortality rate after fissuration is estimated to be between 52% and 85.7%. The final therapeutic decision results from a balance between the risk of rupture and risks related to the aneurysmal exclusion. Analysis of the risk of rupture risk enables a classification of risk factors. Depending on the circumstances of diagnosis, we considered the ICUA at high risk of rupture for incidental ICUA larger than 7 mm and in the event of associated aneurysms. Classifying by morphologic features, high-risk ICUA were located in the vertebrobasilar system (RR: 4.4; 95%CI: 2.7-6.8), those with a size between 7 and 12 mm (RR: 3.3; 95%CO: 1.3-8.2), larger than 12 mm (RR: 17; 95%CI: 8-36.1), those that were multilobular or a larger size and those ones with a index P/L superior to 3.4 (risk x20). Familial ICUA would expose to a major rupture risk (2 to 7 times sporadic ICUA). Some systemic factors were related to ICUA rupture: arterial hypertension (RR: 1.46; 95%CI: 1.01-2.11) and smoking addiction (RR: 3.04; 95%CI: 1.21-7.66). After microsurgical exclusion, the morbidity and mortality rates were 10% and 2% respectively. Some microsurgical morbidity factors were identified: age (32%>65 years), size (14%>15 mm), vertebrobasilar location and temporary occlusion. The rupture incidence after microsurgical exclusion was estimated 0.26%/year. After endovascular exclusion, the morbidity and mortality rates were 8% and 1% respectively. The complete exclusion rate varied between 47% and 67%. The rupture risk was estimated at 0.9%/year. Treatment recommendations were classified into 3 categories.