Mechanical thrombectomy: can it be safely delivered out of hours in the UK?

BACKGROUND: Mechanical thrombectomy was approved by NICE as a treatment for stroke in 2016. However, most of the evidence is from studies conducted during working hours. Only few centres in the UK perform thrombectomies out-of-hours. The Royal Stoke University Hospital (RSUH) has offered thrombectomies over 24 h (24/7) since 2010. The aim of this service review is to compare the outcomes for patients treated in regular working hours to those treated outside normal working hours within this unit. METHODS: This retrospective service analysis includes all patients treated with mechanical thrombectomy at RSUH since the start of the service in January 2010 to June 2019. Data on key demographics, timings, procedural complications, and long-term outcomes including death and disability at 90 days were collected. In-hours was defined as the time between 8:00-17:00 h, Monday to Friday; out-of-hours was defined as any time outside this period. RESULTS: In total, 516 mechanical thrombectomies were performed in this time period; data were available on 501 of these. Successful recanalization (TICI 2b/3) was achieved in 86% of patients. By 90 days 96 (19%) had died and 234 (47%) were functionally independent (modified Rankin Scale score ≤ 2). 211 (42%) of the procedures were performed in-hours and 290 (58%) out-of-hours. Door-to-CT and door-to-groin times were significantly longer out-of-hours than in-hours, but thrombectomy duration was significantly shorter. There were no significant differences in complications and short- and long-term outcomes. CONCLUSION: Mechanical thrombectomy was delivered safely and effectively 24/7 in this UK hospital, with no difference in clinical outcomes.

Can a single brief intervention improve participants' readiness for interprofessional learning?

Interprofessional learning (IPL) was introduced for University of Nottingham 3rd year medical and nursing students at the Lincoln County Hospital. An evaluation of the subsequently implemented IPL intervention allowed us to ask the research question: can a single brief IPL intervention improve attitudes to IPL? A low fidelity simulation intervention was chosen as the mode of IPL, focusing on teamwork in the context of the assessment of the acutely ill patient. To assess the intervention's effect on students' attitudes, a validated questionnaire (RIPLS) was completed before and after the session. Nine of the nineteen questions in RIPLS had significantly different responses following the intervention. This reflected a more positive attitude to IPL following the intervention. This evaluation of this intervention suggests that IPL is valued by students and significantly improves attitudes to IPL, at least in the immediate post-intervention period.

Is intraprocedural intravenous aspirin safe for patients who require emergent extracranial stenting during mechanical thrombectomy?

BACKGROUND: Intraoperative antiplatelet therapy is recommended for emergent stenting during mechanical thrombectomy (MT). Most patients undergoing MT are also given thrombolysis. Antiplatelet agents are contraindicated within 24 hours of thrombolysis. We evaluated outcomes and complications of patients stented with and without intravenous aspirin during MT. METHODS: All patients who underwent emergent extracranial stenting during MT at the Royal Stoke University Hospital, UK between 2010 and 2020, were included. Patients were thrombolysed before MT, unless contraindicated. Aspirin 500 mg intravenously was given intraoperatively at the discretion of the operator. Symptomatic intracranial haemorrhage (sICH) and the National Institutes for Health Stroke Scale score (NIHSS) were recorded at 7 days, and mortality and functional recovery (modified Rankin Scale: mRS ≤2) at 90 days. RESULTS: Out of 565 patients treated by MT 102 patients (median age 67 IQR 57-72 years, baseline median NIHSS 18 IQR 13-23, 76 (75%) thrombolysed) had a stent placed. Of these 49 (48%) were given aspirin and 53 (52%) were not. Patients treated with aspirin had greater NIHSS improvement (median 8 IQR 1-16 vs median 3 IQR -9-8 points, p=0.003), but there were no significant differences in sICH (2/49 (4%) vs 9/53 (17%)), mRS ≤2 (25/49 (51%) vs 19/53 (36%)) and mortality (10/49 (20%) vs 12/53 (23%)) with and without aspirin. NIHSS improvement (median 12 IQR 4-18 vs median 7 IQR -7-10, p=0.01) was greater, and mortality was lower (4/33 (12%) vs 6/15 (40%), p=0.05) when aspirin was combined with thrombolysis, than for aspirin alone, with no increase in bleeding. CONCLUSION: Our findings based on registry data derived from routine clinical care suggest that intraprocedural intravenous aspirin in patients undergoing emergent stenting during MT does not increase sICH and is associated with good clinical outcomes, even when combined with intravenous thrombolysis.

Neutrophil-Lymphocyte ratio is associated with poor clinical outcome after mechanical thrombectomy in stroke in patients with COVID-19.

BACKGROUND: The neutrophil-lymphocyte ratio (NLR) is emerging as an important biomarker of acute physiologic stress in a myriad of medical conditions, and is a confirmed poor prognostic indicator in COVID-19. OBJECTIVE: We sought to describe the role of NLR in predicting poor outcome in COVID-19 patients undergoing mechanical thrombectomy for acute ischemic stroke. METHODS: We analyzed NLR in COVID-19 patients with large vessel occlusion (LVO) strokes enrolled into an international 12-center retrospective study of laboratory-confirmed COVID-19, consecutively admitted between March 1, 2020 and May 1, 2020. Increased NLR was defined as ≥7.2. Logistic regression models were generated. RESULTS: Incidence of LVO stroke was 38/6698 (.57%). Mean age of patients was 62 years (range 27-87), and mortality rate was 30%. Age, sex, and ethnicity were not predictive of mortality. Elevated NLR and poor vessel recanalization (Thrombolysis in Cerebral Infarction (TICI) score of 1 or 2a) synergistically predicted poor outcome (likelihood ratio 11.65, p = .003). Patients with NLR > 7.2 were 6.8 times more likely to die (OR 6.8, CI95% 1.2-38.6, p = .03) and almost 8 times more likely to require prolonged invasive mechanical ventilation (OR 7.8, CI95% 1.2-52.4, p = .03). In a multivariate analysis, NLR > 7.2 predicted poor outcome even when controlling for the effect of low TICI score on poor outcome (NLR p = .043, TICI p = .070). CONCLUSIONS: We show elevated NLR in LVO patients with COVID-19 portends significantly worse outcomes and increased mortality regardless of recanalization status. Severe neuro-inflammatory stress response related to COVID-19 may negate the potential benefits of successful thrombectomy.

Acute Disseminated Encephalomyelitis Following Thoracic Endovascular Aortic Repair.

Acute disseminated encephalomyelitis (ADEM) is a central nervous system demyelinating condition. The postulated etiology is an autoimmune reaction, however, the mechanistic details are yet unknown. While infection and immunization are the most prevalent precipitating causes of ADEM, we postulate that radiopaque contrast material might have played a role as an immunological trigger. This presentation is unusual and has not been recorded so far. This case also emphasizes the challenges involved in evaluating emerging neurological problems following a period of intubation/sedation among these patients. We present a patient who passed away due to the manifestations of ADEM following admission to the intensive care unit after thoracic endovascular aortic repair for type B aortic dissection. Magnetic resonance imaging (MRI) performed following multiple attempts at sedation weaning demonstrated typical features of this condition. Clinicians and radiologists should be diligent and consider ADEM as a differential diagnosis when treating patients who present with neurological symptoms following radiological interventional procedures and have a high index suspicion to reduce mortality and achieve satisfactory clinical outcomes.

Haemorrhagic Brain Metastasis From Malignant Pleural Mesothelioma: A Rare Case.

Malignant pleural mesothelioma (MPM) typically has a short median survival of only a few months from diagnosis, with death usually due to thoracic disease. This has led to the belief in the past that mesothelioma rarely has distant metastasis, with cerebral metastasis accounting for only 3%. The multiple cases of brain metastasis from MPM recorded so far were discovered after death at autopsy. This report describes a rare case of known malignant mesothelioma with distant haemorrhagic metastasis to the brain, reviews current literature about its metastatic potential to the brain and discusses prognosis and management. We also review the imaging evaluation in known MPM patients with suspected intracranial involvement and describe typical imaging findings of parenchymal brain metastasis on computed tomography (CT) and magnetic resonance imaging (MRI).

Radiological Appearance and Imaging Techniques in the Diagnosis of Advanced Central Pontine Myelinolysis.

Conventional magnetic resonance imaging (MRI) and computed tomography (CT) are used to diagnose central pontine myelinolysis (CPM), which is seen in the setting of osmotic changes, typically with the rapid correction of hyponatremia. However, they typically follow clinical symptoms and fail to detect myelinolytic lesions within the first two weeks, limiting their efficacy in early diagnosis. CPM can mimic brainstem ischaemic changes on CT head and a glioma on MRI. This case reviews the relationship between radiological changes seen with clinical symptoms and serum sodium levels, combined with reviewing pioneering advances in radiomic analysis, including diffusion-weighted MRI, CT brain perfusion and MR spectroscopy.

Incidence, Characteristics and Outcomes of Large Vessel Stroke in COVID-19 Cohort: An International Multicenter Study.

BACKGROUND: While there are reports of acute ischemic stroke (AIS) in coronavirus disease 2019 (COVID-19) patients, the overall incidence of AIS and clinical characteristics of large vessel occlusion (LVO) remain unclear. OBJECTIVE: To attempt to establish incidence of AIS in COVID-19 patients in an international cohort. METHODS: A cross-sectional retrospective, multicenter study of consecutive patients admitted with AIS and COVID-19 was undertaken from March 1 to May 1, 2020 at 12 stroke centers from 4 countries. Out of those 12 centers, 9 centers admitted all types of strokes and data from those were used to calculate the incidence rate of AIS. Three centers exclusively transferred LVO stroke (LVOs) patients and were excluded only for the purposes of calculating the incidence of AIS. Detailed data were collected on consecutive LVOs in hospitalized patients who underwent mechanical thrombectomy (MT) across all 12 centers. RESULTS: Out of 6698 COVID-19 patients admitted to 9 stroke centers, the incidence of stroke was found to be 1.3% (interquartile range [IQR] 0.75%-1.7%). The median age of LVOs patients was 51 yr (IQR 50-75 yr), and in the US centers, African Americans comprised 28% of patients. Out of 66 LVOs, 10 patients (16%) were less than 50 yr of age. Among the LVOs eligible for MT, the average time from symptom onset to presentation was 558 min (IQR 82-695 min). A total of 21 (50%) patients were either discharged to home or discharged to acute rehabilitation facilities. CONCLUSION: LVO was predominant in patients with AIS and COVID-19 across 2 continents, occurring at a significantly younger age and affecting African Americans disproportionately in the USA.