Douglas Graeb

Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke A Canadian Hospital’s Experience

Background and Purpose In the United States, tissue plasminogen activator (tPA) was approved for treatment of acute ischemic stroke in 1996. Its use has only recently been approved in Canada. We sought to evaluate the safety, feasibility, and efficacy of treatment in a Canadian hospital setting. Methods A combined retrospective and prospective review is presented of 46 consecutive patients treated with intravenous tPA at our hospital with a treatment protocol similar to that of the National Institute of Neurological Disorders and Stroke (NINDS) trial. Results Symptomatic intracranial hemorrhage at 36 hours occurred in 1 patient (2.2%). The median time to treat was 165 minutes, with a median “door-to-needle” time of 84 minutes. Compared with patients presenting initially at our hospital, patients transferred from another institution for tPA therapy were treated closer to the 3-hour time window (mean 173 versus 148 minutes, P <0.001) but had a shorter door-to-needle time (43 versus 102 minutes, P <0.001). For every 10 minutes closer to the 3-hour time window that any patient arrived at the hospital, 7 minutes was saved in the door-to-needle time (correlation coefficient 0.9, P <0.001). Patient outcome did not differ from that in the NINDS trial (P >0.75). Conclusions Our safety and patient outcome data compare favorably with NINDS and Phase IV data. Although a 3-hour treatment window was feasible, the median door-to-needle time lengthened as more treatment time was available and the door-to-needle time was beyond recommended standards. This review has prompted changes in our community to improve treatment efficiency.

Multidisciplinary Approaches to Complicated Vascular Lesions of the Orbit

BACKGROUND Hemodynamically active vascular lesions of the orbit are often clinically challenging to treat, both because of the complexity of the vascular anatomy and the delicacy of the cardinal structures that are involved and vulnerable to damage. Attempts to achieve complete embolization of such vascular lesions may result in damage to vital visual structures. Conversely, incomplete closure of the feeders or vascular shunts will usually result in recanalization and, therefore, recurrence of such lesions. METHODS Surgical excision after selective optimal embolizations may convert dynamic lesions into static ones with controlled surgical risks and could provide a solution to these problems. Cyanoacrylic polymerization was used to embolize the lesions, which were then excised with careful microsurgical and microvascular techniques. RESULTS The authors present four cases of different hemodynamically active orbital vascular lesions (a post-traumatic arteriovenous fistula, a complex venous anomaly, a cavernous hemangioma of bone, and an arteriovenous malformation), which were treated successfully with the combination of presurgical embolization and surgery. CONCLUSION The authors believe that, from their experience with these cases, a multidisciplinary approach to complicated orbital vascular lesions is ideal and practical.

Vascular malformations of the orbit: classification and the role of imaging in diagnosis and treatment strategies*.

Purpose: To describe the authors’ experience with orbital vascular malformations using the International Society for the Study of Vascular Anomalies (ISSVA) classification and the preferred radiologic techniques. Methods: Review of clinical and radiologic experience from 1976 to 2012. This article presents the findings from several studies conducted on vascular malformations of the orbit, all of which received institutional review board approval when needed. Results: The orbital vascular malformations can be evaluated, classified, and managed according to the ISSVA classification to provide a common language of communication between specialties, which takes into account flow dynamics. Conclusions: The ISSVA can be applied for vascular malformations of the orbit.

Cerebral infarction and regression of widespread aneurysms in Kawasaki's disease: case report.

The prevalence of Kawasakis disease has increased in the last decade and it is now recognized worldwide. Coronary aneurysms are an important complication often causing death. The widespread vascular changes which can occur are illustrated by a patient who presented with a cerebral infarct and who developed widespread aneurysmal disease which regressed.

Resolution of Existing Intimal Plaque in a Patient with Carotidynia

SUMMARY: We present a case of carotidynia that was imaged with 3 techniques: sonography, CT angiography, and gadolinium-enhanced MR imaging. We describe a previously unreported finding, the resolution of an intimal plaque noted on imaging at the time of initial presentation, presumably due to changes induced by the healing phase of the carotid inflammatory process.