itored consecutive patients with MRI-proven sCAD by duplex ultrasound imaging daily in the hospital, monthly for the first 6 months after discharge, and every 6 months thereafter.The authors studied 105 sCADs in 76 patients. The mean follow-up was 58 months (range, 28-96 months). Of the 105 dissections in this study, 61 (58.1%) involved the internal carotid artery and 44 (41.9%) involved the vertebral artery. Four patients had multiple sCADs. Follow-up was available for 74 (103 vessels) of the 76 patients (97.3%). Complete and hemodynamically significant (Ͻ50% stenosis) recanalization rates were 51.4% and 20.4%. All but one of the complete recanalizations occurred within the first 9 months after the initial event. Early recurrences (in-hospital recurrence) were common, with a second sCAD occurring in 20 previously unaffected arteries. There were only two late recurrences (2.7%) at a site of a previous sCAD. Six patients had a family history of arterial dissection and all had a sCAD recurrence. Recurrence rate in patients without a family history of arterial dissection was much less, with only 16 arteries (22.8%) affected (P Ͻ .001).Comment: There are several interesting points here. First, although recurrence of sCAD is reasonably uncommon, it generally occurs early after the initial event and in a different cervical artery. The authors' early recurrence of 25% is much higher than previously suspected and may relate to the rigorous follow-up protocol in the study. The fact that late sCAD recurrence can happen in previously affected artery suggests recurrence after sCAD in the early and late periods may have different pathologies. Perhaps, as the authors point out, early recurrences are correlated with a transient arterial disorder, such as a vasculitis, while late recurrences may be indicative of underlying persistent connective tissue weakness. The high early recurrence rate suggests that aggressive treatment of sCADs, including control of double product and lowering blood pressure within the constraints imposed by the neurologic pathology, should be implemented.
Increasing evidence implies the existence of a visceral pain pathway in the dorsal column of the spinal cord. Limited midline myelotomy has been used to treat intractable pelvic cancer pain. However, no obvious evidence has been provided that high cervical punctate midline myelotomy (CPMM) relieves visceral pain originating from the abdomen. This study was designed to examine the pain relief effect of CPMM in a mouse model of visceral pain. Thirty-six Institute of Cancer Research (ICR) mice were divided into three groups: Group 1, healthy controls; Group 2, treated with CPMM at C1 and C2; and Group 3, a sham group that underwent laminectomy at C1 and C2 without CPMM. All animals were tested for antinociception in the writhing test 24 hours after surgery. Visceral pain-related behaviors were counted from 5-20 minutes after intraperitoneal injection of 0.6% acetic acid. Writhing test scores were not significantly different between Groups 1 (56.7 +/- 10.7) and 3 (50.7 +/- 17.4). However, Group 2 (30.0 +/- 14.3) showed more than 40% antinociception after treatment, and writhing test scores were significantly different from those of Groups 1 and 3 (p < 0.001). Our results confirm that midline punctate myelotomy can relieve visceral pain and imply that there is a pathway in the posterior funiculus that signals visceral pain. Punctate midline myelotomy at the cervical or high thoracic level may be an alternative strategy in the management of intractable visceral pain due to abdominal or pelvic cancers.
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