Purpose— The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH). Methods— A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years. Results— Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications. Conclusions— aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.

Purpose— The aim of this updated statement is to provide comprehensive and evidence-based recommendations for management of patients with unruptured intracranial aneurysms. Methods— Writing group members used systematic literature reviews from January 1977 up to June 2014. They also reviewed contemporary published evidence-based guidelines, personal files, and published expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulated recommendations using standard American Heart Association criteria. The guideline underwent extensive peer review, including review by the Stroke Council Leadership and Stroke Scientific Statement Oversight Committees, before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. Results— Evidence-based guidelines are presented for the care of patients presenting with unruptured intracranial aneurysms. The guidelines address presentation, natural history, epidemiology, risk factors, screening, diagnosis, imaging and outcomes from surgical and endovascular treatment.

Objective The contribution of bacterial co-infection to critical illness associated with 2009 influenza A (H1N1) [pH1N1] virus infection remains uncertain. The objective of this study was to determine if bacterial co-infection increased the morbidity and mortality of pH1N1. Design Retrospective and Prospective cohort study Setting 35 adult U.S. intensive care units over the course of one year Patients 683 critically ill adults with confirmed or probable pH1N1 Interventions None Measurements and Main Results A confirmed or probable case was defined as a positive pH1N1 test result or positive test for influenza A that was otherwise not subtyped. Bacterial co-infection was defined as documented bacteremia or any presumed bacterial pneumonia with or without positive respiratory tract culture within 72 hours of ICU admission. The mean age was 45±16 years, mean BMI 32.5±11.1 kg/m2, and mean APACHE II score 21±9, with 76% having at least one co-morbidity. Of 207 (30.3%) patients with bacterial co-infection on ICU admission, 154 had positive cultures with Staphylococcus aureus (n=57) and Streptococcus pneumoniae (n=19) the most commonly identified pathogens. Bacterial co-infected patients were more likely to present with shock (21 vs. 10%; P=0.0001), require mechanical ventilation at the time of ICU admission (63 vs. 52%; P=0.005) and have longer duration of ICU care (median 7 vs. 6 days; P=0.05). Hospital mortality was 23%; 31% in bacterial co-infected patients and 21% in patients without co-infection (P=0.002). Immunosuppression (RR 1.57; 95% CI 1.20–2.06; P=0.0009) and Staphylococcus aureus at admission (RR 2.82; 95% CI: 1.76–4.51; P<0.0001) were independently associated with increased mortality. Conclusions Among ICU patients with pH1N1, bacterial co-infection diagnosed within 72 hours of admission, especially with Staphylococcus aureus, was associated with significantly higher morbidity and mortality.

Intraoperative diagnosis is essential for providing safe and effective care during cancer surgery 1. The existing workflow for intraoperative diagnosis based on hematoxylin and eosin-staining of processed tissue is time-, resource-, and labor-intensive 2,3. Moreover, interpretation of intraoperative histologic images is dependent on a contracting, unevenly distributed pathology workforce 4. Here, we report a parallel workflow that combines stimulated Raman histology (SRH) 5-7 , a label-free optical imaging method, and deep convolutional neural networks (CNN) to predict diagnosis at the bedside in near real-time in an automated fashion. Specifically, our CNN, trained on over 2.5 million SRH images, predicts brain tumor diagnosis in the operating room in under 150 seconds, an order of magnitude faster than conventional techniques (e.g., 20-30 minutes) 2. In a multicenter, prospective clinical trial (n = 278) we demonstrated that CNN-based diagnosis of SRH images was non-inferior to pathologist-based interpretation of conventional histologic images (overall accuracy, 94.6% vs. 93.9%). Our CNN learned a hierarchy of recognizable histologic feature representations to classify the major histopathologic classes of brain tumors. Additionally, we implemented a semantic segmentation method to identify tumor infiltrated, diagnostic regions within SRH images. These results demonstrate how intraoperative cancer diagnosis can be streamlined, creating a complimentary pathway for tissue diagnosis that is independent of a traditional pathology laboratory.

Perfusion computed tomography (CT) is a relatively new technique that allows rapid qualitative and quantitative evaluation of cerebral perfusion by generating maps of cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT). The technique is based on the central volume principle (CBF = CBV/MTT) and requires the use of commercially available software employing complex deconvolution algorithms to produce the perfusion maps. Some controversies exist regarding this technique, including which artery to use as input vessel, the accuracy of quantitative results, and the reproducibility of results. Despite these controversies, perfusion CT has been found to be useful for noninvasive diagnosis of cerebral ischemia and infarction and for evaluation of vasospasm after subarachnoid hemorrhage. Perfusion CT has also been used for assessment of cerebrovascular reserve by using acetazolamide challenge in patients with intracranial vascular stenoses who are potential candidates for bypass surgery or neuroendovascular treatment, for the evaluation of patients undergoing temporary balloon occlusion to assess collateral flow and cerebrovascular reserve, and for the assessment of microvascular permeability in patients with intracranial neoplasms. This article is a review of the technique, clinical applications, and controversies surrounding perfusion CT.