First Pass Effect: A New Measure for Stroke Thrombectomy Devices.

BACKGROUND AND PURPOSE: In acute ischemic stroke, fast and complete recanalization of the occluded vessel is associated with improved outcomes. We describe a novel measure for newer generation devices: the first pass effect (FPE). FPE is defined as achieving a complete recanalization with a single thrombectomy device pass. METHODS: The North American Solitaire Acute Stroke Registry database was used to identify a FPE subgroup. Their baseline features and clinical outcomes were compared with non-FPE patients. Clinical outcome measures included 90-days modified Rankin Scale score, National Institutes of Health Stroke Scale score, mortality, and symptomatic intracranial hemorrhage. Multivariate analyses were performed to determine whether FPE independently resulted in improved outcomes and to identify predictors of FPE. RESULTS: A total of 354 acute ischemic stroke patients underwent thrombectomy in the North American Solitaire Acute Stroke registry. FPE was achieved in 89 out of 354 (25.1%). More middle cerebral artery occlusions (64% versus 52.5%) and fewer internal carotid artery occlusions (10.1% versus 27.7%) were present in the FPE group. Balloon guide catheters were used more frequently with FPE (64.0% versus 34.7%). Median time to revascularization was significantly faster in the FPE group (median 34 versus 60 minutes; P=0.0003). FPE was an independent predictor of good clinical outcome (modified Rankin Scale score ≤2 was seen in 61.3% in FPE versus 35.3% in non-FPE cohort; P=0.013; odds ratio, 1.7; 95% confidence interval, 1.1-2.7). The independent predictors of achieving FPE were use of balloon guide catheters and non-internal carotid artery terminus occlusion. CONCLUSIONS: The achievement of complete revascularization from a single Solitaire thrombectomy device pass (FPE) is associated with significantly higher rates of good clinical outcome. The FPE is more frequently associated with the use of balloon guide catheters and less likely to be achieved with internal carotid artery terminus occlusion.

Case report: A novel case of paraneoplastic voltage gated calcium channel antibodies secondary to appendiceal adenocarcinoma.

Voltage gated calcium channels (VGCCs) play a critical role in neural transmission. Antibodies that target these ion channels can disrupt cellular signal transmission resulting in various clinical presentations. VGCC antibodies are most commonly associated with paraneoplastic syndromes such as Lambert-Eatons myasthenic syndrome. Here, we report a 47-year-old female with Stage IV appendiceal adenocarcinoma status post appendectomy and right hemicolectomy, who presented with progressive memory impairment, aphasia, ataxia, weakness, and headache. Neurologic exam was notable for right-sided parietal drift, decreased right arm swing, and ataxia of the bilateral upper extremities, more prominent on the right side. MRI of the brain with and without contrast was unremarkable. Cerebrospinal fluid (CSF) was notable for an elevated myelin basic protein (4.9 ng/mL, normal reference 0.0-3.7 ng/mL) with normal cell count, flow cytometry, and cytology. An extensive serum autoimmune neurology antibody evaluation revealed elevated VGCC autoantibodies (observed value: 96.1 pmol/L, normal range 0.0-30.0 pmol/L). A diagnosis of paraneoplastic voltage gated calcium channel antibodies secondary to appendiceal adenocarcinoma was made. The patient was treated with five exchanges with plasmapheresis over 10 days with significant clinical improvement in her symptoms. Upon literature review, this would be the first reported case of VGCC antibodies associated with appendiceal adenocarcinoma.

Outcomes of Endovascular Stenting in Symptomatic Vertebral Artery Ostial Stenosis.

Vertebral artery ostial stenosis is implicated in one-fifth of all posterior circulation cerebrovascular accidents. However, uniform treatment guidelines and data on the different treatment modalities are still lacking. Endovascular stenting is an emerging therapy for symptomatic vertebral artery ostial stenosis when medical management fails. This manuscript will examine the safety and efficacy of endovascular revascularization with drug-eluting stents in a series of ten consecutive patients that had failed medical management. We also report the rate of complications and in-stent restenosis, as well as the rate of recurrent cerebrovascular accidents.

Case of Cocaine Induced Coronary and Carotid Artery Dissection.

Cocaine use has been individually linked to both carotid and coronary artery dissections. However, their simultaneous occurrence has not been previously reported. A 30-year-old man who suffered an acute ischemic stroke and myocardial infarction secondary to acute carotid and coronary artery dissections, respectively, 16 hours after snorting cocaine. To our knowledge, this is the first reported case describing the simultaneous occurrence of carotid and coronary artery dissections resulting from cocaine use.

mG-FAST, a single pre-hospital stroke screen for evaluating large vessel and non-large vessel strokes.

Background: Several stroke scales have been implemented to enhance early recognition of large vessel occlusion (LVO) in the field. These scales necessitate a tiered approach requiring emergency medical services (EMS) to utilize two scales, one for identifying stroke and another for differentiating LVO from non-LVO. Ideally, a single stroke scale should be utilized by EMS for triage. Methods: This is a prospective analysis of 150 consecutive patients presenting with stroke symptoms from the field. The stroke scale modified Gaze-Face-Arm-Speech-Time (mG-FAST) was used to simultaneously identify stroke and detect LVO in the pre-hospital setting. Imaging was used to confirm the presence of a LVO and determine the sensitivity and specificity of mG-FAST. The receiver operating curve (ROC) was plotted to calculate the area under the curve (AUC). Youden's index was used to determine the optimal cutoff score. Inter-rater reliability was obtained by comparing the EMS and stroke provider mG-FAST scores. EMS dispatch-to-thrombectomy-capable stroke center (mothership, MS) arrival time and groin puncture time were compared before and after the implementation of mG-FAST. Results: 33/150 patients had a confirmed LVO by imaging. 32/33 patients had an mG-FAST score ≥3. The AUC of mG-FAST was 0.899. An mG-FAST cut-off point of ≥3 yielded a sensitivity of 0.97 and specificity of 0.55 for LVO. The accuracy of this cut-off point was 64%. The EMS dispatch-to-MS time and groin puncture time decreased by 22 and 40 min after implementation of mG-FAST, respectively. With admission to the MS, the EMS dispatch-to-MS time decreased by 174.7 min compared to admission to a drip-and-ship (DS) hospital. Conclusions: Utilizing a single stroke scale in the field improves EMS dispatch-to-MS time, EMS dispatch-to-groin puncture time, and EMS door-to-intervention time. Implementation of mG-FAST as a pre-hospital screening tool is an effective method of triaging patients to the MS or DS hospitals.

Broken heart syndrome in myasthenia gravis.

Broken heart syndrome or stress-induced non-ischemic cardiomyopathy (SICM) has rarely been reported in the setting of myasthenic crisis. We describe a case of reversible SICM that occurred simultaneously with myasthenic crisis in a 77-year-old man without prior cardiac history, and we discuss the previous findings that support an association of other cardiac disorders with myasthenia gravis.

Determinants of Chiari I progression in pregnancy.

Chiari Malformation type 1 (CM-I) is congenital or an acquired anomaly of the hind brain; develops when the cerebellar tonsils recede downwards below the foramen magnum. Recurrent post tussive suboccipital headache is the common presentation in a pregnant woman and the diagnosis is usually missed or delayed due to lack of formal understanding of this neurological pathology. Much has been written regarding presentation, morphology and the treatment of CM-I; however, little is known when the etiology is acquired or an iatrogenic in its evolution. Similarly, unknown is the progression of CM-I (diagnosed or undiagnosed) in pregnancy. The objective of this study is to elucidate the causes of progression of CM-I in pregnancy, and how this can be avoided. A detailed literature review has been conducted to find the case reports or case studies on association of CM-I in pregnancy; therefore, the risk factors regarding the progression have been sought. There is a lack of literature on timing, mode of anesthesia, and the management of CM-I. Moreover, authors have sought a questionnaire to screen these patients at pre-conception, intrapartum visits if, the initial diagnosis is delayed. Crucial points of concern including but not limited to the diagnosis, pre-conception counseling, timing of intervention during pregnancy, and mode of anesthesia, have been discussed in detail. In summary, a formal management algorithm has been proposed to avoid the rapid progression of this complex neurological pathology especially, in women of child bearing age and/or during pregnancy.

Review of the Mobile Stroke Unit Experience Worldwide.

BACKGROUND: The treatment of stroke is dependent on a narrow therapeutic time window that requires interventions to be emergently pursued. Despite recent "FAST" initiatives that have underscored "time is brain," many patients still fail to present within the narrow time window to receive maximum treatment benefit from advanced stroke therapies, including recombinant tissue plasminogen activator (tPA) and mechanical thrombectomy. The convergence of emergency medical services, telemedicine, and mobile technology, including transportable computed tomography scanners, has presented a unique opportunity to advance patient stroke care in the prehospital field by shortening time to hyperacute stroke treatment with a mobile stroke unit (MSU). SUMMARY: In this review, we provide a look at the evolution of the MSU into its current status as well as future directions. Our summary statement includes historical and implementation information, economic cost, and published clinical outcome and time metrics, including the utilization rate of thrombolysis. KEY MESSAGES: Initially hypothesized in 2003, the first MSUs were launched in Germany and adopted worldwide in acute, prehospital stroke management. These specialized ambulances have made the diagnosis and treatment of many neurological emergencies, in addition to ischemic and hemorrhagic stroke, possible at the emergency site. Providing treatment as early as possible, including within the prehospital phase of stroke management, improves patient outcomes. As MSUs continue to collect data and improve their methods, shortened time metrics are expected, resulting in more patients who will benefit from faster treatment of their acute neurological emergencies in the prehospital field.

World's First 24/7 Mobile Stroke Unit: Initial 6-Month Experience at Mercy Health in Toledo, Ohio.

BACKGROUND AND PURPOSE: As the fourth mobile stroke unit (MSU) in the nation, and the first 24/7 unit worldwide, we review our initial experience with the Mercy Health MSU and institutional protocols implemented to facilitate rapid treatment of acute stroke patients and field triage for patients suffering other time-sensitive, acute neurologic emergencies in Lucas County, Ohio, and the greater Toledo metropolitan area. METHODS: Data was prospectively collected for all patients transported and treated by the MSU during the first 6 months of service. Data was abstracted from documentation of on-scene emergency medical services (EMS) personnel, critical care nurses, and onboard physicians, who participated through telemedicine. RESULTS: The MSU was dispatched 248 times and transported 105 patients after on-scene examination with imaging. Intravenous (IV) tissue plasminogen activator (tPA) was administered to 10 patients; 8 patients underwent successful endovascular therapy after a large vessel occlusion was identified using CT performed within the MSU without post treatment symptomatic hemorrhage. Moreover, 14 patients were treated with IV anti-epileptics for status epilepticus, and 19 patients received IV anti-hypertensive agents for malignant hypertension. MSU alarm to on-scene times and treatment times were 34.7 min (25-49) and 50.6 min (44.4-56.8), respectively. CONCLUSION: The world's first 24/7 MSU has been successfully implemented with IV-tPA administration rates and times comparable to other MSUs nation-wide, while demonstrating rapid triage and treatment in the field for neurologic emergencies, including status epilepticus. With the rising number of MSUs worldwide, further data will drive standardized protocols that can be adopted nationwide by EMS.