Predictors of clinical improvement, angiographic recanalization, and intracranial hemorrhage after intra-arterial thrombolysis for acute ischemic stroke

BACKGROUND AND PURPOSE

We sought to evaluate predictors of clinical outcome, angiographic success, and adverse effects after intra-arterial administration of urokinase for acute ischemic stroke.

METHODS

We designed a Brain Attack program at University Hospitals of Cleveland for diagnosis and treatment of patients presenting within 6 hours of onset of neurological deficit. Patients with ischemia referable to the carotid circulation were treated with intra-arterial urokinase. Angiographic recanalization was assessed at the end of medication infusion. Intracerebral hemorrhage was investigated immediately after and 24 hours after treatment. Stroke severity was determined, followed by long-term outcome.

RESULTS

Fifty-four patients were treated. There was improvement of >/=4 points on the National Institutes of Health Stroke Scale from presentation to 24 hours after onset in 43% of the treated patients, and this was related to the severity of the initial deficit. Forty-eight percent of patients had a Barthel Index score of 95 to 100 at 90 days, and total mortality was 24%. Cranial CT scans revealed intracerebral hemorrhage in 17% of patients in the first 24 hours, and these patients had more severe deficits at presentation. Eighty-seven percent of patients received intravenous heparin after thrombolysis, and 9% of them developed a hemorrhage into infarction. Angiographic recanalization was the rule in complete occlusions of the horizontal portion of the middle cerebral artery, but distal carotid occlusions responded less well to thrombolysis.

CONCLUSIONS

The intra-arterial route for thrombolysis allows for greater diagnostic precision and achievement of a higher concentration of the thrombolytic agent in the vicinity of the clot. Disadvantages of this therapy lie in the cost and delay. Severity of stroke and site of angiographic occlusion may be important predictors of successful treatment.

Brain attack: emergency treatment of ischemic stroke

Thrombolysis has been demonstrated to be an effective treatment for ischemic stroke. The major obstacles to more widespread use of this therapy are lack of awareness that the treatment is possible and the short (less than three hours) therapeutic window. Indiscriminant use of this therapy can lead to an unacceptably high rate of intracerebral hemorrhage. Early recognition of the onset of stroke. Immediate transfer to a suitably equipped treatment facility and careful screening of a computed tomographic scan of the head for signs of early infarction are necessary for the safe administration of intravenous thrombolysis.

Good clinical outcome in a patient with a large CT scan hypodensity treated with intra-arterial urokinase after an embolic stroke

Hypodense regions demonstrated by CT within 6 hours of the onset of stroke may reflect irreversibly damaged tissue, and some have suggested that patients with such findings should be spared the risks of thrombolytic therapy since they are unable to benefit from it. We report here a patient with a low-density area demonstrated by CT less than 6 hours after onset of symptoms who improved dramatically after successful intra-arterial thrombolysis.

The interosseous membrane of the forearm: structure and its role in Galeazzi fractures

A cadaveric study was performed to anatomically describe and mechanically document the interosseous membrane of the forearm using gross, histologic, scanning electron microscopic, and mechanical testing. The membrane was found to be a complex structure composed of nerves and vessels but mainly of collagen fibers that thicken to form bands coursing from radius to ulna. Strain-gauge studies demonstrated that the load transfer occurs from the radius to the ulna via the membrane and changes with supination or pronation. With specimens under a specific test load, sectioning of the membrane allowed the fractured radius to shorten by 6.25 mm and sectioning of the triangular fibrocartilage complex resulted in shortening of 7.7 mm. Total shortening after osteotomy and sectioning of the complex structure and membrane ranged from 15 to 40 mm. In Galeazzi fractures, the interosseous membrane acts as a constraint to radial shortening. Anatomic reduction with internal fixation is indicated for this fracture-dislocation.

Angular deformities and forearm function

Angular deformities were created in cadaver forearms at proximal, middle, and distal third levels of the radius and ulna separately, and at middle and distal third levels of both bones, to determine the corresponding limitations of pronation and supination. The ranges of pronation and supination were recorded using a rotational motion measurement apparatus instrumented with a 360 degrees goniometer. These experimental results were compared to data obtained from clinical and radiographic examination of 105 patients with similar residual deformities following treatment of fractures by nonsurgical means, to evaluate the accuracy of the experimental model and to determine if loss of rotational motion could be predicted based on radiographic findings. With cadaver forearms, on the average, angulation of 10 degrees of the radius or ulna in coronal or sagittal planes limited pronation and supination by less than 24 degrees, whereas angulation of 10 degrees of both the radius and the ulna limited pronation and supination by less than 18%. Comparison of experimental results with clinical findings showed that, despite the errors involved in measuring forearm deformities in patients using biplanar radiographs, the experimental results predicted the clinical loss of pronation and supination to within 17% for the fractures of the radius, and within 8% accuracy for the fractures of the ulna.

Measurements of thermal properties for human femora

In this study, density, specific heat, thermal conductivity, and thermal diffusivity were measured experimentally along the lengths of human cadaveric femora. Fresh and dry bone samples were selected from both male and female specimens, and for different age groups varying between 44 and 73 years old. Measured values for specific heat vary between 1.14 and 2.37 J/gm degrees C; for thermal conductivities the range is from 0.16 to 0.34 W/m degrees C; and for thermal diffusivities the range is from 0.10 to 0.23 cm2/sec, depending on whether the bone samples were fresh or dry, cancellous or cortical. The experimental results are presented in non-dimensional coordinates and are compared with the few other data available in the literature.

Plain film evaluation of patients with abdominal pain: are three radiographs necessary?

Current recommendations for the plain radiographic evaluation of abdominal pain suggest a minimum three-film series including an erect and supine abdominal view and an erect chest study. Three film radiographic abdominal "series" were obtained in 252 consecutive emergency-room patients who presented with abdominal pain. The views were analyzed independently for their relative diagnostic value. Radiologic pathologic findings were present in 20% of the abdominal films and in 13% of the chest radiographs. The supine abdominal view and the erect chest study diagnosed normality or abnormality in 98% of these patients. The elimination of the erect abdominal view from the routine abdominal series could result in financial savings, decreased radiation exposure, and a more efficient use of technician time, without significant loss of diagnostic information.

Dislocations after total hip-replacement arthroplasties

In a series of 300 total hip replacements, nine (3 per cent) dislocated. Precise measurements of the orientation of the acetabular cup were made and it was found that anterior dislocations were associated with increased acetabular-component anteversion. There was no significant correlation between cup-orientation angle and posterior dislocation. The dislocation rate for cup orientation with anteversion of 15 +/- 10 degrees and lateral opening of 40 +/- 10 degrees was 1.5 per cent, while outside this "safe" range the dislocation rate was 6.1 per cent. Other factors that were documented include time after surgery (with the greatest risk in the first thirty days) and surgical history (with a greater risk in hips that have had prior surgery).