Treatment of intracranial atherosclerotic disease with a balloon-expandable paclitaxel eluting stent: procedural safety, efficacy and mid-term patency.

PURPOSE: Procedural safety and high rates of in-stent recurrent stenotic lesions (ISR) remain a concern in the endovascular treatment of intracranial atherosclerotic disease (ICAD). In the present study technical feasibility, safety and efficacy of the paclitaxel eluting balloon-expandable coronary stent Coroflex(®) Please was assessed in the treatment of ICAD. METHODS: A total of 95 patients (79 male; median age 68 years) with 106 intracranial atherosclerotic stenotic lesions underwent endovascular treatment using Coroflex(®) Please stents (B. Braun, Melsungen, Germany). Location and degree of target stenoses before and after treatment and at follow-up and adverse clinical sequelae of treatment were registered. Post-procedural medication included 100 mg acetylsalicylic acid (ASA) and 75 mg clopidogrel for 1 year. Angiographic follow-up was scheduled for 6, 12, 26 and 52 weeks after the treatment. RESULTS: The lesion locations were as follows: internal carotid artery (ICA) petrous (n = 44, 42%), ICA cavernous (n = 43, 41%), ICA paraclinoid (n = 4, 4%), intradural vertebral artery (VA; n = 11, 10%) and basilar artery (BA; n = 4, 4%). Of the lesions seven could not be treated due to difficult anatomy and stent stiffness (7% technical failure rate). The combined post-interventional neurological morbidity and mortality rate, including stroke, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH) and carotid cavernous fistula (CCF) was n = 4 (3.7%) within and n = 1 (0.9%) at and beyond 30 days, respectively. Angiographic and clinical follow-up examinations were carried out for 78 (78%) of the lesions (mean 16.1 months, maximum 48 months). Asymptomatic recurrent stenosis was seen in 3 out of 78 (3.8%) lesions and there was 1 case of late stent thrombosis (0.9%). CONCLUSIONS: Treatment of ICAD using drug-eluting coronary stents is safe and effective but technical failure due to stent stiffness remains a problem. Application of the more flexible, newest generation thin-strut stents, however, shows promising results.

Neurovascular in-stent stenoses: treatment with conventional and drug-eluting balloons.

BACKGROUND AND PURPOSE: ISRs remain a major issue in the endovascular management of ICAD, requiring retreatment by reangioplasty. The aim of the present study was to evaluate the technical feasibility, safety, and efficiency of the novel DEBs for neurovascular ISRs. MATERIALS AND METHODS: Fifty-one patients (median age, 67 years; age range, 34-82 years; male/female ratio, 37:14) underwent 63 balloon dilation procedures for ISRs in intracranial stented arterial segments between November 2007 and August 2010 in a single center. Of the 63 procedures, 20 (32%) were performed by using a conventional balloon and 43 (68%), by using a paclitaxel-eluting balloon (SeQuent Please). Angiographic and clinical follow-up was performed at 6 and 12 weeks, 6 and 12 months, and yearly thereafter. Technical success rate, periprocedural complications, occurrence of recurrent ischemic symptoms, and the development of a recurrent ISR after reangioplasty were analyzed. RESULTS: Technical success, defined as <50% residual stenosis was achieved in all cases (100%), with failure of the DEB treatment in 6% of the attempts; those lesions were finally successfully treated with a conventional balloon. The combined permanent neurologic morbidity and mortality rate (stroke, ICH, and SAH) at 30 days was 1.6%. Substantial difference was found in the rate of recurrent stenosis when comparing conventional balloons and DEBs, with recurrent stenosis rates of 50% and 9%, respectively. CONCLUSIONS: The initial results of reangioplasty of intracranial ISRs with DEBs are encouraging; further technical developments are, nevertheless, mandatory.

Treatment of intracranial aneurysms by functional reconstruction of the parent artery: the Budapest experience with the pipeline embolization device.

BACKGROUND AND PURPOSE: Aneurysm treatment by intrasaccular packing has been associated with a relatively high rate of recurrence. The use of mesh tubes has recently gained traction as an alternative therapy. This article summarizes the midterm results of using an endoluminal sleeve, the PED, in the treatment of aneurysms. MATERIALS AND METHODS: A total of 19 wide-neck aneurysms were treated in 18 patients: 10 by implantation of PEDs alone and 9 by a combination of PED and coils. Angiographic and clinical results were recorded immediately and at 6 months following treatment. RESULTS: Immediate angiographic occlusion was achieved in 4 and flow reduction, in another 15 aneurysms. Angiography at 6 months demonstrated complete occlusion in 17 and partial filling in 1 of 18 patients. There was no difference between coil-packed and unpacked aneurysms. Of 28 side branches covered by > or =1 device, the ophthalmic artery was absent immediately in 1 and at 6 months in another 2 cases. One patient experienced abrupt in-stent thrombosis resulting in a transient neurologic deficit, and 1 patient died due to rupture of a coexisting aneurysm. All giant aneurysms treated with PED alone were demonstrated by follow-up cross-sectional imaging to have involuted by 6 months. CONCLUSIONS: Treatment of large, wide-neck, or otherwise untreatable aneurysms with functional reconstruction of the parent artery may be achieved with relative safety using dedicated flow-modifying devices with or without adjunctive use of intrasaccular coil packing.

Treatment of stenoses of vertebral artery origin using short drug-eluting coronary stents: improved follow-up results.

BACKGROUND AND PURPOSE: Recent studies on stent placement of significant stenoses at the origin of the vertebral artery reported excellent immediate results. Long-term outcomes, however, were disappointing due to high restenosis rates and stent breakage. In the present study, we evaluated the application of a short drug-eluting balloon-expandable coronary stent for the endovascular treatment of these frequent lesions. MATERIALS AND METHODS: In a period of 23 months, 48 patients (12 women, 36 men) with a mean age of 68 years (range, 46-82 years) harboring 52 significant ostial vertebral artery stenoses underwent treatment with short (8 mm) balloon-expandable paclitaxel-eluting coronary stents. Stents were deployed as closely as possible so that the proximal end was just at the origin of the vertebral artery, with high inflation pressure applied. Patients were under continuous medication with acetylsalicylic acid and clopidogrel before and after the treatment. Follow-up clinical assessment and angiography were performed in all patients. RESULTS: Periprocedural complications were not encountered. Stenosis severity was reduced from 62 +/- 2% (mean +/- standard error of the mean) preprocedurally to 15 +/- 2% postprocedurally. Follow-up angiography at 7.7 +/- 0.6 months revealed a mean stenosis degree of 24 +/- 3%. None of the patients developed posterior circulation symptoms related to the treated segment during the follow-up period. Recurrent stenosis (>50%) at follow-up was found in 6 (12%) lesions. CONCLUSIONS: Stent placement of significant ostial vertebral artery stenosis by using short drug-eluting stents is safe and yields good midterm patency rates and excellent protection from posterior circulation ischemia.

Studies of mdx mice.

Cerebral water accumulation-clinically denoted as brain edema-is a potentially life threatening complication of almost every intracranial neuropathological state. The molecular membrane water channel aquaporin-4 (AQP4) has been shown to be present at the blood-brain barrier (BBB) where it plays pivotal role in the transport of water between the tissue water compartments of the brain. Accumulating evidence indicates that the blockade of AQP4 function at the BBB would be a new therapeutic approach to the treatment and prevention of brain swelling. The cytoskeletal protein dystrophin has been shown to be involved in the maintenance of the polarized expression of AQP4 at the BBB. In order to further elucidate the mechanisms responsible for the highly polarized AQP4 expression, we studied brain tissue water accumulation during induction of brain edema in dystrophin-null transgenic mice (mdx-bgeo) and control mice. Immunofluorescence and immunoelectron microscopic analyses of dystrophin-null brains revealed a dramatic reduction of AQP4 in astroglial end-feet surrounding capillaries (BBB) and at the glia limitans (cerebrospinal fluid-brain interface). The AQP4 protein is mislocalized, because immunoblotting showed that the total AQP4 protein abundance was unaltered. Brain edema was induced by i.p. injection of distilled water and 8-deamino-arginine vasopressin. Changes in cerebral water compartments were assessed by diffusion-weighted MRI (DWI) with determination of the apparent diffusion coefficient (ADC). In dystrophin-null mice and control mice, ADC gradually decreased by 5-6% from baseline levels during the first 35 min, indicating the initial phase of intracellular water accumulation is similar in the two groups. At this point, the control mice sustained an abrupt, rapid decline in ADC to 58%+/-2.2% of the baseline at 52.5 min, and all of the animals were dead by 56 min. After a consistent delay, the dystrophin-null mice sustained a similar decline in ADC to 55%+/-3.4% at 66.5 min, when all of the mice were dead. These results demonstrate that dystrophin is necessary for polarized distribution of AQP4 protein in brain where facilitated movements of water occur across the BBB and cerebrospinal fluid-brain interface. Moreover, these results predict that interference with the subcellular localization of AQP4 may have therapeutic potential for delaying the onset of impending brain edema.

SNAP-25-associated Hrs-2 protein colocalizes with AQP2 in rat kidney collecting duct principal cells.

The vasopressin-induced trafficking of aquaporin-2 (AQP2) water channels in kidney collecting duct is likely mediated by vesicle-targeting proteins (N-ethylmaleimide-sensitive factor attachment protein receptors). Hrs-2 is an ATPase believed to have a modulatory role in regulated exocytosis. To examine whether Hrs-2 is expressed in rat kidney, we carried out RT-PCR combined with DNA sequence analysis and Northern blotting using a digoxigenin-labeled Hrs-2 RNA probe. RT-PCR and Northern blotting revealed that Hrs-2 mRNA is localized in all zones of rat kidney. The presence of Hrs-2 protein in rat kidney was confirmed by immunoblotting, revealing a 115-kDa protein in kidney and brain membrane fractions corresponding to the expected molecular size of Hrs-2. Immunostaining and confocal laser scanning microscopy of LLC-PK(1) cells (a porcine proximal tubule cell line) transfected with Hrs-2 DNA confirmed the specificity of the antibody and revealed that Hrs-2 is mainly localized in intracellular compartments, including cathepsin D-containing lysosomal/endosomal compartments. The cellular and subcellular localization of Hrs-2 in rat kidney was examined by immunocytochemistry and confocal laser scanning microscopy. Hrs-2 immunoreactivity was observed in collecting duct principal cells, and weaker labeling was detected in other nephron segments. The labeling was predominantly present in intracellular vesicles, but labeling was also observed in the apical plasma membrane domains of some cells. Colabeling with AQP2 revealed colocalization in vesicles and apical plasma membrane domains, suggesting a role for Hrs-2 in regulated AQP2 trafficking.

Effects of centrally administered arginine vasopressin and atrial natriuretic peptide on the development of brain edema in hyponatremic rats.

OBJECTIVE: Centrally released arginine vasopressin (AVP) and atrial natriuretic peptide (ANP) have been shown to participate in brain volume regulation. The aim of the present study was to evaluate the effects of centrally administered AVP and ANP on the time course of development of brain edema in vivo in hyponatremic rats, using diffusion-weighted magnetic resonance imaging. METHODS: We performed intracerebroventricular (ICV) administration of 120 microg AVP, 20 microg ANP, or physiological saline into the right lateral ventricle in 18 rats. Twenty-five minutes after the treatment, we induced systemic hyponatremia by the intraperitoneal administration of 140 mmol/L dextrose solution. Serial diffusion-weighted imaging scans were obtained up to 96 minutes after the start of the hyponatremia. Changes in the brain extra-to intracellular volume fraction ratio were estimated as changes in the apparent diffusion coefficient (ADC). RESULTS: No change in the ADC was observed after the ICV injection of saline or AVP. The onset of hyponatremia induced a rapid and marked ADC reduction in both groups, indicating an increased intracellular space. However, the ADC decrease became significantly more pronounced in the ICV AVP group (83.3+/-4.7% of baseline level, mean +/- standard deviation) than in the saline group (93.7+/-3.3% of baseline, P < 0.001) after 78 minutes of hyponatremia. The ICV injection of ANP induced a prompt ADC increase to 111.5+/-10.0% (P < 0.05) of the baseline level, indicating a rapid reduction in the intracellular compartment. In the initial phase of hyponatremia, the ADC values in the ANP group were consistently higher than those in the saline group, decreasing finally to 86.9+/-9.6% after 96 minutes of hyponatremia. CONCLUSION: Our findings demonstrate the opposite effects of AVP and ANP on the intracellular volume fraction of the brain during the development of cellular brain edema, with an immediate effect on ANP and a delayed effect on AVP. The results emphasize the direct effects of these hormones on the cellular volume regulatory mechanisms in the brain during the development of cerebral edema.

Adrenalectomy causes loss of zinc ions in zinc-enriched (ZEN) terminals and decreases seizure-induced neuronal death.

Chelatable zinc ions from synaptic vesicles have been suggested to be involved in neuronal death caused by stroke, epilepsy and head trauma. Elevated glucocorticoid concentration exacerbates such neuron loss, while low levels protect. We have tested the notion that the neuroprotective effect of prior glucocorticoid reduction is mediated by a reduction of zinc ions contained in zinc-enriched (ZEN) synaptic vesicles. The level of vesicular zinc ions was evaluated by toluene sulfonamide quinoline (TSQ) fluorometry and zinc autometallography (ZnS(AMG)) 10 and 30 days, respectively, after adrenalectomy. The hippocampus showed significant vesicular zinc ion depletion following adrenalectomy. After the kainate injection, adrenalectomized rats showed proconvulsive seizure behavior, i.e. shortened latency to seizure onset time and increased seizure score. Additionally they showed decreased hippocampal CA3 neuronal death as compared to control animals. The present data suggest that zinc ions released from damaged ZEN terminals are involved in seizure-induced neuronal death.

[Aquaporins in cerebral volume regulation and edema formation]. / Aquaporinok az agyi térfogat-szabályozásban és az agyödéma kialakulásában.

Regulation of tissue water content and brain volume is of critical importance for the normal functioning of the central nervous system (CNS), which, surrounded by the rigid cranium, is highly sensitive to any increase in the intracranial pressure. Alterations in cerebral water homeostasis and distribution may lead to neuronal and glial swelling known as cytotoxic brain edema, due to accumulation of intracellular water. Although numerous investigations have been performed to elucidate the underlying molecular basis and pathophysiology of brain edema, little is known about the regulation of water transport across the blood-brain barrier and between extra- and intracellular compartments of the brain parenchyma. The discovery and characterization of the aquaporin (AQP) family of membrane water channels provided molecular insight into fundamental processes of water transport across plasma membranes. Two AQPs are expressed abundantly in the mammalian brain: AQP1 in the apical plasma membranes of the cells of choroid plexus in the ventricles, where it has been suggested to participate in the secretion of cerebrospinal fluid and AQP4 in plasma membranes of ependymal cells and astrocytes. The role of AQP4 in the formation of brain oedema was suggested by some recent studies. These findings offer new potentials in brain oedema treatment.

Brain water and proton magnetic resonance relaxation in preterm and term rabbit pups: their relation to tissue hyaluronan.

The present study was performed to investigate simultaneously total brain water, T1 and T2 relaxation times, and hyaluronan (HA) in fetal and neonatal rabbits. Attempts were also made to establish the relationship of HA to total brain water and to T2-derived motionally distinct water fractions, since HA is known to bind water and to limit tissue water mobility. Experiments were carried out in fetal Pannon white rabbit pups at gestational ages of 25, 27, 29, and 31 days and at a postnatal age of 4 days. The brain tissue water content (desiccation method), T1 and T2 relaxation times (H1-NMR method), and HA concentration (radioassay HA 50) were measured, and free and bound water fractions were calculated by using multicomponent fits of the T2 relaxation curves. Compared with values in newborn pups, water and HA contents were found to be highly elevated in the preterm brain and decreased markedly during early postnatal life. The trends and time courses of T1 and T2 relaxation times proved to be similar, but the postnatal decrease in T2 was preceded by a significant decline in late gestation. Maturity-related changes occurred in the T2 relaxation derived bound water fraction which amounted to 4-19% of brain water. The bound water fraction appeared to be independent of total brain water and HA concentration, and HA is, therefore, unlikely to be the only factor controlling brain water mobility. The clear dissociation of bound water fraction from total water suggests restructuring of brain water during the perinatal period.

Immunolocalization of AQP9 in liver, epididymis, testis, spleen, and brain.

The aims of this study were to determine the cellular and subcellular localization of aquaporin-9 (AQP9) in different rat organs by immunoblotting, immunohistochemistry and immunoelectron microscopy. To analyze this, we used rabbit antibodies to rat AQP9 raised against three different AQP9 peptides (amino acids 267-287, 274-295, and 278-295). In Cos7 cells transfected with rat AQP9, the affinity-purified antibodies exhibited marked labeling, whereas nontransfected cells and cells transfected with aquaporin-8 (AQP8) exhibited no labeling, indicating the specificity of the AQP9 antibodies. Immunoblotting revealed a predominant band of 28 kDa in membranes of total rat liver, epididymis, testes, spleen, and brain. Preabsorption with the immunizing peptides eliminated the labeling. Immunohistochemistry showed strong anti-AQP9 labeling in liver hepatocytes. The labeling was strongest at the sinusoidal surface, and there was little intracellular labeling. Immunoelectron microscopy revealed that the labeling was associated with the plasma membrane of the hepatocytes. In testes Leydig cells exhibited anti-AQP9 labeling, and in epididymis, the stereocilia of the ciliated cells (principal cells) exhibited significant labeling, whereas there was no labeling of the nonciliated cells (basal cells). This was confirmed by immunoelectron microscopy. In spleen strong labeling of cells was observed of leukocytes in the red pulp, whereas there was no labeling of cells in the white pulp. In rat brain, AQP9 immunolabeling was confined to ependymal cells lining the ventricles and to the tanycytes of the mediobasal hypothalamus. Antibody preabsorbed with the immunizing peptide revealed no labeling. In conclusion, AQP9 proteins is strongly expressed in rat liver, testes, epididymis, spleen, and brain.

Increased aquaporin-4 immunoreactivity in rat brain in response to systemic hyponatremia.

The present study was undertaken to assess whether the protein and mRNA expression levels of the glial water channel aquaporin-4 (AQP4) undergo downregulation and whether there is a subcellular redistribution of AQP4 protein in rat brain in response to systemic hyponatremia and brain edema. Systemic hyponatremia was induced for 4 or 48 h by combined administration of hypotonic dextrose i.p. and 8-deamino-arginine vasopressin (dDAVP) s.c. Semiquantitative immunoblotting of membrane enriched fractions showed significantly increased immunoreactivity to 164 +/- 12% (n = 6) and 153 +/- 12% (n = 6) of control levels in brain after 4 or 48 h of systemic hyponatremia, respectively. Similarly, immunoblots of cerebellar samples revealed an increase in AQP4 immunoreactivity to 136 +/- 6% (n = 6) and 218 +/- 44% (n = 6) of control levels, after 4 or 48 h of hyponatremia. In contrast, AQP4 mRNA levels were unchanged after 4 h of severe hyponatremia (104 +/- 14% of control levels; n = 17), indicating that there are no changes in AQP4 expression in response to systemic hypoosmolarity. Immunocytochemistry and high-resolution immunogold electron microscopy revealed highly polarized labeling of AQP4 in astrocyte end-feet surrounding capillaries and forming the glia limitans. This pattern of labeling was not changed whereas an increased labeling intensity of AQP4 could be observed in response to hyponatremia. In conclusion, hyponatremia causes a pronounced and rapid increase in AQP4 immunoreactivity that is not accompanied by any increase in AQP4 mRNA expression. The increased AQP4 immunosignal may reflect secondary conformational modifications of AQP4 protein, leading to enhanced antibody binding. This post-translational modification of AQP4 may participate in the adaptation of cerebral tissue to systemic hyponatremia.

Brain adaptation to water loading in rabbits as assessed by NMR relaxometry.

The present study was undertaken to investigate the cerebral adaptation to hypoosmolar stress in adult Pannon white rabbits by applying proton nuclear magnetic resonance relaxometry. Progressive hyponatremia was induced by combined administration of hypotonic dextrose in water and 8-deamino-arginine vasopressin over a hydration period of 3, 24, and 48 h. Each group comprised five animals. After completing the hydration protocols, blood was taken to determine plasma osmolality (freezing point depression) and sodium concentration (ion-selective electrode) and, at about the same time, T2-weighted images were made. After the in vivo measurements, the animals were killed and brain tissue samples were obtained to measure water content (desiccation method) and T1 and T2 relaxation times (proton nuclear magnetic resonance method). Free and bound water fractions were calculated by using multicomponent fits of the T2 relaxation curves. It was shown that brain water content and T1 relaxation time remained unchanged despite the progressing hyponatremia. By contrast, T2 relaxation time increased steadily from the control value of 100.2 +/- 7.7 ms to attain its maximum of 107.5 +/- 8.5 ms (p < 0.05) after 48 h of hydration. Using biexponential analysis, fast and slow components of the T2 relaxation curve could be distinguished that corresponded to the bound (T21) and free (T22) water fractions. In response to hyponatremia, the bound water fraction was markedly depressed from 6.5 +/- 3.0% to 3.6 +/- 0.9% (3 h, p < 0.05) and 3.9 +/- 0.8% (24 h, p < 0.05); then it approached the initial value of 5.3 +/- 2.5% by the end of the hydration period of 48 h. It is concluded that restructuring of brain water is a contributory factor to the successful adaptation to hypotonic environment.

Transcranial Doppler-determined pulsatility index in the evaluation of endoscopic third ventriculostomy (preliminary data).

OBJECTIVE: Endoscopic 3rd ventriculostomy has become the method of choice in the management of occlusive hydrocephalus. The treatment is accompanied by significantly less peri-operative complications than the cerebrospinal fluid shunting procedures previously employed. Close surveillance of patients, however, is necessary to avoid the consequences of raised intracranial pressure that may develop in case of obstruction of the artificial outlet of the 3rd ventricle. The aim of this study was to confirm the value of transcranial Doppler-determined pulsatility index (PI) in the assessment of the patency of endoscopic 3rd ventriculostomy and to elucidate its usefulness in early postoperative recognition of increased intracranial pressure. METHODS: In twenty-two patients suffering from occlusive hydrocephalus, transcranial Doppler sonography (TCD) was performed before, immediately after, and five days after endoscopic fenestration of the floor of the 3rd ventricle. PI was defined with fast Fourier transformation. Mean PI values were determined in both middle cerebral arteries (MCA), over five cardiac cycles. RESULTS: In nineteen cases, PI values showed a significant decrease immediately as well as five days after the intervention as compared to the pre-operative values, and flow-sensitive MRI confirmed the patency of the fenestration in all cases. In one patient the operation failed to produce an effective diversion of cerebrospinal fluid as shown by flow-sensitive MRI, and the pulsatility index was unchanged. In two patients, a significant immediate postfenestration drop in PI was followed by a recurrence of PI to pre-operative levels without any clinical deterioration. CONCLUSIONS: Preliminary results suggest that the transcranial Doppler-determined pulsatility index is a useful non-invasive tool for the evaluation of the patency of the fenestration in the early follow-up of patients who underwent endoscopic third ventriculostomy.

The occurrence of Chlamydia trachomatis in the semen of men participating in an IVF programme.

Chlamydia trachomatis is one of the most common causative agents of sexually transmitted diseases. The authors studied the occurrence of C. trachomatis in the semen of 184 asymptomatic men participating in the IVF programme. Twenty-six (14.1%) of the 184 tested were positive for C. trachomatis, these patients and their wives receiving doxycycline capsules twice, 100 mg on the first day and 100 mg/day for the following 13 days. This treatment was effective in 88.5% of the cases and in the rest, treatment continued with erithromycin 250 mg four times/day for 2 weeks. The authors compared the semen parameters (cell count, motility, morphology, bovine mucus penetration and hypo-osmotic swelling test) in the infected and non-infected groups and observed no significant difference between these two groups.