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

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

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Abstract Number: LBA8 Thin Cut Non‐Contrast Computed Tomography for Periprocedural Planning: Thrombus Burden Assessment Prior to Mechanical Thrombectomy

Introduction In patients presenting with acute ischemic stroke (AIS), non‐contrast CT (NCCT) and CT angiography (CTA) are used to determine large vessel occlusions (LVO). Using thin‐cut NCCT, hyperdense signs represent thrombus. NCCT provides information on thrombus characteristics such as length and morphology that is not evidenced by CTA. The aim of this study is to determine if hyperdense signs identified on thin‐cut NCCT are a valid tool in periprocedural planning for endovascular thrombectomy (EVT). Methods At our comprehensive stroke center, patients presenting with AIS who had thin‐cut NCCT defined as 0.625mm per slice followed by EVT and subsequent High Resolution Photographs (HRPs) of post‐EVT thrombus were identified. High‐resolution photographs were taken by operating physician with adjacent ruler for accurate measurement. Thin‐cut NCCT and associated fully extracted thrombus HRPs were reviewed by two board certified vascular neurologists to determine agreement. Cohen’s K was used to determine kappa inter‐rater agreement. Wilcoxon signed‐rank test was used to determine if significant difference existed between thrombus length and independently measured hyperdense sign. Social science statistics software was used for data analysis. Results From January 2019 to December 2021, out of 87 cases where thrombus was extracted after EVT, 57 met inclusion criteria and had associated initial CT head. Mean age was 68.22 (95% CI 64.26, 72.18), and 49% were female (n = 28). Mean thrombus length was 12.49mm (95% CI 10.19, 14.80). Mean hyperdense sign length measured by Interpreter 1 was 12.86mm (95% CI 10.54, 15.18). Mean hyperdense sign length measured by Interpreter 2 was 12.61mm (95% CI 10.40, 14.83). Kappa score was 1. There was no significant difference in thrombus length and Interpreter 1 hyperdense sign (z = 0.99; p‐value 0.317) or Interpreter 2 hyperdense sign (z = ‐0.92; p‐value = 0.36). Conclusions Our study suggests that in acute ischemic stroke patients, hyperdense sign on thin‐cut NCCT may be a valid reliable marker of thrombus length and morphology that assists in peri‐procedural planning for mechanical thrombectomy. Larger, prospective studies are needed to validate our results

Abstract 1122‐000150: Novel Ischemic Stroke Treatment Protocol for Salvageable Penumbra in Acute Small Vessel Disease

Introduction: In small vessel disease (SVD)‐related acute ischemic stroke (AIS), no specific acute treatment exists. We propose an acute treatment protocol for patients with fluctuating exam secondary to salvageable micropenumbra in high risk SVD‐related AIS. Methods: Inclusion criteria included acute SVD‐related stroke with NIHSS fluctuation ≥ 2 previously described as a sensitive indicator of neurological deterioration in SVD ischemic stroke. Patients with large vessel atheroma secondarily causing stroke were excluded. Treatment protocol consisted of albumin IV, eptifibatide IV, magnesium sulfate IV, cilostazol PO, normoglycemia, normothermia, aggressive fluid resuscitation, and targeted blood pressure parameters in a neurocritical care setting. Protocol was prospectively initiated in August 2020 at onset of exam fluctuation and continued until plateau NIHSS was reached. Retrospective data for subjects from January 2017 to July 2020 was collected for historical controls. Primary outcomes measures included safety and early efficacy end points. Efficacy was measured by change from maximum NIHSS to plateau NIHSS (NIHSS‐diff). Wilcoxon rank‐sum test was used to evaluate significant difference of NIHSS‐diff in both groups. Social Science Statistics was used for data analysis. Results: From January 2017 ‐ May 2021, out of 7,146 AIS patients, 30 met selection criteria. From August 2020 to May 2021, consecutive subjects received treatment protocol (n = 15, baseline NIHSS 4.93, 95% CI [3.3572, 6.5028]). They were compared with historical controls (n = 15, baseline NIHSS 5.87, 95% CI [2.9407, 8.7993]). There was no significant difference in baseline characteristics (p = 1; U = 112 at p<0.05; z‐score 0). In the SVD group, no subjects had adverse events leading to early termination. Early efficacy as suggested by NIHSS‐diff between groups was statistically significant (p = 0.00228; U = 38.5; z‐score 3.04864; 80% power at p<0.05). Conclusions: To our knowledge, this is the first systematic demonstration of safety and early efficacy of multimodal intervention for acute SVD‐related ischemic stroke. Larger randomized trials using concurrent controls are required to corroborate our findings