Intravenous thrombolysis before endovascular therapy for large vessel strokes can lead to significantly higher hospital costs without improving outcomes.

BACKGROUND: Limited efficacy of IV recombinant tissue plasminogen activator (rt-PA) for large vessel occlusions (LVO) raises doubts about its utility prior to endovascular therapy. PURPOSE: To compare outcomes and hospital costs for anterior circulation LVOs (middle cerebral artery, internal carotid artery terminus (ICA-T)) treated with either primary endovascular therapy alone (EV-Only) or bridging therapy (IV+EV)). METHODS: A single-center retrospective analysis was performed. Clinical and demographic data were collected prospectively and relevant cost data were obtained for each patient in the study. RESULTS: 90 consecutive patients were divided into EV-Only (n=52) and IV+EV (n=38) groups. There was no difference in demographics, stroke severity, or clot distribution. The mean (SD) time to presentation was 5:19 (4:30) hours in the EV-Only group and 1:46 (0:52) hours in the IV+EV group (p<0.0001). Recanalization: EV-Only 35 (67%) versus IV+EV 31 (81.6%) (p=0.12). Favorable outcome: EV-Only 26 (50%) versus IV+EV 22 (58%) (p=0.45). For patients presenting within 4.5 hours (n=64): Recanalization: EV-Only 21/26 (81%) versus IV+EV 31/38 (81.6%) (p=0.93). Favorable outcome: EV-Only 14/26 (54%) versus IV+EV 22/38 (58%) (p=0.75). There was no significant difference in rates of hemorrhage, mortality, home discharge, or length of stay. A stent retriever was used in 67 cases (74.4%), with similar recanalization, outcomes, and number of passes in the EV-Only and IV+EV groups. The mean (SD) total hospital cost was $33 810 (13 505) for the EV-Only group and $40 743 (17 177) for the IV+EV group (p=0.02). The direct cost was $23 034 (8786) for the EV-Only group and $28 711 (11 406) for the IV+EV group (p=0.007). These significantly higher costs persisted for the subgroup presenting in <4.5 hours and the stent retriever subgroup. IV rt-PA administration independently predicted higher hospital costs. CONCLUSIONS: IV rt-PA did not improve recanalization, thrombectomy efficacy, functional outcomes, or length of stay. Combined therapy was associated with significantly higher total and direct hospital costs than endovascular therapy alone.

Acute calcific longus colli tendonitis.

Acute calcific longus colli tendonitis is an inflammatory response of the neck flexor musculature. Patients present with symptoms suggestive of a retropharyngeal abscess or meningitis. Adjunctive medical imaging is required to confirm the diagnosis and dispel other, more serious and life threatening, pathologies. We present a case of acute calcific longus colli tendonitis, and provide a discussion on the topic as to avoid unnecessary medical and surgical intervention because the entity can be easily confused with more severe diseases.

Iron(II) complexes of 2,6-di(1H-pyrazol-3-yl)-pyridine derivatives with hydrogen bonding and sterically bulky substituents.

Syntheses of 2,6-di(5-aminopyrazol-3-yl)pyridine (L(1)), 2,6-di(5-tertbutylcarboxamidopyrazol-3-yl)pyridine (L(2)), 2,6-di(5-tertbutylpyrazol-3-yl)pyridine (L(3)), 2-(5-tertbutylpyrazol-3-yl)-6-(5-methylpyrazol-3-yl)pyridine (L(4)) and 2-(5-tertbutylpyrazol-3-yl)-6-(5-aminopyrazol-3-yl)pyridine (L(5)) are reported. Iron complex salts of the first four ligands were crystallographically characterised. The structures exhibit intermolecular hydrogen bonding between the cations and the anions and/or solvent, leading to a fluorite (flu) net, a 1D ladder structure, and a homochiral self-penetrating helical network related to the (10,3)-a (srs) topology. All the complexes are high-spin in the crystal, and bulk samples are also fully or predominantly high-spin at room temperature and below although two of the dried materials exhibit partial spin-state transitions on cooling.

Disseminated blastomycosis presenting as mastoiditis and epidural abscess.

Blastomycosis is a systemic fungal infection that affects primarily the lungs. Head and neck involvement has been reported most commonly in the larynx as well as oral and nasal mucosa. Temporal bone involvement is extremely rare. We report a case of disseminated blastomycosis presenting as mastoiditis and epidural abscess. We discuss the importance of early diagnosis and prompt initiation of treatment for optimal outcome.

Isostructural salts of the same complex showing contrasting thermal spin-crossover mediated by multiple phase changes.

Two salts of [FeL2](2+) (L = 2,6-bis[5-methyl-1H-pyrazol-3-yl]pyridine) are isostructural under ambient conditions but show different thermal spin-crossover behaviour, involving a variety of crystallographic phase changes.

Endovascular therapy yields significantly superior outcomes for large vessel occlusions compared with intravenous thrombolysis: is it time to randomize?

BACKGROUND AND PURPOSE: We compared outcomes between endovascular (EV) therapy and intravenous (IV) thrombolysis in large vessel strokes. METHODS: 223 patients who had received either IV (n=100) or EV (n=123) therapy were analyzed. Only patients with strokes involving the internal carotid artery terminus (ICA-T, n=45), the middle cerebral artery (M1, n=107) or the bifurcation branches (M2, n=71) were included. The primary endpoint was 3 month outcome based on the modified Rankin Scale (mRS) score, good-outcome defined as mRS ≤2. RESULTS: The good outcome was 44.7% in the EV group and 26% in the IV group (p=0.003, OR 2.3, 95% CI 1.3 to 4.1). There was no difference in mortality or hemorrhage. For ICA-T occlusions, the good outcome was 27.6% in the EV and 0% in the IV group (p=0.004); for M1 occlusions, 40.6% in the EV versus 10.5% in the IV group (p=0.0006, OR 5.8, 95% CI 1.9 to 18.2); and for M2 occlusions, 76% in the EV versus 47.8% in the IV group (p=0.01, OR 3.5, 95% CI 1.2 to 10.2). For M1 occlusions, the death rate was 27.5% for the EV compared with 57.9% for the IV group (p=0.002, OR 3.6, 95% CI 1.6 to 8.3) with no difference observed in mortality for ICA-T or M2 occlusions. In the univariate analysis, age, National Institutes of Health Stroke Scale score and occlusion site were significant predictors of outcome and mortality (p<0.0001 for all). In the multivariable analysis, EV therapy (p=0.0004, OR 3.9, 95% CI 1.8 to 9) and younger age (p<0.0001, OR 0.96, 95% CI 0.9 to 0.98) were significant independent predictors of good outcome. CONCLUSIONS: There are significantly higher odds of a favorable outcome with EV compared with IV therapy for large vessel strokes. The data support the rationale of a randomized trial for large vessel occlusions.

CT perfusion imaging pitfall related to fetal posterior cerebral artery.

OBJECTIVE: The purpose of this article is to discuss how a unilateral fetal posterior cerebral artery (PCA) causes perfusion map asymmetry due to anteroposterior bolus arrival discrepancy. We performed region of interest analysis of asymmetric perfusion maps before and after delay correction was performed. CONCLUSION: Perfusion asymmetry becomes unapparent using a delay correction algorithm, indicating bolus arrival delay on the side opposite the fetal PCA. Delay correction algorithms can eliminate deconvolution errors related to bolus arrival delay.