Carotid Artery Stenting and Its Impact on Cognitive Function: A Prospective Observational Study

Purpose Carotid artery stenting (CAS) has evolved as a first-line therapeutic option for carotid revascularization in indicated patients for stroke prevention, but there is still a lack of data on its effect on cognitive function (CF), especially among Indian patients. To determine the effect of CAS on CF and to study the immediate and delayed complications of CAS in Indian patients. Materials and Methods This was a prospective, observational, single-center study. CF was assessed using Addenbrooke’s cognitive examination version III (ACE) before and 3 months after stenting. The demographic and clinical parameters were also assessed. A follow-up evaluation after 3 months was done to compare CF and to observe the occurrence of any complications. Results Out of 31 patients, 3 were lost to follow up. There were no immediate or delayed procedure-related complications. There was a statistically significant improvement in overall ACE score and memory before and after stenting. On subgroup analysis of those with and without strokes, there was a significant improvement in visuospatial function and mean ACE score. Those with left CAS had significant improvement in memory, visuospatial, language, and ACE scores than right CAS. Conclusion CAS was associated with significant improvement in CF in patients

Decline in subarachnoid haemorrhage volumes associated with the first wave of the COVID-19 pandemic

BACKGROUND: During the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study\u27s objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines. METHODS: We conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March-31 May 2020. The prior 1-year control period (1 March-31 May 2019) was obtained to account for seasonal variation. FINDINGS: There was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI -24.3% to -20.7%, p\u3c0.0001). Embolisation of ruptured aneurysms declined with 1170-1035 procedures, respectively, representing an 11.5% (95%CI -13.5% to -9.8%, p=0.002) relative drop. Subgroup analysis was noted for aneurysmal SAH hospitalisation decline from 834 to 626 hospitalisations, a 24.9% relative decline (95% CI -28.0% to -22.1%, p\u3c0.0001). A relative increase in ruptured aneurysm coiling was noted in low coiling volume hospitals of 41.1% (95% CI 32.3% to 50.6%, p=0.008) despite a decrease in SAH admissions in this tertile. INTERPRETATION: There was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction

Rapid processing of perfusion and diffusion for ischemic strokes in the extended time window: An Indian experience

Background: Endovascular treatment of acute ischemic stroke with large-vessel occlusion is the standard of care now. Initially restricted to 6 h after onset, the treatment can now be offered to selected patients up to 24 h based on clinical and imaging criteria. Objective: Perfusion imaging can help in identifying patients who may benefit from endovascular treatment in the extended time window. Manual analysis of perfusion images is time and skill intensive. Rapid processing of perfusion and diffusion (RAPID) is an automated image analysis system that analyzes perfusion maps. We report our initial experience of using this system in selection of patients for endovascular stroke treatment. Methods: All patients who presented with acute stroke underwent baseline imaging with computed tomography (CT) and CT angiogram or magnetic resonance imaging (MRI) and MR angiogram. Patients presenting between 6 and 24 h after onset underwent perfusion imaging, which was analyzed by RAPID. The results were used to select the patients who then underwent mechanical thrombectomy. Results: RAPID results identifying ischemic core and hypoperfused tissue were available within 5 min in each of the three cases. At 3 months, all patients showed improvement in the modified Rankin Scale. Conclusion: In extended time windows, RAPID provides a fast and reliable estimate of salvageable brain tissue to help select patients for endovascular treatment

Mechanical device the Penumbra system in the management of acute stroke: Report of five cases

Use of mechanical devices in acute ischemic stroke has shown promise not only in recanalization rates but also with better clinical outcome and also extension of the window period to 8 hours. This is the first reported series of use of mechanical devices in India. We report five patients with acute stroke in whom mechanical devices (Penumbra System, Alameda, California) were used for thrombolysis. All the treated vessels (100%) were successfully re-canalized, Trials In Myocardial Infarction (TIMI) score of 3. At 90-day follow-up, of the 5 patients treated, 2 had modified Rankin score (mRS) of < 2. This small series shows the safety and efficacy of the Penumbra System in the thrombolysis of large vessel occlusive disease

Unusual complication of coronary angiogram: Spinal epidural hematoma

AbstractCoronary angiogram is considered a relatively safe procedure but unusual complications do occur. Such an unusual case was happened post radial artery approach angiogram leading to severe co-morbidity to patient. We are reporting this case of a female patient who developed acute spinal epidural hematoma two hours after coronary angiogram

Intra-arterial thrombolysis in acute ischemic stroke: A single center experience

Intra-arterial thrombolysis (IAT) is a treatment modality in patients with acute large vessel occlusive ischemic stroke. To our knowledge, this is probably the first reported study of intra-arterial thrombolysis in acute ischemic stroke from India. Of the 17 patients treated who recieved IAT, successful recanalization was achieved in nine patients, Thrombolysis in Myocardial Infarction (TIMI) score of 2 or 3. At 90-day follow-up, eight patients achieved modified Rankin Scale (mRS) score of < 2

Thrombolysis in acute ischemic stroke: Experience from a tertiary care centre in India

The management of acute ischemic stroke has undergone a sea of change with the introduction of intravenous thrombolysis (IVT). Current guidelines state that the window period for IVT using rTPA is 4.5 hours. The MERCI, Multi Merci, and Penumbra trials in which patients with acute ischemic stroke were treated using endovascular treatment demonstrated better recanalisation in patients having a large vessel occlusion. However, recently published data from the three large trials IMS 3, Synthesis Expansion, and MR rescue, which compared endovascular treatment with intravenous therapy, failed to demonstrate superiority of endovascular treatment over IVT. In these trials, stent retrievers were used in very few patients. We present our results from a tertiary care center in India where patients are treated using intravenous as well as endovascular modalities. Among the 53 patients with acute ischemic stroke treated between 2010 and 2012, 23 were treated with IVT and 30 with endovascular methods. Stent retriever was used in majority of the endovascular cases. Aims: To compare the outcomes of acute ischemic stroke patients treated with IVT versus those who were managed using endovascular therapy. To evaluate outcomes of patients with acute ischemic stroke with a large vessel occlusion in whom endovascular modalities were used and to compare them with those of patients who were treated with IVT in presence of a large vessel occlusion. Settings and Design: Data of patients who underwent thrombolysis at our centre was collected over a 3-year period, that is, from 2010 to 2012. Endovascular treatment was done by an interventional neurologist. Materials and Methods: Data of patients with acute ischemic stroke who underwent IVT or endovascular treatment at our centre between 2010 and 2012 was analyzed. Parameters included age, National Institutes of Health Stroke Scale (NIHSS) on admission, door to needle time, stroke subtype, modality of treatment, outcome based on modified Rankin Scale (mRS) Score at 90 days follow up and mortality rates at 90 days. Statistical Analysis: Tabulated results were analysed using INSTAT Graphpad analyser. Data were analysed using paired and unpaired t-test, Chi-square test, and Fishers test as applicable. P value was considered significant when it was <0.05. Results: Upon comparison of the outcomes of patients with acute ischemic stroke and large vessel disease treated with endovascular therapy with those treated with IVT, it was found that the former group had better outcomes. We also found that in spite of there being a significant difference in the NIHSS on admission and a significant difference in the door to needle time, the outcomes of patients treated using intravenous or endovascular therapy were similar. There was no statistically significant difference in mortality rates between intravenous and endovascular groups. Conclusions: IVT is currently the standard of care in the management of acute ischemic stroke. Endovascular treatment during the window period is reserved for those patients with contraindication to IVT. In this study, we found that patients with documented large vessel disease with no evidence of cross flow through Willisian collaterals benefit from endovascular treatment. We recommend that all patients of acute ischemic stroke, be subjected to a baseline angiogram either computed tomography (CT) or magnetic resonance imaging (MRI) to document vessel status. This will help in identifying patients who may benefit from early endovascular treatment, if they fail to improve with IVT. Further, large trials using stent retrievers are needed, to prove that endovascular treatment is superior to IVT, in presence of documented large vessel disease