Julio Viera

Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial.

BACKGROUND Only 2-5% of patients who have a stroke receive thrombolytic treatment, mainly because of delay in reaching the hospital. We aimed to assess the efficacy of a new approach of diagnosis and treatment starting at the emergency site, rather than after hospital arrival, in reducing delay in stroke therapy. METHODS We did a randomised single-centre controlled trial to compare the time from alarm (emergency call) to therapy decision between mobile stroke unit (MSU) and hospital intervention. For inclusion in our study patients needed to be aged 18-80 years and have one or more stroke symptoms that started within the previous 2·5 h. In accordance with our week-wise randomisation plan, patients received either prehospital stroke treatment in a specialised ambulance (equipped with a CT scanner, point-of-care laboratory, and telemedicine connection) or optimised conventional hospital-based stroke treatment (control group) with a 7 day follow-up. Allocation was not masked from patients and investigators. Our primary endpoint was time from alarm to therapy decision, which was analysed with the Mann-Whitney U test. Our secondary endpoints included times from alarm to end of CT and to end of laboratory analysis, number of patients receiving intravenous thrombolysis, time from alarm to intravenous thrombolysis, and neurological outcome. We also assessed safety endpoints. This study is registered with ClinicalTrials.gov, number NCT00153036. FINDINGS We stopped the trial after our planned interim analysis at 100 of 200 planned patients (53 in the prehospital stroke treatment group, 47 in the control group), because we had met our prespecified criteria for study termination. Prehospital stroke treatment reduced the median time from alarm to therapy decision substantially: 35 min (IQR 31-39) versus 76 min (63-94), p<0·0001; median difference 41 min (95% CI 36-48 min). We also detected similar gains regarding times from alarm to end of CT, and alarm to end of laboratory analysis, and to intravenous thrombolysis for eligible ischaemic stroke patients, although there was no substantial difference in number of patients who received intravenous thrombolysis or in neurological outcome. Safety endpoints seemed similar across the groups. INTERPRETATION For patients with suspected stroke, treatment by the MSU substantially reduced median time from alarm to therapy decision. The MSU strategy offers a potential solution to the medical problem of the arrival of most stroke patients at the hospital too late for treatment. FUNDING Ministry of Health of the Saarland, Germany, the Werner-Jackstädt Foundation, the Else-Kröner-Fresenius Foundation, and the Rettungsstiftung Saar.

Carotid Artery Stenting in Acute Stroke

OBJECTIVES The purpose of this study is to demonstrate the technical success of carotid artery stenting in acute extracranial internal carotid artery (ICA) occlusion as well as the benefit in clinical outcome. BACKGROUND Stroke caused by acute occlusion of the ICA is associated with a significant level of morbidity and mortality. For this type of lesion, treatment with standard intravenous thrombolysis alone leads to a good clinical outcome in only 17% of the cases, with a death rate as high as 55%. Recanalization of the occluded ICA can lead to an improvement in acute symptoms of stroke, prevent possible deterioration, and reduce long-term stroke risk. At present, there is no consensus treatment for patients with acute ischemic stroke presenting with severe clinical symptoms due to atherosclerotic occlusion of the extracranial ICA. METHODS Carotid artery stenting was performed in 22 patients with acute atherosclerotic extracranial ICA occlusion within 6 h of stroke symptom onset. In 18 patients, there was an additional intracranial occlusion at the level of the terminal segment of the ICA (n = 4) and at the level of the middle cerebral artery (n = 14). Intracranial occlusions were either treated with the Penumbra system or the Solitaire stent-based recanalization system, or a combination of mechanical recanalization and intra-arterial thrombolysis. Recanalization results were assessed by angiography immediately after the procedure. The neurologic status was evaluated before and after the treatment with a follow-up as long as 90 days using the National Institutes of Health Stroke Scale and the modified Rankin Scale. RESULTS Successful revascularization of extracranial ICA with acute stent implantation was achieved in 21 patients (95%). There was no acute stent thrombosis. After successful recanalization of the origin of the ICA, the intracranial recanalization with Thrombolysis In Myocardial Infarction flow grade 2/3 was achieved in 11 of the 18 patients (61%). The overall recanalization rate (extracranial and intracranial) was 14 of 22 patients (63%). Nine patients (41%) had a modified Rankin Scale score of ≤2 at 90 days. The mortality rate was 13.6% at 90 days. CONCLUSIONS Carotid artery stenting in acute atherosclerotic extracranial ICA occlusion with severe stroke symptoms is feasible, safe, and useful within the first 6 h after symptom onset.

Mechanical Recanalization With Flow Restoration in Acute Ischemic Stroke : The ReFlow (Mechanical Recanalization With Flow Restoration in Acute Ischemic Stroke) Study

OBJECTIVES This study sought to assess the feasibility and safety of a recently described technique of mechanical recanalization with the help of a stent-like device. BACKGROUND In the special group of acute stroke patients with an intracranial large vessel occlusion, intravenous tissue-type plasminogen activator on its own leads to a good clinical outcome (mRS ≤ 2) in only 15% to 25% of cases. The aforementioned technique of mechanical recanalization showed very promising clinical results. METHODS Forty patients presenting within 6 h from stroke symptom onset were enrolled. Mechanical recanalization was performed using a Solitaire FR revascularization device. The primary endpoint of the study was the clinical outcome rated with the help of the modified Rankin Scale (mRS) after 90 days. RESULTS Twenty-four patients (60%) showed a good clinical outcome (mRS ≤ 2) at 90 days. One symptomatic hemorrhage was detected on follow-up computed tomography. The death rate was 12.5% (5 patients). Successful recanalization (Thrombolysis In Cerebral Infarction score ≥ 2b) of the target vessel was achieved in 95% of the patients with a mean of 1.8 runs with the device. CONCLUSIONS The ReFlow (Mechanical Recanalization With Flow Restoration in Acute Ischemic Stroke) study shows that mechanical recanalization with flow restoration is highly effective in stroke patients with a large intracranial vessel occlusion presenting within 4.5 h after symptom onset. (Mechanical Recanalization With Flow Restoration in Acute Ischemic Stroke [ReFlow]; NCT01210729).

Degenerative Erkrankungen der Wirbelsäule

Degenerative alterations of the spine are among the most common causes of complaints of the musculoskeletal system. Imaging procedures are an established component of diagnostics and differential diagnoses. A reduction in height of the intervertebral space and sclerotization of the basal and covering plates are part of the first radiological alterations and in the further course can be accompanied by formation of spondylophytes, arthrosis of the intervertebral joints and degenerative vertebral surface gliding. However, early changes of the mobile segments can often not be visualized in x-ray images. Computed tomography (CT) and magnetic resonance imaging (MRI) substantially improve the diagnostic options. Using MRI the spinal column and the surrounding soft tissues can be visualized in 3-D and a differential diagnostic differentiation between inflammatory, traumatized or neoplastic processes is possible. A lack of correlation between the imaging findings and clinical symptoms remains problematic. A meaningful interpretation of x-ray images and MRI can only be made with the appropriate knowledge of the symptoms and possible diseases.ZusammenfassungDegenerative Veränderungen der Wirbelsäule gehören zu den häufigsten Ursachen für Beschwerden im Bereich des Bewegungsapparats. Für die Diagnostik und Differenzialdiagnostik haben bildgebende Verfahren ihren festen Platz. Eine Höhenminderung des Intervertebralraums und Sklerosierungen der Grund- und Deckplatten gehören zu den ersten radiologischen Veränderungen und können im weiteren Verlauf von Spondylophytenbildungen, Arthrosen der Intervertebralgelenke und einem degenerativem Wirbelgleiten begleitet werden. Frühveränderungen der Bewegungssegmente sind jedoch mit dem Röntgenbild oft nicht zu erfassen. Mit der Computertomographie (CT) und Magnetresonanztomographie (MRT) wurden die diagnostischen Möglichkeiten wesentlich verbessert. Mit der MRT können die Wirbelsäule und die beteiligten Weichteile dreidimensional dargestellt werden. Eine differenzialdiagnostische Abgrenzung zu inflammatorischen, traumatischen oder neoplastischen Prozessen ist möglich. Unverändert problematisch ist die mangelnde Korrelation zwischen den bildgebenden Befunden mit der klinischen Symptomatik. Röntgenbild und MRT können somit nur bei entsprechender Kenntnis über die Symptome und möglichen Krankheitsbilder sinnvoll interpretiert werden.AbstractDegenerative alterations of the spine are among the most common causes of complaints of the musculoskeletal system. Imaging procedures are an established component of diagnostics and differential diagnoses. A reduction in height of the intervertebral space and sclerotization of the basal and covering plates are part of the first radiological alterations and in the further course can be accompanied by formation of spondylophytes, arthrosis of the intervertebral joints and degenerative vertebral surface gliding. However, early changes of the mobile segments can often not be visualized in x-ray images. Computed tomography (CT) and magnetic resonance imaging (MRI) substantially improve the diagnostic options. Using MRI the spinal column and the surrounding soft tissues can be visualized in 3-D and a differential diagnostic differentiation between inflammatory, traumatized or neoplastic processes is possible. A lack of correlation between the imaging findings and clinical symptoms remains problematic. A meaningful interpretation of x-ray images and MRI can only be made with the appropriate knowledge of the symptoms and possible diseases.

Degenerative diseases of the spine

Degenerative alterations of the spine are among the most common causes of complaints of the musculoskeletal system. Imaging procedures are an established component of diagnostics and differential diagnoses. A reduction in height of the intervertebral space and sclerotization of the basal and covering plates are part of the first radiological alterations and in the further course can be accompanied by formation of spondylophytes, arthrosis of the intervertebral joints and degenerative vertebral surface gliding. However, early changes of the mobile segments can often not be visualized in x-ray images. Computed tomography (CT) and magnetic resonance imaging (MRI) substantially improve the diagnostic options. Using MRI the spinal column and the surrounding soft tissues can be visualized in 3-D and a differential diagnostic differentiation between inflammatory, traumatized or neoplastic processes is possible. A lack of correlation between the imaging findings and clinical symptoms remains problematic. A meaningful interpretation of x-ray images and MRI can only be made with the appropriate knowledge of the symptoms and possible diseases.ZusammenfassungDegenerative Veränderungen der Wirbelsäule gehören zu den häufigsten Ursachen für Beschwerden im Bereich des Bewegungsapparats. Für die Diagnostik und Differenzialdiagnostik haben bildgebende Verfahren ihren festen Platz. Eine Höhenminderung des Intervertebralraums und Sklerosierungen der Grund- und Deckplatten gehören zu den ersten radiologischen Veränderungen und können im weiteren Verlauf von Spondylophytenbildungen, Arthrosen der Intervertebralgelenke und einem degenerativem Wirbelgleiten begleitet werden. Frühveränderungen der Bewegungssegmente sind jedoch mit dem Röntgenbild oft nicht zu erfassen. Mit der Computertomographie (CT) und Magnetresonanztomographie (MRT) wurden die diagnostischen Möglichkeiten wesentlich verbessert. Mit der MRT können die Wirbelsäule und die beteiligten Weichteile dreidimensional dargestellt werden. Eine differenzialdiagnostische Abgrenzung zu inflammatorischen, traumatischen oder neoplastischen Prozessen ist möglich. Unverändert problematisch ist die mangelnde Korrelation zwischen den bildgebenden Befunden mit der klinischen Symptomatik. Röntgenbild und MRT können somit nur bei entsprechender Kenntnis über die Symptome und möglichen Krankheitsbilder sinnvoll interpretiert werden.AbstractDegenerative alterations of the spine are among the most common causes of complaints of the musculoskeletal system. Imaging procedures are an established component of diagnostics and differential diagnoses. A reduction in height of the intervertebral space and sclerotization of the basal and covering plates are part of the first radiological alterations and in the further course can be accompanied by formation of spondylophytes, arthrosis of the intervertebral joints and degenerative vertebral surface gliding. However, early changes of the mobile segments can often not be visualized in x-ray images. Computed tomography (CT) and magnetic resonance imaging (MRI) substantially improve the diagnostic options. Using MRI the spinal column and the surrounding soft tissues can be visualized in 3-D and a differential diagnostic differentiation between inflammatory, traumatized or neoplastic processes is possible. A lack of correlation between the imaging findings and clinical symptoms remains problematic. A meaningful interpretation of x-ray images and MRI can only be made with the appropriate knowledge of the symptoms and possible diseases.

Degenerative Erkrankungen der Wirbelsäule@@@Degenerative diseases of the spine

Degenerative alterations of the spine are among the most common causes of complaints of the musculoskeletal system. Imaging procedures are an established component of diagnostics and differential diagnoses. A reduction in height of the intervertebral space and sclerotization of the basal and covering plates are part of the first radiological alterations and in the further course can be accompanied by formation of spondylophytes, arthrosis of the intervertebral joints and degenerative vertebral surface gliding. However, early changes of the mobile segments can often not be visualized in x-ray images. Computed tomography (CT) and magnetic resonance imaging (MRI) substantially improve the diagnostic options. Using MRI the spinal column and the surrounding soft tissues can be visualized in 3-D and a differential diagnostic differentiation between inflammatory, traumatized or neoplastic processes is possible. A lack of correlation between the imaging findings and clinical symptoms remains problematic. A meaningful interpretation of x-ray images and MRI can only be made with the appropriate knowledge of the symptoms and possible diseases.ZusammenfassungDegenerative Veränderungen der Wirbelsäule gehören zu den häufigsten Ursachen für Beschwerden im Bereich des Bewegungsapparats. Für die Diagnostik und Differenzialdiagnostik haben bildgebende Verfahren ihren festen Platz. Eine Höhenminderung des Intervertebralraums und Sklerosierungen der Grund- und Deckplatten gehören zu den ersten radiologischen Veränderungen und können im weiteren Verlauf von Spondylophytenbildungen, Arthrosen der Intervertebralgelenke und einem degenerativem Wirbelgleiten begleitet werden. Frühveränderungen der Bewegungssegmente sind jedoch mit dem Röntgenbild oft nicht zu erfassen. Mit der Computertomographie (CT) und Magnetresonanztomographie (MRT) wurden die diagnostischen Möglichkeiten wesentlich verbessert. Mit der MRT können die Wirbelsäule und die beteiligten Weichteile dreidimensional dargestellt werden. Eine differenzialdiagnostische Abgrenzung zu inflammatorischen, traumatischen oder neoplastischen Prozessen ist möglich. Unverändert problematisch ist die mangelnde Korrelation zwischen den bildgebenden Befunden mit der klinischen Symptomatik. Röntgenbild und MRT können somit nur bei entsprechender Kenntnis über die Symptome und möglichen Krankheitsbilder sinnvoll interpretiert werden.AbstractDegenerative alterations of the spine are among the most common causes of complaints of the musculoskeletal system. Imaging procedures are an established component of diagnostics and differential diagnoses. A reduction in height of the intervertebral space and sclerotization of the basal and covering plates are part of the first radiological alterations and in the further course can be accompanied by formation of spondylophytes, arthrosis of the intervertebral joints and degenerative vertebral surface gliding. However, early changes of the mobile segments can often not be visualized in x-ray images. Computed tomography (CT) and magnetic resonance imaging (MRI) substantially improve the diagnostic options. Using MRI the spinal column and the surrounding soft tissues can be visualized in 3-D and a differential diagnostic differentiation between inflammatory, traumatized or neoplastic processes is possible. A lack of correlation between the imaging findings and clinical symptoms remains problematic. A meaningful interpretation of x-ray images and MRI can only be made with the appropriate knowledge of the symptoms and possible diseases.