Intravenous thrombolysis for patients with in-hospital stroke onset: propensity-matched analysis from the Safe Implementation of Treatments in Stroke-East registry.

BACKGROUND AND PURPOSE: Recent cross-sectional study data suggest that intravenous thrombolysis (IVT) in patients with in-hospital stroke (IHS) onset is associated with unfavorable functional outcomes at hospital discharge and in-hospital mortality compared to patients with out-of-hospital stroke (OHS) onset treated with IVT. We sought to compare outcomes between IVT-treated patients with IHS and OHS by analysing propensity-score-matched data from the Safe Implementation of Treatments in Stroke-East registry. METHODS: We compared the following outcomes for all propensity-score-matched patients: (i) symptomatic intracranial hemorrhage defined with the safe implementation of thrombolysis in stroke-monitoring study criteria, (ii) favorable functional outcome defined as a modified Rankin Scale (mRS) score of 0-1 at 3 months, (iii) functional independence defined as an mRS score of 0-2 at 3 months and (iv) 3-month mortality. RESULTS: Out of a total of 19 077 IVT-treated patients with acute ischaemic stroke, 196 patients with IHS were matched to 5124 patients with OHS, with no differences in all baseline characteristics (P > 0.1). Patients with IHS had longer door-to-needle [90 (interquartile range, IQR, 60-140) vs. 65 (IQR, 47-95) min, P < 0.001] and door-to-imaging [40 (IQR, 20-90) vs. 24 (IQR, 15-35) min, P < 0.001] times compared with patients with OHS. No differences were detected in the rates of symptomatic intracranial hemorrhage (1.6% vs. 1.9%, P = 0.756), favorable functional outcome (46.4% vs. 42.3%, P = 0.257), functional independence (60.7% vs. 60.0%, P = 0.447) and mortality (14.3% vs. 15.1%, P = 0.764). The distribution of 3-month mRS scores was similar in the two groups (P = 0.273). CONCLUSIONS: Our findings underline the safety and efficacy of IVT for IHS. They also underscore the potential of reducing in-hospital delays for timely tissue plasminogen activator delivery in patients with IHS.

Benefit of thrombolysis for stroke is maintained around the clock: results from the SITS-EAST Registry.

BACKGROUND AND PURPOSE: The outcome of thrombolysis for early morning and sleep time strokes may be worse because of uncertainty of stroke onset time or differences in logistics. The aim of the study was to analyze if stroke outcome after intravenous thrombolysis differs depending on time of day when the stroke occurs. METHODS: The data collected in the Safe Implementation of Treatments in Stroke - Eastern Europe (SITS-EAST) Registry between September 2000 and December 2011 were used. Strokes were categorized as night-time 00:00-07:59, day-time 08:00-15:59 and evening-time 16:00-23:59 and were compared in terms of several outcome measures. All results were adjusted for baseline differences. RESULTS: A total of 8878 patients were enrolled: 18% had night-time, 54% day-time and 28% evening-time strokes. Onset-to-treatment time in patients with night-time strokes was 10 min longer than in day-time and evening-time strokes (P < 0.001). Symptomatic intracerebral hemorrhage by ECASS II definition occurred in 5.6%, 5.6% and 5.3% (adjusted P = 0.41) of the night-time, day-time and evening-time stroke patients, respectively; by SITS definition it occurred in 2.5%, 1.9% and 1.3% (adjusted P = 0.013) and by NINDS definition in 7.8%, 7.6% and 7.5% (adjusted P = 0.74). Patients with night-time, day-time and evening-time strokes achieved modified Rankin Scale score 0-1 in 33%, 31%, 31% (adjusted P = 0.34) and 0-2 in 52%, 51%, 50% (adjusted P = 0.23), and 13%, 15%, 16% respectively of patients died (adjusted P = 0.17) by 3 months. CONCLUSIONS: The time when stroke occurs (day versus evening versus night) does not affect the outcome after thrombolysis despite the fact that patients with night-time strokes have worse time management.

Nasal nerve ablation, nasal swell body and inferior turbinate reduction for nasal obstruction and congestion relief.

OBJECTIVE: Nasal obstruction and congestion can occur because of turbinate and septal variations with or without rhinitis. A combined treatment for nasal obstruction and congestion was examined retrospectively in cases where the nasal swell body was addressed with inferior turbinectomy, with or without posterior nasal nerve ablation. METHODS: A 940 nm laser was utilised for contact (nasal swell body, septum and inferior turbinate) and non-contact (posterior nasal nerve) ablation. Total Nasal Symptoms Score, visual analogue scale pain score, complications and procedure location (office vs operating theatre) were recorded. RESULTS: All 242 patients underwent nasal swell body reduction with inferior turbinate reduction, and 150 had posterior nasal nerve ablation also. No laser complications were observed. An 80 per cent reduction in medication usage was noted. Total Nasal Symptoms Score decreased by 73 per cent; rhinorrhoea and congestion scores decreased by 54 per cent and 81 per cent respectively. Crusting, epistaxis and infections were minimal, and resolved within two weeks. CONCLUSION: Nasal swell body with inferior turbinate reduction, with or without posterior nasal nerve ablation, is a new method of treating nasal obstruction and congestion. Laser posterior nasal nerve ablation can be utilised as a complementary tool to deliver anatomical obstruction relief.

Image-guided keyhole evacuation of spontaneous supratentorial intracerebral hemorrhage.

INTRODUCTION: Treatment of spontaneous supratentorial intracerebral hemorrhage (SICH) is controversial. This study aims to evaluate the outcome and invasiveness of one surgical approach that provides complete evacuation of SICH, the image-guided keyhole evacuation. METHODS: The technique was employed in 20 consecutive patients, nine of whom harbored deep hematomas. The hematoma was evacuated through a keyhole minicraniotomy, 2.5 cm in diameter. Computerised tomographic (CT) scan was performed at the end of the procedure to confirm completeness of evacuation. Invasiveness was assessed by comparing initial neurological status determined by Glasgow Coma Scale (GCS) scores and National Institutes of Health Stroke Scale (NIHSS) scores with the third and seventh postoperative day scores, and by radiological findings. Outcome at six months was assessed by the Extended Glasgow Outcome Scale, and by comparing the initial and 6 month modified Rankin Scale scores. RESULTS: Mean age was 63.7+/-14.8 years, mean volume was 41.6+/-17.5 mL, and mean time to surgery was 17.6+/-13.2 h. CT scans at the end of the procedure showed complete evacuation (mean 97.5%), and 60% decrease of both mean midline shift and mean edema volume (p=0.005). Neurological assessment at the end of the first postoperative week showed significant improvement (p<0.0001). At six months, 90% of the patients had achieved recovery to independence, and one patient had died. CONCLUSION: The image-guided keyhole approach allowed prompt evacuation of SICH and resulted in a high rate of functional recovery and low mortality. This is a minimally invasive technique that is highly effective in immediate and complete hematoma evacuation.

Lethal photosensitization of oral pathogens via red-filtered halogen lamp.

UNLABELLED: OBJECTIVE OF INVESTIGATION: The ability of laser irradiation in the presence of photosensitizing agent to induce lethal effect on oral bacteria is well documented. We designed an in-vitro experiment to achieve phototoxic results on two common oral pathogens, using a high intensity, red filtered halogen lamp. Our goal was to determine the minimum duration of light exposure and drug dilution to achieve at least 50% reduction in bacteria counts. METHODS: Two common oral pathogens, Porphyromonas gingivalis and Prevotella intermedia were used in experiments. The source for light energy was a continuous working, high intensity, red filtered, halogen lamp (HL) with light transmitted through a flexible light guide over petri dishes containing live bacteria. Microorganisms were exposed to light for 5, 10 and 20 min. Methylene Blue (MB) in concentrations of 0.1, 0.075, 0.05, 0.025 and 0.01% was used as a photosensitizing agent. Light energy alone and MB alone was used as controls. RESULTS AND DISCUSSION: Optimum lethal photosensitization (50% or more bacteria killing) of oral pathogens was achieved using halogen light illumination for 5 min and longer with 0.05% MB or exposure to light for 20 min in the presence of 0.025 and 0.01% MB. Light exposure of 20 min in the absence of MB was not effective in killing bacteria. In the absence of light, MB at concentrations of 0.025 and 0.001% was not effective. Reduction of bacteria with the use of 0.05% MB alone was also insignificant. However, 0.075 and 0.1% MB, even in the absence of light was found to be bacteriocidal. CONCLUSIONS: Our in-vitro data indicate that we were able to achieve lethal photosensitization of two common oral pathogens with high intensity red filtered HL in the presence of diluted MB. In this era of increased incidence of antibiotic resistance, bacterial killing with laser or light energy in the presence of photosensitizing agent can prove to be a valuable treatment modality.

Stroke unit versus neurology ward--a before and after study.

INTRODUCTION: Few studies have tested the hypothesis of whether the beneficial effect of Stroke Units (SUs) can be reproduced in routine clinical practice and whether SU are also superior to neurological wards [NWs]. We aimed to compare the outcomes of patients of a newly implemented SU to the outcomes of patients hospitalized in a NW. METHODS: We made a before-after comparison of 352 SUs and 352 NWs patients after adjusting for case-mixes by the multivariate method. Subgroup analyses were also performed to evaluate which patient groups benefit the most. In-hospital case-fatality, proportion of independent patients at discharge, length of hospital stay (LOHS), medical complication rate were the main outcome measures. RESULTS: Adjusted in-hospital case fatality was significantly reduced in the SUs (OR: 0.44, 95 % CI: 0.26-0.76; p = 0.003). The proportion of independent patients at discharge and patients having medical complications was not different. Length of hospital stay was shorter in SU patients (13.76 days vs. 16.72 days, p = 0.003). Treatment in the SUs decreased case fatality in many subgroups [men, elderly, early admitted, severe stroke, co-morbidity present and ischemic stroke groups]. DISCUSSION: The results of randomized trials in favor of SUs can be reproduced in routine clinical practice. The benefit of SU care seems to be more apparent with advancing age and increasing stroke severity. Stroke Unit seems to be a better alternative to an experienced NW.

Transnasal correction of choanal atresia.

A simple life-saving modification of the transnasal approach, which does not require endotracheal anesthesia or preoperative tracheostomy, is described. The use of polyethylene tubes, flanged at the distal end and split at the proximal end, is the most significant feature of this technique. In 14 of the 16 cases of choanal atresia presented, this was the definitive corrective procedure, and further revisions or a later transpalatal approach were not required. The advantages of this technique are that it is simple, it may be used in the first 24 hours of life or at any age, the patient may be released from the hospital in 1 to 2 weeks, and minimal postoperative care is required.

The pectoralis major myocutaneous island flap for reconstruction of the head and neck.

The anatomy, design, and blood supply of the pectoralis major myocutaneous island flap are described. This versatile, nondelayed flap has, for the most part, replaced the usual cutaneous flaps. Clinical examples of its use in head and neck reconstructive surgery are presented.

Massive necrotizing infections of the neck.

Necrotizing fascitis of the head and neck is a rare condition with only 7 cases recorded in the literature. Two cases are presented in which there was massive necrosis of the soft tissues of the neck with extension into the mediastinum. The offending organisms were a mixed bacterial flora which produced gangrene accompanied by subcutaneous emphysema. Both patients were successfully treated with a regimen of intravenous antibiotics, fasciotomy, radical debridement, and hyperbaric oxygenation (1 case). The clinical features, bacteriology, and treatment of necrotizing faciities are reviewed.

Peripheral nerve sheath tumors of the paranasal sinuses.

Only 4% of peripheral nerve sheath tumors of the head and neck occur in the paranasal sinuses. The most commonly involved sinus is the maxillary antrum and the most common histologic type is benign schwannoma. Two new cases of schwannoma occurring in the sphenoid and maxillary sinuses are reported. The clinical pathologic, and radiographic features of these lesions are reviewed.

Synchronicity, multicentricity, and metachronicity of head and neck cancer.

Two hundred patients with squamous carcinoma of the head and neck were evaluated prospectively for synchronous second primary tumors. Complete head and neck examination, chest x-ray, and barium study (when indicated) revealed synchronous tumors of the upper aerodigestive tract in 24 patients (12%). Eleven patients had a second primary in the head and neck area. Nine patients had carcinoma of the lung, while four had carcinoma of the esophagus. Seven patients had a second primary outside the upper aerodigestive tract either in large bowel or prostate. During the period of this study, an additional 13 patients were seen with metachronous tumors 1-12 years after initial treatment of their index tumor. Most of these metachronous tumors were in the lung and esophagus and were noted within 1-3 years of treatment of the primary head and neck cancer. Detection of synchronous second primary is very important for prognosis and management of the index tumor, while early diagnosis of metachronous lesion is crucial in the follow-up of these patients.

Cutaneous sarcoidosis associated with sarcoidosis of the upper airway.

The diagnosis of laryngeal sarcoidosis is frequently delayed because it is rare and often develops insidiously. A 24-year-old woman with the annular scarring form of cutaneous sarcoidosis later contracted laryngeal sarcoidosis. Despite a two-year history of upper respiratory tract symptoms, the patient's progressive respiratory distress was attributed to sarcoidal pulmonary involvement. Dermatologists should be aware of the risk of airway obstruction from laryngeal granulomas in patients with cutaneous sarcoidosis. Although most commonly associated with the lupus pernio form of sarcoidosis, upper airway granulomas also develop in patients with other cutaneous manifestations of sarcoidosis.

Airway obstruction. New modalities in treatment.

The key to successful therapy of airway obstruction is always to first secure the airway. The primary care physician needs to understand the airway anatomy and the causes of airway obstruction. As a team, the primary care physician and the otolaryngologist can evaluate and treat these disorders.

Reconstruction after total or subtotal glossectomy.

Total or subtotal resection of the tongue for malignant lesions creates difficult reconstructive problems. Though the introduction of myocutaneous flaps revolutionized the reconstruction of the oral cavity, most patients with total and subtotal (more than 75 percent) glossectomy require laryngectomy as a concommittant or subsequent procedure to prevent persistant aspiration. Two groups of patients have been compared in this study. Group I consisted of 10 patients in whom an attempt was made to preserve voice with a total (4 patients) or subtotal (6 patients) glossectomy without laryngectomy. To decrease the chance of aspiration, the tip of the epiglottis was sutured to the posterior pharyngeal wall (epiglottopexy). This additional surgical step allowed swallowing without aspiration by blocking the glottic entrance. Group II consisted of six patients who underwent total glossectomy and laryngectomy. They had reconstruction with a pectoralis myocutaneous flap in one stage. These patients were rehabilitated without any major morbidity and they resumed an oral diet within 3 weeks after surgery. The muscle bulk of the flap and the additional protection of the airway by epiglottopexy in Group I were the keys to successful reconstruction.

Transmandibular exposure of the skull base.

The combined transmandibular-transcervical approach to the skull base ensures a wide field exposure to the lateral and midline compartments of the middle cranial fossa with attendant vascular control. Splitting the lip and mandible in the midline and dividing the floor of the mouth structures along the lateral border of the tongue exposes the parapharyngeal space, infratemporal fossa (lateral compartment), and clivus, nasopharynx, and cervical spine (midline compartment). A variety of benign and malignant intracranial and extracranial skull base lesions have been treated using this approach.

Is routine triple endoscopy cost-effective in head and neck cancer?

The multicentric occurrence of tumors of the upper aerodigestive tract has been well described, with an incidence ranging from 5 to 16 percent. Detection of a synchronous primary tumor at the time of initial work-up is crucial both for management and final outcome. However, there is a diversity of opinions regarding the extent of the work-up to search for a second primary tumor. Some investigators consider routine panendoscopy to be essential for every patient with a head and neck primary tumor. Routine esophagoscopy and bronchoscopy with bronchial washings in the absence of specific symptoms appear to have minimal benefit and high cost. In our study of 140 consecutive patients with primary squamous cell carcinoma of the head and neck seen over a period of 3 years, detailed history, thorough head and neck examination, routine chest radiograph, and barium swallow when indicated were sufficient to identify 18 patients (13 percent) with a second primary tumor in the upper aerodigestive tract. The synchronous tumors of eight patients were in the head and neck area, seven patients had carcinoma of the lung, and three patients had a second primary in the esophagus. Two patients had three synchronous primaries. Follow-up of these patients ranged from 1 to 4 years. Panendoscopy with cytologic washings was performed routinely. We questioned the cost-effectiveness of routine triscopy in every patient with head and neck cancer.

Prosthetic reconstruction of the trachea.

Tracheal reconstruction has been a difficult and challenging problem over the years, mainly because of graft infection and extrusion. A small segment of the trachea can be resected and primary anastomosis can be performed easily with satisfactory results. The problem is always complex when a substantial portion of the trachea must be resected. A variety of prosthetic materials have been used, both in experimental animals and human subjects, with limited short-term success. This study describes an experiment using polytetrafluoroethylene (PTFE) grafts in dogs. PTFE patch and interposition grafts were used for tracheal reconstruction with very satisfactory results. Inflammatory reaction near the grafts and nonincorporation of long graft segments continue to be problems, but despite this, prosthetic reconstruction of the trachea using PTFE provided very satisfactory results in our experimental study.

Preoperative combination chemotherapy for advanced stage head and neck cancer. Promising early results.

We treated 19 consecutive patients with cisplatin, bleomycin, and methotrexate before definitive surgery or radiation therapy. Fourteen patients (74 percent) had partial or complete tumor regression after chemotherapy. With a minimum follow-up time of 27 months, none of the 4 patients who had a major histologic response relapsed, and only 2 of the remaining 15 patients continued disease-free. The achievement of a complete histologic response after preoperative chemotherapy may correlate with long-term disease-free survival after surgery and radiation therapy for head and neck cancer.

Venous infarction of brainstem and cerebellum.

The authors describe 2 cases of posterior fosa venous infarction. A 56-year-old woman with essential thrombocytemia presented with fluctuating complaints of headache, nausea, vomiting, left-sided numbness-weakness, and dizziness and became progressively stuporous. Cranial magnetic resonance imaging (MRI) showed bilateral parasagittal fronto-parietal and left cerebellar contrast-enhancing hemorrhagic lesions. On magnetic resonance venography, the left transverse and sigmoid sinuses were occluded. The second patient, a 39-year-old woman, presented with acute onset of diplopia, numbness of the tongue, vertigo, and right-sided weakness following a gestational age stillbirth. MRI revealed lesions in the right half of midbrain and pons and in the superior part of the right cerebellar hemisphere. Digital subtraction angiography showed right transverse and sigmoid sinus occlusion. The authors suggest that one should investigate the possibility of venous infarction in the presence of posterior fossa lesions that are often hemorrhagic and are not within any arterial territory distribution but respect a known venous drainage pattern. Recognition of the observed clinical and neuroimaging features can lead to earlier diagnosis and, potentially, more effective management.

Lateral skull base surgery for cancer.

The management of malignant tumors of the lateral skull base remains a challenging problem. Sixty-two patients underwent lateral skull base resection for cancer. Preoperative evaluation included complete neurotologic examination, CT scan, MRI, and carotid angiography. During surgery, the nasopharynx, the posterior maxilla, the infratemporal fossa structures, the mandibular ramus, and the parotid gland were resected en bloc. Reconstruction of the surgical defect was performed using pectoralis and/or rhombotrapezius myocutaneous flaps. Although the overall cure rate was not greatly improved, patients with lateral skull base malignancies now enjoy extended periods of palliation and a better quality of life.