Permanent Neurological Dysfunction Research Articles

Identification of CTA-Based Predictive Findings for Temporary and Permanent Neurological Dysfunction after Repair in Acute Type A Aortic Dissection

The aim of this study was to determine CT risk findings predictive of temporary neurological dysfunction (TND) and permanent neurological dysfunction (PND) after surgical repair for acute type A aortic dissection (ATAAD). A total of 255 patients (41 ± 16 years, 79% male) with ATAAD underwent aortic CT angiography (CTA) and surgical repair consecutively from January 2013 to June 2016. The CTA findings of the 255 patients for the thoracic aorta and carotid artery were analysed to identify risk factors predictive of TND and PND. Thirty-eight patients (15%) suffered TND, and 18 (7%) exhibited PND. Common carotid artery (CCA) dissection (OR = 4.63), lower enhancement of unilateral ICA (OR = 3.02) and aortic arch tears (OR = 2.83) were predictors of postoperative TND, while PND was best predicted by retrograde ascending aorta (aAO) dissection (OR = 5.62) and aortic arch tears (OR = 6.74). In CCA dissection, the extent of the entire CCA and proximal ICA (P = 0.014), a low-enhancement false lumen with re-entry (P = 0.000) and a severely narrowed true lumen without re-entry (P = 0.005) significantly increased the risk of postoperative TND. In patients with ATAAD, specific CT findings allow the individual risk of postoperative TND and PND to be identified and may guide subsequent surgical management.

AKR1B1 Upregulation Contributes to Neuroinflammation and Astrocytes Proliferation by Regulating the Energy Metabolism in Rat Spinal Cord Injury.

Spinal cord injury (SCI) is one of the most common and serious condition, which leads to permanent neurological dysfunction and poor prognosis in patients. Hyperglycemia impairs neural functional recovery after SCI resulting in the overproduction of reactive oxygen species (ROS) and inflammatory cytokines. However, the effect of glucose metabolism in the spinal cord after injury remains unclear. AKR1B1, one member of the aldo/keto reductase superfamily, is involved in the energy metabolism of plasm glucose and ROS production. The role of AKR1B1 in cancer cell proliferation and invasion has been confirmed. Meanwhile, Akt, one pivotal transcription factor particularly, is involved in the regulation of cell cycle and ROS-mediated secondary injury in the lesion site. In our study, we established an acute SCI rat model to identify the expression of AKR1B1 and its role in neural recovery processes. Western blotting revealed the expression of AKR1B1 protein was elevated after injury, peaked at 3days and declined gradually to normal at 14days. Similar results was illustrated in immunohistochemistry staining of white matter. Double immunofluorescence staining showed AKR1B1 was expressed in glial cells and its expression was significantly increased in proliferative astrocytes during the pathological processes. Further experiments showed AKR1B1 was co-located with Akt protein in GFAP positive cells and immunoprecipitated with Akt in injured spinal cord as well. In summary, the present study demonstrated AKR1B1 played a vital role in astrocytes proliferation through Akt pathway, associated with the metabolism of hyperglycemia induced by SCI.

Risk Factors for Permanent Neurological Dysfunction and Early Mortality in Patients with Type A Aortic Dissection Requiring Total Arch Replacement.

Surgery is a definitive treatment for patients with type A aortic dissection. The aim of this study was to identify and analyze the risk factors for permanent neurological dysfunction (PND) and 30-day mortality in patients following total arch replacement and stented elephant trunk implantation in the descending aorta.Methods: The clinical data of 85 consecutive patients who underwent this surgical procedure between December 2013 and May 2017 were reviewed. Multivariate logistic regression analysis was performed to determine the independent predictors of postoperative PND and 30-day mortality.Results: There were 62 males and 23 females, with a mean age of 47.6 ± 11.7 years (range, 26-73 years). Ten patients (11.76%) developed PND after surgery. Postoperative 30-day mortality was 11.76% (10/85), including one death during hospitalization and nine deaths after discharge. Multivariate analysis showed that hypertension was independently associated with postoperative PND (OR = 4.407, 95% CI: 1.021-19.023, P = .047), and age and postoperative PND were independent predictors for 30-day mortality (OR, 1.120; 95% CI, 1.026-1.221; P = .011 and OR, 7.503; CI, 1.290-43.634; P = .025, respectively).Conclusion: Hypertension was independently associated with postoperative PND, and age and postoperative PND were predictors for early mortality in patients who underwent total arch replacement and stented elephant trunk implantation.

Direct Cannulation of Ascending Aorta versus Standard Femoral Artery Cannulation in Acute Aortic Dissection Type A.

During surgery for ascending aortic dissection, the dissected ascending aorta itself has traditionally been rejected as a cannulation option. The purpose of this study is to prove that direct cannulation of the ascending aorta in patients operated for acute aortic dissection type A (AADA) is at least as effective and safe as classic femoral cannulation. Between September 2008 and January 2015, we operated on 117 patients with AADA through median sternotomy. Cannulation was accomplished in 32 cases (27%) through the femoral artery (group A), and in 85 patients (73%) through the dissected ascending aorta (group B). Moderate hypothermic circulatory arrest with bilateral antegrade cerebral perfusion was used in 108 patients (92%). The mean time of circulatory arrest was 17 minutes (range: 9-52 minutes). The 30-day mortality rate was 22% (7 patients) in group A, and 18% (15 patients) in group B (P = not significant). Temporary neurologic dysfunction (TND) including postoperative confusion, delirium, or agitation occurred in four patients (13%) in group A, and four patients (5%) in group B (P = not significant). The incidence of permanent neurologic dysfunction (stroke) was 9% (3 patients) in group A and 3% (3 patients) in group B. The direct cannulation of the ascending aorta is a safe alternative for patients with AADA, offering the opportunity for antegrade cerebral perfusion. It is easy to perform, reliable, and associated with acceptable early results.

Selective Cerebral Perfusion with the Open Proximal Technique during Descending Thoracic or Thoracoabdominal Aortic Repair: An Option of Choice to Reduce Neurologic Complications

Selective cerebral perfusion with the open proximal technique for thoracoabdominal aortic repair has not been conclusively validated because of its procedural complexity and unreliability. We report the clinical outcomes, particularly the cerebroneurological complications, of an open proximal procedure using selective cerebral perfusion. A retrospective chart review identified 30 patients between 2007 and 2015 who underwent aortic repair through left lateral thoracotomy with selective cerebral perfusion, established through endoluminal brachiocephalic and left carotid artery and retrograde left axillary artery. The mean durations of the open proximal procedure and cerebral ischemia (the duration of the open proximal procedure minus the duration of selective cerebral perfusion) were 110.3 ± 40.1 min and 24.8 ± 13.0 min, respectively. There were two cases (7%) of permanent neurologic dysfunction (PND) but no in-hospital deaths. Multivariate analysis identified the duration of cerebral ischemia as an independent risk factor for neurologic complications including temporary neurologic dysfunction (TND; odds ratio (OR): 1.13; p = 0.007), but no correlation was found between selective cerebral perfusion duration and neurologic complications. Despite the relatively long duration of the open proximal procedure, selective cerebral perfusion has a potential to protect against cerebral complications during thoracic aortic repair through a left lateral thoracotomy.

The Risk of Neurological Dysfunctions after Deep Hypothermic Circulatory Arrest with Retrograde Cerebral Perfusion

Retrograde cerebral perfusion (RCP) is a brain protection technique that is adopted generally for anticipated short periods of deep hypothermic circulatory arrest (DHCA). However, the real impact of this technique on cerebral protection during DHCA remains a controversial issue. For 344 (59.5%) of 578 consecutive patients (mean age, 66.9 ± 10.9 years) who underwent cardiovascular surgery under DHCA at the present authors' institution (1999-2015), RCP was the sole technique of cerebral protection that was adopted in addition to deep hypothermia. Surgery of the thoracic aorta was performed in 95.9% of these RCP patients; in 92 cases there was an aortic arch involvement. Outcomes were reviewed retrospectively. The focus was on postoperative neurological dysfunctions. There were 33 (9.6%) in-hospital deaths. Thirty-one (9%) patients had permanent neurological dysfunctions and 66 (19.1%) transitory neurological dysfunctions alone. Age older than 74 years (odds ratio [OR], 1.88, P = .023), surgery for acute aortic dissection (OR, 2.57; P = .0009), and DHCA time longer than 25 minutes (OR, 2.44; P = .0021) were predictors of neurological dysfunctions. The 10-year nonparametric estimate of freedom from all-cause death was 61.8% (95% confidence interval, 57.8%-65.8%). Permanent postoperative neurological dysfunctions were risk factors for cardiac or cerebrovascular death (hazard ratio, 2.6; P = .039) even after an adjusted survival analysis (P < .04). According to the study findings, RCP, in addition to deep hypothermia, combines with a low risk of neurological dysfunctions provided that DHCA length is 25 minutes or less. Permanent postoperative neurological dysfunctions are predictors of poor late survival.

Elective Aortic Arch Repair: Factors Influencing Neurologic Outcome in 791 Patients

The aim of this study was to determine perioperative factors influencing neurologic outcome in a single-center cohort of patients undergoing elective aortic arch operations. From January 2005 to June 2015, 791 consecutive patients received open aortic arch operations with either antegrade selective cerebral perfusion (ASCP) (636 patients [80.4%]) or deep hypothermic circulatory arrest (DHCA) (155 patients [19.6%]). Main indications were degenerative aneurysm (85%) and chronic postdissection aneurysm (9.1%). Hospital mortality (30 days) was 5.3%. Permanent neurologic dysfunction (PND) was observed in 42 patients (5.3%). Significant risk factors for PND appeared to be femoral artery cannulation (p= 0.003), progressive cardiopulmonary bypass (p= 0.001), circulatory arrest (p= 0.001), and ASCP time (p= 0.011). ASCP, in contrast to DHCA, was protective against PND (odds ratio [OR], 0.37; p= 0.003). Temporary neurologic dysfunction (TND) was observed in 49 patients (6.2%). Preoperative transient ischemic attack (TIA) (p= 0.001), progressive EuroSCORE (p= 0.001), left ventricular ejection fraction (LVEF) less than 50% (p= 0.003), and the use of femoral artery cannulation (p= 0.049) showed correlation in the univariate analysis. Stepwise logistic regression indicated TIA (p= 0.002; OR, 3.24) and the EuroSCORE (p= 0.003; OR, 1.23) as independent predictors of TND. Contemporary elective aortic arch repair can be achieved with low mortality and a low incidence of neurologic dysfunction. ASCP was confirmed to be the safest method of cerebral protection. The extent of aortic arch replacement (apart from the frozen elephant trunk [FET] procedure) was not related to increased rates of TND or PND.

A rare case report on cauda equina syndrome

Cauda Equina Syndrome (CES) is a rare but serious neurologic condition in which neurological dysfunction affects the lumbar and sacral nerve roots within the vertebral canal. CES is a clinical entity consisting of low back ache, bilateral leg pain with motor and sensory deficits, genitourinary dysfunction, saddle anaesthesia and faecal incontinence. It is a rare condition with a prevalence in the general population estimated between 1:100000 and 1:33000. The presentation of CES may vary, especially in the early stages of compression. Magnetic Resonance Imaging (MRI) is the accepted gold standard modality of choice for diagnosing CES which identifies potential mimics such as aortic dissection or spinal infarction. Here we discuss a rare and unique case of CES with atypical presentation, knowledge of which is essential for early diagnosis, treatment and prevention of permanent neurological dysfunction.

PC022 Thoracic Endovascular Repair for Acute Complicated Type B Aortic Dissections

This study assessed in-hospital mortality and midterm results of emergency thoracic endovascular aortic repair (TEVAR) stent grafting for patients with life-threatening complications of acute type B aortic dissections (acTBD). Between March 2001 and Sept 2016, 53 patients (38 men; mean age, 55 ± 13) with an acTBD were treated with TEVAR for malperfusion (55%), aortic rupture (15%), or persistent untreatable pain (30%) as a sign of pending rupture. Four patients (8%) had undergone previous aortic surgery. Technical success (coverage of the primary tear site) was achieved in 48 patients (91%). Overall hospital mortality rate was 9% (n = 5). Causes of death were rupture during the procedure or on the first postinterventional day in two patients and redissection (ascending aorta n = 2, descending aorta n = 1) with consequent aortic rupture after TEVAR in the remaining three. Permanent neurologic dysfunction occurred in 3 patients (stroke n = 1, paraplegia n = 2). Nineteen patients (36%) developed early endoleaks (type Ia, n = 5; type Ib, n = 11; type II, n = 2; type Ib plus II, n = 1) and were observed throughout the postinterventional period. These seven patients (37%) needed secondary endovascular intervention (n = 3) or conventional surgery (n = 4) due to aortic progression (mean interval after procedure 92 ± 56 months). Secondary endoleaks were observed in nine patients with consequent reintervention in three patients. The actuarial survival was 88%, 76%, and 58% at 1, 5, and 10 years, respectively. Freedom from treatment failure at 1, 5, and 10 years (including reintervention, aortic rupture, device-related complications, aortic-related death, or sudden, unexplained late death) was 76 %, 74%, and 74%, respectively. TEVAR in the treatment of acute complicated type B aortic dissection proves to be an excellent treatment modality in this high risk patient cohort. Refinements, especially in stent design and application, may further reduce the rate of endoleaks and improve the prognosis of patients in this life-threatening situation.

Clinical value of collateral venous circulation assessment in operations of parasagittal meningiomas

Objective To evaluate the clinical value of collateral venous circulation assessment in operations of parasagittal meningiomas (PSM). Methods A total of 71 patients with PSM were enrolled in this study who underwent surgical operations at Department of Neurosurgery, Fuzhou General Hospital from October 2011 to December 2015. The examination of MRV was conducted prior to operation to reveal the location of tumors and degrees of their invasion of the venous sinus. The collateral venous circulation was graded from 0 to 4 based on the Qureshi Collateral Circulation Assessment with certain modifications, guided by which operations were conducted and the patients' outcomes were retrospectively analyzed. Results Among the 71 patients, tumors were located in the anterior (n=12), middle (n=46) and posterior (n=13) regions of superior sagittal sinus. Collateral venous circulation was not observed (grade 0) in 26 (36.6%) cases; 8 (11.3%) patients were graded class 1; 12 (16.9%) and 25 (35.2%) patients belonged to grade 3 and 4, respectively. Simpson grade Ⅰ/Ⅱ and Ⅲ resections were achieved in 67 (94.4%) and 4 (5.6%) cases, respectively. The superior sagittal sinus was excised in 15(21.1%) cases, reconstructed in 8 (11.3%) cases and electrocoagulated in 48 (67.6%) cases. The median length of postoperative follow-up was 34 months (range 3-70 months). Fourteen (19.7%) patients reported post-operative new neurological dysfunctions or deterioration of original symptoms, and permanent neurological dysfunctions occurred in 8 (11.3%) cases. The percentages of poor outcomes in patients with grade 0-4 collateral venous circulation were 2/26, 1/8, 1/12 and 4/25, respectively, and their differences were not statistically significant (P=0.830). Postoperative venous sinus thrombosis occurred in 3 (4.2%) patients, among whom one (1.4%) was cured, one (1.4%) died and one (1.4%) reported recurrence 1 year post surgery. Conclusions Extracranial collateral venous circulation plays an important role in the design of incision. Preoperative assessment of collateral venous circulations for PSM patients help guide the venous treatment and improve their outcomes. Key words: Meningioma; Collateral circulation; Cerebral veins; Neurosurgical procedures

Simplified total aortic arch replacement with an in situ stent graft fenestration technique for acute type A aortic dissection

ObjectiveTotal arch replacement combined with stented elephant trunk implantation in the descending aorta has successfully improved the outcomes of acute type A aortic dissection (AAAD). However, the optimal surgical strategy for the left subclavian artery (LSA) during the procedure remains a challenge. This study aimed to present our new technique of in situ stent graft fenestration to simplify the surgical procedure for suitable cases of AAAD. MethodsFrom August 2008 to December 2015, a total of 106 patients underwent simplified total aortic arch replacement with an in situ stent graft fenestration technique. The mean age of the patients was 50.71 ± 11.54 years (range, 24-78 years). Both perioperative variables and postoperative follow-up outcome of the procedure were assessed. ResultsThe in-hospital mortality rate was 7.5%. The mean cardiopulmonary bypass time was 162.73 ± 68.49 minutes, cross-clamp time was 93.13 ± 22.29 minutes, and circulatory arrest time was 23.28 ± 5.56 minutes. Transient neurologic dysfunction was observed in five patients. No permanent neurologic dysfunction was observed, and no stroke or left arm ischemia occurred. During the follow-up period (mean, 43.4 ± 21.53 months), the survival rates of patients were 90.6%, 85.5%, and 78.8% at 1 year, 2 years, and 7 years, respectively. No stroke or left limb ischemia was observed. The LSA perfusion was well preserved in all surviving patients, and there was no endoleak or dissection around the LSA. All patients were free from reoperation. ConclusionsThe in situ graft fenestration technique could simplify the procedure of LSA reconstruction during total arch replacement, provide a good surgical view for anastomosis and hemostasis, shorten the operation time, and yield satisfactory early and midterm results. It is a safe and effective alternative approach for suitable patients with AAAD. However, the long-term results of this technique need further evaluation.

Efficacy of superficial temporal artery pressure-guided selective cerebral perfusion during deep hypothermic circulatory arrest in patients undergoing aortic arch surgery

Objective To evaluate the efficacy of superficial temporal artery(STA)pressure-guided selective cerebral perfusion(SCP)during deep hypothermic circulatory arrest(DHCA)in patients undergoing aortic arch surgery. Methods Ninety-six patients of both sexes, aged 35-64 yr, with body mass index of 19-23 kg/m2, of American Society of Anesthesiologists physical status Ⅲ or Ⅳ, undergoing aortic arch surgery, were divided into STA pressure group(group A)and clinical experience group(group B)using a random number table, with 48 patients in each group.In group A, STA catheterization was performed after tracheal intubation, and arterial pressure was monitored.SCP flow was adjusted to maintain the target value of STA pressure between 30 and 40 mmHg during DHCA in group A. SCP flow rate was set at 5-10 ml·kg-1·min-1 according to clinical experience in group B. The volume of fluid perfused during SCP, emergence time, extubation time and duration of intensive care unit stay were recorded.Neurological function was evaluated during length of hospitalization after surgery, and the development of permanent and transient neurological dysfunction and mortality in hospital were recorded. Results Compared with group B, the volume of fluid perfused during SCP was significantly decreased, the emergence time, extubation time and duration of intensive care unit stay were shortened, the incidence of permanent and transient neurological dysfunction(2% and 4%, respectively)was decreased(P 0.05). Conclusion Maintaining STA pressure at 30-40 mmHg is a reliable method for guiding SCP during DHCA in patients undergoing aortic arch surgery. Key words: Temporal arteries; Blood pressure; Cerebrovascular circulation; Circulatory arrest, deep hypothermia induced; Prognosis

Bilateral versus unilateral antegrade cerebral perfusion in total arch replacement for type A aortic dissection

BackgroundAntegrade cerebral perfusion (ACP) is the most widely used cerebral protection strategy for complex aortic repair and includes unilateral (u-ACP) and bilateral (b-ACP) techniques. The superiority of b-ACP over u-ACP has been the subject of much debate. Focusing on type A aortic dissection requiring total arch replacement, we investigated the clinical effects of b-ACP versus u-ACP. MethodsBetween September 2006 and August 2014, 203 patients presenting with type A aortic dissection (median age, 51.0 ± 13 years; range, 17-72 years; 128 males) underwent total aortic arch replacement with hypothermic circulatory arrest. ACP was used in all patients, including u-ACP in 82 (40.3%) and b-ACP in 121 (59.7%). ResultsThere was no significant difference between the u-ACP and b-ACP groups in terms of cardiopulmonary bypass (CPB) time, cross-clamp time, or circulatory arrest time. Overall 30-day mortality was comparable in the 2 groups (11.6% for b-ACP vs 20.7% for u-ACP; P = .075). The prevalence of postoperative permanent neurologic dysfunction (PND) was comparable as well (8.4% vs 16.9%; P = .091). Mean ventilation time was lower in the b-ACP group (95.5 ± 45.25 hours vs 147.0 ± 82 hours; P < .001). Mean lengths of stay in the intensive care unit and the hospital overall were comparable in the 2 groups (intensive care unit: 16 ± 17.75 days vs 17 ± 11.5 days, P = .454; hospital: 26.5 ± 20.6 days vs 24.8 ± 10.3 days, P = .434). The P values from logistic regression models indicated that in the 2 groups combined, CPB time and circulatory arrest time were independent risk factors for both mortality and PND. ConclusionsIn this, the first published study focusing on the efficacy of u-ACP and b-ACP in total arch replacement for type A aortic dissection, the b-ACP group did not demonstrate significantly lower 30-day mortality or PND rate compared with the u-ACP group. Future large-sample studies are warranted to thoroughly examine this critical issue.

A modified collagen scaffold facilitates endogenous neurogenesis for acute spinal cord injury repair

A linearly ordered collagen scaffold was specifically modified with collagen-binding EGFR antibody, allowed for sustained release of this EGFR neutralizing factor, to block the myelin associated inhibitory molecules and guide spinal cord regeneration along its linear fibers. Dorsal root ganglion neurons and neural stem cells induced by CBD-Fab exhibited enhanced neurite outgrowth and neuronal differentiation rate under myelin in vitro. Transplantation of the modified collagen scaffold with moderate EGFR neutralizing proteins showed greatest advantage on endogenous neurogenesis of injury-activated neural stem cells for acute spinal cord injury repair.

Inflammatory Activation of Microglia and Astrocytes in Manganese Neurotoxicity.

Neurotoxicity due to excessive exposure to manganese (Mn) has been described as early as 1837 (Couper, Br Ann Med Pharm Vital Stat Gen Sci 1:41-42, 1837). Extensive research over the past two decades has revealed that Mn-induced neurological injury involves complex pathophysiological signaling mechanisms between neurons and glial cells. Glial cells are an important target of Mn in the brain, both for sequestration of the metal, as well as for activating inflammatory signaling pathways that damage neurons through overproduction of numerous reactive oxygen and nitrogen species and inflammatory cytokines. Understanding how these pathways are regulated in glial cells during Mn exposure is critical to determining the mechanisms underlying permanent neurological dysfunction stemming from excess exposure. The subject of this review will be to delineate mechanisms by which Mn interacts with glial cells to perturb neuronal function, with a particular emphasis on neuroinflammation and neuroinflammatory signaling between distinct populations of glial cells.

Application of descending neurogenic evoked potentials monitoring during spinal deformity surgery

Objective To elevate the efficacy and safety of descending neurogenic evoked potentials (DNEP) monitoring during severe rigid spinal deformity surgery. Methods All of 108 patients (43 males, 65 females) who underwent surgical treatment for spinal deformity in our spinal center from July 2010 to August 2013 were retrospectively reviewed. The average age (17.5± 5.8) ys(range 12-50 ys), the average following period is 38.6 months(range 24-52 months). Combined monitoring of SEP, MEP and DNEP model were used during surgery. All subjects with no neurological deficits preoperatively and got satisfied outcomes. Respectively evaluate the results of neurophysiological intraoperative monitoring (IOM). Data were collected to elevate the efficacy and safety of DNEP monitoring. Results All of 108 patients, 15 patients (13.9%, 15/108) showed significant changes of neuro-physiological parameters, of which 9 cases (60%, 9/15) were identified as true positive and 6 cases (40%, 6/15) were identified as false positive. During the following-up period, 2 patients developed permanent neurological deficit, and 3 patients showed transient neurological deficit who got fully recovered within 6 months after operation. DNEP showed alert in all 5 patients with truepositive alarm, of which 2 patients developed permanent neurological dysfunction and 3 cases showed postoperative short nerve dysfunction that got fully recovery within 6 months after operation. The sensitivity and specificity of SEP+MEP and DNEP were 100% and 97.98%, 100% and 98.99%, respectively. Conclusion Combining use of MEP+SEP+DNEP monitoring during surgical treatment of spinal deformities presented to be a highly reliable method for the detection and prevention of iatrogenic injury. The results confirmed a high efficacy and safety of DNEP monitoring during spinal surgery. Key words: Spinal curvatures; Osteotomy; Evoked potentials, somatosensory; Evoked potentials, motor

Abstract 11981: Can Preoperative Intensive Carotid And Intracranial Artery Screening Reduce Perioperative Strokes in Cardiovascular Surgery?

Introduction: The occurrence of stroke is a concern in patients undergoing cardiac surgery (CS) concomitant with carotid and/or intracranial artery disease (CIAD). Although the 2011 American Heart Association guidelines recommend screening only selected patients referred for elective CS, the clinical utility of CIAD screening is poorly understood. Objectives: To evaluate the effectiveness of CIAD screening for patients undergoing elective CS. Methods: Between February 2004 and December 2014, 1095 of 1134 patients (97%) underwent routine CIAD screening before CS at our institute. CS included coronary artery bypass grafting (CABG) in 378 (34%) patients, CABG + valve surgery in 151 (13%), valve surgery in 480 (42%), aortic surgery without brain protection in 43 (4%), and others in 82 (7%). Patients were divided as follows: those who underwent CS before (n=500) and those after (n=634) the introduction of intensive screening (IS) in January 2009. Preoperative screening had undergone transition in 2009, from the evaluation of carotid atherosclerosis alone to that of carotid and intracranial atherosclerosis. Moreover, patients detected with ≥moderate stenosis on IS underwent single-photon emission computed tomography (SPECT) with acetazolamide (ACZ). CIAD was classified based on the degree of stenosis as mild (0%-49% stenosis: n=836 [before/after: 370/466]), moderate (50%-69%: n=118 [56/62]), or severe (70%-100%: n=141 [36/105]). Results: One of 166 (0.6%) patients with ≥moderate stenosis undergoing SPECT with ACZ was diagnosed with impaired cerebral autoregulation and underwent prophylactic superficial temporal artery to middle cerebral artery anastomosis 1 month before CABG. Subsequently, the patient underwent CABG without experiencing postoperative stroke. The introduction of IS significantly reduced the prevalence of perioperative stroke (2.8% vs. 0.9%, P=0.03) and permanent neurological dysfunction (2.4% vs. 0.5%, P=0.01). Additionally, prevalence of intraoperative stroke decreased significantly after the introduction of IS (1.4% vs. 0.2%, P=0.03). Conclusions: Incidence of perioperative stroke decreased following the introduction of IS. Therefore, IS might help identify patients at risk of perioperative stroke.

Long-Term Outcomes of Open Arch Repair After a Prior Aortic Operation: Our Experience in 154 Patients

This study assessed the early and long-term results of arch operations performed after a prior aortic operation. From 1994 to 2014, 154 consecutive patients (mean age, 59.7 years) underwent an aortic arch repair, after a previous aortic operation, at our institution. Antegrade selective cerebral perfusion was used in all cases. Chronic postdissection aortic aneurysm (87 [56.5%]) and degenerative aneurysm (43 [27.9%]) represented the most common indications for surgical intervention. A complete arch replacement was performed in 119 patients (77.3%), an associated root repair in 70 (45.5%), and the frozen elephant trunk technique was used in 55 (35.7%). Hospital mortality was 11.7% (n= 18). Postoperative permanent neurologic dysfunction occurred in 10 patients (6.4%). On multivariate analysis, cardiopulmonary bypass time (odds ratio, 1.02 per minute; p= 0.005) emerged as the only independent predictor of hospital death. Follow-up was 100% complete. The estimated survival at 1, 5, and 10 years was 79.6%, 69.9%, and 46.8%, respectively. Freedom from reoperation was 75.6% at 5 years and 54.6% at 10 years. Cox regression identified chronic postdissection aortic aneurysm (odds ratio, 4.2; p= 0.006) to be the only independent predictor of aortic reintervention. Late survival was comparable between degenerative aneurysm patients and the Italian population matched for age and sex (standardized mortality ratio, 1.9; p= 0.1). Longevity was reduced in patients operated on for chronic postdissection aortic aneurysm (standardized mortality ratio, 6.3; p < 0.001). Arch operations after a previous open aortic repair can be performed with acceptable mortality and good long-term outcomes. Complete aortic resection did not increase hospital deaths and was associated with a low need for aortic reinterventions at follow-up.

Open aortic arch reconstruction for acute type a aortic dissection: a single-center experience with 267 consecutive patients.

BackgroundThis study aimed to analyze the mortality and morbidity of patients undergoing open aortic arch reconstruction for acute type A aortic dissection.MethodsBetween September 2005 and January 2012, 267 consecutive patients underwent open aortic arch reconstruction for acute type A aortic dissection at our center. The mean age was 51.2 ± 10.0 years, and 200 patients were male. Sixty-three and 184 patients underwent hemiarch replacement and total arch replacement, respectively, whereas the remaining 20 patients underwent single- or triple-branched stent graft implantation. Long-term mortality was estimated by Kaplan–Meier method.ResultsThe in-hospital and operative mortality rates within 30 days were 11.2 % and 8.2 %, respectively. The cardiopulmonary bypass, myocardial ischemic, and antegrade cerebral perfusion times were 150.2 ± 43.3, 71.9 ± 33.2, and 33.6 ± 14.4 min, respectively. The overall in-hospital and intensive care unit durations and mean ventilation time were 23.9 ± 18.4 and 9.5 ± 12.7 days and 122.7 ± 183.4 h, respectively. We observed new postoperative permanent neurological dysfunction in 29 patients and temporary neurological dysfunction in 17 patients. The mean follow-up duration was 52.4 ± 27.9 months; 76.4 % of patients completed follow-up and 143 remained alive. Overall long-term survival was 82.2 % at 5 years.ConclusionsThe open aortic arch reconstruction technique for acute type A dissection carries a relatively high in-hospital mortality risk, although the late results are encouraging. Patients with an advanced age or impaired renal function may opt for endovascular or modified single- or triple-branched stent graft implantation therapy.

Mice with sclerostin gene deletion are resistant to the severe sublesional bone loss induced by spinal cord injury.

The bone loss secondary to spinal cord injury (SCI) is associated with several unique pathological features, including the permanent immobilization, neurological dysfunction, and systemic hormonal alternations. It remains unclear how these complex pathophysiological changes are linked to molecular alterations that influence bone metabolism in SCI. Sclerostin is a key negative regulator of bone formation and bone mass. We hypothesized that sclerostin could function as a major mediator of bone loss following SCI. To test this hypothesis, 10-week-old female sclerostin knockout (SOST KO) and wild type (WT) mice underwent complete spinal cord transection or laminectomy (Sham). At 8weeks after SCI, substantial loss of bone mineral density was observed at the distal femur and proximal tibia in WT mice but not in SOST KO mice. By μCT, trabecular bone volume of the distal femur was markedly decreased by 64% in WT mice after SCI. In striking contrast, there was no significant reduction of bone volume in SOST KO/SCI mice compared with SOST KO/sham. Histomorphometric analysis of trabecular bone revealed that the significant reduction in bone formation rate following SCI was observed in WT mice but not in SOST KO mice. Moreover, SCI did not alter osteoblastogenesis of marrow stromal cells in SOST KO mice. Our findings demonstrate that SOST KO mice were protected from the major sublesional bone loss that invariably follows SCI. The evidence indicates that sclerostin is an important mediator of the marked sublesional bone loss after SCI, and that pharmacological inhibition of sclerostin may represent a promising novel approach to this challenging clinical problem.