To determine the hospital mortality rates associated with elective surgical clipping and endovascular coiling of unruptured intracranial aneurysms.
We identified a cohort of patients electively ...admitted to US hospitals with the diagnosis of unruptured intracranial aneurysm from the National Inpatient Sample database for the years 2000 through 2006. Patient demographics, hospital-associated complications, and in-hospital mortality were compared among the treatment groups. A multivariate logistic regression analysis was used to identify independent variables associated with hospital mortality. Cochrane-Armitage test was used to assess the trend of hospital use of these procedures.
After data cleansing, 3738 (34.3%) patients had aneurysm clipping and 3498 (32.1%) had endovascular coiling. The basic demographics including age, race, and comorbidity indices were similar between the groups. The length of hospital stay was longer in the clipped population (median 4 versus 1 day; P<0.0001), incurring a higher hospital charge in the coiled population (median $42 070 versus $38 166; P<0.0001). Hospital mortality was higher in the clipped population: 60 (1.6%) versus 20 (0.57%; adjusted odds ratio 3.63; 95% CI, 1.57, 8.42). Perioperative intracerebral hemorrhage and acute ischemic stroke were higher in the clipped population. The rate of hospital use of the endovascular coiling has increased over the years included in this study (<0.0001).
Elective coiling of unruptured intracranial aneurysms is associated with fewer deaths and perioperative complications compared with elective clipping. The trend of hospital use of the coiling procedures has increased during recent years.
The first pass effect (FPE; achieving complete recanalization with a single thrombectomy device pass) has been shown to be associated with higher rates of good clinical outcomes in patients with ...acute ischemic stroke. Here, we investigate clinical and radiographic factors associated with FPE in a large U.S. post-marketing registry (TRACK, Trevo Stent-Retriever Acute Stroke).
We analyzed the TRACK database (multicenter registry of 634 patients from 23 centers from March 2013 through August 2015), which 609 patients were included in the final analysis. FPE was defined as a single pass/use of device, TICI 2c/3 recanalization, and no use of rescue therapy. Analysis of individual patient data from TRACK were performed to analyze clinical and radiographic characteristics associated with FPE as well-compared clinical outcomes defined as modified Rankin Scale (mRS) score at 30 and 90 days from hospital discharge to the non-FPE group.
The rate of FPE in TRACK was 23% (140/609). There was no association between patient demographics and FPE, including age (
= 0.36), sex (
= 0.50), race (
= 0.50), location of occlusion (
= 0.26), baseline NIHSS (
= 0.62), or past medical history. There was no difference in the use of a balloon-guide catheter or general anesthesia (49 and 57% with FPE vs. 47 and 64%,
= 0.63 and
= 0.14, respectively). Clinical outcomes were significantly associated with FPE; 63 vs. 44% in non-FPE patients achieved mRS 0-2 at 90 days (
= 0.0004).
Our study showed that achieving complete recanalization with a single thrombectomy pass using the Trevo device was highly beneficial. The most common clinical factors that are used to determine eligibility for endovascular therapy, such as NIHSS severity, location of occlusion or patient age were not predictive of the ability to achieve FPE.
Acute ischemic stroke due to tandem occlusions of the extracranial internal carotid artery and intracranial arteries has a poor natural history. We aimed to evaluate our single-center experience with ...endovascular treatment of this unique stroke population.
Consecutive patients with tandem occlusions of the internal carotid artery origin and an intracranial artery (ie, internal carotid artery terminus, M1 middle cerebral artery, or M2 middle cerebral artery) were studied retrospectively. Treatment consisted of proximal revascularization with angioplasty and stenting followed by intracranial intervention. Endpoints were recanalization of both extracranial and intracranial vessels (Thrombolysis In Myocardial Ischemia ≥2), parenchymal hematoma, and good clinical outcome (modified Rankin Scale ≤2) at 3 months.
We identified 77 patients with tandem occlusions. Recanalization occurred in 58 cases (75.3%) and parenchymal hematoma occurred in 8 cases (10.4%). Distal embolization occurred in 3 cases (3.9%). In 18 of 77 patients (23.4%), distal (ie, intracranial) recanalization was observed after proximal recanalization, obviating the need for distal intervention. Good clinical outcomes were achieved in 32 patients (41.6%). In multivariate analysis, Thrombolysis In Myocardial Ischemia ≥2 recanalization, baseline National Institutes of Health Stroke Scale score, baseline Alberta Stroke Programme Early CT score, and age were significantly associated with good outcome.
Endovascular therapy of tandem occlusions using extracranial internal carotid artery revascularization as the first step is technically feasible, has a high recanalization rate, and results in an acceptable rate of good clinical outcome. Future randomized, prospective studies should clarify the role of this approach.
The use of bare metal stents to treat symptomatic intracranial stenosis may be associated with significant restenosis rates. The advent of drug-eluting stents (DESs) in the coronary circulation has ...resulted in a reduction of restenosis rates. We report our technical success rate and short-term restenosis rates after stenting with DESs in the intracranial and extracranial circulation.
This study was a retrospective review of the period between April 1, 2004, and April 15, 2006, of 59 patients with 62 symptomatic intracranial or extracranial atherosclerotic lesions at 2 medical centers (University of Pittsburgh and Borgess Medical Center).
The mean age of our cohort was 61+/-12 years. The location of the 62 lesions was as follows: extracranial vertebral artery 31 (50%), intracranial vertebral artery or basilar artery 18 (29%), extracranial internal carotid artery (ICA) near the petrous bone 5 (8%), and intracranial ICA 8 (13%). There were 2 (3%) periprocedural complications: 1 non-flow-limiting dissection and 1 disabling stroke. Fifty vessels were available for follow-up angiography or computed tomography angiography at a median time of 4.0+/-2 months. A total of 2 of 36 extracranial stents (7%) and 1 of 26 intracranial stents (5%) were found to have restenosis > or = 50% at follow-up.
This report demonstrates that DES delivery in the intracranial and extracranial circulation is technically feasible. A small percentage of patients developed short-term in-stent restenosis. Longer-term follow-up is required in the setting of a prospective study to determine the late restenosis rates for DESs in comparison with bare metal stents.
Introduction
We have demonstrated in a multicenter cohort that the COVID-19 pandemic has led to a delay in intravenous thrombolysis (IVT) among stroke patients. Whether this delay contributes to ...meaningful short-term outcome differences in these patients warranted further exploration.
Methods
We conducted a nested observational cohort study of adult acute ischemic stroke patients receiving IVT from 9 comprehensive stroke centers across 7 U.S states. Patients admitted prior to the COVID-19 pandemic (1/1/2019–02/29/2020) were compared to patients admitted during the early pandemic (3/1/2020–7/31/2020). Multivariable logistic regression was used to estimate the effect of IVT delay on discharge to hospice or death, with treatment delay on admission during COVID-19 included as an interaction term.
Results
Of the 676 thrombolysed patients, the median age was 70 (IQR 58–81) years, 313 were female (46.3%), and the median NIHSS was 8 (IQR 4–16). Longer treatment delays were observed during COVID-19 (median 46 vs 38 min,
p
= 0.01) and were associated with higher in-hospital death/hospice discharge irrespective of admission period (OR per hour 1.08, 95% CI 1.01–1.17,
p
= 0.03). This effect was strengthened after multivariable adjustment (aOR 1.15, 95% CI 1.07–1.24,
p
< 0.001). There was no interaction of treatment delay on admission during COVID-19 (
p
interaction
= 0.65). Every one-hour delay in IVT was also associated with 7% lower odds of being discharged to home or acute inpatient rehabilitation facility (aOR 0.93, 95% CI 0.89–0.97,
p
< 0.001).
Conclusion
Treatment delays observed during the COVID-19 pandemic led to greater early mortality and hospice care, with a lower probability of discharge to home/rehabilitation facility. There was no effect modification of treatment delay on admission during the pandemic, indicating that treatment delay at any time contributes similarly to these short-term outcomes.
Unprecedented workflow shifts during the coronavirus disease 2019 (COVID-19) pandemic have contributed to delays in acute care delivery, but whether it adversely affected endovascular thrombectomy ...metrics in acute large vessel occlusion (LVO) is unknown.
We performed a retrospective review of observational data from 14 comprehensive stroke centers in nine US states with acute LVO. EVT metrics were compared between March to July 2019 against March to July 2020 (primary analysis), and between state-specific pre-peak and peak COVID-19 months (secondary analysis), with multivariable adjustment.
Of the 1364 patients included in the primary analysis (51% female, median NIHSS 14 IQR 7-21, and 74% of whom underwent EVT), there was no difference in the primary outcome of door-to-puncture (DTP) time between the 2019 control period and the COVID-19 period (median 71 vs 67 min, P=0.10). After adjustment for variables associated with faster DTP, and clustering by site, there remained a trend toward shorter DTP during the pandemic (β
=-73.2, 95% CI -153.8-7.4, Pp=0.07). There was no difference in DTP times according to local COVID-19 peaks vs pre-peak months in unadjusted or adjusted multivariable regression (β
=-3.85, 95% CI -36.9-29.2, P=0.80). In this final multivariable model (secondary analysis), faster DTP times were significantly associated with transfer from an outside institution (β
=-46.44, 95% CI -62.8 to - -30.0, P<0.01) and higher NIHSS (β
=-2.15, 95% CI -4.2to - -0.1, P=0.05).
In this multi-center study, there was no delay in EVT among patients treated for intracranial occlusion during the COVID-19 era compared with the pre-COVID era.
Stroke-to-recanalization time is a strong predictor of outcomes in anterior circulation large-vessel occlusion (LVO). The authors aimed to evaluate functional outcomes in early (<6 h) vs. late (6-24 ...h) time windows for thrombectomy-treated basilar artery occlusions.
Patients were derived from the Posterior Circulation Ischemic Stroke Evaluation: Analyzing Radiographic and Intra-procedural Predictors of Mechanical Thrombectomy (PC-SEARCH) Registry and retrospectively analyzed early and late basilar artery thrombectomy time windows cohorts. Patients were dichotomized based on the last known well and correlated to 90-day functional outcomes (mRS 0-3). A multiple logistic regression analysis was performed.
A total of 405 patients were included in this study: 216 and 189 patients in the early and late time windows, respectively. Baseline demographic, stroke, radiographic, and intraprocedural characteristics were similar between the groups. A total of 99 (46%) and 79 (42%) patients in the early and late time windows, respectively, achieved favorable functional outcomes at 90 days (
= 0.41), and multiple logistic regression analysis did not reveal differences between cohorts (OR: 0.74; 95% CI: 0.46-1.19;
= 0.22). Symptomatic hemorrhage (7% vs. 5%;
= 0.69) and neurological complications (8% vs. 9%;
= 0.83) were similar between the groups; however, hospital complications were more common in the early time window cohort (22% vs. 13%;
= 0.01).
The early and late thrombectomy time windows can achieve similar rates of 90-day favorable functional outcomes. However, timely thrombectomy influences the likelihood of achieving excellent functional outcomes (mRS ≤ 2) within the early time window.
We sought to identify pretreatment neuroimaging markers associated with intracerebral hemorrhage (ICH) after reperfusion therapy for acute ischemic stroke.
A literature review using available online ...medical literature databases was performed to identify noninvasive imaging markers correlated with ICH after reperfusion therapy. Key words, including different neuroimaging modalities such as noncontrast CT, multimodal CT, and MRI techniques, were queried. The review included randomized, controlled trials, post hoc studies, and institutional registries. Studies of IV as well as intra-arterial reperfusion therapies were considered. Articles were organized on the basis of imaging modality and type of treatment. Each imaging modality was given 1 of 3 grades for consideration of use in clinical practice (grade 1: a modality whose use for hemorrhage prediction is supported by randomized controlled trials or post hoc studies from prospective trials; grade 2: a modality that is largely available but requires further prospective validation; and grade 3: a modality which is rarely used and has limited clinical utility).
Grade 1 imaging modalities included the size of infarction as seen on noncontrast CT or diffusion MRI. Higher hemorrhagic risk has been seen with larger infarctions, suggesting that these imaging modalities may be effective screening tests to exclude specific patients. Perfusion imaging using CT or MRI was considered to have a grade 2 recommendation, pending further validation. The use of xenon CT, radionuclide imaging, voxel-based MRI analysis, and blood-brain barrier disruption imaging still require further design improvements (grade 3).
Future reperfusion trials require clearly defined protocols for imaging and determination of symptomatic ICH. Future trials may consider the use of perfusion imaging and the inclusion of patients without large territorial infarctions to accurately predict those at risk for ICH with reperfusion therapy.
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