Challenges of decision making regarding futility in a randomized trial: the Interventional Management of Stroke III experience.

Background And Purpose: Interventional Management of Stroke (IMS) III is a randomized, parallel arm trial comparing the approach of intravenous tissue-type plasminogen activator followed by endovascular treatment with intravenous tissue-type plasminogen activator alone in patients with acute ischemic stroke presenting <3 hours of symptom onset. The trial intended to enroll 900 subjects to ensure adequate statistical power to detect an absolute 10% difference in the percentage of subjects with good outcome, defined as modified Rankin Scale score of 0 to 2 at 3 months. In April 2012, after 656 subjects were randomized, further enrollment was terminated by the National Institute of Neurological Disorders and Stroke based on the prespecified criterion for futility using conditional power<20%.

Sodium time course using 23Na MRI in reversible focal brain ischemia in the monkey.

Purpose: To demonstrate the use of sodium MRI for measuring the time course of tissue sodium concentration (TSC) in a nonhuman primate model of reversible focal brain ischemia.

Materials And Methods: Reversible endovascular focal brain ischemia was induced in nonhuman primates (n = 4), and sodium MRI was performed on a 3 Tesla scanner for monitoring changes in TSC during both the middle cerebral artery (MCA) occlusion and MCA reperfusion portions of the experiment.

Results: The TSC increased linearly in the ischemic tissue during MCA occlusion (ranging from a mean TSC increase of 5.

MAP2 immunostaining in thick sections for early ischemic stroke infarct volume in non-human primate brain.

The delineation of early infarction in large gyrencephalic brain cannot be accomplished with triphenyl-tetrazolium chloride (TTC) due to its limitations in the early phase, nor can it be identified with microtubule-associated protein 2 (MAP2) immunohistochemistry, due to the fragility of large thin sections. We hypothesize that MAP2 immunostaining of thick brain sections can accurately identify early ischemia in the entire monkey brain. Using ischemic brains of one rat and three monkeys, a thick-section MAP2 immunostaining protocol was developed to outline the infarct region over the entire non-human primate brain.

Emergent stenting of extracranial internal carotid artery occlusion in acute stroke has a high revascularization rate.

Background And Purpose: Acute ischemic stroke attributable to extracranial internal carotid artery (ICA) occlusion is frequently associated with severe disability or death. In selected cases, revascularization with carotid artery stenting has been reported, but the safety, recanalization rate, and clinical outcomes in consecutive case series are not known.

Methods: We retrospectively reviewed all of the cases of ICA occlusions that underwent cerebral angiography with the intent to revascularize over a 38-month period.

Mechanical thrombolysis in acute ischemic stroke with endovascular photoacoustic recanalization.

Background And Purpose: We present the results of endovascular photoacoustic recanalization (EPAR) treatment for acute ischemic stroke from the Safety and Performance Study at 6 centers in Europe and North America. The objectives of mechanical thrombolysis are rapid vessel recanalization and minimal use of chemical thrombolysis.

Methods: This study was a prospective, nonrandomized study.

Model of reversible cerebral ischemia in a monkey model.

We have developed a model of reversible cerebral ischemia in a high-level nonhuman primate. By using endovascular techniques, the posterior cerebral artery is permanently occluded with coils, and the ipsilateral middle cerebral artery is temporarily occluded with a balloon. The balloon can be deflated and/or removed to reestablish flow at precise time intervals.

Symptomatic cavernous sinus aneurysms: management and outcome after carotid occlusion and selective cerebral revascularization.

Background And Purpose: Therapeutic internal carotid artery (ICA) occlusion for symptomatic intracavernous artery aneurysms can result in ischemic infarction despite normal clinical balloon test occlusion (BTO). We evaluated outcomes in patients with symptomatic cavernous sinus aneurysms in whom clinical BTO was normal, who underwent carotid occlusion with selective bypass surgery guided by physiologic BTO using quantitative cerebral blood flow (CBF) analysis by means of stable xenon-enhanced CT.

Methods: After a normal clinical BTO, 26 consecutive patients with symptomatic cavernous sinus aneurysms underwent a baseline xenon-enhanced CT CBF analysis followed by a second CBF analysis, during which repeat BTO was performed.

Diffusion-weighted MRI in Creutzfeldt-Jakob disease: a better diagnostic marker than CSF protein 14-3-3?

Two middle-aged patients presented with rapidly progressive dementia and ataxia, nonspecific electroencephalography findings, and negative cerebrospinal fluid (CSF) protein 14-3-3. Both patients underwent brain magnetic resonance imaging (MRI) scans that demonstrated abnormalities on diffusion-weighted imaging (DWI) sequences, and both were later confirmed to have Creutzfeldt-Jakob disease. (CJD) by tissue examination.

Delayed rupture of a previously coiled unruptured anterior communicating artery aneurysm: case report.

Objective And Importance: We describe a case of an unruptured anterior communicating aneurysm that was treated successfully with Guglielmi detachable coils, which subsequently ruptured 23 months after initial therapy. This report discusses only the second published case of an unruptured lesion that was well embolized (>95% occlusion) and stable at 6-month angiographic follow-up that ruptured in a delayed fashion almost 2 years after the primary procedure.

Clinical Presentation: An 80-year-old man presented in Hunt and Hess Grade IV as a result of a ruptured anterior communicating artery aneurysm.