ARISE I Consensus Statement on the Management of Chronic Subdural Hematoma.

ARISE (Aneurysm/AVM/cSDH Roundtable Discussion With Industry and Stroke Experts) organized a one-and-a-half day meeting and workshop and brought together representatives from academia, industry, and government to discuss the most promising approaches to improve outcomes for patients with chronic subdural hematoma (cSDH). The emerging role of middle meningeal artery embolization in clinical practice and the design of current and potential future trials were the primary focuses of discussion. Existing evidence for imaging, indications, agents, and techniques was reviewed, and areas of priority for study and key questions surrounding the development of new and existing treatments for cSDH were identified. Multiple randomized, controlled trials have met their primary efficacy end points, providing high-level evidence that middle meningeal artery embolization is a potent adjunctive therapy to the standard (surgical and nonsurgical) management of neurologically stable cSDH patients in terms of reducing rates of disease recurrence. Pooled data analyses following the formal conclusion and publication of these trials will form a robust foundation upon which guidelines can be strengthened for cSDH treatment modalities and optimal patient selection, as well as delineate future lines of investigation.

Risk of adjacent level fracture after percutaneous vertebroplasty and kyphoplasty vs natural history for the management of osteoporotic vertebral compression fractures: a network meta-analysis of randomized controlled trials.

OBJECTIVES: Percutaneous vertebroplasty and kyphoplasty are common interventions for osteoporotic vertebral compression fractures. However, there is concern about an increased risk of adjacent-level fractures after treatment. This study aimed to compare the risk of adjacent-level fractures after vertebroplasty and kyphoplasty with the natural history after osteoporotic vertebral compression fractures. MATERIALS AND METHODS: A network meta-analysis of randomized controlled trials (RCTs) was conducted to evaluate the risk of adjacent-level fractures after vertebroplasty and kyphoplasty compared to the natural history after osteoporotic vertebral compression fractures. Frequentist network meta-analysis was conducted using the "netmeta" package, and heterogeneity was assessed using Q statistics. The pooled risk ratio (RR) and 95% confidence intervals (CI) were calculated using random effects. RESULTS: Twenty-three RCTs with a total of 2838 patients were included in the analysis. The network meta-analysis showed comparable risks of adjacent-level fractures between vertebroplasty, kyphoplasty, and natural history after osteoporotic vertebral compression fractures with a mean follow-up of 21.2 (range: 3-49.4 months). The pooled RR for adjacent-level fractures after kyphoplasty compared to natural history was 1.35 (95% CI, 0.78-2.34, p = 0.23) and for vertebroplasty compared to natural history was 1.16 (95% CI, 0.62-2.14) p = 0.51. The risk of bias assessment showed a low to moderate risk of bias among included RCTs. CONCLUSION: There was no difference in the risk of adjacent-level fractures after vertebroplasty and kyphoplasty compared to natural history after osteoporotic vertebral compression fractures. The inclusion of a large patient number and network meta-analysis of RCTs serve evidence-based clinical practice. CLINICAL RELEVANCE STATEMENT: The risk of adjacent-level fracture following percutaneous vertebroplasty or kyphoplasty is similar to that observed in the natural history after osteoporotic vertebral compression fractures. KEY POINTS: RCTs have examined the risk of adjacent-level fracture after intervention for osteoporotic vertebral compression fractures. There was no difference between vertebroplasty and kyphoplasty patients compared to the natural disease history for adjacent compression fractures. This is strong evidence that interventional treatments for these fractures do not increase the risk of adjacent fractures.

Non-invasive Brain Stimulation Can Reduce Unilateral Spatial Neglect after Stroke: ELETRON Trial.

OBJECTIVE: Rehabilitation top-down techniques based on brain stimulation present variable outcomes in unilateral spatial neglect (USN) after stroke. This study aimed to examine the effects of physical therapy after anodal and cathodal transcranial direct current stimulation (A-tDCS and C-tDCS, respectively) to improve visuospatial and functional impairments in individuals with USN after stroke. METHODS: This double-blinded, pilot randomized clinical trial enrolled patients with USN after ischemic stroke. Randomization was stratified according to the Behavior Inattention Test-Conventional (BIT-C) and Catherine Bergego Scale (CBS). Outpatient physical therapy was conducted for 7.5 weeks after 20 minutes of tDCS. The primary outcome was the USN degree evaluated by the BIT-C. Secondary outcomes were the difference in CBS score, stroke severity (National Institutes of Health Stroke Scale [NIHSS]), disability (modified Rankin Scale), autonomy (Barthel Index, Functional Independence Measure), and quality of life (EuroQol Group 5-Dimension Self-Report Questionnaire). Outcomes were analyzed using an analysis of covariance model corrected by age, baseline NIHSS, and baseline BIT-C. Pairwise post hoc comparisons were performed using Bonferroni correction. RESULTS: In the primary outcomes, A-tDCS led to greater improvement in BIT-C after intervention (mean difference [MD] = 18.4, 95% confidence interval [CI] = 3.9-32.8, p = 0.008) compared to sham. However, no significant differences were observed between A-tDCS and C-tDCS (MD = 13.9, 95% CI = -0.3 to 28.1, p = 0.057), or C-tDCS and sham (MD = 4.5, 95% CI = -9.7 to 18.8, p = 0.99). There were no significant differences between groups in terms of secondary outcomes. INTERPRETATION: A-tDCS associated with physical therapy can decrease the severity of USN after stroke. However, these preliminary findings must be confirmed by collecting additional evidence in a larger phase 3 trial. ANN NEUROL 2022;92:400-410.

Maintaining high thrombectomy rates during pandemics.

PURPOSE OF REVIEW: The aim of this article is to review the current literature on endovascular treatment of acute ischemic stroke in the aftermath of the coronavirus disease 2019 (COVID-19) lockdown. RECENT FINDINGS: The outbreak of the COVID-19 has had effect of unprecedented magnitude on the social, economic and personal aspects around the globe. Healthcare providers were forced to expand capacity to provide care to the surging number of symptomatic COVID-19 patients, while maintaining a fully operating service for all non-COVID patients. The recent literature suggesting an overall decrease in acute ischemic stroke admissions as well as total number of endovascular treatments will be reviewed. Although the underlying reasons therefore remain the matter of debate, it seems that the imposed restrictions, requiring social distancing, and stopping all nonessential services, have led to a higher threshold for patients to seek medical attention, in particular in those with less severe symptoms. Thus, raising public awareness on the importance of strokes and transient ischemic attacks is even more important in the light of the current situation to avoid serious healthcare, economic consequences, and limit long term morbidity. SUMMARY: The priority remains maintaining a fast and efficient pre and in-hospital work-flow while mitigating nosocomial transmission and protecting the patient and the healthcare workers with appropriate personal protective equipment.

Endovascular Therapy of Acute Ischemic Stroke in Patients with Large-Vessel Occlusion Associated with Active Malignancy.

PURPOSE: There is limited data on the effectiveness of endovascular therapy (EVT) in stroke patients with active malignancy. In this study, we investigated the outcome of EVT for acute ischemic stroke for patients with active malignancy compared to those without malignancy. METHODS: We selected patients who underwent EVT for acute ischemic stroke between January 2015 and July 2019. Patients were divided into two groups, those with active malignancy (oncology group - OG) and those without (non-oncology group, NOG). RESULTS: 300 patients were included in this study. There were 19 EVT procedures (18 patients) in the OG and 285 procedures (282 patients) in the NOG. There was no difference in recanalization success rate (mTICI 2b & 3) between the groups: 94.7% versus 80.9% in OG and NOG respectively (p = 0.13). Success rate using the direct aspiration (ADAPT) technique of EVT was not different between compared groups (42.9% versus 67.7%; p = 0.18). However, when using smaller-caliber aspiration devices, ADAPT was less successful in OG (0.0% versus 64.7%, p < 0.05). There was no difference in recanalization success rate of EVT when using a stent-retriever or combined technique. Patients in the OG had a less favorable functional outcome than in the NOG group (mRS 0-2 at 90-days post event: 22.2% versus 48.2%, p < 0.05) CONCLUSION: The technical success rate of EVT in patients with active malignancy is similar to the general population of stroke patients. Interestingly, the success rate of EVT using the ADAPT technique was lower in the OG when using smaller caliber aspiration devices.

Mechanical thrombectomy in patients with proximal occlusions and low NIHSS: Results from a large prospective registry.

BACKGROUND: Mechanical thrombectomy is now standard of care for treatment of acute ischemic stroke secondary to large vessel occlusion in the setting of high NIHSS. We analysed a large nationwide registry focusing on patients with large vessel occlusion and low NIHSS on admission to evaluate the efficacy and safety of thrombectomy in this patient population METHODS: 2826 patients treated with mechanical thrombectomy were included in a multicentre registry from January 1, 2011 to December 31, 2015. We included patients with large vessel occlusion and NIHSS ≤ 6 on admission. Baseline characteristics, imaging, clinical outcome, procedure adverse events and positive and negative outcome predictors were analysed. RESULTS: 134 patients were included. 90/134 had an anterior circulation and 44 a posterior circulation stroke. One patient died before treatment. Successful revascularization (mTICI 2b-3) was achieved in 73.7% (98/133) of the patients. Intraprocedural adverse event was observed in 3% (4/133) of cases. Symptomatic intracranial haemorrhage rate was 5.3% (7/133). At three months, 70.9% (95/134) of the patients had mRS score 0-2, 15.7% (21/134) mRS 3-5 and 13.4% (18/134) mRS 6. Age and successful recanalization were significant predictors of a good clinical outcome on both univariate (p= 0.005 and p=0.007) and multivariable (p=0.0018 and p=0.009 [nat log]) analysis. Absence of vessel recanalization and symptomatic intracranial hemorrhage were independent predictors of poor outcome (p=0.021) . CONCLUSIONS: Our study suggests that patients with large vessel occlusion and low NIHSS score on admission can benefit from mechanical thrombectomy. Randomized trials are warranted.

Thrombectomy Outcomes of Intracranial Atherosclerosis-Related Occlusions.

Background and Purpose- Intracranial atherosclerosis (ICAS) is an important cause of large vessel occlusion and poses unique challenges for emergent endovascular thrombectomy. The risk factor profile and therapeutic outcomes of patients with ICAS-related occlusions (ICAS-O) are unclear. We performed a systematic review and meta-analysis of studies reporting the clinical features and thrombectomy outcomes of large vessel occlusion stroke secondary to underlying ICAS (ICAS-O) versus those of other causes (non-ICAS-O). Methods- A literature search on thrombectomy for ICAS-O was performed. Random-effect meta-analysis was used to analyze the prevalence of stroke risk factors and outcomes of thrombectomy between ICAS-O and non-ICAS-O groups. Results- A total of 1967 patients (496 ICAS-O and 1471 non-ICAS-O) were included. The ICAS-O group had significantly higher prevalence of hypertension (odds ratio [OR] 1.46; 95% CI, 1.10-1.93), diabetes mellitus (OR, 1.68; 95% CI, 1.29-2.20), dyslipidemia (OR, 1.94; 95% CI, 1.04-3.62), smoking history (OR, 2.11; 95% CI, 1.40-3.17) but less atrial fibrillation (OR, 0.20; 95% CI, 0.13-0.31) than the non-ICAS-O group. About thrombectomy outcomes, ICAS-O had higher intraprocedural reocclusion rate (OR, 23.7; 95% CI, 6.96-80.7), need for rescue balloon angioplasty (OR, 9.49; 95% CI, 4.11-21.9), rescue intracranial stenting (OR, 14.9; 95% CI, 7.64-29.2), and longer puncture-to-reperfusion time (80.8 versus 55.5 minutes, mean difference 21.3; 95% CI, 11.3-31.3). There was no statistical difference in the rate of final recanalization (modified Thrombolysis in Cerebral Infarction score of 2b/3; OR, 0.67; 95% CI, 0.36-1.27), symptomatic intracerebral hemorrhage (OR, 0.79; 95% CI, 0.50-1.24), good functional outcome (modified Rankin Scale score of 0-2; OR, 1.16; 95% CI, 0.85-1.58), and mortality (OR, 0.94; 95% CI, 0.64-1.39) between ICAS-O and non-ICAS-O. Conclusions- Patients with ICAS-O display a unique risk factor profile and technical challenges for endovascular reperfusion therapy. Intraprocedural reocclusion occurs in one-third of patients with ICAS-O. Intraarterial glycoprotein IIb/IIIa inhibitors infusion, balloon angioplasty, and intracranial stenting may be viable rescue treatment to achieve revascularization, resulting in comparable outcomes to non-ICAS-O.

Neurovascular stent artifacts in 3D-TOF and 3D-PCMRI: Influence of stent design on flow measurement.

PURPOSE: The morphological and hemodynamic evaluations of neurovascular diseases treated with stents would benefit from noninvasive imaging techniques such as 3D time-of-flight MRI (3D-TOF) and 3D phase contrast MRI (3D-PCMRI). For this purpose, a comprehensive evaluation of the stent artifacts and their impact on the flow measurement is critical. METHODS: The artifacts of a representative sample of neurovascular stents were evaluated in vitro with 3D-TOF and 3D-PCMRI sequences. The dependency of the artifacts with respect to the orientation was analyzed for each stent design as well as the impact on the flow measurement accuracy. Furthermore, the 3D-PCMRI data of four patients carrying intracranial aneurysms treated with flow diverter stents were analyzed as illustrative examples. RESULTS: The stent artifacts were mainly confined to the stent lumen therefore indicating the leading role of shielding effect. The influence of the stent design and its orientation with respect to the transmitting MR coils were highlighted. The artifacts impacted the 3D-PCMRI velocities mainly in the low magnitude domains, which were discarded from the analysis ensuring reliable near-stent velocities. The feasibility of in-stent flow measurements was confirmed in vivo on two patients who showed strong correlation between flow and geometric features. In two other patients, the consistency of out-of-stent velocities was verified qualitatively through intra-aneurysmal streamlines except when susceptibility artifacts occurred. CONCLUSION: The present results motivate the conception of low inductance or nonconductive stent design. Furthermore, the feasibility of near-stent 3D-PCMRI measurements opens the door to clinical applications like the post-treatment follow-up of stenoses or intracranial aneurysms.

Proposed achievable levels of dose and impact of dose-reduction systems for thrombectomy in acute ischemic stroke: an international, multicentric, retrospective study in 1096 patients.

BACKGROUND: International dose reference levels are lacking for mechanical thrombectomy in acute ischemic stroke patients with large vessel occlusions. We studied whether radiation dose-reduction systems (RDS) could effectively reduce exposure and propose achievable levels. MATERIALS AND METHODS: We retrospectively included consecutive patients treated with thrombectomy on a biplane angiography system (BP) in five international, high-volume centers between January 2014 and May 2017. Institutional Review Board approvals were obtained. Technical, procedural, and clinical characteristics were assessed. Efficacy, safety, radiation dose, and contrast load were compared between angiography systems with and without RDS. Multivariate analyses were adjusted according to Bonferroni's correction. Proposed international achievable cutoff levels were set at the 75th percentile. RESULTS: Out of the 1096 thrombectomized patients, 520 (47%) were treated on a BP equipped with RDS. After multivariate analysis, RDS significantly reduced dose-area product (DAP) (91 vs 140 Gy cm2, relative effect 0.74 (CI 0.66; 0.83), 35% decrease, p < 0.001) and air kerma (0.46 vs 0.97 Gy, relative effect 0.63 (CI 0.56; 0.71), 53% decrease, p < 0.001) with 75th percentile levels of 148 Gy cm2 and 0.73 Gy, respectively. There was no difference in contrast load, rates of successful recanalization, complications, or clinical outcome. CONCLUSION: Radiation dose-reduction systems can reduce DAP and air kerma by a third and a half, respectively, without affecting thrombectomy efficacy or safety. The respective thresholds of 148 Gy cm2 and 0.73 Gy represent achievable levels that may serve to optimize current and future radiation exposure in the setting of acute ischemic stroke treatment. As technology evolves, we expect these values to decrease. KEY POINTS: • Internationally validated achievable levels may help caregivers and health authorities better assess and reduce radiation exposure of both ischemic stroke patients and treating staff during thrombectomy procedures. • Radiation dose-reduction systems can reduce DAP and air kerma by a third and a half, respectively, without affecting thrombectomy efficacy or safety in the setting of acute ischemic stroke due to large vessel occlusion.

Association of single and multiple aneurysms with tobacco abuse: an @neurIST risk analysis.

OBJECTIVE: Although several studies have suggested that the incidence of intracranial aneurysms (IAs) is higher in smokers, the higher prevalence of subarachnoid hemorrhage (SAH) in smokers remains uncertain. It is unclear whether smoking additionally contributes to the formation of multiple aneurysms and the risk of rupture. The aim of this study was to determine whether smoking is associated with IA formation, multiplicity, or rupture. METHODS: Patients from the prospective multicenter @neurIST database (n = 1410; 985 females [69.9%]) were reviewed for the presence of SAH, multiple aneurysms, and smoking status. The prevalence of smokers in the population of patients diagnosed with at least one IA was compared with that of smokers in the general population. RESULTS: The proportion of smokers was higher in patients with IAs (56.2%) than in the reference population (51.4%; p < 0.001). A significant association of smoking with the presence of an IA was found throughout group comparisons (p = 0.01). The presence of multiple IAs was also significantly associated with smoking (p = 0.003). A trend was found between duration of smoking and the presence of multiple IAs (p = 0.057). However, the proportion of smokers among patients suffering SAH was similar to that of smokers among patients diagnosed with unruptured IAs (p = 0.48). CONCLUSIONS: Smoking is strongly associated with IA formation. Once an IA is present, however, smoking does not appear to increase the risk of rupture compared with IAs in the nonsmoking population. The trend toward an association between duration of smoking and the presence of multiple IAs stresses the need for counseling patients with IAs regarding lifestyle modification.

External validation of cerebral aneurysm rupture probability model with data from two patient cohorts.

BACKGROUND: For a treatment decision of unruptured cerebral aneurysms, physicians and patients need to weigh the risk of treatment against the risk of hemorrhagic stroke caused by aneurysm rupture. The aim of this study was to externally evaluate a recently developed statistical aneurysm rupture probability model, which could potentially support such treatment decisions. METHODS: Segmented image data and patient information obtained from two patient cohorts including 203 patients with 249 aneurysms were used for patient-specific computational fluid dynamics simulations and subsequent evaluation of the statistical model in terms of accuracy, discrimination, and goodness of fit. The model's performance was further compared to a similarity-based approach for rupture assessment by identifying aneurysms in the training cohort that were similar in terms of hemodynamics and shape compared to a given aneurysm from the external cohorts. RESULTS: When applied to the external data, the model achieved a good discrimination and goodness of fit (area under the receiver operating characteristic curve AUC = 0.82), which was only slightly reduced compared to the optimism-corrected AUC in the training population (AUC = 0.84). The accuracy metrics indicated a small decrease in accuracy compared to the training data (misclassification error of 0.24 vs. 0.21). The model's prediction accuracy was improved when combined with the similarity approach (misclassification error of 0.14). CONCLUSIONS: The model's performance measures indicated a good generalizability for data acquired at different clinical institutions. Combining the model-based and similarity-based approach could further improve the assessment and interpretation of new cases, demonstrating its potential use for clinical risk assessment.

Safety and Efficacy of Solitaire Stent Thrombectomy: Individual Patient Data Meta-Analysis of Randomized Trials.

BACKGROUND AND PURPOSE: Recent positive randomized trials of endovascular therapy for ischemic stroke used predominantly stent retrievers. We pooled data to investigate the efficacy and safety of stent thrombectomy using the Solitaire device in anterior circulation ischemic stroke. METHODS: Patient-level data were pooled from trials in which the Solitaire was the only or the predominant device used in a prespecified meta-analysis (SEER Collaboration): Solitaire FR With the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME), Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times (ESCAPE), Extending the Time for Thrombolysis in Emergency Neurological Deficits-Intra-Arterial (EXTEND-IA), and Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting Within Eight Hours of Symptom Onset (REVASCAT). The primary outcome was ordinal analysis of modified Rankin Score at 90 days. The primary analysis included all patients in the 4 trials with 2 sensitivity analyses: (1) excluding patients in whom Solitaire was not the first device used and (2) including the 3 Solitaire-only trials (excluding ESCAPE). Secondary outcomes included functional independence (modified Rankin Score 0-2), symptomatic intracerebral hemorrhage, and mortality. RESULTS: The primary analysis included 787 patients: 401 randomized to endovascular thrombectomy and 386 to standard care, and 82.6% received intravenous thrombolysis. The common odds ratio for modified Rankin Score improvement was 2.7 (2.0-3.5) with no heterogeneity in effect by age, sex, baseline stroke severity, extent of computed tomography changes, site of occlusion, or pretreatment with alteplase. The number needed to treat to reduce disability was 2.5 and for an extra patient to achieve independent outcome was 4.25 (3.29-5.99). Successful revascularization occurred in 77% treated with Solitaire device. The rate of symptomatic intracerebral hemorrhage and overall mortality did not differ between treatment groups. CONCLUSIONS: Solitaire thrombectomy for large vessel ischemic stroke was safe and highly effective with substantially reduced disability. Benefits were consistent in all prespecified subgroups.

Mechanical Thrombectomy in Acute Ischemic Stroke: A Systematic Review.

Although intravenous thrombolysis increases the probability of a good functional outcome in carefully selected patients with acute ischemic stroke, a substantial proportion of patients who receive thrombolysis do not have a good outcome. Several recent trials of mechanical thrombectomy appear to indicate that this treatment may be superior to thrombolysis. We therefore conducted a systematic review and meta-analysis to evaluate the clinical effectiveness and safety of new-generation mechanical thrombectomy devices with intravenous thrombolysis (if eligible) compared with intravenous thrombolysis (if eligible) in patients with acute ischemic stroke caused by a proximal intracranial occlusion. We systematically searched seven databases for randomized controlled trials published between January 2005 and March 2015 comparing stent retrievers or thromboaspiration devices with best medical therapy (with or without intravenous thrombolysis) in adults with acute ischemic stroke. We assessed risk of bias and overall quality of the included trials. We combined the data using a fixed or random effects meta-analysis, where appropriate. We identified 1579 studies; of these, we evaluated 122 full-text papers and included five randomized control trials (n=1287). Compared with patients treated medically, patients who received mechanical thrombectomy were more likely to be functionally independent as measured by a modified Rankin score of 0-2 (odds ratio, 2.39; 95% confidence interval, 1.88-3.04; I2=0%). This finding was robust to subgroup analysis. Mortality and symptomatic intracerebral hemorrhage were not significantly different between the two groups. Mechanical thrombectomy significantly improves functional independence in appropriately selected patients with acute ischemic stroke.

State-of-the-art endovascular treatment of acute ischemic stroke.

Stroke is the third leading cause of death in the USA. An estimated 795,000 new or recurrent stroke events occur annually, mostly ischemic in nature. Arterial recanalization and subsequent reperfusion performed shortly after symptom onset can help to restore brain function in acute ischemic stroke (AIS). The only treatment currently approved by the United States Food and Drug Administration is intravenous tissue plasminogen activator, administered within 4.5 h of symptom onset. However, this short window often precludes effective intervention. Mechanical neurothrombectomy devices offer many potential advantages over pharmacologic thrombolysis, including more rapid achievement of recanalization, enhanced efficacy in treating large-vessel occlusions, and a potentially lower risk of hemorrhagic events. The goal of this chapter is to describe the state-of-the-art neurothrombectomy devices and stenting techniques for endovascular treatment of acute ischemic stroke, as well as to highlight recent advances in reperfusion therapies. Ongoing clinical trials, some with randomized, controlled designs, are included.

Current status of mechanical thrombectomy for acute stroke treatment.

Acute ischemic stroke is a morbid and disabling medical condition with a significant social and economic impact throughout the world. Intravenous thrombolysis (IVT) has been the first line treatment for patients presenting up to 4.5 hours after symptom onset for many years. Endovascular stroke treatment has been used successfully as rescue therapy after failed IVT; in patients with contraindications to rtPA or presenting outside the 4.5-hour window. The effectiveness of IVT is high for distal thrombi but significantly lower for proximal occlusions. Endovascular treatment has been revolutionized by the evolution from intra-arterial thrombolysis and first generation mechanical devices to the current generation of stent retrievers and aspiration systems with large bore catheters. These devices have been associated with excellent revascularization, improved clinical outcomes, shorter procedure times and reduced device and procedure related complications. We report the current literature, clinical standards and perspectives on mechanical thrombectomy in acute ischemic stroke.

Wall shear stress distribution of small aneurysms prone to rupture: a case-control study.

BACKGROUND AND PURPOSE: Subarachnoid hemorrhage after intracranial aneurysm rupture remains a serious condition. We performed a case-control study to evaluate the use of computed hemodynamics to detect cerebral aneurysms prone to rupture. METHODS: Four patients with incidental aneurysms that ultimately ruptured (cases) were studied after initially being included in a prospective database including their 3-dimensional imaging before rupture. Ruptures were located in different arterial segments: M1 segment of the middle cerebral artery; basilar tip; posterior inferior cerebellar artery; and anterior communicating artery. For each case, 5 controls matched by location and size were randomly selected. An empirical cumulative distribution function of aneurysm wall shear stress percentiles was evaluated for every case and used to define a critical prone-to-rupture range. Univariate logistic regression analysis was then used to assess the individual risk of rupture. RESULTS: A cumulative wall shear stress distribution characterizing a hemodynamic prone-to-rupture range for small-sized aneurysms was identified and fitted independent of the location. Sensitivity and specificity of the preliminary tests were 90% and 93%, respectively. CONCLUSIONS: The wall shear stress cumulative probability function may be a potential predictor of small-sized aneurysm rupture.

Optimal workflow and process-based performance measures for endovascular therapy in acute ischemic stroke: analysis of the Solitaire FR thrombectomy for acute revascularization study.

BACKGROUND AND PURPOSE: We report on workflow and process-based performance measures and their effect on clinical outcome in Solitaire FR Thrombectomy for Acute Revascularization (STAR), a multicenter, prospective, single-arm study of Solitaire FR thrombectomy in large vessel anterior circulation stroke patients. METHODS: Two hundred two patients were enrolled across 14 centers in Europe, Canada, and Australia. The following time intervals were measured: stroke onset to hospital arrival, hospital arrival to baseline imaging, baseline imaging to groin puncture, groin puncture to first stent deployment, and first stent deployment to reperfusion. Effects of time of day, general anesthesia use, and multimodal imaging on workflow were evaluated. Patient characteristics and workflow processes associated with prolonged interval times and good clinical outcome (90-day modified Rankin score, 0-2) were analyzed. RESULTS: Median times were onset of stroke to hospital arrival, 123 minutes (interquartile range, 163 minutes); hospital arrival to thrombolysis in cerebral infarction (TICI) 2b/3 or final digital subtraction angiography, 133 minutes (interquartile range, 99 minutes); and baseline imaging to groin puncture, 86 minutes (interquartile range, 24 minutes). Time from baseline imaging to puncture was prolonged in patients receiving intravenous tissue-type plasminogen activator (32-minute mean delay) and when magnetic resonance-based imaging at baseline was used (18-minute mean delay). Extracranial carotid disease delayed puncture to first stent deployment time on average by 25 minutes. For each 1-hour increase in stroke onset to final digital subtraction angiography (or TICI 2b/3) time, odds of good clinical outcome decreased by 38%. CONCLUSIONS: Interval times in the STAR study reflect current intra-arterial therapy for patients with acute ischemic stroke. Improving workflow metrics can further improve clinical outcome. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01327989.

Treatment of a posterior cerebral artery aneurysm in the context of complex cardio-cerebrovascular variations using the Tubridge flow diverter.

We present a case of intracranial aneurysm located in the P1 segment of left posterior cerebral artery in the context of tetralogy of Fallot. Complex variations included right aortic arch with abnormal branching. Also, the bilateral vertebral arteries were absent, with a type I persistent proatlantal intersegmental artery of the left side. The aneurysm was treated with endovascular intervention with a Tubridge flow diverter and was noted to be completely cured on 6-month follow-up. We discuss the many considerations in this patient including developmental and modern-era treatment.

Perspectives on Remote Robotic-Assisted Stroke Treatment: A Commentary Paper.

The proved feasibility of robotic-assisted endovascular treatment of intracranial aneurysms has stimulated the idea of a potential application of remote robotics for the treatment of acute ischemic stroke. The possibility of developing a more advanced remote-controlled robotic system capable of performing a complete mechanical thrombectomy procedure would help bridge the health care gap of lack of technical expertise in isolated areas. This possibility could allow a more equitable access to mechanical thrombectomy to a larger number of patients and be a breakthrough for acute ischemic stroke care worldwide. Many aspects around the technical, human, financial, and regulatory requirements should be discussed to implement remote robotic-assisted procedures. In this State of Practice article, we aimed to outline the major challenges that must be considered, as well as proposed solutions. However, different solutions may be applied in different health care systems on the basis of the availability of human and financial resources.

Clinical Uncertainty in Large Vessel Occlusion ischemic stroke (CULVO): Does automated perfusion scanning make a difference? Protocol of an intrarater and interrater agreement study.

BACKGROUND: Guidelines recommend the use of perfusion computed tomography (CT) to identify emergent large vessel ischemic stroke (ELVIS) patients who are likely to benefit from endovascular thrombectomy (EVT) if they present within 6-24 hour (late window) of stroke onset. We aim to determine if the interrater and intrarater reliability among physicians when recommending EVT is significantly different when perfusion CT or non-perfusion CT is reviewed. METHODS: A total of 30 non-consecutive patients will be selected from our institutional database comprising 3144 cranial CT scans performed for acute stroke symptoms January 2018 to August 2022. The clinical and radiologic data of the 30 patients will be presented in random order to a group of 29 physicians in two separate sessions at least three weeks apart. In each session, the physicians will evaluate each patient once with automated perfusion images and once without. We will use non-overlapping 95% confidence intervals and difference in agreement classification as criteria to suggest a difference between the Gwet AC1 statistics (κG). DISCUSSION: The results obtained from this study, combined with the clinical outcomes data of patients categorized through the two imaging techniques and a cost-effectiveness analysis, will offer a comprehensive evaluation of the clinical utility of perfusion CT neuroimaging. Should there be no significant disparity in the reliability of decisions made by clinicians using the two neuroimaging protocols, it may be necessary to revise existing recommendations regarding neuroimaging in the later time window to align with these findings.