The emerging age of endovascular treatment of acute ischaemic stroke and the role of CT angiography in patient work-up: a guide for the radiologist.

Recent trial evidence suggests that for patients suffering large-vessel occlusive stroke, endovascular therapy based on the stent-retriever technique is associated with superior clinical outcomes when compared to intravenous thrombolysis alone. The challenge now is how this service is to be delivered. This may involve both centralisation of services around large cities and development of robust networks to receive patients from district general hospitals situated further afield. Both diagnostic and interventional neuroradiology will need to expand. Furthermore, we suggest that it would be advantageous for radiology departments in those hospitals receiving hyperacute stroke patients to perform computed tomography (CT) angiography in addition to non-contrast CT, which also has implications for service delivery in these units. This could swiftly aid identification of patients who might benefit from thrombectomy and improve decision-making through demonstration of occlusive thrombus and of collateral status.

Thunderclap headache: diagnostic considerations and neuroimaging features.

Thunderclap headache (TCH) is an acute and severe headache that has maximum intensity at onset; TCH can be primary or secondary. Primary TCH is diagnosed when no underlying cause is discovered; however, imaging is crucial in distinguishing secondary causes, which are wide-ranging. The radiologist should be aware of the list of potential diagnoses. Subarachnoid haemorrhage (SAH) is the most common cause of secondary TCH. Aneurysmal SAH accounts for the majority of cases, although other causes should also be considered and these include perimesencephalic haemorrhage, arteriovenous malformations, and dural arteriovenous fistula as well as reversible cerebral vasoconstriction syndrome. Conditions that may present with TCH, with or without SAH include cervical artery dissection and cerebral venous sinus thrombosis. Ischaemic stroke, pituitary apoplexy, and posterior reversible leucoencephalopathy are other potential causes, whereas non-vascular causes include colloid cysts of the third ventricle and spontaneous intracranial hypotension. Imaging features are reviewed with reference to clues gleaned from initial imaging using computed tomography, as well as characteristics that should be sought using magnetic resonance imaging or angiographic imaging.

Cranial neuroimaging in pregnancy and the post-partum period.

Several diverse neurological conditions may be seen during pregnancy and the post partum period. These usually require neuroimaging for definitive diagnosis and range from a predisposition to neurovascular abnormalities, such as acute ischaemic stroke and cerebral venous sinus thrombosis, through to more specific pregnancy-related conditions, such as eclampsia/posterior reversible leukoencephalopathy and post-partum angiopathy. Additionally, the pregnant patient is predisposed to pituitary disease. It is necessary that the radiologist has an awareness of these conditions to allow swift specific diagnoses or suggest the most appropriate diagnosis when imaging findings are non-specific. We describe epidemiological and radiological features to allow the radiologist to guide the clinician in management, and review guidelines for safe cranial imaging of the pregnant patient.

Dressings and topical agents for arterial leg ulcers.

BACKGROUND: It is estimated that people in industrialised countries have a 1% chance of suffering from a leg ulcer at some time in their life. The majority of leg ulcers are associated with circulation problems; poor blood return in the veins causes venous ulcers (around 70% of ulcers) and poor blood supply to the legs causes arterial ulcers (around 25% of ulcers). Treatment of arterial leg ulcers is directed towards correcting the poor arterial blood supply, for example, by surgically correcting arterial blockages, and by supporting ulcer healing using topical agents (medicines in cream/ointment) and wound dressings. There are a large number of topical agents and wound dressings available and it is unclear what impact these have on ulcer healing. OBJECTIVES: To determine whether topical agents and wound dressings affect the rate of healing in arterial ulcers. To compare healing rates, costs and patient-centred outcomes between wound dressings and topical agents. SEARCH STRATEGY: Potential trials were sought through the Specialised Trials Registers of the Cochrane Wounds Group (last searched April 2002), the Cochrane Peripheral Vascular Diseases Group (last searched November 2006) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, Issue 4, 2006 SELECTION CRITERIA: Randomised controlled trials (RCTs), or controlled clinical trials (CCTs) of dressings and topical agents for arterial leg ulcers were eligible for inclusion. The participants had to have ulcers that were described as arterial, and the time to healing, proportion completely healed, or rate of reduction in ulcer area had to be reported. All wound dressings and topical agents were eligible for inclusion in this review. DATA COLLECTION AND ANALYSIS: Information on the participants' characteristics, the interventions, and outcomes, as well as data on the trial methods, such as blinding of patients and clinicians, and allocation concealment were extracted using a standardised data extraction form. MAIN RESULTS: One trial met the inclusion criteria. This small trial compared ketanserin ointment with vehicle alone, changed twice a day. The trial was too small and for too short a follow-up period to be able to determine whether there was any difference in healing rates. AUTHORS' CONCLUSIONS: There is insufficient evidence to determine whether the choice of topical agent or dressing affects the healing of arterial leg ulcers. Inadequate description of the people in the one included trial means that the results cannot be easily applied to other clinical populations.

Dressings and topical agents for arterial leg ulcers.

BACKGROUND: It is estimated that people in industrialised countries have a 1% chance of suffering from a leg ulcer at some time in their life. The majority of leg ulcers are associated with circulation problems; poor blood return in the veins causes venous ulcers (around 70% of ulcers) and poor blood supply to the legs causes arterial ulcers (around 25% of ulcers). Treatment of arterial leg ulcers is directed towards correcting the poor arterial blood supply, for example, by surgically correcting arterial blockages, and by supporting ulcer healing using topical agents (medicines in cream/ointment) and wound dressings. There are a large number of topical agents and wound dressings available and it is unclear what impact these have on ulcer healing. OBJECTIVES: To determine whether topical agents and wound dressings affect the rate of healing in arterial ulcers. To compare healing rates, costs and patient-centred outcomes between wound dressings and topical agents. SEARCH STRATEGY: Publications describing (or potentially describing) randomised controlled trials (RCTs), or controlled clinical trials (CCTs) of dressings and topical agents for arterial leg ulcers were sought through the Specialised Trials Registers of the Cochrane Wounds Group (last searched January 2002) and the Cochrane Peripheral Vascular Diseases Group (last searched April 2002). SELECTION CRITERIA: RCTs or CCTs (trials with non-randomised concurrent comparison groups) were eligible for inclusion. The participants had to have ulcers that were described as arterial, and the time to healing, proportion completely healed, or rate of reduction in ulcer area had to be reported. All wound dressings and topical agents were eligible for inclusion in this review. DATA COLLECTION AND ANALYSIS: Information on the participants' characteristics, the interventions, and outcomes, as well as data on the trial methods, such as blinding of patients and clinicians, and allocation concealment were extracted using a standardised data extraction form. MAIN RESULTS: One trial met the inclusion criteria. This small trial compared ketanserin ointment with vehicle alone, changed twice a day. The trial was too small and for too short a follow-up period to be able to determine whether there was any difference in healing rates. REVIEWER'S CONCLUSIONS: There is insufficient evidence to determine whether the choice of topical agent or dressing affects the healing of arterial leg ulcers. Inadequate description of the people in the one included trial means that the results cannot be easily applied to other clinical populations.

Tibioperoneal angioplasty and bypass.

Revascularisation by angioplasty or bypass of narrowing and occlusion of the tibio-peroneal segment is done infrequently compared with the more proximal arteries, particularly the superficial femoral artery. The indication for intervention is critical limb ischaemia and the pattern of disease when it predominantly affects the calf arteries is most commonly seen in diabetics. Surgical bypass is the orthodox technique, with well-documented long-term results. Balloon dilation has recently been tried, particularly using the sub-intimal technique. The advantage of minimal invasiveness has to be set against the inapplicability of the method if severe calcification is present, as is often the case in diabetics, the high restenosis rate, and the absence of controlled trials showing good evidence of long-term patency.

Endovascular treatment of 300 consecutive middle cerebral artery aneurysms: clinical and radiologic outcomes.

BACKGROUND AND PURPOSE: There is controversy as to the best mode of treating MCA aneurysms. We report the results of a large endovascular series of patients treated at our center. MATERIALS AND METHODS: This study was a retrospective analysis of a prospectively acquired data base. All patients with saccular MCA aneurysms treated between November 1996 and June 2012 were included. World Federation of Neurosurgical Societies grade, aneurysm site, size, and aneurysm neck size were recorded, along with clinical outcome assessed with the Glasgow Outcome Scale and radiographic occlusion assessed with the Raymond classification at 6 months and 2.5 years. RESULTS: A total of 295 patients with 300 MCA aneurysms were treated including 244 ruptured aneurysms (80.7%). The technical failure rate was 4.3% (13 patients). Complete occlusion or neck remnant was achieved in 264 (91.4%). Complications included rupture in 15 patients (5%), thromboembolism in 17 patients (5.7%), and early rebleeding in 3 patients (1%). Overall permanent procedural-related morbidity and mortality were seen in 12 patients (7.8%). Of the ruptured aneurysms, 189 (79.4%) had a favorable clinical outcome (Glasgow Outcome Scale score, 4-5). A total of 33 patients (13.6%) died. On initial angiographic follow-up, aneurysm remnant was seen in 18 aneurysms (8.1%). A total of 13 patients (4.3%) were re-treated. CONCLUSIONS: Our experience demonstrates that endovascular treatment of MCA aneurysms has an acceptable safety profile with low rates of technical failure and re-treatment. Therefore, coiling is acceptable as the primary treatment of MCA aneurysms.

Sibling power: influence of older siblings' persuasive appeals on younger siblings' judgements about risk taking behaviours.

OBJECTIVES: Although many injuries happen when school age children are away from home and in the company of other children, we know surprisingly little about interpersonal influences on children's risk taking decisions. The aim of the present study was to examine the influence of older siblings' persuasive appeals on young children's decisions about engaging in behaviours that could threaten their physical safety. METHODS: Forty same sex sibling pairs participated. Children were shown drawings of play scenes (bicycling, river crossing, and sledding), with each depicting lower and higher risk paths of travel. Children of 8 years made initial decisions as to which paths they would take. Subsequently, their older sibling acted as a confederate and tried to persuade them to change their decisions. RESULTS: After the appeals of older siblings, younger children significantly shifted their decisions: choices of less risky paths replaced the initial selection of more risky paths, and vice versa. A positive sibling relationship was predictive of younger siblings' decision changes. Boys and girls were equally effective in persuasion but they did so using different types of arguments, with boys communicating primarily appeals to fun and girls emphasizing appeals to safety. CONCLUSIONS: These findings highlight the effect that older siblings can have on risk taking decisions of younger siblings. Accordingly, they document the importance of considering the interpersonal context of risk taking when designing interventions to reduce injuries among elementary schoolchildren.

Benign keratotic squamous epithelial neoplasm of the palate: a unique lesion.

BACKGROUND: This case report describes a unique palatal tumor with features of a dermal neoplasm. Microscopically, the lesion appeared similar to a trichoepithelioma and trichoadenoma. METHODS: Light microscopic and immunohistochemical studies were performed to arrive at the final diagnosis. RESULTS: The lesion arose from the surface epithelium and had features of a dermal tumor. CONCLUSIONS: The case report describes a unique benign palatal neoplasm.

Outcome of ventilatory support for acute respiratory failure in motor neurone disease.

OBJECTIVES: To review the outcome of acute ventilatory support in patients presenting acutely with respiratory failure, either with an established diagnosis of motor neurone disease (MND) or with a clinical event where the diagnosis of MND has not yet been established. METHODS: Outcome was reviewed in 24 patients with respiratory failure due to MND who received endotracheal intubation and intermittent positive pressure ventilation either at presentation or as a result of the unexpected development of respiratory failure. Patients presenting to local hospitals with acute respiratory insufficiency and requiring tracheal intubation, ventilatory support, and admission to an intensive therapy unit (ITU) before transfer to a regional respiratory care unit were selected. Clinical features of presentation, management, and outcome were studied. RESULTS: 24 patients with MND were identified, all being intubated and ventilated acutely within hours of presentation. 17 patients (71%) were admitted in respiratory failure before the diagnosis of MND had been made; the remaining seven patients (29%) were already known to have MND but deteriorated rapidly such that intubation and ventilation were initiated acutely. Seven patients (29%) died on ITU (between seven and 54 days after admission). 17 patients (71%) were discharged from ITU. 16 patients (67%) received long term respiratory support and one patient required no respiratory support following tracheal extubation. The daily duration of support that was required increased gradually with time. CONCLUSION: When a patient with MND is ventilated acutely, with or without an established diagnosis, independence from the ventilator is rarely achieved. Almost all of these patients need long term ventilatory support and the degree of respiratory support increases with time as the disease progresses. The aim of management should be weaning the patient to the minimum support compatible with symptomatic relief and comfort. Respiratory failure should be anticipated in patients with MND when the diagnosis has been established.