Blood supply to the brain is secured by an extensive collateral circulation system, which can be divided into primary routes, i.e., the Circle of Willis, and secondary routes, e.g., collaterals from ...the external to the internal carotid artery and leptomeningeal collaterals. Collateral flow is the basis for acute stroke treatment, since neurones will only survive long enough to be rescued with reperfusion therapies if there is sufficient collateral flow. Poor collateral flow is associated with worse outcome and faster growth of larger infarcts in acute stroke treatment. Therapeutic promotion of collateral flow theoretically offers the chance for outcome improvement, but randomised trials are lacking. The extent of collateral flow is highly variable between individuals. As a consequence, the speeds of infarct growth are highly variable, resulting in varying individual treatment time windows until the whole salvageable tissue has become infarcted. An ideal patient selection for reperfusion therapies should be based on imaging of the salvageable tissue, the so called penumbra. The penumbra can be approximately visualised by computed tomography (CT) and magnetic resonance imaging (MRI), but both methods are significantly inaccurate in about 25% of the patients. There is a need for improved penumbra imaging by CT and MRI, and first studies applying machine learning techniques have shown promising results.
Objective
Faster time from onset to recanalization (OTR) in acute ischemic stroke using endovascular therapy (ET) has been associated with better outcome. However, previous studies were based on ...less‐effective first‐generation devices, and analyzed only dichotomized disability outcomes, which may underestimate the full effect of treatment.
Methods
In the combined databases of the SWIFT and STAR trials, we identified patients treated with the Solitaire stent retriever with achievement of substantial reperfusion (Thrombolysis in Cerebral Infarction TICI 2b–3). Ordinal numbers needed to treat values were derived by populating joint outcome tables.
Results
Among 202 patients treated with ET with TICI 2b to 3 reperfusion, mean age was 68 (±13), 62% were female, and median National Institutes of Health Stroke Scale (NIHSS) score was 17 (interquartile range IQR: 14–20). Day 90 modified Rankin Scale (mRS) outcomes for OTR time intervals ranging from 180 to 480 minutes showed substantial time‐related reductions in disability across the entire outcome range. Shorter OTR was associated with improved mean 90‐day mRS (1.4 vs. 2.4 vs. 3.3, for OTR groups of 124‐240 vs. 241‐360 vs. 361‐660 minutes; p < 0.001). The number of patients identified as benefitting from therapy with shorter OTR were 3‐fold (range, 1.5–4.7) higher on ordinal, compared with dichotomized analysis. For every 15‐minute acceleration of OTR, 34 per 1,000 treated patients had improved disability outcome.
Interpretation
Analysis of disability over the entire outcome range demonstrates a marked effect of shorter time to reperfusion upon improved clinical outcome, substantially higher than binary metrics. For every 5‐minute delay in endovascular reperfusion, 1 of 100 patients has a worse disability outcome. Ann Neurol 2015;78:584–593
The purpose of this study was to evaluate safety and efficacy of the Solitaire FR device in the treatment of patients with acute ischemic stroke secondary to large artery occlusion.
We conducted a ...retrospective study of consecutive patients presenting with acute ischemic stroke treated with Solitaire FR as the first-line device to restore blood flow in 6 experienced European centers. This study was entirely funded and supported by Coviden Neurovascular. An independent Corelab determined modified Thrombolysis in Cerebral Infarction scores on the preprocedure and postprocedure angiograms. Complete revascularization was defined as modified Thrombolysis in Cerebral Infarction 2b or 3 post-Solitaire FR device use. Symptomatic intracranial hemorrhage was defined as parenchymal hemorrhage Type 2 associated with a decline of ≥ 4 points in the National Institutes of Health Stroke Scale score within 24 hours or causing death. Favorable functional outcome was considered as modified Rankin Scale score ≤ 2 at Day 90.
We studied 141 patients (mean age, 66 years; median National Institutes of Health Stroke Scale, 18); 74 patients received intravenous tissue-type plasminogen activator before endovascular treatment. Complete revascularization was achieved in 120 of 142 occlusion sites (85%) and good outcome in 77 of 141 (55%) patients. Good outcome was more frequent in patients treated with intravenous tissue-type plasminogen activator than in those without (66% versus 42%; P<0.01). Symptomatic intracranial hemorrhage was reported in 5 patients (4%) and 29 of 141 (20%) patients died or were lost during follow-up (3 cases).
This retrospective study with centralized evaluation shows that the use of Solitaire FR is safe and achieves good revascularization rates and functional outcomes in patients with acute ischemic stroke and large artery occlusion.
BACKGROUND AND PURPOSE—Whether maximal treatment should be offered to elderly patients suffering from poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is controversial. The survival of patients ...in this subgroup beyond the usual outcome measurements 6 to 12 months after aSAH is unclear. The purpose of this study is to provide survival and outcome data to support clinicians making decisions on treatment for this subgroup of patients.
METHODS—We performed a retrospective analysis of the Bernese SAH database for poor-grade (World Federation of Neurosurgical Societies grade IV and V) elderly patients (age ≥60 years) suffering from aSAH admitted to our institution from 2005 to 2017. Patients were divided into 3 age groups (60–69, 70–79, and 80–90 years). Survival analysis was performed to estimate mean survival and hazard ratios for death. Binary logarithmic regression was used to estimate the odds ratio for favorable (modified Rankin Scale score of 0–3) and unfavorable (modified Rankin Scale score of 4–6) outcome.
RESULTS—Increasing age was associated with an increasing risk of death after aSAH. The hazard ratio increased by 6% per year of age (P<0.001; hazard ratio, 1.06; 95% CI, 1.03–1.09) and 76% per decade (P<0.001; hazard ratio, 1.76; 95% CI, 1.35–2.29). Mean survival was 56.3±8 months (patients aged 60–69 years), 31.6±7.6 months (70–79 years), and 7.6±5.8 months (80–90 years). Unfavorable outcomes 6 to 12 months after aSAH were strongly related to older age. The odds ratio increased by 11% per year of age (P<0.001; odds ratio, 1.11; 95% CI, 1.05–1.18) and 192% per decade (P<0.001; odds ratio, 2.92; 95% CI, 1.63–5.26).
CONCLUSIONS—Risk for death and unfavorable outcome increases markedly with older age in elderly patients with poor-grade aSAH. Despite a high initial mortality, treatment resulted in a reasonable proportion of favorable outcomes up to 79 years of age and only a small number of patients who were moderately or severely disabled 6 to 12 months after aSAH. Mean survival and proportion of favorable outcomes decreased markedly in patients older than 80 years.
BACKGROUND AND PURPOSE—Sustained successful reperfusion is an important prognostic factor for good clinical outcome in acute ischemic stroke. We aimed to identify the prevalence, clinical impact, and ...predictors of early reocclusion after initially successful thrombectomies within a prospective cohort.
METHODS—A total of 711 stroke patients with successful reperfusion (modified Thrombolysis in Cerebral Infarction, 2b/3) followed with magnetic resonance or computed tomographic angiography at 24 to 48 hours were included. Multivariable logistic regression analysis was used to evaluate associated factors and clinical impact. Results are displayed as adjusted odds ratio (aOR) and 95% CI. Improvement in accuracy of additional imaging findings on angiography control runs after the intervention was evaluated by area under the curve.
RESULTS—Early reocclusion was observed in 16 of 711 successfully reperfused patients (2.3%; 95% CI, 1.1–3.3; median delay20 hours). Suggestive predictors were higher platelets on admission (aOR, 1.01; 95% CI, 1.01–1.02), prestroke functional dependence (aOR, 7.12; 95% CI, 1.49–34.03), and stroke of undetermined or other specified pathogenesis in the TOAST classification (aOR, 7.19; 95% CI, 1.10–47.05 and aOR, 36.50; 95% CI, 4.47–298.11, respectively). When implementing residual embolic fragments or stenosis at the thrombectomy site into the logistic regression model, discrimination between patients with and without reocclusion improved significantly (area under the curve, 0.955 versus 0.854; P=0.023). Early reocclusion was an independent predictor of unfavorable outcome at 90 days (aOR for modified Rankin Scale ≤2, 0.13; 95% CI, 0.03–0.57).
CONCLUSIONS—Early reocclusion within 48 hours after successful mechanical thrombectomy is rare but associated with poor outcome. Patients with high platelets on admission and residual embolic fragments or stenosis at the thrombectomy site are at high risk for reocclusion, which may be prevented or corrected after carefully re-evaluating the last angiographic run.
OBJECTIVE Frontal ventriculostomy is one of the most frequent and standardized procedures in neurosurgery. However, many first and subsequent punctures miss the target, and suboptimal placement or ...misplacement of the catheter is common. The authors therefore reexamined the landmarks and rules to determine the entry point and trajectory with the best hit rate (HtR). METHODS The authors randomly selected CT scans from their institution's DICOM pool that had been obtained in 50 patients with normal ventricular and skull anatomy and without ventricular puncture. Using a 5 × 5-cm frontal grid with 25 entry points referenced to the bregma, the authors examined trajectories 1) perpendicular to the skull, 2) toward classic facial landmarks in the coronal and sagittal planes, and 3) toward an idealized target in the middle of the ipsilateral anterior horn (ILAH). Three-dimensional virtual reality ventriculostomies were simulated for these entry points; trajectories and the HtRs were recorded, resulting in an investigation of 8000 different virtual procedures. RESULTS The best HtR for the ILAH was 86% for an ideal trajectory, 84% for a landmark trajectory, and 83% for a 90° trajectory, but only at specific entry points. The highest HtRs were found for entry points 3 or 4 cm lateral to the midline, but only in combination with a trajectory toward the contralateral canthus; and 1 or 2 cm lateral to the midline, but only paired with a trajectory toward the nasion. The same "pairing" exists for entry points and trajectories in the sagittal plane. For perpendicular (90°) trajectories, the best entry points were at 3-5 cm lateral to the midline and 3 cm anterior to the bregma, or 4 cm lateral to the midline and 2 cm anterior to the bregma. CONCLUSIONS Only a few entry points offer a chance of a greater than 80% rate of hitting the ILAH, and then only in combination with a specific trajectory. This "pairing" between entry point and trajectory was found both for landmark targeting and for perpendicular trajectories, with very limited variability. Surprisingly, the ipsilateral medial canthus, a commonly reported landmark, had low HtRs, and should not be recommended as a trajectory target.
Objective
Spinal cerebrospinal fluid (CSF) leaks cause spontaneous intracranial hypotension (SIH). Microsurgery can sufficiently seal spinal CSF leaks. Yet, some patients suffer from residual ...symptoms. Aim of the study was to assess predictors for favorable outcome after surgical treatment of SIH.
Methods
We included consecutive patients with SIH treated surgically from January 2013 to May 2020. Subjects were surveyed by a questionnaire. Primary outcome was resolution of symptoms as rated by the patient. Secondary outcome was postoperative headache intensity on the numeric rating scale (NRS). Association between variables and outcome was assessed using univariate and multivariate regression. A cut-off value for continuous variables was calculated by a ROC analysis.
Results
Sixty-nine out of 86 patients (80.2%) returned the questionnaire and were analyzed. Mean age was 46.7 years and 68.1% were female. A significant association with the primary and secondary outcome was found only for preoperative symptom duration (
p
= 0.001 and
p
< 0.001), whereby a shorter symptom duration was associated with a better outcome. Symptom duration remained a significant predictor in a multivariate model (
p
= 0.013). Neither sex, age, type of pathology, lumbar opening pressure, nor initial presentation were associated with the primary outcome. ROC analysis yielded treatment within 12 weeks as a cut-off for better outcome.
Conclusion
Shorter duration of preoperative symptoms is the most powerful predictor of favorable outcome after surgical treatment of SIH. While an initial attempt of conservative treatment is justified, we advocate early definitive treatment within 12 weeks in case of persisting symptoms.
OBJECTIVE:To compare long-term outcome of children and young adults with arterial ischemic stroke (AIS) from 2 large registries.
METHODS:Prospective cohort study comparing functional and psychosocial ...long-term outcome (≥2 years after AIS) in patients who had AIS during childhood (1 month–16 years) or young adulthood (16.1–45 years) between January 2000 and December 2008, who consented to follow-up. Data of children were collected prospectively in the Swiss Neuropediatric Stroke Registry, young adults in the Bernese stroke database.
RESULTS:Follow-up information was available in 95/116 children and 154/187 young adults. Median follow-up of survivors was 6.9 years (interquartile range 4.7–9.4) and did not differ between the groups (p = 0.122). Long-term functional outcome was similar (p = 0.896)53 (56%) children and 84 (55%) young adults had a favorable outcome (modified Rankin Scale 0–1). Mortality in children was 14% (13/95) and in young adults 7% (11/154) (p = 0.121) and recurrence rate did not differ (p = 0.759). Overall psychosocial impairment and quality of life did not differ, except for more behavioral problems among children (13% vs 5%, p = 0.040) and more frequent reports of an impact of AIS on everyday life among adults (27% vs 64%, p < 0.001). In a multivariate regression analysis, low Pediatric NIH Stroke Scale/NIH Stroke Scale score was the most important predictor of favorable outcome (p < 0.001).
CONCLUSION:There were no major differences in long-term outcome after AIS in children and young adults for mortality, disability, quality of life, psychological, or social variables.
OBJECTIVETo test the hypothesis that selection by initial imaging modality (MRI vs CT) is associated with rate of futile recanalizations (FRs) after mechanical thrombectomy (MT), we assessed this ...association in a multicenter, retrospective observational registry (BEYOND-SWIFT Registry for Evaluating Outcome of Acute Ischemic Stroke Patients Treated With Mechanical Thrombectomy, NCT03496064).
METHODSIn 2,011 patients (49.7% female, median age 73 years 61–81) included between 2009 and 2017, we performed univariate and multivariate analyses regarding the occurrence of FR. FRs were defined as 90-day modified Rankin Scale (mRS) score 4–6 despite successful recanalization in patients selected by MRI (n = 690) and CT (n = 1,321) with a sensitivity analysis considering only patients with mRS 5–6 as futile.
RESULTSMRI as compared to CT resulted in similar rates of subsequent MT (adjusted odds ratio aOR 1.048, 95% confidence interval CI 0.677–1.624). Rates of FR were as follows571/1,489 (38%) FR mRS 4–6 including 393/1,489 (26%) FR mRS 5–6. CT-based selection was associated with increased rates of FRs compared to MRI (44% 41%–47% vs 29% 25%–32%, p < 0.001; aOR 1.77 95% CI 1.25–2.51). These findings were robust in sensitivity analysis. MRI-selected patients had a delay of approximately 30 minutes in workflow metrics in real-world university comprehensive stroke centers. However, functional outcome and mortality were more favorable in patients selected by MRI compared to patients selected with CT.
CONCLUSIONSCT selection for MT was associated with an increased risk of FRs as compared to MRI selection. Efforts are needed to shorten workflow delays in MRI patients. Further research is needed to clarify the role of the initial imaging modality on FR occurrence and to develop a reliable FR prediction algorithm.
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