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PURPOSE: During endovascular treatment of intracranial aneurysms using coils, migration is a serious complication that increases neurological morbidity. The aim of this experimental study was to assess the effectiveness and complications of retrieving volume coils with different, currently available clot retrievers in a porcine model. METHODS: Volume coils of three-dimensional (3D) shape and different sizes were placed in the axillary artery of pigs. By means of 4 different clot retrievers (Trevo ProVue; Solitaire FR; 3D-Separator; ERIC) a total of 40 retrieval maneuvers (10 per retriever) were performed by deploying the retrievers within the migrated coils and trying to trap parts of the coils by advancing the microcatheter. Retrieval rates, retrieval duration, retrieval attempts, and complications were assessed. RESULTS: Overall coil retrieval was successful in 31 of 40 cases (77.5%). Retrieval rates using the Trevo ProVue (9/10), Solitaire FR (8/10), and the 3D-Separator (9/10) were higher than when using the ERIC (5/10). Duration of retrieval and retrieval attempts were significantly higher using the ERIC (p < 0.05). Complications like inadvertent deployment were only observed in one case using the Solitaire FR. Additional entrapment of the coil-retriever complex at the intermediate catheter was seen in 9 cases (22.5%). There was no case of vasospasm, perforation, or dissection. CONCLUSIONS: Retrieval of migrated volume coils using new-generation clot retrievers is a feasible and effective method. Retrieval rates and duration with the Trevo ProVue, Solitaire FR, and 3D-Separator are superior when compared to the ERIC.
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Modelos Animales de Enfermedad , Embolización Terapéutica/instrumentación , Migración de Cuerpo Extraño/terapia , Embolia Intracraneal/terapia , Trombectomía/instrumentación , Animales , Arteria Axilar , Catéteres , Diseño de Equipo , PorcinosRESUMEN
PURPOSE: Treatment of intracranial aneurysm with flow-diverting devices has become widespread in recent years. Despite that, intra-aneurysmal flow changes are yet not fully understood and can lead to different complications. Our aim was an in vitro contrast-based evaluation of the influence of flow diverter size and position on intra-aneurysmal flow dynamics. METHODS: Flow-diverting devices with different sizes (diameters 4.0, 4.5, and 6.0 mm) were deployed in seven silicone aneurysm models at different positions relative to the aneurysm neck (proximal, central, distal). Using syngo iFlow, we defined quantitative evaluation criteria based on contrast medium intensity and performed a flow evaluation. RESULTS: Intra-aneurysmal flows were heavily dependent on both size and position of flow-diverting devices at the aneurysm neck. We observed a higher peak intensity delay and intra-aneurysmal washout delay with the centrally placed 4.0- and 4.5-mm device, respectively, compared to the proximal and distal positions. Especially distally placed 4.0-mm devices led to an earlier filling of the aneurysm and increased intra-aneurysmal contrast agent intensity compared to the parent vessel, due to a potential endoleak. CONCLUSIONS: Not only size but also position of flow-diverting devices have a considerable impact on the intra-aneurysmal flow dynamics. The suggested evaluation criteria allowed a quantitative comparison of flow-diverting effect using syngo iFlow and could represent an efficient tool for predicting flow diversion pre-procedurally.
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Angiografía de Substracción Digital/métodos , Velocidad del Flujo Sanguíneo , Medios de Contraste/administración & dosificación , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/terapia , Stents , Circulación Cerebrovascular , Diseño de Equipo , Procesamiento de Imagen Asistido por Computador , Técnicas In Vitro , Modelos Anatómicos , Modelos Cardiovasculares , Programas InformáticosRESUMEN
BACKGROUND AND PURPOSE: A new generation of carotid artery stents that uses a second micromesh layer to reduce embolic events during carotid artery stenting has recently been introduced. The purpose of this study was to compare acute occlusion rates of these new dual-layer stents with those of single-layer stents in the setting of emergency carotid artery stenting with intracranial mechanical thrombectomy in acute ischemic stroke. METHODS: Consecutive patients with acute tandem (intra- and extracranial) lesions of the anterior circulation who were endovascularly treated at our institution were identified from our registry of neuroendovascular interventions. Clinical, angiographic, and neuroimaging data were analyzed. End points included acute occlusions of the carotid stents (within 72 hours after stenting) and symptomatic intracerebral hemorrhage. RESULTS: Forty-seven patients were included. Dual-layer stents (n=20) had a significantly higher rate of acute occlusions than single-layer stents (n=27; 45% versus 3.7%; P=0.001; odds ratio, 21.3; 95% confidence interval, 2.4-188.4). There were no significant differences in the rates of patients who had any antiplatelet or dual antiplatelet medication before admission, in the rates of postinterventional symptomatic intracerebral hemorrhage, the mean National Institutes of Health Stroke Scale scores at admission, or the modified Rankin Scale scores at discharge. CONCLUSIONS: The recently introduced dual-layer stents have a higher risk of acute occlusion compared with single-layer stents in the treatment of acute stroke.
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Isquemia Encefálica/cirugía , Estenosis Carotídea/diagnóstico , Tratamiento de Urgencia/efectos adversos , Procedimientos Endovasculares/efectos adversos , Stents/efectos adversos , Accidente Cerebrovascular/cirugía , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico , Estenosis Carotídea/etiología , Tratamiento de Urgencia/métodos , Procedimientos Endovasculares/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Accidente Cerebrovascular/diagnóstico , Trombectomía/efectos adversos , Trombectomía/métodos , Resultado del TratamientoRESUMEN
Spinal perimedullary arteriovenous fistulas (PMAVFs) are rare entities among vascular malformations of the spinal cord. Due to progressive myelopathy, spastic paresis, sensory disturbance, and bowl and bladder dysfunction can be the presenting symptoms. Cervical spinal arteriovenous fistulas (AVFs) are even rarer. These lesions differ from the ones in the thoracolumbar region and have an even wider mode of presentation. We report on a 9-year-old boy with a cervical PMAVF manifesting with headache and vertigo.
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Malformaciones Arteriovenosas/diagnóstico por imagen , Cefalea/etiología , Médula Espinal/irrigación sanguínea , Vértigo/etiología , Angiografía de Substracción Digital , Malformaciones Arteriovenosas/terapia , Angiografía Cerebral , Niño , Embolización Terapéutica , Estudios de Seguimiento , Cefalea/terapia , Humanos , Hemorragias Intracraneales/diagnóstico por imagen , Hemorragias Intracraneales/terapia , Angiografía por Resonancia Magnética , Imagen por Resonancia Magnética , Masculino , Examen Neurológico , Médula Espinal/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Vértigo/terapiaRESUMEN
INTRODUCTION: Flow diverters are increasingly being used to treat intracranial aneurysms. This study evaluates occurring complications of flow-diverting devices in the treatment of experimental aneurysms, involving the use of micro-CT and small animal MRI at 9.4 T, in correlation to angiographic and histological findings. METHODS: We previously published two preclinical studies, in which we assessed two different flow diverters in the treatment of elastase-induced aneurysms. Devices have been implanted across the aneurysm neck as well as in the abdominal aorta. From these studies, a total of 65 devices (prototype FD (n = 30) and Derivo embolization device (n = 35)) additionally underwent micro-CT and MRI after angiographic follow-up and before being histologically examined. RESULTS: The different architectures of both devices were precisely comparable due to high-resolution micro-CT imaging. Micro-CT revealed wire fractures in nine cases (30 %) only with the prototype FD. In three cases (10 %), severe wire fractures correlated with an in-stent stenosis due to intimal hyperplasia. Other complications, like distal stent occlusions and post-stent stenosis, were seen in both groups and verified with both imaging techniques. Osseous metaplasia were correlated to calcifications seen with micro-CT. MRI enabled visualization of the position of the implanted devices relative to the aneurysm and revealed incomplete aneurysm neck coverage with the prototype FD in two cases (6.7 %). CONCLUSION: Micro-CT and 9.4-T MRI are valid to discover and understand occurring complications of flow diverters in the preclinical phase and can serve as evaluation tools to minimize complication rates of endovascular devices in the future.
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Revascularización Cerebral/efectos adversos , Revascularización Cerebral/instrumentación , Oclusión de Injerto Vascular/etiología , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/terapia , Angiografía por Resonancia Magnética/métodos , Microtomografía por Rayos X/métodos , Animales , Angiografía Cerebral/métodos , Revascularización Cerebral/métodos , Angiografía por Tomografía Computarizada/métodos , Diseño de Equipo , Análisis de Falla de Equipo , Femenino , Oclusión de Injerto Vascular/diagnóstico por imagen , Aneurisma Intracraneal/inducido químicamente , Elastasa Pancreática , Conejos , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Resultado del TratamientoRESUMEN
BACKGROUND AND PURPOSE: New techniques have substantially raised recanalization rates of mechanical thrombectomy in acute ischemic stroke in the last few years with initial prospective trials reporting good neurological outcome in up to 58 % of the cases. However some recent reports questioning the benefit of endovascular therapy have initiated a discussion about the importance of patient-selection. The purpose of this study was to investigate whether an elongation of the carotid artery affects the angiographic outcome of the recanalization procedure in middle cerebral artery (MCA)-occlusions. MATERIALS AND METHODS: The data of 54 patients with occlusions of the M1-segment who underwent mechanical thrombectomy were included. The lengths of the carotid arteries were measured using preinterventional computed tomography (CT)-angiograms. To take individual patient's height into account these lengths were divided by the length of the spine from the tip of the dens to the bottom of the th3 vertebral body (referred to as carotid-to-spine (CS)-Ratio). Angiographic results were scored according to the modified thrombolysis in cerebral infarction (mTICI)-score. RESULTS: Recanalization with mTICI ≥ 2b was achieved in 83.3 %. The mean CS-Ratio was 1.32 ± 0.13. There was a significant correlation between the CS-Ratio and the age of the patients. There were no significant differences in the CS-Ratios of occlusions that were successfully recanalized and those that were not. Neither were there significant correlations of the CS-Ratio and the length of procedure or the number of deployments of the stentretrievers. CONCLUSION: In this retrospective analysis we report that carotid elongation does not affect angiographic results of mechanical thrombectomy in acute stroke.
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Arterias Carótidas/diagnóstico por imagen , Arterias Carótidas/patología , Angiografía Cerebral , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/terapia , Trombolisis Mecánica , Anciano , Femenino , Humanos , Masculino , Tamaño de los Órganos , Selección de Paciente , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: For patients with acute ischemic stroke, intra-arterial treatment (IAT) is considered to be an effective strategy for removing the obstructing clot. Because outcome crucially depends on time to treatment ('time-is-brain' concept), we assessed the effects of an intervention based on performing all the time-sensitive diagnostic and therapeutic procedures at a single location on the delay before intra-arterial stroke treatment. METHODS: Consecutive acute stroke patients with large vessel occlusion who obtained IAT were evaluated before and after implementation (April 26, 2010) of an intervention focused on performing all the diagnostic and therapeutic measures at a single site ('stroke room'). RESULT: After implementation of the intervention, the median intervals between admission and first angiography series were significantly shorter for 174 intervention patients (102 min, interquartile range (IQR) 85-120 min) than for 81 control patients (117 min, IQR 89-150 min; p < 0.05), as were the intervals between admission and clot removal or end of angiography (152 min, IQR 123-185 min vs. 190 min, IQR 163-227 min; p < 0.001). However, no significant differences in clinical outcome were observed. CONCLUSION: This study shows for the, to our knowledge, first time that for patients with acute ischemic stroke, stroke diagnosis and treatment at a single location ('stroke room') saves crucial time until IAT.
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Fibrinolíticos/uso terapéutico , Unidades Hospitalarias/organización & administración , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/terapia , Terapia Trombolítica , Activador de Tejido Plasminógeno/uso terapéutico , Enfermedad Aguda , Anciano , Angiografía Cerebral , Protocolos Clínicos , Terapia Combinada , Femenino , Hospitales Universitarios/organización & administración , Humanos , Infusiones Intraarteriales , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente , Estudios Prospectivos , Accidente Cerebrovascular/tratamiento farmacológico , Centros de Atención Terciaria/organización & administración , Trombectomía , Tiempo de Tratamiento , Tomografía Computarizada por Rayos XRESUMEN
INTRODUCTION: In this study, we analyzed angiographic and histologic aneurysm occlusion of a newly designed flow diverting device. Visibility and flexibility, as well as occlusions of side branches and neointimal proliferation were also evaluated. METHODS: Aneurysms were induced in 18 New Zealand white rabbits and treated with a braided, "closed-loop-designed" device of nitinol. Additional devices were implanted in the abdominal aorta to cover the origin of branch arteries.Angiographic follow-ups were performed immediately after placement of the device, after 3 months (n=9) and 6 months(n =9). The status of aneurysm occlusion (using a five-point scale) and the patency of branch arteries were assessed. RESULTS: Aneurysm occlusion rates were noted as grade 0 in 2 (11 %), grade I in 1 (6 %), grade II in 1 (6 %), grade III in 9(50 %), and grade IV in 5 (28 %) of 18 aneurysms, respectively, indicating a complete or near-complete occlusion of 78 % under double antiplatelet therapy. Aneurysm occlusion was significantly higher at 6 months follow-up (P =0.025). Radiopaque markers provided excellent visibility. Limited device flexibility led to incomplete aneurysm neck coverage and grade 0 occlusion rates in two cases. Distal device occlusions were found in three cases, most likely due to an extremely undersized vessel diameter in the subclavian artery.No case of branch artery occlusion was seen. Intimal proliferation and diameter stenosis were moderate. CONCLUSION: The tested flow diverter achieved near-complete and complete aneurysm occlusion under double antiplatelet therapy of elastase-induced aneurysms in 78 %, while preserving branch arteries.
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Prótesis Vascular , Revascularización Cerebral/instrumentación , Modelos Animales de Enfermedad , Aneurisma Intracraneal/patología , Aneurisma Intracraneal/cirugía , Stents , Animales , Revascularización Cerebral/métodos , Análisis de Falla de Equipo , Femenino , Humanos , Aneurisma Intracraneal/inducido químicamente , Angiografía por Resonancia Magnética/métodos , Elastasa Pancreática , Diseño de Prótesis , Conejos , Resultado del TratamientoRESUMEN
INTRODUCTION: In this study, we analyzed angiographic and histologic aneurysm occlusion of a newly designed flow-diverting device. Visibility and flexibility, as well as occlusions of side branches and neointimal proliferation were also evaluated. METHODS: Aneurysms were induced in 18 New Zealand white rabbits and treated with a braided, "closed-loop-designed" device of nitinol. Additional devices were implanted in the abdominal aorta to cover the origin of branch arteries. Angiographic follow-ups were performed immediately after placement of the device, after 3 months (n = 9) and 6 months (n = 9). The status of aneurysm occlusion (using a five-point scale) and the patency of branch arteries were assessed. RESULTS: Aneurysm occlusion rates were noted as grade 0 in 2 (11 %), grade I in 1 (6 %), grade II in 1 (6 %), grade III in 9 (50 %), and grade IV in 5 (28 %) of 18 aneurysms, respectively, indicating a complete or near-complete occlusion of 78 % under double antiplatelet therapy. Aneurysm occlusion was significantly higher at 6 months follow-up (P = 0.025). Radiopaque markers provided excellent visibility. Limited device flexibility led to incomplete aneurysm neck coverage and grade 0 occlusion rates in two cases. Distal device occlusions were found in three cases, most likely due to an extremely undersized vessel diameter in the subclavian artery. No case of branch artery occlusion was seen. Intimal proliferation and diameter stenosis were moderate. CONCLUSION: The tested flow diverter achieved near-complete and complete aneurysm occlusion under double antiplatelet therapy of elastase-induced aneurysms in 78 %, while preserving branch arteries.
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Magnetic resonance imaging and cranial -ultrasound are the most frequently implemented imaging methods for investigating the infantile hydrocephalic brain. A general and reliable measurement index that can be equally applied in both imaging methods to assess dimension of ventricular dilatation is currently not available. For this purpose, a new parameter called the frontal and temporal horn ratio - determinable in coronal slices of the brain - was developed and evaluated in a comparative volumetric retrospective study: Statistical analyses of 118 MRIs of 46 different shunt-treated pediatric patients revealed a good linear correlation between the new index and the actual ventricular volume.
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Lóbulo Frontal/patología , Hidrocefalia/patología , Lóbulo Temporal/patología , Niño , Preescolar , Femenino , Lóbulo Frontal/diagnóstico por imagen , Humanos , Hidrocefalia/diagnóstico por imagen , Procesamiento de Imagen Asistido por Computador , Lactante , Recién Nacido , Imagen por Resonancia Magnética , Masculino , Estudios Retrospectivos , Lóbulo Temporal/diagnóstico por imagen , UltrasonografíaRESUMEN
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).
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Isquemia Encefálica/terapia , Circulación Cerebrovascular , Trombolisis Mecánica , Accidente Cerebrovascular/terapia , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidad , Isquemia Encefálica/fisiopatología , Evaluación de la Discapacidad , Estudios de Factibilidad , Femenino , Alemania , Humanos , Masculino , Trombolisis Mecánica/efectos adversos , Trombolisis Mecánica/instrumentación , Trombolisis Mecánica/mortalidad , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Diseño de Prótesis , Recuperación de la Función , Stents , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/fisiopatología , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
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.
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Cuidados Críticos/organización & administración , Servicios Médicos de Urgencia/organización & administración , Unidades Móviles de Salud/organización & administración , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/terapia , Anciano , Angioplastia , Diagnóstico Diferencial , Intervención Médica Temprana/organización & administración , Femenino , Humanos , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/mortalidad , Análisis de Supervivencia , Terapia Trombolítica , Estudios de Tiempo y MovimientoRESUMEN
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.
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Implantación de Prótesis Vascular/métodos , Arteria Carótida Interna/cirugía , Estenosis Carotídea/cirugía , Stents , Accidente Cerebrovascular/cirugía , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Angiografía , Arteria Carótida Interna/diagnóstico por imagen , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico por imagen , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Estudios Retrospectivos , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/etiología , Tomografía Computarizada por Rayos X , Resultado del TratamientoAsunto(s)
Eccema/etiología , Histiocitosis de Células de Langerhans/diagnóstico , Enfermedades de la Hipófisis/etiología , Dermatosis del Cuero Cabelludo/etiología , Acantoma/complicaciones , Acantoma/patología , Adulto , Enfermedad Crónica , Condiloma Acuminado/complicaciones , Condiloma Acuminado/cirugía , Diabetes Insípida/tratamiento farmacológico , Diabetes Insípida/etiología , Errores Diagnósticos , Enfermedades del Oído/tratamiento farmacológico , Enfermedades del Oído/etiología , Oído Externo , Eccema/patología , Enfermedades de los Genitales Masculinos/complicaciones , Enfermedades de los Genitales Masculinos/cirugía , Enfermedades de los Genitales Masculinos/virología , Histiocitosis de Células de Langerhans/complicaciones , Histiocitosis de Células de Langerhans/tratamiento farmacológico , Humanos , Células de Langerhans/patología , Terapia por Láser , Enfermedades Linfáticas/tratamiento farmacológico , Enfermedades Linfáticas/etiología , Enfermedades Linfáticas/patología , Masculino , Infecciones por Papillomavirus/complicaciones , Infecciones por Papillomavirus/cirugía , Enfermedades de la Hipófisis/tratamiento farmacológico , Enfermedades de la Hipófisis/patología , Neoplasias Hipofisarias/diagnóstico , Prednisolona/administración & dosificación , Prednisolona/uso terapéutico , Dermatosis del Cuero Cabelludo/tratamiento farmacológico , Dermatosis del Cuero Cabelludo/patología , Vinblastina/administración & dosificación , Vinblastina/uso terapéuticoRESUMEN
BACKGROUND: Early treatment with rt-PA is critical for favorable outcome of acute stroke. However, only a very small proportion of stroke patients receive this treatment, as most arrive at hospital too late to be eligible for rt-PA therapy. METHODS AND FINDINGS: We developed a "Mobile Stroke Unit", consisting of an ambulance equipped with computed tomography, a point-of-care laboratory system for complete stroke laboratory work-up, and telemedicine capabilities for contact with hospital experts, to achieve delivery of etiology-specific and guideline-adherent stroke treatment at the site of the emergency, well before arrival at the hospital. In a departure from current practice, stroke patients could be differentially treated according to their ischemic or hemorrhagic etiology even in the prehospital phase of stroke management. Immediate diagnosis of cerebral ischemia and exclusion of thrombolysis contraindications enabled us to perform prehospital rt-PA thrombolysis as bridging to later intra-arterial recanalization in one patient. In a complementary patient with cerebral hemorrhage, prehospital diagnosis allowed immediate initiation of hemorrhage-specific blood pressure management and telemedicine consultation regarding surgery. Call-to-therapy-decision times were 35 minutes. CONCLUSION: This preliminary study proves the feasibility of guideline-adherent, etiology-specific and causal treatment of acute stroke directly at the emergency site.