Association between Peripheral Arterial Lactate Levels and Malignant Brain Edema Following Endovascular Treatment for Ischemic Stroke.

AIMS: To investigate the factors of postoperative malignant brain edema (MBE) in patients with acute ischemic stroke (AIS) treated with endovascular treatment (EVT). BACKGROUND: MBE is a severe complication following EVT for AIS, and it is essential to identify risk factors early. Peripheral arterial lactate (PAL) levels may serve as a potential predictive marker for MBE. OBJECTIVE: To determine whether immediate postoperative PAL levels and the highest PAL level within 24 hours of EVT are independently associated with MBE development in AIS patients. METHODS: We retrospectively analyzed patients with AIS who underwent EVT from October 2019 to October 2022. Arterial blood was collected every 8 h after EVT to measure PAL, and record the immediate postoperative PAL and the highest PAL level within 24 h. Brain edema was evaluated using brain computed tomography scans within 7 days of EVT. RESULTS: The study included 227 patients with a median age of 71 years, of whom 59.5% were male and MBE developed in 25.6% of patients (58/227). Multivariate logistic regression analysis showed that the immediate postoperative PAL (odds ratio, 1.809 [95% confidence interval (CI), 1.215-2.693]; p = 0.004) and the highest PAL level within 24 h of EVT (odds ratio, 2.259 [95% CI, 1.407-3.629]; p = 0.001) were independently associated with MBE. The area under the curve for predicting MBE based on the highest PAL level within 24 hours of EVT was 0.780 (95% CI, 0.711-0.849). CONCLUSION: Early increase in PAL levels is an independent predictor of MBE after EVT in AIS patients.

A dynamic nomogram for predict individual risk of malignant brain edema after endovascular thrombectomy in acute ischemic stroke.

The aim of this study was to develop a dynamic nomogram combining clinical and imaging data to predict malignant brain edema (MBE) after endovascular thrombectomy (EVT) in patients with large vessel occlusion stroke (LVOS). We analyzed the data of LVOS patients receiving EVT at our center from October 2018 to February 2023, and divided a 7:3 ratio into the training cohort and internal validation cohort, and we also prospectively collected patients from another stroke center for external validation. MBE was defined as a midline shift or pineal gland shift > 5 mm, as determined by computed tomography (CT) scans obtained within 7 days after EVT. A nomogram was constructed using logistic regression analysis, and its receiver operating characteristic curve (ROC) and calibration were assessed in three cohorts. A total of 432 patients were enrolled in this study, with 247 in the training cohort, 100 in the internal validation cohort, and 85 in the external validation cohort. MBE occurred in 24% (59) in the training cohort, 16% (16) in the internal validation cohort and 14% (12) in the external validation cohort. After adjusting for various confounding factors, we constructed a nomogram including the clot burden score (CBS), baseline neutrophil count, core infarct volume on CTP before EVT, collateral index, and the number of retrieval attempts. The AUCs of the training cohorts were 0.891 (95% CI 0.840-0.942), the Hosmer-Lemeshow test showed good calibration of the nomogram (P = 0.879). And our nomogram performed well in both internal and external validation data. Our nomogram demonstrates promising potential in identifying patients at elevated risk of MBE following EVT for LVOS.

Hemodynamic predictors of early neurological deterioration and clinical outcome after endovascular treatment in large artery occlusion.

Objective: Half of the patients with acute large artery occlusion (LAO) have poor outcomes after endovascular treatment (EVT). Early complications such as cerebral edema and symptomatic intracranial hemorrhage (sICH) can lead to early neurological deterioration (END), which correlates with hemodynamics. This study aimed to identify the hemodynamic predictors of END and outcomes in LAO patients after EVT. Methods: A total of 76 patients with anterior circulation LAO who underwent EVT and received transcranial Doppler (TCD) monitoring were included. Bilateral middle cerebral artery (MCA) blood flow velocities (BFVs) were measured repeatedly within 1 week. Mean flow velocities (MFV) and MFV index (ipsilateral MFV/contralateral MFV) were calculated. The primary outcome was the incidence of END within 72 h. The secondary outcome was the functional outcome at 90 days-a good outcome was defined as a modified Rankin scale (mRS) score of 0-2, while a poor outcome was defined as an mRS score of 3-6. Results: A total of 13 patients (17.1 %) experienced END within 72 h, including 5 (38.5 %) with cerebral edema, 5 (38.5 %) with sICH, and 3 (23.0 %) with infarct progression. Multivariable logistic regression analysis showed that a higher 24 h MFV index was independently associated with END (aOR 10.5; 95 % CI 2.28-48.30, p = 0.003) and a poor 90-day outcome (aOR 5.10; 95 % CI 1.38-18.78, p = 0.014). The area under the receiver operating characteristic (ROC) curve (AUC) of the 24 h MFV index for predicting END was 0.807 (95 % CI 0.700-0.915, p = 0.0005), the sensitivity was 84.6 %, and the specificity was 66.7 %. At the 1-week TCD follow-up, patients who had poor 90-day outcomes showed significantly higher 1-week iMFV [73.5 (58.4-99.0) vs. 57.7 (45.3-76.3), p = 0.004] and MFV index [1.24 (0.98-1.57) vs.1.0 (0.87-1.15) p = 0.007]. A persistent high MFV index (PHMI) was independently associated with a poor outcome (aOR 7.77, 95 % CI 1.81-33.3, p = 0.006). Conclusion: TCD monitoring within 24 h after EVT in LAO patients can help predict END, while dynamic follow-up within 1 week is valuable in predicting clinical outcomes.

Asymmetric deep cerebral venous filling predicts poor outcome of acute basilar artery occlusion after endovascular treatment.

OBJECTIVE: To explore the relationship between asymmetric deep cerebral venous (ADCV) filling and poor outcomes after endovascular treatment (EVT) in patients with acute basilar artery occlusion (ABAO). METHODS: ABAO patients were selected from a prospectively collected data at our center. The DCV filling was evaluated using computed tomography perfusion (CTP)-derived reconstructed 4D-DSA or mean venous map. ADCV filling was defined as the internal cerebral vein (ICV), thalamostriate vein (TSV), or basal vein of Rosenthal (BVR) presence of ipsilateral filling defects or delayed opacification compared to the contralateral side. Poor prognosis was defined as a modified Rankin scale score >3 at the 90-day follow-up. RESULTS: A total of 90 patients were enrolled in the study, with a median Glasgow Coma Scale of 6, 46 (51.1%) showed ADCV filling, 59 (65.6%) had a poor prognosis, and 27 (30.7%) had malignant cerebellar edema (MCE). Multivariate adjusted analysis revealed significant associations between asymmetric TSV and poor prognosis (odds ratio, 9.091, p = 0.006); asymmetric BVR (OR, 9.232, p = 0.001) and asymmetric ICV (OR, 4.028, p = 0.041) were significantly associated with MCE. CONCLUSION: Preoperative ADCV filling is an independent influencing factor for the poor outcome after EVT in ABAO patients.

Blood-brain barrier permeability by CT perfusion predicts parenchymal hematoma after recanalization with thrombectomy.

BACKGROUND AND PURPOSE: Parenchymal hematoma is a dreaded complication of mechanical thrombectomy after acute ischemic stroke. This study evaluated whether blood-brain barrier permeability measurements based on CT perfusion could be used as predictors of parenchymal hematoma after successful recanalization and compared the predictive value of various permeability parameters in patients with acute ischemic stroke. METHODS: We enrolled 53 patients with acute ischemic stroke who underwent mechanical thrombectomy and achieved successful recanalization. Each patient underwent CT, CT angiography, and CT perfusion imaging before treatment. We used relative volume transfer constant (rKtrans ) values, relative permeability-surface area product (rP·S), and relative extraction fraction (rE) to evaluate preoperative blood-brain barrier permeability in the delayed perfusion area. RESULTS: Overall, 22 patients (37.7%) developed hemorrhagic transformation after surgery, including 10 patients (16.9%) with hemorrhagic infarction and 11 patients (20.8%) with parenchymal hematoma. The rP·S, rKtrans , and rE of the hypoperfusion area in the parenchymal hematoma group were significantly higher than those in the hemorrhagic infarction and no-hemorrhage transformation groups (p < .01). We found that rE and rP·S were superior to rKtrans in predicting parenchymal hematoma transformation after thrombectomy (P·S area under the curve [AUC] .844 vs. rKtrans AUC .753, z = 2.064, p = .039; rE AUC .907 vs. rKtrans AUC .753, z = 2.399, p = .017). CONCLUSIONS: Patients with parenchymal hematoma after mechanical thrombectomy had higher blood-brain barrier permeability in hypoperfusion areas. Among blood-brain barrier permeability measurement parameters, rP·S and rE showed better accuracy for parenchymal hematoma prediction.

Construction and effectiveness evaluation of a knowledge-based infectious disease monitoring and decision support system.

To improve the hospital's ability to proactively detect infectious diseases, a knowledge-based infectious disease monitoring and decision support system was established based on real medical records and knowledge rules. The effectiveness of the system was evaluated using interrupted time series analysis. In the system, a monitoring and alert rule library for infectious diseases was generated by combining infectious disease diagnosis guidelines with literature and a real medical record knowledge map. The system was integrated with the electronic medical record system, and doctors were provided with various types of real-time warning prompts when writing medical records. The effectiveness of the system's alerts was analyzed from the perspectives of false positive rates, rule accuracy, alert effectiveness, and missed case rates using interrupted time series analysis. Over a period of 12 months, the system analyzed 4,497,091 medical records, triggering a total of 12,027 monitoring alerts. Of these, 98.43% were clinically effective, while 1.56% were invalid alerts, mainly owing to the relatively rough rules generated by the guidelines leading to several false alarms. In addition, the effectiveness of the system's alerts, distribution of diagnosis times, and reporting efficiency of doctors were analyzed. 89.26% of infectious disease cases could be confirmed and reported by doctors within 5 min of receiving the alert, and 77.6% of doctors could complete the filling of 33 items of information within 2 min, which is a reduction in time compared to the past. The timely reminders from the system reduced the rate of missed cases by doctors; the analysis using interrupted time series method showed an average reduction of 4.4037% in the missed-case rate. This study proposed a knowledge-based infectious disease decision support system based on real medical records and knowledge rules, and its effectiveness was verified. The system improved the management of infectious diseases, increased the reliability of decision-making, and reduced the rate of underreporting.

Moving toward a standardized diagnostic statement of pituitary adenoma using an information extraction model: a real-world study based on electronic medical records.

PURPOSE: Diagnostic statements for pituitary adenomas (PAs) are complex and unstandardized. We aimed to determine the most commonly used elements contained in the statements and their combination patterns and variations in real-world clinical practice, with the ultimate goal of promoting standardized diagnostic recording and establishing an efficient element extraction process. METHODS: Patient medical records from 2012 to 2020 that included PA among the first three diagnoses were included. After manually labeling the elements in the diagnostic texts, we obtained element types and training sets, according to which an information extraction model was constructed based on the word segmentation model "Jieba" to extract information contained in the remaining diagnostic texts. RESULTS: A total of 576 different diagnostic statements from 4010 texts of 3770 medical records were enrolled in the analysis. The first ten diagnostic elements related to PA were histopathology, tumor location, endocrine status, tumor size, invasiveness, recurrence, diagnostic confirmation, Knosp grade, residual tumor, and refractoriness. The automated extraction model achieved F1-scores that reached 100% for all ten elements in the second round and 97.3-100.0% in the test set consisting of an additional 532 diagnostic texts. Tumor location, endocrine status, histopathology, and tumor size were the most commonly used elements, and diagnoses composed of the above elements were the most frequent. Endocrine status had the greatest expression variability, followed by Knosp grade. Among all the terms, the percentage of loss of tumor size was among the highest (21%). Among statements where the principal diagnoses were PAs, 18.6% did not have information on tumor size, while for those with other diagnoses, this percentage rose to 48% (P < 0.001). CONCLUSION: Standardization of the diagnostic statement for PAs is unsatisfactory in real-world clinical practice. This study could help standardize a structured pattern for PA diagnosis and establish a foundation for research-friendly, high-quality clinical information extraction.

Unique and interactive effects of parental neglect, school connectedness, and trait self-control on mobile short-form video dependence among Chinese left-behind adolescents.

BACKGROUND: Mobile short-form video is becoming increasingly popular among Chinese adolescents. Mobile short-form video dependence has become a pressing issue in Chinese adolescents, especially in left-behind adolescents. Previous studies, however, have focused on general mobile phone dependence and neglected specific types of mobile phone dependence. Few studies have explored the environmental and individual predictors of mobile short-form video dependence. OBJECTIVE: Based on theoretical and empirical evidence, the present study examined the unique and interactive effects of parental neglect, school connectedness, and trait self-control on mobile short-form video dependence among Chinese left-behind adolescents. METHODS: A total of 618 left-behind adolescents between 11 and 15 years of age completed the anonymous self-report survey. The PROCESS macro for SPSS was applied for data analysis. RESULTS: Parental neglect was positively associated with mobile short-form video dependence, whereas school connectedness and trait self-control were negatively associated with mobile short-form video dependence in left-behind adolescents. Examination of the two-way interactions indicated that school connectedness and trait self-control could buffer the association between parental neglect and left-behind adolescents' mobile short-form video dependence. However, self-control could not moderate the association between school connectedness and mobile short-form video dependence. In addition, the three-way interaction of parental neglect, school connectedness, and trait self-control showed a significant effect on mobile short-form video dependence. The moderating role of school connectedness was stronger for left-behind adolescents with low trait self-control than for those with high trait self-control, and the moderating role of trait self-control was stronger for left-behind adolescents with low school connectedness than for those with high school connectedness. CONCLUSIONS: The findings contribute significantly to revealing the complex mechanisms of mobile short-form video dependence and providing comprehensive and specific practical suggestions for the prevention and intervention of mobile short-form video dependence among left-behind adolescents.

Large mismatch profile predicts rapidly progressing brain edema in acute anterior circulation large vessel occlusion patients undergoing endovascular thrombectomy.

Background: Brain edema is a severe complication in patients with large vessel occlusion (LVO) that can reduce the effectiveness of endovascular therapy (EVT). This study aimed to investigate the association of the perfusion profile at baseline computed tomography (CT) perfusion with rapidly progressing brain edema (RPBE) after EVT in patients with acute anterior LVO. Methods: We retrospectively reviewed consecutive data collected from 149 patients with anterior LVO who underwent EVT at our center. Brain edema was measured by the swelling score (0-6 score), and RPBE was defined as the swelling score increased by more than 2 scores within 24 h after EVT. We investigated the effect of RPBE on poor outcomes [National Institute of Health Stroke Scale (NIHSS) score and modified Rankin scale (mRS) score at discharge, the occurrence of hemorrhagic transformation, and mortality rate in the hospital] using the Mann-Whitney U-test and chi-square test. A multivariate logistic regression model was used to assess the relationship between perfusion imaging parameters and RPBE occurrence. Results: Overall, 39 patients (26.2%) experienced RPBE after EVT. At discharge, RPBE was associated with higher NIHSS scores (Z = 3.52, 95% CI 2.0-12.0, P < 0.001) and higher mRS scores (Z = 3.67, 95% CI 0.0-1.0, P < 0.001) including the more frequent occurrence of hemorrhagic transformation (χ2 = 22.17, 95% CI 0.29-0.59, P < 0.001) and higher mortality rates in hospital (χ2 = 9.54, 95% CI 0.06-0.36, P = 0.002). Univariate analysis showed that intravenous thrombolysis, baseline ischemic core volume, and baseline mismatch ratio correlated with RPBE (all P < 0.05). After dividing the mismatch ratio into quartiles and performing a chi-square test between quartiles, we found that the occurrence of RPBE in Q4 (mismatch ratio > 11.3) was significantly lower than that in Q1 (mismatch ratio ≤ 3.0) (P < 0.05). The result of multivariate logistic regression analysis showed that compared with baseline mismatch ratio <5.1, baseline mismatch ratio between 5.1 and 11.3 (OR:3.85, 95% CI 1.06-14.29, P = 0.040), and mismatch ratio >11.3 (OR:5.26, 95% CI 1.28-20.00, P = 0.021) were independent protective factors for RPBE. Conclusion: In patients with anterior circulation LVO stroke undergoing successful EVT, a large mismatch ratio at baseline is a protective factor for RPBE, which is associated with poor outcomes.

Case report: Spiller syndrome initially mimicking vestibular neuritis.

Spiller syndrome is a rare subtype of medial medullary infarction (MMI). Herein, we report on a patient with progressing stroke who presented with the initial features of acute peripheral vestibulopathy and MMI (Spiller syndrome), as confirmed by magnetic resonance imaging (MRI). A 42-year-old man experienced acute persistent vertigo with nausea, vomiting, and severe gait instability for 6 h before presenting to the emergency department. He exhibited spontaneous right-beating horizontal-torsional nystagmus that intensified on rightward gaze. The patient fell to the left side during the Romberg test. Cranial computed tomography (CT) performed immediately upon admission did not provide evidence for ischemia or hemorrhage of the brainstem and cerebellum; however, the symptoms underwent exacerbation 4 h after admission, manifesting as left-sided limb weakness and dysarthria, without dysphagia. Furthermore, bedside examination revealed difficulty in extending the tongue to the right, positive left Babinski's sign, and abnormal vibration and position sense in the paralyzed limb. Head impulse test recording revealed a normal gain in the vestibulo-ocular reflex, and numerous consistent covert corrective saccades were captured upon turning the head to the left side. Cranial MRI depicted an acute infarct confined to the right side of the medial medulla, which met the diagnostic criteria for Spiller syndrome. Our study underscores the importance of considering the possibility of a nucleus prepositus hypoglossi lesion even if the signs and symptoms support the diagnosis of peripheral lesions in patients with acute vestibular syndrome exhibiting vascular risk factors.

Anatomical Association Between Schizophrenia and Cerebellum.

The pathogenesis of schizophrenia is rarely attributed to dysfunction of the cerebellum. However, coordination of mental processes might involve the cerebellum and a cortico-cerebellar-thalamic-cortical circuit (CCTCC) that can mediate that process has been proposed. We present the case of a 31-year-old male patient with a family history of psychosis who developed schizophrenia in association with a slow-growing glioblastoma at the left posterior cerebellar pontine angle. Of interest is that his psychosis became refractory after surgical removal of the tumor that had no motor deficit consequences, suggesting that the greater disruption of the CCTCC due to surgical excision might be related to the worsening psychosis. The case supports the hypothesis of cognitive dysmetria and psychosis.

10-mm Laparo-Endoscopic Single-Site Cholecystectomy Using Multiple Magnetically Anchored and Controlled Instruments.

BACKGROUND: To study the feasibility of laparo-endoscopic single-site (LESS) cholecystectomy through a 10-mm incision using a miniature magnetically anchored and controlled laparoscopy system and a grasper system. METHODS: The miniature magnetically anchored and controlled laparoscopy system consisted of a miniature magnetically anchored camera (MMAC), an external magnetic anchoring unit, and a vision output device. The camera weighed 9.8 g and measured Φ10 mm × 50 mm. The magnetically anchored and controlled grasper system consisted of a magnetically anchored grasper (MAG), an external magnetic anchoring unit, and a push-pull device. The MAG had a titanium alloy clip head and a magnetic tail. The laparoscopy system and grasper system were used simultaneously to perform LESS cholecystectomy through a single 10-mm incision in model canines. RESULTS: LESS cholecystectomy through a 10-mm incision using the MMAC and MAG was attempted in six dogs. The mean operative time was 85.75 ± 7.14 min. The operation was completed successfully in four cases, with failure occurring in one case due to gallbladder rupture and in another due to bile duct injury. The MMAC provided clear imaging, and the MAG provided sufficient exposure to perform the cholecystectomy. The use of multiple magnetically anchored and controlled instruments did not result in notable collisions. CONCLUSIONS: The designed MMAC and MAG system could be easily maneuvered. LESS cholecystectomy may be feasible through a single 10-mm incision with the simultaneous use of multiple magnetically anchored and controlled instruments.

An application research on a novel internal grasper platform and magnetic anchoring guide system (MAGS) in laparoscopic surgery.

BACKGROUND: Laparoendoscopic single-site surgery and natural orifice transluminal endoscopic surgery attempt to reduce transabdominal port sites. These require all instruments to pass through a single access point, leading to instruments collide or work at unfamiliar angles. Thus, we designed an internal grasper under magnetic anchoring guide system (MAGS) platform and investigated its utility and operability. METHODS: We measured the configuration for magnetic force decay over distance using a standardized, ex vivo laboratory testing apparatus. An electronic balance was used to measure the force of the gallbladder pull in ten patients with gallbladder stones. One pig (11 mm abdominal wall thickness) underwent a compressed trial of MAGS platform. The device was left in place for 20 min before tissue sections were harvested, and histologic assessment was performed. The utility and operability were investigated in four pigs (38-280 kg weight). RESULTS: The magnetic attraction force decayed exponentially over distance; the force of pulling gallbladder was 7.46 ± 0.54 N. This pairing of components allowed for coupling to a theoretical distance of 10 mm. No gross tissue damage was observed. H-E stain showed no necrosis in all specimens. One failed due to wall thickness of 45 mm. Others showed the critical view, triangulation of instruments was obtained, and instrument collision or "sword fighting" was reduced. CONCLUSIONS: The MAGS platform overcomes limitations such as collisions and lack of triangulation, reduces transabdominal port sites, and is easy to operate. However, our internal grasper requires the abdominal wall thickness below 10 mm.

Co-administration of grapefruit juice increases bioavailability of tacrolimus in liver transplant patients: a prospective study.

PURPOSE: The interactions between grapefruit juice (GFJ) and tacrolimus (FK506) metabolism remain obscure. The aim of this prospective study was to explore the effect of GFJ on the blood concentration of FK506 in liver transplant patients. METHODS: Thirty liver transplant patients were enrolled in the study 1 month post-transplant and randomly divided into three equal-sized groups. Group A patients were treated with the standard FK506-based immunosuppressant regimen only and therefore served as the control; group B and C patients were treated with the standard FK506-based immunosuppressant regimen as well as one of two different kinds of GFJ, respectively. The blood concentrations of FK506 on the seventh day after GFJ intake were compared within each group and among groups. The dose of FK506 was adjusted depending on the valley concentration measured to a treatment window. RESULTS: The blood concentration of FK506 in both group B and group C patients was significantly enhanced, by 1.56 +/- 0.95 and 10.33 +/- 5.59 ng/ml, respectively, following the administration of GFJ for 1 week (compared with the concentration at the start of the experiment in each group; p < 0.05). However, at the end time point, the blood concentration of FK506 in group C patients was significantly increased (p < 0.05) relative to that of the control patients, while this was not the case in group B patients (p > 0.05). Group C patients could be treated with a smaller dose of FK506 (decreased by 2.3 +/- 1.3 mg/day for all patients; p = 0.011), amounting to a decrease in drug costs of approximately $8.70 +/- 5.60/day (p = 0.011). CONCLUSION: In the setting of a controlled clinical study, the co-administration of GFJ with FK506 increased the bioavailability of FK506. However, the concentration of tacrolimus should be closely monitored and the dose adjusted to the treatment window.