Radial Versus Femoral Access for Mechanical Thrombectomy in Patients With Stroke: A Noninferiority Randomized Clinical Trial.

BACKGROUND: Transfemoral access is predominantly used for mechanical thrombectomy in patients with stroke with a large vessel occlusion. Following the interventional cardiology guidelines, routine transradial access has been proposed as an alternative, although its safety and efficacy remain controversial. We aim to explore the noninferiority of radial access in terms of final recanalization. METHODS: The study was an investigator-initiated, single-center, evaluator-blinded, noninferiority randomized clinical trial. Patients with stroke undergoing mechanical thrombectomy, with a patent femoral artery and a radial artery diameter ≥2.5 mm, were randomly assigned (1:1) to either transradial (60 patients) or transfemoral access (60 patients). The primary binary outcome was the successful recanalization (expanded Treatment in Cerebral Ischemia score, 2b-3) assigned by blinded evaluators. We established a noninferiority margin of -13.2%, considering an acceptable reduction of 15% in the expected recanalization rates. RESULTS: From September 2021 to July 2023, 120 patients were randomly assigned and 116 (58 transradial access and 58 transfemoral access) with confirmed intracranial occlusion on the initial angiogram were included in the intention-to-treat analysis. Successful recanalization was achieved in 51 (87.9%) patients assigned to transfemoral access and in 56/58 (96.6%) patients assigned to transradial (adjusted 1 side risk difference [RD], -5.0% [95% CI, -6.61% to +13.1%]) showing noninferiority of transradial access. Median time from angiosuite arrival to first pass (femoral, 30 [interquartile range, 25-37] minutes versus radial: 41 [interquartile range, 33-62] minutes; P<0.001) and from angiosuite arrival to recanalization (femoral: 42 (IQR, 28-74) versus radial: 59.5 (IQR, 44-81) minutes; P<0.050) were longer in the transradial access group. Both groups presented 1 severe access complication and there was no difference in the rate of access conversion: transradial 7 (12.1%) versus transfemoral 5 (8.6%) (P=0.751). CONCLUSIONS: Among patients who underwent mechanical thrombectomy, transradial access was noninferior to transfemoral access in terms of final recanalization. Procedural delays may favor transfemoral access as the default first-line approach. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT05225636.

Radial Versus Femoral Access for Mechanical Thrombectomy in Patients With Stroke: A Noninferiority Randomized Clinical Trial.

BACKGROUND: Transfemoral access is predominantly used for mechanical thrombectomy in patients with stroke with a large vessel occlusion. Following the interventional cardiology guidelines, routine transradial access has been proposed as an alternative, although its safety and efficacy remain controversial. We aim to explore the noninferiority of radial access in terms of final recanalization. METHODS: The study was an investigator-initiated, single-center, evaluator-blinded, noninferiority randomized clinical trial. Patients with stroke undergoing mechanical thrombectomy, with a patent femoral artery and a radial artery diameter ≥2.5 mm, were randomly assigned (1:1) to either transradial (60 patients) or transfemoral access (60 patients). The primary binary outcome was the successful recanalization (expanded Treatment in Cerebral Ischemia score, 2b-3) assigned by blinded evaluators. We established a noninferiority margin of -13.2%, considering an acceptable reduction of 15% in the expected recanalization rates. RESULTS: From September 2021 to July 2023, 120 patients were randomly assigned and 116 (58 transradial access and 58 transfemoral access) with confirmed intracranial occlusion on the initial angiogram were included in the intention-to-treat analysis. Successful recanalization was achieved in 51 (87.9%) patients assigned to transfemoral access and in 56/58 (96.6%) patients assigned to transradial (adjusted 1 side risk difference [RD], -5.0% [95% CI, -6.61% to +13.1%]) showing noninferiority of transradial access. Median time from angiosuite arrival to first pass (femoral, 30 [interquartile range, 25-37] minutes versus radial: 41 [interquartile range, 33-62] minutes; P<0.001) and from angiosuite arrival to recanalization (femoral: 42 (IQR, 28-74) versus radial: 59.5 (IQR, 44-81) minutes; P<0.050) were longer in the transradial access group. Both groups presented 1 severe access complication and there was no difference in the rate of access conversion: transradial 7 (12.1%) versus transfemoral 5 (8.6%) (P=0.751). CONCLUSIONS: Among patients who underwent mechanical thrombectomy, transradial access was noninferior to transfemoral access in terms of final recanalization. Procedural delays may favor transfemoral access as the default first-line approach. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT05225636.

Stent retriever AssIsted Lysis (SAIL) Technique with Tirofiban: A Potential Bailout Alternative to Angioplasty and Stenting.

BACKGROUND AND PURPOSE: Angioplasty and stenting (A&S) have been described as bailout technique in individuals with failed thrombectomy. We aim to investigate Stent retriever AssIsted Lysis (SAIL) with tirofiban prior to A&S. MATERIALS AND METHODS: Patients from 2 comprehensive stroke centers were reviewed (2020-2023). We included patients with failed thrombectomy and/or underlying intracranial stenosis who received SAIL with tirofiban prior to intended A&S.SAIL consisted in deploying a SR through the occluding lesion to create a by-pass channel and infuse 10ml of tirofiban over 10 minutes either intraarterially (IA) or intravenously (IV). The SR was re-sheathed before retrieval. Primary endpoints were successful reperfusion (eTICI 2b-3) and sICH. Additional endpoints included 90-day mRS 0-2 and mortality. RESULTS: After a median of 3 (IQR 2-4) passes, 44 patients received the SAIL bridging protocol with tirofiban and later they were considered potential candidates for A&S bailout (43.2% IA-SAIL). Post-SAIL successful reperfusion was obtained in 79.5%. A significant residual stenosis (>50%) after successful SAIL was observed in 45.7%.No significant differences were detected according to post-SAIL successful reperfusion (IA-SAIL 80.0% vs IV-SAIL 78.9%; p=0.932), post-SAIL significant stenosis (33.3% vs 55.0%; p=0.203), early symptomatic reocclusion (0% vs 8.0%; p=0.207), or sICH (5.3% vs 8.0%; p=0.721). Rescue A&S was finally performed in 15 (34.1%) patients (IA-SAIL 21.0% vs IV-SAIL 44%; p=0.112).At 90 days, mRS 0-2 (IA-SAIL 50.0% vs IV-SAIL 43.5%; p=0.086) and mortality (26.3% vs 12.0%; p=0.223) were also similar. CONCLUSIONS: In stroke patients in which A&S bailout is considered, SAIL with tirofiban, either intraarterial or intravenous, seems to safely induce sustained recanalization, offering a potential alternative to definitive A&S. ABBREVIATIONS: A&S = Angioplasty and stenting, ICAD = Intracranial Atherosclerotic Disease, ICAS-LVO = Intracranial atherosclerosis related large vessel occlusion, EVT = Endovascular Treatment, LVO = Large Vessel Occlusion; MT = Mechanical Thrombectomy; SR = SR Stent Retriever; SAIL = Stent retriever AssIsted Lysis, sICH = Symptomatic Intracranial Hemorrhage.

Absceso hipofisiario como causa de meningitis crónica / Pituitary abscess as cause of chronicle meningitis

Se presenta el caso clínico de una paciente con un cuadro de Meningitis crónica recurrente en que el diagnóstico de absceso selar sólo se logró al operarla con el diagnóstico de Adenoma Hipofisiario. Siendo el absceso hipofisiario una patología de muy baja frecuencia, la presencia de una Meningitis crónica recurrente como forma de presentación es aún más infrecuente. La literatura en general presenta muy pocas series de abscesos hipofisiarios, siendo la mayoría sólo comunicaciones de casos clínicos.

We present the case of a patient with a history of Recurrent Chronic Meningitis, in which the diagnosis of Pituitary abscess was only made after surgery under the diagnosis of Pituitary Adenoma. Given the low frequency of the Pituitary Abscess, the presence of a Recurrent Chronic Meningitis as its presentation is even more infrequent. The common literature presents only a few series of pituitary abscess, which, in most cases, are only case reports.

Síndrome de Immunodeficiencia Adquirida en Panameños / Acquired immunodeficiency syndrome in Panama

El Síndrome de Inmunodeficiencia Adquirida (SIDA) descrito inicialmente en los Estados Unidos de América (E.U.A.), se ha reportado en casi todo el mundo, incluso latinoamérica. En Panamá hay seis casos confirmados, cinco de los cuales han muerto. Describimos a continuación tres casos manejados en el Complejo Hospitalario Metropolitano de la Caja de Seguro Social (CHM, CSS). Todos fueron pacientes panameños del sexo masculino, dos de ellos viveron en el exterior por mucho tiempo. Uno era homosexual y drogadicto, otro promiscuo heterosexual mientras que el otro negaba cualquier factor de riesgo. El cuadro clínico inicial fue variable, pero todos tuvieron en común: fiebre y pérdida de peso. Las infecciones oportunistas encontradas fueron múltiples. Se destacó: la Candidiasis oral, la enteritis por Isospora belli y la histoplasmosis diseminada. Uno tuvo el Sarcoma de Kaposi (SK). En los tres casos hubo altereción de la función inmune confirmada mediante anergia cutánea, disminución de los linfocitos T cooperadores con inversión de la relación de linfocitos T cooperadores (OKT4) a linfocitos T supresores (OKT8)y una hipergammaglobulinemia policlonal. Todos presentaron el anticuerpo del virus linfotrópico de las células T humanas (HTLV-III/LAV). Los tres pacientes murieron: dos con histoplasmosis diseminada y uno con candidiasis sistémica y probable herpes diseminado. Alertamos a la comunidad médica panameña sobre esta entidad clínica cuya incidencia sospechamos va a ir aumentando debido a muchos