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

Evaluating the Effect of Telestroke Intervention on Patient Treatment and Outcomes

Acute ischemic strokes (AIS) are a prominent cause of death and have the potential to cause lifelong neurological deficits. We hypothesize that through telestroke intervention, patients will receive treatment more rapidly and therefore have reduced complications as a result of AIS. To analyze the efficacy of telestroke intervention, we completed a retrospective chart review of suspected AIS patients at hospitals in the greater Philadelphia region from 2015-2019. We then assessed whether a patient received a telestroke consultation and any subsequent care. Several variables were then used to determine the effectiveness of this intervention, such as the promptness of treatment, length of stay in the hospital, and the need for surgical intervention. The total study cohort included 9072 patients, with 811 (8.9%) patients fulfilling the criteria to receive tPA therapy. For patients with a known time of onset, the average amount of time to receive a consultation was 227 minutes, within the 4.5-hour time frame needed for tPA administration. Furthermore, a total of 195 (2.1%) patients experienced a major complication and 155 (1.7%) patients expired despite receiving telestroke intervention. This large cohort is further evidence that quicker access to neurological consultation results in more prompt treatment and an increase in positive patient outcomes. Additionally, we expect this study will push the medical field towards more widespread use of telemedicine; an especially relevant topic as medicine becomes more reliant on technology in the face of potential public health crises

Aneurysm Formation, Growth, and Rupture: The Biology and Physics of Cerebral Aneurysms.

Cerebral aneurysms (CAs) are characterized by a pathological wall structure with internal elastic lamina and media disruption, which leads to focal weakened pouches of the arterial wall. The prevalence of unruptured CAs has been estimated to be 2%-5% in the general population. During the past few decades, the pathophysiological mechanisms behind the formation, growth, and rupture of CAs have been the focus of numerous research studies. In the present review, we have summarized the inflammatory pathways, genetics, and risk factors for the formation, growth, and rupture of CAs. In addition, we have discussed the concepts of geometric indexes, flow patterns, and fluid dynamics that govern CA development

Evaluating the Efficacy of Telestroke Intervention on Stroke Care in a Large Hospital Network

Introduction: Telestroke medicine (TM) involves clinical stroke care by digitally connecting patients and their providers to neurovascular specialists to decrease the time to thrombolytic reperfusion during an acute ischemic stroke (AIS). Rapid administration of intravenous tissue plasminogen activator (iv-tPA) improves AIS outcomes yet no large scale research has evaluated the effectiveness of TM. This study proposes that TM utilization across the Jefferson University Hospital network will increase thrombolytic reperfusion rates and improve overall stroke outcomes. Methods: A retrospective cohort study design with data from a Jefferson Telestroke database contained information for 9,702 patients across 36 hospital affiliates. These patients were evaluated for an AIS through Telestroke from 2014-2019. The rate of iv-tPA administration and NIHSS stroke severity scores were collected. This data was then compared to previous studies that represent the current standard of care without Telestroke through utilization of T-test and ANOVA analysis. Results: An analysis is currently in progress. Preliminary analysis demonstrated that 807 out of 9,702 patients (8.3%) evaluated for AIS received iv-tPA when compared to a national average of 3.4%-5.2%. Additionally, a statistically significant improvement in NIHSS score from baseline to after administration of iv-tPA (p\u3c0.0001; 95% confidence interval [CI] = 4.27, 7.80) was found in this cohort. Discussion: The results of this study support the hypothesis that TM increases the rate of administration of iv-tPA when compared to the national average and improves AIS outcomes. The study describes the effectiveness of TM and demonstrates a need for implementation of Telestroke nationally to improve stroke care

Evaluating the Efficacy of Telestroke Intervention in a Large Community Hospital Network

Introduction: Telemedicine for acute ischemic stroke (Telestroke) allows live consultation between patients, remote stroke specialists, and providers to facilitate administration of IV tissue plasminogen activator (IV-tPA) within the 4.5 hour window. Small cohort studies have demonstrated thrombolytic therapy conveys significant benefit to stroke outcomes and yet is underutilized due to difficulties in recognition and delivery of medication. This study proposes that access to telestroke care across the Thomas Jefferson University Hospital network will result in increased thrombolytic reperfusion rates and improved patient outcomes for stroke. Methods: A retrospective cohort study was designed to utilize a telestroke database collecting information from 9,702 patients evaluated through telestroke across the Jefferson network of 36 community hospitals from 2014-2019. The rate of tPA administration and NIHSS stroke scores were collected. These rates were compared to values in the literature that represent current standard of care without telestroke. Results: Analysis is not complete due to difficulties with the size of the dataset. Preliminary analysis reveals that 807 of the 9,702 patients (8.3%) evaluated for stroke received tPA compared to a national rate of 3.4-5.2% in stroke patients. Furthermore, tPA administration resulted in a significant improvement in NIHSS stroke scale (p\u3c0.0001; 95% confidence interval [CI] = 4.27, 7.80). Discussion: The results support the hypothesis that tPA is administered effectively though a telestroke system. The greater rate of administration across a large cohort implies significantly improved outcomes for patients on a large scale. The study supports the implementation of large telestroke systems similar to Jefferson’s for improved care

Comparative Observational Study for Bifurcating aneurysm treatment; open versus endovascular approaches and classical versus new techniques.

Introduction: Aneurysm occur in approximately 3.2% of the population with a mean age of 50 years, a 1:1 gender ratio, and an estimate mortality rate of 70%. Aneurysms develop at branch points with elevated intravascular turbulence and vessel wall shear stress. we aim to compare the efficacy and safety of different surgical treatment modalities for bifurcating intracranial aneurysms. Methods: A retrospective review of 398 patients who underwent surgical management of a bifurcating aneurysm at Thomas Jefferson University hospital from 2010 to 2020. Aneurysm size, location, modality of treatment, and treatment complications were assessed. Results: Data analysis is expected to return from the statistician in early to mid-December. Data analysis has not been returned to date. Discussion: We hypothesize that those treated with endovascular techniques have better outcomes than those who received intracranial clippings. Additionally, we expect that coil embolization will have better results for saccular aneurysms, while balloon assisted stenting or stent assisted coiling of aneurysm will provide better outcomes for fusiform aneurysms. If these hypotheses hold true, then our data will suggest that there are specific surgical treatment modalities that improve patient outcomes based upon aneurysm type

Pediatric Moyamoya Presenting as a Subarachnoid Hemorrhage from a Ruptured Anterior Cerebral Artery Aneurysm.

BACKGROUND: The incidence of Moyamoya disease (MMD)-associated intracranial aneurysms ranges from 3% to 14% in adult patients, whereas this complication has rarely been reported in children. CASE DESCRIPTION: We herein report the first case, to our knowledge, of an extremely rare subarachnoid hemorrhage presentation of a child with a ruptured anterior cerebral artery dissecting aneurysm secondary to a newly discovered, unilateral Moyamoya-like pathology. CONCLUSIONS: MMD-associated aneurysms are extremely rare in children, and hemorrhage may be the initial presentation of the disease. Prompt intervention is essential to exclude the ruptured aneurysm that is at risk of rebleeding because of persistent hemodynamic stress

Selection Criteria for Posterior Circulation Stroke and Functional Outcome Following Mechanical Thrombectomy

Objective: 20% of all acute ischemic strokes (AIS) are caused by posterior circulation strokes, which carry an intensified mortality touching 95%. Early recanalization improves outcome as shown by several reports; however, safety, patient selection, and prognostic factors remain lacking. An investigation of the safety and prognostic factors for posterior circulation mechanical thrombectomy (MT) was performed. Methods: A retrospective review of patients presenting with posterior circulation AIS, who underwent MT between 2010 and 2018. Results: Of 443 patients who underwent MT for AIS, 83 patients had posterior circulation strokes. 95% of procedures were conducted under general anesthesia. The median NIHSS upon admission was 19.1. Half of the patients underwent MT 8 hours from symptom onset, and half required a salvage contact thrombus aspiration after a stent retriever trial with an average of two passes for successful recanalization. The time to achieve revascularization was 61.6 minutes. Mortality rate was 28%, and modified Rankin Scale (mRS) \u3c 2 at three months was seen in 40.1% of surviving patients. A higher functional outcome trend (mRS\u3c2) was seen in patients who underwent MT within 8 hours of symptom onset. The overall complication rate was 28%. Regression analysis showed that stroke subtype, baseline NIHSS, and posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) before thrombectomy were independent predictive factors of positive clinical outcomes. Conclusions: MT is an effective intervention for posterior circulation strokes, and long-term functional independence relies upon proper patient selection. Baseline NIHSS and pc-ASPECTS are independent predictive factors

Angiogram Negative Subarachnoid Hemorrhage: Incidence, Outcomes, and Predisposition

Introduction: Subarachnoid hemorrhage (SAH) is a medical emergency that may lead to deleterious outcomes unless the underlying cause is determined and managed promptly to prevent further rebleed. Though a significant percentage of cases of SAH have no identifiable pathology, there is a lack of data related to outcomes, predispositions, and whether there has been an increase in the incidence of angiogram negative SAH (anSAH). This study aimed to assess the current incidence of anSAH and factors that are associated with outcomes and predisposition among patients diagnosed with anSAH. Methods: A retrospective chart review was performed. Medical records of patients at Jefferson Hospital for Neuroscience who underwent cerebral angiography between 2010 and 2019 were reviewed to create a database from which patients diagnosed with anSAH were identified. Data related to clinical outcome, medical history, and demographics were collected. When data collection is complete, statistical analysis will be performed to evaluate the significance of the data. Results: Of 4914 patients in the database, 1038 patients were identified as likely having anSAH, though the results must be verified. The incidence of anSAH was 21.1%. Due to ongoing data collection, no interim analysis was possible to assess variables associated with outcomes and predisposition for anSAH. Discussion: As a result of incomplete data, the impact of the study on predicting outcomes and assessing predisposition for anSAH is unknown. However, the data suggest increased anSAH incidence in recent times, indicating that anSAH remains a significant subtype of SAH that clinicians should consider in the differential diagnosis