Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia
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Referral from other hospitals is one of the primary causes of delayed thrombolysis therapy after acute ischemic stroke (AIS). We aimed to evaluate whether direct access to a hospital offering intravenous thrombolysis therapy was associated with good functional outcome in AIS patients treated with thrombolysis. We enrolled patients who received intravenous thrombolysis within 3 hours of symptom onset at our stroke center. ⋯ Patients who were directly admitted to our stroke center had a shorter onset-to-door time (61 versus 120 minutes, p<0.001) and onset-to-rtPA time (103 versus 155 minutes, p<0.001) than those referred from other hospitals. Direct admission was associated with a good outcome with an odds ratio of 2.03 (95% confidence interval 1.051-3.917, p=0.035), after adjusting for baseline variables. Thrombolysis after direct admission to a hospital offering intravenous thrombolysis therapy could shorten onset-to-rtPA time and improve stroke outcome in patients with AIS.
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Comparative Study
Safety, efficacy, and cost of intraoperative indocyanine green angiography compared to intraoperative catheter angiography in cerebral aneurysm surgery.
Intraoperative angiography in cerebrovascular neurosurgery can drive the repositioning or addition of aneurysm clips. Our institution has switched from a strategy of intraoperative digital subtraction angiography (DSA) universally, to a strategy of indocyanine green (ICG) videoangiography with DSA on an as-needed basis. We retrospectively evaluated whether the rates of perioperative stroke, unexpected postoperative aneurysm residual, or parent vessel stenosis differed in 100 patients from each era (2002, "DSA era"; 2007, "ICG era"). ⋯ There were no differences in the rate of perioperative stroke or rate of false-negative studies. The per-patient cost of intraoperative imaging within the DSA era was significantly higher than in the ICG era. The replacement of routine intraoperative DSA with ICG videoangiography and selective intraoperative DSA in cerebrovascular aneurysm surgery is safe and effective.
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Acute subdural hematoma is an uncommon presentation of aneurysmal hemorrhage that has been identified as a poor prognostic sign. Current series are small, have short follow-up, or were collected over a long period during which treatment evolved. To evaluate prognostic factors, we analyzed a large modern series of aneurysmal subdural hematoma (aSDH) with long-term follow-up. ⋯ There was no difference between good and poor outcomes in terms of time to treatment or hematoma evacuation. Poor clinical presentation may be exaggerated by mass effect of hematoma; aggressive treatment is not futile. Presenting neurological status, age, and aneurysm size are predictors of outcome, while laterality and size of hematoma and extent of midline shift are not, suggesting that clinical status is more important than radiographic findings.
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Stereo-electroencephalography (SEEG) has advantages for exploring deeper epileptic foci. Nevertheless, SEEG can only sample isolated cortical areas and its spatial limitation, with the inability to record contiguous cortical regions, may cause difficulties in interpretation. In light of these limitations, the authors describe the hybrid technique of SEEG and subdural strip electrode placement. ⋯ The dura was opened and, under live fluoroscopic guidance, strip electrodes were slid into the subdural space. In these patients, the additional subdural strip electrodes provided (1) information regarding the precise description of seizure spread in the cortical surface adjacent to the subdural space, (2) identification of epileptogenic zones located near the crown, (3) more precise definition of functional cortex and (4) a better delineation of the interface between epileptogenic zones and functional cortex. This hybrid technique provides additional data compared to either technique alone, offering superior understanding of the dynamics of the epileptic activity and its interaction with functional cortical areas.
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Wide-necked bifurcation aneurysms often require the use of the technically complex Y-stent technique, which has recently been shown to narrow bifurcation angle in a hemodynamically favorable manner. We sought to evaluate the single center efficacy and safety of Y-stent supported aneurysm coil embolization. All patients undergoing Y-stent supported coiling between September 2006 and December 2012 were identified; records were analyzed for procedural results and complications, with follow-up evaluated for occlusion rate and neurological adverse events. ⋯ At latest follow-up, Raymond grade I occlusion was achieved in 16 patients (80%), Raymond grade II occlusion achieved in four patients (20%) and Raymond grade III occlusion in zero patients. Y-stenting for complex intracranial aneurysms appears effective in achieving durable aneurysm occlusion with an acceptable safety profile. Though the procedure is technically more complex than single-stent procedures, the Y-stent configuration should be considered when single-stent supported coiling is not feasible or sufficient.