Outcome in patients with acute ischaemic stroke is significantly better in those who undergo thrombolysis compared with those who do not. Increasing age is associated with poorer outcome but the association between thrombolysis treatment and improved outcome is maintained in very elderly people. Age alone should not be a barrier to treatment.

Differences in research methodology have hampered the optimization of Computer Tomography Perfusion (CTP) for identification of the ischemic core. We aim to optimize CTP core identification using a novel benchmarking tool. The benchmarking tool consists of an imaging library and a statistical analysis algorithm to evaluate the performance of CTP. The tool was used to optimize and evaluate an in-house developed CTP-software algorithm. Imaging data of 103 acute stroke patients were included in the benchmarking tool. Median time from stroke onset to CT was 185 min (IQR 180-238), and the median time between completion of CT and start of MRI was 36 min (IQR 25-79). Volumetric accuracy of the CTP-ROIs was optimal at an rCBF threshold of <38%; at this threshold, the mean difference was 0.3 ml (SD 19.8 ml), the mean absolute difference was 14.3 (SD 13.7) ml, and CTP was 67% sensitive and 87% specific for identification of DWI positive tissue voxels. The benchmarking tool can play an important role in optimizing CTP software as it provides investigators with a novel method to directly compare the performance of alternative CTP software packages.

What ' s known on the subject? and What does the study add? During radical prostatectomy, urological surgeons have tried to identify the " cord-like NVB " at the lateral aspect of the prostate. However, little histological or physiological investigation was conducted to verify that the NVB identifi ed at surgery really included the cavernous nerve. Recently, there have been observations that refute the dogma that the cavernous nerve is always within the NVB.In this study, we have described a hammock-like distribution of the nerves on which the prostate rests, demonstrating that the NVB is more a network of multiple fi ne dispersed nerves than a distinct structure. We presented a novel nerve-sparing approach to complete hammock preservation. This risk-stratifi ed approach for determining the degree of nerve sparing based on the patient ' s likelihood of ipsilateral EPE seeks to categorize patients for optimal balance between oncological outcomes and functional outcomes. OBJECTIVES• To report the potency and oncological outcomes of patients undergoing robotassisted radical prostatectomy (RARP) using a risk-stratifi ed approach based on layers of periprostatic fascial dissection.• We also describe the surgical technique of complete hammock preservation or nerve sparing grade 1. PATIENTS AND METHODS• This is a retrospective study of 2317 patients who had robotic prostatectomy by a single surgeon at a single institution between January 2005 and June 2010.• Included patients were those with ≥ 1 year of follow-up and who were potent preoperatively, defi ned as having a sexual health inventory for men (SHIM) questionnaire score of > 21; thus, the fi nal number of patients in the study cohort was 1263.• Patients were categorized pre-operatively by a risk-stratifi ed approach into risk grades 1 -4, where risk grade 1 patients received nerve-sparing grade 1 or complete hammock preservation and so on for risk grades 2 -4, as long as intraoperative fi ndings permitted the planned nerve sparing.• We considered return to sexual function post-operatively by two criteria: i) ability to have successful intercourse (score of ≥ 4 on question 2 of the SHIM) and ii) SHIM > 21 or return to baseline sexual function. RESULTS• There was a signifi cant difference across different NS grades in terms of the percentages of patients who had intercourse and returned to baseline sexual function ( P < 0.001), with those that underwent NS grade 1 having the highest rates (90.9% and 81.7%) as compared to NS grades 2 (81.4% and74.3%), 3 (73.5% and 66.1%), and 4 (62% and 54.5%).• The overall positive surgical margin (PSM) rates for patients with NS grades 1, 2, 3, and 4 were 9.9%, 8.1%, 7.2%, and 8.7%, respectively ( P = 0.636).• The extraprostatic extension rates were 11.6%, 14.3%, 29.3%, and 36.2%, respectively ( P < 0.001).• Similarly, in patients younger than 60, intercourse and return to baseline sexual function rates were 94.9% and 84.3% for NS grade 1 as compared to 85.5% and 77.2% for NS grades 2, 76.9% and 69% for NS grades 3, and 64.8% and...

Background and Purpose-Clinical benefit from thrombolysis is reduced as stroke onset to treatment time increases. The use of "mismatch" imaging to identify patients for delayed treatment has face validity and has been used in case series and clinical trials. We undertook a meta-analysis of relevant trials to examine whether present evidence supports delayed thrombolysis among patients selected according to mismatch criteria. Methods-We collated outcome data for patients who were enrolled after 3 hours of stroke onset in thrombolysis trials and had mismatch on pretreatment imaging. We selected the trials on the basis of a systematic search of the Web of Knowledge. We compared favorable outcome, reperfusion and/or recanalization, mortality, and symptomatic intracerebral hemorrhage between the thrombolyzed and nonthrombolyzed groups of patients and the probability of a favorable outcome among patients with successful reperfusion and clinical findings for 3 to 6 versus 6 to 9 hours from poststroke onset. Results are expressed as adjusted odds ratios (a-ORs) with 95% CIs. Heterogeneity was explored by test statistics for clinical heterogeneity, I 2 (inconsistency), and L'Abbé plot. Results-We identified articles describing the DIAS, DIAS II, DEDAS, DEFUSE, and EPITHET trials, giving a total of 502 mismatch patients thrombolyzed beyond 3 hours. The combined a-ORs for favorable outcomes were greater for patients who had successful reperfusion (a-ORϭ5.2; 95% CI, 3 to 9; I 2 ϭ0%). Favorable clinical outcome was not significantly improved by thrombolysis (a-ORϭ1.3; 95% CI, 0.8 to 2.0; I 2 ϭ20.9%). Odds for reperfusion/recanalization were increased among patients who received thrombolytic therapy (a-ORϭ3.0; 95% CI, 1.6 to 5.8; I

Background and Purpose-Intravenous thrombolysis with alteplase is approved for acute ischemic stroke, but its use is limited by numerous contraindications and warnings arising from trial selection criteria or expert opinions. We examined outcomes from alteplase-treated versus untreated patients, registered in a trials archive, according to presence or absence of specified contraindications and warnings. Methods-We analyzed 90-day modified Rankin Scale across the whole distribution of scores using the Cochran-MantelHaenszel test, with adjustment for age and baseline National Institutes of Health Stroke Score, followed by proportional odds logistic regression analysis to estimate the odds ratios for preferred outcome. Results-We used data from 9613 ischemic stroke patients of whom 2755 were treated with thrombolysis. Adjusted odds ratios showed a broad trend of more favorable 3-month outcome associated with alteplase treatment versus no treatment in various subgroups of patients with contraindications and warnings; for example,

Objective To assess the utility of CT perfusion for selection of patients for endovascular therapy up to 18 hours after symptom onset. Methods We conducted a multicenter cohort study of consecutive acute stroke patients scheduled to undergo endovascular therapy within 90 min after a baseline CTP. Patients were classified as ‘target mismatch’ if they had a small ischemic core and a large penumbra on their baseline CT perfusion. Reperfusion was defined as >50% reduction in critical hypoperfusion between the baseline CT perfusion and the 36-hour follow-up MRI. Results Of the 201 patients enrolled, 190 patients with an adequate baseline CT perfusion study who underwent angiography were included; mean age 66 years, median NIHSS 16, median time from symptom onset to endovascular therapy 5.2 hours. Rate of reperfusion was 89%. In patients with target mismatch (n=131), reperfusion was associated with higher odds of favorable clinical response, defined as an improvement of ≥8 points on the NIH Stroke Scale (83% vs 44%, p=0.002; adjusted OR=6.6; 95% CI 2.1–20.9). This association did not differ between patients treated within 6 hrs (OR = 6.4; 95% CI 1.5–27.8) and those treated beyond 6 hrs after symptom onset (OR = 13.7; 95% CI 1.4–140). Interpretation The robust association between endovascular reperfusion and good outcome among patients with the CT perfusion target mismatch profile treated up to 18 hours after symptom onset supports a randomized trial of endovascular therapy in this patient population.

Background and Purpose-Simple and rapid measures of intraventricular hemorrhage (IVH) volume are lacking. We developed and validated a modification of the original Graeb scale to facilitate rapid assessment of IVH over time. Methods-We explored the relationship between the modified Graeb scale (mGS), original Graeb scale, measured IVH volume, and outcome using data from the Clot Lysis: Evaluating Accelerated Resolution of Hemorrhage with rtPA B (CLEAR B) study. We also explored its reliability. We then evaluated the relationship between mGS and outcome in a large sample of participants with IVH using data contained within the Virtual International Stroke Trials Archive (VISTA). We defined outcome using the modified Rankin scale (>3 signifying poor outcome). Results-The CLEAR B study included 360 scans from 36 subjects. The mGS score and IVH volume were highly correlated (R = 0.80, P<0.0001, R 2 0.65). Baseline mGS was predictive of poor outcome (area under receiving operating characteristic curve 0.74, 95% confidence interval, 0.57-0.91), whereas the original Graeb scale was not. The VISTA study included 399 participants. Each unit increase in the mGS led to a 12% increase in the odds of a poor outcome (odds ratio, 1.12; 95% confidence interval, 1.05-1.19). Measures of reliability (intra-and inter-reader) were good in both studies. Conclusions-The

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 StrokeEvolution 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 6 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 5 0.03) and attenuation of lesion growth (p 5 0.02). Time to treatment did not modify these effects (p value for the time 3 reperfusion interaction is 0.6 for good functional outcome and 0.3 for lesion growth). Similarly, in the subgroup of patients with reperfusion (n 5 46), time to treatment was not associated with good functional outcome (p 5 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. Recent endovascular trials have demonstrated benefit from endovascular therapy for patients treated within 6 hours after symptom onset. [1][2][3][4] Whether patients treated outside of this time window also benefit from endovascular therapy remains unknown. Some studies suggest a lack of benefit from endovascular reperfusion beyond 7 hours after symptom onset. 5,6 However, this time threshold is likely not uniformly valid 7 because the duration of the therapeutic time window depends on the degree to which cerebral blood flow is reduced in an individual patient. [8][9][10] Patients with good collaterals can have substantial volumes of salvageable tissue for a relatively long time and may remain good candidates for endovascular treatment even beyond 12 hours after symptom onset. 11,12 Patient selection in the delayed time window (.6 hours after symptom onset) will therefore have to rely on an assessment of salvageable brain tissue. The best-studied biomarker of salvageable brain tissue is the volumetric mismatch between the magnetic resonance perfusion (MRP) lesion, segmented using a validated threshold, and the diffusion-weighted imaging (DWI) lesion.