Manual aspiration thrombectomy using the Penumbra catheter in patients with acute M1 occlusion: A single-center study

Purpose

The efficacy and safety of aspiration thrombectomy using Penumbra in acute occlusion of intracranial artery have been proved in many previous studies. Our study aimed to retrospectively assess the efficacy and safety of a manual aspiration thrombectomy using Penumbra in patients with M1 occlusion.

Materials and methods

We conducted a retrospective review of 70 patients who underwent manual aspiration thrombectomy using Penumbra catheters for treatment of M1 occlusion between January 2012 and December 2014. We evaluated immediate angiographic results and clinical outcomes through review of patient electronic medical records.

Results

Male was the dominant sex in this study (M:F = 38:32) and median age was 72 (age range, 36–91). The rate of successful recanalization (TICI grade ≥2 b) was 91.4% (64/70). The successful recanalization rate by single Penumbra was 82.9% (58/70). Six patients were treated in combination with Solitaire stent. Median NIHSS score was 11 (range, 4–20) at admission and was 3 (range 0–23) at discharge. Favorable clinical outcomes (mRS score at three months ≤2) were seen in 42 patients (60%). Two patients were observed to have subarachnoid hemorrhage after the procedure. Another two patients died related to massive symptomatic hemorrhage, brain edema and herniation in the hospital.

Conclusion

Manual aspiration thrombectomy appears to be safe and is capable of achieving a high rate of successful recanalization and favorable clinical outcomes in patients with M1 occlusion.     

Significant aortic stenosis associated with poorer functional outcomes in patients with acute ischaemic stroke undergoing endovascular therapy

Background and aimBi-directional feedback mechanisms exist between the heart and brain, which have been implicated in heart failure. We postulate that aortic stenosis may alter cerebral haemodynamics and influence functional outcomes after endovascular thrombectomy for acute ischaemic stroke. We compared clinical characteristics, echocardiographic profile and outcomes in patients with or without aortic stenosis that underwent endovascular thrombectomy for large vessel occlusion acute ischaemic stroke.MethodsConsecutive acute ischaemic stroke patients with anterior and posterior circulation large vessel occlusion (internal carotid artery, middle cerebral artery and basilar artery) who underwent endovascular thrombectomy were studied. Patients were divided into those with significant aortic stenosis (aortic valve area <1.5 cm²) and without. Univariate and multivariate analyses were employed to compare and determine predictors of functional outcomes measured by modified Rankin scale at three months.ResultsWe identified 26 (8.5%) patients with significant aortic stenosis. These patients were older (median age 76 (interquartile range 68–84) vs. 67 (interquartile range 56–75) years, p = 0.001), but similar in terms of medical comorbidities and echocardiographic profile. Rates of successful recanalisation (73.1% vs. 78.0%), symptomatic intracranial haemorrhage (7.7% and 7.9%) and mortality (11.5% vs. 12.6%) were similar. Significant aortic stenosis was independently associated with poorer functional outcome (modified Rankin scale >2) at three months (adjusted odds ratio 2.7, 95% confidence interval 1.1–7.5, p = 0.048), after adjusting for age, door-to-puncture times, stroke severity and rates of successful recanalisation.ConclusionIn acute ischaemic stroke patients managed with endovascular thrombectomy, significant aortic stenosis is associated with poor functional outcome despite comparable recanalisation rates. Larger cohort studies are needed to explore this relationship further.     

CGRP and PACAP-38 play an important role in diagnosing pediatric migraine

BackgroundAn increasing number of studies have suggested that the important role of vasoactive peptides, such as pituitary adenylate cyclase-activating polypeptide-38 (PACAP-38) and calcitonin gene-related peptide (CGRP), in the pathophysiology of migraine seems undeniable in adults, but studies in pediatric migraine patients remain scarce. We prospectively investigated CGRP and PACAP-38 plasma levels in children with migraine during ictal and interictal periods and compared the results between migraine patients with aura and without aura. We were the first to explore the diagnostic value of a combination of CGRP and PACAP-38.MethodsSeventy-six migraine patients aged 4–18 years and seventy-seven age-matched healthy children were included in the study. Plasma vasoactive peptides were measured using the enzyme-linked immunosorbent assay (ELISA). Differences and correlations of groups were analyzed using the independent samples t-test, analysis of variance (ANOVA), Mann-Whitney U test, and multiple linear regression. We also performed logistic regression and receiver operating characteristic curve (ROC) analyses to evaluate the diagnostic value of CGRP and PACAP-38 in pediatric migraine.ResultsPACAP-38 and CGRP levels in migraine patients during the ictal and interictal periods were higher than those in controls (p < 0.001). PACAP-38 and CGRP levels in migraine patients with aura and without aura were higher than those in controls (p < 0.001). PACAP-38 and CGRP were independent risk factors in diagnosing pediatric migraine (adjusted OR (PACAP-38) =1.331, 95% CI: 1.177–1.506, p < 0.001; adjusted OR (CGRP) = 1.113, 95% CI: 1.064–1.165, p < 0.001). Area Under Curve (AUC) comparison: Combination (0.926) > CGRP (0.869) > PACAP-38 (0.867).ConclusionsOur study found almost the same changes in CGRP and PACAP levels in pediatric migraine, suggesting that CGRP and PACAP-38 may work together to play an integral role in pediatric migraine. Higher CGRP levels were found in the ictal phase than in the interictal phase and with aura group than without aura group, indicating that CGRP may take part in the formation of pain and aura. Moreover, ROC and logistic regression analyses suggested that CGRP and PACAP-38 are good indicators to diagnose pediatric migraine, and the combination of CGRP and PACAP-38 was valuable in diagnosing pediatric migraine and differentiating pediatric migraine from non-migraine headaches.Trial registrationThe study has been registered at the Chinese Clinical Trial Registry (ChiCTR2100043157).     

De novo headache in ischemic stroke patients treated with thrombectomy: a prospective study

Background and aimHeadache attributed to intracranial endovascular procedures is described in the ICHD-3. Our aim was to study the frequency and characteristics of headache specifically related to thrombectomy in patients with ischemic stroke.MethodsProspective evaluation of clinical features of headache after thrombectomy using an ad hoc questionnaire.ResultsOne hundred seventeen patients were included (52.1% females). Most had an anterior circulation artery occlusion (91.5%). 93 (79.5%) received general anaesthesia. 111 (94.9%) required stent retriever, 21 (24.4%) angioplasty and 19 (16.2%) aspiration thrombectomy. 31 (26.5%; 95% CI 18.8–35.5%) had headache related to thrombectomy, and it was associated with a history of primary headache (p = 0.004). No differences about sex, initial NIHSS score, or the type or complexity of the procedure were observed. Headache was usually moderate and oppressive, ipsilateral to the artery occlusion and usually lasted less than 48 hours.ConclusionsAlmost one-third of patients with ischemic stroke who undergo endovascular thrombectomy experience headache in the first 24 hours, occurring more frequently in patients who had a previous history of headaches regardless of the procedure complexity.Supplementary InformationThe online version contains supplementary material available at 10.1186/s10194-022-01455-3.     

Favorable first-pass recanalization rates with NeVa™ thrombectomy device in acute stroke patients: Initial clinical experience

BackgroundThe NeVa™ thrombectomy device (Vesalio LLC, Nashville, USA) has been reported to succeed in large vessel occlusion thrombectomy in animal, in-vitro, and clinical studies. Designed with Drop Zone technology, a closed distal tip, and strong expansive radial force, the device demonstrated particular efficiency in resistant “white” thrombi in preclinical research. Our goal is to determine the safety and performance of this novel stent retriever on first-pass rates and overall recanalization.MethodsThe Interventional Neurology Database is a prospectively maintained database of anterior and posterior circulation stroke thrombectomy cases. We retrospectively analyzed cases where the NeVa™ thrombectomy device was used as the first-line treatment strategy. Data collection occurred between January 2019 and January 2020. First-pass recanalization, final recanalization, 90-day functional outcome, complication, and bleeding rates are reported.ResultsOne hundred eighteen patients were treated with the NeVa™ thrombectomy device. The mean patient age was 69 ± 14 years, the median baseline National Institutes of Health Stroke Scale was 14, and the median initial Alberta Stroke Program Early Computed Tomography score was 8. The median time from groin puncture to successful recanalization was 29 min (interquartile range (IQR): 20–40). First-pass recanalization rates were 56.8% (modified treatment in cerebral infarction (mTICI) 2b/3) and 44.9% (mTICI 2c/3). Final successful recanalization rate was 95.8% (thrombolysis in cerebral infarction 2b/3). Favorable functional outcome (modified Rankin Scale 0–2) was 53% in the “first-pass” subgroup and 42.4% in the total patient population. The median number of passes to achieve the final recanalization score was 1 (IQR 1–2). The rate of embolization into new territory was 1.7%. Four patients (3.3%) had symptomatic hemorrhage.ConclusionsIn our experience, the NeVa™ device demonstrated high first-pass and overall recanalization rates along with a good safety profile.     

Emergent extracranial internal carotid artery stenting and mechanical thrombectomy in acute ischaemic stroke

Objective

Tandem occlusions involving both the extracranial internal carotid artery (ICA) and an intracranial artery typically respond poorly to intravenous (IV) tissue plasminogen activator (t-PA). We retrospectively review our experience with proximal ICA stenting and stent-assisted thrombectomy of the distal artery.

Methods

The data included patients that underwent carotid stenting and mechanical thrombectomy between 2012–2013. Radiographic, clinical, and procedural data were drawn from case notes, imaging records and discharge reports. Clinical outcomes were evaluated using the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin scale (mRs).

Results

Seven patients, with a mean age of 66.4 years and a mean admission NIHSS of 18.3, underwent this procedure and were included. Each presented with an occlusion of the proximal ICA, with additional occlusions of the ICA terminus (n = 3), middle cerebral artery (n = 5), or anterior cerebral artery (n = 1). Recanalisation of all identified occlusions was achieved in all patients, with a Thrombolysis in Myocardial Infarction (TIMI) score of 3 and a Thrombolysis in Cerebral Infarction (TICI) score >2b achieved in each case. Mean time from onset of stroke symptoms to recanalisation was 287 min; mean time from first angiography to recanalisation was 52 min. Intracranial haemorrhages occurred in two patients, with no increase in NIHSS. There were no mortalities. Mean NIHSS at discharge was 4.9, and mRs at 90 days was one in all patients.

Conclusions

Treatment of tandem extracranial ICA and intracranial occlusions in the setting of acute ischaemic stroke with extracranial carotid artery stenting followed by adjunctive intracranial mechanical thrombectomy is both safe and effective, but further evaluation of this treatment modality is necessary.     

Diaphragm ultrasound as indicator of respiratory effort in critically ill patients undergoing assisted mechanical ventilation: a pilot clinical study

IntroductionPressure-support ventilation, is widely used in critically ill patients; however, the relative contribution of patient’s effort during assisted breathing is difficult to measure in clinical conditions. Aim of the present study was to evaluate the performance of ultrasonographic indices of diaphragm contractile activity (respiratory excursion and thickening) in comparison to traditional indices of inspiratory muscle effort during assisted mechanical ventilation.MethodConsecutive patients admitted to the ICU after major elective surgery who met criteria for a spontaneous breathing trial with pressure support ventilation were enrolled. Patients with airflow obstruction or after thoracic/gastric/esophageal surgery were excluded. Variable levels of inspiratory muscle effort were achieved by delivery of different levels of ventilatory assistance by random application of pressure support (0, 5 and 15 cmH₂O). The right hemidiaphragm was evaluated by B- and M-mode ultrasonography to record respiratory excursion and thickening. Airway, gastric and oesophageal pressures, and airflow were recorded to calculate indices of respiratory effort (diaphragm and esophageal pressure–time product).Results25 patients were enrolled. With increasing levels of pressure support, parallel reductions were found between diaphragm thickening and both diaphragm and esophageal pressure–time product (respectively, R = 0.701, p < 0.001 and R = 0.801, p < 0.001) during tidal breathing. No correlation was found between either diaphragm or esophageal pressure–time product and diaphragm excursion (respectively, R = −0.081, p = 0.506 and R = 0.003, p = 0.981), nor was diaphragm excursion correlated to diaphragm thickening (R = 0.093, p = 0.450) during tidal breathing.ConclusionsIn patients undergoing in assisted mechanical ventilation, diaphragm thickening is a reliable indicator of respiratory effort, whereas diaphragm excursion should not be used to quantitatively assess diaphragm contractile activity.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0894-9) contains supplementary material, which is available to authorized users.     

Pro-adrenomedullin,pro-endothelin-1, procalcitonin,C-reactive protein and mortality risk in critically ill children: a prospective study

Introduction

We tested the hypothesis that higher mid-regional pro-adrenomedullin (MR-proADM), carboxy-terminal pro-endothelin-1 (CT-proET-1), procalcitonin (PCT) and C-reactive protein (CRP) plasma concentrations would be associated with increased prediction of mortality risk scores.

Methods

Prospective observational study set in two pediatric intensive care units (PICUs). Two-hundred-thirty-eight patients were included. MR-proADM, CT-proET-1, PCT and CRP levels were compared between children with PRISM III and PIM 2 > p75 (Group A; n = 33) and the rest (Group B; n = 205).

Results

Median (range) MR-proADM levels were 1.39 nmol/L (0.52–12.67) in group A versus 0.54 (0.15–3.85) in group B (P < 0.001). CT-proET-1 levels were 172 pmol/L (27–500) versus 58 (4–447) (P < 0.001). PCT levels were 7.77 ng/mL (0.34–552.00) versus 0.28 (0.02–107.00) (P < 0.001). CRP levels were 6.23 mg/dL (0.08-28.25) versus 1.30 mg/dL (0.00-42.09) (P = 0.210). The area under the ROC curve (AUC) for the differentiation of group A and B was 0.87 (95% CI:0.81–0.821) for MR-proADM, 0.86 (95% CI:0.79–0.92) for CT-proET-1 and 0.84 (95% CI:0.74–0.94) for PCT. A MR-proADM > 0.79 nmol/L had 93% sensitivity and 76% specificity to differentiate groups, whereas a CT-proET-1 > 123 pmol/L had 77% sensitivity and 84% specificity, and a PCT concentration > 2.05 ng/mL had 80% sensitivity and specificity.

Conclusions

In critically ill children, high levels of MR-proADM, CT-proET-1 and PCT were associated with increased prediction of mortality risk scores. MR-proADM, CT-proET-1 and PCT concentrations higher than 0.80 nmol/L, 123 pmol/L and 2 ng/mL, respectively, could be used by clinicians to identify critically ill children at higher prediction of risk death scores.     

Efficacy and safety of citrate-based anticoagulation compared to heparin in patients with acute kidney injury requiring continuous renal replacement therapy: a randomized controlled trial

IntroductionA systemic anticoagulation is often required to prevent circuit and filter clotting in ICU patients undergoing continuous renal replacement therapy (CRRT). A regional citrate-based anticoagulation (RCA) does not induce a systemic anticoagulation and prolongs the filter lifespan, but metabolic side-effects have been associated with this therapy. We conducted a randomized controlled trial with patients requiring CRRT to determine whether RCA using a balanced predilution replacement fluid is more effective than heparin in terms of renal replacement delivered dose and safety profile.MethodsOne hundred and three patients with AKI requiring CRRT were included. The patients were randomized to either CRRT with RCA or heparin anticoagulation. Primary endpoints were effective daily delivered RRT dose during the first 3 days of CRRT and filter lifespan. Secondary endpoints were 28-day and 90-day survival and severe metabolic complications and bleeding disorders.ResultsMedian CRRT duration was 3.0 (2–6) days. Effective delivered daily RRT doses were 29 ± 3 and 27 ± 5 mL/kg/hr in the RCA and heparin groups, respectively (p = 0.005). Filter lifespans were 49 ± 29 versus 28 ± 23 hrs in the RCA and heparin groups (p = 0.004). Survival rates at 28 and 90 days were 80-74% in the RCA and 74-73% in the heparin group. Electrolytes and acid–base disturbances were uncommon and transient in patients treated with RCA.ConclusionsThese results show that RCA is superior to heparin-based anticoagulation in terms of delivered RRT dose and filter life span and is a safe and feasible method. This does not translate into an improvement in short term survival.

Trial registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01269112","term_id":"NCT01269112"}}NCT01269112. Registered 3rd January 2011.     

Prognostic value of GRACE and CHA2DS2-VASc score among patients with atrial fibrillation undergoing percutaneous coronary intervention

AimsThe GRACE and CHA2DS2-VASc risk score are developed for risk stratification in patients with acute coronary syndrome and AF, respectively. We aimed to assess the predictive performance of the GRACE score and CHA2DS2-VASc score among patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI).MethodsConsecutive patients with a diagnosis of AF admitted to our hospital for PCI between January 2016 and December 2018 were included and followed up for at least 1 year. The primary endpoint was a composite of major adverse cardiac events (MACEs) including all-cause mortality, repeat revascularization, myocardial infarction, or ischaemic stroke.ResultsA total of 1452 patients were identified. Cox regression demonstrated that the GRACE (HR 1.014, 95% CI 1.008–1.020, p < 0.001) but not the CHA2DS2-VASc score was associated with the risk of MACEs. Both GRACE and CHA2DS2-VASc scores were predictive of all-cause mortality with HR of 1.028 (95% CI 1.020–1.037, p < 0.001) and 1.334 (95% CI 1.107–1.632, p = 0.003). Receiver operating characteristic analyses showed both scores had similar discrimination capacity for all-cause mortality (C-statistic: 0.708 for GRACE vs. 0.661 for CHA2DS2-VASc, p = 0.299). High GRACE score was also significantly associated with increased risk of ischaemic stroke (HR 1.018, 95% CI 1.005–1.031, p = 0.006) and major bleeding (HR 1.012, 95% CI 1.001–1.024, p = 0.039), whereas high CHA2DS2-VASc score was not.ConclusionsHigh GRACE score but not CHA2DS2-VASc score were both associated with an increased risk of MACEs after PCI in patients with AF. The GRACE and CHA2DS2-VASc scores have similar predictive performance for predicting all-cause mortality.

Key messages:

• In patients with AF undergoing PCI, increasing GRACE but not CHA2DS2-VASc scores was independently associated high risk of MACEs.
• The GRACE score could also help identify patients at higher risk of stroke and major bleeding.
• Both GRACE and CHA2DS2-VASc scores showed good ability in the prediction of all-cause mortality.

     

Risk profile,antithrombotic treatment and clinical outcomes of patients in Nordic countries with atrial fibrillation – results from the GARFIELD-AF registry

AimsThe objective was to evaluate the clinical characteristics, management and two-year outcomes of patients with newly diagnosed non-valvular atrial fibrillation at risk for stroke in Nordic countries.MethodsWe examined the baseline characteristics, antithrombotic treatment, and two-year clinical outcomes of patients from four Nordic countries.ResultsA total of 52,080 patients were enrolled in the GARFIELD-AF. Out of 29,908 European patients, 2,396 were recruited from Nordic countries. The use of oral anticoagulants, alone or in combination with antiplatelet (AP), was higher in Nordic patients in all CHA₂DS₂-VASc categories: 0–1 (72.8% vs 60.3%), 2–3 (78.7% vs 72.9%) and ≥4 (79.2% vs 74.1%). In Nordic patients, NOAC ± AP was more frequently prescribed (32.0% vs 27.7%) and AP monotherapy was less often prescribed (10.4% vs 18.2%) when compared with Non-Nordic European patients. The rates (per 100 patient years) of all-cause mortality and non-haemorrhagic stroke/systemic embolism (SE) were similar in Nordic and Non-Nordic European patients [3.63 (3.11–4.23) vs 4.08 (3.91–4.26), p value = .147] and [0.98 (0.73–1.32) vs 1.02 (0.93–1.11), p value = .819], while major bleeding was significantly higher [1.66 (1.32–2.09) vs 1.01 (0.93–1.10), p value < .001].ConclusionNordic patients had significantly higher major bleeding than Non-Nordic-European patients. In contrast, rates of all-cause mortality and non-haemorrhagic stroke/SE were comparable. Clinical Trial RegistrationUnique identifier: NCT01090362. URL: http://www.clinicaltrials.gov. Key MessageNordic countries had significantly higher major bleeding than Non-Nordic-European countries. Rates of mortality and non-haemorrhagic stroke/SE were similar .     

Influence of coronavirus disease 2019 (COVID-19) on working flow,safety and efficacy outcome of mechanical thrombectomy for acute ischemic stroke with large vessel occlusion

AimThe epidemic of COVID-19 has greatly affect the world health care system, particular measures have been taken not only to provide safety for health care providers but also to maintain the treatment quality. We evaluate the effect of COVID-19 epidemic to acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) received endovascular treatment (EVT) in our institution.MethodsAIS patients with LVO who underwent EVT in the period of January 1st to April 30th between 2015 and 2020 from our stroke center. The baseline characteristics, working flow time, safety and efficacy outcome and the hospitalization status were retrospectively reviewed, compared and analyzed.ResultsThere is significant decline in the number of AIS patients with LVO treated compared with the previous year (36 Vs 72 patients) during the epidemic period. The door to puncture time was significantly prolong (225 minutes versus 115 minutes) as well as the length of hospital stay with increase of the hospitalization costs (P < 0.05 for all). There is no significant difference on the safety and efficacy outcome, such recanalization rate, incidence of intracranial hemorrhage, functional independence and mortality during the epidemic (P > 0.05 for all).ConclusionsProlongation of the working time flow during the COVID-19 epidemic did not influence the safety and efficacy of EVT in AIS patients with LVO. However, special policy and particular measures in this circumstances is still need to evolve to improve the treatment quality.     

Patient-reported outcomes,health-related quality of life,and acute medication use in patients with a ≥ 75% response to eptinezumab: subgroup pooled analysis of the PROMISE trials

BackgroundPROMISE-1 and PROMISE-2 evaluated the preventive efficacy, tolerability, and safety of eptinezumab, a calcitonin gene-related peptide–targeted monoclonal antibody, in adults with episodic (EM) and chronic migraine (CM), finding significant reductions in migraine frequency. This post hoc analysis compared patient-reported outcomes (PROs), health-related quality of life (HRQoL) and acute medication use in patients with a ≥ 75% migraine responder rate (MRR) after treatment with eptinezumab to patients with a ≥ 50– < 75% MRR.MethodsPROMISE-1 and PROMISE-2 were phase 3, randomized, double-blind, placebo-controlled studies. This analysis included patients from both studies treated with eptinezumab 100 mg or 300 mg who experienced ≥ 75% and ≥ 50–< 75% MRR over Weeks 1–12 (wks1–12). In both studies, HRQoL was measured by the 36-item Short-Form Health Survey (SF-36) and acute medication usage. PROMISE-2 also included the 6-item Headache Impact Test (HIT-6), patient-identified most bothersome symptom (PI-MBS), and Patient Global Impression of Change (PGIC).ResultsIn PROMISE-1, a total of 115/443 (26.0%; 100 mg, n = 49, 300 mg, n = 66) and 120/443 (27.0%; 100 mg, n = 61, 300 mg, n = 59) eptinezumab-treated patients achieved ≥ 75% and ≥ 50–< 75% MRR over wks1–12, respectively. In PROMISE-2, a total of 211/706 (30.0%; 100 mg, n = 95; 300 mg, n = 116) and 209/706 (29.6%; 100 mg, n = 110, 300 mg, n = 99) eptinezumab-treated patients achieved ≥ 75% and ≥ 50–< 75% MRR over wks1–12, respectively. EM and CM patients with ≥ 75% and ≥ 50–< 75% MRR over wks1–12 showed reduced use of acute headache medication and increased HRQoL to normative levels across SF-36 domains of bodily pain, social functioning, and physical functioning. In CM patients with ≥ 75% and ≥ 50–< 75% MRR over wks1–12, the mean change in HIT-6 total score with eptinezumab (pooled) was − 11.7 and − 7.6, respectively. “Very much” or “much” improvement responses were reported in 41.8% and 16.5% on PI-MBS and 36.2% and 20.0% on PGIC in ≥ 75% and ≥ 50–< 75% MRR, respectively.ConclusionEptinezumab treatment induced a ≥ 75% MRR over wks1–12 in the majority of patients. This patient subgroup reported substantial improvements in PROs associated with headache-related life impact and HRQoL, and reductions in acute headache medication use, which were more marked than those in the ≥ 50–< 75% responders. This study supports the clinical meaningfulness of ≥ 75% MRR for patients with either EM or CM.Trial registrationClinicalTrials.gov identifiers: {"type":"clinical-trial","attrs":{"text":"NCT02559895","term_id":"NCT02559895"}}NCT02559895 (PROMISE-1), {"type":"clinical-trial","attrs":{"text":"NCT02974153","term_id":"NCT02974153"}}NCT02974153 (PROMISE-2).Supplementary InformationThe online version contains supplementary material available at 10.1186/s10194-022-01386-z.     

Stent-based thrombectomy versus intravenous tissue plasminogen activator in acute ischaemic stroke: A systematic review and meta-analysis

Purpose

To date only a few studies have compared the effectiveness and functional outcomes of stent retrievers versus intravenous thrombolysis in acute ischaemic stoke. Our aim was to identify and collate all the available data and to assess for statistical differences in patient outcomes between the two treatments.

Materials and methods

We performed a systematic review and meta-analysis of studies with a randomised controlled design which utilised stentrievers and intravenous thrombolysis in acute ischaemic stroke.

Results

Five randomised controlled studies published in 2015 were identified. Second-generation thrombectomy devices constituted at least 80% of thrombectomy devices in the included studies, namely MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME and REVASCAT. No significant heterogeneity was seen in the included studies and the five trials were therefore included in the meta-analysis.A total of 46.10% of patients treated with stentrievers achieved an independent functional outcome (mRS < 2) at 90 days compared with 26.46% of those treated with intravenous thrombolysis with an odds ratio of 2.40 (p < 0.001). The weighted recanalisation mean in the thrombectomy arms was 76.02%.A lower mortality rate was observed with stentrievers compared to intravenous thrombolysis (15.33% vs 18.74%; OR 0.81, p = 0.15). Stentrievers were also associated with a lower risk of symptomatic intracranial haemorrhage (7.86% vs 8.64%; OR 1.02, p = 0.93). The differences in the secondary/safety outcomes were not statistically significant.

Conclusion

Stentrievers can achieve a high rate of recanalisation and functional independence in acute ischaemic stroke and have a relatively good safety profile. Our meta-analysis demonstrates a clear benefit of an intra-arterial mechanical approach vs standard treatment.     

An observational study of surface versus endovascular cooling techniques in cardiac arrest patients: a propensity-matched analysis

IntroductionVarious methods and devices have been described for cooling after cardiac arrest, but the ideal cooling method remains unclear. The aim of this study was to compare the neurological outcomes, efficacies and adverse events of surface and endovascular cooling techniques in cardiac arrest patients.MethodsWe performed a multicenter, retrospective, registry-based study of adult cardiac arrest patients treated with therapeutic hypothermia presenting to 24 hospitals across South Korea from 2007 to 2012. We included patients who received therapeutic hypothermia using overall surface or endovascular cooling devices and compared the neurological outcomes, efficacies and adverse events of both cooling techniques. To adjust for differences in the baseline characteristics of each cooling method, we performed one-to-one matching by the propensity score.ResultsIn total, 803 patients were included in the analysis. Of these patients, 559 underwent surface cooling, and the remaining 244 patients underwent endovascular cooling. In the unmatched cohort, a greater number of adverse events occurred in the surface cooling group. Surface cooling was significantly associated with a poor neurological outcome (cerebral performance category 3–5) at hospital discharge (p = 0.01). After propensity score matching, surface cooling was not associated with poor neurological outcome and hospital mortality [odds ratio (OR): 1.26, 95% confidence interval (CI): 0.81-1.96, p = 0.31 and OR: 0.85, 95% CI: 0.55-1.30, p = 0.44, respectively]. Although surface cooling was associated with an increased incidence of adverse events (such as overcooling, rebound hyperthermia, rewarming related hypoglycemia and hypotension) compared with endovascular cooling, these complications were not associated with surface cooling using hydrogel pads.ConclusionsIn the overall matched cohort, no significant difference in neurological outcomes and hospital morality was observed between the surface and endovascular cooling methods.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0819-7) contains supplementary material, which is available to authorized users.     

Post-COVID-19 neuropsychiatric manifestations among COVID-19 survivors suffering from migraine: a case–control study

BackgroundThe burden of post-coronavirus disease (COVID)-19 symptoms has been increasing and is of great concern in patients with pre-existing chronic medical conditions.This study aimed to delineate the post-COVID-19 neuropsychiatric symptoms among migraine patients compared to the non-migraine control group.MethodsTwo groups, each of 204 COVID-19 survivors, were enrolled in the study after 3 months of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection, one group fulfilling the episodic migraine criteria and the other serving as a matching control group. Subjects were evaluated through an in-person interview for post-COVID-19 neuropsychiatric symptoms, including detailed headache patterns and severity, using the visual analogue scale.ResultsThe Frequency of headache during the acute phase of COVID-19 was more frequent in migraine patients (OR = 1.60, 95%CI = 1.04–2.45, P-value = 0.031). The reported significant post-COVID-19 neuropsychiatric symptoms in migraine patients compared to controls were fatigue (OR = 1.662, 95%CI = 1.064–2.596, P-value = 0.025), anosmia/hyposmia (OR = 2.06, 95%CI = 1.164- 3.645, P-value = 0.012), cacosmia (OR = 2.663, 95%CI = 1.145–6.195, P-value = 0.019), depression (OR = 2.259, 95%CI = 1.284- 3.975, P-value = 0.004), anxiety (OR = 3.267, 95%CI = 1.747- 6.108, P-value ≤ 0.001), insomnia (OR = 2.203, 95%CI = 1.298- 3.739, P-value = 0.003), and headache (OR = 3.148, 95%CI = 1.616–6.136, P-value =  ≤ 0.001).While there was no statistically significant difference between migraine patients and controls regarding the post-COVID-19 functional status score (P-value = 0.102). The pattern of post-COVID-19 headache was reported as chronic headache transformation in 17.6% of the migraine group, with the median intensity rate being 5.5 and IQR (3–7). In the control group, 14% experienced chronic headache attributed to systemic viral infection with a median intensity rate of 2 and IQR (2–5), while 12% experienced a new daily persistent headache with a median intensity of 5 and IQR (1–6).ConclusionThe study highlighted the importance of follow-up migraine patients upon recovery from COVID-19 infection, being more vulnerable to post-COVID-19 symptoms.     

Predictive value on diffusion weighted imaging scores for basilar artery occlusion after endovascular treatment

PurposeTo assess the predictive value of three scoring systems based on diffusion weighted imaging in basilar artery occlusion patients after endovascular treatment.MethodsWe analyzed clinical and radiological data of patients with basilar artery occlusion from January 2010 to June 2019, with modified Rankin Scale of 0–2 and 3–6 defined as favorable outcome and unfavorable outcome at three months. Diffusion weighted imaging posterior circulation ASPECTS Score (DWI pc-ASPECT Score), Renard diffusion weighted imaging Score, and diffusion weighted imaging Brainstem Score were used to evaluate the early ischemic changes.ResultsThere were a total of 88 basilar artery occlusion patients enrolled in the study after endovascular treatment, with 33 of them getting a favorable outcome. According to the analysis, the time from onset to puncture within 12 h (odds ratio: 4.34; 95% confidence interval: 1.55–12.16; P = 0.01), presence of collateral flow via PCoA (odds ratio: 0.31; 95%CI: 0.12–0.79; P = 0.01) or between PICA and SCA (odds ratio: 0.18; 95%CI: 0.07–0.47; P = 0.00), equal or less than 15 points on baseline NIHSS (area under the curve 0.79, 95% CI 0.69–0.89; sensitivity = 69.1%, specificity = 81.8%; P = 0.00), and equal or less than 1.5 points on diffusion weighted imaging Renard score (area under the curve 0.63, 95% CI 0.51–0.75; sensitivity = 83.6%, specificity = 39.4%; P = 0.046) were independently associated with favorable outcome.ConclusionsRenard diffusion weighted imaging score may be an independent predictor of functional outcome in basilar artery occlusion patients after endovascular treatment.     

Mechanical thrombectomy in patients with acute basilar occlusion using stent retrievers

Background

Early arterial recanalisation with stent retrievers (SR) has been recently demonstrated to improve clinical outcome of patients with large-vessel occlusion of the anterior circulation. However, the benefit of SR thrombectomy in the setting of acute basilar artery occlusion (BAO) has not been proven yet. This study evaluated a series of consecutive patients with BAO treated with SR, focusing on the efficacy, safety and clinical results.

Methods

We analysed 24 consecutive patients with acute BAO who were treated with SR mechanical thrombectomy. Good clinical outcome at three months was defined as mRS ≤ 2. Data from patients with good outcome were compared to that from patients with poor outcome.

Results

Sufficient recanalisation (TICI 2 b or 3) was achieved in 63% (15/24) of patients. At three months, 33% (8/24) of patients had died; good clinical outcome was obtained in 21% (5/24). Age (46 vs. 60 years old, p = 0.05) and time from symptoms onset to recanalisation (370 vs. 521 minutes, p = 0.048) was significantly lower in patients with good outcome as compared to patients with poor outcome. There were three cases (12.5%) of periprocedural complications, all of them related to arterial wall dissection/perforation.

Conclusions

SR thrombectomy might be an efficient and safe treatment for patients with acute BAO occlusion and might help improve outcome.     

Aortic and supra-aortic arterial tortuosity and access technique: Impact on time to device deployment in stroke thrombectomy

BackgroundLonger intervals to reperfusion in patients treated with mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) stroke are associated with worse outcomes and influenced by the operator’s ability to navigate individual anatomy. Our aims were to assess the impact of time from puncture to first deployment of the MT device (DT) on technical and clinical outcomes, develop an Anatomical Assessment for Mechanical Thrombectomy Score (ASMETS) that could predict DT and assess how different methods of intracranial access (coaxial-direct or exchange) influence this.MethodsRetrospective review of a prospective database of patients treated with MT for ELVO between November 2015 and August 2018. CTAs were assessed for ASMETS. Intracranial access technique was at the discretion of the operator. Technical and clinical outcomes and complications were recorded. Linear and logistic regression analysis was performed.Results92 patients were included. The impact of DT on clinical outcomes was significant. An unfavourable ASMET score is significantly associated with longer DT (p = 0.002) and linear regression showed DT time can be predicted by ASMETS – F(1,90) = 6.182, p = 0.015. No difference was demonstrated between different access techniques.ConclusionCTA-based ASMETS can predict time between arterial puncture and deployment of the mechanical thrombectomy device in stroke patients, irrespective of the technique used to catheterise the target ICA. This could inform the operator in preparing appropriate strategies to overcome challenging vascular anatomy in patients undergoing MT.     

Management of idiopathic intracranial hypertension in children utilizing venous sinus stenting

BackgroundVenous sinus stenting (VSS) is an accepted and minimally invasive treatment for adult idiopathic intracranial hypertension (IIH) associated with lateral sinus stenosis (LSS). The efficacy and safety of venous sinus stenting (VSS) in children with IIH has not been established.MethodsThis is a retrospective analysis of IIH patients 18 years of age or younger with LSS treated with VSS at our institution. Included patients have fulminant disease course or are refractory or intolerant to medical management.ResultsEight patients were identified; 4 males and 4 females. Mean age is 13.4 years (range 4–18). All patients had severe headaches, 5 had blurred vision, 3 had diplopia and 3 had pulsatile tinnitus. Papilledema was present in 4 patients. Three patients had prior surgical procedures. Four patients were intolerant to medical management, 3 were refractory and 1 had fulminant course. Cerebral venography demonstrated severe stenosis of the dominant sinus in 6 patients and of bilateral co-dominant sinuses in 2 patients. Six patients had intrinsic stenosis and 2 had extrinsic stenosis. Venous sinus stenting (VSS) resulted in improvement of symptoms, papilledema and normalization of CSF opening pressure in 7 patients. No immediate complications were observed. Mean follow-up period is 21 months (range 6–42). Two patients required re-stenting; one responded well and the other had persistent symptoms and underwent subsequent surgical procedures of CSF diversion, suboccipital decompression and duraplasty which were also ineffective.ConclusionVSS may provide a viable option for pediatric IIH patients who are intolerant to medication, have failed conservative management or prior surgical interventions, or present with fulminant disease.