Intracranial aneurysms in microcephalic primordial dwarfism: a systematic review.

BACKGROUND: Microcephalic primordial dwarfism (MPD) is a heterogeneous group of rare disorders. Recent studies have reported a significant percentage of patients with MPD suffering from a spectrum of cerebrovascular abnormalities, including intracranial aneurysms (IAs) and moyamoya syndrome. The neurological literature has not as yet specifically assessed IAs in this population. This systematic review aimed to assess the clinical behavior, characteristics, treatment modalities and outcomes of IAs in patients with MPD. METHODS: We performed a systematic search in PubMed, Ovid MEDLINE and Ovid EMBASE for cases of MPD with IAs. We included three illustrative cases from our institution. RESULTS: Twenty-four patients with 71 aneurysms were included in this study. Twelve patients (50%) presented with subarachnoid hemorrhage. The majority of patients were aged ≤18 years (70.8%), with a mean age of 16.2 years at presentation. Median aneurysm size was 3 (IQR 1.8-6) mm, and the most frequent locations were the internal carotid (37.3%) and middle cerebral arteries (23.8%). Concomitant moyamoya disease was reported in nine (37.5%) patients. Median age of aneurysm detection in screened patients was significantly lower than in non-screened patients (P=0.02). Microsurgical clipping (55.3%) and endovascular coiling (26.3%) were the most used modalities. Twenty-two cases were managed conservatively. Overall, mortality occurred in 45.8% of cases. CONCLUSIONS: Screening for cerebrovascular disease seems reasonable and effective to detect aneurysms at an earlier age in this population. Efforts in the literature to emphasize early and regular screening for these patients can positively impact outcomes in this population, however more evidence is needed.

Accuracy and Reliability of the Recommendation for IV Thrombolysis in Acute Ischemic Stroke Based on Interpretation of Head CT on a Smartphone or a Laptop.

OBJECTIVE. The objective of this study was to assess the accuracy and reliability of IV thrombolysis recommendations made after interpretation of head CT images of patients with symptoms of acute stroke displayed on smartphone or laptop reading systems compared with those made after interpretation of images displayed on a medical workstation monitor. MATERIALS AND METHODS. This retrospective study was institutional review board-approved, and the requirement for informed consent was waived. We used a factorial design including 2256 interpretations (188 patients, four neuroradiologists, and three reading systems). To evaluate the reliability, we calculated the intraobserver and interobserver agreements using the intraclass correlation coefficient (ICC) and the following interpretation variables: hemorrhagic lesions, intraaxial neoplasm, stroke dating (acute, subacute, and chronic), hyperdense arteries, and infarct size assessment. Accuracy equivalence tests were performed for the IV thrombolysis recommendation; for this variable, sensitivity, specificity, and ROC curves were evaluated. RESULTS. Good or very good interobserver and intraobserver agreements were obtained after interpretation of each variable. The IV thrombolysis recommendation showed very good interobserver agreements (ICC ≥ 0.85) and very good intraobserver agreements (ICC ≥ 0.81). For the IV thrombolysis recommendation, the AUC values (0.83-0.84) and sensitivities (0.94-0.95) were equivalent among all the reading systems at a 5% equivalent threshold. CONCLUSION. Our study found that mobile devices are reliable and accurate to help stroke teams to decide whether to administer IV thrombolysis in patients with acute stroke.

A systematic review of non-trunk basilar perforator aneurysms: is it worth chasing the small fish?

BACKGROUND AND PURPOSE: Non-trunk basilar artery perforator aneurysms (BAPAs) are rare intracranial vascular pathologies that have long been underdiagnosed, under-reported, and under-analyzed. We performed a systematic review of the efficacy and safety endpoints between conservative and active treatment approaches for non-trunk BAPAs. METHODS: Major databases were analyzed for relevant publications between 1995 and 2019. Studies comparing the outcomes between conservative and active treatment approaches such as coiling, stenting, clipping, liquid embolization, and flow diversion were included. Mortality rate, rate of permanent neurological deficit as determined by the modified Rankin Score (mRS), rate of second treatment occurrence, and perioperative complication rate were also assessed. RESULTS: A total of 24 studies, including 54 patients with 56 non-trunk BAPAs, were included. The mean maximum aneurysm diameter was 2.70 mm (range 1-10). A diagnosis was achieved with the initial DSA in 50.0% (27/54) of the patients. A conservative approach was used in 16 patients while active treatment was used in the other 38. Thirteen of 15 (86.7%) patients in the conservative group and 27/34 (79.4%) in the active treatment group had an mRS score 0-2. A non-significant higher odds of a positive outcome was observed in the conservative group (OR 1.51, 95% CI 0.50 to 4.54). The event-related mortality rate was 3.55% (3/54) with one procedure-related death in the active treatment group. CONCLUSIONS: In patients with non-trunk BAPAs unamenable to active treatment, conservative approaches may result in acceptable functional outcomes and low morbidity. Small sample sizes and under-reporting of outcomes warrant further study.

Outcome in Direct Versus Transfer Patients in the DAWN Controlled Trial.

Background and Purpose- The impact of transfer status on clinical outcomes in the DAWN (DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention With Trevo) population is unknown. We analyzed workflow and clinical outcome differences between direct versus transfer patients in the DAWN population. Methods- The following time metrics were analyzed for each group: (1) last known well to hospital arrival, (2) hospital arrival to eligibility imaging, (3) hospital arrival to arterial puncture, (4) qualifying imaging to arterial puncture, (5) last known well to arterial puncture, (6) last known well to reperfusion. The primary end point was the rate of functional independence (90-day modified Rankin Scale [mRS] score, 0-2). Using univariate unconditional logistic regression, we calculated odds ratios and 95% CIs for the association between clinically relevant time metrics, transfer status, and functional independence (mRS 0-2). Results- A total of 206 patients were enrolled. Among these, 121 (59%) patients were transferred, and 85 (41%) patients presented directly to a thrombectomy capable center. Median time last seen well to hospital arrival time was similar between the 2 groups (678 versus 696 minutes). The time from hospital arrival to groin puncture was significantly longer in direct patients compared with transferred patients 140 minutes (interquartile range, 105.5-177.5 minutes) and 88 minutes (interquartile range, 55-125 minutes), respectively (P<0.001). Differences in treatment effect or differences in rates of mRS 0-2 in the thrombectomy treated patients were not statistically significant in direct versus transfer patients (odds ratios for mRS 0-2, thrombectomy versus control, were 5.62 in direct and 6.63 in transfer patients, respectively, Breslow-Day P=0.817). Conclusions- Although transfer patients had a faster door to puncture time, benefits of thrombectomy, and rates of mRS 0 to 2 in the treatment group were similar between direct and transferred patients in the DAWN population. These results may inform prehospital and primary stroke centers triage protocols in patients presenting in the late time window. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT02142283.

HIV vasculopathy versus VZV vasculitis in an HIV patient with multiple brain ischaemic infarcts.

We report the case of a 56-year-old man who presented to the emergency department with a 3-day onset of left limb weakness and feeling intoxicated with poor balance. Stroke hospitalisations in the USA decreased from 2000 to 2010, however the number of hospitalised patients with ischaemic stroke and HIV infection has increased significantly. Herein, we discuss the management of this unique case to highlight the importance of a broad differential diagnosis when approaching HIV/AIDS patients presenting with acute or subacute neurological focalisation. Given that HIV vasculopathy is a diagnosis of exclusion, it requires a thoughtful elimination of all possible aetiologies.

Facing the crossroads: acute stroke with bilateral carotid occlusion.

We present a previously unreported case of endovascular therapy in the acute setting of ischaemic stroke in a patient with bilateral carotid occlusion (BCO). A 54-year-old man presents with sudden onset of right-sided weakness, difficulty speaking and left-sided gaze, with National Institute of Health Stroke Scale of 22 and no abnormalities on plain CT head. CT angiography showed BCO and CT perfusion demonstrated extensive area of penumbra in both hemispheres. The patient was sent for cerebral angiography that confirmed BCO. Since symptomatology was a left middle cerebral arteries syndrome, decision was made to angioplasty and stent the left internal carotid artery emergently, which was performed successfully and the patient had complete resolution of symptoms. Acute stroke with BCO represents a challenge in decision making regarding acute management and individual assessment must be made.

Workflow Optimization for Ischemic Stroke in a Community-Based Stroke Center.

BACKGROUND: We analyzed the effect of specific optimization steps to reduce treatment delays in a nonacademic stroke hospital setting. METHODS: The data from patients with ischemic stroke who had been treated with intravenous tissue plasminogen activator or endovascular therapy, or both, were analyzed. The metrics were divided into 2 periods: preoptimization period (October 1, 2015 to September 30, 2016) and postoptimization period (October 1, 2016 to September 30, 2017). The key interventions were 1) notification by the emergency medical service to the emergency department and stroke team; 2) division of the stroke alert between level 1 (intravenous/intra-arterial candidate) and level 2; 3) direct transportation of level 1 patients to brain computed tomography; 4) limitation of nonessential interventions; 5) stroke orientation; 6) 24-hour, 7-day code stroke response by a vascular neurologist; 7) earlier notification of the interventional radiology team; 8) direct transportation from computed tomography to angiography suite for large vessel occlusion; and 9) multidisciplinary monthly meetings to discuss delayed cases. RESULTS: A total of 279 patients were identified. No significant differences in any of the baseline characteristics were documented. Almost all metrics favored the postoptimization period, with remarkable improvement in the door-to-puncture time (median, 64 minutes; interquartile range, 36-86; vs. 47 minutes; interquartile range, 20-62; P = 0.001). We observed an increased percentage of good clinical outcomes in the postoptimization group (60.1% vs. 54.8%; P = 0.500). We found an 8.4% increase in patients with good clinical outcomes in the postoptimization group compared with our previously reported work. CONCLUSIONS: For acute reperfusion therapies, significant reductions in workflow intervals can be achieved after simple optimization methods in a nonacademic community-based hospital.

A De Novo Sphenoparietal Dural Arteriovenous Fistula: Unveiling the Deceitful Culprit.

INTRODUCTION: Intracranial dural arteriovenous fistulas (DAVFs) are an uncommon pathology, and a sphenoparietal drainage pattern is certainly rare. We present a case of a de novo sphenoparietal DAVF in a prepubescent patient previously treated for a cerebellar arteriovenous malformation (AVM) 10 years before. CASE DESCRIPTION: A 10-year-old boy presented with worsening headaches for the past few weeks, swelling of the right side of face and eye, and chemosis and proptosis of the right eye. Of note, the patient had been treated successfully for a cerebellar AVM at 6 weeks of age with advanced imaging follow-up until 4 years previously demonstrating resolution of AVM and no other abnormalities whatsoever. Suspecting a carotid cavernous fistula, we performed angiography, which revealed a sphenoparietal DAVF with feeders from both the external and internal carotid artery. Despite sudden onset of symptoms and recent previously negative imaging, bony erosion was noted on computed tomography of the head and orbits. Successful treatment was achieved via transvenous embolization. CONCLUSIONS: This case highlights the different array of presentations that sphenoparietal fistulas may display. Even though most DAVFs are acquired, secondary lesions and spontaneous malformations must be considered in a differential diagnosis.

Stent-Assisted Coiling of Pseudoaneurysm After Vertebro-Carotid Transposition: Harmonious Combination of Open and Endovascular Neurosurgical Techniques.

BACKGROUND: Most cases of vertebral artery stenosis are treated either conservatively or surgically. When non-conservative treatment is chosen, whether to treat it with open surgery or endovascular intervention remains a topic of divergence. In the setting of endovascular therapy failure, the vertebral to common carotid artery transposition certainly is an appropriate choice to recover the posterior circulation. Like any other open surgery, it is not devoid of soft-tissue-related complications. A pseudoaneurysm following this procedure and at this particular location is a rare but lethal complication and, to the best of our knowledge, has not yet been reported. CASE DESCRIPTION: We present the case of an 80-year-old man with previous ischemic stroke who presented to the emergency department with aphasia, right-sided weakness, and dysarthria. Invasive imaging revealed right vertebral stenosis and hypoplastic left vertebral artery that failed endovascular therapy. The patient was then treated with a right vertebral to common carotid artery transposition. During follow-up, a pseudoaneurysm was found and treated with a stent-assisted coiling. CONCLUSIONS: Pseudoaneurysms at the extracranial carotid and vertebral circulation are rare and have potential for deadly outcomes. Despite several treatments available, this anatomical location requires endovascular therapy due to efficacy and promptitude of this treatment. This is an interesting case where the patient's management required open and endovascular procedures. The pseudoaneurysm was a rare complication that, to the best of our knowledge, has not previously been reported. This case is an illustration of complementary work between open surgery and endovascular intervention.

Cured from a Cardiac Myxoma? Brain Intraparenchymal Hemorrhage in a Patient with a 10-Year Successfully Resected Cardiac Myxoma.

BACKGROUND: A cardiac myxoma (CM) is the most common primary tumor of the heart. This case report highlights that for metastatic CMs, even after a successful total resection, there is a small but real risk of recurrence that can manifest as late as 10 years after initial tumor resection. CASE DESCRIPTION: We present the case of a 53-year-old woman who visited the emergency room after a 4-day worsening right-sided weakness. The patient was diagnosed with a left CM 10 years previously, and a complete surgical resection was performed at that time. A noncontrast computed tomography of the head revealed a left parietal hematoma and a contrast computed tomography scan of the head revealed an enlarged left parieto-occipital vein that was subsequently shown to be part of an arteriovenous fistula. After embolization of the fistula was performed, postprocedure magnetic resonance imaging of the brain showed redemonstration of acute intraparenchymal hemorrhage with vasogenic edema. The history of a previously resected CM and the multifocal distribution of brain lesions opened the possibility of slow-growing metastasis from the previous myxoma. CONCLUSIONS: Our case report demonstrates the metastatic nature of CMs to the central nervous system, even after successful gross total resection and no local relapsing mass in subsequent ultrasonographic follow-ups. A comprehensive evaluation on clinical and imagological grounds is mandatory to rule out the presence of myxomatous metastatic disease. Awareness and recognition of the potential neurologic manifestations of a metastatic CM will prevent unnecessary diagnostic workup and treatments.

Basilar Occlusion and Rupture Secondary to Rare Fungal Sinusitis.

BACKGROUND: Intracranial vascular infections of fungal etiology are extremely rare. Most cases occur in immunocompromised patients with invasive fungal disease, most commonly originating in the paranasal sinuses or the lungs. Granulomatous invasive rhinosinusitis, which is extremely rare in North America, has been reported to affect immunocompetent patients in most cases, and its causative strain has potential to invade the intracranial arteries. We present a rare case of basilar artery rupture and infarction secondary to granulomatous invasive rhinosinusitis. CASE DESCRIPTION: A 50-year-old man in Florida presented with ischemic symptoms and a 6-month history of headache, dizziness, and falls. After biopsy, the patient developed subarachnoid hemorrhage and thrombosis. Several thrombectomy attempts were performed, resulting in persistent occlusion of the basilar artery and subsequent comatous state. After discussion with the patient's family, compassionate weaning and autopsy were authorized. CONCLUSIONS: Invasive fungal rhinosinusitis is more frequent nowadays owing to increased use of immunosuppressive therapies. However, it is still a disease that mostly affects immunocompromised patients. The development of new microbiologic investigation techniques has enabled the discovery of fungal diseases that can also affect immunocompetent hosts, such as granulomatous invasive rhinosinusitis. This is an extremely rare condition in North America, with very few cases documented in the last few decades.

Stent-assisted coiling of cerebral aneurysms using the Y-stenting technique: a systematic review and meta-analysis.

BACKGROUND: Bifurcation aneurysms can be treated with stent-assisted coiling using two stents in a Y-configuration. We aim to investigate the angiographic and clinical outcomes of Y-stent constructs for the treatment of intracranial aneurysms. METHODS: A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE databases was conducted based on PRISMA guidelines. The study selection was performed using the 'Ryyan' application. Our analysis included 18 studies with 327 patients. Inclusion criteria were: articles published from January 2000 to November 2017, English language, including cerebral aneurysms treated via Y-stenting, and ≥5 cases with radiographic/clinical outcomes. Technical notes, editorials, reviews, and animal studies were excluded. A random-effect meta-analysis was performed on angiographic and clinical outcomes, including aneurysm occlusion, modified Rankin Scale, neurological outcome, and procedure-related mortality. 95% CIs and event rates were estimated. Statistical heterogeneity was assessed using I2 statistics. RESULTS: The procedure-related good outcome rate was 92% and complete occlusion rate was 91%. The permanent neurological deficit rate was 4% and procedure-related mortality was 2%. The procedure-related stroke rate was 12%. A total of 28/146 (19%) patients had ruptured aneurysms. At long-term follow-up, overall stroke rate was 9% in patients with unruptured aneurysm. The mortality rate was higher in cases with ruptured aneurysms than in those with unruptured aneurysms (18% vs 0.8%; p<0.001). CONCLUSIONS: Y-stenting for bifurcation aneurysms yields a high rate of complete occlusion and low rates of mortality and stroke. Careful patient selection is needed.

Endovascular Recanalization of Symptomatic Intracranial Arterial Stenosis Despite Aggressive Medical Management.

BACKGROUND: The optimal management of intracranial arterial stenosis is unclear, particularly in patients who have failed medical management. We report a multicenter real-world experience of endovascular recanalization of intracranial atherosclerotic stenosis refractory to aggressive medical therapy. METHODS: Retrospective multicenter case series of consecutive endovascularly treated patients presenting with symptomatic (transient ischemic attack [TIA] or stroke) intracranial stenosis who had failed medical therapy. Patients were divided into 2 groups: patients with recurrent TIA or stroke despite medical management (group 1) versus patients presenting with a stroke and worsening symptoms (progressive or crescendo stroke) despite medical management (group 2). RESULTS: A total of 101 patients were treated in 8 stroke centers from August 2009 to May 2017. Sixty-nine presented with recurrent TIA or stroke and 32 with stroke and worsening symptoms. Successful recanalization was achieved in 84% of patients. Periprocedural stroke occurred in 3 patients and 2 had a recurrent ischemic stroke at the 90-day follow-up. Symptomatic intraparenchymal hemorrhage secondary to reperfusion injury occurred in 3 patients and 1 had a hemorrhagic stroke after discharge. There were 2 periprocedural perforations that resulted in death. At 90 days, 86% of patients (64/74) did not have a recurrence of stroke and the 90-day cumulative ischemic stroke rate was 6.7% with 90-day mortality of 11.2%. The 90-day favorable outcome (modified Rankin Scale score, ≤2) rate was 77.5%. CONCLUSIONS: Endovascular recanalization of unstable intracranial atherosclerotic stenosis in patients who have failed medical therapy is feasible. Future randomized trials need to determine if recanalization is of any value for this population.

Republished: Revisiting the therapeutic time window dogma: successful thrombectomy 6 days after stroke onset.

Stroke is the leading cause of serious long-term disability in the USA. Recent clinical trials, DAWN and DEFUSE 3, have expanded the endovascular therapeutic time window which has been adopted by the American Heart Association stroke guideline. However, there continues to be a dilemma as to what is the best approach for patients who present beyond the time window set by these trials and the current guideline. The interval from arterial occlusion to completion of brain tissue infarction varies from patient to patient and depends on the actual time and also a physiological clock or a tissue time window. Offering endovascular treatment based solely on a rigid time criterion excludes patients who may have a clinical benefit because of potentially salvageable tissue. We present a case of a patient who underwent successful stroke thrombectomy 6 days after stroke onset.

Safety and efficacy of cangrelor in acute stenting for the treatment of cerebrovascular pathology: preliminary experience in a single-center pilot study.

BACKGROUND: Treatment of acute cerebrovascular pathology, such as acute ischemic stroke or intracranial aneurysms, presents a challenge if an extracranial or intracranial stent is required; immediate platelet inhibition is vital. To date, there is no standardized approach for antiplatelet inhibition in an acute setting. OBJECTIVE: To report our preliminary experience and lessons learnt using cangrelor in acute neurointervention. METHODS: A single-arm pilot study was performed to assess the safety and efficacy of cangrelor plus aspirin for platelet inhibition in patients who require acute stenting in the setting of neuroendovascular treatment. RESULTS: Eight patients were enrolled between October 2017 and August 2018. Median age was 71 years (53-86). Seven patients were treated in an acute setting according to the stroke protocol at our institution, while one patient was treated for a symptomatic, unruptured aneurysm with flow diversion and coiling. At admission, the median National Institutes of Health Stroke Scale score for the patients with stroke was 12.5 (range 2-22.3). Cangrelor was infused and all patients achieved adequate platelet inhibition (<200 PRU (P2Y12 reaction units)). Six of seven patients with ischemic stroke had a carotid stent placed and one had an intracranial stent deployed in the middle cerebral artery. None of the patients experienced intraprocedural thromboembolic complications, intraprocedural in-stent thrombosis, hemorrhagic complications, or stroke within 24 hours after the intervention. The majority of patients (6/8) had a good clinical outcome at discharge (modified Rankin Scale score 0-2). CONCLUSIONS: Our findings suggest that cangrelor is a promising alternative in acute stenting for the treatment of cerebrovascular pathology. However, further studies with larger samples are required to accurately elucidate its safety and effectiveness in neuroendovascular procedures.

Mobile device for thrombolysis decisions for telestroke / Dispositivo móvil para decisiones de trombólisis mediante Telestroke

Abstract Aim: This study compares the reliability of brain CT interpretations performed using a diagnostic workstation and a mobile tablet computer in a telestroke context. Methods: A factorial design with 1,452 interpretations was used. Reliability was evaluated using the Fleiss' kappa coefficient on the agreements of the interpretation results on the lesion classification, presence of imaging contraindications to the intravenous recombinant tissue-type plasminogen activator (t-PA) administration, and on the Alberta Stroke Program Early CT Score (ASPECTS). Results: The intra-observer agreements were as follows: good agreement on the overall lesion classification (κ= 0.63, p<0.001), very good agreement on hemorrhagic lesions (κ= 0.89, p<0.001), and moderate agreements on both without acute lesion classification and acute ischemic lesion classification (κ= 0.59 and κ= 0.58 respectively, p<0.001). There was good intra-observer agreement on the dichotomized-ASPECTS (κ= 0.65, p<0.001). Conclusions: The results of our study allow us to conclude that the reliability of the mobile solution for interpreting brain CT images of patients with acute stroke was assured, which would allow efficient and low-cost telestroke services.

Resumen Objetivo: Este estudio compara la confiabilidad de interpretaciones de TAC de cráneo simple realizadas utilizando una estación de trabajo de diagnóstico y un computador tableta en un contexto de teleACV. Métodos: Se utilizó un diseño factorial con 1,452 interpretaciones. La confiabilidad se evaluó utilizando el coeficiente kappa de Fleiss en las concordancias sobre los resultados de la interpretación en la clasificación de la lesión, la presencia de contraindicaciones en la imagen para la administración intravenosa del activador del plasminógeno tisular (AP-t) y con el Alberta Stroke Programme Early CT Score (ASPECTS). Resultados: Se obtuvieron las siguientes concordancias intraobservadores: buena concordancia en la clasificación general de la lesión (κ= 0.63, p<0.001), muy buena concordancia en lesiones hemorrágicas (κ= 0.89, p< 0.001), y concordancia moderada en ambos sin clasificación de lesión aguda y clasificación de lesión isquémica aguda (κ= 0.59 y κ= 0.58 respectivamente, p<0.001). Hubo una buena concordancia intraobservadores en el ASPECTS dicotomizado (κ= 0.65, p<0.001). Conclusiones: Los resultados de nuestro estudio permiten concluir que la confiabilidad de la solución móvil para la interpretación de imágenes de TAC de cráneo simple de pacientes con accidente cerebrovascular agudo (ACV) estaba garantizada, lo que permitiría servicios de teleACV eficientes y de bajo costo.

Revisiting the therapeutic time window dogma: successful thrombectomy 6 days after stroke onset.

Stroke is the leading cause of serious long-term disability in the USA. Recent clinical trials, DAWN and DEFUSE 3, have expanded the endovascular therapeutic time window which has been adopted by the American Heart Association stroke guideline. However, there continues to be a dilemma as to what is the best approach for patients who present beyond the time window set by these trials and the current guideline. The interval from arterial occlusion to completion of brain tissue infarction varies from patient to patient and depends on the actual time and also a physiological clock or a tissue time window. Offering endovascular treatment based solely on a rigid time criterion excludes patients who may have a clinical benefit because of potentially salvageable tissue. We present a case of a patient who underwent successful stroke thrombectomy 6 days after stroke onset.

Mobile device for thrombolysis decisions for telestroke.

AIM: This study compares the reliability of brain CT interpretations performed using a diagnostic workstation and a mobile tablet computer in a telestroke context. METHODS: A factorial design with 1,452 interpretations was used. Reliability was evaluated using the Fleiss' kappa coefficient on the agreements of the interpretation results on the lesion classification, presence of imaging contraindications to the intravenous recombinant tissue-type plasminogen activator (t-PA) administration, and on the Alberta Stroke Program Early CT Score (ASPECTS). RESULTS: The intra-observer agreements were as follows: good agreement on the overall lesion classification (κ= 0.63, p<0.001), very good agreement on hemorrhagic lesions (κ= 0.89, p<0.001), and moderate agreements on both without acute lesion classification and acute ischemic lesion classification (κ= 0.59 and κ= 0.58 respectively, p<0.001). There was good intra-observer agreement on the dichotomized-ASPECTS (κ= 0.65, p<0.001). CONCLUSIONS: The results of our study allow us to conclude that the reliability of the mobile solution for interpreting brain CT images of patients with acute stroke was assured, which would allow efficient and low-cost telestroke services.

OBJETIVO: Este estudio compara la confiabilidad de interpretaciones de TAC de cráneo simple realizadas utilizando una estación de trabajo de diagnóstico y un computador tableta en un contexto de teleACV. MÉTODOS: Se utilizó un diseño factorial con 1,452 interpretaciones. La confiabilidad se evaluó utilizando el coeficiente kappa de Fleiss en las concordancias sobre los resultados de la interpretación en la clasificación de la lesión, la presencia de contraindicaciones en la imagen para la administración intravenosa del activador del plasminógeno tisular (AP-t) y con el Alberta Stroke Programme Early CT Score (ASPECTS). RESULTADOS: Se obtuvieron las siguientes concordancias intraobservadores: buena concordancia en la clasificación general de la lesión (κ= 0.63, p<0.001), muy buena concordancia en lesiones hemorrágicas (κ= 0.89, p< 0.001), y concordancia moderada en ambos sin clasificación de lesión aguda y clasificación de lesión isquémica aguda (κ= 0.59 y κ= 0.58 respectivamente, p<0.001). Hubo una buena concordancia intraobservadores en el ASPECTS dicotomizado (κ= 0.65, p<0.001). CONCLUSIONES: Los resultados de nuestro estudio permiten concluir que la confiabilidad de la solución móvil para la interpretación de imágenes de TAC de cráneo simple de pacientes con accidente cerebrovascular agudo (ACV) estaba garantizada, lo que permitiría servicios de teleACV eficientes y de bajo costo.

Multilocular Cystic Nephroma: A Systematic Literature Review of the Radiologic and Clinical Findings.

OBJECTIVE: The objective of our study was to systematically summarize the published evidence of demographic, clinical, diagnostic imaging, and therapeutic characteristics of patients with multilocular cystic nephroma (MLCN). CONCLUSION: Cross-sectional imaging evaluation is important for suggesting the diagnosis of MLCN but has several limitations. The number of radical nephrectomies reported for MLCN encourages discussion concerning the utility of percutaneous presurgical biopsy and frozen-section intraoperative biopsy as a more conservative diagnostic approach.