A Retrospective Single-Center Case Series of Direct Aspiration Thrombectomy as First-Line Approach in Ischemic Stroke and Review of the Literature.

INTRODUCTION: The benefit of the direct aspiration thrombectomy (ADAPT) technique for the treatment of ischemic stroke due to large vessel occlusion are challenged after publishing of the ASTER trial that failed to show superiority of ADAPT compared to stent retriever. Aim of the present single-center study was a retrospective evaluation of the ADAPT technique comparing our results with literature. MATERIAL/METHODS: We retrospectively analyzed institutional data of stroke procedures in patients with mainstem occlusion of the middle cerebral artery treated between November 2016 and December 2017 with an initial attempt of manual thrombaspiration. Reperfusion rate (thrombolysis in cerebral infarction), procedural times, early clinical outcome and complications were recorded. RESULTS: Forty patients were treated by using direct thrombaspiration in middle cerebral artery mainstem occlusion. Median age was 67.5 (±17.8) years (m = 27.5%). Median Baseline National Institutes of Health Stroke Scale score was 12 (IQR 7) preintervention and 3 (IQR 11) postintervention. Twenty-eight (70%) patients received intravenous thrombolysis. Successful recanalization (modified thrombolysis in cerebral infarction ≥ 2b) could be achieved in 85% with direct aspiration alone. Mean time from groin puncture to recanalization was 25.2 ± 14.3 minutes. Embolization to new territories occurred in 1 of 40 (2.5%) cases and symptomatic intracranial hemorrhage in 3 of 40 (7.5%). Nineteen of 40 (47.5%) patients achieved favorable outcome (modified Rankin scale 0-2) at discharge. CONCLUSIONS: The ADAPT technique presented as a safe and efficient first-line recanalization strategy with good clinical outcome for treatment of acute ischemic stroke resulting from large vessel occlusions in this single-center study and review of the literature. However, the concept of ADAPT as an equivalent first-line approach to stent retriever thrombectomy has to be proven by future randomized studies.

Reduced severe hypoglycemia with insulin glargine in intensively treated adults with type 1 diabetes.

BACKGROUND: The goal of new therapies introduced for type 1 diabetes should be to decrease hypoglycemic episodes while improving glycemic control. METHODS: A database was used to computer match the baseline A1C values in 196 subjects with type 1 diabetes receiving multiple daily injections (MDI) consisting of four or more injections per day. There were 98 patients transferred from NPH to insulin glargine (Lantus, Aventis Pharmaceuticals, Bridgewater, NJ), and 98 patients remained on NPH throughout the study. The gender distribution and mean age (approximately 32 years), duration of diabetes (approximately 16 years), and duration of treatment (approximately 13 months) were not significantly different between the groups. The majority of patients were well controlled (>50% in both groups had an A1C <7%). RESULTS: The mean A1c values were not significantly different in the groups at baseline or at follow-up. Severe hypoglycemic episodes per patient per year were significantly lower in the glargine group compared with the NPH group (0.5 vs. 1.2, respectively; P = 0.04). The mean end-of-study total (P = 0.03) and long-acting (P = 0.0001) doses were significantly reduced from baseline in the group that switched to glargine, but not in the group that remained on NPH, with no change in the short-acting dose in either group. The weight gain was significantly higher in the NPH group at the end of the study (P = 0.004) with no significant change in the glargine group. CONCLUSIONS: Transfer to glargine treatment from NPH in MDI regimens significantly reduces severe hypoglycemic episodes despite a decline in long-acting basal insulin without significant weight gain.