Past, present, and future of endovascular stroke therapies.

Endovascular therapy in the acute management of ischemic stroke has become more common with technologic advances, such as easier navigation into the intracranial circulation and improved treatment efficacy with the advent of revascularization devices. This select review outlines milestones in the application of endovascular therapy in acute ischemic stroke (AIS) and offers some insight into important factors influencing the future directions of endovascular AIS treatment. In particular, we discuss the evolution of endovascular devices for AIS and how ingenuity continues to offer novel treatments. With these advances, the future of endovascular AIS treatment is promising.

Does dementia increase risk of thrombolysis?: a case-control study.

BACKGROUND: Dementia represents a potential challenge when thrombolysis is a treatment option. In this study, we assess the impact of dementia on the rate of intracerebral hemorrhage (ICH) and hospital mortality associated with acute ischemic stroke (AIS) in patients treated with thrombolysis. METHODS: A cohort of patients with AIS was identified from the National Inpatient Sample database for the years 2000 to 2007. Vascular and degenerative types of dementia were identified by the International Classification of Diseases-9-CM codes. A matched random sample without dementia was selected from a pool of those with AIS and treated with thrombolysis. RESULTS: In this analysis, 35,557 patients with diagnosis of dementia were included; 207 (0.56%) received thrombolysis. In-hospital mortality (17.48% vs 8.63%) and ICH (5.80% vs 0.38%) were higher in the thrombolysis group (p < 0.0001) compared to those who did not receive thrombolysis. Multivariate analysis showed that thrombolysis was associated with increased hospital mortality (odds ratio [OR] 16.15; 95% confidence interval [CI] 8.54-30.53) and ICH (OR 2.80; 95% CI 1.82-4.32). Compared to a matched population of patients without dementia treated with thrombolysis (n = 621), those who had dementia and were treated with thrombolysis had similar risks of ICH (5.80% vs 4.51%, p = 0.45) and mortality (17.39% vs 14.49%, p = 0.31) rates. With thrombolysis, ICH remained a predictor of mortality for both dementia and control groups (OR 2.25; 95% CI 1.02-4.99). CONCLUSION: The administration of thrombolysis for AIS in patients with dementia was not associated with increased risk of ICH or death compared to the counterparts without dementia. ICH remained as predictor of mortality.

Acutely ruptured intracranial saccular aneurysms treated with stent assisted coiling: complications and outcomes in 42 consecutive patients.

BACKGROUND: Antiplatelet agents are required to prevent thromboembolic complications from recently deployed intracranial stents, yet they carry a risk of bleeding complications that may be serious in patients with recent subarachnoid hemorrhage. METHOD: Consecutive patients at a single institution who had ruptured intracranial saccular aneurysms treated with stent assisted coiling were retrospectively reviewed. Our primary outcomes were ischemic stroke related to the stent and bleeding complications possibly related to antithrombotic therapy. Secondary outcomes included 3 month follow-up National Institute of Health Stroke Scale (NIHSS) scores and modified Rankin Scale (mRS) scores. RESULTS: 44 aneurysms in 42 patients were treated. Seven patients experienced ischemic strokes during their hospitalization. Five ischemic strokes were secondary to vasospasm; one was definitely related to thrombus formation within the stent and one was possibly related to the stent. Two patients had asymptomatic intracranial hemorrhages and one patient had a symptomatic intracranial hemorrhage. Patients with Hunt and Hess grades I-II (n=25) experienced no stent associated ischemic strokes or symptomatic intracranial hemorrhages. The two stent associated ischemic strokes and one symptomatic intracranial hemorrhage occurred in patients with Hunt and Hess grades III-V (n=17) and patients with external ventricular drains (EVDs) (n=17). Only one patient had disability at the 3 month follow-up that was possibly related to the stent (mRS score of 3 and NIHSS score of 2). CONCLUSION: These data suggest that higher grade hemorrhage patients, especially those with EVDs, are at greater risk for ischemic stroke and/or bleeding complications than lower grade patients. However, the complications had a small impact on mid-term disability outcomes in this cohort.

Education Research: The challenge of incorporating formal research methodology training in a neurology residency.

BACKGROUND: Physicians often do not have good understanding of research methodology. Unfortunately, the mechanism to achieve this important competency in a busy neurology residency program remains unclear. We tested the value and degree of acceptance by neurology residents of a multimodal educational intervention that consisted of biweekly teaching sessions in place of an existing journal club, as a way to provide formal training in research and statistical techniques. METHODS: We used a pre- and post-test design with an educational intervention in between using neurology residents at the University of Iowa as subjects. Each test had 40 questions of research methodology. The educational intervention consisted of a biweekly, structured, topic-centered, research methodology-oriented elective seminar following a year-long predefined curriculum. An exit survey was offered to gather resident's perceptions about the course. RESULTS: While a majority of residents agreed that the intervention enhanced their knowledge of research methodology, only 23% attended more than 40% of the sessions. There was no difference between pretest and post-test scores (p = 0.40). CONCLUSIONS: Our experience suggests that, in order to accomplish the Accreditation Council for Graduate Medical Education goals regarding increasing competency of residents in knowledge about research methodology, a major restructuring in the neurology residency curriculum with more intense formal training would be necessary.

Lysosomal malfunction accompanies alpha-synuclein aggregation in a progressive mouse model of Parkinson's disease.

We have detected granular and filamentous inclusions that are alpha-synuclein- and ubiquitin-immunoreactive in the cytoplasm of dopaminergic and cortical neurons of C57/black mice treated chronically with 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) and probenecid. The immunoreactive aggregates only become evident several weeks after large-scale dopaminergic cell death and a downregulation of alpha-synuclein gene expression. Numerous lipofuscin granules accumulate alpha-synuclein in the nigral and limbic cortical neurons of treated mice. These data provide evidence that insoluble proteins, such as alpha-synuclein, build up as granular and filamentous inclusions in dopaminergic neurons that survive the initial toxic MPTP insult. They further suggest that defective protein degradation rather than altered gene expression underlies deposition of alpha-synuclein and that abundant lysosomal compartments are present to seal off the potentially toxic material.