Revisiting the NIH Stroke Scale as a screening tool for proximal vessel occlusion: can advanced imaging be targeted in acute stroke?

BACKGROUND AND PURPOSE: Most patients with stroke-like symptoms screened by advanced imaging for proximal occlusion will not have a thrombus accessible by neurointerventional techniques. Development of a sensitive clinical scoring system for rapidly identifying patients with an emergent large vessel occlusion could help target limited resources and reduce exposure to unnecessary imaging. METHODS: This historical cohort study included patients who underwent non-contrast CT and CT angiography in the emergency department for stroke-like symptoms. NIH Stroke Scale (NIHSS) criteria were extended to include resolved symptoms and dichotomized as present or absent. Combinations of NIHSS criteria were considered as tests for proximal occlusion. RESULTS: Proximal cerebral vascular occlusion was present in 19.2% (100/522) of the population and, of these, 13% (13/100) had an NIHSS score of 0. The presence on examination or history of diminished consciousness with inability to answer questions, leg weakness, dysarthria, or gaze deviation had 96% sensitivity and 39% specificity for proximal occlusion. If implemented in this population, the use of CT angiography would have been decreased by 32.4% (169/522 patients) while missing 0.76% with proximal occlusions (4/522). Half of those missed (2/4) would have been identified as large vessel infarcts on non-contrast CT, while the remainder (2/4) were transient ischemic attacks associated with carotid stenosis. CONCLUSIONS: In this cohort, specific NIHSS criteria were highly sensitive for emergent large vessel occlusion and, if validated, may allow for clinical screening prior to advanced imaging with CT angiography.

Abdominal aortic aneurysm with inferior vena cava compression in association with deep venous thrombosis.

Deep venous thrombosis (DVT) of the lower extremity may be caused by external compression of the inferior vena cava (IVC) by a neighboring mass. A 55-year-old male presented with 8 months of intermittent left lower extremity swelling and signs of chronic venous stasis. Duplex ultrasound showed extensive DVT in the left leg. Subsequent imaging revealed a 4.2 cm infrarenal abdominal aortic aneurysm (AAA) compressing the IVC. In cases of chronic, unilateral DVT, work-up should include imaging for an anatomic cause. AAA is a rare cause of IVC compression with DVT, and is most commonly related to inflammatory AAAs. Previously reported cases of IVC compression by non-inflammatory AAAs have been secondary to large aneurysms (greater than 6 cm). This case illustrates that smaller AAAs lacking hemodynamically significant IVC obstruction may be found in association with DVT.

Early detection of ovarian cancer with conventional and contrast-enhanced transvaginal sonography: recent advances and potential improvements.

Recently, there have been several major technical advances in the sonographic diagnosis of ovarian cancer in its early stages. These include improved assessment of tumor morphology with transvaginal sonography (TVS), and detection and characterization of tumor neovascularity with transvaginal color Doppler sonography (TV-CDS) and contrast-enhanced transvaginal sonography (CE-TVS). This paper will discuss and illustrate these improvements and describe how they enhance detection of early-stage ovarian cancer. Our initial experience with parametric mapping of CE-TVS will also be mentioned.

Individuated finger control in focal hand dystonia: an fMRI study.

OBJECTIVES: To better understand deficient selective motor control in focal hand dystonia by determining changes in striatal activation and connectivity in patients performing individuated finger control. METHODS: Functional imaging with a 3-Tesla magnetic resonance scanner was performed on 18 patients and 17 controls during non-symptom producing tasks requiring right-handed individuated or coupled finger control. A global linear model and psychophysiologic interaction model compared individuated to coupled tasks for patients and controls separately, and the results were submitted to a group analysis. The sensorimotor (posterior) and associative (anterior) parts of the putamen were considered as seed regions for the connectivity analysis. RESULTS: Compared to controls, patients had significant differences in activations and connectivity during individuated compared to coupled tasks: (i) decreased activations in the bilateral postcentral gyri, right associative posterior parietal areas, right cerebellum and left posterior putamen, while activations in the left anterior putamen were not different; (ii) increased connectivity of the left posterior putamen with the left cerebellum and left sensorimotor cortex; and (iii) increased connectivity of the left anterior putamen with bilateral supplementary motor areas, the left premotor cortex, and left cerebellum. INTERPRETATION: Decreased activations in the sensorimotor putamen and cerebellum controlling the affected hand might underlie low levels of surround inhibition during individuated tasks. For identical motor performance in both groups, increased connectivity of sensorimotor and associative striato-cortical circuits in FHD suggests that both affected and unaffected territories of the striatum participate in compensatory processes.

Exostoses of the external auditory canal in white-water kayakers.

OBJECTIVES/HYPOTHESIS: Exostoses of the external auditory canal are benign bony tumors associated with frequent cold-water exposure. Obstruction may lead to conductive hearing loss and recurrent otitis externa, requiring surgical correction when symptoms become intolerable. This study aimed to characterize the prevalence of exostoses in white-water kayakers and identify associated risk factors and protective measures. STUDY DESIGN: Cross-sectional. METHODS: Six hundred eleven white-water kayakers from across the United States were included in the study. Percent occlusion was graded as minimal (<25%), moderate (25%-75%) or severe (>75%). Subjects completed a survey of risk factors and protective measures. Kruskal-Wallis and chi(2) tests were performed to determine significant associations with percent occlusion. A multivariate proportional odds regression model was fit to adjust for confounding between the variables. RESULTS: The prevalence of exostoses in kayakers was 79% (482/611); 13% (78/611) had >or=75% occlusion. Percent occlusion was associated with total years kayaked (P < .001), frequency >or=1 day/week (P < .001), male gender (P < .001), and increasing age (P = .005), although frequency, gender, and age were confounded by total years. Styles that involve repeated submersion were also associated with greater occlusion (freestyle, P = .036; squirt, P = .016). Subjects who used earplugs for a greater proportion of their kayaking career were less likely to have exostoses (P < .001). When adjusted for confounding, only total years (P = .0003) and age (P = .0027) remained significant. CONCLUSIONS: Kayakers are the first inland population to experience exostoses at the rates seen in coastal populations (e.g., surfers). When used long-term, earplugs may be protective.