Single-Center Experience With the Bare p48MW Low-Profile Flow Diverter and Its Hydrophilically Covered Version for Treatment of Bifurcation Aneurysms in Distal Segments of the Anterior and Posterior Circulation.

Background and Purpose: Flow diversion has profoundly changed the way aneurysms are treated. However, it conventionally requires dual antiplatelet medication and has yet been considered off-label use in the posterior circulation or within peripheral vessels of the anterior circulation. Here, we report our experience with the p48MW/p48MW hydrophilic coating (HPC) in the anterior and posterior circulation. This novel low-profile flow diverter is specifically designed for treatment of small peripheral vessels, and the p48MW HPC has an anti-thrombotic polymer coating, which allows application of a single antiplatelet function medication in conditions that expectably require further surgery. Materials and Methods: Thirty-two patients were prospectively included. Twenty-six treatments were performed with one flow diverter, four required two overlapping flow diverters, one case demanded three overlapping flow diverters, and in one case, extensive dissecting aneurysm telescoping with eight flow diverters was necessary. Twenty-two complex bifurcation aneurysms were treated. Three months' follow-up was available for 14 patients. Results: Deployment was uneventful in all cases. In four cases, undersizing was unavoidable and resulted in significant shortening of the flow diverter, which demanded implantation of further flow diverters to sufficiently treat the target aneurysm. Three flow diverters required balloon angioplasty for optimal wall approximation. All parent vessels remained patent. Available 3-month follow-up studies showed decreased influx or delayed washout in all aneurysms; none was occluded completely. There were no device-related clinical complications. Conclusions: Implantation of the p48MW/p48MW HPC is safe and effective for treatment of distally located cerebral aneurysms. Considering the reported rates of ischemic complications associated with flow diversion of complex bifurcation aneurysms, the p48MW/p48MW HPC potentially provides increased safety for complex bifurcation aneurysms in the anterior and posterior circulation.

Flow diversion in challenging vascular anatomies: the use of low profile stent retrievers for safe and accurate positioning of the microcatheter.

BACKGROUND: Hemodynamic therapy with Flow-Diverters has become a fundamental option for treatment of cerebral aneurysms. A major obstacle of Flow-Diverters is the comparatively stiff microcatheter required for implantation. Consequentially, maneuverability is limited and primary catheterization of peripheral targets may be difficult or even futile in challenging vascular anatomies. To overcome this, a highly navigable microcatheter must be used to attain the desired vascular segment, followed by a hardly controllable exchange-maneuver via a long microwire, involving a high risk for wire-perforation. Our study aimed to investigate the value of low-profile stent-retrievers as a railway for introduction of the required microcatheter, which allows to maintain a stable endovascular position and reduce the risk for procedural vessel injury. METHODS: 14cases (8females, mean-age 59y) of Flow-Diverter-Implantation requiring the use of a low-profile stent-retriever were reviewed. All cases featured a challenging vascular anatomy. After micro-catheterization of the desired segment, the stent-retriever was carefully deployed as an anchor in a secure, distal location. In all cases a pREset/LITE-stent-retriever was used for introduction of the equipment required for implantation. RESULTS: In all cases the anchoring-maneuver was performed without technical complications. The stent-retrievers maintained a stable position after deployment in all situations. No potential traumatic sudden movements of the microcatheter occurred. No procedure-related perforations, dissections or vasospasms were observable during the interventions or their aftermath. CONCLUSIONS: In our experience the stent-retriever-anchoring-maneuver represents a potentially essential and safe amendment for flow diverter treatment in technically challenging situations.

Severe leptospirosis complicated by Epstein-Barr Virus reactivation.

INTRODUCTION: Weil's disease is a severe, potentially fatal illness following Leptospira interrogans infection. The reported case of a patient suffering from acute renal failure, jaundice, thrombocytopenia, rhabdomyolysis and encephalitis syndrome highlights the clinical challenge in reference to Weil syndrome complicated by Epstein-Barr Virus (EBV) reactivation. MATERIALS AND METHODS: The diagnosis of leptospirosis was performed using four different diagnostic methods. Sera were analyzed with an in-house IgM and IgG enzyme-linked immunosorbent assay (ELISA) and indirect haemagglutination assay (IHA). Microscopic agglutination test (MAT) was done using 17 reference strains comprising 14 serogroups and 17 serovars. Polyvalent EBV-IgG analysis, EBV-IgG/IgM/IgA western blot analysis as well as quantitative EBV polymerase chain reaction (PCR) were performed. RESULTS: Leptospira IHA showed an initial titer of 1:640 (cut-off 1:320), leptospiral IgG was negative, but IgM was positive. MAT was negative at that time for all 17 strains analyzed. One week later, leptospirosis IHA titer increased to 1:20,480. Leptospiral IgG was now positive, -IgM remained positive and urine was tested negative for leptospiral DNA. The MAT showed positive results for L. interrogans serovar Bataviae, serovar Copenhageni, serovar Pyrogenes and L. borgpetersenii serovar Serjoe. During follow-up examinations, both the leptospiral IgM and IgG remained positive and MAT showed positive results for L. interrogans of different serovars. EBV IgA immunoblot taken at admission was positive for VCA-p18, quantitative EBV-PCR showed an EBV viral load of 2.8E3 copies/ml indicating acute EBV-reactivation. CONCLUSION: Leptospirosis represents a neglected and re-emerging disease which is difficult to diagnose since Leptospira-PCR from whole blood or urine is frequently negative in the case of early empiric antibiotic treatment. EBV-reactivation might represent a severe complication in Weil's disease which potentially aggravates clinical manifestations of leptospirosis including hepatitis, nephritis, and rhabdomyolysis. Thus, there might be a need for peripheral blood EBV-PCR and EBV blotting in patients suffering from complicated Weil syndrome, also in terms of the choice of antibiotic treatment.

High-resolution flat-panel volumetric CT images show no correlation between human age and sagittal suture obliteration--independent of sex.

This study investigated whether digital, high-resolution CT-images of the internal human sagittal suture structure include information that enables a novel method of age at death (aad) determination. To accomplish this, coronal, flat-panel-based volumetric computed tomography (eXplore Locus Ultra scanner) images were automatically analyzed by a software implementation of an algorithm that determines user independent whether a suture is open or closed. 29,205 images of the local vicinity of the sagittal suture of 164 males and 85 females of European descent were investigated separately for both sexes. We used conditional probabilities and a chi(2)-test to investigate whether there is a correlation between aad and suture obliteration or not. The computer-aided analysis enables us to handle huge volumes of data that could not otherwise be analyzed within a reasonable time frame. The implemented algorithm ensured a strongly reproducible, reliable, accurate, and fast differentiation between closed and open sutures. The evaluation of various statistical parameters suggests that there is no reason to assume a correlation between age and suture closure--with equal findings for both sexes. Therefore, we conclude that determination of aad based on the evaluation of sagittal suture obliteration is not possible. This agrees well - thus unsatisfactorily - with the recent literature.