Cerebral venous thrombosis: continental disparities.

Cerebral venous thrombosis (CVT) usually accounts for < 1% of all strokes. Global disparity and diversity in their demographics, etiology, clinical features, radiological presentation, and mortality have not been previously explored. A systematic search was performed for publications in PubMed using key words "cerebral venous thrombosis," "Cerebral vein thrombosis," and "Cortical vein Thrombosis." A total of 600 relevant studies were abstracted with strict selection criteria, and a total of 7048 patient's data were used for the final analysis. The frequency and relative frequency statistics were used to describe the data. Cases reported were Europe-3152, Asia-2722, North America-852, Africa-122, Australia-121, and South America-79. Overall male to female ratio was 1:2.2; among clinical characteristics, headache was the most common symptom and hematological factors were the most common etiology. Location of the thrombosis was described mostly in the transverse sinus. Intercontinental differences in relation to demographics, etiology, clinical features, radiological presentation, and mortality were identified. CVT can have significant disparity in their demographics, etiology, clinical features, radiological presentation, and mortality when compared from one continent to other. It is important for the worldwide physicians to recognize these differences and to follow the most recent guidelines, diagnostic methods, and treatment to insure the best outcome and prognosis.

Awareness of the CDC "Heads Up!" to Youth Sports Campaign among Pediatric Sports Coaches: A Pilot Survey Study.

OBJECTIVES: This study sought to: 1) estimate the penetrance (in terms of youth coaches being aware of them) of the CDC "Heads Up!" guidelines, 2) determine whether these guidelines changed the coaches' practice, and 3) understand whether these guidelines resulted in a perceived decrease in the number of concussions. METHODS: This was a cross-sectional survey of pediatric sports coaches in the United States designed to assess the impact of the CDC "Heads Up!" GUIDELINES: "Heads Up!" Concussion in Youth Sports is a free, online course available to coaches, parents, and others helping to keep athletes safe from concussions. The "Heads Up!" fact sheet provides important information on preventing, recognizing, and responding to a concussion. RESULTS: Half the cohort had heard of the CDC "Heads Up!" campaign. Fifty-five percent of the cohort thought that pediatric concussions in youth sports was a "big deal" (rated on a Likert scale from 1-10). Coaches who were also parents (58%) were significantly more likely to have heard of the campaign (P=0.0032, 95% CI=0.1153-0.5513). Having heard of the "Heads Up!" campaign was significantly associated with how important coaches thought pediatric concussions are (P=0.0133, 95% CI=0.0590-0.4960), as was higher income of the coaches (P=0.0100), and this was significantly correlated with the coach being more likely to call the athlete's parent at injury (P=0.0030, 95% CI=0.1160-0.5471). Coaches of football/soccer were significantly more likely to think pediatric concussions were a "big deal" (P=0.0021,95% CI=0.1374-0.5947). More than a third of coaches 35% reported that the "Heads Up!" campaign decreased the number of concussions on their team.

Rare Etiology of Bow Hunter's Syndrome and Systematic Review of Literature.

BACKGROUND: Bow Hunter's Syndrome is a mechanical occlusion of the vertebral artery which leads to a reduction in blood flow in posterior cerebral circulation resulting in transient reversible symptomatic vertebrobasilar insufficiency. CASE DESCRIPTION: We present a case of Bow Hunter's syndrome in a 53-year-old male that occurred after the patient underwent surgical correction of a proximal left subclavian artery aneurysm. Shortly after the surgery, the patient began to complain of transient visual changes, presyncopal spells, and dizziness upon turning his head to the left. A transcranial doppler ultrasound confirmed the diagnosis of Bow Hunter's syndrome. SYSTEMIC REVIEW: We analyzed the data on 153 patients with Bow Hunter's syndrome from the literature. An osteophyte was the most common cause of vertebral artery occlusion, and left vertebral artery was more commonly involved in patients with Bow Hunter's syndrome. Dynamic angiography was the definitive imaging modality to confirm the diagnosis, and surgery was most successful in alleviating symptoms. CONCLUSION: We believe that this is the first case of iatrogenic Bow Hunter's syndrome after surgical intervention for an aneurysm repair, and the largest review of literature of Bow Hunter's syndrome. Dynamic angiography is the gold standard for the diagnosis of Bow Hunter's syndrome. Surgery should be considered as the primary treatment approach in these patients, especially those who have bony compression as the etiology.

Hemispheric differences in malignant middle cerebral artery stroke.

BACKGROUND: We recently reported that left versus right hemisphere cerebral infarctions patients more frequently have worse outcomes. However our clinical experience led us to suspect that the incidence of malignant middle cerebral artery infarctions (MMCA) was higher in the right compared to the left hemispheric strokes. OBJECTIVE: To determine whether laterality in MMCA stroke is an important determinant of stroke sequelae. METHODS: A systematic search was performed for publications in PubMed using "malignant middle cerebral artery and infarction". A total of 73 relevant studies were abstracted. RESULTS: MMCA laterality data were available for 2673 patients, with 1687 (63%) right hemispheric involvement, thus right being more commonly associated with MMCA (binomial test, p<0.05). While mortality rates were similar, right hemispheric MMCA (n=271) had mortality of 31% (n=85) whereas left hemispheric MMCA (n=144) had mortality of 36% (n=53), morbidity rates were worse on the right. CONCLUSION: MMCA stroke appears to be more common on the right, and this laterality is also associated with significantly higher morbidity. Further prospective studies are needed to more completely understand the nature of this laterality as well as test possible new treatments to reduce mortality and morbidity associated with MMCA.

Mechanisms of arm paresis in middle cerebral artery distribution stroke: pilot study.

The development of effective neurobiological adjuvants to rehabilitation of paresis caused by stroke will depend on understanding mechanisms of paresis. Our objective was to determine the extent to which upper-limb (UL) paresis after nonlacunar ischemic middle cerebral artery (MCA) distribution stroke is caused by infarction of posterior periventricular white matter (PVWM), where corticospinal fibers serving movement descend, and caused by infarction of the arm-hand region of precentral gyrus (ahPCG). We conducted a blinded, retrospective analysis of computed tomography and magnetic resonance imaging from a convenience sample of 64 prospectively evaluated subjects with UL paresis resulting from MCA distribution stroke. Of the subjects, 96.5% had PVWM involvement while 53% had minimal or no ahPCG involvement. Even in subjects with no UL function, 56% had very minimal infarction (<25%) of the ahPCG. Degree of paresis was statistically associated with presence or absence of detectable posterior PVWM damage but not with extent of ahPCG involvement. These preliminary findings suggest that posterior PVWM involvement may be a major, if not the principal, determinant of paresis in all hemispheric ischemic strokes and motivate further prospective studies of this problem.

Endothelin-1 induced middle cerebral artery occlusion model for ischemic stroke with laser Doppler flowmetry guidance in rat.

Stroke is the number one cause of disability and third leading cause of death in the world, costing an estimated $70 billion in the United States in 2009. Several models of cerebral ischemia have been developed to mimic the human condition of stroke. It has been suggested that up to 80% of all strokes result from ischemic damage in the middle cerebral artery (MCA) area. In the early 1990s, endothelin-1 (ET-1) was used to induce ischemia by applying it directly adjacent to the surface of the MCA after craniotomy. Later, this model was modified by using a stereotaxic injection of ET-1 adjacent to the MCA to produce focal cerebral ischemia. The main advantages of this model include the ability to perform the procedure quickly, the ability to control artery constriction by altering the dose of ET-1 delivered, no need to manipulate the extracranial vessels supplying blood to the brain as well as gradual reperfusion rates that more closely mimics the reperfusion in humans. On the other hand, the ET-1 model has disadvantages that include the need for a craniotomy, as well as higher variability in stroke volume. This variability can be reduced with the use of laser Doppler flowmetry (LDF) to verify cerebral ischemia during ET-1 infusion. Factors that affect stroke variability include precision of infusion and the batch of the ET-1 used. Another important consideration is that although reperfusion is a common occurrence in human stroke, the duration of occlusion for ET-1 induced MCAO may not closely mimic that of human stroke where many patients have partial reperfusion over a period of hours to days following occlusion. This protocol will describe in detail the ET-1 induced MCAO model for ischemic stroke in rats. It will also draw attention to special considerations and potential drawbacks throughout the procedure.