4,958 research outputs found
Health economic impact of first-pass success among patients with acute ischemic stroke treated with mechanical thrombectomy: a United States and European perspective
Economics; Stroke; ThrombectomyEconomia; Ictus; TrombectomiaEconomĂa; Ictus; TrombectomĂaBackground First-pass effect (FPE), restoring complete or near complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2c-3) in a single pass, is an independent predictor for good functional outcomes in the endovascular treatment of acute ischemic stroke. The economic implications of achieving FPE have not been assessed.
Objective To assess the economic impact of achieving complete or near complete reperfusion after the first pass.
Methods Post hoc analyses were conducted using ARISE II study data. The target population consisted of patients in whom mTICI 2câ3 was achieved, stratified into two groups: (1) mTICI 2câ3 achieved after the first pass (FPE group) or (2) after multiple passes (non-FPE group). Baseline characteristics, clinical outcomes, and healthcare resource use were compared between groups. Costs from peer-reviewed literature were applied to assess cost consequences from the perspectives of the United States (USA), France, Germany, Italy, Spain, Sweden, and United Kingdom (UK).
Results Among patients who achieved mTICI 2câ3 (n=172), FPE was achieved in 53% (n=91). A higher proportion of patients in the FPE group reached good functional outcomes (90-day modified Rankin Scale score 0â2 80.46% vs 61.04%, p<0.01). The patients in the FPE group had a shorter mean length of stay (6.10 vs 9.48 days, p<0.01) and required only a single stent retriever, whereas 35% of patients in the non-FPE group required at least one additional device. Driven by improvement in clinical outcomes, the FPE group had lower procedural/hospitalization-related (24â33%âreduction) and annual care (11â27%âreduction) costs across all countries.
Conclusions FPE resulted in improved clinical outcomes, translating into lower healthcare resource use and lower estimated costs.This study was funded by Cerenovus, a subsidiary of Johnson and Johnson
Benchmarking the Extent and Speed of Reperfusion: First Pass TICI 2c-3 Is a Preferred Endovascular Reperfusion Endpoint
IsquĂšmia cerebral; Trombectomia mecĂ nica; ReperfusiĂłIsquemia cerebral; TrombectomĂa mecĂĄnica; ReperfusiĂłnBrain ischaemia; Mechanical thrombectomy; ReperfusionBackground and Purpose: End-of-procedure substantial reperfusion [modified Treatment in Cerebral Ischemia (mTICI) 2b-3], the leading endpoint for thrombectomy studies, has several limitations including a ceiling effect, with recent achieved rates of ~90%. We aimed to identify a more optimal definition of angiographic success along two dimensions: (1) the extent of tissue reperfusion, and (2) the speed of revascularization.
Methods: Core-lab adjudicated TICI scores for the first three passes of EmboTrap and the final all-procedures result were analyzed in the ARISE II multicenter study. The clinical impact of extent of reperfusion and speed of reperfusion (first-pass vs. later-pass) were evaluated. Clinical outcomes included 90-day functional independence [modified Rankin Scale (mRS) 0â2], 90-day freedom-from-disability (mRS 0â1), and dramatic early improvement [24-h National Institutes of Health Stroke Scale (NIHSS) improvement â„ 8 points].
Results: Among 161 ARISE II subjects with ICA or MCA M1 occlusions, reperfusion results at procedure end showed substantial reperfusion in 149 (92.5%), excellent reperfusion in 121 (75.2%), and complete reperfusion in 79 (49.1%). Reperfusion rates on first pass were substantial in 81 (50.3%), excellent reperfusion in 62 (38.5%), and complete reperfusion in 44 (27.3%). First-pass excellent reperfusion (first-pass TICI 2c-3) had the greatest nominal predictive value for 90-day mRS 0â2 (sensitivity 58.5%, specificity 68.6%). There was a progressive worsening of outcomes with each additional pass required to achieve TICI 2c-3.
Conclusions: First-pass excellent reperfusion (TICI 2c-3), reflecting rapid achievement of extensive reperfusion, is the technical revascularization endpoint that best predicted functional independence in this international multicenter trial and is an attractive candidate for a lead angiographic endpoint for future trials.Cerenovus sponsored the ARISE II study, and provided support for open access to this article
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Clinical Outcome after Intra-Arterial Stroke Therapy in the Very Elderly: Why is it so Heterogeneous?
Very elderly patients (i.e., â„80 years) are disproportionally affected by acute ischemic stroke. They account for a third of hospital stroke admissions, but two-thirds of overall stroke-related morbidity and mortality. There is some evidence of clinical benefit in treating selected very elderly patients with intravenous thrombolysis (IVT). For very elderly patients ineligible or non-responsive to IVT, intra-arterial therapy (IAT) may have promise in improving clinical outcome. However, its unequivocal efficacy in the general population remains to be proven in randomized trials. Small cohort studies reveal that the rate of good clinical outcome for very elderly patients after IAT is highly variable, ranging from 0 to 28%. In addition, they experience higher rates of futile reperfusion than younger patients. Thus, it is imperative to understand the factors that impact on clinical outcome in very elderly patients after IAT. The aim of this review is to examine the factors that may be responsible for the heterogeneous clinical response of the very elderly to IAT. This will allow the reader to integrate the current available evidence to individualize intra-arterial stroke therapy in very elderly patients. Placing emphasis on pre-stroke independent living, smaller infarct core size, short procedure times, and avoiding general anesthesia where feasible, will help improve rates of good clinical outcome
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Delayed Endovascular Coil Extrusion following Internal Carotid Artery Embolization
Internal carotid artery injury is a rare and devastating complication of endoscopic sinus and skull base surgery that has an associated mortality rate of 15%. This case describes a patient who developed massive epistaxis following routine sinus surgery and was eventually diagnosed with a pseudoaneurysm of the cavernous internal carotid artery. Endovascular coiling and Onyx (Covidien, Irvine, California, United States) liquid embolization were ultimately used to completely occlude the internal carotid artery with resolution of bleeding; however, the patient had an unexpected late complication of coil extrusion through the pseudoaneurysm sac into the sphenoid sinus and nasal cavity. The endoscopic skull base team safely excised the coils endoscopically without recurrent bleeding. We describe the multidisciplinary operative management of this case of endovascular coil extrusion to increase awareness of this potentially life-threatening complication
Navigated interventions in the head and neck area: standardized assessment of a new handy field generator
Electromagnetic (EM) tracking enables localization of surgical instruments
within the magnetic field emitted by an EM field generator (FG). Usually, the
larger a FG is, the larger its tracking volume is. However, the company NDI
(Northern Digital Inc., Waterloo, ON, Canada) recently introduced the Planar
10-11 FG, which combines a compact construction (97mm x 112mm x 31mm) with a
relatively large, cylindrical tracking volume (diameter: 340mm, height: 340mm).
Using the standardized assessment protocol of Hummel et al., the FG was tested
with regard to its tracking accuracy and to its robustness with respect to
external sources of disturbance. The mean positional error (5cm distance metric
according to Hummel protocol) was 0.59mm, with a mean jitter of 0.26mm in the
standard setup. The mean orientational error was found to be 0.10{\deg}. The
highest positional error (4.82mm) due to metallic sources of disturbance was
caused by the steel SST 303. In contrast, steel SST 416 caused the lowest
positional error (0.10mm). Overall, the Planar 10-11 FG tends to achieve better
tracking accuracy results compared to other NDI FGs. Due to its compact
construction and portability, the FG could contribute to increased clinical use
of EM tracking systems.Comment: This is the preprint version of the BVM paper already published in
the conference proceedings of "Bildverarbeitung in der Medizin 2019". Paper
written in Germa
Intravenous Thrombolysis Before Endovascular Treatment in Posterior Circulation Occlusions:A MR CLEAN Registry Study
BACKGROUND: The effectiveness of intravenous thrombolysis (IVT) before endovascular treatment (EVT) has been investigated in randomized trials and meta-analyses. These studies mainly concerned anterior circulation occlusions. We aimed to investigate clinical, technical, and safety outcomes of IVT before EVT in posterior circulation occlusions in a nationwide registry. METHODS: Patients were included from the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), a nationwide, prospective, multicenter registry of patients with acute ischemic stroke due to a large intracranial vessel occlusion receiving EVT between 2014 and 2019. All patients with a posterior circulation occlusion were included. Primary outcome was a shift toward better functional outcome on the modified Rankin Scale at 90 days. Secondary outcomes were favorable functional outcome (modified Rankin Scale scores, 0â3), occurrence of symptomatic intracranial hemorrhages, successful reperfusion (extended Thrombolysis in Cerebral Ischemia â„2B), first-attempt successful reperfusion, and mortality at 90 days. Regression analyses with adjustments based on univariable analyses and literature were applied. RESULTS: A total of 248 patients were included, who received either IVT (n=125) or no IVT (n=123) before EVT. Results show no differences in a shift on the modified Rankin Scale (adjusted common odds ratio, 1.04 [95% CI, 0.61â1.76]). Although symptomatic intracranial hemorrhages occurred more often in the IVT group (4.8% versus 2.4%), regression analysis did not show a significant difference (adjusted odds ratio, 1.65 [95% CI, 0.33â8.35]). Successful reperfusion, favorable functional outcome, first-attempt successful reperfusion, and mortality did not differ between patients treated with and without IVT. CONCLUSIONS: We found no significant differences in clinical, technical, and safety outcomes between patients with a large vessel occlusion in the posterior circulation treated with or without IVT before EVT. Our results are in line with the literature on the anterior circulation. GRAPHIC ABSTRACT: A graphic abstract is available for this article.</p
Early Intubation in Endovascular Therapy for Basilar Artery Occlusion:A Post Hoc Analysis of the BASICS Trial
BACKGROUND: The optimal anesthetic management for endovascular therapy (EVT) in patients with posterior circulation stroke remains unclear. Our objective was to investigate the impact of early intubation in patients enrolled in the BASICS trial (Basilar Artery International Cooperation Study). METHODS: BASICS was a multicenter, randomized, controlled trial that compared the efficacy of EVT compared with the best medical care alone in patients with basilar artery occlusion. In this post hoc analysis, early intubation within the first 24 hours of the estimated time of basilar artery occlusion was examined as an additional covariate using regression modeling. We estimated the adjusted relative risks (RRs) for favorable outcomes, defined as modified Rankin Scale scores of 0 to 3 at 90 days. An adjusted common odds ratio was estimated for a shift in the distribution of modified Rankin Scale scores at 90 days. RESULTS: Of 300 patients in BASICS, 289 patients were eligible for analysis (151 in the EVT group and 138 in the best medical care group). compared with medical care alone, EVT was related to a higher risk of early intubation (RR, 1.29 [95% CI, 1.09â1.53]; P<0.01), and early intubation was negatively associated with favorable outcome (RR, 0.61 [95% CI, 0.45â0.84]; P=0.002). Whereas there was no overall treatment effect of EVT on favorable outcome (RR, 1.22 [95% CI, 0.95â1.55]; P=0.121), EVT was associated with favorable outcome (RR, 1.34 [95% CI, 1.05â1.71]; P=0.018) and a shift toward lower modified Rankin Scale scores (adjusted common odds ratio, 1.63 [95% CI, 1.04â2.57]; P=0.033) if adjusted for early intubation. CONCLUSIONS: In this post hoc analysis of the neutral BASICS trial, early intubation was linked to unfavorable outcomes, which might mitigate a potential benefit from EVT by indirect effects due to an increased risk of early intubation. This relationship may be considered when assessing the efficacy of EVT in patients with basilar artery occlusion in future trials.</p
First Measurement of Coherent Elastic Neutrino-Nucleus Scattering on Argon
We report the first measurement of coherent elastic neutrino-nucleus
scattering (\cevns) on argon using a liquid argon detector at the Oak Ridge
National Laboratory Spallation Neutron Source. Two independent analyses prefer
\cevns over the background-only null hypothesis with greater than
significance. The measured cross section, averaged over the incident neutrino
flux, is (2.2 0.7) 10 cm -- consistent with the
standard model prediction. The neutron-number dependence of this result,
together with that from our previous measurement on CsI, confirms the existence
of the \cevns process and provides improved constraints on non-standard
neutrino interactions.Comment: 8 pages, 5 figures with 2 pages, 6 figures supplementary material V3:
fixes to figs 3,4 V4: fix typo in table 1, V5: replaced missing appendix, V6:
fix Eq 1, new fig 3, V7 final version, updated with final revision
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DoorâtoâPuncture: A Practical Metric for Capturing and Enhancing System Processes Associated With Endovascular Stroke Care, Preliminary Results From the Rapid Reperfusion Registry
Background: In 2011, the Brain Attack Coalition proposed doorâtoâtreatment times of 2 hours as a benchmark for patients undergoing intraâarterial therapy (IAT). We designed the Rapid Reperfusion Registry to capture the percentage of stroke patients who meet the target and its impact on outcomes. Methods and Results: This is a retrospective analysis of anterior circulation patients treated with IAT within 9 hours of symptom onset. Data was collected from December 31, 2011 to December 31, 2012 at 2 centers and from July 1, 2012 to December 31, 2012 at 7 centers. Short âDoorâtoâPunctureâ (D2P) time was hypothesized to be associated with good patient outcomes. A total of 478 patients with a mean age of 68±14 years and median National Institutes of Health Stroke Scale (NIHSS) of 18 (IQR 14 to 21) were analyzed. The median times for IAT delivery were 234 minutes (IQR 163 to 304) for âlast known normalâtoâgroin punctureâ time (LKNâtoâGP) and 112 minutes (IQR 68 to 176) for D2P time. The overall good outcome rate was 39.7% for the entire cohort. In a multivariable model adjusting for age, NIHSS, hypertension, diabetes, reperfusion status, and symptomatic hemorrhage, both short LKNâtoâGP (OR 0.996; 95% CI [0.993 to 0.998]; P<0.001) and short D2P times (OR 0.993, 95% CI [0.990 to 0.996]; P<0.001) were associated with good outcomes. Only 52% of all patients in the registry achieved the targeted D2P time of 2 hours. Conclusions: The time interval of D2P presents a clinically relevant time frame by which system processes can be targeted to streamline the delivery of IAT care nationally. At present, there is much opportunity to enhance outcomes through reducing D2P
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