Impact of Extracranial-Intracranial Bypass on Cognitive Function in a Patient with Chronic Cerebral Ischemia.
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SUBMITTER: Aono T
PROVIDER: S-EPMC8202360 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ContextPatients with symptomatic atherosclerotic internal carotid artery occlusion (AICAO) and hemodynamic cerebral ischemia are at high risk for subsequent stroke when treated medically.ObjectiveTo test the hypothesis that extracranial-intracranial (EC-IC) bypass surgery, added to best medical therapy, reduces subsequent ipsilateral ischemic stroke in patients with recently symptomatic AICAO and hemodynamic cerebral ischemia.DesignParallel-group, randomized, open-label, blinded-adjudication clinical treatment trial conducted from 2002 to 2010.SettingForty-nine clinical centers and 18 positron emission tomography (PET) centers in the United States and Canada. The majority were academic medical centers.ParticipantsPatients with arteriographically confirmed AICAO causing hemispheric symptoms within 120 days and hemodynamic cerebral ischemia identified by ipsilateral increased oxygen extraction fraction measured by PET. Of 195 patients who were randomized, 97 were randomized to receive surgery and 98 to no surgery. Follow-up for the primary end point until occurrence, 2 years, or termination of trial was 99% complete. No participant withdrew because of adverse events.InterventionsAnastomosis of superficial temporal artery branch to a middle cerebral artery cortical branch for the surgical group. Antithrombotic therapy and risk factor intervention were recommended for all participants.Main outcome measureFor all participants who were assigned to surgery and received surgery, the combination of (1) all stroke and death from surgery through 30 days after surgery and (2) ipsilateral ischemic stroke within 2 years of randomization. For the nonsurgical group and participants assigned to surgery who did not receive surgery, the combination of (1) all stroke and death from randomization to randomization plus 30 days and (2) ipsilateral ischemic stroke within 2 years of randomization.ResultsThe trial was terminated early for futility. Two-year rates for the primary end point were 21.0% (95% CI, 12.8% to 29.2%; 20 events) for the surgical group and 22.7% (95% CI, 13.9% to 31.6%; 20 events) for the nonsurgical group (P = .78, Z test), a difference of 1.7% (95% CI, -10.4% to 13.8%). Thirty-day rates for ipsilateral ischemic stroke were 14.4% (14/97) in the surgical group and 2.0% (2/98) in the nonsurgical group, a difference of 12.4% (95% CI, 4.9% to 19.9%).ConclusionAmong participants with recently symptomatic AICAO and hemodynamic cerebral ischemia, EC-IC bypass surgery plus medical therapy compared with medical therapy alone did not reduce the risk of recurrent ipsilateral ischemic stroke at 2 years.Trial registrationclinicaltrials.gov Identifier: NCT00029146.
| S-EPMC3601825 | biostudies-literature
Project description:BackgroundThe safety of extracranial-intracranial (EC-IC) bypass in the management of anterior circulation intracranial aneurysms (IAs) remains to be determined. This systematic review aims to summarize the existing evidence and provide guidance for the precise management of IAs.Data sourceWe constructed search strategies and comprehensively searched Pubmed, Medline, Embase, Web of science, and Cochrane library.MethodsThis systematic review was actualized according to the PRISMA statement. We evaluated study quality using the methodological index for non-randomized study (MINORS). Effect sizes were pooled using a random-effects model. Heterogeneity between studies was assessed using the I 2 test. Publication bias was assessed using the Egger's test. The registration number for this systematic review is CRD42023396730.ResultThis systematic review included a total of 21 articles, involving 915 patients. Postoperative bypass patency rate was 99% (95% CI 0.98-1.00); short-term follow-up was 98% (95% CI 0.94-1.00); long-term follow-up was 95% (95% CI 0.93-0.97). The long-term follow-up occlusion rate of saphenous vein was higher than that of radial artery (OR 6.10 95% CI 1.04-35.59). Short-term surgery-related mortality was 0.3% (95% CI 0.000-0.012); long-term follow-up was 0.4% (95% CI 0.000-0.013); The proportion of patients with a score of 0-2 on the modified Rankin Scale (mRS) during long-term follow-up was 92% (95% CI 0.86-0.98). The incidence rates of long-term follow-up complications were: ischemic 3% (95% CI 0.01-0.06); hemorrhagic 1% (95% CI 0.00-0.03); neurological deficit 1% (95% CI 0.00-0.03); other 3% (95% CI 0.01-0.06).LimitationMost of the included studies were retrospective studies. Studies reporting preoperative status were not sufficient to demonstrate postoperative improvement. Lack of sufficient subgroup information such as aneurysm rupture status.ConclusionEC-IC therapy for anterior circulation IAs has a high safety profile. Higher level of evidence is still needed to support clinical decision.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023396730, identifier: CRD42023396730.
| S-EPMC10102499 | biostudies-literature
Project description:Background/purposeVascular factor is an important risk factor in the process of cognitive impairment or dementia. Tooth loss could cause impairments of spatial learning and memory in mice, and nitric oxide (NO) and its synthase might be involved in the process. The objectives of this study were to investigate and compare the behavioral impairments between the Wistar rats with tooth loss and those with chronic ischemia and to determine the changes in nitric oxide (NO) and its synthases under those two conditions.Materials and methodsThe Morris water maze was used to test the spatial learning and memory abilities in the Wistar rats 8 weeks after the molar extraction procedure and the occlusion of 2 blood vessels to produce cerebral ischemia. The changes in NO and its synthases were evaluated using the Griess assay, Western blotting, and immunohistochemistry.ResultsSimilar impairments in the spatial learning and memory of Wistar rats were found after tooth loss and the induction of cerebral ischemia. The levels of NO and iNOS in the rat hippocampus increased, and the levels of eNOS decreased. Conclusion: For Wistar rats, the results of cognitive impairments related to tooth loss and those that occur due to chronic cerebral ischemia were statistically not significant and that NO, iNOS and eNOS in the hippocampus are involved in both cases.
| S-EPMC7109480 | biostudies-literature
Project description:BackgroundOcclusive atherosclerotic disease of the anterior cerebral circulation is one of the most common causes of anterior circulation ischemia and stroke. Treatment options include medical therapies (including antiplatelet use, blood pressure control, lipid reduction, and lifestyle modification) and extracranial-intracranial bypass surgery (such as superficial temporal artery-middle cerebral artery bypass). However, the optimal treatment remains unclear. The objective of this study will be to compare the efficacy of and extracranial-intracranial bypass surgery with that of other medical therapy in adult patients with occlusive atherosclerotic disease of the anterior cerebral circulation.MethodsThis is the study protocol for a systematic review. We will search MEDLINE, EMBASE, Web of Science, and the Cochrane Library (from January 1980 onwards). We will include randomized controlled trials, quasi-experimental studies (non-randomized, interrupted time series), and observational studies (e.g., cohort studies and case-control studies), examining the efficacy of extracranial-intracranial bypass surgery compared to other treatments for adult patients with occlusive atherosclerotic disease of anterior cerebral circulation. Two team members will independently screen all citations, full-text articles, and abstract data. Potential conflicts will be resolved through discussion. The primary outcome will include stroke or death. The secondary outcomes will include intracranial hemorrhage, transient ischemic attack, and myocardial infarction. The study methodological quality (or bias) will be appraised using appropriate tools. If feasible, we will conduct random effects meta-analysis. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., study design, geographical location, or risk of bias).DiscussionThis review will evaluate the evidence on the efficacy of extracranial-intracranial bypass surgery for adult patients with occlusive atherosclerotic disease of the anterior cerebral circulation. We anticipate that our findings will be of interest to patients, their families, caregivers, healthcare professionals, and in making optimal treatment selection. Implications for future clinical and epidemiological research will be discussed.Systematic review registrationPROSPERO CRD42018105513.
| S-EPMC7118989 | biostudies-literature
Project description:This study aimed to demonstrate the effectiveness of nonemergent extracranial-to-intracranial bypass (EIB) in symptomatic chronic large artery atherosclerotic stenosis or occlusive disease (LAA) through quantitative analysis of computed tomography perfusion (CTP) parameters using RAPID software. We retrospectively analyzed 86 patients who underwent nonemergent EIB due to symptomatic chronic LAA. CTP data obtained preoperatively, immediately postoperatively (PostOp0), and 6 months postoperatively (PostOp6M) after EIB were quantitatively analyzed through RAPID software, and their association with intraoperative bypass flow (BF) was assessed. The clinical outcomes, including neurologic state, incidence of recurrent infarction and complications, were also analyzed. The time-to-maximum (Tmax) > 8 s, > 6 s and > 4 s volumes decreased significantly at PostOp0 and up through PostOp6M (preoperative, 5, 51, and 223 ml (median), respectively; PostOp0, 0, 20.25, and 143 ml, respectively; PostOp6M, 0, 7.5, and 148.5 ml, respectively; p < 0.001, p < 0.001, and p < 0.001, respectively). The postoperative improvement in the Tmax > 6 s and > 4 s volumes was significantly correlated with the BF at PostOp0 and PostOp6M (PostOp0, r = 0.367 (p = 0.001) and r = 0.275 (p = 0.015), respectively; PostOp6M r = 0.511 (p < 0.001) and r = 0.391 (p = 0.001), respectively). The incidence of recurrent cerebral infarction was 4.7%, and there were no major complications that produced permanent neurological impairment. Nonemergent EIB under strict operation indications can be a feasible treatment for symptomatic, hemodynamically compromised LAA patients.
| S-EPMC9988922 | biostudies-literature
Project description:ObjectUnited States healthcare reforms are focused on curtailing rising expenditures. In neurosurgical domain, limited or no data exists identifying potential modifiable targets associated with high-hospitalization cost for cerebrovascular procedures such as extracranial-intracranial (ECIC) bypass. Our study objective was to develop a predictive model of initial cost for patients undergoing bypass surgery.MethodsIn an observational cohort study, we analyzed patients registered in the Nationwide Inpatient Sample (2002-2011) that underwent ECIC bypass. Split-sample 1:1 randomization of the study cohort was performed. Hospital cost data was modelled using ordinary least square to identity potential drivers impacting initial hospitalization cost. Subsequently, a validated clinical app for estimated hospitalization cost is proposed (https://www.neurosurgerycost.com/calc/ec-ic-by-pass).ResultsOverall, 1533 patients [mean age: 45.18 ± 19.51 years; 58% female] underwent ECIC bypass for moyamoya disease [45.1%], cerebro-occlusive disease (COD) [23% without infarction; 12% with infarction], unruptured [12%] and ruptured [4%] aneurysms. Median hospitalization cost was $37,525 (IQR: $16,225-$58,825). Common drivers impacting cost include Asian race, private payer, elective admission, hyponatremia, neurological and respiratory complications, acute renal failure, bypass for moyamoya disease, COD without infarction, medium and high volume centers, hospitals located in Midwest, Northeast, and West region, total number of diagnosis and procedures, days to bypass and post-procedural LOS. Our model was validated in an independent cohort and using 1000-bootstrapped replacement samples.ConclusionsIdentified drivers of hospital cost after ECIC bypass could potentially be used as an adjunct for creation of data driven policies, impact reimbursement criteria, aid in-hospital auditing, and in the cost containment debate.
| S-EPMC5659612 | biostudies-literature
Project description:Toxoplasma gondii is an obligate intracellular protozoan parasite that can invade various organs in the host body, including the central nervous system. Chronic intracranial T. gondii is known to be associated with neuroprotection against neurodegenerative diseases through interaction with host brain cells in various ways. The present study investigated the neuroprotective effects of chronic T. gondii infection in mice with cerebral ischemia experimentally produced by middle cerebral artery occlusion (MCAO) surgery. The neurobehavioral effects of cerebral ischemia were assessed by measurement of Garcia score and Rotarod behavior tests. The volume of brain ischemia was measured by triphenyltetrazolium chloride staining. The expression levels of related genes and proteins were determined. After cerebral ischemia, corrected infarction volume was significantly reduced in T. gondii infected mice, and their neurobehavioral function was significantly better than that of the uninfection control group. Chronic T. gondii infection induced the expression of hypoxia-inducible factor 1-alpha (HIF-1α) in the brain before MCAO. T. gondii infection also increased the expression of vascular endothelial growth factor after the cerebral ischemia. It is suggested that chronic intracerebral infection of T. gondii may be a potential preconditioning strategy to reduce neural deficits associated with cerebral ischemia and induce brain ischemic tolerance through the regulation of HIF-1α expression.
| S-EPMC7462801 | biostudies-literature
Project description:Cerebral perfusion is determined by segmental perfusion pressure for the intracranial compartment (SPP), which is lower than cerebral perfusion pressure (CPP) because of extracranial stenosis. We used the Thevenin model of Starling resistors to represent the intra-extra-cranial compartments, with outflow pressures ICP and Pe, to express SPP = Pd-ICP = FFR*CPP-Ge(1 - FFR)(ICP-Pe). Here Pd is intracranial inflow pressure in the circle of Willis, ICP-intracranial pressure; FFR = Pd/Pa is fractional flow reserve (Pd scaled to the systemic pressure Pa), Ge-relative extracranial conductance. The second term (cerebral venous steal) decreases SPP when FFR < 1 and ICP > Pe. We verified the SPP equation in a bench of fluid flow through the collapsible tubes. We estimated Pd, measuring pressure in the intra-extracranial collateral (supraorbital artery) in a volunteer. To manipulate extracranial outflow pressure Pe, we inflated the infraorbital cuff, which led to the Pd increase and directional Doppler flow signal reversal in the supraorbital artery. SPP equation accounts for the hemodynamic effect of inflow stenosis and intra-extracranial flow diversion, and is a more precise perfusion pressure target than CPP for the intracranial compartment. Manipulation of intra-extracranial pressure gradient ICP-Pe can augment intracranial inflow pressure (Pd) and reverse intra-extracranial steal.
| S-EPMC8032738 | biostudies-literature
Project description:High normal concentrations of serum uric acid (UA) are associated with mild cognitive dysfunction and increased cerebral ischemia as indexed by white matter hyperintensity volumes. We hypothesized that individual differences in white matter hyperintensities mediate the association between UA and mild cognitive dysfunction.One hundred eighty community-dwelling adults aged 20 to 96 years completed neuropsychological testing, laboratory blood studies, and a brain MRI scan.Serum UA was associated (P<0.05) with greater white matter hyperintensities and poorer working memory, processing speed, fluency, and verbal memory. Associations remained after controlling for age, sex, race, education, hypertension, diabetes, alcohol abuse, smoking, and body mass. Adding a term for white matter hyperintensity attenuated these associations such that UA no longer predicted cognitive performance.Severity of cerebral ischemia might mediate the association between UA and cognitive dysfunction. Even mild elevations in UA appear to contribute to structural and functional brain changes.
| S-EPMC4876431 | biostudies-literature
Project description:Stromal cell-derived factor-1 and its receptor CXCR4 are essential regulators of the neurogenesis that occurs in the adult hippocampal dentate gyrus. However, the effects of CXCR7, a new atypical receptor of stromal cell-derived factor-1, on hippocampal neurogenesis after a stroke remain largely unknown. Our study is the first to investigate the effect of a CXCR7-neutralizing antibody on neurogenesis in the dentate gyrus and the associated recovery of cognitive function of rats in the chronic stage of cerebral ischemia. The rats were randomly divided into sham, sham + anti-CXCR7, ischemia and ischemia + anti-CXCR7 groups. Endothelin-1 was injected in the ipsilateral motor cortex and striatum to induce focal cerebral ischemia. Sham group rats were injected with saline instead of endothelin-1 via intracranial injection. Both sham and ischemic rats were treated with intraventricular infusions of CXCR7-neutralizing antibodies for 6 days 1 week after surgery. Immunofluorescence staining with doublecortin, a marker for neuronal precursors, was performed to assess the neurogenesis in the dentate gyrus. We found that anti-CXCR7 antibody infusion enhanced the proliferation and dendritic development of doublecortin-labeled cells in the dentate gyrus in both ischemic and sham-operated rats. Spatial learning and memory functions were assessed by Morris water maze tests 30-32 days after ischemia. CXCR7-neutralizing antibody treatment significantly reduced the escape latency of the spatial navigation trial and increased the time spent in the target quadrant of spatial probe trial in animals that received ischemic insult, but not in sham operated rats. These results suggest that CXCR7-neutralizing antibody enhances the neurogenesis in the dentate gyrus and improves the cognitive function after cerebral ischemia in rats. All animal experimental protocols and procedures were approved by the Institutional Animal Care and Use Committee of China Medical University (CMU16089R) on December 8, 2016.
| S-EPMC7034276 | biostudies-literature