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Objective To determine factors associated with patients refusing IV t- PA for suspected acute ischemic stroke ( AIS), and to compare the outcomes of patients who refused t- PA ( RT) with those treated with t- PA. Methods Patients who were treated with and refused t- PA at our stroke center were identified retrospectively. Demographics, clinical presentation, and outcome measures were collected and compared. Clinical outcome was defined as excellent ( mRS: 0-1), good ( mRS: 0-2), and poor ( mRS: 3-6). Results Over 7·5 years, 30 (4·2%) patients refused t- PA. There were no demographic differences between the treated and RT groups. The rate of RT decreased over time ( OR 0·63, 95% CI 0·50-0·79). Factors associated with refusal included a later symptom onset to emergency department presentation time ( OR 1·02, 95% CI 1·01-1·03), lower NIHSS ( OR 1·11, 95% CI 1·03-1·18), a higher proportion of stroke mimics ( OR 17·61, 95% CI 6·20-50·02) and shorter hospital stay ( OR 1·32, 95% CI 1·09-1·61). Among patients who were subsequently diagnosed with ischemic stroke, only length of stay was significantly shorter for refusal patients ( OR 1·37, 95% CI 1·06-1·78). After controlling for mild strokes and stroke mimics, clinical outcome was not different between the groups ( OR 1·61, 95% CI 0·69-3·73). Conclusion The incidence of patients refusing t- PA has decreased over time, yet it may be a cause for t- PA under-utilization. Patients with milder symptoms were more likely to refuse t- PA. Refusal patients presented later to the hospital and had shorter hospital stays. One out of six refusal patients (16·6%) had a stroke mimic. [ABSTRACT FROM AUTHOR]

The article presents a study which extends the cortical and leptomeningeal manifestations of amyloid beta peptide-related angiitis and shows that this deficiency will possibly spread from the sites of amyloid deposition to the other parts of the brain. The study presents the case of the 57-year-old woman with inactive Crohn's disease to clearly illustrates the possible spreading of this disease to the other sides of the brain. Discussions of the results are offered after the examination.

The prophylactic use of antibiotics has become a routine procedure in many areas of medicine. In neurosurgery, however, there is considerable debate over their use in the prevention of postoperative infection. We pose several ethical questions about antibiotic prophylaxis in a neurosurgical setting. These questions are discussed under the following categories: responsible usage of antibiotics; the ethical dilemmas of controlled, antibiotic clinical trials, and some problems inherent in not using prophylactic antibiotics. [ABSTRACT FROM AUTHOR]

There has always been controversy about the indications for prescribing antibiotics to prevent postoperative sepsis in patients undergoing cranial and spinal surgery. The earlier specialists in infectious diseases warned that the effectiveness of antimicrobial drugs was leading to indiscriminate administration for the prevention of wound infection. Three clinical researchers present a review of the history of prophylactic antibiotic use in neurosurgery, including their own work, and raise a number of ethical issues not previously discussed in the literature about: (1) scientific methodology; (2) random selection; (3) prospective study; (4) blinded control; (5) placebo medication; (6) professional equipoise; (7) statististical analysis; (8) informed consent; (9) utilitarian philosophy; and (10) managed care. Also discussed are the dual role of physician and investigator and the ethical dilemma of depending upon meticulous technique versus adopting regimens of prophylactic antibiotics. [ABSTRACT FROM AUTHOR]

Comments on the article written by M. Whitby et al on the comparative efficacy of intravenous cefotaxime and trimethoprim/sulfamethoxazole in preventing infection after neurosurgery; M. Whitby et al's failure to employ the blinded methodology in their study; Absence of definitive demonstration of the efficacy of prophylactic antibiotics for any operation for which the infection rate is 5% or less.