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Biomedical subjects

Harry J Cloft

Publications and source records attributed to Harry J Cloft.

33 records · Page 2Linked to original sources
PubMed2004

Management of acute ischemic stroke.

The treatment of acute ischemic stroke has evolved from observation and the passage of time dictating outcome to an approach that emphasizes time from ictus, rapid response, and a dedicated treatment team. We review the treatment of acute ischemic stroke from the prehospital setting, to the emergency department, to the inpatient hospital setting. We discuss the importance of prehospital assessment and treatment, including the use of elements of the neurologic examination, recognition of symptoms that can mimic those of acute ischemic stroke, and rapid transport of patients who are potential candidates for thrombolytic therapy to hospitals with that capability. Coordinated management of acute ischemic stroke in the emergency department is critical as well, beginning with non-contrast-enhanced computed tomography of the brain. The advantages of a multidisciplinary dedicated stroke team are discussed, as are thrombolytic therapy and other inpatient treatment options. Finally, we cover evolving management strategies, treatments, and tools that could improve patient outcomes.

Acute Disease↗
PubMed2004

Evaluation and management of asymptomatic carotid artery stenosis.

Internal carotid artery stenosis (ICAS) is responsible for approximately 30% of ischemic strokes. Internal carotid artery stenosis of greater than 50% is present in about 4% to 8% of the population aged 50 to 79 years. Natural history studies and clinical trials have shown a small increase in stroke risk in patients with increasing degrees of ICAS, especially in those with greater than 80% reduction in carotid artery diameter. Randomized, prospective multicenter trials have revealed the superiority of carotid endarterectomy (CEA) over medical therapy in recently symptomatic patients with severe ICAS. However, the evidence from several randomized controlled trials of CEA in asymptomatic patients does not support the use of CEA in most of these patients; also, the role of noninvasive screening in this patient population remains uncertain and controversial. Furthermore, there is considerable uncertainty about whether the statistical benefit of avoiding a nondisabling stroke is worth the overall cost and risk of the procedure. Clinicians continue to struggle with treatment decisions for patients with asymptomatic ICAS. Carotid endarterectomy for asymptomatic ICAS should be considered only for medically stable patients with 80% or greater stenosis who are expected to live at least 5 years, and only in centers with surgeons who have a demonstrated low (<3%) perioperative complication rate. We outline the prevalence and natural history of ICAS, the evidence for CEA in patients with asymptomatic ICAS, the roles of screening and monitoring for ICAS, the methods of evaluating ICAS, and the implications for practicing clinicians.

Carotid Artery, Internal↗
PubMed2004

Carotid revascularization for prevention of stroke: carotid endarterectomy and carotid artery stenting.

Carotid endarterectomy (CEA) has been used for the past several decades in patients with carotid occlusive disease. Large randomized controlled trials have documented that CEA is a highly effective stroke preventive among patients with carotid stenosis and recent transient ischemic attack or cerebral infarction. In asymptomatic patients with carotid stenosis, clinical trial data suggest that the degree of stroke prevention from CEA is less than among symptomatic patients. However, otherwise healthy men and women with an asymptomatic carotid stenosis of 60% or greater have a lower risk of future cerebral infarction, including disabling cerebral infarction, if treated with CEA compared with those treated with medical management alone. More recently, carotid artery stenting has been performed Increasingly for patients with carotid occlusive disease. As technology has improved, procedural risks have declined and are approaching those reported for CEA. The benefits and durability of CEA compared with carotid artery stenting are still unclear and are being studied in ongoing randomized controlled trials.

Aged↗
PubMed2004

Aneurysm packing with HydroCoil Embolic System versus platinum coils: initial clinical experience.

The HydroCoil Embolic System (HES; MicroVention, Aliso Viejo, CA) was developed to improve the efficacy of endovascular treatment of cerebral aneurysms. The HES may reduce recurrences of aneurysms by allowing for increased packing density as compared with platinum coils. We report our initial experience with the HES in the treatment of 11 patients with cerebral aneurysms and compare findings to those in size-matched control cases treated with platinum coils. The HES provided substantially improved volumetric packing of the aneurysm lumen relative to standard platinum coils (73% vs. 32%; P=.0001).

Case-Control Studies↗
PubMed2004

The use of hydrocoil for parent artery occlusion.

The HydroCoil Embolic System (HES) comprises a platinum microcoil coated with an expansile polymer and is approved by the United States Food and Drug Administration for cerebral aneurysm occlusion. We report a series of five cases, two in the internal carotid artery and three in the vertebral artery, in which the HES was used for parent artery occlusion procedures. In each of these cases, the HES allowed rapid, short-segment occlusion.

Aortic Dissection↗
PubMed2003

Evolution of the management of tentorial dural arteriovenous malformations.

OBJECTIVE: Tentorial dural arteriovenous malformations (DAVMs) are uncommon lesions associated with an aggressive natural history. Controversy exists regarding their optimal treatment. We present a single-institution series of tentorial DAVMs treated during a 12-year period, address the current controversies, and present the rationale for our current therapeutic strategy. METHODS: Twenty-two patients with tentorial DAVMs were treated between 1988 and 2000. Treatment consisted of transarterial or transvenous embolization, surgical resection, disconnection of venous drainage, or a combination of these therapies. The clinical presentations, radiological features, treatment strategies, and results were studied. RESULTS: Eighteen patients (82%) presented with intracranial hemorrhage or progressive neurological deficits. Retrograde leptomeningeal venous drainage was documented in 22 cases (100%), classifying the lesions as Borden Type III. Angiographic follow-up monitoring was performed for 0 to 120 months and clinical follow-up monitoring for 1 to 120 months. Posttreatment angiography demonstrated obliteration in 22 cases (100%). Two patients experienced neurological decline after endovascular treatment and died. All of the 20 surviving patients exhibited clinical improvement; there were no episodes of rehemorrhage or new neurological deficits. Outcomes were excellent in 17 cases (77%), good in 2 cases (9%), and fair in 1 case (5%), and there were 2 deaths (9%). CONCLUSION: Tentorial DAVMs are aggressive lesions that require prompt total angiographic obliteration. Disconnection of the venous drainage from the fistula may be accomplished with transarterial embolization to the venous side, transvenous embolization, or surgical disconnection of the fistula. We think that extensive nidal resections carry more risk and are unnecessary. We do not think there is a role for stereotactic radiosurgery in the treatment of these lesions.

Adult↗
PubMed2002

Elastase-induced saccular aneurysms in rabbits: a dose-escalation study.

BACKGROUND AND PURPOSE: Reproducible animal models facilitate preclinical assessment of aneurysm therapies. Our purpose was to determine if increased elastase doses enlarge aneurysms and parent arteries. METHODS: Rabbit right common carotid artery (CCA) aneurysms were created with distal ligation and intraluminal elastase incubation. Groups were 1) sham (no elastase, n = 3), 2) 25% elastase (10 minutes, n = 9), 3) 50% elastase (10 minutes, n = 7), and 4) 50% elastase (20 minutes, n = 41). Angiography was performed after 14 days. Resultant aneurysm width and height and parent artery diameters were measured and compared with the Student t or Mann-Whitney (Wilcoxon rank sum) test. RESULTS: Proximal segments were enlarged in all elastase subjects and no sham subjects. Mean measurements were significantly smaller in the sham group than in other groups. Aneurysm widths and heights, respectively, were 3.8 mm +/- 0.8 and 7.4 mm +/- 2.0 in the low-dose group; 3.9 mm +/- 1.3 and 8.5 mm +/- 3.8, medium-dose group; and 4.1 mm +/- 1.1 and 8.7 mm +/- 2.6, high-dose group. Differences were not significant. Parent artery widths were 3.5 mm +/- 0.7, 3.8 mm +/- 0.7, and 4.3 mm +/- 1.4 in the low-, medium-, and high-dose groups, respectively; the high-dose group had larger arteries (P =.07). CONCLUSION: Aneurysms were reliably created and were sized similar to human intracranial aneurysms. Elastase concentration and incubation duration did not affect resultant size. Relatively short incubation (eg, 10 minutes) and 25% elastase can be used to create rabbit aneurysms, especially if dilatation of adjacent parent arteries is to be avoided.

Angiography, Digital Subtraction↗
PubMed2002

Interaction of vascular smooth muscle cells with collagen-impregnated embolization coils studied with a novel quantitative in vitro model.

BACKGROUND AND PURPOSE: Modifications of aneurysm occlusion devices and other biologically active molecules may reduce the risk of recanalization by promoting vascular cell migration, adhesion, and proliferation. Our purpose was to apply in vitro methods in the qualitative and quantitative analysis of vascular smooth muscle cell (VSMC) interactions with collagen-impregnated microcoils. METHODS: The adhesion of rat aortic VSMCs to collagen fiber bundles (CFBs), nitinol coils, and collagen-impregnated nitinol coils (CINCs) was examined by using an assay consisting of monopulse exposure to increasing concentrations of rat aortic VSMCs. Exposed devices were washed and examined by using confocal fluorescence microscopy. Adhesion coefficients, which quantitatively express the cell-binding quality of a surface, were determined by using a mathematical model for cell-device interactions. RESULTS: VSMCs, attached to devices, spread out and extended cytoplasmic projections over the contact surface. Cell distribution was random on CFBs and within interloop troughs on nitinol coils. On collagen-impregnated coils, VSMCs were selectively concentrated on the collagen between coil loops. The average adhesion coefficient was 25.0 for CFBs, 8.5 for CINCs (250-microm pitch), and 6.5 for nitinol coils. Adhesion coefficient differences for the three devices were significant (P =.044). CONCLUSION: The monopulse exposure assay is a simple and reproducible in vitro test that provides qualitative information about the morphology and topography of cell-device contacts and permits quantitative measurement of the intrinsic cell-binding quality of the test device. VSMCs exposed to collagen-impregnated microcoils selectively attach to collagen. Collagen enhances the rate of VSMC adhesion to embolic devices, and the degree of enhancement correlates with the surface area constituted by collagen.

Alloys↗
PubMed2002

Thrombus formation at the neck of cerebral aneurysms during treatment with Guglielmi detachable coils.

BACKGROUND AND PURPOSE: Thromboembolic events are a common source of complications during Guglielmi detachable coil (GDC) treatment of intracranial aneurysms. Thrombus formation at the coil-parent artery interface is not commonly reported but is an important potential source of emboli. We describe nine cases in which thrombus propagated from GDCs into the parent artery during coil therapy of cerebral aneurysms and subsequent treatment of the thrombus. METHODS: A retrospective review of a procedural database was performed to identify cases in which thrombus occurred during GDC treatment of cerebral aneurysms during a 30-month period. All images were reviewed at the time of the procedure. Nine cases of thrombus forming at the coil-parent artery interface and five cases of distal emboli were identified among 210 cases. All patients underwent anticoagulation with heparin during GDC treatment procedures. RESULTS: Thrombus was identified at the coil-parent artery interface during GDC treatment in nine (4.3%) of 210 cases. In each case, the thrombus was recognized before distal embolic complication occurred and was successfully treated with heparin alone (five patients) or with heparin plus a glycoprotein IIb-IIIa inhibitor (four patients). CONCLUSION: Potential clinical complications can be avoided by early recognition of thrombus at the coil-parent artery interface and by administering appropriate medical therapy.

Abciximab↗
PubMedDate not supplied

Spontaneous regression of cerebral arteriovenous malformation in hereditary hemorrhagic telangiectasia.

Cerebral arteriovenous malformations (AVMs) are associated with hereditary hemorrhagic telangiectasia (HHT). I report a case of a patient with HHT with four cerebral AVMs in whom one AVM spontaneously regressed during a 5-year period. The spontaneous regression of this AVM in this patient with HHT supports the theory that AVMs associated with this syndrome have a different natural history than that of typical sporadic AVMs.

Adolescent↗
PubMedDate not supplied

Cerebral aneurysm perforations complicating therapy with Guglielmi detachable coils: a meta-analysis.

BACKGROUND AND PURPOSE: The risk of intraprocedural aneurysm perforation in patients with previously ruptured aneurysms tends to be higher than that of patients with previously unruptured aneurysms, but a statistically significant difference has not been shown. Our purpose was to define the rates of occurrence and of morbidity and mortality associated with aneurysmal perforation associated with coil embolization. METHODS: A meta-analysis of the results from 17 published retrospective reports of aneurysm perforations complicating therapy with Guglielmi detachable coils (GDCs) was performed. Rates of perforation and associated morbidity and mortality in previously ruptured and unruptured aneurysms were calculated. The mechanism of perforation was noted. RESULTS: The risk of intraprocedural perforation was significantly higher in patients with ruptured aneurysms compared with patients with unruptured aneurysms (4.1% vs 0.5%; P <.001). The combined risk of permanent neurologic disability and death associated with intraprocedural aneurysm perforation was 38% for ruptured aneurysms and 29% for unruptured aneurysms. The morbidity and mortality rates with perforations caused by coils (39%) and microcatheters (33%) were similar. The morbidity and mortality rate for microguidewire perforations was considerably lower (0%, n = 4) than the rates for coils and microcatheters, but number of cases was too low to indicate statistical significance. CONCLUSION: The risk of aneurysm perforation during GDC therapy is much higher in patients with previously ruptured aneurysms than in those with unruptured aneurysms. The morbidity and mortality rates are substantial for perforations caused by coils and microcatheters, whereas they seem to be much lower for perforations caused by microguidewires.

Aneurysm, Ruptured↗
PubMedDate not supplied

Histopathologic and immunohistochemical comparison of human, rabbit, and swine aneurysms embolized with platinum coils.

BACKGROUND AND PURPOSE: The purpose of this study was to clarify the cellular mechanisms of aneurysmal healing by comparing histologic and immunohistochemical findings in experimental rabbit and swine aneurysms to a human aneurysm embolized with platinum coils. METHODS: Swine sidewall aneurysms (n = 5, harvested at 12 weeks) and elastase-induced rabbit aneurysms (n = 6, harvested at 24 weeks) were created and embolized. A single human aneurysm, embolized 6 years before death, was harvested following autopsy. All specimens were processed by using a modified paraffin embedding technique. Tissue was sectioned and stained with hematoxylin and eosin and Masson trichrome. Immunohistochemistry and immunofluorescence were performed with multiple antibodies, including alpha smooth muscle actin, myosin heavy chain, desmin, vimentin, and CD31. RESULTS: The human aneurysm's dome was filled with loose, hypocellular, amorphous tissue. The aneurysm's neck was completely covered with a thin layer of hypocellular tissue. Collagen and myofibroblasts were sparse in both the dome and neck. Rabbit aneurysms' domes were also filled with a loose, hypocellular tissue, amorphous matrix. In 5 of 6 aneurysms, a thin layer of hypocellular tissue ran along the neck. Collagen and myofibroblasts were sparse in the dome. Swine aneurysms were filled with densely infiltrated tissue, including chronic inflammatory tissue and extensive, attenuated collagen fiber bundles associated with myofibroblasts. Thick layers of myofibroblasts entirely bridged the necks. CONCLUSIONS: Absence of collagen deposition and scant myofibroblastic reaction to platinum coil embolization are seen in the rabbit model but not in swine aneurysms. The elastase-induced aneurysm model in rabbits is more suitable than sidewall swine aneurysms for testing of modified devices aimed at improving intra-aneurysmal fibrosis.

Actins↗