Cerebrovascular events and outcomes in hospitalized patients with COVID-19: The SVIN COVID-19 Multinational Registry

Background Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients. Aim To summarize the findings of a multinational observational cohort of patients with SARS-CoV-2 and cerebrovascular disease. Methods Retrospective observational cohort of consecutive adults evaluated in the emergency department and/or admitted with coronavirus disease 2019 (COVID-19) across 31 hospitals in four countries (1 February 2020–16 June 2020). The primary outcome was the incidence rate of cerebrovascular events, inclusive of acute ischemic stroke, intracranial hemorrhages (ICH), and cortical vein and/or sinus thrombosis (CVST). Results Of the 14,483 patients with laboratory-confirmed SARS-CoV-2, 172 were diagnosed with an acute cerebrovascular event (1.13% of cohort; 1130/100,000 patients, 95%CI 970–1320/100,000), 68/171 (40.5%) were female and 96/172 (55.8%) were between the ages 60 and 79 years. Of these, 156 had acute ischemic stroke (1.08%; 1080/100,000 95%CI 920–1260/100,000), 28 ICH (0.19%; 190/100,000 95%CI 130–280/100,000), and 3 with CVST (0.02%; 20/100,000, 95%CI 4–60/100,000). The in-hospital mortality rate for SARS-CoV-2-associated stroke was 38.1% and for ICH 58.3%. After adjusting for clustering by site and age, baseline stroke severity, and all predictors of in-hospital mortality found in univariate regression (p \u3c 0.1: male sex, tobacco use, arrival by emergency medical services, lower platelet and lymphocyte counts, and intracranial occlusion), cryptogenic stroke mechanism (aOR 5.01, 95%CI 1.63–15.44, p \u3c 0.01), older age (aOR 1.78, 95%CI 1.07–2.94, p = 0.03), and lower lymphocyte count on admission (aOR 0.58, 95%CI 0.34–0.98, p = 0.04) were the only independent predictors of mortality among patients with stroke and COVID-19. Conclusions COVID-19 is associated with a small but significant risk of clinically relevant cerebrovascular events, particularly ischemic stroke. The mortality rate is high for COVID-19-associated cerebrovascular complications; therefore, aggressive monitoring and early intervention should be pursued to mitigate poor outcomes

Decline in subarachnoid haemorrhage volumes associated with the first wave of the COVID-19 pandemic

BACKGROUND: During the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study\u27s objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines. METHODS: We conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March-31 May 2020. The prior 1-year control period (1 March-31 May 2019) was obtained to account for seasonal variation. FINDINGS: There was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI -24.3% to -20.7%, p\u3c0.0001). Embolisation of ruptured aneurysms declined with 1170-1035 procedures, respectively, representing an 11.5% (95%CI -13.5% to -9.8%, p=0.002) relative drop. Subgroup analysis was noted for aneurysmal SAH hospitalisation decline from 834 to 626 hospitalisations, a 24.9% relative decline (95% CI -28.0% to -22.1%, p\u3c0.0001). A relative increase in ruptured aneurysm coiling was noted in low coiling volume hospitals of 41.1% (95% CI 32.3% to 50.6%, p=0.008) despite a decrease in SAH admissions in this tertile. INTERPRETATION: There was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction

Abstract Number ‐ 87: Successfull thrombectomy followed by balloon mount stent placement on acute basilar artery occlusion

Introduction Basilar artery occlusion accounts for 10% of all ischemic stroke caused by intracranial large vessel occlusion (LVO) with high morbidity and mortality. Endovascular intervention has been shown effective in the anterior circulation LVO but multiple trials, however a few trials failed to demonstrate the benefit of endovascular intervention over medical therapy, furthermore, there is no trial regarding the benefit of permanent stent deployment in the basilar artery over maximized medical therapy. Here we present a patient who presented with right side hemiplegia, facial droop, and dysmetria with National Institute of Health Stroke Scale of 19. CT head and neck angiography revealed acute basilar occlusion. Endovascular procedure was performed with successful thrombectomy utilizing stent retriever followed by placement of balloon mounted stent due to persistent critical basilar stenosis. Methods A case report Results MRI of the brain revealed acute ischemic stroke of bilateral cerebellar hemisphere, mid and left pons, left cerebral peduncles, and left thalamus. Repeat non‐contrast CT head revealed small bilateral thalamic hemorrhage but due to small size, dual antiplatelet therapy with aspirin and ticagrelor was initiated. After discharge, the patient developed upper extremity deep vein thrombosis for which apixaban was started. Despite dual antiplatelet therapy and anticoagulation, the patient continued to improve. Clinical follow‐up at 6 weeks the patient remained stable with mild residual weakness of the right extremities. Conclusions Thrombectomy with subsequent deployment of permanent stent can be considered as a safe and effective measure of basilar artery occlusion

Predicting poor response to anti-coagulation therapy in cerebral venous thrombosis using a simple clinical-radiological score.

BACKGROUND: Multiple studies have attempted to determine predictors of poor clinical outcomes in cerebral venous thrombosis (CVT). Fewer studies target to identify predictors of poor response to anticoagulation therapy in CVT. OBJECTIVE: We aimed to determine the predictors of poor clinical response to therapeutic anticoagulation in patients with acute CVT. METHODS: We performed a retrospective analysis of patients therapeutically anticoagulated for acute CVT. We defined poor clinical outcomes as death, need for mechanical thrombectomy during the hospitalization, or a modified Rankin Scale (mRS) \u3e 3 at clinical follow-up. Bivariate and multivariate analyses identified factors associated with poor outcomes in anticoagulated patients for acute CVT, and we used the identified factors to create the PRACT-CVT (Poor Response to Anticoagulation Therapy in CVT) score. RESULTS: We included 109 patients anticoagulated with acute CVT. The mean patient age was 37 years old (SD 19); nine patients were \u3e 65 years, ten patients were \u3c 10 years, and 64 (59%) were female. Twenty-one (19%) patients had poor clinical outcomes. Age \u3e 65 or \u3c 10 years (OR: 3.16, 95% CI: 1.06-9.44), a GCS ≤ 12 upon presentation (OR: 19.2, 95% CI: 4.05-91.4), focal motor deficits at admission (OR: 5.03, 95% CI: 1.64-15.44), clinical deterioration following admission (OR: 28.18, CI: 4.81-164.86), seizures following admission (OR: 5.59, 95% CI: 1.27-24.51), evidence of brain bleeding/ischemia on admission (OR: 4.67, 95% CI: 1.42-15.34), involvement of the superior sagittal sinus (OR: 3.88, CI: 1.33-11.32), or involvement of both transverse sinuses (OR: 3.87, 95% CI: 1.01-14.90) predicted poor clinical outcome despite therapeutic anticoagulation. A PRACT-CVT score (0-22 points) of ≥ 7 points provided a sensitivity of 71% and a specificity of 95% for predicting poor clinical outcomes with anticoagulation alone. CONCLUSION: Patients with acute CVT aged \u3e 65 or \u3c 10 years old, presenting with a GCS ≤ 12, with focal motor deficits, showing clinical deterioration after admission, having clinical seizures during hospitalization, with brain bleeding/ischemia on initial neuroimaging, involvement of the superior sagittal sinus, or involvement of both transverse sinuses had poor response to anticoagulation. Clinicians may employ the PRACT-CVT score to predict poor response to anticoagulation for acute CVT

Abstract 1122‐000212: INARI FlowTriever system: First Endovascular Clinical Experience to Treat Diffuse Cerebral Venous Sinus Thrombosis

Introduction: Cerebral Venous Sinus Thrombosis (CVST) is a rare stroke with a wide range of symptomatology at presentation ranging from headache, focal weakness, and coma. Anticoagulation remains the mainstay of treatment. However, in a subset of patients endovascular treatment can be potentially beneficial. Here we describe the first clinical experience using the INARI FlowTriever system to treat a patient presented with focal weakness and found to have diffuse cerebral venous sinus thrombosis. Methods: Case report of CSVT treated with INARI FlowTriever system. Results: A 78‐year‐old female with past medical history of Autoimmune hepatitis and hypothyroidism, was brought to the hospital with left arm weakness. CT head revealed left temporoparietal intraparenchymal hemorrhage and right frontal subarachnoid hemorrhage. CTA of the head and neck revealed extensive CVST involving superior sagittal sinus, bilateral transverse and sigmoid sinuses. She was started on heparin drip. Patient was taken for venous thrombectomy due to persistent left‐sided weakness and multicompartment bleeding while being on anticoagulation for 48 hours. She underwent successful endovascular venous thrombectomy using the INARI FlowTriever system with large clot burden extracted. She was switched to novel oral anticoagulation prior to discharge. During the 3 months follow‐up–MRI brain with and without contrast revealed near complete resolution of the clot burden in the superior sagittal sinus and left transverse/sigmoid complex and her modified Rankin score was at 0. Conclusions: Here we discussed a case of diffuse CVST who was treated initially with heparin drip then underwent endovascular venous thrombectomy using INARI FlowTriever system with large clot burden aspirated with a reasonable safety profile. The INARI medical FlowTriever system is the only mechanical thrombectomy system indicated for the treatment of pulmonary embolism. It is specifically designed for venous clots. It is composed of a trackable large bore aspiration catheter. The INARI FlowTriever Catheter; has 3 expanding nitinol mesh disks; designed to engage and disrupt venous clots and subsequently deliver it to the large bore aspiration catheter. Its larger size makes it an attractive candidate for venous sinus clot retrieval. This study illustrates the first clinical use of INARI thrombectomy device in CVST with a reasonable safety profile. Anticoagulation is the mainstay first line treatment for CVST. However, a small subset of patients would potentially benefit from endovascular treatment but it still uncertain how to select these patients and what is the best timeline to offer early endovascular treatment. Various neuro endovascular techniques has been attempted to treat cerebral venous sinus thrombosis. However; it is unclear which approach and device provides the optimal restoration of venous blood flow. Current neuro endovascular techniques and devices are not particularly designed for CVST pathology treatment and there is need for further innovation and new devices

Mechanical Venous Thrombectomy Using Indigo Aspiration System: A Case Report.

We present a case of successful endovascular thrombectomy of cerebral venous sinus thrombosis utilizing Penumbra\u27s Indigo Aspiration System (Penumbra Inc., Place Alameda, CA), a minimally invasive system with a large-lumen (Indigo System CAT7, 7F) catheter predominantly used for the removal of thromboembolism involving the peripheral arterial and venous systems. A 30-year-old female presented with a seizure and focal neurological deficits and was found to have a left posterior temporal lobe hemorrhagic infarct secondary to an extensive cerebral venous sinus thrombosis extending from the left transverse sinus to the ipsilateral internal jugular bulb. We considered the combination of seizure, motor deficit, and hemorrhagic infarct high-risk features for poor response to standard medical therapy with therapeutic anticoagulation. Therefore, we performed a mechanical venous thrombectomy with the above device in addition to anticoagulation treatment with heparin infusion. This combination therapy resulted in a technically successful radiographic recanalization of the involved sinuses and an excellent functional outcome at follow-up. This case demonstrates that this trackable, atraumatic, large-bore system was safe and efficacious in the cerebral venous system, permitting near-complete thrombus removal

Abstract 014: Beveled‐Tip Aspiration Catheters Reduce Stoke Procedure Time And Cost For Large And Medium Vessel Occlusions

Introduction Thrombectomy catheters with a unique angled‐tip design (ZoomTM Aspiration Catheters, Imperative Care Inc., Campbell, CA) have recently emerged as promising devices for treating acute ischemic stroke. The angled‐tip configuration is engineered to enhance device trackability and optimize clot engagement. Following promising initial results observed during our catheter evaluation, we integrated these novel catheters into the majority of thrombectomy procedures at our institution. In this study, we aimed to determine whether the utilization of angled‐tip catheters could lead to reduced procedural expenses and shorter time to reperfusion in our patient population. Methods We conducted a retrospective single‐center cohort study involving consecutive patients with acute ischemic stroke due to large and medium vessel occlusions. All patients were treated by a single operator between January 2020 and March 2023. Patients treated within the 18‐month period preceding the introduction of the Zoom aspiration catheters using traditional straight‐tip catheters were assigned to the straight‐tip group, while those treated with the Zoom aspiration catheters were assigned to the angled‐tip group. Our primary analysis was a cost comparison between the angled‐tip and straight‐tip groups using the list prices associated with each device employed in the procedures. The secondary analysis was focused on safety and procedural outcomes including self‐adjudicated modified Thrombolysis in Cerebral Infarction (mTICI) reperfusion scores and time from puncture to reperfusion. Frequencies were compared using the Fisher’s exact test and means were compared using a two‐sample t‐test. P‐values <0.05 were considered significant. Results A total of 163 patients were included, with 68 (41.7%) in the straight‐tip group and 95 (58.3%) in the angled‐tip group. There were no significant difference in age, sex, comorbidities, initial National Institutes of Health Stroke Scale score, access site, or procedure type between the two groups. However, utilization of the ADAPT thrombectomy technique was significantly higher in the angled‐tip group (55.9%, 38/68) compared to the straight‐tip group (13.7%, 13/95) which primarily used the Solumbra technique, p<0.001. Overall, the angled‐tip group demonstrated a significant decrease in mean procedure cost ($9,728 vs$12,127; p=0.002). Sub‐group analyses based on the procedure type showed that the angled‐tip group was associated with a numeric decrease in cost; however, due to the lower sample size statistical significance was not achieved (Table). The angled‐tip group was also associated with significantly shorter times to achieve mTICI ≥2B reperfusion (38.30 min vs 53.26 min; p=0.018), mTICI ≥2C reperfusion (45.09 min vs 58.74 min; p=0.042), and procedure completion (46.42 min vs 62.38 min; p=0.022). There were no significant differences in the overall rate of hemorrhage between the angled‐tip (17.9%) and straight‐tip groups (20.6%), p=0.690, though we did observe a numerical decrease in the rate of larger hemorrhages (HI2 and PH2) in the angled‐tip group (Table). Both groups achieve similar rates of mTICI ≥2B reperfusion. Conclusion The angled‐tip catheters were associated with a lower procedure cost and shorter time to achieve reperfusion. Similar rates of reperfusion and intracranial hemorrhages were observed in both groups

Impact of Age and Alberta Stroke Program Early Computed Tomography Score 0 to 5 on Mechanical Thrombectomy Outcomes: Analysis From the STRATIS Registry

Background and Purpose: This study investigates clinical outcomes after mechanical thrombectomy in adult patients with baseline Alberta Stroke Program Early CT Score (ASPECTS) of 0 to 5. Methods: We included data from the STRATIS Registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) from patients who underwent mechanical thrombectomy within 8 hours of symptom onset and had available ASPECTS data adjudicated by an independent core laboratory. Angiographic and clinical outcomes were collected, including successful reperfusion (modified Thrombolysis in Cerebral Infarction ≥2b), functional independence (modified Rankin Scale score 0–2), 90-day mortality, and symptomatic intracranial hemorrhage at 24 hours. Outcomes were stratified by ASPECTS scores and age. Results: Of the 984 patients enrolled, 763 had available ASPECTS data. Of these patients, 57 had ASPECTS of 0 to 5 with a median age of 63 years (interquartile range, 28–100), whereas 706 patients had ASPECTS of 6 to 10 with a median age of 70 years of age (interquartile range, 19–100). Ten patients had ASPECTS of 0 to 3 and 47 patients had ASPECTS of 4 to 5 at baseline. Successful reperfusion was achieved in 85.5% (47/55) in the ASPECTS of 0 to 5 group. Functional independence was achieved in 28.8% (15/52) in the ASPECTS of 0 to 5 versus 59.7% (388/650) in the 6 to 10 group ( P 75 years with ASPECTS of 0 to 5 (0/12) achieved functional independence versus 44.8% (13/29) of those age ≤65 ( P =0.005). Conclusions: Patients 75 years of age. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02239640

Cerebrovascular events and outcomes in hospitalized patients with COVID-19 : The SVIN COVID-19 Multinational Registry

Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients. To summarize the findings of a multinational observational cohort of patients with SARS-CoV-2 and cerebrovascular disease. Retrospective observational cohort of consecutive adults evaluated in the emergency department and/or admitted with coronavirus disease 2019 (COVID-19) across 31 hospitals in four countries (1 February 2020-16 June 2020). The primary outcome was the incidence rate of cerebrovascular events, inclusive of acute ischemic stroke, intracranial hemorrhages (ICH), and cortical vein and/or sinus thrombosis (CVST). Of the 14,483 patients with laboratory-confirmed SARS-CoV-2, 172 were diagnosed with an acute cerebrovascular event (1.13% of cohort; 1130/100,000 patients, 95%CI 970-1320/100,000), 68/171 (40.5%) were female and 96/172 (55.8%) were between the ages 60 and 79 years. Of these, 156 had acute ischemic stroke (1.08%; 1080/100,000 95%CI 920-1260/100,000), 28 ICH (0.19%; 190/100,000 95%CI 130-280/100,000), and 3 with CVST (0.02%; 20/100,000, 95%CI 4-60/100,000). The in-hospital mortality rate for SARS-CoV-2-associated stroke was 38.1% and for ICH 58.3%. After adjusting for clustering by site and age, baseline stroke severity, and all predictors of in-hospital mortality found in univariate regression (p < 0.1: male sex, tobacco use, arrival by emergency medical services, lower platelet and lymphocyte counts, and intracranial occlusion), cryptogenic stroke mechanism (aOR 5.01, 95%CI 1.63-15.44, p < 0.01), older age (aOR 1.78, 95%CI 1.07-2.94, p = 0.03), and lower lymphocyte count on admission (aOR 0.58, 95%CI 0.34-0.98, p = 0.04) were the only independent predictors of mortality among patients with stroke and COVID-19. COVID-19 is associated with a small but significant risk of clinically relevant cerebrovascular events, particularly ischemic stroke. The mortality rate is high for COVID-19-associated cerebrovascular complications; therefore, aggressive monitoring and early intervention should be pursued to mitigate poor outcomes