Inflammatory-associated proteomic predictors of cognitive outcome in subjects with ELVO treated by mechanical thrombectomy.

BACKGROUND: Emergent Large Vessel Occlusion (ELVO) stroke causes devastating vascular events which can lead to significant cognitive decline and dementia. In the subset of ELVO subjects treated with mechanical thrombectomy (MT) at our institution, we aimed to identify systemic and intracranial proteins predictive of cognitive function at time of discharge and at 90-days. These proteomic biomarkers may serve as prognostic indicators of recovery, as well as potential targets for novel/existing therapeutics to be delivered during the subacute stage of stroke recovery. METHODS: At the University of Kentucky Center for Advanced Translational Stroke Sciences, the BACTRAC tissue registry (clinicaltrials.gov; NCT03153683) of human biospecimens acquired during ELVO stroke by MT is utilized for research. Clinical data are collected on each enrolled subject who meets inclusion criteria. Blood samples obtained during thrombectomy were sent to Olink Proteomics for proteomic expression values. Montreal Cognitive Assessments (MoCA) were evaluated with categorical variables using ANOVA and t-tests, and continuous variables using Pearson correlations. RESULTS: There were n = 52 subjects with discharge MoCA scores and n = 28 subjects with 90-day MoCA scores. Several systemic and intracranial proteins were identified as having significant correlations to discharge MoCA scores as well as 90-day MoCA scores. Highlighted proteins included s-DPP4, CCL11, IGFBP3, DNER, NRP1, MCP1, and COMP. CONCLUSION: We set out to identify proteomic predictors and potential therapeutic targets related to cognitive outcomes in ELVO subjects undergoing MT. Here, we identify several proteins which predicted MoCA after MT, which may serve as therapeutic targets to lessen post-stroke cognitive decline.

External validation of TICI-ASPECTS-glucose score as a predictive model for symptomatic intracranial hemorrhage following mechanical thrombectomy.

INTRODUCTION: The indication for mechanical thrombectomy for acute ischemic stroke (AIS) secondary to large vessel occlusion has substantially increased in the past few years, but predictors of symptomatic intracranial hemorrhage (sICH) remain largely unstudied. A recent study assessing these predictors, led to the development of the TICI-ASPECTS-glucose (TAG) score, an internally validated model to predict sICH following thrombectomy. METHODS: To externally validate this scoring system and identify other potential risk factors for hemorrhagic conversion following endovascular therapy for AIS, 420 consecutive patients treated with mechanical thrombectomy from 2014-2017 were retrospectively reviewed. Data were collected pertaining to admission factors, procedural metrics, and functional outcomes. The components comprising the TAG score consist of modified thrombolysis in cerebral infarction (mTICI) score (mTICI 0-2a=2 points; 2b-3=0 points), Alberta stroke program early CT (ASPECTS) score (<6=4 points, 6-7=2 points, ≥8=0 points), and glucose (≥150 mg/dL=1 point, <150 mg/dL=0 points). Statistical analyses including univariate analysis, logistic regression analysis, and area under the receiver-operating curve (AUROC) were performed to validate the predictive capability of the model. RESULTS: The patients with sICH presented with lower ASPECTS (8.13±1.55 v 9.16±1.24, p < 0.001), but no significant correlation with mTICI scores and admission glucose was observed. Decreasing ASPECTS correlated with increased risk of sICH (OR 1.57, 95% CI 1.25-1.96, p < 0.001), and increasing TAG score was associated with increased sICH (OR 1.46, 95% CI 1.11-1.94, p < 0.01). AUROC of the model was 0.633. Stratifying patients into low (TAG 0-2), intermediate,3,4 and high5-7 risk groups identified similar results to the original study with sICH risks of 5.2%, 10.5%, and 33.3%, respectively. CONCLUSION: The TICI-ASPECTS-glucose (TAG) score adequately predicts sICH following mechanical thrombectomy, and appropriately stratifies individual patient risk. Further inclusion of additional predictors of sICH would likely yield a more robust model.

Biographies of international women leaders in neurosurgery.

We received so many biographies of women neurosurgery leaders for this issue that only a selection could be condensed here. In all of them, the essence of a leader shines through. Many are included as "first" of their country or color or other achievement. All of them are included as outstanding-in clinical, academic, and organized neurosurgery. Two defining features are tenacity and service. When faced with shocking discrimination, or numbing indifference, they ignored it or fought valiantly. When choosing their life's work, they chose service, often of the most neglected-those with pain, trauma, and disability. These women inspire and point the way to a time when the term "women leaders" as an exception is unnecessary.-Katharine J. Drummond, MD, on behalf of this month's topic editors.

Negative pressure wound therapy in spinal fusion patients.

Post-operative wound complications are some of the most common acute complications following spine surgery. These surgical site infections (SSI) contribute to increased healthcare related costs. Negative pressure wound therapy (NPWT) has long been used for treatment of soft tissue injury or defects. NPWT may reduce the incident of SSI following spinal fusion procedures; however, its potential applications need further clarification. Thus, we conducted a retrospective analysis of two cohorts to compare NPWT to traditional sterile dressings following spinal fusions in regards to post-operative outcomes. Following institutional review board approval, 42 patients who had a NPWT were matched by type of surgery to 42 patients who had traditional dressings. A retrospective chart-review was completed. Outcome measures, particularly SSI and need for reoperation, were analyzed using one-way ANOVA for both univariate and multivariate analysis. When controlled for sex and body-mass index, the use of a NPWT was independently correlated with decreased SSI (P = .035). Superficial dehiscence, seroma, need for additional outpatient care, and need for operative revision were all found to occur at higher rates in the traditional dressing cohort. Closed incisional negative pressure wound therapy provides a cost-effective method of decreasing surgical site infection for posterior elective spine surgeries.

Preclinical Development of a vWF Aptamer to Limit Thrombosis and Engender Arterial Recanalization of Occluded Vessels.

Endothelial surface and circulating glycoprotein von Willebrand factor (vWF) regulates platelet adhesion and is associated with thrombotic diseases, including ischemic stroke, myocardial infarction, and peripheral vascular disease. Thrombosis, as manifested in these diseases, is the leading cause of disability and death in the western world. Current parenteral antithrombotic and thrombolytic agents used to treat these conditions are limited by a short therapeutic window, irreversibility, and major risk of hemorrhage. To overcome these limitations, we developed a novel anti-vWF aptamer, called DTRI-031, that selectively binds and inhibits vWF-mediated platelet adhesion and arterial thrombosis while enabling rapid reversal of this antiplatelet activity by an antidote oligonucleotide (AO). Aptamer DTRI-031 exerts dose-dependent inhibition of platelet aggregation and thrombosis in whole blood and mice, respectively. Moreover, DTRI-031 can achieve potent vascular recanalization of platelet-rich thrombotic occlusions in murine and canine carotid arteries. Finally, DTRI-031 activity is rapidly (<5 min) and completely reversed by AO administration in a murine saphenous vein hemorrhage model, and murine toxicology studies indicate the aptamer is well tolerated. These findings suggest that targeting vWF with an antidote-controllable aptamer potentially represents an effective and safer treatment for thrombosis patients having platelet-rich arterial occlusions in the brain, heart, or periphery.

Inadvertent Arterial Placement of Central Venous Catheters: Systematic Review and Guidelines for Treatment.

Inadvertent arterial placement of central venous catheters carries serious sequelae, including pseudoaneurysm development and stroke. Although numerous strategies for therapeutic repair after arterial injury have been employed, no treatment provides a definitive standard of care. All articles published between January 2000 and July 2018 involving the placement of central venous catheters in the brachiocephalic or subclavian arteries, carotid artery, vertebral artery, and aortic arch and subsequent treatment were systematically reviewed. Arterial repair consisted of manual pressure, endovascular techniques (balloon tamponade, percutaneous closure devices, and covered stent placement), and open surgery. Success rates favored endovascular techniques and surgery over manual compression.

Pipeline embolization device for recurrence of previously treated aneurysms.

OBJECTIVE The utilization of the Pipeline embolization device (PED) has increased significantly since its inception and original approval for use in large, broad-necked aneurysms of the internal carotid artery. While microsurgical clipping and advances in endovascular techniques have improved overall efficacy in achieving complete occlusion, recurrences still occur, and the best modality for retreatment remains controversial. Despite its efficacy in this setting, the role of PED utilization in the setting of recurrent aneurysms has not yet been well defined. This study was designed to assess the safety and efficacy of PED in the recurrence of previously treated aneurysms. METHODS The authors reviewed a total of 13 cases in which patients underwent secondary placement of a PED for aneurysm recurrence following prior treatment with another modality. The PEDs were used to treat aneurysm recurrence or residual following endovascular coiling in 7 cases, flow diversion in 2, and microsurgical clipping in 4. The mean time between initial treatment and retreatment with a PED was 28.1 months, 12 months, and 88.7 months, respectively. Clinical outcomes, including complications and modified Rankin Scale (mRS) scores, and angiographic evidence of complete occlusion were tabulated for each treatment group. RESULTS All PEDs were successfully placed without periprocedural complications. The rate of complete occlusion was 80% at 6 months after PED placement and 100% at 12 months in these patients who underwent PED placement following failed endovascular coiling; there were no adverse clinical sequelae at a mean follow-up of 26.1 months. In the 2 cases in which PEDs were placed for treatment of residual aneurysms following prior flow diversion, 1 patient demonstrated asymptomatic vessel occlusion at 6 months, and the other exhibited complete aneurysm occlusion at 12 months. In patients with aneurysm recurrence following prior microsurgical clipping, the rate of complete occlusion was 100% at 6 and 12 months, with no adverse sequelae noted at a mean clinical follow-up of 27.7 months. CONCLUSIONS The treatment of recurrent aneurysms with the PED following previous endovascular coiling, flow diversion, or microsurgical clipping is associated with a high rate of complete occlusion and minimal morbidity.

Now that the door is open: an update on ischemic stroke pharmacotherapeutics for the neurointerventionalist.

The last 10 years have seen a major shift in management of large vessel ischemic stroke with changes towards ever-expanding use of reperfusion therapies (intravenous thrombolysis and mechanical thrombectomy). These strategies 'open the door' to acute therapeutics for ischemic tissue, and we should investigate novel therapeutic approaches to enhance survival of recently reperfused brain. Key insights into new approaches have been provided through translational research models and preclinical paradigms, and through detailed research on ischemic mechanisms. Additional recent clinical trials offer exciting salvos into this new strategy of pairing reperfusion with neuroprotective therapy. This pairing strategy can be employed using drugs that have shown neuroprotective efficacy; neurointerventionalists can administer these during or immediately after reperfusion therapy. This represents a crucial moment when we emphasize reperfusion, and have the technological capability along with the clinical trial experience to lead the way in multiprong approaches to stroke treatment.

Quantitative evaluation of the effects of flow diverter treatment on aneurysm hemodynamics using time-resolved rotational angiography.

BACKGROUND: There have been immense advancements in the hardware and software of digital subtraction angiography systems over the last several years. These advancements continue to make progress toward the goals of offering better visualization and reducing radiation exposure. A newer advancement in this arena is presenting three-dimension data over time resulting in four-dimensional-digital subtracted angiography visualization. We have evaluated these protocols related to the evaluation of the treatment of intracranial aneurysms with pipeline flow diversion. METHODS: Four-dimensional-digital subtracted angiography imaging was acquired on an Artis Q Biplane angiographic system (Siemens Healthcare AG, Forchheim, Germany). A six second four-dimensional-digital subtracted angiography protocol was performed pre and post flow diverter placement. Pre and post reconstructed images were sent through a dedicated prototype research workstation (Syngo X-Workplace; Siemens Healthineers AG) for further flow evaluation. RESULTS: The treatment of an aneurysm with flow diversion led to a filling delay of 0.278 ± 0.422 s inside the aneurysms, whereas distal to the aneurysms the filling of the vessel segment occurred earlier post procedural (negative filling delay of -0.15 ± 0.31 s. The flow ratio inside the aneurysm decreased to 63.6 ± 23% of its pre-treatment value and distal to the aneurysm the flow remained substantially the same (flow ratio: 95.6 ± 0.29%). Data showed a relative filling delay of the aneurysm normalized to the distal vessel of 0.43 ± 0.36 s. The relative flow ratio of the aneurysm in comparison to the distal parent vessel was 72.2 ± 31%. CONCLUSIONS: Analysis of a four-dimensional-digital subtracted angiography acquisition allows assessment of the effects of flow diversion treatment on aneurysm hemodynamic parameters and shows a significant decrease in flow inside the aneurysm compared to the parent vessel distal to the aneurysm.

The neurosurgery research & education foundation-young neurosurgeons committee webinar series: Providing education and inspiration during the COVID-19 pandemic.

OBJECTIVE: During the COVID-19 pandemic, the American Association of Neurological Surgeons (AANS) Young Neurosurgeons Committee (YNC) and Neurosurgery Research & Education Foundation (NREF) launched the YNC-NREF Webinar Series to provide young and aspiring neurosurgeons with timely information, education, and inspiration in the absence of in-person programming. DESIGN: Five 90-minute Zoom webinars were evaluated, each including 1-2 keynote speakers, a panel discussion, and an audience question-and-answer section. Topics included overviews of neurosurgery, the match, subspecialties, and inspirational career stories. Optional pre- and post-webinar surveys with 11-point Likert-type scores were distributed to attendees. We compared groups using chi-squared and Kruskal-Willis tests, and perceptions pre- and post-webinar using Mann-Whitney tests. SETTING: The webinars were live using Zoom, and the recordings were published on NREF's YouTube channel. PARTICIPANTS: The webinar series targeted young neurosurgeons. The first five episodes had a particular focus on medical students and undergraduates. RESULTS: A total of 673 unique participants attended the webinar series; 257 (38%) and 78 (11%) attendees completed the pre- and post-webinar survey, respectively. Respondents had high baseline interest in neurosurgery and were motivated to learn about the match and training in the US, understand neurosurgeons' day-to-day lives, and ask questions. There were significant differences in perceptions between USMSs, IMSs, and undergraduate students. The webinar improved attendees' knowledge about neurosurgical specialties, the match, and US neurosurgery training. CONCLUSIONS: The YNC and NREF effectively engaged a large, diverse audience through an online webinar series, building a foundation for future virtual programming by organized neurosurgery. ACGME competencies.

Preoperative prescription opioid use as an independent predictor of 90-day mortality and adverse events in craniotomy and craniectomy patients.

OBJECTIVE: A growing body of literature suggests that preoperative opioid exposure is an independent predictor of poor outcomes in surgical patients. No outcomes data exist on preoperative opioid use and craniotomies/craniectomies. The objective of this study was to determine the impact of preoperative opioid use on 90-day adverse events after craniotomy or craniectomy. METHODS: A single-center retrospective cohort study of 2445 patients undergoing a craniotomy/craniectomy between January 1, 2013, and October 1, 2018, was conducted. Baseline demographics, pre- and postoperative opioid use (morphine milligram equivalents [MMEs]), and surgical metrics were recorded. Patients were categorized based on whether they took prescription opioids preoperatively, defined as within 1 month of surgery, or were opioid naive. The outcomes were mortality and adverse events 90 days after craniotomy/craniectomy. RESULTS: Overall, 26.6% of patients composed the preoperative opioid group. The median daily MME intake among this group was 34.6 (IQR 14.1-90) MMEs. Lower employment rates (p < 0.001), uninsured status (p = 0.016), and intravenous drug use (p = 0.006) were associated with preoperative opioid use. Preoperative opioid use was associated with increased venous thromboembolism (p = 0.001), acute kidney injury (p = 0.002), acute respiratory failure (p < 0.001), myocardial infarction (p = 0.002), delirium (p < 0.001), and infection (p < 0.001). Preoperative opioid use was an independent predictor of overall 90-day adverse events (OR 1.643, 95% CI 1.289-2.095; p < 0.001) and 90-day mortality (OR 1.690, 95% CI 1.254-2.277; p < 0.001). CONCLUSIONS: Preoperative opioid use was independently associated with 90-day postoperative adverse events and mortality. Opioid use increases vulnerability in craniotomy/craniectomy patients and necessitates close monitoring to improve outcomes.

Beyond a team: The comprehensive interdisciplinary endocarditis program in the United States.

Although multidisciplinary teams have been shown to decrease in-hospital mortality for patient with infectious endocarditis, most studies have focused on the inpatient role of these teams, and are primarily based at European tertiary care centers. There is limited literature available on the optimal longitudinal care of this patient population. Here we outline our experience developing an interdisciplinary endocarditis program at the University of Kentucky, which cares for patients from their index hospitalization into the outpatient setting, while also coordinating transfers from regional hospitals and offering education to regional providers.

Preischemic exercise reduces brain damage by ameliorating metabolic disorder in ischemia/reperfusion injury.

Physical exercise preconditioning is known to ameliorate stroke-induced injury. In addition to several other mechanisms, the beneficial effect of preischemic exercise following stroke is due to an upregulated capacity to maintain energy supplies. Adult male Sprague-Dawley rats were used in exercise and control groups. After 1-3 weeks of exercise, several enzymes were analyzed as a gauge of the direct effect of physical exercise on cerebral metabolism. As a measure of metabolic capacity, an ADP/ATP ratio was obtained. Glucose transporters (GLUT1 and GLUT3) were monitored to assess glucose influx, and phosphofructokinase (PFK) was measured to determine the rate of glycolysis. Hypoxia-induced factor-1α (HIF-1α) and 5'AMP-activated protein kinase (AMPK) levels were also determined. These same analyses were performed on preconditioned and control rats following an ischemic/reperfusion (I/R) insult. Our results show that GLUT1, GLUT3, PFK, AMPK, and HIF-1α were all increased following 3 weeks of exercise training. In addition, the ADP/ATP ratio was chronically elevated during these 3 weeks. After I/R injury, HIF-1α and AMPK were significantly higher in exercised rats. The ADP/ATP ratio was reduced in preconditioned rats in the acute phase after stroke, suggesting a lower level of metabolic disorder. GLUT1 and GLUT3 were also increased in the acute phase in exercise rats, indicating that these rats were better able to increase rates of metabolism immediately after ischemic injury. In addition, PFK expression was increased in exercise rats showing an enhanced glycolysis resulting from exercise preconditioning. Altogether, exercise preconditioning increased the rates of glucose metabolism, allowing a more rapid and more substantial increase in ATP production following stroke.

The Committee on Advanced Subspecialty Training-accredited postgraduate neurosurgery fellowship application experience: a national survey.

OBJECTIVE: The neurosurgery fellowship application process is heterogenous. Therefore, the authors conducted a survey of individuals graduating from Committee on Advanced Subspecialty Training (CAST)-accredited fellowships in the past 5 years to examine 1) experiences with the fellowship application process, 2) perspectives on the process, 3) reasons for pursuing a given subspecialty and fellowship, and 4) post-fellowship practices. METHODS: A survey querying demographics, experiences with and perspectives on the fellowship application process, and factors contributing to the pursuit of a given fellowship was distributed to individuals who had graduated from CAST-accredited fellowships in the past 5 years. The survey response period was May 22, 2021-June 22, 2021. RESULTS: Of 273 unique individuals who had graduated from CAST-accredited fellowships in the past 5 years, 65 (29.7%) were included in this analysis. The most common postgraduate year (PGY) during which respondents applied for fellowship positions was PGY5 (43.8%), whereas the most common training level at which respondents accepted a fellowship position was PGY6 (46.9%), with a large degree of variability for both (range PGY4-PGY7). Only 43.1% respondents reported an application deadline for their fellowship. A total of 77.4% respondents received 1-2 fellowship position offers, and 13.4% indicated that there was a match process. In total, 64.5% respondents indicated that the fellowship offer timeline was mostly or very asynchronous. The time frame for applicants to decline or accept a fellowship offer was heterogeneous and mismatched among institutions. Respondents agreed that a more standardized application timeline would be beneficial (median response "agree"), and 83.1% of respondents indicated that PGY5 or PGY6 was the appropriate time to interview for a fellowship. CONCLUSIONS: Respondents reported heterogeneous experiences in applying for a fellowship, indicated that a standardized application timeline including interviews at PGY5 or PGY6 would be beneficial, and preferred streamlining the fellowship application process.

Assessing opportunities for formal exposure to clinical neurosurgery within United States allopathic medical education curricula.

OBJECTIVE: The objective of this study was to evaluate opportunities for early clinical exposure to neurosurgery at US allopathic medical schools and to assess associations between early exposure and recruitment into neurosurgery. METHODS: The authors conducted a standardized review of online curriculum documentation for all US allopathic medical schools, including descriptive review of opportunities for clinical neurosurgical training among medical students. Chi-square analysis was used to compare baseline characteristics of institutions. Logistic regression was performed to assess factors predictive of early exposure to clinical neurosurgery, defined as completion of a formal rotation at least 6 months prior to Electronic Residency Application Service submission. RESULTS: Among 155 allopathic US medical schools, 143 are fully accredited by the Liaison Committee on Medical Education. Eleven schools have no affiliated hospitals with a neurosurgery practice, and 26 do not have an American Association of Neurological Surgeons (AANS) medical student chapter. Overall, 94 (60.6%) have a traditional preclinical curriculum lasting 21-25 months, 50 (32.3%) offer an intermediate preclinical period of 15-20 months, and 11 (7.1%) report a short preclinical curriculum of 12-14 months. Early formal exposure to clinical neurosurgery was offered by 113 schools (72.9%). Early clinical exposure to neurosurgery was associated with a short (100%) or intermediate (76%) preclinical curriculum, as compared with a traditional curriculum (68.1%; p = 0.066). Early exposure was significantly associated with a shorter preclinical curriculum (OR 0.784, p = 0.005). AANS medical student chapters were present at a high majority of schools with early exposure (OR 4.114, p = 0.006). Medical schools with a higher percentage of graduating medical students matching into neurosurgery were associated with a shorter preclinical curriculum length (ß = -0.287, p < 0.001), were more commonly private medical schools (ß = 0.338, p < 0.001), and had early clinical exposure to neurosurgery (ß = 0.191, p = 0.032). CONCLUSIONS: Early exposure to clinical neurosurgery is available at most US allopathic medical schools and is associated with shorter preclinical curricula and institutions with AANS medical student chapters. Medical schools with a higher proportion of medical students entering neurosurgery had a shorter preclinical curriculum length and early clinical exposure to neurosurgery. Further study is recommended to characterize the impact of early exposure on long-term pedagogical outcomes.

Competitive neurosurgery residency programs: Predictors of matching outcome and research productivity.

OBJECTIVE: The aim of this study was to provide a comprehensive assessment of preresidency research and school as predictors of competitive neurosurgery matching and to assess for any correlations between preresidency and intraresidency research productivity. METHODS: Individuals who graduated from US neurosurgery programs from 2018 through 2020 were assessed for medical school, degree (MD, DO, or PhD), preresidency versus intraresidency publications, author order, article type, and neurosurgery matching outcomes. RESULTS: Medical school ranking (top 50) and the number of published papers (≥3) before intern year were predictors for matching to a top-25 residency program after adjusting for other covariates (p < 0.001, p = 0.002, respectively). On average, individuals who published more papers before residency published more papers during residency. For the comprehensive clinical papers category, there was a significant difference between individuals from the top 25 residency programs and others, with a stronger correlation between the number of preresidency publications and intraresidency publications for neurosurgeons who attended a top-25 residency program (r = 0.378 and r = 0.179, respectively; p = 0.02). CONCLUSION: Medical school ranking and research productivity as measured by the number of published papers were independently associated with matching to the top 25 residency programs. In addition, high research productivity in the preresidency years was associated with continued productivity during residency, especially in the category of comprehensive clinical papers.

Flat-panel detector CT to assess intracranial hemorrhage immediately following mechanical thrombectomy.

BACKGROUND AND PURPOSE: The risk of symptomatic intracranial hemorrhage (ICH) approaches 5% despite mechanical thrombectomy (MT) efficacy for ischemic stroke secondary to large vessel occlusion. Flat-panel detector CT (FDCT) imaging with Syngo Dyna CT imaging (Siemens Medical Solutions, Malvern, PA) can be used immediately following MT to detect ICH. PURPOSE: To evaluate the accuracy and reliability of FDCT imaging with Dyna CT compared to conventional post-MT CT and MRI. METHODS: Head FDCT (20 second, 70 kV) was performed immediately following MT on 26 consecutive patients; postprocedural CT or MRI was obtained ∼24 hours later. Two blinded, independent neuroradiologists evaluated all imaging, identifying ICH, stroke, and presence of subarachnoid contrast. Cohen's κ statistic was used to assess interrater agreement for each imaging outcome and compared the FDCT to conventional imaging. RESULTS: FDCT for ICH demonstrated a strong degree of interrater reliability (κ = 0.896; 95% confidence interval [CI], 0.734-1.057). Negligible reliability was seen for ischemia determination on immediate post-MT FDCT (κ = 0.149; 95% CI, -0.243 to 0.541). ICH evaluation between FDCT and post-MT conventional CT revealed modest interrater reliability (κ = 0.432; 95% CI, -0.100 to 0.965), which did not reach statistical significance. There was no substantive reliability in the evaluation of ICH between FDCT and post-MT MRI (κ = 0.118, 95% CI, -0.345 to 0.580). CONCLUSION: FDCT, such as Dyna CT, immediately post-MT is a promising tool that can expedite the detection of ICH with a high degree of reliability, although the detection of ischemic parenchymal changes is limited.

Current State of the Art in Endovascular Stroke Treatment.

Following the successful completion of 5 major trials establishing the clinical efficacy of endovascular thrombectomy for ELVO in the setting of AIS, there has been a tremendous focus on identifying additional patient populations that may benefit from the intervention. Improved imaging modalities and subsequent trials found thrombectomy to be highly efficacious in patients presenting up to 24 hours after stroke onset, particularly with good collaterals and large penumbral regions. Iterative catheter and device development have improved the safety profile and enhanced the efficacy of the procedure with the introduction of balloon-guide catheters, larger bore navigable aspiration catheters, and smaller catheters and devices to access medium and distal vessel occlusions. While trials are ongoing to assess the utility of thrombectomy in patients presenting with large core infarcts, distal occlusions, and direct aspiration as a first-line approach, the highly effective nature of thrombectomy for ELVO is continuing to drive the field of endovascular stroke care forward.

Influence of BMI on adenosine deaminase and stroke outcomes in mechanical thrombectomy subjects.

BACKGROUND: Emergent Large Vessel Occlusion (ELVO) strokes are ischemic vascular events for which novel biomarkers and therapies are needed. The purpose of this study is to investigate the role of Body Mass Index (BMI) on protein expression and signaling at the time of ELVO intervention. Additionally, we highlight the protein adenosine deaminase (ADA), which is a deaminating enzyme that degrades adenosine, which has been shown to be neuroprotective in ischemia. We investigate the relationship between ADA and BMI, stroke outcomes, and associated proteomic networks which might aid in personalizing prognosis and future treatment of ELVO stroke. METHODS: The Blood And Clot Thrombectomy And Collaboration (BACTRAC) study is a continually enrolling tissue bank (clinicaltrials.gov NCT03153683) and registry from stroke patients undergoing mechanical thrombectomy (MT). N â€‹= â€‹61 human carotid plasma samples were analyzed for inflammatory and cardiometabolic protein expression by Olink Proteomics. Statistical analyses used t-tests, linear, logistic, and robust regressions, to assess the relationship between BMI, proteomic expression, and stroke-related outcomes. RESULTS: The 61 subjects studied were broken into three categories: normal weight (BMI 18.5-24.9) which contained 19 subjects, overweight (BMI 25-30) which contained 25 subjects, and obese (BMI ≥30) which contained 17 subjects. Normal BMI group was a significantly older population (mean 76 years) when compared to overweight (mean 66 years) and obese (mean 61 years) with significance of p â€‹= â€‹0.041 and p â€‹= â€‹0.005, respectively. When compared to normal weight and overweight categories, the obese category had significantly higher levels of adenosine deaminase (ADA) expression (p â€‹= â€‹0.01 and p â€‹= â€‹0.039, respectively). Elevated levels of ADA were found to have a significant positive correlation with both infarct volume and edema volume (p â€‹= â€‹0.013 and p â€‹= â€‹0.041, respectively), and were associated with a more severe stroke (NIHSS on discharge) and greater stroke related disability (mRS on discharge) with significance of p â€‹= â€‹0.053 and p â€‹= â€‹0.032, respectively. CONCLUSIONS: When examined according to BMI, subjects undergoing MT for ELVO demonstrate significant differences in the expression of certain plasma proteins, including ADA. Levels of ADA were found to be significantly higher in the obese population when compared to normal or overweight groups. Increased levels of ADA in the obese group were predictive of increased infarct volume, edema volume, and worse NIHSS scores and mRS at discharge. These data provide novel biomarker candidates as well as treatment targets while increasing the personalization of stroke prognosis and treatment.