Developments in mechanical thrombectomy devices for the treatment of acute ischemic stroke

Several recent prospective randomized controlled trials of endovascular stroke therapy using latest generation thrombectomy devices, so called stent-retrievers, have shown significantly improved clinical outcome compared to the standard treatment with intra-venous thrombolysis using r-tPA alone. Despite some differences in inclusion criteria between these studies, all required non-invasive vessel imaging to proof occlusion of a major brain supplying vessel. Furthermore, in most studies additional imaging techniques were used to exclude patients with already established large cerebral infarction or unfavorable collateral or penumbral status. Patients with small infarct volume, severe neurological deficits and in whom thrombectomy can be initiated within the first 6 hours after symptom onset seem to benefit the most. Therefore, mechanical thrombectomy using stent-retrievers in addition to intra-venous thrombolysis is recommended for the treatment of acute ischemic stroke with proven major vessel occlusion in the anterior circulation.

A total variation discontinuous Galerkin approach for image restoration

The focal point of this paper is to propose and analyze a P 0 discontinuous Galerkin (DG) formulation for image denoising. The scheme is based on a total variation approach which has been applied successfully in previous papers on image processing. The main idea of the new scheme is to model the restoration process in terms of a discrete energy minimization problem and to derive a corresponding DG variational formulation. Furthermore, we will prove that the method exhibits a unique solution and that a natural maximum principle holds. In addition, a number of examples illustrate the effectiveness of the method.

Neuroanatomical correlates of tube dependency and impaired oral intake after hemispheric stroke.

BACKGROUND AND PURPOSE Acute stroke patients with severely impaired oral intake are at risk of malnutrition and dehydration. Rapid identification of these patients is necessary to establish early enteral tube feeding. Whether specific lesion location predicts early tube dependency was analysed, and the neural correlates of impaired oral intake after hemispheric ischaemic stroke were assessed. METHODS Tube dependency and functional oral intake were evaluated with a standardized comprehensive swallowing assessment within the first 48 h after magnetic resonance imaging proven first-time acute supratentorial ischaemic stroke. Voxel-based lesion symptom mapping (VLSM) was performed to compare lesion location between tube-dependent patients versus patients without tube feeding and impaired versus unimpaired oral intake. RESULTS Out of 119 included patients 43 (36%) had impaired oral intake and 12 (10%) were tube dependent. Both tube dependency and impaired oral intake were significantly associated with a higher National Institutes of Health Stroke Scale score and larger infarct volume and these patients had worse clinical outcome at discharge. Clinical characteristics did not differ between left and right hemispheric strokes. In the VLSM analysis, mildly impaired oral intake correlated with lesions of the Rolandic operculum, the insular cortex, the superior corona radiata and to a lesser extent of the putamen, the external capsule and the superior longitudinal fascicle. Tube dependency was significantly associated with affection of the anterior insular cortex. CONCLUSIONS Mild impairment of oral intake correlates with damage to a widespread operculo-insular swallowing network. However, specific lesions of the anterior insula lead to severe impairment and tube dependency and clinicians might consider early enteral tube feeding in these patients.

Animal Guts as Nonideal Chemical Reactors: Partial Mixing and Axial Variation in Absorption Kinetics

Animal guts have been idealized as axially uniform plug-flow reactors (PFRs) without significant axial mixing or as combinations in series of such PFRs with other reactor types. To relax these often unrealistic assumptions and to provide a means for relaxing others, I approximated an animal gut as a series of n continuously stirred tank reactors (CSTRs) and examined its performance as a Function of n. For the digestion problem of hydrolysis and absorption in series, I suggest as a first approximation that a tubular gut of length L and diameter D comprises n=L/D tanks in series. For n greater than or equal to 10, there is little difference between performance of the nCSTR model and an ideal PFR in the coupled tasks of hydrolysis and absorption. Relatively thinner and longer guts, characteristic of animals feeding on poorer forage, prove more efficient in both conversion and absorption by restricting axial mixing, in the same total volume, they also give a higher rate of absorption. I then asked how a fixed number of absorptive sites should be distributed among the n compartments. Absorption rate generally is maximized when absorbers are concentrated in the hindmost few compartments, but high food quality or suboptimal ingestion rates decrease the advantage of highly concentrated absorbers. This modeling approach connects gut function and structure at multiple scales and can be extended to include other nonideal reactor behaviors observed in real animals.

Familial aggregation, candidate genes and genome scans: Analyzing the role of genetics in stroke

The genetic etiology of stroke likely reflects the influence of multiple loci with small effects, each modulating different pathophysiological processes. This research project utilized three analytical strategies to address the paucity of information related to the identification and characterization of genetic variation associated with stroke in the general population. ^ First, the general contribution of familial factors to stroke susceptibility was evaluated in a population-based sample of unrelated individuals. Increased risk of subclinical cerebral infarction was observed among individuals with a positive parental history of stroke. This association did not appear to be mediated by established stroke risk factors, specifically blood pressure levels or hypertension status. ^ The need to identify specific gene variation associated with stroke in the general population was addressed by evaluating seven candidate gene polymorphisms in a population-based sample of unrelated individuals. Three polymorphisms were significantly associated with increased subclinical cerebral infarction or incident clinical ischemic stroke risk. These relationships include the G-protein β3 subunit 825C/T polymorphism and clinical stroke in Whites, the lipoprotein lipase S/X447 polymorphism and subclinical and clinical stroke in men, and the angiotensin I-converting enzyme Ins/Del polymorphism and subclinical stroke in White men. These associations did not appear to be obfuscated by the stroke risk factors adjusted for in the analysis models specifically blood pressure levels or anti-hypertensive medication use. ^ The final research strategy considered, on a genome-wide scale, the idea that genetic variation may contribute to the occurrence of hypertension or stroke through a common etiologic pathway. Genomic regions were identified for which significant evidence of heterogeneity was observed among hypertensive sibpairs stratified by family history of stroke information. Regions identified on chromosome 15 in African Americans, and chromosome 13 in Whites and African Americans, suggest the presence of genes influencing hypertension and stroke susceptibility. ^ Insight into the role of genetics in stroke is useful for the potential early identification of individuals at increased risk for stroke and improved understanding of the etiology of the disease. The ultimate goal of these endeavors is to guide the development of therapeutic intervention and informed prevention to provide a lasting and positive impact on public health. ^

Are anatomic brain locations important in determining the clinical outcomes in acute ischemic stroke? --- An exploratory analysis of the NINDS Stroke Trial data

Background and purpose. Brain lesions in acute ischemic stroke measured by imaging tools provide important clinical information for diagnosis and final infarct volume has been considered as a potential surrogate marker for clinical outcomes. Strong correlations have been found between lesion volume and clinical outcomes in the NINDS t-PA Stroke Trial but little has been published about lesion location and clinical outcomes. Studies of the National Institute of Neurological Disorders and Stroke (NINDS) t-PA Stroke Trial data found the direction of the t-PA treatment effect on a decrease in CT lesion volume was consistent with the observed clinical effects at 3 months, but measure of t-PA treatment benefits using CT lesion volumes showed a diminished statistical significance, as compared to using clinical scales. ^ Methods. We used the global test to evaluate the hypothesis that lesion locations were strongly associated with clinical outcomes within each treatment group at 3 months after stroke. The anatomic locations of CT scans were used for analysis. We also assessed the effect of t-PA on lesion location using a global statistical test. ^ Results. In the t-PA group, patients with frontal lesions had larger infarct volumes and worse NIHSS score at 3 months after stroke. The clinical status of patients with frontal lesions in t-PA group was less likely to be affected by lesion volume, as compared to those who had no frontal lesions in at 3 months. For patients within the placebo group, both brain stem and internal capsule locations were significantly associated with a lower odd of having favorable outcomes at 3 months. Using a global test we could not detect a significant effect of t-PA treatment on lesion location although differences between two treatment groups in the proportion of lesion findings in each location were found. ^ Conclusions. Frontal, brain stem, and internal capsule locations were significantly related to clinical status at 3 months after stroke onset. We detect no significant t-PA effect on all 9 locations although proportion of lesion findings in differed among locations between the two treatment groups.^

Inappropriate imaging utilization in Texas: Geographic variation and predictive factors

Objective::Describe and understand regional differences and associated multilevel factors (patient, provider and regional) to inappropriate utilization of advance imaging tests in the privately insured population of Texas. Methods: We analyzed Blue Cross Blue Shield of Texas claims dataset to study the advance imaging utilization during 2008-2010 in the PPO/PPO+ plans. We used three of CMS "Hospital Outpatient Quality Reporting" imaging efficiency measures. These included ordering MRI for low back pain without prior conservative management (OP-8) and utilization of combined with and without contrast abdominal CT (OP-10) and thorax CT (OP-11). Means and variation by hospital referral regions (HRR) in Texas were measured and a multilevel logistic regression for being a provider with high values for any the three OP measures was used in the analysis. We also analyzed OP-8 at the individual level. A multilevel logistic regression was used to identify predictive factors for having an inappropriate MRI for low back pain. Results: Mean OP-8 for Texas providers was 37.89%, OP-10 was 29.94% and OP-11 was 9.24%. Variation was higher for CT measure. And certain HRRs were consistently above the mean. Hospital providers had higher odds of high OP-8 values (OP-8: OR, 1.34; CI, 1.12-1.60) but had smaller odds of having high OP-10 and OP-11 values (OP-10: OR, 0.15; CI, 0.12-0.18; OP-11: OR, 0.43; CI, 0.34-0.53). Providers with the highest volume of imaging studies performed, were less likely to have high OP-8 measures (OP-8: OR, 0.58; CI, 0.48-0.70) but more likely to perform combined thoracic CT scans (OP-11: OR, 1.62; CI, 1.34-1.95). Males had higher odds of inappropriate MRI (OR, 1.21; CI, 1.16-1.26). Pattern of care in the six months prior to the MRI event was significantly associated with having an inappropriate MRI. Conclusion::We identified a significant variation in advance imaging utilization across Texas. Type of facility was associated with measure performance, but the associations differ according to the type of study. Last, certain individual characteristics such as gender, age and pattern of care were found to be predictors of inappropriate MRIs.^

Neurotoxicity of advanced glycation endproducts during focal stroke and neuroprotective effects of aminoguanidine.

Cerebral infarction (stroke) is a potentially disastrous complication of diabetes mellitus, principally because the extent of cortical loss is greater in diabetic patients than in nondiabetic patients. The etiology of this enhanced neurotoxicity is poorly understood. We hypothesized that advanced glycation endproducts (AGEs), which have previously been implicated in the development of other diabetic complications, might contribute to neurotoxicity and brain damage during ischemic stroke. Using a rat model of focal cerebral ischemia, we show that systemically administered AGE-modified bovine serum albumin (AGE-BSA) significantly increased cerebral infarct size. The neurotoxic effects of AGE-BSA administration were dose- and time-related and associated with a paradoxical increase in cerebral blood flow. Aminoguanidine, an inhibitor of AGE cross-linking, attenuated infarct volume in AGE-treated animals. We conclude that AGEs may contribute to the increased severity of stroke associated with diabetes and other conditions characterized by AGE accumulation.

Choroidal Thickness And Volume In Healthy Young Whites And Their Relationship With Axial Length, Ammetropy And Sex

Purpose: To evaluate choroidal thickness in young subjects using Enhanced Depth Imaging Spectral Domain Optical Coherence Tomography (EDI SD-OCT) describing volume differences between all the defined areas of the Early Treatment Diabetic Retinopathy Study (ETDRS). Design: Prospective, clinical study. Methods: Seventy-nine eyes of 95 healthy, young (23.8±3.2years), adult volunteers were prospectively enrolled. Manual choroidal segmentation on a 25-raster horizontal scan protocol was performed. The measurements of the nine subfields defined by the ETDRS were evaluated. Results: Mean subfoveal choroidal thickness was 345.67±81.80μm and mean total choroidal volume was 8.99±1.88mm3. Choroidal thickness and volume were higher at the superior and temporal areas compared to inferior and nasal sectors of the same diameter respectively. Strong correlations between subfoveal choroidal thickness and axial length (AL) and myopic refractive error were obtained, r = -0.649, p<0.001 and r = 0.473, p<0.001 respectively. Emmetropic eyes tended to have thicker subfoveal choroidal thickness (381.94±79.88μm versus 307.04±64.91μm) and higher total choroidal volume than myopic eyes (9.80± 1.87mm3 versus 8.14±1.48mm3). The estimation of the variation of the subfoveal choroidal thickness with the AL was-43.84μm/mm. In the myopic group, the variation of the subfoveal choroidal thickness with the myopic refractive error was -10.45μm/D. Conclusions: This study establishes for the first time a normal database for choroidal thickness and volume in young adults. Axial length, and myopic ammetropy are highly associated with choroidal parameters in healthy subjects. EDI SD-OCT exhibited a high degree of intraobserver and interobserver repeatability.

Comparison Between Dcrit Considering the Abrupt Variation and Inflexion in the Concrete Mercury Intrusion Porosimetry Curve

Mercury intrusion porosimetry (MIP) has been widely used to evaluate the quality of concrete through the pore size distribution parameters. Two of these parameters are the critical pore diameter (Dcrit) and the percentage of the most interconnected net of pores compared to the total volume of pores. Some researchers consider Dcrit as the diameter obtained from the inflexion point of the cumulative mercury intrusion curve while others consider Dcrit as the diameter obtained from the point of abrupt variation in the same curve. This study aims to analyze two groups of concretes of varying w/c ratios, one cast with pozzolanic cement and another with high initial strength cement, in order to determine which of these diameters feature a better correlation with the quality parameters of the concretes. The concrete quality parameters used for the evaluations were (1) the w/c ratios and (2) chloride diffusion coefficients measured at approximately 90 days. MIP cumulative distributions of the same concretes were also measured at about 90 days, and Dcrit values were determined (1) from the point of abrupt variation and alternatively, (2) from the inflexion point of each of these plots. It was found that Dcrit values measured from the point of abrupt variation were useful indicators of the quality of the concrete, but the Dcrit values based on the inflexion points were not. Hence, it is recommended that Dcrit and the percentage of the most interconnected volume of pores should be obtained considering the point of abrupt variation of the cumulative curve of pore size distribution.

Latitudinal variation in the planktic foraminifer Contusotruncana contusa in the terminal Cretaceous ocean

The morphological variability (coiling properties, size and shape) of the planktic foraminifer Contusortuncana contusa (Cushman) in the terminal Cretaceous ocean was examined at eight deep-sea sites and two continental sections from low (16°) to middle (42°) paleolatitudes in both hemispheres. The material used in this study includes samples from the South Atlantic (DSDP Sites 356, 527 and 525A), North Atlantic (Sites 384 and 548A), Indian and Pacific Oceans (DSDP Site 465A and ODP Sites 761C and 762C) and Tethyan Ocean (outcrop sections from El-Kef and Caravaca). On average 45 specimens from two samples per location were analysed, from an interval corresponding approximately to the last 60 kyr of the Cretaceous. No differences in coiling direction (dextral proportions were > 90% in all samples), percentage of kummerform specimens (usually > 50%) and number of chambers in the last whorl (4-5) were observed between the sites. Both test size (expressed as spiral outline area and test volume) and total number of chambers increase significantly towards lower latitudes. Similarly, test conicity, examined by shape coordinate and eigenshape methods, and angularity of the spiral outline show a rather continuous, slight increase towards lower latitudes. Kummerform specimens of C. contusa were slightly larger and more conical than normalforms and possessed substantially more chambers (both totally and in the last whorl). A principal components analysis of the sample means of five variables describing size and shape clearly distinguished high-latitude sites (525A, 527, 548A, 761C and 762C) from low-latitude sites (384, 465A, Caravaca and El-Kef). Specimens from Site 356 are transitional with respect to those two groups. The results indicate: (1) considerable morphological variation in C. contusa during the terminal Cretaceous comparable to that known in many Recent planktic foraminiferal species and (2) a geographical distribution of this variation corresponding to previously suggested biogeographic schemes based on quantitative analysis of planktic foraminiferal assemblages. Despite the differences in sample means, the overall morphology of C. contusa overlaps among the sites studied, supporting the classification of all C. contusa morphotypes as a single species. Similarly, no discrete morphologic groups could be distinguished within any of the samples.

A natural history of the British butterflies ; their world-wide variation and geographical distribution. A text-book for students and collectors.

Volume 4 edited by George Wheeler.

Octane requirement increase arising from the use of lead free fuel

Lead in petrol has been identified as a health hazard and attempts are being made to create a lead-free atmosphere. Through an intensive study a review is made of the various options available to the automobile and petroleum industry. The economic and atmospheric penalties coupled with automobile fuel consumption trends are calculated and presented in both graphical and tabulated form. Experimental measurements of carbon monoxide and hydrocarbon emissions are also presented for certain selected fuels. Reduction in CO and HC's with the employment of a three-way catalyst is also discussed. All tests were carried out on a Fiat 127A engine at wide open throttle and standard timing setting. A Froude dynamometer was used to vary engine speed. With the introduction of lead-free petrol, interest in combustion chamber deposits in spark ignition engines has ben renewed. These deposits cause octane requirement increase or rise in engine knock and decreased volumetric efficiency. The detrimental effect of the deposits has been attributed to the physical volume of the deposit and to changes in heat transfer. This study attempts to assess why leaded deposits, though often greater in mass and volume, yield relatively lower ORI when compared to lead-free deposits under identical operating conditions. This has been carried out by identifying the differences in the physical nature of the deposit and then through measurement of the thermal conductivity and permeability of the deposits. The measured thermal conductivity results are later used in a mathematical model to determine heat transfer rates and temperature variation across the engine wall and deposit. For the model, the walls of the combustion cylinder and top are assumed to be free of engine deposit, the major deposit being on the piston head. Seven different heat transfer equations are formulated describing heat flow at each part of the four stroke cycle, and the variation of cylinder wall area exposed to gas mixture is accounted for. The heat transfer equations are solved using numerical methods and temperature variations across the wall identified. Though the calculations have been carried out for one particular moment in the cycle, similar calculations are possible for every degree of the crank angle, and thus further information regarding location of maximum temperatures at every degree of the crank angle may also be determined. In conclusion, thermal conductivity values of leaded and lead-free deposits have been found. The fundamental concepts of a mathematical model with great potential have been formulated and it is hoped that with future work it may be used in a simulation for different engine construction materials and motor fuels, leading to better design of future prototype engines.

Regional variation in peripapillary retinal blood flow in primary open angle glaucoma:a follow-up study

Purpose: To investigate whether regional long-term changes in peripapillary retinal flow, measured by scanning laser Doppler flowmetry (SLDF), occur in patients with primary open angle glaucoma (POAG). Methods: 31 healthy volunteers (mean age: 65 8.3 years) and 33 POAG patients (mean age: 71.2 7.6 years) were followed up every 4 months for 16 months. Using SLDF, three images of the superior and inferior optic nerve head were obtained for each subject. A 1010-pixel frame was used to measure blood flow, volume and velocity in the four quadrants of the peripapillary retina. Central 24-2 visual field testing was carried out at each visit. Repeated measures analysis of covariance was used to assess change over time between the normal and POAG groups for the SLDF parameters. Univariate linear regression analysis for mean deviation and glaucoma change probability (GCP) analysis were used to identify visual field progression. Results: Blood volume, flow and velocity measured in the inferior nasal quadrant of the peripapillary retina decreased significantly over time for the POAG group compared to the normal group (p=0.0073, 0.0097, 0.0095 respectively). Overall, 2 glaucoma patients showed a significantly deteriorating MD slope, while 7 patients showed visual field progression with GPA. All of the patients progressing with GPA, showed change in the superior hemifield and, of those, 14% showed change in the inferior hemifield. Conclusion: Glaucoma patients showed a decrease in blood flow, volume and velocity in the inferior nasal peripapillary retina. A regional variation in microvascular retinal capillary blood flow may provide insight into the pathogenesis of glaucomatous optic neuropathy. Keywords: 331 blood supply • 554 retina • 624 visual fields

Volume strain sensor based on spectra analysis of in-fiber modal interferometer

An optical in-fiber modal interferometer-based volume strain sensor for earthquake prediction is proposed and experimentally demonstrated. The sensing element is formed by wrapping a multimode-singlemode-multimode fiber structure onto a polyurethane hollow column. Due to the modal interference between the excited guided modes in the fiber, strong interference pattern could be observed in the transmission spectrum. Theoretical analysis verifies that the resonant wavelength shifts as a result of the volume strain variation caused by the column deformation with square root relationship. Sensitivity > 3.93 pm/με within the volume strain ranging from 0 to 1300 με is also experimentally demonstrated. By taking the response of bidirectional change of volume strain and the sluggish character of the employed sensing material into consideration, the sensing system presents good repeatability and stability. © 2001-2012 IEEE.