Neurosurgery
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Large vessel occlusions (LVOs), variably defined as blockages of the proximal intracranial anterior and posterior circulation, account for approximately 24% to 46% of acute ischemic strokes. Commonly refractory to intravenous tissue plasminogen activator (tPA), LVOs place large cerebral territories at ischemic risk and cause high rates of morbidity and mortality without further treatment. Over the past few years, an abundance of high-quality data has demonstrated the efficacy of endovascular thrombectomy for improving clinical outcomes in patients with LVOs, transforming the treatment algorithm for affected patients. In this review, we discuss the epidemiology, pathophysiology, natural history, and clinical presentation of LVOs as a framework for understanding the recent clinical strides of the endovascular era.
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Advances in neuroimaging in the last 2 decades have revolutionized the management of acute ischemic stroke (AIS). Here we review the development of computed tomography (CT) and magnetic resonance imaging (MRI) modalities used to guide treatment of patients with AIS characterized by large vessel occlusion. In particular, we highlight recent randomized trials and their patient selection methodologies to detail the progression of these selection paradigms. ⋯ While limitations exist for methodologies to quantify core and penumbra, commercially available fully automated software packages provide useful information to guide treatment decisions. Randomized controlled trials implementing perfusion imaging to patient selection algorithms have demonstrated marked success in improving functional outcomes in patients with large vessel occlusions. As such, imaging has become a vital aspect of AIS treatment in selecting patients who may benefit from mechanical thrombectomy.
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Intracranial pressure (ICP) is a clinically important variable after severe traumatic brain injury (TBI) and has been monitored, along with clinical outcome, for over 25 yr in Addenbrooke's hospital, Cambridge, United Kingdom. This time period has also seen changes in management strategies with the implementation of protocolled specialist neurocritical care, expansion of neuromonitoring techniques, and adjustments of clinical treatment targets. ⋯ We demonstrate the evolving trends in neurophysiological monitoring over the past 25 yr from a single, academic neurocritical care unit. ICP and CPP were responsive to the introduction of an ICP/CPP protocol while PRx has remained unchanged.