EmboTrap II is a novel stent retriever with a dual-layer design and distal mesh designed for acute ischemic stroke emergent large-vessel occlusions. We present the first postmarket prospective ...multicenter experience with the EmboTrap II stent retriever.
A prospective registry of patients treated with EmboTrap II at 7 centers following FDA approval was maintained with baseline patient characteristics, treatment details, and clinical/radiographic follow-up.
Seventy patients were treated with EmboTrap II (mean age, 69.9 years; 48.6% women). Intravenous thrombolysis was given in 34.3%, and emergent large-vessel occlusions were located in the ICA (
= 18), M1 (
= 38), M2 or M3 (
= 13), and basilar artery (
= 1). The 5 × 33 mm device was used in 88% of cases. TICI ≥ 2b recanalization was achieved in 95.7% (82.3% in EmboTrap II-only cases), and first-pass efficacy was achieved in 35.7%. The NIHSS score improved from a preoperative average of 16.3 to 12.1 postprocedure and to 10.5 at discharge. An average of 2.5 SD, 1.8 passes was recorded per treatment, including non-EmboTrap attempts. Definitive treatment was performed with an alternative device (aspiration or stent retriever) in 9 cases (12.9%). Some hemorrhagic conversion was noted in 22.9% of cases, of which 4.3% were symptomatic. There were no device-related complications.
Initial postmarket results with the EmboTrap II stent retriever are favorable and comparable with those of other commercially available stent retrievers. Compared with EmboTrap II, the first-generation EmboTrap may have a higher first-pass efficacy; however, data are limited by retrospective case analysis, incomplete clinical follow-up, and small sample size, necessitating future trials.
Rabies is one of the most important zoonotic infections worldwide. The burden of the disease continues to be significant in countries in the Middle East where the most important vector is stray dogs. ...Control efforts are hindered by lack of awareness and incomplete post-exposure prophylaxis. The aim of this article is to re-assess the situation of rabies in Lebanon and compare it to other Middle Eastern countries. Eight cases of rabies and 5280 incidents of animal bites to humans were reported to the Lebanese Ministry of Public Health between 2001 and 2012. Dogs were the only vector of infection and were responsible for most reported animal bites to humans. An average of 3·2 doses of vaccine per bite was administered as post-exposure prophylaxis. The status of human and canine rabies control, the risks associated with children's behaviour and the hazards of secondary wild reservoirs are discussed. Our data illustrates the importance of prevention through vector control, public awareness and education, and timely administration of active and passive immunization, as well as the significance of regional cooperation and monitoring the circulation of viral variants in wild animals.
BackgroundDespite the revolutionary impact of endovascular thrombectomy on acute ischemic stroke (AIS) management, stroke remains a major cause of morbidity and mortality in the US and globally. Less ...than a third of AIS patients are eligible for intervention and among successfully recanalized patients, more than half of patients do not achieve functional independence. Post-ischemic neuroinflammation remains a major contributor to secondary injury and worsening of outcomes after ischemic stroke by promoting loss of otherwise salvageable brain tissue. In this work, we designed a fusion protein (Psel-Crry) that binds to P-selectin, a protein expressed on inflamed endothelium and promotes platelet adhesion, and Crry which inhibits activation of the inflammatory system by targeting complement activation.HypothesisFollowing transient middle cerebral artery occlusion (MCAO) in mice, Psel-Crry homes specifically to the ischemic brain preventing complement activity and platelet aggregation leading to improved neurological outcome.MethodsThe fusion protein Psel-Crry was constructed by linking the single-chain variable fragment (scFv) of anti-Pselectin antibody and the extracellular region of mouse Crry using overlapping PCR with the inclusion of a (G4S2)2 linker sequence. The fusion was cloned into Expi293 cell, and purified using His60 Nickel column prior to concentration for intravenous injection. In-vitro complement inhibitory activity and Pselectin binding was assessed. Stroke was induced in 8-week-old C57bl6/j mice using the transient MCAO model by placing an intraluminal filament through the internal carotid artery ending at the MCA origin for 60 min followed by withdrawal of filament and reperfusion. In-vivo targeting was assessed using in-vivo fluorescent tomography. Neurological deficit was assessed over 3 days using the Neurological Severity Scale in mice, and infarct volume was computed from Nissl Stain.ResultsUsing surface plasmon resonance, Psel-Crry retained the ability to bind to Pselectin with moderate binding affinity, and demonstrated dose-dependent suppression of complement activity. Using in-vivo fluorescent tomography, administration of labeled Psel-Crry was found to specifically localize to the ipsilateral hemisphere when administered 2 h after MCAO and was retained at the site for at least 72 hours. Compared with vehicle (N=8), mice treated with Psel-Crry (N=10) showed significant reduction in C3 activation (40% reduction, p<0.05), overall cerebral edema (55% reduction, p<0.01), and infarct volume (p<0.05) 3 days after stroke. Psel-Crry significantly improved neurological deficit scores at 24 and 72 h after stroke (p<0.05). Mortality rate within 72 hrs was 70% in Psel-Crry compared to 40% in vehicle controls.ConclusionPsel-Crry is a novel approach to target both platelet aggregation and complement-mediated neuroinflammation after stroke resulting in improved neurological outcomes in murine MCAO. Further preclinical characterization of chronic outcomes is ongoing in anticipation for clinical development.Disclosures A. Alawieh: 1; C; Department of VA. 6; C; US Patent App. 17/335,355. S. Tomlinson: 1; C; Department of VA, NIH/NINDS. 4; C; Q3 Bio. 6; C; US Patent App. 17/335,355.
BackgroundAneurysmal subarachnoid hemorrhage is a devastating neurological condition which requires complex neurocritical care and neurosurgical decision-making and results in remarkably variable ...outcomes. Robust methods of identifying patients who may need operative or critical care intervention, such as those who develop hydrocephalus requiring long term shunting, cerebral vasospasm and delayed cerebral ischemia, or patients with worsened neurological outcome, are lacking.MethodsTo this end, we applied artificial neural networks and machine learning techniques to a curated aneurysmal subarachnoid hemorrhage database collected at a large academic medical center between 2015–2020, (n = 855).ResultsUsing this data, we have generated artificial neural network models with hyperparameter tuning which predict the need for long-term cerebrospinal fluid (CSF) diversion via placement of a shunt (receiver operating characteristic area under the curve (ROC AUC) = 0.9916), delayed cerebral ischemia (ROC AUC = 0.9903), and vasospasm (ROC AUC = 0.9834) from information available during the first few days of a patient’s admission. This data included demographic and medical history information including gender, age, race, Hunt and Hess Scale, hypertension, diabetes, smoking, coronary artery disease, dyslipidemia, and the category of aneurysmal treatment. Additionally, external ventricular drainage variables such as external ventricular drain (EVD) output, EVD level, EVD age, and CSF parameters, such as CSF protein level, were used. The models were trained on a subpopulation of 80% of subjects and then individually validated in the withheld 20% of subjects with high reproducibility and accuracy. Finally, using the same data, another model was generated which accurately predicted categorical disposition at time of discharge (home, subacute rehabilitation, acute rehabilitation, long-term acute care, expiration in hospital) (ROC AUC = 0.9934).ConclusionWe hope the use of artificial intelligence and machine learning techniques will continue to demonstrate power in predicting complex medical outcomes and ultimately help neurosurgeons and neuro-critical care personnel to provide appropriate and timely treatment.Disclosures T. Steed: None. A. Alawieh: None. F. Akbik: None. O. Sadan: None. O. Samuels: None. J. Grossberg: 1; C; Grant: GRA, EMCF, Neurosurgery Catalyst. 2; C; Cognition.
IntroductionFirearm related injuries and fatalities have been steadily increasing over the last two decades. 30,000 firearm-related traumatic brain injuries (TBI) occur in the United States yearly. ...Mortality remains greater than 50% and morbidity remains high. For those that do survive the initial injury, it is essential to prevent secondary neurological injuries. Guidelines for managing these injuries are twenty years old. Recommendations for diagnosis and management of cerebrovascular injuries (CVI) are not provided. Single-institution retrospective cohort studies have shown an association between CVI and both mortality and bad functional outcome following gunshot wound to the head (GSWH). Further, ischemic stroke or re-hemorrhage secondary to the original CVI has been associated with worse outcomes. However, these studies are limited and with small cohorts. In this study, we evaluated the role of CVI and subsequent stroke or re-hemorrhage in patients with following firearm related TBI.MethodsRecords for patients with firearm related TBI from GSWH at six major centers in the United States and Europe between 2014 and 2023 were retrospectively reviewed for patient characteristics, imaging findings, laboratory values, clinical exam findings, disposition, and follow up. Patients with adequate cerebrovascular imaging (including CT angiogram, MR angiogram, and digital subtraction angiogram) were included. Univariate and multivariate regression models were used to compare patients with and without CVI to determine if CVI or secondary vascular insult (stroke or re-hemorrhage) were independent predictors of mortality or poor functional outcome (Glasgow outcome score of 1 - 3).ResultsA total of 285 patients presented with firearm related TBI and met inclusion criteria with cerebrovascular imaging. 240 (84.2%) patients were males and the mean (SD) age was 35.0 (±15.6) years. The incidence of intracranial CVI was 42.8% (122/285 patients) in patients with GSWH who received vascular imaging. Secondary vascular insult occurred in 30.6% (37/121 patients). There were 24 patients with ischemic infarctions and 13 patients with re-hemorrhage. Patients with CVI had significantly higher mortality (44.3 vs. 17.2%; OR 3.8; CI 2.2 - 6.4; p <0.001) and were less likely had have a good functional outcome with GOS 4–5 at follow up (34.4 vs. 69.3%; OR 0.23; CI 0.14 - 0.38; p < 0.001). Patients with CVI and subsequent secondary vascular insult with stroke or re-hemorrhage were significantly less likely to have a good functional outcome (10.8 vs 44.7%; OR 0.15; CI 0.05 - 0.46; p < 0.001) compared to patients with CVI but without secondary insult.ConclusionIn this multicenter retrospective cohort study, intracranial CVI from firearm related TBI were associated with increased mortality and poor functional outcomes. Secondary vascular insult with stroke or re-hemorrhage from the CVI was associated with even worse functional outcomes. Given the incidence of 42.8% in screened patients and association with both mortality and poor functional outcome, it would be reasonable to screen patients with survivable firearm related TBI for vascular injuries with CT angiogram or digital subtraction angiogram. Early identification and management of these injuries will prove critical to improve outcomes.Disclosures J. Lamanna: None. A. Alawieh: None. R. Grandhi: None. W. Khalid Salah: None. I. Abecassis: None. D. Ding: None. A. Paul: None. M. Psychogios: None. I. Fragata: None. D. Kuroedov: None. J. Grossberg: None.
BackgroundInfectious intracranial aneurysms (IIAs) or mycotic aneurysms are rare neurological manifestations of infective endocarditis or systemic infections. To date, data on long-term outcomes of ...IIAs remain limited, and there is no guidelines or standard protocols for management. We explored long-term clinical outcomes in patients treated for IIA using medical, endovascular and microsurgical approaches.MethodsWe retrospectively reviewed patients treated for IIAs at Emory University Hospitals or Grady memorial hospital between May 2015 and May 2020 using diagnosis code and reviewing records of patients with infective endocarditis and concurrent intracranial hemorrhage. Patient charts, imaging data, procedure notes and pathological reports were reviewed including the different treatment approaches including medical, endovascular and microsurgical management. Outcome measures included aneurysm progression or re-rupture, 90-day mRS scores, and mortality. Patients were followed up to 5 years from diagnosis.ResultsAmong 1714 patients with infective endocarditis, 322 (19%) developed intracranial hemorrhage of which 17 patients were found to have IIA. In patients with IE, presence of IIA was associated with higher odds of disposition to hospice or death compared to those without IIA (OR = 6.9, p < 0.05). In addition, 7 patients with systemic infections were found to have IIA during the same period. Our cohort included 24 patients with 38 IIAs of which 67% presented with rupture and the remaining were incidental on surveillance imaging. The majority of aneurysms involved the middle cerebral artery (74%), and multiple aneurysms were noted in 30% of subjects. A trial of antibiotics was used 82% of cases whereas primary open or endovascular intervention was used in 18% of patients. Treatment failure defined as progression of aneurysm, rupture or re-rupture was noted in 48% of patients managed medically, and required endovascular or open microsurgical salvage. Treatment failure occurred within 2 weeks of initiation of antibiotics in 50% of cases and independently predicted worse mRS scores and mortality at 90 days. The 2-year survival in this cohort was 70%.ConclusionsPatients with IIA are at higher risk of neurological decline and mortality in the event of rupture. Patients treated with antibiotics have higher risk of treatment failure requiring salvage surgical or endovascular intervention. Medical treatment failure occurred mostly within 2 weeks of onset and had negative prognostic value emphasizing the need for close follow-up and early surgical or endovascular management if possible.Disclosures A. Alawieh: None. L. Dimisko: 1; C; T32NR012715. S. Newman: None. J. Grossberg: None. C. Cawley: None. G. Pradilla: None. O. Samuels: None. D. Barrow: None. B. Howard: None.
IntroductionInfectious intracranial aneurysms (IIAs) are a rare complication of infective endocarditis as well as systemic and intracranial infections. IIAs are often diagnosed upon rupture but have ...a similar presentation to non-infectious aneurysms (NIAs) with subarachnoid hemorrhage (SAH). Although vasospasm is a common complication of both SAH and meningitis, the incidence, timing, and management of vasospasm in IIA patients are yet to be studied which is the objective of this work.MethodsThis is a retrospective study of patients presenting with SAH secondary to IIAs or NIAs between 5/2015 and 1/2023. Patients with SAH who died within 48 hours were excluded from this study. Patients’ charts were reviewed for demographics, imaging findings, management, the timing of vasospasm, severity of vasospasm, and vasospasm management. Propensity score matching was used to compare patients with IIAs versus NIAs. The patients were matched with a ratio of 1:5 based on their age, gender, race, comorbidities, and fisher score. Incidence, rate, and management of vasospasm were computed for each cohort.ResultsA total of 20 patients with ruptured IIAs were included in this study of which 30% (n=6) developed post-ruptured vasospasm. Vasospasm was diagnosed using combined daily trans-cranial doppler (TCD) and surveillance CTA in all patients. Of patients with vasospasm, 1 patient had mild vasospasm, 2 had moderate and 3 had severe, as defined on CTA by an independent radiologist. Among patients with vasospasm, 83% had neurological deficits due to vasospasm. Vasospasm was managed using intrathecal nicardipine in 5 patients (83%), while 1 patient required intra-arterial milrinone and 1 patient underwent angioplasty and stenting. When comparing with the NIAs matched cohort, there was no significant difference in age, comorbidities, modified fisher score, smoking history, or time to presentation indicating balanced matching. Compared to NIAs, patients with IIAs had a comparable rate of vasospasm (30% vs 39%, p= 0.448). However, patients with IIAs developed vasospasm significantly earlier with a mean time from rupture to spasm of 3.5±1.05 days compared to 5.81±3.48 days in NIAs (p=0.002).ConclusionPatients with ruptured IIAs are at a similar risk of vasospasm compared to NIAs with similar blood pattern and modified fisher score; however, they develop symptomatic and radiographic evidence of vasospasm earlier in the course of their disease. These findings argue for the need for routine and early screening for vasospasm in patients with ruptured IIAs.Disclosures Y. Zohdy: None. L. Dimisko: None. J. Grossberg: None. G. Pradilla: None. T. Garzon-Muvdi: None. D. Barrow: None. C. Cawley: None. O. Sadan: None. O. Samuels: None. A. Alawieh: None. B. Howard: None.
IntroductionClip ligation of ruptured aneurysm is more commonly associated with vasospasm compared to endovascular embolization. Here, we examine if this relationship holds true for middle cerebral ...artery (MCA) aneurysms, given the difference in operative technique and dissection required for their clipping.MethodsA retrospective cohort study was performed of aSAH patients with ruptured anterior circulation aneurysms admitted to a tertiary care center between January 1, 2012 and March 31, 2019. Patients were grouped based on aneurysm; MCA vs. other anterior circulation aneurysms (non-MCA) and the type of procedure performed (endovascular embolization vs open clip ligation). Baseline characteristics, rate of radiographic vasospasm, delayed cerebral ischemia (DCI),and clinical outcomes were compared.Results712 patients were included for analysis, 109 (15.3%) MCA aneurysms and 603 (84.7%) non-MCA aneurysms. In the MCA group, 75 (68.8%) of patients underwent clip ligation compared with 147 (24.4%) patients in the non-MCA group. Baseline demographics, Hunt-Hess Score, and modified Fischer Score were comparable in both groups for the clip and endovascular cohorts.Peri-procedural radiographic ischemia was increased in both clip ligation cohorts (56.4% vs. 6.7% in the non-MCA cohort and 52% vs 8.8% in the MCA cohort, p<0.01). The rate of radiographic vasospasm was significantly higher in the surgical, non-MCA cohort (57.1% vs. 43.8%, p<0.01). In the MCA cohort, no difference was detected in the rate of spasm between the surgical and endovascular groups (57.3% vs 52.9%,p=0.67). This dichotomy held true when examining only the patients with higher Hunt-Hess or Modified Fischer Scores. In terms of vasospasm intervention, the non-MCA patients treated with clip ligation were more likely to undergo endovascular vasospasm treatment (16.3% vs 8.5%, p<0.01). In the MCA cohort, coil embolization patents were more likely to undergo endovascular vasospasm treatment (23.5% vs 6.7%, p=0.01).Radiologic delayed cerebral ischemia was more common in patients treated by clipping in the non-MCA cohort (17.7% vs 11%, p=0.03), but not in the MCA patients (9.3% vs. 20.6%, p=0.1). Length of ICU stay did not differ between the groups. Endovascularly treated patients in both groups were more likely to be discharged home and have a discharge modified Rankin Score(mRS)2 (p<0.01). 90-day mRS2 was more common in the embolization group compared to surgery for non-MCA patients (87.5% vs. 84.9%,p=0.04), but was similar in the MCA cohort (75% vs. 89%, p=0.15).ConclusionsIn this retrospective cohort study, patients with ruptured anterior circulation, non-MCA aneurysms treated with clip ligation were more likely to develop vasospasm and DCI compared with endovascular treated patients. This relationship did not hold true for MCA aneurysms as no difference in vasospasm or DCI was identified between patients treated by coiling versus clipping.Disclosures F. Akbik: None. J. Lamanna: None. Z. Bernstein: None. R. Greenberg: None. A. Alawieh: None. F. Tong: None. C. Cawley: None. O. Samuels: None. O. Sadan: None. B. Howard: None. J. Grossberg: None.
Background and ObjectivesCerebrovascular injury (CVI) following civilian gunshot wound to the head (GSWH) is likely a significant contributor to poor outcomes, but little supporting evidence exists. ...The purpose of this study was to determine whether intracranial CVI from GSWH and secondary vascular insult (stroke or re-hemorrhage) were associated with poor outcomes in a large civilian population.MethodsThis was a single-institution, retrospective cohort study between January 2014 and July 2022, at a large, metropolitan, level-1 trauma center. Multivariate regression models and propensity score matching were used to balance baseline features including age, gender, isolated GSWH, admission Glasgow Coma Scale (GCS), trajectory type, dural penetration, bihemispheric injury, lobes involved, and intraventricular hemorrhage.ResultsA total of 512 civilian patients presented with GSWH and a cohort of 172 (33.5%) met inclusion criteria with 143 (83.1%) males and a mean (SD) age of 34.3 (±14.2) years. The incidence of intracranial CVI was 50.6% (87/172 patients), including 40 (23.2%) venous sinus injuries, 32(18.6%) arterial intimal injuries/dissections, 12(7.0%) pseudoaneurysms, 10(5.8%) large vessel occlusions, 13(7.6%) transections, and 3(1.7%) high flow carotid-cavernous fistulas (Figure). Bifrontal trajectories (adjusted odds ratio aOR 13.11; 95% confidence interval CI 2.45-70.25; p=0.003) and the number of lobes traversed by the projectile (aOR 3.18; CI 1.77-5.71; p<0.001) were associated with increased odds of resultant CVI. In both the overall and propensity matched cohorts, patients with CVI were less likely to discharge home (20% vs 51%; OR 0.23; CI 0.09-0.62; p=0.015), less likely to achieve a good functional outcome of Glasgow Outcome Score (GOS) of 4-5 (34% vs. 68%; OR 0.24; CI 0.1-0.6; p=0.004), and suffered higher rate of mortality (34% vs. 20%; OR 2.1; CI 0.78-5.85; p=0.015). Among patients with a primary CVI, 28(32.2%) patients had a secondary vascular insult, which included re-hemorrhage (55.7%) or delayed stroke (2326.4%), attributable to the underlying CVI. When compared to patients with CVI but without secondary vascular insult, patients with CVI who suffered secondary vascular insult were significantly less likely to achieve a good functional outcome GOS 4-5 (16.7% vs 39.0%; aOR 0.012; CI 0.001-0.169, p=0.001).ConclusionThese data suggest that intracranial CVI from GSWH and associated secondary vascular insult are associated with poor outcomes. Given the high prevalence and potentially reversible nature of these secondary injuries, early screening with vascular imaging and treatment of underlying cerebrovascular injury may prove critical to improve outcomes by reducing the rate of stroke and re-hemorrhage.Abstract E-211 Figure 1Disclosures J. Lamanna: None. J. Gutierrez: None. A. Alawieh: None. C. Funk: None. R. Rindler: None. F. Ahmad: None. B. Howard: None. S. Gupta: None. D. Gimbel: None. R. Smith: None. G. Pradilla: None. J. Grossberg: None.
