Passing the thrombus in endovascular treatment of acute ischemic stroke: Do we penetrate the thrombus?

Mechanical thrombectomy is increasingly applied during the treatment of acute stroke. Various devices have been advocated with different sites of force effect at the thrombus. The purpose of this study was to evaluate the angiographic route of passing systematically and therefore to assess the site of deployment of mechanical devices in correlation to the thrombus in interventional stroke treatment. Twenty-one consecutive patients with endovascular treatment for acute ischemic stroke with 26 passing procedures were evaluated prospectively. Occlusion site was the M1-segment in 17 cases (65.4%), ICA termination in five cases (19.2%), M2-segment in two cases (7.7%), the A2-segment in one case (3.8%) and basilar artery in one case (3.8%). On angiographic images the microwire and microcatheter passage was evaluated by illustrating the entry point and course across the occlusion site in relation to the thrombus in different projections and in correlation to the recanalisation result. Results were correlated to the origin of the thrombi according to the TOAST criteria. In all cases the point of entry to the occlusion site was delineated laterally to the thrombus in at least one projection. The course of the wire across the occluded segment in relation to the thrombus was found to be laterally in 22 procedures (84.6%). In the majority of M1-occlusions (12/17, 70.6%) the passage was found in the cranial aspect of the thrombus. In four procedures (15.4%) angiograms in different projections did not unequivocally confirm a passage laterally to the thrombus. The route of passing the thrombus was independent of thrombus origin according to the TOAST criteria. In the majority of cases the complete route of passing the occlusion site was visualized angiographically. Entrance of the microwire and microcatheter at proximal surface of the thrombus takes place laterally to the thrombus and accordingly the passage takes place between the thrombus and the vessel wall independent of thrombus origin. A penetration of the thrombus was not observed. This route of passing has implications on deployment and transmission of force in relation to the thrombus in mechanical approaches and consequently on the development of retrieval devices.

Negative laparotomy in trauma: are we getting better?

One of the trauma surgeons' daily challenges is the balancing act between negative laparotomy and missed abdominal injury. We opted to characterize the indications that prompted a negative trauma exploratory laparotomy and the rate of missed abdominal injuries in an effort to optimize patient selection for laparotomy. At the Los Angeles County + University of Southern California Medical Center, negative laparotomies and missed injuries are consecutively captured and reviewed at the weekly mortality + morbidity (MM) conferences. All written reports of the MM meetings from January 2003 to December 2008 were reviewed to identify all patients who underwent a negative laparotomy or a laparotomy as a result of an initially missed abdominal injury. Over the 6-year study period, a total of 1871 laparotomies were performed, of which 73 (3.9%) were negative. The rate of missed injuries requiring subsequent laparotomy was 1.3 per cent (25 of 1871). The negative laparotomy rate and the rate of missed injuries did not vary significantly during the study period (2.8 to 4.7%, P = 0.875, and 0.7 to 2.9%, P = 0.689). Penetrating mechanisms accounted for the majority of negative laparotomies (58.9%). The primary indication for negative laparotomy was peritonitis (54.8%) followed by hypotension (28.8%) and suspicious computed tomographic scan findings (27.4%). The complication rate after negative laparotomy was 14.5 per cent, and of these, 10.1 per cent were directly related to the procedure. A low but steady rate of negative laparotomies and missed abdominal injuries after trauma remains. Negative laparotomies and missed abdominal injuries when they occur are still associated with significant complication rates and a prolonged length of stay.

Global Change and the World's Mountain. Where are we coming from, and where are we going to?

The history of mountain research is most fascinating. Three names for 3 centuries may give an idea of the growing knowledge about the world's mountains: Horace Bénédict de Saussure, who climbed and studied the Mont Blanc in 1787; Alexander von Humboldt, ever investigating the environment during his attempt to ascend the Chimborazo in 1802; and Carl Troll, who founded the International Geographical Union's Commission on High-altitude Geoecology in 1968. Awareness of the growing impact of human activities on the environment led to scientific and political initiatives at the global level, beginning in the 1970s. The Perth conference in 2010 has offered an opportunity to both look back on these developments and explore the future of the world's mountains in a time of rapidly growing “global change” problems and processes.

The hepato-pulmonary syndrome--where do we stand in the year 2006?

The hepato-pulmonary syndrome (HPS) is characterized by a combination of liver disease and pulmonary gas exchange abnormalities with arterial hypoxemia, intrapulmonary vasodilatation and arteriovenous shunting in the absence of intrinsic cardiopulmonary disease. The course of the disease is typically progressive. The mortality rate correlates with the pulmonary shunt volume and the degree of hypoxemia at room air. While the patho-physiology of HPS is still not fully understood, a multifactorial etiology is favored. Apart from functional intrapulmonary arteriovenous shunts which appear to represent a major factor in the development of HPS, both ventilation-perfusion mismatch and limited oxygen diffusion contribute to the HPS. Regarding its clinical appearance, pulmonary and hepatic symptoms have to be distinguished. Contrast echocardiography is the primary diagnostic tool. Symptomatically, hypoxemia can be treated with oxygen. So far, the only successful treatment approach which has been tested in larger patient groups, is liver transplantation. Given this background, the aim of this review is to critically discuss current concepts of this serious complication of liver diseases.

Post-traumatic symptoms after childbirth: what should we offer?

Most studies on post-traumatic stress symptoms after childbirth have focused on prevalence of and looked at etiological factors and predictors. While most authors agree that around 1.5% of the women develop post-traumatic stress disorder (PTSD) and significantly more present with post-traumatic stress symptoms, the studies still lack a proper diagnosis using diagnostic interviews to validate the enhanced stress scores found in questionnaires. Also, some relevant predicting factors such as pre-existing psychopathology and dissociation during labor have not been investigated so far. Mostly, however, research on counseling strategies for women with post-traumatic symptoms after childbirth has been neglected. While most women remain in a mother-child unit during the first days after birth, there is a unique opportunity to systematically assess birth experience in this setting and screen for women at risk for developing trauma symptoms. This article presents a multilevel counseling approach including postnatal counseling and counseling in a subsequent pregnancy.

Facial affect recognition training in autism: can we animate the fusiform gyrus?

One of the most consistent findings in the neuroscience of autism is hypoactivation of the fusiform gyrus (FG) during face processing. In this study the authors examined whether successful facial affect recognition training is associated with an increased activation of the FG in autism. The effect of a computer-based program to teach facial affect identification was examined in 10 individuals with high-functioning autism. Blood oxygenation level-dependent (BOLD) functional magnetic resonance imaging (fMRI) changes in the FG and other regions of interest, as well as behavioral facial affect recognition measures, were assessed pre- and posttraining. No significant activation changes in the FG were observed. Trained participants showed behavioral improvements, which were accompanied by higher BOLD fMRI signals in the superior parietal lobule and maintained activation in the right medial occipital gyrus.