双支架并联取栓术治疗急性基底动脉闭塞初步研究

目的初步探讨双支架取栓治疗急性基底动脉闭塞患者的可行性、有效性及安全性。方法回顾性分析采用Solitaire FR双支架并联取栓术治疗血栓负荷重的急性基底动脉闭塞所致脑梗死5例患者,统计手术时间,评价取栓后即刻血流再灌注、24 h神经功能改善及术后90天随访mRS评分。结果 5例患者均通过双支架并联取栓术获得闭塞血管良好再通,改良脑梗死溶栓分级(mTICI)为2b-3级,其中完全再通4例(mTICI 3级)。无明显与操作相关并发症,术后24 h NIHSS评分较术前减少10分。术后90天随访,2例患者预后良好,2例残疾,1例患者死亡。结论使用Solitaire FR双支架并联取栓术治疗血栓负荷重的部分后循环急性脑梗死患者是安全有效的。     

Transcatheter pulmonary embolectomy after fontan

Pulmonary embolism (PE) is a significant cause of morbidity and mortality among hospitalized patients, and thrombolytics are the mainstay of treatment. However, for patients who fail or have contraindications to thrombolytic therapy, catheter‐based therapies, such as the AngioVac aspiration system, have emerged as an alternative to surgical embolectomy. Here, we present the novel case of a 22 year‐old woman with Fontan circulation who developed severe postpartum cardiomyopathy and a saddle PE. She failed thrombolytic therapy but underwent successful pulmonary embolectomy by AngioVac aspiration. Patients with Fontan circulation have an increased incidence of thromboembolic events, and AngioVac thrombectomy is a valuable treatment option in these complex patients. © 2015 Wiley Periodicals, Inc.     

Use of the Rocket Technique after Failure of the Direct Aspiration First-Pass Technique in Acute Stroke Thrombectomy

The technical feasibility of the rocket technique was evaluated for patients treated for stroke where the direct aspiration first-pass technique (ADAPT) failed to reach the occlusion site. This single-center retrospective study included data on consecutive patients with a large vessel occlusion of the anterior circulation who underwent mechanical thrombectomy. Of 138 patients, 100 met the inclusion criteria. In 84 patients, a large 0.072-inch inner lumen aspiration catheter was able to reach the occlusion site when deployed with a coaxial microcatheter. In 16 patients, this technique failed, and the microcatheter was replaced with a compliant balloon inflated at the extremity of the aspiration catheter (rocket technique). In 15 of these 16 patients, the rocket technique brought the catheter into contact with the thrombus. In conclusion, when deployment of the ADAPT with a coaxial microcatheter fails to reach the clot site, the rocket technique can safely advance the aspiration catheter to the clot.     

Idarucizumab for Intravenous Thrombolysis and Endovascular Thrombectomy in Acute Stroke: A Case Report

BackgroundNon–vitamin K antagonist oral anticoagulants (NOACs), such as dabigatran, are widely used to prevent ischemic stroke in patients with nonvalvular atrial fibrillation. Nonetheless, stroke occurs in 1–2% of patients, and the use of NOACs may increase the bleeding risk for patients who are receiving acute treatment of intravenous thrombolysis (IVT) or endovascular thrombectomy (EVT). Idarucizumab, a monoclonal antibody developed to bind dabigatran, has been proven safe and effective for patients with uncontrolled bleeding or for patients planning to receive emergent procedures. It is now accepted that patients taking dabigatran with recurrent stroke may benefit from IVT after idarucizumab. However, there are limited data regarding idarucizumab use in patients planning to have EVT.Case ReportWe present the case of a male patient taking dabigatran who had a stroke and who was treated with idarucizumab followed by combined IVT and EVT. The patient had immediate recanalization of the occluded vessel and near total recovery of function after 3 months.Why Should an Emergency Physician be Aware of This?Our case report supports the evidence that patients presenting with acute ischemic stroke (AIS) despite being under dabigatran therapy should be evaluated for reversal by idarucizumab which can contribute to the eligibility for IVT as well as EVT. It has also been proved to provide better outcomes for patients with AIS. The availabilities of specific reversal agents for NOACs will probably alter the current management of patients with AIS.     

Heparin Flush Use in Transfemoral Cerebral Angiography Survey

The drug concentration of heparinized saline used for transfemoral catheter angiography flush during different types of cerebral angiogram procedures varies among providers and centers worldwide. Although heparin is recommended for use during cerebral angiograms to minimize the risk of thromboembolic events associated with the utilization of multiple endovascular devices and lengthy procedures, there is a paucity of information available regarding protocols for administration of heparin and heparinized saline. Higher concentrations of heparinized saline flush may benefit patients undergoing elective nonruptured intracranial aneurysm embolization procedures by decreasing the risk of thromboembolism. However, it could potentially place patients undergoing revascularization procedures for acute ischemic stroke at higher risk of symptomatic intracerebral hemorrhage, particularly if they received intravenous tissue plasminogen activator immediately before endovascular thrombectomy. After obtaining permission from the Association for Radiologic and Imaging Nursing (ARIN) Board of Directors, a survey was presented in English and electronically distributed by the ARIN to all current and past ARIN members with valid e-mail addresses. The survey was preceded by an introductory letter explaining the study purpose and its voluntary nature. Response to the survey was identified as consent to participate. Subjects were asked to participate if they were currently involved in the management of patients undergoing cerebral angiography with a variety of interventions including management of acute ischemic and hemorrhagic stroke. There is a paucity of evidence supporting use of a specific concentration of heparinized saline solution. It ranges from no heparin added to concentrations exceeding 5 units/mL for transfemoral flush. The most frequently used concentration is 2 units/mL (32.8–34.8% of respondents depending on endovascular intervention), and the least frequently utilized concentrations are 3 units/mL and higher than 5 units/mL (4.3–5.7% of respondents depending on endovascular intervention). Mixing and labeling bags with heparinized saline flush was noted to be the responsibility of interventional radiology registered nurse (39%, n = 46), pharmacy (26.3%, n = 31), or the angiography technologist (8.5%, n = 10). More than quarter (26.5%) of respondents noted not having readily available premixed heparinized saline flush. Twenty-four (20.3%) of survey participants claimed using only premixed bags of heparinized saline solution. Despite the Institute for Healthcare Improvement, Institute for Safe Medication Practices and Joint Commission recommendations, there are no standard protocols across stroke centers identifying optimal heparinized saline flush solution concentration, preparation, and documentation. Replication of this survey among members of the American Society of Neuroradiology is recommended to validate the findings from the present study. If confirmed, a consensus on safety of heparinized saline flush use during neuroradiology interventions is strongly advised.     

Large-Bore Aspiration Thrombectomy versus Catheter-Directed Thrombolysis for Acute Pulmonary Embolism: A Propensity Score–Matched Comparison

PurposeTo compare effectiveness and safety of large-bore aspiration thrombectomy (LBAT) with catheter-directed thrombolysis (CDT) for treatment of acute massive and submassive pulmonary embolism (PE).Materials and MethodsThis retrospective review included patients with acute PE treated with LBAT or CDT using tissue plasminogen activator (tPA) between December 2009 and May 2020. A propensity score based on Pulmonary Embolism Severity Index class and PE severity (massive vs submassive) was calculated, and 26 LBAT cases (age 60.2 y ± 17.1, 14/26 women) were matched with 26 CDT cases (age 59.7 y ± 14.2, 14/26 women).ResultsThe CDT group had 22.1 mg ± 8.1 tPA infused over 21.2 h ± 6.6. Both groups demonstrated similar initial and final systolic pulmonary artery pressure (PAP) (LBAT: 54.5 mm Hg ± 12.9 vs CDT: 54.5 mm Hg ± 16.3, P = .8, and LBAT: 42.5 mm Hg ± 14.1 vs CDT: 42.6 mm Hg ± 12.1, P = .8, respectively) and similar reductions in heart rate (LBAT: −5.4 beats/min ± 19.2 vs CDT: −9.6 beats/min ± 15.8, P = .4). CDT demonstrated a higher reduction in Miller score (−10.1 ± 3.9 vs −7.5 ± 3.8, P = .02). LBAT resulted in 1 minor hemorrhagic complication and 2 procedure-related mortalities, and CDT resulted in 1 minor and 1 major hemorrhagic complication.ConclusionsLBAT and CDT resulted in similar reductions of PAP and heart rate when used to treat acute PE. CDT reduced thrombus burden to a greater degree. Although hemorrhagic complications rates were not significantly different, the LBAT group demonstrated a higher rate of procedure-related mortality. Larger studies are needed to compare the safety of these techniques.     

Neuroendovascular Treatment of Acute Stroke During COVID-19: A Guide From the Frontlines

Since the initial reports surfaced of a novel coronavirus causing illness and loss of life in Wuhan, China, COVID-19 has rapidly spread across the globe, infecting millions and leaving hundreds and thousands dead. As hospitals cope with the influx of patients with COVID-19, new challenges have arisen as health-care systems care for patients with COVID-19 while still providing essential emergency care for patients with acute strokes and acute myocardial infarction. Adding to this complex scenario are new reports that patients with COVID-19 are at increased risk of thromboembolic complications including strokes. In this article, we detail our experience caring for acute stroke patients and provide some insight into neurointerventional workflow modifications that have helped us adapt to the COVID-19 era.