Critical limb ischemia (CLI), defined as ischemic rest pain or the presence of a nonhealing arterial ulcer or gangrene, is the most advanced and debilitating form of peripheral artery disease (PAD). An estimated 10% of patients with PAD progress to CLI within 5 years, with the annual incidence of CLI ranging between 500 and 1,000 new cases per 1 million individuals (1). Within 3 months from the time of diagnosis, 9% of CLI patients will die and 12% will require major amputation. One- and 2-year mortality rates of 21% and 31.6% have been reported (1). Collectively, CLI substantially affects patient quality of life and exerts a substantial economic burden to the overall health care system (1,2).

High explosive treatment for ultra Acute Stroke

High explosive treatment for ultra Acute Stroke - is it a hype or hope?

Treatments for acute stroke can be categorized in to four groups. They are 1. Target population based(Ischemic stroke, Intra Cerebral Hemorrhage), 2. Utility ( Proportion of patients who can be treated), 3. magnitude of efficacy and 4.cost.  We can also divide them as High cost therapies and low cost therapies. High cost therapies can be justified of there is high efficacy ( intravenous alteplase, mechanical thrombectomy, hemicraniectomy). Aspirin, the cost therapy typically will have low efficacy. Is it not reasonable to expect and see that medium to high efficacy therapies which are inexpensive are available to our patients.

Intensive blood pressure control has been found to be beneficial in ICH (INTERACT- II trial), but we are not clear if intensive blood pressure is helpful in ischemic stroke patients!

In the recent studies (ENOS trial, RIGHT trial) early GTN therapy has shown benefits in ICH, Ischemic stroke patients. This may change the future of the early stroke management even before the patients are shifted to the hospitals. GTN, the explosive may change the future game plan! Is it a hype or hope? we have to see !! 

Alberta stroke program early CT score ( ASPECTS)

What is Alberta stroke program early CT score?

Dr Owen Kang and Dr Haris Sair et al.

The Alberta stroke programe early CT score (ASPECTS) is a 10-point quantitative topographic CT scan score used in patients with middle cerebral artery (MCA) stroke. Segmental assessment of the MCA vascular territory is made and 1 point is deducted from the initial score of 10 for every region involved:

• caudate
• putamen
• internal capsule
• insular cortex
• M1: "anterior MCA cortex," corresponding to frontal operculum
• M2: "MCA cortex lateral to insular ribbon" corresponding to anterior temporal lobe
• M3: "posterior MCA cortex" corresponding to posterior temporal lobe
• M4: "anterior MCA territory immediately superior to M1"
• M5: "lateral MCA territory immediately superior to M2"
• M6: "posterior MCA territory immediately superior to M3"

Important points

1. the initial paper ¹ specifically referred to the internal capsule only involving the posterior limb, however subsequent articles indicate any portion of the internal capsule may be included
2. M1 to M3 are at the level of the basal ganglia
3. M4 to M6 are at the level of the ventricles immediately above the basal ganglia

Clinical use

An ASPECTS score less than or equal to 7 predicts worse functional outcome at 3 months as well as symptomatic haemorrhage.
According to study done by R.I Aviv et al ³ patients with ASPECTS score less than 8 treated with thrombolysis did not have a good clinical outcome.