Massive Cerebral Infarction Research Articles

Elevated Serum MicroRNA Let-7c in Moyamoya Disease

Few studies have examined the relationship between mircroRNAs and moyamoya disease (MMD). We performed a study of the significance of let-7c expression in the serum of MMD patients. The experimental group includes 49 MMD patients, and the control group consists of 30 normal people, 20 cerebral hemorrhage patients, 20 massive cerebral infarction patients, 20 nonmassive cerebral infarction patients, and 20 neurological autoimmune disease patients. Let-7 family levels were determined by polymerase chain reaction. A dual luciferase assay was used to test whether let-7c recognized the 3'UTR of RNF213. The expression level of let-7c in MMD patients is higher than that observed in the control groups (P < .001). The luciferase assay results indicated that hsa-let-7c could diminish luciferase activity from a reporter vector containing the 3'-UTR of RNF213 (P < .05). The suppression of luciferase activity is not found in mutRNF213 (P > .05). Increased expression of let-7c in MMD patients may contribute to MMD pathogenesis by targeting RNF213. Thus, let-7c may be a potential biomarker for the diagnosis of MMD.

Application of percutaneous balloon mitral valvuloplasty in patients of rheumatic heart disease mitral stenosis combined with tricuspid regurgitation.

Background:Tricuspid regurgitation (TR) is frequently associated with severe mitral stenosis (MS), the importance of significant TR was often neglected. However, TR influences the outcome of patients. The aim of this study was to investigate the efficacy and safety of percutaneous balloon mitral valvuloplasty (PBMV) procedure in rheumatic heart disease patients with mitral valve (MV) stenosis and tricuspid valve regurgitation.Methods:Two hundred and twenty patients were enrolled in this study due to rheumatic heart disease with MS combined with TR. Mitral balloon catheter made in China was used to expand MV. The following parameters were measured before and after PBMV: MV area (MVA), TR area (TRA), atrial pressure and diameter, and pulmonary artery pressure (PAP). The patients were followed for 6 months to 9 years.Results:After PBMV, the MVAs increased significantly (1.7 ± 0.3 cm2 vs. 0.9 ± 0.3 cm2, P < 0.01); TRA significantly decreased (6.3 ± 1.7 cm2 vs. 14.2 ± 6.5 cm2, P < 0.01), right atrial area (RAA) decreased significantly (21.5 ± 4.5 cm2 vs. 25.4 ± 4.3 cm2, P < 0.05), TRA/RAA (%) decreased significantly (29.3 ± 3.2% vs. 44.2 ± 3.6%, P < 0.01). TR velocity (TRV) and TR continue time (TRT) as well as TRV × TRT decreased significantly (183.4 ± 9.4 cm/s vs. 254.5 ± 10.7 cm/s, P < 0.01; 185.7 ± 13.6 ms vs. 238.6 ± 11.3 ms, P < 0.01; 34.2 ± 5.6 cm vs. 60.7 ± 8.5 cm, P < 0.01, respectively). The postoperative left atrial diameter (LAD) significantly reduced (41.3 ± 6.2 mm vs. 49.8 ± 6.8 mm, P < 0.01) and the postoperative right atrial diameter (RAD) significantly reduced (28.7 ± 5.6 mm vs. 46.5 ± 6.3 mm, P < 0.01); the postoperative left atrium pressure significantly reduced (15.6 ± 6.1 mmHg vs. 26.5 ± 6.6 mmHg, P < 0.01), the postoperative right atrial pressure decreased significantly (13.2 ± 2.4 mmHg vs. 18.5 ± 4.3 mmHg, P < 0.01). The pulmonary arterial pressure decreased significantly after PBMV (48.2 ± 10.3 mmHg vs. 60.6 ± 15.5 mmHg, P < 0.01). The symptom of chest tightness and short of breath obviously alleviated. All cases followed-up for 6 months to 9 years (average 75 ± 32 months), 2 patients with severe regurgitation died (1 case of massive cerebral infarction, and 1 case of heart failure after 6 years and 8 years, respectively), 2 cases lost access. At the end of follow-up, MVA has been reduced compared with the postoperative (1.4 ± 0.4 cm2 vs. 1.7 ± 0.3 cm2, P < 0.05); LAD slightly increased compared with the postoperative (45.2 ± 5.7 mm vs. 41.4 ± 6.3 mm, P < 0.05), RAD slightly also increased compared with the postoperative (36.1 ± 6.3 mm vs. 28.6 ± 5.5 mm, P < 0.05), but did not recover to the preoperative level. TRA slightly increased compared with the postoperative, but the difference was not statistically significant (P > 0.05). The PAP and left ventricular ejection fraction appeared no statistical difference compared with the postoperative (P > 0.05), the remaining patients without serious complications.Conclusions:PBMV is a safe and effective procedure for MS combined with TR in patients of rheumatic heart disease. It can alleviate the symptoms and reduce the size of TR. It can also improve the quality-of-life and prognosis. Its recent and mid-term efficacy is certain. While its long-term efficacy remains to be observed.

SU‐E‐T‐620: Planning and Dosimetry for Pulsed Low Dose Rate RT for Recurrent Lung, Spine, GYN and Head and Neck Cancers

Purpose:Extensive in vitro and in vivo studies have shown that pulsed low dose rate (PLDR) radiotherapy has potential to provide significant local tumor control and to reduce normal tissue toxicities. This work investigated the planning and dosimetry of PLDR re‐irradiation for recurrent cancers.Methods:We analyzed the treatment plans and dosimetry for 13 recurrent patients who were treated with the PLDR technique in this study. All cases were planned with the 3DCRT technique with optimal beam angle selection. The treatment was performed on a Siemens accelerator using 6MV beams. The target volume ranged between 161 and 703cc. The previous RT dose was 40–60Gy while the re‐irradiation dose was 16–60Gy. The interval between previous RT and re‐irradiation was 13–336 months, and the follow‐up time was up to 27months. The total prescription dose was administered in 2Gy/day fractions with the daily dose delivered in 10 sub‐fractions (pulses) of 20cGy with a 3min interval between the pulses to achieve an effective dose rate of 6.7cGy/min.Results:The clinical outcome was analyzed based on the treatment plans. All pulses were kept with Dmax&lt;40cGy. The PLDR treatments were effective (CR: 3 patients, PR: 10 patients). The acute and late toxicities were all acceptable (generally grade II or under). Two patients died three months after the PLDR re‐irradiation, one due to massive cerebral infarction and the other due to acute cardiac failure. All others survived more than 8 months. Five patients showed good conditions at the last follow‐up. Among them two recurrent lung cancer patients had survived 23 months and one nasopharyngeal cancer patient had survived 27 months.Conclusion:The PLDR technique was effective for the palliative treatment of head and neck, lung, spine and GYN cancers. Further phase II and III studies are warranted to quantify the efficacy of PLDR for recurrent cancers.

Endoscope-assisted Transorbital Keyhole Surgical Approach to Ruptured Supratentorial Aneurysms.

Many different surgical approaches have been described to treat intracranial aneurysms. A common feature of all the approaches has been relatively extensive brain exposure and brain retraction with increasing surgical morbidity. Transorbital keyhole is one of the minimally invasive approaches. Endoscope-assisted transorbital keyhole surgery (EATOKS) combines minimally invasive transorbital keyhole surgery with endoscope-assisted microneurosurgery. We describe our experience with this approach and its efficacy in treating ruptured supratentorial aneurysms. We retrospectively reviewed 62 patients (18 men [29%] and 44 women [71%]) with a ruptured supratentorial aneurysm who underwent surgical clipping via the EATOKS approach from April 2003 to July 2012. In all our cases, we use a rigid endoscope of 0, 30, or 45 degrees to inspect the aneurysm and its surrounding anatomy before clipping and ultimately to verify the completeness of the aneurysm clipping and the patency of the adjacent neurovascular structures. All patients with ruptured supratentorial aneurysms were successfully clipped including three with multiple aneurysms. Surgically related major and minor as well as medically related complications were 10%, 15%, and 10%, respectively. Three patients (4.8%) died of massive cerebral infarction due to fulminant postoperative vasospasm, multiorgan failure, and adult respiratory distress syndrome. At 6-month follow-up, 81% of patients achieved good outcomes with Glasgow Outcome Scales of 4 and 5. Patients' satisfaction with the cosmetic results was satisfactory to excellent in most cases. EATOKS is a viable and safe option in the neurosurgical armamentarium to treat ruptured supratentorial aneurysms.

Intravitreal Recombinant Tissue Plasminogen Activator Without Gas Injection in a Patient with Massive Submacular Hemorrhage Associated with Age-Related Macular Degeneration: A Case Report

Introduction: Submacular hemorrhage (SMH) is a leading cause of severe visual loss. Pneumatic displacement of SMH from the macular area using intravitreal injection of tissue plasminogen activator (tPA) and gas and vitrectomy with subretinal injection of tPA and intravitreal injection of gas have recently been used as the standard therapies for SMH patients. However, little has been reported on single intravitreal administration of tPA for SMH patients. Case report: A 62-year-old male patient noted both blurred vision in his left eye and difficulty speaking (dysarthria) 1 day before admission. He was diagnosed with both massive SMH and cerebral infarction. Funduscopy revealed that the fovea was shifted to the inferonasal side due to a massive subretinal blood clot, and optical coherence tomography (OCT) revealed steep retinal detachment, hyper-reflective material representing a blood clot under the retina, and multiple large retinal pigment epithelial detachments (PEDs). The patient received a single intravitreal administration of tissue plasminogen activator. After vitreous injection, nearly all of the massive subretinal blood clot moved to the peripheral retina, and the fovea returned to the appropriate position. His best corrected visual acuity improved from 20/250 to 20/100. Conclusion: The present study showed a favorable outcome of a patient with a massive SMH complicated by cerebral infarction after receiving a single intravitreal administration of tPA. We hope that the single intravitreal administration of tPA can be applied for SMH patients who are not appropriate for surgery.

Use of Intravenous Thrombolytic Therapy in Acute Ischemic Stroke Patients: Evaluation of Clinical Outcomes.

The use of intravenous thrombolytic therapy (ITT) in acute ischemic stroke (AIS) patients is still debated in China. We present the analysis of clinico-demographic retrospective data of 646 AIS patients that were treated by alteplase ITT at our hospital. The data collected included age, gender, education, income, drug use before disease onset, and awareness of stroke/ITT. The risk factors studied were hypertension, diabetes, hyperlipidemia, atrial fibrillation, coronary heart disease, cerebral infarction, transient ischemic attack, valvular heart disease, thyroid disease, migraine, asymptomatic carotid stenosis, family history of stroke, hyperhomocysteinemia, smoking, drinking, and gingivitis. Pre-ITT patient data included blood pressure and time from onset to hospital. Post-ITT patient data included National Institutes of Health Stroke Scale (NIHSS) scores, clinical outcome, revascularization, hemorrhage, healing rate, and 90-day mortality. Hospital management information included monthly ITT cases, discharges, bed turnaround times, length of hospital stay, bed utilization, drug ratio, massive cerebral infarction decompressive craniectomy, and social impact. Prognosis evaluation was based on post-ITT NIHSS and modified Rankin Scale (mRS) scores. We found that ITT success rate was 75.85 %, with a bleeding rate of 1.55 % and a 90-day mortality rate of 2.01 %. Overall, the data suggest that the ITT therapy was highly successful in AIS patients treated at our hospital.

Massive cerebral infarction following evacuation of intracerebral hematoma

Rarely primary ICH and infarction can occur simultaneously and development of cerebral infarction soon after intracerebral hemorrhage is still rarer. Uncontrolled atherosclerotic risk factors including hypertension and hyperlipidemia together with antithrombotic therapy are the major reasons for the simultaneous ischemic and hemorrhagic lesions. We report a 67 year male presented with history of sudden onset of left hemiplegia. An urgent CT scan brain showed a large right basal ganglionic hematoma with mass effect and midline shift. The patient underwent evacuation of hematoma. After initial improvement the patient again deteriorated on day 3. A follow up CT scan showed hemorrhagic infarct at the site of surgery with mass effect and midline shift.

Risk factors for post-traumatic massive cerebral infarction secondary to space-occupying epidural hematoma.

Post-traumatic massive cerebral infarction (MCI) is a fatal complication of concurrent epidural hematoma (EDH) and brain herniation that commonly requires an aggressive decompressive craniectomy. The risk factors and surgical indications of MCI have not been fully elucidated. In this retrospective study, post-traumatic MCI was diagnosed in 32 of 176 patients. The performance of a decompressive craniectomy simultaneously with the initial hematoma-evacuation surgery improved their functional outcomes, compared with delayed surgery (on the 6-month Extended Glasgow Outcome Scale, 5.6±1.5 vs. 3.4±0.6; p<0.001). Significantly increased risks for MCI were observed in patients with an EDH at a transtemporal location (adjusted odds ratio [OR], 16.48; p=0.003), an EDH larger than 100 mL in volume (OR, 7.04; p=0.001), preoperative shock for longer than 30 min (OR, 13.78; p=0.002), bilateral mydriasis (OR, 7.08; p=0.004), preoperative brain herniation for longer than 90 min (OR, 6.41; p<0.001), and a Glasgow Coma Score of 3-5 points (OR, 2.86; p<0.053). Multi-variate logistic regression analysis revealed no significant association between post-traumatic MCI and age, gender, mid-line shift, Rotterdam computed tomography score, intraoperative hypotension, or serum concentrations of sodium or glucose. Incidence of post-traumatic MCI increased from 16.4% in those having any two of the six risk factors to 47.7% in those having any three or more of the six risk factors (p<0.001). Patients with concurrent EDH and brain herniation exhibited an increased risk for post-traumatic MCI with the accumulation of several critical clinical factors. Early decompressive craniectomy based on accurate risk estimation is recommended in efforts to improve patient functional outcomes.

Complications associated with laparoscopic adrenalectomy: Description and standardized assessment

ObjectiveLaparoscopic adrenalectomy (LA) is the procedure of choice for surgical management of the adrenal masses. Our objective is to show a standardized assessment of perioperative complications in one LA series. Materials and methods322 LA were performed consecutively between June of 1993 and September of 2012 in patients diagnosed with suprarenal tumor. In order to evaluate perioperative complications, data were collected prospectively and analyzed retrospectively. Intraoperative complications were defined using Satava classification and Clavien–Dindo classification of postoperative complications. ResultsTwenty five LA showed perioperative complications (7.3%); 11 (3.2%) were intraoperative complications, most of them vascular diaphragmatic lesions (Satava Grade 2); and 14 (4.1%) were postoperative complications. Six patients showed complications requiring surgery (Clavien IIIa/IIIb) and/or support in Intensive Care Unit (Clavien IV). Conversion to open surgery was necessary in one case (0.3%). Despite all appropriate preoperative endocrine measures were taken, an uncontrolled hypertensive crisis and cardio-respiratory arrest recovered were developed during surgery in one patient carrier of pheochromocytoma who died from massive cerebral infarction at 5 days (Clavien V). ConclusionsStandardized criteria of surgical complications are necessary. Standardization is possible by combined application of two tools. We believe that this evaluation concept of the surgery morbidity must be used systematically in order to achieve a new standard refined, concise and comparative for reports of adverse perioperative events.

Propofol in combination with mild hypothermia for cerebral infarction in large area

Objective To explore the curative effect of propofol in combination with mild hypothermia for cerebral infarction in large area and provide some references for its clinical treatment.Methods 42 patients with cerebral infarction in large area were randomly divided into a treatment group (22 cases) and a control groups (20 cases).The control group received conventional treatment and mild hypothermia.In addition,the treatment group were treated with propofol.The clinical efficacies of both groups was compared.Results 5 datys after the treatment,the effective rate of neurologic deficits was 39.9％ in treatment group and was 20.0％ in the control group; the mortality rate was 9.1％ in the treatment group and was 20.0％ in the control group; with statistical differences (P＜0.05).The state of consciousness was improved more in the treatment group than in the control group.Conclusions Propofol can recover the neurological function of the patients with acute massive cerebral infarction and reduce the mortality. Key words: Propofol; Mild hypothermia; Cerebral infarction

Descripción y evaluación estandarizada de complicaciones asociadas a adrenalectomía laparoscópica

ObjectiveLaparoscopic adrenalectomy (LA) is the procedure of choice for surgical management of the adrenal masses. Our objective is to show a standardized assessment of perioperative complications in one LA series. Material and methods322 LA were performed consecutively between June of 1993 and September of 2012 in patients diagnosed with suprarenal tumour. In order to evaluate perioperative complications, data were collected prospectively and analysed retrospectively. Intraoperative complications were defined using Satava classification and Clavien-Dindo classification of postoperative complications. ResultsTwenty five LA showed perioperative complications (7.3%); 11 (3.2%) were intraoperative complications, most of them vascular diaphragmatic lesions (Satava Grade 2); and 14 (4.1%) were postoperative complications. Six patients showed complications requiring surgery (Clavien IIIa/IIIb) and/or support in Intensive Care Unit (Clavien IV). Conversion to open surgery was necessary in one case (.3%). Despite all appropriate preoperative endocrine measures were taken, an uncontrolled hypertensive crisis and cardio-respiratory arrest recovered were developed during surgery in one patient carrier of pheochromocytoma who died from massive cerebral infarction at 5 days (Clavien V). ConclusionsStandardized criteria of surgical complications are necessary. Standardization is possible by combined application of two tools. We believe that this evaluation concept of the surgery morbidity must be used systematically in order to achieve a new standard refined, concise and comparative for reports of adverse perioperative events.

Peripartum cardiomyopathy with biventricular thrombus which led to massive cerebral embolism

A 37-year-old female who delivered her second child via a cesarean section 4 months previously presented to our hospital with gradual worsening of dyspnea on effort. Chest radiographic appearance showed cardiomegaly (cardiothoracic ratio 61%) and slight bilateral pulmonary congestion. Echocardiogram revealed diffuse hypokinesis of both left and right ventricles (left ventricular ejection fraction 29%) and large biventricular thrombus [left ventricular apex (28mm×21mm, 22mm×14mm) and right ventricular apex (16mm×11mm)]. She was diagnosed as having peripartum cardiomyopathy (PPCM) and anticoagulation therapy was started. Surgical thrombectomy was not selected because of risk of complications. Massive cerebral infarction occurred 10 days after diagnosis. She was discharged with aphasia and right incomplete hemiplegia 65 days after admission.Biventricular thrombus is a rare complication of PPCM. If high risk of massive embolism is considered, surgical thrombectomy may be warranted even in cases with low cardiac function.<Learning objective: Biventricular thrombus is a rare complication of peripartum cardiomyopathy (PPCM). We report a case of biventricular thrombus secondary to PPCM. The decision to perform prophylactic surgical approach to ventricular thrombus is difficult in cases with low cardiac function.>

The relationship between the levels and variability of blood glucose and the prognosis of massive cerebral infarction

To investigate the relationship between the levels and variability of blood glucose and the prognosis of massive cerebral infarction. A retrospective study involving 72 massive cerebral infarction patients without diabetes mellitus admitted to Taizhou Enze Medical Centre Luqiao Hospital from January 2012 to June 2013 was conducted. The mean blood glucose level (GluAve), standard deviation of blood glucose level (GluSD), and coefficient of variation of blood glucose level (GluCV) during the first 72 hours were monitored. Complications such as cerebrocardiac syndrome, pulmonary infection, stress ulcer bleeding, urinary system infection, decubitus sore, electrolyte disturbances, and epileptic seizures were also recorded. According to the 28-day outcome after admission, patients were divided into survivor group (n=60) and non-survivor group (n=12). The values of GluAve, GluSD and GluCV were compared between the two groups. The patients were again divided into three groups based on the level of GluAve (<7.8, 7.8-11.1, >11.1 mmol/L). Finally, patients were divided into four groups based on the level of GluCV (<15%, 15%-30%, 30%-50%, >50%). Acute physiology and chronic health evaluation II (APACHEII) score, mortality, and complications were compared among groups. The levels of GluAve, GluSD and GluCV in non-survivor group were significantly higher than those in survivor group [GluAve: 17.91 ± 5.33 mmol/L vs. 12.41 ± 3.12 mmol/L, t=3.145, P=0.002; GluSD:2.87 ± 1.96 mmol/L vs. 1.83 ± 1.08 mmol/L, t=2.611, P=0.017; GluCV: (27.56 ± 14.73)% vs. (20.12±10.97)%, t=2.020, P=0.043]. With the gradual increase of GluAve level, the mortality and total complication rate were elevated significantly [28-day mortality: 5.00% (1/20), 13.89% (5/36), 37.50% (6/16), χ²=7.16, P=0.028; total complication rate: 35.00% (7/20), 55.56% (20/36), 93.75% (15/16), χ²=12.85, P=0.002]. But there was no significant difference in APACHEII score (9.80 ± 4.17, 12.11 ± 5.81, 13.69 ± 6.57, F=2.241, P=0.114) and stress ulcer incidence rate [5.00% (1/20), 11.11% (4/36), 31.25% (5/16), χ²=5.59, P=0.061]. With the gradual increase of GluCV level, APACHEII score, 28-day mortality, the incidence of various complications, and total complication rate were all raised significantly [APACHEII score: 7.00 ± 1.56, 10.08 ± 1.88, 13.14 ± 5.76, 16.76 ± 7.17, F=12.486, P=0.000; mortality: 0 (0/15), 8.70% (2/23), 23.81% (5/21), 38.46% (5/13), χ²=9.27, P=0.026; total complication rate: 40.00% (6/15), 47.83% (11/23), 57.14% (12/21), 100.00% (13/13), χ²=12.42, P=0.006]. Both the GluAve level and GluCV level are significantly correlated with the outcome of patients suffering from massive cerebral infarction. The change in GluCV level seems to be more sensitive in predicting the prognosis of massive cerebral infarction than GluAve.

Evidence-Based Neurocritical Care

Neurocritical care is a pioneering subspecialty dedicated to the treatment of patients with life-threatening neurological illnesses, postoperative neurosurgical complications, and neurological manifestations of systemic disease. The care of these patients requires specialized neurological monitoring and specific clinical expertise and has generated a body of literature commensurate with the expansion of the field. This article reviews landmark studies over the last 10 years in the management and treatment of common acute neurological illnesses including massive cerebral infarction, intracerebral hemorrhage, subarachnoid hemorrhage, traumatic brain injury, and status epilepticus.

Study on risk factors of hemorrhagic transformation in acute massive cerebral infarction

Objective To investigate the factors that influence the occurrence of hemorrhagic transformation (HT) in patients with acute massive cerebral infarction,and to provide references for clinical treatment.Methods The clinical data of 60 patients with acute ischemic stroke were retrospectively analyzed.All the 60 patients were divided into HT group and non-hemorrhagic transformation (NHT) group.Risk factors associated with cerebrovascular disease,such as general data (gender,age,histories of drink and smoke),history of past illness (hypertension,diabetes,coronary disease,atrial fibrillation and cerebral stroke) and clinical data (infarction location,therapeutic methods,blood pressure,blood glucose,blood fat,cholesterol,fibrinogen and et al),were compared between the two groups.Results Of all the 60 patients,HT rate was 35％ (21/60).Incidence of HT was higher in patients with past and present hypertension and hyperglycemia(P =0.009,0.013,0.005,0.008,0.017),and in patients with atrial fibrillation,anti-platelet therapy,infarction in cortex,and hypocholesterolemia (P =0.020,0.037,0.003,0.009).But gender,age,histories of drink and smoke and history of coronary disease were not significantly different between the two groups(P=0.935,0.309,0.196,0.717,0.058).Conclusion Hypertension,hyperglycemia,atrial fibrillation,hypocholesterolemia,anti-platelet therapy could be independent risk factors for HT in patients with acute massive cerebral infarction. Key words: Hemorrhagic transformation; Brain infarction; Risk factors

Extensive clot propagation involving the aorta and brachiocephalic artery: unusual consequence of paradoxical embolism

A 73-year old woman with factor V Leiden deficiency and a history of deep venous thrombosis ceased taking oral warfarin. She sustained a massive cerebral infarct following extensive paradoxical embolism involving the brachiocephalic artery and the aorta (Fig. 1A and B). Transoesophageal echo findings (Fig. 2A and B) can be viewed in Supplementary Videos 1 and 2. Supplementary material (Videos 1 and 2) is available at EJCTS online. Video 1: Transoesophageal echocardiogram showing a large free-floating luminal thrombus within the aortic arch. Video 2: Transoesophageal echocardiogram demonstrating a large patent foramen ovale and an aneurysmal interatrial septum with a right-to-left shunt.

Takayasu arteritis presenting with massive cerebral ischemic infarction in a 35-year-old woman: a case report

IntroductionTakayasu arteritis is a relatively rare type of large-vessel arteritis that primarily affects the aorta and its major branches, the coronary arteries, and the pulmonary arteries. Depending on the different groups of blood vessels involved in the disease process, the clinical presentation of Takayasu arteritis varies. Here we report a case of a woman presenting with a debilitating massive cerebral ischemic infarct that turned out to be a relatively rare first presentation of Takayasu arteritis.Case presentationA 35-year-old Chinese woman presented to the Emergency Department with left hemiparesis, pain and numbness of her arms and weak radial pulses. Her laboratory results showed an elevated C-reactive protein and erythrocyte sedimentation rate, and subsequent digital subtraction angiography demonstrated narrowing and occlusion of the major branches of her aortic arch. We report the case of a patient with Takayasu arteritis presenting with a massive cerebral ischemic infarct and review the current literature on this topic.ConclusionTakayasu arteritis is a relatively rare disease with various and sometimes devastating clinical manifestations, such as massive cerebral ischemic infarction as in our case. Currently, there are multiple diagnostic tools and treatment options available, and more under investigation. Early, appropriate diagnosis and initiation of proper therapy could avoid further progression and reduce complications of the disease.

Medical image of the week: massive cerebral infarction

Medical image of the week: massive cerebral infarction

Early prediction of poor outcome in severe hemispheric stroke by EEG patterns and gradings

Objectives: To find out the EEG abnormal patterns in massive cerebral hemispheric infarction (MCHI) and their correlation with poor outcome, and to construct an EEG grading for predicting the outcome of MCHI patients.Methods: Between 2000 and 2010, 162 patients with MCHI who met the selection criterions were selected for this study. All the patients underwent EEG examinations within 3 days after stroke onset and repeated on day 2 and 3. We classified the EEG recordings into 9 patterns and anglicized the correlation between EEG patterns and outcome. Then according to the results of the correlation between EEG patterns and outcome we constructed an EEG grading for predicting the outcome of MCHI patients.Results: We revealed that patterns of dominant alpha without reactivity, RAWOD, burst-suppression, α/θ-coma, epileptiform activity (without burst-suppression), and generalized suppression were correlated to poor outcome. We further modified the Young grading according to the correlation between EEG patterns and outcome. We found that the modified grading was superior to existing EEG gradings in predicting the outcome of MCHI patients, and it could predict the outcome of MCHI more accurately.Conclusions: MCHI is common in N-ICU (Neurology Intensive Care Unit). The EEG analysis would detect the degree of brain lesion during the ischemia within the acute stage after stroke onset. The EEG evaluation might assist the neurophysicians to predict outcome of patients and make decisions on the treatments.

Cranioplasty Infections—Adding Insult to Injury

ranioplasty infections represent a dreaded complication in patientswho have generally already experienced a serious, C usually traumatic event. Craniectomies are frequently performed in an effort to decrease the intracranial hypertension that accompanies a massive cerebral infarct or a serious head injury. Patients considered candidates for a decompressive craniectomy (DC) after a traumatic brain injury (TBI) are those younger in agewith reactive pupils with a good Glasgow Coma Scale score. In contrast, patients with bilateral fixed and dilated pupils or with brain stem involvement, which can include Duret hemorrhages, are usually excluded fromsurgical consideration.A recentCochraneReviewon theutility ofDCconcluded that therewasnoevidence tosupport the routine use of DC to improve mortality and quality of life in braininjured adults with high intracranial pressure (8). Overall, DC does not improve the outcome in good prognosis adult patients but can convert mortality to severe disability in poor prognosis patients. There are 2 ongoing randomized controlled trials of decompressive craniectomy (RescueICP and DECRA) that will hopefully provide further conclusions on the efficacy of DC in adults. Bilateral hemicraniectomy for TBI carries 67% mortality and provides benefit primarily to very young adults (10). In addition, DC may improve survival and neurological outcomes in pediatric patients with raised intracranial pressure froma TBI forwhomothermedical treatments had failed. The results in the pediatric population are based on 1 randomized controlled trial in 27 children.