Perhaps no one has ever been such a survivor as álvar Núñez Cabeza de Vaca. Member of a 600-man expedition sent out from Spain to colonize "La Florida" in 1527, he survived a failed exploration of ...the west coast of Florida, an open-boat crossing of the Gulf of Mexico, shipwreck on the Texas coast, six years of captivity among native peoples, and an arduous, overland journey in which he and the three other remaining survivors of the original expedition walked some 1,500 miles from the central Texas coast to the Gulf of California, then another 1,300 miles to Mexico City. The story of Cabeza de Vaca has been told many times, beginning with his own account, Relación de los naufragios, which was included and amplified in Gonzalo Fernando de Oviedo y Váldez's Historia general de las Indias. Yet the route taken by Cabeza de Vaca and his companions remains the subject of enduring controversy. In this book, Alex D. Krieger correlates the accounts in these two primary sources with his own extensive knowledge of the geography, archaeology, and anthropology of southern Texas and northern Mexico to plot out stage by stage the most probable route of the 2,800-mile journey of Cabeza de Vaca. This book consists of several parts, foremost of which is the original English version of Alex Krieger's dissertation (edited by Margery Krieger), in which he traces the route of Cabeza de Vaca and his companions from the coast of Texas to Spanish settlements in western Mexico. This document is rich in information about the native groups, vegetation, geography, and material culture that the companions encountered. Thomas R. Hester's foreword and afterword set the 1955 dissertation in the context of more recent scholarship and archaeological discoveries, some of which have supported Krieger's plot of the journey. Margery Krieger's preface explains how she prepared her late husband's work for publication. Alex Krieger's original translations of the Cabeza de Vaca and Oviedo accounts round out the volume.
Hypothermia is effective in improving outcome in experimental models of brain infarction. We studied the feasibility and safety of hypothermia in patients with acute ischemic stroke treated with ...thrombolysis.
An open study design was used. All patients presented with major ischemic stroke (National Institutes of Health Stroke Scale NIHSS score >15) within 6 hours of onset. After informed consent, patients with a persistent NIHSS score of >8 were treated with hypothermia to 32+/-1 degrees C for 12 to 72 hours depending on vessel patency. All patients were monitored in the neurocritical care unit for complications. A modified Rankin Scale was measured at 90 days and compared with concurrent controls.
Ten patients with a mean age of 71.1+/-14.3 years and an NIHSS score of 19.8+/-3.3 were treated with hypothermia. Nine patients served as concurrent controls. The mean time from symptom onset to thrombolysis was 3.1+/-1.4 hours and from symptom onset to initiation of hypothermia was 6.2+/-1.3 hours. The mean duration of hypothermia was 47.4+/-20.4 hours. Target temperature was achieved in 3.5+/-1.5 hours. Noncritical complications in hypothermia patients included bradycardia (n=5), ventricular ectopy (n=3), hypotension (n=3), melena (n=2), fever after rewarming (n=3), and infections (n=4). Four patients with chronic atrial fibrillation developed rapid ventricular rate, which was noncritical in 2 and critical in 2 patients. Three patients had myocardial infarctions without sequelae. There were 3 deaths in patients undergoing hypothermia. The mean modified Rankin Scale score at 3 months in hypothermia patients was 3.1+/-2.3.
Induced hypothermia appears feasible and safe in patients with acute ischemic stroke even after thrombolysis. Refinements of the cooling process, optimal target temperature, duration of therapy, and, most important, clinical efficacy, require further study.
The study defined the incidence of cerebral hyperperfusion syndrome and intracranial hemorrhage (ICH) and the risk factors for their development following carotid artery stenting (CAS).
...Hyperperfusion syndrome and ICH can complicate carotid revascularization, be it endarterectomy or CAS. Although extensive effort has been devoted to reducing the incidence of ischemic stroke complicating CAS, little is known about the incidence, etiology, and prevention strategies for hyperperfusion and ICH following CAS.
We retrospectively reviewed the prospective database of 450 consecutive patients who were treated with CAS in our department to identify patients who developed hyperperfusion syndrome and/or ICH.
The mean age of the patients was 72.7 +/- 10.9 years, and the mean diameter narrowing was 84 +/- 12.8%. Five (1.1% 95% confidence interval 0.4% to 2.6%) patients developed hyperperfusion. Three (0.67%) of the five developed ICH. Two of these patients died (0.44%). Symptoms developed within a median of 10 h (range, 6 h to 4 days) following stenting. All five patients had correction of a severe internal carotid stenosis (mean 95.6 +/- 3.7%) with a concurrent contralateral stenosis >80% or contralateral occlusion and peri-procedural hypertension. These same risk factors are involved in cerebral hyperperfusion following carotid endarterectomy. The use of platelet glycoprotein IIb/IIIa receptor blockers did not appear to increase the risk ICH.
The hyperperfusion syndrome occurs infrequently following CAS, and ICH occurs in 0.67% of patients. Patients with severe bilateral carotid stenoses may be predisposed to ICH, particularly if there is concurrent arterial hypertension. Patients with these factors may require more intensive hemodynamic monitoring after CAS, including prolongation of hospitalization in some cases.
Intraarterial and intravenous thrombolysis are often ineffective for the treatment of acute ischemic stroke and are associated with a significant risk of intracranial hemorrhage (ICH). Multimodal ...rescue therapy combining mechanical disruption and platelet GPIIb/IIIa receptor antagonists may improve recanalization.
Patients who did not recanalize with thrombolysis were treated with GPIIb/IIIa antagonists, angioplasty, or an embolectomy device. Treatment was individualized based on vascular anatomy, stroke mechanism, patient status, and symptom duration.
Twelve patients were treated within 3.8+/-2.2 hours. The mean National Institutes of Health Stroke Scale (NIHSS) score was 19.4+/-4.1. Six patients had carotid terminus occlusion, whereas 5 had middle cerebral artery and 1 had basilar artery occlusion. The average doses of intraarterial tPA and reteplase were 17.1+/-8.6 mg and 2+/-0.6 units, respectively. All patients received either an intravenous or intraarterial abciximab bolus (mean 11.8+/-5.8 mg) and heparin (mean 3278+/-1716U). Eleven were treated with angioplasty and 4 had mechanical embolectomy or stenting. Complete (8) or partial (3) recanalization was achieved in 11 cases. There was only one (8.3%) symptomatic hemorrhage. Patients had a favorable outcome at discharge (mean NIHSS 8.9+/-8.7) and 6 (50%) had an NIHSS < or =4 at discharge.
Multimodal rescue therapy was effective at recanalizing occluded cerebral vessels that failed thrombolysis without an excess risk of ICH.
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