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Stability of large diffusion/perfusion mismatch in anterior circulation strokes for 4 or more hours

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      BackgroundThe stability of hypoperfused brain tissue in stroke patients with major artery occlusions is unknown. The purpose of this study was to determine the persistence of a diffusion/perfusion mismatch in patients with ICA or proximal MCA occlusions.MethodsFourteen patients with ICA and/or proximal MCA occlusion and a diffusion/perfusion mismatch at presentation were studied. All were enrolled in a pilot randomized study of normobaric oxygen therapy. None received thrombolytic therapy; 8 received normobaric oxygen and 6 room air. Diffusion/perfusion MRI was performed at baseline, 4 hours, 24 hours, and 1 week. Abnormal DWI, ADC, and MTT volumes were determined using standard image analysis methods.ResultsThe mean time from symptom onset to baseline MRI was 7.5 ± 1 hours. Across all 4 time points there was a significant difference in DWI lesion (ANOVA, P < 0.0001) and abnormal MTT volumes (ANOVA, P < 0.01) with the 24 hour and 1 week abnormal volumes different from the earlier studies. However, comparing baseline and 4 hour scans, there was no significant interval change in the mean abnormal DWI volume (29.4 ± 8.2 ml vs. 28.1 ± 7.4 ml) or abnormal MTT volumes (137 ± 17.7 ml vs. 130.9 ± 13.8). By 24 hours, only 2 patients did not maintain a mismatch of 20% or greater.ConclusionsPatients who present outside the time window for thrombolytic therapy, and who have a large diffusion/perfusion mismatch on MRI may have a stable mismatch for 4 or more hours.

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      Most cited references 19

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      A global optimisation method for robust affine registration of brain images.

      Registration is an important component of medical image analysis and for analysing large amounts of data it is desirable to have fully automatic registration methods. Many different automatic registration methods have been proposed to date, and almost all share a common mathematical framework - one of optimising a cost function. To date little attention has been focused on the optimisation method itself, even though the success of most registration methods hinges on the quality of this optimisation. This paper examines the assumptions underlying the problem of registration for brain images using inter-modal voxel similarity measures. It is demonstrated that the use of local optimisation methods together with the standard multi-resolution approach is not sufficient to reliably find the global minimum. To address this problem, a global optimisation method is proposed that is specifically tailored to this form of registration. A full discussion of all the necessary implementation details is included as this is an important part of any practical method. Furthermore, results are presented for inter-modal, inter-subject registration experiments that show that the proposed method is more reliable at finding the global minimum than several of the currently available registration packages in common usage.
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        Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists.

        Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included. Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council's Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years. Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.
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          Time is brain--quantified.

          The phrase "time is brain" emphasizes that human nervous tissue is rapidly lost as stroke progresses and emergent evaluation and therapy are required. Recent advances in quantitative neurostereology and stroke neuroimaging permit calculation of just how much brain is lost per unit time in acute ischemic stroke. Systematic literature-review identified consensus estimates of number of neurons, synapses, and myelinated fibers in the human forebrain; volume of large vessel, supratentorial ischemic stroke; and interval from onset to completion of large vessel, supratentorial ischemic stroke. The typical final volume of large vessel, supratentorial ischemic stroke is 54 mL (varied in sensitivity analysis from 19 to 100 mL). The average duration of nonlacunar stroke evolution is 10 hours (range 6 to 18 hours), and the average number of neurons in the human forebrain is 22 billion. In patients experiencing a typical large vessel acute ischemic stroke, 120 million neurons, 830 billion synapses, and 714 km (447 miles) of myelinated fibers are lost each hour. In each minute, 1.9 million neurons, 14 billion synapses, and 12 km (7.5 miles) of myelinated fibers are destroyed. Compared with the normal rate of neuron loss in brain aging, the ischemic brain ages 3.6 years each hour without treatment. Altering single input variables in sensitivity analyses modestly affected the estimated point values but not order of magnitude. Quantitative estimates of the pace of neural circuitry loss in human ischemic stroke emphasize the time urgency of stroke care. The typical patient loses 1.9 million neurons each minute in which stroke is untreated.
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            Author and article information

            Affiliations
            [1 ]Neuroradiology Division, Department of Radiology, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, MA 02114, USA
            [2 ]Department of Neurosciences, University of Genoa, Via De Toni, 5-16132 Genoa, Italy
            [3 ]AA Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
            [4 ]Department of Neurology, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, MA 02114, USA
            Contributors
            Journal
            BMC Neurol
            BMC Neurology
            BioMed Central
            1471-2377
            2010
            10 February 2010
            : 10
            : 13
            2830931
            1471-2377-10-13
            20146800
            10.1186/1471-2377-10-13
            Copyright ©2010 González et al; licensee BioMed Central Ltd.

            This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

            Categories
            Research article

            Neurology

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