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  • 1
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    Cell death in experimental intracerebral hemorrhage: The “black hole” model of hemorrhagic damage
    Wiley ; 2002
    In:  Annals of Neurology Vol. 51, No. 4 ( 2002-04), p. 517-524
    Details
    In: Annals of Neurology, Wiley, Vol. 51, No. 4 ( 2002-04), p. 517-524
    Abstract: Intracerebral hemorrhage (ICH) has a poor prognosis that may be the consequence of the hematoma's effect on adjacent and remote brain regions. Little is known about the mechanism, location, and severity of such effects. In this study, rats subjected to intracerebral blood injection were examined at 100 days. Stereology (neuronal count and density) and volume measures in the perihematoma rim, the adjacent and overlying brain, and the substantia nigra pars reticulata (SNr) were compared with contralateral brain regions at 100 days and the perihemorrhage region at 24 hours and 7 days. In addition, cytochrome c release was investigated at 24 hours, 3 days, and 7 days. At 100 days, post‐ICH rats showed no difference in neuronal density in the perihemorrhagic scar region or regions of the striatum immediately surrounding and distal to the perihemorrhage scar. The cell density index in the ipsilateral field was 16.2 ± 3.8 versus the contralateral control field of 15.6 ± 3.2 (not significant). Volume measurements of the ipsilateral striatum revealed a 20% decrease that was compensated by an increase in ipsilateral ventricular size. The area of the initial ICH as measured by magnetic resonance imaging correlated with the degree of atrophy. In the region immediately surrounding the hematoma, cytochrome c immunoreactivity increased at 24 hours and 3 days, and returned toward baseline by day 7. At 24 hours, stereology in the peri‐ICH region showed decreased density in the region where cytochrome c immunoreactivity was the highest. Neuronal density of the ipsilateral SNr was significantly less than the contralateral side (9.6 ± 1.9 vs 11.6 ± 2.3). Histologic damage from ICH occurred mainly in the immediate perihemorrhage region. Except for SNr, we found no evidence of neuronal loss in distal regions. We have termed this continued destruction of neurons, which occurs over at least 3 days as the neurons come into proximity to the hematoma, the “black hole” model of hemorrhagic damage.
    Type of Medium: Online Resource
    ISSN: 0364-5134 , 1531-8249
    URL: Issue
    URL: Article
    DOI: 10.1002/ana.v51:4
    DOI: 10.1002/ana.10160
    Language: English
    Publisher: Wiley
    Publication Date: 2002
    detail.hit.zdb_id: 2037912-2
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  • 2
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    Catheter-Based Treatment for Patients With Acute Ischemic Stroke Ineligible for Intravenous Thrombolysis
    Ovid Technologies (Wolters Kluwer Health) ; 2004
    In:  Stroke Vol. 35, No. 5 ( 2004-05)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 35, No. 5 ( 2004-05)
    Abstract: Background and Purpose— We present our single-center experience using catheter-based therapy for acute ischemic stroke patients who were not candidates for intravenous thrombolytic therapy. Methods— Neurologic outcomes were assessed in patients with acute ischemic stroke, ineligible for intravenous thrombolysis, treated with an emergent catheter-based therapy. Results— Nonparametric analysis of neurological outcomes demonstrated a benefit in National Institutes of Health Stroke Scale (NIHSS) at long-term follow-up ( P =0.036). Independence in daily activities and improvement in NIHSS of ≥4 points were achieved in 38% and 56% of patients, respectively. Four patients (25%) died, including 2 patients (12.5%) who died from intracranial hemorrhage. Conclusions— Catheter-based treatment offers a promising treatment strategy in patients with acute ischemic stroke ineligible for intravenous thrombolysis.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/01.STR.0000125711.94465.78
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2004
    detail.hit.zdb_id: 1467823-8
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  • 3
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    Validity and Reliability of the Thrombolysis in Brain Infarction (TIBI) Flow Grades
    Ovid Technologies (Wolters Kluwer Health) ; 2001
    In:  Stroke Vol. 32, No. suppl_1 ( 2001-01), p. 324-325
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 32, No. suppl_1 ( 2001-01), p. 324-325
    Abstract: 48 Background: In patients eligible for thrombolytic therapy, the TIBI grading system defines residual transcranial Doppler (TCD) flow signals at the site of clot location. In addition, TIBI flow grades correlate with angiography and predict short-term improvement following TPA therapy. The aim of this study was to develop a valid and reliable instrument to assess how accurately health professionals determine TIBI flow grades. Methods: Two expert sonographers developed a 60 question computerized examination of the 6 TIBI flow grades. Gold standard interpretation was determined by a consensus interpretation by a pool of expert sonographers. All items were equally weighted and written in a standard format. A computerized TIBI grading tutorial and standard interpretation rules were available for all test-takers. To assess content validity and reliability, a blinded panel of 3 experts independently took the examination. Inter-rater agreement was determined among experienced sonographers, stroke neurologists, and other health professionals (N=11). Results: Expert assessment of each test item measured objective congruence at 1.0, overall test validity coefficient of 0.996 (95%CI 0.993–0.997), and an item/TIBI flow grade validity coefficient of 0.992 (95%CI 0.996–0.997). Overall test and individual item reliability had coefficients of 0.98(95%CI 0.97–0.99) and 0.97 (95%CI 0.95–0.98, p 〈 0.0001) respectively. Inter-rater agreement was 0.89 (coefficient of contingency) and 0.86 (kappa) for all participants. Kappa range included 0.98 for an experienced interpreter, 0.81–0.89 for stroke neurologists with beginner experience in TCD and 0.65 for those without previous TCD experience (66% of correct answers after 1 hour tutorial). Conclusions: Our computerized examination is a valid and reliable tool to assess an individuals ability to score TIBI flow grades. In addition, TIBI flow grade evaluation has a high degree of inter-rater reliability, even among those with limited experience in ultrasound.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.32.suppl_1.324-e
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2001
    detail.hit.zdb_id: 1467823-8
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  • 4
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    Online Resource
    Thrombolysis in Brain Ischemia (TIBI) Transcranial Doppler Flow Grades Predict Clinical Severity, Early Recovery, and Mortality in Patients Treated With Intravenous Tissue Plasminogen Activator
    Ovid Technologies (Wolters Kluwer Health) ; 2001
    In:  Stroke Vol. 32, No. 1 ( 2001-01), p. 89-93
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 32, No. 1 ( 2001-01), p. 89-93
    Abstract: Background and Purpose —TIMI angiographic classification measures coronary residual flow and recanalization. We developed a Thrombolysis in Brain Ischemia (TIBI) classification by using transcranial Doppler (TCD) to noninvasively monitor intracranial vessel residual flow signals. We examined whether the emergent TCD TIBI classification correlated with stroke severity and outcome in patients treated with intravenously administered tPA (IV-tPA). Methods —TCD examination occurred acutely and on day 2. TIBI flows were determined at distal MCA and basilar artery depths, depending on occlusion site. TIBI waveforms were graded as follows: 0, absent; 1, minimal; 2, blunted; 3, dampened; 4, stenotic; and 5, normal. National Institutes of Health Stroke Scale (NIHSS) scores were obtained at baseline and 24 hours after administration of tPA. Results —One hundred nine IV tPA patients were studied. Mean±SD age was 68±16 years; median NIHSS score before administration of tPA (pre-tPA) was 17.5. The tPA bolus was administered 143±58 minutes and the TCD examination 141±57 minutes after symptom onset. Pre-tPA NIHSS scores were higher in patients with TIBI grade 0 than TIBI grade 4 or 5 flow. TIBI flow improvement to grade 4 or 5 occurred in 35% of patients (19/54) with an initial grade of 0 or 1 and in 52% (12/23) with initial grade 2 or 3. The 24-hour NIHSS scores were higher in follow-up in patients with TIBI grade 0 or 1 than those with TIBI grade 4 or 5 flow. TIBI flow recovery correlated with NIHSS score improvement. Lack of flow recovery predicted worsening or no improvement. In-hospital mortality was 71% (5/7) for patients with posterior circulation occlusions; it was 22% (11/51) for patients with pre-tPA TIBI 0 or 1 compared with 5% (1/19) for those with pre-tPA TIBI 2 or 3 anterior circulation occlusions. Conclusions —Emergent TCD TIBI classification correlates with initial stroke severity, clinical recovery, and mortality in IV-tPA–treated stroke patients. A flow-grade improvement correlated with clinical improvement.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/01.STR.32.1.89
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2001
    detail.hit.zdb_id: 1467823-8
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  • 5
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    High Rate of Complete Recanalization and Dramatic Clinical Recovery During tPA Infusion When Continuously Monitored With 2-MHz Transcranial Doppler Monitoring
    Ovid Technologies (Wolters Kluwer Health) ; 2000
    In:  Stroke Vol. 31, No. 3 ( 2000-03), p. 610-614
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 31, No. 3 ( 2000-03), p. 610-614
    Abstract: Background and Purpose —Clot dissolution with tissue plasminogen activator (tPA) can lead to early clinical recovery after stroke. Transcranial Doppler (TCD) with low MHz frequency can determine arterial occlusion and monitor recanalization and may potentiate thrombolysis. Methods —Stroke patients receiving intravenous tPA were monitored during infusion with portable TCD (Multigon 500M; DWL MultiDop-T) and headframe (Marc series; Spencer Technologies). Residual flow signals were obtained from the clot location identified by TCD. National Institutes of Health Stroke Scale (NIHSS) scores were obtained before and after tPA infusion. Results —Forty patients were studied (mean age 70±16 years, baseline NIHSS score 18.6±6.2, tPA bolus at 132±54 minutes from symptom onset). TCD monitoring started at 125±52 minutes and continued for the duration of tPA infusion. The middle cerebral artery was occluded in 30 patients, the internal carotid artery was occluded in 11 patients, the basilar artery was occluded in 3 patients, and occlusions were multiple in 7 patients; 4 patients had no windows; and 1 patient had a normal TCD. Recanalization on TCD was found at 45±20 minutes after tPA bolus: recanalization was complete in 12 (30%) and partial in 16 (40%) patients. Dramatic recovery during tPA infusion (total NIHSS score 〈 3) occurred in 8 (20%) of all patients (baseline NIHSS range 6 to 22; all 8 had complete recanalization). Lack of improvement or worsening was associated with no recanalization, late recanalization, or reocclusion on TCD (C=0.811, P ≤0.01). Improvement by ≥10 NIHSS points or complete recovery was found in 30% of all patients at the end of tPA infusion and in 40% at 24 hours. Improvement by ≥4 NIHSS points was found in 62.5% of patients at 24 hours. Conclusions —Dramatic recovery during tPA therapy occurred in 20% of all patients when infusion was continuously monitored with TCD. Recovery was associated with recanalization on TCD, whereas no early improvement indicated persistent occlusion or reocclusion. At 24 hours, 40% of all patients improved by ≥10 NIHSS points or recovered completely. Ultrasonic energy transmission by TCD monitoring may expose more clot surface to tPA and facilitate thrombolysis and deserves a controlled trial as a way to potentiate the effect of tPA therapy.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/01.STR.31.3.610
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2000
    detail.hit.zdb_id: 1467823-8
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  • 6
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    Editorial Comment—The MOST Score: Modifying the Open-Artery “Good”–Closed-Artery “Bad” Approach to Thrombolysis Prognosis
    Ovid Technologies (Wolters Kluwer Health) ; 2004
    In:  Stroke Vol. 35, No. 1 ( 2004-01), p. 156-157
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 35, No. 1 ( 2004-01), p. 156-157
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/01.STR.0000108266.11282.BF
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2004
    detail.hit.zdb_id: 1467823-8
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  • 7
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    Specific Transcranial Doppler Flow Findings Related to the Presence and Site of Arterial Occlusion
    Ovid Technologies (Wolters Kluwer Health) ; 2000
    In:  Stroke Vol. 31, No. 1 ( 2000-01), p. 140-146
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 31, No. 1 ( 2000-01), p. 140-146
    Abstract: Background and Purpose —Transcranial Doppler (TCD) can localize arterial occlusion in stroke patients. Our aim was to evaluate the frequency of specific TCD flow findings with different sites of arterial occlusion. Methods —Using a standard insonation protocol, we prospectively evaluated the frequency of specific TCD findings in patients with or without proximal extracranial or intracranial occlusion determined by digital subtraction or MR angiography. Results —Of 190 consecutive patients studied, angiography showed occlusion in 48 patients. With proximal internal carotid artery (ICA) occlusion, TCD showed abnormal middle cerebral artery (MCA) waveforms (AMCAW) in 66.7%, reversed ophthalmic artery (OA) in 70.6%, anterior cross-filling via anterior communicating artery (ACoA) in 78.6%, posterior communicating artery (PCoA) in 71.4%, and contralateral compensatory velocity increase (CVI) in 84.6% of patients. With distal ICA occlusion, TCD showed AMCAW in 88.9%, OA in 16.7%, ACoA in 50%, PCoA in 60%, and CVI in 88.9% of patients. With MCA occlusion, TCD showed AMCAW in 100%, OA in 23.5%, ACoA in 31.3%, PCoA in 23.1%, and CVI in 62.5%. With no anterior circulation occlusion at angiography, TCD showed these parameters in 1.8% to 17.9%, χ 2 P ≤0.003. Parameters localizing anterior circulation occlusion were stenotic terminal ICA velocities 46% versus 10% in patent vessels; flow diversion to perforators 73% versus 1.8%; OA 70.6% versus 5.6%; ACoA 78.6% versus 8.2%; PCoA 71.4% versus 8.5%, all at P 〈 0.05. In patients with basilar artery (BA) occlusion, ABAW were found in 80% versus 3% (patent BA); flow diversion to anterior vessels in 60% versus 5.7%; BA flow reversal in 20% versus 0%; and PCoA in 100% versus 13.7%, all at P 〈 0.001. No individual parameters differentiated BA from the terminal vertebral occlusion. Conclusions —Specific TCD findings are common with major arterial occlusion and can be used to broaden diagnostic batteries and improve the predictive value of noninvasive screening in stroke patients. TCD findings useful to localize anterior circulation occlusion include collaterals, abnormal waveforms or velocities, and flow diversion to perforators.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/01.STR.31.1.140
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2000
    detail.hit.zdb_id: 1467823-8
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  • 8
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    In-Transit Telemedicine Speeds Ischemic Stroke Treatment : Preliminary Results
    Ovid Technologies (Wolters Kluwer Health) ; 2016
    In:  Stroke Vol. 47, No. 9 ( 2016-09), p. 2413-2415
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 47, No. 9 ( 2016-09), p. 2413-2415
    Abstract: Time to treatment is critically important in ischemic stroke. We compared the efficacy and cost of teleneurology evaluation during patient transport with that of mobile stroke transport units. Methods— Using cellular-connected telemedicine devices, we assessed 89 presumptive stroke patients in ambulances in transit. Paramedics assisted remote teleneurologists in obtaining a simplified history and examination, then coordinating care with the receiving emergency department. We prospectively assessed door-to-needle and last-known-well-to-needle times for all intravenous alteplase–treated stroke patients brought to our emergency departments by emergency medical services’ transport, comparing those with and without in-transit telestroke. Results— From January 2015 through March 2016, 111 stroke patients received intravenous alteplase at study emergency departments. Mean door to needle was 13 minutes less with in-transit telestroke (28 versus 41; P =0.02). Although limitations in cellular communication degraded transmission quality, this did not prevent the completion of satisfactory patient evaluations. Conclusions— Improvement in time to treat seems comparable with in-transit telestroke and mobile stroke transport units. The low cost/unit makes this approach scalable, potentially providing rapid management of more patients.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.116.014270
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2016
    detail.hit.zdb_id: 1467823-8
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  • 9
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    Neuroprotection and the Ischemic Cascade
    Cambridge University Press (CUP) ; 2000
    In:  CNS Spectrums Vol. 5, No. 3 ( 2000-03), p. 52-58
    Details
    In: CNS Spectrums, Cambridge University Press (CUP), Vol. 5, No. 3 ( 2000-03), p. 52-58
    Abstract: Brain ischemia is a process of delayed neuronal cell death, not an instantaneous event. The concept of neuroprotection is based on this principle. Diminished cerebral blood flow initiates a series of events (the “ischemic cascade”) that lead to cell destruction. This ischemic cascade is akin to a spreading epidemic starting from a hypothesized core of ischemia and radiating outward. If intervention occurs early, the process may be halted. Interventions have been directed toward salvaging the ischemic penumbra. Hypothermia decreases the size of the ischemic insult in both anecdotal clinical and laboratory reports. In addition, a wide variety of agents have been shown to reduce infant volume in animal models. Pharmacologic interventions that involve thrombolysis, calcium channel blockade, and cell membrane receptor antagonism have been studied and have been found to be beneficial in animal cortical stroke models. Human trials of neuroprotective therapies have been disappointing. Other than thrombolytics, no agents, have shown an unequivocal benefit. The future of neuroprotection will require a logical extension of what has been learned in the laboratory and previous human trials. A sensible approach to the use of multiple-agent cocktails used in combination with thrombolytics is likely to offer the highest chance for benefit.
    Type of Medium: Online Resource
    ISSN: 1092-8529 , 2165-6509
    URL: Article
    DOI: 10.1017/S1092852900012967
    Language: English
    Publisher: Cambridge University Press (CUP)
    Publication Date: 2000
    detail.hit.zdb_id: 2149753-9
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  • 10
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    Online Resource
    Early Dramatic Recovery During Intravenous Tissue Plasminogen Activator Infusion : Clinical Pattern and Outcome in Acute Middle Cerebral Artery Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2002
    In:  Stroke Vol. 33, No. 5 ( 2002-05), p. 1301-1307
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 33, No. 5 ( 2002-05), p. 1301-1307
    Abstract: Background and Purpose — Acute-stroke patients receiving standard intravenous tissue plasminogen activator (tPA) have been noted to experience early dramatic recoveries. The prevalence, clinical characteristics, and outcome of patients experiencing dramatic recovery is not well described. Methods — We prospectively studied all patients presenting with acute middle cerebral artery (MCA) stroke syndromes and transcranial Doppler (TCD) evidence of an MCA obstruction. All patients received intravenous tPA per the National Institute of Neurological and Communicative Disorders and Stroke protocol, with serial National Institutes of Health Stroke Scale (NIHSS) scores and continuous TCD monitoring. Dramatic recovery was defined as an improvement of ≥10 NIHSS points or a decrease to an NIHSS score of ≤3 by the end of infusion. Outcome at the end of infusion, at 24 hours, and at long-term follow-up were obtained. The timing and pattern of deficit recovery during dramatic recovery was also studied. Results — Dramatic recovery occurred in 22% of all patients. Compared with patients who did not experience dramatic recovery, those patients who did had significantly lower end-infusion NIHSS (median 2 and range 0 to 16 for dramatic-recovery patients versus median 17 and range 6 to 35 for non–dramatic-recovery patients, P 〈 0.01) and 24-hour NIHSS (median 2 and range 0 to 16 for dramatic-recovery patients versus median 13 and range 2 to 35 for non–dramatic-recovery patients, P 〈 0.01). A long-term modified Rankin Score benefit was noted (median 1 and range 0 to 6 for dramatic-recovery patients versus median 4 and range 0 to 6 for non–dramatic-recovery patients, P 〈 0.01). Baseline clinical characteristics were similar. The only difference was improved TCD-determined flow values at the end of infusion (normal restoration of flow was 58% in dramatic-recovery patients versus 14% in non–dramatic-recovery patients, P 〈 0.01). A characteristic pattern of recovery of deficit was noted. Conclusions — Early dramatic recovery in acute MCA stroke patients treated with intravenous tPA is relatively frequent. The benefit of dramatic recovery is maintained at 24 hours and over the long term. TCD monitoring suggests that dramatic recovery is a result of early restoration of MCA flow during the tPA infusion. The consistent pattern of early clinical recovery may help explain the mechanisms by which thrombolysis improves outcome and could suggest targets for enhancing the therapeutic effect of intravenous tPA.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/01.STR.0000015556.48283.74
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2002
    detail.hit.zdb_id: 1467823-8
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