Ethan A. Benardete

BACKGROUND: The requirements for a comprehensive stroke center (CSC) include the capability to perform endovascular stroke therapy (EST). EST is a complex process requiring early identification of appropriate patients and effective delivery of intervention. In order to provide prompt intervention for stroke, CSCs have been established away from large academic centers in community-based hospitals. We hypothesized that quantifiable improvements would occur during the first 2 years of a community-based CSC as the processes and personnel evolved. We report the results over time of EST at a new community-based CSC. METHODS: We have retrospectively analyzed demographic data and outcome metrics of EST from the initiation phase of a new community-based CSC. Data was divided into year 1 and year 2. Statistical analysis (Student's t test and Fisher's exact test) was performed to compare the patient population and outcomes across the two time periods. Outcome variables included the thrombolysis in cerebral infarction (TICI) score, a change in the NIH stroke scale score and the modified Rankin Scale (mRS) score. Analysis of variance (ANOVA) was used to statistically analyze the relationship between population variables and outcome. Computed tomography (CT) angiography and CT perfusion analysis were used to select patients for EST. Approximately half of the patients undergoing EST were excluded from receiving intravenous recombinant tissue plasminogen activator (IV rt-PA) by standard criteria, while the other half showed no sign of improvement following 1 h of IV rt-PA treatment. Mechanical thrombolysis with a stentriever was performed in the majority of cases with or without intra-arterial medication. The majority of treated occlusions were in the middle cerebral artery. RESULTS: A total of 18 patients underwent EST during year 1 and year 2. A statistically significant increase in good outcomes (mRS score ≤2 at discharge) was seen from year 1 to year 2 (p = 0.05). There were trends towards faster interventions, decreased complications and mortality as well as an improved TICI score from year 1 to year 2. With ANOVA, mortality was statistically correlated with age (p = 0.06), while decreases in the NIH stroke scale (NIHSS) score following EST correlated with decreased mortality (p = 0.01). A higher TICI score was significantly associated with a decreased NIHSS score following EST (p = 0.01). CONCLUSIONS: At a new community-based CSC, improved outcome occurred from year 1 to year 2, and trends towards decreased mortality, fewer complications, and improved revascularization were observed. Furthermore, the data shows that improvement in NIHSS score after EST is associated with decreased mortality following stroke in this setting, implying a net benefit.

PURPOSE: Cortical dysplasia (CD) is associated with epilepsy in both the pediatric and adult populations. The mechanism underlying seizures with cortical malformations is still poorly understood. To study the physiology of dysplastic cortex, we developed an experimental model of CD. METHODS: Pregnant rats were given intraperitoneal injections of carmustine (1-3-bis-chloroethyl-nitrosourea; BCNU) on embryonic day 15 (E15). Cortical histology was examined in the resulting pups at P0, P28, and P60. In addition, evoked and spontaneous field potential recordings were obtained in cortical slices from adult control and BCNU-exposed rats. Finally, we used whole-cell recordings to compare physiologic properties of pyramidal neurons and gamma-aminobutyric acid (GABA) responses in control and BCNU-treated animals. RESULTS: Features characteristic of CD were found in the offspring, including laminar disorganization, cytomegalic neurons, and neuronal heterotopias. Dysplastic cortex also contained abnormal clusters of Cajal-Retzius (CR) cells and disruption of radial glial fibers, as demonstrated with immunohistochemistry. Under conditions of partial GABAA-receptor blockade with 10 microM bicuculline methiodide (BMI), slices of dysplastic cortex demonstrated a significant increase in the number of spontaneous and evoked epileptiform discharges. Individual pyramidal neurons in dysplastic cortex were less sensitive to application of GABA compared with controls. CONCLUSIONS: BCNU exposure in utero produces histologic alterations suggestive of CD in rat offspring. Dysplastic cortex from this model demonstrates features of hyperexcitability and decreased neuronal sensitivity to GABA. Such physiologic alterations may underlie the increased epileptogenicity of dysplastic cortex.

To the Editor: Keeping track of cases is essential for almost any neurosurgeon. Many neurosurgeons have set up databases on their personal computers to store names, medical record numbers, and images of cases that they have done. This activity is very useful because the information can be used later to verify clinical information for hospital/board certification, to write academic papers, and to judge outcomes. Because almost every neurosurgeon carries an Internet-capable mobile phone (smartphone), it should be possible that once a neurosurgeon completes a case, he or she can open the Web browser on his or her smartphone and enter the case data into a personal database on a secure remote computer. However, previously, it was frustrating to set up a fully capable, inexpensive personal or group practice database that can be accessed over the Internet (the Web). This situation, however, has changed. I want to describe for those who may not be familiar with some aspects of computer technology the ease with which this sort of database can now be constructed and set up for personal or group use. No special programming experience is required. Several different computer software packages exist for database creation. Here I illustrate the process of setting up an Internet-accessible database using Filemaker Pro 11 (Filemaker, Inc, Santa Clara, California), which is one of the most popular software packages. Setting up a database with a current database software package is relatively simple. The database creation software allows the user to set up different fields, which hold data values for each patient. These fields are then arranged in a layout, where the data will be entered and reviewed. The program saves the data for each patient as a “record.” The database for tracking operative cases would typically hold data such as “ date of surgery,” “last name,” and “procedure.” Setting up such a database can take less than 1 hour.1 The database software will allow searching, sorting, editing as well as adding and deleting records. The goal of the next step is to allow the database to be accessed from anywhere on the Internet. For this step, the computer storing the database (the database “server”) needs to have a static IP (internet protocol) address. A typical high-speed Internet connection that a consumer obtains from the local phone or cable company allows for a dynamic IP address. In other words, a new IP address is assigned periodically to the computer (often every time the computer connects to the Internet). This configuration is not adequate to communicate with the database computer routinely. Most Internet service providers (ISPs) will set up a static IP address in a home or office for a monthly subscription charge, which is slightly more than the typical home high-speed service cost. A high-speed modem connected to the cable or phone line will need to be configured by a technician from the ISP. This modem is then connected to a “router” so that the Internet connection can be shared in the home or office with several computers. The router needs to be configured so that Internet “traffic” is sent to the database server on the local (home or office) network. This assignment usually consists of setting a “port” for Internet traffic (typically port 80) to the local IP address of the server. Most consumer routers will have simple software that allows the user to do this. In addition, the server computer needs to run software that guides Internet traffic to the directory containing the database to be displayed.2 One simple computer server, which is usable almost out of the box, is the Mac Mini Server (Apple, Inc, Cupertino, California, $999 US). With a commercial database server program like Filemaker Server 11 ($999; Filemaker, Inc), the database can now be published to the Internet. First, the person who is setting up the database establishes usernames and passwords for the users. This step is important so that unauthorized access to the database is blocked. Next, with Filemaker Server 11, all the necessary files for an Internet-accessible database are created in a directory on the server. A database user then accesses the server from the Internet by using the appropriate IP address (or Web address) and directory name. The user will initially encounter a “log-in” page and enter a username and password to log in. An Internet-capable database that has been generated in this way will allow sorting, searching, adding, and deleting of records from any smartphone. I have used such an Internet-accessible database to enter more than 150 cases over the course of the past year. The system proved reliable without any problems such as loss of data or security issues. The database was useful for tracking the volume of cases performed in different categories (eg, vascular, spine, tumor), the volume at different hospitals, and the results of different procedures. To be sure, there are other database solutions available, but most are more limited than what I have described. For example, a surgeon can carry a laptop computer around and enter case data “in-the-field,” but this can be risky because the computer can be lost, damaged, or stolen, and the database may be lost or corrupted. On the other hand, office staff can be tasked with maintaining and creating a database, but this “human” solution can be unreliable and the database may be inaccessible if staff are absent or occupied. An Internet-accessible computer database like the one described here can be available at all times for data entry and query. Filemaker Inc offers a database program called Filemaker Go for Iphone or Ipad (Apple, Inc), which allows intermittent synchronization of the database on the mobile device with a database found on a home or office PC. However, this limitation adds an extra step. On the other hand, a program such as “Go to My PC” (Citrix Online, Inc, Goleta, California) can be used to access a remote computer with the database on it. This is a viable option if a high-speed Internet connection and the remote PC are always available, but it is less attractive for surgeons who may want to enter and review data primarily from a smartphone. Finally, several companies offer professional Filemaker Pro hosting services so that a consumer can upload their database to a third-party server and accomplish tasks similar to what has been described here for a monthly subscription fee. A note of caution is warranted. Once a database is filled with patient records, it becomes a precious resource. As such, users need to establish a protocol for backing up the database to guard against hardware failures or unwanted modification. Fortunately, database software can be programmed to make backups automatically. In addition, there are many options for automated backups including both software (which periodically saves a duplicate copy of the database to a new location) and hardware, such as a RAID (redundant array of inexpensive disks) drive, which provides additional security against data loss by using specialized data storage methods. Finally, the Health Insurance Portability and Accountability Act (HIPAA) regulations require that any individually identifiable health-related information be protected. Strict measures need to be taken to prevent unauthorized access to the database. Surgeons may want to anonymize their data in some way in addition to preventing unauthorized access by using password protection. In addition, the database ideally should be placed on a dedicated computer server, not a server that hosts, for example, the Web page for the neurosurgery department or the practice to further prevent any unauthorized access. Ethan A. Benardete Philadelphia, Pennsylvania

Objective: To compare the effectiveness of two different revascularization techniques in a single patient with moyamoya disease. Setting: Academic neurosurgery practice. Design: Retrospective chart review and evaluation of radiographic results. Participants: North American adult Caucasian female with moyamoya disease, who underwent direct revascularization in one hemisphere (superficial temporal artery–middle cerebral artery bypass) and indirect revascularization in the other hemisphere (pial synangiosis) in close temporal proximity. Outcome measures: Clinical evaluation and radiographic follow-up for two years. Catheter-based cerebral angiography, CT angiography, and CT perfusion imaging were used to assess results. Results: Both hemispheres showed revascularization following bypass with significant cortical supply. The direct bypass demonstrated superior flow and territory coverage. Conclusions: This case provides a demonstration of both main revascularization techniques for moyamoya disease in a single adult patient over the same time period, allowing for a direct comparison. While the indirect technique showed evidence of revascularization, the direct bypass showed more vascular supply. A comprehensive review of recent case series supports this conclusion.

Background: The requirements for a comprehensive stroke center (CSC) include the capability to perform endovascular stroke therapy (EST). EST is a complex process requiring early identification of appropriate patients and effective delivery of intervention. In order to provide prompt intervention for stroke, CSCs have been established away from large academic centers in community-based hospitals. We hypothesized that quantifiable improvements would occur during the first 2 years of a community-based CSC as the processes and personnel evolved. We report the results over time of EST at a new community-based CSC. Methods: We have retrospectively analyzed demographic data and outcome metrics of EST from the initiation phase of a new community-based CSC. Data was divided into year 1 and year 2. Statistical analysis (Student’s t test and Fisher’s exact test) was performed to compare the patient population and outcomes across the two time periods. Outcome variables included the thrombolysis in cerebral infarction (TICI) score, a change in the NIH stroke scale score and the modified Rankin Scale (mRS) score. Analysis of variance (ANOVA) was used to statistically analyze the relationship between population variables and outcome. Computed tomography (CT) angiography and CT perfusion analysis were used to select patients for EST. Approximately half of the patients undergoing EST were excluded from receiving intravenous recombinant tissue plasminogen activator (IV rt-PA) by standard criteria, while the other half showed no sign of improvement following 1 h of IV rt-PA treatment. Mechanical thrombolysis with a stentriever was performed in the majority of cases with or without intra-arterial medication. The majority of treated occlusions were in the middle cerebral artery. Results: A total of 18 patients underwent EST during year 1 and year 2. A statistically significant increase in good outcomes (mRS score ≤ 2 at discharge) was seen from year 1 to year 2 (p = 0.05). There were trends towards faster interventions, decreased complications and mortality as well as an improved TICI score from year 1 to year 2. With ANOVA, mortality was statistically correlated with age (p = 0.06), while decreases in the NIH stroke scale (NIHSS) score following EST correlated with decreased mortality (p = 0.01). A higher TICI score was significantly associated with a decreased NIHSS score following EST (p = 0.01). Conclusions: At a new communitybased CSC, improved outcome occurred from year 1 to year 2, and trends towards decreased mortality, fewer complications, and improved revascularization were observed. Furthermore, the data shows that improvement in NIHSS score after EST is associated with decreased mortality following stroke in this setting, implying a net benefit.