Echocardiography practice, training and accreditation in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS)

Echocardiography is increasingly used in the management of the critically ill patient as a non-invasive diagnostic and monitoring tool. Whilst in few countries specialized national training schemes for intensive care unit (ICU) echocardiography have been developed, specific guidelines for ICU physicians wishing to incorporate echocardiography into their clinical practice are lacking. Further, existing echocardiography accreditation does not reflect the requirements of the ICU practitioner. The WINFOCUS (World Interactive Network Focused On Critical UltraSound) ECHO-ICU Group drew up a document aimed at providing guidance to individual physicians, trainers and the relevant societies of the requirements for the development of skills in echocardiography in the ICU setting. The document is based on recommendations published by the Royal College of Radiologists, British Society of Echocardiography, European Association of Echocardiography and American Society of Echocardiography, together with international input from established practitioners of ICU echocardiography. The recommendations contained in this document are concerned with theoretical basis of ultrasonography, the practical aspects of building an ICU-based echocardiography service as well as the key components of standard adult TTE and TEE studies to be performed on the ICU. Specific issues regarding echocardiography in different ICU clinical scenarios are then described

How to WEB: a practical review of methodology for the use of the Woven EndoBridge.

Wide-necked bifurcation aneurysms (WNBAs) make up 26-36% of all brain aneurysms. Treatments for WNBAs pose unique challenges due to the need to preserve major bifurcation vessels while achieving a durable occlusion of the aneurysm. Intrasaccular flow disruption is an innovative technique for the treatment of WNBAs. The Woven EndoBridge (WEB) device is the only United States Food and Drug Administration approved intrasaccular flow disruption device. In this review article we discuss various aspects of treating WNBAs with the WEB device, including indications for use, aneurysm/device selection strategies, antiplatelet therapy requirement, procedural technique, potential complications and bailouts, and management strategies for residual/recurrent aneurysms after initial WEB treatment

Implications of limiting mechanical thrombectomy to patients with emergent large vessel occlusion meeting top tier evidence criteria

Background: Recent guidelines for endovascular management of emergent large vessel occlusion (ELVO) award top tier evidence to the same selective criteria in recent trials. We aimed to understand how guideline adherence would have impacted treatment numbers and outcomes in a cohort of patients from a comprehensive stroke center. Methods: A retrospective observational study was conducted using consecutive emergent endovascular patients. Mechanical thrombectomy (MT) was performed with stent retrievers or large bore clot aspiration catheters. Procedural outcomes were compared between patients meeting, and those failing to meet, top tier evidence criteria. Results: 126 patients receiving MT from January 2012 to June 2015 were included (age 31–89 years, National Institutes of Health Stroke Scale (NIHSS) score 2–38); 62 (49%) patients would have been excluded if top tier criteria were upheld: pretreatment NIHSS score 360 min (58%). 26 (42%) subjects had more than one top tier exclusion. Symptomatic intracerebral hemorrhage (sICH) and systemic hemorrhage rates were similar between the groups. 3 month mortality was 45% in those lacking top tier evidence compared with 26% (p=0.044), and 3 month mRS score 0–2 was 33% versus 46%, respectively (NS). After adjusting for potential confounders, top tier treatment was not associated with neurological improvement during hospitalization (β −8.2; 95% CI −24.6 to −8.2; p=0.321), 3 month mortality (OR=0.38; 95% CI 0.08 to 1.41), or 3 month favorable mRS (OR=0.97; 95% CI 0.28 to 3.35). Conclusions: Our study showed that with strict adherence to top tier evidence criteria, half of patients may not be considered for MT. Our data indicate no increased risk of sICH and a potentially higher mortality that is largely due to treatment of patients with basilar occlusions and those treated at an extended time window. Despite this, good functional recovery is possible, and consideration of MT in patients not meeting top tier evidence criteria may be warranted

Abstract 1122‐000138: De Novo Intracranial Stenosis after Mechanical Thrombectomy with Stent Retrievers

Introduction: Increased vascular damage with the use of stent‐retrievers (SR) has been shown on histopathological analysis of the vascular tissue immediately after mechanical thrombectomy (MT) in animal models. We hypothesized that intraoperative endovascular damage‐intimal injury could result in fibrosis and de novo vascular stenosis (dnVS). The purpose of the study is to identify de novo or worsening intracranial stenosis (wICS) of the treated vessel(s) on patients who underwent MT for the treatment of acute ischemic stroke with SR, on follow‐up vascular imaging (FVI). Methods: This was a retrospective chart review. Patients who underwent MT with SR at two centers from January 2015‐December 2020, who had FVI (CTA, MRA or cerebral angiogram) were included. Patient characteristics, procedural details, timing for FVI and clinical outcomes were collected. Two neuroradiologists reviewed baseline angiograms and FVI to assess for the presence of dnVS or wICS, and graded each stenosis and collateral scores (CS), when stenosis was present. CS were calculated using the multiphase CT angiography collateral score (mCTA). Fischer exact test and Mann‐Whitney U test were used to assess for differences in categorical and continuous variables, respectively. Statistical analysis was performed using SPSS 28.0 (IBM Corp.). Results: Forty‐six patients within this cohort had FVI with 9 patients developing dnVS or wICS in the follow‐up period (19.6%) with a median follow‐up of 113 days. Five of these patients demonstrated a complete occlusion of the target vessel on FVI. Of the remaining 4 patients, mean degree of stenosis was 55%. Only 2 of these patients had underlying stenosis on baseline post‐treatment angiogram: one with 44% stenosis which progressed to 95% in 2 months. Another with mild stenosis that progressed to complete occlusion in 50 days. Adequate revascularization, defined as TICI score >2b was achieved in 88.8% of patients with dnVS or wICS, and in 89.2% of patients with stable FVI. No significant differences were observed in baseline demographics, NIHSS score at presentation or initial ASPECTS. Median number of passes was identical between patients who developed dnVS or wICS (median 1, IQR [1, 2], p = 0.683). Mean CS for dnVS or wICS was 3. No significant differences were observed in discharge or follow‐up NIHSS scores, mRS, mortality, or recurrent stroke or TIA between the two cohorts. Conclusions: MT with SR can be associated with dnVS or wICS in some patients. The number of passes with SR did not seem to have an impact on this. Patients with dnVS or wICS did not have a higher incidence of recurrent stroke or TIA. This could be due to the development of new collaterals in this population. Our study is limited by a small cohort, however, larger studies might be challenging as standardized radiological follow up of these patients has not been implemented