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Background: The increasing frequency of elderly patients with severe tortuous anatomy, especially when combined with fibromuscular dysplasia, can make intracranial canalization severely difficult or impossible. Computed tomography angiography was used to determine the feasibility of accessing the internal carotid artery (ICA) via a percutaneous translacerum approach., Methods: Twenty consecutive stroke activations with CT angiography were reconstructed in three-dimensional models to take measurements to assess if currently available technologies could safely provide access. We assessed the diameter of the foramen lacerum and ICA. Entry points and angulations were measured based on trajectory. Our trajectory was based on anatomic observations that provided a safe corridor from the angle of the jaw to the foramen lacerum., Results: Based on the 40 carotid arteries from 20 patients, 77.5% had a large enough foramen lacerum to provide access to the ICA. Although there were no traversals of the pharynx, we noted a 20% traversal of the eustachian tube and 5% traversal of a small maxillary artery branch. There was no large-vessel traversal by the trajectory. All patients with bilateral stenotic foramen lacerum were African-American women; 44% of African-American women had bilateral stenotic foramen lacerum. The diameter of the ICA and foramen lacerum would not be prohibitive of sheath placement in patients without stenosis with adequate canalized length of sheath necessary for stability., Conclusions: Access of the ICA via the foramen lacerum can be safely performed with currently available technologies., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Assessment for source of stroke is a common indication for transoesophageal echocardiography (TOE). Although an abnormality is frequently found, it remains uncertain how frequently the findings alter patient management. Also, the role of transthoracic echocardiography (TTE) prior to or instead of TOE is not well defined. We sought to determine the use of TTE prior to TOE, the outcome of the TOE and its impact on management., Methods: We retrospectively reviewed the records and echocardiography results of 100 consecutive patients who underwent TOE for any reason at a tertiary hospital. In 35 subjects (35%), the indication was evaluation for source of stroke. Among these, we determined clinical risk factors for stroke, if a TTE was performed prior to their TOE, the results of the TOE and its effect on management., Results: The mean age of the stroke patients was 64.6 years (17-90) and 49% were women. Eighty per cent had at least one risk factor for stroke and 17% had atrial fibrillation. A TTE, performed in 40% prior to the TOE, found an abnormality in 14% (2/14). The TOE showed an abnormality in 71% of patients; 54% had aortic atheroma; 17% PFO; 14% spontaneous echo contrast; 6% left atrial appendage thrombus, 3% left ventricular thrombus and 3% vegetation. In only one patient (3%) the management was altered based on the abnormal TOE findings., Conclusion: An abnormality on TOE, although common (71%) and more sensitive than TTE, altered management in only 3% of subjects referred for stroke assessment. Its role requires further consideration., (© 2010 The Authors. Internal Medicine Journal © 2010 Royal Australasian College of Physicians.)

Several thrombolytic agents for the treatment of acute ischaemic stroke have been examined; however, to date, only the i.v. administration of recombinant tissue plasminogen activator is licensed in Australia. Although no trials directly comparing intra-arterial and i.v. delivery of thrombolytics exist, intra-arterial thrombolysis has several potential advantages, including angiographic assessment of the thrombus and the site of occlusion and collateral circulation, improved recanalization, and delivery of higher local concentrations of thrombolytic agents and extending the therapeutic time window for treatment. We conducted a retrospective audit of our experience with the use of intra-arterial urokinase to treat acute ischaemic stroke at an Australian tertiary-care hospital between June 1993 and June 2003. We examined time from stroke onset to assessment, computerized tomography scan, cerebral angiography and thrombolysis, anatomical classification of intra-arterial thrombus, rates of symptomatic intracerebral haemorrhage, and clinical outcome at 3 months. We believe that in carefully selected individuals in appropriate centres of expertise, intra-arterial thrombolytic therapy holds great promise.