Background and hypothesis Intravenous thrombolysis with alteplase remains standard care prior to thrombectomy for eligible patients within 4.5 h of ischemic stroke onset. However, alteplase only succeeds in reperfusing large vessel arterial occlusion prior to thrombectomy in a minority of patients. We hypothesized that tenecteplase is non-inferior to alteplase in achieving reperfusion at initial angiogram, when administered within 4.5 h of ischemic stroke onset, in patients planned to undergo endovascular therapy. Study design EXTEND-IA TNK is an investigator-initiated, phase II, multicenter, prospective, randomized, open-label, blinded-endpoint non-inferiority study. Eligibility requires a diagnosis of ischemic stroke within 4.5 h of stroke onset, pre-stroke modified Rankin Scale≤3 (no upper age limit), large vessel occlusion (internal carotid, basilar, or middle cerebral artery) on multimodal computed tomography and absence of contraindications to intravenous thrombolysis. Patients are randomized to either IV alteplase (0.9 mg/kg, max 90 mg) or tenecteplase (0.25 mg/kg, max 25 mg) prior to thrombectomy. Study outcomes The primary outcome measure is reperfusion on the initial catheter angiogram, assessed as modified treatment in cerebral infarction 2 b/3 or the absence of retrievable thrombus. Secondary outcomes include modified Rankin Scale at day 90 and favorable clinical response (reduction in National Institutes of Health Stroke Scale by ≥8 points or reaching 0-1) at day 3. Safety outcomes are death and symptomatic intracerebral hemorrhage. Trial registration ClinicalTrials.gov NCT02388061.
Norfloxacin is not superior to placebo in reducing HVPG in subjects with clinically significant portal hypertension. Furthermore, norfloxacin does not appear to modulate the l-Arg transporter mechanism in this patient population. Although plasma UII correlates positively with HVPG, UII does not appear to have a direct role in modulating HVPG.
The authors describe the cases of two patients with unilateral traumatic caroticocavernous fistulas in whom a self-expanding covered stent was successfully used to obliterate the fistula after failed occlusion with detachable balloons and coils. They discuss this option as a primary therapeutic modality in cases in which detachable balloons or coils, with or without a bare stent, have failed to obliterate the fistula. The placement of a covered stent to occlude the lesion from the outset may represent a new therapeutic approach to the treatment of these lesions.
Cerebral aneurysms can be treated by coil embolization within the aneurysm sac to alter the local hemodynamics and lower the wall shear stress (WSS) by making the aneurysmal flow inactive. This study investigates the hemodynamics of a lateral wall cerebral aneurysm with coils incorporating fluid-structure interaction (FSI) where the effect of apparent viscosity on thrombus formation is analysed considering the non-Newtonian behaviour of the blood. Three-dimensional transient incompressible laminar flow fields were predicted inside the aneurysm with coils at the proximal and distal neck ends with straight and curved parent vessels. The predictions showed the WSS and the effective stress were highest at the neck region, but the maximum wall displacement occurred at the dome. The coils at the distal neck performed better compared to the coils at the proximal neck in terms of reduced flow rate and higher apparent viscosity. The cerebral aneurysm with coils and curved parent vessel was subjected to higher inflow, displacement and WSS but lower apparent viscosity compared to the one with a straight parent vessel, and therefore has a greater risk of aneurysm wall damage. Hypertension increased the effective stress and displacement on the aneurysm. In patients with hypertension, more emphasis should be placed on ensuring that coils are densely packed at the distal end, especially for curved parent vessels.
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