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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
\n\nThis achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
\n\nWe are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
\n\nThank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
\n\n\n\n\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"8753",leadTitle:null,fullTitle:"Tannins - Structural Properties, Biological Properties and Current Knowledge",title:"Tannins",subtitle:"Structural Properties, Biological Properties and Current Knowledge",reviewType:"peer-reviewed",abstract:"Tannins are one of the polyphenols group found in plants and are mainly studied because of their structural properties and bioactive behavior. Every year new findings concerning their properties and functions are made, and today concerns are mainly focused on how they can be used efficiently in the wood, food, textile, health, and pharmaceutical industries. Thus, the aim of this book is to present the most updated information on the structural properties of tannins, their food sources and variations, biological properties, and health, among other important issues. In addition, the most recent methods used for their isolation, quantifications, and industrial applications will also be covered.",isbn:"978-1-78984-797-0",printIsbn:"978-1-78984-796-3",pdfIsbn:"978-1-83968-358-9",doi:"10.5772/intechopen.80170",price:119,priceEur:129,priceUsd:155,slug:"tannins-structural-properties-biological-properties-and-current-knowledge",numberOfPages:148,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"d18f8d68a470cabaa124ad01ea455859",bookSignature:"Alfredo Aires",publishedDate:"January 8th 2020",coverURL:"https://cdn.intechopen.com/books/images_new/8753.jpg",numberOfDownloads:9480,numberOfWosCitations:13,numberOfCrossrefCitations:21,numberOfCrossrefCitationsByBook:4,numberOfDimensionsCitations:64,numberOfDimensionsCitationsByBook:5,hasAltmetrics:1,numberOfTotalCitations:98,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"November 15th 2018",dateEndSecondStepPublish:"December 27th 2018",dateEndThirdStepPublish:"February 25th 2019",dateEndFourthStepPublish:"May 16th 2019",dateEndFifthStepPublish:"July 15th 2019",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"175895",title:"Dr.",name:"Alfredo",middleName:null,surname:"Aires",slug:"alfredo-aires",fullName:"Alfredo Aires",profilePictureURL:"https://mts.intechopen.com/storage/users/175895/images/system/175895.jpg",biography:"Alfredo Aires (Ph.D) is actually a post-doc researcher in University of Trás-os-Montes e Alto Douro, Vila Real, Portugal, and he is a full member of Centre for the Research and Technology of Agro-Environmental and Biological Sciences (CITAB) at the same institution. In the last 15 years, he is devoted to the study and research of plant secondary metabolites, their properties, variations, biological effects and health beneficial properties. In addition, he has published different works about isolation and quantification methods of polyphenols. Actually, their research is focused on the recovery of polyphenols, tannins and other type of secondary metabolites from agricultural crop residues to be used in agri-food and pharmaceutical industry.",institutionString:"University of Trás-os-Montes e Alto Douro",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"4",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"University of Trás-os-Montes and Alto Douro",institutionURL:null,country:{name:"Portugal"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"371",title:"Phytochemistry",slug:"agricultural-and-biological-sciences-plant-biology-phytochemistry"}],chapters:[{id:"69608",title:"Hardwood Tannin: Sources, Utilizations, and Prospects",doi:"10.5772/intechopen.86003",slug:"hardwood-tannin-sources-utilizations-and-prospects",totalDownloads:927,totalCrossrefCites:1,totalDimensionsCites:4,hasAltmetrics:0,abstract:"Tannins are found in widely distributed species of plants, and it protects plant from predators and pests. There are three major groups of tannins, that is, hydrolyzable, complex, and proanthocyanidins. Tannins are being used as a significant element for the tanning of animal hides in the leather production industry from the beginning of tannin industry. Then, these have been used for mineral absorption and protein precipitation purposes since the 1960s. Tannins are used for iron gall ink production and wood-based industry as adhesive and anticorrosive, recovering uranium from seawater and removing mercury and methylmercury from solution. In addition, tannins are considered as bioactive compound in nutrition science, and their possible effects on health are to be identified. This chapter outlines the structural and biological properties of hardwood tannins to indicate the positive utilization of them. It also describes the contemporary information on tannins.",signatures:"Atanu Kumar Das, Md. Nazrul Islam, Md. Omar Faruk, Md. Ashaduzzaman, Rudi Dungani, Enih Rosamah, Sri Hartati and Alfi Rumidatul",downloadPdfUrl:"/chapter/pdf-download/69608",previewPdfUrl:"/chapter/pdf-preview/69608",authors:[null],corrections:null},{id:"67219",title:"Food Ellagitannins: Structure, Metabolomic Fate, and Biological Properties",doi:"10.5772/intechopen.86420",slug:"food-ellagitannins-structure-metabolomic-fate-and-biological-properties",totalDownloads:1267,totalCrossrefCites:2,totalDimensionsCites:7,hasAltmetrics:1,abstract:"Food sources of ellagitannins (ETs) are numerous, and dietary intake of these compounds is estimated up to 12 mg/day in some countries, even though ETs have been considered in the past as not bioavailable like other tannins and were mostly neglected by nutritionists. Nonetheless, new insights show that ETs are bioconverted by microbiota in the gut into metabolites called urolithins, which are bioavailable and can reach relatively high physiological concentration in the body up to 7 days after ingestion. According to the initial structure of ETs in the food source, the extent of bioconversion into urolithins may differ but all urolithins are susceptible to exert potential health benefits. Nonetheless, due to the intervention of microbiota, the production and excretion of urolithins are highly variable according to individuals, which have led to the classification of consumers into metabotype. According to metabotype, the potential health benefits of ellagitannins may differ among consumers. In in vitro, cellular and animal studies, numerous health benefits of ellagitannins and urolithins are reported mainly for the chemoprevention of hormone-dependent cancer and cardiovascular disease. Nonetheless, ellagitannins deserve closer attention from the scientific community to unravel more biological properties of this particular compound.",signatures:"Karen Johana Ortega Villalba, Fabrice Vaillant Barka, Carlos Vélez Pasos and Pablo Emilio Rodríguez",downloadPdfUrl:"/chapter/pdf-download/67219",previewPdfUrl:"/chapter/pdf-preview/67219",authors:[null],corrections:null},{id:"68709",title:"Tannins as Antiviral Agents",doi:"10.5772/intechopen.86490",slug:"tannins-as-antiviral-agents",totalDownloads:1288,totalCrossrefCites:4,totalDimensionsCites:12,hasAltmetrics:1,abstract:"Tannins possess a variety of biological effects, not a small part of which is of medical significance. Tannins, isolated from plants as well as synthetically obtained, manifest activity against a large spectrum of viruses: enteroviruses (polio- and coxsackie-), caliciviruses (feline calicivirus, mouse norovirus), rotavirus, influenza virus A, rhabdo- (vesicular stomatitis virus), paramyxoviruses (Sendai and Newcastle disease viruses), human immunodeficiency virus, herpes simplex virus, and adenoviruses. A special importance merits several ellagitannins manifesting pronounced effects against herpes simplex virus type 1 and 2 and on some herpes viruses affecting domestic animals, causing diseases of economic importance. An advantage of ellagitannins as anti-herpesvirus agents is that they have a non-nucleoside structure. Their targets are virus-specific proteins, so they retain activity against acyclovir-resistant strains of HSV types 1 and 2. Besides, these tannins manifest a synergistic effect with acyclovir when combined. Some initial results on their mechanism of action were carried out. In addition, it was found that most of the tannins have antioxidant properties in experimental models in vitro as well as in experimental influenza viral infection in mice.",signatures:"Neli Vilhelmova-Ilieva, Angel S. Galabov and Milka Mileva",downloadPdfUrl:"/chapter/pdf-download/68709",previewPdfUrl:"/chapter/pdf-preview/68709",authors:[null],corrections:null},{id:"67043",title:"Tannins: Extraction from Plants",doi:"10.5772/intechopen.86040",slug:"tannins-extraction-from-plants",totalDownloads:2114,totalCrossrefCites:1,totalDimensionsCites:7,hasAltmetrics:0,abstract:"The chapter presents mainly on different extraction methods of tannin. Some technical means required for effective extraction are also presented, for example, collection and treatment of plant and drying and storage of plant. Opportunity and challenges in application of extraction methods are also exhibited in the chapter.",signatures:"Dang Xuan Cuong, Nguyen Xuan Hoan, Dinh Huu Dong, Le Thi Minh Thuy, Nguyen Van Thanh, Hoang Thai Ha, Dang Thi Thanh Tuyen and Dang Xuan Chinh",downloadPdfUrl:"/chapter/pdf-download/67043",previewPdfUrl:"/chapter/pdf-preview/67043",authors:[null],corrections:null},{id:"67773",title:"Hydrolysable Tannins in Agriculture",doi:"10.5772/intechopen.86610",slug:"hydrolysable-tannins-in-agriculture",totalDownloads:1022,totalCrossrefCites:1,totalDimensionsCites:4,hasAltmetrics:0,abstract:"Hydrolysable tannins, water-extracted from sweet chestnut (Castanea sativa Mill.) (CHT) and membrane concentrated, have several effects as antioxidant, antimicrobial, and metal complexing agents. Some patents described their use as nitrogen release modulators and iron complexing agent to fight plant chlorosis and to control legume seed-borne disease and nitrosamine and mycotoxin during plant and food processing. Biostimulating activity of raw CHT, placed near seed or transplant seedlings, was assessed on early plant growth (starter effect) and found related to earlier production of a larger plant fine root mass, with greater P early uptake. Increased resistance to nematodes, with CHT applications on tobacco, was investigated. Recent process stream fractioning permitted to identify some CHT fractions with antimicrobial and antioxidant effects which were tested for their potential in promoting selected aspects of plant yield, quality, and protection and maintaining and improving feed and food quality during processing. EU Life+2013 Evergreen found a method of application of a CHT fraction to protect tobacco and carrot plants in nematode-infested fields. A protective effect of CHT on some bacterial diseases of olive tree and kiwi was disclosed. Environmental and soil toxicities were also investigated finding very low impacts and the possibility to reduce Cu use in agriculture.",signatures:"Sergio Miele, Stefania Tegli, Carlos Garcia Izquierdo, Matteo Cerboneschi and Enrica Bargiacchi",downloadPdfUrl:"/chapter/pdf-download/67773",previewPdfUrl:"/chapter/pdf-preview/67773",authors:[null],corrections:null},{id:"67149",title:"Applications of Tannin Resin Adhesives in the Wood Industry",doi:"10.5772/intechopen.86424",slug:"applications-of-tannin-resin-adhesives-in-the-wood-industry",totalDownloads:1308,totalCrossrefCites:6,totalDimensionsCites:16,hasAltmetrics:0,abstract:"Tannin is extracted from natural sustainable materials. It is widely used to prepare tannin resin adhesives owing to its naturally occurring phenolic structure. This chapter aims to introduce the resources and structures of tannin, existing reactions that are involved in the synthesis of tannin resin, and the applications of tannin resin adhesives in the wood industry. Additionally, the advancements in the research based on the use of tannin resins in manufacturing plywood, particleboard, wood preservation, decoration paper impregnation, structural glulam, impregnated fibers, and other wooden products are reviewed. Herein, the main limitations encountered during the application of tannin resin adhesives and the future key research points are identified. Finally, the potential applications of tannin resin adhesives in the wood industry have been discussed.",signatures:"Xiaojian Zhou and Guanben Du",downloadPdfUrl:"/chapter/pdf-download/67149",previewPdfUrl:"/chapter/pdf-preview/67149",authors:[{id:"289729",title:"Dr.",name:"Xiaojian",surname:"Zhou",slug:"xiaojian-zhou",fullName:"Xiaojian Zhou"},{id:"291315",title:"Prof.",name:"Guanben",surname:"Du",slug:"guanben-du",fullName:"Guanben Du"}],corrections:null},{id:"69199",title:"Applications of Tannins in Industry",doi:"10.5772/intechopen.85984",slug:"applications-of-tannins-in-industry",totalDownloads:1555,totalCrossrefCites:6,totalDimensionsCites:14,hasAltmetrics:0,abstract:"Tannins are water-soluble natural polyphenols mainly present in plant-based materials, including food. Tannins play a very significant role as a raw material for sustainable green industries. Therefore, they are mainly used in diverse types of industries such as leather, feed, fisheries, beverages, etc. They also find application as potential medicinal agents, antioxidants, metal chelators; and cater as inhibitors of harmful pro-oxidative enzymes and of lipid peroxidation process. Recently, several important properties like antiseptics, anticarcinogenic, and anti-inflammatory of tannins have been documented in the human that make them suitable candidates for pharmaceuticals and nutraceutical industries. Because of current concerns related to synthetic compounds used in the human health and food industries, which leave highly adverse effects on the human body and environment, tannins can offer an alternative to these harmful chemicals in recently emerging industries.",signatures:"Akhlash P. Singh and Sunil Kumar",downloadPdfUrl:"/chapter/pdf-download/69199",previewPdfUrl:"/chapter/pdf-preview/69199",authors:[null],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"3244",title:"Soybean",subtitle:"Bio-Active Compounds",isOpenForSubmission:!1,hash:"b21aa6107fce439bd06d53fbe0bc3c9e",slug:"soybean-bio-active-compounds",bookSignature:"Hany A. 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The aim of this chapter is to present the current state of stent-assisted techniques for the treatment of intracranial aneurysms. Most of the information that is presented here is based on recent international literature, as well as the personal experience of the authors. It is illustrated with diagrams of key procedures. Since it is a technical chapter, the subject will be discussed from an operative point of view, and the topics will be presented in the order in which they would probably be approached by the operator:
In the early years of endovascular techniques, the main method for the treatment of wide-neck aneurysms was surgical. Attempts at embolization presented significant risks of coil herniation, migration, parent artery occlusion and poor mid-term morphological results with high recurrence rates. A great effort has been made by engineers and manufacturers to develop coils that present a better arrangement inside the aneurysm sac and fulfil two important conditions: a good apposition with the aneurysm wall, and a stable three-dimensional conformation, so that loops do not herniate through the aneurysm neck.
The first issue was approached by the development of coils with a geometry intended to fill the aneurysm sac, even if it is irregular. A good apposition with all regions of the cavity may improve the aneurysm embolization ratio and increase the stability of the coil mass, preventing migration. The second issue was approached through the development of coils with a memory of their three-dimensional shape, so that they may be used to create a relatively predictable cage that would keep the subsequent coils inside. As one may imagine, the above properties are relatively antagonistic. A coil that penetrates irregular spaces and has a good position to the aneurysm wall is also a coil that may herniate through a large aneurysm neck. In this context of technical difficulty, balloon and stent-assisted techniques have been used to provide protection for the parent artery as well as to treat coil mass herniation.
Intracranial stents also serve as scaffolding for neo-endothelization, providing additional reduction of the flow into the aneurysm. Consequently, their use improves intrasaccular thrombosis and decreases the risk of recanalization.
Even if these concepts seem attractive, manufacturers were rapidly confronted with technical difficulties, such as the narrowness and fragility of the intracranial vasculature, the need to navigate tortuous vessels, and the obligation to provide materials that were thin enough so that a microcatheter could be placed simultaneously in the vasculature.
The first case of intracranial stenting for treating a brain aneurysm was reported by Higashida et al. in 1997 (Higashida et al., 2005). In that occasion, the authors used a balloon-expandable cardiac stent in combination with Guglielmi detachable coils to treat a fusiform aneurysm of the vertebrobasilar junction. At that time, other authors had already attempted the placement of stent and coils in a fusiform aneurysm in an experimental context in pigs. Soon after, different groups reported a number of strategies using a combination of balloon-mounted stents and coils. In 2000, the use of stents for managing coil migration during the treatment of wide neck aneurysms was reported (Fessler et al., 2000, Lavine et al., 2000) and the case series became progressively larger.
The first stent specifically designed for the intracranial area to obtain Food and Drug Administration (FDA) approval was the NeuroformTM (Boston Scientific Corporation, Natick, USA). The device was approved for \'humanitarian device exemption\' in 2002. This means that its use was complicit to the additional approval of an Institutional Review Board and was supposed to be limited to use on no more than 4000 individuals per year in the United States of America (USA).
Outside the USA, especially in Europe and in the context of clinical research, other stents became rapidly available. That was the case with the LeoTM (Balt, Montmorency, France), the first self-expanding closed cell design stent released in Europe in 2003, and then the EnterpriseTM (Cordis Neurovascular I., Miami Lakes, USA), which was approved by the FDA in the US in 2007.
Flow diverters are the last technical advances bringing the concept of \'reverse remodeling\' for intracranial aneurysm treatment. SilkTM (Balt, Montmorency, France) and PipelineTM (Chestnut Medical Technologies Incorporation, Menlo Park, CA, USA) are in this category. These devices are intended to exclude the aneurysm sac from the parent artery by creating significant flow disruption, so that blood significantly stagnates inside the aneurysm sac and thromboses.
For treatment of intracranial aneurysms, stents are used mainly in two different situations: wide neck aneurysm and unfavourable anatomy. Wide neck aneurysm has been defined as a saccular aneurysm in the diameter of the neck larger than 4 mm, in which the dome–to-neck ratio is less than 2, or in which the ASPECT ration is superior to 1.6. These circumstances are associated with an increased risk of coil migration and compromising of parent artery patency during non-assisted endovascular coiling. Both situations are not uncommon with large and giant sacciform aneurysms. Circumstances for unfavourable anatomy are MCA trifurcation, neck-to-parent artery diameter <1 and fusiform aneurysms.
The indication stent-assisted endovascular treatment of cerebral aneurysms goes beyond vascular morphology. In the last few years, issues regarding patient selection have received progressively more attention, with the aim of reducing perioperative complications. A candidate for such a procedure must understand the risks and benefits, and be capable of following medical recommendations, especially the use of double antiplatelet therapy. As a consequence, any social and psychiatric conditions in which the compliance of the use of such medications and follow-up are significantly compromised should be considered as relative contra-indications.
Caution should be taken with individuals who may need surgery or a ventricular drainage shortly after the aneurysm treatment - situations that are more frequent with ruptured aneurysms. As the use of antiplatelet medication is mandatory, significant controversy exists on the placement of intracranial stents in the acute phase of intracranial haemorrhage. If subtotal embolization of the aneurysm sac may be performed with coils only, a valuable strategy is to complete treatment in a different session. In such a case, stenting would be performed far from the subarachnoid haemorrhage. Other relative contra-indications are exaggerated; vessel tortuosity, significant atherosclerotic disease and coagulation disorders.
The decision to deploy an intracranial stent is taken after considering the feasibility of performing the treatment without it (e.g. aneurysm coiling to be safely treatable using balloon remodeling techniques), or the possibility of not completing the treatment due to technical difficulties such as poor navigability. The diameter and length of each device is chosen according to the diameter of the native vessel and the extension of the pathological segment.
Important issues for treatment planning are: exact aneurysm anatomical location, parent artery morphology and presence of side branches and perforators. These factors are studied on CT, MRI or DSA images before the operative procedure. The size and shape of the aneurysm, as well as the diameter of the neck, are recorded. The diameter of the parent artery is then measured, as well as the segment of the artery that will be covered by the stent. The operator will then be able to choose the adequate diameter and length of the device to use so that adequate covering of the neck can be assured.
The tortuosity of the parent artery and the technique for coiling (e.g. jailing, semi-jailing, \'X\' and Y\' stents, etc.) also influences the type of stent used (open cell versus closed cell, self-expandable versus balloon-mounted, etc). It is particularly important to detect potential irregularities due to other vascular pathologies such as atherosclerosis or fibromuscular dysplasia. Part of the assessment of feasibility of the stent-assisted treatment is the study of branches presenting with sharp angle of bifurcation or incorporation of its origin into the neck of the aneurysm. Such vessels may be very difficult to catheterize. If it needs to be stented, this may result in a longer and more laborious procedure. If the progression of a microguidewire and a microcatheter inside a recurrent branch is impossible after numerous attempts, other treatment modalities (e.g. surgical) must be considered. As a consequence, the patient must be properly informed before the endovascular procedure that his or her treatment presents elements of technical complexity, and that endovascular treatment may not be feasible.
A baseline neurological examination is performed and neurological scores are attributed when applicable (e.g. modified Rankin and NIHSS score), which are useful for follow-up, especially for patients who have a past history of neurological disease.
Antiplatelet agents are highly recommended in the preparation patients undergoing intracranial stenting. Insufficient platelet inhibition (PI) has been associated with an augmented risk of thrombus formation and embolic complications. As a consequence, patients receive either a loading-dose or a period of antiplatelet therapy. A loading-dose of 300 or 600 mg of clopidogrel is then administered the day before the endovascular treatment. Alternatively a dose of 75mg PO QD for five or more days has also been proposed for some authors. This is supported by both literature to date and previous experience in the cardiology field.
Since double antiaggregation is recommended, administration of acethyl-salicic acid (ASA) is also performed perioperatively. Some authors have suggested the use of preparations of 325mg or more for three or more days before the procedure, concomitant with clopidogrel. Other teams have preferred to administer a single intravenous bolus of 250-500 mg of injectable ASA at the moment of the endovascular procedure. This presents the advantage of avoiding the use of double antiaggregation in the pre-operative period, in which the aneurysm is not yet secured. However, injectable preparations are not available in all countries worldwide.
Whilst ASA resistance seems relatively uncommon, clopidogrel resistance seems to be frequent. The prevalence of low-response to this drug varies from 28% to 66% in literature. Little data is available specifically for patients undergoing stent-assisted treatment of intracranial aneurysms, but thromboembolic adverse events do seem highly concentrated in the low responder group. Some authors have consequently recommended a level of at least 40% of platelet inhibition.
Individual response to clopidogrel may be evaluated using different techniques. Recently, point-of-care assays have been commercially available, allowing practitioners to perform prompt measurements pre-operatively. The level of PI is now routinely assessed before intracranial stenting in a number of centers. In selected cases, the doses of antiplatelet agents might be adapted in order to achieve the desired levels. Another advantage of these point-of-care assays is the fact that they may be performed per-operatively, so that the operator is informed of the percentage of antiaggregation at the moment of stent deployment.
Such an approach requires systematic blood sampling, subsequent drug administration and financial investment. At present, no prospective study assessed the potential benefits in achieving a level of anti-aggregation over 40% in patients undergoing intracranial procedures. The same applies for the assessment of the risk of hemorrhagic adverse events that may be related to the combination of intravenous heparin and double antiaggregation.
We have witnessed a proliferation of portable devices and this technology is increasingly being used, and particularly in the cardiology field. Different assays are now commercially available: VerifyNow (Accumetrics, San Diego,USA), PlateletWorks (Helena Lab.; Beaumont,USA), IMPACT-R (with and without ADP stimulation, DiaMed AG, Cressier sur Morat,Switzerland), DADE PFA collagen/ADP test (Siemens Healthcare Diagnostics Products, Marburg,Germany) and others. Even so, there is some evidence that only measurements using light transmittance aggregometry (VerifyNow and PlateletWorks) are significantly correlated to the occurrence of ischemic adverse events in interventional cardiology as suggested by the POPULAR study in 2010 (Breet et al., 2010). Other studies, such as the BOCLA (Neubauer et al., 2011), showed that the concept of clopidogrel resistance may be relative, and that more than half of poor responders may have a good response by increasing (two-fold) the dose.
In the field of interventional neuroradiology, studies specifically focused on the importance of antiaggregation are rare. Four case series were published in 2008 (Lee et al., 2008, Muller-Schunk et al., 2008, Pandya et al., 2008, Prabhakaran et al., 2008). Only two have studied the incidence of thromboembolism using techniques and different cut-offs. We recently performed a study on 271 procedures in which the VerifyNow assay was used and observed a significant association between thromboembolism and poor antiagregation. The ability to predict the risk of a thromboembolic event occuring does exist, but it is moderate given the multifactorial nature of these events. In our experience, body weight should be considered as an important factor to observe. After a homogenous, single loading dose of 300mg of clopidogrel, the prevalence of low-response (<40% of PI) is significantly lower in patients weighing less than 60 kilograms (43% versus 29%). If a stent has to be deployed urgently and the patient has not been prepared with antiplatelet agents, the risk of thromboembolic events may be significant, since post-operative aspirin and clopidogrel will take time to act. Some authors have suggested the use of a loading dose just after the procedure. Others have preferred to use a GPIIb/IIIa inhibitor. A bolus of 0.025 mg/Kg of intravenous abciximab may be administered and followed by infusion at 10 mcg/min per 12 hours. Evidently, this strategy should be used with caution and not as routine in view of the well-known hemorrhagic side effects of intravenous GPIIb-IIIa inhibitors.
LeoTM (Balt, Montmorency, France) was the first closed-cell stent to be released in the market. A second generation was released thereafter as Leo+TM. This is a self-expandable device made of nitinol (nickeltitanium) wires with a braided design. Its main features are good visibility and the availability of long devices (up to 75 mm). According to the manufacturer, the following product characteristics should be noted:
Available in four nominal diameters: 2.5, 3.5, 4.5 and 5.5 mm, for vessels from 2.0 to 6.5 mm;
Available in nine lengths: 12, 18, 25, 30, 35, 40, 50, 60, 75 mm;
Braided design of nitinol wires;
Self-expandable;
Good wall apposition;
Very good visibility;
Significant shortening after deployment;
Retrievable up to its 90% deployment;
Equipped with a double helix radio-opaque, easily visible strands;
Equipped with delivery microguidewire with a radio-opaque distal tip;
Compatible and recommended to be delivered with a Vasco+ microcatheter;
Recommended to be used in a triaxial system with a distal access system 6F Fargo-Fargomax.
The first version of the Neuroform stent was approved in 2002 for the treatment of wide-neck, intracranial aneurysms. It was designed for vessels with diameters from 2 to 4.5 mm. It was the first self-expandable device specifically designed for assisting the treatment of brain aneurysms with coils. Made of nitinol, the Neuroform stent has an open-cell design. In its first version, a low radial force resulted in a number of cases of inadequate support for the coil mass within the aneurysm and technical problems such as stent migration. The Neuroform2 stent was launched in 2003 and the Neuroform3 in 2005. According to the manufacturer, the following product characteristics should be noted:
Available in a range of sizes from 10 to 30 mm in length;
Available in a range of diameters from 2.5 to 4.5 mm;
Open cell geometry;
Minimal shortening after deployment;
Self-expandable;
Flexibility and conformable in tortuous distal anatomy;
Capable of apposition in tapered vessels;
Interstices of 2–2.5 F (<1mm), allowing the positioning of a microcatheter through the stent;
Proximal and distal stent markers
Thin mesh;
Minimal radial force;
Not retrievable.
Equipped with 131cm delivery microcatheter (3F proximal, 2.8F distal)
Compatible and more appropriate for use with 0.014" Transend 300 Floppy microguidewire
Equipped with a 150cm (2F) stabilizer (pusher) catheter with a marker band at the distal tip that indicates the proximity of the stabilizer catheter to the proximal end of the stent.
In 2010, the fourth version of the Neuroform stent was released: Neuroform EZTM. This newest version eliminated the need for an exchange maneuver using a 3m microguidewire. It may be delivered using a standard 3F microcatheter. As a consequence, the following features should be noted:
Equipped with a Neuro Renegade™ Hi-Flo™ Microcatheter for deployment (total usable length 150cm, flexible tip length 10 cm)
Equipped with a 185cm stainless stent delivery wire with a radio-opaque 19mm 45º pre-shaped distal tip and two radio-opaque positioning bumpers, one proximal, the other distal to the stent.
The Cordis Enterprise Vascular Reconstruction Device and Delivery System consists of a self-expanding closed-cell stent and a delivery system. Its design is that of tubular mesh made of nitinol. The delivery system is composed of a delivery wire that acts also as a pusher. A major characteristic of this device is its easy placement, with good wall apposition and excellent support of the coil mass. A partially deployed device can be recaptured once and redeployed. A disadvantage of the delivery system is the absence of a very long microguidewire distal to the parent artery. In the context of very tortuous vessels, this may be a factor of instability during deployment. According to the manufacturer, the following product characteristics should be noted:
Available in one diameter, 4.5 mm and can be used in vessels from 2.5 to 4 mm;
Available in four lengths: 14, 22, 28, and 37 mm;
Closed-cell geometry;
Self-expandable;
Good wall apposition;
May present significant shortening after deployment, from 1.1 to 4.7mm, depending on the length of the stent and the diameter of the parent vessel;
Proximal and distal stent markers;
Equipped with a delivery wire with three radio-opaque segments (distal, at the tip of the wire; intermediate, long radio-opaque segment for stent positioning; and proximal marker, just before the proximal stent markers)
Retrievable once, if the proximal end of the stent-positioning marker the (intermediate marker on the delivery wire) is not beyond the distal microcatheter markerband.
Compatible and recommended with a 0.021 Prowler Select Plus Infusion Catheter, positioned at least 12 mm beyond aneurysm neck before stent delivery.
The Solitaire AB (aneurysm bridging) Neurovascular remodeling Device (ev3 Cooperate, Plymouth, USA) is the first fully deployable and retrievable device for assisting intracranial aneurysm embolization with coils. It is a nitinol self-expanding stent that can be delivered and deployed by a single operator. The stent works with an open longitudinal split and is fixed to its pusher. There is no guidewire beyond the distal markers. It can be detached electrolytically using a dedicated detachment system. According to the manufacturer, the following product characteristics should be noted:
Available in two diameters, 4mm for vessels from 3 to 4mm, and 6 mm for vessels from 5 to 6mm. Since recently, a new 3mm version is also available.
Available in three lengths: 15 (only with 4mm diameter), 20 (both 4 and 6 mm diameter) and 30mm (only with 6 mm diameter);
Closed-cell geometry;
Self-expandable;
Presence of a longitudinal split with overlapping of the stent cells, depending on the diameter of the parent vessel;
Good wall apposition;
High cell deformation resistance;
Presents significant shortening after deployment, depending on the length of the stent and the diameter of the parent vessel;
One Proximal and three distal stent markers;
Equipped with a delivery wire, with a detachment zone just before the proximal marker;
Can be retrieved and repositioned before detachment, even when fully deployed;
Compatible and recommended with a Rebar 18-27 Microcatheter (*but also compatible with a 0.021 Prowler Select Plus Infusion Catheter).
The Pharos stent (Micrus, San Jose, USA) was launched in 2006 in Europe for the treatment of ischemic disease. The Pharos Vitesse stent is the second generation of this balloon-expandable stent for both intracranial ischemic stenosis and wide-neck aneurysm treatment. It is a rapid exchange balloon-delivered device, which enables the operator to deliver and deploy the stent in one step. Made of cobalt chromium, the stent is opened by the radial force of the balloon. There is no self-expansion of the device. According to the manufacturer, the following product characteristics should be noted:
Available in eight diameters: 2, 2,5, 2,75, 3, 3,5, 4, 4,5 and 5 mm, for vessels from 2 to 5 mm;
Available in six lengths: 8, 10, 13, 15, 18 and 20 mm;
Double helix geometry with thin struts (60 micra);
Not self-expandable;
Good wall apposition;
High radial force
Good visibility;
Compatible with a 0.014" microguidewire
Very low shortening after deployment (<1%);
Proximal and distal stent markers;
The Low-profile Visualized Intraluminal Support (MicroVention Incorporation, Tustin, USA) is a very recent generation of devices intended for use with embolic coils, now available in Europe. It is a hybrid closed-cell stent in nitinol with flared ends and a double helix of tantalum strands to assist full-length visualization. It presents a high metal-to-surface coverage intended to help promote neo-endothelization. However, the sliding design of its cells ensures the feasibility of crossing the struts with a microcatheter. According to the manufacturer, the following product characteristics should be noted:
Available in three nominal diameters, 2,5, 3.5, and 4.0 mm, respectively for vessels from 2 to 3 mm, 2.5 to 3.5 mm and 3.5 to 4.5 mm;
Available in six lengths, 17 and 25 mm for the 2.5 mm diameter, 15, 25 and 41 mm for the 3.0 mm diameter, 35 and 49 mm for the 4.0 diameter stent;
Hybrid, compliant closed-cell geometry with thin struts;
Self-expandable;
Good wall apposition;
Flared ends;
Good visibility;
High metal-to-surface coverage;
Significant shortening after deployment;
Retrievable up to 80% deployment;
Proximal and distal stent markers, as well as double helix radio-opaque tantalum strands;
Equipped with delivery microguidewire with a radio-opaque distal tip;
Compatible with a 0.021 Headway microcatheter.
These are braided, tubular stents with very small struts that are intended to provide significant flow disruption along the aneurysm neck, but allow preservation of both large branches and small perforators. Such devices may reduce shear stress on the aneurysm wall and promote intra-aneurysmal blood stagnation and thrombosis (Pierot, 2011). Besides their effects on flow, these devices also provide significant scaffolding for neo-endothelization across the aneurysm neck. They are high-cost devices and their main characteristic is the very high metal-to-artery coverage in comparison to conventional stents. Two devices are currently available, as follows.
The Silk and its more recent version Silk Plus (Balt, Montmorency, France) are self expanding stents made of braided nitinol strands, with the following technical characteristics.
Available in eight nominal diameters: 2.0, 2.5, 3.0, 3.5, 4.0, 4.5, 5.0 and 5.5 mm, for vessels from 1.5 to 5.75 mm;
Available in six nominal lengths, 15, 20, 25, 30, 35 and 40 mm;
Also available in tapered version (Tapered Silk+) in three combinations of diameters: 4.0 mm proximal and 3.0 mm distal (30mm long), 4.5 mm proximal and 3.0 distal (25 mm long), 4.5 proximal and 3.5 distal (30 mm long);
Dense mesh geometry with very high metal-to-surface coverage;
High radial force (Silk Plus has 15% more radial force than Silk) thanks to a different strut configuration;
Good wall apposition;
Good visibility;
Slight flared ends
Double helix radio-opaque markers through the entire body of the stent, combined with extra Platinum small wires in the Silk Plus version, that allow visualization of the borders of the stent;
Equipped with delivery pusher/microguidewire with a radio-opaque distal tip;
Compatible and recommended with a Vasco+ microcatheter for delivery and a triaxial system with a long introducer and a distal access system 6F Fargo-Fargomax;
Compatible with concentric Leo+ stents for lumen reconstruction before deployment of Silk or Silk Plus, if needed in fusiform aneurysms.
The Pipeline Embolisation Device (ev3-MTI, Irvine, USA) is a newer, self-expanding, flexible device, composed of 25% platinum tungsten and 75% cobalt chromium in interwoven strands. According to the manufacturer, the following product characteristics should be noted:
Available in eleven nominal diameters: 2.0, 2.75, 3.0, 3.25, 3.5, 3.75, 4.0, 4.25, 4.5, 4.75 and 5.0;
Available in nine nominal lengths, 10, 12, 14, 16, 18, 20, 25, 30 and 35 mm;
Dense mesh geometry with braided construction and very high metal-to-surface coverage, which can be customized according to the push that is imposed to the microcatheter (increased push narrows stent cells);
High radial force and flexibility, resistant to kinking;
Good wall apposition;
Uniform visibility through entire device;
Ability to telescope multiple devices, one inside another to create longer constructs;
Equipped with delivery pusher/microguidewire with a radio-opaque distal tip and a \'capture coil\' that keeps the device in contact to the guidewire until significant length is deployed;
Compatible and recommended with a 2.8F/3.2F MarksmanTM microcatheter for delivery and deployment.
It is worth noting that a number of stents that were not specifically designed for use with intracranial aneurysms have non-rarely been used as adjunctive devices. This situation was much more frequent in the early times of stent-assisted aneurysm embolization, when a lesser variety of devices were available. That is the case with the Jostent GraftMaster Stent Graft (Abbott Vascular, Redwood City, Calif), a balloon-mounted system consisting of two stainless steel flexible devices with an expandable layer of polytetrafluoroethylene between them. It was developed for use within the coronary circulation, particularly for cases of leakage or vessel perforation. However, cases of repair of internal carotid artery, middle cerebral artery and vertebral artery aneurysms were regularly reported with this system (Chan et al., 2004, Mehta et al., 2003, Pero et al., 2006, Saatci et al., 2004, Wang et al., 2009). During the advancement of neurointerventional tools for wide-neck aneurysms, several stents initially designed for the cervical carotid or coronary circulation were also used as adjunctive devices, such as WallstentTM (Boston Scientific, Natick, USA), MultilinkTM (Abbott Vascular, Redwood City, Calif), and others (Lavine & Meyers, 2007, Morizane et al., 2000, Wanke & Forsting, 2008).
An intracranial stent may be used at the end of an aneurysm embolization when coils have been used, which is particularly useful in cases in which the aneurysm neck was not fully respected by the coil mass, or to insure protection of the parent artery against coil migration. In addition, when a stent is deployed after an aneurysm coil, significant scaffolding for neo-endothelisation is provided and an increase in pack density may be observed. This technique may be particularly useful for small aneurysms, in which the introduction of a microcatheter and repetitive manipulations may be dangerous. The coil is deployed first and then a preloaded stent is released, pushing the coil loop into the sac. This method has been also been known as a \'stent-jack\' technique.
Finishing stent\'.
When non-assisted coiling is performed, coil migration or herniation of the coil mass may be observed, even if the neck is not very wide. This may also be observed during balloon-assisted embolization. If a large amount of material is present in the lumen of the parent artery, its patency may be threatened, or the patient may be exposed to a risk of embolic phenomena. In such a situation, a valuable technique can be the deployment of what is called a \'rescue stent\', which pushes the herniated coils against the vessel wall or back inside the aneurysm sac.
When stent-assisted coiling is performed, the microcatheter tip may be placed inside the aneurysm the through the stent struts. The choice between this method and placement of the microcatheter before stenting depends on the operator\'s experience, the vascular morphology and aneurysm size. Placement of a microcatheter into the aneurysm is evidently more difficult after stenting, especially if a closed-cell device was used. In this last case, a thinner microcatheter may be necessary. Some practitioners prefer using a Neuroform stent in such situations, for the same reason. Furthermore, with a Neuroform stent, it is easier to regain access to the aneurysm sac in cases of microcatheter kickback into the parent vessel.
If the operator experiences difficulty in penetrating the aneurysm sac, especially when the angle of penetration is not favorable, caution should be taken in order to avoid abrupt release of energy accumulated in the system, which may have disastrous consequences, especially with small or ruptured cerebral aneurysms.
Crossing a deployed stent with a microcatheter.
The technique of placement of the microcatheter tip inside the aneurysm before deployment of the stent has the advantages of being technically easier and being less susceptible to microcatheter kickback phenomena. However, when significant kickback occurs, it may be problematic to regain access to the aneurysm sac. Some authors argue that the previous deployment of coil loops before stent placement may be useful. The previously deployed coil may be used as a guidewire and allow reintroduction of the microcatheter in case of early kickback (Kim et al., 2011).
In this technique, a stent is partially deployed in front of the aneurysm neck to act as a remodeling device. For this, the operator chooses a retrievable device such as Solitaire AB or Enterprise (retrievable if the proximal end intermediate marker of the delivery wire is not beyond the distal microcatheter markerband). This technique presents several advantages: the possibility to regain access to the aneurysm sac in case of kickback by a slight repositioning of the stent; the absence of blood flow arrest as observed with balloon-remodeling techniques; the possibility to chose to either retrieve or definitely deploy the stent after coiling; and the possibility of not using double antiplatelet treatment if the stent is retrieved at the end of the procedure.
The \'jailing technique\'.
The \'semi-jailing\' technique with a partially deployed stent.
If one stent is not able to adequately protect the parent artery or a bifurcation branch, a possible solution is the deployment of two devices in a \'Y\' configuration. A first stent is deployed in one of the branches, preferably an open-cell device. A microcatheter is then navigated into the other branch and a second stent is released. Another possibility is to place both stents in a parallel configuration, without crossing the first one. For confluent vessels such as in the anterior communicating territory, crossing stents are also possible, what has been called an \'X\' configuration (Kim et al., 2011).
The \'Y\' Stent Technique.
Similar to the \'semi-jailing\' technique, temporary stenting consists of using a stent as a remodeling device, with full retrieval of the device at the end of the procedure. Up to date, only stents from the Solitaire group may be retrieved after full deployment. It is worth noting that with this kind of stent (but not exclusive to this brand) the use of a dynamic push in the delivery wire increases notoriously the apposition to the vascular walls, an effect that is important to remember when using this device as a remodeling tool.
Temporary stenting with a Solitaire AB device.
Even though a large part of the deployment steps are common for the majority of intracranial stents, the technique for flow diverters differs in some details that make the method more challenging. The operator must work within a technique of pushing the delivery microguidewire forward, of pulling the microcatheter back, and pushing the entire system so that the stent opening and apposition are optimal. In addition, the phenomenon of shortening after deployment must be taken into consideration for the adequate selection of the stent length.
For the Pipeline Embolization Device, adequate pushing on the microcatheter is also important to release the distal extremity of the device from the capture coil that keeps it attached to the delivery microguidewire. In addition, forward pushing may increase mesh density, and accounts for the customization that is possible with this type of device. With an adequate push at the right site, one may deploy a PED with an increased metal-to-artery coverage at the aneurysm neck.
Treatment of a cerebral aneurysm using flow diversion with a Pipeline Embolization Device.
The morphological results on immediate and late post-operative angiograms are categorized according to the revised Raymond classification into 1 of the following groups: complete occlusion, neck remnant, and residual aneurysm. Follow-up examinations with Digital Substraction Angriography or Magnetic Resonance Angiograms are then scheduled at minimum intervals of 6, 18 and 36 months. In cases of early recanalization, a DSA would be preferred in order to properly assess the need for retreatment.
The rates of complete occlusion differ significantly from the results observed on the immediate postoperative angiogram after stent-assisted coiling. In a recent study on the Neuroform Stent in our institution, we observed that the percentage of complete occlusion tends to stabilize after six months. However, progressive thrombosis and subsequent increase of the degree of aneurysm occlusion between the immediate postoperative and six-month angiograms are observed in roughly 50% of the aneurysms treated with stent-assisted techniques (Maldonado et al., 2010). Of 76 aneurysms studied, 31.6% were completely occluded in the initial embolization, 63.8 at six months and 64.7% at 18 months. However, in three years of follow-up, six aneurysms with an initial complete occlusion and five with a neck remnant recanalized. The analysis by type of coil did not demonstrate any association between complete occlusion and coil type.
Endovascular treatment of a repermeabilized aneurysm of the right middle cerebral artery using the Neuroform Stent System.
Stents may contribute to the progression of thrombosis, independent to the size of the aneurysm and type of coils used. Fiorella et al (Fiorella et al., 2005) reported an improvement of anatomic results with progressive thrombosis in 52% of cases of patients treated with the Neuroform stent. Lubicz et al (Lubicz et al., 2009) observed progressive thrombosis in 53% of aneurysms coiled with MicroPlex bare coils or GDCs using the Leo stent.
The overall complete occlusion rate obtained with stent-assisted coiling seems superior to results obtained with coils alone or other adjunctive devices in cases of large or complex aneurysms. Sedat et al (Sedat et al., 2009) documented 9.5% of aneurysmal regrowth at a mean follow-up of 42 months.
Recent case series report incidences of adverse events ranging from 8.4 to 18.9%. Risk factors for complications are age, presence of significant atherosclerotic disease, subarachnoid hemorrhage, small aneurysm and large/giant aneurysm. The most common of those adverse events in the peri-operative phase are navigation problems, stent misplacement, stent migration, vessel dissection or perforation, and thromboembolic events.
Delayed stroke due to intrastent thrombosis or intrastent stenosis are less frequent but may be observed, especially in patients with irregular use of antiplatelets. In a recent study published by the authors on 76 aneurysms treated with a Neuroform Stent-assisted technique, a five-month delayed symptomatic stroke and three clinically silent in-stent stenosis were observed.
There is currently significant concern about the risk of delayed rupture after flow-diversion treatment. The exact mechanism of this adverse event is not completely understood. There are two main hypotheses for this phenomenon. First, the mural thrombus may act as a source of inflammatory substances such as proteases leading to chemical degradation and weakening of the aneurysm wall. Second, flow diversion may induce changes in intra-aneurysmal flow pattern with a consequent increase in stress to areas that were not previously exposed. In a series of recent international cases of rupture after flow diversion, the following risk factors seemed to be important (Kulcsar et al., 2010):
Large or giant aneurysm;
Symptomatic aneurysm;
Saccular aneurysm with AR>1.6;
Morphologic characteristics predisposing to an inertia-driven inflow.
During the procedure, patients are anticoagulated with a bolus of standard heparin (70–100 IU/kg) followed by an intravenous drip through an automated syringe (40–60 IU/kg/h) to maintain an activated clotting time of 250 seconds, which may be continued for 12-24 hours. At the end of the procedure, they receive an IV dose of 250–500 mg of ASA unless they are already using oral Aspirine. A daily dose of clopidogrel (75 mg) and ASA (75 mg) is then administered for two or three months. After that period, only one of those antiplatelet agents is continued, for a period of time that has varied in literature from three months to indefinitely.
We would like to express our thanks to Mr José Alberto Maldonado Via for his assistance with the illustrations.
Conventional clinical relationships are centered on a triad, consisting of the physician, the patient, and his/her family. Nowadays, individuals in need or seeking medical care, as well as their intimate circle, interact with a great variety of stakeholders and clustered interests. Three important factors contribute to this more complex situation.
The progress of life sciences and technological innovations as well as the development of the health system and the medical-industrial complex create new medical situations and redefine the role of both family members and health professionals.
The potential of modern healthcare, including resuscitation and life-sustaining technologies, their impact on the quality of life, as well as problems of costs and resource allocation in the context of market economies, also redefine the role of family members. This opens a myriad of ethical questions, from coping with frail, sick, or disabled relatives, over socialization and commercialization of traditional household tasks, to substitute decision-making for minors and patients with diminished autonomy, as well as dealing with end-of-life situations.
The nature of neurosurgical problems forces neurosurgeons to face their patients’ families in different emotional situations, frustrated to see good results, disappointed with the outcome, confused, denying, or angry. Neurosurgeons should learn the skill to absorb the first reaction of the patients’ family and work with them as one team to help their loved one. The patient’s family can play a very positive part in the caregiving team for the patient and may have a great and unreplaceable input for their patient care.
Values-based medicine (VsBM) is the concept to ensure that the principles of medical ethics are strictly implemented and observed in every step of a patient’s management.
The concept of values-based medicine (VsBM) stresses on the fact that patient, patient care, and well-being are the center of care in modern medicine. The treating neurosurgeons, physicians, or healthcare givers should spare no effort to improve their skills, update their knowledge, and learn to use the latest technology in order to provide the best care for the patient. The treating team should have a vision and build up a strategy of management and follow-up of their patients. All these necessary steps should be performed within a frame of values and medical ethics. The treating teams should respect and observe the patient and value and respect the culture of the society. Evidence-based medicine should be considered an important component of values-based medicine [1].The key elements of values-based medicine which, like evidence-based medicine, influence any clinical decisions may be taken for patients’ management (Figure 1).
The concept of values-based medicine (VsBM): patient is the center of care.
Based on the Hippocratic Oath, the main ethical principles were beneficence (do the best for patients) and non-maleficence (do no harm). These two principles were considered to be the fundamental principles of medical ethics for hundreds of years. The principles of medical ethics/bioethics were expanded to include autonomy (patient’s right to accept or refuse the method of treatment) and justice. Justice in medicine considers the distribution of healthcare facilities and the access of all patients to these facilities. One of the positive characters of the last and this century is the respect and observation of human rights. Therefore the human rights were manifested clearly in the medical ethics, as the medical ethics expanded again to (a) autonomy, (b) beneficence, (c) non-maleficence, (d) justice, (e) dignity, and (f) truthfulness and honesty. Figure 2 demonstrates these principles.
The principles of medical ethics.
The respect of patients’ rights is one of the main foundations of the concept of values-based medicine. Patients should be considered as partners and share in the process of management. Patients should agree and consent to every step of treatment. Patients have the right to be fairly and properly treated; follow-up should be guaranteed. A patient’s privacy, dignity, and confidentiality should be respected. Dignity encompasses a feeling of self-worth and equality. It is paramount that the patient be treated as a person with a disease, rather than a disease that a person has. The patient should also feel he is an equal partner in decision-making, and not just a bystander or subordinate. Patients should be educated and learn about their medical problems, treatment options, and the prognosis. Patients must know who the treating team is, their experiences and qualifications. Patients should have the right to complain in the cases of dissatisfaction about the treatment or lack of communication. Most of these rights are illustrated in Figure 3. These fundamental human rights are listed in the WHO recommendation [2] and the World Federation of Neurological Societies as good practice guideline [3].
The Patient’s rights.
The concept of values-based medicine draws the outlines of the duties and tasks of the treating team as illustrated in Figure 4. These duties include respecting the patient and preserving their dignity. It is the duty of every doctor to improve skills and update the knowledge. Doctors should research answers to previously unanswered medical questions. Doctors should be good citizens and advocate for good health. They should maintain a high level of professionalism at all times.
The tasks and duties of a medical team.
Healthcare is considered as a universal human right. Culture, faith, socioeconomic factors, and the perception of the value of the education, work, and status of doctors in differing societies are some of the causes of the variance of healthcare in those societies. That variance cannot be deemed as right or wrong, which led to the study and introduction of ethical relativism. Ethical relativism is the view that there are no ethical standards that are absolutely true and must be applied to the societies, without variance. According to the Relativism Theory, a certain event, attitude, or practice may be considered right, if it is accepted as morally correct by the people of the involved society. The same event or attitude may be considered wrong by a society that does not accept it as morally correct.
Throughout the world, most neurosurgical training programs are designed to produce safe, effective neurosurgeons trained to find evidence for the treatment of different neurosurgical problems [4].
Neurosurgeons are obliged to establish ethical and professional relationships with their patients and to that end, should listen to and be guided by both the patient’s medical complaint and their perception of the possible outcomes. It is the duty of neurosurgeons to explain to their patients all the steps of investigation, treatment, operation, and possible outcome.
The neurosurgeon can gain valuable knowledge of the patient’s culture and beliefs while discussing the benefits and risks of a particular method of management during the course of obtaining informed consent. This knowledge and exchange of information assist in gaining the patient’s respect and trust and compliance for both the agreed-upon treatment and its follow-up. Ethical informed consent requires that autonomy and beneficence are applied in equal measure. In applying beneficence, at the expense of autonomy, neurosurgeons may cause irreparable psychological damage [5, 6, 7] . Pressure or influence for a particular course of treatment can never be considered ethical, because, although it may be applying the principle of beneficence, it is at the expense of autonomy.
An “evidence” is considered as evidence according to data of a particular cohort study under particular condition of some patient group somewhere. Several scholars and ethicists have raised concern about using the stereotype of evidence to promote a chosen type of therapy or surgery [8]. This attitude may cause bias in selecting evidence to justify certain methods of treatment.
Ross defined the clinical evidence as “In essence, evidence—narrowly defined or not—is a provisional departure point in the consideration of whether or not a particular course of action is to be taken in any clinical context.” [9] This definition directly links the evidence to its application but not to the strength, validity, and reliability of the source of that evidence.
The introduction of evidence-based medicine 40–50 years ago had a great impact on medical practice almost everywhere. That concept became very popular in a very short time. The main reason being that it offers a strong foundation for the justification of decision-making in the course of management of clinical cases. The evidence-based medicine was defined by El Kayaly et al. as “Evidence-based clinical medicine can be seen as the conscious incorporation of the best evidence that is currently available into daily clinical practice covering prevention, diagnostics, clinical assessments, treatments and patient-centered care” [10]. The implementation of the concept of EBM is significantly helpful and challenging for many practitioners for several reasons such as:
EBM aims to manage uncertainty regarding the short- and long-term outcome of management of certain cases. However, this aim cannot be always achieved.
From the physicians’ perspective, the conscious belief of the treating team that the best evidence and recommended method of a case management is followed has a definitely positive impact on the treating team and increases their confidence about the line of treatment they decided to choose.
In the cases when good and suitable evidence are not found or not agreed about, the integration of the principles of values-based medicine is a must.
From the patients’ perspective, knowing that the course of management offered to them is supported by good evidence helps the patient and his family to accept that method of treatment. The patient’s perception of receiving treatment according to EBM has good psychological impact.
In the cases of medical litigation or argument, the documents of the best evidence have an important value to balance the argument. EBM documents should have an important value in a court of law.
EBM has also important educational values as it challenges all the practitioners to continuously update their knowledge in the course of their striving to find the best evidence. It definitely promotes the practitioners’ professional development. EBM seeks to inculcate lifelong learning process.
In daily clinical practice, the application and implementation of EBM simply means that choosing a treatment for a patient is based on the strongest available evidence. However, the concept of EBM does not consider as much, but should consider patient’s values and beliefs or other factors such as experiences of the treating team and facilities available at that hospital. Sackett et al. defined EBM as “Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values” [11]. In that definition “Patient values” is not clearly explained in that definition which may refer to what does the patient want? In fact, the implementation of EBM does not generally seek patients sharing in decision-making. The science, practice, and application of EBM do not consider that patient’s values, faith, and culture are factors for grading or leveling evidence (hierarchy of evidence). Several studies showed the importance of the patient being a partner in decision-making [12, 13].
Evidence-based medicine has been popularized in the last 30 years and to a certain extent has been considered a good measure of medical practice. However, the use of EBM shows these limitations:
Patient preferences and values were not always considered during the decision-making process [7].
Limitations in incorporating health-related quality of life (HRQoL) [14] .
EBM is based on finding and following the highest-quality evidence. However, in the absence of randomized clinical trials, the veracity of the evidence comes into question.
Ethically there are a few serious questions regarding presumed evidence collection. Those queries are legitimate as most of the evidence is obtained from the analysis of large data (meta-analysis) which has subsequently inherited all the problems of analyzing the large data of multiple sources. This problem has been discussed by several authors including Dagi [15]. He mentioned “The ethical question is what to do about the data once it has been collected and analyzed. It is ethically important to separate the results of statistical analysis from, for example, [1] statistically significant but clinically irrelevant outcomes, [2] judgments about how data about the set should be applied to specific individuals within the set, [3] the protection of the prerogatives of individual patients in the face of population-based protocols, and [4] the protection of the surgeon’s prerogatives in personalizing the treatment of individual patients. The question of what should be done with probabilities and statistics is not statistical in the least: it is entirely a value judgment.” Both scientifically and ethically, there is a clear line between what is considered fact and what should be or ought to be. The philosophical debate about is/ought (fact/value) has continued for hundreds of years and remains unsettled. Hume produced what is called Hume’s law “From causes which appear similar we expect similar effects. This is the sum of all our experimental conclusions.” He recognized as well the “is-ought” controversy. The idea of linking what ought to be to what is, is seriously ethically and clinically challenged.
Randomized controlled studies are the main factors that were used to level validity and strength of evidence. The value of evidence from randomized controlled studies is considered the strongest or best evidence and top leveled and graded as “Grade I Evidence.” Evidence obtained from nonrandomized studies is considered as “Grade II Evidence.” However, evidence based on valid experiences and thoughts and opinions of distinguished medical and surgical authorities are considered as “Grade III Evidence.”
Ethical concerns have been raised about double-blind randomized controlled studies. It has been debated that denying a group of patients (control group), the experimental treatment or method of management believed to be beneficial, is ethically challenged. There is also an ethical issue concerning the validity of evidence which is a result of double-blind randomized controlled studies which were carried out in certain circumstances, homogenous or not subjects, variable controls, and particular role to be used as the base for making decision for treating patients in different circumstances. Therefore, the integration of the best research evidence with clinical expertise and patient values should be carefully and cautiously considered.
There is a very important and distinct difference between the methods and approaches of clinical randomized controlled studies and the methods and approaches to established treatment. In the cases of clinical research, the physician (researcher in that case) and the patient are not standing on the same platform and may not have the same motivation and goals of the treatment. Therefore ideal clinical equipoise may not be achieved in such cases. Clinical equipoise should be carefully observed in any clinical research. The patient-physician relationship is a complex relationship regardless of the circumstances or the status of the patient. The patient has rights which should be and must be respected fully. The treating physician or surgeon should be a partner who has the main task to provide the best available treatment to the patient and share the very same goals with patient to cure the medical illness.
Respecting and observing patient values and quality of life are core to the implementation of VsBM. These principles and values somehow are overlooked by evidence-based medicine [12, 13].
The obtained and presented clinical evidence should not be out of the ethics frame (values-based medicine). The evidence should be valid and applicable in that particular condition, scientifically proven and adherent to the ethical principles and rules. VsBM and EBM should be integrated in daily medical practice and medical research. Ross [9] wrote “attention to evidence, however conceived, is linked to commitment to care. Rather than being seen as distinct spheres, ethics and evidence become part of an integrated whole.”
The core of the concept of values-based medicine is to value the human being’s dignity and respect patient’s rights and lay a foundation for ethical and meaningful good medical practice. Values-based medicine is an expression of medical ethics, considering patient as the center of care. So the frequent question of the clinician is “what is the best management for that particular patient?” If the uncertainty is the answer, the question should be brought as “which method of management ought to be better for that particular patient?” The answer to this question should be based on both clinical evidence and ethical values. Medical ethics should guide decisions in the daily medical practice. There are several branches of ethics which are normative ethics, applied ethics, descriptive ethics, and metaethics.
Normative ethics are ethical theories which highlight what is morally right or wrong in order to lead to proper decision. Normative ethics constitutes/includes/is explained by several ethical theories, including:
Applied ethics may be described as it mandates the professional code of ethics or ethical guidelines for a certain profession such as medical profession or counseling.
Comparative ethics focus on the beliefs of individuals, what people believe. Descriptive ethics is concerned with what is believed, not what should be believed.
This type of ethics is mainly concerned with the ethics itself. Metaethics studies the nature of values.
Medical professionalism in this context encompasses all qualities obtained and expressed to conduct or perform tasks and medical duties as described by the governing organization and hospital and as expected by the society.
Professional ethics is the use of knowledge and skills to providing patient care governed by the ethical code of the workplace [16]. It is akin to moving from abstract values to daily behavior of individuals in their workplaces or societies.
Professional ethics (as it is one of the elements of values-based medicine) should observe values and standards of medical professionals and their medical societies, along with the expected behavior of the organizations and hospitals [17]. Medical professionals have to continuously gain and update their knowledge and skills in order to improve their career and consequently the patient’s care. Medical researchers strive to find facts either in deductive or inductive ways. That effort should be governed by values and ethics of the patients and patients’ culture and beliefs, not purely the eagerness to obtain knowledge or achieve professional goals [9, 18, 19].
The code of medical ethics is general ethical guidelines adopted by medical societies, organizations, and hospitals. The code is mandatory for all medical and paramedical professionals in that organization to strictly observe. The code of ethics is not only for the benefit of patients but also for benefit for the medical and paramedical professionals.
Professional decision-making cannot be overemphasized in medicine in general and neurosurgery in particular. The medical professional should be able to balance the principles of values-based medicine within the roles of the governing organization and hospital. This balance is very important to avoid conflicts of patient’s values or hospital policies.
The most critical step in patient management is the decision made by the treating team. The correct decision for a particular patient at the right time is the most determinative factor for the outcome of management. Medical decision-making depends on empirical knowledge and rational and analytical thinking. Evidence-based medicine depends on knowledge and accumulated information over rational thinking and individual experiences and to a certain extent ignores the patient’s own values. In brief, there are in general two ways of logical thinking in order to make medical decisions, deductive and inductive methods. However, the rapid development of science, discoveries, medical technology, understanding the roots of pathophysiological disorders, and introduction of new treatments should allow for a less tightly constructed and rigid clinical decision. With uncertainty, the increased probability of causing risk, unsure outcome, and treatment of specific problems in a field like neurosurgery, the patient’s autonomy and values should be paramount. The concept of values-based medicine which focuses on patient’s best care allows more flexibility to adapt any scientific method which may help the patient. Patient and patient values should be part of any management equation.
The patient’s family rights should be observed. The engagement of the patient and patient’s family in making decisions created what is called “Patient-patient’s family-doctor complex relationship.” Such relationship is needed not only for the patient’s comfort and well-being but also for the treating team to prevent any misconduct and future unnecessary troubles.
The nature and pathophysiology of variable types of neurosurgical disorders may not help the neurosurgeons to ascertain an accurate predication of the prognostic outcome for a specific patient. Sometimes predictable answers can be hard to attain. This unfortunately is not rare which complicates the discussion, communication, and the relationship between a medical team and the patient and patient’s family. Agonized and apprehensive extremely worried families are eager to hear answers to their painful questions. It is vital to reach the right diagnosis. Right diagnosis is always the fundamental base for management of the patient, however, in pediatric group may not give an accurate predication for long outcome. Usually the families regardless of their age, culture, religion, or race have many very similar nagging and worrying questions regarding the survival and well-being of their loved one.
Effective communication with patients and their families to discuss every step of the management and the prognostic information to the family is very important to create a good relationship and trust between the treating teams and patients and patients’ families. The effective communication has profound influence on decisions regarding goals of care and clinical management of the patient, especially when prognostic information is clouded with a confusion of uncertainties [18].
Modern medicine may be based on EBM, which is a positive aspect of modern medicine; however, medicine since its inception, thousands of years ago, is based on values. The core of values-based medicine (VsBM) is creating a status to provide the patients the best possible available treatment within a frame of ethics and values which appreciate their culture and keep their dignity. Evidence-based medicine is, and should be, based on ethical and clinical principles which permit the best proven method of management. Values-based medicine and evidence-based medicine are and should be integrated, complementary to each other, not conflicting. The holistic approach to a human who has a disease needs to be treated, not just the disease should be treated. Humanity comes first, always.
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Transportation system became part of the infrastructure due its connection between two destinations, using maritime, land, or aerial methods, creating a link for social and economic activity. Bridges are widely used to cross rivers, valleys, and roads, providing a passage with other parts of the land since ancient times to modernity. Each structure has different requirements to cover, such span clearage, traffic flow, geometry and characteristics of the place to build; therefore, a great variety of bridges can be developed. Common materials used on construction are structural steel, reinforced concrete, pre-stressed concrete, or post-tensioned concrete; depending on the structural behavior of each type of bridge, there will be a maximum clear span to cover, which depends directly on the project’s budget. There are a variety of loads and environmental conditions that the new and existing structure needs to support effectively, including dead load, traffic, rain, wind, flood, and seismic events, using effective structural design process and techniques; on the other hand, there are long-term deterioration process, such as corrosion, wear, and fatigue, which should be considered on the maintenance process, avoiding additional costs, several damages, and catastrophic failures. Prevention and control of degradation process is achieved by effective maintenance methods applying protection technology such as paints, coating and cathodic protection. The purpose of this chapter is to show a brief review of ancient and modern bridges, including the process of design, material selection, construction, and maintenance.",book:{id:"8355",slug:"infrastructure-management-and-construction",title:"Infrastructure Management and Construction",fullTitle:"Infrastructure Management and Construction"},signatures:"Arturo Gonzalez, Michael Schorr, Benjamin Valdez and Alejandro Mungaray",authors:[{id:"16436",title:"Dr.",name:"Michael",middleName:null,surname:"Schorr",slug:"michael-schorr",fullName:"Michael Schorr"},{id:"65522",title:"Dr.",name:"Benjamin",middleName:null,surname:"Valdez",slug:"benjamin-valdez",fullName:"Benjamin Valdez"},{id:"311533",title:"MSc.",name:"Arturo",middleName:null,surname:"Gonzalez",slug:"arturo-gonzalez",fullName:"Arturo Gonzalez"},{id:"311534",title:"Dr.",name:"Alejandro",middleName:null,surname:"Mungaray",slug:"alejandro-mungaray",fullName:"Alejandro Mungaray"}]},{id:"60236",title:"The Feasibility of Constructing Super-Long-Span Bridges with New Materials in 2050",slug:"the-feasibility-of-constructing-super-long-span-bridges-with-new-materials-in-2050",totalDownloads:1847,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"This chapter explores the possibility of designing and constructing a super-long-span bridge with new materials in 2050. The proposed bridge design has a total span of 4440 m with two 330-m end spans and a central span of 3780 m. The height of the two pylons is 702 m, and the deck width is 40 m. The features of this structure include the combination of a suspension bridge and cable-stayed bridge, application of carbon fibre materials, extension of deck width and pretension techniques. Linear static analysis, dynamic analysis and theoretical analysis are conducted under different loading cases. In linear static analysis, the stresses under critical load combinations are smaller than the ultimate strength of the materials. However, the maximum deflection under the dead and wind load combination exceeds the specified serviceability limit.",book:{id:"6395",slug:"bridge-engineering",title:"Bridge Engineering",fullTitle:"Bridge Engineering"},signatures:"Faham Tahmasebinia, Samad Mohammad Ebrahimzadeh\nSepasgozar, Hannah Blum, Kakarla Raghava Reddy, Fernando\nAlonso-Marroquin, Qile Gao, Yang Hu, Xu Wang and Zhongzheng\nWang",authors:[{id:"211659",title:"Dr.",name:"Faham",middleName:null,surname:"Tahmasebinia",slug:"faham-tahmasebinia",fullName:"Faham Tahmasebinia"},{id:"221172",title:"Dr.",name:"Samad M.E.",middleName:null,surname:"Sepasgozar",slug:"samad-m.e.-sepasgozar",fullName:"Samad M.E. 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Today, the social structure of mass housing estates becomes more heterogeneous, what puts new requirements on the design of open public spaces and, as well as, on the regeneration and design of children’s playgrounds, to serve the rising demands of the inhabitants and to enhance the livability of the housing estates. The study examines the current examples of the children’s playgrounds from Slovak mass housing estates, which show that nowadays the typified design of the standardized catalog type elements is used and preferred.",book:{id:"7205",slug:"housing",title:"Housing",fullTitle:"Housing"},signatures:"Katarína Kristiánová",authors:[{id:"224853",title:"Dr.",name:"Katarina",middleName:null,surname:"Kristianova",slug:"katarina-kristianova",fullName:"Katarina Kristianova"}]},{id:"66232",title:"Geotechnical Engineering Applied on Earth and Rock-Fill Dams",slug:"geotechnical-engineering-applied-on-earth-and-rock-fill-dams",totalDownloads:2328,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"This chapter presents the importance of geotechnical engineering on the site selection, design, construction, operation, and maintenance of earth-rock dams and earth structures; it emphasizes the geotechnical engineering work related to dam safety during the operation stage. Preliminary geological studies required to select the best dam site are described first. Next, the field and laboratory studies related to the curtain design and dam foundation treatment, as well as geotechnical studies required for the construction, operation, and maintenance of the dam, are discussed. Recent developments in the following three areas are also included: (a) seismic considerations for the design, construction, and maintenance of earth dams; (b) importance of water flow control through the dam embankment and dam foundation, required to avoid internal soil erosion and excessive pore pressure; and (c) dam safety in Mexico and around the world. A case history of a recent failure is used for illustration purposes. In this example, design and construction shortcomings resulted in serious damages on an earth dam. Conclusions and recommendations related to this topic are presented at the end of this chapter.",book:{id:"7587",slug:"hydraulic-structures-theory-and-applications",title:"Hydraulic Structures",fullTitle:"Hydraulic Structures - Theory and Applications"},signatures:"Raúl Flores-Berrones and Norma Patricia López-Acosta",authors:[{id:"58505",title:"Dr.",name:"Raul",middleName:null,surname:"Flores-Berrones",slug:"raul-flores-berrones",fullName:"Raul Flores-Berrones"}]}],onlineFirstChaptersFilter:{topicId:"114",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"1084630",title:"Analysing the Possibility of Failure of Cascade Dam System and a Case Study from Brazil",slug:null,totalDownloads:7,totalDimensionsCites:0,doi:"10.5992/intechopen.1000202",abstract:'
A cascade dam system poses more hazards for downstream life and structures, when compared with a single dam located on a river. Therefore, there is a need to develop differentiated procedures to classify and regulate these dams. In the state of Mato Grosso (MT), Brazil, it is common to find multipurpose dams, which can be considered as a cascade, when a dam failure causes adverse effects in downstream dams. The objective of the study is to analyse the possibility of dam failure located in the cascade system operated by the municipality of Várzea Grande, MT by the Associated Potential Damage (APD) classification used throughout the country. In order to do this, the specification namely “Simplified Methodology to Define the Classification Flood Zone of Associated Potential Damage of a Dam” developed by the National Laboratory for Civil Engineering in Portugal (LNEC in Portuguese) was utilised. This specification was adapted by the National Water and Sanitation Agency (ANA in Portuguese) in Brazil. In the case study, there are three dams (Dam 1, Dam 2 and Dam 3) in the cascade system. Dam 1 can cause overtopping problem for Dam 2 and Dam 3. According to APD classification, dams considered for the study are categorised as “high dam”.
',book:{id:"11187",title:"Special Topics in Dam Engineering",coverURL:"https://cdn.intechopen.com/books/images_new/11187.jpg"},signatures:"Angélica Luciana Barros de Campos, Ruben Jose Ramos Cardia and Welitom Ttatom Pereira da Silva"},{id:"1081439",title:"Recent Evaluation on Total Risk of Cascade Dams on Murat River of Upper Euphrates Basin, Turkey",slug:null,totalDownloads:20,totalDimensionsCites:0,doi:"10.5992/intechopen.1000206",abstract:'The dams within a cascade system pose a high total risk to the downstream life, even if they provide significant benefits in terms of flood protection, irrigation water, and domestic water supply and energy production; a dam in a cascade system also poses a substantial risk from the point of view of other structures in the basin and causes the danger to grow due to the triggering effect from the point of view of dam failure. In this study, the total hazard of the dams in the Murat River located in the upper part of the Euphrates-Tigris Basin, the largest basin in Turkey, will be evaluated, and calculations made about it will be summarized. The possible hazards in a cascade system will be highlighted. Ten large dams of various types ranging from 36 m to 138 m in height from the river basin have been considered in this context. The analysis results show that six dams are under near-source effect in terms of seismicity, and all of the dams considered have a high total risk, although they have different hazard ratios. In addition, three separate dams located within the cascade structure carry a much greater risk regarding the dangers that other structures may create.
',book:{id:"11187",title:"Special Topics in Dam Engineering",coverURL:"https://cdn.intechopen.com/books/images_new/11187.jpg"},signatures:"Hasan Tosun"},{id:"1082008",title:"Uncertainty Factors Influencing Hydroelectric LCA Studies: A Review",slug:null,totalDownloads:5,totalDimensionsCites:0,doi:"10.5992/intechopen.1000185",abstract:'Despite the increase in research on Life Cycle Assessment (LCA) of Hydroelectric Power Plants (HPP) there are issues that need to be better discussed. This review aims to discuss factors that influence HPP LCAs such as: indirect emissions, different stages of HPPs (construction, operation, and decommissioning), scale/productivity of HPPs, types of projects (reservoir and run-of-river) and use of the ground. Most of the results obtained by HPP LCAs indicate that the construction phase is the most influential phase for indirect emissions due to the use of steel and concrete. The comparison of the HPP’s LCA results with the LCA of other energy sources indicates that for the analyzed category Global Warming Potential (GWP), the HPPs present a good environmental performance considering the quantified emissions, their productivity and useful life. The present review highlights some uncertainty factors that influence HPP LCA studies and cites the need to carry out future studies on the environmental impacts of HPPs including these factors.
',book:{id:"11187",title:"Special Topics in Dam Engineering",coverURL:"https://cdn.intechopen.com/books/images_new/11187.jpg"},signatures:"Marla T.B. Geller and Anderson Alvarenga de Moura Meneses"},{id:"1083097",title:"Managing the Quality of the Impounded Water",slug:"tbc-29",totalDownloads:6,totalDimensionsCites:0,doi:"10.5992/intechopen.1000168",abstract:'Design, construction, and operation of a dam should involve planning and careful consideration not only of the foundation and mass of the dam itself but also of the proper management of the reservoir, and of communities displaced by the reservoir, and impacted in any way upstream or downstream. Many management problems involve a reservoir’s density stratification, resulting in low oxygen, phosphorus release, and hydrogen sulfide (H2S) in the lower layers. Control measures include selective withdrawal and artificial aeration. Case examples are given. Other problems introduced by damming are often best dealt with by measures slow and well-considered, as illustrated by examples. References for further study are provided.
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