White Matter Hyperintensity Volume Influences Symptoms in Patients Presenting With Minor Neurological Deficits.

Background and Purpose- Acute minor neurological deficits are a common complaint in the emergency department and differentiation of transient ischemic attack/minor stroke from a stroke mimic is difficult. We sought to assess the ability of white matter hyperintensity (WMH) volume to aid the diagnosis in such patients. Methods- This is a post hoc analysis of the previously published SpecTRA study (Spectrometry in TIA Rapid Assessment) of adult patients that presented to the emergency department with acute minor neurological deficits between December 2013 and March 2017. WMH volumes were measured if fluid-attenuated inversion recovery imaging was available. Outcomes of interest were final diagnosis, symptoms at presentation, and 90-day stroke recurrence. Results- WMH volume was available for 1485 patients. Median age was 70 years (interquartile range, 59-80), and 46.7% were female. Mean WMH volume was higher in transient ischemic attack/minor strokes compared with stroke mimics (1.71 ln mL [95% CI, 1.63-1.79 ln mL] versus 1.15 ln mL [95% CI, 1.02-1.27 ln mL], P<0.001). In multivariable-adjusted logistic regression analysis, WMH volume was not associated with final diagnosis. However, the combination of both diffusion-weighted imaging positivity and high WMH volume led to lower odds of focal symptoms at presentation (P=0.035). Conclusions- The combination of diffusion-weighted imaging positivity and high WMH volume was associated with lower odds of focal symptoms at presentation in patients seen with minor neurological deficits in the emergency department. This suggests that WMH volume might be an important consideration and the absence of focal symptoms at presentation should not discourage clinicians from further investigating patients with suspected cerebral ischemia.

Association of White Matter Hyperintensities With Short-Term Outcomes in Patients With Minor Cerebrovascular Events.

BACKGROUND AND PURPOSE: White matter lesions (WML) are associated with cognitive decline, increased stroke risk, and disability in old age. We hypothesized that superimposed acute cerebrovascular occlusion on chronic preexisting injury (leukoaraiosis) leads to worse outcome after minor cerebrovascular event, both using quantitative (volumetric) and qualitative (Fazekas scale) assessment, as well as relative total brain volume. METHODS: WML volume assessment was performed in 425 patients with high-risk transient ischemic attack (TIA; motor/speech deficits >5 minutes) or minor strokes from the CATCH study (CT and MRI in the Triage of TIA and Minor Cerebrovascular Events to Identify High Risk Patients). Complete baseline characteristics and outcome assessment were available in 412 patients. Primary outcome was disability at 90 days, defined as modified Rankin Scale score of >1. Secondary outcomes were stroke progression, TIA recurrence, and stroke recurrence. Analysis was performed using descriptive statistics and regression models including interaction terms. RESULTS: Median age was 69 years, 39.8% were female. Sixty-two patients (15%) had unfavorable outcome with disability at 90 days (modified Rankin Scale score >1). Higher Fazekas scores were strongly correlated with higher WML volume (r=0.79). Both higher Fazekas score and higher WMH volume were associated with disability at 90 days in univariate regression (odds ratio 1.22; 95% confidence interval, 1.04-1.43 and odds ratio, 1.25 per milliliter increase; 95% confidence interval, 1.02-1.54, respectively) but not with stroke progression, TIA recurrence, or stroke recurrence. In multivariable-adjusted analyses, additive interaction terms were associated with unfavorable outcome (adjusted odds ratio 3.99, 95% confidence interval, 1.87-8.49). CONCLUSIONS: Our data suggest that quantitative and qualitative WML assessments are highly correlated and comparable in TIA/minor stroke patients. WML burden is associated with short-term outcome of patients with good prestroke function in the presence of intracranial stenosis/occlusion.

Validation of a proteomic biomarker panel to diagnose minor-stroke and transient ischaemic attack: phase 2 of SpecTRA, a large scale translational study.

OBJECTIVE: To validate our previously developed 16 plasma-protein biomarker panel to differentiate between transient ischaemic attack (TIA) and non-cerebrovascular emergency department (ED) patients. METHOD: Two consecutive cohorts of ED patients prospectively enrolled at two urban medical centers into the second phase of SpecTRA study (training, cohort 2A, n = 575; test, cohort 2B, n = 528). Plasma samples were analyzed using liquid chromatography/multiple reaction monitoring-mass spectrometry. Logistic regression models which fit cohort 2A were validated on cohort 2B. RESULTS: Three of the panel proteins failed quality control and were removed from the panel. During validation, panel models did not outperform a simple motor/speech (M/S) deficit variable. Post-hoc analyses suggested the measured behaviour of L-selectin and coagulation factor V contributed to poor model performance. Removal of these proteins increased the external performance of a model containing the panel and the M/S variable. CONCLUSIONS: Univariate analyses suggest insulin-like growth factor-binding protein 3 and serum paraoxonase/lactonase 3 are reliable and reproducible biomarkers for TIA status. Logistic regression models indicated L-selectin, apolipoprotein B-100, coagulation factor IX, and thrombospondin-1 to be significant multivariate predictors of TIA. We discuss multivariate feature subset analyses as an exploratory technique to better understand a panel's full predictive potential.

Progressive Perineal Urethroplasty for Pelvic Fracture Urethral Distraction Defect in Prepubertal Children: The Outcome.

BACKGROUND: Urethroplasty in pediatric patients is a challenging task. In this study, we have tried to assess the complexity and evaluate the outcome of progressive perineal anastomotic urethroplasty in prepubertal children. MATERIALS AND METHODS: Retrospective data of all the prepubertal children who underwent progressive perineal urethroplasty between March 2009 and April 2014 were analyzed. Patients were evaluated with history, examination, essential laboratory investigations, retrograde urethrogram, and voiding cystourethrogram. Before subjecting the patients for definitive surgery, antegrade and retrograde endoscopic assessment was done. The surgery was performed by the transperineal route with the help of ×2.5 magnification. Patients were followed up with uroflowmetry for every 3 months in the 1st year and for every 6 months in the subsequent years. RESULTS: Mean age of the patients was 7.3 (range 5-11) years. Mean urethral distraction defect was 1.7 (range 1-2.5) cm. All the patients were successfully managed by the perineal approach. Crural separation was performed in all the patients while additional inferior pubectomy was required in six patients. Mean operating time was 298 (range 180-400) min. Mean blood loss was 174 (range 100-500) ml. One patient had the left calf hematoma in the immediate postoperative period. Seven out of nine (77.7%) patients had successful urethroplasty. Two patients had failed urethroplasty who were successfully managed by redo-urethroplasty. Transient incontinence was observed in one patient. Erectile function could not be assessed in these patients. CONCLUSION: This study shows the feasibility of progressive perineal urethroplasty by the perineal route in prepubertal children. An endoscopic assessment should be performed before the definitive surgery. Use of loupe helps in performing better anastomosis and hence yielding a better result.

Cerebral Microbleeds and Cortical Superficial Siderosis in Patients Presenting With Minor Cerebrovascular Events.

BACKGROUND AND PURPOSE: Transient focal neurological episodes occur in cerebral amyloid angiopathy (CAA) and can mimic transient ischemic attack (TIA). Risk factors and outcomes of minor ischemic stroke or TIA might differ in patients with and without cerebral microbleeds (CMBs), including CAA-consistent lobar CMB. METHODS: Baseline magnetic resonance imaging (MRI) was analyzed for CMBs and cortical superficial siderosis in 416 patients in the prospective computed tomography and MRI in the CATCH study (Triage of TIA and Minor Cerebrovascular Events to Identify High Risk Patients). Clinical symptoms, baseline characteristics, recurrence, and 90-day modified Rankin Scale were prospectively collected. MRI white-matter hyperintensity was measured using the Fazekas scale. RESULTS: CMBs were detected in 65 (15.6%) and cortical superficial siderosis in 11 patients (2.6%). Lobar CMBs were present in 49 (11.8%). In multivariable logistic regression adjusted for risk factors and age, subcortical Fazekas score was associated with lobar CMB (odds ratio, 2.07; 95% confidence interval, 1.23-3.48; P=0.006). Forty-two patients (10.1%) had lobar-only CMBs with or without cortical superficial siderosis consistent with modified Boston criteria for possible/probable CAA. The possible/probable CAA pattern was not predictive of recurrent TIA (odds ratio, 0.42; 95% confidence interval, 0.05-3.31; P=0.41), stroke (odds ratio, 1.24; 95% confidence interval, 0.26-5.99; P=0.79), or 90-day modified Rankin Scale score ≥2 (odds ratio, 1.38; 95% confidence interval, 0.62-3.07; P=0.42). CONCLUSIONS: CMBs in TIA and minor stroke are moderately common but do not predict recurrence or 90-day outcome. CAA-related transient focal neurological episodes and TIA have overlapping clinical symptoms, suggesting that MRI may be needed for differentiation.

Early cerebral small vessel disease and brain volume, cognition, and gait.

OBJECTIVE: Decline in cognitive function begins by the 40s, and may be related to future dementia risk. We used data from a community-representative study to determine whether there are age-related differences in simple cognitive and gait tests by the 40s, and whether these differences were associated with covert cerebrovascular disease on magnetic resonance imaging (MRI). METHODS: Between 2010 and 2012, 803 participants aged 40 to 75 years in the Prospective Urban Rural Epidemiological (PURE) study, recruited from prespecified postal code regions centered on 4 Canadian cities, underwent brain MRI and simple tests of cognition and gait as part of a substudy (PURE-MIND). RESULTS: Mean age was 58 ± 8 years. Linear decreases in performance on the Montreal Cognitive Assessment, Digit Symbol Substitution Test (DSST), and Timed Up and Go test of gait were seen with each age decade from the 40s to the 70s. Silent brain infarcts were observed in 3% of 40- to 49-year-olds, with increasing prevalence up to 18.9% in 70-year-olds. Silent brain infarcts were associated with slower timed gait and lower volume of supratentorial white matter. Higher volume of supratentorial MRI white matter hyperintensity was associated with slower timed gait and worse performance on DSST, and lower volumes of the supratentorial cortex and white matter, and cerebellum. INTERPRETATION: Covert cerebrovascular disease and its consequences on cognitive and gait performance and brain atrophy are manifest in some clinically asymptomatic persons as early as the 5th decade of life.

Can deceased donor with recurrent primary brain tumor donate kidneys for transplantation?

Kidney transplantation from deceased donors is in its infancy in India. Cadaver organ donation was accepted legally in 1994 by the "Human Organs Transplantation Act." Marginal donors are now accepted by many centers for kidney transplantation. We report a case of procurement of both kidneys from a young deceased donor having recurrent primary brain tumor, transplanted into two adult recipients with successful outcome.

Etiologic classification of TIA and minor stroke by A-S-C-O and causative classification system as compared to TOAST reduces the proportion of patients categorized as cause undetermined.

BACKGROUND: The assortment of patients based on the underlying pathophysiology is central to preventing recurrent stroke after a transient ischemic attack and minor stroke (TIA-MS). The causative classification of stroke (CCS) and the A-S-C-O (A for atherosclerosis, S for small vessel disease, C for Cardiac source, O for other cause) classification schemes have recently been developed. These systems have not been specifically applied to the TIA-MS population. We hypothesized that both CCS and A-S-C-O would increase the proportion of patients with a definitive etiologic mechanism for TIA-MS as compared with TOAST. METHODS: Patients were analyzed from the CATCH study. A single-stroke physician assigned all patients to an etiologic subtype using published algorithms for TOAST, CCS and ASCO. We compared the proportions in the various categories for each classification scheme and then the association with stroke progression or recurrence was assessed. RESULTS: TOAST, CCS and A-S-C-O classification schemes were applied in 469 TIA-MS patients. When compared to TOAST both CCS (58.0 vs. 65.3%; p < 0.0001) and ASCO grade 1 or 2 (37.5 vs. 65.3%; p < 0.0001) assigned fewer patients as cause undetermined. CCS had increased assignment of cardioembolism (+3.8%, p = 0.0001) as compared with TOAST. ASCO grade 1 or 2 had increased assignment of cardioembolism (+8.5%, p < 0.0001), large artery atherosclerosis (+14.9%, p < 0.0001) and small artery occlusion (+4.3%, p < 0.0001) as compared with TOAST. Compared with CCS, using ASCO resulted in a 20.5% absolute reduction in patients assigned to the 'cause undetermined' category (p < 0.0001). Patients who had multiple high-risk etiologies either by CCS or ASCO classification or an ASCO undetermined classification had a higher chance of having a recurrent event. CONCLUSION: Both CCS and ASCO schemes reduce the proportion of TIA and minor stroke patients classified as 'cause undetermined.' ASCO resulted in the fewest patients classified as cause undetermined. Stroke recurrence after TIA-MS is highest in patients with multiple high-risk etiologies or cryptogenic stroke classified by ASCO.

Validity of the diagnostic criteria for chronic cerebrospinal venous insufficiency and association with multiple sclerosis.

BACKGROUND: The chronic cerebrospinal venous insufficiency theory proposes that altered cerebral venous hemodynamics play a role in the pathophysiology of multiple sclerosis. We aimed to explore the validity of this hypothesis by assessing the diagnostic criteria for chronic cerebrospinal venous insufficiency in persons with and without multiple sclerosis. METHODS: We compared the proportion of venous outflow abnormalities between patients with multiple sclerosis and healthy controls using extracranial Doppler ultrasonography and gadolinium-enhanced magnetic resonance venography. Interpreting radiologists were blinded to the clinical status of participants. RESULTS: We enrolled 120 patients with multiple sclerosis and 60 healthy controls. High proportions of both patients (67/115 [58%]) and controls (38/60 [63%]) met 1 or more of the proposed ultrasound criteria for diagnosis of chronic cerebrospinal venous insufficiency (p = 0.6). A minority of patients (23/115 [20%]) and controls (6/60 [10%]) fulfilled 2 or more of the proposed criteria (p = 0.1). There were no differences between patients and controls in the prevalence of each individual ultrasound criterion. Similarly, there were no differences in intracranial or extracranial venous patency between groups, as measured by magnetic resonance venography. INTERPRETATION: We detected no differences in the proportion of venous outflow abnormalities between patients with multiple sclerosis and healthy controls. Moreover, our study revealed significant methodologic concerns regarding the proposed diagnostic criteria for chronic cerebrospinal venous insufficiency that challenge their validity.

Robotic assisted kidney transplantation.

Kidney transplantation is the standard of care for patients with end stage renal disease. While open surgery remains the gold standard, minimally invasive surgery has recently been introduced for the recipient undergoing kidney transplantation. We review the evolution of techniques of minimally invasive surgery for kidney transplantation with specific emphasis on technical aspects of robotic assisted kidney transplantation.

Early magnetic resonance imaging in transient ischemic attack and minor stroke: do it or lose it.

BACKGROUND AND PURPOSE: The use of magnetic resonance imaging (MRI) after transient ischemic attack (TIA) or minor stroke may be affected by the relative timing of imaging. We measured the impact of scanning an individual patient late versus early after TIA and minor stroke. METHODS: Two hundred sixty-three TIA or minor stroke (National Institute of Health Stroke Scale score ≤3) patients with a baseline MRI completed within 24 hours of symptom onset and a follow-up MRI at 90 days were included. Baseline and 90-day scans were assessed independently for the presence of any stroke lesions that could explain the presenting symptoms. The presence and pattern of any stroke lesions were compared at the 2 time points. RESULTS: The presence of a stroke (acute or chronic) in any location was more common on baseline MRI versus 90-day MRI (68% vs 56%; P=0.005). Thirty percent of subjects with negative scans at 90 days had a clearly identifiable stroke at baseline. When interpreted blinded to the baseline scan, the presumed relevant lesion on the 90-day MR scan was the correct lesion in only 53% patients. One-third (34%) of patients had a different lesion pattern on the baseline scan compared with the 90-day scan. Ninety percent (80/89) of these patients had more lesions on the baseline MRI and 10% (9/89) had new lesions on the 90-day MRI. CONCLUSIONS: Delayed MRI after TIA or minor stroke reduces the diagnostic yield and results in missed understanding of the lesion pattern. MRI of minor stroke and TIA patients should occur early after symptom onset, and delayed imaging should be interpreted with caution.

Perfusion MR predicts outcome in high-risk transient ischemic attack/minor stroke: a derivation-validation study.

BACKGROUND AND PURPOSE: Transient or minor ischemic stroke is associated with an early risk of deterioration. Baseline perfusion-diffusion mismatch may predict clinical deterioration and infarct growth in this population. METHODS: High-risk transient ischemic attack and minor stroke (National Institutes of Health Stroke Scale ≤3) subjects were prospectively enrolled and imaged with MRI within 24 hours of symptom onset as part of sequential derivation and validation cohorts. Baseline diffusion-weighted imaging, perfusion-weighted imaging (Tmax≥4 s), mismatch (Tmax≥4 s-diffusion-weighted imaging), and follow-up fluid-attenuated inversion recovery infarct volumes were measured. Primary outcome was infarct growth on fluid-attenuated inversion recovery, and secondary outcome was symptom progression. RESULTS: One hundred thirty-seven and 281 subjects were included in the derivation and validation cohorts, respectively. Infarct growth occurred in 18.5% of the derivation and 5.5% of the validation cohorts. Symptom progression occurred in 9.5% of the derivation and 4.5% of the validation cohorts. In the derivation cohort, subjects with baseline mismatch were significantly more likely to show infarct growth on fluid-attenuated inversion recovery (relative risk [RR], 13.5; 95% confidence interval [CI], 4.2-38.9) and symptom progression (RR, 7.0; 95% CI, 2.0-7.3). A baseline mismatch volume of 10 mL in the derivation cohort was the optimal threshold to predict infarct growth (area under the curve, 0.89; 95% CI, 0.80-0.98). This threshold was highly predictive of infarct growth in the validation cohort (P=0.001). Baseline mismatch was associated with clinical deterioration in the derivation (area under the curve, 0.81; 95% CI, 0.67-0.96) and validation cohorts (area under the curve, 0.66; 95% CI, 0.46-0.85). CONCLUSIONS: Among subjects with high-risk transient ischemic attack and minor stroke, diffusion-weighted imaging-perfusion-weighted imaging mismatch predicts infarct growth and clinical deterioration. These findings suggest that reperfusion strategies would be beneficial in this population.

The ICV sign as a marker of increased cerebral blood transit time.

OBJECTIVE/BACKGROUND: We describe the internal cerebral vein (ICV) sign, which is a hypo-opacification of the ICV on computed tomogram angiography (CTA) as a new marker of increased cerebral blood transit-time in ipsilateral internal carotid artery occlusions (ICAO). METHODS: A retrospective analysis of 153 patients with acute unilateral M1 middle cerebral artery (MCA) occlusions ± ICAOs was performed. The degree of contrast opacification of the ICV on the ipsilesional side was compared to that of the unaffected side. RESULTS: Of 153 patients in our study, 135 had M1 MCA occlusions ± intra-cranial ICAO (M1±iICAO) and 18 had isolated extracranial ICAO (eICAO). In the patients with proximal M1±iICAO, 57/65 (87.1%) showed the ICV sign. Of the 8 patients without the ICV sign in this group, 6 had prominent lenticulostriate arteries arising from the non-occluded M1 segment, 1 had a recurrent artery of Huebner, and 1 had filling of distal ICA/M1 segment through prominent Circle of Willis collaterals. For the 70 patients with isolated distal M1±iICAO, 7/70 (10%) showed the ICV sign, with all 7 showing occluded lenticulostriate arteries. Of the patients with eICAO, 8/18 showed the ICV sign, all 8 with the ICV sign had poor Circle of Willis collaterals. CONCLUSIONS: The ICV sign correlates well with presence of proximal M1±iICAO in patients with either occluded lenticulostriate arteries or poor Circle of Willis collaterals. In patients with eICAO, the sign correlates with reduced Circle of Willis collaterals and may be a marker of increased ipsilateral cerebral blood transit time.

Spontaneous closure of urethrovaginal fistula associated with pelvic fracture.

Female urethral injury following pelvic fracture is a rare entity. Due to the absence of large series, management guidelines are still not standardized. Patients can have associated urethrovaginal or vesicovaginal fistula, management of which poses a major challenge to the reconstructive urologist. Spontaneous closure of fistula produced by gynecological or obstetrical injuries have been described in the literature. Spontaneous closure of fistula caused due to pelvic fracture has not been described in the literature.

High rate of magnetic resonance imaging stroke recurrence in cryptogenic transient ischemic attack and minor stroke patients.

BACKGROUND AND PURPOSE: Cryptogenic stroke is common in patients with transient ischemic attack (TIA) and minor stroke. It is likely that the imaging recurrence risk is higher than the clinical recurrence rate. We sought to determine the rate of clinical and radiographic stroke recurrence in a population of cryptogenic TIA and minor stroke. METHODS: Patients with TIA/minor stroke (National Institutes of Health Stroke Scale score≤3) were prospectively enrolled and imaged within 24 hours of symptom onset as part of 2 cohorts. Patients were assessed at 3 months to document any clinical recurrence and underwent repeat magnetic resonance imaging (MRI) at either 30 or 90 days. Stroke mechanism was categorized as cryptogenic after standard etiologic work-up was completed and was negative. Follow-up MRI was assessed for any new lesions in comparison with baseline imaging. RESULTS: Three hundred thirty-three of 693 (48%) patients had cryptogenic stroke. Of these cryptogenic patients, 207 (62%) had follow-up imaging. At 30-day MRI follow-up, 6.6% (5/76) had new lesions (3 in a remote arterial territory). At 90-day MRI follow-up, 14.5% (19/131) had new lesions (9 in a remote arterial territory). Clinical recurrent stroke was seen in 1.2% (4/333) of patients within 90 days. CONCLUSIONS: Cryptogenic etiology is common in a TIA/minor stroke population. This population shows a high rate of silent radiographic recurrence, suggesting active disease. Use of MRI as a surrogate marker of disease activity is 1 potential way of assessing efficacy of new treatments in this population with reduced sample size.

CT/CT angiography and MRI findings predict recurrent stroke after transient ischemic attack and minor stroke: results of the prospective CATCH study.

BACKGROUND AND PURPOSE: Transient ischemic attack and minor stroke portend a substantial risk of recurrent stroke. MRI can identify patients at high risk for a recurrent stroke. However, MRI is not commonly available as an emergency. If similarly clinically predictive, a CT/CT angiographic (CTA) imaging strategy would be more widely applicable. METHODS: Five hundred ten patients with consecutive transient ischemic attack and minor stroke underwent CT/CTA and subsequent MRI. We assessed the risk of recurrent stroke within 90 days using standard clinical variables and predefined abnormalities on the CT/CTA (acute ischemia on CT and/or intracranial or extracranial occlusion or stenosis ≥50%) and MRI (diffusion-weighted imaging-positive). RESULTS: There were 36 recurrent strokes (7.1%; 95% CI, 5.0-9.6). Median time to the event was 1 day (interquartile range, 7.5). Median time from onset to CTA was 5.5 hours (interquartile range, 6.4 hours) and to MRI was 17.5 hours (interquartile range, 12 hours). Symptoms ongoing at first assessment (hazard ratio, 2.2; 95% CI, 1.02-4.9), CT/CTA abnormalities (hazard ratio, 4.0; 95% CI, 2.0-8.5), and diffusion-weighted imaging positivity (hazard ratio, 2.2; 95% CI, 1.05-4.7) predicted recurrent stroke. In the multivariable analysis, only CT/CTA abnormalities predicted recurrent stroke. In a secondary analysis, CT/CTA and MRI were not significantly different in their discriminative value in predicting recurrent stroke (0.67; (95% CI, 0.59-0.76 versus 0.59; 95% CI, 0.52-0.67; P=0.09). CONCLUSIONS: Early assessment of the intracranial and extracranial vasculature using CT/CTA predicts recurrent stroke and clinical outcome in patients with transient ischemic attack and minor stroke. In many institutions, CTA is more readily available than MRI and physicians should access whichever technique is more quickly available at their institution.

What causes disability after transient ischemic attack and minor stroke?: Results from the CT and MRI in the Triage of TIA and minor Cerebrovascular Events to Identify High Risk Patients (CATCH) Study.

BACKGROUND AND PURPOSE: Minor stroke and transient ischemic attack portend a significant risk of disability. Three possible mechanisms for this include disability not captured by the National Institutes of Health Stroke Scale, symptom progression, or recurrent stroke. We sought to assess the relative impact of these mechanisms on disability in a population of patients with transient ischemic attack and minor stroke. METHODS: Five hundred ten consecutive minor stroke (National Institutes of Health Stroke Scale<4) or patients with transient ischemic attack who were previously not disabled and had a CT/CT angiography completed within 24 hours of symptom onset were prospectively enrolled. Disability was assessed at 90 days using the modified Rankin Scale. Predictors of disability (modified Rankin Scale≥2) and the relative impact of the initial event versus recurrent events were assessed. RESULTS: Seventy-four of 499 (15%; 95% CI, 12%-18%) patients had a disabled outcome. Baseline factors predicting disability were: age≥60 years, diabetes mellitus, premorbid modified Rankin Scale 1, ongoing symptoms, baseline National Institutes of Health Stroke Scale, CT/CT angiography-positive metric, and diffusion-weighted imaging positivity. In the multivariable analysis ongoing symptoms (OR, 2.4; 95% CI, 1.3-4.4; P=0.004), diabetes mellitus (OR, 2.3; 95% CI, 1.2-4.3; P=0.009), female sex (OR, 1.8; 95% CI, 1.1-3; P=0.025), and CT/CT angiography-positive metric (OR, 2.4; 95% CI, 1.4-4; P=0.001) predicted disability. Of the 463 patients who did not have a recurrent event, 55 were disabled (12%). By contrast 19 of 36 (53%) patients were disabled after a recurrent event (risk ratio, 4.4; 95% CI, 3-6.6; P<0.0001). CONCLUSIONS: We found that a substantial proportion of patients with transient ischemic attack and minor stroke become disabled. In terms of absolute numbers, most patients have disability as a result of their presenting event; however, recurrent events have the largest relative impact on outcome.

Initial experience with a self-expanding retrievable stent for recanalization of large vessel occlusions in acute ischemic stroke.

INTRODUCTION: Quicker recanalization results in better clinical outcomes in patients with acute ischemic strokes. We describe our experience with the use of a self-expanding, fully retrievable stent in acute intracranial occlusions. METHODS: Patients who underwent intra-arterial procedures with a self-expanding, fully retrievable stent for acute ischemic strokes at our center in 2009 were included in this study. The primary outcome was recanalization [Thrombolysis in Myocardial Infarction (TIMI) grade 2/3] at end of procedure. Secondary endpoints were procedural interval times, incidence of vasospasm, rupture of vessels, device-related complications, groin complications, postprocedural intracerebral hemorrhage (ICH) on noncontrast CT, and all-cause mortality. RESULTS: Fourteen patients (mean age 62.1 years, range 34-81 years; six males) were included in the study. Sites of occlusion are as follows: M1 middle cerebral artery (MCA, n = 8), M2 MCA (n = 1), proximal basilar artery (n = 1), and distal basilar artery (n = 4). An additional device or technique was used in 9 of 14 patients prior to the use of the retrievable stent. Twelve out of 14 (85.7%) achieved TIMI 2-3 recanalization with 4 of 14 (28.6%) achieving TIMI 3. Eight of 14 (57.1%) patients had modified Rankin Scale (0-2) at 3 months or discharge. ICH on follow-up CT was noted in 28.6% (4 of 14) of patients. All-cause mortality was 2 of 14 (14.3%). CONCLUSION: Use of a novel self-expanding, fully retrievable stent resulted in fast and very high recanalization rates in acute ischemic strokes with intravascular occlusions.

Initial experience with the Penumbra Stroke System for recanalization of large vessel occlusions in acute ischemic stroke.

INTRODUCTION: The Penumbra system is a newly approved mechanical device for the treatment of acute stroke designed for better and faster recanalization. We describe our initial experience with the use of this device. METHODS: We studied 27 consecutive patients with acute ischemic strokes due to arterial occlusions presenting at our center from January to October 2009. The primary outcome was the degree of recanalization measured by thrombolysis in myocardial infarction (TIMI grade 2/3) at the end of the procedure. Secondary end points were the proportion of patients who achieved a modified Rankin scale (mRS) ≤2 at 3 months, all-cause mortality and intracerebral hemorrhage (ICH) on non contrast computed tomography at 24 h. Procedural complications were also recorded. RESULTS: Of 27 patients (13 male, mean age 61 years) in the study, 22 (81%) patients had anterior circulation strokes and five (18%) had posterior circulation strokes. Twenty-three (85%) patients achieved TIMI grade 2/3 recanalization at completion of the procedure. Excluding five patients who needed use of a second device, the Penumbra system achieved TIMI grade 2/3 recanalization in 67% of patients. Thirteen (48%) patients had mRS ≤2 at 3-month follow-up. Procedural and post-procedural complications included vasospasm (3.7%), distal emboli (48.1%), and ICH (33.3%). The distribution of ICH is as follows: hemorrhagic infarct type 1 (25.9%), parenchymal hemorrhage type 1 (3.7%), and parenchymal hemorrhage type 2 (3.7%). All-cause mortality was 19%. CONCLUSIONS: High recanalization rates and good clinical outcomes are achievable with the Penumbra system. Complication rates are comparable to a previously published literature.

A smartphone client-server teleradiology system for primary diagnosis of acute stroke.

BACKGROUND: Recent advances in the treatment of acute ischemic stroke have made rapid acquisition, visualization, and interpretation of images a key factor for positive patient outcomes. We have developed a new teleradiology system based on a client-server architecture that enables rapid access to interactive advanced 2-D and 3-D visualization on a current generation smartphone device (Apple iPhone or iPod Touch, or an Android phone) without requiring patient image data to be stored on the device. Instead, a server loads and renders the patient images, then transmits a rendered frame to the remote device. OBJECTIVE: Our objective was to determine if a new smartphone client-server teleradiology system is capable of providing accuracies and interpretation times sufficient for diagnosis of acute stroke. METHODS: This was a retrospective study. We obtained 120 recent consecutive noncontrast computed tomography (NCCT) brain scans and 70 computed tomography angiogram (CTA) head scans from the Calgary Stroke Program database. Scans were read by two neuroradiologists, one on a medical diagnostic workstation and an iPod or iPhone (hereafter referred to as an iOS device) and the other only on an iOS device. NCCT brain scans were evaluated for early signs of infarction, which includes early parenchymal ischemic changes and dense vessel sign, and to exclude acute intraparenchymal hemorrhage and stroke mimics. CTA brain scans were evaluated for any intracranial vessel occlusion. The interpretations made on an iOS device were compared with those made at a workstation. The total interpretation times were recorded for both platforms. Interrater agreement was assessed. True positives, true negatives, false positives, and false negatives were obtained, and sensitivity, specificity, and accuracy of detecting the abnormalities on the iOS device were computed. RESULTS: The sensitivity, specificity, and accuracy of detecting intraparenchymal hemorrhage were 100% using the iOS device with a perfect interrater agreement (kappa=1). The sensitivity, specificity, and accuracy of detecting acute parenchymal ischemic change were 94.1%, 100%, and 98.09% respectively for reader 1 and 97.05%, 100%, and 99.04% for reader 2 with nearly perfect interrater agreement (kappa=.8). The sensitivity, specificity, and accuracy of detecting dense vessel sign were 100%, 95.4%, and 96.19% respectively for reader 1 and 72.2%, 100%, and 95.23% for reader 2 using the iOS device with a good interrater agreement (kappa=.69). The sensitivity, specificity, and accuracy of detecting vessel occlusion on CT angiography scans were 94.4%, 100%, and 98.46% respectively for both readers using the iOS device, with perfect interrater agreement (kappa=1). No significant difference (P<.05) was noted in the interpretation time between the workstation and iOS device. CONCLUSION: The smartphone client-server teleradiology system appears promising and may have the potential to allow urgent management decisions in acute stroke. However, this study was retrospective, involved relatively few patient studies, and only two readers. Generalizing conclusions about its clinical utility, especially in other diagnostic use cases, should not be made until additional studies are performed.