Outcomes After Direct Thrombectomy or Combined Intravenous and Endovascular Treatment Are Not Different.

BACKGROUND AND PURPOSE: Whether intravenous thrombolysis adds a further benefit when given before endovascular thrombectomy (EVT) is unknown. Furthermore, intravenous thrombolysis delays time to groin puncture, mainly among drip and ship patients. METHODS: Using region-wide registry data, we selected cases that received direct EVT or combined intravenous thrombolysis+EVT for anterior circulation strokes between January 2011 and October 2015. Treatment effect was estimated by stratification on a propensity score. The average odds ratios for the association of treatment with good outcome and death at 3 months and symptomatic bleedings at 24 hours were calculated with the Mantel-Haenszel test statistic. RESULTS: We included 599 direct EVT patients and 567 patients with combined treatment. Stratification through propensity score achieved balance of baseline characteristics across treatment groups. There was no association between treatment modality and good outcome (odds ratio, 0.97; 95% confidence interval, 0.74-1.27), death (odds ratio, 1.07; 95% confidence interval, 0.74-1.54), or symptomatic bleedings (odds ratio, 0.56; 95% confidence interval, 0.25-1.27). CONCLUSIONS: This observational study suggests that outcomes after direct EVT or combined intravenous thrombolysis+EVT are not different. If confirmed by a randomized controlled trial, it may have a significant impact on organization of stroke systems of care.

Functional outcome after primary endovascular therapy or IV thrombolysis alone for stroke. An observational, comparative effectiveness study.

BACKGROUND: Among the acute ischemic stroke patients with large vessel occlusions and contraindications for the use of IV thrombolysis, mainly on oral anticoagulation or presenting too late, primary endovascular therapy is often performed as an alternative to the standard therapy even though evidence supporting the use of endovascular reperfusion therapies is not yet established. Using different statistical approaches, we compared the functional independence rates at 3 months among patients undergoing primary endovascular therapy and patients treated only with IV thrombolysis. METHODS: We used data from a prospective, government-mandated and externally audited registry of reperfusion therapies for ischemic stroke (January 2011 to November 2012). Patients were selected if treated with either IV thrombolysis alone (n = 1,582) or primary endovascular thrombectomy (n = 250). A series of exclusions were made to homogenize the clinical characteristics among the two groups. We then carried out multivariate logistic regression and propensity score matching analyses on the final study sample (n = 1,179) to compare functional independence at 3 months, as measured by the modified Rankin scale scores 0-2, between the two groups. RESULTS: The unadjusted likelihood of good outcome was poorer among the endovascular group (OR: 0.69; 95% CI: 0.47-1.0). After adjustment, no differences by treatment modality were seen (OR: 1.51; 95% CI: 0.93-2.43 for primary endovascular therapy). Patients undergoing endovascular thrombectomy within 180-270 min (OR: 2.89; 95% CI: 1.17-7.15) and patients with severe strokes (OR: 1.84; 95% CI: 1.02-3.35) did better than their intravenous thrombolysis counterparts. The propensity score-matched analyses with and without adjustment by additional covariates showed that endovascular thrombectomy was as effective as intravenous thrombolysis alone in achieving functional independence (OR for unadjusted propensity score matched: 1.35; 95% CI: 0.9-2.02, OR for adjusted propensity score matched: 1.45; 95% CI: 0.91-2.32). CONCLUSION: This comparative effectiveness study shows that in ischemic stroke patients with contraindications for IV thrombolysis, primary endovascular treatment might be an alternative therapy at least as effective as IV thrombolysis alone. Randomized controlled trials are urgently needed.

Percutaneous arterial embolization in the management of rectus sheath hematoma.

OBJECTIVE: Spontaneous rectus sheath hematoma can become clinically relevant and necessitate hemostatic intervention. The aim of this study was to describe the efficacy of percutaneous arterial embolization in the management of this condition. CONCLUSION: Selective transcatheter embolization is effective hemostatic treatment of patients with large, clinically relevant rectus sheath hematoma.

Transarterial embolization of an inferior genicular artery pseudoaneurysm with arteriovenous fistula after arthroscopy.

Arthroscopic meniscectomy of the knee is generally a safe and effective procedure with a low rate of vascular complications. We report here on a unique case of a 55-year-old man with a lateral inferior genicular artery pseudoaneurysm and a concomitant arteriovenous fistula that developed after arthroscopic meniscectomy; this was successfully treated with selective angiographic embolization. This case illustrates the effectiveness of an endovascular approach as a minimally invasive treatment for this uncommon complication that occurs after an arthroscopic procedure.

Congenital and acquired pulmonary artery anomalies in the adult: radiologic overview.

Various congenital and acquired anomalies may affect the pulmonary arteries in adult patients. Congenital anomalies (proximal interruption, anomalous origin of the left pulmonary artery [pulmonary artery sling], and idiopathic dilatation of the pulmonary trunk) are usually found incidentally at chest radiography or computed tomography (CT). Acquired anomalies include diffuse or focal enlargement of the arteries because of pulmonary hypertension, aneurysm, and intravascular pulmonary metastasis; decreased arterial diameter because of bronchial carcinoma, mediastinal fibrosis, and Takayasu arteritis; and intraluminal filling defects due to pulmonary thromboembolism and pulmonary artery sarcoma. An awareness of the radiologic manifestations of the disease entities and potential pulmonary artery complications secondary to infection or vasculitis may enable an early diagnosis. CT angiography is becoming the standard method for evaluating patients in whom the presence of pulmonary embolism is suspected. CT assessment of the extent of heart effects in patients with pulmonary hypertension and pulmonary embolism is particularly important because such effects largely determine the prognosis.