Long-term functional outcome following minimally invasive endoscopic intracerebral hemorrhage evacuation.

BACKGROUND AND PURPOSE: Preclinical studies suggest that clot removal may mitigate primary and secondary brain injury following intracerebral hemorrhage (ICH). Although the MISTIE trial did not demonstrate an overall outcome benefit, it did demonstrate outcome benefit from effective reduction of clot burden. Minimally invasive endoscopic ICH evacuation may provide an alternative option for clot evacuation. METHODS: Patients presenting to a single healthcare system from December 2015 to October 2018 with supratentorial spontaneous ICH were evaluated for minimally invasive endoscopic evacuation. Inclusion and exclusion criteria were prospectively established by a multidisciplinary group in the healthcare system. The prespecified primary analysis was the proportion of patients with modified Rankin Score (mRS) 0-3 at 6 months. RESULTS: One hundred patients met the inclusion and exclusion criteria and underwent minimally invasive endoscopic ICH evacuation. The mean (SD) hematoma size was 49.7 (30.6) mL, the mean (SD) evacuation percentage was 88.2 (20.3)%, and 86% of patients had postoperative residual hematoma ≤15 mL. At 6 months the proportion of patients with an mRS of 0-3 was 46%. CONCLUSIONS: This study suggests that minimally invasive endoscopic ICH evacuation may produce favorable long-term functional outcomes. Further evaluation of this technique in a randomized clinical trial is necessary.

Aneurysmal Subarachnoid Hemorrhage with Spinal Subdural Hematoma: A Case Report and Systematic Review of the Literature.

OBJECTIVE: Spinal subdural hematoma (S-SDH) rarely occurs after aneurysmal subarachnoid hemorrhage (SAH). Little information is known regarding the management and prognosis of patients with both S-SDH and SAH. Here, we present an illustrative case and provide a systematic review of S-SDH in the setting of SAH. METHODS: A systematic literature review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines revealed 11 previous cases of concurrent intracranial SAH and spinal SDH, which are presented with our new reported case. RESULTS: Intracranial sources of spontaneous SAH included 8 aneurysms, 1 pseudoaneurysm, and 3 angiogram-negative cases. Hunt Hess grades ranged from 1 to 4, mean time between SAH and S-SDH was 5.8 days, and S-SDH presented most frequently in the lumbar spine. Eight patients showed significant to complete clinical recovery, 2 had continued plegia of the lower extremities, and 2 expired. Modified Rankin scores (mRS) ranged from 0 to 6, with mRS >2 for 4 of 12 patients. Patients with a poor clinical outcome (mRS >2) had an initially negative cerebral angiogram, earlier presentation with less time between SAH and S-SDH (0.8 vs. 7.6 days), use of antithrombotic medication, no diversion of cerebrospinal fluid, and cervical or thoracic S-SDH. CONCLUSION: S-SDH is uncommon in the setting of aneurysmal SAH; better outcomes are associated with lumbar location, delayed presentation, cerebrospinal fluid diversion, and lack of antithrombotic use. Conservative treatment may be sufficient in patients with delayed S-SDH and lack of significant neurologic deficits. More reported cases will allow greater understanding of this clinical entity.

Meeting the evolving demands of neurointervention: Implementation and utilization of nurse practitioners.

Growth in the neurointerventional field, as a result of the emergence of thrombectomy as the gold standard treatment for large vessel occlusions, has created complex challenges. In an effort to meet evolving demands and fill workflow gaps, nurse practitioners have taken on highly specialized roles. Neurointerventional care has rapidly evolved similarly to interventional cardiac care, in that nurse practitioners are successfully being incorporated as procedural assistants in catheterization laboratories. Similar utilization of nurse practitioners in interventional neuroradiology holds the capacity to decrease physician workload, mitigate stresses contributing to burn-out, and reallocate more physician time to procedures. Nurse practitioner practice faces procedural, clinical, legal and interpersonal barriers. Despite calls for expanded practice by the Institutes of Medicine, a paucity of nurse practitioner training opportunities exists. Fragmented privileging processes contribute to environments where nurse practitioners must navigate hurdles without established interventional neuroradiology-specific precedent. Increased nurse practitioner mentorship, fluoroscopy law standardization, physician support surrounding nurse practitioner autonomy, and role consistency is imperative for optimal nurse practitioner utilization. Nurse practitioners are uniquely equipped to bridge evolving gaps through the provision of safe, efficacious care, and generating revenue at lower costs. Discussion surrounding nurse practitioner use to bridge workflow gaps is an exciting opportunity for future practice development.