Postoperative Vasospasm Research Articles

Long-term follow-up analysis of microsurgical clip ligation and endovascular coil embolization for dorsal wall blister aneurysms of the internal carotid artery

Blister aneurysms at non-branching sites of the dorsal internal carotid artery (dICA) are fragile, rare, and often difficult to treat. The purpose of this study is to address the demographics, treatment modalities, and long-term outcome of patients treated for dICA blister aneurysms. A retrospective review of medical records identified all consecutive patients who presented with a blister aneurysm from 2002 to 2011 at our institution. Eighteen patients (M=7, F=11; mean age: 48.4±15.1years; range: 15–65years) harbored a total of 43 aneurysms, 25 of which were dorsal wall blister aneurysms of the ICA. Eleven (61.1%) patients presented with aneurysmal subarachnoid hemorrhage (aSAH), and 10 (55.6%) patients had multiple aneurysms at admission. Twelve patients had 18 aneurysms that were treated microsurgically. Five (41.7%) of these patients had a single recurrence that was retreated with subsequent repeat clip ligation. Six patients had 7 blister aneurysms that were treated with endovascularly. One (16.7%) of these patients had a single recurrence that was retreated with subsequent coil embolization. Postoperative vasospasm occurred in 8 (44.4%) patients, one of whom suffered from a stroke. This is one of the largest single-institution dICA blister aneurysm studies to date. There was no detected significant difference between microsurgical clip ligation and endovascular coil embolization in terms of surgical outcome. These blister aneurysms demonstrate a propensity to be associated with multiple cerebral aneurysms. Strict clinical and angiographic long-term follow-up may be warranted. Statement of SignificanceBlister aneurysms are focal wall defects covered by a thin layer of fibrous tissue and adventitia, lacking the usual collagenous layer. Due to their pathologically thin vessel wall, blister aneurysms are prone to rupture. The management of these rare and fragile aneurysms presents a number of challenges. Here, we address the long-term outcome of patients treated for blister aneurysms at non-branching sites of the dICA. The presented data and analysis is imperative to determine the necessary strict long-term clinical and angiographic follow-up.

Outcome of Microsurgical Revascularization in Patients with Moyamoya Disease: First Report from the Iranian Population.

To report the outcome of microsurgical revascularization in patients with Moyamoya Disease (MMD) in Southern Iran. This cross-sectional study was conducted in Southern Iran during a 7-year period from 2009 to 2016. All the patients with Moyamoya Disease (confirmed with digital substraction angiography) who underwent microsurgical revascularization (extracranial-intracranial bypass or synangiosis) were included. All the patients were followed for at least 1 year and the outcome was measured using the Glasgow outcome scale (GOS) and modified Rankin scale (MRS). Overall we included 13 patients with 14 involved hemispheres undergoing direct and indirect revascularization. The mean age of the patients was 20.6±17.5 (ranging from 0.5 to 55) years and there were 5 (38.4%) males and 8 (61.6%) females. We did not have any unfavorable outcome defined as mortality and persistent vegetative state. We performed 12 (85.7%) superficial temporal artery (STA)-middle cerebral artery (MCA) bypass and 2 (14.3%) encephalo-myo-synangiosis (EMS) procedures. The symptoms improved in 7 (53.8%) patients and remained as the preoperative course in 5 (38.5%) patients. Only 1 (7.7%) patient developed immediate postoperative vasospasm and brain swelling, and was managed successfully with decompressive craniectomy and subsequent cranioplasty (GOS=5, MRS=0). This is the first study to report the safety, efficacy and outcome of the direct (STA-MCA bypass) and indirect (EMS) revascularization in patients with MMD in the Iranian population. As the prevalence of MMD is low in Iranian population, the experience and technique remains in its infancy and further advancements in the field is required.

Application of actuator-driven pulsed water jet in aneurysmal subarachnoid hemorrhage surgery: its effectiveness for dissection around ruptured aneurysmal walls and subarachnoid clot removal.

In clipping surgery for aneurysmal subarachnoid hemorrhage (aSAH), critical steps include clot removal and dissection of aneurysms without premature rupture or brain injuries. To pursue this goal, a piezo actuator-driven pulsed water jet (ADPJ) system was introduced in this study. This study included 42 patients, who suffered aSAH and underwent clipping surgery. Eleven patients underwent surgery with the assistance of the ADPJ system (ADPJ group). In the other 31 patients, surgery was performed without the ADPJ system (Control group). The ADPJ system was used for clot removal and aneurysmal dissection. The clinical impact of the ADPJ system was judged by comparing the rate of premature rupture, degree of clot removal, and clinical outcomes. Intraoperatively, a premature rupture was encountered in 18.2 and 25.8% of cases in the ADPJ and control groups, respectively. Although the differences were not statistically significant, intraoperative observation suggested that the ADPJ system was effective in clot removal and dissection of aneurysms in a safe manner. Computed tomography scans indicated the achievement of higher degrees of clot removal, especially when the ADPJ system was used for cases with preoperative clot volumes of more than 25ml (p=0.047, Mann-Whitney U test). Clinical outcomes, including incidence of postoperative brain injury or symptomatic vasospasm, were similar in both groups. We described our preliminary surgical results using the ADPJ system for aSAH. Although further study is needed, the ADPJ system was considered a safe and effective tool for clot removal and dissection of aneurysms.

Predictors of Acute Vertebrobasilar Vasospasm following Tumor Resection in the Foramen Magnum Region.

ObjectiveCerebral vasospasm can occur after skull base tumor removal. Few studies concentrated on the posterior circulation vasospasm after tumor resection in the posterior fossa. We aimed to identify the risk factors associated with postoperative vertebrobasilar vasospasm after tumor resection in the foramen magnum.MethodsWe retrospectively reviewed the data of 62 patients with tumors in the foramen magnum at our institution from January 2010 to January 2015. The demographic data, tumor features, surgical characteristics were collected. Vertebrobasilar vasospasm was evaluated by bedside transcranial Doppler before surgery and on postoperative day 1, 3, 7. Univariate and multivariate analyses were performed to determine the predictors of postoperative vasospasm in the posterior circulation.ResultsVertebrobasilar vasospasm was detected in 28 (53.8%) of the 62 patients at a mean time of 3.5 days after surgery. There were 5 (8%) patients with severe vasospasm according to the grading criteria. Age, tumor type, tumor size, vertebral artery encasement, and surgical time were significantly related to vasospasm in the univariate analysis. Further multivariate analysis demonstrated that only age and vertebral artery encasement were independent risk factors predicting the occurrence of postoperative vertebrobasilar vasospasm.ConclusionsThe incidence of acute vertebrobasilar vasospasm is not uncommon after foramen magnum tumor resection. Age and vertebral artery encasement are significantly correlated with postoperative vasospasm. Close monitoring of vasospasm should be given to patients with younger age and the presence of vertebral artery encasement on the preoperative imaging to facilitate early diagnosis and intervention.

Abstract TMP108: Absence of Cortical Microvessel Spasm During Large Vessel Spasm Following Experimental Subarachnoid Hemorrhage

Introduction: A significant portion of the morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH) is due to delayed ischemic neurological deficits (DIND). Although large vessel vasospasm has been implicated as a cause of DIND, the presence of such spasm is not always correlated with DIND. In the present experiment we examined the cortical microvasculature in awake mice after SAH in an experimental model typically associated with large vessel vasospasm. Methods: Twenty adult mice underwent cisterna magna (CM) injection of 60ul syngenic donor blood or artificial cerebrospinal fluid (aCSF). The mice were perfused at 72 hours, and Circle of Willis (COW) vessel diameters were measured. In a separate experiment, polished and reinforced thinned skull cranial windows were created in 10 mice that then underwent CM blood or aCSF injection. Cortical microvessels were measured in living, awake mice in the postoperative vasospasm period using two photon laser scanning microscopy. Results: A pairwise comparison of COW vessels revealed a statistically significant difference in vessel diameter between the experimental and control groups at each of the sites measured (ACA, P=0.0012; MCA, P=0.0259; Pcom, P=0.0053). In the second experiment, there were no significant differences in cortical microvessel diameter between the experimental and control groups. Conclusions: This study represents the first report of in vivo imaging of cortical microvessels during large vessel spasm following SAH. In a CM injection SAH model, we observed significant large vessel spasm but no cortical microvessel spasm. These results may have important implications for understanding the mechanisms of DIND.

Endoscope-assisted Transorbital Keyhole Surgical Approach to Ruptured Supratentorial Aneurysms.

Many different surgical approaches have been described to treat intracranial aneurysms. A common feature of all the approaches has been relatively extensive brain exposure and brain retraction with increasing surgical morbidity. Transorbital keyhole is one of the minimally invasive approaches. Endoscope-assisted transorbital keyhole surgery (EATOKS) combines minimally invasive transorbital keyhole surgery with endoscope-assisted microneurosurgery. We describe our experience with this approach and its efficacy in treating ruptured supratentorial aneurysms. We retrospectively reviewed 62 patients (18 men [29%] and 44 women [71%]) with a ruptured supratentorial aneurysm who underwent surgical clipping via the EATOKS approach from April 2003 to July 2012. In all our cases, we use a rigid endoscope of 0, 30, or 45 degrees to inspect the aneurysm and its surrounding anatomy before clipping and ultimately to verify the completeness of the aneurysm clipping and the patency of the adjacent neurovascular structures. All patients with ruptured supratentorial aneurysms were successfully clipped including three with multiple aneurysms. Surgically related major and minor as well as medically related complications were 10%, 15%, and 10%, respectively. Three patients (4.8%) died of massive cerebral infarction due to fulminant postoperative vasospasm, multiorgan failure, and adult respiratory distress syndrome. At 6-month follow-up, 81% of patients achieved good outcomes with Glasgow Outcome Scales of 4 and 5. Patients' satisfaction with the cosmetic results was satisfactory to excellent in most cases. EATOKS is a viable and safe option in the neurosurgical armamentarium to treat ruptured supratentorial aneurysms.

Analysis on surgery coordination of refractory intracranial aneurysm in the process of cerebral revascularization therapy

Objective To observe cerebral revascularization procedures in patients with refractory intracranial aneurysm surgery with analysis and prognosis.Methods According the digital table,89 patients with refractory intracranial aneurysm surgery were divided,the control group uesed the intervention operation,and the observation group with vessel revascularization.The complications after the operation,cerebrospinal fluid of red blood cells and pressure indicator,and postoperative quality of life in the two groups were observed.Results Observation group of patients with postoperative cerebral vasospasm (CVS) rate was 20.00％,which was significantly lower than that in the control group 40.00％ (x2 =6.79,P ＜ 0.05).Psychological state (SAS,SDS),self esteem (SES) and other related quality of life evaluation score,the observation group was obviously better than the control group (t =6.27,8.69,7.45,all P ＜ 0.05).Cerebrospinal fluid pressure of red blood cells and obviously than the control group after treatment (t =6.18,8.38,17.82,0.57,all P ＜ 0.05).Conclusion Cerebral revascularization in patients with refractory intracranial aneurysm has better reduce operation and operation complications as well as the ability to relieve mental depression,improve the quality of life,is worth the clinical promotion. Key words: Cerebral revascularization; Interventional embolization; Intracranial aneurysms

Highly flexible and rapidly degradable papaverine-loaded electrospun fibrous membranes for preventing vasospasm and repairing vascular tissue

Vasospasm is a common post-operative complication after vascular anastomosis. Currently, the main treatment is a local injection of antispasmodic drugs. However, this method has a high rate of relapse and is subject to a large degree of individual variation, and repeated injections cause additional pain for patients. In this study, we developed highly flexible and rapidly degradable papaverine-loaded electrospun fibrous membranes to be wrapped around vascular suturing to prevent vasospasm. Poly-l-lactic acid/polyethylene glycol (PLLA/PEG) electrospun fibers containing papaverine maintained a high degree of flexibility and could withstand any folding, and are therefore suitable for wrapping vascular suturing. A rapid release of papaverine, between 2 and 7days, was achieved by adjusting the proportions of PEG and PLLA. PLLA electrospun fibers containing 40% PEG (PLLA-40%) could control drug release and polymer degradation most effectively during the first 2weeks post-operation. Testing using an in vivo rabbit model showed that PLLA-40% fibrous membranes produced significant antispasmodic effect without observable inflammation or hyperplasia, and the fibrous membranes were ideally biodegradable, with no impact on regional blood flow, pressure, vessel diameter or surrounding tissue hyperplasia. Therefore, papaverine-loaded electrospun fibrous membranes show the potential to greatly reduce post-operative vasospasm and maintain regular vascular morphology during antispasmodic therapy.

Posterior communicating aneurysm with oculomotor nerve palsy: clinical outcome after aneurysm clipping.

One of the clinical presentations of intracranial aneurysm is unilateral oculomotor nerve palsy (ONP). The most common location is the posterior communicating artery. Surgical clipping and/or endovascular coiling of the aneurysm are the treatments. The aim of this study was to identify the factors that influence the postoperative recovery of patients who have posterior communicating aneurysm with ONP. We included 13 patients diagnosed at our hospital from 1993 to 2008 with posterior communicating aneurysm with ONP. Ten patients underwent craniotomy to clip the aneurysm; 3 patients refused surgery. Five (50%) patients presented with periorbital pain. Seven (70%) patients had complete ONP recovery with a median recovery time of 58 days. We found that the first recovered component of ONP after clipping was the parasympathetic fibers with a mean recovery time of 4.4 days. Nine patients had a good recovery outcome; one patient died from postoperative vasospasm. There was no significant linear trend in complete recovery rate across palsy symptom periods. However, the palsy symptom period was significant correlated with recovery time. Early decompression of the posterior communicating aneurysm yielded satisfactory recovery and ONP can be reversible. In our patients, the first component of oculomotor function to recover was the parasympathetic fibers.

Effect of intraoperative brain protection with propofol on postoperative cognition in patients undergoing temporary clipping during intracranial aneurysm surgery.

Cognitive dysfunction after subarachnoid hemorrhage (SAH) has been attributable to presence of subarachnoid blood, hydrocephalus (HCP), cerebral edema, vasospasm, and temporary clipping of intracranial aneurysm. Provision of neuroprotection during temporary clipping may improve postoperative cognition in such patients. Good-grade aneurysmal SAH patients undergoing temporary clipping during surgery were allocated either to group C (control) or group P (propofol). Patients in group P received propofol in titrated doses to attain a burst suppression ratio of 75 ± 5% on bispectral index (BIS) monitor. The cognitive function as assessed by Hindi-language modification of mini-mental state examination (HMSE) score was evaluated preoperatively, 24 h after surgery, and at discharge from hospital. A score of ≤23 was indicative of cognitive dysfunction. Perioperative complications, duration of intensive care unit (ICU) and hospital stay, and outcome at discharge were noted. A total of 66 patients (32 and 34 in group C and P respectively) were included in the study. 97% of the patients had anterior circulation aneurysms. At 24 h after surgery, eight and 12 patients in group C and P respectively; and at discharge, five patients in each group had cognitive dysfunction. In both groups, the trend showed a decline in cognition at 24 h followed by improvement at discharge. Glasgow outcome score in both the groups was comparable (P > 0.05). Intraoperative brain bulge, postoperative vasospasm, and cerebral infarction were found to be independent risk factors for cognitive dysfunction. Pharmacologic neuroprotection with propofol at the time of temporary clipping during surgery for aneurysmal SAH did not offer any advantage as far as preservation of cognition is concerned.

Imaging classification of middle cerebral artery aneurysms and its value for clipping surgery: a single -center retrospective analysis of 134 cases

Objective To introduce a imaging classification of middle cerebral artery aneurysms (MCAAs) based on angiography and to explore its guidance value for the clipping surgery.Methods A total of 168 aneurysms were found in 134 patients,of which 143 were MCAAs.According to the direction of aneurysmal projections,they were classified into 4 types:58 point to the temporal side,29 to frontal,52 to the posterior superior part of Sylvius cistern,and 4 to the posterior inferior part of Sylvius cistern. 141 aneurysms were successfully direct clipped.Results According to Glasgow outcome score ( GOS),111 patients (82.8％) had an excellent clinical outcome of GOS 5,14 ( 10.5％ ) GOS 4,4(3.0％ ) GOS 2 ～ 3 and 5 deaths (3.7％,GOS 1 ).Conclusions Preoperative imaging classification of MCAAs may play an important guiding role to the microsurgical treatment which could provide individually optimal strategies for aneurysm dissecting and neck clipping,and could reduce postoperative cerebral vasospasm and improve the therapeutic effect of surgical treatment. Key words: Middle cerebral artery aneurysms; Microsurgery; Imaging classification

Intraoperative brain oxygenation monitoring and vasospasm in aneurysmal subarachnoid hemorrhage

Background: Vasospasm is a frequent complication of subarachnoid hemorrhage (SAH), implicated in poor outcome, and prediction of its occurrence might be important on the therapeutic approach of this condition. Brain oxygenation in aneurysmal SAH was prospectively monitored during surgery in 28 patients, using brain tissue oxygen pressure (PbtO2), studying its association with the occurrence of post-operative vasospasm, detected by transcranial Doppler.Methods: PbtO2 monitoring was performed during surgery of 28 patients with aneurysmal SAH, using a polarographic microcatheter (Licox; GMS, Kiel, Germany), inserted into the cerebral tissue. The aneurysms were localized in the anterior communicating artery (AcoA) complex (eight cases), in the posterior communicating artery (Pcom) origin (seven cases), and in the middle cerebral artery (MCA) bifurcation (13 cases). Basal PbtO2 values, obtained immediately before application of temporary or definitive clips, were studied according to age, clinical status and CT findings. The association between the basal values and the occurrence of increased blood flow velocity in the post-operative transcranial Doppler (TCD vasospasm) was investigated.Results: Post-operative TCD vasospasm developed in 13 patients, all of them with basal values inferior to 10 mmHg. PbtO2 basal value was significantly lower in cases that developed TCD vasospasm. This association was independent of age, clinical status, or CT findings.Conclusion: The finding of low intraoperative basal PbtO2 values may be an indicator for a high risk of occurrence of post-operative TCD vasospasm in cases of aneurysmatic SAH.

Unilateral neurogenic pulmonary oedema: An unusual cause for post-operative respiratory dysfunction following clipping of ruptured intracranial aneurysm

A variety of central nervous system lesions like stroke, subarachnoid haemorrhage, trauma and seizure activity can result in neurogenic pulmonary oedema (NPE). Unilateral neurogenic pulmonary oedema is very rare. There are no reports of unilateral NPE with aneurysmal vasospasm. We present the case of a 55-year-old female who developed respiratory distress with unilateral pulmonary oedema and mild left ventricular dysfunction in the context of postoperative cerebral vasospasm following clipping of ruptured intracranial aneurysm. Neurogenic pulmonary oedema should always be in the differential diagnosis when patients with presumed neurogenic pathology develop respiratory compromise. The diagnosis of unilateral neurogenic pulmonary oedema requires a high index of suspicion. Early initiation of supportive treatment results in good outcome.

A Novel Approach for Preventing the Development of Persistent Vasospasms after Microsurgery for the Extremities: Intermittent Topical Lidocaine Application

Vasospasm is often encountered after harvesting the recipient artery in tissue transfer surgery, particularly in the extremities. Further, after anastomosis, thrombosis is a major complication arising due to vasoconstriction. Therefore, we decided to apply lidocaine topically on the recipient artery to prevent postoperative vasospasm. We had applied lidocaine topically on the recipient artery in seven patients with persistent vasospasm before the completion of the surgery. After surgery, 0.2 mL lidocaine (4%) was directly applied on the vascularized region every 15 minutes for the first 3 hours, every 30 minutes for the next 3 hours, and every 1 hour for the next 18 hours. Although four patients experienced a disturbance in the blood flow immediately after the surgery, they showed improvements after lidocaine application. In three of these four patients, vasospasm was also suspected to occur at 15 minutes after the surgery; however, topical application of lidocaine was found to be effective in these patients. Thrombosis was not observed in any case. We believe that if the site of lidocaine application is appropriate, even a small dose of low-concentration lidocaine (4%) can produce an adequate effect. Moreover, the intervals between lidocaine applications should be carefully considered.

Use of a hybrid operating room to diagnose and treat delayed coronary spasm after mitral valve repair

From the Vanderbilt Heart and Vascular Institute, Nashville, Tenn. Disclosures: None. Received for publication June 10, 2009; revisions received July 14, 2009; accepted for publication July 31, 2009; available ahead of print Sept 27, 2009. Address for reprints: John G. Byrne, MD, Vanderbilt University Medical Center, Nashville, TN 37232-8802 (E-mail: john.byrne@vanderbilt.edu). J Thorac Cardiovasc Surg 2010;140:e25-7 0022-5223/$36.00 Copyright 2010 by The American Association for Thoracic Surgery doi:10.1016/j.jtcvs.2009.07.074

Radiographic Evaluation for AVN Following Distal Metatarsal Stoffella Bunion Osteotomy

Avascular necrosis of the metatarsal head, delayed bone healing and nonunion are complications that may occur after distal first metatarsal osteotomies. Intraoperative damage to the extraosseous blood supply, the location of the osteotomy and postoperative vasospasm have been cited as possible causes of such changes. We evaluated Stoffella's subcapital osteotomies which were performed at our department for the correction of moderate to severe hallux valgus deformities. Standardized radiographs of 300 feet, taken 6weeks, 3 months, and 6 months postoperatively and at the final followup were examined with regard to postoperative AVN or signs of delayed bone healing. Of 228 patients, 202 were women and 26 were men. The patients' mean age was 49 years, and the mean followup was 12 months. In 278 cases the radiographs revealed an unremarkable first metatarsal head. Seventeen cases showed diffuse or localized osteopenia or small cysts in the subchondral bone. These changes fully resolved on subsequent radiographs. The X-rays of two patients revealed progressive narrowing of the joint space, irregular contours on the surface of the joint and an abnormal bone structure. The patients subsequently developed a characteristic picture of avascular necrosis, in one case combined with nonunion. Three patients had delayed bone healing, but ultimately healed successfully. Ischemic changes in bone are known to occur after distal first metatarsal osteotomies. There is a very low incidence of postoperative perfusion problems after Stoffella;s technique, even with lateral soft tissue release.

The Effect of Intensive Insulin Therapy on Infection Rate, Vasospasm, Neurologic Outcome, and Mortality in Neurointensive Care Unit After Intracranial Aneurysm Clipping in Patients With Acute Subarachnoid Hemorrhage

It is unclear if avoiding hyperglycemia during intensive care after acute brain injury improves morbidity, mortality, and neurologic outcome. This prospective randomized trial tested whether intensive insulin therapy affected infection rates, vasospasm, mortality, or long-term neurologic outcome in subarachnoid hemorrhage patients during their intensive care unit (ICU) stay. Comparison was made against conventional insulin therapy using a randomized trial design. The primary outcome measure was infection rate until the fourteenth postoperative day in the ICU or until patient discharge. Secondary end points were the incidence of vasospasm until the fourteenth postoperative day in the ICU or until patient discharge, and neurologic outcome and mortality at 6 months follow-up. A total of 78 patients were prospectively enrolled and randomly assigned either to conventional insulin therapy or to intensive insulin therapy (38 and 40 patients, respectively). The infection rate during the study was significantly higher in patients who received conventional insulin therapy than in patients who received intensive insulin therapy (42% vs. 27%; P<0.001). The incidence of vasospasm during the study was also similar in conventional and intensive therapy groups (31.5% vs. 27.6% in the conventional and intensive insulin therapy groups; P=0.9). Overall mortality rates at 6 months were similar in the 2 groups (18% vs.15%; P=0.9), as was the neurologic outcome at 6 months [modified Rankin score >3 in 22/38 patients (57.8%) in the conventional therapy group vs. 21/40 patients (52.5%) in the intensive insulin therapy group; P=0.7]. Intensive insulin therapy in patients with acute subarachnoid hemorrhage admitted to a postoperative neurosurgical ICU after surgical clipping of intracranial aneurysms decreases infection rates. The benefit of strict glycemic control on postoperative vasospasm, neurologic outcome, and mortality rates does not seem to be affected by intensive insulin therapy.

Commentary

Blister aneurysms at non-branching sites of the dorsal internal carotid artery (dICA) are fragile, rare, and often difficult to treat. The purpose of this study is to address the demographics, treatment modalities, and long-term outcome of patients treated for dICA blister aneurysms. A retrospective review of medical records identified all consecutive patients who presented with a blister aneurysm from 2002 to 2011 at our institution. Eighteen patients (M = 7, F = 11; mean age: 48.4 ± 15.1 years; range: 15–65 years) harbored a total of 43 aneurysms, 25 of which were dorsal wall blister aneurysms of the ICA. Eleven (61.1%) patients presented with aneurysmal subarachnoid hemorrhage (aSAH), and 10 (55.6%) patients had multiple aneurysms at admission. Twelve patients had 18 aneurysms that were treated microsurgically. Five (41.7%) of these patients had a single recurrence that was retreated with subsequent repeat clip ligation. Six patients had 7 blister aneurysms that were treated with endovascularly. One (16.7%) of these patients had a single recurrence that was retreated with subsequent coil embolization. Postoperative vasospasm occurred in 8 (44.4%) patients, one of whom suffered from a stroke. This is one of the largest single-institution dICA blister aneurysm studies to date. There was no detected significant difference between microsurgical clip ligation and endovascular coil embolization in terms of surgical outcome. These blister aneurysms demonstrate a propensity to be associated with multiple cerebral aneurysms. Strict clinical and angiographic long-term follow-up may be warranted.Blister aneurysms are focal wall defects covered by a thin layer of fibrous tissue and adventitia, lacking the usual collagenous layer. Due to their pathologically thin vessel wall, blister aneurysms are prone to rupture. The management of these rare and fragile aneurysms presents a number of challenges. Here, we address the long-term outcome of patients treated for blister aneurysms at non-branching sites of the dICA. The presented data and analysis is imperative to determine the necessary strict long-term clinical and angiographic follow-up.

Development of a local vasodilator delivery system using fibrin glue to prevent arterial graft from spasm

The clinical benefits of coronary artery bypass graft operations can be compromised by postoperative vasospasm. Traditionally, local papaverine (PPV) has been employed during the procedure to prevent and counteract vasospasm. But the relatively short action period limited its application. Fibrin glue (FG) might be a potential carrier of PPV for counteracting vasospasm in a longer action period than PPV solution. After FG incorporated with PPV (PPV-FG) was locally administrated in axillary and femoral arteries of dogs, PPV concentrations in artery vessels surrounding the administration sites were compared with the concentrations at the same sites in dogs given PPV solution. The properties of PPV's release in vitro and maintenance in vessel as well as the influence on the mean peripheral blood pressure and drug concentration in peripheral vein after the introduction PPV-FG on the surface of artery in dogs were evaluated. FG was considered to provide a sustained release of PPV and could maintain a high PPV concentration in artery vessel around the administration site. The results suggested that FG was an effective substrate for reserving PPV in the administrated site in a defined period.

Regulation of Human Internal Mammary and Radial Artery Contraction by Extracellular and Intracellular Calcium Channels and Cyclic Adenosine 3′, 5′ Monophosphate

The internal mammary (IMA) and radial arteries (RA), which are routinely used in coronary artery bypass grafting, show a significant incidence of postoperative vasospasm. The present study evaluated the respective roles of calcium (Ca2+)-dependent and cyclic adenosine 3', 5' monophosphate-dependent (cAMP) signaling in mediating contraction and relaxation of the IMA and RA. We examined the contractile responses of the IMA and RA to potassium chloride, a depolarizing agent; phenylephrine, an alpha-adrenergic agonist; and U46619, a thromboxane analogue, in the absence and presence (0.045 to 1.500 mM) of extracellular Ca2+. Potassium chloride elicited little or no contraction in the absence of extracellular Ca2+. Contractions elicited by U46619 were similar in the IMA and RA, both in the absence and presence of extracellular Ca2+. By contrast, phenylephrine elicited significantly greater extracellular Ca2+-dependent contraction of the IMA than the RA. Estimation of cyclic guanosine 3', 5' monophosphate (cGMP) and cAMP revealed levels of cAMP to be about fourfold higher than cGMP in both the RA and IMA. Whereas forskolin and milrinone elicited similar relaxation of IMA and RA precontracted with either U46619 or phenylephrine and increased adenylate cyclase-catalyzed cAMP production, isoproterenol-induced relaxation of the arteries precontracted with U46619 was significantly impaired compared with arteries precontracted with phenylephrine. Our findings suggest that thromboxane A2 receptor-dependent pathways activate contraction of IMA and RA through both extracellular Ca2+-dependent and Ca2+-independent pathways. In addition, adenylate cyclase appears to play a key role in attenuating thromboxane A2 and alpha-adrenergic receptor-mediated contraction through both pathways.