Rescue stenting for failed mechanical thrombectomy procedures

Background: Mechanical thrombectomy (MT) has dramatically changed the natural history of acute ischemic stroke. The disease that was associated with high morbidity, mortality, and significant cost on the health care system became a treatable disease. One of the most important variables to improve outcomes is time to revascularize the ischemic tissue. Rescue stenting (RS) is an option for patients who fail MT. Methods: A retrospective chart review for patients who underwent a MT procedure and either failed (defined as TICI 0-2a) or required a RS from 2015 – 2019 composed the study population. IRB approval was obtained and the consent was waived due to the study design. Medical charts and imaging were reviewed for baseline characteristics, stroke characteristics, complications, and functional outcome. Comparison was performed between the rescue group and the failed group to analyze outcomes. Results: From 2015-2019, 96 patients failed a MT procedure, and 26 patients required an intracranial stent. Initial NIHSS scores were comparable between the groups, (16.1 ± 7.2 vs. 15.2 ± 8.0, p = 0.552). Patients received comparable pre-procedure care as indicated by similar rate of tPA administration (38.5% vs. 34.6%, p = 0.804) and symptom onset to procedure time (1043.5 ± 3556 vs. 1505.3 ± 5183, p = 0.652). While receiving an intracranial stent led to a longer procedure time (66.1 ± 43.4 vs. 86.6 ± 36.2, p = 0.040), patients receiving a stent had a reduced mortality (32 (36.0%) vs. 3 (12.0%), p = 0.027) and NIHSS at discharge (23.0 ± 14.7 vs. 14.5 ± 13.6, p = 0.034). In the RS group, 4 patients had symptomatic intracranial hemorrhage as opposed to 2 in the non-RS group (3.6% vs 15.4%, p = 0.08). Conclusion: Rescue stenting was associated with good outcomes as indicated by decreased mortality and NIHSS at discharge

Stroke Centers of Excellence in the United States: Certification, Access and Outcomes

Introduction: Stroke is a leading cause of morbidity, mortality and healthcare costs in the United States. Evidence suggests that certified stroke centers have improved patient outcomes relative to non-certified hospitals. Our study explains the process, associated cost, quality and geographic proclivities of different certifying organizations. Methods: Data was collected from published literature, information on certifying organizations’ websites and through direct communication with representatives of The Joint Commission (TJC), Det Norske Veritas and Germanischer Lloyd (DNV-GL), and Healthcare Facilities Accreditation Program (HFAP). Geographic mapping of thrombectomy capable centers and comprehensive stroke centers was performed with the ArcGIS online tool. Results: Among the three certifying organizations, standards for recognition as acute, primary, thrombectomy capable and comprehensive stroke centers are not standardized. At the time of this review, there were 1406 TJC-certified stroke centers, 241 DNV-GL certified stroke centers and 66 HFAP-certified stroke centers in the United States. Cost for certification was similar with price scaled by complexity of capabilities. Quality metrics revealed a significantly higher rate of tPA administration and shorter door-to-needle time for TJC and DNV-GL centers than HFAP. All primary stroke centers exhibited improved in-hospital, 30-day and 1-year mortality when compared to non-stroke centers. Discussion: Despite lack of standardization of criteria between organizations, certification provides a mechanism for ensuring hospitals deliver higher standards of stroke care. Understanding variations in quality and scope of different organizations enables targeting of at-risk regions to maximize access and availability of care

International Experience of Mechanical Thrombectomy During the COVID-19 Pandemic: Insights from STAR and ENRG

Background: In response to the COVID-19 pandemic, many centers altered stroke triage protocols for the protection of their providers. However, the effect of workflow changes on stroke patients receiving mechanical thrombectomy (MT) has not been systematically studied. Methods: A prospective international study was launched at the initiation of the COVID-19 pandemic. All included centers participated in the Stroke Thrombectomy and Aneurysm Registry (STAR) and Endovascular Neurosurgery Research Group (ENRG). Data was collected during the peak months of the COVID-19 surge at each site. Collected data included patient and disease characteristics. A generalized linear model with logit link function was used to estimate the effect of general anesthesia (GA) on in-hospital mortality and discharge outcome controlling for confounders. Results: 458 patients and 28 centers were included from North America, South America, and Europe. Five centers were in high-COVID burden counties (HCC) in which 9/104 (8.7%) of patients were positive for COVID-19 compared with 4/354 (1.1%) in low-COVID burden counties (LCC) (P<0.001). 241 patients underwent pre-procedure GA. Compared with patients treated awake, GA patients had longer door to reperfusion time (138 vs 100 min, P=<0.001). On multivariate analysis, GA was associated with higher probability of in-hospital mortality (RR 1.871, P=0.029) and lower probability of functional independence at discharge (RR 0.53, P=0.015). Conclusion: We observed a low rate of COVID-19 infection among stroke patients undergoing MT in LCC. Overall, more than half of the patients underwent intubation prior to MT, leading to prolonged door to reperfusion time, higher in-hospital mortality, and lower likelihood of functional independence at discharge.info:eu-repo/semantics/publishedVersio

Characteristics and Outcomes in Patients With COVID-19 and Acute Ischemic Stroke: The Global COVID-19 Stroke Registry

Recent case-series of small size implied a pathophysiological association between coronavirus disease 2019 (COVID-19) and severe large-vessel acute ischemic stroke. Given that severe strokes are typically associated with poor prognosis and can be very efficiently treated with recanalization techniques, confirmation of this putative association is urgently warranted in a large representative patient cohort to alert stroke clinicians, and inform pre- and in-hospital acute stroke patient pathways. We pooled all consecutive patients hospitalized with laboratory-confirmed COVID-19 and acute ischemic stroke in 28 sites from 16 countries. To assess whether stroke severity and outcomes (assessed at discharge or at the latest assessment for those patients still hospitalized) in patients with acute ischemic stroke are different between patients with COVID-19 and non-COVID-19, we performed 1:1 propensity score matching analyses of our COVID-19 patients with non-COVID-19 patients registered in the Acute Stroke Registry and Analysis of Lausanne Registry between 2003 and 2019. Between January 27, 2020, and May 19, 2020, 174 patients (median age 71.2 years; 37.9% females) with COVID-19 and acute ischemic stroke were hospitalized (median of 12 patients per site). The median National Institutes of Health Stroke Scale was 10 (interquartile range [IQR], 4-18). In the 1:1 matched sample of 336 patients with COVID-19 and non-COVID-19, the median National Institutes of Health Stroke Scale was higher in patients with COVID-19 (10 [IQR, 4-18] versus 6 [IQR, 3-14]), P=0.03; (odds ratio, 1.69 [95% CI, 1.08-2.65] for higher National Institutes of Health Stroke Scale score). There were 48 (27.6%) deaths, of which 22 were attributed to COVID-19 and 26 to stroke. Among 96 survivors with available information about disability status, 49 (51%) had severe disability at discharge. In the propensity score-matched population (n=330), patients with COVID-19 had higher risk for severe disability (median mRS 4 [IQR, 2-6] versus 2 [IQR, 1-4], P<0.001) and death (odds ratio, 4.3 [95% CI, 2.22-8.30]) compared with patients without COVID-19. Our findings suggest that COVID-19 associated ischemic strokes are more severe with worse functional outcome and higher mortality than non-COVID-19 ischemic strokes

Characteristics and Outcomes in Patients With COVID-19 and Acute Ischemic Stroke: The Global COVID-19 Stroke Registry.

Recent case-series of small size implied a pathophysiological association between coronavirus disease 2019 (COVID-19) and severe large-vessel acute ischemic stroke. Given that severe strokes are typically associated with poor prognosis and can be very efficiently treated with recanalization techniques, confirmation of this putative association is urgently warranted in a large representative patient cohort to alert stroke clinicians, and inform pre- and in-hospital acute stroke patient pathways. We pooled all consecutive patients hospitalized with laboratory-confirmed COVID-19 and acute ischemic stroke in 28 sites from 16 countries. To assess whether stroke severity and outcomes (assessed at discharge or at the latest assessment for those patients still hospitalized) in patients with acute ischemic stroke are different between patients with COVID-19 and non-COVID-19, we performed 1:1 propensity score matching analyses of our COVID-19 patients with non-COVID-19 patients registered in the Acute Stroke Registry and Analysis of Lausanne Registry between 2003 and 2019. Between January 27, 2020, and May 19, 2020, 174 patients (median age 71.2 years; 37.9% females) with COVID-19 and acute ischemic stroke were hospitalized (median of 12 patients per site). The median National Institutes of Health Stroke Scale was 10 (interquartile range [IQR], 4-18). In the 1:1 matched sample of 336 patients with COVID-19 and non-COVID-19, the median National Institutes of Health Stroke Scale was higher in patients with COVID-19 (10 [IQR, 4-18] versus 6 [IQR, 3-14]), P=0.03; (odds ratio, 1.69 [95% CI, 1.08-2.65] for higher National Institutes of Health Stroke Scale score). There were 48 (27.6%) deaths, of which 22 were attributed to COVID-19 and 26 to stroke. Among 96 survivors with available information about disability status, 49 (51%) had severe disability at discharge. In the propensity score-matched population (n=330), patients with COVID-19 had higher risk for severe disability (median mRS 4 [IQR, 2-6] versus 2 [IQR, 1-4], P&lt;0.001) and death (odds ratio, 4.3 [95% CI, 2.22-8.30]) compared with patients without COVID-19. Our findings suggest that COVID-19 associated ischemic strokes are more severe with worse functional outcome and higher mortality than non-COVID-19 ischemic strokes

Left Transradial Approach

The left transradial access has an essential role in the cerebrovascular armamentarium in limited indications. Access to the posterior circulation via the left vertebral artery is one of the main indications, in addition to cases that require bilateral access. It has several advantages such as using the nondominant hand, ergonomic when accessing through the anatomical snuffbox, and overcomes certain anatomical variations. This chapter will delve the advantages, limitations, and technical nuances of the left transradial approach

Intraoperative Transradial Angiogram

Intraoperative angiogram (IOA) is a valuable tool for cerebrovascular surgery. It confirms surgical outcomes for a variety of pathologies. It allows early identification of any residue or compromise of a parent vessel. This chapter will delve into the advantages, limitations, and technical nuances of IOA via a radial approach. IOA is a valuable tool for cerebrovascular surgery. IOA allows early diagnosis and identification of any residue and obviates the need for postoperative diagnostic angiogram. It confirms surgical outcomes for a variety of pathologies such as aneurysm occlusion and parent vessel patency, arteriovenous malformation resection, dural fistula ligation, bypass patency, and adequate carotid revascularization after endarterectomy. Though there are alternatives, such as indocyanine green fluorescence (ICGA) angiography, formal angiography remains the gold standard as it overcomes the limitations of ICGA. Femoral access has been the main approach for IOA with an excellent safety profile. Recently the radial approach has been gaining wide interest among neurointerventionalists, and there are several advantages for the radial approach over the femoral approach in IOA

On the Landau-Levich problem for a viscoplastic fluid

A systematic investigation of the Landau-Levich problem of a viscoplastic material (Carbopol 980 is presented). The validity of the Landau-Levich scaling is assessed via integral scale measurements of the width of the coating films thickness performed for various Carbopol concentrations in the presence and in the absence of wall slip. To gain a deeper insight into the physical origins of the experimentally observed deviations from the classical 2/3 scaling a full characterisation of the time resolved flow field around the moving solid is performed and the main differences of the viscoplastic flow patterns with respect to their Newtonian counterpart are highlighted. The experimental investigation is complemented by a preliminary asymptotic analysis performed within the framework of the Bingham model

Numerical Results on the Exploitation of Gold Nanostructures in Plastic Optical Fibers Based Plasmonic Sensors

The use of Nanostructured SPR sensors on Plastic Optical Fibers opens new challenges, because in an SPR sensor made by a continuous metal layer, the sensorâ\u80\u99s response is basically related to the metal properties at optical frequencies and to the waveguide characteristics. On the other hand, when a Nanostructured SPR sensor is used, the behavior is also related to the geometric parameters of the Nanostructures. Working on them it is potentially possible to tune the sensorâ\u80\u99s behavior. In this work the Authors present a numerical investigation in order to evaluate the behavior of two different SPR Nanostructured platforms, made by â\u80\u9clongâ\u80\u9d gold Nanorods, and comparing them to an SPR sensor with a continuous gold layer. The difference between these two Nanostructured platforms is the orientation of the Nanorods, with respect to the lightâ\u80\u99s propagation direction. The numerical results seem to indicate an increase of the sensitivity, when an SPR Sensor with long Nanorods is used, with respect to the sensor made by a continuous gold film, with some benefits