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Stroke. 2000 Nov;31(11):2552-7.
Combined intravenous and intra-arterial recombinant tissue plasminogen activator in acute ischemic stroke.
Ernst R, Pancioli A, Tomsick T, Kissela B, Woo D, Kanter D, Jauch E, Carrozzella J, Spilker J, Broderick J.
Department of Radiology, Section of Neuroradiology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA.
BACKGROUND AND PURPOSE: A retrospective analysis was performed on 20 consecutive patients who presented with severe acute ischemic stroke and were evaluated for a combined intravenous (IV) and local intra-arterial (IA) recombinant tissue plasminogen activator (rtPA) thrombolytic approach within 3 hours of onset. METHODS: Twenty consecutive patients with carotid artery distribution strokes were evaluated and treated using a combined IV and IA rtPA approach over a 14-month period (September 1998 to October 1999). rtPA (0.6 mg/kg) was given intravenously (maximum dose 60 mg); 15% of the IV dose was given as bolus, followed by a continuous infusion over 30 minutes. A maximal IA dose, up to 0.3 mg/kg or 24 mg, whichever was less, was given over a maximum of 2 hours. IV treatment was initiated within 3 hours in 19 of 20 patients. All 20 patients underwent angiography, and 16 of 20 patients received local IA rtPA. RESULTS: The median baseline National Institutes of Health Stroke Scale (NIHSS) score for the 20 patients was 21 (range 11 to 31). The median time from stroke onset to IV treatment was 2 hours and 2 minutes, and median time to initiation of IA treatment was 3 hours and 30 minutes. Ten patients (50%) recovered to a modified Rankin Scale (mRS) of 0 or 1; 3 patients (15%), to an mRS of 2; and 5 patients (25%), to an mRS of 4 or 5. One patient (5%) developed a symptomatic intracerebral hemorrhage and eventually died. One other patient (5%) expired because of complications from the stroke. CONCLUSIONS: We believe that the greater-than-expected proportion of favorable outcomes in these patients with severe ischemic stroke reflects the short time to initiation of both IV and IA thrombolysis.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11062274&dopt=Abstract hemorrhage
Endoscopy. 2000 Oct;32(10):804-6.
Adherence of cyanoacrylate which leaked from gastric varices to the left renal vein during endoscopic injection sclerotherapy: a histopathologic study.
Irisawa A, Obara K, Sato Y, Saito A, Orikasa H, Ohira H, Sakamoto H, Sasajima T, Rai T, Odajima H, Abe M, Kasukawa R.
Dept. of Internal Medicine II, Fukushima Medical University School of Medicine, Fukushima City, Japan. med2fmo.sphere.ne.jp
We report a case involving leakage of cyanoacrylate (CA) to the inferior vena cava (IVC) through a gastrorenal shunt and left renal vein. A 72-year-old man with liver cirrhosis was admitted to our hospital to undergo emergency treatment for massive hemorrhage of gastric varices. Endoscopic injection sclerotherapy (EIS) using CA was performed on the varices. Radiographic fluoroscopy revealed that most of the injected CA had adhered firmly to the gastric varices, but a certain portion of the CA had flowed to the IVC through the gastrorenal shunt and left renal vein. At that point, the patient did not complain of any symptoms. However, 6 months later, he died of hepatic failure and an autopsy was performed. Histopathologic examination of the wall of the IVC and renal vein, to which CA had adhered, revealed that the CA was covered with endothelial cells of the vessel and no nearby thrombus was present. Long-term anticoagulant therapy may not be indicated in cases of leakage of CA from the gastric varices to other veins, since the leaked CA may be readily covered with endothelium without thrombus formation as in our patient. It is possible for CA to flow to the IVC and have a fatal impact. Our patient was fortunate, and for safe EIS it is important that these complications are prevented.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11068842&dopt=Abstract hemorrhage
Neurosurgery. 2000 Nov;47(5):1206-14; discussion 1214-5.
Adenoviral gene transfer of nitric oxide synthase increases cerebral blood flow in rats.
Luders JC, Weihl CC, Lin G, Ghadge G, Stoodley M, Roos RP, Macdonald RL.
Section of Neurosurgery, Pritzker School of Medicine, University of Chicago Medical Center, Illinois 60637, USA.
OBJECTIVE: Depletion of nitric oxide may play a role in the development of vasospasm after aneurysmal subarachnoid hemorrhage. Replenishment of nitric oxide might be a useful treatment for vasospasm. Using rats, we performed intracisternal injections of replication-defective adenovirus containing the endothelial nitric oxide synthase (eNOS) gene and determined the localization of and effect on cerebral blood flow of transgene expression. METHODS: Rats underwent baseline measurement of cortical cerebral blood flow using laser Doppler flowmetry. Replication-defective adenovirus containing the Escherichia coli LacZ gene (Ad327beta-Gal, n = 2/time point) or the bovine eNOS gene (AdCD8-NOS, n = 4/time point) or physiological saline solution was injected into the cisterna magna. Cerebral blood flow was measured 1, 2, 4, 7, or 14 days later, and the animals were killed. Expression of beta-galactosidase activity from the LacZ gene was examined by histochemical staining and that of eNOS was examined by polymerase chain reaction assays of messenger ribonucleic acid. Brains were histopathologically examined for inflammation. RESULTS: Beta-galactosidase activity was observed throughout the leptomeninges and in some cells in the adventitia of small subarachnoid blood vessels in the Ad327beta-Gal-injected rats. Messenger ribonucleic acid for eNOS was detected in the leptomeninges and brainstem 1 and 2 days after injection of AdCD8-NOS. Rats injected with Ad327beta-Gal or physiological saline solution exhibited decreased cerebral blood flow beginning 2 days after virus injection and lasting up to 14 days after injection. Rats injected with AdCD8-NOS developed significant transient increases in cerebral blood flow 2 days after virus injection, followed by slight decreases in blood flow. There was inflammation in the subarachnoid space of all animals; the inflammation was qualitatively worse in animals injected with Ad327beta-Gal, compared with rats injected with AdCD8-NOS or saline solution. CONCLUSION: Intracisternal injection of replication-defective adenovirus containing the eNOS gene can transiently increase cerebral blood flow.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11063115&dopt=Abstract hemorrhage
Cardiovasc Intervent Radiol. 2000 Sep-Oct;23(5):351-7.
Bronchial artery embolization for hemoptysis due to benign diseases: immediate and long-term results.
Kato A, Kudo S, Matsumoto K, Fukahori T, Shimizu T, Uchino A, Hayashi S.
Department of Radiology, Saga Medical School, Nabeshima-5-1-1, Saga, 849, Japan.
PURPOSE: To clarify the immediate effect and long-term results of bronchial artery embolization (BAE) for hemoptysis due to benign diseases and the factors influencing the outcomes. METHODS: One hundred and one patients (aged 34-89 years) received bronchial artery embolization with polyvinyl alcohol particles and gelatin sponge for massive or continuing moderate hemoptysis caused by benign pulmonary diseases and resistant to medical treatment. RESULTS: After BAE, bleeding stopped in 94 patients (94%). The immediate effect was unfavorable in cases where feeder vessels were overlooked or the embolization of the intercostal arteries was insufficient. Long-term cumulative hemoptysis nonrecurrence rates after the initial embolization were 77.7% for 1 year and 62.5% for 5 years. In bronchitis (n = 9) and active tuberculosis (n = 4) groups, an excellent (100%) 5-year cumulative nonrecurrence rate was obtained. The rate was lower in groups with pneumonia/abscess/pyothorax (n = 8) or with pulmonary aspergillosis (n = 9) (53.3%, 1-year cumulative nonrecurrence). There were higher incidences of early recurrence among patients with massive hemorrhage or more marked vascularity and systemic artery-pulmonary artery shunt in angiography: however, these trends were not statistically significant CONCLUSIONS: BAE can yield long-term benefit in patients with hemoptysis due to benign diseases. Technical problems in the procedure had an impact on the short-term effect. The degree of hemorrhage or the severity of angiographical findings were not significant factors affecting the outcome. The most significant factor affecting long-term results was whether the inflammation caused by the underlying disease was medically well controlled.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11060364&dopt=Abstract hemorrhage
Curr Surg. 2000 Sep 1;57(5):493-496.
Impact of blood transfusion on outcome in patients admitted for gastrointestinal hemorrhage.
Clarke CS, Afifi AY.
Surgical Flight, 81st Medical Group, Keesler Air Force Base, Mississippi, USA
PURPOSE:Patients admitted with the diagnosis of gastrointestinal bleeding at our institution typically undergo diagnostic/therapeutic endoscopy. Surgery is consulted and operative intervention considered when the patient has reached a 6-unit transfusion requirement for resuscitation. The purpose of this study is to examine the association between number of units transfused and clinical outcome in patients admitted for gastrointestinal hemorrhage.A retrospective review of records of patients admitted to the 81st Medical Group between January 1996 and January 2000 was conducted. Patients admitted with a diagnosis of upper or lower gastrointestinal hemorrhage were identified. Of this group, the records of those patients receiving at least 1 unit of packed red blood cells were examined.Thirty-five complete records were available for review. Patients ranged from 3 to 79 years of age. The male to female ratio was 4:1. The group received an average of 5.2 units of packed red blood cells. Eight patients were identified as having received more than 6 units of packed red cells. Three of 4 patients who underwent operative intervention had transfusion requirements in excess of 6 units. All 4 operative patients were classified as ASA class IIIE. Seven deaths (20%) occurred among the 35 patients, 3 of whom had received more than 6 units of blood.Patients admitted with gastrointestinal hemorrhage who require less than 6 units of blood may have a lower chance of dying (15%) than do patients requiring more than 6 units of blood (38%). Emergent surgical intervention, even in high-risk patients, can be safely performed.
Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11064075&dopt=Abstract hemorrhage [PubMed - as supplied by publisher]
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