Fern Reproduction at Woodman Hollow, Central Iowa: Preliminary Observations and a Consideration of the Feasibility of Studying Fern Reproductive Biology in Nature

Field observations of spore availability, gametophyte establishment and survival, and sporophyte production were made over a one-year period. Maximum spore release for most species occurred shortly after spore maturation in mid to late summer, but some spores remained on sporophyte fronds through the winter and were available for germination the following spring. Gametophytes of Cystopteris fragilis, Woodsia obtusa and Adiantum pedatum became established in late summer and fall. Production of sporophytes occurred both in fall and in the following spring. Both gametophytes and juvenile sporophytes survived the winter in relatively unchanged condition. Results indicate that it is feasible and important to correlate field studies with current laboratory studies of fern reproductive biology

Prefrontal and auditory input to intercalated neurons of the Amygdala

The basolateral amygdala (BLA) and prefrontal cortex (PFC) are partners in fear learning and extinction. Intercalated (ITC) cells are inhibitory neurons that surround the BLA. Lateral ITC (IITC) neurons provide feed-forward inhibition to BLA principal neurons, whereas medial ITC (mITC) neurons form an inhibitory interface between the BLA and central amygdala (CeA). Notably, infralimbic prefrontal (IL) input to mITC neurons is thought to play a key role in fear extinction. Here, using targeted optogenetic stimulation, we show that IITC neurons receive auditory input from cortical and thalamic regions. IL inputs innervate principal neurons in the BLA but not mITC neurons. These results suggest that (1) these neurons may play a more central role in fear learning as both IITCs and mITCs receive auditory input and that (2) mITC neurons cannot be driven directly by the IL, and their role in fear extinction is likely mediated via the BLA

Selection Criteria for Posterior Circulation Stroke and Functional Outcome Following Mechanical Thrombectomy

Objective: 20% of all acute ischemic strokes (AIS) are caused by posterior circulation strokes, which carry an intensified mortality touching 95%. Early recanalization improves outcome as shown by several reports; however, safety, patient selection, and prognostic factors remain lacking. An investigation of the safety and prognostic factors for posterior circulation mechanical thrombectomy (MT) was performed. Methods: A retrospective review of patients presenting with posterior circulation AIS, who underwent MT between 2010 and 2018. Results: Of 443 patients who underwent MT for AIS, 83 patients had posterior circulation strokes. 95% of procedures were conducted under general anesthesia. The median NIHSS upon admission was 19.1. Half of the patients underwent MT 8 hours from symptom onset, and half required a salvage contact thrombus aspiration after a stent retriever trial with an average of two passes for successful recanalization. The time to achieve revascularization was 61.6 minutes. Mortality rate was 28%, and modified Rankin Scale (mRS) \u3c 2 at three months was seen in 40.1% of surviving patients. A higher functional outcome trend (mRS\u3c2) was seen in patients who underwent MT within 8 hours of symptom onset. The overall complication rate was 28%. Regression analysis showed that stroke subtype, baseline NIHSS, and posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) before thrombectomy were independent predictive factors of positive clinical outcomes. Conclusions: MT is an effective intervention for posterior circulation strokes, and long-term functional independence relies upon proper patient selection. Baseline NIHSS and pc-ASPECTS are independent predictive factors

Stroke Centers of Excellence in the United States: Certification, Access and Outcomes

Introduction: Stroke is a leading cause of morbidity, mortality and healthcare costs in the United States. Evidence suggests that certified stroke centers have improved patient outcomes relative to non-certified hospitals. Our study explains the process, associated cost, quality and geographic proclivities of different certifying organizations. Methods: Data was collected from published literature, information on certifying organizations’ websites and through direct communication with representatives of The Joint Commission (TJC), Det Norske Veritas and Germanischer Lloyd (DNV-GL), and Healthcare Facilities Accreditation Program (HFAP). Geographic mapping of thrombectomy capable centers and comprehensive stroke centers was performed with the ArcGIS online tool. Results: Among the three certifying organizations, standards for recognition as acute, primary, thrombectomy capable and comprehensive stroke centers are not standardized. At the time of this review, there were 1406 TJC-certified stroke centers, 241 DNV-GL certified stroke centers and 66 HFAP-certified stroke centers in the United States. Cost for certification was similar with price scaled by complexity of capabilities. Quality metrics revealed a significantly higher rate of tPA administration and shorter door-to-needle time for TJC and DNV-GL centers than HFAP. All primary stroke centers exhibited improved in-hospital, 30-day and 1-year mortality when compared to non-stroke centers. Discussion: Despite lack of standardization of criteria between organizations, certification provides a mechanism for ensuring hospitals deliver higher standards of stroke care. Understanding variations in quality and scope of different organizations enables targeting of at-risk regions to maximize access and availability of care

Predictors of Ventriculostomy Infection in a Large Cohort

Introduction: External ventricular drains (EVDs) are neurosurgical devices used to treat hydrocephalus and monitor intracranial pressure. Ventriculostomy-associated infections (VAIs) are a complication of EVD placement associated with increased morbidity and mortality, as well as cost. A previous study at Jefferson reported a decrease in VAI’s with the use of antibiotic-coated catheters. Objective: The aim of this study was to assess the current rate of VAI’s and determine risk factors associated with infections. Methods: Using Epic, the electronic medical records software, we conducted a retrospective review of patients who underwent EVD placement at Thomas Jefferson University Hospital and Jefferson Hospital for Neuroscience between January 2010 and January 2018. Results: During this time period, 1107 EVD’s were placed in 1034 patients. The most common indications for placement were acute subarachnoid hemorrhage (51%), intraparenchymal hemorrhage (15.4%), and brain tumors (9.7%). 38 patients suffered from a VAI, for an infection rate of 0.03%. Patients with VAI’s had a significantly longer duration of EVD placement (19.4 vs. 11.1 days). Risk factors for VAI included CSF leak (OR 2.35), EVD placement greater than 11 days (OR 2.14), and concurrent infection (OR 1.74). There was no association with patient age, sex, initial diagnosis, drain replacement, number of samples drawn, or prophylactic antibiotics. Discussion: Despite the use of antibiotic-coated catheters, VAI’s still remain a prevalent complication of EVD placement. By working to prevent CSF leaks, minimize the duration of EVD placement, and appropriately treat concurrent infections, it may be possible to further lower VAI rates

Improving Serial Imaging Protocols in Spontaneous Intracerebral Hemorrhage

There is no universally agreed upon protocol to image patient presenting with intra-parenchymal hemorrhage of non-traumatic etiology (sICH). At our institution, it is common practice for a patient to have 3 CT’s done within 24 hours. They are often at onset of symptoms or presentation, 6 hours post onset of symptoms, and finally 24 hours post bleed onset. The goal of this project will be to assess the safety and efficacy of obtaining this repeat imaging in our patients in the hopes that limiting unnecessary CT head studies will decrease resource utilization, decrease patient radiation, expedite movement of stable patients out of the ICU and/or disposition

Ictal asystole secondary to suspected herpes simplex encephalitis: a case report

Herpes simplex virus is a leading cause of sporadic encephalitis. While seizures are a common feature of Herpes simplex virus encephalitis, and periods of asystole have been reported in Herpes simplex virus patients, there have been no prior reports of ictal asystole secondary to such an infection

Management of patients with isolated acute cervical carotid artery occlusion and normal neurological exam: Technical note and case series

Objectives Limited data exists on the management and outcome of patients with isolated acute cervical internal carotid artery (cICA) occlusion presenting with normal neurologic exam after experiencing a period of neurological deficits. These patients are at risk for progressive neurologic deterioration but have not yet progressed to stroke. Current management is no intervention due to intervention risk of embolization. We aim to determine the optimal management of patients with isolated acute cICA occlusion presenting with a normal neurological exam after experiencing neurological deficits. Patients and methods Data was collected on 3 patients with acute cICA occlusion that presented with a normal neurological exam to our institution. Patient 1 was treated according to standard protocol, while patients 2 and 3 were treated according to the management discussed. Associations between perfusion imaging studies and clinical outcome were analyzed to determine stroke risk. A revascularization technique to minimize risk of distal embolization is described. Results A total of 3 consecutive patients with acute cICA occlusion were successfully revascularized. Patients 2 and 3 (66.67%) were neurologically intact post-operatively, while patient 1 (33.33%) had residual hemiparesis. It seems that MTT ≥ 200% or Tmax \u3e 6 s is the optimal penumbra threshold predicting infarction and neurologic deterioration. There were no embolic complications as a result of endovascular therapy (EVT). Conclusion Cerebral perfusion imaging of patients presenting with normal neurological exam after experiencing neurological deficits is warranted to help identify patients at risk for stroke due to collateral failure. These patients should be monitored in the ICU for neurologic deterioration and given the option of intervention if mismatch is noted on CT perfusion imaging. Perfusion studies identifying penumbra and delayed MTT ≥ 200% or Tmax \u3e 6 s are indicators for possible collateral failure. In patients undergoing intervention, we suggest a technique using proximal flow arrest to minimize risk of shower emboli. Further studies are needed to verify our findings

Mechanical Thrombectomy in Acute Ischemic Stroke Patients Greater than 90 years of age experience in 26 patients in a Large Tertiary Care Center: Outcome comparison with younger patients

Introduction: Several independent randomized control trials have shown the superior efficacy of mechanical thrombectomy for acute ischemic stroke (AIS). However, the elderly has been underrepresented or excluded in these trials. In this study, we investigated the feasibility and safety of mechanical thrombectomy in patients with AIS aged 90 years or greater. Methods: A retrospective review of patients age 90 years or older presenting with AIS who underwent mechanical thrombectomy between 2010 and 2018. Results: Of total 453 patients with AIS, 5.74 % (26) were aged 90 or older, and 69.32 % (314) ranged from 60-89 years of age. Of all baseline characteristics between both groups, there is a significant difference in age, gender, body mass index (BMI), smoking, hyperlipidemia (HLD), atrial fibrillation, and diabetes mellitus. The mean NIHSS upon admission was higher in the nonagenarians (17 vs. 15). Similar proportions of both groups received tPA (57.69%, 15 vs. 42.68%, 134, p=0.14). There was no difference in peri & post-procedural complications, good TICI score (88.46%, 23 vs. 87.58%, 275, p=1.00), “good” mRS scores (34.62%, 4 vs. 49.36%, 155, p=0.40), and mortality (11.54%, 3 vs. 13.06%, 41, p= 0.82). Discussion: Age is one of the factors that affect functional outcome following mechanical thrombectomy. Advancements in catheter techniques, technical experience, and great outcomes with mechanical thrombectomy allow for pushing the envelope to deal with age as one of the factors, rather, than an exclusion criterion. Our results show that mechanical thrombectomy is safe and feasible in nonagenarians