Endovenous Iliocaval Revascularization for Transplant Kidney Salvage

Purpose: We report the case of a venous iliocaval recanalization to preserve a transplant kidney. Case Report: A young patient with a nephrotic syndrome caused by focal segmental glomerulosclerosis (FSGS) underwent a robot-assisted living-donor kidney transplant. The postoperative course was uneventful; serum creatinine at discharge was 1.51 mg/dL (normal range = 0.72–1.17 mg/dL). In the course of the following months, the patient was readmitted repeatedly due to acute kidney failure not related to rejection, recurrent FSGS, or anastomotic stenosis. All episodes started after prolonged standing and renal function improved after bed rest. Several hospital admissions and investigations later, phlebography revealed an occlusion of the inferior vena cava (IVC) and both common iliac veins with large collateral vessels through the azygos system. An endovenous recanalization of the iliocaval tract was performed, with subsequent normalization of transplant kidney function. Conclusion: Vascular complications after renal transplantation are an important cause of graft loss. We present an endovenous treatment option for a chronic occlusion of the IVC and common iliac vein with intermittent venous congestion as a cause of transplant failure.

Rare yet catastrophic presentation of undiagnosed antiphospholipid syndrome

A previously well 31-year-old woman initially presented to the emergency department with pneumonia, however, was found to be hypertensive and have new-onset cardiomegaly. She was admitted for intravenous antibiotics and concurrently a series of investigations were conducted to investigate hypertension and cardiomegaly. During the course of admission, she developed acute kidney injury and was found to have acute chronic occlusion in the abdominal aorta. She was diagnosed with catastrophic antiphospholipid syndrome. This is a rare form of antiphospholipid syndrome with a high mortality rate. Thus, it is important that clinicians are aware of this syndrome to facilitate early diagnosis and initiation of treatment.

Investigation of Altered Spontaneous Brain Activities in Patients With Moyamoya Disease Using Percent Amplitude of Fluctuation Method: A Resting-State Functional MRI Study

Background: Moyamoya disease (MMD) is a chronic progressive cerebrovascular abnormality characterized by chronic occlusion of large intracranial vessels with smoky vascular development at the base of the skull. In patients with MMD, abnormal spontaneous brain activity would be expected.Purpose: To assess the brain activity changes in patients with MMD by resting-state functional MRI (rs-fMRI), using the percent amplitude of fluctuation (PerAF) analysis method.Materials and Methods: A total of 17 patients with MMD (3 males and 14 females) and 17 healthy control (HC) subjects with matched gender and age were recruited for this study. We used rs-fMRI to scan all the patients with MMD. Spontaneous neural activity was evaluated using the PerAF approach. The receiver operating characteristic (ROC) curve analysis was used to assess the ability of the PerAF to distinguish patients with MMD from HCs. The Hospital Anxiety and Depression Scale (HADS) tests were performed to assess the emotional status of patients with MMD and retinal nerve fiber layer thickness (RNFLT) was measured using high-resolution optical coherence tomography (hr-OCT). The relationship between the HADS scores, RNFLT values, and the PerAF signals was assessed using the Pearson's correlation analysis.Results: Compared with HCs, the PerAF signals in patients with MMD were decreased in the Frontal_Sup_Medial_R and Precentral_L, whereas those in the Caudate_L were increased. The areas under the ROC curves indicated that signals in these brain regions could distinguish between patients with MMD and HCs. The PerAF value of Frontal_Sup_Medial_R was positively correlated with the left and right eye RNFLT values and negatively correlated with the HADS scores.Conclusion: In patients with MMD, reduced PerAF signals in the Frontal_Sup_Medial_R, Precentral_L, and Caudate_L may be associated with psychiatric diseases including anxiety and depression and decreased RNFLT may be associated with ophthalmic complications due to the compression of terminal branches of the internal carotid artery in the retinal fiber layer. The PerAF can be used as an effective indicator of ocular complications of MMD and to study the neural mechanism underpinning emotional complications in patients with MMD.

Aplastic or twig-like middle cerebral artery and cardiogenic cerebral embolism mimicking moyamoya disease with RNF213 polymorphism: A case report

Progressive stenosis and occlusion of the bilateral internal carotid artery terminals and circle of Willis are typical features of Moyamoya disease. However, aplastic or twig-like middle cerebral artery (Ap/T-MCA)—wherein the unilateral main trunk of the middle cerebral artery (MCA) is not depicted, and a plexiform arterial network is formed—is similar to the findings of Moyamoya disease. Here, we describe a 78-year-old man who presented with mild right paralysis and aphasia. Magnetic resonance angiography (MRA) at admission did not show the bilateral MCAs. The findings were similar to those of Moyamoya disease, and his symptoms worsened after hospitalization. Endovascular treatment was performed, and the left MCA was completely recanalized. Later, paroxysmal atrial fibrillation was detected, and we finally determined that left MCA occlusion had occurred due to embolism. The right MCA was completely occluded at its origin, indicating an Ap/T-MCA. Embolic occlusion of the unilateral MCA and contralateral Ap/T-MCA made this case resemble Moyamoya disease in the acute stage. Even when chronic occlusion is suspected on MRA in acute cerebral infarction, endovascular treatment should be considered. Additionally, a heterotypic R4810K polymorphism was later found in the RNF213 gene. To our knowledge, this is the second report of Ap/T-MCA with the RNF213 gene polymorphism; however, their association remains unclear and requires further analyses.

Open supra-aortic revascularization and arch reconstruction after previous TEVAR in a complex arch anatomy

We propose a technique to minimize the neurological and systemic risks involved in rerouting the blood flow toward the brain in a “single remaining vessel” configuration with a 90% stenosis by means of complete hypothermic cerebral protection associated with normothermic systemic blood flow with a “restitutio ad integrum” of the supra-aortic trunks flow. The perfusion of the brain and the arms was almost completely separated from the systemic perfusion by the deployment 1 year before of a thoracic endoprosthesis in association with complete chronic occlusion of the brachiocephalic trunk and a functioning carotid-subclavian bypass. The Free Flow of the prosthesis, which acted as a hook, moved the calcium toward the left carotid ostium, creating a 90% stenosis with intermittent acute cerebral hypoperfusion and amaurosis. We achieved an optimal result: The patient was discharged on postoperative day 7 with no neurological problems and with patency and direct blood flow in all the supra-aortic trunks.

Creatine benzyl ester is effective for prevention and treatment of neurological and cognitive disorders caused by focal cerebral ischemia in rats

Введение. Ишемический инсульт головного мозга является одной из главных причин преждевременных смертей во всем мире, вызванные им когнитивные и функциональные нарушения ведут к инвалидизации. Для клинического использования в настоящее время одобрено лишь одно средство - рекомбинантный активатор плазминогена, который обеспечивает восстановление (реканализацию) мозгового кровотока. Средства эффективной нейропротекции, обеспечивающие непосредственную защиту нейронов от ишемии (предотвращение апоптоза, сохранение функциональной активности), несмотря на огромное число исследований, по-прежнему не найдены. Поиск новых подходов к профилактике и лечению острых нарушений мозгового кровообращения по-прежнему остается одной из наиболее актуальных проблем современной медицины. Цель исследования - изучение влияния бензилового эфира креатина, нового синтетического соединения, обладающего способностью проникать через гематоэнцефалический барьер и осуществлять нейропротекторное действие на неврологические и когнитивные нарушения, вызванные фокальной ишемией головного мозга у крыс линии Спрэг-Доули. Методика. Фокальную ишемию головного мозга (ФИМ) индуцировали путем хронической окклюзии левой средней мозговой артерии (СМА) в соответствии с модификацией методики A. Tamura и соавт., 1981. Использовали комбинированный наркоз: Золетил/Домитор (внутрибрюшинно (в/б) по 50 мг/кг и 0.2 мг/кг, соответственно), температуру тела поддерживали постоянной на уровне 38±0.5 oC. Окклюзию СМА производили путем биполярной высокочастотной электрокоагуляции (аппарат ЭХВЧ-25-11-С, «Медия», Россия) наиболее проксимального участка артерии, начиная с 0.5 мм от места ее отхождения от Виллизиева круга и на протяжении 2-3 мм. Процедура имитации ишемии (ложная операция) была аналогична вышеизложенной, но без электрокоагуляции СМА. Оценку степени неврологических нарушений проводили с использованием неврологической шкалы Гарсии и модифицированной шкалы тяжести неврологических нарушений (ОТНН) последовательно за 1 сут до и через 1, 3 и 7 сут после моделирования ФИМ. Для выявления когнитивных нарушений использовали водный лабиринт Морриса. Стандартный тест исследования процессов обучения и памяти применяли в версии для оценки пространственной референтной памяти, заключающейся в поиске животным скрытой под водой платформы при ориентации только по приметам окружающей обстановки. Бензиловый эфир креатина вводили внутрибрюшинно трижды - за 3, 2 и 1 ч до фокальной ишемии при профилактическом применении, либо через 1, 2 и 3 ч после моделирования ишемии при лечебном применении. Результаты. Получены приоритетные данные о том, что бензиловый эфир креатина при профилактическом введении эффективно предупреждает развитие неврологических нарушений и ослабляет когнитивные нарушения после фокальной ишемии мозга; при лечебном применении препарат ослабляет тяжесть неврологических нарушений и снижает выраженность когнитивных расстройств. Заключение. Результаты исследования позволяют рекомендовать данное производное креатина (после оценки возможной токсичности) для проведения первой фазы клинических испытаний в качестве препарата противоишемического действия. Background. Ischemic stroke is one of the main causes for premature death worldwide. Cognitive and functional disorders induced by stroke result in disability. Currently, only one agent has been approved for the clinical use, recombinant plasminogen activator, which provides recovery (recanalization) of cerebral blood flow. Despite numerous studies, an effective treatment to protect directly neurons from ischemia (preventing apoptosis, maintaining functional activity) has not been found so far. Thus, search for new approaches to prevention and treatment of acute cerebrovascular accidents remains one of the most pressing challenges of modern medicine. The aim of this work was to study the effect of creatine benzyl ester, a new synthetic compound capable for penetrating the blood-brain barrier to provide neuroprotection, on neurological and cognitive disorders induced by focal cerebral ischemia in Sprague-Dawley rats. Methods. Focal cerebral ischemia was induced by chronic occlusion of the left middle cerebral artery (MCA) by a A. Tamura et al. (1981) modified method. Combined intraperitoneal (i.p.) anesthesia with Zoletil/Domitor (50 mg/kg and 0.2 mg/kg, respectively) was used. Body temperature was maintained at 38±0.5 oC. MCA occlusion was performed by bipolar high-frequency electrocoagulation (EKVCh-25-11-C, Media, Russia) of the most proximal part of the artery, from 0.5 mm from the place where it originates from the circle of Willis and over 2-3 mm. The sham ischemia procedure was similar to that described above but without MCA electrocoagulation. Severity of neurological disorders was assessed with the Garcia neurological scale and a modified scale for severity of neurological disorders (OTTN) one day before and at 1, 3, and 7 days following ischemia. Cognitive impairment was assessed with the Morris water maze, a standard test for learning and memory. This test was used in a version for studying spatial reference memory, which consists of finding a platform hidden under the water by the animal guided only by surrounding marks. Creatine benzyl ester was injected i.p. three times, 3, 2 and 1 h before focal ischemia for prevention or 1, 2 and 3 h after ischemia for treatment. Results. The study produced priority data showing that preventive administration of creatine benzyl ester effectively abolished the development of neurological disorders and alleviated the cognitive impairment after focal cerebral ischemia whereas the therapeutic treatment restricted the severity of neurological and cognitive disorders. Conclusion. The results of the study supported recommendation of this creatine derivative (after assessing potential toxicity) for the first phase of clinical trials as an anti-ischemic drug.