Cerebral Microembolization During Aortic Valve Replacement Using Minimally Invasive or Conventional Extracorporeal Circulation: A Randomized Trial.

To compare intraoperative cerebral microembolic load between minimally invasive extracorporeal circulation (MiECC) and conventional extracorporeal circulation (CECC) during isolated surgical aortic valve replacement (SAVR), we conducted a randomized trial in patients undergoing primary elective SAVR at a tertiary referral hospital. The primary outcome was the procedural phase-related rate of high-intensity transient signals (HITS) on transcranial Doppler ultrasound. HITS rate was used as a surrogate of cerebral microembolism in pre-defined procedural phases in SAVR using MiECC or CECC with (+F) or without (-F) an oxygenator with integrated arterial filter. Forty-eight patients were randomized in a 1:1 ratio to MiECC or CECC. Due to intraprocedural Doppler signal loss (n = 3), 45 patients were included in final analysis. MiECC perfusion regimen showed a significantly increased HITS rate compared to CECC (by a factor of 1.75; 95% confidence interval, 1.19-2.56). This was due to different HITS rates in procedural phases from aortic cross-clamping until declamping [phase 4] (P = 0.01), and from aortic declamping until stop of extracorporeal perfusion [phase 5] (P = 0.05). Post hoc analysis revealed that MiECC-F generated a higher HITS rate than CECC+F (P = 0.005), CECC-F (P = 0.05) in phase 4, and CECC-F (P = 0.03) in phase 5, respectively. In open-heart surgery, MiECC is not superior to CECC with regard to gaseous cerebral microembolism. When using MiECC for SAVR, the use of oxygenators with integrated arterial line filter appears highly advisable. Only with this precaution, MiECC confers a cerebral microembolic load comparable to CECC during this type of open heart surgery.

Clinical prediction of large vessel occlusion in anterior circulation stroke: mission impossible?

Simple clinical scores to predict large vessel occlusion (LVO) in acute ischemic stroke would be helpful to triage patients in the prehospital phase. We assessed the ability of various combinations of National Institutes of Health Stroke Scale (NIHSS) subitems and published stroke scales (i.e., RACE scale, 3I-SS, sNIHSS-8, sNIHSS-5, sNIHSS-1, mNIHSS, a-NIHSS items profiles A-E, CPSS1, CPSS2, and CPSSS) to predict LVO on CT or MR arteriography in 1085 consecutive patients (39.4 % women, mean age 67.7 years) with anterior circulation strokes within 6 h of symptom onset. 657 patients (61 %) had an occlusion of the internal carotid artery or the M1/M2 segment of the middle cerebral artery. Best cut-off value of the total NIHSS score to predict LVO was 7 (PPV 84.2 %, sensitivity 81.0 %, specificity 76.6 %, NPV 72.4 %, ACC 79.3 %). Receiver operating characteristic curves of various combinations of NIHSS subitems and published scores were equally or less predictive to show LVO than the total NIHSS score. At intersection of sensitivity and specificity curves in all scores, at least 1/5 of patients with LVO were missed. Best odds ratios for LVO among NIHSS subitems were best gaze (9.6, 95 %-CI 6.765-13.632), visual fields (7.0, 95 %-CI 3.981-12.370), motor arms (7.6, 95 %-CI 5.589-10.204), and aphasia/neglect (7.1, 95 %-CI 5.352-9.492). There is a significant correlation between clinical scores based on the NIHSS score and LVO on arteriography. However, if clinically relevant thresholds are applied to the scores, a sizable number of LVOs are missed. Therefore, clinical scores cannot replace vessel imaging.

Grain size composition of sediment cores from the Weddell Sea, Antarctica

Sedimentary processes in the southeastern Weddell Sea are influenced by glacial-interglacial ice-shelf dynamics and the cyclonic circulation of the Weddell Gyre, which affects all water masses down to the sea floor. Significantly increased sedimentation rates occur during glacial stages, when ice sheets advance to the shelf edge and trigger gravitational sediment transport to the deep sea. Downslope transport on the Crary Fan and off Dronning Maud and Coats Land is channelized into three huge channel systems, which originate on the eastern-, the central and the western Crary Fan. They gradually turn from a northerly direction eastward until they follow a course parallel to the continental slope. All channels show strongly asymmetric cross sections with well-developed levees on their northwestern sides, forming wedge-shaped sediment bodies. They level off very gently. Levees on the southeastern sides are small, if present at all. This characteristic morphology likely results from the process of combined turbidite-contourite deposition. Strong thermohaline currents of the Weddell Gyre entrain particles from turbidity-current suspensions, which flow down the channels, and carry them westward out of the channel where they settle on a surface gently dipping away from the channel. These sediments are intercalated with overbank deposits of high-energy and high-volume turbidity currents, which preferentially flood the left of the channels (looking downchannel) as a result of Coriolis force. In the distal setting of the easternmost channel-levee complex, where thermohaline currents are directed northeastward as a result of a recirculation of water masses from the Enderby Basin, the setting and the internal structures of a wedge-shaped sediment body indicate a contourite drift rather than a channel levee. Dating of the sediments reveals that the levees in their present form started to develop with a late Miocene cooling event, which caused an expansion of the East Antarctic Ice Sheet and an invigoration of thermohaline current activity.

Stable isotope ratios, carbon content and primary production of three sediment cores from the subantarctic eastern Atlantic

We present three new benthic foraminiferal delta13C, delta18O, and total organic carbon time series from the eastern Atlantic sector of the Southern Ocean between 41°S and 47°S. The measured glacial delta13C values belong to the lowest hitherto reported. We demonstrate a coincidence between depleted late Holocene (LH) delta13C values and positions of sites relative to ocean surface productivity. A correction of +0.3 to +0.4 [per mil VPDB] for a productivity-induced depletion of Last Glacial Maximum (LGM) benthic delta13C values of these cores is suggested. The new data are compiled with published data from 13 sediment cores from the eastern Atlantic Ocean between 19°S and 47°S, and the regional deep and bottom water circulation is reconstructed for LH (4-0 ka) and LGM (22-16 ka) times. This extends earlier eastern Atlantic-wide synoptic reconstructions which suffered from the lack of data south of 20°S. A conceptual model of LGM deep-water circulation is discussed that, after correction of southernmost cores below the Antarctic Circumpolar Current (ACC) for a productivity-induced artifact, suggests a reduced formation of both North Atlantic Deep Water in the northern Atlantic and bottom water in the southwestern Weddell Sea. This reduction was compensated for by the formation of deep water in the zone of extended winter sea-ice coverage at the northern rim of the Weddell Sea, where air-sea gas exchange was reduced. This shift from LGM deep-water formation in the region south of the ACC to Holocene bottom water formation in the southwestern Weddell Sea, can explain lower preformed d13CDIC values of glacial circumantarctic deep water of approximately 0.3 per mil to 0.4 per mil. Our reconstruction brings Atlantic and Southern Ocean d13C and Cd/Ca data into better agreement, but is in conflict, however, with a scenario of an essentially unchanged thermohaline deep circulation on a global scale. Benthic delta18O-derived LGM bottom water temperatures, by 1.9°C and 0.3°C lower than during the LH at deepest southern and shallowest northern sites, respectively, agree with the here proposed reconstruction of deep-water circulation in the eastern South Atlantic Ocean.

Posterior circulation cerebrovascular syndromes: diagnosis and management.

One in five strokes affects the posterior circulation. Diagnosing posterior circulation stroke can be challenging, as the vascular anatomy can be variable, and because presenting symptoms are often non-specific and fluctuating. Nevertheless, making the correct diagnosis is important, as these strokes have a high chance of recurrence, can be life threatening, and can lead to equally life-threatening complications. Investigation and management largely follow those for stroke in general, although some specific differences exist. These include the preferred use of MRI for diagnosing posterior fossa lesions, the management of basilar artery thrombosis, which may have a longer time window for recanalisation therapy, and the use of endovascular therapies for secondary prevention, which, so far, have not shown any benefit in the treatment of vertebral or basilar artery stenosis. In this review, we summarise the anatomy, aetiology and presentation of posterior circulation stroke, and discuss current approaches to management.