Organization and Implementation of a Stroke Center in Panamá, a Model for Implementation of Stroke Centers in Low and Middle Income Countries.

Background: Stroke is the second leading cause of death and disability worldwide. Stroke centers have become a central component of modern stroke services in many high-income countries, but their feasibility and efficacy in low, middle, and emerging high-income countries are less clear. Also, despite the availability of international guidelines, many hospitals worldwide do not have organized clinical stroke care. We present a methodology to help hospitals develop stroke centers and review quality data after implementation. Objectives: To describe and compare demographics, performance, and clinical outcomes of the Pacífica Salud, Hospital Punta Pacífica (PSHPP) stroke center during its first 3 years 2017-2019. Methods: Pacífica Salud, Hospital Punta Pacífica was organized to implement protocols of care based on the best practices by international guidelines and a quality improvement process. The methodology for implementation adapts a model for translating evidence into practice for implementation of evidence-based practices in medicine. This is a retrospective study of prospectively collected quality data between March of 2017 to December of 2019 for patients admitted to PSHPP with primary diagnosis stroke. Data collected include demographics, clinical data organized per the Joint Commission's STK Performance Measures, door to needle, door to groin puncture, 90 day modified Rankin Score, and hemorrhagic complications from IV thrombolysis and mechanical thrombectomy (MT). Primary outcome: year over year proficiency in documenting performance measures. Secondary outcome: year over year improvement. Results: A total of 143 patients were admitted for acute ischemic stroke, TIA, or hemorrhagic stroke. Of these, 36 were admitted in 2017, 50 in 2018, and 57 in 2019. Performance measure proficiency increased in the year-over-year analysis as did the total number of patients and the number of patients treated with IV thrombolysis and MT. Conclusions: We present the methodology and results of a stroke program implementation in Panamá. This program is the first in the country and in Central America to achieve Joint Commission International (JCI) certification as a Primary Stroke Center (PSC). We postulate that the dissemination of management guidelines is not sufficient to encourage the development of stroke centers. The application of a methodology for translation of evidence into practice with mentorship facilitated the success of this program.

Color-coded digital subtraction angiography in the management of a rare case of middle cerebral artery pure arterial malformation. A technical and case report.

The advent of flow dynamics and the recent availability of perfusion analysis software have provided new diagnostic tools and management possibilities for cerebrovascular patients. To this end, we provide an example of the use of color-coded angiography and its application in a rare case of a patient with a pure middle cerebral artery (MCA) malformation. A 42-year-old male chronic smoker was evaluated in the emergency room due to sudden onset of severe headache, nausea, vomiting and left-sided weakness. Head computed tomography revealed a right basal ganglia hemorrhage. Cerebral digital subtraction angiography (DSA) showed a right middle cerebral artery malformation consisting of convoluted and ectatic collateral vessels supplying the distal middle cerebral artery territory-M1 proximally occluded. An associated medial lenticulostriate artery aneurysm was found. Brain single-photon emission computed tomography with and without acetazolamide failed to show problems in vascular reserve that would indicate the need for flow augmentation. Twelve months after discharge, the patient recovered from the left-sided weakness and did not present any similar events. A follow-up DSA and perfusion study using color-coded perfusion analysis showed perforator aneurysm resolution and adequate, albeit delayed perfusion in the involved vascular territory. We propose a combined congenital and acquired mechanism involving M1 occlusion with secondary dysplastic changes in collateral supply to the distal MCA territory. Angiographic and cerebral perfusion work-up was used to exclude the need for flow augmentation. Nevertheless, the natural course of this lesion remains unclear and long-term follow-up is warranted.

Efficacy of temporal lobe surgery for epilepsy in patients with negative MRI for mesial temporal lobe sclerosis.

Epilepsy surgery is a successful treatment for refractory temporal lobe epilepsy (TLE). Reports suggest fewer seizure-free outcomes for patients with TLE and who have a negative brain MRI (nMRI) for mesial temporal sclerosis. Data were collected prospectively from patients with nMRI who underwent temporal lobe surgery for TLE characterized by unilateral ictal temporal lobe seizure onset based on a scalp video electroencephalogram or invasive subdural electrode recordings. A total of 86 patients were followed for at least 24 months after surgery. Outcome was evaluated using the Engel classification. Seizure control was obtained by 55% (47/86) of patients (Class [CL]-I), 27% (23/86) showed significant improvement (CL-II) and 19% (16/86) were deemed surgical failures. Shorter duration of epilepsy, later onset of seizures, and ictal theta rhythm (5-7 Hz) were the most significant predictors of postoperative seizure control. Although hypometabolism on positron emission tomography scan and significant memory disparity (>2.5/8) were not significant prognosticators independently, cumulatively they were predictors for favorable outcome.

Computed tomography-based morphometric analysis of the human occipital condyle for occipital condyle-cervical fusion.

OBJECT: Occipital condyle screws serve as an alternative fixation point in occipital-cervical fusion. Their placement requires a thorough understanding of the anatomy of the occipital condyles and associated structures. This study is a CT-based morphometric analysis of occipital condyles as related to occipital condyle-cervical fusion. METHODS: A total of 170 patients were examined with CT scans of the craniocervical junction at a single institution, for a total of 340 occipital condyles, between March 6, 2006, and July 30, 2006. All CT scans were negative for traumatic, degenerative, and neoplastic pathological entities. Condylar anteroposterior (AP) length, transverse width, height, projected screw angle, and projected screw lengths were measured on an EBW Portal 2.5 CT Viewer Workstation (Philips Electronics). The longest axis in the AP orientation of the occipital condyle was accepted as the length. The transverse width was a line perpendicular to the midpoint of the long axis. The height was measured in the coronal projection that had the thickest craniocaudal portion of the condyle. The screw trajectory started 5 mm lateral to the medial edge of the condyle and a line was directed anteromedially in the longest axis. The angle was measured relative to the sagittal midline. The screw length was measured from the outer cortex of the posterior wall to the outer cortex of the anterior wall. RESULTS: The mean ± SD values for occipital condyle measurements were as follows: AP length was 22.38 ± 2.19 mm (range 14.7-27.6 mm); width was 11.18 ± 1.44 mm (range 7.4-19.0 mm); height was 9.92 ± 1.30 mm (range 5.1-14.3 mm); screw angle was 20.30° ± 4.89° (range 8.0°-34.0°); and screw length was 20.30 ± 2.24 mm (range 13.0-27.6 mm). CONCLUSIONS: These measurements correlate with previous cadaveric and radiographic studies of the occipital condyle, and emphasize the role of preoperative planning for the feasibility of placement of an occipital condyle screw.

Extracranial carotid artery stenting: the Puerto Rico medical center endovascular neurosurgery service experience.

OBJECTIVE: Extracranial carotid artery stenting (CAS) represents a viable alternative for high-risk surgical patients. The aim of this study was to determine the clinical features and outcome of 25 patients that underwent CAS at the Puerto Rico Medical Center. METHODS: A retrospective review of a series of 25 high-risk surgical patients that underwent CAS from June 2005 to January 2010 was performed. Patients were followed-up at clinics with computed tomography angiography and/or digital subtraction angiography. RESULTS: Patient ages ranged from 52 to 88 years. Twenty-one of the patients had severe cervical carotid stenosis (more than 80%). Those with moderate stenosis (from 50% to 80%) were treated when they were symptomatic or when stenosis recurred after carotid endarterectomy. Among the 25 patients, only 2 presented with restenosis (more than 50% luminal diameter). Both had a history of radiation-induced disease, but neither required retreatment. Five patients required post-stenting angioplasty due to a less than 50% improvement in luminal diameter. There was 1 death, and 1 patient presented delayed neurocognitive deterioration. The combined long-term morbidity and mortality in the subgroup with at least two years of follow-up was 8.3%. There were no intracerebral hemorrhages or recurrent strokes/transient ischemic attacks. CONCLUSION: The restriction of post-stenting angioplasty to only those cases without significant revascularization appears to help reduce restenosis rates while ensuring a gradual increase in intracranial blood flow. The latter may not apply to patients with a prior history of radiotherapy.