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View this table:
Table 1:

Demographic, radiographic, and clinical data of all patients

View this table:
Table 2:

Comparisons of mean scores for demographic and clinical variables between the total revascularized group (A) and the successfully revascularized group (B)

This series of 11 patients demonstrates the potential feasibility of offering endovascular revascularization to patients presenting beyond 8 hours based on CDM, with no incidence of associated ICH. The common premise among these patients with delayed presentations is that their moderately severe clinical syndromes represent the ischemic penumbra, and limited areas of DWI abnormality suggest potentially lower risk of hemorrhage with revascularization efforts. Such endeavors at extended time windows must take into consideration safety and the likelihood of achieving any clinical benefit at late junctures.

It is conceivable that CDM may most benefit patients who very likely experienced the stroke directly before presentation, though lacking a witness to the event, cannot establish a time of onset, such as patients with “wake-up stroke,” who represent approximately 25% of all annual AIS admissions. 15 17 Patients in this analysis were seen to generally fall into 1 of 3 categories: those with wake-up strokes, those with well-established long duration of symptoms of the posterior circulation, or those with stenotic nonocclusive lesions and fluctuating neurologic syndromes. These groups may be ideal focuses of intervention in further studies of therapies at later times. Additionally, in many patients, ischemic regions may be partially supported by collateral circulation ( Fig 2 ), which maintains tissue viability though it does not prevent clinical neurologic dysfunction. 18 Revascularization restores the preferential circulation and normal blood flow to the brain, potentially limiting ultimate infarct expansion.

Fig 2.

Panel shows left internal carotid artery angiography of an 84-year-old woman 13 hours after she was last seen at normal neurologic baseline, with acute aphasia, found to have small areas of scattered diffusion abnormality ( Fig 1 ). Top panel shows angiograms in the anterior oblique projection, and the bottom panel, in lateral projections as seen in early arterial and late arterial phases pretreatment and final posttreatment. Initial divisional middle cerebral artery occlusion is seen in the early arterial phase (). Retrograde pial collateralization () can be seen in the late arterial phase. Posttreatment angiography shows recanalization of this division, though with persistent distal branch vessel occlusion ().

Certain points merit further discussion, namely the choice of imaging technique serving as the clinical basis for guiding therapy and, second, the treatment options offered in these cases (endovascular therapy rather than systemic thrombolysis). Perfusion-weighted imaging (PWI) has been widely studied in conjunction with DWI (PWI-DWI mismatch [PDM]) as a means of identifying patients who may benefit from thrombolysis outside of standard time windows, 19 but is limited by the time and expertise required for technical postprocessing. However, PDM may have a role in patients presenting with lower NIHSS scores who would not otherwise fulfill the above criteria of CDM. This may particularly be the case in strokes involving the nondominant hemisphere, which in fact are unrepresented among our patients, perhaps highlighting this very statement. Apart from this, we believe that the use of CDM is well grounded. In comparison with PDM and CDM, Prosser et al 11 found that patients who did not meet the CDM criteria but were found to have PDM tended to have larger DWI lesions of injury early on and would likely benefit less from revascularization.

California is home to some of the largest deposits of naturally occurring asbestos in the world. The state leads the nation in mesothelioma deaths. In 2015 alone, California had 247 mesothelioma-related deaths, according to the CDC. In comparison, Florida, which is second to California, had 143 deaths.

The SEER age-adjusted incidence rate for California from 2010 to 2014 was 0.89 new cases per 100,000.

Quick Fact

One of the most prominent hot spots is Libby, Montana. This city was home to an asbestos-tainted vermiculite mine that was owned and operated by W.R. Grace and Co. for more than 40 years.

Researchers predict that New York City is also destined to become a hot spot. Because of the large clouds of asbestos dust released by the collapse of the Twin Towers at the World Trade Center , it is believed that mesothelioma could become a huge concern for New York City paramedics, police, firefighters or anyone else who lived in lower Manhattan immediately after the tragedy.

Although asbestos use is not officially banned in the U.S., government regulations severely restricted the toxic mineral’s use since the 1970s. As a result, researchers believe the incidence of mesothelioma may have already peaked in the U.S.

Quick Fact

In the last 20 years tracked in the SEER database (1995-2014), the highest mesothelioma incidence was 1.16 in 1995.

Although mesothelioma cases in the U.S. appear to be on the decline, people exposed to asbestos decades ago will continue to develop the cancer in coming years because of its lengthy latency period.

One study projected approximately 85,000 cases from 2008 to 2054.

Today, most U.S. workers are exposed to asbestos through the demolition, renovation and maintenance of homes and buildings built before the 1980s.

Occupational asbestos exposure accounts for most of the world’s exposure to asbestos. In many of the world’s industrialized countries, workplace exposure to asbestos reached its peak and is receding. This is because the mining, consumption and manufacturing of asbestos were banned outright, limited by law and regulation, or they declined because of an increased understanding of asbestos-related health risks.

The importation, production and use of asbestos and asbestos-containing products are banned in all 28 countries of the European Union. Australia and the United Kingdom — two nations with historically high incidence rates of mesothelioma — have comprehensive asbestos bans in place.

Canada plans to ban the toxic mineral by 2018, leaving the U.S. as the only major industrialized nation without a complete asbestos ban. Developing counties such as China, Kazakhstan, Russia, Brazil, India, Pakistan, Mexico, Indonesia and Thailand continue to use, produce and export asbestos. In these countries, asbestos exposure is still on the rise.

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