Cerebral Angiography Can Demonstrate Changes in Collateral Flow During Induced Hypertension

AbstractA 52-year-old woman with a large left-hemispheric stroke was transferred to our hospital for possible endovascular treatment. The patient underwent a cerebral angiogram at 7 hours after symptom onset with intent to treat and was found to have occlusion of the proximal M1-segment of the left middle cerebral artery (MCA). At that time it was felt that this was a high-risk patient for mechanical clot retrieval and it was decided to treat her with induced hypertension. The diagnostic catheter was left in place in the left internal carotid artery (ICA) and hypertension was induced in the angiography suite by means of an infusion of neosynephrine. Ten minutes after the goal blood pressure levels had been reached, a repeat left ICA injection was performed, which demonstrated more extensive collateralization of the MCA territory from anterior cerebral artery branches. Mean transit times (MTT) for the left ICA circulation improved from 9.5 seconds prior to induced hypertension to 6.0 seconds. The neosynephrine infusion was continued for a total of 24 hours and the patient showed neurological improvement. We suggest that induced hypertension led to the improved collateralization to the left MCA as evidenced by the improved MTT and augmentation of leptomeningeal collaterals, which in turn led to the patient's clinical improvement

Intracranial Angioplasty and Stent Placement After Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) Trial: Present State and Future Considerations

Objective: The results of prematurely terminated stenting and aggressive medical management for preventing recurrent stroke in intracranial stenosis (SAMMPRIS) due to excessively high rate of stroke and death in patients randomized to intracranial stent placement is expected to affect the practice of endovascular therapy for intracranial atherosclerotic disease. The purpose of this report is to review the components of the designs and methods SAMMPRIS trial and to describe the influence of those components on the interpretation of trial results. Methods: A critical review of the patient population included in SAMMPRIS is conducted with emphasis on "generalizability of results" and "bias due to cherry picking phenomenon." The technical aspects of endovascular treatment protocol consisting of intracranial angioplasty and stent placement using the Gateway balloon and Wingspan self-expanding nitinol stent and credentialing criteria of trial interventionalists are reviewed. The influence o

Pomona large vessel occlusion screening tool for prehospital and emergency room settings

Background: Early identification of patients with acute ischemic strokes due to large vessel occlusions (LVO) is critical. We propose a simple risk score model to predict LVO. Method: The proposed scale (Pomona Scale) ranges from 0 to 3 and includes 3 items: gaze deviation, expressive aphasia, and neglect. We reviewed a cohort of all acute stroke activation patients between February 2014 and January 2016. The predictive performance of the Pomona Scale was determined and compared with several National Institutes of Health Stroke Scale (NIHSS) cutoffs (≥4, ≥6, ≥8, and ≥10), the Los Angeles Motor Scale (LAMS), the Cincinnati Prehospital Stroke Severity (CPSS) scale, the Vision Aphasia and Neglect Scale (VAN), and the Prehospital Acute Stroke Severity Scale (PASS). Results: LVO was detected in 94 of 776 acute stroke activations (12%). A Pomona Scale ≥2 had comparable accuracy to predict LVO as the VAN and CPSS scales and higher accuracy than Pomona Scale ≥1, LAMS, PASS, and NIHSS. A Pomona Scale ≥2 had an accuracy (area under the curve) of 0.79, a sensitivity of 0.86, a specificity of 0.70, a positive predictive value of 0.71, and a negative predictive value of 0.97 for the detection of LVO. We also found that the presence of either neglect or gaze deviation alone had comparable accuracy of 0.79 as Pomona Scale ≥2 to detect LVO. Conclusion: The Pomona Scale is a simple and accurate scale to predict LVO. In addition, the presence of either gaze deviation or neglect also suggests the possibility of LVO