Pre-hospital stroke screening and notification of patients with reperfusion-eligible acute ischaemic stroke using modified Face Arm Speech Time test.

OBJECTIVES: To investigate the effects of pre-hospital stroke screening and notification on reperfusion therapy for patients with acute ischaemic stroke. METHODS: Pre-hospital stroke screening criteria were established based on a modified version of the Face Arm Speech Time (FAST) test. Screening was performed during ambulance transport by emergency medical service (EMS) personnel who completed a 2-hour training session on stroke screening. Temporal trends affecting acute ischaemic stroke investigation and intervention were compared before and after implementation of the pre-hospital screening. RESULTS: From July 2018 to October 2019, 298 patients with suspected stroke were screened by EMS personnel during ambulance transport prior to hospital arrival. Of these 298 patients, 213 fulfilled the screening criteria, 166 were diagnosed with acute stroke, and 32 received reperfusion therapy. The onset-to-door time was shortened by more than 1.5 hours (100.6 min vs 197.6 min, P<0.001). The door-to-computed tomography time (25.6 min vs 32.0 min, P=0.021), door-to-needle time (49.2 min vs 70.1 min, P=0.003), and door-to-groin puncture time for intra-arterial mechanical thrombectomy (126.7 min vs 168.6 min, P=0.04) were significantly shortened after implementation of the pre-hospital screening and notification, compared with historical control data of patients admitted from January 2018 to June 2018, before implementation of the screening system. CONCLUSION: Implementation of pre-hospital stroke screening using criteria based on a modified version of the FAST test, together with pre-arrival notification, significantly shortened the door-to-reperfusion therapy time for patients with ischaemic stroke. Pre-hospital stroke screening during ambulance transport by EMS personnel who complete a 2-hour focused training session is effective for identifying reperfusion-eligible patients with stroke.

Outcome of Flow Diverters with Surface Modifications in Treatment of Cerebral Aneurysms: Systematic Review and Meta-analysis.

BACKGROUND: Newer flow diverters are enhanced with antithrombogenic surface modifications like the Pipeline Embolization Device with Shield Technology and the Derivo Embolization Device and are purported to facilitate deployment and reduce ischemic events. PURPOSE: Our aim was to review the safety and efficacy of surface-modified flow diverters in treating patients with cerebral aneurysms. DATA SOURCES: We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review and meta-analysis covering 3 major data bases and gray literature between 2014 and 2019. STUDY SELECTION: Two reviewers independently reviewed human studies of surface-modified flow diverters for eligibility based on predetermined criteria. DATA ANALYSIS: The random effects model and Freeman-Tukey arcsine transformation were used to pool efficacy outcomes (technical success, aneurysm occlusion at 6 and 12 months) and safety outcomes (mortality, morbidity, all ischemia, and serious ischemia). Subgroup analysis was performed to compare outcomes between 2 different flow diverters. DATA SYNTHESIS: Eight single-arm case series involving 911 patients and 1060 aneurysms were included. The median follow-up was 8.24 months. Pooled estimate for technical success was 99.6%, while the aneurysm occlusion at 6 and 12 months were 80.5%, and 85.6%, respectively. Pooled estimates for mortality, morbidity, total ischemia, and serious ischemia rates were 0.7%, 6.0%, 6.7%, and 1.8%, respectively. Most studies were of good quality, and no significant heterogeneity was observed. LIMITATIONS: Limitations include a retrospective, observational design in some studies; heterogeneous and underreported antiplatelet therapy; and potential performance and ecologic bias. CONCLUSIONS: Early-to-midterm safety and efficacy for surface-modified flow diverters appear comparable with older devices, especially for small, unruptured anterior circulation aneurysms. Long-term clinical data are required to further corroborate these results.

Single-Needle Lateral Sacroplasty Technique.

Sacral insufficiency fractures result in significant morbidity, and percutaneous sacroplasty has emerged as a promising technique for their treatment. We present a technical note regarding our method of treating these fractures using a "single-needle" lateral technique with a combination of conebeam CT and biplane fluoroscopy. We treated 10 patients, in whom the median Visual Analog Scale pain score decreased from 7.0 to 0 (P < .001). We concluded that single-needle sacroplasty is feasible and safe using this technique.

Sentinel Angiographic Signs of Cerebral Hyperperfusion after Angioplasty and Stenting of Intracranial Atherosclerotic Stenosis: A Technical Note.

Cerebral hyperperfusion syndrome is a serious complication of endovascular angioplasty and stent placement for long-standing intracranial stenosis, resulting in neurologic dysfunction, seizure, or reperfusion hemorrhage. Rigorous control of blood pressure is commonly used in the perioperative period to prevent cerebral hyperperfusion syndrome, but the optimal blood pressure is often arbitrary. We describe the angiographic features that reflect impaired cerebral autoregulation and microvascular transit abnormality, which may be used to gauge the optimal blood pressure parameters in the immediate postintervention period for prevention of cerebral hyperperfusion syndrome.

Facial Venous Malformations Are Associated with Cerebral Developmental Venous Anomalies.

BACKGROUND AND PURPOSE: A number of studies have demonstrated the existence of segmental vascular disorders affecting soft tissues of the head and neck along with the intracranial vasculature. The purpose of this study was to determine whether there is an association between cerebral developmental venous anomalies and venous malformations of the face, head, and neck. MATERIALS AND METHODS: A consecutive series of patients with head and neck venous malformations who underwent MR imaging of the brain with postcontrast T1- or T2*-weighted imaging were included. Developmental venous anomaly prevalence in this patient population was compared with an age- and sex-matched control group without venous malformations at a ratio of 1:2. All images were interpreted by 2 neuroradiologists. Data were collected on venous malformation location, developmental venous anomaly location, developmental venous anomaly drainage pattern, and metameric location of venous malformations and developmental venous anomalies. Categoric variables were compared using χ2 tests. RESULTS: Forty-two patients with venous malformations were included. The mean age was 38.1 ± 11.1 years, and 78.6% of patients were female. The prevalence of developmental venous anomalies in this patient population was 28.6%. The control population of 84 patients had a mean age of 40.0 ± 5.9 years, and 78.6% of patients were female. The prevalence of developmental venous anomalies in this patient population was 9.5% (P = .01). In 83.3% of cases, developmental venous anomalies were ipsilateral to the venous malformation, and in 75% of cases, they involved the same metamere. CONCLUSIONS: Our case-control study demonstrated a significant association between brain developmental venous anomalies and superficial venous malformations. These findings suggest that there may be a similar pathophysiologic origin for these 2 entities.

Over-expression of FoxM1 stimulates cyclin B1 expression.

FoxM1 (previously named WIN, HFH-11 or Trident) is a Forkhead box (Fox) transcription factor widely expressed in proliferating cells. Various findings, including a recent analysis of FoxM1 knockout mice, suggest that FoxM1 is required for normal S-M coupling during cell cycle progression. To study the regulatory role of FoxM1 and its downstream regulatory targets, three stably transfected HeLa lines that display doxycycline (dox)-inducible FoxM1 expression were established. Over-expression of FoxM1 by dox induction facilitates growth recovery from serum starvation. Quantitation of cyclin B1 and D1 levels using flow cytometric, Western and Northern analyses reveals that elevated FoxM1 levels lead to stimulation of cyclin B1 but not cyclin D1 expression. Transient reporter assays in the dox-inducible lines and upon co-transfection with a constitutive FoxM1 expression plasmid suggest that FoxM1 can activate the cyclin B1 promoter.

Brightness alters Heidelberg retinal flowmeter measurements in an in vitro model.

PURPOSE: The Heidelberg Retinal Flowmeter (HRF), a laser Doppler flowmetry device, has captured interest as a research and clinical tool for measurement of ocular blood flow. Concerns remain about the range and accuracy of the values that it reports. METHODS: An in vitro blood-flow model was constructed to provide well-controlled laminar flow through a glass capillary for assessment by HRF. A change in material behind the glass capillary was used to simulate changing brightness conditions between eyes. RESULTS: Velocities reported by the HRF correlated linearly to true velocities below 8.8 mm/sec. Beyond 8.8 mm/sec, HRF readings fluctuated randomly. True velocity and HRF reported velocities were highly correlated, with r = 0.967 (P < 0.001) from 0.0 mm/sec to 2.7 mm/sec mean velocity using a light background, and r = 0.900 (P < 0.001) from 2.7 mm/sec to 8.8 mm/sec using a darker background. However, a large change in the y-intercept occurred in the calibration curve with the background change. CONCLUSIONS: The HRF may report velocities inaccurately because of varying brightness in the fundus. In the present experiment, a darker background produced an overreporting of velocities. An offset, possibly introduced by a noise correction routine, apparently contributed to the inaccuracies of the HRF measurements. Such offsets vary with local and global brightness. Therefore, HRF measurements may be error prone when comparing eyes. When used to track perfusion in a single eye over time, meaningful comparison may be possible if meticulous care is taken to align vessels and intensity controls to achieve a similar level of noise correction between measurements.

Cement-mantle thickness affects cement strains in total hip replacement.

Bone cement is commonly used to affix femoral implants to the bone during total hip reconstruction. Previous studies suggest that the expected life of a cemented femoral implant may depend on the thickness of the cement mantle surrounding the implant and the implant geometry. The purpose of this study was to determine whether different cement-mantle thicknesses and femoral stem sizes affected strain patterns in the bone cement around cemented femoral stems. Two different sizes of cobalt-chromium stems were cemented into composite femora with varying cement-mantle thickness. Strain gages were embedded in the cement mantle and the implanted stems were loaded axially and under conditions simulating walking and standing. An increase in stem size with the same cement-mantle thickness (approximately 2.2 mm) caused a 65% decrease in proximal medial cement strains. Increasing cement mantle thickness from 2.4 to 3.7 mm caused substantial strain reductions in the distal cement (40-49%). We conclude that increased cement-mantle thickness around femoral stems may increase the fatigue life of a bone-implant system by reducing peak strains within the cement.

A case of oral myiasis due to Chrysomya bezziana.

Chrysomya bezziana is a causative agent of obligatory myiasis. We report the first case of human infestation of Chrysomya bezziana in Hong Kong in an 89-year-old woman who had previously had a stroke. One day after hospital admission for fever, a small fissure at the labial gingiva of the upper incisors and several ulcerative lesions at the hard palate were noticed during routine mouth care. A live maggot was seen protruding from the small fissure. In the following few days, a total of seven maggots were removed by forceps. Urgent computed tomography and magnetic resonance imaging of the oral cavity showed an ulcerative soft-tissue lesion over the anterior palate, with a fistula communicating to the labial gingiva. The tissue loss was limited to the bony margin of the hard palate. The infestation was managed by manual removal of maggots and surgical debridement. Medical personnel taking care of old or debilitated patients need to bear in mind the possibility of Chrysomya bezziana infestation to be able to make a prompt diagnosis and implement relevant intervention to prevent extensive tissue destruction.

A study of the comparative efficacy of three common analgesics in the control of pain after third molar surgery under local anaesthesia.

BACKGROUND: The aim of this study was to evaluate the comparative efficacy of three commonly used analgesics (Panadeine, Diflunisal and Etodolac) in the control of pain after third molar surgery under local anaesthesia. METHODS: A randomized control study. Outcome of primary efficacy was judged by overall assessment of the area under the curve of graphs for pain intensity, measured from serial visual analogue scales over a 24-hour period. Other measures of efficacy included the number (per cent) of patients who took 'additional' analgesics and the incidence of adverse effects occurring in each treatment group over the study period. RESULTS: The three drugs were effective in the control of post-operative pain (p<0.01). Variations in pain intensity and the use of additional medication between the treatment groups were observed over the study period. The Diflunisal group experienced less pain than the Panadeine or Etodolac group (p<0.01). Furthermore, a lesser number of those in the Diflunisal group used additional medication compared to the other two groups (p<0.01). The incidence of side effects from all three drugs was low. CONCLUSION: Diflunisal is superior in the control of pain following third molar surgery under local anaesthesia than either Panadeine or Etodolac, and has few side effects.

Pipeline embolization device for intracranial aneurysm: a systematic review.

INTRODUCTION: The pipeline embolization device (PED) is a new endovascular stent designed for the treatment of challenging intracranial aneurysms (IAs). Its use has been extended to nonruptured and ruptured IAs of a variety of configurations and etiologies in both the anterior and posterior circulations. METHODS: We conducted a systematic review of ten eligible reports on its clinical efficacy and safety. RESULTS: There were 414 patients with 448 IAs. The majority of the IAs were large (40.2 %), saccular or blister-like (78.3 %), and were located mostly in the anterior circulation (83.5 %). The regimens of antiplatelet therapy varied greatly between and within studies. The mean number of the PED used was 2.0 per IA. Deployment was successful in around 95 % of procedures. Aneurysm obliteration was achieved in 82.9 % of IAs at 6-month. The overall incidences of periprocedural intracranial vascular complication rate and mortality rate were 6.3 and 1.5 %, respectively. CONCLUSION: The PED is a safe and effective treatment for nonruptured IAs. Its use in the context of acute subarachnoid hemorrhage (SAH) should be cautioned. Its main limitations include the need for prolonged antiplatelet therapy, as well as the potential risks of IA rupture and non-IA-related intracerebral hemorrhages (ICH). Future studies should aim at identifying factors that predispose to incomplete obliteration, delayed rupture, and thromboembolic complications.