Smartphone teleradiology application is successfully incorporated into a telestroke network environment.

BACKGROUND AND PURPOSE: ResolutionMD mobile application runs on a Smartphone and affords vascular neurologists access to radiological images of patients with stroke from remote sites in the context of a telemedicine evaluation. Although reliability studies using this technology have been conducted in a controlled environment, this study is the first to incorporate it into a real-world hub and spoke telestroke network. The study objective was to assess the level of agreement of brain CT scan interpretation in a telestroke network between hub vascular neurologists using ResolutionMD, spoke radiologists using a Picture Archiving and Communications System, and independent adjudicators. METHODS: Fifty-three patients with stroke at the spoke hospital consented to receive a telemedicine consultation and participate in a registry. Each CT was evaluated by a hub vascular neurologist, a spoke radiologist, and by blinded telestroke adjudicators, and agreement over clinically important radiological features was calculated. RESULTS: Agreement (κ and 95% CI) between hub vascular neurologists using ResolutionMD and (1) the spoke radiologist; and (2) independent adjudicators, respectively, were: identification of intracranial hemorrhage 1.0 (0.92-1.0), 1.0 (0.93-1.0), neoplasm 1.0 (0.92-1.0), 1.0 (0.93-1.0), any radiological contraindication to thrombolysis 1.0 (0.92-1.0), 0.85 (0.65-1.0), early ischemic changes 0.62 (0.28-0.96), 0.58 (0.30-0.86), and hyperdense artery sign 0.40 (0.01-0.80), 0.44 (0.06-0.81). CONCLUSIONS: CT head interpretations of telestroke network patients by vascular neurologists using ResolutionMD on Smartphones were in excellent agreement with interpretations by spoke radiologists using a Picture Archiving and Communications System and those of independent telestroke adjudicators using a desktop viewer. CLINICAL TRIAL REGISTRATION INFORMATION: www.clinicaltrials.gov unique identifier NCT00829361.

Anti-inflammatory activities, triterpenoids, and diarylheptanoids of Alnus acuminata ssp. arguta.

CONTEXT: The main use of stem bark infusions of Alnus acuminata ssp. arguta (Schlecht.) Furlow (Betulaceae) includes treatments for acute inflammation in Mexican traditional medicine. OBJECTIVE: n-Hexane (CHE), chloroform (CCE), and methanol (CME) extracts of the stem bark were investigated for anti-inflammatory activity and its safety. MATERIALS AND METHODS: The anti-inflammatory effects of the orally administered CME, CCE, and CHE extracts, using carrageenan-induced rat hind paw edema model, and acute oral toxicity in mice, using Lorke's method, were determined. RESULTS AND DISCUSSION: The column chromatographic fraction (CME-3) showed a higher anti-inflammatory activity (92.2%) (IC(50): 60.8 mg/mL) as compared with CME (76.9%); both were in the same order of magnitude as that of indomethacin, the positive control drug. Safety parameters for acute oral toxicity test showed that CME was not toxic (LD(50): >5000). Several triterpenoids (1-7) from hexane extracts and diarylheptanoids (10-14) from methanol extracts of A. acuminata ssp. arguta were isolated and characterized. CONCLUSIONS: These results confirm the traditional uses of A. acuminata in acute inflammatory conditions and its safety for consumption.

Update in intracerebral hemorrhage.

Spontaneous, nontraumatic intracerebral hemorrhage (ICH) is defined as bleeding within the brain parenchyma. Intracranial hemorrhage includes bleeding within the cranial vault and encompasses ICH, subdural hematoma, epidural bleeds, and subarachnoid hemorrhage (SAH). This review will focus only on ICH. This stroke subtype accounts for about 10% of all strokes. The hematoma locations are deep or ganglionic, lobar, cerebellar, and brain stem in descending order of frequency. Intracerebral hemorrhage occurs twice as common as SAH and is equally as deadly. Risk factors for ICH include hypertension, cerebral amyloid angiopathy, advanced age, antithrombotic therapy and history of cerebrovascular disease. The clinical presentation is "stroke like" with sudden onset of focal neurological deficits. Noncontrast head computerized tomography (CT) scan is the standard diagnostic tool. However, newer neuroimaging techniques have improved the diagnostic yield in terms of underlying pathophysiology and may aid in prognosis. Intracerebral hemorrhage is a neurological emergency. Medical care begins with stabilization of airway, breathing function, and circulation (ABCs), followed by specific measures aimed to decrease secondary neurological damage and to prevent both medical and neurological complications. Reversal of coagulopathy when present is of the essence. Blood pressure management can be key and continues as an area of debate and ongoing research. Surgical evacuation of ICH is of unproven benefit though a subset of well-selected patients may have improved outcomes. Ventriculostomy and intracranial pressure (ICP) monitoring are interventions also used in this patient population. To date, hemostatic medications and neuroprotectants have failed to result in clinical improvement. A multidisciplinary approach is recommended, with participation of vascular neurology, vascular neurosurgery, critical care, and rehabilitation medicine as the main players.

The role of corticosteroids in the management of chronic subdural hematomas: a critically appraised topic.

BACKGROUND: Chronic subdural hematomas (CSDH) occur most commonly in the elderly population. When CSDH patients present with a moderate or severe neurologic deficit and are good surgical candidates, surgery is regarded as the ideal option. However, CSDH patients often have only mild neurologic deficits or are not optimal candidates for surgery. Corticosteroids are often used on these subgroups, but the benefit of this intervention is unknown. Optimal treatment for these patients is not well established. OBJECTIVE: Critically evaluate the role of corticosteroids in the management of CSDH. METHODS: The objective was addressed through the development of a structured critically appraised topic. This included a clinical scenario with a structured question, search strategy, critical appraisal, results, evidence summary, commentary, and bottom line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and clinical content experts in the fields of vascular neurology and neurosurgery. RESULTS: No randomized controlled trials on the topic were discovered. A prospective cohort study was selected as the best currently available evidence. CONCLUSION: The role of corticosteroids in the management of CSDH is not well defined. Current evidence neither supports nor refutes the use of corticosteroids. A randomized controlled trial is warranted.

Does prophylactic postoperative hypervolemic therapy prevent cerebral vasospasm and improve clinical outcome after aneurysmal subarachnoid hemorrhage?

BACKGROUND: Delayed cerebral vasospasm is a common cause of morbidity and mortality after acute aneurysmal subarachnoid hemorrhage. Hypovolemia and fluid restriction are risk factors for delayed vasospasm; hypervolemic therapeutic approaches are commonly used in patients with subarachnoid hemorrhage to prevent and to treat cerebral vasospasm. OBJECTIVE: To determine if postoperative prophylactic hypervolemic therapy prevents cerebral vasospasm and improves clinical outcome in patients with aneurysmal subarachnoid hemorrhage. METHODS: The objective was addressed through the development of a structured critically appraised topic. This included a clinical scenario, structured question, search strategy, critical appraisal, results, evidence summary, commentary, and bottom line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of vascular neurology. RESULTS: One randomized controlled trial addressed the questions. There was no difference in the incidence of symptomatic cerebral vasospasm (20% each) or clinical outcome at 14 days and 3 months between the hypervolemic and normovolemic groups. Hypervolemic therapy also had no effect on measures of cerebral blood flow. A second quasi-randomized trial reached the same conclusions. CONCLUSION: Available evidence is insufficient to support use of prophylactic hypervolemic therapy after surgery in patients with aneurysmal subarachnoid hemorrhage. Although completed studies may be insufficiently sensitive (underpowered) to detect a treatment effect, the magnitude of any as yet undetected benefit of prophylactic hypervolemic therapy is likely modest and its risks have not been systematically evaluated.