Patients with primary posterior fossa catastrophic lesions, who clinically seem to be brain-dead, evolve from retaining to losing supratentorial blood flow. If absent cerebral blood flow is used as an additional criterion for the declaration of death by neurological criteria, these patients are not different than those who become brain death due to supratentorial lesions.

Background. Calcineurin-inhibitor nephrotoxicity plays a role in the pathogenesis of chronic allograft nephropathy by causing renal ischemia mediated by vasoconstrictive metabolites of the prostanoid pathway. The purpose of our study was to evaluate whether altering the prostanoid profile using juniper oil (JO) would afford renoprotection in rats treated with tacrolimus.Methods. Diets supplemented with biologic oils (no supplementation, JO, fish oil [FO], safflower oil [SO], and arachidonic acid [AA]) were fed to five groups of rats for 5 weeks; during the last 2 weeks, tacrolimus was administered to all groups except for a control group of animals. At week 5, urinary prostaglandin (PG)F 2-␣ and inulin clearances were measured. The rat kidneys were harvested to determine the renal cell membrane composition for arachidonic, eicosatrienoic, and eicosapentaenoic acids.Results. Both JO and FO completely reversed the decrease in inulin clearance seen with tacrolimus, the greatest effect being with JO (inulin clearance 15.1؎3 vs. 6.0؎1.1 ml/min in the nonsupplemented group; P<0.001); urinary PGF 2-␣ excretion was also highest in the JO group (328؎23 pg/mL, P<0.001 vs. the nonsupplemented group). Fatty acid membrane analysis showed greatest incorporation of eicosapentaenoic and eicosatrienoic acids in the JO-(5.7؎0.6% and 3.1؎0.4%, respectively) and FO-(8.1؎0.7% and 2.8؎0.6%, respectively) treated animals.Conclusions. JO supplementation in tacrolimustreated rats was associated with incorporation of vasodilatory prostanoids in the renal-cell membrane and elevated urinary PGF 2-␣ excretion, and the precipitous fall in inulin clearance induced by tacrolimus was completely prevented. Whether this benefit will translate into a reduction in chronic allograft nephropathy remains to be determined. However, our preliminary data point towards the need for human trials.

United States (US) and worldwide telestroke programs frequently focus only on emergency room hyper-acute stroke management. This article describes a comprehensive, telemedicine-enabled, stroke care delivery system that combines "drip and ship" and "drip and keep" models with a comprehensive stroke center primary hub at Ochsner Medical Center in New Orleans, advanced stroke-capable regional hubs, and geographically-aligned, "stroke-ready" spokes. The primary hub provides vascular neurology expertise via telemedicine and monitors care for patients remaining at regional hubs and spokes using a multidisciplinary team approach. By 2014, primary hub telestroke consults grew to ≈1000/year with 16 min average door to consult initiation and 20 min to completion, and 29% of ischemic stroke patients received recombinant tissue-type plasminogen activator (rtPA), increasing 275%. Most patients remained in hospitals close to home, but neurointensive care and interventional procedures were common reasons for primary hub transfer. Given the time sensitivity and expert consultation needed for complex acute stroke care delivery paradigms, telestroke programs are effective for fulfilling unmet care needs. Combining drip and ship and drip and keep management allows more patients to stay "local," limiting primary hub transfer unless more advanced services are required. Post admission telestroke management at spokes increases personnel efficiency and can positively impact stroke outcomes.

The management of the acute ischemic stroke patient spans the time course from the emergency evaluation and treatment period through to the eventual discharge planning phase of stroke care. In this article we evaluate the literature and describe what have become standard treatments in the care of the stroke patient. We will review the literature that supports the use of a dedicated stroke unit for routine stroke care which has demonstrated reduced rates of morbidity and mortality. Also reviewed is the use of glycemic control in the initial setting along with data supporting the use of prophylactic treatments options in order to aide in the prevention of life threatening medical complications. In addition, lifesaving treatments will be discussed in light of new literature demonstrating reduced mortality in large hemispheric stroke patients undergoing surgical decompressive surgery. Both medical and surgical treatment options are discussed and compared.