Mechanical Thrombectomy Access Score: A Systematic Review and Modified Delphi of Global Barriers to Endovascular Therapy.

BACKGROUND: The availability of mechanical thrombectomy (MT) for acute ischemic stroke is limited, and vast disparities exist between countries. We aim to create a MT access score to measure the drivers of access to help quantify and accelerate treatment worldwide. METHODS: We used a systematic review complemented by a modified Delphi method. In the first of 3 rounds, 4 independent investigators performed a systematic literature review using key search terms that drive MT access, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In the second round, a panel of 6 anonymous international experts selected key attributes needed for scoring. In the final round, a total of 12 attributes were selected on consensus, each given a score on a 0 to 3 scale. An ultimate MT access score (range, 0-36) was proposed as a new tool to use in identifying barriers to MT access and assist in providing an initial framework for public health interventions. RESULTS: Of 2864 abstracts screened, 121 studies were included in the final systematic review. A total of 34 attributes that potentially drive MT access were initially identified. In the final round, 12 attributes were selected by the expert panel: public awareness, emergency medical services transportation, prehospital large vessel occlusion screening, interhospital transfer policy, emergency department protocols, stroke imaging protocols, emergency department stroke expertise or telestroke availability, interventionalists, MT-capable centers, device availability, and insurance coverage. These attributes were weighted as part of the final score of 0 to 36. CONCLUSIONS: The MT access score represents the first tool to quantify barriers to global MT access. Its implementation stands not just as an academic achievement but as a beacon of hope for improving stroke care and outcomes worldwide, bringing us a step closer to bridging the gap in stroke treatment disparities.

Utilizing RNA sequencing to identify gene expression markers of stroke-causing thrombi origin: A pilot study.

INTRODUCTION: Stroke embolic source have an unknown origin in 30-40% of cases. Mechanical thrombectomy for acute large vessel occlusion stroke has provided us with a method to directly retrieve the thrombi from patients for analysis. By collecting stroke-causing thrombi from known sources, we can then use high-throughput RNA sequencing (RNAseq) technology to directly measure the gene expression signatures of these clots. This may allow us to identify genetic markers to predict the cause of cryptogenic embolism. METHODS: This is a prospective study in which RNAseq was used to analyze cerebral thrombi retrieved by mechanical thrombectomy devices in acute ischemic stroke patients. Samples were separated into two groups based on known stroke thrombus etiology, including Carotid group (patients with ipsilateral >70% carotid stenosis) and Atrial fibrillation (AF) group (patients with atrial fibrillation). Gene expression was compared by RNAseq analysis between the groups. RESULTS: From October 2016 to September 2017, 8 thrombi (4 in Carotid group, 4 in Afib group) were included in this study. There were 131 genes that were significantly up- or down-regulated between the two groups defined as a false discovery rate ≤ 0.05 and a fold change ≥ 2. Twenty-six genes were selected as candidate gene biomarkers based on the criteria in the methods section. Candidate genes HSPA1B, which encodes a heatshock protein, and GPRC5B, which encodes a G-protein, showed the greatest fold differences in expression between the two groups. CONCLUSION: This study has shown that RNA sequencing of acute ischemic stroke thrombi is feasible and indentified potential novel biomarkers for identifying stroke-causing thrombi origin, especially in cryptogenic stroke.

Optimal technique for canine mesenchymal stem cells labeling with novel SPIO, MIRB™: for MRI detection of transplanted stem cells canine stroke model.

BACKGROUND: Cell-based therapy has emerged as a promising avenue for post-stroke recovery. A significant challenge lies in tracking the distribution and engraftment of transplanted cells within the target cerebral tissue. To address this, we turn to the potential of Brain MRI detection of mesenchymal stem cells (MSCs), achieved by labeling these cells with superparamagnetic iron oxide (SPIO). This is the first report of a technique to label canine MSCs using a commercially available SPIO, Molday ION Rhodamine B (MIRB), to optimize both viability and labeling efficacy for transplantation purposes." METHOD: Canine MSCs were incubated with addition of different MIRB concentration from 0, 10, 20, 30 µg Fe/ml. The cellular uptake of MIRB was confirmed through the analysis of fluorescent images and flow cytometry. The morphological characteristics of MSCs were assessed via microscopic visualization. Cellular viability was evaluated using both a cellometer and flow cytometry. RESULT: Fluorescent microscopic images of all MIRB incubated MSCs groups show >70% labeled cells with homogenous signal intensity. Notably, the morphology of MSCs remained unaltered in the 10 µg Fe/ml group compared to the control group. Furthermore, among the labeled groups, the 10 µg Fe/ml concentration exhibited the highest viability when assessed using two different flow cytometry methods (95.3%, p < 0.05). CONCLUSION: This study successfully labels canine MSCs with MIRB. The optimal concentration of 10 µg Fe/ml demonstrates optimal viability, labeling efficacy, and preserved cellular morphology.

Global, Regional, and National Economic Consequences of Stroke.

BACKGROUND: An understanding of global, regional, and national macroeconomic losses caused by stroke is important for allocation of clinical and research resources. The authors investigated the macroeconomic consequences of stroke disease burden in the year 2019 in 173 countries. METHODS: Disability-adjusted life year data for overall stroke and its subtypes (ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage) were collected from the GBD study (Global Burden of Disease) 2019 database. Gross domestic product (GDP, adjusted for purchasing power parity [PPP]) data were collected from the World Bank; GDP and disability-adjusted life year data were combined to estimate macroeconomic losses using a value of lost welfare (VLW) approach. All results are presented in 2017 international US dollars adjusted for PPP. RESULTS: Globally, in 2019, VLW due to stroke was $2059.67 billion or 1.66% of the global GDP. Global VLW/GDP for stroke subtypes was 0.78% (VLW=$964.51 billion) for ischemic stroke, 0.71% (VLW=$882.81 billion) for intracerebral hemorrhage, and 0.17% (VLW=$212.36 billion) for subarachnoid hemorrhage. The Central European, Eastern European, and Central Asian GBD super-region reported the highest VLW/GDP for stroke overall (3.01%), ischemic stroke (1.86%), and for subarachnoid hemorrhage (0.26%). The Southeast Asian, East Asian, and Oceanian GBD super-region reported the highest VLW/GDP for intracerebral hemorrhage (1.48%). CONCLUSIONS: The global macroeconomic consequences related to stroke are vast even when considering stroke subtypes. The present quantification may be leveraged to help justify increased spending of finite resources on stroke in an effort to improve outcomes for patients with stroke globally.

Endovascular Treatment of Infective Endocarditis-Related Acute Large Vessel Occlusion Stroke.

OBJECTIVES: Embolic stroke is a frequent complication of infective endocarditis yet lacks acute treatment as intravenous thrombolysis should be avoided due to high risk of intracerebral hemorrhage. Mechanical thrombectomy for large vessel occlusion may be a promising treatment but there is limited data on safety outcomes in infective endocarditis. MATERIALS AND METHODS: In this multi-center retrospective case series, we reviewed data from patients with infective endocarditis-related large vessel occlusion who underwent mechanical thrombectomy in 9 US hospitals. RESULTS: We identified 15 patients at 9 hospitals. A minority presented with signs suggesting infection (2 patients (14%) had fever, 7 (47%) were tachycardic, 2 (13%) were hypotensive, and 8 (53%) had leukocytosis). The median National Institute of Health Stroke Score decreased from 19 (range 9-25) at presentation to 7 post-thrombectomy (range 0-22, median best score post-thrombectomy), and the median modified Rankin Scale on or after discharge for survivors was 3 (range 0-6). Approximately 57% of patients had a modified Rankin Scale between 0 and 3 on or after discharge. Hemorrhagic transformation was observed in 7/15 (47%). The mechanical thrombectomy group had 2/9 petechial hemorrhagic transformation (22%), compared to 4/6 parenchymal hematomas (67%) in the tissue plasminogen activator + mechanical thrombectomy group. CONCLUSIONS: Our findings suggest that patients with large vessel occlusion due to infective endocarditis may not present with overt signs of infection. Mechanical thrombectomy may be an effective treatment in this patient population for whom intravenous thrombolysis should be avoided.

Intravenous tPA Delays Door-To-Puncture Time in Acute Ischemic Stroke with Large Vessel Occlusion.

OBJECTIVE: Although intravenous thrombolysis (IVT) is recommended among acute ischemic stroke (AIS) patients secondary to large vessel occlusion (LVO) undergoing mechanical thrombectomy (MT), time delays with bridging therapy (IVT prior to MT) and its potential benefit remains unclear. We compared the time delays and clinical outcomes among AIS SECONDARY TO LVO patients treated with bridging therapy or direct MT (dMT) at a comprehensive stroke center (CSC). METHODS: We performed a retrospective analysis of prospectively collected data of AIS secondary to LVO patients admitted between 2012 and 2017 at a large volume CSC. AIS secondary to LVO patients arriving directly from field to CSC within 4.5 h were included. Demographic characteristics, clinical and radiological data, treatment and procedural information were extracted and analyzed. RESULTS: Among 777 AIS secondary to LVO patients treated with MT, 237 patients (156 dMT, 81 bridging therapy) were included. Mean age was 70.3 year-old, median NIHSS score was 18, and door-to-needle time was 40 min (IQR 31-56 min). The median door-to-puncture (DTP) time was 22 min longer in bridging therapy group in comparison to dMT group, 74 vs 52 min (p<0.001). Additionally, no difference was observed between the groups for successful recanalization or functional independence. CONCLUSION: At a large volume CSC, bridging therapy (vs. dMT) was observed to have a longer DTP time without any difference in successful recanalization or clinical outcomes.

The Proportion of Preventable Thrombectomy Procedures with Improved Atrial Fibrillation Stroke Prevention.

BACKGROUND: Large vessel occlusion (LVO) strokes can in part be prevented with better atrial fibrillation (AF) stroke prevention strategies; thus we evaluated the rate of AF in patients presenting with acute LVO strokes undergoing mechanical thrombectomy (MT) and assessed patterns of oral anticoagulant (OAC) use prior to the index stroke. METHODS AND RESULTS: We identified 347 MT cases from February 2015 to September 2018. A retrospective chart review was conducted to identify patient sociodemographics, presence of AF, use of anticoagulation, stroke severity, CHA2DS2-VASc scores, and functional outcomes. AF was present in 161 (46%) cases. Patients with AF were older (mean 76 ± 11 years vs. 66 ± 15 years) and more likely to be female (56% vs. 46%) with higher rates of hypertension, dyslipidemia, heart failure and smoking. Of the 100 patients with known AF, 59 were not on anticoagulation prior to the index stroke. Of 39 patients with known AF on OAC, 57% were not therapeutic on warfarin and 20% were not taking prescribed direct OACs. A total of 72 (21%) thrombectomy cases were performed on patients with known AF who were not effectively anticoagulated. After multivariate adjustments, there was no significant difference in modified Rankin Scale score at discharge, in-hospital mortality, or symptomatic intracranial hemorrhage between the AF and non-AF groups. CONCLUSION: In our study, 21% of patients with LVO stroke had known AF and were not effectively anticoagulated. Improved stroke preventive measures could potentially reduce the occurrence of stroke and avoid unnecessary procedures for patients with AF.

Deep Learning for Hemorrhagic Lesion Detection and Segmentation on Brain CT Images.

Stroke is an acute cerebral vascular disease that is likely to cause long-term disabilities and death. Immediate emergency care with accurate diagnosis of computed tomographic (CT) images is crucial for dealing with a hemorrhagic stroke. However, due to the high variability of a stroke's location, contrast, and shape, it is challenging and time-consuming even for experienced radiologists to locate them. In this paper, we propose a U-net based deep learning framework to automatically detect and segment hemorrhage strokes in CT brain images. The input of the network is built by concatenating the flipped image with the original CT slice which introduces symmetry constraints of the brain images into the proposed model. This enhances the contrast between hemorrhagic area and normal brain tissue. Various Deep Learning topologies are compared by varying the layers, batch normalization, dilation rates, and pre-train models. This could increase the respective filed and preserves more information on lesion characteristics. Besides, the adversarial training is also adopted in the proposed network to improve the accuracy of the segmentation. The proposed model is trained and evaluated on two different datasets, which achieve the competitive performance with human experts with the highest location accuracy 0.9859 for detection, 0.8033 Dice score, and 0.6919 IoU for segmentation. The results demonstrate the effectiveness, robustness, and advantages of the proposed deep learning model in automatically hemorrhage lesion diagnosis, which make it possible to be a clinical decision support tool in stroke diagnosis.

Patterns of Mechanical Thrombectomy for Stroke Before and After the 2015 Pivotal Trials and US National Guideline Update.

BACKGROUND: Positive pivotal trials followed by guideline endorsement can be a major driver of change in US national medical practice patterns. We therefore analyzed national trends in the use and outcomes of mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion before and after the 2015 publication of pivotal trials and the US guideline update. METHODS: We analyzed the National Inpatient Sample from 2012-2016. Ischemic stroke and mechanical thrombectomy patients were identified using ICD-9 and ICD-10. The primary efficacy outcome measure was discharge to home, which strongly correlates with mild degree of disability at discharge. Safety outcomes include in-hospital mortality and in-hospital medical complications. RESULTS: From 2012-2016, 2,394,550 discharges were recorded with a diagnosis of ischemic stroke, including 39,150 (1.6%) treated with mechanical thrombectomy. The number and proportion of stroke patients undergoing mechanical thrombectomy annually rose from 4,910/452,905 (1.1%) in 2012 to 11,860/509,215 (2.3%) in 2016. The largest annual increase occurred between 2014, when 6,460 stroke patients were treated with thrombectomy, and 2015, when 10,280 underwent thrombectomy. Comparing the pre (Q1 2012 - Q4 2014) and post (Q4 2015 - Q4 2016) RCT/Guideline epochs, in addition to increased thrombectomy rates, the proportion of thrombectomy patients who received IV-tPA decreased (46% to 24%, p<0.001). Rates of mild disability outcome increased from 16% to 20% (p<0.001), while mortality decreased from 15% to 13% (p=0.01). The odds of pulmonary embolism, urinary tract infection, and pneumonia decreased, while intracerebral hemorrhage, septicemia, deep venous thrombosis, shock, and cardiac arrest were unchanged. CONCLUSION: In the United States, thrombectomy treatment for acute ischemic stroke increased rapidly and substantially in frequency following publication of positive clinical trials and US guideline update in 2015, accompanied by improved functional outcomes and reduced peri-procedural mortality.

Efficient Multimodal MRI Evaluation for Endovascular Thrombectomy of Anterior Circulation Large Vessel Occlusion.

BACKGROUND: MRI and CT modalities are both current standard-of-care options for initial imaging in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). MR provides greater lesion conspicuity and spatial resolution, but few series have demonstrated multimodal MR may be performed efficiently. METHODS: In a prospective comprehensive stroke center registry, we analyzed all anterior circulation LVO thrombectomy patients between 2012-2017 who: (1) arrived directly by EMS from the field, and (2) had initial NIHSS ≥6. Center imaging policy was multimodal MRI (including DWI/GRE/MRA w/wo PWI) as the initial evaluation in all patients without contraindications, and multimodal CT (including CT with CTA, w/wo CTP) in the remainder. RESULTS: Among 106 EMS-arriving endovascular thrombectomy patients, initial imaging was MRI 62.3%, CT in 37.7%. MRI and CT patients were similar in age (72.5 vs 71.3), severity (NIHSS 16.4 v 18.2), and medical history, though MRI patients had longer onset-to-door times. Overall, door-to-needle (DTN) and door-to-puncture (DTP) times did not differ among MR and CT patients, and were faster for both modalities in 2015-2017 versus 2012-2014. In the 2015-2017 period, for MR-imaged patients, the median DTN 42m (IQR 34-55) surpassed standard (60m) and advanced (45m) national targets and the median DTP 86m (IQR 71-106) surpassed the standard national target (90m). CONCLUSIONS: AIS-LVO patients can be evaluated by multimodal MR imaging with care speeds faster than national recommendations for door-to-needle and door-to-puncture times. With its more sensitive lesion identification and spatial resolution, MRI remains a highly viable primary imaging strategy in acute ischemic stroke patients, though further workflow efficiency improvements are desirable.

Association of Menopausal Age with Unruptured Intracranial Aneurysm Morphology.

BACKGROUND: The prevalence of unruptured intracranial aneurysms (UIAs) increases rapidly in aging women compared with younger women. The impact of menopausal age on UIAs and treatment outcomes with endovascular therapy has not been well studied. We hypothesized that premenopausal age may have a protective effect on presentation size and treatment outcomes. OBJECTIVE: To evaluate the association of menopause with UIA size and outcome with endovascular therapy. METHODS: Retrospective analysis of consecutive female patients with UIAs treated with endovascular therapy at our academic tertiary care center. UIA characteristics, complications, and outcomes were recorded and compared. RESULTS: 117 patients were included: 23 patients in the premenopausal age (PRM) group and 94 in the postmenopausal age (POM) group. 93.6% of all aneurysms in the PRM group were in the internal carotid artery (ICA) segments (p < 0.05). Hence only ICA segment aneurysms were further studied. A total of 21 patients in the PRM group and 60 in the POM group were found to have ICA segment aneurysms. Baseline characteristics were similar between the 2 groups. The mean size of the aneurysms in the PRM group was 8.6 ± 3.9 versus 10.8 ± 5.6 mm in the POM group (p = 0.055). There was a trend to higher aneurysm neck size seen in the POM group (4.7 ± 2.5 vs. 3.7 ± 1.7 mm; p = 0.07). The number of aneurysm lobes was higher in the PRM group (1.23 ± 0.54 vs. 1.07 ± 0.31; p = 0.18). In multivariate analysis, the PRM group had a significantly higher number of UIA lobes. Complications and endovascular therapy outcomes were similar between the 2 groups. CONCLUSIONS: A trend to increased UIA maximal diameter and neck size was seen in the POM group compared to the PRM group. The PRM group had a significantly higher number of UIA lobes. Larger prospective trials are needed to confirm these findings.

Impact of MRI Selection on Triage of Endovascular Therapy in Acute Ischemic Stroke: The MRI in Acute Management of Ischemic Stroke (MIAMIS) Registry.

BACKGROUND: The recently published multicenter randomized DAWN trial confirmed greater outcome benefit of endovascular therapy (ET) for anterior circulation large vessel occlusion ischemic stroke from 6 to 24 h from symptom onset compared to medical management in patients selected by advanced imaging with MRI or perfusion CT to identify mismatch between clinical deficit and infarct volume, which represents salvageable penumbra. The debate of CT over MRI is usually the potentially increase time consumption and the difficulty in establishing an adequate standardized workflow utilizing MRI during the hyperacute phase. PURPOSE: While CT-based selection of patients is the current standard of care, we sought to determine the time impact of the alternative approach of MRI selection in the 0-12 h window. METHODS: In the MRI in Acute Management of Ischemic Stroke (MIAMIS) registry, we retrospectively analyzed 89 consecutive patients from January 2008 to January 2010 who presented with acute stroke symptoms with a National Institutes of Health Stroke Scale score ≥5 or aphasia within 0-12 h from symptom onset. The presence of penumbra was determined by MR perfusion-diffusion mismatch or clinical diffusion mismatch. Patients were stratified based on the presence of mismatch and clinical outcomes in patients who received ET. Imaging times were recorded. RESULTS: The MRI turnaround time was 95.5 ± 48.5 min. The total MRI time was 27.7 ± 12.8 min. Seventeen (19.1%) patients were found to have nonvascular etiology. Mismatch was found in 35 (48.6%) patients with acute ischemic stroke (AIS). Patients with nonvascular etiology were younger (55.7 vs. 65.6 years, p < 0.02), without any vessel occlusion or mismatch noticed in this group. We dichotomized the 39 AIS patients with vessel occlusion into two subgroups: these with mismatch and these without. Patients without mismatch were older (76.7 vs. 64.4 years, p < 0.05), more likely to have congestive heart failure (71.4 vs. 22%, p < 0.03), a higher total serum cholesterol level (196 vs. 156 mg/dL, p < 0.04), and medium to large lesions on diffusion-weighted imaging (DWI) (85.7 vs. 37.5%, p < 0.04). CONCLUSIONS: Multimodality MRI screening for AIS symptoms for ET is feasible. Optimizing each center's protocol and the utilization of MRI with DWI only may be a time-saving alternative.

Thrombectomy Outcomes in Acute Ischemic Stroke due to Middle Cerebral Artery M2 Occlusion with Stent Retriever versus Aspiration: A Multicenter Experience.

OBJECTIVE: To examine outcomes for thrombectomy devices used for treatment of acute ischemic stroke (AIS) with middle cerebral artery (MCA) M2 segment emergent large vessel occlusion (ELVO) as the optimal device for such reperfusion is not clearly defined. METHODS: A retrospective cohort study of consecutive AIS patients with MCA M2 ELVO undergoing thrombectomy from 3 academic medical centers was conducted from October 1999 through June 2016. The patients were divided based on the device utilized. Multivariate analysis of associations between devices (stent retriever or aspiration only [manual or pump aspiration system]) was performed. Primary outcomes were good recanalization (i.e., modified thrombolysis in cerebral infarction score ≥2b) and a favorable modified Rankin scale (mRS) score (i.e. ≤2). The secondary outcome was symptomatic intracerebral hemorrhage (sICH). RESULTS: A total of 197 AIS patients underwent MCA M2 ELVO thrombectomy with either a stent retriever (n = 120) or aspiration only (n = 77). The aspiration-only group utilized either manual (n = 38) or pump aspiration (n = 39). Utilization of a stent retriever over manual aspiration is independently associated with higher odds of a favorable mRS score (OR = 3.2; 95% CI 1.02-9.7) and lower odds of sICH (OR = 0.09; 95% CI 0.03-0.31). Utilization of a stent retriever over a pump aspiration system is independently associated with higher odds of good recanalization (OR = 3.8; 95% CI 1.5-9.6). Utilization of a newer-generation pump aspiration catheter compared to a stent retriever resulted in similar rates of favorable mRS scores, sICH, successful recanalization, and mortality. CONCLUSION: Utilization of a newer-generation pump aspiration catheter compared to a stent retriever resulted in similar outcomes, but worse outcomes were seen with the manual aspiration technique. These findings need to be confirmed with a large randomized trial utilizing stent retrievers and newer-generation pump aspiration systems.

Interaction between time, ASPECTS, and clinical mismatch.

BACKGROUND: Imaging-based patient selection for neurothrombectomy is reliant on the identification of irreversibly damaged brain tissue (core) and salvageable tissue (penumbra). The DAWN trial used the clinical-core mismatch (CCM) paradigm (clinical deficit out of proportion to infarct volume). We aim to determine the prevalence of CCM in large vessel occlusion (LVO) strokes and study the impact of time and the Alberta Stroke Program Early CT Score (ASPECTS) on the likelihood of mismatch. METHODS: We performed a retrospective observational analysis of internal carotid artery/middle cerebral artery M1 occlusions with available advanced imaging (relative cerebral blood flow/MRI). We used automated software for infarct volume analysis and ASPECTS determination. The prevalence of CCM and the impact of time and ASPECTS were analyzed. RESULT: One hundred and eighty-five LVO strokes were included. Mean age was 71±15 years and median National Institutes of Health Stroke Scale score was 17 (range 12-21). Mean ischemic core volume was 50±69 mL. Within 0-24 hours, CCM was present in 53% and ranged from 63% in 0-3 hours to 25% at 21-24 hours (p=0.03). Prevalence of mismatch reduced 1.6% for every 1 hour increase in time to imaging. CCM prevalence by ASPECTS groups was: ASPECTS 9-10: 77%, ASPECTS 6-8: 65%, ASPECTS 0-5: 13% (p<0.01), with a 6.4% decrement for every 1 point decrease in ASPECTS. The prevalence of mismatch did not diminish over time among ASPECTS groups and higher ASPECTS was an independent predictor of CCM (OR 1.4 (95% CI 1.1 to 1.7), p<0.001). CONCLUSIONS: CCM is present in 57% and 50% of LVO strokes in the 0-6 and 6-24 hour window, respectively. The prevalence of mismatch declines with increasing time (1.6%/hour) and decreasing ASPECTS (6.4%/point). Among ASPECTS groups the prevalence of mismatch does not decline over time. These data support the use of an ASPECTS-based paradigm for late window patient selection.

Target Stroke: Best Practice Strategies Cut Door to Thrombolysis Time to <30 Minutes in a Large Urban Academic Comprehensive Stroke Center.

The therapeutic window for acute ischemic stroke with intravenous recombinant tissue plasminogen activator (IV rt-PA) is brief and crucial. The American Heart Association/American Stroke Association Target: Stroke Best Practice Strategies (TSBPS) aim to improve intravenous thrombolysis door-to-needle (DTN) time. We assessed the efficacy of implementation of selected TSBPS to reduce DTN time in a large tertiary care hospital. A multidisciplinary DTN committee assessed causes of delayed DTN time and implemented focused TSBPS in our urban academic medical center. We analyzed door-to-CT time, DTN time, and CT to IV rt-PA time in consecutive patients treated with IV rt-PA over 27 months preimplementation and 13 months postimplementation. One hundred forty-eight patients were included in the preimplementation and 126 in the postimplementation group. We found no significant difference between the groups in demographics, comorbidities, anticoagulation status, prethrombolysis hypertension treatment, arrival by EMS, after-hours arrival, or in stroke etiology. After implementation, median DTN time improved from 59 (interquartile range [IQR]: 52-80) to 29 (IQR: 20-41) minutes (P < .001). Door-to-CT time decreased from 17 (14-21) to 16 (12-19) minutes (P = .016), and CT-to-IV rt-PA time improved from 43 (IQR: 31-59) to 13 (IQR: 6-23) minutes (P < .001). Rates of symptomatic intracranial hemorrhage (2.7% vs 3.2%, P = .82) and treatment of stroke mimics (9% vs 13%, P = .31) were similar in both the groups. Individualized hospital gap analysis identifies targeted interventions that lead to rapid and sustained improvement in treatment times.

Association of hypothyroidism with unruptured cerebral aneurysms: a case-control study.

OBJECTIVE Thyroid disorder has been known to affect vascular function and has been associated with aortic aneurysm formation in some cases; however, the connection has not been well studied. The authors hypothesized that hypothyroidism is associated with the formation of cerebral aneurysms. METHODS The authors performed a retrospective case-control study of consecutive patients who had undergone cerebral angiography at an academic, tertiary care medical center in the period from April 2004 through April 2014. Patients with unruptured aneurysms were identified from among those who had undergone 3-vessel catheter angiography. Age-matched controls without cerebral aneurysms on angiography were also identified from the same database. Patients with previous subarachnoid hemorrhage or intracranial hemorrhage were excluded. History of hypothyroidism and other risk factors were recorded. RESULTS Two hundred forty-three patients with unruptured cerebral aneurysms were identified and age matched with 243 controls. Mean aneurysm size was 9.6 ± 0.8 mm. Hypothyroidism was present in 40 patients (16.5%) and 9 matched controls (3.7%; adjusted OR 3.2, 95% CI 1.3-7.8, p = 0.01). Subgroup analysis showed that men with hypothyroidism had higher odds of an unruptured cerebral aneurysm diagnosis than the women with hypothyroidism, with an adjusted OR of 12.7 (95% CI 1.3-121.9) versus an OR of 2.5 (95% CI 1.0-6.4) on multivariate analysis. CONCLUSIONS Hypothyroidism appears to be independently associated with unruptured cerebral aneurysms, with a higher effect seen in men. Given the known pathophysiological associations between hypothyroidism and vascular dysfunction, this finding warrants further exploration.

Utilizing CT with Maximum Intensity Projection Reconstruction Bypassing CTA Improves Time to Groin Puncture in Large Vessel Occlusion Stroke Thrombectomy.

BACKGROUND AND PURPOSE: Prior to thrombectomy for proximal anterior circulation large vessel occlusion (LVO) stroke, recent trials have utilized CT angiography (CTA) for vascular imaging immediately following noncontrast CT (NCCT) for decision-making, but thin-section NCCT with automated maximum intensity projection (MIP) reconstruction also has high accuracy in demonstrating the site of an occluding thrombus. We hypothesized that performing thin-section NCCT with MIP alone prior to thrombectomy improves the time to groin puncture (GP) compared to performing CTA after NCCT. MATERIALS AND METHODS: We performed a retrospective cohort study of anterior circulation LVO thrombectomy at our tertiary care academic medical center. All stroke patients evaluated with thin-section NCCT (0.625 mm) with automated MIP reconstructions alone and those who had additional CTA were included. We excluded transfer patients, in-hospital strokes, posterior circulation strokes, and patients that were evaluated with stroke imaging other than NCCT or CTA prior to thrombectomy. The study groups were compared for duration from NCCT to GP and total stroke imaging duration. RESULTS: From March 2008 through August 2015, 34 thrombectomy patients met the inclusion/exclusion criteria - 13 in the NCCT and 20 in the NCCT+CTA group. The total stroke imaging duration was shorter in the NCCT group than in the NCCT+CTA group (2 min [1-6] vs. 28 min [23-65]; p < 0.001). The NCCT-only group had a shorter time from NCCT to GP (68 min [32-99] vs. 104 min [79-128]; p = 0.030). CONCLUSION: Avoiding advanced imaging for patients with anterior circulation LVO in whom thin-section NCCT with MIPs reveals a hyperdense sign significantly shortens the imaging-to-GP time.

White Matter Hyperintensity Volume and Outcome of Mechanical Thrombectomy With Stentriever in Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Finding of white matter hyperintensity (WMH) has been associated with an increased risk of parenchymal hematoma and poor clinical outcomes after mechanical thrombectomy using old-generation endovascular devices. Currently, no data exist with regard to the risk of mechanical thrombectomy using stentriever devices in patients with significant WMH. We hypothesized that WMH volume will not affect the hemorrhagic and clinical outcome in patients with acute ischemic stroke undergoing thrombectomy using new-generation devices. METHODS: A retrospective cohort of consecutive acute ischemic stroke patients >18-year-old receiving mechanical thrombectomy with stentriever devices at a single academic center was examined. WMH volume was assessed by a semiautomated volumetric analysis on T2 fluid attenuated inversion recovery-magnetic resonance imaging. Outcomes included the rate of any intracerebral hemorrhage, 90-day modified Rankin Score (mRS), the rate of good outcome (discharge mRS ≤2), and the rate of successful reperfusion (thrombolysis in cerebral ischemia score 2b or 3). RESULTS: Between June 2012 and December 2015, 56 patients with acute ischemic stroke met the study criteria. Median WMH volume was 6.76 cm3 (4.84-16.09 cm3). Increasing WMH volume did not significantly affect the odds of good outcome (odds ratio [OR], 0.811; 95% confidence interval [CI], 0.456-1.442), intracerebral hemorrhage (OR, 1.055; 95% CI, 0.595-1.871), parenchymal hematoma (OR, 0.353; 95% CI, 0.061-2.057), successful recanalization (OR, 1.295; 95% CI, 0.704-2.383), or death (OR, 1.583; 95% CI, 0.84-2.98). CONCLUSIONS: Mechanical thrombectomy using stentrievers seems to be safe in selected patients with acute ischemic stroke with large vessel occlusion, nonwithstanding the severity of WMH burden in this population. Larger prospective studies are warranted to validate these findings.

Large Amount of Cannabis Ingestion Resulting in Spontaneous Intracerebral Hemorrhage: A Case Report.

Although multiple cases of cannabis-associated ischemic stroke have been reported, there are only 2 reported cases of hemorrhagic stroke with an associated cerebral vasoconstriction. To our knowledge, we present the first case of basal ganglia hemorrhage after a large-volume oral ingestion of cannabis without other identified risk factors. In our case, cerebral digital subtraction angiography within 24 hours of presentation did not reveal vasoconstriction leading to a possible alternative explanation for hemorrhagic stroke, including cannabis-induced transient arterial hypertension and autoregulation disruption.