Campbell, B. C.V. et al. (2019) Penumbral imaging and functional outcome in patients with anterior circulation ischaemic stroke treated with endovascular thrombectomy versus medical therapy: a meta-analysis of individual patient-level data.ABSTRACT Background: CT-perfusion (CTP) and MRI may assist patient selection for endovascular thrombectomy. We aimed to establish whether imaging assessments of ischaemic core and penumbra volumes were associated with functional outcomes and treatment effect.

Background and Purpose-We investigated whether computed tomography (CT) perfusion-derived cerebral blood flow (CBF) and cerebral blood volume (CBV) could be used to differentiate between penumbra and infarcted gray matter in a limited, exploratory sample of acute stroke patients. Methods-Thirty patients underwent a noncontrast CT (NCCT), CT angiography (CTA), and CT perfusion (CTP) scan within 7 hours of stroke onset, NCCT and CTA at 24 hours, and NCCT at 5 to 7 days. Twenty-five patients met the criteria for inclusion and were subsequently divided into 2 groups: those with recanalization at 24 hours (nϭ16) and those without (nϭ9). Penumbra was operationally defined as tissue with an admission CBF Ͻ25 mL ⅐ 100 g Ϫ1 ⅐ min

Campbell, B. C. V. et al. (2018) Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data. Lancet Neurology, 17(1), pp. 47-53. (doi:10.1016/S1474-4422(17)30407-6) This is the author's final accepted version.There may be differences between this version and the published version. You are advised to consult the publisher's version if you wish to cite from it.http://eprints.gla.ac.uk/149670/ variables. An alternative approach using propensity-score stratification was also used. To account for between-trial variance we used mixed-effects modeling with a random effect for trial incorporated in all models. Bias was assessed using the Cochrane tool.Findings: Of 1764 patients in 7 trials, 871 were allocated to endovascular thrombectomy. After exclusion of 74 patients (72 who did not undergo the procedure and 2 with missing data on anaesthetic strategy), 236/797 (30%) of endovascular patients were treated under GA. At baseline, GA patients were younger and had shorter time to randomisation but similar pre-treatment clinical severity compared to non-GA. Endovascular thrombectomy improved functional outcome at 3 months versus standard care in both GA (adjusted common odds ratio (cOR) 1·52, 95%CI 1·09-2·11, p=0·014) and non-GA (adjusted cOR 2·33, 95%CI 1·75-3·10, p<0·001) patients. However, outcomes were significantly better for those treated under non-GA versus GA (covariate-adjusted cOR 1·53, 95%CI 1·14-2·04, p=0·004; propensitystratified cOR 1·44 95%CI 1·08-1·92, p=0·012). The risk of bias and variability among studies was assessed to be low.Interpretation: Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons. Funding:The HERMES collaboration was funded by an unrestricted grant from Medtronic to the University of Calgary. Research in contextEvidence before this study between abolition of the thrombectomy treatment effect in MR CLEAN and no effect in THRACE. Three single-centre randomised trials of general anaesthesia versus conscious sedation found either no difference in functional outcome between groups or a slight benefit of general anaesthesia. Added value of this studyThese data from contemporary, high quality randomised trials form the largest study to date of the association between general anesthesia and the benefit of endovascular thrombectomy versus standard care. We used two different approaches to adjust for baseline imbalances (multivariable logistic regression and propensity-score stratification). We found that GA for endovascular thrombectomy, as practiced in contemporary clinical care across a wide range of expert centres during the rand...

The question of which is the optimum technique to intubate the trachea in a patient who may have a cervical(C)-spine injury remains unresolved. We compared, using fluoroscopic video, C-spine motion during intubation for Macintosh 3 blade, GlideScope, and Intubating Lighted Stylet, popularly known as the Lightwand or Trachlight. Thirty-six healthy patients were randomized to participate in a crossover trial of either Lightwand or GlideScope to Macintosh laryngoscopy, with in-line stabilization. C-spine motion was examined at the Occiput-C1 junction, C1-2 junction, C2-5 motion segment, and C5-thoracic motion segment during manual ventilation via bag-mask, laryngoscopy, and intubation. Time to intubate was also measured. C-spine motion during bag-mask ventilation was 82% less at the four motion segments studied than during Macintosh laryngoscopy (P < 0.001). C-spine motion using the Lightwand was less than during Macintosh laryngoscopy, averaging 57% less at the four motion segments studied (P < 0.03). There was no significant difference in time to intubate between the Lightwand and the Macintosh blade. C-spine motion was reduced 50% at the C2-5 segment using the GlideScope (P < 0.04) but unchanged at the other segments. Laryngoscopy with GlideScope took 62% longer than with the Macintosh blade (P < 0.01). Thus, the Lightwand (Intubating Lighted Stylet) is associated with reduced C-spine movement during endotracheal intubation compared with the Macintosh laryngoscope.

Thrombi defined as intraluminal filling defects detected by angiography were identified in 30 patients (29 in the carotid system, one in the vertebral artery). Stroke was the presentation ipsilateral to the thrombus in 22 patients (12 had previous transient ischemic attacks), transient ischemic attacks occurred alone in seven cases, and one patient was asymptomatic. Angiography revealed a severe stenosis in association with the thrombus in 23 patients, a moderate stenosis in four patients, and, in the three patients with only minimal stenosis presumably due to atherosclerosis, there was evidence for a coagulopathy. Sixteen of the 30 patients were operated on urgently, 10 within 24 hours of detection of the thrombus. Twelve of these 16 surgical patients were given anticoagulation before surgery. At endarterectomy, thrombus was identified in 11 of the 14 surgical patients in whom the thrombus was accessible; the other two surgical patients had intracranial thrombus only. In this group, four of 11 surgical patients with accessible thrombi suffered perioperative episodes of new or larger infarction. Fourteen of the 30 patients initially received medical management with no complication. Eight of these 14 medical patients had repeat angiography; seven exhibited complete resolution of thrombus, and six of these seven patients subsequently underwent delayed endarterectomy for the stenosis. No thrombus was identified at surgery in any of the six. One of the six delayed surgery patients suffered a perioperative stroke. Although these numbers are small, reflecting the rarity of thrombus demonstrated by angiography, undetected thrombus is often found at endarterectomy. Its presence may increase operative risk. This increased risk could possibly be countered with a preoperati ve period of anticoagulation and a delay of days or weeks before surgery. (Stroke 1988;19:681-687) P atients are said to require emergency surgery in the presence of symptoms appropriate to an intraluminal thrombus related to a stenosing lesion. 1 No one has had much experience with this condition, but doubt has been expressed about the basis for this dogmatic statement. 2 We review here our experience with intraluminal thrombus in an attempt to define the clinical presentation, to justify the angjographic diagnosis, and to weigh the benefits and risks of both medical and surgical treatment. The timing of surgery in relation to the presence of thrombus and the risks of arterial occlusion and distal embolization are considered.Carotid endarterectomy requires a low operative stroke rate if it is to be an effective prophylaxis against stroke. The detection of thrombus may define a high-risk factor for perioperative stroke in patients undergoing carotid endarterectomy. Subjects and MethodsAll cerebral angiography reports between 1975 and 1985 at University Hospital were reviewed for evidence of free intraluminal thrombus within the cerebral circulation. The films of these patients were obtained, and each case was accepted if a filling defect could be seen i...

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.

Of 68 patients with unclippable aneurysms treated by proximal artery occlusion with detachable balloons, permanent occlusion was achieved in 65; of these patients, 37 had carotid artery aneurysms below the origin of the ophthalmic artery, 21 had aneurysms arising from the supraclinoid portion of the carotid artery, six had basilar trunk aneurysms, and one had a distal vertebral aneurysm. Examination for treatment selection included assessment of the circle of Willis by compression angiography and xenon blood flow studies, with the ultimate evaluation being test occlusion under systemic heparinization with the balloon temporarily placed in the desired position. Of 67 patients who underwent a formal occlusion test, eight with carotid artery aneurysms did not initially tolerate the occlusion test, and ischemic signs disappeared instantaneously with deflation and removal of the balloon. During test occlusion, two additional patients had ischemic events that proved to be embolic; these reversed immediately upon balloon deflation. Of the 65 patients in whom permanent occlusion was effected by detachable balloon, there were nine instances of delayed cerebral events. One of these was a seizure leading to respiratory arrest and resuscitation 3 days following occlusion in a patient who had presented with seizures. The other eight cases were delayed ischemic events; seven were completely reversed and one patient had residual weakness in one leg (1.5% permanent morbidity). Extracranial-intracranial bypass procedures were performed in 25 of the 65 cases. All aneurysms of the carotid artery below the level of the ophthalmic artery presented angiographic proof of complete thrombosis. Ten of 21 aneurysms arising from the supraclinoid portion of the carotid artery were completely thrombosed by proximal occlusion alone, without additional trapping procedures. Similarly, in three of six basilar trunk aneurysms, proximal occlusion alone initiated complete aneurysm thrombosis without trapping. The conclusion is that proximal balloon occlusion for unclippable cerebral aneurysms is a convenient, safe, and effective way of producing arterial occlusion in these cases.

Cervical spine extension and time to intubation are similar for the Macintosh laryngoscope with ILS and the Bullard laryngoscope without ILS. However, time to intubation is significantly prolonged when the Bullard laryngoscope is used in a simulated emergency with cervical spine precautions taken. This suggests that the Bullard laryngoscope may be a useful adjunct to intubation of patients with potential cervical spine injury when time to intubation is not critical.