Comparative study between Embosphere®and Marine gel®as embolic agents for chemoembolization of hepatocellular carcinoma

BACKGROUND While gelatin sponge particles and calibrated microspheres are commonly used as embolic materials in conventional transarterial chemoembolization(cTACE),direct comparisons between these embolic agents are rare.AIM To compare the efficacy and safety of superselective cTACE using Embosphere®or Marine gel®in patients with early-stage hepatocellular carcinoma(HCC).METHODS This retrospective study included 70 patients with small(<4 cm)HCC who underwent cTACE with Embosphere®(n=33)or Marine gel®(n=37)as the embolic agent at a single center between March 2021 and July 2022.The radiologic images and clinical data were retrospectively reviewed,with an emphasis on tumor response,procedure-related complications,and local tumor recurrence.The primary index tumor was assessed on a 1-mo follow-up image,and local progression-free survival was obtained using the Kaplan-Meier method and was compared by the log-rank test.RESULTS The median tumor size of both groups was 1.5 cm,and 69 patients achieved a complete response one month after cTACE.The cumulative local recurrence rate at 12 mo was 15.5%in the Embosphere®group and 14.4%in the Marine gel®group.The local progression-free survival was not significantly different between the two groups(P=0.83).In the multivariate analysis,high serum alphafetoprotein was the only significant poor prognostic factor for local tumor progression(P=0.01).Postembolization syndrome occurred in 36.4%of the Embosphere®group and 35.1%of the Marine gel®group,and there were no cases of biloma,biliary duct dilation,or liver abscess in either group.CONCLUSION Calibrated gelatin sponge particles(Marine gel®)and calibrated microspheres(Embosphere®)have similar outcomes in terms of tumor response for superselective cTACE of small HCC.

Embolization of brain arteriovenous malformations with squid co-polymer embolic material:Initial experience

Objective:To analyze the safety and effectiveness of the ethylene-vinyl alcohol copolymer(EVOH)liquid embolic agent Squid(Emboflu,Switzerland)for the treatment of brain arteriovenous malformations.Materials and procedures:Between April 2015 and July 2017,46 embolization treatments for brain arteriovenous malformations(BAVM)were performed in 25 patients using two Squid formulations(18 and 12).Six female and 19 male patients with a mean age of 34 years(range,9–62 years)were included.A total of 46 procedures were performed.The BAVMs were classified as Spetzler-Martin gradeⅡin 4 procedures,Ⅲin 27 procedures,and 1V in 15 procedures.Among the 25 patients,15 presented with hemorrhage,5 with seizures,and 5 with headache and neurology.The BAVMs were located in the temporal lobe in 5 patients,parietal lobe in 7 patients,frontal lobe in 3 patients,posterior fossa in 6 patients,basal ganglia in 3 patients,and parasagittal lobe in 1 patient.Results:The obliteration rate of the BAVMs ranged from 10%to 100%,with a mean of 33%.Most patients underwent their first or second embolization procedure.Four patients(8%)developed intracranial bleeding post procedure,with one death(2%).One patient(2%)experienced a seizure during the procedure;however,no intracranial bleeding was observed.Seven patients(15%)experienced perforations during catheter manipulation.One case(2%)of fractured catheter was recorded,but no significant complications were observed.The average volume of copolymer injected was 0.6 ml per nidus.Thirteen procedures used the Squid-12 formulation,29 procedures used the Squid-18 formulation,and 3 procedures used a combination of Squid-12 and-18 formulations.Conclusion:Squid is a safe and effective embolic agent for treating BAVMs.

Venous Thromboembolic Disease in a Regional Hospital in Mali

Introduction: Venous thromboembolism (VTE) is a nosological group which mainly includes deep vein thrombosis (DVT) and pulmonary embolism (PE), it is frequently associated with high morbidity and mortality. We initiated this study with the aim of studying VTE in a cardiological hospital environment in a regional hospital in Mali. Methodology: This was a descriptive study with prospective recruitment over 1 year from June 20, 2019 to June 20, 2020, covering patients hospitalized and followed in consultation in the cardiology department of the Ségou regional hospital in Mali. Results: We collected 31 cases of VTE out of 366 patients, representing a frequency of 8.47%. The sex ratio was 0.88. VTE risk factors were dominated by immobilization (29.03%), pregnancy and postpartum (16.12%), heart failure (16.12%). The reason for consultation was dyspnea (93.54%) followed by chest pain (83.87%). On admission the clinical manifestations were tachycardia (74.19%), tachypnea (90.32%), muffled heart sounds (70.96%), global heart failure syndrome (51.6%). According to VTE probability scores;51.61% of patients had an intermediate clinical probability according to the simplified Wells score for PE and 54.84% had an intermediate clinical probability for the simplified Geneva score for DVT. D-Dimers were only performed in 12 patients (38.70%) and were elevated in all. A chest CT angiogram showed PE in 90% of patients (n = 28/31). Venous Doppler ultrasound of the lower limbs showed venous thrombosis in 3 patients. Conclusion: Venous thromboembolism, although underdiagnosed, is common in our health structures. Prevention, particularly heparinoprophylaxis and early recovery in a hospital environment, remains the effective means of combating this condition.

Polyethylene glycol microspheres loaded with irinotecan for arterially directed embolic therapy of metastatic liver cancer

AIM To study tumor response, and tolerability of arterially directed embolic therapy(ADET) with polyethylene glycol embolics loaded with irinotecan for the treatment of colorectal cancer liver metastases(CRC-LM). Secondary objectives were to monitor quality of life, time to progression and survival of patients.METHODS Patients were included in the study if they were affected by CRC-LM, refractory to systemic chemotherapy, treated with ADET using polyethylene glycol embolics, and had liver involvement < 50%. Tumor response, performance status(PS), tumor marker antigens, and quality of life(QoL) were monitored at 1, 3 and 6 mo after ADET. QoL was assessed with the Palliative Performance Scale(PPS).RESULTS We treated 50 consecutive CRC-LM patients with ADET using polyethylene glycol embolics. Their tumor response one month after ADET was: 28% of complete response(CR), 48% of partial response(PR), 8% stable disease(SD), and 16% of progression. Tumor response 3 mo after ADET was CR 24%, PR 38%, SD 19% and progression disease(PD) 19%. Tumor response 6 mo after ADET was CR 18%, PR 44%, SD 21% and PD 18%. QoL was 90% PPS at each time point. Median time to progression for patients who progressed was 2.5 mo(range 0.8-6). Median follow-up was 14 mo(0.8-25 range). ADETs were performed with no complications. Observed side effects(mild or moderate intensity) were: Pain in 32% of patients, increase of transaminase levels in 20% and fever in 14%, whereas 30% of patients did not complain any adverse event. CONCLUSION The treatment of unresectable CRC-LM with ADET using polyethylene glycol microspheres loaded with irinotecan was effective in tumor response and resulted in mild toxicity, and good QoL.

Aspiration therapy for acute embolic occlusion of the superior mesenteric artery

BACKGROUND Embolic superior mesenteric artery(SMA) occlusion is associated with high mortality rates. Delayed treatment often leads to serious consequences, including intestinal necrosis, resection, and even patient death. Endovascular repair is being introduced, which can improve clinical symptoms and prognosis and decrease the incidence of exploratory laparotomy. Many reports have described successful endovascular revascularization of embolic SMA occlusion. However,most of those reports are case reports, and there are few reports on Chinese patients. In this paper, we describe the technical and clinical outcomes of aspiration therapy using a guiding catheter and long sheath technique which facilitates the endovascular repair procedure.AIM To evaluate the complications, feasibility, effectiveness, and safety of endovascular treatment for the acute embolic occlusion of the SMA.METHODS This retrospective study reviewed eight patients(six males and two females)from August 2013 to October 2018 at Xuanwu Hospital, Capital Medical University. The patients presented with acute embolic occlusion of the SMA on admission and were initially diagnosed by computed tomography angiography(CTA). The patients who underwent endovascular treatment with a guiding catheter had no obvious evidence of bowel infarct. No intestinal necrosis was identified by gastrointestinal surgeons through peritoneal puncture or CTA. The complications, feasibility, effectiveness, safety, and mortality were assessed.RESULTS Six(75%) patients were male, and the mean patient age was 70.00 ± 8.43 years(range, 60-84 years). The acute embolic occlusion of the SMA was initially diagnosed by CTA. All patients had undertaken anticoagulation primarily, and percutaneous aspiration using a guiding catheter was then undertaken because the emboli had large amounts of thrombus residue. No death occurred among the patients. Complete patency of the suffering artery trunk was achieved in six patients, and defect filling was accomplished in two patients. The in-hospital mortality was 0%. The overall 12-mo survival rate was 100%. All patients survived, and two of the eight patients had complications(the clot broke off during aspiration).CONCLUSION Aspiration therapy is feasible, safe, and beneficial for acute embolic SMA occlusion. Aspiration therapy has many benefits for reducing patients' death,resolving thrombi, and improving symptoms.

Treatment of the acute thromboembolic event during endovascular embolization of intracranial aneurysm

Objective:The study aimed to discuss the treatment of acute thromboembolic event(TE)during endovascular embolization of intracranial aneurysms.Methods:Between April 2013 and April 2019,158 patients with 167 intracranial aneurysms were treated with endovascular embolization in our hospital,in which 9 cases of acute TEs occurred during the embolization procedures.The clinical data,radiological findings and treatments of the 9 patients were reviewed and analyzed.Results:The TEs occurred at the aneurysmal neck in 3 patients,at distal part of the parent artery in 3,in the stent in 2,and at the proximal part of the parent artery in 1.Intra-arterial(IA)infusion of tirofiban were performed in 6 patients,mechanical thromboectomy(MT)with a stent in 2 patients,and combined use of the two methods in 1 patients.According to the modified Thrombolysis In Cerebral Infarction(mTICI)score,7 patients had recanalization of 2b/3a,1 patients had recanalization of 1,and 1 patients had recanalization of 0.At discharge,the mRS score was 0 in 3 patients,1 in 3 patients,and 2,3,4 in 1 patient each.6 months after the endovascular treatment,the mRS score was 0 in 5 patients,1 in 2 patients,and 3 in 1 patient.Conclusions:IA tirofiban and MT are effective remedies for the acute TE during endovascular embolization of intracranial aneurysm,reasonable selection of which may improve the prognosis of patients.

Evaluation of the Protégé^(TM) stent in the treatment of carotid artery stenosis with adjunctive use of a filter Embolic Protection Device (PROCAR)-one-month follow-up data on 77 patients

Objective The trial was designed to evaluate the safety and performance of the ev3 Protégé TM stent in the treatment of de novo or re-stenotic common and/or internal carotid artery stenoses with adjunctive use of a CE-marked filter embolic protection device.Methods This study was a prospective multi-center, single-arm trial. Between June and October 2003, 77 patients were enrolled in 8 investigational centers throughout Europe. The primary endpoint was the incidence of Major Neurological Events (MANE) through one month. Other endpoints were the ability to properly place the stent, and primary patency and MANE after six months. Eligible for the study were patients with a de novo or restenotic target lesion located in the common and/or internal carotid artery (>70% stenosis for asymptomatic and >50% stenosis for symptomatic patients). The ev3 Spider (Embolic Protection Filter was used in 75 of 77 cases. Results In 76 out of the 77 patients (99%), the stent could be successfully implanted with a residual stenosis ≤30% as criterion. Of the 74 patients that had a carotid ultrasound at one month follow-up, none had a re-stenosis of the target lesion. There were three MANEs during or immediately after the procedure (3.9%), two were major and one was a minor stroke. There were eight severe complications (9.1%); six of these happened during or immediately after the procedure and were related to the procedure, none was related to the device. They are resolved without sequelae. No deaths have occurred.Conclusions The Protégé stent is safe and performs well in the treatment of carotid artery stenosis. The technical success rate for placement of the Protégé stent as assessed by the residual stenosis post implant was very high and all stents were successfully deployed. The incidence of MANE was comparable with that in other recent carotid stent studies and still lower than standard CEA.

Embolic protection device, the next advancement in TAVR?

The approval of commercial application transcatheter aortic valve replacement(TAVR)by the FDA in 2011 has revolutionized the management of high-risk surgical patients with severe aortic stenosis(AS).With TAVR being expanded to intermediate surgical risk patients in 2016,the number of patients undergoing TAVR has been increasing rapidly.In fact,since the very first human TAVR procedure in 2002,more than 300,000 TAVRs have been performed worldwide.[1,2]The technological advancements in the TAVR since its early days of clinical adaptation has made this procedure a routine practice in many institutions worldwide.However,one of the most feared complications,ischemic stroke,remains a major concern for clinicians and patients despite all the advancements in the procedure.

Thromboembolic events in metastatic testicular cancer treated with cisplatin-based chemotherapy

BACKGROUND Testicular germ cell tumor(TGCT)is the most curable solid tumor and most common cancer among men 18-39 years.While cisplatin-based chemotherapy has significantly lengthened the survival of patients with TGCT,it is associated with a high rate of thromboembolic events(TEE).AIM To summarize our single-center experience highlighting patients who were diagnosed with TGCT and received platinum-based chemotherapy,with special attention to those patients who suffered a TEE.METHODS A retrospective analysis of the medical records and imaging studies of 68 consecutive individuals who were diagnosed with TGCT and received platinumbased chemotherapy at our Institution in a metropolitan community between January 1,2014 and December 31,2019.RESULTS A total of 19(28%)patients experienced a TEE following orchiectomy which occurred during chemotherapy in 13(68%)of these patients.Patients with a higher pathologic stage(stage III)were significantly(P=0.023)more likely to experience a TEE compared to patients who had a lower stage.Additionally,patients who were treated with 3 cycles of bleomycine,etoposide,and cisplatin and 1 cycle of etoposide and cisplatin or 4 cycles of etoposide and cisplatin were significantly 5(P=0.02)times more likely to experience a TEE compared to patients who were treated with only 3 cycles of bleomycine,etoposide,and cisplatin.CONCLUSION Due to numerous factors that predispose to a TEE such as large retroperitoneal disease,higher clinical stage,greater number of chemotherapy cycle,central venous catheter,cigarette smoking,and possible cannabis use,high-risk ambulatory patients with TGCT treated with cisplatin-based chemotherapy may benefit from prophylactic anticoagulation.Randomized studies to evaluate the safety and efficacy of prophylactic anticoagulants are warranted in this young patient population generally devoid of medical co-morbidities.

Idiopathic cholesterol crystal embolism with atheroembolic renal disease and blue toes syndrome:A case report

BACKGROUND Cholesterol crystal embolization(CCE)is a multisystemic and fatal disease with multiple clinical manifestations;however,there are few cases of idiopathic CCE.Here we report a patient with idiopathic CCE accompanied by atheroembolic renal disease and blue toes who had a relatively good prognosis in the short-term due to early treatment with corticosteroids and statins.CASE SUMMARY A 76-year-old man complained of coldness,numbness and purple color change in his left foot for 7 d.He had a feeling of fatigue,constipation,foamy urine,poor appetite and sleep.He had a lacunar infarction for 5 years and hypertension for 9 mo.Laboratory results showed elevated eosinophils,cholesterol,uric acid,serum creatinine,urea and 24 h urine analysis revealed proteinuria.A renal biopsy revealed atheroembolic renal disease.Taken together,these findings strongly supported the diagnosis of idiopathic CCE and atheroembolic renal disease.CONCLUSION Atheroembolic renal disease and blue toes syndrome can be caused by idiopathic CCE,and early treatment with corticosteroids is effective but requires further investigation.

Double-edged blinde, hemorrhagic or cardioembolic cognitive impairment

To the Editor I have read the article entitled ＂Cognitive function and adherence to antieoagulation treatment in patients with atrial fibrillation＂ by Jankowska-Polafiska, et al., with great interest. The investigators reported that cognitive impairment is an independent determinant of compliance with pharmacological therapy in elderly patients with atrial fibrillation （AF）.

Delayed post-dilated stenting to treat an embolic myocardial infarction

Thromboembolism infrequently occurs in coronary arteries. In contrast to an in situ thrombosis, a thrombus is not fresh and floating. There has been no recommended treatment strategy for this rare condition, especially for large thrombi in main arteries. Here, we report a modified stenting strategy to treat thromboembolism in the left main coronary artery.

Recent Progress on Water-based Liquid Embolic Agents in Endovascular Treatment

Vascular embolization treatment,a minimally invasive surgery for various blood vessel-related conditions,has emerged as a crucial method in treating such as hemorrhage,arteriovenous malformation,aneurysms,and hypervascular tumors.Liquid embolic agents are gaining prominence due to their distinct advantage in infiltrating distal regions,expanding the scope of embolization beyond the reach of solid agents.Recent strides in biomaterials and technologies have spurred the development of novel liquid embolic agents,addressing challenges posed by traditional options.This mini-review provides a concise overview of the recent progress in water-based liquid embolic agents,highlighting their potential to overcome limitations associated with current embolic materials.By presenting selected research outcomes,we illuminate advancements that enhance the efficacy of liquid embolic agents.Furthermore,the review outlines essential properties for effective liquid embolic agents,offering insights for future developments in this field.

Impact of uterine artery embolization on ovarian function and pregnancy outcome after uterine-fibroids treatment:A prospective study

Uterine fibroids are benign tumors that originate from smooth muscle cells of the uterus.It is the most common gynecological disorder,affecting up to 80%of women of reproductive age.Uterine fibroids can cause various symptoms such as abnormal uterine bleeding,pelvic pain,infertility,and pregnancy complications.The treatment options for uterine fibroids include medical therapy,surgical intervention,and minimally invasive techniques.AIM To compare ovarian function of women with uterine fibroids who did or did not undergo uterine artery embolization(UAE).METHODS This prospective cohort study enrolled 87 women with symptomatic uterine fibroids who underwent UAE,and 87 women with the same symptoms who did not undergo UAE but received conservative management or other treatments.The two groups were matched for age,body mass index,parity,and baseline characteristics of uterine fibroids.The primary outcome was ovarian function that was evaluated by serum levels of follicle-stimulating hormone(FSH),luteinizing hormone(LH),estradiol(E2),and anti-Müllerian hormone(AMH),as well as ovarian reserve tests,such as antral follicle count(AFC)and ovarian volume(OV).The secondary outcome was fertility that was evaluated based on the menstrual cycle,ovulation,conception,pregnancy,and delivery.The participants were followed-up for 36 months and assessed at 1,3,6,12,24,and 36 months after treatment.RESULTS The study found that the most common minor complication of UAE was postembolization syndrome in 73.6% of women,resolving within a week.No significant differences were observed between the UAE group and the control group in serum levels of reproductive hormones(FSH,LH,E2,AMH)and ovarian reserve indicators(AFC,OV)at any point up to 36 months post-treatment.Additionally,there were no significant differences in conception,pregnancy,or delivery rates,with the average time to conception and gestational age at delivery being similar between the two groups.Birth weights were also comparable.Finally,there was no significant correlation between ovarian function,fertility indicators,and the type or amount of embolic agent used or the change in fibroids posttreatment.CONCLUSION UAE resulted in significantly positive pregnancy outcomes,no adverse events post-treatment,and is a safe and effective treatment for uterine fibroids that preserves ovarian function and fertility.

Acute Colonic Pseudo-Obstruction (ACPO): An Expanding Colon with Unusual Risk Factors

The distention of the colon without mechanical or anatomical obstruction, Acute Colonic Pseudo-obstruction (ACPO), is a common condition occurring in the critically ill. ACPO in the setting of an acute pulmonary embolism and embolic stroke is a rarity. A 76-year-old female with shortness of breath, left hemiparesis and right-sided paresthesias presented with acute pulmonary embolism and acute infarcts of the left caudate nucleus, thalamus and occipital lobe. Her hospitalization was complicated with persistent distention of the large bowel without dilation of the small bowel. Empiric antibiotics were initiated without improvement and laboratory studies including Clostridium difficile were negative. She underwent nasogastric decompression and two decompressive colonoscopies with a resolution of her symptoms. This case illustrates an example of acute abdominal distension, without underlying etiology, in the setting of acute embolism of the pulmonary and cerebral vasculature. Early identification and action with decompressive colonoscopy were key to preventing further bowel damage or rupture.

Uterine artery pseudoaneurysm caused by hysteroscopic surgery: A case report

BACKGROUND We report a case of uterine artery pseudoaneurysm(UAP)occurrence during hysteroscopic endometrial polypectomy and its treatment via uterine artery embolization(UAE).CASE SUMMARY A 48-year-old primigravid,primiparous patient was incidentally found to have an endometrial polyp during a health checkup,and underwent a hysteroscopic polypectomy at another hospital.Her cervix was dilated with a Laminken-R®device.After the Laminken-R®was withdrawn,a large amount of genital bleeding was observed.This bleeding persisted after the hysteroscopic polypectomy,and,as hemostasis became impossible,the patient was transferred to our hospital by ambulance.On arrival,transvaginal ultrasonography revealed a 3-cm hypoechoic mass with a swirling internal pulse on the right side of the uterus,and color Doppler ultrasonography showed feeder vessels penetrating the mass.Pelvic contrast-enhanced computed tomography(CT)confirmed the presence of a mass at this site,and vascular proliferation was observed within the uterine cavity.Consequently,UAP was diagnosed,and UAE was performed.The patient’s postoperative course was uneventful,and 6 mo post-UAE,no recurrence of blood flow to the UAP was observed.CONCLUSION When abnormal genital bleeding occurs during hysteroscopic surgery,ultrasonography and contrast-enhanced CT can assist in the detection of early UAPs.

Impact of Different Embolic Agents for Transarterial Chemoembolization (TACE) Procedures on Systemic Vascular Endothelial Growth Factor (VEGF) Levels

Background and Aims:Intermediate stage hepatocellular carcinoma (HCC) can be treated by transarterial chemoem-bolization (TACE).However,there appear to be side effects,such as induction of proangiogenic factors,e.g.vascular endothelial growth factor (VEGF),which have been shown to be associated with a poor prognosis.This prospective study was designed to compare serum VEGF level response after TACE with different embolic agents in patients with HCC.Methods:Patients were assigned to one of three different TACE regimens:degradable starch microspheres (DSM) TACE,drugeluting bead (DEBDOX) TACE or Lipiodol TACE (cTACE).All patients received 50 mg doxorubicin/m2 body surface area (BSA) during TACE.Serum VEGF levels were assessed before TACE treatment,24 h post-treatment and 4 weeks later.Results:Twenty-two patients with 30 TACE treatments were enrolled.Compared to baseline VEGF levels,a marked increase was observed for 24 h post-TACE (164% of baseline level) and during the 4-week follow-up (170% of baseline level) only for the cTACE arm (p < 0.05).In contrast,the increase of serum VEGF levels were only 114% and 123% for DEBDOX and 121% and 124% for DSM,respectively.Conclusions:Conventional TACE using Lipiodol shows marked increase in blood levels of the proangiogenic factor VEGF,while DEBDOX and DSM TACE induce only a moderate VEGF response.

Expression of recombinant adeno-associated virus in the brain of rats with a focal embolic stroke via carotid artery

OBJECTIVE: To study whether recombinant adeno-associated virus (rAAV) mediated foreign gene, LacZ, could pass the blood brain barrier by intra-carotid artery delivery and express in vivo in ischemic brain of the focal embolic stroke rats to investigate a possibility of delivering foreign gene through carotid artery to treat acute ischemic stroke. METHODS: The carotid artery territory in 41 rats was embolized with or without arterial-like fibrin rich clots to make a model of focal embolic stroke rat. rAAV containing LacZ gene (rAAV-LacZ) was constructed in 293 cells by calcium phosphate cotransfection. The rats were assigned to one of the following treatments: 1 control (without embolism) groups, including PBS treated (n = 6), pLacZ treated (n = 6 ) and rAAV-LacZ treated (n = 6): 2 embolic groups, including embolism + PBS (n =7),embolism + pLacZ (n = 8) and embolism + rAAV-LacZ (n = 8). Brains were cryosectioned and kappa-Gal stain was performed at 2, 4, and 8 weeks, respectively, after transfection, and then infarct volume was measured and the percentage of LacZ staining-positive cells was calculated. RESULTS: In all the control groups and embolism + PBS treated animal, no kappa-Gal staining-positive cells were found, but in embolism + pLacZ (n = 8) and embolism+rAAV-LacZ groups a lot of kappa-Gal staining-positive cells were found. The expression cells were in the tissues around the infarction. The gene expression persisted only nearly four weeks in embolic group with pLacZ. In the embolic group with rAAV-LacZ the expression was very stable during the experiment course (eight weeks) and the percentage of the expressed cells was significantly higher than that of its contralateral areas at the same time points, respectively. CONCLUSIONS: The plasmid vector and rAAV could enter the brain through the ischemia-damaged blood barrier and foreign gene can be expressed in brain. The positive gene expression is mainly in the peripheral areas of the infarction. rAAV as a permanent expression vector may ultimately be used for gene therapy of human ischemia cerebravascular diseases.

Dual versus mono antiplatelet therapy for acute non-cardioembolic ischaemic stroke or transient ischaemic attack:a systematic review and meta-analysis

Objective Recent years have seen new evidence on the efficacy and safety of dual antiplatelet therapy for secondary stroke prevention.We updated a meta-analysis of randomised controlled trials evaluating dual antiplatelet versus monotherapy for patients with acute non-cardioembolic ischaemic stroke(IS)or transient ischaemic attack(TIA).Methods We searched PubMed and identified randomised controlled trials evaluating dual antiplatelet versus monotherapy for acute non-cardioembolic IS or TIA within 3 days of ictus up to May 2018.Risk ratio(RR)with 95%CI were calculated using random effects models.Clinical endpoints included stroke recurrence,composite vascular events and major bleeding.results 18 randomised controlled trials including 15515 patients were pooled in the meta-analysis.When compared with monotherapy among patients with acute IS or TIA,dual antiplatelet therapy reduced the risk of stroke recurrence(RR 0.69;95%CI 0.61 to 0.78;p<0.001)and composite vascular events(RR 0.72;95%CI 0.64 to 0.80;p<0.001).Dual therapy was associated with a significant increase in the risk of major bleeding(RR 1.77;95%CI 1.09 to 2.87;p=0.02)when all trial data were combined.However,when all previous trials before the completion of the POINT trial were analysed,dual antiplatelet versus monotherapy was not associated with a significant increase in the risk of major bleeding(RR 1.46;95%CI 0.77 to 2.75;p=0.25).Conclusions Among patients with acute noncardioembolic IS or TIA within 3 days of ictus,dual antiplatelet therapy was associated with a reduction in stroke recurrence,and composite vascular events,when compared with monotherapy.However,a significant increase in the risk of major bleeding was observed.

Technical feasibility and histopathologic studies of poly (N-isopropylacrylamide) as a non-adhesive embolic agent in swine rete mirabile

Background Non-adhesive liquid embolic agents are increasingly gaining importance in the embolization of cerebral arteriovenous malformations （AVMs）. We investigated the use of poly （N-isopropylacrylamide） （PNIPAM） as a non-adhesive embolic agent in swine rete mirabile. Methods The PNIPAM hydrogel was mixed with iohexol and embolization was performed in swine rete mirabile in 30 animals. The microcatheter was examined after embolization. Follow-up angiography was performed for embolic efficacy after embolization. Embolized retia were examined histopatholgically, and the alterations of inside rete and surrounding tissue were observed. Results The copolymer hydrogel was used for rete embolization in 30 swine, 28 swine survived the procedure, 2 swine died, 1 swine died of cerebrum infarction and the other died of embolic agent reflux into the occipital artery. The inside wall of the microcatheter was smooth, without copolymer adhering to it. Follow-up angiography was performed in 22 swine, there was no rete recanalization in 20 swine and partial rete recanalization in 2 swine because of the trunk embolization of ascending pharyngeal arteries. Histopatholgically, the copolymer was found diffused into vessels of 100-- 150 μm in diameter. In acute group, neutrophils scattered surrounding the copolymer and endothelial integrity was observed, without endothelial denuding and necrosis. In subacute and chronic groups, the copolymer was found inside retia, a few mononuclear cells and eosinocytes scattered inside and surrounding it. The muscular layer was loosened with most muscular nuclei degraded. Conclusion Experimental rete embolization with PNIPAM, made radiopaque with iohexol, is technically feasible in swine. Because of its properties, PNIPAM has great potential as a therapeutic non-adhesive embolic agent.