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Pairs of magnets were applied to the loose skin on the backs of mice in order to cause ischemia for periods of 1.5, 2, 2.5 and 3 h followed by reperfusion. We found 1.5 h of ischemia resulted in the most reliable outcome of blanched skin but no redness or skin breakdown. Histological analysis at 4 h of reperfusion showed, in the centre of the insult, condensed nuclei in the epidermis and sebaceous glands with a build up of neutrophils in the blood vessels, and a reduction in the number of fibroblasts. At 24 h, spongiosis was seen in the epidermis and pockets of neutrophils began to accumulate under it, as well as being scatted through the dermis. In the centre of the insult there was a loss of sebaceous gland nuclei and fibroblasts. Four days after the insult, spongiosis was reduced in the epidermis at the edge of the insult but enhanced in the centre and in hair follicles. Leukocytes were seen throughout the central dermis. At 8 days, spongiosis and epidermal thickness had reduced and fibroblasts were reappearing. However, blood vessels still had leukocytes lining the lumen. The gap junction protein connexin 43 was significantly elevated in the epidermis at 4 h and 24 h reperfusion. Ischemia of 1.5 h generates a sterile inflammatory reaction causing the loss of some cell types but leaving the epidermis intact reminiscent of a stage I pressure ulcer., (Copyright © 2021 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.)

Clinical outcomes of acute ischaemic stroke patients have significantly improved with the advent of reperfusion therapy. However, time continues to be a critical factor. Reducing treatment delays by improving workflows can improve the efficacy of acute reperfusion therapy. Systems-based approaches have improved in-hospital temporal parameters, maximizing the utility of reperfusion therapies and improving clinical benefit to patients. However, studies aimed at optimizing and hence reducing treatment delays in emergency department (ED) settings are limited. The aim of this article is to discuss existing systems-based approaches to optimize ED acute stroke workflows and its value in reducing treatment delays and identify gaps in existing workflows that need optimization. Identifying gaps in acute stroke workflow, variations in processes and challenges in implementation, in the in-hospital settings, is essential for systems-based interventions to be effective in delivering improved outcomes for patients with acute ischaemic stroke., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Acute pulmonary embolism is a frequent cardiovascular emergency with an increasing incidence. The prognosis of patients with high-risk and intermediate-high-risk pulmonary embolism has not improved over the last decade. The current treatment strategies are mainly based on anticoagulation to prevent recurrence and reduce pulmonary vasculature obstruction. However, the slow rate of thrombus lysis under anticoagulation is unable to acutely decrease right ventricle overload and pulmonary vasculature resistance in patients with severe obstruction and right ventricle dysfunction. Therefore, patients with high-risk and intermediate-high-risk pulmonary embolism remain a therapeutic challenge. Reperfusion therapies may be discussed for these patients, and include systemic thrombolysis, catheter-directed therapies and surgical thrombectomy. High-risk patients require systemic thrombolysis, but may have contraindications as a result of the high risk of bleeding. In addition, intermediate-high-risk patients should not receive systemic thrombolysis, despite its high efficacy, because of prohibitive bleeding complications. Recently, percutaneous reperfusion techniques have been developed to acutely decrease pulmonary vascular obstruction with lower-dose or no thrombolytic agents and, thus, potentially higher safety than systemic thrombolysis. Some of these techniques improve key haemodynamic variables. Cardiac surgical techniques and venoarterial extracorporeal membrane oxygenation as temporary circulatory support may be useful in selected cases. The development of pulmonary embolism centres with multidisciplinary pulmonary embolism teams is mandatory to enable adequate use of reperfusion and improve outcomes. We aim to present the state of the art regarding reperfusion therapies in pulmonary embolism, but also to provide guidance on their indications and patient selection., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Background: The Advanced Thrombectomy System (ANCD) provides a new funnel component designed to reduce clot fragmentation and facilitate retrieval in patients with stroke by locally restricting flow, allowing distal aspiration in combination with a stent retriever (SR)., Objective: To evaluate the preclinical efficacy and safety of the ANCD in a swine clot model., Methods: Soft and firm clots were implanted in the lingual and cervical arteries of 11 swine to obtain Thrombolysis in Cerebral Infarction (TICI) 0 blood flow. Mechanical thrombectomy was performed with either a balloon guide catheter+Solitaire 2 stent retriever (BGC+SR, n=13) or ANCD+SR (n=13). TICI flow was evaluated and successful revascularization was defined as TICI 3 (normal perfusion). To characterize safety, a total of 3 passes were performed in each vessel independent of recanalization. Tissues were explanted for histopathological analysis after 3 and 30 days, respectively., Results: First pass reperfusion rates were ANCD+SR: 69% and BGC+SR: 46%. Reperfusion increased after the third pass in both groups (ANCD+SR: 100%, vs BGC+SR: 77%). Recanalization was achieved after an average of 1.4 and 1.9 passes in ANCD+SR and BGC+SR (p=0.095), respectively. Vessel injury was comparable in both groups; endothelial loss at 3 days was the most common injury seen (ANCD+SR: 1.78±1.22; BGC+SR: 2.03±1.20; p=0.73), while other histopathological markers were absent or minimal. Tissues downstream from targeted vessels also showed absence or minimal lesions across both groups., Conclusions: Results in a swine clot model support the high efficacy of the ANCD+SR without causing clinically significant vessel injury potentially related to the new funnel component., Competing Interests: Competing interests: SS, HV, AR, and IG are employees of Anaconda Biomed. LB and RD are employees of CBSET, a not-for-profit research organization, which received research funding from Anaconda Biomed for the reported work. MR is a shareholder in Anaconda Biomed, consultant for Cerenovus, Medtronic, Stryker, Apta Targets, and Vesalio. TA is clinical consultant for Anaconda, Ablynx, Amnis Therapeutics, Cerenovus/Neuravi, Medtronic, and Rapid Medical. RN: Stryker Neurovascular (DAWN trial principal investigator- no compensation, TREVO Registry Steering Committee – no compensation, Trevo-2 trial principal investigator- modest; consultant - significant); Medtronic (SWIFT Trial Steering Committee - modest; SWIFT-Prime Trial Steering Committee – no compensation; STAR Trial Angiographic Core Lab - significant); Penumbra (3D Separator Trial Executive Committee – no compensation); Cerenovus/ Neuravi (ENDOLOW Trial Principal Investigator, EXCELLENT Registry Principal Investigator, ARISE-2 trial Steering Committee – no compensation, Physician Advisory Board, modest); Phenox (PROST Trial Principal Investigator, Physician Advisory Board, modest); Anaconda (Physician Advisory Board, modest); Genentech (Physician Advisory Board – modest); Biogen (CHARM Trial Steering Committee; Physician Advisory Board – modest). Pharmaceuticals (Physician Advisory Board – modest); Allm Inc. (Physician Advisory Board – no compensation); IschemaView (Speaker, modest); Brainomix (Physician Advisory Board, stock options); Sensome (Research Device Use – no compensation); Viz-AI (Physician Advisory Board, stock options); Philips (Research Software Use – no compensation, Speaker - modest); Corindus Vascular Robotics (Physician Advisory Board, stock options); Vesalio (Physician Advisory Board, stock options); Ceretrieve (Physician Advisory Board, stock options); Astrocyte (Physician Advisory Board, stock options). CC is consultant for Sequent Medical, MicroVention, Stryker and Codman., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Editor's Note: The article "Update on Treatment of Acute Ischemic Stroke" by Dr Rabinstein was first published in the February 2017 Cerebrovascular Disease issue of Continuum: Lifelong Learning in Neurology as "Treatment of Acute Ischemic Stroke" and has been updated by Dr Rabinstein for this issue at the request of the Editor-in-Chief., Abstract: PURPOSE OF REVIEWThis article provides an update on the state of the art of the treatment of acute ischemic stroke with particular emphasis on the indications for reperfusion therapy.RECENT FINDINGSIn addition to the previously established indications for intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rtPA) within 4.5 hours of stroke symptom onset and endovascular therapy with mechanical thrombectomy for patients with large artery occlusion who can be treated within 6 hours of symptom onset, recent randomized controlled trials have now established new indications for emergency reperfusion in patients with wake-up stroke or delayed presentation (up to 24 hours from last known well in the case of mechanical thrombectomy). Identification of patients who may benefit from acute reperfusion therapy within this extended time window requires screening with perfusion brain imaging or, in the case of IV thrombolysis for wake-up strokes, emergency brain MRI. Collateral status and time to reperfusion remain the primary determinants of outcome.SUMMARYTimely successful reperfusion is the most effective treatment for patients with acute ischemic stroke. Recent evidence supports the expansion of the time window for reperfusion treatment in carefully selected patients.

Background and Purpose: Direct aspiration is a recognized technique for revascularization in large-vessel ischemic strokes. There is ongoing debate regarding its efficacy compared with stent retrievers. Every delay in achieving revascularization and a decrease in reperfusion rates reduces the likelihood of patients achieving functional independence. We propose a standardized setup technique for aspiration-first for all anterior circulation thrombectomy procedures for increasing speed and recanalization rates., Materials and Methods: We analyzed 127 consecutive patients treated by a standardized approach to thrombectomy with an intention to perform aspiration-first compared with 127 consecutive patients treated with a stent retriever-first approach. Key time metrics evaluated included groin to first angiogram, first angiogram to reperfusion, groin to first reperfusion, and length of the procedure. The degree of successful recanalization (TICI 2b-3) and the number of passes were compared between the 2 groups., Results: In 127 patients who underwent the standardized technique, the median time from groin puncture to first reperfusion was 18 minutes compared with 26 minutes ( P < .001). The duration of the procedure was shorter compared with the stent retriever group (26 minutes in the aspiration first group versus 47 minutes, P < .001) and required fewer passes (mean, 2.4 versus 3.1; P < .05). A higher proportion of patients had a TICI score of 2b-3 in the aspiration-first group compared with stent retriever group (96.1% versus 85.8%, P < .005)., Conclusions: Our study highlights the increasing speed and recanalization rates achieved with fewer passes in a standardized approach to thrombectomy with an intention to attempt aspiration-first. Any attempt to reduce revascularization time and increase successful recanalization should be used., (© 2019 by American Journal of Neuroradiology.)

Background: Mechanical thrombectomy (MT) has become the cornerstone of acute ischemic stroke management in patients with large vessel occlusion (LVO). The aim of this guideline document is to assist physicians in their clinical decisions with regard to MT., Methods: These guidelines were developed based on the standard operating procedure of the European Stroke Organisation, and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. An interdisciplinary working group identified 15 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach., Results: We found high quality evidence to recommend MT plus best medical management (BMM, including intravenous thrombolysis whenever indicated) to improve functional outcome in patients with LVO related acute ischemic stroke within 6 hours after symptom onset. We found moderate quality of evidence to recommend MT plus BMM in the 6-24 hour time window in patients meeting the eligibility criteria of published randomized trials. These guidelines further detail aspects of prehospital management, patient selection based on clinical and imaging characteristics, and treatment modalities., Conclusions: MT is the standard of care in patients with LVO related acute stroke. Appropriate patient selection and timely reperfusion are crucial. Further randomized trials are needed to inform clinical decision making with regard to the mothership and drip-and-ship approaches, anesthaesia modalities during MT, and to determine whether MT is beneficial in patients with low stroke severity or large infarct volume., Competing Interests: Competing interests: Intellectual and financial disclosures of working group members are presented in Supplemental table I, (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Purpose- Preinterventional reperfusion before endovascular treatment (ET) is a benefit of bridging with intravenous tPA (tissue-type plasminogen activator). However, detailed data on reperfusion quality and rates of obviating ET in a cohort of patients with immediate access to ET is lacking. Purpose of this analysis was to evaluate prevalence and quality of preinterventional reperfusion in mothership patients. Methods- All mothership patients (n=627) from a prospective registry subjected to angiography with an intention to perform ET were reviewed. Preinterventional change of occlusion site (COS) was categorized into COS with Thrombolysis in Cerebral Infarction (TICI) 0/1, COS with TICI ≥2a, COS with TICI ≥2b, and COS with perfusion worsening. Predictors and clinical relevance were evaluated using multivariable logistic regression and results are displayed as adjusted odds ratios (aOR) and corresponding 95% confidence intervals (95% CI). Results- Prevalence of COS in all patients was 10.7% (95% CI, 8.3%-13.1%), subdividing into 2.7% COS with TICI 0/1, 6.2% COS with ≥TICI 2a (including 2.9% with TICI ≥2b), and 1.8% COS with perfusion worsening. Factors related to COS with ≥TICI 2a were intravenous tPA (aOR, 11.98; 95% CI, 4.5-31.6), cardiogenic thrombus origin (aOR, 2.3; 95% CI, 1.1-4.6), and thrombus length (aOR per 1 mm increase 0.926; 95% CI, 0.87-0.99). Additional ET was performed despite COS with ≥TICI 2a in 51.3%. COS with ≥TICI 2a showed a tendency for favorable outcomes (modified Rankin Scale, ≤2; aOR, 2.65; 95% CI, 0.98-7.17). Rates of COS with ≥TICI 2a were particularly low in internal carotid artery and proximal M1 occlusions (2.2%; 95% CI, 0.9%-5%), where intravenous tPA was associated with perfusion worsening (aOR, 4.33; 95% CI, 1.12-16.80). Conclusions- Prevalence of preinterventional reperfusion is non-negligible in patients with direct access to ET and is clearly favored by intravenous tPA treatment. However, it is often incomplete and often requires additional ET. Preinterventional reperfusion of internal carotid artery and proximal M1 occlusions is rare and usually of low quality, where intravenous tPA may also promote perfusion worsening.

Purpose of Review: Recent randomized clinical trials (RCTs) have demonstrated strong efficacy of endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) from large vessel occlusions (LVO). SIESTA, AnSTROKE, GOLIATH showed no deleterious effects of general anesthesia on patient outcome after EVT compared with conscious sedation. DAWN and DEFUSE 3 are extending the time window for EVT up to 24 h in carefully selected patients. This review discusses the current literature on the rapidly expanding subject of endovascular stroke therapy and optimal anesthetic management., Recent Findings: Recent retrospective studies of RCT data sets show that general anesthesia is associated with negative clinical outcome in AIS patients undergoing EVT when compared with sedation. Two of the possible mechanisms of this finding are systolic hypotension and hypocapnia. SIESTA, AnSTROKE, GOLIATH showed no difference in short-term clinical outcome between EVT patients treated with general anesthesia versus conscious sedation. DAWN and DEFUSE 3 demonstrated improved functional outcomes after EVT in those treated up to 24 h after selection with perfusion imaging, increasing the number of patients eligible for EVT., Summary: Effective reperfusion with stent retriever technology, careful patient selection using perfusion imaging, and careful use of anesthetic technique affect outcome.

Acute ischemic stroke is a major cause of mortality and morbidity in the United States and worldwide. Despite the development of specialized stroke centers, mortality and morbidity as a result of acute ischemic strokes can and do happen anywhere. These strokes are emergency situations requiring immediate intervention. This article covers the fundamentals of care involved in treating patients with acute ischemic stroke, including essentials for the initial evaluation, basic neuroimaging, reperfusion therapies, critical care management, and palliative care, as well as current controversies. National guidelines and current research are presented, along with recommendations for implementation., (©2018 American Association of Critical-Care Nurses.)

Current guidelines recommend that patients with non-ST elevation myocardial infarction (NSTEMI) are treated with medical management alone, or in combination with coronary angiography within 24 h. Recent research suggests that NSTEMIs show angiographic evidence of complete occlusion at rates comparable to STEMIs, suggesting a subgroup of NSTEMI patients who require urgent angiography. Novel ECG changes, termed 'STEMI-equivalents', have been described as a way of identifying this subgroup. The aim of this study was to determine whether patients with STEMI-equivalent ECG changes experience similar degrees of myocardial damage, and would thus benefit from urgent PCI. Cardiac catheterisation databases at The Wollongong Hospital were searched for STEMI, and NSTEMI patients with complete occlusion of the culprit vessel, between January 2011 and December 2013. A total of 1429 patients underwent angiography during this time period. Of these, 220 were eligible for ECG analysis. We found 10-25% of NSTEMIs with 'STEMI equivalent' ECG changes correlated with complete vessel occlusion on angiography. These patients demonstrated equivalent initial troponin readings. Recognition of STEMI-equivalents represent a chance for earlier intervention with prompt coronary angiography, as these findings are often associated with complete occlusion of the culprit vessel. These findings provide further evidence supporting the potential inclusion of STEMI-equivalents in future ACS guidelines.

Background: In acute stroke due to large vessel occlusion, faster reperfusion leads to better outcomes. We analyzed the effect of optimization steps aimed to reduce treatment delays at our center., Methods: Consecutive patients with ischemic stroke treated with endovascular therapy were prospectively analyzed. We divided the patients into pre-optimization (20 April 2012 to 8 October 2013) and post-optimization (9 October 2013 to 29 July 2014) periods. The main interventions included: (1) continuous feedback; (2) standardized immediate emergency department attending to stroke attending communication with interventional team activation for all potential interventions; (3) pre-notification by the emergency medical service; (4) minimizing additional diagnostic testing; (5) direct transport to the CT scanner; (6) transport directly from the CT scanner to the angiography suite. The main metric used to measure improvement was door to groin puncture time (D2P)., Results: We included a total of 286 patients (178 pre-optimization, 108 post-optimization). There were no significant differences between major baseline characteristics between the groups with the exception of higher median CT Alberta Stroke Program Early CT Score in the pre-optimization group (p=0.01). Median D2P improved from 105 min pre-optimization to 67 min post-optimization (p=0.0002). Rates of good clinical outcomes (modified Rankin Scale 0-2 at 3 months) were similar in both groups, with a trend toward a better outcome in the post-optimization group in a subgroup analysis of patients with anterior circulation occlusion who received intravenous tissue plasminogen activator., Conclusions: This pilot study demonstrates that D2P times can be significantly reduced with a standardized multidisciplinary approach. There was no significant difference in the rate of 3-month good outcome, which is most likely due to the small sample size and confounding baseline patient characteristics., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objective: To summarize the current literature regarding the initial hospital management of patients with acute ischemic stroke (AIS) secondary to emergent large vessel occlusion (ELVO), and to offer recommendations designed to decrease the time to endovascular treatment (EVT) for appropriately selected patients with stroke., Methods: Using guidelines for evidenced-based medicine proposed by the Stroke Council of the American Heart Association, a critical review of all available medical literature supporting best initial medical management of patients with AIS secondary to ELVO was performed. The purpose was to identify processes of care that most expeditiously determine the eligibility of a patient with an acute stroke for interventions including intravenous fibrinolysis with recombinant tissue plasminogen activator (IV tPA) and EVT using mechanical embolectomy., Results: This review identifies four elements that are required to achieve timely revascularization in ELVO. (1) In addition to non-contrast CT (NCCT) brain scan, CT angiography should be performed in all patients who meet an institutional threshold for clinical stroke severity. The use of any advanced imaging beyond NCCT should not delay the administration of IV tPA in eligible patients. (2) Activation of the neurointerventional team should occur as soon as possible, based on either confirmation of large vessel occlusion or a prespecified clinical severity threshold. (3) Additional imaging techniques, particularly those intended to physiologically select patients for EVT (CT perfusion and diffusion-perfusion mismatch imaging), may provide additional value, but should not delay EVT. (4) Routine use of general anesthesia during EVT procedures, should be avoided if possible. These workflow recommendations apply to both primary and comprehensive stroke centers and should be tailored to meet the needs of individual institutions., Conclusions: Patients with ELVO are at risk for severe neurologic morbidity and mortality. To achieve the best possible clinical outcomes stroke centers must optimize their triage strategies. Strategies that provide patients with ELVO with the fastest access to reperfusion depend upon detail-oriented process improvement., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: In Central Europe, cold-induced injuries are much less common than burns. In a burn center in western Germany, the mean ratio of these two types of injury over the past 10 years was 1 to 35. Because cold-induced injuries are so rare, physicians often do not know how to deal with them., Methods: This article is based on a review of publications (up to December 2014) retrieved by a selective search in PubMed using the terms "freezing," "frostbite injury," "non-freezing cold injury," and "frostbite review," as well as on the authors' clinical experience., Results: Freezing and cold-induced trauma are part of the treatment spectrum in burn centers. The treatment of cold-induced injuries is not standardized and is based largely on case reports and observations of use. distinction is drawn between non-freezing injuries, in which there is a slow temperature drop in tissue without freezing, and freezing injuries in which ice crystals form in tissue. In all cases of cold-induced injury, the patient should be slowly warmed to 22°-27°C to prevent reperfusion injury. Freezing injuries are treated with warming of the body's core temperature and with the bathing of the affected body parts in warm water with added antiseptic agents. Any large or open vesicles that are already apparent should be debrided. To inhibit prostaglandin-mediated thrombosis, ibuprofen is given (12 mg/kg body weight b.i.d.)., Conclusion: The treatment of cold-induced injuries is based on their type, severity, and timing. The recommendations above are grade C recommendations. The current approach to reperfusion has yielded promising initial results and should be further investigated in prospective studies.

Objective: To evaluate whether time to treatment modifies the effect of endovascular reperfusion in stroke patients with evidence of salvageable tissue on MRI., Methods: Patients from the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 2 (DEFUSE 2) cohort study with a perfusion-diffusion target mismatch were included. Reperfusion was defined as a decrease in the perfusion lesion volume of at least 50% between baseline and early follow-up. Good functional outcome was defined as a modified Rankin Scale score ≤2 at day 90. Lesion growth was defined as the difference between the baseline and the early follow-up diffusion-weighted imaging lesion volumes., Results: Among 78 patients with the target mismatch profile (mean age 66 ± 16 years, 54% women), reperfusion was associated with increased odds of good functional outcome (adjusted odds ratio 3.7, 95% confidence interval 1.2-12, p = 0.03) and attenuation of lesion growth (p = 0.02). Time to treatment did not modify these effects (p value for the time × reperfusion interaction is 0.6 for good functional outcome and 0.3 for lesion growth). Similarly, in the subgroup of patients with reperfusion (n = 46), time to treatment was not associated with good functional outcome (p = 0.2)., Conclusion: The association between endovascular reperfusion and improved functional and radiologic outcomes is not time-dependent in patients with a perfusion-diffusion mismatch. Proof that patients with mismatch benefit from endovascular therapy in the late time window should come from a randomized placebo-controlled trial., (© 2015 American Academy of Neurology.)

Background: Patients who have successful reperfusion following endovascular therapy for acute ischemic stroke have improved clinical outcomes. We sought to determine if the chance of successful reperfusion differs among hospitals, and if hospital site is an independent predictor of reperfusion., Methods: Nine hospitals recruited patients in the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution Study 2 (DEFUSE 2), a prospective cohort study of endovascular stroke treatment conducted between 2008 and 2011. Patients were included for analysis if they had a baseline Thrombolysis in Cerebral Infarction (TICI) score of 0 or 1. Successful reperfusion was defined as a TICI reperfusion score of 2b or 3 at completion of the procedure. Collaterals were assessed using the Collateral Flow Grading System and were dichotomized as poor (0-2) or good (3-4). The association between hospital site and successful reperfusion was first assessed in an unadjusted analysis and subsequently in a multivariate analysis that adjusted for predictors of successful reperfusion., Results: 36 of 89 patients (40%) achieved successful reperfusion. The rate of reperfusion varied from 0% to 77% among hospitals in the univariate analysis (χ(2) p<0.001) but hospital site did not remain as an independent predictor of reperfusion in multivariate analysis (p=0.81) after adjustment for the presence of good collaterals (p<0.01) and use of the Merci retriever (p<0.05)., Conclusions: Reperfusion rates vary among hospitals, which may be related to differences in treatment protocols and patient characteristics. Additional studies are needed to identify all of the factors that underlie this variability as this could lead to strategies that reduce interhospital variability in reperfusion rates and improve clinical outcomes., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: We explore the impact of discharge disposition (independent rehabilitation facility (IRF) vs skilled nursing facility (SNF)) on 90 day outcomes in persons with stroke who received acute endovascular treatment., Methods: Using a database from a single primary care stroke center, discharge disposition, National Institutes of Health Stroke Scale (NIHSS), Totaled Health Risks in Vascular Events (THRIVE), Houston Intra-Arterial Therapy 2 (HIAT-2), and Acute Physiology and Chronic Health Evaluation (APACHE II) scores, and successful reperfusion were obtained. Univariate analysis was performed to assess predictors of good clinical outcome, as defined by 90 day modified Rankin Scale (mRS) scores ≤2. A binary logistic regression model was used to determine the impact of placement to an IRF versus an SNF on clinical outcomes., Results: 147 subjects were included in the analysis with a mean age of 63±14 years and median NIHSS of 18 (IQR 14-21). Final infarct volumes, and modified APACHE II, THRIVE, and HIAT-2 scores were similar between those discharged to an IRF and those discharged to an SNF.However, their 90 day outcomes were significantly different, with far fewer patients at SNFs achieving good clinical outcomes (25% vs 46%; p=0.023). Disposition to SNF was significantly associated with a lower probability of achieving an mRS score of 0-2 at 90 days (OR = 0.337 (95% CI 0.12 to 0.94); p<0.04)., Conclusions: Subjects discharged to SNFs and IRFs after thrombectomy have similar medical and neurological severity at admission and similar final infarct volumes at discharge. Despite these similarities, patients discharged to an SNF had a significantly lower probability of achieving a good neurological outcome. These results have implications for future acute stroke trial design., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background and Purpose: Recanalization status after intravenous thrombolysis (IVT) in patients with ischemic stroke is a reference point to proceed with a rescue reperfusion intervention, although early neurological improvement (NI) may preclude endovascular procedures. We aimed to evaluate the importance of restoration of blood flow at the arterial occlusion site in subgroups of patients with stroke stratified by early NI after IVT., Methods: The following patients were recruited from the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Register: (1) with baseline vessel occlusion documented by computed tomographic (CT) or magnetic resonance (MR) angiography and follow-up angioimaging between 22 and 36 hours after IVT available; and (2) with dense cerebral artery sign on admission CT scan and results of follow-up CT reported. Recanalization at 24 hours was defined as absence of vessel occlusion or as resolution of dense cerebral artery sign on follow-up 22- to 36-hour imaging. NI was assessed at 2 hours and 24 hours after IVT and was defined as improvement by 20% from baseline National Institute of Health Stroke scale score. Primary outcome measure was independence, defined as modified Rankin scale score 0 to 2 after 3 months., Results: Of 28136 cases registered between December 2003 and November 2009, 5324 cases (19%) met the inclusion criteria. Patients with both NI at 2 hours post-treatment and vessel recanalization had the best chances to achieve independence at 3 months (adjusted odds ratio, 15.8; 95% confidence interval, 12.5-20.0), followed by those who had NI despite persistent occlusion (adjusted odds ratio, 4.7; 95% confidence interval, 3.6-6.1); and those without NI despite recanalization (adjusted odds ratio, 2.7; 95% confidence interval, 2.2-3.3)., Conclusions: Recanalization of an occluded artery in acute stroke is associated with favorable functional outcome both in patients with and without NI after IVT. In future evaluations of mechanical thrombectomy and other additional strategies, recanalization should be considered in patients with persisting occlusion after IVT even after significant NI.

Background and Purpose: Technological advances have helped to improve the efficiency of treating patients with large vessel occlusion in acute ischemic stroke. Unfortunately, the sequence of events prior to reperfusion may lead to significant treatment delays. This study sought to determine if high-volume (HV) centers were efficient at delivery of endovascular treatment approaches., Methods: A retrospective review was performed of nine centers to assess a series of time points from obtaining a CT scan to the end of the endovascular procedure. Demographic, radiographic and angiographic variables were assessed by multivariate analysis to determine if HV centers were more efficient at delivery of care., Results: A total of 442 consecutive patients of mean age 66 ± 14 years and median NIH Stroke Scale score of 18 were studied. HV centers were more likely to treat patients after intravenous administration of tissue plasminogen activator and those transferred from outside hospitals. After adjusting for appropriate variables, HV centers had significantly lower times from CT acquisition to groin puncture (OR 0.991, 95% CI 0.989 to 0.997, p=0.001) and total procedure times (OR 0.991, 95% CI 0.986 to 0.996, p=0.001). Additionally, patients treated at HV centers were more likely to have a good clinical outcome (OR 1.86, 95% CI 1.11 to 3.10, p<0.018) and successful reperfusion (OR 1.82, 95% CI 1.16 to 2.86, p<0.008)., Conclusions: Significant delays occur in treating patients with endovascular therapy in acute ischemic stroke, offering opportunities for improvements in systems of care. Ongoing prospective clinical trials can help to assess if HV centers are achieving better clinical outcomes and higher reperfusion rates.

Background and Purpose: Recent studies have demonstrated that in acute ischemic stroke patients, thin section non-contrast CT (NCCT) can be used to determine the length of the hyperdense intracranial thrombus, and that clot length using this approach predicts the likelihood of vessel recanalization after intravenous tissue plasminogen activator., Summary of Case: An acute ischemic stroke patient presented with a left middle cerebral artery occlusion and underwent emergent catheter based therapy. Clot length was determined using pretreatment thin section NCCT and was independently confirmed by the pathologist after whole clot extraction., Conclusions: The concordance between the NCCT measured clot length and the pathological examination in this case provides additional support for the accuracy of using thin section NCCT data to determine clot length in all patients.

Importance: Studies comparing the efficacy of intra-arterial therapy (IAT) and medical therapy in reducing final infarct volume (FIV) in intracranial large-vessel occlusions (ILVOs) are lacking., Objectives: To assess whether patients with ILVOs who received IAT have smaller FIVs than patients who received either intravenous tissue plasminogen activator therapy (IVT) or no reperfusion therapy (NRT) and to determine a National Institutes of Health Stroke Scale (NIHSS) threshold score that identifies patients most likely to benefit from IAT., Design: Retrospective cohort study of patients with ILVOs between 2009 and 2011., Setting: Two large-volume stroke centers., Participants: Adults with anterior circulation ILVOs who presented within 360 minutes from the time last seen as normal. Patients with isolated extracranial occlusions were not included., Exposure: Intra-arterial therapy, IVT, or NRT., Main Outcomes and Measures: Final infarct volumes, rates of acceptable outcome defined as a modified Rankin Scale score of 0 to 3 at hospital discharge, and NIHSS threshold scores., Results: A total of 203 consecutive patients with ILVOs were evaluated. Baseline characteristics were similar among the 3 groups. The median infarct volume was significantly smaller for the IAT group (42 cm3) than for the IVT group (109 cm3; P = .001) or the NRT group (110 cm3; P < .01). A higher magnitude of infarct volume reduction in more proximal occlusions was noted in the IAT group compared with the IVT and NRT groups combined: internal carotid artery terminus (75 vs 190 cm3; P < .001), M1 middle cerebral artery (39 vs 109 cm3; P = .004), and M2 middle cerebral artery (33 vs 59 cm3; P = .04) occlusions. Patients were stratified based on NIHSS score at presentation (8-13, 14-19, and ≥20). For patients with an NIHSS score of 14 or higher at presentation, IAT significantly reduced FIV (46 cm3 with IAT vs 149 cm3 with IVT or NRT; P < .001) compared with patients with an NIHSS score of 8 to 13 (22 cm3 with IAT vs 44 cm3 with IVT or NRT; P = .40). Patients with an NIHSS score of 14 or higher who received IAT appear to benefit most from IAT., Conclusions and Relevance: Our data suggest a greater reduction of FIV with IAT compared with either IVT or NRT. Moreover, patients with an NIHSS score of 14 or higher may be the best candidates for endovascular reperfusion therapy.

Purpose: Advanced neuroimaging techniques may improve patient selection for endovascular stroke treatment but may also delay time to reperfusion. We studied the effect of advanced modality imaging with CT perfusion (CTP) or MRI compared with non-contrast CT (NCT) in a multicenter cohort., Materials and Methods: This is a retrospective study of 10 stroke centers who select patients for endovascular treatment using institutional protocols. Approval was obtained from each institution's review board as only de-identified information was used. We collected demographic and radiographic data, selected time intervals, and outcome data. ANOVA was used to compare the groups (NCT vs CTP vs MRI). Binary logistic regression analysis was performed to determine factors associated with a good clinical outcome., Results: 556 patients were analyzed. Mean age was 66 ± 15 years and median National Institutes of Health Stroke Scale score was 18 (IQR 14-22). NCT was used in 286 (51%) patients, CTP in 190 (34%) patients, and MRI in 80 (14%) patients. NCT patients had significantly lower median times to groin puncture (61 min, IQR (40-117)) compared with CTP (114 min, IQR (81-152)) or MRI (124 min, IQR (87-165)). There were no differences in clinical outcomes, hemorrhage rates, or final infarct volumes among the groups., Conclusions: The current retrospective study shows that multimodal imaging may be associated with delays in treatment without reducing hemorrhage rates or improving clinical outcomes. This exploratory analysis suggests that prospective randomised studies are warranted to support the hypothesis that advanced modality imaging is superior to NCT in improving clinical outcomes.

Background and Purpose: Revascularization of acute ischemic stroke from a large vessel occlusion continues to be a challenge with current thrombectomy devices. The purpose of the SPEED study was to report the safety and effectiveness of the Penumbra 054 Reperfusion Catheter System in revascularizing large vessel occlusions., Methods: In this retrospective multicenter study, data were collected from patients with angiographic evidence of large vessel occlusion treated with the Penumbra 054 device as the intended primary therapy. Clinical outcome data were collected with 90-day follow-up and the results were compared with those from the Penumbra Pivotal trial., Results: Eighty-seven target vessels in 86 consecutive patients treated with the Penumbra 054 device were included. The Thrombolysis In Myocardial Infarction (TIMI) 2 or 3 revascularization rate was 91% compared with a reported 82% in the Penumbra Pivotal trial. This was accomplished in a median time of 20 min compared with 45 min in the Penumbra Pivotal trial (p<0.0001). Eighteen (21%) patients experienced an intracranial hemorrhage of which 12 (14%) were symptomatic. Good neurologic outcome (modified Rankin scores ≤ 2) at 90-day follow-up was achieved in 34.9% of patients compared with 25% reported in the Penumbra Pivotal trial. All-cause mortality was 25.6%., Conclusions: These results suggest that the Penumbra 054 is a fast, safe and effective revascularization tool for patients experiencing ischemic stroke secondary to large vessel occlusive disease. Improvements in speed and effectiveness of revascularization probably contributed to improved outcomes.

Background and Purpose: We sought to evaluate the diagnostic accuracy of ultrasound criteria for recanalization during real-time transcranial Doppler monitoring of intra-arterial reperfusion procedures in acute ischemic stroke patients in an international, multicenter study., Methods: Consecutive acute ischemic stroke patients with proximal intracranial occlusions underwent intra-arterial reperfusion procedures with simultaneous real-time transcranial Doppler monitoring at 3 tertiary-care stroke centers. Residual flow signals at the site of angiographically confirmed occlusions were monitored at a constant transtemporal insonation angle using a standard head-frame. Recanalization was assessed simultaneously by digital subtraction angiography and ultrasound using thrombolysis in myocardial infarction and thrombolysis in brain ischemia (TIBI) criteria, respectively. Independent readers blinded to digital subtraction angiography performed validation of TIBI flow grades. The interrater reliability for assessment of TIBI grades was investigated., Results: We evaluated time-linked real-time digital subtraction angiography transcranial Doppler images from 96 diagnostic digital subtraction angiography runs during intra-arterial reperfusion procedures in 62 acute ischemic stroke patients (mean age, 59 ± 17 years; 58% men; median baseline National Institutes of Health Stroke Scale score, 18 [interquartile range 12-21]; median time from symptom onset to intra-arterial procedure initiation, 240 minutes [interquartile range 163-308]). The interrater reliability for evaluation of TIBI grades and assessment of recanalization was good (Cohen κ: 0.838 and 0.874, respectively; P<0.001). Compared with angiography, transcranial Doppler had the following accuracy parameters for detection of complete recanalization (TIBI 4 and 5 versus thrombolysis in myocardial infarction 3, flow grades): sensitivity, 88% (95% confidence interval, 72%-96%); specificity, 89% (79%-95%); positive predictive value, 81% (65%-91%); negative predictive value, 93% (84%-98%); and overall accuracy 89% (80%-94%)., Conclusions: At laboratories with high-interrater reliability, TIBI criteria can accurately predict brain recanalization in real time as compared with thrombolysis in myocardial infarction angiographic scores.

Objective: To investigate whether postischemic administration of minocycline attenuates hind-limb motor dysfunction and gray and white matter injuries after spinal cord ischemia., Design: A prospective, randomized, laboratory investigation., Setting: Laboratory in university, single institution., Participants: Male New Zealand White rabbits., Intervention: Spinal cord ischemia was induced by an occlusion of the infrarenal aorta for 15 minutes. The groups were administered minocycline 1 hour after reperfusion (M-1; n = 8), minocycline 3 hours after reperfusion (M-3; n = 8), saline 1 hour after reperfusion (control [C]; n = 8), or saline and no occlusion (sham; n = 4). Minocycline was administered intravenously at 10 mg/kg 6 times at 12-hour intervals until 60 hours after the initial administration., Measurement and Main Results: Hind-limb motor function was assessed using the Tarlov score. For histologic assessments, gray and white matter injuries were evaluated 72 hours after reperfusion using the number of normal neurons and the percentage of areas of vacuolation, respectively. Motor function 72 hours after reperfusion was significantly better in group M-1 than in group C. The number of neurons in the anterior horn was significantly larger in group M-1 than in groups M-3 or C but did not differ significantly between groups M-3 and C. No significant difference was noted in the percentage of areas of vacuolation among the ischemia groups., Conclusions: Minocycline administration beginning at 1 hour after reperfusion improved hind-limb motor dysfunction and attenuated gray matter injury in a rabbit spinal cord ischemia model., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: To demonstrate the value of a Reentry-Catheter for true lumen access after subintimal revascularization of chronic iliac artery occlusions., Materials and Methods: Subintimal revascularization was performed in 5 patients (mean age: 67 ± 12 years; female: 3, male: 2) with total iliac artery occlusion (TASC B to D), but without gaining access to the true lumen distal to the occlusion. Subsequently, a Reentry-Catheter was used to establish reentry and a new subintimal tract. Patients were followed up after 6, 12 and 24 months for clinical re-evaluation to determine the Rutherford score and the ankle brachial index (ABI). In addition, duplex ultrasound was performed to evaluate vessel patency., Results: The primary technical success rate was 100 %. In all cases angioplasty was followed by stent placement to establish the subintimal tract. The mean Rutherford score decreased from 3.6 ± 0.9 to 0.33 ± 0.57 after 24 months, while the ABI increased from 0.67 ± 0.06 to 1.2 ± 0. Vessel patency was observed in all patients available for follow-up examinations., Conclusion: The Reentry-Catheter reliably allowed access to the true lumen after subintimal revascularization of occluded iliac arteries. Results in this small patient cohort showed a significant reduction in the Rutherford score, increase in the ABI, and a good patency rate after two years., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aortic surgery frequently extends the boundaries of perfusion knowledge learned from non aortic cardiac surgery.This is due to the extremes of temperature, prolonged bypass times, hypothermic arrest, and selective organ(s) perfusion. Suboptimal perfusion can potentially affect outcomes even after technically successful aortic surgery. We present the concepts of patient directed bypass with regard to blood pressure, flow-during cardiopulmonary bypass (CPB), oxygen delivery, cooling, and carbon dioxide levels on bypass. Quality of perfusion during aortic surgery is then addressed in the context of Perfusion Standards of Reporting Trials (PERFSORT, www.perfsort.net). PERFSORT analyses these variables during bypass: blood pressure, hematocrit, lactate, glucose, and temperature, all of which are known to affect outcomes. PERFSORT can be applied to individual cases or a series, and although primarily designed for research publications, is equally useful in a purely clinical setting. A new concept from engineering called Lissajous figures is then discussed to potentially retrospectively assess the effects of ischemia during aortic surgery. This may help identify why some patients despite flawless surgery, anesthesia, and perfusion, in the absence of bleeding, stroke, and obvious causes of organ damage at the time of aortic surgery develop multi organ dysfunction.

Background and Purpose: Reperfusion and recanalization have both been used as surrogate markers of clinical outcome in trials of stroke thrombolysis. We aimed to prove that the beneficial impact of recanalization with intravenous tissue plasminogen activator on clinical outcomes is attributable to reperfusion in the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET)., Methods: EPITHET was a prospective, randomized, placebo-controlled trial of intravenous tissue plasminogen activator in the 3- to 6-hour window. Reperfusion was defined as >90% reduction in magnetic resonance perfusion-weighted imaging lesion volume and recanalization as improvement of MR angiographic Thrombolysis In Myocardial Infarction grading by > or =2 points from baseline to Day 3 to 5., Results: At Day 3 to 5, reperfusion and recanalization with intravenous tissue plasminogen activator were strongly correlated. Reperfusion was associated with improved clinical outcome independent of whether recanalization occurred. In contrast, recanalization was not associated with clinical outcome when reperfusion was included as a covariate in regression analyses., Conclusions: Reperfusion is a surrogate marker of clinical outcomes independent of recanalization based on the criteria applied in EPITHET. The impact of recanalization on clinical outcomes was attributable to reperfusion.

Background and Purpose: Endovascular therapies using mechanical and pharmacological modalities for large vessel occlusions in acute stroke are rapidly evolving. Our aim was to determine whether one modality is associated with higher recanalization rates., Methods: We retrospectively reviewed 168 consecutive patients treated with intra-arterial (IA) therapy for acute ischemic stroke between May 1999 and November 15, 2005. Demographic, clinical, radiographic, angiographic, and procedural notes were reviewed. Recanalization was defined as achieving thrombolysis in myocardial infarction 2 or 3 flow after intervention. A logistic regression model was constructed to determine independent predictors of successful recanalization., Results: A total of 168 patients were reviewed with a mean age of 64+/-13 years and mean National Institutes of Health Stroke Scale score of 17+/-4. Recanalization was achieved in 106 (63%) patients. Independent predictors of recanalization include: the combination of IA thrombolytics and glycoprotein IIb/IIIa inhibitors (odds ratio [OR], 2.9 [95% CI, 1.04 to 6.7]; P<0.048), intracranial stent placement with angioplasty (OR, 4.8 [95% CI, 1.8 to 10.0]; P<0.001), or extracranial stent placement with angioplasty (OR, 4.2 [95% CI, 1.4 to 9.8]; P<0.014). Lesions at the terminus of the internal carotid artery were recalcitrant to revascularization (OR, 0.34 [95% CI, 0.16 to 0.73]; P value 0.006)., Conclusions: Intracranial or extracranial stenting or combination therapy with IA thrombolytics and glycoprotein IIb/IIIa inhibitors in the setting of multimodal therapy is associated with successful recanalization in patients treated with multimodal endovascular reperfusion therapy for acute ischemic stroke.

Loco-regional thrombolysis for deep-vein thrombosis (DVT) has been claimed to be equally effective and safe compared with systemic thrombolysis. It is not known whether a loco-regional thrombolytic effect exists and of what it might consist. To investigate this issue, we studied eight patients with DVT undergoing loco-regional thrombolysis with 20 mg alteplase infused over 4 h in a dorsal foot-vein of the affected leg, while the leg was kept tightly bandaged; alteplase infusions were repeated every 24 h, the number of therapy cycles (TC) was seven, and full-dose heparin was given. For coagulation analyses, 'loco-regional' blood samples were taken from a vein of the affected leg and 'systemic' samples were taken from an antecubital vein. After a median number of six TC, good partial reperfusion was achieved in 4/8 patients, moderate partial reperfusion in 2/8, major bleedings occurred in 2/8, and minor bleedings in 1/8 patients. During the first TC, recombinant tissue-type plasminogen activator (rtPA) activity and antigen, as well as FgDPs and d-dimers, were elevated significantly loco-regionally over systemic values, and a complete breakdown of plasmin-inhibitor activity occurred with only a slight systemic reduction; no other differences were found. During successive TC, differences in rtPA-activity and -antigen levels decreased, and no significant differences were found for all other parameters. Thus, a local fibrinolytic effect was demonstrable during loco-regional thrombolysis for DVT; the magnitude of this effect diminished during successive TC, giving rise to the hypothesis that the fibrinolytic efficacy may be decreased due to growing, antifibrinolytic activity. The preserved, loco-regional plasmin-inhibitor activities during the later TC, in contrast to the complete breakdown during the first TC, suggest that part of the enhanced antifibrinolytic activity is due to loco-regionally increased plasmin-inhibitor activity. The ultimate goal of loco-regional thrombolysis, the induction of local fibrinolysis without systemic effects, has not, however, been achieved.

Moderate alcohol consumption (MAC) and platelet inhibition have been independently associated with a reduced risk for the development of acute myocardial infarction (AMI). The effects of MAC on the initial platelet status in patients presenting with AMI are not elucidated. Here we sought to define the effects of MAC on platelet characteristics in AMI patients before applying any reperfusion strategies. The study was designed as an analysis within the cohort study in 23 patients with AMI enrolled in the GUSTO-III. Platelets were investigated by different techniques, including aggregometry, flow cytometry, and ELISA. MAC patients exhibited mild, but consistent, inhibition of platelet aggregability, surface receptor expression, and released substances as compared to non-alcohol consuming patients. These differences were significant for 5 microM ADP (p = 0.04), 10 microM ADP-induced aggregation (p = 0.02); P-selectin (p = 0.01), and PECAM-1 (p = 0.02) platelet-bound expression. Our study confirms that moderate alcohol consumption is associated with diminished platelet activation in patients presenting with AMI. The ability of MAC to favorably modulate the pre-reperfusion platelet status in such patients is of clinical importance, and further investigation in large-scale clinical trials seem warranted.

Achieving early reperfusion with thrombolytic agents or primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI) is the cornerstone of current therapy. Two advances in pharmacologic therapy are: (1) bolus thrombolysis, which simplifies therapy, reduces door-to-needle time, and reduces the potential for medication errors, and (2) Low-dose fibrinolytic therapy combined with a glycoprotein (GP) IIb/IIIa inhibitor which can achieve higher rates of reperfusion than fibrinolytic therapy alone. In addition, the IIb/IIIa inhibitor as part of the reperfusion regimen will support any acute-phase interventions that are performed. The combination of fibrinolytic therapy and GP IIb/IIIa inhibition to "facilitate" PCI is being examined in TIMI-14, SPEED, and GUSTO IV. Early findings in the SPEED trial have shown promising results with "facilitated" PCI when patency is achieved before PCI is attempted. Results of these trials will further define the role of combination therapy in facilitating mechanical interventions.

Objective: Brain reanimation after prolonged ischemia is limited by post-ischemic reperfusion deficits (no-reflow phenomenon). The present study was undertaken to establish whether after 30 min cardiac arrest extracorporeal circulation is able to restore brain reperfusion and to promote functional and metabolic recovery., Design: Adult normothermic cats were submitted to 30 min cardiac arrest by KCl-induced cardioplegia. Resuscitation was carried out by extracorporeal circulation (ECC) until spontaneous heart function returned. The quality of brain recovery was assessed 3 h later by electrophysiological recording and by imaging of the regional distribution of brain energy metabolites., Results: In 6 of 10 cats cardiac sinus rhythm returned after 32 +/- 15 min. In the other 4 cats cardiac function did not return or only intermittently returned during the 3 h observation period. Cerebral blood flow measured by laser Doppler flowmetry returned to 102% +/- 40% of control immediately after the beginning of resuscitation but then gradually declined to 43% +/- 32% after 3 h despite normotensive perfusion. In all cats pupils started to constrict within less than 5 min of recirculation but in 2 animals they secondarily dilated 1.5 and 2 h later, respectively. Spontaneous EEG activity reappeared in 4 of the 6 successfully resuscitated cats after 111 +/- 40 min but failed to recover in the others. Bioluminescent imaging of ATP after 3 h recirculation revealed near-complete depletion throughout the brain in all 4 cats without cardiac recovery. Of the 6 successfully resuscitated cats 5 exhibited patchy areas of low ATP, glucose and pH in 22%-92% of the cross sectional area of brain; in one cat recovery of energy metabolism and acid-base homoeostasis was homogeneous without any focal deficits. The cross sectional area of ATP recovery correlated directly with CBF and hematocrit and inversely with the plasma lactate level., Conclusions: This study demonstrates for the first time that ECC is able to restore electrophysiological and metabolic brain function after cardiac arrest of as long as 30 min, but recovery is heavily restricted by delayed post-ischemic disturbances of recirculation. Progress in cardiac resuscitation by ECC requires substantial improvement in the efficiency of cerebrovascular reperfusion.

The causes of vascular failures of a series of 183 injured fingers treated by microsurgery (80 reimplantations, 103 revascularisations) were investigated. This consecutive series was characterised by the fact that the operation was performed even in the presence of classical factors of poor prognosis: patients over the age of 40 years (27%), smoking (51%), crush injury or avulsion (32%), ischaemia time longer than 7 hours (46%). The overall intraoperative and postoperative failure rate was 49% (69% in reimplantations and 31% in revascularisations). Preoperative factors (age, smoking, mechanism, ischaemia time) were not sufficiently important to constitute contraindications to vascular microsurgery. Only storage of the segment in contact with iced water made failure almost certain. Suture of 2 arteries and one or several veins (in the absence of a skin bridge) improved the prognosis. The postoperative use of subcutaneous heparin in reimplantations significantly decreased the failure rate from 77% to 55%. Postoperative surveillance is essential to rapidly detect the arterial or venous mechanism responsible for vascular disorders and to decide appropriate emergency treatment. Arterial ischaemia warrants revision of the sutures with a success rate of about one in two. Disturbances of the venous drainage should initially be treated medically (2/3 of preservation after drainage by leeches), but, when this is not effective, surgical revision salvages one third of failures. Emergency microsurgery units must therefore have access to a specialised postoperative surveillance unit.

The authors report their experience in vascular and nervous microsurgery. They remark that there is a long time between the emergency reception of the wounded person and the appeal to plastic surgery. They deplore also the bad collaboration between the different department of emergency surgery. Finally they emphasize that the scarcity of cases is due to insufficient information of different departments of emergency surgery in microsurgery era.

Although it was initially performed in 1935, aortic fenestration has been infrequently employed and reported in recent years. We have continued to use fenestration for descending aortic dissection with complicating organ ischemia (lower-extremity ischemia, renal ischemia, and paraplegia). Our technique involves complete transection of the infrarenal abdominal aorta, removal of a generous intimal flap proximally, and reconstitution of layers distally. We report our experience with 12 patients, all of whom survived the operative procedure. Nine patients were discharged from the hospital, and with a mean follow-up of 6.8 years, 7 are still alive. Fenestration immediately restored organ perfusion in all but 1 of the patients, and no patient died of late rupture. We recommend fenestration for descending aortic dissection in patients presenting with organ ischemia. Fenestration is not recommended for acute dissection with rupture or for chronic enlarging dissection.

Optimal factors for small DC current electrical stimulation for nerve regeneration were studied. These studies are consistent with previous data and values expected for a return of function following Peripheral Nervous System (PNS) damage. This work represents the first detailed investigation of a dose response in the PNS using applied electric fields. As such, using the stimulator design described herein, we have found that a delivery of 1.4 microA DC (about 8mV/cm field strength) to a nerve cuff will result in a more rapid increase of axon numbers in the distal slump with no detectable adverse influence of chronic delivery of current. Since it appears as though the regenerative capacity in the PNS and CNS is related to increased blood flow brought upon by the electric field, then it is important to consider this result in the final analysis of the mechanism of electric field induced nerve regeneration. Studies aimed at describing the mechanisms by which such regeneration occurs are now underway.