Intra-arterial cerebral thrombolysis for acute ischemic stroke in a community hospital.

BACKGROUND AND PURPOSE: Advances in thrombolytic therapy, brain imaging, and neurointerventional techniques provide new therapeutic options for acute stroke. Intra-arterial thrombolysis has proved to be a potent therapeutic tool. To show that this procedure can be performed in community hospitals, we describe our experience with a group of 11 patients treated for middle cerebral artery occlusions. METHODS: Twenty-two patients seen during a period of 1 year with clinical findings of acute major-vessel stroke met screening criteria and were evaluated under an institutional review board-approved protocol. After CT scanning, 17 of those patients met strict criteria, gave informed consent, and underwent angiography. Eleven patients had M1 and M2 middle cerebral artery occlusions and received local thrombolytic therapy with urokinase. Recanalization efficacy, complications, and outcome data were compiled. RESULTS: The average score on the National Institutes of Health Stroke Scale was 22.2 at the onset of treatment and 12.5 after therapy, with 91% of patients showing neurologic improvement. Complete (TIMI 3) recanalization occurred in 73% of cases and partial recanalization (TIMI 2) in 18%. At the 90-day follow-up evaluation, 56% of patients had good outcomes (modified Rankin score, 0 to 1). One intracranial hemorrhage occurred. CONCLUSION: Intra-arterial thrombolysis can be performed in a community hospital by radiologists with interventional and neuroradiologic skills given appropriate institutional preparation.

The influence of clinical history on visual search with single and multiple abnormalities.

RATIONALE AND OBJECTIVES: Facilitation of detection by clinical history generally has been found with a single abnormality per image but not with multiple abnormalities. Multiple abnormalities per image can occasion a "satisfaction-of-search" effect in which detection of one lesion is reduced in the presence of other distant lesions. Our experiment studied the combined effect of multiple abnormalities and clinical history on accuracy. METHODS: Detection of native lesions was measured 1) with histories suggestive of the native abnormality; 2) with these histories and added simulated pulmonary nodules; and 3) with the same added nodules and histories suggestive of metastatic disease. These conditions also were compared with those of a previous experiment that were similar but included no history. RESULTS: Detection was substantially improved for appropriately prompted abnormalities even in the presence of a pulmonary nodule. In fact, satisfaction of search was not found in the presence of an appropriate history. Detection of unprompted abnormalities was unchanged when prompts indicated other abnormalities actually present. Prompted abnormalities were detected earlier in search. CONCLUSIONS: History appears to direct perceptual resources to the prompted abnormalities, thereby alleviating satisfaction of search. The presence of nodules yielded a small but consistent reduction in total search time for searches involving false responses, suggesting that satisfaction of search may depend more on reduction in search time than had been indicated by previous research.

Ultrafast computed tomography in experimental pulmonary embolism.

Computed tomography (CT) has proven useful in the diagnosis of central pulmonary embolism; however, its ability to detect peripheral emboli has not been established. The authors evaluate the usefulness of ultrafast CT (UFCT) in detecting experimental peripheral pulmonary emboli. Three Gelfoam emboli measuring 0.7 x 1.5 cm were introduced into the pulmonary arteries of each of seven dogs, and contiguous, 3-mm, axial UFCT images from the lung apex to the base were obtained after the administration of a contrast bolus. After scanning, the dogs were killed, and the locations of the emboli were determined by a pulmonary pathologist blinded to the imaging results. Concomitantly, the locations of the emboli on the UFCT images were determined by consensus of three chest radiologists blinded to the autopsy results. All 21 emboli were identified on UFCT images; the locations of the emboli corresponded exactly with the autopsy findings. The authors conclude that UFCT can reliably detect Gelfoam emboli in second- to fourth-division pulmonary vessels. Further studies are needed to determine if in vivo blood clots can be similarly visualized.

Fatal puerperal cerebral vasospasm and stroke in a young woman.

A woman who experienced postpartum cerebral infarction, brain edema, and death is described. Angiography implicated cerebral vasospasm as the primary etiology.

Severe neuropathy in a patient with acquired immune deficiency syndrome (AIDS). Evidence for widespread cytomegalovirus infection of peripheral nerve and human immunodeficiency virus-like immunoreactivity of anterior horn cells.

A patient with acquired immune deficiency syndrome (AIDS) developed a progressive neuromuscular disorder which included a sensory component, severe weakness and muscle wasting, and fasciculations. At autopsy, there was evidence of severe peripheral neuropathy, as well as widespread cytomegalovirus (CMV) infection within the central and peripheral nervous system. Although the anterior horn cell complement within the spinal cord appeared normal, there was also evidence of human immunodeficiency virus (HIV)-like immunoreactivity of rare anterior horn cells, as judged by immunohistochemical staining. This patient illustrates the complexity of pathogenetic mechanisms operative in AIDS patients with neuromuscular disease, and suggests that at least some examples of neuromuscular disease in patients with this syndrome may be related to widespread CMV infection of the peripheral nerve (including microvascular endothelial cells) and, more rarely, direct HIV infection of some anterior horn cells.

Association between essential tremor and Parkinson's disease.

To examine a possible relationship of essential tremor to Parkinson's disease (PD), 130 patients with essential tremor were studied. Twenty-five patients had both essential tremor and PD. These 25 patients were matched for age and duration of PD symptoms with 25 patients who had idiopathic PD. Bradykinesia, postural instability, and gait difficulty were more severe in the patients with idiopathic PD. Degree of tremor, rigidity, and functional disability did not differ in the two groups. The prevalence of PD in the population with essential tremor was 24 times greater than expected. This study suggests that some patients with essential tremor have a genetically increased risk for PD.