Endovascular Cure of a Locked-In Patient

We report the case of a 60 year-old right-handed gentleman who became acutely “Locked-In” several days after a lower extremity orthopedic procedure. He underwent emergent endovascular treatment and had complete resolution of his neurologic findings except for mild dysarthria and dysphagia. Endovascular intervention for posterior circulation thrombosis is highly effective when patients are treated within 24 hours

Understanding Neurosurgery Through Experimental and Computer Models

Endovascular neurosurgery is an evolving field, with the goal of treating neurological disease with minimal invasion of the body. The current approach is to deliver focused therapies via catheters traveling through the vascular tree. Refinement and advancement of these techniques requires not just new ideas, but new ideas that hold up when tested through the scientific method. Before clinical trials can begin, ethics and law demand that the ideas are tested first under experimental models. One benefit of these pre-clinical tests is the early identification of side effects. Another is the opportunity to practice and polish surgical technique in advance of human surgery. Historically, the best models of human systems have been similar systems in appropriate animals. Like human care, animal use is governed by strict laws and regulations. Violating these rules can not only result in criminal penalties, they can also make the research worthless: an animal poorly cared for may have physical symptoms that mask or confound the response to treatment. As computing power has increased, mathematical models have become more popular. The advantages of computational models include relative costs and relative speed. No animals, drugs or equipment have to be purchased, just a computer and software. The disadvantage is that the computational model can only represent those aspects of the modeled system that are understood and quantifiable. This article is an overview of how both animal and computational models have been used to approximate neurovascular conditions by researchers seeking to explore treatment options

Delayed presentation of acute ischemic strokes during the COVID-19 crisis

This article is made available for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.Background: The COVID-19 pandemic has disrupted established care paths worldwide. Patient awareness of the pandemic and executive limitations imposed on public life have changed the perception of when to seek care for acute conditions in some cases. We sought to study whether there is a delay in presentation for acute ischemic stroke patients in the first month of the pandemic in the US. Methods: The interval between last-known-well (LKW) time and presentation of 710 consecutive patients presenting with acute ischemic strokes to 12 stroke centers across the US were extracted from a prospectively maintained quality database. We analyzed the timing and severity of the presentation in the baseline period from February to March 2019 and compared results with the timeframe of February and March 2020. Results: There were 320 patients in the 2-month baseline period in 2019, there was a marked decrease in patients from February to March of 2020 (227 patients in February, and 163 patients in March). There was no difference in the severity of the presentation between groups and no difference in age between the baseline and the COVID period. The mean interval from LKW to the presentation was significantly longer in the COVID period (603±1035 min) compared with the baseline period (442±435 min, P<0.02). Conclusion: We present data supporting an association between public awareness and limitations imposed on public life during the COVID-19 pandemic in the US and a delay in presentation for acute ischemic stroke patients to a stroke center

A Review of Size and Location of Ruptured Intracranial Aneurysms

ABSTRACT OBJECTIVE To review our experience and examine the size at which aneurysms ruptured in our patient population. METHODS Patient charts and angiograms for all patients admitted with a diagnosis of subarachnoid hemorrhage to the Thomas Jefferson/Wills Eye Hospital between April 1996 and March 2000 were reviewed. RESULTS Of the 362 cases reviewed, definite measurements of the ruptured aneurysm were obtained in 245. The data clearly showed that most ruptured aneurysms presenting to our institution were less than 10 mm in diameter. We found that, regardless of location on the circle of Willis, 85.6% of all aneurysms presenting with rupture were less than 10 mm. Review by location shows that aneurysms of the anterior communicating artery most often presented with rupture at sizes less than 10 mm (94.4%). A large number of ruptured posterior communicating artery aneurysms also presented at sizes less than 10 mm (87.5%). This trend continued for all aneurysm sites in our review. The incidence of subarachnoid hemorrhage in Western countries is estimated at 10 per 100,000 people per year. Recent reports have indicated that aneurysms less than 10 mm in size are unlikely to rupture. CONCLUSION We argue that the risk of small aneurysms rupturing is not insignificant, especially those of the anterior communicating artery. Our findings indicate that surgery on unruptured aneurysms should not be predicated on aneurysm size alone

Mechanisms of Endothelial Cell Attachment, Proliferation, and Differentiation on 4 Types of Platinum-Based Endovascular Coils

Objective: A subarachnoid hemorrhage is neurologically devastating, with 50% of patients becoming disabled or deceased. Advent of Guglielmi detachable coils in 1995 permitted endovascular treatment of cerebral aneurysms. Coiling is efficacious and safe, but durability needs improvement, as nearly 20% of patients require further invasive intervention secondary to aneurysm recurrence. The aim of this study is to develop an in vitro model of endothelial cell (EC) proliferation and differentiation on four types of platinum-based coils, using gene expression profiling to understand EC biology as they colonize and differentiate on coils. Methods: Human umbilical vein ECs were grown in vitro on platinum coil segments. Growth patterns were assessed as a function of coil type. Gene expression profiles for coil attached versus coil unattached ECs were determined using immunohistochemistry and gene array analysis. Results: ECs showed rapid, robust attachment to all coil types. Some detachment occurred within 24-48 hours. Significant growth of remaining attached cells occurred during the next week, creating a confluence on coils and within coil grooves. Similar growth curve results were obtained with human brain ECs on platinum-based coil surfaces. Differentiation markers in attached cells (α1, α2, β1 integrins) were expressed on immunostaining, whereas microarray gene expression revealed 48 up-regulated and 68 down-regulated genes after 24-hour growth on coils. Major pathways affected as a function of time of colonization on coils and coil type included those involved in regulation of cell cycle and cell signaling. Conclusions: We developed an in vitro model for evaluating endothelialization of platinum coils to optimize coil design to support robust EC colonization and differentiation. © 2014 Elsevier Inc. All rights reserved

Safety and feasibility of an early mobilization program for patients with aneurysmal subarachnoid hemorrhage.

BACKGROUND: Survivors of aneurysmal subarachnoid hemorrhage (SAH) are faced with a complicated recovery, which typically includes surgery, prolonged monitoring in the intensive care unit, and treatment focusing on the prevention of complications. OBJECTIVE: The purpose of this study was to determine the safety and feasibility of an early mobilization program for patients with aneurysmal SAH. DESIGN: This study was a retrospective analysis. METHODS: Twenty-five patients received early mobilization by a physical therapist or an occupational therapist, or both, which focused on functional training and therapeutic exercise in more progressively upright positions. Participation criteria focused on neurologic and physiologic stability prior to the initiation of early mobilization program sessions. RESULTS: Patients met the criteria for participation in 86.1% of the early mobilization program sessions attempted. Patients did not meet criteria for the following reasons: Lindegaard ratio \u3e3.0 or middle cerebral artery (MCA) mean flow velocity (MFV) \u3e120 cm/s (8.1%), mean arterial pressure (MAP)(1.8%), intracranial pressure (ICP) \u3e15 mm Hg (1.8%), unable to open eyes in response to voice (0.9%), respiratory rate \u3e40 breaths/min (0.6%), MAP \u3e110 mm Hg (0.3%), and heart rate(0.3%). Adverse events occurred in 5.9% of early mobilization program sessions for the following reasons: MAP(3.1%) or \u3e120 mm Hg (2.4%) and heart rate \u3e130 bpm (0.3%). The 30-day mortality rate for all patients was 0%. Participation in the early mobilization program began a mean of 3.2 days (SD=1.3) after aneurysmal SAH, and patients received an average of 11.4 sessions (SD=4.3). Patients required a mean of 5.4 days (SD=4.2) to participate in out-of-bed activity and a mean of 10.7 days (SD=6.2) to walk ≥15.24 m (50 ft). CONCLUSIONS: The results of this study suggest that an early mobilization program for patients with aneurysmal SAH is safe and feasible

The Orbit Galaxy XTRASOFT Coils: A Multicenter Study of Coil Safety and Efficacy in Both Ruptured and Unruptured Cerebral Aneurysms

Increase packing density with the use of softer three-dimensional (3D) coils has been indicated in reducing aneurysm recurrence. We are reporting a multicenter initial experience of using the Orbit Galaxy XTRASOFT which is a stretch-resistant, softer 3D coil in both ruptured and unruptured aneurysms. A total of 57 consecutive patients from five high-volume neurointerventional centers were reported where at least one Galaxy XTRASOFT coil was used during a procedure. There were 25 patients with ruptured aneurysm and 32 with elective coiling. The overall complication rate was 3.5%, one patient with nonoperative retroperitoneal hematoma and one patient with intraoperative rupture but with no neurological deficit. The occlusion rate of 90% or greater was achieved in 86% of the cases. The discharge modified Rankin score of 0 or 1 was achieved in 100% of the elective coiling and 65% in the ruptured cases. Early experience with Galaxy XTRASOFT coils for both ruptured and unruptured aneurysms appears to be safe with good aneurysm obliteration and low complication rate