Simultaneous Bilateral Carotid Thrombectomies: A Technical Note.

BACKGROUND: Although extremely rare, acute bilateral large vessel occlusion (LVO) is a morbid condition that requires prompt intervention. OBJECTIVE: To report the technique used to achieve recanalization of bilateral internal carotid artery (ICA) terminus occlusions. METHODS: This is a case of bilateral ICA terminus occlusions managed with simultaneous bilateral thrombectomies with poor collateral circulation. RESULTS: Recanalization of bilateral ICA with thrombolysis in cerebral infarction (TICI) grade 0 to left TICI 2b flow with distal left A1 occlusion and right TICI 3 flow was achieved in 32 min with the use of simultaneous catheterization and aspiration thrombectomies. CONCLUSION: The described technique offers an efficient and feasible means to reduce time to recanalization and radiation in cases of bilateral LVO.

Functional Outcomes of Intravenous Thrombolysis in Octogenarians and Nonagenarians Through Telestroke: Single-Center Experience.

Background: Patients aged ≥80 years are often underrepresented in stroke trials. Observational studies have shown that older patients have worse outcomes compared with younger patients, but outcomes in patients aged ≥80 years treated with intravenous (IV)-alteplase specifically through telestroke (TS) have not been studied. Aim: To compare clinical and safety outcomes in stroke patients aged ≥80 and 60-79 years treated with IV-alteplase via TS. Methods: The Medical University of South Carolina TS database was analyzed to identify IV-alteplase-treated patients aged 60-79 and ≥80 years between January 2015 and March 2018. Baseline demographics and TS-specific variables were compared. Clinical outcomes were assessed using the 90-day modified Rankin Scale (mRS). Safety outcomes were evaluated by comparing symptomatic intracranial hemorrhage (sICH). Multivariate logistic regression analysis was performed to determine odds ratio (OR) for good outcome (mRS 0-2) in the older age group at 90 days. Results: IV-alteplase was used in 151 patients in ≥80 years age group and 273 patients in 60-79 years age group. The older age group had more women and a higher National Institutes of Health Stroke Scale. The mean "ED-door-to-TS-consultant-login" time was shorter (21.6 min vs. 25.6 min; p = 0.048), but "TS-consultant-login-to-alteplase" time was longer (22.1 min vs. 19.3 min; p = 0.01) in the older age group. No difference was noted in eventual "door-to-needle" time. The older age group had fewer good outcomes (39.1% vs. 74%; p = 0.001) and more deaths (38% vs. 14%; p = 0.001) at 90 days. The sICH rates were similar in the two groups. The OR for good outcome in ≥80 years age group was 0.20 (95% CI: 0.12-0.34) after controlling for baseline variables. Conclusions: Stroke patients aged ≥80 years treated via TS have similar post-thrombolysis hemorrhage rates but worse clinical outcomes compared with patients aged 60-79 years.

Pneumocephalus following Dorsal Laminectomy: An Unusual Complication.

A 16-year-old male presented at Bangur Institute of Neurosciences Neurosurgery Outpatient Department with history of gradually progressive paraparesis for 5 months associated with stiffness, urinary hesitancy, and urge incontinence for last 2 months. Magnetic resonance imaging spine was done which showed cystic intradural extramedullary space occupying lesion at D4/D5 to D9. Patient had 2 episodes of generalized tonic-clonic seizure on the day 4. Computed tomography scan showed pneumocephalus. Histopathological examination report was that of nonspecific inflammatory cyst.

Stroke Caused by Atherosclerosis of the Major Intracranial Arteries.

Our goal in this review is to discuss the pathophysiology, diagnosis, and treatment of stroke caused by atherosclerosis of the major intracranial arteries. References for the review were identified by searching PubMed for related studies published from 1955 to June 2016 using search terms intracranial stenosis and intracranial atherosclerosis. Reference sections of published randomized clinical trials and previously published reviews were searched for additional references. Intracranial atherosclerotic disease is a highly prevalent cause of stroke that is associated with a high risk of recurrent stroke. It is more prevalent among blacks, Hispanics, and Asians compared with whites. Diabetes mellitus, hypertension, metabolic syndrome, smoking, hyperlipidemia, and a sedentary lifestyle are the major modifiable risk factors associated with intracranial atherosclerotic disease. Randomized clinical trials comparing aggressive management (dual antiplatelet treatment for 90 days followed by aspirin monotherapy and intensive management of vascular risk factors) with intracranial stenting plus aggressive medical management have shown medical management alone to be safer and more effective for preventing stroke. As such, aggressive medical management has become the standard of care for symptomatic patients with intracranial atherosclerotic disease. Nevertheless, there are subgroups of patients who are still at high risk of stroke despite being treated with aggressive medical management. Future research should aim to establish clinical, serological, and imaging biomarkers to identify high-risk patients, and clinical trials evaluating novel therapies should be focused on these patients.

Mechanical thrombectomy in cerebral venous thrombosis: systematic review of 185 cases.

BACKGROUND AND PURPOSE: Cerebral venous thrombosis is generally treated with anticoagulation. However, some patients do not respond to medical therapy and these might benefit from mechanical thrombectomy. The aim of this study was to gain a better understanding of the efficacy and safety of mechanical thrombectomy in patients with cerebral venous thrombosis, by performing a systematic review of the literature. METHODS: We identified studies published between January 1995 and February 2014 from PubMed and Ovid. We included all cases of cerebral venous thrombosis in whom mechanical thrombectomy was performed with or without intrasinus thrombolysis. Good outcome was defined as normal or mild neurological deficits at discharge (modified Rankin Scale, 0-2). Secondary outcome variables included periprocedural complications and recanalization rates. RESULTS: Our study included 42 studies (185 patients). Sixty percent of patient had a pretreatment intracerebral hemorrhage and 47% were stuporous or comatose. AngioJet was the most commonly used device (40%). Intrasinus thrombolysis was used in 131 patients (71%). Overall, 156 (84%) patients had a good outcome and 22 (12%) died. Nine (5%) patients had no recanalization, 38 (21%) had partial, and 137 (74%) had near to complete recanalization. The major periprocedural complication was new or increased intracerebral hemorrhage (10%). The use of AngioJet was associated with lower rate of complete recanalization (odds ratio, 0.2; 95% confidence interval, 0.09-0.4) and lower chance of good outcome (odds ratio, 0.5; 95% confidence interval, 0.2-1.0). CONCLUSIONS: Our systematic review suggests that mechanical thrombectomy is reasonably safe but controlled studies are required to provide a definitive answer on its efficacy and safety in patients with cerebral venous thrombosis.

Mechanical thrombectomy versus intrasinus thrombolysis for cerebral venous sinus thrombosis: a non-randomized comparison.

Small retrospective studies have shown the benefit of endovascular treatment with intrasinus thrombolysis (IST) or mechanical thrombectomy (MT) with/without IST (MT ± IST) in cases of multifocal cerebral venous thrombosis (CVT). Our study compares the mortality, functional outcome and periprocedural complications among patients treated with MT ± IST versus IST alone. We reviewed clinical and angiographic findings of 63 patients with CVT who received endovascular treatment at three tertiary care centers. Primary outcome variables were discharge mortality and neurological dysfunction, and intermediate (three months) and long-term (>six months) morbidity. The modified Rankin scale (mRS) was used to assess morbidity. mRS ≤ 1 was considered a good recovery. Neurological dysfunction was rated as neuroscore: 0, normal; 1, mild (ambulatory, communicative); 2, moderate (non-ambulatory, communicative); and 3, severe (non-ambulatory, non-communicative/comatose). In patients who received IST alone, presenting neurological deficits were comparatively minor (p<0.001). When the two groups were adjusted for admission neuroscore, there was no statistical significance between discharge mortality [7(21%) versus 4(14%), p=0.228], neurological dysfunction (p=0.442), intermediate (p=0.336) and long-term morbidity (p=0.988). Patients who received MT ± IST had a higher percentage of periprocedural complications without reaching statistical significance. Compared to IST, MT was performed in severe cases with extensive sinus involvement. When adjusted for admission neurological dysfunction, both groups had similar mortality and discharge neurological dysfunction and similar intermediate and long-term morbidity.

The unusual volvulus : a five year retrospective analysis of nine cases.

The ileosigmoid knot is a rare surgical emergency. It is an unusual type of bowel obstruction in which the ileum usually wraps around the base of the sigmoid colon and forms a pseudoknot. It is usually associated with difficult preoperative diagnosis and poor surgical outcome. To analyze the clinical presentations, operative findings, management, postoperative complications and outcome of patients with ileosigmoid knotting. A retrospective analysis of nine cases of ileosigmoid knotting over a 6-year period from July 2005 to May 2011. Ileosigmoid knotting was common in males in the fifth decade. Mean duration of symptoms prior to admission was 42.67 h. Both the ileum and the sigmoid colon were gangrenous in all the patients. Mortality was 22.22 %. The mean duration of hospital stay was 13.67 days. To conclude, ileosigmoid knotting, though a rare cause of intestinal obstruction, carries a significant risk of mortality. In our study, ileostomy along with colorectal anastomosis seemed to be a better and safer alternative than primary repair in the management of ileosigmoid knotting. Awareness of this condition among surgeons will help to reduce the morbidity and mortality associated with this unusual form of intestinal obstruction.

Combination therapy of intravenous glycoprotein IIB/IIIA inhibitors and tissue plasminogen activator for acute ischemic stroke.

OBJECTIVES: Retrospective pooled analysis of data from published prospective studies and randomized phase 1 and 2 trials was done to assess efficacy and safety profile of intravenous combination therapy [glycoprotein IIb/IIIa inhibitors and IV tissue plasminogen activator (tPA)] in management of acute ischemic stroke. MATERIALS AND METHODS: We searched Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, and EMBASE databases; two reviewers independently selected studies reporting safety endpoints and outcome measures in acute ischemic stroke patients treated with combination therapy. tPA arm of the National Institute of Neurological Disorders and Stroke (NINDS) tPA trial was included in tPA-only group. Weighted means and proportions were calculated for numeric and categorical variables respectively. Bivariate analysis using Fisher's exact test was done to compare baseline descriptors, safety endpoints, and outcome measures. RESULTS: Combination therapy arm included 188 patients and IV tPA arm had 218 patients. Mean National Institutes of Health Stroke Scale (NIHSS) in two groups were 12.8 and 14.6, respectively. Mean time-to-treatment was 2.3 hours in combination therapy arm and 2.55 hours in tPA arm. Treatment with combination therapy was associated with significant reduction in rate of symptomatic intracranial hemorrhage (sICH) [odds ratio (OR) 0.26, 95% cumulative incidence (CI) 0.07 0.83, P value 0.01). Difference in better functional outcome at 90 days (OR 0.87, 95% CI 0.59-1.30, P value 0.54) and death at 90 days (OR 1.16, 95% CI 0.69-1.93, P value 0.60) were not significantly different in two groups. CONCLUSION: Combination of low dose IV TPA with glycoprotein IIb/IIIa inhibitors is associated with reduction in sICH rates in patients with acute ischemic stroke as compared to standard dose of IV tPA.

Clinical Reasoning: a woman with recurrent aphasia and visual field defects.

A 73-year-old woman with a history of hypertension and a recent stroke presented with recurrent nonsensical speech and visual problems. One month prior, she had been diagnosed with a stroke, after sudden-onset speech and visual difficulties that resolved after a few hours. Thirteen days before, she had had a second episode of similar symptoms. She was seen in our institution after a few hours of sudden-onset unintelligible speech. Her vital signs were within normal limits. She was not in distress, but appeared frustrated. Her general physical examination was unremarkable. She had no carotid, ophthalmic, or cranial bruits. Her neurologic examination was notable for fluent aphasia, with paraphasic errors and inability to name, read, or write. She also had right homonymous hemianopia, right-sided sensory loss, and generalized brisk deep tendon reflexes. The rest of her neurologic examination showed no abnormalities.

Duration of diabetes and risk of ischemic stroke: the Northern Manhattan Study.

BACKGROUND AND PURPOSE: Diabetes increases stroke risk, but whether diabetes status immediately before stroke improves prediction and whether duration is important are less clear. We hypothesized that diabetes duration independently predicts ischemic stroke. METHODS: Among 3298 stroke-free participants in the Northern Manhattan Study, baseline diabetes and age at diagnosis were determined. Incident diabetes was assessed annually (median, 9 years). Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% CI for incident ischemic stroke using baseline diabetes, diabetes as a time-dependent covariate, and duration of diabetes as a time-varying covariate; models were adjusted for demographic and cardiovascular risk factors. RESULTS: Mean age was 69 ± 10 years (52% Hispanic, 21% white, and 24% black); 22% had diabetes at baseline and 10% had development of diabetes. There were 244 ischemic strokes, and both baseline diabetes (HR, 2.5; 95% CI, 1.9-3.3) and diabetes considered as a time-dependent covariate (HR, 2.4; 95% CI, 1.8-3.2) were similarly associated with stroke risk. Duration of diabetes was associated with ischemic stroke (adjusted HR, 1.03 per year with diabetes; 95% CI, 1.02-1.04). Compared to nondiabetic participants, those with diabetes for 0 to 5 years (adjusted HR, 1.7; 95% CI, 1.1-2.7), 5 to 10 years (adjusted HR, 1.8; 95% CI, 1.1-3.0), and ≥ 10 years (adjusted HR, 3.2; 95% CI, 2.4-4.5) were at increased risk. CONCLUSIONS: Duration of diabetes is independently associated with ischemic stroke risk adjusting for risk factors. The risk increases 3% each year, and triples with diabetes ≥ 10 years.

Comparative study between omentopexy and omental plugging in treatment of giant peptic perforation.

Giant peptic perforation is a life threatening surgical emergency with high mortality.. This study aims to compare the success rate between omental plugging and standard omentopexy in the emergency management of giant perforations. A prospective non-randomized study of 23 patients with giant peptic perforation (≥2 cm in diameter) was carried out over a period of 18 months. The highest incidence was seen in the age group of 41-50 years. Intestinal fistula occurred in 23.08% of the omentopexy group compared to none in the omental plugging group. The mean hospital stay was slightly higher in the omentopexy group. Three patients died in the omentopexy group post operatively after 24 h compared to none in the omental plugging group and this was statistically significant (p < 0.05). Omental plugging is associated with lesser morbidity and mortality compared to omentopexy in the management of giant peptic perforations.