Effects of Achieving Rapid, Intensive, and Sustained Blood Pressure Reduction in Intracerebral Hemorrhage Expansion and Functional Outcome.

BACKGROUND AND OBJECTIVES: The time taken to achieve blood pressure (BP) control could be pivotal in the benefits of reducing BP in acute intracerebral hemorrhage (ICH). We aimed to assess the relationship between the rapid achievement and sustained maintenance of an intensive systolic BP (SBP) target with radiologic, clinical, and functional outcomes. METHODS: Rapid, Intensive, and Sustained BP lowering in Acute ICH (RAINS) was a multicenter, prospective, observational cohort study of adult patients with ICH <6 hours and SBP ≥150 mm Hg at 4 Comprehensive Stroke Centers during a 4.5-year period. Patients underwent baseline and 24-hour CT scans and 24-hour noninvasive BP monitoring. BP was managed under a rapid (target achievement ≤60 minutes), intensive (target SBP <140 mm Hg), and sustained (target stability for 24 hours) BP protocol. SBP target achievement ≤60 minutes and 24-hour SBP variability were recorded. Outcomes included hematoma expansion (>6 mL or >33%) at 24 hours (primary outcome), early neurologic deterioration (END, 24-hour increase in NIH Stroke Scale score ≥4), and 90-day ordinal modified Rankin scale (mRS) score. Analyses were adjusted by age, sex, anticoagulation, onset-to-imaging time, ICH volume, and intraventricular extension. RESULTS: We included 312 patients (mean age 70.2 ± 13.3 years, 202 [64.7%] male). Hematoma expansion occurred in 70/274 (25.6%) patients, END in 58/291 (19.9%), and the median 90-day mRS score was 4 (interquartile range, 2-5). SBP target achievement ≤60 minutes (178/312 [57.1%]) associated with a lower risk of hematoma expansion (adjusted odds ratio [aOR] 0.43, 95% confidence interval [CI] 0.23-0.77), lower END rate (aOR 0.43, 95% CI 0.23-0.80), and lower 90-day mRS scores (aOR 0.48, 95% CI 0.32-0.74). The mean 24-hour SBP variability was 21.0 ± 7.6 mm Hg. Higher 24-hour SBP variability was not related to expansion (aOR 0.99, 95% CI 0.95-1.04) but associated with higher END rate (aOR 1.15, 95% CI 1.09-1.21) and 90-day mRS scores (aOR 1.06, 95% CI 1.04-1.10). DISCUSSION: Among patients with acute ICH, achieving an intensive SBP target within 60 minutes was associated with lower hematoma expansion risk. Rapid SBP reduction and stable sustention within 24 hours were related to improved clinical and functional outcomes. These findings warrant the design of randomized clinical trials examining the impact of effectively achieving rapid, intensive, and sustained BP control on hematoma expansion. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that in adults with spontaneous ICH and initial SBP ≥150 mm Hg, lowering SBP to <140 mm Hg within the first hour and maintaining this for 24 hours is associated with decreased hematoma expansion.

Wall enhancement as a biomarker of intracranial aneurysm instability: a histo-radiological study.

BACKGROUND: The aim of this is to explore the histological basis of vessel wall enhancement (WE) on magnetic resonance imaging (MRI), which is a strong radiological biomarker of aneurysmal prone to rupture compared to other classical risk predictors (e.g., PHASES score, size, morphology). METHODS: A prospective observational study was performed including all consecutive patients presenting with a saccular intracranial aneurysm at Vall d'Hebron University Hospital between October 2017 and May 2019. The patients underwent high-resolution 3 T MRI, and their aneurysms were classified into asymptomatic, symptomatic, and ruptured. A histological and immunohistochemical study was performed in a subgroup of patients (n = 20, of which 15 presented with WE). Multiple regression analyses were performed to identify predictors of rupture and aneurysm symptoms. RESULTS: A total of 132 patients were enrolled in the study. WE was present in 36.5% of aneurysms: 22.9% asymptomatic, 76.9% symptomatic, and 100% ruptured. Immunohistochemical markers associated with WE were CD3 T cell receptor (p = 0.05) and CD45 leukocyte common antigen (p = 0.05). Moreover, WE is an independent predictor of symptomatic and ruptured aneurysms (p < 0.001). CONCLUSIONS: Aneurysms with WE present multiple histopathological changes that may contribute to wall disruption and represent the pathophysiological basis of radiological WE. Moreover, WE is an independent diagnostic predictor of aneurysm symptoms and rupture.

Derivation and validation of three intracerebral hemorrhage expansion scores using different CT modalities.

OBJECTIVES: To derivate and validate three scores for the prediction of intracerebral hemorrhage (ICH) expansion depending on the use of non-contrast CT (NCCT), single-phase CTA, or multiphase CTA markers of hematoma expansion, and to evaluate the added value of single-phase and multiphase CTA over NCCT. METHODS: After prospectively deriving NCCT, single-phase CTA, and multiphase CTA hematoma expansion scores in 156 patients with ICH < 6 h, we validated them in 120 different patients. Discrimination and calibration of the three scores was assessed. Primary outcome was substantial hematoma expansion > 6 mL or > 33% at 24 h. RESULTS: The evaluation of single-phase and multiphase CTA markers gave a steadily increase in discrimination for substantial hematoma expansion over NCCT markers. The C-index (95% confidence interval) in derivation and validation cohorts was 0.69 (0.58-0.80) and 0.59 (0.46-0.72) for NCCT score, significantly lower than 0.75 ([0.64-0.87], p = 0.038) and 0.72 ([0.59-0.84], p = 0.016) for single-phase CTA score, and than 0.79 ([0.68-0.89], p = 0.033) and 0.73 ([0.62-0.85], p = 0.031) for multiphase CTA score, respectively. The three scores showed good calibration in both derivation and validation cohorts: NCCT (χ2 statistic 0.389, p = 0.533; and χ2 statistic 0.352, p = 0.553), single-phase CTA (χ2 statistic 2.052, p = 0.359; and χ2 statistic 2.230, p = 0.328), and multiphase CTA (χ2 statistic 0.559, p = 0.455; and χ2 statistic 0.020, p = 0.887) scores, respectively. CONCLUSION: This study shows the added prognostic value of more advanced CT modalities in acute ICH evaluation. NCCT, single-phase CTA, and multiphase CTA scores may help to refine the selection of patients at risk of expansion in different decision-making scenarios. KEY POINTS: • This study shows the added prognostic value of more advanced CT modalities in acute intracerebral hemorrhage evaluation. • The evaluation of single-phase and multiphase CTA markers provides a steadily increase in discrimination for intracerebral hemorrhage expansion over non-contrast CT markers. • Non-contrast CT, single-phase CTA, and multiphase CTA scores may help clinicians and researchers to refine the selection of patients at risk of intracerebral hemorrhage expansion in different decision-making scenarios.

Increased Number of Passes and Double Stent Retriever Technique Induces Cumulative Injury on Arterial Wall After Mechanical Thrombectomy in a Swine Model.

The number of stentriever passes during endovascular thrombectomy impacts clinical outcomes in acute ischemic stroke. Previous studies suggest that the simultaneous double stent retriever technique (DSRT) could improve the efficacy and reduce the number of passes. We aim to analyze the degree of vessel wall injury according to the number of passes and technique (single vs. simultaneous devices). Histological changes were evaluated in renal arteries (RAs) of swine models after thrombectomy (1, 2, or 3 passes) with single stent (SSRT) and DSRT. Thrombectomy passes were performed in 12 RA: 3 samples from each artery were studied by optical microscopy to assess a vascular damage score. All thirty-six samples showed endothelial denudation and different degrees of damage in the deepest layers of the arterial wall; however, all arteries remained patent by the time of assessment. In all cases, the degree of vascular injury increased with the number of passes. Compared with a SSRT, DSRT showed a higher severity of histological damage corresponding to the damage caused by 1.4 SSRT passes. However, in distal arteries, vascular damage was relatively similar when comparing SSRT with multiple passes and DSRT with one pass. The degree of vessel injury increases with the number of passes. Even though histological damage per pass was 1.4 higher with DSRT than SSRT, short-term vessel patency was not compromised after up to 3 DSRT passes. Further studies are needed to characterize the risk-benefit ratio of the DSRT in routine clinical practice.

Multiparametric Neuroimaging and Its Association with Non-Contrast Computed Tomography in Late-Window Large Vessel Occlusion Acute Stroke.

INTRODUCTION: Endovascular treatment (EVT) for acute ischemic stroke (AIS) between 6 and 24 h is established as a standard of care among patients selected by multiparametric neuroimaging. We aimed to explore neuroimaging parameters in late-window large vessel occlusion (LVO) patients and its association with non-contrast computed tomography (NCCT) findings. METHODS: We included consecutive AIS patients within 6-24 h from the symptoms onset with LVO. We described multiparametric imaging findings, the rate of patients who fulfilled imaging perfusion criteria according to the DAWN and DEFUSE-3 trials that define the computed tomography perfusion mismatch (CTP-MM) group and its association with NCCT focused on Alberta Stroke Program Early CT Score (ASPECTS). We also analyzed the association between neuroimaging parameters and the clinical outcome determined by the 90-day modified Rankin scale (mRS). RESULTS: We included 206 patients, of them, 176 (85.4%) presented CTP-MM and 184 (89.3%) presented an ASPECTS ≥6 on admission. The rate of CTP-MM was 90.8% in patients with ASPECTS ≥6, compared with 40.9% in those with low ASPECTS. ASPECTS was moderately correlated with ischemic core determined by cerebral blood flow <30% volume (rS = -0.557, p < 0.001). In EVT-treated patients (185, 89.8%), after adjusting for identifiable confounders, the presence of CTP-MM was a predictor of 90-day functional independence (OR: 3.38; 95% CI: 1.01-11.29; p = 0.048). We did not find an association between CTP-MM and 90-day functional disability (ordinal mRS shift, aOR: 1.39; 95% CI: 0.58-3.34; p = 0.459). CONCLUSIONS: A great majority of patients who presented a LVO in the late window fulfilled guidelines imaging criteria to undergo EVT, especially those with high ASPECTS (≥6). Our data suggest that NCCT with CT angiography could be a reasonable approach for AIS treatment selection also in the late window.

Monocyte-to-Lymphocyte Ratio in Clot Analysis as a Marker of Cardioembolic Stroke Etiology.

The aim of the study was to find markers of high-risk cardioembolic etiology (HRCE) in patients with cryptogenic strokes (CS) through the analysis of intracranial clot by flow cytometry (FC). A prospective single-center study was designed including patients with large vessel occlusion strokes. The percentage of granulocytes, monocytes, lymphocytes, and monocyte-to-lymphocyte ratio (MLr) were analyzed in clots extracted after endovascular treatment (EVT) and in peripheral blood. Large arterial atherosclerosis (LAA) strokes and high-risk cardioembolic (HRCE) strokes were matched by demographics and acute reperfusion treatment data to obtain FC predictors for HRCE. Multilevel decision tree with boosting random forest classifiers was performed with each feature importance for HRCE diagnosis among CS. We tested the validity of the best FC predictor in a cohort of CS that underwent extensive diagnostic workup. Among 211 patients, 178 cases underwent per-protocol workup. The percentage of monocytes (OR 1.06, 95% CI 1.01-1.11) and MLr (OR 1.83, 95% CI 1.12-2.98) independently predicted HRCE diagnosis when LAA clots (n = 28) were matched with HRCE clots (n = 28). Among CS (n = 82), MLr was the feature with the highest weighted importance in the multilevel decision tree as a predictor for HRCE. MLr cutoff point of 1.59 yield sensitivity of 91.23%, specificity of 44%, positive predictive value of 78.79%, and negative predictive value of 68.75 for HRCE diagnosis among CS. MLr ≥ 1.6 in clot analysis predicted HRCE diagnosis (OR, 6.63, 95% CI 1.85-23.71) in a multivariate model adjusted for age. Clot analysis by FC revealed high levels of monocyte-to-lymphocyte ratio as an independent marker of cardioembolic etiology in cryptogenic strokes.

A Pictorial Review of Postpartum Complications.

The postpartum period, also known as the puerperium, begins immediately after delivery of the neonate and placenta and ends 6-8 weeks after delivery. The appearance of physiologic uterine changes during puerperium can overlap with that of postpartum complications, which makes imaging interpretation and diagnosis difficult. Obstetric and nonobstetric postpartum complications are a considerable source of morbidity and mortality in women of reproductive age, and the radiologist plays an important role in the assessment of these entities, which often require a multimodality imaging approach. US and contrast material-enhanced CT are the techniques of choice in the emergency department, and they can show characteristic radiologic findings that enable differentiation between normal and abnormal features to help radiologists and emergency department practitioners to reach a correct diagnosis and provide timely treatment. The spectrum of postpartum complications ranges from relatively self-limiting to life-threatening conditions that can be divided into six categories: infectious conditions (endometritis), thrombotic complications (eg, deep vein thrombosis, ovarian vein thrombophlebitis, HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome, or cerebral sinus thrombosis), hemorrhagic conditions (eg, uterine atony, trauma of the lower portion of the genital tract, retained products of conception, uterine artery arteriovenous malformations, or uterine artery pseudoaneurysm), cesarean delivery-related complications (eg, bladder flap hematoma, subfascial hematoma, rectus sheath hematoma, abscess formation, uterine dehiscence, uterine rupture, vesicovaginal fistula, or abdominal wall endometriosis), iatrogenic conditions (eg, uterine perforation), and nonobstetric complications (eg, acute cholecystitis, acute appendicitis, uterine fibroid degeneration, renal cortical necrosis, pyelonephritis, posterior reversible encephalopathy syndrome, or pituitary gland apoplexy). The online slide presentation from the RSNA Annual Meeting is available for this article. ©RSNA, 2020.

Time Matters: Adjusted Analysis of the Influence of Direct Transfer to Angiography-Suite Protocol in Functional Outcome.

Background and Purpose- Direct transfer to angiography-suite (DTAS) protocol is a promising measure to improve onset to recanalization time in patients who undergo endovascular treatment. The magnitude of the improvement of good outcome rates in function of time depends of several factors. We aim to analyze the benefit of DTAS according to time from symptom onset. Methods- Retrospective case-control study of 174 consecutive DTAS cases matched with 175 patients initially transferred to computed tomography (directly transferred to computed tomography) from February 2016 to June 2019. To obtain comparable groups on admission, cases and controls were matched by occlusion location, age (±2 years), baseline National Institutes of Health Stroke Scale score (±2 points), and time from symptoms onset to hospital arrival (±30 minutes). We analyzed the rate of good functional outcome at 3 months (modified Rankin Scale score, 0-2) and safety variables stratified in less or more than 3 hours from onset to arrive. Results- There were no significant differences regarding age, sex, or baseline National Institutes of Health Stroke Scale score. Median door-to-groin time was shorter in the DTAS patients (16 [3-21] minutes versus 70 [41.5-98.5]; P<0.01). DTAS patients presented lower National Institutes of Health Stroke Scale score at 24 hours (9 [3.5-17] versus 14 [5-19]; P=0.01) and a lower rate of symptomatic hemorrhagic transformation (4.6% versus 10.9%, P<0.03). At 90 days, DTAS patients had a higher rate of good functional outcome (43% versus 29%; odds ratio, 1.81 [95% CI, 1.14-2.87]; P=0.01). Better outcome in DTAS was observed in patients admitted in the 0 to 3 hours form onset window (n=156, odds ratio 2.63 [95% CI, 1.31-5.28]; P<0.01), but not in patients admitted in the 3 to 6 hours window (n=193, odds ratio, 1.37 [95% CI, 0.72-2.60]; P=0.2). Conclusions- DTAS seems a feasible and safe strategy to improve functional outcome in patients who undergo endovascular treatment mainly within 3 hours from symptoms onset.

Predictors of response to endovascular treatment of posterior circulation stroke.

BACKGROUND: Endovascular treatment is considered a reasonable approach for patients with acute posterior circulation stroke, but it remains uncertain which patients will benefit the most from it. OBJECTIVE: To find independent clinical and angiographic predictors of outcome after endovascular treatment for posterior circulation stroke. METHODS: We evaluated consecutive patients with acute posterior circulation stroke who underwent endovascular treatment in our comprehensive stroke center from January 2015 to December 2017. Good outcome was defined as a modified Rankin score of 0-3 at 90 days. Intracranial atheromatous disease was established on focal stenosis recorded during endovascular treatment. Associations were sought between a good outcome and clinical and angiographic factors. Adjusted logistic regression models were used to define independent outcome predictors. RESULTS: Forty-seven consecutive patients were included: mean age 70.9 ± 12.1 years, median admission NIHSS score, 16 (IQR: 8-30). On univariate analysis, age (p = 0.01), smoking (p = 0.04), hypertension (p = 0.03), successful reperfusion (p = 0.04), presence of extracranial atherosclerosis (p = 0.02), and absence of atherosclerosis (p = 0.03) were significantly associated with a good outcome. On multivariate analysis, age <70 years (odds ratio = 6.20, 95%CI 1.52-25.47, p = 0.01) and absence of intracranial atherosclerosis (odds ratio = 6.45, 95% CI 1.09-38.24, p = 0.04) were independently associated with a good outcome. CONCLUSIONS: Pretreatment determination of the presence or absence of intracranial atherosclerosis can aid management of posterior circulation stroke patients. The absence of intracranial atherosclerosis may have value as a positive selection criterion for endovascular treatment in future trials. The presence of intracranial atherosclerosis could be used as a selection tool in future studies investigating new treatment protocols for this population.

Usefulness of brain perfusion CT in focal-onset status epilepticus.

OBJECTIVE: To evaluate the perfusion computed tomography (PCT) patterns in patients with status epilepticus (SE). METHODS: We included consecutive SE patients, diagnosed by ictal encephalography (EEG) findings and clinical semiology, who prospectively underwent a dedicated PCT study of SE in the ictal phase. The perfusion maps were visually analyzed. For the quantitative assessment, regions of interest in areas where the maps suggested abnormalities were compared with the corresponding area in the unaffected contralateral cortex. Asymmetry indices between affected and unaffected hemispheres were calculated for the regional cerebral blood flow (rCBF), regional cerebral blood volume (rCBV), time to peak (TTP), and mean transit time (MTT). Nine patients underwent a follow-up PCT after SE resolution, and the corresponding maps were compared to the ictal maps. In addition, we included a control group of 10 sex- and age-matched patients with SE mimics or postictal phenomena, who also underwent acute PCT during the study period. RESULTS: The study included 19 patients: mean age 69.47 ± (standard deviation) 15.9 years, 68.4% men. On visual analysis of parametric perfusion maps during the ictal phase, regional cortical hyperperfusion was depicted in 78.9% of patients. Quantitative analysis showed significantly increased rCBF (P = 0.002) and rCBV (P = 0.004) values and decreased TTP (P < 0.001) and MTT (P = 0.001) in cortical areas of the affected vs the unaffected side. The mean asymmetry index was 12.8 for rCBF, 13.7 for rCBV, -3.0 for TTP, and -3.7 for MMT. In the nine patients with a follow-up PCT, eight showed decreased intensity, rCBV (P = 0.035), and rCBF (P = 0.024) in the hyperperfusion areas. The sensitivity of hyperperfusion detection for the diagnosis of SE was 78.95%, specificity 90%, positive predictive value 93.75%, and negative predictive value 69.23%. Comparative quantitative analysis of asymmetry indices for rCBF, rCBV, and MTT between ictal PCT and control patients showed significant differences for all parameters (rCBF P = 0.001; rCBV P = 0.002; TTP P = 0.001; and MTT P = 0.001). SIGNIFICANCE: Visual and quantitative analysis of perfusion maps detects regional hyperperfusion in SE patients with good diagnostic capability. Perfusion was increased in PCT maps of the affected cerebral hemisphere as compared to the contralateral region during the ictal phase. PCT may provide valuable diagnostic information in patients with SE and complement the diagnostic value of EEG.

Procedural approaches and angiographic signs predicting first-pass recanalization in patients treated with mechanical thrombectomy for acute ischaemic stroke.

BACKGROUND: First-pass recanalization via mechanical thrombectomy (MT) has been associated with improved clinical outcome in patients with acute ischaemic stroke. The optimal approach to achieve first-pass effect (FPE) remains unclear. No study has evaluated angiographic features associated with the achievement of FPE. We aimed to determine the procedural approaches and angiographic signs that may predict FPE. METHODS: We performed a prospective, multi-centre, observational study of FPE in patients with anterior circulation stroke treated with MT between February and June 2017. MTs were performed using different devices, deployment manoeuvres (standard versus 'Push and Fluff' technique), proximal balloon guide catheter (PBGC), distal aspiration catheter (DAC) or both. The angiographic clot protrusion sign (ACPS) was recorded. Completed FPE (cFPE) was defined as a modified thrombolysis in cerebral infarction score of 2c-3. Associations were sought between cFPE and procedural approaches and angiographic signs. RESULTS: A total of 193 patients were included. cFPE was achieved in 74 (38.3%) patients. The use of the push and fluff technique (odds ratio (OR) 3.45, 95% confidence interval (CI): 1.28-9.29, p = 0.010), PBGC (OR 3.81, 95% CI: 1.41-10.22, p = 0.008) and ACPS (OR 4.71, 95% CI: 1.78-12.44, p = 0.002) were independently associated with cFPE. Concurrence of these three variables led to cFPE in 82 vs 35% of the remaining cases (p = 0.002). CONCLUSIONS: The concurrence of the PBGC, the push and fluff technique, and the ACPS was associated with the highest rates of cFPE. Appropriate selection of the thrombectomy device and deployment technique may lead to better procedural outcomes. ACPS could be used to assess clot integration strategies in future trials.

Ghost Infarct Core and Admission Computed Tomography Perfusion: Redefining the Role of Neuroimaging in Acute Ischemic Stroke.

BACKGROUND: Determining the size of infarct extent is crucial to elect patients for reperfusion therapies. Computed tomography perfusion (CTP) based on cerebral blood volume may overestimate infarct core on admission and consequently include ghost infarct core (GIC) in a definitive lesional area. PURPOSE: Our goal was to confirm and better characterize the GIC phenomenon using CTP cerebral blood flow (CBF) as the reference parameter to determine infarct core. METHODS: We performed a retrospective, single-center analysis of consecutive thrombectomies of middle cerebral or intracranial internal carotid artery occlusions considering noncontrast CT Alberta Stroke Program Early CT Score ≥6 in patients with pretreatment CTP. We used the RAPID® software to measure admission infarct core based on initial CBF. The final infarct was extracted from follow-up CT. GIC was defined as initial core minus final infarct > 10 mL. RESULTS: A total of 123 patients were included. The median National Institutes of Health Stroke Scale score was 18 (13-20), the median time from symptoms to CTP was 188 (67-288) min, and the recanalization rate (Thrombolysis in Cerebral Infarction score 2b, 2c, or 3) was 83%. Twenty patients (16%) presented with GIC. GIC was associated with shorter time to recanalization (150 [105-291] vs. 255 [163-367] min, p = 0.05) and larger initial CBF core volume (38 [26-59] vs. 6 [0-27] mL, p < 0.001). An adjusted logistic regression model identified time to recanalization < 302 min (OR 4.598, 95% CI 1.143-18.495, p = 0.032) and initial infarct volume (OR 1.01, 95% CI 1.001-1.019, p = 0.032) as independent predictors of GIC. At 24 h, clinical improvement was more frequent in patients with GIC (80 vs. 49%, p = 0.01). CONCLUSIONS: CTP CBF < 30% may overestimate infarct core volume, especially in patients imaged in the very early time window and with fast complete reperfusion. Therefore, the CTP CBF technique may exclude patients who would benefit from endovascular treatment.

Direct Transfer to Angio-Suite to Reduce Workflow Times and Increase Favorable Clinical Outcome.

Background and Purpose- Time to reperfusion is fundamental in reducing morbidity and mortality in acute stroke. We aimed to demonstrate that direct transfer to angio-suite (DTAS) of patients with suspected large vessel occlusion stroke improves workflow times and outcomes. Methods- A case-control matched study of the first 79 DTAS patients with confirmed large vessel occlusion (cases) and 145 no-DTAS patients (controls). DTAS protocol included a cone beam computed tomography in the angio-suite to rule out intracerebral hemorrhage for those patients with no prior neuroimaging in a referring center. Cases and controls were matched by location of vessel occlusion, age, baseline National Institutes of Health Stroke Scale (NIHSS) score and time from symptoms onset to Comprehensive Stroke Center arrival. Dramatic clinical improvement was defined as a decrease in NIHSS score of >10 points or final NIHSS score of ≤2. Favorable outcome was defined as modified Rankin Scale score of ≤2 at 90 days. Results- During an 18 months period a total of 97 patients were directly transferred to the angio-suite after admission: 11 (11.6%) showed an intracerebral hemorrhage on cone beam computed tomography, 7 (7.2%) did not have a large vessel occlusion on initial angiogram, and 79 (76.3%) had a large vessel occlusion and received endovascular treatment (cases). There were no differences in age, baseline NIHSS score, level of occlusion and time from onset-to-door between cases and controls. The median door-to-groin time (16 [12-20] versus 70 [45-105] minutes; P<0.01) and onset-to-groin times (222 [152-282] versus 259 [190-345] minutes; P<0.01) were shorter in the DTAS group. At 24 hours, DTAS patients presented lower NIHSS score (7 [4-16] versus 14 [4-20]; P=0.01), higher rate of dramatic improvement (50.6% Vs. 31.7%; P=0.04), and higher rate of favorable clinical outcome at 90 days (41% versus 28%; P=0.05). A logistic regression model adjusting for all matching variables showed that DTAS protocol was independently associated with 3 months favorable outcome (odds ratio, 2.5; 95% CI, 1.2-5.3; P=0.01). Conclusions- DTAS is an effective strategy to reduce workflow time which may significantly increase the odds of achieving a favorable outcome.

Complicaciones vasculares durante la trombectomía mecánica en el ictus agudo, una experiencia multicéntrica en España / Vascular Complications during Mechanical Thrombectomy in Acute Stroke, a Multicentric Experience in Spain

Objetivo Determinar la frecuencia de las complicaciones observadas durante la trombectomía en el ictus isquémico agudo. Materiales y Métodos Se revisó de forma retrospectiva las trombectomías realizadas en nuestra institución cuando los ictus isquémicos tuvieron una indicación de tratamiento endovascular. Se registraron los diferentes dispositivos utilizados en ese periodo de tiempo y si presentaron relación con el desarrollo de las complicaciones inmediatas mediante arteriografía. Resultados De un total de 228 casos, se registraron complicaciones en el 16,6% de los casos. Se identificaron embolias (n » 31), hemorragias subaracnoideas (n » 2), hemorragia gangliobasal (n » 1), vasoespasmo (n » 1), disección (n » 1) y peusoaneurismas (n » 2). La embolia a nuevos territorios se presentó solo en 5 casos. Discusión El tratamiento endovascular ha demostrado ser efectivo para la recanalización en oclusión de gran vaso. El uso de dispositivos presume un riesgo por la manipulación de los vasos. Conclusión La embolia fue la complicación más frecuente. El tratamiento endovascular en el ictus genera un desenlace clínico favorable de los pacientes, al mismo tiempo, el bajo porcentaje de complicaciones que encontramos no suponen una afectación negativa en el desenlace final.

Purpose To determine the complications we observed during thrombectomy in acute ischemic stroke. Materials and Methods We reviewed retrospectively thrombectomies performed in our institution when endovascular treatment for stroke was done. The different devices used in this period of time were recorded and we determined if these were related to the development of immediate complications duringthe procedure visualized in arteriography. Results We had 228 cases, complications were found in 16.6% of the cases. Embolisms (n » 31), subarachnoid hemorrhages (n » 2), gangliobasal hemorrhage (n » 1), vasospasm (n » 1), dissection (n » 1) and peusoaneurysms (n » 2) were identified. 5 embolisms happened to new territories during thrombectomy. Discussion Endovascular treatment has been shown to be effective for recanalization in large vessel occlusion. The use of devices presumes a risk for the manipulation of the vessels. Conclusion Embolism was the most frequent complication. The endovascular treatment in the acute stroke produces a favorable clinical outcome of the patients and we found a low percentage of complications that would not suppose a negative affectation in the final outcome.

Prehospital Systolic Blood Pressure Is Related to Intracerebral Hemorrhage Volume on Admission.

BACKGROUND AND PURPOSE: Ultra-early blood pressure (BP) management in the prehospital setting could improve the efficacy of this treatment on attenuating intracerebral hemorrhage (ICH) expansion. We aimed to determine the association of prehospital systolic BP (SBP) with ICH volume, ultra-early hematoma growth, and the spot sign on admission. METHODS: We conducted a retrospective study of a prospective database of 219 consecutive patients with spontaneous ICH admitted to the emergency department of a tertiary stroke center during a 3-year period. Prehospital SBP and ICH volume, ultra-early hematoma growth (ICH volume/onset-to-imaging time), and presence of the spot sign on admission were prospectively recorded. Primary outcome was ICH volume on admission. Secondary outcomes included ultra-early hematoma growth and frequency of the spot sign in patients scanned within 6 hours from symptom onset (hyperacute group). RESULTS: Prehospital SBP was positively correlated with both SBP (r=0.552; P<0.001) and ICH volume (ρ=0.189; P=0.006) on admission. Patients with ICH volume above the median value presented higher prehospital SBP (172.3±35.0 versus 163.7±27.8 mm Hg; P=0.049). This association remained significant in adjusted multiple logistic regression analysis (odds ratio, 1.01 for a 1-U increase in SBP; 95% confidence interval, 1.01-1.02; P=0.018). In the hyperacute group (n=126), prehospital SBP was unrelated to ultra-early hematoma growth (ρ=0.115; P=0.203) nor the presence of the spot sign (172.2±27.6 versus 171.8±31.6 mm Hg; P=0.959). CONCLUSIONS: Prehospital SBP is correlated with SBP on admission and independently associated with ICH volume on admission. These findings support the rationale of testing whether prehospital initiation of BP-lowering attenuates ICH expansion.

Direct transfer to angiosuite to reduce door-to-puncture time in thrombectomy for acute stroke.

OBJECTIVE: To evaluate direct transfer to the angiosuite protocol of patients with acute stroke, candidates for endovascular treatment (EVT). METHODS: We studied workflow metrics of all patients with stroke who had undergone EVT in the past 12 months. Patients followed three protocols: direct transfer to emergency room (DTER), CT room (DTCT) or angiosuite (DTAS, only last 6 months if admission National Institute of Health Stroke Scale (NIHSS) score >9 and time from onset <4.5 hours) according to staff/suite availability. DTAS patients underwent cone-beam CT before femoral puncture. Dramatic clinical improvement was defined as 10 NIHSS points drop at 24 hours. RESULTS: 201 patients were included: 87 DTER (43.3%), 74 DTCT (36.8%), 40 DTAS (19.9%).Ten DTAS patients (25%) did not receive EVT: 3 (7.5%) showed intracranial hemorrhage on cone-beam CT and 7 (17.5%) did not show an occlusion on angiography. Mean door-to-puncture (D2P) time was shorter in DTAS (17±8 min) than DTCT (60±29 min; p<0.01). D2P was longer in DTER (90±53 min) than in the other protocols (p<0.01). For outcome analyses only patients who received EVT were compared; no significant differences in baseline characteristics, including time from symptom-onset to admission, puncture-to-recanalization, or recanalization rate, were seen. However, time from symptom-to-puncture (DTAS: 197±72 min, DTER: 279±156, DTCT: 224±142 min; p=0.01) and symptom-to-recanalization (DTAS: 257±74, DTER: 355±158, DTCT: 279±146 min; p<0.01) were longer in the DTER group. At 24 hours, there were no differences in NIHSS score (p=0.81); however, the rate of dramatic clinical improvement was significantly higher in DTAS: 48.6% (DTER 24.1%, DTCT 27.4%); p=0.01). An adjusted model pointed to shorter onset-to-puncture time as an independent predictor of dramatic improvement (OR=1.23, 95% CI 1.13 to 133; p<0.01) CONCLUSION: In a subgroup of patients direct transfer and triage in the angiosuite seems feasible, safe, and achieves significant reduction in hospital workflow times.

Trombectomía retrógrada en ictus isquémico basilar sin acceso vascular posterior / Retrograde thrombectomy in basilar ischemic ictus without posterior vascular access

RESUMEN INTRODUCCIÓN: El 10 % de los ictus afecta la circulación posterior, tiene una importante repercusión neurológica y llegan a comprometer la vida. El manejo inicial de estos pacientes incluye la trombolisis farmacológica y mecánica para reestablecer el flujo de la irrigación de estructuras vitales como el mesencéfalo y las estructuras del puente. METODOLOGÍA: Se presenta el caso de un paciente de 81 años que presentó inestabilidad de la marcha con hemianopsia izquierda. Se documentó en angiotomografía la oclusión de la arterial basilar, arterial vertebral izquierda y la estenosis crítica de arteria vertebral derecha. Debido a que la cateterización de las arterias vertebrales no era posible, se decidió acceder a la arteria basilar a través de la arteria comunicante posterior. RESULTADOS: Se realizó una adecuada revascularización de la arteria basilar, comprobada por arteriografía. Sin embargo, 12 horas después, el paciente presentó reoclusión de territorio basilar que provocó muerte cerebral. CONCLUSIÓN: Los pacientes con difícil cateterización de circulación posterior por oclusión o estenosis crítica proximal del territorio posterior, con patencia y permeabilidad del polígono de Willis, serían candidatos a este tipo de procedimiento, se deben realizar más estudios con pacientes que presenten condiciones similares para optimizar su desenlace neurológico posterior a ictus en territorio de estructuras vitales.

SUMMARY INTRODUCTION: 10% of the strokes affect the posterior circulation, with important neurological deficit and they may compromise the life. Initial management of these patients includes pharmacological thrombolysis and mechanical thrombectomy to re-establish the flow of irrigation from vital structures such as the midbrain and brainstem. METHOD: We present the case of an 81-year-old patient, with unsteady gait with left hemianopsia. Basilar and left vertebral artery occlusion were demonstrated by angiotomography, and critical right vertebral artery stenosis. Due a catheterization of the vertebral arteries was not possible, Basilar artery access through a posterior communicating artery was performed. RESULTS: Adequate revascularization of the basilar artery was performed, by angiography. However, 12 hours later, the patient presented the re-occlusion of the basilar artery that caused brain death. CONCLUSION: Patients with occlusion or severe stenosis in posterior circulation with patency and permeability of the Willis polygon would be candidates for this type of procedure. Further studies are needed to confirm the neurological outcome after stroke in the territory of vital structures with limited vascular access.

Multiphase CT Angiography Improves Prediction of Intracerebral Hemorrhage Expansion.

Purpose To determine the prevalence of the spot sign and the accuracy of using the spot sign to predict intracerebral hemorrhage (ICH) expansion with standardized multiphase computed tomographic (CT) angiography. Materials and Methods This prospective observational cohort study included 123 consecutive patients with acute ICH (onset <6 hours). Patients underwent multiphase CT angiography in three automated phases after injection of contrast material. Patients were classified as having one of four patterns (pattern A, B, C, or D) according to the presence of the spot sign in the three phases. Pattern A was the more arterial pattern, and pattern D was the more venous pattern. Ninety-five patients underwent follow-up unenhanced CT 24 hours after symptom onset. Primary outcome was substantial hematoma expansion (>33% or >6 mL) at 24 hours. Associations between the presence of the spot sign and substantial hematoma expansion were assessed by using the Pearson χ2 test. Results The later the phase of CT angiography, the higher the frequency of the spot sign. The spot sign was seen in 29.3% of patients in phase 1, 43.1% of patients in phase 2, and 46.3% of patients in phase 3 (P < .001). The presence of the spot sign in any phase was related to substantial hematoma expansion (P < .001 for all comparisons; Bonferroni adjusted α = .0125), with highest positive predictive value in phase 1 (64.0%) and highest negative predictive value in phase 2 (90.2%). The more arterial the pattern of spot sign presentation, the greater the frequency of substantial hematoma expansion (P = .013). Absolute hematoma growth analysis revealed a hierarchical pattern of spot sign presentations, as follows: A > B > C > D > no spot sign (P = .002). Conclusion Multiphase CT angiography can help differentiate among different forms of spot sign presentation and can help stratify patients at risk for hematoma expansion. The more arterial the spot sign pattern, the greater the frequency and extent of expansion. © RSNA, 2017.

Target location after deep cerebral biopsies using low-volume air injection in 75 patients. Results and technical note.

BACKGROUND: Stereotactic biopsy is a minimally invasive technique that allows brain tissue samples to be obtained with low risk. Classically, different techniques have been used to identify the biopsy site after surgery. OBJECTIVE: To describe a technique to identify the precise location of the target in the postoperative CT scan using the injection of a low volume of air into the biopsy cannula. METHODS: Seventy-five biopsies were performed in 65 adults and 10 children (40 males and 35 females, median age 51 years). Frame-based biopsy was performed in 46 patients, while frameless biopsy was performed in the remaining 29 patients. In both systems, after brain specimens had been collected and with the biopsy needle tip in the center of the target, a small volume of air (median 0.7 cm3) was injected into the site. RESULTS: A follow-up CT scan was performed in all patients. Intracranial air in the selected target was present in 69 patients (92%). No air was observed in two patients (air volume administered in these 2 cases was below 0.7 cm3), while in the remaining four patients blood content was observed in the target. The diagnostic yield in this series was 97.3%. No complications were found to be associated with intracranial air injection in any of the 75 patients who underwent this procedure. CONCLUSIONS: The air-injection maneuver proposed for use in stereotactic biopsies of intracranial mass lesions is a safe and reliable technique that allows the exact biopsy site to be located without any related complications.