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AIM To explore the association between haemorrhagic transformation (HT) subtypes and functional outcome in acute ischaemic stroke (AIS) patients with successful recanalization treated by endovascular thrombectomy (EVT). MATERIALS and METHODS Consecutive patients with AIS due to large-vessel occlusion in the anterior circulation, who were treated between January 2015 and June 2019 and achieved successful EVT, were enrolled in this retrospective study. HT was categorized according to the Heidelberg Bleeding Classification. Functional outcome was evaluated using the 90-day modified Rankin Scale (mRS) after stroke onset. Ordinal logistic regression analysis was performed to determine the association of HT subtypes with functional outcomes. RESULTS A total of 243 patients were included for further analysis. Among them, 121 (49.8%) had HT. Ten (4.1%) patients were classified as haemorrhagic infarction (HI) subtype 1, 61 (25.1%) as HI subtype 2, 17 (7.0%) as parenchymal haematoma (PH) subtype 1, and 33 (13.6%) as PH subtype 2. Ordinal logistic regression analysis suggested that HI subtype 2 (adjusted common OR 0.357, 95% CI: 0.192–0.667), PH1 (adjusted common OR 0.254, 95% CI: 0.093–0.696) and PH subtype 2 (adjusted common OR 0.017, 95% CI: 0.006–0.051) were significantly associated with poor functional outcomes. CONCLUSION The present study shows that HI subtype 2, PH subtype 1, and PH subtype 2 are independently associated with poor clinical outcomes in AIS patients with successful recanalization after EVT.

To evaluate the frequency and the degree of vital signs elevation, as well as to elucidate the risk factors for elevation of cardiopulmonary parameters. We retrospectively evaluated the medical records of 101 patients who received microwave ablation (MWA) under deep sedation with propofol. Univariate analysis followed by multivariate linear regression analysis was performed to determine the risk factors associated with the elevation of cardiopulmonary parameters. The heart rate (HR), mean blood pressure (BP) and respiratory rate (RR) were elevated in 53.5%, 45.5% and 30.7%. Hyperhemodynamic state (mean BP or HR increased > 30% of the baseline) and high RR (RR > 20 times/min) were detected in 23.8% and 13.9%. Age ≤ 50 years was signifiant for mean BP and HR elevation (p = 0.032; p = 0.027), ablation zone abutting the parietal peritoneum (p = 0.001; p = 0.001; p

Sarcopenia is emerging as a prognostic factor in patients with malignant diseases. The prognostication of perihilar cholangiocarcinoma (PHC) with obstructive jaundice was complex, because these patients suffered compete mortality events beyond cancer itself. Our study was to investigate the association between low skeletal-muscle index and overall survival (OS) after percutaneous transhepatic biliary drainage (PTBD) for obstructive jaundice due to PHC. We performed a retrospective survival analysis of patients undergoing PTBD for PHC-related obstructive jaundice between January 2016 and March 2019. Using computed tomography, we measured skeletal-muscle mass at the third lumbar vertebra (L3) to obtain a skeletal-muscle index (SMI). Then, we compared OS between low- and high-SMI groups. Furthermore, factors that could potentially affect OS were assessed. One hundred and four patients (56 males; mean age 66 ± 12 years) were analyzed. Median OS after PTBD was 150 days. OS was shorter in patients with low SMI than in those with high SMI (median OS, 120 vs. 270 days; P

To compare the feasibility and efficacy of emergency transarterial embolization (TAE) followed by staged hepatectomy (SH) with emergency hepatectomy (EH) for ruptured hepatocellular carcinoma (HCC). Between January 2012 and December 2017, 102 patients with HCC rupture received EH or emergency TAE followed by SH in our center. Patients were followed until April 2019. Propensity score matching (PSM) analysis was used at a 1:2 ratio, resulting in 20 patients in the SH group and 40 patients in the EH group. We retrospectively compared the operative variables, recurrence status, disease-free survival (DFS), and overall survival (OS) of patients between the two matched groups. Compared with the matched EH group, the SH group showed significantly decreased perioperative blood loss or blood transfusion, shortened intraoperative duration of clamping and postoperative hospital stay (P

PURPOSE: We aimed to identify the treatment options and prognostic factors for patients with initially unresectable ruptured hepatocellular carcinoma (HCC). METHODS: Between June 2012 and December 2016, 94 consecutive patients with initially unresectable ruptured HCC were analyzed retrospectively. Patients were followed until December 2017. Predictors of short-term (≤30 days) and long-term (>30 days) survival were identified by using logistic regression model and Cox proportional hazard model, respectively. RESULTS: Of the 94 patients, initial hemostasis was achieved by transarterial embolization (TAE) in 59 patients, surgical hemostasis in 14 patients, and conservative treatment in 21 patients. Twenty-five (26.6%) patients died within 30 days of tumor rupture. In the multivariate analysis, patients treated with aggressive initial treatment strategies (TAE or surgical hemostasis) (P < 0.001) or those with better Child-Pugh class (P = 0.003) and absence of shock on admission (P = 0.001) had a better chance of short-term survival. For 69 patients who survived more than 30 days after initial treatment, the median survival time was 268 days. In the multivariate analysis, among the 69 who survived, early modified LCSGJ stage (P = 0.003) and staged hepatectomy as definitive treatment (P < 0.001) were significant predictors of increased long-term survival. CONCLUSION: Short-term survival of patients with initially unresectable ruptured HCC could be achieved in the presence of better Child-Pugh class, absence of shock, and with the use of aggressive initial treatment strategies. Among survivors of the emergency phase of tumor rupture, long-term survival was significantly increased with early modified LCSGJ stage and staged hepatectomy therapy.

Background The benefit of endovascular thrombectomy for patients with in-hospital stroke remains unclear. Thus, the aim of this study was to compare the endovascular thrombectomy outcomes between in-hospital stroke and community-onset stroke among patients with acute ischemic stroke. Methods From January 2015 to July 2019, 362 consecutive patients with acute ischemic stroke with large vessel occlusion in the anterior circulation received endovascular thrombectomy in our centre. After propensity score matching with a ratio of 1:2 (in-hospital stroke:community-onset stroke), clinical characteristics and functional outcomes were compared between in-hospital stroke and community-onset stroke groups. Results Thirty-six patients with in-hospital stroke and 72 patients with community-onset stroke were enrolled. The number of patients with New York Heart Association classification III/IV (41.7% vs. 6.9%, p Conclusion Patients with in-hospital stroke had more disadvantageous comorbidities than those with community-onset stroke. Cardiac dysfunction seems to be associated with poor outcomes after thrombectomy. Nevertheless, endovascular thrombectomy still appears to be safe and effective for patients with in-hospital stroke.

Purpose: To compare different percutaneous approaches to manage occluded primary uncovered self-expandable metal stents (SEMS) in patients with unresectable malignant hilar biliary obstruct...

Our objective was to assess the impact of hs-cTnT elevation on functional outcome and mortality in AIS patients with large vessel occlusion (LVO) in the anterior circulation 3 months after ET and explore factors affecting hs-cTnT elevation. A total of 143 consecutive AIS patients with large vessel occlusion (LVO) in the anterior circulation following ET in a single stroke center were enrolled between January 2015 and November 2017. Hs-cTnT was quantitated on admission. Demographic characteristics, clinical data, functional outcome and all-cause mortality were compared between patients with elevated hs-cTnT levels (14 ng/L) and those with normal hs-cTnT levels (≤14 ng/L). 58/143(40.6%) patients showed elevated hs-cTnT levels before ET. Factors independently associated with hs-cTnT elevation were admission NIHSS score (OR = 1.08, 95% CI 1.01-1.16, p = 0.032), coronary heart disease (OR = 4.89, 95% CI 1.82-13.11, p = 0.002) and congestive heart failure (OR = 4.10, 95% CI 1.07-15.68, p = 0.039). In the univariate analysis, patients with elevated hs-cTnT levels were at significantly higher risk of 3-month poor outcome (p = 0.029) and mortality (p 0.001) than those with normal hs-cTnT levels. After multivariable analysis, hs-cTnT elevation remained an independent predictor of 3-month mortality (OR = 4.49, 95% CI 1.68-11.98, p = 0.003). In this cohort of AIS patients with LVO in the anterior circulation undergoing ET, hs-cTnT elevation is an independent predictor of 3-month mortality. Admission NIHSS score, coronary heart disease and congestive heart failure are independently associated with elevated hs-cTnT levels.

To evaluate the efficacy and prognostic factors following transarterial embolization (TAE) as initial treatment for spontaneously ruptured hepatocellular carcinoma (HCC). From June 2012 to June 2016, a total of 57 spontaneously ruptured HCC patients who received TAE as initial therapy were retrospectively studied at our institution. Patients were followed until October 2016. Survival rates were estimated using the Kaplan–Meier method, and prognostic factors related to survival were evaluated using Cox regression analysis. Among them, 8 (14.0%) patients died within 30 days after initial TAE. The median overall survival time was 208 days. The 6-month, 1-year, and 2-year cumulative overall survival rates were 50.3%, 35.9%, and 14.7%, respectively. Multivariate analysis indicated that tumor size [HR (hazard ratio) 1.12; 95% CI (confidence interval) 1.02–1.23, P = 0.022] Child–Pugh class (HR 1.78; 95% CI 1.13–2.80; P = 0.013), absence of shock on admission (HR 0.40; 95% CI 0.17–0.95; P = 0.039), and embolization with lipiodol and gelatin sponge particles (HR 0.33; 95% CI 0.16–0.70; P = 0.004) were independent prognostic factors for survival. TAE appeared to be an effective initial treatment for spontaneously ruptured HCC. The results indicated that large tumors, poor Child–Pugh class, and shock on admission were associated with poor prognosis. For these patients, embolization with lipiodol and gelatin sponge particles could achieve better survival than PVA particles used.

BACKGROUND Gadolinium (Gd)-based contrast agents (GBCAs) have been widely used in MRI. However, several studies have reported Gd deposition in the brain, which has raised concerns about safety. PURPOSE To investigate the effects of ischemic stroke on Gd deposition in the brain after repeated administration of linear or macrocyclic GBCAs and to determine whether GBCAs aggravate astrocyte injury after stroke. STUDY TYPE Animal study. ANIMAL MODEL Twenty-seven male Sprague-Dawley rats were randomized to an exposure group (n = 24) and a healthy control group (n = 3). Half of the exposure group (n = 12) underwent transient middle cerebral artery occlusion (tMCAO) and half (n = 12) had a sham procedure. In each subgroup (tMCAO or sham), the rats had repeated gadopentetate (n = 6) or gadobutrol (n = 6) injections. Oxygen-glucose deprivation and reoxygenation (OGD/R) was used as an in vitro model of stroke. ASSESSMENT On day 3 and day 28 after the last injection (p.i.), the Gd concentration in the cerebrum was quantified by inductively coupled plasma mass spectrometry. Cell viability, reactive oxygen species (ROS), and mitochondrial membrane potential (MMP) were analyzed in vitro. STATISTICAL TESTS One-way analysis of variance and two-sample t-tests were performed. RESULTS The Gd concentration in the ipsilateral hemisphere homogenates of tMCAO group was significantly higher than that in the brain homogenates of the sham group on day 3 p.i. of either gadobutrol (0.065 ± 0.006 vs. 0.042 ± 0.007 μg/g, P

BackgroundPrevious studies suggest that recurrence of hemoptysis after arterial embolization is associated with the underlying pulmonary disease.PurposeTo compare the baseline information and imagi...

Acute pulmonary embolism (APE)-induced inflammation contributes to cardiomyocyte injury and dysfunction in the right ventricle (RV) of the heart. The interactions of cyclophilin A with its ligand extracellular matrix metalloproteinase inducer (EMMPRIN or CD147) may be involved in this inflammatory process. To this end, here we induced APE by intravenous injections of microspheres in Sprague-Dawley rats. We found that after the APE, cyclophilin A and CD147 levels increased synchronously in RV tissue following APE and peaked at 24 h. The cyclophilin A inhibitor cyclosporine A attenuated the APE-induced cyclophilin A levels, and a monoclonal antibody of CD147 (anti-CD147) abrogated the elevation of CD147 in the RV but not the increase of cyclophilin A. Importantly, treatment with cyclosporine A, anti-CD147, or both attenuated APE-induced increases in RV systolic pressure, plasma cardiac troponin-I (cTnI) concentrations, the RV/left ventricle diameter ratio, and the Tei index, measured by echocardiography 24 h after APE induction. These beneficial effects were associated with reduced RV neutrophil infiltration and prevention of matrix metalloproteinase 9 (MMP-9) and MMP-2 activation. These findings suggested that inhibiting the cyclophilin A–CD147 interaction attenuates APE-associated RV cardiomyocyte injury and dysfunction by suppressing inflammation. We further proposed that cyclophilin A and CD147 might participate in APE-induced pathological processes by partly activating the ERK1/2 kinase–nuclear factor-κB pathway. We conclude that the cyclophilin A–CD147 interaction may represent a potential therapeutic target for managing APE.

Objective To identify the risk factors for early and late relapse of haemoptysis after bronchial artery embolisation (BAE). Design We performed a retrospective study of 255 patients with haemoptysis who underwent BAE from January 2009 to June 2016 at the First Affiliated Hospital of Nanjing Medical University, Nanjing, China. Using a Cox regression model, risk factors contributing to early (within the first month) and late (>1 month) recurrence were analysed. We censored recurrence-free patients at 1 month and patients without rebleeding after 1 month. Results The cumulative recurrence rate at 1, 6, 12, 24 and 48 months was respectively 14.9%, 16.9%, 20.6%, 31.0% and 39.9%, with a median follow-up of 574 days. Early relapse occurred in 38 of 255 patients, while late recurrence was found in 45 of the remaining 217 patients. The risk factors related to early recurrence were lung destruction on computed tomography of the chest and involvement of non-bronchial systemic arteries. The risk factors associated with late recurrence were tuberculosis sequelae, the presence of shunts and the use of gelfoam as an embolisation material. Conclusions The variables related to incomplete embolisation were the risk factors for early rebleeding. The variables associated with same-vessel recanalisation and formation of a new collateral circulation influenced late recurrence.

Background/Aims: Metal stent insertion is a common palliative treatment for distal malignant biliary obstruction (MBO) but whether placement across the sphincter of Oddi (SO) causes more complications or shorter survival is in question. The aim of this study was to compare the clinical outcomes of percutaneous uncovered self-expandable metal stent placement above and across the SO in patients with distal MBO. Patients and Methods: We retrospectively studied 59 patients who underwent uncovered metal stent placement for distal MBO between January 2012 and March 2016. Stents were placed above the SO for 22 subjects (group A) and across the SO for 37 subjects (group B). Early cholangitis, stent occlusion, and overall survival time were compared between the two groups. Results: Clinical success was 90.9 and 86.5% for groups A and B, respectively. Early cholangitis occurred in 2 patients (9.1%) in group A and in 6 patients (16.2%) in group B (P = 0.645). Median stent patency and median survival time was 105 and 140 days for group A, 120 and 160 days for group B, respectively. The stent occlusion (31.8% in group A and 21.6% in group B, P = 0.454) and the cumulative stent patency times (P = 0.886) did not differ between the two groups. There was no significant difference in cumulative patient survival between the two groups (P = 0.810). Conclusion: Uncovered metal stent placement across the SO did not significantly affect early cholangitis, stent patency, or patient survival.

Oculomotor nerve palsy (ONP) may result from Posterior communicating artery (Pcom) aneurysms. Endovascular treatment of ruptured Pcom aneurysms generally is a safe procedure, but the effect of this therapy on ONP is incompletely elucidated. This retrospective study evaluates outcomes of ONP after endovascular treatment for ruptured Pcom aneurysm and with the intention to clarify predictors of recovery. From May 2010 to October 2015, 210 patients with Pcom aneurysms underwent endovascular treatment at our institution. Among them, 34 patients with ruptured aneurysms and either complete or incomplete ONP were identified. The outcomes and predictors of ONP recovery were analyzed. At the last available clinical follow-up, ONP resolution was complete in 21 (61.8%) patients and incomplete in 8 (23.5%) patients. The mean resolution time after embolization was 24.5 days. Five patients showed no signs of ONP recovery. In no case was an initial incomplete ONP observed to worsen. There was a statistically insignificant trend toward complete recovery among patients with initial incomplete ONP (OR = 4.17; 95% CI, 0.75–23.18; P = 0.103). Endovascular treatment appears to be an effective treatment modality for ruptured Pcom aneurysm and related ONP. The initial incomplete ONP might encourage complete ONP recovery after endovascular treatment.

Early reperfusion of occluded arteries via recombinant tissue plasminogen activator (rtPA) administration is considered to be an effective strategy for the treatment of acute ischemic stroke. However, delayed administration of rtPA may cause severe hemorrhagic transformation (HT) and undesirable neurological outcomes. The current study aims to establish a canine HT model using rtPA administration and to investigate the potential mechanisms underlying HT. Following anesthesia, two autologous clots were injected into the middle cerebral artery (MCA) to induce ischemic stroke. To induce reperfusion, rtPA (2 mg/kg) was administrated intravenously 4.5 h after the establishment of stroke. The occurrence of HT was determined by computed tomography (CT) and by pathological assessment. Transmission electron microscopy was utilized to assess blood-brain barrier (BBB) damage. The expression of matrix metalloprotein 9 (MMP-9) was analyzed by enzyme linked immunosorbent assay (ELISA), immunofluorescence (IF), and western blot. Administration of rtPA 4.5 h after stroke induced reperfusion in 73.9% of the canines, caused evident HT, and did not improve neurological outcomes compared to canines that did not receive rtPA. There was a significant increase in expression of MMP-9 after rtPA administration, accompanied by BBB disruption. We have established a canine HT model that closely mimics human HT by using rtPA administration after the induction of middle cerebral artery occlusion (MCAO) with autologous clots. Our data suggest that a potential mechanism underlying rtPA-caused HT may be related to BBB dysfunction induced by an increase in MMP-9 expression.

Previous studies have indicated that the temporal change of relative diffusion weighted imaging (rDWI) signal intensity may help to determine the onset time of a stroke. Furthermore, several studies have indicated that high b value DWI offered improved detection rates for hyper-acute ischemic lesions compared with standard b value DWI. However, the temporal changes of the rDWI on high b value DWI remain unclear. Therefore, based on our embolic canine stroke model, we evaluated the temporal evolution of rDWI on high b value DWI, and further compared its diagnostic value in predicting the onset time of ischemic stroke with rDWI on standard b value DWI. Twelve canine MCAO models were established, and DWI was performed at 1, 2, 3, 4, 5 and 6 h after MCAO, with 3 b values of 1,000, 2,000 and 3,000. High b value DWI detected all ischemic lesions after 1 h, while standard b value did not detect the ischemic lesions in one dog at 1 h. With all three of the tested b values, rDWIs increased continuously within 6 h, while relative apparent diffusion coefficient (rADC) values rapidly decreased in 1 h, then became relatively stable. The area under the curve values for rDWI with b value of 1,000, 2,000 and 3,000, in predicting ischemic lesions within 3 h were 0.897, 0.929 and 0.938, while for rADC were 0.645, 0.583 and 0.599, respectively. Therefore, the results indicated that the rDWI was helpful in aging hyper-acute ischemic stroke, while rADC appeared not to be. High b value DWI had a higher detection rate for ischemic lesions and better predictive efficacy in determining the onset time of hyper-acute stroke.

Transarterial embolization (TAE) appears to be a safe and effective treatment for patients with intractable epistaxis, despite different etiologies or angiography findings. Idiopathic epistaxis is prone to present with negative angiographic findings.To retrospectively evaluate the safety and effectiveness of TAE for intractable epistaxis, and focus on the factors of etiology and angiographic findings.From March 2008 to December 2014, the data of 43 patients with intractable bleeding undergoing TAE were reviewed. The outcomes of interventional therapy were assessed according to different etiology (malignant or benign disease) and angiographic finding (positive or negative angiogram).Positive angiographic findings were found in 11 of 12 cases with malignant diseases and 22 of 31 cases with benign diseases, respectively (p = 0.237). Among the 10 cases with negative angiographic findings, the negative angiography rate of idiopathic epistaxis was higher than that of epistaxis with definite etiology (p = 0.003). Bleeding was controlled successfully in all of the 43 patients after embolization. During the mean follow-up period of 24.0 ± 16.7 months, five patients relapsed. No significant difference was found in recurrence rates between malignant and benign diseases or between positive and negative angiography (p = 0.241, p = 0.704, respectively).

Setting Tertiary referral centre. Objective To retrospectively observe the characteristics of bronchial angiograms in the setting of systemic artery-pulmonary circulation shunts (SPS), and to evaluate the safety and effectiveness of bronchial artery embolisation (BAE) for these patients with life-threatening haemoptysis. Design The records of life-threatening haemoptysis patients with SPS who presented to a tertiary referral centre from January 2009 to March 2014 were reviewed. Results SPS consisted of bronchial artery-pulmonary artery shunt (AAS) in 30 cases, bronchial artery-pulmonary vein shunt (AVS) in 4 cases, non-bronchial systemic artery-pulmonary circulation shunt (n-BPS) in 7 cases and more than one type of SPS in 4 cases (AAS and AVS in 3 cases, three types of SPS in 1 case). BAE using polyvinyl alcohol (PVA) was successful in 97.8% (44/45) of the patients. Cumulative rates of freedom from recurrence at 1 month, 1 year and 2 years were respectively 97.8%, 93.2% and 85.4%. No major procedure-related complications occurred. No significant differences were found in recurrence rates or cumulative haemoptysis control rates among patients with different types of SPS complications (P = 0.55 and 0.46, respectively). Conclusion BAE with PVA was safe and effective for life-threatening haemoptysis complicated by SPS.

BACKGROUND/AIMS: For distal malignant biliary obstruction (MBO), a percutaneous metal stent is usually inserted by the transpapillary method. However, stent-related complications and recurrent biliary obstruction following transpapillary stent placement are concerns, and survival analysis of patients with distal MBO has rarely been done. MATERIALS AND METHODS: From January 2012 to March 2016, 104 patients underwent transpapillary uncovered metal stent placement for distal MBO at our institution. Clinical success, complications, recurrent biliary obstruction rates, and predictors of survival were analyzed. RESULTS: Of the total 104 patients, clinical success after stent insertion was achieved in 93 patients (90.3%). Major complications were observed in 24 patients (23.1%), which were as follows: cholangitis in 19 patients; pancreatitis in four patients; and biloma in one patient. Recurrent biliary occlusion was observed in 28 patients (26.9%). The median overall survival period was 162 days. The 3-, 6-, and 12-month overall survival rates after stent insertion were 64.4%, 41.3%, and 10.6%, respectively. Results of multivariate analysis indicated that metastatic carcinoma compared with ampullary carcinoma (HR=3.82; 95% CI, 1.30–11.24; p=0.015) and longer biliary stricture (HR=1.04; 95% CI, 1.02–1.06; p

To evaluate predictive factors of recurrent biliary obstruction (RBO) following percutaneous uncovered metal stent placement for unresectable distal malignant biliary obstruction (MBO) by using a competing risk model. Between March 2012 and March 2016, 119 patients underwent percutaneous uncovered metal stent placement with distal MBO at our institution. Univariate and multivariate analyses were conducted to identify the prognostic factors for RBO using a competing risk model. The median overall survival period was 170 days (range 19–775 days). Recurrent biliary obstruction before death was observed in 34 patients (28.6%). The 3-, 6-, and 12-month cumulative incidences of RBO were 14.3%, 21.0%, and 27.7%, respectively. A multivariate analysis indicated that ampullary carcinoma compared with metastatic carcinoma (hazard ratio [HR] = 4.86; 95% confidence interval [CI], 1.74–13.54; P = 0.003) and a stent insertion above the sphincter of Oddi (HR 2.49; 95% CI, 1.11–5.62; P = 0.028) were the independent risk factors for RBO when we considered death to be a competing risk. Ampullary carcinoma and stent insertion above the sphincter of Oddi were risk factors for RBO in these patients who received percutaneous transhepatic stent placement.

We performed a meta-analysis to evaluate the outcomes of acute ischemic stroke (AIS) in patients treated with mechanical thrombectomy (MT), according to diabetes mellitus and admission glucose level (AGL). We systematically reviewed previous studies in PubMed that reported outcomes of MT in AIS patients and their relationships with diabetes mellitus or AGL. We used functional independence (modified Rankin score ≤ 2 at 3 months) as the primary end point. Data from 12,653 patients in 47 articles that evaluated the effect of diabetes mellitus or AGL on outcomes after MT were included. Compared with patients without a history of diabetes mellitus, patients with a diabetes mellitus history had significantly lower odds of functional independence in both the unadjusted meta-analysis (odds ratio [OR] 0.64; 95% confidence interval [CI] 0.54–0.75) and the multivariable analysis (OR 0.48; 95% CI 0.33–0.71). Similarly, higher AGL was associated with an unfavorable functional outcome in the unadjusted meta-analysis (pooled effect size − 0.38; 95% CI − 0.45 to − 0.31), and the adjusted OR (95% CI) per 1 mmol/L increase in AGL was 0.87 (0.83–0.92) for functional independence according to the combined multivariable results. Recanalization rate and symptomatic intracranial hemorrhage were neither related to AGL nor different in patients with or without diabetes mellitus. The present study confirms that a history of diabetes mellitus and high AGL are associated with unfavorable functional outcomes at 3 months after MT in AIS patients. However, the causal relationship between hyperglycemia and poor prognosis remains undetermined, and further investigations are required to ascertain whether AIS patients receiving MT could benefit from intensive glucose control.

The role of CD40/CD40 ligand (CD40L) in microvascular thrombosis is now widely accepted. However, the exact mechanisms linking the CD40/CD40L system and the soluble form of CD40L (sCD40L) with microvascular thrombosis are currently a topic of intensive research. The objective of this study was to assess the potential mechanisms in CD40/CD40L system-regulated microvascular thrombosis after focal ischemia/reperfusion (I/R).Rats were subjected to 60-min transient middle cerebral artery occlusion (MCAO). The experiments were divided into three groups: sham operation, MCAO, and MCAO + CD40 antagonist. Dynamic changes of serum-free sCD40L levels for 0, 1, 3, 5, 6, and 12 h by ELISA detecting kit after focal I/R were observed, and the CD40 expression levels in both platelet surface and vascular endothelial cell surface were measured by flow cytometry and immunofluorescence, respectively. Cerebral infarct volume was analyzed 12 h after reperfusion. mTOR/S6K signaling was determined by Western blot.A comparison of thrombus formation between MCAO and CD40 antagonist treatment rats revealed a role for CD40 and/or CD40L in the inflammation-enhanced thrombosis responses in both of the platelet and vascular endothelial cell. MCAO rats yielded an acceleration of thrombus formation that was accompanied by increased CD40 levels in serum. The brain infarction was significantly decreased in CD40 antagonist treatment group compared to MCAO model group. The mTOR/S6K signaling was activated in MACO model than that of CD40 antagonist treatment group.Our findings indicate that CD40/CD40L system contributes to microvascular thrombosis and brain infarction induced by MCAO and reperfusion. The mTOR/S6K signaling pathway is involved in the regulation of cerebral microvasculature after focal I/R by CD40/CD40L.AKT: protein kinase B; CD40L: CD40 ligand; CSF: cerebrospinal fluid; FITC: fluorescein isothiocyanate; I/R: ischemia/reperfusion; MCAO: middle cerebral artery occlusion; mTOR: mechanistic target of rapamycin; PE: P-phycoerythrin; sCD40L: soluble form of CD40L; TNF-a: tumor necrosis factor-alpha; WT: wild type.

In recent years, studies have shown that the secretome of bone marrow mesenchymal stromal cells (BMSCs) contains many growth factors, cytokines, and antioxidants, which may provide novel approaches to treat ischemic diseases. Furthermore, the secretome may be modulated by hypoxic preconditioning. We hypothesized that conditioned medium (CM) derived from BMSCs plays a crucial role in reducing tissue damage and improving neurological recovery after ischemic stroke and that hypoxic preconditioning of BMSCs robustly improves these activities. Rats were subjected to ischemic stroke by middle cerebral artery occlusion and then intravenously administered hypoxic CM, normoxic CM, or Dulbecco modified Eagle medium (DMEM, control). Cytokine antibody arrays and label-free quantitative proteomics analysis were used to compare the differences between hypoxic CM and normoxic CM. Injection of normoxic CM significantly reduced the infarct area and improved neurological recovery after stroke compared with administering DMEM. These outcomes may be associated with the attenuation of apoptosis and promotion of angiogenesis. Hypoxic preconditioning significantly enhanced these therapeutic effects. Fourteen proteins were significantly increased in hypoxic CM compared with normoxic CM as measured by cytokine arrays. The label-free quantitative proteomics analysis revealed 163 proteins that were differentially expressed between the two groups, including 107 upregulated proteins and 56 downregulated proteins. Collectively, our results demonstrate that hypoxic CM protected brain tissue from ischemic injury and promoted functional recovery after stroke in rats and that hypoxic CM may be the basis of a potential therapy for stroke patients.

The present study compared the safety and efficacy of oxycodone with those of fentanyl under non-intubated general anaesthesia in percutaneous microwave ablation (MWA) of a liver tumour abutting the capsule. Thirty-eight patients underwent MWA of liver cancers abutting the capsule. Patients received 0.1 mg/kg oxycodone (O group) or 1 μg/kg fentanyl (F group) prior to the start of ablation. Both groups received continuous infusions of propofol for non-intubated general anaesthesia during ablation. The primary outcomes were the pain scores (11-point numeric rating scale, NRS) within 24 h after MWA. Vital signs, body movement during ablation, and opioid side effects after ablation were recorded. The need for additional analgesics was recorded 24 h after MWA. The pain NRS scores were lower in the O group than in the F group at 0.5 (P = 0.035), 3 (P = 0.002), and 6 h (P = 0.001) after MWA, and fewer patients required additional analgesics in the O group (6 of 20 vs. 13 of 18, P = 0.022) within 24 h. The average 24-h dose of dezocine was 5.5 ± 4.1 mg in the F group and 2.1 ± 3.3 mg in the O group (P = 0.008). A significant reduction in the respiratory rate (P = 0.020) and more body movements were observed in the F group (P = 0.027) during ablation with non-intubated general anaesthesia. No differences in post-operative nausea and vomiting (PONV) were observed between the two groups, but dizziness occurred significantly more often in the O group (P = 0.033). No significant differences in other vital signs were observed before, during, and after the procedure. Oxycodone provides better analgesia and reduces post-operative opioid consumption without significant respiratory or hemodynamic instability.

In acute stroke magnetic resonance imaging, many attempts have been made to identify the onset time of ischemic events using the simply quantitative judgment of relative signal intensity (rSI) from various MR images. However, no uniform opinion has been achieved broadly till now. The controversy might derive from the potential patients’ selection bias of clinical retrospective study, the discrepant MR parameters, and the various sample sizes among different studies. Thus, we evaluated the temporal change of the relative DWI signal intensity (rDWI), relative ADC value (rADC), relative FLAIR signal intensity (rFLAIR), and relative T2 signal intensity (rT2), and further compare their diagnostic value in identifying the hyperacute lesions based on our embolic canine model with clear onset time. Twenty ischemic models were successfully established. All rSI values were linearly correlated to time with significance until 24 h after model establishment (P < 0.05). Paired comparison of ROC curves showed that significant difference was found between rADC and other three rSIs (P < 0.0001). However, no significant difference was found among rDWI, rT2 and rFLAIR. Our results indicated that rDWI, rFLAIR and rT2 may be helpful to predict the onset time of ischemic events with the similar diagnostic value. However, the rADC does not have comparable predictive value in our embolic canine model.

To assess the influence of the hyperintense acute reperfusion marker (HARM) on the relative signal intensity (rSI) and apparent diffusion coefficient (ADC) of hyper-acute ischemic lesions in a canine stroke model. Middle cerebral artery occlusion models were established using autologous clot embolization. Diffusion-weighted (DW) and fluid-attenuated inversion recovery (FLAIR) imaging was performed at 1, 2, 3, 4.5 and 6 h after embolization. HARM was defined as the delayed enhancement of cerebrospinal fluid on the subsequent FLAIR images after contrast media used. Twenty-four stroke models were successfully established and divided into the HARM (n = 16) and No-HARM group (n = 8). No significant differences were found in the rSI on DWI (b0 and b1000 map) and relative ADC between the two groups at each time point after embolization (all P > 0.05). There were no significant differences in the rSI on FLAIR at 1 and 2 h after embolization between the two groups (P > 0.05), while the HARM group showed significantly higher rSI on FLAIR than the No-HARM group at 3, 4.5 and 6 h after embolization (P = 0.044, 0.036 and 0.001, respectively). HARM should be noted during the quantitative analysis of FLAIR images in future clinical practice.

Stroke is one of the leading causes of death worldwide and the main reason for long-term disability. An appropriate animal model of stroke is urgently required for understanding the exact pathophysiological mechanism of stroke and testing any new therapeutic regimen. Our work aimed to establish a canine stroke model occluding the middle cerebral artery (MCA) and blocking the ipsilateral internal carotid artery (ICA), and to assess the infarct lesions by magnetic resonance imaging. The stroke model was generated by injecting two autologous clots into each MCA, followed by 2-h ipsilateral ICA blockade (ilICAB) using a catheter in 15 healthy adult beagles. Outcome measurements included 24-h and 7-day postocclusion T2-weighted imaging (T2WI)-based infarct volume calculation. In addition, pial collateral score, canine neurobehavioral score and histopathologic results were documented. Out of 15 dogs, 12 with successful MCA occlusion (MCAO) and ilICAB survived 7 days without complications or casualties and MCA were reperfused at 7 days after occlusion. High signal intensity in the basal ganglia and cerebral cortex on T2WI was initially observed in each dog at 6 h after the procedure. The mean percentage hemispherical infarct volume corrected for edema in all dogs on T2WI at 24 h after occlusion was 12.99±1.57%, and the degree of variability was 12.08%. The infarct volumes at 24 h after occlusion correlated with pial collateral scores and canine neurobehavioral scores well. This canine stroke model with combined MCAO and ilICAB reported here were proven to be highly feasible and reproducible.

To evaluate the effectiveness of interventional therapy for complications of transplanted renal allografts.Between January 2009 and March 2014, 14 patients underwent interventional therapy for complications of renal allografts. Complications included transplant renal artery stenosis (TRAS), TRAS combined with pseudoaneurysms, transplant renal venous kinking and ureteral obstruction (UO). Serum creatinine (S.Cr) levels were evaluated before and after procedure. The characteristics and procedure outcomes of these patients with vascular and nonvascular complications were also analyzed.All primary procedures were successfully performed, which included percutaneous transluminal angioplasty (PTA) for TRAS (n = 4), stenting and coil embolization for TRAS combined with pseudoaneurysms (n = 1), stenting for renal vein kinking (n = 2), and percutaneous nephrostomy (PCN) for UO (n = 7) and secondary antegrade stent placement in six UO patients after 1 week of PCN. No major procedure related complications occurred. S.Cr level subsequently improved from 6.0 ± 3.6 to 2.6 ± 2.1 mg/dL (p 0.001), as well as patients' clinical features within 1 week after procedure. In our study, the onset time of vascular complications was earlier (6 months) than nonvascular complications with significant difference (p 0.001). During follow-up, the patient with TRAS and pseudoaneurysms suffered acute rejection 1 month after treatment and received transplant renal artery embolization. One patient with TRAS showed restenosis 4 months after procedure, and was retreated successfully with stenting. Thirteen cases reserved their transplanted renal allografts.Interventional therapy could be prior considered for transplanted renal allograft complications as its effectiveness and minimal invasiveness in saving the transplanted renal grafts.

PURPOSE Diffusion-weighted imaging (DWI) - fluid attenuated inversion recovery (FLAIR) mismatch was proven useful to time the onset of wake-up stroke; however, identifying the status of FLAIR imaging has been mostly subjective. We aimed to evaluate the value of relative DWI signal intensity (rDWI), and relative apparent diffusion coefficient (rADC) in identifying the FLAIR status in the acute period. METHODS Autologous clot was used to embolize left middle cerebral artery in 20 dogs. Magnetic resonance imaging was performed 3-6 hours and 24 hours after embolization. DWI-FLAIR mismatch was defined as hyperintense signal detected on DWI, but not on FLAIR. The mean values of rDWI or rADC of FLAIR- and FLAIR+ lesions were compared and the critical cutoff values of rDWI and rADC for identifying the FLAIR status were determined. RESULTS Stroke models were successfully established in all animals. DWI+ lesions were found in all 20 dogs from three hours, while FLAIR+ lesions were found in three, 11, 16, 19, and 20 dogs at five time points after embolization, respectively. The mean rDWI values were significantly different between FLAIR- and FLAIR+ lesions (P < 0.001), but rADC values were not (P = 0.73). Using rDWI=1.90 as the threshold value, excellent diagnostic efficacy was achieved (AUC, 0.88; sensitivity, 0.77; specificity, 0.88). However, rADC appeared not useful (AUC, 0.48; sensitivity, 0.52; specificity, 0.58) in identifying the FLAIR status. CONCLUSION In our embolic canine stroke model, rDWI was useful to identify FLAIR imaging status in the acute period, while rADC was not.

Transplantation using bone marrow mesenchymal stem cells (BMSCs) is emerging as a potential regenerative therapy after ischemic attacks in the brain. However, it has been questioned because very few transplanted BMSCs are detected homing to and survived in the ischemic region. Improving the cell viability and migration ability under the complex ischemic condition seems very important. The aim of our study is to identify whether hypoxic condition and granulocyte colony-stimulating factor (G-CSF) could improve the cell survival and migration ability of transplanted cells or hypoxic condition could promote BMSC's neural differentiation. BMSCs were treated under either normoxic (21% O2) or hypoxic (1% O2) (HP-BMSCs) conditions, no significant apoptosis was observed in hypoxic precondition (HP) group, our study confirmed that HP improves BMSCs proliferation and migration. Meanwhile, neural induction of BMSCs under hypoxic condition exhibited significant superior results than normoxic condition. Additionally, the addition of G-CSF in HP-BMSCs culture media promoted HP efficiency on BMSCs. These findings shed light on novel efficient strategy on the prosperity of BMSCs. Hypoxic preconditioning and cultured with G-CSF may become a promising therapeutics for cell-based therapy in the treatments of ischemia stroke.

Objective To determine the relationship between intravoxel incoherent motion (IVIM) imaging derived quantitative metrics and serum soluble CD40 ligand (sCD40L) level in an embolic canine stroke model. Materials and Methods A middle cerebral artery occlusion model was established in 24 beagle dogs. Experimental dogs were divided into low- and high-sCD40L group according to serum sCD40L level at 4.5 hours after establishing the model. IVIM imaging was scanned at 4.5 hours after model establishment using 10 b values ranging from 0 to 900 s/mm2. Quantitative metrics diffusion coefficient (D), pseudodiffusion coefficient (D*), and perfusion fraction (f) of ischemic lesions were calculated. Quantitative metrics of ischemic lesions were normalized by contralateral hemisphere using the following formula: normalized D = Dstroke / Dcontralateral. Differences in IVIM metrics between the low- and high-sCD40L groups were compared using t test. Pearson's correlation analyses were performed to determine the relationship between IVIM metrics and serum sCD40L level. Results The high-sCD40L group showed significantly lower f and normalized f values than the low-sCD40L group (f, p < 0.001; normalized f, p < 0.001). There was no significant difference in D*, normalized D*, D, or normalized D value between the two groups (All p > 0.05). Both f and normalized f values were negatively correlated with serum sCD40L level (f, r = −0.789, p < 0.001; normalized f, r = −0.823, p < 0.001). However, serum sCD40L level had no significant correlation with D*, normalized D*, D, or normalized D (All p > 0.05). Conclusion The f value derived from IVIM imaging was negatively correlated with serum sCD40L level. f value might serve as a potential imaging biomarker to assess the formation of microvascular thrombosis in hyperacute period of ischemic stroke.

BACKGROUND: This study aimed to evaluate the feasibility of intraarterial (IA) delivery and in vivo MR imaging of superparamagnetic iron oxide (SPIO)-labeled mesenchymal stem cells (MSCs) in a canine stroke model. METHODOLOGY: MSCs harvested from beagles' bone marrow were labeled with home-synthesized SPIO. Adult beagle dogs (n = 12) were subjected to left proximal middle cerebral artery (MCA) occlusion by autologous thrombus, followed by two-hour left internal carotid artery (ICA) occlusion with 5 French vertebral catheter. One week later, dogs were classified as three groups before transplantation: group A: complete MCA recanalization, group B: incomplete MCA recanalization, group C: no MCA recanalization. 3×10(6) labeled-MSCs were delivered through left ICA. Series in vivo MRI images were obtained before cell grafting, one and 24 hours after transplantation and weekly thereafter until four weeks. MRI findings were compared with histological studies at the time point of 24 hours and four weeks. PRINCIPAL FINDINGS: Home-synthesized SPIO was useful to label MSCs without cell viability compromise. MSCs scattered widely in the left cerebral hemisphere in group A, while fewer grafted cells were observed in group B and no cell was detected in group C at one hour after transplantation. A larger infarction on the day of cell transplantation was associated with more grafted cells in the brain. Grafted MSCs could be tracked effectively by MRI within four weeks and were found in peri-infarction area by Prussian blue staining. CONCLUSION: It is feasible of IA MSCs transplantation in a canine stroke model. Both the ipsilateral MCA condition and infarction volume before transplantation may affect the amount of grafted cells in target brain. In vivo MR imaging is useful for tracking IA delivered MSCs after SPIO labeling.

Background and Purpose This study evaluated the clinical value of detachable-balloon embolization for traumatic carotid-cavernous fistula (TCCF), focusing on the frequency, risk factors, and retreatment of recurrence. Methods Fifty-eight patients with TCCF underwent transarterial detachable-balloon embolization between October 2004 and March 2011. The clinical follow-up was performed every 3 months until up to 3 years postprocedure. Each patient was placed in either the recurrence group or the nonrecurrence group according to whether a recurrence developed after the first procedure. The relevant factors including gender, fistula location, interval between trauma and the interventional procedure, blood flow in the carotid-cavernous fistula, number of balloons, and whether the internal carotid artery (ICA) was sacrificed were evaluated. Results All 58 TCCFs were successfully treated with transarterial balloon embolization, including 7 patients with ICA sacrifice. Recurrent fistulas occurred in seven patients during the follow-up period. Univariate analysis indicated that the interval between trauma and the interventional procedure (p=0.006) might be the main factor related to the recurrence of TCCF. The second treatments involved ICA sacrifice in two patients, fistula embolization with balloons in four patients, and placement of a covered stent in one patient. Conclusions Detachable balloons can still serve as the first-line treatment for TCCFs and recurrent TCCFs despite having a nonnegligible recurrence rate. Shortening the interval between trauma and the interventional procedure may reduce the risk of recurrence.

It is estimated that lacunar infarcts account for 25% of all ischemic strokes, but its exact etiology is still on debating. The existing controversies include whether the embolisms can indeed cause lacunar stroke in humans or animal models. We hypothesized that lacunar infarction can be induced by the proximal middle cerebral artery (MCA) segmental occlusion involving the orifices of lenticulostriate arteries in animal models, which have abundant distal cerebral collateral anastomosis. Our work here establishes a proximal MCA occlusion model using thrombi (autologous blood clots about 1.7 mm in diameter and 5 mm in length) in 8 beagle dogs, evaluates the progression of ischemic lesions at 30 min interval within 6 h after embolization using the diffusion weighted imaging (DWI), and discusses the potential mechanisms of lacunar infarction. Our results indicate that the left proximal MCAs can be successfully occluded in all dogs using interventional single-thrombus method. The small solitary or multiple ischemic lesions shown in DWI were observed in the deep brain area, with the mean detecting time of 1.21 ± 0.45 h using DWI and diameter of 6.62 ± 0.60 mm in 6h-DWI after procedure. In conclusion, our method established an ischemic model which can recapitulate the radiologic and histologic changes in lacunar infarcts, suggesting that emboli can cause lacunar infarcts in animal model.