Restoration of an adequate cerebral blood supply after an ischemic attack is a primary clinical goal. However, the blood-brain barrier may break down after a prolonged ischemia causing the fluid in the blood plasma to filtrate and accumulate into the cerebral tissue interstitial space. Accumulation of this filtration fluid causes the cerebral tissue to swell, a condition known as vasogenic oedema. Tissue swelling causes the cerebral microvessels to be compressed, which may further obstruct the blood flow into the tissue, thus leading to the no-reflow phenomenon or a secondary ischemic stroke. The actual mechanism of this however is still not fully understood. A new model is developed here to study the effect of reperfusion on the formation of vasogenic oedema and cerebral microvessel collapse. The formation of vasogenic oedema is modelled using the capillary filtration equation while vessel collapse is modelled using the tube law of microvessel. Tissue swelling is quantified in terms of displacement, which is modelled using poroelastic theory. The results show that there is an increase in tissue displacement and interstitial pressure after reperfusion. In addition, the results also show that vessel collapse can occur at high value of reperfusion pressure, low blood osmotic pressure, high cerebral capillary permeability and low cerebral capillary stiffness. This model provides insight on the formation of ischemia-reperfusion injury by tissue swelling and vessel collapse.
This paper describes the preliminary work required to understand cultural differences in palliative care in the United Kingdom and three countries in the Asia-Pacific region, in preparation for a cross-country study. The study is intended to address cultural understandings of palliative care, the role of the family in end of life care, what constitutes good care and the ethical issues in each country. Suggestions are then made to shape the scope of the study and to be considered as outcomes to improve care of the dying in these countries. It is anticipated that the method used to achieve consensus on cross-country palliative care issues will be both qualitative and quantitative. Identifying key priorities in the delivery and quality measures of palliative care will involve participants in focus groups, a Delphi survey and in the development of clinical indicators towards creating standards of palliative care common to the Asian Pacific region.
The original concept of the ischaemic penumbra suggested imaging of regional cerebral blood flow and metabolism would be required to identify tissue that may benefit from intervention. Amide proton transfer magnetic resonance imaging, a chemical exchange saturation transfer technique, has been used to derive cerebral intracellular pH in preclinical stroke models and has been proposed as a metabolic marker of ischaemic penumbra. In this proof of principle clinical study, we explored the potential of this pH-weighted magnetic resonance imaging technique at tissue-level. Detailed voxel-wise analysis was performed on data from a prospective cohort of 12 patients with acute ischaemic stroke. Voxels within ischaemic core had a more severe intracellular acidosis than hypoperfused tissue recruited to the final infarct (P < 0.0001), which in turn was more acidotic than hypoperfused tissue that survived (P < 0.0001). In addition, when confined to the grey matter perfusion deficit, intracellular pH (P < 0.0001), but not cerebral blood flow (P = 0.31), differed between tissue that infarcted and tissue that survived. Within the presenting apparent diffusion coefficient lesion, intracellular pH differed between tissue with early apparent diffusion lesion pseudonormalization and tissue with true radiographic recovery. These findings support the need for further investigation of pH-weighted imaging in patients with acute ischaemic stroke.