Publications by authors named "Adam Dmytriw"

104 Publications

Sylvian fissure arteriovenous malformations: case series and systematic review of the literature.

Neuroradiol J 2021 Jun 4:19714009211021776. Epub 2021 Jun 4.

Brain and Spinal Cord Injury Research Center, Tehran University of Medical Sciences, Iran.

Background: Sylvian fissure arteriovenous malformations are rare but important vascular lesions, whose importance lies in both haemorrhage and seizure risk. Although surgery has been recommended as a treatment, the overall estimation of success has not been reported to render outcomes easier to understand in comparison to other treatment modalities.

Objectives: This systematic review of the literature and two cases aims to illustrate the results of surgery as a contemporary treatment option and present a novel anatomical classification system for Sylvian fissure arteriovenous malformations.

Materials And Methods: A systematic review was performed by searching MEDLINE (PubMed), EMBASE and Cochrane electronic bibliographic databases from conception to 2018. The following keywords were used: 'Sylvian fissure' AND 'AVM' OR 'arteriovenous malformation' OR 'intracranial arteriovenous malformation' OR 'cerebral arteriovenous malformation' OR 'brain arteriovenous malformation'. The search strategy was not limited by study design but only included keywords in the English language. In addition, two local institution Sylvian fissure arteriovenous malformations are presented and incorporated.

Results: A total of nine full-text articles were included in the analysis. The results of reported cases and the literature review emphasise the role of surgery in the treatment of Sylvian fissure arteriovenous malformations, with an acceptable result in carefully selected patients. We propose a classification system which may inform the choice of surgical approach for these lesions.

Conclusions: Surgery remains the cornerstone of Sylvian fissure arteriovenous malformation treatment, which may apply to high-grade lesions in this special anatomical location.
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http://dx.doi.org/10.1177/19714009211021776DOI Listing
June 2021

Long Vascular Sheaths for Transfemoral Neuroendovascular Procedures in Children.

Neurointervention 2021 Jun 3. Epub 2021 Jun 3.

Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada.

Purpose: To evaluate the safety and efficacy of long vascular sheaths for transfemoral neuroendovascular procedures in children.

Materials And Methods: A retrospective evaluation of transfemoral neuroendovascular procedures in children <18 years, using long sheaths was undertaken analyzing procedure type, fluoroscopic times, technical success, access site and systemic complications. Twenty-seven consecutive procedures were included over a two-year period. Mean age was 8.4 years (standard deviation [SD] 6.3) (range 17.0 months-16.3 years).

Results: Patients were 44% female and mean weight was 35.0 kg (SD 22.8) (range 9.8-72.2 kg). A third of the procedures were performed in ≤15 kg children. The most common procedure was for embolization (n=13, 48.1%) and the most common indication was dual microcatheter technique (52%). The most common device used was the 5 Fr Cook Shuttle sheath. Mean fluoroscopy time was 61.9 minutes (SD 43.1). Of these procedures, 93% were technically successful. Femoral vasospasm, when present, was self-limiting. Complications (3/27, 11.1%) included groin hematoma (n=1), neck vessel spasm that resolved with verapamil (n=1), and intracranial thromboembolism (n=1), with no significant difference between the ≤15 kg and >15 kg subcohorts. There were no aorto-femoro-iliac or limb-ischemic complications.

Conclusion: Long vascular sheaths without short femoral sheaths can be safely used for pediatric neuroendovascular procedures as they effectively increase inner diameter access without increasing the outer sheath diameter. This property increases the range of devices used and intracranial techniques that can be safely performed without arterial compromise, thus increasing the repertoire of the neurointerventionalist.
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http://dx.doi.org/10.5469/neuroint.2021.00192DOI Listing
June 2021

The Woven EndoBridge device for ruptured intracranial aneurysms: international multicenter experience and updated meta-analysis.

Neuroradiology 2021 May 25. Epub 2021 May 25.

Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Neuroendovascular Program, 55 Fruit St, WAC 745, Boston, MA, USA.

Purpose: The Woven EndoBridge (WEB) can be used to treat wide-necked aneurysms without antiplatelet medications, suggesting it may have advantages in the setting of aneurysmal subarachnoid hemorrhage (aSAH). The goal was assessment of safety and efficacy of WEB in aSAH given the delayed nature of aneurysmal thrombosis.

Methods: An international retrospective analysis of patients with aSAH treated with WEB was conducted at 7 tertiary centers from 2016 to 2020. Outcomes included rates of rebleeding, retreatment, complications, and complete occlusion. Furthermore, a systematic review and meta-analysis was conducted from 2011 to 2020 assessing the same outcomes. All pooled event rates were calculated using a random effect model.

Results: Consecutive patients with aSAH harbored 25 aneurysms that were treated with 29 WEB devices. The mean age was 53 years, and 65% were female. Zero experienced rebleeding, 2 were retreated, 2 experienced complications, 16 were completely occluded at 3 months, and 21 were completed occluded at 9-12 months. Meta-analysis of 309 WEB treatments for aSAH from 7 case series revealed 2.5% (95% CI 1-5%) had rebleeding, 9% (95% CI 4-17%) were retreated, 17% (95% CI 10-30%) had complications, and 61% (95% CI 51-71%) were completely occluded at 3-6 months.

Conclusion: WEB embolization in the setting of aSAH provides similar protection against rebleeding with comparable retreatment rates to traditional approaches. However, there is a higher rate of incomplete radiographic occlusion and operative complications compared to WEB embolization of unruptured aneurysms. Long-term prospective studies are needed to fully delineate the role of WEB embolization in aSAH.
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http://dx.doi.org/10.1007/s00234-021-02727-6DOI Listing
May 2021

Corticosteroid therapy for COVID-19: A systematic review and meta-analysis of randomized controlled trials.

Medicine (Baltimore) 2021 May;100(20):e25719

Superior Medical Experts, St. Paul.

Background: Corticosteroid treatment is an effective and common therapeutic strategy for various inflammatory lung pathologies and may be an effective treatment for coronavirus disease 2019 (COVID-19). The purpose of this systematic review and meta-analysis of current literature was to investigate the clinical outcomes associated with corticosteroid treatment of COVID-19.

Methods: We systematically searched PubMed, medRxiv, Web of Science, and Scopus databases through March 10, 2021 to identify randomized controlled trials (RCTs) that evaluated the effects of corticosteroid therapies for COVID-19 treatment. Outcomes of interest were mortality, need for mechanical ventilation, serious adverse events (SAEs), and superinfection.

Results: A total of 7737 patients from 8 RCTs were included in the quantitative meta-analysis, of which 2795 (36.1%) patients received corticosteroids plus standard of care (SOC) while 4942 (63.9%) patients received placebo and/or SOC alone. The odds of mortality were significantly lower in patients that received corticosteroids as compared to SOC (odds ratio [OR] = 0.85 [95% CI: 0.76; 0.95], P = .003). Corticosteroid treatment reduced the odds of a need for mechanical ventilation as compared to SOC (OR = 0.76 [95% CI: 0.59; 0.97], P = .030). There was no significant difference between the corticosteroid and SOC groups with regards to SAEs and superinfections.

Conclusion: Corticosteroid treatment can reduce the odds for mortality and the need for mechanical ventilation in severe COVID-19 patients.
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http://dx.doi.org/10.1097/MD.0000000000025719DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8137023PMC
May 2021

#RadialFirst and #RadialForNeuro: A descriptive analysis of Twitter conversations regarding transradial access.

Neuroradiol J 2021 Apr 30:19714009211012363. Epub 2021 Apr 30.

Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, USA.

Background: Transradial access for neurointerventional procedures was adopted and modified from cardiovascular intervention and is increasingly established as a safe and effective alternative to transfemoral catheterization. As social media influences public opinion on medical treatment, this study analyzes Twitter conversations to elucidate social media's depiction of transradial access as a neurointerventional tool.

Materials And Methods: Twitter hashtags #RadialFirst and #RadialForNeuro were evaluated using a mixed-method analysis of quantitative social media metrics and qualitative thematic analysis.

Results: Between January 2015 and April 2020, 104,146 tweets from 141 countries employed the hashtag #RadialFirst (2015 (1); 2016 (0); 2017 (22,804); 2018 (33,074); 2019 (38,352); 2020 (9,915 January-April)). These generated 226,909,374 impressions and were retweeted 80,120 times by 13,707 users. Media was present in 62.5% of tweets (e.g. wrist image, angiographic runs) but only 14.5% had a reference article. Physicians authored 70.8% of tweets; interventional cardiologists accounted for 83% of top 100 influencers. #RadialForNeuro is more nascent (6 posts in 2019; 323 posts January-April 2020), with 392,662 impressions, and 254 retweets by 177 users; physicians authored 35.6%. Compared to #RadialFirst, #RadialforNeuro tweets were more likely to include media (76%), less likely to include citations (9.7%), and more likely to discuss complications and troubleshooting techniques.

Conclusion: Twitter activity regarding transradial access permits information dissemination and discussion on approach benefits and challenges. However, many posts arise from non-physician sources and lack links to peer-reviewed publication. The public should be mindful that tweets may reflect opinions, rather than experience or scientific evidence.
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http://dx.doi.org/10.1177/19714009211012363DOI Listing
April 2021

Optical Coherence Tomography of Plaque Erosion and Thrombus in Severe Vertebral Artery Stenosis.

Diagnostics (Basel) 2021 Apr 1;11(4). Epub 2021 Apr 1.

Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute (China-INI), Beijing 100053, China.

A 69-year-old male presented with medically refractory vertebrobasilar insufficiency and paroxysmal subjective dizziness for six months. Severe stenosis of a dominant left V2 vertebral artery segment was identified on digital subtraction angiography (DSA) with an irregular intraluminal filling defect immediately above the stenosis. Optical coherence tomography (OCT) demonstrated a normal lumen at the distal end, with red thrombus detected distal to the stenosis. Atherosclerotic plaque containing fibro-lipid was also identified and treated with a drug-eluting stent. Distal red thrombi were not covered by stenting, indicating embolization risk in the future. Clear posterior fossa symptoms occurred after intervention, and treatment with a standard dual antiplatelet regimen and statin therapy was prescribed for one year. Six months after treatment, the symptoms improved, and six-minute walking distances were successful with no gait impairment. To our knowledge, this is the first V2 segment stenosis assessed by OCT imaging before and after stenting, indicating an intact fibrous cap with thrombus formation, as well as plaque erosion. Understanding the role and careful use of OCT may improve the identification of red thrombus and plaque erosion when clinically indicated.
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http://dx.doi.org/10.3390/diagnostics11040638DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8065715PMC
April 2021

Factors Influencing Recanalization After Mechanical Thrombectomy With First-Pass Effect for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

Front Neurol 2021 9;12:628523. Epub 2021 Apr 9.

China International Neuroscience Institute, Beijing, China.

First-pass effect (FPE) is increasingly recognized as a predictor of good outcome in large vessel occlusion (LVO). This systematic review and meta-analysis aimed to elucidate the factors influencing recanalization after mechanical thrombectomy (MT) with FPE in treating acute ischemic stroke (AIS). Main databases were searched for relevant randomized controlled trials (RCTs) and observational studies reporting influencing factors of MT with FPE in AIS. Recanalization was assessed by the modified thrombolysis in cerebral ischemia (mTICI) score. Both successful (mTICI 2b-3) and complete recanalization (mTICI 2c-3) were observed. Risk of bias was assessed through different scales according to study design. The statistic was used to evaluate the heterogeneity, while subgroup analysis, meta-regression, and sensitivity analysis were performed to investigate the source of heterogeneity. Visual measurement of funnel plots was used to evaluate publication bias. A total of 17 studies and 6,186 patients were included. Among them, 2,068 patients achieved recanalization with FPE. The results of meta-analyses showed that age [mean deviation (MD):1.21,95% confidence interval (CI): 0.26-2.16; = 0.012], female gender [odds ratio (OR):1.12,95% CI: 1.00-1.26; = 0.046], diabetes mellitus (DM) (OR:1.17,95% CI: 1.01-1.35; = 0.032), occlusion of internal carotid artery (ICA) (OR:0.71,95% CI: 0.52-0.97; = 0.033), occlusion of M2 segment of middle cerebral artery (OR:1.36,95% CI: 1.05-1.77; = 0.019), duration of intervention (MD: -27.85, 95% CI: -42.11-13.58; < 0.001), time of onset to recanalization (MD: -34.63, 95% CI: -58.45-10.81; = 0.004), general anesthesia (OR: 0.63,95% CI: 0.52-0.77; < 0.001), and use of balloon guide catheter (BGC) (OR:1.60,95% CI: 1.17-2.18; = 0.003) were significantly associated with successful recanalization with FPE. At the same time, age, female gender, duration of intervention, general anesthesia, use of BGC, and occlusion of ICA were associated with complete reperfusion with FPE, but M2 occlusion and DM were not. Age, gender, occlusion site, anesthesia type, and use of BGC were influencing factors for both successful and complete recanalization after first-pass thrombectomy. Further studies with more comprehensive observations indexes are need in the future.
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http://dx.doi.org/10.3389/fneur.2021.628523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8062801PMC
April 2021

Outcomes of acute respiratory distress syndrome in COVID-19 patients compared to the general population: a systematic review and meta-analysis.

Expert Rev Respir Med 2021 May 5:1-8. Epub 2021 May 5.

Department of Internal Medicine, Kamineni Academy of Medical Sciences and Research Centre, Hyderabad, India.

Introduction: Acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19) often leads to mortality. Outcomes of patients with COVID-19-related ARDS compared to ARDS unrelated to COVID-19 is not well characterized.

Areas Covered: We performed a systematic review of PubMed, Scopus, and MedRxiv 11/1/2019 to 3/1/2021, including studies comparing outcomes in COVID-19-related ARDS (COVID-19 group) and ARDS unrelated to COVID-19 (ARDS group). Outcomes investigated were duration of mechanical ventilation-free days, intensive care unit (ICU) length-of-stay (LOS), hospital LOS, and mortality. Random effects models were fit for each outcome measure. Effect sizes were reported as pooled median differences of medians (MDMs), mean differences (MDs), or odds ratios (ORs).

Expert Opinion: Ten studies with 2,281 patients met inclusion criteria (COVID-19: 861 [37.7%], ARDS: 1420 [62.3%]). There were no significant differences between the COVID-19 and ARDS groups for median number of mechanical ventilator-free days (MDM: -7.0 [95% CI: -14.8; 0.7], p = 0.075), ICU LOS (MD: 3.1 [95% CI: -5.9; 12.1], p = 0.501), hospital LOS (MD: 2.5 [95% CI: -5.6; 10.7], p = 0.542), or all-cause mortality (OR: 1.25 [95% CI: 0.78; 1.99], p = 0.361). Compared to the general ARDS population, results did not suggest worse outcomes in COVID-19-related ARDS.
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http://dx.doi.org/10.1080/17476348.2021.1920927DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8108193PMC
May 2021

In vivo detection of beta-amyloid at the nasal cavity and other skull-base sites: a retrospective evaluation of ADNI1/GO.

Ann Nucl Med 2021 Jun 12;35(6):728-734. Epub 2021 Apr 12.

Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, M4N 3M5, Canada.

Introduction: Amyloid beta (Aβ) is partially cleared from the CSF via skull base perivascular and perineural lymphatic pathways, particularly at the nasal cavity. In vivo differences in Aβ level at the nasal cavity between patients with Alzheimer's disease (AD), subjects with mild cognitive impairment (MCI) and cognitively normal (CN) individuals have not been previously assessed.

Methods: This is a retrospective evaluation of subject level data from the ADNI-1/GO database. Standardized uptake value ratio (SUVR) maximum on C-Pittsburgh compound-B (PiB)-PET was assessed at the nasal cavity on 223 scans. Exploratory ROI analysis was also performed at other skull base sites. SUVR maximum values and their differences between groups (CN, MCI, AD) were assessed. CSF Aβ levels and CSF Aβ 42/40 ratios were correlated with SUVR maximum values.

Results: 103 subjects with 223 PiB-PET scans (47 CN, 32 AD and 144 MCI) were included in the study. The SUVR maxima at the nasal cavity were significantly lower in subjects with AD [1.35 (± 0.31)] compared to CN [1.54 (± 0.30); p = 0.024] and MCI [1.49 (± 0.33); p = 0.049]. At very low CSF Aβ, less than 132 pg/ml, there was significant correlation with nasal cavity SUVR maximum. The summed averaged SUVR maximum values were significantly lower in subjects with AD [1.35 (± 0.16)] compared to CN [1.49 (± 0.17); p = 0.003] and MCI [1.40 (± 0.17); p = 0.017].

Conclusion: Patients with AD demonstrate reduced nasal cavity PiB-PET radiotracer uptake compared to MCI and CN, possibly representing reduced Aβ clearance via perineural/perivascular lymphatic pathway. Further work is necessary to elucidate the true nature of this finding.
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http://dx.doi.org/10.1007/s12149-021-01614-7DOI Listing
June 2021

Efficacy of aspirin for sporadic vestibular schwannoma: a meta-analysis.

Neurol Sci 2021 Mar 26. Epub 2021 Mar 26.

Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines.

Background: Pharmacologic treatment of vestibular schwannomas (VSs) may increase the success of conservative management for small lesions, and offer an alternative to surgery and stereotactic radiotherapy in symptomatic cases in the high-risk population. Agents that have been studied include aspirin (ASA), but the results of the preliminary studies have been conflicting. In this study, we aimed to systematically review the evidence on the effect of ASA intake on tumor growth in patients with VSs.

Methods: Pubmed, Cochrane, Scopus, Embase, ClinicalTrials.gov , and Web of Science were searched for studies comparing VS tumor growth in patients with aspirin intake and those without. Random-effect meta-analysis was used to evaluate the outcomes in terms of linear and/or volumetric tumor growth.

Results: Four retrospective cohort studies were included in the meta-analysis. No significant difference was found in tumor growth between VS patients with aspirin intake and those without. This result held true for the analysis of linear tumor growth (OR 1.23; 95% CI 0.49, 3.10), volumetric tumor growth (OR 1.41; 95% CI 0.36, 5.59), and both combined (OR 1.02; 95% CI 0.56, 1.86).

Conclusions: Our meta-analysis suggests that there is insufficient evidence to recommend ASA therapy in patients with VSs. High-quality randomized controlled trials are warranted to determine the efficacy of this drug in reducing VS tumor growth.
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http://dx.doi.org/10.1007/s10072-021-05193-3DOI Listing
March 2021

Incidence, Characteristics and Outcomes of Large Vessel Stroke in COVID-19 Cohort: An International Multicenter Study.

Neurosurgery 2021 Mar 18. Epub 2021 Mar 18.

Department of Neurology, Miller School of Medicine, Miami, Florida, USA.

Background: While there are reports of acute ischemic stroke (AIS) in coronavirus disease 2019 (COVID-19) patients, the overall incidence of AIS and clinical characteristics of large vessel occlusion (LVO) remain unclear.

Objective: To attempt to establish incidence of AIS in COVID-19 patients in an international cohort.

Methods: A cross-sectional retrospective, multicenter study of consecutive patients admitted with AIS and COVID-19 was undertaken from March 1 to May 1, 2020 at 12 stroke centers from 4 countries. Out of those 12 centers, 9 centers admitted all types of strokes and data from those were used to calculate the incidence rate of AIS. Three centers exclusively transferred LVO stroke (LVOs) patients and were excluded only for the purposes of calculating the incidence of AIS. Detailed data were collected on consecutive LVOs in hospitalized patients who underwent mechanical thrombectomy (MT) across all 12 centers.

Results: Out of 6698 COVID-19 patients admitted to 9 stroke centers, the incidence of stroke was found to be 1.3% (interquartile range [IQR] 0.75%-1.7%). The median age of LVOs patients was 51 yr (IQR 50-75 yr), and in the US centers, African Americans comprised 28% of patients. Out of 66 LVOs, 10 patients (16%) were less than 50 yr of age. Among the LVOs eligible for MT, the average time from symptom onset to presentation was 558 min (IQR 82-695 min). A total of 21 (50%) patients were either discharged to home or discharged to acute rehabilitation facilities.

Conclusion: LVO was predominant in patients with AIS and COVID-19 across 2 continents, occurring at a significantly younger age and affecting African Americans disproportionately in the USA.
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http://dx.doi.org/10.1093/neuros/nyab111DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8108633PMC
March 2021

Management of Ruptured Intracranial Aneurysms in the Post-International Subarachnoid Aneurysm Trial Era: A Single-Centre Prospective Series.

Can J Neurol Sci 2021 Mar 17:1-8. Epub 2021 Mar 17.

Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada.

Background: Aneurysmal subarachnoid haemorrhage (aSAH) is associated with significant morbidity and mortality. The International Subarachnoid Aneurysm Trial (ISAT) reported reduced morbidity in patients treated with endovascular coiling versus surgical clipping. However, recent studies suggest that there is no significant difference in clinical outcomes. This study examines the outcomes of either technique for treating aSAH during the 15 years post-ISAT at a Canadian quaternary centre.

Methods: We reviewed prospectively collected data of patients admitted with aSAH from January 2002 to December 2017. Glasgow Outcome Scale (GOS) was compared at discharge, 6 months and 12 months' follow-up using univariate and multivariable ordinal logistic regression. Post-operative complications were assessed using binary logistic regression.

Results: Two-hundred and eighty-seven patients were treated with coiling and 95 patients with clipping. The mean age of clipped patients was significantly younger, and hypertension was significantly commoner in coiled patients. A greater proportion of coiled aneurysms were located in the posterior circulation. No difference in the odds of having a favourable GOS was seen between patients who were clipped versus coiled at any of follow-up time points on univariate or multivariable analysis. In both treatment groups, patient recovery to independence (GOS 4-5) was seen from discharge to 6 months, but not from 6 to 12 months' follow-up, without difference between clipping and coiling.

Conclusion: These real-world findings suggest clipping remains an effective and important treatment option for patients with aSAH who do not meet ISAT inclusion criteria. The results can assist in clinical decision-making processes and understanding of the natural recovery progression of aSAH.
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http://dx.doi.org/10.1017/cjn.2021.45DOI Listing
March 2021

Neovascularization in Human Intracranial Atherosclerotic In-Stent Restenosis.

Diagnostics (Basel) 2021 Feb 17;11(2). Epub 2021 Feb 17.

Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China.

Optical coherence tomography (OCT) has seen widespread use in cardiovascular and interventional endovascular imaging. While scattered reports of intracranial usage have been reported for the assessment of atherosclerotic stenosis, nutrifying neovasculature supplying plaque and neointima have not been demonstrated until now. We report the first in-vivo illustration of this phenomenon, which is a high-resolution depiction of a critical pathway for in-stent restenosis.
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http://dx.doi.org/10.3390/diagnostics11020322DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7922829PMC
February 2021

Cognitive rehabilitation interventions after stroke: protocol for a systematic review and meta-analysis of randomized controlled trials.

Syst Rev 2021 03 4;10(1):66. Epub 2021 Mar 4.

Department of Neurology, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China.

Background: Stroke is the second leading cause of death worldwide, and 53.4% of stroke survivors suffer from post-stroke cognitive impairment. Post-stroke cognitive impairment can increase hospitalization rate and cost of care and decrease the quality of life of stroke patients. To date, multiple cognitive rehabilitation interventions have been tested in stroke populations with post-stroke cognitive impairment. However, the most efficacious intervention has not been established. This systematic review aims to compare the efficacy of cognitive rehabilitation interventions for patients with post-stroke cognitive impairment.

Methods: We will search MEDLINE, EMBASE, CENTRAL, PsycINFO, CINAHL, PubMed, and clinical trial registries to identify eligible randomized clinical trials with no restrictions in the date of publication and language. Studies conducted with patients aged 18 or over, with the presence of cognitive impairment after being diagnosed with stroke will be included. Studies will be restricted to randomized controlled trials comparing a cognitive rehabilitation intervention with another intervention. The primary outcome is any clinical changes in the general or specific cognitive domain (e.g., executive function, attention, memory, or perception). The secondary outcomes that will be collected include adverse effects (e.g., stroke, disability, or mortality) and quality of life. Two independent reviewers will assess articles to identify trials eligible for inclusion. Data extraction and risk of bias assessment of the included studies will also be done independently. Any discrepancies will be solved by discussion, or a third reviewer will be consulted if necessary. A meta-analysis will be carried out if appropriate.

Discussion: This systematic review for patients with post-stroke cognitive impairment will assess the efficacy of cognitive rehabilitation interventions. And our results will help clinical decision-making and support the development of clinical practice guidelines.

Trial Registration: Systematic review registration: PROSPERO CRD42020173988.
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http://dx.doi.org/10.1186/s13643-021-01607-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7931553PMC
March 2021

Recurrence and Coniglobus Volumetric Resolution of Subacute and Chronic Subdural Hematoma Post-Middle Meningeal Artery Embolization.

Diagnostics (Basel) 2021 Feb 7;11(2). Epub 2021 Feb 7.

Interventional Neuro Associates, 43 Westminster Avenue, Bergenfield, NJ 06721, USA.

Objective: To study the efficacy of middle meningeal artery (MMA) embolization for the treatment of chronic subdural hematoma (SDH) and characterize its post-embolization volumetric resolution.

Methods: Ten patients diagnosed with 13 cSDH underwent MMA embolization. SDH volumes were measured from time of initial discovery on imaging to pre-operative, post-operative, short-term and long-term follow-up. Time between procedure to obliteration was also measured. Volumetric analysis was done using the coniglobus formula, and recurrence rate as well as resolution timeline was defined using best-fit models.

Results: Out of 10 patients, five were recurrent lesions, three were bilateral and seven unilateral cSDH. Average and median pre-operative volumes were 105.3 cc and 97.4 cc, respectively. Embolization on average was performed 21 days after discovery. Sixty percent of patients had concurrent antiplatelets or anticoagulation use. Forty percent underwent embolization treatment as the primary therapy. Recurrence was not seen in any patients treated with embolization. There were no peri- or post-operative complications. Five patients experienced complete or near-complete obliteration, while those with partial resolution showed a composite average of 75% volumetric reduction in 45 days. Post-embolization, the volumetric resolution followed an exponential decay curve over time and was independent of initial volume.

Conclusion: MMA embolization contributed to a marked reduction in SDH volume post-operatively and can be used as a curative therapy for primary or recurrent chronic SDH.
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http://dx.doi.org/10.3390/diagnostics11020257DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7915255PMC
February 2021

Use of radial access sheaths for transfemoral neuroendovascular procedures in children.

Neuroradiology 2021 Apr 9;63(4):633-635. Epub 2021 Feb 9.

Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada.

Purpose: Pediatric neuroendovascular procedures require special considerations. Given small vessel sizes, risk for arterial injury must be weighed against use of larger devices, with the diameter of the sheath being a known association with arterial complications. We recently transitioned to using thin-walled radial sheaths for transfemoral angiography in children, given their lower profile. Here, we report on these sheaths' technical success and complications, comparing against a historical cohort where regular vascular sheaths were employed.

Methods: We retrospectively recorded patient and procedural data from 168 consecutive procedures from September 2017 to January 2019 when radial-specific sheaths were exclusively used at our tertiary pediatric hospital. These results were compared to data from September 2015 to January 2017, when regular vascular sheaths were exclusively used in 152 consecutive procedures. Statistical analysis was performed using unpaired t test or chi-square test, with p < 0.05 considered statistically significant.

Results: Patient characteristics (age, sex, weight) were not statistically different between the case and control group. No significant differences were found in the procedural data with the exception of heparin use which was higher in the radial-sheath cohort. There was a decrease in the rate of complications in the case group (1.2%) versus control group (2.6%), though not statistically different.

Conclusion: Radial-specific sheaths have numerous beneficial characteristics that make them well-suited to the pediatric population. In our study, we show that radial sheaths are equally effective and safe perioperatively. Follow-up research may show if radial sheaths used transfemorally decrease long-term complications such as limb-length discrepancy and mortality.
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http://dx.doi.org/10.1007/s00234-021-02664-4DOI Listing
April 2021

Efficacy of convalescent plasma therapy for COVID-19: A systematic review and meta-analysis.

J Clin Apher 2021 Jun 5;36(3):470-482. Epub 2021 Feb 5.

Department of Neuroradiology, Valley Baptist Medical Center, Harlingen, Texas, USA.

The purpose of this systematic review and meta-analysis was to examine clinical outcomes associated with convalescent plasma therapy in COVID-19 patients. We performed a literature search on PubMed, medRxiv, Web of Science, and Scopus to identify studies published up to December 10th, 2020 that examined the efficacy of convalescent plasma treatment for COVID-19. The primary endpoints were mortality, clinical improvement, and hospital length of stay. We screened 859 studies that met the search criteria, performed full-text reviews of 56 articles, and identified 15 articles that fulfilled inclusion criteria for meta-analysis. The odds of mortality were significantly lower in the convalescent plasma group compared to the control group (OR = 0.59 [95% CI = 0.44; 0.78], P < .001), although results from two key randomized controlled trials did not support the mortality benefit. The odds of clinical improvement were significantly higher in the convalescent plasma group compared to the control group (OR = 2.02 [95% CI = 1.54; 2.65], P < .001). There was no difference in hospital length of stay between the convalescent plasma group and the control group (MD = -0.49 days [95% CI = -3.11; 2.12], P = .713). In all, these data indicate that a mortality benefit with convalescent plasma is unclear, although there remain benefits with convalescent plasma therapy for COVID-19.
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http://dx.doi.org/10.1002/jca.21881DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014691PMC
June 2021

In search of predictive and response markers in antiangiogenic therapy of glioblastoma.

Neuro Oncol 2021 02;23(2):184-185

Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1093/neuonc/noaa293DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7906059PMC
February 2021

Venous dysfunction plays a critical role in "normal" white matter disease of aging.

Med Hypotheses 2021 Jan 24;146:110457. Epub 2020 Dec 24.

Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada. Electronic address:

A ubiquitous finding on MRI in older individuals, age-related cerebral white matter hyperintensities (WMHs) are associated with cognitive decline, dementia, disability, and death. Currently, these findings are thought to represent small infarcts secondary to lipohyalinotic arteriosclerosis. Commonly though, the anatomic distribution of WMHs is often non-arterial, and parallel the deep venous system. Furthermore, there is discrepant evidence for the role of conventional vascular risk factors such as hypertension, carotid atherosclerosis and diabetes for the development and progression of these. Interventions targeting conventional vascular risk factors lack consistency in preventing the progression of WMHs. There is evidence for age-related hemodynamic cervical venous dysfunction resulting in reduced internal jugular vein venous compliance, venous dilatation, and venous reflux. Similarly, venous collagenosis increases with age. Increased blood-brain barrier (BBB) permeability is also noted with aging. Both hemodynamic venous dysfunction, venous sclerosis, and increased BBB permeability are associated with WMHs. We propose that age-related WMHs are a sequalae of venous dysfunction. Venous dysfunction results initially in increased transmission of venous pressures to the brain. Subsequent BBB disruption leads to increased permeability with progression to end-stage findings of age-related WMHs.
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http://dx.doi.org/10.1016/j.mehy.2020.110457DOI Listing
January 2021

Endovascular treatment versus standard medical treatment for acute basilar artery occlusion: protocol for a systematic review and meta-analysis.

BMJ Open 2020 11 27;10(11):e040415. Epub 2020 Nov 27.

Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China

Introduction: Acute basilar artery occlusion (BAO) can cause posterior circulation stroke. There are two predominant therapies for BAO: standard medical treatment (SMT) and SMT plus endovascular thrombectomy (EVT). However, a conclusive systematic comparison of the safety and efficacy of SMT and those of SMT plus EVT for the treatment of BAO is lacking. Thus, a systematic review and meta-analysis is needed to evaluate the safety and efficacy of SMT and SMT plus EVT for the treatment of BAO.

Methods And Analysis: This protocol is drafted referring to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols guidelines. We will search eligible studies from four main databases including MEDLINE, Web of Science, Cochrane Library and Embase. Randomised controlled trials (RCTs) and observational studies published before 1 October 2020 will be included. Two reviewers in our team will conduct the study selection and data extraction independently. Risk of bias will be assessed by Cochrane Collaboration criteria and the Newcastle-Ottawa scale for RCTs and observational studies, respectively. We will assess the good functional outcomes defining the modified Rankin scale score ≤2 at 90 days after treatment, short-term stroke severity as National Institutes of Health Stroke Scale score at 24 hours after intervention, and successful recanalisation as a modified Thrombolysis in Cerebral Infarction scale score of ≥2b after intervention. Also, safety outcomes will be assessed. The performance of this meta-analysis will depend on the quantity of included studies. The assessment of study heterogeneity will be performed by the I statistic. If there is mild heterogeneity (I<20%) of intervention outcomes in included studies, the fixed-effect model will be applied; otherwise, the random-effect model will be performed. Subgroup analyses and an assessment of publication bias will also be conducted with sufficient data.

Ethics And Dissemination: No collection of primary data from patients is needed. Therefore, the ethical approval is unnecessary. The results may be presented in a peer-reviewed journal and related conferences.

Prospero Registration Number: CRD42020176764.
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http://dx.doi.org/10.1136/bmjopen-2020-040415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7703427PMC
November 2020

Efficacy and safety of lopinavir/ritonavir in the treatment of COVID-19: A systematic review.

Expert Rev Anti Infect Ther 2021 06 21;19(6):679-687. Epub 2020 Dec 21.

Department of Data Research, Nested Knowledge, St. Paul, MN, USA.

: To systematically review the clinical literature reporting the use of Lopinavir/ritonavir (LPV/r) for the treatment of patients with Cornonavirus disease 19 (COVID-19) to assess the efficacy of LPV/r for the treatment of COVID-19.: The authors systematically searched PubMed and MedRxiv databases for studies describing treatment of COVID-19 patients using LPV/r compared to other therapies. Articles were excluded if they were case reports, opinion editorials, preclinical studies, single-armed studies, not written in English, not relevant to the topic, or published before May 2020. The included outcomes were viral clearance as measured by reverse-transcription polymerase chain reaction (RT-PCR) negativity and/or improvement on chest computed tomography (CT), mortality, and adverse events.: Among 858 total studies, 16 studies met the inclusion criteria and were included in the qualitative review. These studies consisted of 3 randomized control trials, 3 open-label trials, and 10 observational studies. Most of these studies did not report positive clinical outcomes with LPV/r treatment.: The systematic review revealed insufficient evidence of effectiveness and clinical benefit of LPV/r in the treatment of COVID-19 patients. Specifically, LPV/r does not appear to improve clinical outcome, mortality, time to RT-PCR negativity, or chest CT clearance in patients with COVID-19.
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http://dx.doi.org/10.1080/14787210.2021.1848545DOI Listing
June 2021

Bibliometric evaluation of systematic review and meta analyses published in the top 5 "high-impact" radiology journals.

Clin Imaging 2021 Mar 6;71:52-62. Epub 2020 Nov 6.

Sunnybrook Health Sciences Centre, Department of Medical Imaging, University of Toronto, Toronto, ON, Canada.

Introduction: Meta-analyses provide high-level evidence and understanding their trends may provide understanding of the field as a whole. Bibliometric analysis was undertaken to understand research trends in a particular field or subfield and to assess citation as a measure of impact.

Methods: All journals categorised as "Radiology, Nuclear Medicine & Medical Imaging" under the Web of Science subject category were included. After analyzing impact factors of the journals in up to 2018, the top five journals were identified. The retrieved results were ordered by citation count based on Web of Science and Scopus. Specific parameters regarding the title, journal, publication year, authors, country of origin, institution and university, field of study and funding sources were analyzed.

Results: A total of 139 articles were identified. The mean number of citations per article was 25.3 and 22.6 in Scopus and Web of Science respectively, with four articles receiving 100 or more citations. European Radiology had the greatest number of top cited articles (n = 68; 49%). Most number of articles originated from South Korea (n = 60; 43%) and the commonest field of focus with the most common being oncology (n = 51; 27%).

Conclusion: The top 5 high impact journals published a large number of meta-analysis and systematic reviews. The greatest number of top-cited articles were from South Korea, shifting away from the United States. Large number of studies focused on oncologic imaging, consistent with recent trends towards development of imaging biomarkers and personalized medicine. Author H index did not predict citation number or density.
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http://dx.doi.org/10.1016/j.clinimag.2020.11.008DOI Listing
March 2021

Intersection between sleep and neurovascular coupling as the driving pathophysiology of Alzheimer's disease.

Med Hypotheses 2020 Nov 17;144:110283. Epub 2020 Sep 17.

Department of Medical Imaging, University of Toronto, Canada. Electronic address:

Alzheimer's disease (AD) is the commonest cause of dementia. There are tremendous personal and systemic costs associated with the disease. Although there has been significant progress in understanding the disease process, the precise pathophysiologic mechanism remains elusive. The amyloid hypothesis is the leading theory with impaired clearance of the amyloid beta (Aβ) believed to be the underpinning disease process. However, what triggers and propagates the accumulation of Aβ remains unclear. We propose that the impairment of neurovascular coupling triggers a cascade that ultimately leads to impaired Aβ clearance. With aging there is a generalized decline in cerebral blood flow and impairment of cerebrovascular reactivity. With impairment of this neurovascular coupling, the normal bulk clearance of cerebrospinal fluid and interstitial fluid (ISF) becomes hindered. We postulate that this clearance process occurs during non-rapid eye movement slow wave sleep, driven by the tight neurovascular coupling, via a pump-like action. The impairment of ISF clearance results in change in the interstitial microenvironment from accumulation of metabolites, reactive oxygen species, metal ions and results in decreased pH. The changes in the microenvironment promotes the accumulation and aggregation of Aβ, heralding the disease process.
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http://dx.doi.org/10.1016/j.mehy.2020.110283DOI Listing
November 2020

Dysphagia rates in single- and multiple-level anterior cervical discectomy and fusion surgery: a meta-analysis.

J Spine Surg 2020 Sep;6(3):581-590

Faculty of Medicine, University of New South Wales, Sydney, Australia.

Background: To conduct a meta-analysis to assess dysphagia complicating single-level and multiple-level (≥2) anterior cervical discectomy and fusion (ACDF) surgery.

Methods: Electronic searches were performed using four electronic databases from their inception to December 2017. Relevant studies reporting the rate of dysphagia as an endpoint for patients undergoing ACDF for degenerative disease, myelopathy, cervical canal stenosis or ossification of the posterior longitudinal ligament were identified according to prior inclusion and exclusion criteria. Statistical analysis was performed using a fixed effect model. P-scores were used to rank the levels of ACDF based on the rate of dysphagia. I was used to explore heterogeneity.

Results: Ten studies were identified and included in the systematic review and meta-analysis, with a total of 4,018 patients identified; 2,362 patients underwent single-level ACDF, while 1,656 underwent multiple level (≥2 ACDF). The mean age ranged from 49.45 to 57.77 years. Mean follow-up time ranged from 2 days to 27.3 months. Overall, meta-analysis demonstrated a statistically significant higher dysphagia rate for multiple-level ACDF (6.6%) than for single-level ACDF (4%) (P heterogeneity =0.151, OR =1.42, 95% CI: 1.05-1.91, I=32%).

Conclusions: Dysphagia is a relatively common complication in the early postoperative period following ACDF and may cause patients significant discomfort and distress. This meta-analysis demonstrates a higher rate of dysphagia with multiple-level ACDF than with single-level ACDF at a period of 12-24 months.
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http://dx.doi.org/10.21037/jss-20-506DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7548829PMC
September 2020

Unfractionated Heparin in SARS-CoV-2 Pneumonia: Ischemic Stroke Case Report.

Front Neurol 2020 25;11:573356. Epub 2020 Sep 25.

Department of Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada.

Thromboembolism is a known phenomenon in patients with Coronavirus disease 2019 (COVID-19). Recent investigations have revealed that a significant proportion of those hospitalized with severe COVID-19 demonstrate clinical and laboratory markers compatible with hypercoagulability, which is differentiated from disseminated intravascular coagulation (DIC), termed COVID-associated coagulopathy. Additionally, there is increasing concern for development of acute ischemic stroke because of this hypercoagulable state. We present a patient with COVID-19 pneumonia who was managed with unfractionated heparin (UFH) infusion and developed a large ischemic infarct shortly after cessation of the infusion. In retrospect, the patient's coagulation parameters were consistent with overt DIC, although some of these parameters are easily masked by the effects of UFH. These findings emphasize the importance of anticoagulation as well as its careful discontinuation, as failure to do so may result in a significant thromboembolic event.
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http://dx.doi.org/10.3389/fneur.2020.573356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545009PMC
September 2020

Etiologic Subtypes of Ischemic Stroke in SARS-CoV-2 Patients in a Cohort of New York City Hospitals.

Front Neurol 2020 17;11:1004. Epub 2020 Sep 17.

Neuroradiology & Neurointervention Service, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States.

To describe the ischemic stroke subtypes related to coronavirus disease 2019 (COVID-19) in a cohort of New York City hospitals and explore their etiopathogenesis. Most neurological manifestations are non-focal, but few have reported the characteristics of ischemic strokes or investigated its pathophysiology. Data were collected prospectively April 1-April 15, 2020 from two centers in New York City to review possible ischemic stroke types seen in COVID-19-positive patients. Patient presentation, demographics, related vascular risk factors, associated laboratory markers, as well as imaging and outcomes were collected. The age of patients ranged between 27 and 82 years. Approximately 81% of patients had known vascular risk factors, the commonest being hypertension (75%) followed by diabetes (50%) coronary disease or atrial fibrillation. Eight patients presented with large vessel occlusion (LVO) with median age 55 years (27-82) and all were male. Eight patients presented with non-LVO syndromes, with median age 65.5 years (59-82) and most were female (62.5%). Both groups were 50% African Americans and 37.5% South Asian. Both groups had similar D-dimer levels although other acute phase reactants/disease severity markers (Ferritin, CRP, procalcitonin) were higher in the LVO group. The LVO group also had a significantly higher mortality compared to the non-LVO group. The most common etiology was cryptogenic (6 patients) followed by small vessel occlusion (3 patients) and undetermined-unclassified (3 patients). For the remaining 4 patients, 2 were identified as cardioembolic and 2 with large artery atherosclerosis. COVID-19-related ischemic events can present as small vessel occlusions, branch emboli or large vessel occlusions. The most common etiology is cryptogenic. Patients with LVO syndromes tend to be younger, male and may have elevated acute inflammatory markers.
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http://dx.doi.org/10.3389/fneur.2020.01004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527497PMC
September 2020

The relationship between physical activity and lymphoma: a systematic review and meta analysis.

BMC Cancer 2020 Oct 6;20(1):962. Epub 2020 Oct 6.

Department of Medical Imaging, University of Toronto, Toronto, ON, Canada.

Background: The literature suggests an increased risk between anthropometrics including higher body mass index and lymphoma incidence; however, the association with physical activity remains unclear. A systematic review/meta-analysis was therefore performed to examine this association with physical activity (total, recreational or occupational).

Methods: PubMed, Web of Science and Embase were reviewed from inception to October 2019 identifying relevant observational studies. Non-Hodgkin lymphoma (NHL) including subtypes diffuse large B cell lymphoma, follicular lymphoma and chronic lymphocytic leukemia/small lymphocytic lymphoma, and Hodgkin lymphoma (HL) were analyzed. Included studies reported activity, lymphoma cases, effect size and variability measures, and were restricted to human subjects of any age. Data was pooled generating summary relative risk (RR) estimates with 95% confidence intervals (CI) using random-effects models with primary outcome of histologically confirmed incident lymphoma.

Results: One thousand four hundred studies were initially identified with 18 studies (nine cohort, nine case-control) included in final analysis. Comparing highest vs. lowest activity categories was protective for all lymphoma (RR 0.89, 95%CI 0.81-0.98). Sensitivity analysis demonstrated effect persistence within case-control studies (RR 0.82, 95% CI 0.71-0.96), but not cohort studies (RR 0.95, 95%CI 0.84-1.07). Borderline protective effect was seen for NHL (RR 0.92, 95%CI 0.84-1.00), but not HL (RR 0.72, 95%CI 0.50-1.04). Analysis by NHL subtype or gender showed no effect. Dose response analysis demonstrated a protective effect (p = 0.034) with a 1% risk reduction per 3 MET hours/week (RR 0.99, 95%CI 0.98-1.00).

Conclusions: Physical activity may have a protective effect against lymphoma development; further studies are required to generate recommendations regarding health policy.

Trial Registration: This study was registered prospectively at PROSPERO: CRD42020156242 .
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http://dx.doi.org/10.1186/s12885-020-07431-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7539461PMC
October 2020

Characterization of Long Non-coding RNA Signatures of Intracranial Aneurysm in Circulating Whole Blood.

Mol Diagn Ther 2020 12;24(6):723-736

Department of Pediatrics, University at Buffalo, Buffalo, NY, USA.

Background And Objective: Long non-coding RNAs (lncRNAs) may serve as biomarkers for complex disease states, such as intracranial aneurysms. In this study, we investigated lncRNA expression differences in the whole blood of patients with unruptured aneurysms.

Methods: Whole blood RNA from 67 subjects (34 with aneurysm, 33 without) was used for next-generation RNA sequencing. Differential expression analysis was used to define a signature of intracranial aneurysm-associated lncRNAs. To estimate the signature's ability to classify aneurysms and to identify the most predictive lncRNAs, we implemented a nested cross-validation pipeline to train classifiers using linear discriminant analysis. Ingenuity pathway analysis was used to study potential biological roles of differentially expressed lncRNAs, and lncRNA ontology was used to investigate ontologies enriched in signature lncRNAs. Co-expression correlation analysis was performed to investigate associated differential protein-coding messenger RNA expression.

Results: Of 4639 detected lncRNAs, 263 were significantly different (p < 0.05) between the two groups, and 84 of those had an absolute fold-change ≥ 1.5. An eight-lncRNA signature (q < 0.35, fold-change ≥ 1.5) was able to separate patients with and without aneurysms on principal component analysis, and had an estimated accuracy of 70.9% in nested cross-validation. Bioinformatics analyses showed that networks of differentially expressed lncRNAs (p < 0.05) were enriched for cell death and survival, connective tissue disorders, carbohydrate metabolism, and cardiovascular disease. Signature lncRNAs shared ontologies that reflected regulation of gene expression, signaling, ubiquitin processing, and p53 signaling. Co-expression analysis showed correlations with messenger RNAs related to inflammatory responses.

Conclusions: Differential expression in whole blood lncRNAs is detectable in patients harboring aneurysms, and reflects expression/signaling regulation, and ubiquitin and p53 pathways. Following validation in larger cohorts, these lncRNAs may be potential diagnostic targets for aneurysm detection by blood testing.
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http://dx.doi.org/10.1007/s40291-020-00494-3DOI Listing
December 2020

Contemporary Challenges of Acute Ischemic Stroke in Takayasu Arteritis.

Stroke 2020 10 21;51(10):e280-e284. Epub 2020 Aug 21.

Department of Interventional Neuroradiology, Neurosurgery & Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China (P.G., T.W., J.R., F.C., L.J.).

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http://dx.doi.org/10.1161/STROKEAHA.120.030249DOI Listing
October 2020