Describe the hemodynamic implications of anaesthetic choice among children with heart disease undergoing cardiac catheterisation.

Study 1 was a secondary analysis of data obtained during catheterisation-based hemodynamic assessment of infants with hypoplastic left heart syndrome following Stage 1 palliation, randomised in the Single Ventricle Reconstruction trial. Measured and calculated hemodynamics including pulmonary and systemic vascular resistance indexed to body surface area (PVRi and SVRi respectively) and pulmonary/systemic blood flow (Qp/Qs) were analysed with respect to anaesthetic employed during catheterisation, classified as moderate sedation or general anaesthesia. Study 2 consisted of a single centre, prospective analysis of patients requiring percutaneous closure of a patent ductus arteriosus or endomyocardial biopsy after orthotopic heart transplant. Participants underwent hemodynamic assessment first using inhaled volatile anaesthesia (IA), and then transitioned to total intravenous anaesthesia, comparing hemodynamic measures with respect to anaesthetic approach.

In Study 1, independent of shunt type, PVRi, and patient size, moderate sedation was associated with a greater than two-fold odds of a Qp/Qs >1 (OR 2.12, 95%CI 1.18–3.87, p = 0.013). In Study 2, while PVRi was similar, SVRi was significantly higher using total intravenous anaesthesia. Among the patent ductus arteriosus subgroup, Qp/Qs increased significantly with a total intravenous anaesthesia relative to IA (p = 0.003); additionally, among the orthotopic heart transplant subgroup, left ventricular end diastolic pressure increased following a transition to total intravenous anaesthesia (p = 0.002).

Analyses of hemodynamics during catheterisation support a significant impact of anaesthetic type on hemodynamic values including SVRi, left ventricular end diastolic pressure, and Qp/Qs. Anaesthesia choice and intraprocedural management of SVRi are important considerations when making clinical decisions based on hemodynamic data.

Adjunctive intraarterial (IA) thrombolysis after endovascular thrombectomy may improve clinical outcomes in patients with large vessel occlusion (LVO) stroke possibly due to improvement in microvascular reperfusion.

We conducted a meta-analysis of randomized controlled trials (RCTs) evaluating IA thrombolysis with tenecteplase, alteplase or urokinase in anterior or posterior circulation LVO stroke after successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b–3). Efficacy outcomes were excellent functional outcome (modified Rankin Scale [mRS] 0–1), functional independence (mRS 0–2) and recovery without any disability (mRS 0) at 90 days. Safety outcomes included symptomatic intracerebral hemorrhage (ICH), any ICH and death. Odds ratios (OR) and 95% confidence intervals (CI) were pooled using random-effects models.

Seven RCTs (n = 2,130; 2022–2025) were included. IA thrombolytic drugs used were alteplase, tenecteplase and urokinase with doses ranging from 10 % to 50% of recommended IV dosage. IA thrombolysis significantly improved excellent functional outcome (mRS 0–1: OR 1.45, 95% CI 1.19–1.76) and recovery without any disability (mRS 0: OR 1.34, 95% CI 1.09–1.64), without safety risks (symptomatic ICH: 5.05% with IA thrombolytics vs. 4.49% in standard). Paradoxically, there was no difference in functional independence (mRS 0–2) (OR 1.09, 95% CI 0.99–1.20). Additionally, tenecteplase or alteplase at doses equivalent to 25% or 50% of recommended IV dosage significantly improved excellent functional outcome.

IA thrombolysis offered immediately following EVT with successful reperfusion improved excellent functional outcome and recovery without disability at 90 days with an acceptable safety profile.

Historically, it has been proposed that functional neurological symptoms occur more frequently on the left side of the body due to a distinct body representation and emotional processing of the right hemisphere, yet objective imaging data to support this are lacking. We aimed to investigate whether patients with acute left-sided symptoms (right hemisphere) suspected of having a minor stroke are more likely to show negative diffusion-weighted imaging (DWI) compared to those with right-sided symptoms.

Data are from the SpecTRA (Spectrometry for Transient Ischemic Attack Rapid Assessment) multicenter prospective cohort study conducted between 2013 and 2017. Patients with mild persistent unilateral hemiparesis and/or hemisensory symptoms (National Institute of Health Stroke Scale ≤ 3) and available DWI were included. The primary outcome was the proportion of patients with a negative DWI.

Of 1731 patients, 584 (30.8%) were included. Of these, 310 (53.1%) patients presented with left-sided symptoms and 274 (46.9%) with right-sided symptoms. Overall, 214 (36.6%) patients had a negative DWI, 126 (58.9%) with left-sided symptoms and 88 (41.1%) with right-sided symptoms: risk ratio (RR) 1.27 (95% CI = 1.02–1.57). Left-sided hemiparesis was associated with negative DWI (RR 1.42 [95% CI = 1.08–1.87]), while left-sided hemisensory symptoms were not (RR 1.11 [95% CI = 0.87–1.41]). There was no effect modification by age or sex on this association (Pinteraction 0.787 and 0.057, respectively).

Unilateral left-sided neurological symptoms were more frequently associated with negative DWI compared to right-sided symptoms in suspected minor stroke patients. This observation is exploratory, as the final diagnosis in DWI-negative cases was not established.

Tenecteplase has been shown to be non-inferior to alteplase for the treatment of acute ischemic stroke within 4.5 hours of stroke onset. While not formally approved by regulatory authorities, many jurisdictions have transitioned to using tenecteplase for routine stroke treatment because it is simpler to use and has cost advantages.

We report a three-phase time-series analysis over 2.5 years and the process for transition from use of alteplase to tenecteplase for the routine treatment of acute ischemic stroke from a system-wide perspective involving an entire province. The transition was planned and implemented centrally. Data were collected in clinical routine, arising from both administrative sources and a prospective stroke registry, and represent real-world outcome data. Data are reported using standard descriptive statistics.

A total of 1211 patients were treated with intravenous thrombolysis (477 pre-transition using alteplase, 180 transition period using both drugs, 554 post-transition using tenecteplase). Baseline characteristics, adverse events and outcomes were similar between epochs. There were four dosing errors with tenecteplase, including providing the cardiac dose to two patients. There were no instances of major hemorrhage associated with dosing errors.

The transition to using intravenous tenecteplase for stroke treatment was seamless and resulted in identical outcomes to intravenous alteplase.

The best prehospital transport strategy for patients with suspected stroke due to possible large vessel occlusion varies by jurisdiction and available resources. A foundational problem is the lack of a definitive diagnosis at the scene. Rural stroke presentations provide the most problematic triage destination decision-making. In Alberta, Canada, the implementation and 5-year experience with a rural field consultation approach to provide service to rural patients with acute stroke is described.

The protocols established through the rural field consultation system and the subsequent transport patterns for suspected stroke patients during the first 5 years of implementation are presented. Outcomes are reported using home time and data are summarized using descriptive statistics.

From April 2017 to March 2022, 721 patients met the definition for a rural field consultation, and 601 patients were included in the analysis. Most patients (n = 541, 90%) were transported by ground ambulance. Intravenous thrombolysis was provided for 65 (10.8%) of patients, and 106 (17.6%) underwent endovascular thrombectomy. The median time from first medical contact to arterial access was 3.2 h (range 1.3–7.6) in the direct transfers, compared to 6.5 h (range 4.6–7.9) in patients arriving indirectly to the comprehensive stroke center (CSC). Only a small proportion of patients (n = 5, 0.8%) were routed suboptimally to a primary stroke center and then to a CSC where they underwent endovascular therapy.

The rural field consultation system was associated with shortened delays to recanalization and demonstrated that it is feasible to improve access to acute stroke care for rural patients.

The Early Minimally Invasive Removal of Intracerebral Hemorrhage (ENRICH) trial demonstrated that minimally invasive surgery to treat spontaneous lobar intracerebral hemorrhage (ICH) improved functional outcomes. We aimed to explore current management trends for spontaneous lobar ICH in Canada to assess practice patterns and determine whether further randomized controlled trials are needed to clarify the role of surgical intervention.

Neurologists, neurosurgeons, physiatrists and trainees in these specialties were invited to complete a 16-question survey exploring three areas: (1) current management for spontaneous lobar ICH at their institution, (2) perceived influence of ENRICH on their practice and (3) perceived need for additional clinical trial data. Standard descriptive statistics were used to report categorical variables. The χ2 test was used to compare responses across specialties and career stages.

The survey was sent to 433 physicians, and 101 (23.3%) responded. Sixty-eight percent of participants reported that prior to publication of the ENRICH trial, spontaneous lobar ICH was primarily managed conservatively, with surgery reserved for life-threatening situations. Forty-three percent of participants did not foresee a significant increase in surgical intervention at their institution. Of neurosurgical respondents, 33% remained hesitant to offer surgical intervention beyond lifesaving operations. Only 5% reported routinely using specifically designed technologies to evacuate ICH. Seventy percent reported that another randomized controlled trial comparing nonsurgical to surgical management for spontaneous lobar ICH is needed.

There is significant practice variability in the management of spontaneous lobar ICH across Canadian institutions, stressing the need for additional clinical trial data to determine the role of surgical intervention.

Diagnosis of acute ischemia typically relies on evidence of ischemic lesions on magnetic resonance imaging (MRI), a limited diagnostic resource. We aimed to determine associations of clinical variables and acute infarcts on MRI in patients with suspected low-risk transient ischemic attack (TIA) and minor stroke and to assess their predictive ability.

We conducted a post-hoc analysis of the Diagnosis of Uncertain-Origin Benign Transient Neurological Symptoms (DOUBT) study, a prospective, multicenter cohort study investigating the frequency of acute infarcts in patients with low-risk neurological symptoms. Primary outcome parameter was defined as diffusion-weighted imaging (DWI)-positive lesions on MRI. Logistic regression analysis was performed to evaluate associations of clinical characteristics with MRI-DWI-positivity. Model performance was evaluated by Harrel’s c-statistic.

In 1028 patients, age (Odds Ratio (OR) 1.03, 95% Confidence Interval (CI) 1.01–1.05), motor (OR 2.18, 95%CI 1.27–3.65) or speech symptoms (OR 2.53, 95%CI 1.28–4.80), and no previous identical event (OR 1.75, 95%CI 1.07–2.99) were positively associated with MRI-DWI-positivity. Female sex (OR 0.47, 95%CI 0.32–0.68), dizziness and gait instability (OR 0.34, 95%CI 0.14–0.69), normal exam (OR 0.55, 95%CI 0.35–0.85) and resolved symptoms (OR 0.49, 95%CI 0.30–0.78) were negatively associated. Symptom duration and any additional symptoms/symptom combinations were not associated. Predictive ability of the model was moderate (c-statistic 0.72, 95%CI 0.69–0.77).

Detailed clinical information is helpful in assessing the risk of ischemia in patients with low-risk neurological events, but a predictive model had only moderate discriminative ability. Patients with clinically suspected low-risk TIA or minor stroke require MRI to confirm the diagnosis of cerebral ischemia.

We investigated the impact of workflow times on the outcomes of patients treated with endovascular thrombectomy (EVT) in the late time window.

Individual patients’ data who underwent EVT in the late time window (onset to imaging >6 hours) were pooled from seven registries and randomized clinical trials. Multiple time intervals were analyzed. Mixed-effects logistic regression was used to estimate the likelihood of functional independence at 90 days (modified Rankin Scale 0–2). Mixed-effects negative binomial regression was used to evaluate the relationship between patient characteristics and workflow time intervals.

608 patients were included. The median age was 70 years (IQR: 58–71), 307 (50.5%) were female, and 310 (53.2%) had wake-up strokes. Successful reperfusion was achieved in 493 (81.2%) patients, and 262 (44.9%) achieved 90-day mRS 0–2. The estimated odds of functional independence decreased by 13% for every 30 minute delay from emergency department (ED) arrival to imaging time and by 7% from ED arrival to the end of EVT in the entire cohort. Also, the estimated odds of functional independence decreased by 33% for every 30 minute delay in the interval from arterial puncture to end of EVT, 16% in the interval from arrival in ED to end of EVT and 6% in the interval from stroke onset to end of EVT among patients who had a wake-up stroke.

Faster workflow from ED arrival to end of EVT is associated with improved functional independence among stroke patients treated in the late window.

Central nervous system (CNS) infections with the dematiaceous fungus Cladophialophora bantiana (C. bantiana) are extremely rare, with approximately 120 confirmed cases reported as of 2016. C. bantiana is a highly neurotropic and thermotolerant fungus found in soil worldwide. The mode of entry into the CNS remains unknown, but inhalation of fungal spores or subcutaneous trauma have been suggested. Entry of fungal spores can cause cerebral phaeohyphomycosis with the main clinical manifestation of a brain abscess. Symptoms are non-specific and can include headache, fever, hemiparesis, aphasia, visual disturbances, and confusion. C. bantiana cerebral phaeohyphomycosis occurs in both immunocompetent and immunocompromised individuals, with a slightly higher prevalence in immunocompetent males for unknown reasons. Diagnosis is often delayed due to its nonspecific presentation and prevalence in individuals without pre-existing immunological disease. Prognosis is poor, with mortality rates of approximately 70% despite aggressive treatment. Treatment is not standardized but may include several anti-fungal agents and surgical intervention. Case reports documenting the variability seen with cerebral phaeohyphomycosis by C. bantiana can provide valuable insight into this emerging disease. C. bantiana’s neurotropic propensity also warrants cognitive investigation of the disease; however, there are currently limited descriptions of cognitive findings in published case reports of C. bantiana CNS infections.

Here, we describe a case of a 35-year-old immunocompetent, college educated male with a CNS C. bantiana infection, presumably following a fall while biking in Costa Rica. First symptoms included left sided facial palsy, headache, and hand weakness, prompting extensive diagnostic workup, with diagnosis of C. bantiana infection confirmed 8 months after symptom onset. Initial treatment included anti-fungal agents and steroids, but his course of infection was complicated by infectious vasculitis with posterior circulation infarcts and obstructive hydrocephalus requiring ventriculoperitoneal shunt placement two years following the fungal infection diagnosis. The most recent brain MRI revealed encephalomalacia in global periventricular areas, two small masses, likely representing small fungal phlegmons, and enhancing lesions in the upper cervical spinal canal.

The patient reported cognitive changes following the infarcts and shunt placement including difficulties with spatial navigation, following directions, and articulating thoughts. Memory concerns and lapses in judgment were also reported. Results from a neuropsychological evaluation revealed high average baseline intellectual abilities with decrements in visuospatial processing, processing speed, executive functioning, and aspects of memory stemming from his executive dysfunction. At the time, his cognitive profile suggested parietal and frontosubcortical systems disruption meeting criteria for mild cognitive impairment. Two years later, the patient reported continuing cognitive difficulties prompting a follow-up neuropsychological evaluation. Results were similar to his first evaluation, revealing deficits in aspects of visuospatial processing, decreased verbal and visual learning, bradyphrenia and processing speed deficits, and difficulties with visual planning and organization. Minimal anxiety and depression, but increased apathy and executive dysfunction were endorsed on self-report measures.

This case report highlights neurological sequela resulting from CNS infection with C. bantiana, -with a course complicated by subsequent strokes, hydrocephalus, and cognitive impairment-, and contributes additional insight into the relatively limited existing reports of an extremely rare but emerging disease.