Causes,Predictors, and Trends of Unplanned Readmissions after Elective Endovascular Embolization of Cerebral Aneurysms

Background: 30- and 90-day readmissions (dRA) are being increasingly scrutinized as quality metrics for hospital and provider performances. Little information regarding risk factors for readmission after elective endovascular treatment (EVT) of an unruptured cerebral aneurysm (UCA) is available. Methods: The Nationwide Readmissions Database was used to identify patients who underwent elective endovascular embolization of an unruptured aneurysm between 2010 and 2014. The primary outcomes of interest were unplanned readmissions occurring within 30 or 90 days of discharge. Binary logistic regressions were used to identify variables related to patients’ demographics, comorbidities, and index hospital admission that were associated with 30dRA and 90dRA. Results: A total of 8588 patients met the inclusion criteria for 30dRA analysis and 7289 patients were eligible for 90dRA analysis. The 5-year 30dRA and 90dRA readmission rates were 7.1% and 13.5%, respectively. The annual incidences of 30dRAs and 90dRAs between 2010 and 2014 decreased significantly (pooled odds ratio (OR) for 30dRA: .874, 95% confidence interval (CI) .765-.998; pooled OR for 90dRA: .841, 95% CI .755-.938). Patients in higher income quartiles experienced decreased odds of 30dRA and 90dRA. Nonroutine disposition following the index admission and greater comorbidity burdens were associated with higher likelihoods of both 30dRA and 90dRA. The presence of pulmonary or cardiac complications was associated with increased odds of 90dRA. Conclusion: Readmission rates after elective EVT of UCAs decreased between 2010 and 2014. We identified several novel risk factors for both 30dRAs and 90dRAs that can be used to identify patients who are at highest risk of readmission.     

Evaluation of safety,efficacy and clinical outcome after endovascular treatment of aneurysmal subarachnoid hemorrhage in coil-first setting. A 10-year series from a single center

Introduction

The endovascular treatment (EVT) of ruptured cerebral aneurysms has been widely adopted after the publication of the International Subarachnoid Aneurysm Trial. In this study, we sought to evaluate the safety and efficacy of the EVT for ruptured aneurysms based on 10-year series from a single center with coil-first strategy.

Continual Transcranial Doppler in the Monitoring of Hemodynamic Change following Aneurysmal Subarachnoid Hemorrhage

Aims: To analyze and compare the value of different treatment methods for acute aneurysmal subarachnoid hemorrhage (aSAH)‐related vasospasm. Cerebral hemodynamic variables’ changes were evaluated by transcranial Doppler (TCD) in aSAH patients within 14 days after onset. Methods: Thirty aSAH patients were enrolled in the study within 72 h after onset. Baseline CT and TCD were used for assessment. Patients were divided into three groups according to SAH severity and patients’ discretion: nonsurgical group, endovascular coiling, and neurosurgical clipping. TCD hemodynamic parameters were measured and Lindegaard index was calculated daily from onset to 14th day after SAH. The group mean cerebral blood velocity (MBFV) and Lindegaard index were compared using repeated measures analysis of variance (reANOVA). Least Significant Difference (LSD) test was used for post hoc comparison. All 30 patients were followed for 90 days after onset for outcome assessment. Results: The values of MBFV and Lindegaard index of anterior cerebral artery (ACA)/middle cerebral artery (MCA) from high to low is nonsurgical group, clipping and coiling (ACA: P= 0.0001/P= 0.006; MCA: P= 0.243/P= 0.317). Conclusions: These results indicate that both neurosurgical clipping and endovascular coiling management may relieve the severity of cerebral vasospasm in acute aSAH.     

Recent Trends in Electively Treated Unruptured Intracranial Aneurysms

Background and Purpose: To determine recent treatment and outcome trends in patients undergoing elective surgical clipping (SC) or endovascular therapy (EVT) for unruptured intracranial aneurysms (UIAs) in the United States. Methods: Data were extracted and analyzed from the National Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality for all patients admitted for elective EVT or SC of UIAs between 2011 and 2014. Treatment trends, in-hospital mortality, complication rates, length of stay (LOS) and total hospital costs were evaluated and analyzed. Results: A total of 31,070 patients with UIAs were included in our analysis, of which 14,411 and 16,659 underwent elective SC and EVT, respectively. There was no significant difference in in-hospital mortality rates between the 2 groups. EVT was associated with lower in-hospital complication rates, decreased median LOS (.8 days versus 3.3 days, P ≤ .0001), and an increased likelihood of discharge to home (92.9% versus 72.9%, P = .0001). Median total hospital charges were similar in both treatment cohorts. Independent predictors of mortality in the elective population were age over 40 years (P ≤ .0001), weekend treatment (P ≤ .0001), and high co-morbidity status (P ≤ .0001). Conclusions: In-hospital mortality rates were similar in elective EVT and SC UIA patients; however, EVT was associated with lower in-hospital complication rates and shorter LOS.     

Endovascular treatment of intracranial aneurysms as the first thérapeutic option

BACKGROUND AND PURPOSE: To prospectively evaluate the results of endovascular treatment (EVT) of intracranial aneurysms when it is considered as first-intention treatment. METHODS: From April 2004-October 2006, 167 consecutive patients with 202 aneurysms were treated in our institution. Five patients with a ruptured aneurysm with an associated haematoma were excluded. In 162 patients with 197 aneurysms, EVT was considered as first-intention treatment. RESULTS: Surgical clipping was performed in 25 aneurysms (25/197=12.7%) including 22 aneurysms excluded from EVT and three EVT failures. EVT was thus attempted in 144 patients with 175 aneurysms and successfully performed in 141 patients with 172 aneurysms (172/197=87.3%). EVT failure rate was 1.7%. Clinical outcome according to the modified Glasgow Outcome Scale was: Excellent, 81.5%; Good, 7%; Poor or Fair, 3.5%; Death, 8%. Procedural complications occurred in 17 cases (10%). Balloon- or stent-assisted techniques were used in 60 cases (34.9%) and were not associated with higher complication rate. Overall procedural morbidity and mortality rates were 4.2 and 2.1%. Initially, complete occlusion was obtained in 68%, neck remnant in 23%, and incomplete occlusion in 9% of aneurysms. Follow-up (mean 11 months) was obtained in 119 aneurysms and showed major recanalisation--that required re-treatment--in 13 cases (11%) and minor recanalisation in 17 cases (14.3%). CONCLUSION: Our findings suggest that new endovascular techniques allow proposing EVT as first-intention treatment in 87.3% of patients with intracranial aneurysms. This therapeutic strategy is associated with good clinical results. However, anatomical results are not improved and remain the EVT limiting factor.     

Efficacy and Safety of Low-Dose Tirofiban for Acute Intracranial Atherosclerotic Stenosis Related Occlusion with Residual Stenosis after Endovascular Treatment

Background: The optimal treatment strategy for residual stenosis in patients with acute intracranial atherosclerotic stenosis related occlusion (ICAS-O) after endovascular treatment (EVT) is unknown. This study aims to evaluate the efficacy and safety of low-dose tirofiban in patients with residual stenosis after EVT due to acute ICAS-O. Methods: Retrospective analysis of prospectively enrolled consecutive patients with residual stenosis after EVT due to acute ICAS-O from March 2015 to May 2019. Patients were divided into EVT alone group or EVT plus tirofiban group. The primary endpoint was the favorable functional outcome (defined as modified Rankin scale score of 0-2) at 90 days. The secondary endpoints were the proportions of reocclusion of recanalized arteries within 72 hours after EVT, symptomatic intracranial hemorrhage (sICH), any ICH, and mortality at 90 days. Logistic regression for predictors of reocclusion and functional outcomes were performed. Results: A total of 98 patients, 50 treated with tirofiban and 48 without tirofiban, were enrolled in this study. Compared with patients in EVT alone group, patients in EVT plus tirofiban group had higher favorable functional outcome rate, lower mortality, and a lower reocclusion rate (56.3% versus 30.4%; P = .014, 8.3% versus 28.3%; P = .016, and 10.4% versus 32.6%; P = .011, respectively). The rates of any ICH and sICH were similar between the 2 groups. The use of tirofiban was associated with the favorable functional outcome (odds ratio [OR], 3.417; 95% confidence interval [CI], 1.149-10.163; P = .027) and lower reocclusion rate (OR, 0.145; 95% CI, 0.038-0.546; P = .004) on multivariate logistic regression analysis. Conclusions: In patients with residual stenosis after EVT due to acute ICAS-O, a low-dose of tirofiban is associated with favorable functional outcome and reduced incidence of reocclusion without increasing any ICH and sICH.     

Endovascular Treatment of Vertebral Artery Dissecting Aneurysms That Cause Subarachnoid Hemorrhage : Consideration of Therapeutic Approaches Relevant to the Angioarchitecture

Objective

Intracranial ruptured vertebral artery dissecting aneurysms (VADAns) are associated with high morbidity and mortality when left untreated due to the high likelihood of rebleeding. The present study aimed to establish an endovascular therapeutic strategy that focuses specifically on the angioarchitecture of ruptured VADAns.

Methods

Twenty-three patients with ruptured VADAn received endovascular treatment (EVT) over 7 years. The patient group included 14 women (60.9%) and 9 men (39.1%) between the ages of 39 and 72 years (mean age 54.2 years). Clinical data and radiologic findings were retrospectively analyzed.

Results

Four patients had aneurysms on the dominant vertebral artery. Fourteen (61%) aneurysms were located distal to the posterior inferior cerebellar artery (PICA). Six (26%) patients had an extracranial origin of the PICA on the ruptured VA, and 2 patients (9%) had bilateral VADAns. Eighteen patients (78%) were treated with internal coil trapping. Two patients (9%) required an adjunctive bypass procedure. Seven patients (30%) required stent-supported endovascular procedures. Two patients experienced intra-procedural rupture during EVT, one of which was associated with a focal medullary infarction. Two patients (9%) exhibited recanalization of the VADAn during follow-up, which required additional coiling. No recurrent hemorrhage was observed during the follow-up period.

Conclusion

EVT of ruptured VADAns based on angioarchitecture is a feasible and effective armamentarium to prevent fatal hemorrhage recurrence with an acceptable low risk of procedural complications. Clinical outcomes depend mainly on the pre-procedural clinical state of the patient. Radiologic follow-up is necessary to prevent hemorrhage recurrence after EVT.     

Mean Platelet Volume/Platelet Count Ratio is Associated with Poor Clinical Outcome After Aneurysmal Subarachnoid Hemorrhage

BackgroundAneurysmal subarachnoid hemorrhage (aSAH) is both a hypercoagulable and inflammation state in which many biomarkers have been studied. Activated platelets have been identified to be of clinical importance in thrombosis and neuroinflammation after aSAH. The aim of this study was to investigate the relationship between mean platelet volume (MPV) to platelet count (PC) ratio, a surrogate parameter for activated platelets, and the functional outcome in aSAH patients.MethodsA retrospective analysis was performed of patients with aSAH admitted to the stroke center of our institution between November 2018 and November 2019. The mean MPV/PC ratio during the first three days after aSAH onset was calculated. Poor outcome was defined as a modified Rankin Scale (mRS) score of 3-6 at 3 months. Receive operating characteristic (ROC) curve analysis was performed to determine the optimal value of MPV/PC ratio for the prediction of poor outcome in patients with aSAH.ResultsA total of 100 patients were included, 13 (13.0%) died and 35 (35.0%) had a poor outcome. Mean MPV/PC ratio (P < 0.001) when measured over the study period, was significantly higher among patients with poor outcome. In multivariable analysis, increased mean MPV/PC ratio was associated with poor functional outcome at 3 months (odds ratio (OR) = 1.94; 95% confidence interval (CI): 1.19-3.17; P = 0.008). The optimal cutoff of MPV/PC ratio for predicting poor outcome at 3 months was 6.77 (sensitivity 74.3%, specificity 61.5%).ConclusionAn increased MPV/PC ratio is associated with poor functional outcome in aSAH patients. MPV/PC ratio may be a useful predictor of outcome after aSAH.     

破裂大脑中动脉瘤多学科会诊治疗方案疗效评价：单中心261例回顾性分析

目的 比较多学科会诊确定破裂大脑中动脉瘤患者行介入栓塞或手术夹闭动脉瘤的治疗效果。      

Pituitary dysfunction after aneurysmal subarachnoid hemorrhage in Japanese patients

To elucidate the pituitary function of Japanese patients after aneurysmal subarachnoid hemorrhage (aSAH) and implicative factors related to growth hormone deficiency (GHD) after aSAH. We evaluated basal pituitary hormone levels among 59 consecutive aSAH patients with a modified Rankin Scale (mRS) ⩽4 at 3 months after aSAH onset. Patients with low insulin-like growth factor 1 (IGF-1) SD score (SDS) or who seemed to develop pituitary dysfunction underwent provocative endocrine testing during a period of 3–36 months after SAH onset. The relationship between IGF-1 SDS and clinical factors of the patients such as severity of SAH, aneurysm location, and treatment modalities, were assessed. Six patients (10.2%) demonstrated their IGF-1 SDS less than −2. Multiple logistic regression analyses revealed that patients who underwent surgical clipping had a significantly lower IGF-1 SDS (<−1 SD) than patients who underwent endovascular embolization with an odds ratio of 5.83 (p = 0.032). Thirty-three patients took provocative tests and five (15.6%) patients were identified as having GHD. The mean IGF-1 SDS of these five GHD patients was 0.08 SD. The aneurysms in all GHD patients were located in internal carotid artery (ICA) or anterior cerebral artery (ACA). To the best of our knowledge, this is the first report describing the prevalence of GHD in Japanese patients after aSAH, and it was not as high as that of previous European studies. We recommend that screening pituitary dysfunction for aSAH survivors with their aneurysms located in ICA or ACA.     

Evaluation of the angiographic outcomes after clipping of intracranial aneurysms: determination of predisposing factors for occurrence of aneurysm remnants

ABSTRACT

Objectives: Aneurysm remnants after microsurgical clipping have a risk of regrowth and rupture and have not been validated in the era of three-dimensional angiography. Therefore, this study aimed to evaluate the angiographic outcome using three-dimensional rotational images and determine the predictors for remnants after microsurgical clipping.

Methods: Between January 2014 and May 2017, 139 aneurysms in 106 patients who were treated with microsurgical clipping, were eligible for this study. For the determination of aneurysm remnants after microsurgical clipping, the angiographic outcomes were evaluated using follow-up digital subtraction angiography within 7 days for unruptured aneurysms or within 2 weeks for ruptured aneurysms. According to the Sindou classification, the aneurysm remnants were dichotomized, and subgroup analysis was performed to identify the predictors of aneurysm remnants after clipping with various imaging parameters and clinical information.

Results: The overall rate of aneurysm remnants was 29.5% (41/139), in which retreatments were needed in 6.5% (9/139). The neck size and maximum diameter of aneurysms were independent predisposing factors for the aneurysm remnants that need retreatment (OR: 2.30; p < 0.001; OR: 1.38; p < 0.001, respectively).

Conclusions: This study demonstrated a low incidence of aneurysm remnants after microsurgical clipping which need to retreatment. However, selective postoperative angiography could provide us clear information of surgical result and evidence for long-term follow-up for some aneurysms with larger neck size (>5.7 mm) and maximum diameter (>7.1 mm).     

The impact of microsurgical clipping and endovascular coiling on the outcome of cerebral aneurysms in patients over 60 years of age

A retrospective study was performed to compare the safety and efficacy in elderly patients of endovascular coiling, with clipping, for cerebral aneurysms. In total, 198 patients over 60 years of age with ruptured intracranial aneurysms were treated by microsurgical clipping (n = 122) or endovascular coiling (n = 76). Endovascular coiling achieved favorable outcome in 88.2% of patients, which was significantly higher than for the microsurgical clipping group. The occurrence of re-bleeding, infarction, and hydrocephalus was similar between the two groups. Intraoperative time for microsurgical clipping was significantly longer than that for endovascular coiling. Length of hospitalization was shorter for the coiling group than for the clipping group. Our results suggest that endovascular coiling should be considered as the first-choice therapy in elderly patients with ruptured aneurysms, as it may reduce duration of both the operation and hospitalization.     

Risk factors for multiple intracranial aneurysms rupture: A retrospective study

Background and purpose

The presence of predicting the rupture risk of intracranial aneurysms has recently generated considerable controversy. We retrospectively investigated the risk factors for multiple intracranial aneurysms related to rupture.

Methods

Between July 2007 and July 2011, 134 patients with 294 aneurysms were identified after review. Every patient had two or more aneurysms. Univariate and multivariate logistic regression models were used to analyze the risk factors for multiple intracranial aneurysms with age, gender, site and size.

Results

134 patients were divided into three groups according to patient age category (<45, 45–65, >65 years of age). The incidence of aneurysms ruptured in the second group was significantly higher. Three groups showed significant difference (P = 0.001 versus >65 years of age). Thirteen of 35 AComA aneurysms were ruptured, accounting for 26% of all ruptured aneurysms, and the rate of rupture at AComA aneurysms in patients was 37.1%. The rate of aneurysm rupture in the AComA was significantly higher than that in other sites (P = 0.001). In all 294 aneurysms, 88.1% of the aneurysms were 5 mm or less, of which 58.2% were less than 3 mm. In the ruptured aneurysms, 68% were 5 mm or less.

Conclusions

Our study reveals the pattern of ruptured multiple intracranial aneurysms, in terms of age, size and location of aneurysms. Age, size, and site of aneurysm should be considered in the decision whether to treat an unruptured aneurysm or not. Especially, in cases of multiple aneurysm, the AComA aneurysm is most prone to hemorrhage.     

International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: A randomized trial

Endovascular detachable coil treatment is being increasingly used as an alternative to craniotomy and clipping for some ruptured intracranial aneurysms, although the relative benefits of these two approaches have yet to be established. We undertook a randomized, multicenter trial to compare the safety and efficacy of endovascular coiling with standard neurosurgical clipping for such aneurysms judged to be suitable for both treatments. We enrolled 2143 patients with ruptured intracranial aneurysms and randomly assigned them to neurosurgical clipping (n = 1070) or endovascular treatment by detachable platinum coils (n = 1073). Clinical outcomes were assessed at both 2 months and at 1 year with interim ascertainment of rebleeds and death. The primary outcome was the proportion of patients with a modified Rankin scale (mRs) score between 3 and 6 (dependency or death) at 1 year. Trial recruitment was stopped by the steering committee after a planned interim analysis. Analysis was per protocol. One hundred and ninety of 801 (23.7%) patients allocated endovascular treatment were dependent or dead at 1 year compared with 243 of 793 (30.6%) of those allocated neurosurgical treatment (P = .0019). The relative and absolute risk reductions in dependency or death after allocation to an endovascular versus neurosurgical treatment were 22.6% (95% CI 8.9-34.2) and 6.9% (2.5-11.3), respectively. The risk of rebleeding from the ruptured aneurysm after 1 year was two per 1276 and zero per 1081 patient-years for patients allocated endovascular and neurosurgical treatment, respectively. In patients with a ruptured intracranial aneurysm, for which endovascular coiling and neurosurgical clipping are therapeutic options, the outcome in terms of survival free of disability at 1 year is significantly better with endovascular coiling. The data available to date suggest that the long-term risks of further bleeding from the treated aneurysm are low with either therapy, although somewhat more frequent with endovascular coiling.     

Contrast Extravasation is Predictive of Poor Clinical Outcomes in Patients Undergoing Endovascular Therapy for Acute Ischemic Stroke in the Anterior Circulation

ObjectiveTo investigate whether contrast extravasation on dual-energy computed tomography (DECT) in patients with acute ischemic stroke (AIS) after endovascular therapy (EVT) are related to hemorrhagic transformation (HT) and poor short-term clinical outcomes.MethodsA retrospective analysis was conducted on AIS patients who underwent EVT at Xuanwu hospital between November 2016 and January 2019. DECT was performed on all patients within 24 hours after EVT. Baseline demographic and clinical data were analyzed between patients with and without contrast extravasation and between patients with HT and non-HT, good and poor outcomes at 3 months post-EVT.ResultsA total of 166 patients were included in the study with 51 (30.7%) patients experiencing contrast extravasation. Compared to patients without contrast extravasation, patients with contrast extravasation had longer onset to reperfusion time (444.8 minutes versus 374.0 minutes, P = .044) and higher percentages of greater than 3 retriever passes (16.7% versus 31.4%, P = .030). Contrast extravasation was associated with higher risk of HT (P = .038), poor outcome after discharge (P = .030), and longer hospital stay (P = .034). Multivariate analysis showed that contrast extravasation occurrence was an independent factor for HT (OR = 2.150, 95% CI 1.060-4.360, P = .034) and poor short-term outcome (OR = 2.936; 95% CI 1.147-7.518, P = .025).ConclusionsThe presence of contrast extravasation within 24 hours of EVT may be associated with higher risks of HT and may be predictive of unfavorable functional outcomes in AIS patients.     

Safety of early rehabilitation in patients with aneurysmal subarachnoid hemorrhage: A retrospective cohort study

ObjectiveTo investigate the safety and efficacy of early rehabilitation in patients with aneurysmal subarachnoid hemorrhage (aSAH) patients.MethodsOne hundred eleven patients with aSAH admitted between April 2015 and March 2019, were retrospectively evaluated. The early rehabilitation program was introduced in April 2017 to actively promote mobilization and walking training for aSAH patients. Therefore, patients were divided into two groups (The conventional group (n = 55) and the early rehabilitation group (n == 56). Clinical characteristics, mobilization progression, and treatment variables were analyzed. Complications (rebleeding, symptomatic cerebral vasospasm, hydrocephalus, disuse complications,) and a modified Rankin Scale (mRS) at 90 days were compared in two groups. Factors associated with favorable outcomes (mRS≤2) at 90 days were also assessed.ResultsThe early rehabilitation group had a significantly shorter span to first walking (9 vs. 5 days; P = 0.007). The prevalence of complications was not significantly increased in the early rehabilitation group. Approximately 40% of patients in both groups had pneumonia and urinary tract infections but significantly reduced antibiotic-administration days (13 vs. 6 days; P < 0.001). mRS at 90 days also showed significant improvement in the early rehabilitation group (3 vs. 2; P=0.01). Multivariate logistic regression analysis of favorable outcomes associated that the administration of the early rehabilitation program has a significant independent factor (odds ratio, 3.03; 95% confidence interval, 1.1-8.37).ConclusionsEarly rehabilitation for patients with aSAH can be feasible without increasing complication occurrences. The early rehabilitation program with active mobilization and walking training reduced antibiotic use and was associated with improved independence.     

Efficacy of Cilostazol in Prevention of Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis

Objectives

Cilostazol, a selective inhibitor of phosphodiesterase 3, may reduce symptomatic vasospasm and improve outcome in patients with aneurysmal subarachnoid hemorrhage considering its anti-platelet and vasodilatory effects. We aimed to analyze the effects of cilostazol on symptomatic vasospasm and clinical outcome among patients with aneurysmal subarachnoid hemorrhage (aSAH).

Intraventricular Nicardipine for Aneurysmal Subarachnoid Hemorrhage Related Vasospasm: Assessment of 90 Days Outcome

Background

Delayed cerebral arterial vasospasm is one of the leading causes of death and disability after aneurysmal subarachnoid hemorrhage (aSAH). We evaluated the safety of intraventricular nicardipine (IVN) for vasospasm (VSP) in aSAH patients, and outcomes compared with a control population.

Methods

A retrospective case?Ccontrol study was conducted for aSAH patients treated with IVN at Mayo Clinic, Jacksonville, FL, from March 2009 to January 2011. Controls were matched by age, gender, and Fisher grade. Safety was evaluated by the incidence of intracranial bleeding and infection. Outcome was measured by Glasgow Outcome Scale at 30 and 90?days. IVN effects on VSP were evaluated by transcranial Doppler (TCD).

Results

Thirteen aSAH patients and one arteriovenous malformation (AVM)-related SAH patient received IVN for VSP and were matched with 14 aSAH patients without IVN therapy for a total of 28 cases. Median dose was 4?mg (range 3?C7), and median number of doses was seven (range 1?C17). Mean flow velocity decreased after IVN (120.2 and 101.6?cm/s?C82.0 and 72.8?cm/s, right and left middle cerebral arteries, respectively). No significant difference was seen in clinical outcomes between controls and cases at 30?days (P?=?0.443) and 90?days (P?=?0.153). There were no incidences of bleeding or infection with 111 nicardipine injections.

Conclusions

IVN appears relatively safe and effective in treating VSP by TCD, but there was no difference in clinical outcomes between nicardipine and control patients at 30 and 90?days. In the future, larger studies are needed to evaluate the clinical outcome with IVN.     

The AGTR1 gene A1166C polymorphism as a risk factor and outcome predictor of primary intracerebral and aneurysmal subarachnoid hemorrhages

Associations between the angiotensin II type 1 receptor (AGTR1) gene A1166C polymorphism and hypertension, aortic abdominal aneurysms (as a risk factor) as well as cardiovascular disorders (as a risk factor and an outcome predictor) have been demonstrated. We aimed to investigate the role of this polymorphism as risk factors and outcome predictors in primary intracerebral hemorrhage (PICH) and aneurysmal subarachnoid hemorrhage (aSAH).We have prospectively recruited 1078 Polish participants to the study: 261 PICH patients, 392 aSAH patients, and 425 unrelated control subjects. The A1166C AGTR1 gene polymorphism was studied using the tetra-primer ARMS-PCR method. Allele and genotype frequencies were compared with other ethnically different populations.The A1166C polymorphism was not associated with the risk of PICH or aSAH. Among the aSAH patients the AA genotype was associated with a good outcome, defined by a Glasgow Outcome Scale of 4 or 5 (p < 0.02). The distribution of A1166C genotypes in our cohort did not differ from other white or other populations of European descent.In conclusion, we found an association between the A1166C AGTR1 polymorphism and outcome of aSAH patients, but not with the risk of PICH or aSAH.     

Mechanical Recanalization after Transfer from a Distant Primary Stroke Center: Effectiveness and Future Directions

Introduction: Little is known about the effectiveness of endovascular treatment (EVT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) admitted to a primary stroke center (PSC). The aim of this study was to assess EVT effectiveness after transfer from a PSC to a distant (156 km apart; 1.5 hour by car) comprehensive stroke center (CSC), and to discuss perspectives to improve access to EVT, if indicated. Patients and Method: Analysis of the data collected in a 6-year prospective registry of patients admitted to a PSC for AIS due to LVO and selected for transfer to a distant CSC for EVT. The rate of transfer, futile transfer, EVT, reperfusion (thrombolysis in cerebral infarction score ≥2b-3), and relevant time measures were determined. Results: Among the 529 patients eligible, 278 (52.6%) were transferred and 153 received EVT (55% of transferred patients) followed by reperfusion in 115 (overall reperfusion rate: 21.7%). Median times (interquartile range) were: 90 minutes (76-110) for PSC-door-in to PSC-door-out, 88 minutes (65-104) for PSC-door-out to CSC-door-in, 262 minutes (239-316) for PSC-imaging to reperfusion, and 393 minutes (332-454) for symptom onset to reperfusion. At 3 months, rates of favorable outcome (modified Rankin Scale 0-2) were not significantly different between patients eligible for EVT (42.4%), transferred patients (49.1%) and patients who underwent EVT (34.1%). Discussion and Conclusions: Our study suggests that transfer to a distant CSC is associated with reduced access to early EVT. These results argue in favor of on-site EVT at high volume PSCs that are distant from the CSC.