Importance of Continuous Pulse Oximetry of the Ipsilateral Thumb/Index Finger during Transradial Angiography

We present a case of a 63-year-old male undergoing attempted basilar artery embolization using a right transradial artery approach in which continuous pulse oximetry of the ipsilateral thumb uncovered unanticipated hand ischemia during the procedure. A preprocedural evaluation using pulse oximetry of the right thumb demonstrated normal waveform and maintenance of normal oxygen saturation during manual compression of the right radial artery. This normal waveform and oxygen saturation was maintained after insertion of a 6Fr sheath into the radial artery. After insertion of a 6Fr guiding catheter into the right vertebral artery, near-complete dampening of the pulse oximetry waveform and precipitous decline in oxygen saturation were noted. Examination of the right hand demonstrated poor tissue perfusion. Immediate removal of the guiding catheter led to return of a normal waveform, oxygen saturation, and tissue perfusion. This case demonstrates the importance of continuous, intraprocedural monitoring of oxygenation of the ipsilateral hand during transradial angiography in order to avoid unanticipated perfusion abnormalities

Catheter design primer for neurointerventionalists

Neurovascular catheter technology has rapidly evolved over the past decade. While performance characteristics are well known to the practitioner, the design features of these new-generation catheters and their implications on performance metrics remain a mystery to most clinicians due to the limited number of available resources. This knowledge gap hampers informed device choices and also limits collaboration between clinicians and engineers. To aid fellow neurointerventionalists, in this primer we have summarized the basic concepts of catheter design and construction

The Effect of Mechanical Thrombectomy on the Incidence of Poststroke Cognitive Impairment: A Systematic Review of Inhomogeneous Literature

Introduction: The aim of this study was to evaluate the effect of mechanical thrombectomy (MT) on the incidence of poststroke cognitive impairment (PSCI) in anterior circulation stroke. Methods: Literature research was performed on PubMed/OVID/Cochrane CENTRAL for studies published in 2015-2022. A review of the references of the included papers was performed for further eligible articles. Clinical characteristics, NIHSS, dementia tests, and outcomes were recorded. The exclusion criteria were nonhuman and non-English. Studies qualities were assessed with MINORS/RoB2 and GRADE. A meta-analysis was performed using the standardized mean difference (Cohen's d) to measure effect size. Results: Four studies were included in the systematic review after screening 749 articles. No significant differences were found for age and gender (years: 66.70 +/- 11.14 vs. 67.59 +/- 10.11, p = 0.37; male 53.8% vs. 56.4%, p = 0.57). MT patients had a more severe stroke than that of the control group (NIHSS: 14.70 +/- 4.31 vs. 11.17 +/- 4.12; p < 0.0001). The control group consisted of medical therapy-alone patients in all studies. I-2 was 76.95%, and Q was 43.4%. MT patients have better performance in overall cognition (d = 0.33 [0.074-0.58]) and in several cognitive domains than in the control group (TMT-A, d = 0.37 [0.04-0.70]; TMT-B, d = 0.35 [0.12-0.58]; digit span test [backward], d = 0.61 [0.18-1.06]; colored progressive matrices, d = 0.48 [0.05-0.91]; Stroop test [word reading], d = 0.60 [0.17-1.03]; color naming, d = 0.51 [0.08-0.94]; Rey-Osterrieth Complex Figure [immediate recall], d = 0.79 [0.35-1.23]; Rey Auditory Verbal Learning Test [immediate recall], d = 0.79 [0.36-1.23]; delayed recall, d = 0.46 [0.035-0.89]; and MOCA, d = 0.46 [-0.04 to 0.96]). Medical therapy patients had a higher score in coping strategy than MT patients (COPE-28 acceptance, d = -1.00 [-1.53 to -0.48]). Conclusions: The incidence of PSCI is lower in MT patients than in the control group. (c) 2023 S. Karger AG, Base

MASTRO I: Meta-Analysis and Systematic Review of Thrombectomy Stent Retriever Outcomes: Comparing Functional, Safety and Recanalization Outcomes Between EmboTrap, Solitaire and Trevo in Acute Ischemic Stroke

Aims: Stent-retriever (SR) thrombectomy has demonstrated superior outcomes in patients with acute ischemic stroke compared with medical management alone, but differences among SRs remain unexplored. We conducted a Systematic Review/Meta-Analysis to compare outcomes between three SRs: EmboTrap®, Solitaire™, and Trevo®. Methods: We conducted a PRISMA-compliant Systematic Review among English-language studies published after 2014 in PubMed/MEDLINE that reported SRs in ≥25 patients. Functional and safety outcomes included 90-day modified Rankin scale (mRS 0-2), mortality, symptomatic intracranial hemorrhage (sICH), and embolization to new territory (ENT). Recanalization outcomes included modified thrombolysis in cerebral infarction (mTICI) and first-pass recanalization (FPR). We used a random effects Meta-Analysis to compare outcomes; subgroup and outlier-influencer analysis were performed to explore heterogeneity. Results: Fifty-one articles comprising 9,804 patients were included. EmboTrap had statistically significantly higher rates of mRS 0-2 (57.4%) compared with Trevo (50.0%, p = 0.013) and Solitaire (45.3%, p \u3c 0.001). Compared with Solitaire (20.4%), EmboTrap (11.2%, p \u3c 0.001) and Trevo (14.5%, p = 0.018) had statistically significantly lower mortality. Compared with Solitaire (7.7%), EmboTrap (3.9%, p = 0.028) and Trevo (4.6%, p = 0.049) had statistically significantly lower rates of sICH. There were no significant differences in ENT rates across all three devices (6.0% for EmboTrap, 5.3% for Trevo, and 7.7% for Solitaire, p = 0.518). EmboTrap had numerically higher rates of recanalization; however, no statistically significant differences were found. Conclusion: The results of our Systematic Review/Meta-Analysis suggest that EmboTrap may be associated with significantly improved functional outcomes compared with Solitaire and Trevo. EmboTrap and Trevo may be associated with significantly lower rates of sICH and mortality compared with Solitaire. No significant differences in recanalization and ENT rates were found. These conclusions are tempered by limitations of the analysis including variations in thrombectomy techniques in the field, highlighting the need for multi-arm RCT studies comparing different SR devices to confirm our findings

Outcomes of carotid artery stenting versus historical surgical controls for radiation-induced carotid stenosis

PurposeTo evaluate the outcomes of carotid artery stenting (CAS) and open surgical repair (OR) for treatment of radiation-induced carotid stenosis (RICS).MethodsWe retrospectively reviewed 60 patients treated for 73 RICSs from a group of 5,824 patients who had carotid interventions between 1992 and 2009. Thirty-three patients (37 arteries) were treated with CAS and 27 patients (36 arteries) with OR. CAS was performed using embolic protection as part of a prospective institutional registry since 2003. End-points included mortality, stroke, myocardial infarction (MI), cranial nerve injury (CNI), wound complication, restenosis, and reintervention.ResultsDemographics and cardiovascular risk factors were similar in both groups, with the exception of higher rates (P < .05) of hyperlipidemia (81% vs 56%) and coronary artery disease (63% vs 33%) in OR patients. There were more patients with tracheostomy (31% vs 4%) and time interval from irradiation to intervention was longer in the CAS group. There were no early deaths. At 30 days, OR was associated with one (3%) stroke, two (5.5%) MIs, six (17%) CNIs, and three (8%) wound complications. OR patients with prior radical neck dissections had more wound complications (14% vs 5%) and CNIs (28% vs 9%) compared with those without neck dissections. In the CAS group, there were two (6%) strokes and no MIs, CNIs, or wound complications. Mean length of hospital stay was longer after OR than CAS (4.1 ± 3.7 days vs 2.4 ± 2.1 days; P = .02). Median follow-up was 58 months. At 7 years, OR was associated with higher patient survival (75% ± 15% vs 29% ± 13%, P = .008) and freedom from neurological events (100% vs 57% ± 9.5%, P = .058), but similar freedom from restenosis (80% ± 10% vs 72% ± 9%) and reinterventions (87% ± 10% vs 86% ± 9%) compared with CAS.ConclusionCarotid artery stenting for radiation-induced stenosis has the advantages of no CNI or wound complications with similar early stroke rate compared with open carotid repair. However, the lower freedom from neurological events may offset the early benefits of carotid stenting in patients who are considered good candidates for open surgery

Screening for brain aneurysm in the Familial Intracranial Aneurysm study: frequency and predictors of lesion detection

Object Approximately 20% of patients with an intracranial saccular aneurysm report a family history of intracranial aneurysm (IA) or subarachnoid hemorrhage. A better understanding of predictors of aneurysm detection in familial IA may allow more targeted aneurysm screening strategies. Methods The Familial Intracranial Aneurysm (FIA) study is a multicenter study, in which the primary objective is to define the susceptibility genes related to the formation of IA. First-degree relatives (FDRs) of those affected with IA are offered screening with magnetic resonance (MR) angiography if they were previously unaffected, are ≥ 30 years of age, and have a history of smoking and/or hypertension. Independent predictors of aneurysm detection on MR angiography were determined using the generalized estimating equation version of logistic regression. Results Among the first 303 patients screened with MR angiography, 58 (19.1%) had at least 1 IA, including 24% of women and 11.7% of men. Ten (17.2%) of 58 affected patients had multiple aneurysms. Independent predictors of aneurysm detection included female sex (odds ratio [OR] 2.46, p = 0.001), pack-years of cigarette smoking (OR 3.24 for 20 pack-years of cigarette smoking compared with never having smoked, p < 0.001), and duration of hypertension (OR 1.26 comparing those with 10 years of hypertension to those with no hypertension, p = 0.006). Conclusions In the FIA study, among the affected patients’ FDRs who are > 30 years of age, those who are women or who have a history of smoking or hypertension are at increased risk of suffering an IA and should be strongly considered for screening

Nephrotoxicity of gadolinium-based contrast in the setting of renal artery intervention: retrospective analysis with 10-year follow-up

PURPOSE:We aimed to determine the incidence rate and potential risk factors for postcontrast acute kidney injury (PC-AKI) as well as the long-term clinical implications on dialysis and mortality in patients with chronic kidney disease (CKD) who underwent renal artery stent placement exclusively with gadolinium-based contrast agents.METHODS:This retrospective study reviewed 412 patients with CKD who underwent renal artery stent placement. Sixty-eight patients underwent intervention exclusively with gadolinium-based contrast agents and were analyzed. Criteria for PC-AKI included either an absolute serum creatinine increase >0.3 mg/dL or percentage increase in serum creatinine >50% within 48 hours of intervention. Logistic regression analysis was performed to identify risk factors for PC-AKI. The cumulative proportion of patients who died or went on to hemodialysis was determined using Kaplan-Meier survival analysis.RESULTS:The incidence of PC-AKI was 14.7%. The rate of AKI decreased for every 1 unit increase in glomerular filtration rate ( GFR, odds ratio [OR]=0.91, P = 0.047). Prehydration was associated with a lower PC-AKI rate (OR=0.17; P = 0.015). Acute kidney injury after intervention was associated with an increased rate of dialysis (Hazard ratio [HR]=4.51, P = 0.002) and mortality (HR=2.52; P = 0.027).CONCLUSION:Gadolinium-based contrast agents are potentially nephrotoxic when used for endovascular intervention in patients with CKD. The risk of PC-AKI increased with lower GFR and decreased with prehydration. Dialysis and mortality risk were increased in patients who developed PC-AKI

Orbit image analysis machine learning software can be used for the histological quantification of acute ischemic stroke blood clots

Our aim was to assess the utility of a novel machine learning software (Orbit Image Analysis) in the histological quantification of acute ischemic stroke (AIS) clots. We analyzed 50 AIS blood clots retrieved using mechanical thrombectomy procedures. Following HandE staining, quantification of clot components was performed by two different methods: a pathologist using a reference standard method (Adobe Photoshop CC) and an experienced researcher using Orbit Image Analysis. Following quantification, the clots were categorized into 3 types: RBC dominant (\u3e/=60% RBCs), Mixed and Fibrin dominant ( \u3e /=60% Fibrin). Correlations between clot composition and Hounsfield Units density on Computed Tomography (CT) were assessed. There was a significant correlation between the components of clots as quantified by the Orbit Image Analysis algorithm and the reference standard approach (rho = 0.944**, p \u3c 0.001, n = 150). A significant relationship was found between clot composition (RBC-Rich, Mixed, Fibrin-Rich) and the presence of a Hyperdense artery sign using the algorithmic method (X2(2) = 6.712, p = 0.035*) but not using the reference standard method (X2(2) = 3.924, p = 0.141). Orbit Image Analysis machine learning software can be used for the histological quantification of AIS clots, reproducibly generating composition analyses similar to current reference standard methods

Tenecteplase vs. alteplase for treatment of acute ischemic stroke: A systematic review and meta-analysis of randomized trials

Background and objectivesSeveral randomized controlled trials (RCTs) have compared tenecteplase to alteplase for treatment of acute ischemic stroke (AIS). Yet, there is no meta-analysis that includes the latest published RCTs of 2022. We sought to compare the safety and efficacy of tenecteplase vs. alteplase for the treatment of AIS through a meta-analysis of all published RCTs.MethodsA systematic literature review of the English language literature was conducted using PubMed, Web of Science, Scopus, and Embase. We included RCTs that focused on patients with AIS treated with tenecteplase and alteplase. Multiple reviewers screened through potential studies to identify the final papers included in our analysis. Following PRISMA guidelines, multiple authors extracted data to ensure accuracy. Data were pooled using a random-effects model.ResultsNine trials, with 3,706 patients, compared outcomes of patients treated with tenecteplase and alteplase for AIS. Both treatments resulted in comparable rates of modified Rankin Scale (mRS) 0–1 at 90 days (RR = 1.03; 95% CI = 0.97–1.10; P-value = 0.359) and mRS 0–2 at 90 days (RR = 1.03; 95% CI = 0.87–1.22; P-value = 0.749). There was no heterogeneity among included studies regarding mRS 0–1 rates (I2 = 26%; P-value = 0.211); however, there was significant heterogeneity in mRS 0–2 rates (I2 = 71%; P-value = 0.002). Similarly, rates of mortality (RR = 0.97; 95% CI = 0.81–1.16; P-value = 0.746) and symptomatic intracranial hemorrhage (sICH) rates (RR = 1.10; 95% CI = 0.75–1.61; P-value = 0.622) were comparable in both treatment groups. There was no significant heterogeneity among included studies in either mortality (I2 = 30%; P-value = 0.181) or sICH (I2 = 0%; P-value = 0.734) rates. Further analysis comparing dosing of tenecteplase (0.1, 0.25, 0.32, and 0.4 mg/kg) yielded no significant differences for any of the endpoints (mRS 0–1, mRS 0–2, sICH, and mortality) compared to alteplase.DiscussionBased on available evidence from completed RCTs, tenecteplase has proven similar safety and efficacy to alteplase for treatment of AIS