Summary Intracranial saccular or berry aneurysms are common, occurring in about 1–2% of the population. Unruptured intracranial aneurysms are increasingly being detected as cross-sectional imaging ...techniques are used more frequently in clinical practice. Once an unruptured intracranial aneurysm is detected, decisions regarding optimum management are made on the basis of careful comparison of the short-term and long-term risks of aneurysmal rupture with the risk associated with the intervention, whether that be surgical clipping or endovascular management. Several factors need to be carefully considered, including aneurysm size and location, the patient's family history and medical history, and the availability of an interventional option that has an acceptable risk. The patient's knowledge that they have an unruptured intracranial aneurysm can lead to substantial stress and anxiety, and their perspective regarding treatment, after hearing an unbiased appraisal of the rupture risks and the risk of interventional treatment, is of the utmost importance. Controversy remains regarding optimum management, and thorough assessments of the risks and benefits of contemporary management options, specific to aneurysm size, location, and many other aneurysm and patient factors, are needed.
The severity of urban heat islands (UHIs) is increasing due to global and urban climate change. The damage caused by UHIs is also increasing. To establish a plan to improve the deteriorating thermal ...environment in cities due to UHIs and to minimize the damage, further research is needed to accurately estimate and analyze the intensity and magnitude of UHIs. This systematic literature review (SLR) is an in-depth review of 51 studies obtained through a five-step filtering process focusing on their analysis of the spatial extent of UHIs, the UHI concept that was used for UHI estimation, and the UHI estimation and analysis methods. This SLR confirmed the need for accurate UHI intensity and magnitude estimation and analysis to reset the existing UHI classification based on the variety of vertical and horizontal ranges where UHIs occur. The results also indicated that the existing UHI energy concepts for estimating UHIs need to be modified and developed to reflect the three-dimensional physical form of the city. Finally, this SLR clarifies the need to develop an optimized analysis method for UHI research. The review results of this SLR will inform future studies and be the cornerstone for establishing policies and plans that can accurately predict and respond to the damage caused by UHIs.
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•Review intensity, magnitude estimation, and analysis of UHIs using an SLR framework.•Lack of general protocols to establish UHI classification criteria to efficiently estimate and analyze UHIs.•Need to develop a UHI estimation and analysis model considering a 3-D form of a city.•Need for further research to develop a model focusing on the intensity and magnitude of UHIs
Summary Background The decision of whether to treat incidental intracranial saccular aneurysms is complicated by limitations in current knowledge of their natural history. We combined individual ...patient data from prospective cohort studies to determine predictors of aneurysm rupture and to construct a risk prediction chart to estimate 5-year aneurysm rupture risk by risk factor status. Methods We did a systematic review and pooled analysis of individual patient data from 8382 participants in six prospective cohort studies with subarachnoid haemorrhage as outcome. We analysed cumulative rupture rates with Kaplan-Meier curves and assessed predictors with Cox proportional-hazard regression analysis. Findings Rupture occurred in 230 patients during 29 166 person-years of follow-up. The mean observed 1-year risk of aneurysm rupture was 1·4% (95% CI 1·1–1·6) and the 5-year risk was 3·4% (2·9–4·0). Predictors were age, hypertension, history of subarachnoid haemorrhage, aneurysm size, aneurysm location, and geographical region. In study populations from North America and European countries other than Finland, the estimated 5-year absolute risk of aneurysm rupture ranged from 0·25% in individuals younger than 70 years without vascular risk factors with a small-sized (<7 mm) internal carotid artery aneurysm, to more than 15% in patients aged 70 years or older with hypertension, a history of subarachnoid haemorrhage, and a giant-sized (>20 mm) posterior circulation aneurysm. By comparison with populations from North America and European countries other than Finland, Finnish people had a 3·6-times increased risk of aneurysm rupture and Japanese people a 2·8-times increased risk. Interpretation The PHASES score is an easily applicable aid for prediction of the risk of rupture of incidental intracranial aneurysms. Funding Netherlands Organisation for Health Research and Development.
Adult primary central nervous system vasculitis Salvarani, Carlo, Dr; Brown, Robert D, Prof; Hunder, Gene G, Prof
The Lancet (British edition),
08/2012, Letnik:
380, Številka:
9843
Journal Article
Recenzirano
Primary CNS vasculitis is an uncommon disorder of unknown cause that is restricted to brain and spinal cord. The median age of onset is 50 years. The neurological manifestations are diverse, but ...generally consist of headache, altered cognition, focal weakness, or stroke. Serological markers of inflammation are usually normal. Cerebrospinal fluid is abnormal in about 80–90% of patients. Diagnosis is unlikely in the presence of a normal MRI of the brain. Biopsy of CNS tissue showing vasculitis is the only definitive test; however, angiography has often been used for diagnosis even though it has only moderate sensitivity and specificity. The size of the affected vessels varies and determines outcome and response to treatment. Early recognition is important because treatment with corticosteroids with or without cytotoxic drugs can often prevent serious outcomes. The differential diagnosis includes reversible cerebral vasoconstriction syndromes and secondary cerebral vasculitis.
Summary Background Cerebral cavernous malformations (CCMs) can cause symptomatic intracranial haemorrhage (ICH), but the estimated risks are imprecise and predictors remain uncertain. We aimed to ...obtain precise estimates and predictors of the risk of ICH during untreated follow-up in an individual patient data meta-analysis. Methods We invited investigators of published cohorts of people aged at least 16 years, identified by a systematic review of Ovid MEDLINE and Embase from inception to April 30, 2015, to provide individual patient data on clinical course from CCM diagnosis until first CCM treatment or last available follow-up. We used survival analysis to estimate the 5-year risk of symptomatic ICH due to CCMs (primary outcome), multivariable Cox regression to identify baseline predictors of outcome, and random-effects models to pool estimates in a meta-analysis. Findings Among 1620 people in seven cohorts from six studies, 204 experienced ICH during 5197 person-years of follow-up (Kaplan-Meier estimated 5-year risk 15·8%, 95% CI 13·7–17·9). The primary outcome of ICH within 5 years of CCM diagnosis was associated with clinical presentation with ICH or new focal neurological deficit (FND) without brain imaging evidence of recent haemorrhage versus other modes of presentation (hazard ratio 5·6, 95% CI 3·2–9·7) and with brainstem CCM location versus other locations (4·4, 2·3–8·6), but age, sex, and CCM multiplicity did not add independent prognostic information. The 5-year estimated risk of ICH during untreated follow-up was 3·8% (95% CI 2·1–5·5) for 718 people with non-brainstem CCM presenting without ICH or FND, 8·0% (0·1–15·9) for 80 people with brainstem CCM presenting without ICH or FND, 18·4% (13·3–23·5) for 327 people with non-brainstem CCM presenting with ICH or FND, and 30·8% (26·3–35·2) for 495 people with brainstem CCM presenting with ICH or FND. Interpretation Mode of clinical presentation and CCM location are independently associated with ICH within 5 years of CCM diagnosis. These findings can inform decisions about CCM treatment. Funding UK Medical Research Council, Chief Scientist Office of the Scottish Government, and UK Stroke Association.
Cities have faced rapid urbanization, which has changed the impact of the micro-thermal environment on residents' thermal comfort level. Therefore, planners need to understand the city's physical ...environment so they can identify and ameliorate the effects of the changing in micro-thermal environment. Researchers also need to identify and understand pedestrians' thermal comfort level in street canyons to determine which urban physical factors planners need to improve. This study aimed to observe how thermal comfort affects pedestrian behavior in micro-thermal environments and to determine which urban geometry factors influence pedestrians' thermal comfort. This study collected data in downtown Austin, TX using a mobile weather station, and analyzed the microclimate conditions experienced by pedestrians. A camera mounted on the weather station also allowed us to observe pedestrian behavior patterns. The results revealed that pedestrians tended to choose walking, sitting, and standing locations with high thermal comfort levels such as in the shade on the sidewalk. There was also some correlation between thermal comfort levels and pedestrian behavior patterns. The sky view factor (SVF) and tree canopy coverage ratio (TCR) were also correlated with pedestrians' thermal comfort. This study highlights the need for future research to develop a data collection method for efficient microscopic thermal environment research and a thermal environment estimation and analysis approach from a three-dimensional perspective.
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•This study analyzed the relationship between pedestrians' thermal comfort levels and their walking, sitting, and standing behavior patterns.•This study analyzed the effect of urban geometry on outdoor thermal environments.•Developing a micro-scale thermal environment estimation model from a 3-D perspective is needed.•Further research on microclimate data collection and pedestrian observation methods is needed
The purpose of this statement is to provide an overview of cerebral venous sinus thrombosis and to provide recommendations for its diagnosis, management, and treatment. The intended audience is ...physicians and other healthcare providers who are responsible for the diagnosis and management of patients with cerebral venous sinus thrombosis.
Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represent different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 1966 and used the American Heart Association 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.
Evidence-based recommendations are provided for the diagnosis, management, and prevention of recurrence of cerebral venous thrombosis. Recommendations on the evaluation and management of cerebral venous thrombosis during pregnancy and in the pediatric population are provided. Considerations for the management of clinical complications (seizures, hydrocephalus, intracranial hypertension, and neurological deterioration) are also summarized. An algorithm for diagnosis and management of patients with cerebral venous sinus thrombosis is described.
Urban heat islands (UHI) in a city tend to vary with changes in time and space. To effectively cope with the accelerating intensity of UHI due to global warming and the resulting damage, it is ...essential to accurately analyze and understand the spatial and temporal variations of UHI. This study conducted a systematic literature review (SLR) to better understand how existing studies have classified and analyzed UHI variations. Research trends and limitations related to UHI variation were reviewed focusing on 55 studies extracted through a five-stage protocol to identify critical studies. The selected studies were analyzed and synthesized in detail. The results showed that studies use different research ranges, data collection methods, analysis, and prediction models depending on the type of UHI variation. These results also indicate that studies have not used universal and specific protocols that apply to UHI variations. To address the limitations of these studies, it is necessary to develop more specific UHI research design methods and an analytical model that reflects the three-dimensional elements of the collected data. In addition, researchers should develop indexes to explain the spatial and temporal variations of UHIs. Further studies can help establish policies and planning codes to counter the spatiotemporal variability of UHIs.
•Review of spatial and temporal variations of UHIs using an SLR framework.•Lack of general protocols to set the research scope and determine data collection methods to efficiently study UHI variations.•Need to develop a model and indexes to explain the intensity and magnitude of UHI variations.
IMPORTANCE: Spinal cord infarction (SCI) is often disabling, and the diagnosis can be challenging without an inciting event (eg, aortic surgery). Patients with a spontaneous SCI are often ...misdiagnosed as having transverse myelitis. Diagnostic criteria for SCI are lacking, hindering clinical care and research. OBJECTIVE: To describe the characteristics of spontaneous SCI and propose diagnostic criteria. DESIGN, SETTING, AND PARTICIPANTS: An institution-based search tool was used to identify patients evaluated at Mayo Clinic, Rochester, Minnesota, from January 1997 to December 2017 with a spontaneous SCI. Patients provided written consent to use their records for research. Participants were 18 years and older with a diagnosis of spontaneous SCI (n = 133), and controls were selected from a database of alternative myelopathy etiologies for validation of the proposed diagnostic criteria (n = 280). MAIN OUTCOMES AND MEASURES: A descriptive analysis of SCI was performed and used to propose diagnostic criteria, and the criteria were validated. RESULTS: Of 133 included patients with a spontaneous SCI, the median (interquartile range) age at presentation was 60 (52-69) years, and 101 (76%) had vascular risk factors. Rapid onset of severe deficits reaching nadir within 12 hours was typical (102 77%); some had a stuttering decline (31 23%). Sensory loss occurred in 126 patients (95%), selectively affecting pain/temperature in 49 (39%). Initial magnetic resonance imaging (MRI) spine results were normal in 30 patients (24%). Characteristic MRI T2-hyperintense patterns included owl eyes (82 65%) and pencil-like hyperintensity (50 40%); gadolinium enhancement (37 of 96 39%) was often linear and located in the anterior gray matter. Confirmatory MRI findings included diffusion-weighted imaging/apparent diffusion coefficient restriction (19 of 29 67%), adjacent dissection/occlusion (16 of 82 20%), and vertebral body infarction (11 9%). Cerebrospinal fluid showed mild inflammation in 7 of 89 patients (8%). Diagnostic criteria was proposed for definite, probable, and possible SCI of periprocedural and spontaneous onset. In the validation cohort (n = 280), 9 patients (3%) met criteria for possible SCI, and none met criteria for probable SCI. CONCLUSIONS AND RELEVANCE: This large series of spontaneous SCIs provides clinical, laboratory, and MRI clues to SCI diagnosis. The diagnostic criteria proposed here will aid clinicians in making the correct diagnosis and ideally improve future care for patients with SCI. The validation of these criteria supports their utility in the evaluation of acute myelopathy.
Due to global warming and rapid urbanization, the frequency and intensity of extreme heat events in the United States have increased. Particularly for pedestrians, excessive heat has been reported as ...a critical barrier to walking activity, which, in turn, can deteriorate walkability and urban vitality. By using a multilevel spatial approach, this study investigates the combined effects of microclimatic urban design features on daytime pedestrian thermal comfort. For this purpose, it uses on-site field measurements taken in July 2019 and estimates how different scales of street- and block-scale design factor impact the physiological thermal comfort of pedestrians on the High Line in New York City. Based on the findings, the High Line experiences high thermal stress conditions, with clusters of hot spots particularly in its upper section. In addition, the urban design features at both the street and block scales are highly correlated with estimated pedestrian thermal comfort. Specifically, at the block-scale level, the mean energy budget value largely depends on block density and volume, while at the street-scale level, the height-to-width ratio, tree view factors, and tree canopy cover ratio have a negative linear relationship with absorbed solar radiation. Moreover, the findings indicate that the combination of urban design factors at the street- and block-scale levels significantly impact pedestrian thermal comfort. This study offers practical knowledge and a deeper understanding about climate-sensitive urban designs that are highly resistant to extreme heat events.
•The effect of microclimatic design features on summer daytime pedestrian thermal comfort is examined using a multilevel analysis.•Streets with high SVFs, low HW ratios, less greenery, and low-density blocks exhibit relatively high levels of thermal stress.•In a deep canyon, terrestrial radiation emitted from the wall and ground surface is the largest contributor to the pedestrians’ thermal loadings.•The combination of street- and block-scale urban design factors significantly impacted pedestrian thermal comfort.
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