Bridging thrombolysis in atrial fibrillation stroke is associated with increased hemorrhagic complications without improved outcomes

BACKGROUND: Atrial fibrillation (AF) associated ischemic stroke is associated with worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Conversely, AF is not associated with hemorrhagic complications or functional outcomes in patients undergoing mechanical thrombectomy (MT). This differential effect of MT and IVT in AF associated stroke raises the question of whether bridging thrombolysis increases hemorrhagic complications in AF patients undergoing MT. METHODS: This international cohort study of 22 comprehensive stroke centers analyzed patients with large vessel occlusion (LVO) undergoing MT between June 1, 2015 and December 31, 2020. Patients were divided into four groups based on comorbid AF and IVT exposure. Baseline patient characteristics, complications, and outcomes were reported and compared. RESULTS: 6461 patients underwent MT for LVO. 2311 (35.8%) patients had comorbid AF. In non-AF patients, bridging therapy improved the odds of good 90 day functional outcomes (adjusted OR (aOR) 1.29, 95% CI 1.03 to 1.60, p=0.025) and did not increase hemorrhagic complications. In AF patients, bridging therapy led to significant increases in symptomatic intracranial hemorrhage and parenchymal hematoma type 2 (aOR 1.66, 1.07 to 2.57, p=0.024) without any benefit in 90 day functional outcomes. Similar findings were noted in a separate propensity score analysis. CONCLUSION: In this large thrombectomy registry, AF patients exposed to IVT before MT had increased hemorrhagic complications without improved functional outcomes, in contrast with non-AF patients. Prospective trials are warranted to assess whether AF patients represent a subgroup of LVO patients who may benefit from a direct to thrombectomy approach at thrombectomy capable centers

Wide-neck aneurysms: Systematic review of the neurosurgical literature with a focus on definition and clinical implications

OBJECTIVE Wide-necked aneurysms (WNAs) are a variably defined subset of cerebral aneurysms that require more advanced endovascular and microsurgical techniques than those required for narrow-necked aneurysms. The neurosurgical literature includes many definitions of WNAs, and a systematic review has not been performed to identify the most commonly used or optimal definition. The purpose of this systematic review was to highlight the most commonly used definition of WNAs. METHODS The authors searched PubMed for the years 1998.2017, using the terms gwide neck aneurysm h and gbroad neck aneurysm h to identify relevant articles. All results were screened for having a minimum of 30 patients and for clearly stating a definition of WNA. Reference lists for all articles meeting the inclusion criteria were also screened for eligibility. RESULTS The search of the neurosurgical literature identified 809 records, of which 686 were excluded (626 with \u3c 30 patients; 60 for lack of a WNA definition), leaving 123 articles for analysis. Twenty-seven unique definitions were identified and condensed into 14 definitions. The most common definition was neck size ≥ 4 mm or dome-to-neck ratio \u3c 2, which was used in 49 articles (39.8%). The second most commonly used definition was neck size ≥ 4 mm, which was used in 26 articles (21.1%). The rest of the definitions included similar parameters with variable thresholds. There was inconsistent reporting of the precise dome measurements used to determine the dome-to-neck ratio. Digital subtraction angiography was the only imaging modality used to study the aneurysm morphology in 87 of 122 articles (71.3%). CONCLUSIONS The literature has great variability regarding the definition of a WNA. The most prevalent definition is a neck diameter of . 4 mm or a dome-to-neck ratio of \u3c 2. Whether this is the most appropriate and clinically useful definition is an area for future study

High rates of conversion of anesthesia modality in agitated thrombectomy patients

Background: Patients with large vessel occlusion acute ischemic stroke (AIS) undergoing thrombectomy can be disruptively agitated. We aimed to determine if procedural and neurological outcomes differ for agitated patients. Methods: We reviewed prospectively collected data of AIS patients undergoing thrombectomy in our tertiary center between January 2014 and July 2017. We divided patients in two cohorts based on the presence of disruptive levels of agitation. We compared the baseline characteristics, procedural details and outcomes between the two cohorts. Results: A total of 156 patients were included, 60 (38.5%) were agitated. The agitated cohort had lower mean ASPECTS (8.3 vs 8.8, p 0.04); but other characteristics were well-matched (age, gender, premorbid mRS, occlusion side, NIHSS and tPA status). There was a trend for longer room arrival-to-recanalization times (87.1 vs 72.9 mins, p 0.09) and higher use of general anesthesia (GA) (35% vs 24%, p 0.14) in the agitated cohort (table 1). In the agitated cohort, pre-planned GA patients had longer arrival to recanalization times when compared with monitored anesthesia care (MAC) only patients (100.5 ± 73.0 vs 75.3 ± 49.8 mins). None of the non-agitated MAC patients required conversion to GA, however 11.6% of the agitated patients were converted to GA intra-procedurally, with the longest arrival-to-recanalization time (125.1 ± 68.7) (p 0.04). Other technical details (method of thrombectomy, number of passes, complications and degree of recanalization) and outcome measures (postoperative NIHSS or good neurological outcome at 90 days) were not different between groups. Conclusions: Agitated patients have a high incidence of conversion from MAC to GA resulting in delay in recanalization compared to pre-planned GA. Our study was limited by a small sample size and larger studies are necessary to elucidate the impact of agitation on outcome and whether there is role for pre-planned GA in agitated thrombectomy patients

Technical Success and Early Efficacy in 851 Patients with Saccular Intracranial Aneurysms: A Subset Analysis of SMART, a Prospective, Multicenter Registry Assessing the Embolization of Neurovascular Lesions using the Penumbra SMART COIL System

The Prospective, Multicenter Registry Assessing the Embolization of Neurovascular Lesions Using the Penumbra SMART COIL® System (SMART) is the largest prospective, multicenter, postmarket registry established to gather real-world experience on Penumbra (Alameda, USA) SMART COIL System, PC400, and POD embolization coils. The goal of this study is to report the technical success and efficacy of SMART COIL System coils in treating saccular intracranial aneurysms. This subgroup analysis from the SMART registry included patients with saccular intracranial aneurysms treated using ≥75% SMART COIL System or PC400 coils. Baseline and procedural data, angiographic data, and clinical outcomes were collected. Predictors of catheter kickout, packing density, and postprocedural angiographic outcome were analyzed using multivariable regression models in saccular aneurysm cases. Between June 2016 and August 2018, the SMART registry enrolled 995 patients at 68 sites, of which 851 of 995 (85.5%) were treated for saccular aneurysms (mean age, 59.9 years). Aneurysms had a mean size of 6.8 mm, were wide neck in 63.1%, and ruptured in 31.0% of patients. Mean aneurysm packing density was 32.3%. Postprocedural Raymond-Roy Occlusion Classification (RROC) I–II was achieved in 80.3% of patients; smaller aneurysms, non–wide-neck aneurysms, and high packing density were predictive of RROC I–II. Overall, mean fluoroscopic time was 43.4 minutes, rate of reaccess attempts because of catheter kickout was 6.2%, and mean procedure time was 83.2 minutes. SMART COIL System coils achieved good technical success and adequate occlusion in treating saccular intracranial aneurysms in a real-world setting

Outcomes of endovascular thrombectomy in the elderly: a ‘real-world’ multicenter study

BackgroundThe efficacy of endovascular thrombectomy (ET) for acute ischemic stroke (AIS) in octogenarians is still controversial.ObjectiveTo evaluate, using a large multicenter cohort of patients, outcomes after ET in octogenarians compared with younger patients.MethodsData from prospectively maintained databases of patients undergoing ET for AIS at seven US-based comprehensive stroke centers between January 2013 and January 2018 were reviewed. Demographic, procedural, and outcome variables were collected. Outcomes included 90-day modified Rankin Scale (mRS) score, postprocedural National Institutes of Health Stroke Scale score, postprocedural hemorrhage, and mortality. Univariate and multivariate analyses were performed to assess the independent effect of age ≥80 on outcome measures. Subgroup analyses were also performed based on location of stroke, success of recanalization, or ET technique used.ResultsRates of functional independence (mRS score 0–2) after ET in elderly patients were significantly lower than for younger counterparts. Age ≥80 was independently associated with increased mortality and poor outcome. Age ≥80 showed an independent negative prognostic effect on outcome even when patients were divided according to thrombectomy technique, location of stroke, or success of recanalization. Age ≥80 independently predicted higher rate of postprocedural hemorrhage, but not success of recanalization. Baseline deficit and number of reperfusion attempts, but not Thrombolysis in Cerebral Infarction score were associated with lower odds of good outcome.ConclusionThe large effect size of ET on AIS outcomes is significantly diminished in the elderly population when using comparable selection criteria to those used in younger counterparts. This raises concerns about the risk–benefit ratio and the cost-effectiveness of performing this procedure in the elderly before optimizing patient selection

Social media usage for neurointerventionalists: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee.

The purpose of this publication is to provide a review of social media usage by neurointerventionalists. Using published literature and available local, regional, and national guidelines or laws, we reviewed data on social media usage as it pertains to neurointerventional surgery. Recommendations are provided based on the quality of information and conformity of medico-legal precedent and law. Social media is a growing entity as it is used both promotionally and educationally. Neurointerventionalists may post de-identified radiographic images with discussions, but should be conscientious and adhere to applicable laws and regulations, strict ethical codes, and institutional policies