Comparison of transradial and transfemoral access for the Woven EndoBridge embolization of intracranial aneurysms: A single-center experience.

BACKGROUND: Transradial access has been adopted more commonly in the neuroendovascular field. However, the experience of using this access for the Woven EndoBridge embolization of intracranial aneurysms is still in the early stage. OBJECTIVE: This study aimed to compare the outcomes between transradial access and transfemoral access for the Woven EndoBridge embolization of intracranial aneurysms. METHODS: This is a retrospective analysis of consecutive intracranial aneurysms treated with Woven EndoBridge placement between May 2019 and August 2020 by the senior author at a high-volume center. The aneurysms of all sizes and locations treated with Woven EndoBridge placement with or without adjunctive stent or coiling were included. Patient demographics, aneurysm and treatment characteristics, procedural complications, and angiographic and functional outcomes were compared between two approaches. RESULTS: This study included a total of 34 patients with intracranial aneurysms (median age 60 years, female-to-male ratio 2:1). Of these, the radial access was utilized in 20 (58.8%) patients, while the femoral access was used in 14 (41.2%) patients. A Woven EndoBridge device was successfully deployed in all cases, and none of the patients required a crossover to another access. There were no significant differences in baseline characteristics, procedure time and fluoroscopy time, outcomes, and complication rates between both groups. CONCLUSION: Our report suggests the possible feasibility and safety of the transradial access for the Woven EndoBridge embolization of intracranial aneurysms. However, the results of this study are suggestive rather than conclusive, and there is still a need for future large prospective studies.

Neurological complications of syncope and sudden cardiac arrest.

Syncope is very common and usually comes with enough warning for the person to assume a safer position rather than fall in a potentially dangerous way. Syncope may be associated with pregnancy, for example, but we rarely encounter significant injury related to the potential for an associated fall. In the elderly, however, there are often comorbid factors such as delayed reaction time and other aspects of cognitive impairment, along with gait instability, that can affect the defensive reflexes to the point that brain injury, including subdural or epidural hematoma, is not uncommonly encountered. Sudden syncope without warning can also have both neurological and general physical implications in terms of driving safety, safety operating potentially dangerous equipment or exposure to heights as well as the potential impact for drowning or near-drowning while swimming or taking a bath. Sudden death, from whatever the mechanism, implies cerebral hypoperfusion with the potential consequences of hypoxic-ischemic brain injury.

Utilization of the large-bore Penumbra JET 7 reperfusion catheter in thrombectomy for acute ischemic stroke: A single-center experience.

BACKGROUND AND PURPOSE: The Penumbra JET 7 reperfusion catheter is used in the revascularization of large vessel occlusions in acute ischemic stroke. Description of its use in clinical practice remains limited. Our purpose is to describe our initial experience with the Penumbra JET 7 reperfusion catheter and to report on its safety and efficacy in different thrombectomy techniques. MATERIALS AND METHODS: We conducted a retrospective study of 50 patients treated with thrombectomy using the Penumbra JET 7 reperfusion catheter. Mean patient age and admission National Institutes of Health Stroke Scale were 70.6 and 17.76, respectively. The most common sites of vessel occlusion were the M1 segment (72%) followed by distal internal carotid artery (14%). Thrombectomy was performed using the direct aspiration first-pass technique and/or aspiration in conjunction with a stent retriever. RESULTS: Revascularization was achieved in a total of 44 cases (88%). Successful navigation of the Penumbra JET 7 reperfusion catheter to the occlusion site with clot engagement was achieved in 94% of cases. Mean time from vascular access to revascularization was 31.60 min. No catheter-related complications occurred. Clinical outcome data were collected from 43 patients (86%). Of those patients, 51% achieved good outcome (modified Rankin score of 0-2) at 60 or more days follow-up, 28% had poor outcome (modified Rankin score of 3-5), and 9 patients died (21%). CONCLUSION: The use of the Penumbra JET 7 reperfusion catheter for treatment of acute ischemic stroke was observed to be safe and effective with appropriate revascularization outcomes in different thrombectomy techniques.

Implications of the use of mechanical thrombectomy on outcome in large vessel occlusion following the 2015 landmark trials.

BACKGROUND: The effectiveness of mechanical thrombectomy (MT) was demonstrated in five landmark trials published in2015.Mechanical thrombectomy is now standard of care for acute ischemic stroke and has been growing in popularity after publication of landmark trials. OBJECTIVE: To analyze outcomes and trends of the use of MT and intravenous thrombolysis (IVT) in patients with acute ischemic stroke in US hospitals before and after publication of these trials. METHODS: Patients discharged with a diagnosis of ischemic stroke between 2012 to 2017 were diagnosed using ICD codes from the National Inpatient Sample. Thereafter, patients given acute stroke treatment were identified using the corresponding procedure codes for IVT and MT. The primary clinical outcomes of in-hospital mortality and disability were then compared between two time periods: 2012-2014 (pre-landmark trials) and 2015-2017 (post-landmark trials). Binary logistic regression and Χ2 tests were used for statistical analysis. RESULTS: A total of 57 675 patients (median age 68.9 years (range 18-90), 50.1% female) were identified with acute procedures. Of these patients, 57.6% were from the post-landmark trials time period. Despite an increased number of cases, the rate of IVT decreased from 84.3% to 75.9% and the rate of IVT+MT decreased from 7.1% to 6.3%. After publication of the pivotal trials in 2015, the rates of MT increased from 8.7% to 17.8%. Significant reductions of in-hospital mortality (7.1% vs 8.7%, p<0.001) and disability (64% vs 66.2%, p<0.001) were noted. CONCLUSION: The analysis showed a significant increase in the proportion of patients receiving MT after 2015. This has translated into reduction of in-hospital mortality and improvement in disability.

Evolving Approaches to Antithrombotics in Stroke Prevention and Treatment.

The optimization of antithrombotic therapy for acute stroke treatment and secondary prevention is an evolving process based on an increasing array of studies that provide an evidence-based approach. Options have increased dramatically with the release of the non-vitamin K oral anticoagulants and with the results of recent randomized clinical trials designed to assess potential benefits versus risks for patients in an individualized fashion. Recent studies have provided important information to guide choice and dosing of antiplatelet agents as well as the length of treatment. Anticoagulant use is particularly pertinent for stroke prevention in patients at higher risk of atrial fibrillation and may have a place in certain other stroke mechanisms. One important focus of study is the potential benefit of combined antiplatelet and anticoagulant therapy. Options for our patients, when the initial choice of therapy does not demonstrate benefit or is not well tolerated, clearly, are valuable. For example, short-term dual antiplatelet therapy for minor stroke and transient ischemic attack is being adopted, but with the recognition that longer-term combined therapy is not worth the increased risk of bleeding. Alternative antiplatelet choices, such as cilostazol and possibly ticagrelor, may be of benefit for refractory patients and this could affect the decision-making process. This review represents an effort to incorporate the information from more recent stroke prevention and treatment studies with information gleaned from prior studies.

Prevalence of ischemic stroke and atrial fibrillation in young patients with migraine national inpatient sample analysis.

OBJECTIVE: To estimate the prevalence of ischemic stroke (IS) and atrial fibrillation (AF) in young patients with migraine and to identify the independent predictors of IS in a large cohort of hospitalized patients. METHODS: A cohort of patients with migraine with aura (MA) and migraine without aura (MO) was identified from the National Inpatient Sample database for the years 2012 to 2015. Ischemic stroke was identified by the International Classification of Diseases-9-CM codes. Binary logistic regression and Chi-square tests were utilized. RESULTS: A total number of 834,875 young patients (18-44 years) were included in this study with a mean age of 33 years. The prevalence of IS was 1.3% and was significantly higher in patients with MA (3.7% versus 1.2%, P <0.001). The prevalence of AF was 0.9% and it was significantly higher in patients with MA (1.2% versus 0.8%, P <0.001). Migraine with aura was an independent predictor of IS (OR 3.23, 95% CI 3.05-3.42, P <0.001) and AF (OR 1.63, 95% CI 1.42-1.88, P <0.001). Other predictors of IS were hypertension (OR 2.2, 95% CI 2.12-2.3, P <0.001), diabetes mellitus (DM) (OR 1.37, 95% CI 1.31-1.42, P <0.001), peripheral vascular disease (PVD) (OR 12.08, 95% CI 11.23-12.98, P <0.001) and smoking (OR 1.37, 95% CI 1.31-1.42, P <0.001). CONCLUSION: In this relatively large study, the overall prevalence of IS in young migraine patients was low at 1.3%. The prevalence of IS and AF was significantly higher in patients with MA. Presence of PVD confers a high risk of IS in young patients with migraine. Migraine aura was observed to be an independent predictor of IS and AF in patients with history of migraine. Optimal control of vascular risk factors in migraine patients appears to be indicated despite the overall low risk.

The impact of pharmacist telephone calls after discharge on satisfaction of oncology patients: A randomized controlled study.

Purpose The aim of the study was to determine the impact of telephone follow-up calls on satisfaction in oncology patients after hospital discharge. Method A randomized controlled study, in which patients were randomized into two groups: The experimental group with the telephone follow-up (TFU) calls (intervention) and the control group (no intervention). The telephone follow-up call was conducted within 72 h after discharge. During the call, patients were asked about their medications, namely, whether they received them, understood how to take them, and whether they developed any medication-related adverse effect. Both groups were contacted by phone two weeks later to assess their satisfaction with the discharge medication instructions and the provided pharmaceutical services, using the 5-point Likert scale. In addition, hospital records were reviewed for emergency room visits and hospital readmissions within 30 days after discharge. Results There was no difference in the percentage of patients who reported being very satisfied between both the intervention and the control groups (45% intervention vs. 48% control, P = 0.68). The mean time of the intervention phone call was 3 ± 1.7 (SD) min. During the telephone follow-up call, medication-related problems were identified in 20% of the patients. There was no significant difference in emergency room visits and hospital readmissions in the intervention group vs. control (44% vs. 53%, P = 0.123) and (37% vs. 43%, P = 0.317), respectively. Conclusion Telephone follow-up calls conducted by a pharmacist to discharged oncology patients did not improve patients' satisfaction, emergency room visits or hospital readmissions; however, they helped to identify medication-related adverse effects in the oncology patients.

The effect of pomelo mix ethyl acetate extract on CYP3A6 and P-glycoprotein gene transcripts in rabbits.

Pomelo fruit juice and pomelo ethylacetate extract have been shown to increase the bioavailability of some CYP3A substrates. The purpose of this study was to investigate if this effect might be contributed to by changes in CYP3A and p-glycoprotein mRNAs levels in the liver and proximal small intestine. The ethyl acetate extract of pomelo mix was administered for 7 days to 10 rabbits. Nine rabbits were administered tap water for 7 days. The administration was through oral intubation to the stomach. On the 8(th) day, the rabbits were sacrificed, and the liver and the proximal 15 cm of the small intestine were dissected. Total RNA was extracted from the specimens and cDNA was prepared by quantitative real-time-polymerase chain reaction (RT-PCR) using specific primers. The ethyl acetate extract of pomelo mix reduced the mRNA expression of CYP3A6 almost 5-folds in the intestine and 2-folds in the liver. In contrast, a 1-fold increase to the p-glycoprotein mRNA expression was observed under the same experimental conditions. In conclusion, the ethyl acetate extract of pomelo mix reduced the mRNA expression of CYP3A6 in both intestine and liver but to different degrees, while the p-glycoprotein mRNA expression was not reduced.