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\"As globalization spreads and as we destroy the ancient ecosystems, we encounter strange and dangerous infections that originate in animals but that can be transmitted to humans. Diseases that were contained are being set free and the results are potentially catastrophic. In a journey that takes him from southern China to the Congo, from Bangladesh to Australia, David Ouammen tracks these infections to their source and asks what we can do to prevent some new pandemic spreading across the face of the earth\"--back cover.

Cervical artery dissection is a major cause of stroke in young people (aged <50 years). Historically, clinicians have preferred using oral anticoagulation with vitamin K antagonists for patients with cervical artery dissection, although some current guidelines—based on available evidence from mostly observational studies—suggest using aspirin. If proven to be non-inferior to vitamin K antagonists, aspirin might be preferable, due to its ease of use and lower cost. We aimed to test the non-inferiority of aspirin to vitamin K antagonists in patients with cervical artery dissection. We did a multicentre, randomised, open-label, non-inferiority trial in ten stroke centres across Switzerland, Germany, and Denmark. We randomly assigned (1:1) patients aged older than 18 years who had symptomatic, MRI-verified, cervical artery dissection within 2 weeks before enrolment, to receive either aspirin 300 mg once daily or a vitamin K antagonist (phenprocoumon, acenocoumarol, or warfarin; target international normalised ratio [INR] 2·0–3·0) for 90 days. Randomisation was computer-generated using an interactive web response system, with stratification according to participating site. Independent imaging core laboratory adjudicators were masked to treatment allocation, but investigators, patients, and clinical event adjudicators were aware of treatment allocation. The primary endpoint was a composite of clinical outcomes (stroke, major haemorrhage, or death) and MRI outcomes (new ischaemic or haemorrhagic brain lesions) in the per-protocol population, assessed at 14 days (clinical and MRI outcomes) and 90 days (clinical outcomes only) after commencing treatment. Non-inferiority of aspirin would be shown if the upper limit of the two-sided 95% CI of the absolute risk difference between groups was less than 12% (non-inferiority margin). This trial is registered with ClinicalTrials.gov, NCT02046460. Between Sept 11, 2013, and Dec 21, 2018, we enrolled 194 patients; 100 (52%) were assigned to the aspirin group and 94 (48%) were assigned to the vitamin K antagonist group. The per-protocol population included 173 patients; 91 (53%) in the aspirin group and 82 (47%) in the vitamin K antagonist group. The primary endpoint occurred in 21 (23%) of 91 patients in the aspirin group and in 12 (15%) of 82 patients in the vitamin K antagonist group (absolute difference 8% [95% CI −4 to 21], non-inferiority p=0·55). Thus, non-inferiority of aspirin was not shown. Seven patients (8%) in the aspirin group and none in the vitamin K antagonist group had ischaemic strokes. One patient (1%) in the vitamin K antagonist group and none in the aspirin group had major extracranial haemorrhage. There were no deaths. Subclinical MRI outcomes were recorded in 14 patients (15%) in the aspirin group and in 11 patients (13%) in the vitamin K antagonist group. There were 19 adverse events in the aspirin group, and 26 in the vitamin K antagonist group. Our findings did not show that aspirin was non-inferior to vitamin K antagonists in the treatment of cervical artery dissection. Swiss National Science Foundation, Swiss Heart Foundation, Stroke Funds Basel, University Hospital Basel, University of Basel, Academic Society Basel.

Background and AimsThe presence of nociceptors has been illustrated in the posterior capsule of hip joint. The articular nerves to the posterior capsule emerge from nerve to quadratus femoris (NQF), superior gluteal nerve (SGL), sciatic nerve (SN) and inferior gluteal nerves (IGN) which are in relation to pyriformis and the quadratus femoris muscle. We hypothesize that a single injection deep to pyriformis would stain these nerves.MethodsIn 6 soft embalmed cadavers (12 specimens) in lateral position, 10 ml blue latex dye injected deep to the pyriformis muscle using ultrasound guidance. Thirty minutes following injection, open dissections in 6 specimens and cross-sections in 6 specimens were performed. At open dissection, the following nerves were evaluated for dye soakage: Superior (SGN) and inferior gluteal nerves (IGN), nerve to quadratus femoris (NQF) and the sciatic nerve (SN). In the cross-sections, the following planes would be investigated: Pathways of SGN, IGN, NQF and SN.ResultsDuring dissection, dye was found superficial to the piriformis: in the supra-piriformis plane staining the SGN in all 12 specimens. Dye spread deep to the piriformis: in sub-piriformis plane staining the IGN in all 12 specimens. The dye spread was longitudinal towards the SN, which was stained in all 12 specimens. NQF was stained in only 2/12 specimens and the Pudendal nerve was stained in 1/12 specimens. Posterior cutaneous nerve of thigh (PCNT) was not stained in all dissections (0/12).ConclusionsBased on our cadaveric study, infra-piriformis injection stains the nerves supplying the posterior capsule: SGN, IGN & SN in all 12 specimens, however NQF was stained in only 2/12 specimens. Moreover, future clinical research based on our cadaveric study will be done to analyze the outcome.

Extracranial carotid and vertebral artery dissection is an important cause of stroke, especially in young people. In some observational studies it has been associated with a high risk of recurrent stroke. Both antiplatelet drugs and anticoagulant drugs are used to reduce risk of stroke but whether one treatment strategy is more effective than the other is unknown. We compared their efficacy in the Cervical Artery Dissection in Stroke Study (CADISS), with the additional aim of establishing the true risk of recurrent stroke. We did this randomised trial at hospitals with specialised stroke or neurology services (39 in the UK and seven in Australia). We included patients with extracranial carotid and vertebral dissection with onset of symptoms within the past 7 days. Patients were randomly assigned (1:1) by an automated telephone randomisation service to receive antiplatelet drugs or anticoagulant drugs (specific treatment decided by the local clinician) for 3 months. Patients and clinicians were not masked to allocation, but investigators assessing endpoints were. The primary endpoint was ipsilateral stroke or death in the intention-to-treat population. The trial was registered with EUDract (2006-002827-18) and ISRN (CTN44555237). We enrolled 250 participants (118 carotid, 132 vertebral). Mean time to randomisation was 3·65 days (SD 1·91). The major presenting symptoms were stroke or transient ischaemic attack (n=224) and local symptoms (headache, neck pain, or Horner's syndrome; n=26). 126 participants were assigned to antiplatelet treatment versus 124 to anticoagulant treatment. Overall, four (2%) of 250 patients had stroke recurrence (all ipsilateral). Stroke or death occurred in three (2%) of 126 patients versus one (1%) of 124 (odds ratio [OR] 0·335, 95% CI 0·006–4·233; p=0·63). There were no deaths, but one major bleeding (subarachnoid haemorrhage) in the anticoagulant group. Central review of imaging failed to confirm dissection in 52 patients. Preplanned per-protocol analysis excluding these patients showed stroke or death in three (3%) of 101 patients in the antiplatelet group versus one (1%) of 96 patients in the anticoagulant group (OR 0·346, 95% CI 0·006–4·390; p=0·66). We found no difference in efficacy of antiplatelet and anticoagulant drugs at preventing stroke and death in patients with symptomatic carotid and vertebral artery dissection but stroke was rare in both groups, and much rarer than reported in some observational studies. Diagnosis of dissection was not confirmed after review in many cases, suggesting that radiographic criteria are not always correctly applied in routine clinical practice. Stroke Association.

IntroductionCervical ICA dissection is a dynamic and potentially embolic or haemodynamically significant lesion, and a relevant cause of stroke, especially in young and middle-aged adults. It may present as a tandem lesion. In selected cases, aggressive medical stabilisation after thrombectomy may allow vessel recovery without permanent implants.Abstract C87 Figure 1[Image Omitted. See PDF.]Case DescriptionA 43-year-old man presented with wake-up stroke and right dominant M2 occlusion (NIHSS 18). No IV thrombolysis was given. Under GA, angiography showed a flame-like occlusion of the ICA. Aspiration navigation of the cervical ICA to the siphon was performed using a RED 62 over a J-curved 0.014’ wire and microcatheter, with brief balloon inflation of the FlowGate in the post-bulbar ICA; the FlowGate was then advanced distally, without further inflation. TICI 3 was obtained with one RED 62 pass. After RED removal, the ICA appeared patent but narrowed and irregular. Nimodipine (1 mg) and IV tirofiban were administered. Serial checks over a retained microwire showed improved calibre and smoother wall profile, without thrombus or emboli, so procedure was concluded. Tirofiban was continued until DAPT was started the next morning, after confirming no haemorrhage on brain CT and patency on angio-CT.Abstract C87 Figure 2[Image Omitted. See PDF.]ConclusionsIn dissection-related strokes, tirofiban may offer a temporary, reversible option to stabilise the cervical segment post-thrombectomy. This avoids early stenting risks—malposition, thrombosis, mandatory DAPT—when the dissection is not haemodynamically critical. Here the intracranial occlusion explained the clinical picture, allowing conservative management, as typically adopted in non-embolic dissection, where medical therapy alone often supports vessel healing and long term patency.Abstract C87 Figure 3[Image Omitted. See PDF.]Conflict of InterestNo

Nita's mother hunts monsters and, after Nita dissects and packages them, sells them online, but when Nita follows her conscience to help a live monster escape, she's sold on the black market in his place.

IntroductionCervical internal carotid artery (ICA) dissections are a significant cause of ischemic stroke, particularly in younger patients. While many cases are managed conservatively, endovascular treatment may be necessary for cases with hemodynamic compromise or embolic risk.Aim of StudyThis study aimed to assess the safety and efficacy of the CARESTO heal stent in treating cervical ICA dissections.MethodBetween August 2024 and May 2025, six patients (aged 40–80) with high-grade cervical ICA dissections were treated at our center. Indications for intervention included persistent flow limitation, progressive symptoms, or contraindications to anticoagulation. The CARESTO heal stent, a highly flexible, self-expanding nitinol stent with a bioactive surface coating, was implanted under dual antiplatelet therapy.ResultsStent deployment was successful in all cases without periprocedural complications. Current Follow-up imaging showed vessel remodeling and maintained stent patency. No in-stent stenosis, thromboembolic events, or neurological deterioration occurred. All patients remained asymptomatic after the procedure.ConclusionThe CARESTO heal stent demonstrated a favorable safety and efficacy profile in treating cervical ICA dissections. These promising initial results support the need for further investigation in larger, prospective clinical trials.Conflict of InterestNo