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Background and Purpose— Many ischemic strokes or transient ischemic attacks are labeled cryptogenic but may have undetected atrial fibrillation (AF). We sought to identify those most likely to have subclinical AF. Methods— We prospectively studied patients with cryptogenic stroke or transient ischemic attack aged ≥55 years in sinus rhythm, without known AF, enrolled in the intervention arm of the 30 Day Event Monitoring Belt for Recording Atrial Fibrillation After a Cerebral Ischemic Event (EMBRACE) trial. Participants underwent baseline 24-hour Holter ECG poststroke; if AF was not detected, they were randomly assigned to 30-day ECG monitoring with an AF auto-detect external loop recorder. Multivariable logistic regression assessed the association between baseline variables (Holter-detected atrial premature beats [APBs], runs of atrial tachycardia, age, and left atrial enlargement) and subsequent AF detection. Results— Among 237 participants, the median baseline Holter APB count/24 h was 629 (interquartile range, 142–1973) among those who subsequently had AF detected versus 45 (interquartile range, 14–250) in those without AF ( P P P =0.0017) and 2 years ( P =0.0027). Compared with the 16% overall 90-day AF detection rate, the probability of AF increased from Conclusions— Among older cryptogenic stroke or transient ischemic attack patients, the number of APBs on a routine 24-hour Holter ECG was a strong dose-dependent independent predictor of prevalent subclinical AF. Those with frequent APBs have a high probability of AF and represent ideal candidates for prolonged ECG monitoring for AF detection. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00846924.

Objective The mismatch negativity (MMN), an auditory event-related potential, has been identified as a good indicator of recovery of consciousness during coma. We explored the predictive value of the MMN and other auditory-evoked potentials including brainstem and middle-latency potentials for predicting awakening in comatose patients after cardiac arrest or cardiogenic shock. Materials and Methods Auditory brainstem, middle-latency (Pa wave), and event-related potentials (N100 and MMN waves) were recorded in 17 comatose patients and 9 surgical patients matched by age and coronary artery disease. Comatose patients were followed up daily to determine recovery of consciousness and classified as awakened and nonawakened. Results Among the auditory-evoked potentials, the presence or absence of MMN best discriminated between patients who awakened or those who did not. Mismatch negativity was present during coma in all patients who awakened (7/7) and in 2 of those (2/10) who did not awaken. In patients who awakened and in whom MMN was detected, 3 of those awakened between 2 and 3 days and 4 between 9 and 21 days after evoked potential examination. All awakened patients had intact N100 waves and identifiable brainstem and middle-latency waves. In nonawakened patients, N100 and Pa waves were detected in 5 cases (50%) and brainstem waves in 9 (90%). Conclusions The MMN is a good predictor of awakening in comatose patients after cardiac arrest and cardiogenic shock and can be measured days before awakening encouraging ongoing life support.

Background Uncertainty regarding the long-term functional outcome of patients who awaken from coma after cardiac operations is difficult for families and physicians and may delay rehabilitation. We studied the long-term functional status of these patients to determine if duration of coma predicted outcome. Methods We followed 71 patients who underwent cardiac operations; recovered their ability to respond to verbal commands after coma associated with postoperative stroke, encephalopathy, and/or seizures; and were discharged from the hospital. The Glasgow Outcome Scale Extended (GOSE) was used to assess functional disability 2 to 4 years after discharge. Outcomes were classified as favorable (GOSE scores 7 and 8) and unfavorable (GOSE scores 1–6). Results Of 71 patients identified, 39 were interviewed, 15 died, 1 refused to be interviewed, and 16 were lost to follow-up. Of the 54 patients with completed GOSE evaluations, only 15 (28%) had favorable outcomes. Among patients with unfavorable outcomes, 15 (28%) died, 14 (26%) survived with moderate disabilities, and 10 (18%) had severe disabilities. Factors associated with unfavorable outcomes were increases in duration of coma ( p = 0.007), time in intensive care ( p = 0.006), length of hospitalization ( p = 0.004), and postoperative serum creatine kinase levels ( p = 0.006). Only duration of coma was an independent predictor of unfavorable outcome (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.008–1.537; p = 0.042). Patients with durations of coma greater than 4 days were more likely to have unfavorable outcomes (OR, 5.1; 95% CI, 1.3–21.3; p = 0.02). Conclusions Two thirds of comatose patients who survived to discharge after cardiac operations had unfavorable long-term functional outcomes. A longer duration of unconsciousness is a predictor of unfavorable outcome.

Background and purpose Diffusion weighted imaging (DWI) may be used to evaluate post-coiling ischemia. Heparinization protocols for cerebral aneurysm coiling procedures differ among operators and centers, with little literature surrounding its effect on DWI lesions. The goal of this study was to determine which factors, including heparinization protocols, may affect DWI lesion load post-coiling. Materials and methods A review of 135 coiling procedures over 5 years at our centre was performed. Procedural data including length of procedure, number of coils used, stent or balloon assistance and operators were collected. Procedures were either assigned as using a bolus dose (>2000 U at any one time) or small aliquots of heparin (≤2000 U). Postprocedure DWI was reviewed and lesions were classified as small ( 10 mm). The cases were then classified into group 1 (≤5 small lesions) or group 2 (>5 small lesions or ≥1 medium or large lesion). Multivariate regression of the procedural variables for the two groups was calculated. A p value of Results There were 78 procedures in group 1 and 57 procedures in group 2. Patients who received small aliquots (n=37) versus boluses of heparin (n=98) intraprocedurally had significantly greater frequency and size of DWI lesions (p=0.03). None of the other procedural variables was found to impact on lesion load. Conclusions More substantial DWI lesions were associated with small aliquots of heparin dosage compared with bolus doses. Heparin boluses should be preferentially administered during aneurysm coiling.

Objectives To describe clinical and brain imaging characteristics of patients who recovered and did not recover consciousness from a coma after cardiac surgery and to investigate predictors of the duration of unconsciousness in those patients who ultimately recovered consciousness. Design A retrospective analysis from a cohort of patients who developed coma after cardiac surgery. Setting A single university hospital. Participants One hundred twelve patients with postoperative stroke, encephalopathy, and/or seizures who remained in coma longer than 24 hours after cardiac surgery. Interventions None. Measurements and Main Results The authors analyzed the patients' perioperative and intraoperative characteristics, laboratory values, noncontrast head computed tomography (CT) scans, and outcomes. Patients who did not recover consciousness (n = 16) were more likely to have been classified preoperatively as New York Heart Association class III/IV ( p = 0.037). In patients who recovered consciousness (n = 96), only increased preoperative serum creatinine was an independent predictor of a longer duration of unconsciousness ( p = 0.011). In patients who eventually recovered consciousness and had no acute findings on brain imaging, preoperative creatinine ( p = 0.014), the lowest postoperative hemoglobin ( p = 0.039), and surgical emergency ( p = 0.045) were independent predictors of the duration of unconsciousness ( p = 0.002). In patients who regained consciousness but had acute findings on brain imaging, cardiogenic shock ( p = 0.012) and the insertion of an intra-aortic balloon pump before or during surgery ( p = 0.025) predicted longer durations of unconsciousness ( p Conclusions In patients who ultimately recovered consciousness after being in a coma for at least 24 hours after cardiac surgery and have no abnormality on a brain CT scan, elevated preoperative serum creatinine, urgent cardiac surgery, and lower postoperative hemoglobin were correlated with an increased duration of unconsciousness.

BACKGROUND AND PURPOSE: The pathophysiology of IIH remains unknown. TS stenoses have been observed in a high proportion of these patients. Stent placement to remove this potential obstruction to venous outflow has been proposed as a treatment option for patients with IIH refractory to medical treatment. MATERIALS AND METHODS: The clinical presentation, treatment, and outcome of patients with refractory IIH evaluated for venous sinus stent placement at a tertiary care center was retrospectively reviewed. RESULTS: Thirteen female patients with IIH were evaluated for sinovenous stent placement. Moderate sinus stenoses with normal intrasinus pressures were found in 3 patients and therefore stent placement was not performed. Ten patients had elevated intrasinus pressures (pressure gradient across stenosis, 11–50 mm Hg), which decreased following unilateral TS stent placement. Headaches improved or resolved in all stented patients. Papilledema resolved completely or almost completely in 8 patients and significantly improved in 2 patients. One patient developed optic atrophy. There were no major periprocedural complications. CONCLUSIONS: In this small case series, restoring the patency of stenotic venous sinuses with a stent in patients with refractory IIH resulted in symptomatic improvement in all treated patients. The safety and efficacy of this procedure should be evaluated in a randomized controlled study to determine its role within the armamentarium of therapeutic options for patients with IIH.

Object Hemodynamic instability may complicate carotid angioplasty and stenting in up to 40% of patients. The authors have previously demonstrated that primary self-expanding stent placement alone can gradually dilate severely stenosed carotid arteries without the use of balloons. The authors hypothesized that eliminating the balloon would reduce carotid baroreceptor stimulation, thereby decreasing the incidence of hemodynamic instability. Methods Ninety-seven high surgical risk patients with symptomatic, severely stenosed carotid arteries were treated with the intention of using a self-expanding stent alone. Seventy-seven arteries (79%) were treated with stenting alone, and 20 required angioplasty (21%). Results Intraprocedural bradycardia (heart rate < 60 bpm) developed in 29 patients (38%) and hypotension (systolic blood pressure < 90 mm Hg) occurred in 1 patient (1%) treated with stenting alone. Fourteen patients (70%) who underwent angioplasty and stenting had bradycardia, and hypotension developed in 4 (20%). Atropine, glycopyrrolate, or vasopressors were required in 8% of patients who received stenting alone, compared to 30% of patients who underwent angioplasty. In the first 24 hours after treatment, hypotension or bradycardia developed in 25 patients (32%) who had undergone stent placement alone, and in 15 patients (75%) after stent placement and balloon angioplasty. There was no difference in the occurrence of intra- or postprocedural hypertension (systolic blood pressure > 160 mm Hg) between patients treated with stenting alone or stenting and balloons. Factors independently associated with hemodynamic depression included baseline heart rate and balloon use. Conclusions Hemodynamic instability during and after carotid artery stenting was observed more frequently when balloon angioplasty was required than when stent placement was performed without concurrent balloon angioplasty.

A 39-year-old man who presented with unilateral proptosis and periocular pain rapidly developed reduced consciousness, facial numbness, dysarthria, and gait ataxia from a direct carotid-cavernous fistula (CCF) with drainage into posterior fossa veins. Brain MRI revealed abnormal signal throughout the brainstem, indicative of venous hypertension and edema. Closure of the fistula by detachable balloon eliminated the clinical and imaging abnormalities. This is the fifth reported case of brainstem complications of a direct CCF. It highlights potentially serious complications of this condition and their reversibility with prompt treatment.

L'administration de l'activateur du plasminogene tissulaire recombinant (rt-PA) est le traitement actuel de l'accident vasculaire cerebral (AVC) ischemique aigu. La presence du signe de l'artere cerebrale moyenne hyperdense (SACMH) a la tomodensitometrie cerebrale avant traitement est consideree comme un signe de mauvais pronostic. Nous avons compare le resultat clinique chez les patients avec et sans SACMH traites par rt-PA IV. Plan de l'etude : Nous avons effectue une analyse retrospective de cas recueillis de facon prospective, traites au moyen de rt-PA IV dans les 3 heures du debut des symptomes. Les criteres d'inclusion etaient les suivants : la presence d'un AVC dans le territoire de la circulation anterieure ; la disponibilite d'un examen tomodensitometrique avant traitement, d'un score du NIH Stroke Scale (NIHSS) avant traitement et d'un score du Modified Rankin Scale (MRS) trois mois apres l'AVC. Resultats : Cent trente patients rencontraient les criteres d'inclusion, dont soixante-quatre (49%) avaient un SACMH. Dans le groupe avec SACMH, la moyenne du score du NIHSS avant traitement avait tendance a etre plus elevee comparee a celle du groupe sans SACMH (13,9 ± 6 vs 12,2 ± 6 ; p = 0,12). Il y avait donc plus de patients atteints d'AVC severes (NIHSS > 10) dans le groupe avec SACMH par rapport au groupe sans SACMH (48/64 = 75% vs 35/66 = 53%; p = 0,009). Le score moyen du NIHSS 24 heures apres le traitement etait de 10,6 (± 8) dans le groupe avec SACMH et de 8,3 (± 7) dans le groupe sans SACMH (p = 0,08). A l'analyse de regression logistique multivariee, le seul predicteur independant d'un mauvais pronostic (MRS 3-6) etait le score du NIHSS avant traitement (p < 0,001). Conclusion: Les patients qui presentaient un SACMH et qui ont recu du rt-PA IV n'etaient pas en plus mauvais etat trois mois plus tard que ceux qui n'en presentaient pas malgre qu'une plus grande proportion d'entre eux etaient atteints d'AVC plus severes. Selon les connaissances actuelles, le rt-PA IV administre dans les trois heures du debut des symptomes est un bon traitement chez les patients porteurs d'un SACMH.

Background and Purpose— The hyperdense middle cerebral artery sign (HMCAS) is a well-established marker of early ischemia on noncontrast computed tomography of the brain (NCCT). Recently the MCA dot sign has been described and proposed to indicate thrombosis of the M2 or M3 middle cerebral artery branches. The purpose of this study was to define the hyperdense ICA sign (HICAS) and determine its prevalence, diagnostic and prognostic value, and its reliability as a marker for ischemia. Methods— Noncontrast computed tomography scans of 71 patients with acute ischemic stroke were analyzed for the presence of a HICAS, HMCAS, or MCA dot sign. For the validation of HICA and HMCA signs on NCCT, 32 of 71 patients who underwent gold standard CT angiography (CTA) before thrombolytic therapy were included in the analysis. The presence of a HICAS was correlated with initial neurological severity and the short and long-term outcomes. Results— A HICAS was found in 24% of patients on NCCT. In patients with a HICAS, mean age was 63±17.4 and mean time from symptom onset to CT was 103 minutes. Interobserver agreement was excellent for the HICAS. The HICAS has high specificity (100%) and positive predictive value (100%) in predicting the presence of distal internal carotid artery thrombus on CTA. Patients with a HICAS had a more severe initial neurological deficit and worse prognosis than patients without a HICAS. Conclusion— The HICAS is a reliable and a highly specific marker of thromboembolic occlusion of the distal ICA and is associated with severe initial neurological deficit and worse outcome despite thrombolytic therapy.

Indices du pronostic de l'etat fonctionnel chez les patients atteints de cancer primitif du cerveau. Introduction: Nous avons compare l'etat fonctionnel et la survie de patients atteints de gliomes malins. Methodes: Cette revue retrospective porte sur 143 patients porteurs d'un gliome malin.Ils ont ete classes selon le diagnostic anatomopathologique. Un score etait attribue a chaque patient selon l'indice fonctionnel de Karnofksy (IFK) a la consultation initiale et apres 1, 3, 6, 9 et 12 mois de suivi et de facon annuelle par la suite. Les donnees ont ete analysees au moyen de methodes descriptives ainsi que du test de Kruskal-Wallis, du test du chi-carre, du test du log-rank et du modele a hasard proportionnel de Cox. Resultats: Quatre-vingt-quatre patients etaient des hommes et l'âge median des patients etait de 63 ans. Selon l'examen anatomopathologique, cent sept patients avaient un glioblastome multiforme, alors que chez 23 la tumeur etait un astrocytome anaplasique et chez 13 un oligodendrogliome anaplasique. Vingt-neuf patients ont recu une polytherapie agressive, 83 ont recu un traitement intermediaire et les 31 autres patients ont recu un traitement conservateur. 33% des patients ont eu des complications importantes dues au traitement, dont quatre deces en periode post-operatoire. Le groupe de patients atteints d'un oligodendrogliome an aplasique, de meme que les patients ayant recu un traitement agressif, avaient une mortalite plus basse et ont maintenu de meilleurs scores IFK pendant la periode d'observation. Les facteurs qui predisaient le mieux l'etat fonctionnel etaient l'âge, l'IFK avant le traitement et le type de traitement recu. Les facteurs les plus importants associes a la survie etaient l'âge, la severite des cormobidites, l'IFK avant traitement, le presence de confusion, le diagnostic anatomopathologique et le type de traitement recu. Conclusion: Chez les patients atteints de gliomes malins, on observe un meilleur etat fonctionnel et une survie plus longue chez ceux qui sont plus jeunes, qui ont un meilleur etat fonctionnel au moment du diagnostic et qui recoivent un traitement multimodal agressif. L'effet d'un traitement multimodal sur l'etat fonctionnel des patients devra etre confirme par un essai clinique controle randomise.

Introduction: Seizures are most commonly associated with positive phenomena such as tonic, clonic or myoclonic movements, automatisms, paresthesias and hallucinations. Negative phenomena, however, are not an uncommon manifestation of seizure activity. Examples of negative seizure phenomena include speech arrest, aphasia, amaurosis, amnesia, numbness, deafness, neglect and atonic seizures. Less commonly described in the literature are focal inhibitory motor seizures. Methods and Results: Two patients presenting with rapidly progressive, prolonged hemiparesis, sensory neglect and hemi-visual field obscuration are described. Computed tomography (CT) and magnetic resonance imaging (MRI) of the brain did not reveal progression of known structural lesions or new lesions. The superficial cortex of the hemisphere contralateral to the hemiparesis and sensory neglect enhanced diffusely with gadolinium on T1-weighted MRI images. Electroencephalography demonstrated periodic lateralized epileptiform discharges (PLEDs) in one patient and lateralized suppression and slowing in the other patient. Single photon emission computed tomography (SPECT) revealed hyperperfusion in the hemisphere contralateral to the hemiparesis and sensory neglect. The changes seen on MRI and SPECT resolved with resolution of the symptoms. Conclusion: Taken together with the clinical history, the results from these investigations suggest focal inhibitory seizure as the underlying etiology. A review of the literature and investigations helpful in making this difficult diagnosis are provided.

Background Coiling of small aneurysms can be technically challenging. These aspects of coiling tend to be less problematic in medium to large aneurysms as they are more accommodating of microcatheters and coils. When physicians are asked their opinion regarding aneurysm coilability in small aneurysms, the decision often lies in the operator9s feeling that they could reasonably exclude the aneurysm with a complication rate similar to larger aneurysms. The purpose of our study was to investigate the feasibility, intraprocedural rupture rates and long term durability of endovascular coiling for small (≤4 mm) aneurysms compared with non-small (>4 mm) aneurysms. To control for factors such as vessel tortuosity and aneurysm location, a control group was chosen matched to the study group both in age and aneurysm location. Materials and methods A retrospective review of 360 intracranial aneurysms coiled at our institution between 2003 and 2008 was performed. For the control group, intracranial aneurysms coiled in the same period matched to location and age were chosen. Results The frequency of intraprocedural perforations was 4/34 (0.12) and 3/68 (0.04) for the small and non-small cohort, respectively (p=0.22). All patients who had a perforation in the small aneurysm groups had a good clinical outcome compared with 1/3 in the non-small group (two mortalities). The frequency of recanalization for the small and non-small groups was 3/34 (0.09) and 23/68 (0.33), respectively (p=0.006). There was no retreatments in the small aneurysm group and five (0.07) in the non-small group (p=0.116). Conclusion Coiling of small (≤4 mm) aneurysms is feasible with a reasonable complication rate. There is a non-significant increase in frequency of intraprocedural rupture with coiling of small aneurysms compared with controls matched to aneurysm location and age but this is not associated with increased morbidity. Coiling of small aneurysms leads to durable results at long term follow-up.

Background Lower haemoglobin levels may impair cerebral oxygen delivery and threaten tissue viability in the setting of acute brain injury. Few studies have examined the association between haemoglobin levels and outcomes after spontaneous intracerebral haemorrhage. Aims We evaluated whether anaemia on admission was associated with greater intracerebral haemorrhage severity and worse outcome. Methods Consecutive patients with spontaneous intracerebral haemorrhage were analyzed from the Registry of the Canadian Stroke Network. Admission haemoglobin was related to stroke severity (using the Canadian Neurological Scale), modified Rankin score at discharge, and one-year mortality. Adjustment was made for potential confounders including age, gender, medical history, warfarin use, glucose, creatinine, blood pressure, and intraventricular haemorrhage. Results Two thousand four hundred six patients with intracerebral haemorrhage were studied of whom 23% had anaemia (haemoglobin Conclusions Anaemia on admission is associated with greater intracerebral haemorrhage severity and worse outcomes. The utility of transfusion remains unclear in this setting.

BACKGROUND AND IMPORTANCE Dural arteriovenous fistulas (dAVFs) represent 10% to 15% of all intracranial arteriovenous malformations. Most often, embolization is accomplished with transfemoral catheter techniques. We present a case in which embolization of a cavernous sinus dAVF was made possible through transcranial cannulation of a cortical draining vein. CLINICAL PRESENTATION An 82-year-old woman presented with diplopia, left sixth cranial nerve palsy, intraocular hypertension, and bilateral chemosis. Angiography revealed a complex cavernous dAVF with cortical venous reflux, supplied by both external carotid arteries and the left meningohypophyseal trunk. Percutaneous transvenous access failed, and only partial occlusion was achieved by transarterial embolization. A frontotemporal craniotomy was performed to access the superficial middle cerebral vein in the left sylvian fissure. Under fluoroscopic guidance, a microcatheter was advanced through this vein to the floor of the middle cranial fossa and into the dAVF, permitting coil occlusion. CONCLUSION This transcranial vein technique may be a useful adjunct in dAVF therapy when percutaneous transarterial or transvenous approaches fail or are not possible.

Coma due to global or focal ischemia or hemorrhage is reviewed. Impaired consciousness due to anoxic-ischemic encephalopathy after cardiac arrest is common but prognostically problematic. Recent guidelines need to be refined for those patients who have received therapeutic hypothermia. Strokes, both ischemic and hemorrhagic, can affect the level of consciousness by damaging specific brain structures involved in alertness because of widespread cerebral injury or secondary cerebral or systemic complications.

A sound approach to practicing evidence-based medicine is an essential component of any contemporary clinical neurology training program. This chapter outlines the objectives and formats of two highly successful evidence-based neurology (EBN) curricula targeting neurology trainees. Integral components of an EBN curriculum, including the development of questions, pretutorial preparation, tutorial discussion, and posttutorial review, are discussed in detail. Helpful resources are identified and the evidence for EBN curricula is reviewed.

Avascularity on CT angiography source images (CTASI) may better predict final infarct volume in acute stroke as compared to early ischemic changes on non-contract CT. These CTASI findings may represent infarct core and help determine the extent of salvageable tissue. However, the extent of avascularity on CTASI may overestimate infarct volume if transit of contrast is prolonged due to proximal artery occlusion. We present a case where CT-perfusion (CTP) and time-resolved CT-angiography (CTA) identified salvageable tissue thought to be infarcted on CTASI.

Background:Carotid angioplasty and stenting is an accepted alternative treatment for severe restenosis following carotid endarterectomy. Balloons may not be required to effectively treat these lesions, given their altered histopathology compared to primary atherosclerotic plaque and tendency to be less calcified. Primary stenting using self-expanding stents alone may, therefore, be a safe and effective treatment for restenosis post-carotid endarterectomy.Methods:We review our experience in the treatment of 12 patients with symptomatic severe restenosis following carotid endarterectomy with primary stent placement alone.Results:Self-expanding stent placement alone reduced the mean internal carotid artery stenosis from 85% to 29%. Average peak systolic velocity determined at the time of ultrasonography decreased from 480 cm/s at initial presentation to 154 cm/s post-stent deployment and further decreased to 104 cm/s at one year follow-up. The stented arteries remained widely patent with no evidence of restenosis. A single peri-procedural ipsilateral transient ischemic event occurred. There were no cerebral or cardiac ischemic events recorded at one year of follow-up.Conclusions:In this series, primary stent placement without use of angioplasty balloons was a safe and effective treatment for symptomatic restenosis following carotid endarterectomy.

Hemodynamic instability may complicate carotid angioplasty and stenting in up to 40% of patients. The authors have previously demonstrated that primary self-expanding stent placement alone can gradually dilate severely stenosed carotid arteries without the use of balloons. The authors hypothesized that eliminating the balloon would reduce carotid baroreceptor stimulation, thereby decreasing the incidence of hemodynamic instability.Ninety-seven high surgical risk patients with symptomatic, severely stenosed carotid arteries were treated with the intention of using a self-expanding stent alone. Seventy-seven arteries (79%) were treated with stenting alone, and 20 required angioplasty (21%).Intraprocedural bradycardia (heart rate60 bpm) developed in 29 patients (38%) and hypotension (systolic blood pressure90 mm Hg) occurred in 1 patient (1%) treated with stenting alone. Fourteen patients (70%) who underwent angioplasty and stenting had bradycardia, and hypotension developed in 4 (20%). Atropine, glycopyrrolate, or vasopressors were required in 8% of patients who received stenting alone, compared to 30% of patients who underwent angioplasty. In the first 24 hours after treatment, hypotension or bradycardia developed in 25 patients (32%) who had undergone stent placement alone, and in 15 patients (75%) after stent placement and balloon angioplasty. There was no difference in the occurrence of intra- or postprocedural hypertension (systolic blood pressure160 mm Hg) between patients treated with stenting alone or stenting and balloons. Factors independently associated with hemodynamic depression included baseline heart rate and balloon use.Hemodynamic instability during and after carotid artery stenting was observed more frequently when balloon angioplasty was required than when stent placement was performed without concurrent balloon angioplasty.

Object Conventional endovascular therapy for carotid stenosis involves placement of an embolic protection device followed by stent insertion and angioplasty. A simpler approach may be placement of a stent alone. The authors determined how often this approach could be used to treat patients with carotid stenosis, and assessed which factors would preclude this approach. Methods Over a period of 6 years, 97 patients with symptomatic carotid stenosis were treated with the intention of using a “stent-only” approach. Arteries in 77 patients (79%) were treated with stents alone, 13 required preinsertion balloon dilation, 6 postinsertion dilation, and 1 both pre- and postinsertion dilation. Results The mean stenosis according to North American Symptomatic Carotid Endarterectomy Trial criteria was reduced from 82 to 40% in the stent-only group and from 89 to 37% in the stent and balloon angioplasty group. The 30-day stroke and death rate was 7.2%. Patients were followed for a mean of 15 months. In the stent-alone group, the mean preoperative Doppler peak systolic velocity (PSV) was 409 cm/second, with an internal carotid artery/common carotid artery (ICA/CCA) ratio of 7.2. At follow-up review, the PSV decreased to 153 cm/second and the ICA/CCA ratio to 2.1. In the angioplasty group the mean preoperative PSV was 496 cm/second and the ICA/CCA ratio was 9.2, decreasing to 163 cm/second and 2, respectfully, at follow-up evaluation. Restenosis occurred in 12.8% of patients at 6 months and in 15.9% at 1 year. One stroke occurred during the follow-up period in each group. Using multivariable analysis, factors precluding the “stent-only” approach were as follows: severity of stenosis, circumferential calcification, and no history of hyperlipidemia. Conclusions Balloons may not be required to treat all patients with carotid stenosis. A stent alone was feasible in 79% of patients, and 79% of patients were alive and free from ipsilateral stroke or restenosis at 1 year. Restenosis rates with this approach are higher than with conventional angioplasty and stent insertion. Carotid arteries with very severe stenoses (> 90%) and circumferential calcification may be more successfully treated with angioplasty combined with stent placement.

BACKGROUND AND PURPOSE: Cervical internal carotid artery (ICA) occlusion with middle cerebral artery (MCA) embolic occlusion is associated with a low rate of recanalization and poor outcome after intravenous thrombolysis. Prompt revascularization is required to prevent disabling stroke. We report our experience on acute ischemic stroke patients with tandem ICA or MCA occlusions treated with microcathether navigation and intra-arterial thrombolysis by use of collateral pathways including the posterior or anterior communicating arteries, or both pathways. MATERIALS AND METHODS: We retrospectively identified 8 patients with proximal ICA occlusion associated with MCA embolic occlusions treated with intra-arterial thrombolysis (IA rtPA). Access to the occluded MCA was obtained via catheter navigation through intact collateral pathways, including posterior communicating (PcomA) or anterior communicating (AcomA) arteries, without passing a microcathether through the acutely occluded ICA. We assessed clinical outcomes using modified Rankin scale (mRS) and National Institutes of Health Stroke Scale (NIHSS). RESULTS: Eight patients with a mean age of 57 ± 4 years and median NIHSS of 14 were identified. Mean time from stroke onset to intra-arterial thrombolysis was 292 ± 44 minutes. The MCA was revascularized completely in 5 of the 8 patients via collateral intra-arterial rtPA administration. All of the patients had a favorable outcome defined as a mRS of ≤2 or more at 1 and 3 months9 follow-up after thrombolytic therapy. One patient had an asymptomatic petechial hemorrhage. CONCLUSION: In this small number of patients with tandem occlusions of the ICA and MCA, intra-arterial thrombolysis and recanalization of the MCA by use of collateral pathways to bypass the occluded ICA is a safe and efficacious therapeutic option.

Background:Clinicians in the neurosciences need to interpret and apply a growing body of evidence about therapy.Methods:Using a clinical scenario about painful diabetic neuropathy and evidence about one treatment option, we review the advantages, limitations, and the clinical interpretation of commonly reported measures of effectiveness, emphasizing their application to the care of individual patients.Results:Absolute differences between treatment and control groups (e.g., absolute risk difference) are clinically intuitive and preferable to relative measures (e.g., relative risk). The number needed to treat is particularly useful and clinically applicable. Continuous measures are best interpreted using thresholds of clinically important change, which provide information about the number of patients experiencing meaningful improvement or worsening.Conclusions:Using simple principles of evidence based care, clinicians can correctly interpret the common measures of treatment effectiveness and apply them to the care of individual patients.