Early brain injury (EBI), delayed cerebral vasospasm (DCVS), and delayed cerebral ischemia (DCI) are common complications of subarachnoid hemorrhage (SAH). Inflammatory processes in the cerebrospinal ...fluid (CSF) are one of the causes for such complications. Our aim to study the effects of an IL-6 receptor antagonist (Tocilizumab) examines the occurrence of DCVS, neuronal cell death, and microclot formation in an acute SAH rabbit model. Twenty-nine New Zealand white rabbits were randomized into one of three groups as the SAH, SAH + Tocilizumab, and sham groups. In SAH groups, hemorrhage was induced by extracranial-intracranial arterial blood shunting from the subclavian artery into the cisterna magna under intracranial pressure (ICP) monitoring. In the second group, Tocilizumab was given once intravenously 1 h after SAH induction. Digital subtraction angiography was performed, and CSF and blood were sampled before and after (day 3) SAH induction. IL-6 plasma and CSF levels were measured. TUNEL, FJB, NeuN, and caspase-3 immunostaining were used to assess cell apoptosis, neurodegeneration, and neuronal cell death, respectively. Microclot formation was detected by fibrinogen immunostaining. Between baseline and follow-up, there was a significant reduction of angiographic DCVS (
p
< 0.0001) in the Tocilizumab compared with the SAH group. Tocilizumab treatment resulted in decreased neuronal cell death in the hippocampus (
p
= 0.006), basal cortex (
p
= 0.001), and decreased microclot formation (
p
= 0.02). Tocilizumab reduced DCVS, neuronal cell death, and microclot formation in a rabbit SAH model, and could be a potential treatment to prevent DCVS and DCI in SAH patients.
Microsurgical clipping creates a subsequent barrier of blood flow into intracranial aneurysms, whereas endovascular treatment relies on neointima and thrombus formation. The source of endothelial ...cells covering the endoluminal layer of the neointima remains unclear. Therefore, the aim of the present study was to investigate the origin of neointima-forming cells after cell-tracer injection in the already well-established Helsinki rat microsurgical sidewall aneurysm model. Sidewall aneurysms were created by suturing decellularized or vital arterial pouches end-to-side to the aorta in male Lewis rats. Before arteriotomy with aneurysm suture, a cell-tracer injection containing CM-Dil dye was performed into the clamped aorta to label endothelial cells in the adjacent vessel and track their proliferation during follow-up (FU). Treatment followed by coiling (n = 16) or stenting (n = 15). At FU (7 days or 21 days), all rats underwent fluorescence angiography, followed by aneurysm harvesting and macroscopic and histological evaluation with immunohistological cell counts for specific regions of interest. None of the 31 aneurysms had ruptured upon follow-up. Four animals died prematurely. Macroscopically residual perfusion was observed in 75.0% coiled and 7.0% of stented rats. The amount of cell-tracer-positive cells was significantly elevated in decellularized stented compared to coiled aneurysms with respect to thrombus on day 7 (p = 0.01) and neointima on day 21 (p = 0.04). No significant differences were found in thrombus or neointima in vital aneurysms. These findings confirm worse healing patterns in coiled compared to stented aneurysms. Neointima formation seems particularly dependent on the parent artery in decellularized aneurysms, whereas it is supported by the recruitment from aneurysm wall cells in vital cell-rich walls. In terms of translation, stent treatment might be more appropriate for highly degenerated aneurysms, whereas coiling alone might be adequate for aneurysms with mostly healthy vessel walls.
Aneurysm wall degeneration is linked to growth and rupture. To address the effect of aspirin (ASA) on aneurysm formation under various wall conditions, this issue was analyzed in a novel rabbit ...bifurcation model.
Bifurcation aneurysms created in 45 New Zealand White rabbits were randomized to vital (n=15), decellularized (n=13), or elastase-degraded (n=17) wall groups; each group was assigned to a study arm with or without ASA. At follow-up 28 days later, aneurysms were evaluated for patency, growth, and wall inflammation at macroscopic and histological levels.
36 rabbits survived to follow-up at the end of the trial. None of the aneurysms had ruptured. Patency was visualized in all aneurysms by intraoperative fluorescence angiography and confirmed in 33 (92%) of 36 aneurysms by MRI/MRA. Aneurysm size was significantly increased in the vital (without ASA) and elastase-degraded (with and without ASA) groups. Aneurysm thrombosis was considered complete in three (50%) of six decellularized aneurysms without ASA by MRI/MRA. Locoregional inflammation of the aneurysm complex was significantly reduced in histological analysis among all groups treated with ASA.
ASA intake prevented inflammation of both the periadventitial tissue and aneurysm wall, irrespective of initial wall condition. Although ASA prevented significant growth in aneurysms with vital walls, this preventive effect did not have an important role in elastase-degraded pouches. In possible translation to the clinical situation, ASA might exert a potential preventive effect during early phases of aneurysm formation in patients with healthy vessels but not in those with highly degenerative aneurysm walls.
Abstract
INTRODUCTION
Chronic subdural hematoma has a high recurrence rate after surgery and postoperative scans often show substantial residuals, eventually leading to a higher rate of reoperation. ...However, the benefit of postsurgical imaging for patient outcome remains unknown.
METHODS
We randomly assigned 368 patients with newly diagnosed chronic subdural hematoma within 48 h after surgery to either a combined radiological and clinical follow-up (CT arm) or a clinical follow-up with scans only in case of neurological deterioration (no-CT arm). The primary outcome was the modified Rankin scale (mRS) score at 90 d; this categorical scale measures functional outcome, with scores ranging from 0 (no symptoms) to 6 (death).
RESULTS
A follow-up protocol with CT imaging did not improve the primary outcome; there was no significant between-arm difference for mRS as a categorical variable (P = .79) or as numerical variable (P = .37). The proportion of patients who survived without severe disability (mRS 0-3) was 89% in the CT arm and 93% in the no-CT arm (odds ratio 1.4, 95% confidence interval 3.72-0.82, P = .15). Death occurred in 12 patients in the CT arm and in 8 patients in the no-CT arm (P = .5). Re-operation for recurrent hematomas was performed in 59 patients in the CT arm and in 39 patients in the no-CT arm (P = .055). Complications were seen in 26 patients in the CT arm and in 19 patients in the no-CT arm (P = .34).
CONCLUSION
Routinely scheduled CT scans after neurosurgical evacuation of chronic subdural hematoma have no benefit on outcome.
Abstract
BACKGROUND
The current gold standard for evaluation of the surgical result after intracranial aneurysm (IA) clipping is two-dimensional (2D) digital subtraction angiography (DSA). While ...there is growing evidence that postoperative 3D-DSA is superior to 2D-DSA, there is a lack of data on intraoperative comparison.
OBJECTIVE
To compare the diagnostic yield of detection of IA remnants in intra- and postoperative 3D-DSA, categorize the remnants based on 3D-DSA findings, and examine associations between missed 2D-DSA remnants and IA characteristics.
METHODS
We evaluated 232 clipped IAs that were examined with intraoperative or postoperative 3D-DSA. Variables analyzed included patient demographics, IA and remnant distinguishing characteristics, and 2D- and 3D-DSA findings. Maximal IA remnant size detected by 3D-DSA was measured using a 3-point scale of 2-mm increments.
RESULTS
Although 3D-DSA detected all clipped IA remnants, 2D-DSA missed 30.4% (7 of 23) and 38.9% (14 of 36) clipped IA remnants in intraoperative and postoperative imaging, respectively (95% CI: 30 12, 49 %; P-value .023 and 39 23, 55 %; P-value = <.001), and more often missed grade 1 (< 2 mm) clipped remnants (odds ratio 95% CI: 4.3 1.6, 12.7, P-value .005).
CONCLUSION
Compared with 2D-DSA, 3D-DSA achieves a better diagnostic yield in the evaluation of clipped IA. Our proposed method to grade 3D-DSA remnants proved to be simple and practical. Especially small IA remnants have a high risk to be missed in 2D-DSA. We advocate routine use of either intraoperative or postoperative 3D-DSA as a baseline for lifelong follow-up of clipped IA.
The current gold standard for evaluation of the surgical result after intracranial aneurysm (IA) clipping is two-dimensional (2D) digital subtraction angiography (DSA). While there is growing ...evidence that postoperative 3D-DSA is superior to 2D-DSA, there is a lack of data on intraoperative comparison.
To compare the diagnostic yield of detection of IA remnants in intra- and postoperative 3D-DSA, categorize the remnants based on 3D-DSA findings, and examine associations between missed 2D-DSA remnants and IA characteristics.
We evaluated 232 clipped IAs that were examined with intraoperative or postoperative 3D-DSA. Variables analyzed included patient demographics, IA and remnant distinguishing characteristics, and 2D- and 3D-DSA findings. Maximal IA remnant size detected by 3D-DSA was measured using a 3-point scale of 2-mm increments.
Although 3D-DSA detected all clipped IA remnants, 2D-DSA missed 30.4% (7 of 23) and 38.9% (14 of 36) clipped IA remnants in intraoperative and postoperative imaging, respectively (95% CI: 30 12, 49 %; P-value .023 and 39 23, 55 %; P-value = <.001), and more often missed grade 1 (< 2 mm) clipped remnants (odds ratio 95% CI: 4.3 1.6, 12.7, P-value .005).
Compared with 2D-DSA, 3D-DSA achieves a better diagnostic yield in the evaluation of clipped IA. Our proposed method to grade 3D-DSA remnants proved to be simple and practical. Especially small IA remnants have a high risk to be missed in 2D-DSA. We advocate routine use of either intraoperative or postoperative 3D-DSA as a baseline for lifelong follow-up of clipped IA.
By their spatially very distributed nature, profitability and impacts of renewable energy resources are highly correlated with the geographic locations of power plant deployments. A web-based Spatial ...Decision Support System (SDSS) based on a Multi-Criteria Decision Analysis (MCDA) approach has been implemented for identifying preferable locations for solar power plants based on user preferences. The designated areas found serve for the input scenario development for a subsequent integrated Environmental Impact Assessment.
The capabilities of the SDSS service get showcased for Concentrated Solar Power (CSP) plants in the region of Andalusia, Spain. The resulting spatial patterns of possible power plant sites are an important input to the procedural chain of assessing impacts of renewable energies in an integrated effort. The applied methodology and the implemented SDSS are applicable for other renewable technologies as well.
•The proposed tool facilitates well-founded CSP plant siting decisions.•Spatial MCDA methods are implemented in a WebGIS environment.•GIS-based SDSS can contribute to a modern integrated impact assessment workflow.•The conducted case study proves the suitability of the methodology.
Previous international literature describes a lack of systematic research about cross-institutional cooperation in social and health services although the need is indicated. More and more children ...and adolescents have complex psychosocial needs. Thus, they require help from different institutions and professions to receive optimal care. However, there is a great need of improvement of the cooperation between institutions in social (e.g. Youth Welfare Office) and health services (e.g. Child and Adolescent Psychiatry (CAP), even in Germany. Therefore, an official Agreement of Cooperation (AoC) between these institutions was implemented as a first attempt to enhance and structure cross-institutional work in Dresden, Germany. This methodological paper describes the corresponding evaluation project that includes cross-sectional and longitudinal assessments. It thereby focuses on the employees' and families' satisfaction as well as the psychosocial development and mental health of children at the intersection of the aforementioned institutions before and after the implementation of the AoC. In addition, it gives a review of literature about cross-institutional work.
•Cross-institutional work between social and health services urgently needs improvement.•Various countries stated difficulties regarding sufficient cross-institutional work.•There is a lack of reliable solutions, cross-sectional and longitudinal evaluation.•We present a methodological broad approach to evaluate cross-institutional work.
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