Update on acute endovascular and surgical stroke treatment

Emergency stroke care has become a natural part of the emerging discipline of neurocritical care and demands close cooperation between the neurologist and neurointerventionists, neurosurgeons, and anesthesiologists. Endovascular treatment (EVT), including intra-arterial thrombolysis, mechanical thrombectomy and angioplasty/stenting, is under rapid development. Although EVT has yet to be shown in randomized controlled trials to improve clinical outcome compared to intravenous thrombolysis, it is far better in achieving recanalization of occluded large cerebral vessels, which is crucial for rescuing the penumbra. Moreover, decompressive craniectomy is now a well-established treatment option for malignant middle cerebral artery infarction and cerebellar stroke. Using a case-based approach, this article reviews recent achievements in advanced treatment options for patients with acute ischemic stroke.

Progression of emphysema evaluated by MRI using hyperpolarized (3)He (HP (3)He) measurements in patients with alpha-1-antitrypsin (A1AT) deficiency compared with CT and lung function tests

BACKGROUND

The progression of emphysema is traditionally measured by pulmonary function test, with forced expiratory volume in 1 s (FEV(1)) being the most accepted and used measurement. However, FEV(1) is insensitive in detecting mild/slow progression of emphysema because of low reproducibility as compared to yearly decline.

PURPOSE

To investigate the progression of emphysema over a period of 2 years using diffusion-weighted hyperpolarized (HP) (3)He magnetic resonance imaging (MRI) in patients with alpha-1-antitrypsin (A1AT) deficiency.

MATERIAL AND METHODS

Nine patients with severe A1AT deficiency were studied over a period of 2 years (baseline, year 1, and year 2) with HP (3)He MRI using apparent diffusion coefficient (ADC), lung function tests (FEV(1) and carbon monoxide lung diffusion capacity [D(L,CO)]), and computed tomography (CT) using densitometric parameters (15th percentile density [CT-PD15] and relative area of emphysema below -910 HU [CT-RA-910]).

RESULTS

Seven patients were scanned three times, one patient two times, and one patient only at baseline. The mean increase in ADC values from first to last HP (3)He MR scanning was 3.8% (0.014 cm(2)/s [SD 0.024 cm(2)/s]; not significant). The time trends for FEV(1), D(L,CO), CT-PD15, and CT-RA-910 were all statistically significant. We found a high correlation between ADC and D(L,CO) (P<0.001).

CONCLUSION

This pilot study indicates the possible use of nonionizing HP (3)He MRI for monitoring the progression of emphysema. However, in the future, larger studies are needed to confirm these preliminary results.

Hyperpolarised 3He MRI versus HRCT in COPD and normal volunteers: PHIL trial

The aim of the present study was to apply hyperpolarised (HP) (3)He magnetic resonance imaging (MRI) to identify patients with chronic obstructive pulmonary disease (COPD) and alpha(1)-antitrypsin deficiency (alpha(1)-ATD) from healthy volunteers and compare HP (3)He MRI findings with high-resolution computed tomography (HRCT) in a multicentre study. Quantitative measurements of HP (3)He MRI (apparent diffusion coefficient (ADC)) and HRCT (mean lung density (MLD)) were correlated with pulmonary function tests. A prospective three centre study enrolled 122 subjects with COPD (either acquired or genetic) and age-matched never-smokers. All diagnostic studies were completed in 94 subjects (52 with COPD; 13 with alpha(1)-ATD; 29 healthy subjects; 63 males; and 31 females; median age 62 yrs). The consensus assessment of radiologists, blinded for other test results, estimated nonventilated lung volume (HP (3)He MRI) and percentage diseased lung (HRCT). Quantitative evaluation of all data for each centre consisted of ADC (HP (3)He MRI) and MLD measurements (HRCT), and correlation with forced expiratory volume in 1 s (FEV(1))/forced vital capacity (FVC) indicating airway obstruction, and the diffusing capacity of the lung for carbon monoxide (D(L,CO)) indicating alveolar destruction. Using lung function tests as a reference, regional analysis of HP (3)He MRI and HRCT correctly categorised normal volunteers in 100% and 97%, COPD in 42% and 69% and alpha(1)-ATD in 69% and 85% of cases, respectively. Direct comparison of HP (3)He MRI and CT revealed 23% of subjects with moderate/severe structural abnormalities had only mild ventilation defects. In comparison with lung function tests, ADC was more effective in separating COPD patients from healthy subjects than MLD (p<0.001 versus 0.038). ADC measurements showed better correlation with D(L,CO) than MLD (r = 0.59 versus 0.29). Hyperpolarised (3)He MRI correctly categorised patients with COPD and normal volunteers. It offers additional functional information, without the use of ionising radiation whereas HRCT gives better morphological information. We showed the feasibility of a multicentre study using different magnetic resonance systems.

Quantitative assessment of regional emphysema distribution in patients with chronic obstructive pulmonary disease (COPD)

PURPOSE

To compare objective and subjective assessment of the distribution of emphysema in unselected patients with chronic obstructive pulmonary disease (COPD).

MATERIAL AND METHODS

167 patients were computed tomography (CT) scanned, and the relative area (RA-910) of emphysema in each CT slice was plotted against table position. The craniocaudal distribution was calculated as the slope of the regression line, and grouped as upper-lung-zone predominance (ULP), lower-lung-zone predominance (LLP), or mild/homogeneous distribution (MHE). CT scans were also classified as ULP, LLP, and MHE based on visual assessment of three high-resolution CT (HRCT) slices, and the leading pattern of emphysema was classified as centrilobular (CLE), paraseptal (PSE), panlobular (PLE), or no emphysema (NE).

RESULTS

By objective classification, scans were divided into almost equal numbers of ULP, LLP, and MHE, whereas visual evaluation classified more scans as ULP (P<0.001) and very few as LLP (P<0.0001). In patients with CLE, 49% had ULP by objective classification, whereas LLP was the commonest leading pattern in PSE, PLE, and NE.

CONCLUSION

We found significant discrepancies between the objective and subjective distributions of emphysema in various morphological patterns, which may be of clinical importance in, for instance, lung-volume-reduction surgery.

Alpha1-antitrypsin deficiency. 7: Computed tomographic imaging in alpha1-antitrypsin deficiency

Computed tomographic scanning may replace lung function tests as the golden standard for assessing the response to known and novel treatments for alpha1-antitrypsin deficiency.

Lymphoscintigraphy using technetium-99m human serum albumin in chylothorax

Chylous effusion is an infrequent complication of abdominothoracic surgery. When conservative therapy cannot cure the patient, surgical closure of the thoracic duct must be performed. If radiological lymphography is impossible to perform, lymphoscintigraphy with Tc-99m human serum albumin is a good alternative. Here, we present two patients who developed chylothorax after abdominothoracic surgery. Successful surgery was performed after lymphoscintigraphy had demonstrated the disruption of the thoracic duct.