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The field of point particle dynamics is correlated with the study of particle dynamics around the black hole and one can initiate the study of a more complex motion of extended/celestial bodies. In this article, we consider the study of the dynamics of the neutral/charged particles around the quantum corrected-Schwarzschild black hole and Schwarzschild black hole. We investigate Noether symmetries and their conservation laws corresponding to the quantum corrected-Schwarzschild spacetime. We also study the effect of angular momentum, quantum parameters and magnetic field on the dynamics of neutral and charged particles around the quantum corrected-Schwarzschild black hole and Schwarzschild black hole.

In this article, we study the dynamics of neutral as well as charged particle in the presence of magnetic field around Reissner-Nordström black hole surrounded by quintessence by taking into account Noether symmetries and conservation laws in the corresponding spacetime. Using these conservation laws, we explore the effect of angular momentum, quintessence parameter, and magnetic field graphically on the dynamics of neutral/charged particles in the context of the effective potential, effective force, and escape velocity. Additionally, we investigate the orbit stability of the said spacetime with the help of the Lyapunov exponent.

Objectives: To determine the safety and tolerability of super-selective intra-arterial magnesium sulfate in combination with intra-arterial nicardipine in patients with cerebral vasospasm after subarachnoid hemorrhage.Methods: Patients were treated in a prospective protocol at two teaching medical centers. Emergent cerebral angiography was performed if there was either clinical, ultrasound, and/or computed tomographic (CT) perfusion deficits suggestive of cerebral vasospasm. Intra-arterial magnesium sulfate (0.25-1 g) was administered via a microcatheter in the affected vessels in combination with nicardipine (2.5-20.0 mg). Mean arterial pressures (MAP) and intracranial pressures (ICP) were monitored during the infusion. Immediate and sustained angiographic and clinical improvement was determined from post-treatment angiograms and clinical follow-up. Angiographic and clinical outcomes were compared to two published case series that has used nicardipine alone.Results: A total of 58 vessels were treated in 14 patients (mean age 42 years; 11 women) with acute subarachnoid hemorrhage. The treatment was either intra-arterial nicardipine and magnesium sulfate alone or in conjunction with primary angioplasty. Forty vessels (69%) had immediate angiographic improvement with intra-arterial nicardipine and magnesium sulfate alone and 18 vessels (31%) required concomitant balloon angioplasty with complete reversal of the vasospasm. Retreatment was required in 13 vessels (22%) and the median time for retreatment was 2 days (range 1-13 days). Nicardipine treatment resulted in the reduction of MAP (12.3 mmHg, standard error [SE] 1.34, P-value <0.0001) without any significant change in ICP. Magnesium sulfate infusion was not associated with change in MAP or ICP. Among 31 procedures, immediate neurological improvement was observed in 22 (71%) procedures. In 12 (86%) patients, there were no infarctions in the follow-up CT scan acquired between 24 and 48 h. No statistical significant difference was observed in angiographic and clinical outcome of patients treated with the combination therapy in comparison with historical controls treated with nicardipine alone.Conclusion: Administration of intra-arterial magnesium sulfate in combination with nicardipine was well tolerated in patients with subarachnoid hemorrhage and cerebral vasospasm without a significant change in MAP and ICP. The efficacy of this combination therapy should be evaluated in a larger, controlled setting. [ABSTRACT FROM AUTHOR]

In order to solve the problem of medical equipment image retrieval，an image retrieval method based on multi feature layer fusion is proposed. Process:This method using color moments to calculate the characteristics of color image，the LBP Operator is used to calculate the texture features of the image，using Fourier descriptors calculated image of the characters，the stratified weighted fusion method of the characteristics of three types of fusion within a similarity measure，and ultimately the formation of retrieval based on. Results and conclusions:According to the experimental study of the endoscopic image and CT image，the experimental results confirm the validity of the proposed method. With continuous improvement of the precision requirements of the proposed method in precision ratio was significantly higher than that of two single feature retrieval method for medical image retrieval.

Aflatoxin B1 (AFB1) a mycotoxin found in chicken feed that possess a global hazard to poultry health. However different potent compounds like bovine lactoferrin (bLF) may prove to be protective effects against AFB1. This study aims to explore the protective effect of bLF against AFB1-induced injury in the liver and kidney in broiler. For this purpose, 600 broilers chicks were randomly alienated into 5 groups (n = 120 each): negative control; positive control (3 mg/kg AFB1), and bLF high, medium, and low dosage groups (600 mg/kg, 300 mg/kg, and 150 mg/kg, respectively). The results highlight that AFB1 toxicity in birds exhibited low feed intake, reduction in weight gain, and a decrease in FCR while, bLF regulated these adverse effects. Meanwhile, AFB1 group showed higher levels of alanine transaminase (ALT) and aspartate aminotransferase (AST) and lower levels of superoxide dismutase (SOD) and glutathione (GSHpx) in liver, while urea and creatinine were decline in kidney. Supplementation with bLF effectively controlled these biomarkers and control the negative effects of toxicity. Furthermore, hematoxylin and eosin (H&E) staining exhibited normal morphological structures within liver and kidney in the bLF treated groups, while degenerative changes were observed in AFB1 group. Similarly, bLF, decreased oxidative stress and thus prevented apoptosis in the liver and kidney cells of the birds. Whereas, mRNA level of mitochondrial apoptosis related gene including Bcl-2 (Bak and Bax), caspase-3 and caspase-9 was upregulated, while bcl2 gene were downregulated in AFB1 group. Dietary supplementation of bLF effectively normalizes the expression of these genes. AFB1 exposed birds shown to decrease gene expression level of the crucial component of Nrf2 pathway, responsible to regulate antioxidant defense. Interestingly, bLF reverse these detrimental effects of and restore the normal expression levels of Nrf2 pathway. Conclusively, our findings demonstrate that bLF mitigates the detrimental effects of AFB1, besides regulation of the apoptosis-related genes via mitochondrial pathways. These findings validate that the bLF (600 mg/kg) could be used as protective agent against AFB1-induced liver and kidney damage., Competing Interests: DISCLOSURES No conflict of interest exists in the submission of this manuscript, and the manuscript is approved by all authors for publication. I would like to declare on behalf of my co-authors that the work described was original research that has not been published previously, and not under consideration for publication elsewhere, in whole or in part. All the authors listed have approved the manuscript that is enclosed., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

The current research was conducted to assess the effect of in ovo feeding (IOF) of selenium (Se) and zinc (Zn) on hatchability, production performance, liver, intestinal morphology, antioxidant levels and expression levels of immune-related genes in broiler chickens. A total of 400 fertilized eggs were equally divided into four groups: control (non-injected), sham (in ovo injection of 0.75% NaCl), Se (@ 1.5 µg/egg in ovo injection) and Zn (500 µg/egg in ovo injection) groups respectively. On the seventeenth day of incubation, treatment solutions were administered into amniotic fluid of fertilized eggs. The results revealed that Se and Zn supplementation significantly (P < 0.05) enhanced hatchability, post-hatch growth, organ development, and liver antioxidant capability. Histopathological examination revealed a typical hepatocyte morphology, well-arranged cells, and a significant (P < 0.05) decrease in apoptosis in both selenium and zinc groups. Additionally, selenium and zinc produced auspicious effects on intestinal epithelium and villi surface area. Interestingly, our results revealed that IOF of Se and Zn modulated the expression of immune-related genes in comparison to the control and sham groups. Conclusively, IOF of Se and Zn augmented health and productivity by enhancing the cellular immunity in the broiler chickens, thus IOF can be utilized as an effective strategy to promote health and immunity in broiler chickens., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Given China's prohibition on the utilization of antibiotics as feed additives in 2020, we aim to investigate nutrition additives that are both efficient and safe. Lactobacillus, a well-recognized beneficial probiotic, has explicitly been investigated for its effects on health status of the host and overall impact on food industry. To evaluate effects of Lactobacillus plantarum (LW) supplementation on broiler chicken, we conducted comprehensive multi-omics analysis, growth performance evaluation, RT-qPCR analysis, and immunofluorescence. The findings revealed that LW supplementation resulted in a substantial progress in growth performance (approximately 205 g increase in final body weight in comparison to the control group (p < 0.01)). Additionally, LW exhibited promising potential for enhancing antioxidant properties of serum and promoting gut integrity and growth as evidenced by improved antioxidant indices (p < 0.01), intestinal villus morphology (p < 0.01), and enhanced gut barrier function (p < 0.01). Meanwhile, the multi-omics analysis, including 16S rRNA sequencing and liquid chromatography-tandem mass spectrometry, revealed an enrichment of beneficial microbes in the gut of broilers that were supplemented with LW, while simultaneously depleting harmful microorganisms. Moreover, a noteworthy modification was observed in gut metabolic profiling subsequent to the execution of the probiotic strategy. Specifically, variations were noticed in the levels of metabolites and metabolic pathways such as parathyroid hormone synthesis, inflammatory mediator regulation of TRP channels, oxidative phosphorylation, and mineral absorption. Taken together, our findings validate that LW administration produces valuable effects on the health and growth performance of broilers owing to its capability to boost the gut microbiota homeostasis and intestinal metabolism. Present findings signify the potential of LW as a dietary additive to promote growth and development in broiler chickens., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Physician transfer is an alternate option to patient transfer for expedient performance of mechanical thrombectomy in patients with acute ischemic stroke., Methods and Results: We conducted a systematic review to identify studies that evaluate the effect of physician transfer in patients with acute ischemic stroke who undergo mechanical thrombectomy. A search of PubMed, Scopus, and Web of Science was undertaken, and data were extracted. A statistical pooling with random-effects meta-analysis was performed to examine the odds of reduced time interval between stroke onset and recanalization, functional independence, death, and angiographic recanalization. A total of 12 studies (11 nonrandomized observational studies and 1 nonrandomized controlled trial) were included, with a total of 1894 patients. Physician transfer was associated with a significantly shorter time interval between stroke onset and recanalization with a pooled mean difference estimate of -62.08 (95% CI, -112.56 to -11.61]; P =0.016; 8 studies involving 1419 patients) with high between-study heterogeneity in the estimates ( I 2 =90.6%). The odds for functional independence at 90 days were significantly higher (odds ratio, 1.29 [95% CI, 1.00-1.66]; P =0.046; 7 studies with 1222 patients) with physician transfer with low between-study heterogeneity ( I 2 =0%). Physician transfer was not associated with higher odds of near-complete or complete angiographic recanalization (odds ratio, 1.18 [95% CI, 0.89-1.57; P =0.25; I 2 =2.8%; 11 studies with 1856 subjects)., Conclusions: Physician transfer was associated with a significant reduction in the mean of time interval between symptom onset and recanalization and increased odds for functional independence at 90 days with physician transfer compared with patient transfer among patients who undergo mechanical thrombectomy.

Lactoferrin is a natural cationic iron-binding glycoprotein of the transferrin family found in bovine milk and other exocrine secretions, including lacrimal fluid, saliva, and bile. Lactoferrin has been investigated for its numerous powerful influences, including anticancer, anti-inflammatory, anti-oxidant, anti-osteoporotic, antifungal, antibacterial, antiviral, immunomodulatory, hepatoprotective, and other beneficial health effects. Lactoferrin demonstrated several nutraceutical and pharmaceutical potentials and have a significant impact on improving the health of humans and animals. Lactoferrin plays a critical role in keeping the normal physiological homeostasis associated with the development of pathological disorders. The current review highlights the medicinal value, nutraceutical role, therapeutic application, and outstanding favorable health sides of lactoferrin, which would benefit from more exploration of this glycoprotein for the design of effective medicines, drugs, and pharmaceuticals for safeguarding different health issues in animals and humans., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: This study aimed to evaluate the extent of confidence in medical and dental students regarding their careers after being enrolled in their germane institutes and to identify the magnitude of uncertainty in medical and dental students about their careers and the important causes of this uncertainty., Methods: This study was conducted among enrolled students in different medical and dental colleges and universities of Pakistan, including the public and private sectors, from March 1 to March 15, 2023. The level of confidence in their career was evaluated using a close-ended questionnaire of a three-point Likert scale developed and tested by the investigators and approved by the Ethical Review Board (ERB) along with the synopsis. Data were managed and analyzed using Microsoft Excel 19 (Microsoft Corporation, USA) and IBM SPSS Statistics for Windows, version 27 (released 2020; IBM Corp., Armonk, New York, United States)., Results: This study included 1,126 students from public and private medical and dental institutes. The majority of participants 965(85.7%) were satisfied with their chosen profession, and 1,042 (92.5%) students believed they could make a positive contribution to society. Out of the total participants, 246 (21.8%) students showed their intention of changing careers if provided with a comparable/alternative opportunity. A very small proportion, 154 (13.7%), were dissatisfied with their current clinical training and studies. The study also revealed that extra and unjustified academic pressure from institutions is the leading cause of uncertainty among students. Moreover, the lack of psychological support and counseling provided during the academic years adds to the magnitude of uncertainty., Conclusion: In Pakistan, a staggering number of medical and dental students are unsure of their future careers and career prospects. The main causes of this uncertainty are the extra, unwarranted academic pressure that institutions place on students and the dearth of psychological support and counseling offered during the course of studies. This study not only highlights the prevailing uncertainty among medical students but also identifies the causes behind it. Addressing these causes can alleviate the prevailing uncertainty and bring about satisfactory and productive academic achievements without suffering from worries about the future., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Sajjad et al.)

Background: We explored the potential of mechanical thrombectomy (MT) for acute ischemic stroke patients at hospitals that perform percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) in the United States., Methods: We analyzed nationally representative data between 2017 and 2020 to determine the numbers, characteristics, and outcomes of acute ischemic stroke patients admitted to hospitals that perform both primary PCI and MT, hospitals that perform primary PCI but not MT and hospitals that perform neither PCI or MT. Multiple logistic regressions were performed to evaluate the effect of hospital type on in-hospital mortality and discharge home (without palliative care)., Results: A total of 1,210,415, 1,002,950, and 488,845 acute ischemic stroke patients were admitted to hospitals that performed both primary PCI and MT, performed primary PCI but not MT, or performed neither PCI nor MT, respectively. Compared with hospitals that performed both PCI and MT, the odds of in-hospital mortality were lower in hospitals that performed PCI only (odds ratio (OR) 0.88 95 % confidence interval (CI) 0.86-0.91, p<0.001) and hospitals that performed neither PCI or MT (OR 0.85 95 %CI 0.82-0.89, p<0.0010). There was no significant difference in the odds of discharge home between the three types of hospitals., Conclusions: Almost 37 % the patients with acute ischemic stroke are admitted to hospitals that perform primary PCI (but not MT) supporting strategies to increase the performance of MT in such hospitals as an option to increase rapid availability of MT in the United States., Competing Interests: Declaration of Competing Interest The authors declare that there is no conflict of interest., (Copyright © 2023. Published by Elsevier Inc.)

Camel milk (CM) is the key component of human diet specially for the population belongs to the arid and semi-arid regions of the world. CM possess unique composition as compare to the cow milk with abundant amount of medium chain fatty acids in fat low lactose and higher concentration of whey protein and vitamin C. Besides the nutritional significance of CM, it also contains higher concentration of bioactive compounds including bioactive peptides, lactic acid bacteria (LAB), lactoferrin (LF), lactoperoxidase, lysozyme casein and immunoglobulin. Recently, CM and their bioactive compounds gaining more attention toward scientific community owing to their multiple health benefits, especially in the current era of emerging drug resistance and untold side effects of synthetic medicines. Consumption of fresh or fermented CM and its products presumed exceptional nutraceutical and medicinal properties, including antimicrobial, anti-inflammatory, antioxidant, anti-diabetic, hepatoprotective, nephroprotective, anticancer and immunomodulatory activities. Moreover, CM isolated LAB exhibit antioxidant and probiotic effects leading to enhance the innate and adaptive immune response against both gram-negative and gram-positive pathogenic bacteria. The main objective of this review is to highlight the nutritional significance, pharmaceutical potential, medicinal value and salient beneficial health aspect of CM for human and animals.

The rapid growth of the Internet of Things (IoT) and its integration into various industries has made it extremely challenging to guarantee IoT systems' dependability and quality, including scalability, dynamicity, and integration with existing IoT frameworks. However, the essential principles, approaches, and advantages of model-driven IoT testing indicate a promising strategy for overcoming these. This paper proposes a metamodeling-based interoperability and integration testing approach for IoT systems that automates the creation of test cases and the assessment of system performance by utilizing formal models to reflect the behavior and interactions of IoT systems. The proposed model-based testing enables the systematic verification and validation of complex IoT systems by capturing the essential characteristics of IoT devices, networks, and interactions. This study describes the key elements of model-driven IoT testing, including the development of formal models, methods for generating test cases, and the execution and assessment of models. In addition, it examines various modeling formalisms and their use in IoT testing, including state-based, event-driven, and hybrid models. This study examines several methods for creating test cases to ensure thorough and effective testing, such as constraint-based strategies and model coverage requirements. Model-driven IoT testing improves defect detection, expands test coverage, decreases testing effort, and increases system reliability. It also offers an organized and automated method to confirm the efficiency and dependability of IoT systems.

This study aimed to evaluate the effect of in ovo feeding (IOF) of L-arginine (Arg) and L-threonine (Thr) in the broiler. For this purpose, 500 embryonated eggs were randomly allocated into five treatment groups of four replicates 25 eggs/replicate. The five treatments were arranged as (1) non-injected control, (2) 0.75% NaCl injected group, (3) 25 mg/egg Arg 4) 25 mg/egg Thr, and (5) Arg + Thr25 mg/egg. On the 17th day of incubation, 0.5 ml of treatment solution was injected into the amniotic fluid of all treatment groups. The result showed that the supplementation group of Arg + Thr significantly (P < 0.05) improved the hatchability, post-hatch growth performance, organ weight, and organ development in compression to sham control and other treatment groups. The antibiotic titer of NDV was improved in Arg + Thr group. Moreover, hematological indices were improved significantly in Arg + Thr group. The plasma concentration of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were noted to decrease in Arg + Thr group. Histopathological investigation revealed that IOF of Arg + Thr increased the villi length and crypt depth of the intestine. Conclusively, the IOF Arg and Thr could be an effective way to optimize the health and productive performance of broilers., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

We examined whether surplus dietary selenium (Se) supply could alleviate high concentrate (HC) diet-induced hepatic oxidative stress (OS) and inflammation. Eighteen young goats were distributed into three groups; were fed low (LC, concentrate: forage; 35: 65), high concentrate (HC, 65: 35), or Se-supplemented HC (HCSe, 65: 35 + 0.5 mg Se kg -1 diet) diets for 10 weeks. Short chain fatty acids, OS markers and immunoinflammatory genes expressions were assessed through gas chromatograph, kits, and RT-qPCR, respectively. Compared with LC, HC diet increased ( p  < .05) colonic and serum lipopolysaccharide (LPS) levels and induced hepatic oxidative injury by increasing ( p  < .05) malondialdehyde (MDA) levels and decreasing ( p  < .05) activities of glutathione peroxidase, superoxide dismutase, and catalase. HC diet altered hepatic mRNA expressions of toll-like receptor-4 (TLR-4), cluster of differentiation-14 (CD-14), tumor necrosis factor-α (TNF-α), TNF receptor-associated factor-6 (TRAF-6), nuclear factor kappa B (NF-κB), interleukin-1β (IL-1β), IL-10, IL-13, LPS-binding protein (LBP), serum amyloid A (SAA), α-acid glycoprotein (AGP), and albumin (ALB). Conversely, extra-Se supply lowered LPS and attenuated antioxidant status and inflammation in liver. In conclusion, HC diet induced oxidative lesions and TLR-4 pathway-mediated inflammation, whereas supranutritional Se alleviated oxidative and inflammatory lesions through TLR-4 pathway regulation in goat liver., Competing Interests: The authors declare no conflict of interest., (© 2022 The Authors. Food Science & Nutrition published by Wiley Periodicals LLC.)

Materials and Methods: Three hundred sixty ( n = 360) broiler chickens were equally divided into control (C) and thiram (T) groups. Furthermore, the C and T groups were dividedinto 8-, 9-, 11-, and 13-day-old chickens., Results: Clinically, it was observed that broiler chickens of group T had abnormal posture, gait, and lameness, and histopathological results revealed dead and abnormal chondrocytes of T group on day 6. Real-time qPCR results showed that HDAC1, MTA1, H4, and PCNA genes were significantly expressed ( P < 0.05). HDAC1 was upregulated on days 1, 2, 4, and 6 ( P < 0.01); MTA1 was upregulated on days 1 and 2 ( P < 0.01); H4 was upregulated on days 2 and 4 ( P < 0.01), and PCNA was downregulated on days 1, 2, and 4 ( P < 0.01). Furthermore, IHC results of HDAC1 protein were significantly ( P < 0.01) expressed in proliferative zone of day 1 and hypertrophic zone of day 6. MTA1 protein was significantly ( P < 0.01) expressed on days 1, 2, and 6 in all zones, except prehypertrophic zone of day 2., Conclusion: In conclusion, the mRNA expressions of HDAC1, MTA1, H4, and PCNA were differentially expressed in the chondrocytes of thiram-induced TD chickens. HDAC1 and MTA1 protein expression found involved and responsible in the abnormal chondrocytes' proliferation of broiler chicken., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2022 Ali Raza Jahejo et al.)

Background and Purpose: To describe the final results of the TARGET Registry, a multicenter, real-world study of patients with intracranial aneurysms treated with new generation TARGET Coils. Methods: The TARGET Registry is a prospective, single-arm study with independent medical event monitoring and core-lab adjudication. Patients with de novo intracranial aneurysms were embolized with either TARGET-360° or helical coils in 12 US centers. The primary outcome was aneurysm packing density (PD), which was assessed immediately post-procedure. The secondary outcomes were immediate and long-term aneurysm occlusion rate using the Raymond Scale, and independent functional outcome using the modified Rankin Scale (mRS). A secondary analysis investigated the influence of the use of 100% 360-complex coils on clinical and angiographic outcomes. Results: 148 patients with 157 aneurysms met the inclusion and exclusion criteria. 58 (39.2%) patients with ruptured and 90 (61.8%) with unruptured aneurysms were treated using TARGET 360°, helical Coils, or both. Median age was 58.3 (IQR 48.1-67.4), 73% female, and 71.6% were Caucasian. Median follow-up time was 5.9 (IQR 4.0-6.9) months. The majority were treated with TARGET 360-coils (63.7%), followed by mixed and helical coils only. Peri-procedural morbidity and mortality was seen in 2.7% of patients. A good outcome at discharge (mRS 0-2) was seen in 89.9% of the full cohort, and in 84.5 and 93.3% in the ruptured and unruptured patients, respectively. The median packing density was 28.8% (IQR 20.3-41.1). Long-term complete and near complete occlusion rate was seen in 90.4% of aneurysms and complete obliteration was seen in 66.2% of the aneurysms. No significant difference in clinical and angiographic outcomes were noted between the pure 360-complex coiling vs. mixed 360-complex/Helical coiling strategies. In a multivariate analysis, predictors for long-term aneurysm occlusion were aneurysm location, immediate occlusion grade, and aneurysm size. The long-term independent functional outcome was achieved in 128/135 (94.8%) patients and all-cause mortality was seen in 3/148 (2%) patients. Conclusion: In the multicenter TARGET Registry, two-thirds of aneurysms achieved long-term complete occlusion and 91.0% achieved complete or near complete occlusion with excellent independent functional outcome. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT01748903.

Background: The effect of endovascular thrombectomy that is performed more than 6 hours after the onset of ischemic stroke is uncertain. Patients with a clinical deficit that is disproportionately severe relative to the infarct volume may benefit from late thrombectomy., Methods: We enrolled patients with occlusion of the intracranial internal carotid artery or proximal middle cerebral artery who had last been known to be well 6 to 24 hours earlier and who had a mismatch between the severity of the clinical deficit and the infarct volume, with mismatch criteria defined according to age (<80 years or ≥80 years). Patients were randomly assigned to thrombectomy plus standard care (the thrombectomy group) or to standard care alone (the control group). The coprimary end points were the mean score for disability on the utility-weighted modified Rankin scale (which ranges from 0 [death] to 10 [no symptoms or disability]) and the rate of functional independence (a score of 0, 1, or 2 on the modified Rankin scale, which ranges from 0 to 6, with higher scores indicating more severe disability) at 90 days., Results: A total of 206 patients were enrolled; 107 were assigned to the thrombectomy group and 99 to the control group. At 31 months, enrollment in the trial was stopped because of the results of a prespecified interim analysis. The mean score on the utility-weighted modified Rankin scale at 90 days was 5.5 in the thrombectomy group as compared with 3.4 in the control group (adjusted difference [Bayesian analysis], 2.0 points; 95% credible interval, 1.1 to 3.0; posterior probability of superiority, >0.999), and the rate of functional independence at 90 days was 49% in the thrombectomy group as compared with 13% in the control group (adjusted difference, 33 percentage points; 95% credible interval, 24 to 44; posterior probability of superiority, >0.999). The rate of symptomatic intracranial hemorrhage did not differ significantly between the two groups (6% in the thrombectomy group and 3% in the control group, P=0.50), nor did 90-day mortality (19% and 18%, respectively; P=1.00)., Conclusions: Among patients with acute stroke who had last been known to be well 6 to 24 hours earlier and who had a mismatch between clinical deficit and infarct, outcomes for disability at 90 days were better with thrombectomy plus standard care than with standard care alone. (Funded by Stryker Neurovascular; DAWN ClinicalTrials.gov number, NCT02142283 .).

Background: Punica granatum L. (pomegranate), is a shrub mostly available in the Mediterranean Sea region. The fruits have gained the substantial attention among researchers due to their promising biological activities including anti-inflammatory, antibacterial, antidiarrheal, immune modulatory, antitumor, wound healing and antifungal that have been attributed to various constituents of seeds, bark, juice, pericarp, and leaf of this tree across the globe. The phenolic compounds of pomegranate have been documented to possess numbers of prophylactic and therapeutic utilities against various pathological infections as well as non-infectious disorders., Objective: The current review expedites the pharmacological role of Punica granatum L. in curing elements related to infectious and non-infectious disorders., Methods: The current review is based on literature and patents already available on various scientific databases highlighting the role of Punica granatum along with its therapeutic potentials against infectious and non-infectious disorders. The databases included under study were PubMed, Med line, PubMed Central, Science Direct and few other scientific databases. The information obtained through these diverse databases is compiled, critically interpreted and presented in the current study., Results: Multi-dimensional beneficial application of pomegranate plant is recorded. The pomegranate seed oil has phytoestrogenic compounds and the fruit is rich in phenolic compounds with strong antioxidant activity. The fruit and bark of pomegranate are used against intestinal parasites, dysentery, and diarrhea in different animals and human models. Since the ancient time the juice and seeds had considered the best therapy for throat and heart disorders. Ellagic acid is one of the main components of pomegranate with potent antioxidant activity. Results from different studies reported that Punica granatum L or its byproducts can be used as natural food additives in human and animal nutrition in order to boost immunity, microbial safety and provide the housing environment without affecting body weight gain. In addition, Punica granatum L. byproducts can modulate immune function and gut microbiota of broiler chickens as well as reduce the odorous gas emissions from excreta. Naturally occurring polyphenols in a pomegranate can be a potential alternative medicine for the prevention of avian Colibacillosis diseases and can also be used as an intestine astringent to relieve diarrhea and enteritis in chickens., Conclusion: The present review gives the insight towards major components of pomegranate as well as their pharmacological activities against pathological disorders. In spite of many beneficial properties of Punica granatum L., more research evidence on a molecular basis is needed to find out the molecular mechanism of action in various animals and human models to validate the usefulness of Punica granatum L. as a potent therapeutic agent., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.)

Purpose: The CT angiography (CTA) spot sign is a strong predictor of hematoma expansion in intracerebral hemorrhage (ICH). However, CTA parameters vary widely across centers and may negatively impact spot sign accuracy in predicting ICH expansion. We developed a CT iodine calibration phantom that was scanned at different institutions in a large multicenter ICH clinical trial to determine the effect of image standardization on spot sign detection and performance., Methods: A custom phantom containing known concentrations of iodine was designed and scanned using the stroke CT protocol at each institution. Custom software was developed to read the CT volume datasets and calculate the Hounsfield unit as a function of iodine concentration for each phantom scan. CTA images obtained within 8 h from symptom onset were analyzed by two trained readers comparing the calibrated vs. uncalibrated density cutoffs for spot sign identification. ICH expansion was defined as hematoma volume growth >33%., Results: A total of 90 subjects qualified for the study, of whom 17/83 (20.5%) experienced ICH expansion. The number of spot sign positive scans was higher in the calibrated analysis (67.8 vs 38.9% p < 0.001). All spot signs identified in the non-calibrated analysis remained positive after calibration. Calibrated CTA images had higher sensitivity for ICH expansion (76 vs 52%) but inferior specificity (35 vs 63%) compared with uncalibrated images., Conclusion: Normalization of CTA images using phantom data is a feasible strategy to obtain consistent image quantification for spot sign analysis across different sites and may improve sensitivity for identification of ICH expansion.

Aim: The aim of this study was to evaluate the impact of therapeutic and high doses of florfenicol on kidney and liver functional indicators in goat species., Materials and Methods: Six mature, healthy goats (combine breed and sex) with average weight 25 kg were selected for this study. The therapeutic (20 mg/kg b.w.) and high doses (40 and 60 mg) of florfenicol were administered for 3 days with 24 h interval. Blood samples were collected at 0, 24, 48, 72, 96, and 120 h following the each administered dose., Results: The results showed that the therapeutic dose of florfenicol produced nonsignificant effect on serum urea, creatinine, total protein (TP), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT) and bilirubin on all timings, and increased (p<0.05) the serum glutamic oxaloacetic transaminase (SGOT) and serum glutamate-pyruvate transaminase (SGPT) levels for 48 h. Whereas the high doses of florfenicol (40 and 60 mg) significantly altered the kidney and liver functional indicators in the blood. In contrast with control, the serum urea level was (p<0.01) increased at all timing points. Creatinine values were altered (p<0.01, <0.05) in increasing manner from 24 to 96 h. The high dose of 40 mg decreased the TP (p<0.05) for 72 h and 60 mg persisted same effect (p<0.01) up to 120 h. The indices of ALP, GGT, SGOT, and SGPT were raised (p<0.01, <0.05) at all timings. The bilirubin indexes also (p<0.05) elevated from 48 to 72., Conclusion: It was concluded that the high doses of florfenicol produced reversible dose-dependent effects on functional indicators of kidney and liver such as urea, creatinine, TP, ALP, SGOT, SGPT, GGT, and bilirubin.

Cytosolic nucleotide oligomerisation domain (NOD)-like receptors play an important role in host defence against infection. Reduced NOD1 expression has been observed in dysfunctional neutrophils derived from periparturient cattle known to be most susceptible to coliform mastitis. However, whether impairment of NOD1 suppresses the immune responses of bovine neutrophils during bacterial infections remains unknown. Crude (phenol extracted) lipopolysaccharide (cLPS), which often contains other immunostimulatory molecules, including NOD1 agonist, is known to induce almost the whole bacterial response. This study was conducted to explore the role of NOD1/nuclear factor (NF)-κB pathway in the cytokine and functional responses of bovine neutrophils challenged with Escherichia coli-derived cLPS. Freshly isolated blood neutrophils from healthy heifers were pre-incubated for 2 h with ML130, a selective inhibitor of NOD1/NF-κB pathway. Cells were then exposed to cLPS for additional 4 h. Inhibition of the NOD1/NF-κB pathway resulted in a decrease in cLPS-induced phosphorylation of the inhibitor of NF-κBα (IκBα) in neutrophils. Impairment of the NOD1/NF-κB pathway tended to down-regulate mRNA levels of pro-inflammatory cytokines interleukin (IL)-1β and tumour necrosis factor (TNF)-α, chemokines IL-8 and C-X-C motif ligand 2 (CXCL2), and adhesion molecules CD11b and CD62L, in cLPS-challenged cells. Functional analyses showed that blocking the NOD1/NF-κB pathway inhibited neutrophil migration and phagocytic killing capacity, and promoted neutrophil death upon cLPS stimulation. The data presented here demonstrate that activation of NOD1/NF-κB pathway contributes to the functional responses of neutrophils to cLPS., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Aneurysms of the vertebrobasilar junction (VBJ) are especially uncommon but carry a significant risk of hemorrhage and historically have been difficult to treat. In recent years, however, advancements in stent-assisted embolization have allowed better access and stabilization of complicated posterior circulation aneurysms., Methods: We describe a novel approach in the treatment of a wide-neck aneurysm at the terminus of the left vertebral artery by a contralateral approach in a patient with ipsilateral subclavian artery occlusion., Results: A complex, wide-neck aneurysm at the verterbrobasilar junction hindered by ipsilateral subclavian occlusion can successfully be treated with stent-assisted coil embolization using a contralateral approach., Conclusion: Contralateral U-shaped stenting offers a viable endovascular option for patients with complex aneurysms of the vertebral basilar junction but should be reserved for appropriate cases with favorable anatomy when the ipsilateral approach from the subclavian artery is unobtainable.

Background: Enrollment of subjects in acute stroke trials is often hindered by narrow timeframes, because a large proportion of patients arrive via transfers from outside facilities rather than primary arrival at the enrolling hospital., Rationale: Telemedicine networks have been increasingly used for provision of care for acute stroke patients at facilities outside of major academic centers. Treatment decisions made through telemedicine networks in patients with acute ischemic stroke have been shown to be safe, reliable, and effective. With the expanding use of this technology and the impediments to enrolling subjects into clinical trials, this approach can be applied successfully to the field of clinical research., Methods and Conclusions: The Antihypertensive Treatment of Acute Cerebral Hemorrhage II trial is a phase III randomized multicenter trial that has developed a protocol in collaboration with participating sites to implement the use of telemedicine networks for the enrollment of research subjects. The protocol describes the operating procedures and legal and Institutional Review Board perspectives for its implementation.

Objectives: This study was conducted to compare phenotypes and in vitro angiogenic capacity of putative endothelial progenitor cells (EPCs) derived from bone marrow (BM) and peripheral blood (PB), from an avian species., Materials and Methods: Mononuclear cells were isolated from chicken BM and PB (BMMNCs and PBMNCs) and cultured in EGM-2 medium. Cells at days 7-14 were used for the experiments. Expression of progenitor and endothelial markers, number of Dil-ac-LDL/lectin dual-positive cells and adipogenic and osteogenic differentiation were determined. Migration and in vitro angiogenic ability between BMMNC- and PBMNC-derived cells were compared., Results: PBMNCs developed typical EPC appearance, with initial spindle shape followed by a cobblestone form, whereas BMMNC-derived cells retained their constitutive spindle-like morphology throughout the study. Cells derived from both sources expressed CD133, CD31 and VEGFR-2, although PBMNCs-derived cells had lower CD133 expression. Nevertheless, number of Dil-ac-LDL/lectin dual-positive cells did not differ between groups. Adipogenic and osteogenic lineages were verified in BMMNC- but not in PBMNC-derived cells. PBMNC-derived cells formed tubular networks on Matrigel. However, BMMNC-derived cells formed few tube-like structures, which were not morphologically comparable to those developed by their counterparts., Conclusion: Our results suggest that so called EPCs derived from BMMNCs are not 'true' EPCs, supporting previous findings on mammals that BM may not serve as an optimal isolation source of EPCs., (© 2014 John Wiley & Sons Ltd.)

Objective: The results of Interventional Management of Stroke (IMS) III, Magnetic Resonance and REcanalization of Stroke Clots Using Embolectomy (MR RESCUE), and SYNTHESIS EXPANSION trials are expected to affect the practice of endovascular treatment for acute ischemic stroke. The purpose of this report is to review the components of the designs and methods of these trials and to describe the influence of those components on the interpretation of trial results., Methods: A critical review of trial design and conduct of IMS III, MR RESCUE, and SYNTHESIS EXPANSION is performed with emphasis on patient selection, shortcomings in procedural aspects, and methodology of data ascertainment and analysis. The influence of each component is estimated based on published literature including multicenter clinical trials reporting on endovascular treatment for acute ischemic stroke and myocardial infarction., Results: We critically examined the time interval between symptom onset and treatment and rates of angiographic recanalization to differentiate between "endovascular treatment" and "parameter optimized endovascular treatment" as it relates to the IMS III, MR RESCUE, and SYNTHESIS EXPANSION trials. All the three trials failed to effectively test "parameter optimized endovascular treatment" due to the delay between symptom onset and treatment and less than optimal rates of recanalization. In all the three trials, the magnitude of benefit with endovascular treatment required to reject the null hypothesis was larger than could be expected based on previous studies. The IMS III and SYNTHESIS EXPANSION trials demonstrated that rates of symptomatic intracerebral hemorrhages subsequent to treatment are similar between IV thrombolytics and endovascular treatment in matched acute ischemic stroke patients. The trials also indirectly validated the superiority/equivalence of IV thrombolytics (compared with endovascular treatment) in patients with minor neurological deficits and those without large vessel occlusion on computed tomographic/magnetic resonance angiography., Conclusions: The results do not support a large magnitude benefit of endovascular treatment in subjects randomized in all the three trials. The possibility that benefits of a smaller magnitude exist in certain patient populations cannot be excluded. Large magnitude benefits can be expected with implementation of "parameter optimized endovascular treatment" in patients with ischemic stroke who are candidates for IV thrombolytics.

We report a man admitted to the hospital after sustaining an ischemic stroke, with a return to isodensity on repeat computed tomography (CT) scan noted at day 9 of his hospital stay. This finding, known as the "fogging effect," has never been noted so early in a patient's course on CT imaging., Abbreviations: CTcomputed tomographyMRImagnetic resonance imaging.

Background: Enrollment of subjects in acute stroke trials is often hindered by narrow timeframes, because a large proportion of patients arrive via transfers from outside facilities rather than primary arrival at the enrolling hospital., Rationale: Telemedicine networks have been increasingly utilized for provision of care for acute stroke patients at facilities outside of major academic centers. Treatment decisions made through Telemedicine networks in patients with acute ischemic stroke have been shown to be safe, reliable, and effective. With the expanding use of this technology and the impediments to enrolling subjects into clinical trials, this approach can be applied successfully to the field of clinical research., Methods and Conclusions: The antihypertensive treatment of acute cerebral hemorrhage II trial is a phase III randomized multicenter trial that has developed a protocol in collaboration with participating sites to implement the use of Telemedicine networks for the enrollment of research subjects. The protocol describes the operating procedures and legal and Institutional Review Board perspectives for its implementation.

Objective: Tenecteplase (TNK) is a third-generation thrombolytic agent. We evaluated the safety and feasibility of intra-arterial (IA) administration of TNK in patients with acute ischemic stroke., Methods: Patients who received endovascular treatment for acute ischemic stroke were identified from prospectively collected databases at three university hospitals. We compared clinical and radiological outcomes of patients treated with TNK to those treated with other IA thrombolytics or mechanical thrombectomy alone. Primary outcome measures were favorable functional outcome at 30 days (modified Rankin Scale score of 0-2), and rate of intracranial hemorrhage (ICH). Early neurological improvement, angiographic recanalization, time to recanalization, and mortality at 30 days were additional outcome measures., Results: We identified 114 patients (mean age 67 ± 15 years, 54 were women). Thirty-three patients received IA TNK, 48 received alteplase (n = 11) or reteplase (n = 37), and 33 patients had mechanical thrombectomy alone. Stroke severity was similar among the three groups. No difference between the groups was found in the secondary outcome measures and ICH. Borderline statistical significance was seen toward favorable functional outcome at 1 month in the TNK-treated patients [odds ratio (OR) = 2.8; 95% confidence interval (CI) .96-8.1, P = .063 vs. other thrombolytics, and OR = 3.0, 95% CI .97-9.5, P = .06 vs. mechanical thrombectomy alone]., Conclusion: Our study demonstrates that administration of IA TNK in acute stroke is safe and results in rates of favorable outcomes that are comparable to those observed with currently used drugs. Additional studies are needed to further determine the safety and efficacy of IA TNK in acute stroke treatment., (© 2011 by the American Society of Neuroimaging.)

Giant cell arteritis (GCA) is the most common form of systemic vasculitis in adults. Patients usually present with headache and visual symptoms, and have an elevated erythrocyte sedimentation rate. It has been reported that 3-4% of patients with GCA develop ischemic events secondary to vertebral artery stenosis or occlusion. The mainstay of therapy of GCA is high dose steroid and/or methotrexate. A case is described of a patient who initially presented with intermittent double vision, mild headache and unremarkable MRI and MR angiography of the head and neck. The patient was diagnosed and treated for ocular myasthenia. The patient was readmitted 2 months later with imbalance and worsening headache, and workup suggested bilateral cerebellar infarction, complete occlusion of the left vertebral artery and a high grade stenosis of the right vertebral artery. Erythrocyte sedimentation rate and C reactive protein were elevated. Temporal artery biopsy demonstrated changes consistent with GCA. During the course of the treatment with corticosteroids and immunosuppressant, the patient developed dysarthria, left facial droop and left hemiplegia, and was found to have complete occlusion of both vertebral arteries. The patient was emergently taken for revascularization of the occluded segment using angioplasty and stent placement. The patient had significant improvement of neurological symptoms within 3 days after the procedure and continued to improve during hospitalization. Endovascular treatment of vasculitis affecting the intracranial vessels is not yet established. Our experience with successful treatment of complete occlusion of the vertebral artery secondary to GCA using endovascular intracranial angioplasty and stent placement is reported.

Objective: The results of prematurely terminated stenting and aggressive medical management for preventing recurrent stroke in intracranial stenosis (SAMMPRIS) due to excessively high rate of stroke and death in patients randomized to intracranial stent placement is expected to affect the practice of endovascular therapy for intracranial atherosclerotic disease. The purpose of this report is to review the components of the designs and methods SAMMPRIS trial and to describe the influence of those components on the interpretation of trial results., Methods: A critical review of the patient population included in SAMMPRIS is conducted with emphasis on "generalizability of results" and "bias due to cherry picking phenomenon." The technical aspects of endovascular treatment protocol consisting of intracranial angioplasty and stent placement using the Gateway balloon and Wingspan self-expanding nitinol stent and credentialing criteria of trial interventionalists are reviewed. The influence of each component is estimated based on previous literature including multicenter clinical trials reporting on intracranial angioplasty and stent placement., Results: The inclusion criteria used in the trial ensured that patients with adverse clinical or angiographic characteristics were excluded. Self-expanding stent as the sole stent, technique of prestent angioplasty, periprocedural antiplatelet treatment, and intraprocedural anticoagulation are unlikely to adversely influence the results of intracranial stent placement. A more permissive policy toward primary angioplasty as an acceptable treatment option may have reduced the overall periprocedural complication rates by providing a safer option in technically challenging lesions. The expected impact of a more rigorous credentialing process on periprocedural stroke and/or death rate following intracranial stent placement in SAMMPRIS such as the one used in carotid revascularization endarterectomy versus stenting trial remains unknown., Conclusion: The need for developing new and effective treatments for patients with symptomatic intracranial stenosis cannot be undermined. The data support modification but not discontinuation of our approach to intracranial angioplasty and/or stent placement for intracranial stenosis. There are potential patients in whom angioplasty and/or stent placement might be the best approach, and a new trial with appropriate modifications in patient selection and design may be warranted., (Copyright © 2012 by the American Society of Neuroimaging.)

Background and Introduction: Patients presenting with posterior circulation acute ischemic events are occasionally noted to have occlusion of bilateral vertebral arteries with basilar artery blood flow entirely dependent from the anterior circulation. There is limited data about prognosis of such patients in literature., Methods: Patients with acute posterior circulation ischemic stroke and bilateral vertebral artery occlusion (including contra-lateral hypoplastic vertebral artery without contribution to the basilar artery system) were identified prospectively from two academic centers. Data including clinical presentation, medical management, angiographic findings, recurrent events and outcome were collected and reported., Results: A total of 4 patients presenting with acute ischemic events in the posterior circulation were identified to have bilateral vertebral artery occlusion at our center. One additional patient had a vertebral artery occlusion and a contra-lateral hypoplastic vertebral artery. In the functional evaluation of the blood flow with catheter angiography, the basilar artery was filling from the anterior circulation, with no antegrade flow from bilateral vertebral arteries injection in all 5 patients. Patients were treated with anti-platelets (n=4) or started on anti-coagulation after failing anti-platelet therapy (n=2). All patients had recurrent ischemic stroke with new ischemic lesions proven by diffusion weighted images on MRI within 2 to 70 days after the initial event., Conclusion: Patients with acute posterior circulation ischemic stroke and bilateral vertebral artery occlusion are at high risk of having early recurrent ischemic events. Reestablishment of the antegrade vertebro-basilar blood flow through endovascular re-canalization might be an option to decrease stroke recurrence in selected patients with acute posterior circulation stroke and bilateral vertebral artery occlusion.

Background: In the treatment of acute ischemic stroke, intravenous (IV) recombinant tissue plasminogen (rt-PA) and intraarterial (IA) interventions are often combined. However, the optimal dose of IV rt-PA preceding endovascular treatment has not been established., Methods: Studies that used combined IV and IA thrombolysis were identified from a search of the MEDLINE, PubMed, and Cochrane databases. We compared the rates of angiographic recanalization, symptomatic intracerebral hemorrhage (sICH), and favorable functional outcome between patients who had been treated with .6 mg/kg IV rt-PA and those who had received .9 mg/kg rt-PA., Results: Eleven studies met our criteria. In 7 studies, .6 mg/kg IV rt-PA had been administered to 317 patients, whereas 140 patients in 4 studies had received .9 mg/kg of IV rt-PA. The weighted mean of median National Institutes of Health Stroke Scale score at presentation was 18.3 in the .6 mg/kg group (median range 9-34), and 17.3 in the .9 mg/kg group (median range 4-39). Patients in the .9 mg/kg group had higher rates of favorable outcome [odds ratio (OR)=1.60, 95% confidence interval (CI)=(1.07-2.40), P=.022] and similar rates of sICH [OR=.86 (95% CI .41-1.83), P=.70]. Depending on the statistics used, the higher angiographic recanalization rate among patients treated with .9 mg/kg was significant (P=.03, events/trial syntax logistic regression) or borderline significant (P=.07, random effects model)., Conclusion: Our analysis suggests that using .9 mg/kg IV rt-PA prior to IA thrombolysis is safe and may be associated with higher recanalization rates and better functional outcome at 3 months., (Copyright © 2009 by the American Society of Neuroimaging.)

A large vein of Galen was diagnosed in a 9-month-old boy. This was not treated at birth, as there was no associated congestive heart failure. The patient was followed conservatively and follow-up magnetic resonance imaging showed increase in the size of the vein of Galen malformation. Subsequent cerebral angiogram demonstrated hypertrophied but thrombosed right posterior choroidal artery, suggesting spontaneous thrombosis of the arterial feeder and thus the embolization was not pursued., (Copyright © 2009 by the American Society of Neuroimaging.)

Background: Viral Hepatitis (HBV and HCV) is a major health problem affecting approximately two billion population worldwide. It is one of the single most important cause of chronic liver disease and hepato-cellular carcinoma in Pakistan and worldwide and is now spreading beyond endemic dimensions. This study was carried out to assess the frequency of Hepatitis B and C infection in patients undergoing elective surgical operations, and to evaluate the associated risk factors., Methods: This was a descriptive study, conducted at Surgical Department of Ghulam Muhammad Mahar Medical College Hospital, Sukkur, from April 2009 to March 2010. All patients who were admitted in the Surgical Department for elective surgical operations were included in the study. The patients were screened for HBsAg and Anti-HCV using immunochromatography (ICT) method. Those who were weak positive by ICT were further confirmed by ELISA., Results: Total 913 patients were admitted in Surgical Department during study period for elective operations and were screened for HBsAg and Anti-HCV. Out of these, 572 (62.65%) were male and 341 (37.34%) were female. Mean age of these patients was 40 years. After screening, 33 (3.61%) patients were found HBsAg positive and 117 (12.8%) were Anti-HCV positive, while 9 (0.98%) were positive for both. Hepatitis-B was found in 21 (2.3%) males and 12 (1.3%) females, and Hepatitis-C was found in 68 (7.44%) males and 49 (5.36%) female patients. Parenteral injections by quacks, previous surgery, blood transfusion and shaving by barbers were found to be the risk factors., Conclusion: Our message is: 'Prevention is better than cure'. It is essential to prevent spread of Hepatitis B and C by screening every patient before surgery and counselling the patients. The doctors and paramedical staff must follow proper ethical practice ensuring use of sterile disposables where indicated and protecting patients and themselves from these viral infections.

Symptomatic occlusive lesions at the origins of the supra-aortic vessels pose challenges for treatment. Endovascular angioplasty and stent placement via the transfemoral approach is possible, but obtaining a stable position for the guide catheter via this approach is technically difficult. The authors describe the case of a 56-year-old man presenting with symptomatic occlusion of a previously placed stent at the origin of the left common carotid artery (CCA). An endovascular revascularization of the left CCA was planned. However, the absence of a lumen proximal to the stent prevented stable placement of a guide catheter via the transfemoral route. Consequently, the authors used a combined surgical and endovascular approach to gain access to the lesion. The left CCA was exposed surgically distal to the occlusion and clamped just proximal to its bifurcation to preserve flow from the external to the internal carotid artery (ICA) and to prevent embolism into the ICA. A wire was passed retrograde through the occlusive lesion and then was subsequently advanced proximally into the femoral sheath. This allowed transfemoral advancement of the appropriate endovascular devices to perform an angioplasty and placement of a stent. The patient remained neurologically stable, and postoperative studies showed improvement in cerebral perfusion. This case demonstrates the feasibility of distal-to-proximal stent delivery with a combined endovascular and surgical approach.

Objective: To report our initial experience in setting up a neuroendovascular service in a university-based comprehensive stroke center., Methods: We determined the rates of referral path, procedural type, and independently adjudicated 1-month outcomes (actual rates) in first 150 procedures (120 patients) and subsequently compared with rates derived from pertinent clinical trials after adjustment for procedural type (predicted rates)., Results: The patients were referred from the emergency department (n= 44), transferred from another hospital (n= 13), or admitted for elective procedures from the clinic (n= 63). The procedures included treatment of acute ischemic stroke (n= 12); extracranial carotid stent placement (n= 33); extracranial vertebral artery stent placement (n= 13); intracranial angioplasty and/or stent placement (n= 12); embolization for intracranial aneurysms (n= 35), arteriovenous malformations (n= 5), and tumors (n= 10); cerebral vasospasm treatment (n= 26); and others (n= 4). The technical success rate was 100% for intracranial aneurysm obliteration and extracranial carotid artery stent placement, and 95% for those undergoing intracranial or vertebral artery stent placements; and partial or complete recanalization was achieved in 72% of patients undergoing intra-arterial thrombolysis. After adjusting for procedural type, the actual adverse event rate of 3% compared favorably with the predicted rate of 7% based on the results of clinical trials., Conclusions: We provide estimates of procedure volumes and outcomes observed in the initial phase of setting up a neuroendovascular service with an active training program.

Introduction: Acute carotid artery occlusion carries a high morbidity and mortality. Acute angioplasty and stenting is a feasible option with little known about the long term outcome. Limiting factor for this approach is hyperperfusion syndrome or hemorrhagic infarction. Spontaneous early or late recanalization for extracranial vessel is in the range of 5% -30%, with no well defined clinical outcome data. We describe a case of spontaneous common carotid recanalization., Case Report: An 88 year old man presented with right sided weakness, global aphasia and visual field loss and was discovered to have common carotid occlusion at its origin. Within 12 hours of symptom onset patient improved neurologically to his baseline exam and repeat imaging demonstrated spontaneous recanalization. This was followed symptomatic occlusion of left middle cerebral artery The patient was treated with multimodality approach resulting in complete revascularization of the middle cerebral artery and angioplasty and stent placement of the internal carotid artery. Patient had a good neurological outcome at 3 months followup., Conclusion: The present case report demonstrates the risk of spontaneous recanalization acutely in patients presenting with common carotid artery occlusion and associated risk of embolic strokes. In such a patient, concomitant treatment for intracranial occlusion and extracranial high grade stenosis may be performed safely after 30 hours from the initial symptom onset.

Introduction: Approximately 20-30% of the patients with acute ischemic stroke do not have any occlusion demonstrated on initial digital subtraction angiography (DSA). We sought to determine the risk and rates of cerebral infarction and favorable neurological outcome in this group of acute ischemic stroke patients., Materials and Methods: Patients were identified from a prospectively maintained stroke database and from literature search of MEDLINE, PubMed, and Cochrane databases. All patients had initial neurological assessment on National Institutes of Health Stroke Scale (NIHSS). Patients then underwent DSA after initial head computed tomography (CT) scans. Follow-up radiological assessment at 24-72 h was performed with CT and magnetic resonance imaging scans. Association of stroke risk factors with clinical and radiological outcomes was estimated., Results: A total of 81 patients was analyzed (mean age 63 years; 28 were women). The median NIHSS score was 8 (range 2-25). None of the patients received either intravenous or intra-arterial thrombolytic. Cerebral infarction was detected in 62 (76%) of the 81 patients. Twenty-four to 48-h NIHSS was available for 51 patients only. Neurological improvement was observed in 22 (43%) of the 51 patients. Favorable outcome ascertained at 3-month follow-up was seen in 48 (59%) of the 81 patients. After adjusting for age, sex, and baseline NIHSS, male patients [odds ratio (OR) 4.5 (1.4-14.3), p value = 0.01] and patients with age >or=65 [OR 4.3 (1.2-16.2), p value = 0.03] have a higher risk of cerebral infarcts on the follow-up imaging. Similarly, patients who presented with <10 NIHSS had a better 3-month outcome than those with >10 NIHSS [OR 0.21 (0.08-0.61), p value = 0.004]., Conclusion: Ischemic stroke patients without arterial occlusion on DSA have a higher risk of cerebral infarction and disability particularly in men, patients over 65 years of age and with NIHSS >or=10. The cause of infarction may have been arterial obstruction with spontaneous recanalization or small vessel occlusion not visible on DSA.

Background: Intractable epistaxis is treated by ipsilateral trans-arterial embolization of the internal maxillary artery, but there is 13-26% recurrence of bleeding. Preemptive embolization of both internal maxillary arteries along with the ipsilateral facial artery could provide maximal protection against recurrent epistaxis. We report our experience with 8 patients treated with bilateral tri-arterial embolization., Methods: We performed a retrospective review of the patients who were treated with bilateral internal maxillary artery and ipsilateral facial artery embolization from January 2005 to January 2007. All patients had bleeding that was refractory to nasal packing., Results: Eight patients were treated with bilateral tri-arterial embolization. The median age was 65 years (range, 35-90 years). Risk factors included hypertension (n=4), smoking (n=2), alcohol (n=2), and use of anticoagulation (n=2). All but 2 of the patients were treated under local anesthesia. All patients had complete obliteration of bleeding during the procedure, with no residual vascular blush. No major peri- or post-procedural complications were noted. Patients stayed in the hospital for 2-4 days (average 2.6 days). One patient developed ipsilateral temporofacial pain which resolved during hospitalization. Another patient had minor recurrent epistaxis on post operative day 2 which resolved with temporary repacking and the patient was discharged the next day., Conclusion: In our experience with 8 cases, bilateral internal maxillary artery and/or ipsilateral facial artery embolization was achieved without complication and was associated with complete obliteration of vascular blush and no significant recurrent epistaxis.

Percutaneous stenting techniques are becoming more commonly used for treatment of carotid artery disease. One outcome of particular concern is in-stent restenosis. Indications for treatment of in-stent restenosis are not clearly defined. Use of traditional balloon angioplasty with or without stent placement is still considered the first option. Cutting balloon angioplasty has recently been used as an alternative treatment option for revascularization of in-stent restenosis with higher procedural success rates and without the use of additional stents. We report our experience with cutting balloon angioplasty in treating 2 patients with carotid in-stent restonosis, and review previous cases reported in the literature. A total of 16 patients have been treated with cutting balloon angioplasty. Among 11 patients for whom the clinical and angiographic information were available, 63% of patients were asymptomatic at the time of treatment, and more than 90% of patients showed either complete angiographic resolution or residual stenosis of less than 30%. Additional stent placement or angioplasty was required in only half of the patients, and 1 patient had recurrent stenosis. The review suggests that the procedure is safe and effective.

Non-traumatic or spontaneous intracerebral hemorrhage (ICH) is defined as intra-parenchymal bleeding with or without extension into the ventricles and rarely into the subarachoid space. Primary ICH in most cases is associated with chronic hypertension. Acute hypertension is associated with hematoma expansion, and poor neurological outcome. The treatment of hypertension in acute ICH is a topic of controversy. Experiments have shown an area of ischemia around the hematoma, with the reduction of regional cerebral blood flow (CBF) secondary to compression of microvasculature. Not all scientific results agree with the above findings. Recent studies have shown that CBF decreases in the perihematoma region but with concomitant reduction of cerebral metabolism, which would argue against an area of ischemia in the perihematoma region. Based on the above result, there have been several clinical trials looking at clinical outcome and decrease in hematoma expansion rates with reduction of blood pressure acutely after ICH. The parameters for the blood pressure control are still under investigation. The American Heart Association has put forward guidelines for blood pressure control which have been adopted in the centers around the country. We have described the protocol we use at our center for the blood pressure control in patients with acute ICH.

Anomalous courses, anastomoses, and origins of the middle meningeal artery have often been described in the literature; however origin from the basilar artery or its branches is exceedingly rare with only five previous reports. We describe a middle meningeal artery originating from a large lateral pontine branch of the basilar artery. The lateral pontine branch also supplied most of the cerebellar hemispheric territory normally vascularized by both the anterior inferior cerebellar artery and posterior inferior cerebellar artery. We discuss the anatomy and possible embryological development of middle meningeal origin from the basilar artery.

Objective: To report experience with intra-arterial (IA) calcium channel blocker (nicardipine) in patients with acute ischemic stroke with and without reteplase, mechanical thrombectomy (snare), and primary angioplasty to achieve maximal recanalization. Selective delivery of calcium channel blocker may improve perfusion and possibly provide neuroprotection in cerebral ischemia., Methods: We performed a retrospective study to determine the angiographic and clinical outcomes among patients treated with IA nicardipine administered as 2.5-5 mg dose either alone or adjunct to intra-arterial thrombolysis. Mean arterial pressure and heart rate were recorded throughout the injection. Angiographic severity of initial occlusion and recanalization was assessed using the Qureshi grading scheme. Neurological examinations and computed tomographic scans were performed prior to, immediately, and 24 h after thrombolysis for each patient, to assess the neurological improvement and symptomatic or asymptomatic intracranial hemorrhages., Results: Ten patients median age of 60 years (age range: 35-93 years) were administered IA nicardipine. The median admission National Institutes of Health Stroke Scale (NIHSS) score was 14 (range 6-19). All patients received IA nicardipine either in combination with thrombolytics (n = 6) or as monotherapy (n = 4). The average decrease in mean arterial pressure (MAP) was 10 mmHg; except one patient who had an asymptomatic decline of 34 mm Hg, which responded to fluid resuscitation. None of the patients suffered any procedural and post-procedural complication. Overall recanalization (improvement in one grade or greater) was observed in 2 of 10 patients with IA nicardipine with or without thrombolytic treatment. Other angiographic changes observed included improvement in collateral flow (n = 2), increase in transit time (n = 1), and vasodilation of distal arteries and branches (n = 4). No patient demonstrated any worsening from the baseline grade in response to IA nicardipine. Of the two patients who underwent serial magnetic resonance imaging (MRI) and one patient demonstrated reversal of pretreatment restricted diffusion. Neurological improvement defined by a decrease of four points or greater was observed in four patients at 24 h following treatment., Conclusion: Intra-arterial delivery of nicardipine in doses up to 5 mg is well tolerated among patients with acute ischemic stroke. Further studies are required to determine the potential efficacy of this approach with or without thrombolytics.