Intra-arterial thrombolysis of embolic middle cerebral artery using collateral pathways

Background and purpose: Cervical internal carotid artery (ICA) occlusion associated with middle cerebral artery (MCA) embolic occlusion requires prompt revascularization to prevent devastating stroke. With the advent of endovascular techniques for chemical and mechanical thrombolysis, the clinical outcome of patients with major arterial occlusions will improve. Finding the most expedient pathway to the site of end organ occlusion for thrombolysis is important. Methods: We present two cases of acute stroke secondary to thrombotic occlusion of the cervical ICA associated with MCA embolic occlusion treated with intra-arterial thrombolysis via catheter navigation through the posterior communicating artery to the site of MCA arterial occlusion. No attempt was made to transverse the occluded ICA. Results: Near complete restoration of flow was achieved in one patient and minimal vessel reopening was observed in the other patient. Both patients had good outcomes. Conclusion: Intra-arterial thrombolysis via Circle of Willis collaterals such as the posterior communicating artery for the treatment of acute thrombotic occlusion of the cervical internal carotid artery associated with embolic occlusion of the middle cerebral artery is a therapeutic option. This treatment option avoids the potential complications of navigating through an occluded proximal internal carotid artery and may expedite reopening of the MCA

Axonal Degeneration of the Vagus Nerve in Parkinson's Disease—A High-Resolution Ultrasound Study

Background: Recent histopathological studies revealed degeneration of the dorsal motor nucleus early in the course of Parkinson's disease (PD). Degeneration of the vagus nerve (VN) axons following neurodegeneration of brainstem vagal nuclei should be detectable by high-resolution ultrasound (HRUS) as a thinning of the VNs.Methods: We measured both VNs cross-sectional area (VN-CSA) of 35 patients with PD and 35 age- and sex-matched healthy controls at the level of the thyroid gland using HRUS.Results: On both sides, the VN-CSA was significantly smaller in PD patients than in controls (right: 2.1 ± 0.4 vs. 2.3 ± 0.5 mm2, left 1.5 ± 0.4 vs. 1.8 ± 0.4 mm2; both p < 0.05). There was no correlation between the right or left VN-CSA and age, the Hoehn & Yahr stage, disease duration, the motor part of the Unified Parkinson's Disease Rating Scale score, the Montreal Cognitive Assessment score, or the Non-motor Symptoms Questionnaire, and Scale for Parkinson's disease score including its gastrointestinal domain.Conclusions: These findings provide evidencethat atrophy of the VNs in PD patients can be detected in-vivo by HRUS

Enlarged cross-sectional area of the left vagus nerve in patients with major depressive disorder

PurposeAutonomic dysfunction and a chronic low-grade inflammation are supposed to play a role in the etiology of major depressive disorder (MDD). The vagus nerves (VN) form a major part of the parasympathetic nervous system and of the gut-brain axis. They are supposed to exert anti-inflammatory and epithelial barrier protective effects in the gut. A reduced vagal activity was described in patients with MDD. We aimed to examine the VN in patients with MDD with high-resolution ultrasound (HRUS) and hypothesized that the cross-sectional area (CSA) and the echogenicity of the VNs were altered in comparison to healthy controls.Materials and methodsThe echogenicity (gray scale mean) and the CSA of the cervical VNs at the level of the thyroid gland and both median nerves were examined with HRUS in 50 patients with MDD and 50 matched healthy controls.ResultsThe left VN-CSA was significantly larger in the MDD group compared to the control group (1.7 ± 0.4 mm2 versus 1.5 ± 0.4 mm2; p = 0.045). The CSA of the right VN and both median nerves (MN) were similar between groups. In MDD subgroup analyses, recurrent depressive disorders were the main contributing factor for the left VN-CSA enlargement. Echogenicity was not altered in the VN and MN between groups.ConclusionThe enlargement of the left VN-CSA in patients with MDD, and especially in these patients with recurrent depressive disorders, might turn out as a promising imaging biomarker. Longitudinal studies are warranted to examine whether the VNs-CSA change in the course of MDD

Evaluation of Best Supportive Care and Systemic Chemotherapy as Treatment Stratified according to the retrospective Peritoneal Surface Disease Severity Score (PSDSS) for Peritoneal Carcinomatosis of Colorectal Origin

Background: We evaluate the long-term survival of patients with peritoneal carcinomatosis (PC) treated with systemic chemotherapy regimens, and the impact of the of the retrospective peritoneal disease severity score (PSDSS) on outcomes. Methods: One hundred sixty-seven consecutive patients treated with PC from colorectal cancer between years 1987-2006 were identified from a prospective institutional database. These patients either received no chemotherapy, 5-FU/Leucovorin or Oxaliplatin/Irinotecan-based chemotherapy. Stratification was made according to the retrospective PSDSS that classifies PC patients based on clinically relevant factors. Survival analysis was performed using the Kaplan-Meier method and comparison with the log-rank test. Results: Median survival was 5 months (95% CI, 3-7 months) for patients who had no chemotherapy, 11 months (95% CI, 6-9 months) for patients treated with 5 FU/LV, and 12 months (95% CI, 4-20 months) for patients treated with Oxaliplatin/Irinotecan-based chemotherapy. Survival differed between patients treated with chemotherapy compared to those patients who did not receive chemotherapy (p = 0.026). PSDSS staging was identified as an independent predictor for survival on multivariate analysis [RR 2.8 (95%CI 1.5-5.4); p < 0.001]. Conclusion: A trend towards improved outcomes is demonstrated from treatment of patients with PC from colorectal cancer using modern systemic chemotherapy. The PSDSS appears to be a useful tool in patient selection and prognostication in PC of colorectal origin

Proactive listening to a training commentary improves hazard prediction

The aim of this work was to explore the effect of Proactive Listening to a Training Commentary, using the recently developed version of the Spanish Hazard Perception test. Firstly, 16 videos were used in the pre-test session in its short version, cut to black just before the hazard appearance. The What Happens Next Assessment (at the pre-test stage) generates expectations about the outcome of the traffic situation. Then, the training (8 minutes in length) uses the complete version of the same 16 videos, revealing the hazards unfolding. It involves listening to a voice with relevant information about where to allocate attention in the complex driving scene in order to recognise and anticipate the hazard successfully. A total of 121 participants were included in this study The sample consisted of learner, novice and experienced drivers, including re-offender and non-offender drivers. The participants were divided into 2 groups: a trained and an untrained group. Two assessment times were used: pre-test (16 videos) and post-test sessions (another 16 videos). The test presented a high internal consistency (Alpha = 0.875). This training shows significant positive effects for all types and groups of participants. No significant differences were found between the non-offender and the offender groups. Performance in gradual-onset hazard events can be improved after training but also by practice; however this training is essential and especially beneficial for training the ability to detect hazards that appear abruptly (which seems to be difficult to improve just by practice)

Hazard prediction discriminates between novice and experienced drivers

Typical hazard perception tests often confound multiple processes in their responses. The current study tested hazard prediction in isolation to assess whether this component can discriminate between novice and experienced drivers. A variant of the hazard perception test, based on the Situation Awareness Global Assessment Technique, found experienced drivers to outperform novices across three experiments suggesting that the act of predicting an imminent hazard is a crucial part of the hazard-perception process. Furthermore three additional hypotheses were tested in these experiments. First, performance was compared across clips of different length. There was marginal evidence that novice drivers' performance suffered with the longest clips, but experienced drivers’ performance did not, suggesting that experienced drivers find hazard prediction less effortful. Secondly, predictive accuracy was found to be dependent on the temporal proximity of visual precursors to the hazard. Thirdly the relationship between the hazard and its precursor was found to be important, with less obvious precursors improving the discrimination between novice and experience drivers. These findings demonstrate that a measure of hazard prediction, which is less confounded by the influence of risk appraisal than simple response time measures, can still discriminate between novice and experienced drivers. Application of this methodology under different conditions can produce insights into the underlying processes that may be at work, whilst also providing an alternative test of driver skill in relation to the detection of hazards

The impact of transcranial direct current stimulation on inhibitory control in young adults

In recent years, many important discoveries have been made to challenge current policy, guidelines, and practice regarding how best to prevent stroke associated with atherosclerotic stenosis of the origin of the internal carotid artery. TheUnited States Center forMedicare andMedicaid Services (CMS), for instance, is calling for expert advice as to whether its current policies should be modified. Using a thorough review of literature, 41 leading academic stroke-prevention clinicians from the United States and other countries, have united to advise CMS not to extend current reimbursement indications for carotid angioplasty/stenting (CAS) to patients with asymptomatic carotid stenosis or to patients with symptomatic carotid stenosis considered to be at low or standard risk from carotid endarterectomy (CEA). It was concluded that such expansion of reimbursement indications would have disastrous health and economic consequences for the United States and any other country that may follow such inappropriate action. This was an international effort because the experts to best advise CMS are relatively few and scattered around the world. In addition, US health policy, practice, and research have tended to have strong influences on other countries. © 2012 The Authors. Published by Wiley Periodicals, Inc

Are situation awareness and decision-making in driving totally conscious processes? Results of a Hazard Prediction task

Detecting danger in the driving environment is an indispensable task to guarantee safety which depends on the driver's ability to predict upcoming hazards. But does correct prediction lead to an appropriate response? This study advances hazard perception research by investigating the link between successful prediction and response selection. Three groups of drivers (learners, novices and experienced drivers) were recruited, with novice and experienced drivers further split into offender and non-offender groups. Specifically, this works aims to develop an improved Spanish Hazard Prediction Test and to explore the differences in Situation Awareness, (SA: perception, comprehension and prediction) and Decision-Making ("DM") among learners, younger inexperienced and experienced drivers and between driving offenders and non-offenders. The contribution of the current work is not only theoretical; the Hazard Prediction Test is also a valid way to test Hazard Perception. The test, as well as being useful as part of the test for a driving license, could also serve a purpose in the renewal of licenses after a ban or as a way of training drivers. A sample of 121 participants watched a series of driving video clips that ended with a sudden occlusion prior to a hazard. They then answered questions to assess their SA ("What is the hazard?" "Where is it located?" "What happens next?") and "DM" ("What would you do in this situation?"). This alternative to the Hazard Perception Test demonstrates a satisfactory internal consistency (Alpha=0.750), with eleven videos achieving discrimination indices above 0.30. Learners performed significantly worse than experienced drivers when required to identify and locate the hazard. Interestingly, drivers were more accurate in answering the "DM" question than questions regarding SA, suggesting that drivers can choose an appropriate response manoeuvre without a totally conscious knowledge of the exact hazard