Effect of General Anesthesia Versus Conscious Sedation/Local Anesthesia on the Outcome of Patients with Minor Stroke and Isolated M2 Occlusion Undergoing Immediate Thrombectomy: A Retrospective Multicenter Matched Analysis.

BACKGROUND: This study investigates the impact of general anesthesia (GA) versus conscious sedation/local anesthesia (CS/LA) on the outcome of patients with minor stroke and isolated M2 occlusion undergoing immediate mechanical thrombectomy (iMT). METHODS: The databases of 16 comprehensive stroke centers were retrospectively screened for consecutive patients with isolated M2 occlusion and a baseline National Institutes of Health Stroke Scale score ≤5 who received iMT. Propensity score matching was used to estimate the effect of GA versus CS/LA on clinical outcomes and procedure-related adverse events. The primary outcome measure was a 90-day modified Rankin Scale (mRS) score of 0-1. Secondary outcome measures were a 90-day mRS score of 0-2 and all-cause mortality, successful reperfusion, procedural-related symptomatic subarachnoid hemorrhage, intraprocedural dissections, and new territory embolism. RESULTS: Of the 172 patients who were selected, 55 received GA and 117 CS/LA. After propensity score matching, 47 pairs of patients were available for analysis. We found no significant differences in clinical outcome, rates of efficient reperfusion, and procedural-related complications between patients receiving GA or LA/CS (mRS score 0-1, P = 0.815; mRS score 0-2, P = 0.401; all-cause mortality, P = 0.408; modified Treatment in Cerebral Infarction score 2b-3, P = 0.374; symptomatic subarachnoid hemorrhage, P = 0.082; intraprocedural dissection, P = 0.408; new territory embolism, P = 0.462). CONCLUSIONS: In patients with minor stroke and isolated M2 occlusion undergoing iMT, the type of anesthesia does not affect clinical outcome or the rate of procedural-related complications. Our results agree with recent data showing no benefit of one specific anesthesiologic procedure over the other and confirm their generalizability also to patients with minor baseline symptoms.

The Charlotte Large Artery Occlusion Endovascular Therapy Outcome Score Predicts Poor Outcomes 1 Year After Endovascular Thrombectomy.

OBJECTIVE: We evaluated the ability of several outcome prognostic scales to predict poor 1-year outcomes and mortality after endovascular thrombectomy. METHODS: In this retrospective analysis from the stroke registry of a large integrated health system, consecutive patients presenting from August 2020 to September 2021 with an anterior circulation large-vessel occlusion stroke treated with endovascular thrombectomy were included. Multivariable logistic regression was performed to determine the ability of each scale to predict the primary outcome (1-year modified Rankin Scale [mRS] score of 4-6) and the secondary outcome (1-year mortality). Area under the curve analyses were performed for each scale. RESULTS: In 237 included patients (mean age 68 [±15] years; median National Institutes of Health Stroke Scale score 16 [11-21]), poor 1-year outcomes were present in 116 patients (49%) and 1-year mortality was 34%. The CLEOS (Charlotte Large Artery Occlusion Endovascular Therapy Outcome Score), which incorporates age, baseline National Institutes of Health Stroke Scale score, initial glucose level, and computed tomography perfusion cerebral blood volume index, had a significant association with poor 1-year outcomes (per 25-point increase; odds ratio, 1.0134; P = 0.02). CLEOS and PRE (Pittsburgh Response to Endovascular Therapy) were both significantly associated with 1-year mortality. Area under the curve values were comparable for CLEOS, PRE, Houston Intra-Arterial Therapy 2, and Totaled Health Risks in Vascular Events to predict 1-year mRS score 4-6 and mortality. Only 1 of 18 patients with CLEOS ≥690 had a 1-year mRS score of 0-3. CONCLUSIONS: CLEOS can predict poor 1-year outcomes and mortality for patients with anterior circulation large-vessel occlusion using prethrombectomy variables.

Effect of intra-arterial nimodipine on iatrogenic vasospasms during endovascular stroke treatment - angiographic resolution and infarct growth in follow-up imaging.

PURPOSE: The treatment of vasospasms during endovascular stroke treatment (EST) with intra-arterial nimodipine (NM) is routinely performed. However, the efficacy of resolving iatrogenic vasospasms during the angiographic intervention and the infarct development in follow-up imaging after EST has not been studied yet. METHODS: Retrospective single-center analysis of patients receiving EST for anterior circulation vessel occlusion between 01/2015 and 12/2021. The primary endpoint was ASPECTS in follow-up imaging. Secondary endpoints were the clinical outcome (combined endpoint NIHSS 24 h after EST and difference between modified Rankin Scale (mRS) before stroke and at discharge (delta mRS)) and intracranial hemorrhage (ICH) in follow-up imaging. Patients with vasospasms receiving NM (NM+) or not (NM-) were compared in univariate analysis. RESULTS: Vasospasms occurred in 79/1283 patients (6.2%), who consecutively received intra-arterial NM during EST. The targeted vasospasm angiographically resolved in 84% (66/79) under NM therapy. ASPECTS was lower in follow-up imaging after vasospasms and NM-treatment (NM - 7 (6-9), NM + 6 (4.5-8), p = 0.013) and the clinical outcome was worse (NIHSS 24 h after EST was higher in patients treated with NM (median, IQR; NM+: 14, 5-21 vs. NM-: 9, 3-18; p = 0.004), delta-mRS was higher in the NM + group (median, IQR; NM+: 3, 1-4 vs. NM-: 2, 1-2; p = 0.011)). Any ICH (NM+: 27/79, 34.2% vs. NM-: 356/1204, 29.6%; p = 0.386) and symptomatic ICH (NM+: 2/79, 2.5% vs. NM-: 21/1204, 1.7%; p = 0.609) was equally distributed between groups. CONCLUSION: Intra-arterial nimodipine during EST resolves iatrogenic vasospasms efficiently during EST without increasing intracranial hemorrhage rates. However, patients with vasospasms and NM treatment show higher infarct growth resulting in lower ASPECTS in follow-up imaging.

Evolution of deep vein thrombosis treatment from leeches to mechanical thrombectomy.

Deep vein thrombosis (DVT) is one of the most common diseases in developed countries with significant socioeconomic consequences. The severity of DVT lies in the potential for life-threatening pulmonary embolism and the development of chronic venous insufficiency, referred to as post-thrombotic syndrome. Virchow contributed to the understanding of the pathophysiological events that lead to thrombosis by describing three basic risk mechanisms. The first therapeutic attempts in the 17th century included venepuncture and the application of leeches. The first anticoagulant drug was heparin, which entered clinical practice after 1935. Subsequent commercialization of oral vitamin K antagonists (warfarin) and the advent of low molecular weight heparin along with compression therapy allowed the expansion of outpatient treatment of DVT. Recently, new oral anticoagulants have been introduced, leading to improved safety due to lower risk of bleeding complications and simplification of the treatment process. The next step in the development of therapeutic options are invasive methods of early thrombus removal, which significantly shorten the process and aim to reduce the occurrence of late complications. These methods include local catheter-directed thrombolysis using tissue plasminogen activator, mechanical thrombectomy and their combination called pharmaco-mechanical thrombectomy. The latter is currently used in patients with acute ilio-femoral DVT.

[Association of nutritional status with clinical outcomes of stroke patients with acute anterior circulation large vessel occlusion after emergency endovascular treatment].

OBJECTIVE: To explore the influence of nutritional status on 90-day functional outcomes of stroke patients with acute large vessel occlusion in the anterior circulation after endovascular treatment (EVT). METHODS: We retrospectively analyzed the baseline, laboratory, surgical and 90-day follow-up data of patients with stroke resulting from acute large vessel occlusion in the anterior circulation, who underwent emergency endovascular treatment in our hospital from July, 2015 to December, 2020. A favorable outcome was defined as a modified Rankin scale score ≤2 at 90 days. Univariate and multivariate regression analyses were performed to explore the relationship between nutritional status and 90-day functional outcomes of the patients. RESULTS: A total of 459 patients (mean age of 68.29±11.21 years, including 260 males) were enrolled in this study. According to their prognostic nutritional index (PNI), the patients were divided into normal nutrition group (392 cases, 85.4%), moderate malnutrition group (44 cases, 9.6%), and severe malnutrition group (23 cases, 5.0%). Univariate analysis showed that the patients with good clinical outcomes had a lower proportion of malnutrition with a younger age, a lower rate of diabetes, lower baseline blood pressure, lower baseline NIHSS score, higher baseline ASPECT score, and higher rates of good collateral circulation and complete vascular recanalization. Multivariate analysis showed that in addition to age, diabetes, baseline systolic blood pressure, successful recanalization, baseline ASPECT score, baseline NIHSS score and collateral circulation, a greater PNI was a protective factor for a good 90-day outcome of patients after EVT (moderate vs severe: OR=0.245, 95% CI: 0.066-0.908, P=0.035; normal vs severe: OR=0.185, 95% CI: 0.059-0.581, P=0.004). CONCLUSION: Nutritional status an important factor affecting the 90-day outcomes after EVT of stroke patients with acute large vessel occlusion in the anterior circulation.

Moving from traditional to more advanced treatments in stroke care is cost-effective: A case study from Greece.

OBJECTIVES: Stroke is the most common cause of disability in high-income countries. Several countries offer a limited range of advanced treatments with implications for outcomes, disability and costs. This study estimates the burden of disability that could have been avoided through the transition from traditional (no intravenous thrombolytic therapy (IVT), or endovascular thrombectomy (EVT)) to modern stroke treatments (treatment in stroke units, IVT and EVT). We perform a cost-effectiveness analysis comparing best practice with traditional stroke care, using Greece as a case study. MATERIALS AND METHODS: A Markov model was used to calculate costs and Quality Adjusted Life Years (QALYs) for each treatment strategy, using a lifetime horizon. Data for model inputs were derived from meta-analyses of trials, and national and international cost databases. Sensitivity analyses were also performed to address potential uncertainty and test the robustness of the findings. RESULTS: Incremental effectiveness comprised 0.22 QALYs per patient and year. Best practice was cost-effective for more than 90% of all iterations (ICER for the baseline scenario: €2,109.25/QALY). Sensitivity analysis demonstrated that the findings remain robust. Considering the stroke incidence in Greece, the annual additional cost to implement best practice was calculated to be between 0.07%-0.15% of the total health expenditure. CONCLUSION: Best practice stroke treatment was cost-effective and affordable in a case study based on Greece. The results could be leveraged by including effects of preventive policies and rehabilitation. They also highlight the importance of adopting modern treatment strategies from a cost-effectiveness perspective, apart from the improved clinical outcomes.

Anaesthesia for mechanical thrombectomy: a narrative review.

Stroke is a leading cause of death and disability, and is associated with a huge societal and economic burden. Interventions for the immediate treatment of ischaemic stroke due to large vessel occlusion are dependent on recanalisation of the occluded vessel. Trials have provided evidence supporting the efficacy of mechanical thrombectomy in ischaemic stroke due to large vessel occlusion. This has resulted in changes in management and organisation of stroke care worldwide. Major determinants of effectiveness of thrombectomy include: time between stroke onset and reperfusion; location of occlusion and local collateral perfusion; adequacy of reperfusion; patient age; and stroke severity. The role of anaesthetic technique on outcome remains controversial with published research showing conflicting results. As a result, choice of conscious sedation or general anaesthesia for mechanical thrombectomy is often dependent on individual operator choice or institutional preference. More recent randomised controlled trials have suggested that protocol-driven general anaesthesia is no worse than conscious sedation and may even be associated with better outcomes. These and other studies have highlighted the importance of optimal blood pressure management as a major determinant of patient outcome. Anaesthetic management should be tailored to the individual patient and circumstances. Acute ischaemic stroke is a neurological emergency; clinicians should focus on minimising door-to-groin puncture time and the provision of high-quality periprocedural care with a particular emphasis on the maintenance of an adequate blood pressure.

Local anesthesia as a distinct comparator versus conscious sedation and general anesthesia in endovascular stroke treatment: a systematic review and meta-analysis.

BACKGROUND: The optimal anesthetic modality for endovascular treatment (EVT) in acute ischemic stroke (AIS) is undetermined. Comparisons of general anesthesia (GA) with composite non-GA cohorts of conscious sedation (CS) and local anesthesia (LA) without sedation have provided conflicting results. There has been emerging interest in assessing whether LA alone may be associated with improved outcomes. We conducted a systematic review and meta-analysis to evaluate clinical and procedural outcomes comparing LA with CS and GA. METHODS: We reviewed the literature for studies reporting outcome variables in LA versus CS and LA versus GA comparisons. The primary outcome was 90 day good functional outcome (modified Rankin Scale (mRS) score of ≤2). Secondary outcomes included mortality, symptomatic intracerebral hemorrhage, excellent functional outcome (mRS score ≤1), successful reperfusion (Thrombolysis in Cerebral Infarction (TICI) >2b), procedural time metrics, and procedural complications. Random effects meta-analysis was performed on unadjusted and adjusted data. RESULTS: Eight non-randomized studies of 7797 patients (2797 LA, 2218 CS, and 2782 GA) were identified. In the LA versus GA comparison, no statistically significant differences were found in unadjusted analyses for 90 day good functional outcome or mortality (OR=1.22, 95% CI 0.84 to 1.76, p=0.3 and OR=0.83, 95% CI 0.64 to 1.07, p=0.15, respectively) or in the LA versus CS comparison (OR=1.14, 95% CI 0.76 to 1.71, p=0.53 and OR=0.88, 95% CI 0.62 to 1.24, p=0.47, respectively). There was a tendency towards achieving excellent functional outcome (mRS ≤1) in the LA group versus the GA group (OR=1.44, 95% CI 1.00 to 2.08, p=0.05, I2=70%). Analysis of adjusted data demonstrated a tendency towards higher odds of death at 90 days in the GA versus the LA group (OR=1.24, 95% CI 1.00 to 1.54, p=0.05, I2=0%). CONCLUSION: LA without sedation was not significantly superior to CS or GA in improving outcomes when performing EVT for AIS. However, the quality of the included studies impaired interpretation, and inclusion of an LA arm in future well designed multicenter, randomized controlled trials is warranted.

Noninvasive thrombectomy of graft by nano-magnetic ablating particles.

Artificial vascular treatment is an emerging interdisciplinary subject of medicine. Although the use of artificial vessels has led to many successful advancements, blood clotting remains a major challenge, especially in terms of mural clots created along the vessel wall that do not completely block the vessel. The main objective of this study is to present a method for declotting artificial vessels. This research introduces a novel thrombectomy technique in artificial vessels by employing nano-magnetic particles under a rotating magnetic field to remove mural clots in artificial vessels. A mathematical model describes the relationship between process parameters. In vitro tests confirm the feasibility of nano-magnetic thrombectomy in cleaning and declotting artificial vessels. The results show that the clot fragments are nano-sized, which eliminates the risk of distal emboli as a concern of using current atherectomy techniques. Meanwhile, no damage to the artificial vessels is observed. The results show that the frequency of rotating the magnetic field has the greatest effect on clot removal. The conceptual principles stated in this study also have the potential to be used in other vascular depositions, such as the accumulation of lipids, and calcification atherosclerosis.

Advances in Mechanical Thrombectomy for Acute Ischemic Stroke Due to Large Vessel Occlusion.

Acute ischemic stroke (AIS) is a significant cause of global morbidity and mortality, with functional implications for quality of life and long-term disability. The limitations of intravenous thrombolytic therapy for the treatment of AIS, especially for emergent large vessel occlusion (ELVO), have paved the way for alternative therapies and the rapidly evolving landscape of endovascular therapy (EVT). Here, we summarize the major landmark trials that have advanced the field largely due to ongoing biomedical engineering device development that have translated into significantly improved clinical outcomes. Our review describes the clinical success of EVT, and current and future trends.

Local Anesthesia Without Sedation During Thrombectomy for Anterior Circulation Stroke Is Associated With Worse Outcome.

BACKGROUND AND PURPOSE: The best anesthetic management for mechanical thrombectomy of large vessel occlusion strokes is still uncertain and could impact the quality of reperfusion and clinical outcome. We aimed to compare the efficacy and safety outcomes between local anesthesia (LA) and conscious sedation in a large cohort of acute ischemic stroke patients with anterior circulation large vessel occlusion strokes treated with mechanical thrombectomy in current, everyday clinical practice. METHODS: Patients undergoing mechanical thrombectomy for anterior large vessel occlusion strokes at 4 comprehensive stroke centers in France between January 1, 2018, and December 31, 2018, were pooled from the ongoing prospective multicenter observational Endovascular Treatment in Ischemic Stroke Registry in France. Intention-to-treat and per-protocol analyses were used. RESULTS: Among the included 1034 patients, 762 were included in the conscious sedation group and 272 were included in the LA group. In the propensity score matched cohort, the rate of favorable outcome (90-day modified Rankin Scale score 0-2) was significantly lower in the LA group than in the conscious sedation group (40.0% versus 52.0%, matched relative risk=0.76 [95% CI, 0.60-0.97]), as well as the rate of successful reperfusion (modified Thrombolysis in Cerebral Infarction grade 2b-3; 76.6% versus 87.1%; matched relative risk=0.88 [95% CI, 0.79-0.98]). There was no difference in procedure time between the 2 groups. In the inverse probability of treatment weighting-propensity score-adjusted cohort, similar significant differences were found for favorable outcomes and successful reperfusion. In inverse probability of treatment weighting-propensity score-adjusted cohort, a higher rate of 90-day mortality and a lower parenchymal hematoma were observed after LA. The sensitivity analysis restricted to our per-protocol sample provided similar results in the matched- and inverse probability of treatment weighting-propensity cohorts. CONCLUSIONS: In the Endovascular Treatment in Ischemic Stroke registry mainly included patients in early time window (<6 hours), LA was associated with lower odds of favorable outcome, successful reperfusion, and higher odds of mortality compared with conscious sedation for mechanical thrombectomy of large vessel occlusion.

Association of local anesthesia versus conscious sedation with functional outcome of acute ischemic stroke patients undergoing embolectomy.

PURPOSE: Compare functional outcomes of acute ischemic stroke patients undergoing embolectomy with either local anesthesia or conscious sedation. Secondarily, identify differences in hemodynamic parameters and complication rates between groups. MATERIALS AND METHODS: Single institution, retrospective review of all acute ischemic stroke patients undergoing embolectomy between January 2014 and July 2018 (n = 185). Patients receiving general anesthesia (n = 27) were excluded. One-hundred and eleven of 158 (70.3%) composed the local anesthesia group, and 47 (29.7%) composed the conscious sedation group. Median age was 71 years (interquartile range 59-79). Seventy-eight (49.4%) were male. The median National Institute of Health stroke scale score was 17.5 (interquartile range 11-21). Hemodynamic, medication, complication, and functional outcome data were collected from the anesthesia protocol and medical records. Good functional outcome was defined as a three-month modified Rankin Scale < 2. A multivariate analysis was performed to estimate the association of anesthesia type on three-month modified Rankin Scale score. RESULTS: Three-month modified Rankin Scale score <2 was similar between groups (p = 0.5). Patients receiving conscious sedation were on average younger than patients receiving local anesthesia (p = 0.01). Conscious sedation patients were more likely to receive intravenous thrombolytic prior to embolectomy (p = 0.025). The complication rate and hemodynamic parameters were similar between groups. CONCLUSION: Functional outcome of acute ischemic stroke patients undergoing embolectomy appears to be similar for patients receiving local anesthesia and conscious sedation. This similarity may be beneficial to a future study comparing general anesthesia to local anesthesia and conscious sedation. The use of local anesthesia or conscious sedation does not significantly impact hemodynamic status.

Diagnosis of hypothenar hammer syndrome in a patient with acute ulnar artery occlusion.

A 56-year-old truck driver with a history of tobacco use presented with acute onset digital ischaemia in the ulnar distribution of his dominant hand, associated with severe pain. Occupational exposures included extensive manual labour and prolonged vibratory stimuli. Workup with Doppler and angiography confirmed the diagnosis of hypothenar hammer syndrome (HHS). After the failure of medical management, he underwent ulnar artery thrombectomy with reconstruction and arterial bypass grafting. His pain improved significantly postsurgically, and he was able to return to a normal routine. This case illustrates the classic presentation, examination, imaging findings and management options of HHS. HHS should be considered in patients with digital ischaemia and associated occupational exposures. Diagnosing the condition appropriately allows for optimal management, aiming at minimising symptoms and maximising quality of life.

General anesthesia vs local anesthesia during mechanical thrombectomy in acute ischemic stroke.

OBJECTIVE: To investigate the effect of general anesthesia (GA) on functional outcomes and complications rates in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT) compared to the use of local anesthesia (LA) at the puncture site. METHODS: This observational study was based on a prospectively registry study. AIS patients underwent MT with GA or LA from January 2013 to October 2017 were included. The primary outcome was the modified Rankin Scale (mRS) score at 90 days post-intervention. Furthermore, we assessed the long-term outcome of these patients. Multivariable logistic regression analysis was conducted to adjust for confounders. RESULTS: We enrolled 187 AIS patients in this study, patients in GA group had a similar mRS score compared to LA group at 90 days (2 [IQR, 1-4] vs 2.5 [IQR, 1-4], P = .917). No differences were found in the rates of functional independence (mRS 0-2), no or minimal disability (mRS 0-1), and mortality (mRS 6) between the 2 groups at 90 days post-intervention as well as long-term follow-up. The procedure-related complications and serious adverse events were similar between the LA group and GA group (P > .05 each). In multivariable analysis, GA use was not associated with functional outcomes. CONCLUSION: AIS patients who received GA during MT had similar functional outcomes and complications rates compared to patients received LA.

Trends in Interhospital Transfers and Mechanical Thrombectomy for United States Acute Ischemic Stroke Inpatients.

OBJECTIVE: Stroke care in the US is increasingly regionalized. Many patients undergo interhospital transfer to access specialized, time-sensitive interventions such as mechanical thrombectomy. METHODS: Using a stratified survey design of the US Nationwide Inpatient Sample (2009-2014) we examined trends in interhospital transfers for ischemic stroke resulting in mechanical thrombectomy. International Classification of Disease-Ninth Revision (ICD-9) codes were used to identify stroke admissions and inpatient procedures within endovascular-capable hospitals. Regression analysis was used to identify factors associated with patient outcomes. RESULTS: From 2009-2014, 772,437 ischemic stroke admissions were identified. Stroke admissions that arrived via interhospital transfer increased from 12.5% to 16.8%, 2009-2014 (P-trend < .001). Transfers receiving thrombectomy increased from 4.0% to 5.2%, 2009-2014 (P-trend = .016), while those receiving tissue plasminogen activator increased from 16.0% to 20.0%, 2009-2014 (P-trend < .001). One in 4 patients receiving thrombectomy were transferred from another acute care facility (n = 6,014 of 24,861). Compared to patients arriving via the hospital "front door" receiving mechanical thrombectomy, those arriving via transfer were more often from rural areas and received by teaching hospitals with greater frequency of thrombectomy. Those arriving via interhospital transfer undergoing thrombectomy had greater odds of symptomatic intracranial hemorrhage (adjusted odds ratio [AOR] 1.19, 95% CI: 1.01-1.42) versus "front door" arrivals. There were no differences in inpatient mortality (AOR 1.11, 95% CI: .93-1.33). CONCLUSIONS: From 2009 to 2014, interhospital stroke transfers to endovascular-capable hospitals increased by one-third. For every ∼15 additional transfers over the time period one additional patient received thrombectomy. Optimization of transfers presents an opportunity to increase access to thrombectomy.

[Role of Thrombectomy in Acute Ischemic Stroke].

This article discusses endovascular thrombectomy in acute ischemic stroke. This treatment is vascular medicine's most significant leap in years. This treatment is complicated, and various technical aspects are discussed. Close cooperation is required between different specialties since patient selection for treatment is complex. Interventionists need close collaboration with stroke neurologists. Government needs to be involved as this treatment mandates structural changes which will incur more manpower and financial resources. Telemedicine is also discussed as it has been shown to be advantageous for augmenting thrombolytic administration for acute ischemic stroke. Due to technical advances, it has been easier to provide such service, but hurdles need to be resolved so it can be fully implemented. It is likely that telemedi-cine will also play a role in thrombectomy. This article proposes how thrombectomy could be delivered in Iceland. It will prove difficult to provide such complex treatment in a scattered population of 343.000 people where expertise is limited to one or two sites. It is important to remember, that coronary intervention was a formidable challenge at one time, but it was accomplished. Can we learn from that experience?

Use of a complete autologous blood recovery system (the Sorin Xtra® Autotransfusion System) during mechanical thrombectomy of extensive cerebral venous sinus thrombosis.

Background The endovascular therapy for cerebral venous sinus thrombosis (CVST) is currently accepted as a second-line treatment for patients who have failed or those in whom systemic anticoagulation is contraindicated or in a subgroup of patients presenting with rapid neurologic deterioration. A number of different mechanical and pharmacologic endovascular strategies have been reported, either as separate or combined approaches. These new catheters and aspiration systems have a high power and vacuum capacity, which carries a risk of anemization of the patient and hypovolemic shock, being necessitating the transfusion of the patient. Material and methods Because of the problems that donor blood transfusion can bring, we describe the use of a Sorin Xtra® Autotransfusion System (ATS). This complete autologous blood recovery system was designed for use in procedures where medium- to high-volume blood loss occurs, such as major surgeries. We have adapted it to recover all the blood aspirated during the mechanical thrombectomy procedures of the dural cerebral venous sinuses, since they are procedures that can cause a significant loss of blood. One advantage to this is the patient receives his or her own blood instead of donor blood, so there is no risk of contracting outside diseases or transfusion reactions. Conclusions This technical note describes a novel and previously unpublished technical approach to CVST that can be immediately applied to clinical practice. It also raises awareness among the interventional neuroradiologist and anesthesiologist communities about novel, potentially lifesaving endovascular treatments in patients with extensive CVST.

Streamlining Workflow for Endovascular Mechanical Thrombectomy: Lessons Learned from a Comprehensive Stroke Center.

BACKGROUND: Recently, 5 randomized controlled trials confirmed the superiority of endovascular mechanical thrombectomy (EMT) to intravenous thrombolysis in acute ischemic stroke with large-vessel occlusion. The implication is that our health systems would witness an increasing number of patients treated with EMT. However, in-hospital delays, leading to increased time to reperfusion, are associated with poor clinical outcomes. This review outlines the in-hospital workflow of the treatment of acute ischemic stroke at a comprehensive stroke center and the lessons learned in reduction of in-hospital delays. METHODS: The in-hospital workflow for acute ischemic stroke was described from prehospital notification to femoral arterial puncture in preparation for EMT. Systematic review of literature was also performed with PubMed. RESULTS: The implementation of workflow streamlining could result in reduction of in-hospital time delays for patients who were eligible for EMT. In particular, time-critical measures, including prehospital notification, the transfer of patients from door to computed tomography (CT) room, initiation of intravenous thrombolysis in the CT room, and the mobilization of neurointervention team in parallel with thrombolysis, all contributed to reduction in time delays. CONCLUSIONS: We have identified issues resulting in in-hospital time delays and have reported possible solutions to improve workflow efficiencies. We believe that these measures may help stroke centers initiate an EMT service for eligible patients.

Current concepts in salvage procedures for failing microvascular flaps: is there a superior technique? Insights from a systematic review of the literature.

Microvascular free tissue transfer is a routine procedure with high predictability and a low complication rate. However, compromised flap perfusion remains a challenge and there is no consensus regarding the appropriate flap salvage protocol. The purpose of this study was to identify techniques with implications for flap salvage procedures and to assess their efficacy. A systematic review of studies published in the literature between 1990 and 2015, with predefined inclusion and exclusion criteria, was performed. The data obtained were pooled and analyzed. A total of 39 studies qualified for data extraction. The overall level of evidence was low and the total number of reported cases was limited (330 flaps). Five studies involved control groups and supplied comparative data. Surgical anastomotic revision and thrombectomy are inevitable in every flap salvage protocol. Four techniques or combinations of these with positive effects on flap salvage success rates were identified: thrombectomy with a Fogarty catheter (six studies, 68 flaps), intraoperative use of thrombolytic drugs (16 studies, 184 flaps), placement of an arteriovenous fistula (five case reports, five flaps), and the postoperative application of medicinal leeches (11 studies, 73 flaps). Currently available data exploring flap salvage procedures are limited. None of the techniques presented yielded superior salvage outcomes.

Predictors of Good Outcome After Stent-Retriever Thrombectomy in Acute Basilar Artery Occlusion.

BACKGROUND AND PURPOSE: Factors related to prognosis after a modern mechanical thrombectomy in patients with acute basilar artery occlusion remain unclear. This study investigated the prognostic factors for patients with acute basilar artery occlusion who underwent a stent-retriever thrombectomy. METHODS: We analyzed clinical and pretreatment diffusion-weighted imaging (DWI) data in 50 consecutive patients with acute basilar artery occlusion treated with stent-retriever thrombectomy. A good outcome was defined as a modified Rankin Scale score of 0 to 2 at 3 months. The association between clinical and DWI parameters and functional outcome was evaluated with logistic regression analysis. RESULTS: In a univariate analysis, the following variables were significantly associated with outcome: age, hypertension, baseline National Institutes of Health Stroke Scale, posterior circulation Acute Stroke Prognosis Early CT Score on a pretreatment DWI, posterior circulation Acute Stroke Prognosis Early CT Score of ≥7 (versus <7), thalamic infarction, and bilateral thalamic infarction. In a multivariate model, only a low initial National Institutes of Health Stroke Scale score (odds ratio, 0.82; 95% confidence interval, 0.709-0.949; P=0.008) and high DWI posterior circulation Acute Stroke Prognosis Early CT Score (odds ratio, 1.854; 95% confidence interval 1.012-3.397; P=0.045) were significant independent predictors of good outcome. In a univariate analysis, bilateral thalamic infarction was associated with a poor outcome (odds ratio, 1.993; 95% confidence interval, 1.187-3.346; P=0.035) but not with a unilateral thalamic infarction (P=0.525). CONCLUSIONS: This study suggested that initial infarction severity and posterior circulation Acute Stroke Prognosis Early CT Score on a pretreatment DWI are independent predictors of clinical outcome after stent-retriever thrombectomy in patients with acute basilar artery occlusion.