Thrombectomy for Large‐Vessel Occlusion With Pretreatment Intracranial Hemorrhage

Background Many patients treated with endovascular thrombectomy (EVT) in clinical practice would not have qualified for inclusion in the initial clinical trials demonstrating benefit for EVT, yet likely will benefit from reperfusion. One such subset for which data are sparse is patients with emergent large‐vessel occlusion and concomitant intracranial hemorrhage (ICH). The objective of this report is to document patients who underwent thrombectomy for large‐vessel occlusion in the presence of concomitant ICH and evaluate their clinical characteristics and outcomes. Methods We retrospectively reviewed prospectively collected patient records at 4 comprehensive stroke centers from 2012 to 2019. Patients were identified who had pre‐EVT ICH. Data collected included baseline patient demographics and laboratory values, stroke characteristics, ICH radiographic variables, antiplatelet/anticoagulant/thrombolytic medication use, and procedural factors. The primary safety outcome was any worsening of ICH on neuroimaging obtained 24 hours after EVT. Results Eight patients were identified who underwent thrombectomy with concomitant ICH. The mean age was 71.9 years (range, 37–90). Median National Institutes of Health Stroke Scale score was 25 (interquartile range, 16.5–28.8), and 5 (63%) received tissue plasminogen activator. All patients underwent EVT and had mTICI2B or greater reperfusion. In 7 patients (88%), the initial ICH remained stable on postprocedure imaging. In 1 patient who received intravenous antiplatelet agents during thrombectomy, the hemorrhagic transformation was radiographically increased but without clinical correlate or mass effect. Conclusions In a multi‐institution evaluation of 8 patients with ICH at the time of thrombectomy, 1 patient had radiographic worsening of hemorrhage, and no patient experienced clinical worsening related to hemorrhage progression. These findings suggest that thrombectomy may be safe in this population

Early mobilisation in critically ill COVID-19 patients: a subanalysis of the ESICM-initiated UNITE-COVID observational study

Background Early mobilisation (EM) is an intervention that may improve the outcome of critically ill patients. There is limited data on EM in COVID-19 patients and its use during the first pandemic wave. Methods This is a pre-planned subanalysis of the ESICM UNITE-COVID, an international multicenter observational study involving critically ill COVID-19 patients in the ICU between February 15th and May 15th, 2020. We analysed variables associated with the initiation of EM (within 72 h of ICU admission) and explored the impact of EM on mortality, ICU and hospital length of stay, as well as discharge location. Statistical analyses were done using (generalised) linear mixed-effect models and ANOVAs. Results Mobilisation data from 4190 patients from 280 ICUs in 45 countries were analysed. 1114 (26.6%) of these patients received mobilisation within 72 h after ICU admission; 3076 (73.4%) did not. In our analysis of factors associated with EM, mechanical ventilation at admission (OR 0.29; 95% CI 0.25, 0.35; p = 0.001), higher age (OR 0.99; 95% CI 0.98, 1.00; p ≤ 0.001), pre-existing asthma (OR 0.84; 95% CI 0.73, 0.98; p = 0.028), and pre-existing kidney disease (OR 0.84; 95% CI 0.71, 0.99; p = 0.036) were negatively associated with the initiation of EM. EM was associated with a higher chance of being discharged home (OR 1.31; 95% CI 1.08, 1.58; p = 0.007) but was not associated with length of stay in ICU (adj. difference 0.91 days; 95% CI − 0.47, 1.37, p = 0.34) and hospital (adj. difference 1.4 days; 95% CI − 0.62, 2.35, p = 0.24) or mortality (OR 0.88; 95% CI 0.7, 1.09, p = 0.24) when adjusted for covariates. Conclusions Our findings demonstrate that a quarter of COVID-19 patients received EM. There was no association found between EM in COVID-19 patients' ICU and hospital length of stay or mortality. However, EM in COVID-19 patients was associated with increased odds of being discharged home rather than to a care facility. Trial registration ClinicalTrials.gov: NCT04836065 (retrospectively registered April 8th 2021)

A rare marginal tentorial artery to ophthalmic artery anastomosis

We report a patient with a marginal tentorial artery to ophthalmic artery anastomosis. A middle-aged man presented with subarachnoid hemorrhage and underwent angiography, where selective microcatheter injection of the meningohypophyseal trunk and marginal tentorial artery revealed a collateral to the distal ophthalmic artery. The radiological findings, embryology behind ophthalmic artery anastomoses and the neurosurgical and neurovascular relevance are discussed

Patient perception of gamma knife stereotactic radiosurgery through twitter and instagram

Background: This study evaluated social media to better understand the patient experience regarding Gamma Knife stereotactic radiosurgery. Methods: Twitter and Instagram posts were queried to identify relevant posts. The initial search for Instagram posts and “tweets” tagged with “#gammaknife” or “@gammaknife” identified 1094 posts on Instagram and 1517 tweets. Nine-hundred seventy-three Instagram posts and 1453 tweets were eliminated that did not involve the patient's own experience. We coded for the number of Gamma Knife procedures that the patient had undergone, whether it was published before or after the patient's procedure, and for classified themes related to patients' experience with the procedure. Results: Thirty-eight of 48 (79.2%) tweets and 61 of 82 (74.4%) Instagram posts were related to patients' first experience. Fifty-eight percent of tweets and 65% of Instagram posts were published post-Gamma Knife treatment. The most common theme in Twitter and Instagram posts was the appearance of the Leksell head frame or the pin sites after treatment (17.2% and 48.8%, respectively). Other common themes included the recounting of personal history of present illness to followers and excitement about having a treatment plan. Conclusions: Social media provides a platform for patients to share their personal experiences and reactions to Gamma Knife radiosurgery. Keywords: Gamma knife, Patient experience, Social media, Stereotactic radiosurger

Angiographic Predictors of Outcomes After Balloon Test Occlusion

Background Balloon test occlusion (BTO) with adjunctive single‐photon emission computed tomography has been used to predict tolerance after permanent internal carotid artery occlusion. Anatomic characteristics of the cerebral circulation might predict BTO outcomes and identify patients susceptible to test failure. Methods We performed a single‐center retrospective analysis of patients who underwent internal carotid artery BTO from July 2013 to June 2020. Patients who passed the clinical BTO underwent single‐photon emission computed tomography imaging; technetium‐99m‐ethyl cysteinate dimer was injected intravenously after 15 to 30 minutes of occlusion and induced hypotension. The diameter of the vessels of the circle of Willis was measured angiographically. Single‐photon emission computed tomography imaging hypoperfusion severity was classified as none, mild, low intermediate, high intermediate, and severe. A threshold vessel diameter with most predicted accuracy for BTO failure was created using the Youden index. The threshold value was tested in a logistic regression for prediction of BTO failure and accuracy as represented with a receiver operator curve. Results Fifty‐seven patients underwent BTO. Neoplasia was the most common indication (n=43, 75%). Twelve (21.1%) patients failed the clinical BTO. Contralateral dominant vertebral artery (P=0.02), smaller anterior communicating artery (ACom; P=0.002), and ipsilateral posterior communicating artery (P=0.03) diameters were correlated with clinical BTO failure. Smaller ACom was most predictive with an area under the curve of 0.907. The Youden index identified an ACom diameter threshold of 1.1 mm, with a sensitivity of 91.7% and specificity of 77.8% (odds ratio, 0.026 [95% CI, 0.003–0.226]; receiver operating characteristic, 0.847) for predicting BTO failure. Patients with severe single‐photon emission computed tomography asymmetry had significantly smaller‐caliber ACom arteries (ACom median diameter, 0.95 versus 1.4 mm; P=0.0073). Conclusions Angiographic findings can be used to predict BTO results. A small ipsilateral posterior communicating artery, and more significantly, a small ACom (<1.1 mm) can be used to identify patients who are likely to fail BTO

More expansive horizons: a review of endovascular therapy for patients with low NIHSS scores

While the landmark 2015 stroke trials demonstrated that endovascular therapy (EVT) was superior to medical management for the treatment of acute ischemic stroke due to large vessel occlusion, the efficacy of EVT for patients presenting with a low NIHSS score remains undetermined. We conducted a review of the EVT low National Institutes of Health Stroke Scale (NIHSS) stroke literature, identifying 24 quantitative and six qualitative publications. Details of study designs and outcome were extracted and critically discussed.All identified qualitative studies were retrospective. There was significant study design heterogeneity, with 18 unique study designs between the 24 identified quantitative manuscripts. Study investigations included low NIHSS EVT feasibility (n=6), EVT versus best medical management (BMM; n=10), EVT versus intravenous therapy (IVT, n=3), and low NIHSS score versus high NIHSS score (n=3). From single-arm EVT feasibility studies, the reported ranges of modified Thrombolysis in Cerebral Infarction and symptomatic intracranial hemorrhage were 78–97% and 0–10%, respectively. The EVT versus BMM literature had heterogeneous results with 40% reporting benefit with EVT and 60% reporting neutral findings. None of the studies comparing EVT with IVT reported a difference between the two revascularization therapies. The four identified meta-analyses had incongruent inclusion criteria and conflicting results. Two randomized trials are currently investigating EVT in patients with a low NIHSS score. Selected meta-analyses do suggest a potential benefit of EVT over BMM; however, current and future randomized clinical trials will better elucidate the efficacy of EVT in this patient population

Ultra‐Early Functional Improvement After Stroke Thrombectomy – Predictors and Implications

Background Neurocritical care is routinely provided to patients post‐endovascular thrombectomy (EVT) for anterior large vessel occlusion strokes. We aim to study the relationship between immediate improvement in National Institutes of Health Stroke Scale (NIHSS) score on outcomes post‐EVT and potential implications for postprocedural care. Methods We performed a retrospective review of anterior circulation large vessel occlusion (internal carotid/proximal middle cerebral artery) patients undergoing EVT. Demographic, clinical, and imaging information was analyzed. Ultra‐early functional improvement (UEFI) was defined as NIHSS score <6 within 30 minutes of successful recanalization. We analyzed the incidence and predictors of UEFI, and explored reasons for neurological decline post‐UEFI. Results Of the 343 anterior large vessel occlusion patients undergoing EVT, mean age was 71 ± 15 and 46% were male. Mean NIHSS was 17 ± 6 and Time Last Known Well (TLKW) to arrival was 9 ± 11 hours. UEFI was observed in 23% (79/343) of patients. Independent predictors of UEFI included lower pretreatment NIHSS, favorable Alberta Stroke Program Early CT Score (ASPECTS), and lower admission systolic blood pressure. Rates of 90‐day‐modified Rankin scale 0–2 were higher (71% versus 33%, P<0.01) and the rate of mortality (8% versus 28%, P<0.01) was lower in the UEFI group compared with the non‐UEFI group. Amongst patients with UEFI, 1.3% (1/79) experienced increase in NIHSS by ≥4 points within 24 hours of EVT. This patient received thrombolysis, achieved TICI‐2B recanalization, and follow‐up neuroimaging revealed a parenchymal hemorrhage and an infarct volume of 44 mL. None of the patients with UEFI required continuous antihypertensive infusions. Conclusions Approximately 1‐in‐4 of anterior large vessel occlusion stroke patients undergoing EVT have an NIHSS score of <6 within 30 minutes of successful recanalization. Only 1% of them experience significant decline in neurological status within 24 hours of the procedure with the majority achieving functional independence at 90 days. The need for advanced neurocritical care should be reevaluated in these patients