Study protocol for measuring stigmatization in persistent tic disorders: development and validation of the Tourette discrimination-stigmatization scale.

Introduction: Persistent Tic Disorders such as Tourette Syndrome are common neurodevelopmental disorders that are highly stigmatized. Many individuals with Persistent Tic Disorders experience peer rejection, loneliness, and self-stigma. Experiencing stigmatization during childhood can influence the persistence of moderate-to-severe tics later in life. Additionally, these factors have been associated with increased suicidal ideation, suicide attempts, and psychiatric symptom severity. There is a need for interventions to reduce stigma and stigmatization in Persistent Tic Disorders. Before developing cost-effective interventions to mitigate stigma's profound downstream health impacts, a reliable measure of stigmatization must be created. The overarching goal of this research is to develop and validate the Tourette Discrimination-Stigmatization (TD-STIGMA) Scale. Methods: This paper presents the study protocol for developing and validating the TD-STIGMA Scale. The study is designed as a mixed methods study to develop the TD-STIGMA scale and evaluate its psychometric properties. The study uses a phased approach: (1) collection of narrative and thematic content data through in-depth qualitative interviews of stakeholders, (2) development of a novel TD-STIGMA self-report scale using the Delphi Method based on these results, and (3) completion of analyses to determine the scale's psychometric properties (confirmatory factor analysis, convergent, known-group, criterion validity, and test-retest reliability). Discussion: This project will result in a personalized approach to stigma measurement about youth and young adults with Persistent Tic Disorders, which to date does not exist. There are several limitations. Comorbidities or spiritual or cultural beliefs may affect perceptions of stigma and are not directly assessed in this study. We will utilize institutional resources for community outreach to purposefully sample underrepresented minorities who may be at disproportionate risk of adverse outcomes. However, this may not be fully representative of the generalized tic population. The study team will be purposeful in maintaining participant engagement for study retention. Lastly, participants from a tertiary referral center may not fully represent the generalized tic community. However, we hope our broad recruitment strategy and virtual study visits will facilitate a diverse and inclusive sampling of the patient population.

The implementation of artificial intelligence significantly reduces door-in-door-out times in a primary care center prior to transfer.

INTRODUCTION: Viz LVO artificial intelligence (AI) software utilizes AI-powered large vessel occlusion (LVO) detection technology which automatically identifies suspected LVO through CT angiogram (CTA) imaging and alerts on-call stroke teams. This analysis was performed to determine whether AI software can reduce the door-in-door-out (DIDO) time interval within the primary care center (PSC) prior to transfer to the comprehensive care center (CSC). METHODS: We compared the DIDO time interval for all LVO transfer patients from a single-spoke PSC to our CSC prior to (February 2017 to November 2018) and after (November 2018 to June 2020) incorporating AI. Using a stroke database at a CSC, demographics, DIDO time at PSC, modified Rankin Scale (mRS) at 90-days, mortality rate at discharge, length of stay (LOS), and intracranial hemorrhage rates were examined. RESULTS: There were a total of 63 patients during the study period (average age 69.99 ± 13.72, 55.56% female). We analyzed 28 patients pre-AI (average age 71.64 ± 12.28, 46.4% female), and 35 patients post-AI (average age 68.67 ± 14.88, 62.9% female). After implementing the AI software, the mean DIDO time interval within the PSC significantly improved by 102.3 min (226.7 versus 124.4 min; p = 0.0374). CONCLUSION: The incorporation of the AI software was associated with a significant improvement in DIDO times within the PSC as well as CTA to door-out time in the PSC. More extensive studies are warranted to expand on the ability of AI technology to improve transfer times and outcomes for LVO patients.

Higher number of stent-retriever thrombectomy passes significantly increases risk of mass effect, poor functional outcome, and mortality.

INTRODUCTION: Endovascular treatment (EVT) is a widely proven method to treat patients diagnosed with intracranial large vessel occlusion (LVO). Through this method of treatment, it has been hypothesized that a lower number of thrombectomy passes is an indicator of higher rates of modified Thrombolysis in Cerebral Infarction 2B-3 (mTICI) reperfusion and favorable outcomes at 90-days defined as modified Rankin Scale 0-2 (mRS). METHODS: Through the utilization of a prospectively collected endovascular database between 2012-2020, variables such as demographics, co-morbid conditions, intracerebral hemorrhage, mass effect, mortality rate, and good/poor outcomes regarding mTICI score and mRS assessment at 90-days were examined. The outcomes between patients receiving EVT who were treated with < 3 thrombectomy passes or ≥3 passes were compared. RESULTS: Out of 454 patients treated with mechanical thrombectomy of qualifying intracranial internal carotid artery (ICA) or middle cerebral artery occlusion, site of occlusion (ICA, ICA-T M1, and M2/M3), a total of 372 (81.9%) were treated with < 3 passes (average age 70.34 ± 13.75 years, 46.0% women), and 82 (18.1%) were treated with ≥3 passes (average age 70.30 ± 13.72 years, 48.8% women). Significantly higher rates of mass effect (p = 0.043), mRS score 3-6 (p = 0.029), mortality (p = 0.025), and poor reperfusion (p < 0.0001) were noted in patients treated with ≥3 passes. CONCLUSION: A higher number of thrombectomy passes, characterized as ≥3 in this study, was associated with significantly worsened patient outcome regarding mRS and mortality. Further research is required to determine whether the number of thrombectomy passes is an accurate predictor of treatment outcome.

Functional and Safety Outcomes of Carotid Artery Stenting and Mechanical Thrombectomy for Large Vessel Occlusion Ischemic Stroke With Tandem Lesions.

Importance: Approximately 10% to 20% of large vessel occlusion (LVO) strokes involve tandem lesions (TLs), defined as concomitant intracranial LVO and stenosis or occlusion of the cervical internal carotid artery. Mechanical thrombectomy (MT) may benefit patients with TLs; however, optimal management and procedural strategy of the cervical lesion remain unclear. Objective: To evaluate the association of carotid artery stenting (CAS) vs no stenting and medical management with functional and safety outcomes among patients with TL-LVOs. Design, Setting, and Participants: This cross-sectional study included consecutive patients with acute anterior circulation TLs admitted across 17 stroke centers in the US and Spain between January 1, 2015, and December 31, 2020. Data analysis was performed from August 2021 to February 2022. Inclusion criteria were age of 18 years or older, endovascular therapy for intracranial occlusion, and presence of extracranial internal carotid artery stenosis (>50%) demonstrated on pre-MT computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography. Exposures: Patients with TLs were divided into CAS vs nonstenting groups. Main Outcomes and Measures: Primary clinical and safety outcomes were 90-day functional independence measured by a modified Rankin Scale (mRS) score of 0 to 2 and symptomatic intracranial hemorrhage (sICH), respectively. Secondary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), discharge mRS score, ordinal mRS score, and mortality at 90 days. Results: Of 685 patients, 623 (mean [SD] age, 67 [12.2] years; 406 [65.2%] male) were included in the analysis, of whom 363 (58.4%) were in the CAS group and 260 (41.6%) were in the nonstenting group. The CAS group had a lower proportion of patients with atrial fibrillation (38 [10.6%] vs 49 [19.2%], P = .002), a higher proportion of preprocedural degree of cervical stenosis on digital subtraction angiography (90%-99%: 107 [32.2%] vs 42 [20.5%], P < .001) and atherosclerotic disease (296 [82.0%] vs 194 [74.6%], P = .003), a lower median (IQR) National Institutes of Health Stroke Scale score (15 [10-19] vs 17 [13-21], P < .001), and similar rates of intravenous thrombolysis and stroke time metrics when compared with the nonstenting group. After adjustment for confounders, the odds of favorable functional outcome (adjusted odds ratio [aOR], 1.67; 95% CI, 1.20-2.40; P = .007), favorable shift in mRS scores (aOR, 1.46; 95% CI, 1.02-2.10; P = .04), and successful reperfusion (aOR, 1.70; 95% CI, 1.02-3.60; P = .002) were significantly higher for the CAS group compared with the nonstenting group. Both groups had similar odds of sICH (aOR, 0.90; 95% CI, 0.46-2.40; P = .87) and 90-day mortality (aOR, 0.78; 95% CI, 0.50-1.20; P = .27). No heterogeneity was noted for 90-day functional outcome and sICH in prespecified subgroups. Conclusions and Relevance: In this multicenter, international cross-sectional study, CAS of the cervical lesion during MT was associated with improvement in functional outcomes and reperfusion rates without an increased risk of sICH and mortality in patients with TLs.

Acute intracranial stenting with mechanical thrombectomy is safe and efficacious in patients diagnosed with underlying intracranial atherosclerotic disease.

OBJECTIVE: To investigate whether significant differences exist in recanalization rates and primary outcomes between patients who undergo mechanical thrombectomy alone versus those who undergo mechanical thrombectomy with acute intracranial stenting. METHODS: Through the utilization of a prospectively collected endovascular database at a comprehensive stroke center between 2012 and 2020, variables such as demographics, co-morbid conditions, symptomatic intracerebral hemorrhage, mortality rate at discharge, and good/poor outcomes in regard to modified thrombolysis in cerebral infarction score and modified Rankin Scale were examined. The outcomes between patients receiving acute intracranial stenting + mechanical thrombectomy and patients that underwent mechanical thrombectomy alone were compared. RESULTS: There were a total of 420 acute ischemic stroke patients who met criteria for the study (average age 70.6 ± 13.01 years; 46.9% were women). Analysis of 46 patients from the acute stenting + mechanical thrombectomy group (average age 70.34 ± 13.75 years; 37.0% were women), and 374 patients from the mechanical thrombectomy alone group (average age 70.64 ± 12.92 years; 48.1% were women). Four patients (8.7%) in the acute stenting + mechanical thrombectomy group experienced intracerebral hemorrhage versus 45 patients (12.0%) in the mechanical thrombectomy alone group (p = 0.506); no significant increases were noted in the median length of stay (7 vs 8 days; p = 0.208), rates of modified thrombolysis in cerebral infarction 2B-3 recanalization (p = 0.758), or good modified Rankin Scale scores (p = 0.806). CONCLUSION: Acute intracranial stenting in addition to mechanical thrombectomy was not associated with an increase in overall length of stay, intracerebral hemorrhage rates, or any change in discharge modified Rankin Scale. Further research is required to determine whether mechanical thrombectomy and acute intracranial stenting in acute ischemic stroke patients is unsafe.

IV tPA is associated with increase in rates of intracerebral hemorrhage and length of stay in patients with acute stroke treated with endovascular treatment within 4.5 hours: should we bypass IV tPA in large vessel occlusion?

BACKGROUND: Endovascular treatment (EVT) is a widely proved method to treat patients diagnosed with intracranial large vessel occlusions (LVOs); however, there has been controversy about the safety and efficacy of incorporating intravenous tissue plasminogen activator (IV tPA) as pretreatment for EVT. OBJECTIVE: To compare the outcomes of all patients with LVO treated with IV tPA +EVT versus EVT alone within 4.5 hours of stroke onset. METHODS: A prospectively collected endovascular database at a comprehensive stroke center between 2012 and 2019 was used to examine variables such as demographics, comorbid conditions, symptomatic/asymptomatic intracerebral hemorrhage (ICH), mortality rate, and good/poor outcomes as shown by the modified Thrombolysis in Cerebral Infarction score and modified Rankin Scale (mRS) assessment at discharge. The outcomes between patients receiving IV tPA+EVT on admission and patients who underwent EVT alone were compared. RESULTS: Of 588 patients with acute ischemic stroke treated with EVT, a total of 189 met the criteria for the study (average age 70.44±12.90 years, 42.9% women). Analysis of 109 patients from the group receiving EVT+IV tPA (average age 68.17±14.28 years, 41.3% women), and 80 patients from the EVT alone group was performed (average age 73.54±9.84 years, 45.0% women). Four patients (5.0%) in the EVT alone group experienced symptomatic ICH versus 15 patients (13.8%) in the IV tPA+EVT group (p=0.0478); significant increases were also noted in the length of stay for patients treated with IV tPA (8.2 days vs 11.0 days; p=0.0056). CONCLUSION: IV tPA in addition to EVT was associated with an increase in the rate of ICH in patients with LVO treated within 4.5 hours and in patients' length of stay. Further research is required to determine whether EVT treatment alone in patients with LVO treated within 4.5 hours is a more effective option.

Early experience utilizing artificial intelligence shows significant reduction in transfer times and length of stay in a hub and spoke model.

BACKGROUND: Recently approved artificial intelligence (AI) software utilizes AI powered large vessel occlusion (LVO) detection technology which automatically identifies suspected LVO through CT angiogram (CTA) imaging and alerts on-call stroke teams. We performed this analysis to determine if utilization of AI software and workflow platform can reduce the transfer time (time interval between CTA at a primary stroke center (PSC) to door-in at a comprehensive stroke center (CSC)). METHODS: We compared the transfer time for all LVO transfer patients from a single spoke PSC to our CSC prior to and after incorporating AI Software (Viz.ai LVO). Using a prospectively collected stroke database at a CSC, demographics, mRS at discharge, mortality rate at discharge, length of stay (LOS) in hospital and neurological-ICU were examined. RESULTS: There were a total of 43 patients during the study period (median age 72.0 ± 12.54 yrs., 51.16% women). Analysis of 28 patients from the pre-AI software (median age 73.5 ± 12.28 yrs., 46.4% women), and 15 patients from the post-AI software (median age 70.0 ± 13.29 yrs., 60.00% women). Following implementation of AI software, median CTA time at PSC to door-in at CSC was significantly reduced by an average of 22.5 min. (132.5 min versus 110 min; p = 0.0470). CONCLUSIONS: The incorporation of AI software was associated with an improvement in transfer times for LVO patients as well as a reduction in the overall hospital LOS and LOS in the neurological-ICU. More extensive studies are warranted to expand on the ability of AI technology to improve transfer times and outcomes for LVO patients.