Search

Background The new SP robot incorporates a single trocar that houses a flexible camera and three bi-articulated arms, which minimizes the number of incisions needed to assess the surgical site, allowing for a less invasive procedure. Objectives To compare the postoperative pain scale and outcomes in patients with similar demographic characteristics undergoing robotic-assisted radical prostatectomy (RARP) with SP and Xi robots. Material and Methods One hundred consecutive patients undergoing RARP with the SP robot were matched, using a propensity score (PS), with 100 patients from a cohort of 1757 who were operated on with the da Vinci Xi from June 2019 to January 2021. We described and compared the perioperative pain scores and outcomes of both groups. Results The SP group had less blood loss (50cc vs. 62.5cc, P

BackgroundStent-assisted coiling of wide-necked intracranial aneurysms (IAs) using the Neuroform Atlas Stent System (Atlas) has shown promising results.ObjectiveTo present the primary efficacy and safety results of the ATLAS Investigational Device Exemption (IDE) trial in a cohort of patients with posterior circulation IAs.MethodsThe ATLAS trial is a prospective, multicenter, single-arm, open-label study of unruptured, wide-necked, IAs treated with the Atlas stent and adjunctive coiling. This study reports the results of patients with posterior circulation IAs. The primary efficacy endpoint was complete aneurysm occlusion (Raymond-Roy (RR) class I) on 12-month angiography, in the absence of re-treatment or parent artery stenosis >50%. The primary safety endpoint was any major ipsilateral stroke or neurological death within 12 months. Adjudication of the primary endpoints was performed by an imaging core laboratory and a Clinical Events Committee.ResultsThe ATLAS trial enrolled and treated 116 patients at 25 medical centers with unruptured, wide-necked, posterior circulation IAs (mean age 60.2±10.5 years, 81.0% (94/116) female). Stents were placed in all patients with 100% technical success rate. A total of 95/116 (81.9%) patients had complete angiographic follow-up at 12 months, of whom 81 (85.3%) had complete aneurysm occlusion (RR class I). The primary effectiveness outcome was achieved in 76.7% (95% CI 67.0% to 86.5%) of patients. Overall, major ipsilateral stroke and secondary persistent neurological deficit occurred in 4.3% (5/116) and 1.7% (2/116) of patients, respectively.ConclusionsIn the ATLAS IDE posterior circulation cohort, the Neuroform Atlas Stent System with adjunctive coiling demonstrated high rates of technical and safety performance.Trial registration numberhttps://clinicaltrials.gov/ct2/show/NCT02340585.

Antiplatelet agents are administered before and after neuroendovascular surgery to minimize implant-associated thromboembolic events. Dual antiplatelet therapy (DAPT) uses aspirin plus P2Y12 receptor inhibitors: clopidogrel, ticagrelor, or prasugrel. Effects are quantified in P2Y12 reactivity units (PRU) and aspirin reactivity units (ARU) by the point-of-care assay, Accumetrics VerifyNow. We hypothesized that intraoperative events such as anesthesia may affect platelet inhibition, increasing the risk of unanticipated ischemic events in the early postoperative period. This retrospective study was approved by the institutional review board. 50 patients who underwent Verify Now testing preoperatively and within 12 hours postoperatively after placement of cervical or intracranial stents at a single institution (January 1, 2018 - May 25, 2021) were included. PRU values > 194 and ARU values > 550 were considered subtherapeutic. Anesthetic agents, heparin dosage, clopidogrel responsiveness, platelet count, liver function, procedure type and length, NIH stroke scale scores, and demographics were compared to perioperative platelet inhibition values. Our results indicate that P2Y12 inhibition is likely affected by intraoperative events. Approximately 25% of patients exhibited marginal (170-193) or subtherapeutic (> 194) PRU values during the first 8 hours following neuroendovascular procedures. The greatest variation occurred in the ticagrelor group (PRU median change 84) and was more likely to occur with reduced doses of both ticagrelor and clopidogrel. A single prasugrel patient (clopidogrel non-responder) exhibited the greatest absolute change (PRU 156 -> 316). ARU variations were less pronounced suggesting that perioperative aspirin platelet inhibition is more resilient. In conclusion, patients undergoing elective neuroendovascular procedures may be at risk for thromboembolic ischemic complications during the first 8 hours postoperatively due to shifts in P2Y12 mediated platelet inhibition. ARU values were less effected, supporting the use of DAPT as an ongoing clinical standard of care.

BACKGROUND Heterogeneous effect of endovascular aneurysm therapy has been observed across different anatomic locations. There is a paucity of data for stent-assisted coiling of middle cerebral artery (MCA) aneurysms. OBJECTIVE To present the results of the MCA aneurysm group from the Neuroform Atlas (Stryker Neurovascular) investigational device exemption (IDE) trial. METHODS The Atlas IDE trial is a prospective, multicenter, single-arm, open-label study of wide-neck aneurysms (neck ≥ 4 mm or dome-to-neck ratio

Supplemental Digital Content is available in the text., Background and Purpose: Stent-assisted coil embolization using the new generation Neuroform Atlas Stent System has shown promising safety and efficacy. The primary study results of the anterior circulation aneurysm cohort of the treatment of wide-neck, saccular, intracranial, aneurysms with the Neuroform Atlas Stent System (ATLAS trial [Safety and Effectiveness of the Treatment of Wide Neck, Saccular Intracranial Aneurysms With the Neuroform Atlas Stent System]) are presented. Methods: ATLAS IDE trial (Investigational Device Exemption) is a prospective, multicenter, single-arm, open-label study of wide-neck (neck ≥4 mm or dome-to-neck ratio 50%) at the target location. The primary safety end point was any major stroke or ipsilateral stroke or neurological death within 12 months. Adjudication of the primary end points was performed by an independent Imaging Core Laboratory and the Clinical Events Committee. Results: A total of 182 patients with wide-neck anterior circulation aneurysms at 25 US centers were enrolled. The mean age was 60.3±11.4 years, 73.1% (133/182) women, and 80.8% (147/182) white. Mean aneurysm size was 6.1±2.2 mm, mean neck width was 4.1±1.2 mm, and mean dome-to-neck ratio was 1.2±0.3. The most frequent aneurysm locations were the anterior communicating artery (64/182, 35.2%), internal carotid artery ophthalmic artery segment (29/182, 15.9%), and middle cerebral artery bifurcation (27/182, 14.8%). Stents were placed in the anticipated anatomic location in all patients. The study met both primary safety and efficacy end points. The composite primary efficacy end point of complete aneurysm occlusion (Raymond-Roy 1) without parent artery stenosis or aneurysm retreatment was achieved in 84.7% (95% CI, 78.6%–90.9%) of patients. Overall, 4.4% (8/182, 95% CI, 1.9%–8.5%) of patients experienced a primary safety end point of major ipsilateral stroke or neurological death. Conclusions: In the ATLAS IDE anterior circulation aneurysm cohort premarket approval study, the Neuroform Atlas stent with adjunctive coiling met the primary end points and demonstrated high rates of long-term complete aneurysm occlusion at 12 months, with 100% technical success and

Background and objectiveStent-assisted coil embolization is a well-established treatment of intracranial wide-necked aneurysms. The Neuroform Atlas Stent System is a new generation microstent designed to enhance coil support, conformability, deliverability, and improve deployment accuracy. We present the 1-year efficacy and angiographic results of the Humanitarian Device Exemption (HDE) cohort from the Atlas Investigational Device Exemption (IDE) clinical trial.MethodThe Atlas IDE trial is a prospective, multicenter, single-arm, open-label study of unruptured wide-necked intracranial aneurysms treated with the Neuroform Atlas stent and approved coils. The primary efficacy endpoint was the rate of 12-month complete aneurysm angiographic occlusion (Raymond class I) without target aneurysm retreatment or significant parent artery stenosis (>50%) at the target location. The primary safety endpoint was the rate of major ipsilateral stroke or neurological death within 12 months. Imaging core laboratory and Clinical EventsCommittee adjudicated the primary endpoints.Results30 patients were enrolled at eight US centers, with 27 patients completing the 12-month angiographic follow-up. The mean age was 59.4±11.8 years and 24/30 patients (80%) were women. The mean aneurysm size was 5.3±1.7 mm and the dome:neck ratio was 1.1±0.2. Procedural technical success of Neuroform Atlas Stent deployment was 100%. 27 patients completed 12-month angiographic follow-up and 30 patients completed their 6-month follow-up. When applying the last observation carried forward method, the primary efficacy endpoint was observed in 26/30 patients (86.7%, 95% CI 69.3% to 96.2%) compared with 25/27 patients (92.6%, 95% CI 75.7% to 99.1%) who completed the 12-month angiographic follow-up. The primary safety endpoint of stroke occurred in one patient (3.3%), who made a complete clinical recovery at discharge. There were no neurological deaths.ConclusionThe Neuroform Atlas stent in conjunction with coils demonstrated a high rate of complete aneurysm occlusion at 12-month angiographic follow-up, with an improved safety profile in the HDE cohort.Clinical trial.gov registration numberNCT0234058;Results

ObjectiveIn this multicenter study, we sought to evaluate comparative safety and efficacy of combined IV thrombolysis (IVT) and mechanical thrombectomy (MT) vs direct MT in emergent large vessel occlusion (ELVO) patients.MethodsConsecutive ELVO patients treated with MT at 6 high-volume endovascular centers were evaluated. Standard safety and efficacy outcomes (successful reperfusion [modified Thrombolysis in Cerebral Infarction IIb/III], functional independence [FI] [modified Rankin Scale (mRS) score of 0–2 at 3 months], favorable functional outcome [mRS of 0–1 at 3 months], functional improvement [mRS shift by 1-point decrease in mRS score]) were compared between patients who underwent combined IVT and MT vs MT alone. Additional propensity score–matched analyses were performed.ResultsA total of 292 and 277 patients were treated with combination therapy and direct MT, respectively. The combination therapy group had greater functional improvement (p = 0.037) at 3 months. After propensity score matching, 104 patients in the direct MT group were matched to 208 patients in the combination therapy group. IVT pretreatment was independently (p < 0.05) associated with higher odds of FI (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.02–2.99) and functional improvement (common OR 1.64; 95% CI 1.05–2.56). Combination therapy was independently (p < 0.05) related to lower likelihood of 3-month mortality (0.50; 95% CI 0.26–0.96).ConclusionsThis observational study provides preliminary evidence that IVT pretreatment may improve outcomes in ELVO patients treated with MT. The question of the potential effect of IVT on ELVO patients treated with MT should be addressed with a randomized controlled trial.Classification of evidenceThis study provides Class III evidence that for stroke patients with emergent large vessel occlusion, combined IVT and MT is superior to direct MT in improving functional outcomes.

Background and purpose Stent-assisted coil embolization using the new generation Neuroform Atlas™ Stent System has shown promising technical, safety, and clinical feasibility and efficacy. Here, we present the one year angiographic and efficacy results of the anterior circulation cohort in the ATLAS Investigational Device Exemption (IDE) Trial. Methods ATLAS IDE is a prospective, multicenter, single-arm, open label study of unruptured wide-necked (neck ≥4 mm or dome-to-neck ratio 50% at the target location. The primary safety endpoint was any major stroke or ipsilateral stroke or neurological death within 12 months. Adjudication of the primary endpoints was performed by an imaging core laboratory and the Clinical Events Committee for ATLAS. Results A total of 182 patients with unruptured wide-necked anterior circulation aneurysms at 25 US centers were enrolled. The mean age was 60.3±11.4 years, 73.1% (133/182) women, and 80.8% (147/182) Caucasian. Mean aneurysm size and dome-to-neck ratio was 6.1±2.2 mm and 1.2±0.3, respectively. Sixty-four (35.2%) aneurysms were located in the anterior communicating artery. Mean procedure duration was 110.2±47.0 minutes. Technical success was achieved in 100% (182/182) of patients. Follow-up imaging data at 12 months was available in 84.1% (153/182) of patients. The primary efficacy endpoint was achieved in 84.7% [95%CI: 78.6,90.9] of subjects and the incidence of primary safety endpoint failure was 4.4% (8/182; 95%CI: 1.9, 8.5). Conclusion In the ATLAS IDE anterior circulation cohort pre-market approval study, the Neuroform ATLAS stent with adjunctive coiling demonstrated high rates of long-term complete occlusion at 12 months, with excellent technical success and safety. Disclosures O. Zaidat: None. R. Hanel: None. E. Sauvageau: None. A. Aghaebrahim: None. E. Lin: None. A. Jadhav: None. T. Jovin: None. A. Khaldi: None. R. Gupta: None. A. Johnson: None. D. Frei: None. D. Loy: None. A. Malek: None. G. Toth: None. A. Siddiqui: None. J. Reavey-Cantwell: None. A. Thomas: None. S. Hetts: None. B. Jankowitz: None.

Intra-arterial therapy (IAT) is most effective when performed rapidly after ischemic stroke onset. However, there are limited performance benchmarks in IAT and there is a scarcity of information on how to structure an effective IAT protocol and its impact on time to treatment. The objective of our study was to detail a standardized IAT protocol, and to assess its influence on time to treatment in ischemic stroke.This was a retrospective observational study over 4 years at a comprehensive stroke center. A standardized IAT protocol was implemented in June 2013 that included pre-notifying the stroke team before hospital arrival, defining clinician roles, processing tasks in parallel, and standardizing IAT procedures. Three time metrics were examined and reported as median (IQR) minutes: arrival to CT imaging, CT to groin puncture, and puncture to recanalization. We compared these metrics in patients admitted before implementation (January 2012-May 2013) to patients admitted after (June 2013-December 2015) using Wilcoxon Mann-Whitney tests.380 patients were included. After the protocol was implemented, there were significant reductions in time from arrival to CT (17 (14-21) vs 13 (11-19) min, p0.001), CT to puncture (46 (30-82) vs 31 (23-54) min, p0.001), and puncture to recanalization (65 (33-90) vs 37 (22-65) min, p0.001). 60% of time was saved during puncture to recanalization. Significant reductions in time were observed during both normal working hours and off-hours.Implementation of a standardized protocol resulted in a significant reduction in time to recanalization for patients with an ischemic stroke. A standardized IAT protocol decreases time to recanalization when team roles are clearly defined, tasks are processed in parallel, and procedures are standardized.

ObjectiveThe safety and efficacy of intra-arterial treatment (IAT) in patients with acute ischemic stroke (AIS) due to cervical artery dissection (CeAD) has not been formally studied. The purpose of this study was twofold: first, describe a large series with CeAD treated with IAT; second, analyze outcomes with CeAD receiving IAT versus (a) CeAD not treated with IAT, (b) CeAD receiving intravenous thrombolysis (IVT) alone, and (c) non-CeAD mechanism of AIS receiving IAT.DesignDemographics, clinical characteristics, treatment, and outcomes were summarized for all CeAD patients treated with IAT from January 2010 to May 2015. Outcomes included favorable 90 day modified Rankin Scale (mRS) score of 0–2, symptomatic intracerebral hemorrhage (sICH), recanalization (Thrombolysis in Cerebral Infarction 2b-3), procedural complications, and mortality. Outcomes were analyzed with χ2 tests and multivariate logistic regression.ResultsThere were 161 patients with CeAD: 24 were treated with IAT and comprised our target population. Dissections were more common in the internal carotid (n=18) than in the vertebral arteries (n=6). All but one patient had intracranial embolus. IAT techniques included thrombectomy (n=19), IA thrombolysis (n=17), stent (n=14), and angioplasty (n=7). Outcomes included favorable 90 day mRS score of 0–2 in 63%, 4 deaths, 1 sICH, and 3 procedural complications. After adjustment, favorable mRS in our target population was similar to comparison populations: (a) in CeAD, IAT versus no IAT (OR 0.62, p=0.56); (b) In CeAD, IAT versus IVT alone (OR 1.32, p=0.79); and (c) IAT in CeAD versus non-CeAD mechanism of AIS (OR 0.58, p=0.34).ConclusionsIAT is a valid alternative therapeutic option for AIS caused by CeAD due to the low complication rate and excellent outcomes observed in this study.

Background Cerebral venous thrombosis is a rare cause of stroke that poses diagnostic, therapeutic, and prognostic challenges. Mainstay treatment is systemic anticoagulation, but endovascular treatment is increasingly advocated. Our objectives were to describe the epidemiology, treatment, and prognosis of 152 patients with cerebral venous thrombosis. Methods and Results This was a retrospective study of consecutive cerebral venous thrombosis cases from 2006 to 2013 at a comprehensive stroke center through hospital discharge. Predictors of full recovery (modified Rankin Scale scores 0–1) were analyzed with multiple logistic regression and presented as adjusted odds ratios ( AORs ) with 95% confidence intervals ( CIs ). The population was young (average age: 42 years), majority female (69%), and commonly presenting with cerebral edema (63%), and 72% were transferred in. All patients received systemic anticoagulation; 49% (n=73) required endovascular treatment. Reasons for requiring endovascular treatment included cerebral edema, herniation, or hemorrhagic infarct (n=38); neurologic decline (n=17); rethrombosis, persistent occlusion, or clot propagation (n=10); extensive clot burden (n=7); and persistent headache despite anticoagulation (n=1). There were 7 (10%) procedural complications. Recanalization was successful (61%), partial (30%), and unsuccessful (9%). Overall, 60% fully recovered. Positive predictors of full recovery included hormonal etiology, particularly for patients who were transferred in ( AOR : 7.06 [95% CI, 2.27–21.96], interaction P =0.03) and who had migraine history ( AOR : 4.87 [95% CI, 1.01–23.50], P =0.05), whereas negative predictors of full recovery were cerebral edema ( AOR : 0.11 [95% CI, 0.04–0.34], P AOR : 0.28 [95% CI, 0.09–0.96], P =0.04). Conclusions As one of the largest cohort studies, our findings suggest that cerebral edema, history of migraine, and hormonal etiology were prognostic and that endovascular treatment might be a safe and effective treatment for cerebral venous thrombosis when conventional management is inadequate.

BACKGROUND Mechanical thrombectomy (MT) is the current standard of care for acute ischemic stroke (AIS) patients with emergent large-vessel occlusions (ELVO). Successful reperfusion of ELVO is traditionally defined by modified Thrombolysis in Cerebral Infarction (mTICI) grades of 2b or 3. OBJECTIVE To evaluate the comparative safety and efficacy of mTICI 2b and mTICI 3 reperfusion in AIS patients treated with MT. METHODS Consecutive ELVO patients who underwent MT at 6 high-volume centers were included in this analysis. Standard safety (3-mo mortality, symptomatic intracranial hemorrhage [sICH]) and efficacy (absolute and relative reduction in NIHSS-scores during hospitalization, functional-improvement [shift analysis in mRS-scores], and functional-independence [mRS-scores of 0-2] at 3-mo) were compared between patients who had mTICI 2b and mTICI 3 reperfusion post MT. RESULTS A total of 416 ELVO patients achieved successful reperfusion with mTICI 2b (n = 216) and mTICI 3 (n = 200) following MT. The mTICI 3 group had significantly (P < .05) greater absolute (11 vs 9 points) and relative (77% vs 63%) reduction in NIHSS-scores during hospitalization, lower sICH (6% vs 12%), and higher 3-mo functional-independence (55% vs 44%) rates. Successful reperfusion with mTICI 3 was independently (P < .05) associated with greater absolute and relative reduction in NIHSS-scores during hospitalization as well as higher odds of 3-mo functional improvement (common odds ratios: 1.67; 95% confidence interval: 1.10-2.56) and functional independence (odds ratio: 2.08; 95% confidence interval: 1.22-3.53) in multivariable regression models adjusting for confounders. CONCLUSION Successful reperfusion with mTICI 3 was associated with greater neurological improvement during hospitalization and better 3-mo functional outcomes in comparison to mTICI 2b reperfusion.

Background Mechanical thrombectomy (MT) for acute ischemic stroke (AIS) patients with emergent large-vessel occlusions (ELVO) has become the standard of care. A recent meta-analysis of the 5 randomized trials demonstrated that 46% of patients in the intervention arm achieved mRS of 0–2 at 3 months. Considering the fact that significant numbers of patients still have residual disability at three months despite MT, it is important to consider other modifiable variables that might improve functional outcomes in patients with ELVO. Successful reperfusion post MT is the strongest modified predictor of the outcome. Thrombolysis in cerebral infarction (TICI) grades are current standard of care for assessment of degree of reperfusion post MT. Recently conducted trials defined both TICI 2b and 3 grades as successful reperfusion. In this multicenter study we sought to evaluate if there are any differences in safety and effectiveness outcomes between ELVO patients who achieved TICI 2b and those who achieved TICI 3 reperfusion post MT. Methods We conducted an observational study on consecutive AIS patients with ELVO who underwent MT at 6 high-volume endovascular centers. Standard safety (3 month mortality, symptomatic intracranial hemorrhage) and effectiveness (3 month functional independence: modified Rankin Scale scores of 0–2) outcomes were compared between patients who had TICI 2b and TICI 3 reperfusion post MT. Results The sample consisted of 583 patients with ELVO who underwent MT. A total of 416 patients achieved successful reperfusion (TICI 2b or 3) post MT. TICI 2b reperfusion was achieved in 216 (52%) patients [mean age 64±15, Male 50%, median NIHSS: 16 (IQR 12–20)], while 200 patients (48%) achieved TICI 3 reperfusion post MT [mean age 66±14, Male, 48%, median NIHSS 16 (IQR: 13–20)]. TICI 2b and TICI 3 reperfusion groups did not differ in terms of intravenous thrombolysis pretreatment (51% vs 56%, p=0.425), median onset to groin puncture time [minutes, median (IQR); 223 (157–318) vs 240 (176–311), p=0.850], median groin puncture to recanalization time [minutes, median (IQR); 38 (23–62 vs 41 (26–57), p=0.282) and 3 months mortality (22% vs 19%, p=0.523). TICI 3 reperfusion group had lower median discharge NIHSS [median (IQR) 3 (1–7) vs 5 (2-12), p=0.029), lower rates of symptomatic intracranial hemorrhage (6% vs 12%, p=0.035) and higher rates of functional independence at 3 months (55% vs 44%, p=0.050) compared to TICI 2b reperfusion group. In multivariate model after adjustment for potential confounders, TICI 3 reperfusion group was associated with greater neurological improvement during hospitalization (OR 1.009; 95% CI: 1.002–1.016, p=0.024), lower rates of sICH (OR 0.28; 95% CI: 0.10–0.78, p=0.027) and tended to have higher rates of 3 months functional independence (OR 1.80; 95% CI; 1.01–3.21, p=0.054) compared to TICI 2b group. Conclusions TICI 3 reperfusion appears to be associated with better early outcomes in comparison to TICI 2b reperfusion in ELVO Patients treated with MT. Future clinical trials involving ELVO patients should differentiate between these reperfusion groups in terms of safety and effectiveness outcomes. Disclosures N. Goyal: None. G. Tsivgoulis: None. D. Frei: None. A. Turk: None. B. Baxter: None. M. Froehler: None. J. Mocco None. M. Ishfaq: None. D. Hoit: None. J. Chang: None. L. Elijovich: None. D. Loy: None. R. Turner: None. J. Mascitelli: None. K. Espaillat: None. A. Alexandrov: None. A. Arthur: None.

As Buddhism infiltrates the West, one of the important and interesting points of contention is sexuality. Buddhism in Asia has been largely a cultural force for celibacy (among monastics) and sexual restraint, so how is Western Buddhism adapting to the sexual revolution?

BackgroundWhile mechanical thrombectomy (MT) has become the standard of care for patients with acute ischemic stroke (AIS) with emergent large-vessel occlusions (ELVO), recently published guidelines appropriately award top-tier evidence to the same selective criteria that were employed in completed clinical trials. We sought to evaluate the safety and effectiveness of MT in patients with AIS with ELVO who do not meet top-tier evidence criteria (TTEC).MethodsWe conducted an observational study on consecutive patients with AIS with ELVO who underwent MT at six high-volume endovascular centers. Standard safety outcomes (3-month mortality, symptomatic intracranial hemorrhage) and effectiveness outcomes (3-month functional independence: modified Rankin Scale scores of 0–2) were compared between patients meeting and failing TTEC.ResultsThe sample consisted of 349 (60%) controls fulfilling TTEC and 234 (40%) non-TTEC patients. Control patients meeting TTEC for MT tended to have higher functional independence rates at 3 months (47% vs 39%; p=0.055), while the rates of symptomatic intracerebral hemorrhage (sICH) were similar (9%) in both groups (p=0.983). In multivariable logistic regression models, adherence to TTEC for MT was not independently related to any safety outcome (sICH: OR 0.71, 95% CI 0.30 to 1.68, p=0.434; 3-month mortality: OR 1.27, 95% CI 0.69 to 2.33, p=0.448) or effectiveness outcome (3-month functional independence: OR 0.81, 95% CI 0.48 to 1.37, p=0.434; 3-month functional improvement: OR 0.73, 95% CI 0.48 to 1.11, p=0.138) after adjusting for potential confounders.ConclusionsApproximately 40% of patients with AIS with ELVO offered MT do not fulfill TTEC for MT. Patients who did not meet TTEC had high rates of good clinical outcome and low complication rates.

Introduction: Cervical artery dissection is a recognized cause of acute ischemic stroke (AIS). Intra-arterial treatment (IAT) may be a complementary option to IV tPA and antithrombotic therapy. Hypothesis/Purpose: To describe a large series of patients with dissection treated with IAT. Methods: Demographics, clinical characteristics, treatment, and outcomes were summarized for all dissection patients treated with IAT from 1/2010 - 5/2015. Outcomes included functional independence (modified Rankin score ≤ 2 at 90 days or discharge, or discharge home), recanalization, procedural complications, sICH, and mortality. Data are presented as median (interquartile range) or (n). Results: Of 161 patients with dissection, 24 (15%) were managed with IAT and comprise our population, which was primarily male (75%) aged 52 (42-59.5) and NIHSS of 13 (12 -16). Internal carotid artery dissections (ICAD, 18) were more common than vertebral artery dissections (VAD, 6); three patients had bilateral dissections (1 ICAD, 2 VAD). In all but two patients there was associated intracranial embolus. Dissections were idiopathic (17), traumatic (5) or cough-related (2). Eleven patients were treated with IV tPA. IAT techniques included thrombectomy (19), IA thrombolysis (17), stent (13), and angioplasty (7). The majority of patients had multiple techniques: 2 (2 -3). Functional independence was achieved in 63% (12/19). There were four deaths, none were attributable to IAT. There was one sICH and three procedural complications (2 groin pseudoaneurysm, one catheter induced acute dissection). Among the 6 VADs, 2 were left untreated and the remaining 4 were successfully recanalized (100%). All 6 VADs had a basilar artery occlusion; recanalization was successful in 2 and partial in 4 cases. Among the 18 ICADs, 6 were left untreated and the remaining 12 were successfully recanalized (100%). Sixteen of 18 ICADs had middle cerebral artery occlusion; recanalization was successful in 4, partial in 10, and unsuccessful in 2 cases. Conclusions: Despite the additional intravascular risk, outcomes appear to be similar to those presented in large RCTs with stroke from all causes, suggesting utility of IAT when performed in patients with dissection.

Introduction: The safety and efficacy of intraarterial treatment (IAT) for acute ischemic stroke (AIS) due to cervical artery dissection (CAD, carotid and vertebral) has not been studied in a controlled trial. Hypothesis: There will be no differences in safety and efficacy of IAT for AIS due to CAD compared to non-CAD mechanism. Methods: We studied consecutive admissions with AIS who received IAT between 1/2010 - 4/2015 and compared outcomes for AIS patients who presented with CAD mechanism vs. other causes. Outcomes included in-hospital mortality, symptomatic intracerebral hemorrhage (sICH), procedural complications, and functional independence (Modified Rankin Score ≤ 2 at 90-days or discharge, or discharge home). Outcomes were univariately analyzed with Chi-square tests. Co-primary outcomes of functional independence and sICH were analyzed with multivariate logistic regression. Results: Of 3,671 patients with AIS, 445 patients received IAT and comprise our study population: 24 with CAD (5%: 18 carotid, 6 vertebral) and 421 with another cause. Patients with CAD were younger (median age: 52 vs. 70, p < 0.001) with less severe stroke (median NIHSS: 13 vs. 18, p=0.03) than those with another cause of AIS. Unadjusted outcomes were similar by AIS cause (Table 1). After adjustment for NIHSS and age, the odds of achieving functional independence (OR: 0.58 [0.19-1.78], p=0.34) and sICH (OR: 0.57 [0.07-4.66], p=0.60) were not significantly different in patients with CAD vs. other mechanism. Conclusions: Intraarterial treatment appears to be as safe and effective when used in patients with ischemic stroke due to CAD as in AIS patients with other causes. Following the major advances in IAT for AIS in the general population, IAT should be considered in patients with AIS due to a CAD.

Accurate diagnosis of spinal cord injury (SCI) severity must be achieved before highly aggressive experimental therapies can be tested responsibly in the early phases after trauma. These studies demonstrate for the first time that axial diffusivity (lambda||), derived from diffusion tensor imaging (DTI) within 3 h after SCI, accurately predicts long-term locomotor behavioral recovery in mice. Female C57BL/6 mice underwent sham laminectomy or graded contusive spinal cord injuries at the T9 vertebral level (5 groups, n = 8 for each group). In-vivo DTI examinations were performed immediately after SCI. Longitudinal measurements of hindlimb locomotor recovery were obtained using the Basso mouse scale (BMS). Injured and spared regions of ventrolateral white matter (VLWM) were reliably separated in the hyperacute phase by threshold segmentation. Measurements of lambda|| were compared with histology in the hyperacute phase and 14 days after injury. The spared normal VLWM determined by hyperacute lambda|| and 14-day histology correlated well (r = 0.95). A strong correlation between hindlimb locomotor function recovery and lambda||-determined spared normal VLWM was also observed. The odds of significant locomotor recovery increased by 18% with each 1% increase in normal VLWM measured in the hyperacute phase (odds ratio = 1.18, p = 0.037). The capability of measuring subclinical changes in spinal cord physiology and murine genetic advantages offer an early window into the basic mechanisms of SCI that was not previously possible. Although significant obstacles must still be overcome to derive similar data in human patients, the path to clinical translation is foreseeable and achievable.

This essay takes seriously the many Buddhist admonitions about ''not settling down in things'' and the importance of wandering freely ''without a place to rest.'' The basic thesis is that delusion (samsāra, ignorance) is awareness trapped (stuck), and liberation (nirvāna, enlightenment) is awareness freed from grasping. The familiar words ''attention'' and ''awareness'' are used to emphasize that the distinction being drawn refers not to some abstract metaphysical entity but simply to how our everyday awareness functions. This way of distinguishing between delusion and enlightenment is not only consistent with basic Buddhist teachings but gives us insight into some of the more difficult ones, such as the way karma works and the Mahāyāna claim that ''form is not other than emptiness, emptiness not other than form.'' Moreover, this perspective illuminates some aspects of our contemporary life-world, including the particular challenges of modern technology and economics. It is important to see the implications for some of the social issues that concern us today. The constriction or liberation of awareness is not only a personal matter. What do societies do to encourage or discourage its emancipation?

We examined in vivo measurements of directional diffusivity derived from diffusion tensor imaging (DTI) to study the evolution of ventrolateral white matter (VWM) changes following contusive spinal cord injury (SCI) in C57BL/6 mice at 1, 3, 7, and 14 days postinjury. Relative anisotropy maps provided excellent gray matter (GM)/white matter (WM) contrast for characterization of evolving WM injury at all time points. Longitudinal DTI measurements clearly demonstrated rostral-caudal injury asymmetry. Axial diffusivity provided a sensitive, noninvasive measure of axonal integrity within the injury epicenter and at remote levels. Quantitative measurements of axial and radial diffusivities in VWM showed a trend of acute primary axonal injury followed by delayed, subacute myelin damage at the impact site, with good histological correlation.

Background: Clinical trials confirmed the safety and efficacy of intra-arterial therapy (IAT) in the management of ischemic stroke. At a community hospital, we compared outcomes in patients aged ≥80 and patients in the age range 55-79 years receiving IAT following ischemic stroke. Methods: Data were retrospectively abstracted for ischemic stroke patients ≥55 years treated with IAT at an urban comprehensive stroke center between 2010 and 2013. Baseline demographics, incidence of symptomatic intracranial hemorrhage (sICH), in-hospital mortality, discharge modified Rankin scale (mRS) score (favorable ≤2) and improvement in National Institutes of Health Stroke Scale Score (NIHSS; decreased score at discharge) were compared between patients in the age range 55-79 and patients ≥80 years. Data were analyzed using univariate analyses and multivariate logistic regression. Results: IAT was performed in 239 patients with ischemic stroke; 63 (26.4%) were ≥80 years. When compared to patients aged 55-79, the elderly patients were more often female and non-smokers, with a history of atrial fibrillation. No differences were observed in those ≥80 years compared to patients in the age range 55-79 years for sICH (10 vs. 5%, p = 0.23), mortality (24 vs. 18%, p = 0.28), favorable discharge mRS score (13 vs. 19%, p = 0.27), or improvement in NIHSS (83 vs. 92%, p = 0.10). The nonsignificant association of age with the outcomes persisted after adjusting for covariates and when analyzing the subset of patients who received IAT only. Conclusions: These findings suggest that in a cohort not subject to the criteria of a clinical trial, age ≥80 years should not be a contraindication to IAT.

Introduction: Acute ischemic stroke (AIS) occurs most frequently in old age. Currently, conflicting evidence exists on the safety and efficacy of intra-arterial treatment (IAT) in the management of AIS in the elderly. We purported to compare the outcomes of patients ≥80 years receiving IAT after AIS to those of patients 55-79 years old. Methods: Data were retrospectively abstracted for consecutive AIS patients ≥55 years treated with IAT at an urban comprehensive stroke center between 2010 and 2013. The following outcomes were compared between patients 55-79 vs. ≥80 years following IAT: safety was assessed by incidence of sICH and in-hospital mortality; efficacy was examined using discharge mRS (favorable, ≤2) and improvement in NIHSS (decreased score at discharge). All analyses were performed with Pearson or Fisher’s exact chi-square tests. The subset of patients receiving IAT only was also examined. Results: IAT was performed in 300 patients, of which 241 were aged ≥55 and comprise our study cohort; of the 241, 104 received IAT only. There were no significant differences between the two age groups receiving IAT in race, presence of comorbidities and time to IAT while significant differences were observed for gender and NIHSS, with the ≥80 population presenting with lower mean stroke severity and more females (p

OBJECTIVE We evaluated whether serum levels of neuron-specific enolase (NSE) and S-100beta protein are biomarkers for traumatic injury in an animal model of spinal cord injury (SCI). METHODS Enzyme-linked immunosorbent assay serum measurements of NSE and S-100beta and assays of serum protein were compared at 6 and 24 hours after a graded contusive SCI (150 or 200 kdyn IH impactor injury (Infinite Horizons, L.L.C., Lexington, KY) or sham laminectomy at T9 in 30 female Sprague-Dawley rats. Serum from control animals was also analyzed. RESULTS Increases in serum levels of NSE were observed for 200-kdyn (3.1-fold, P < 0.001) and 150-kdyn (2.3-fold, P < 0.001) injury groups at 6 hours after injury, which decreased by 73.7% (P < 0.001) and 65.2% (P < 0.001) at 24 hours after SCI, respectively; the levels were still greater than in sham animals (P < 0.001, P = 0.001). The 200- and 150-kdyn injury groups were not different at either time point. S-100beta serum levels increased at 6 hours in the 200-kdyn injury group (P < 0.05), and no differences from sham levels were seen at 24 hours. No differences in total protein concentrations were observed between the injury and control groups. CONCLUSION Present data suggest that NSE and S-100beta serum levels may be useful experimental tools for the acute measurement of tissue loss after SCI. Despite significant shortcomings, NSE and S-100beta serum measurements in acute SCI patients with clinically defined functional deficits should allow comparisons with well-characterized SCI animal models. Future efforts to develop biomarkers that predict functional outcomes in the acute phase should focus on axon-specific proteins as markers of secondary axonal loss and regeneration.

I was surprised to receive this lengthy response to my short review-yet not displeased, for the important question is, of course, how much Professor Ziporyn's reply helps to clarify the issues at stake, which we agree deserve to be pursued. One of the many admirable aspects of his Evil and/or/as the Good is that, in addition to presenting the Tiantai ethical position in its historical context, it argues forcefully for the validity and relevance of that approach today. Moreover, I am pleased at the way Ziporyn's response focuses the argument of his rich and dense book, so I welcome this opportunity to continue the discussion. And perhaps those who have read this far will also be pleased that I am able to present my main concerns somewhat more concisely. Ziporyn begins with the relationship between ultimate and provisional truth, usually the crux of the matter from a Mahayana perspective. In response to a point I make-that ethically the nondual 'ultimate' point of view needs to be supplemented by a provisional 'lower truth' that distinguishes between good and evil-he emphasizes that according to Tiantai "conventional truth and ultimate truth are actually identical" (his italics) and that the conventional truth embraces all possible assertions, beliefs, and positions. Later, he elaborates that "provisional truth is a portion of ultimate truth, in a peculiar omnicentric sort of whole/part relation in which each part in fact contains the whole." The important term remains identity, for according to Tiantai "the idea that two entities might be mutually implicative and dependent, not adventitiously but in their nature, and yet not identical, is logically impossible." Ethically, of course, this means something more than the interdependence of good and evil: it is not only that "the most horrible evils are ineradicable, built into the absolute unchangeable nature of all existence, and fully and eternally present even in Buddhahood," but that "greed, anger, and delusion would be seen to be identical with Buddhahood, in accordance with precisely this Tiantai doctrine of the interpenetration of good and evil." As in the original review, my main point is that this emphasis on the identity of conventional truth and ultimate truth is an important insight, but one that turns out to be quite problematic ethically. Its value is mostly epistemological and metaphysical: it helps us escape from the kind of dualism that often postulates some 'higher' transcendental reality corresponding to a 'higher' ultimate truth. Instead, the 'higher' is not separate from the provisional and conventional, but the truth (whether realized or not) is that the whole 'ultimate' is completely contained within each conventional part or provisional position. Dogen somewhere makes the point that the goal is not to eradicate concepts (which is a dualistic approach to practice, seeking a purified mind that transcends language) but to liberate concepts. What becomes important is our ability to move