The Society of Vascular and Interventional Neurology (SVIN) Mechanical Thrombectomy Registry: Methods and Primary Results

Background A better understanding of real‐world practice patterns in the endovascular treatment for large vessel occlusion acute ischemic stroke is needed. Here, we report the methods and initial results of the Society of Vascular and Interventional Neurology (SVIN) Registry. Methods The SVIN Registry is an ongoing prospective, multicenter, observational registry capturing patients with large vessel occlusion acute ischemic stroke undergoing endovascular treatment since November 2018. Participating sites also contributed pre‐SVIN Registry data collected per institutional prospective registries, and these data were combined with the SVIN Registry in the SVIN Registry+ cohort. Results There were 2088 patients treated across 11 US centers included in the prospective SVIN Registry and 5372 in SVIN Registry+. In the SVIN Registry cohort, the median number of enrollments per institution was 160 [interquartile range 53–243]. Median age was 67 [58–79] years, 49% were women, median National Institutes of Health Stroke Scale 16 [10–21], Alberta stroke program early CT score 9 [7–10], and 20% had baseline modified Rankin scale (mRS)≥2. The median last‐known normal to puncture time was 7.7 [3.1–11.5] hours, and puncture‐to‐reperfusion was 33 [23–52] minutes. The predominant occlusion site was the middle cerebral artery‐M1 (45%); medium vessel occlusions occurred in 97(4.6%) patients. The median number of passes was 1 [1–3] with 93% achieving expanded Treatment In Cerebral Ischemia2b50–3 reperfusion and 51% expanded Treatment In Cerebral Ischemia3/complete reperfusion. Symptomatic intracranial hemorrhage occurred in 5.3% of patients, with 37.3% functional independence (mRS0–2) and 26.4% mortality rates at 90‐days. Multivariable regression indicated older age, longer last‐normal to reperfusion, higher baseline National Institutes of Health Stroke Scale and glucose, lower Alberta stroke program early CT score, heart failure, and general anesthesia associated with lower 90‐day chances of mRS0–2 at 90‐days. Demographic, imaging, procedural, and clinical outcomes were similar in the SVIN Registry+. A comparison between AHA Guidelines‐eligible patients from the SVIN Registry against the Highly Effective Reperfusion evaluated in Multiple Endovascular Stroke Trials study population demonstrated comparable clinical outcomes. Conclusions The prospective SVIN Registry demonstrates that satisfactory procedural and clinical outcomes can be achieved in real‐world practice, serving as a platform for local quality improvement and the investigation of unexplored frontiers in the endovascular treatment of acute stroke

Acute ischaemic stroke associated with SARS-CoV-2 infection in North America

BACKGROUND: To analyse the clinical characteristics of COVID-19 with acute ischaemic stroke (AIS) and identify factors predicting functional outcome. METHODS: Multicentre retrospective cohort study of COVID-19 patients with AIS who presented to 30 stroke centres in the USA and Canada between 14 March and 30 August 2020. The primary endpoint was poor functional outcome, defined as a modified Rankin Scale (mRS) of 5 or 6 at discharge. Secondary endpoints include favourable outcome (mRS ≤2) and mortality at discharge, ordinal mRS (shift analysis), symptomatic intracranial haemorrhage (sICH) and occurrence of in-hospital complications. RESULTS: A total of 216 COVID-19 patients with AIS were included. 68.1% (147/216) were older than 60 years, while 31.9% (69/216) were younger. Median [IQR] National Institutes of Health Stroke Scale (NIHSS) at presentation was 12.5 (15.8), and 44.2% (87/197) presented with large vessel occlusion (LVO). Approximately 51.3% (98/191) of the patients had poor outcomes with an observed mortality rate of 39.1% (81/207). Age \u3e60 years (aOR: 5.11, 95% CI 2.08 to 12.56, p\u3c0.001), diabetes mellitus (aOR: 2.66, 95% CI 1.16 to 6.09, p=0.021), higher NIHSS at admission (aOR: 1.08, 95% CI 1.02 to 1.14, p=0.006), LVO (aOR: 2.45, 95% CI 1.04 to 5.78, p=0.042), and higher NLR level (aOR: 1.06, 95% CI 1.01 to 1.11, p=0.028) were significantly associated with poor functional outcome. CONCLUSION: There is relationship between COVID-19-associated AIS and severe disability or death. We identified several factors which predict worse outcomes, and these outcomes were more frequent compared to global averages. We found that elevated neutrophil-to-lymphocyte ratio, rather than D-Dimer, predicted both morbidity and mortality

MRI findings in the diagnosis and monitoring of rasmussen's encephalitis Achados de RM no diagnóstico e monitorização da encefalite de Rasmussen

Rasmussen's encephalitis is a devastating syndrome of multifocal brain dysfunction and focal seizures. Magnetic resonance (MR) findings, associated with clinical data and electroencephalogram (EEG), may indicate the diagnosis and could be an indicative of prognosis. We studied 5 patients with Rasmussen's encephalitis, assessing clinical history and MR images. All patients had refractory focal seizures with a predominant motor component associated with hemispheric atrophy, that was proportional to severity of disease and neurological deficits in these patients. Gray and white matter abnormal signal on T2 MR images were found in patients who had hemiparesis. It was not related to the duration of the disease but to aggressiveness. MR proton spectroscopy in severe disease showed lactate and choline increase and decreased NAA, reflecting neuronal and axonal loss, gliosis and elevated membrane turnover and recent - crisis (not controlled). MR studies, in addition to help in diagnosis, may be useful for monitoring metabolic changes and progression of disease in Rasmussen's encephalitis.A encefalite de Rasmussen é uma devastadora síndrome com disfunção cerebral multifocal e convulsões focais. Achados de ressonância magnética (RM), associados aos dados clínicos e de eletrencefalograma (EEG), podem indicar o diagnóstico e podem ser indicativos de prognóstico. Foram estudados 5 pacientes com encefalite de Rasmussen, avaliando a história clínica e imagens de RM. Todos os pacientes apresentavam crises epilépticas focais refratárias com componente predominantemente motor associadas à atrofia hemisférica, que foi proporcional à gravidade da doença e déficits neurológicos nestes pacientes. Alteração da intensidade de sinal nas substâncias branca e cinzenta, nas sequências ponderadas em T2, foram encontradas nos pacientes com hemiparesia. Ela não estava relacionada com a duração da doença, mas à severidade. A espectroscopia de prótons por RM na doença severa demonstrou aumento dos níveis de colina e lactato e diminuição de N-acetilaspartato, refletindo perda neuronal e axonal, gliose e aumento de turnover de membrana e crise recente (não controlada). Estudos de RM, além de ajudar no diagnóstico, podem ser úteis para acompanhar alterações metabólicas e progressão da doença na encefalite de Rasmussen

Abstract Number ‐ 8: HEMERA 1 CarboxyHEMoglobin OxygEn delivery for Revascularization in Acute Stroke: Phase 1 Clinical Trial

Introduction Despitehigh rates ofrecanalizationafter mechanical thrombectomy(MT),only 33–71% of patients achieve functional independence at 90 days.Experimental ischemia hashighlightedthe complexity of several pathophysiological events occurring at the level of the neurovascular unit and has revealed potential targets for neuroprotection. Apossible target is to increasebloodflow in the collateral circulationwhile delivering high levels of oxygen in the ischemic area.Hemoglobin based oxygen carriers (HBOC) as a transfusion media that can treat ischemic tissue have been investigatedfor a decade. More recently, a polyethylene glycol modifiedHBOCin the carboxy state (PP‐007)increases blood flow in the collateral circulationinrat modelsof middle cerebral artery occlusion (MCAO).PP‐007 may deliver more oxygen than Hb contained in RBCs because of increased diffusional surface area in plasma, and by facilitation of oxygen transport from RBC to endothelium.In addition,dilation ofcollateral circulationby diffusion of CO mayslow down infarct expansion andimprove the efficacy of reperfusion. Methods HEMERA 1 is a phase 1 safety clinical trialof PP‐007 in patient with acute ischemic strokewith LVO (ClinicalTrials.gov NCT04677777). Inclusion criteria are patients with Intracranial ICA and/or MCA‐M1 or M2 occlusion,baseline NIHSS ≥ 6, Baseline ASPECTS score ≥ 5 on NCCT and/or Core Volumes 50mL on CT perfusion (CTP), time fromlast seen well to start ofPP‐007infusion ≤ 24 hours,pre‐MorbidmRS< 2, and ineligibility for intravenous thrombolysis. The trial plans to enroll approximately 16–20 subjectswith3:1 randomizationtoPP‐007 (320 mg/kg with 30 min bolus + 2‐hour infusion) plus MT versus MT alone. Results Tenpatients have been enrolled so far.Mean age was 76.1 (STD±11.6), ASPECT score = 7.8 (±1.8), NIHSS at baseline = 17.3 (±5.6),TICI 2b or c in 7, TICI 3 in 3. Seven patients were randomized PP‐007 and received the complete infusion. Two patients were randomized to standard of care (MT only) and1was randomized to PP‐007 but not treated.Three patients had elevation of Partial Prothrombin Time (PTT) after the PP‐007 infusion that however had no clinical consequences. Conclusions HEMERA 1 isphase 1 clinical trialcurrently enrolling patients.No safety concerns were identified so far

Treatment of complex anterior cerebral artery aneurysms with Pipeline flow diversion: mid-term results

BACKGROUND: The off-label use of flow diverters in the treatment of distal aneurysms continues to be debated. OBJECTIVE: To report our multicenter experience in the treatment of complex anterior cerebral artery aneurysms with the Pipeline embolization device (PED). METHODS: The neurointerventional databases of the four participating institutions were retrospectively reviewed for aneurysms treated with PED between October 2011 and January of 2016. All patients treated for anterior cerebral artery aneurysms were included in the analysis. Clinical presentation, location, type, vessel size, procedural complications, clinical and imaging follow-up were included in the analysis. RESULTS: Twenty patients (13 female) with 20 aneurysms met the inclusion criteria in our study. Fifteen aneurysms were classified as saccular and five as fusiform (mean size 7.3 mm). Thirteen aneurysms were located in the anterior communicating region (ACOM or A1/2 junction), six were A2-pericallosal, and one was located in the A1 segment. Six patients had presented previously with subarachnoid hemorrhage and had their aneurysms initially clipped or coiled. There was one minor event (a small caudate infarct) and one major event (intraparenchymal hemorrhage). Sixteen of the 20 patients had angiographic follow-up (mean 10 months). Eleven aneurysms were completely occluded, one had residual neck, and four had residual aneurysm filling. CONCLUSIONS: The treatment of complex anterior cerebral artery aneurysms with the PED as an alternative for patients who are not good candidates for conventional methods is technically feasible and safe. Mid-term results are promising but larger series with long-term follow-up are required to assess its effectiveness

Mechanical thrombectomy decision making and prognostication: Stroke treatment Assessments prior to Thrombectomy In Neurointervention (SATIN) study

Background Mechanical thrombectomy (MT) is the standard-of-care treatment for stroke patients with emergent large vessel occlusions. Despite this, little is known about physician decision making regarding MT and prognostic accuracy. Methods A prospective multicenter cohort study of patients undergoing MT was performed at 11 comprehensive stroke centers. The attending neurointerventionalist completed a preprocedure survey prior to arterial access and identified key decision factors and the most likely radiographic and clinical outcome at 90 days. Post hoc review was subsequently performed to document hospital course and outcome. Results 299 patients were enrolled. Good clinical outcome (modified Rankin Scale (mRS) score of 0–2) was obtained in 38% of patients. The most frequently identified factors influencing the decision to proceed with thrombectomy were site of occlusion (81%), National Institutes of Health Stroke Scale score (74%), and perfusion imaging mismatch (43%). Premorbid mRS score determination in the hyperacute setting accurately matched retrospectively collected data from the hospital admission in only 140 patients (46.8%). Physicians correctly predicted the patient’s 90 day mRS tertile (0–2, 3–4, or 5–6) and final modified Thrombolysis in Ischemic Cerebral Infarction score preprocedure in only 44.2% and 44.3% of patients, respectively. Clinicians tended to overestimate the influence of occlusion site and perfusion imaging on outcomes, while underestimating the importance of pre-morbid mRS. Conclusions This is the first prospective study to evaluate neurointerventionalists’ ability to accurately predict clinical outcome after MT. Overall, neurointerventionalists performed poorly in prognosticating patient 90 day outcomes, raising ethical questions regarding whether MT should be withheld in patients with emergent large vessel occlusions thought to have a poor prognosis