Femoral Access-Site Complications with Tenecteplase versus Alteplase before Mechanical Thrombectomy for Large-Vessel-Occlusion Stroke.

BACKGROUND AND PURPOSE: IV thrombolysis with alteplase before mechanical thrombectomy for emergent large-vessel-occlusion stroke is associated with access-site bleeding complications. However, the incidence of femoral access-site complications with tenecteplase before mechanical thrombectomy requires exploration. Here, femoral access-site complications with tenecteplase versus alteplase before mechanical thrombectomy for large-vessel-occlusion stroke were compared. MATERIALS AND METHODS: All patients receiving IV thrombolytics before mechanical thrombectomy for large-vessel-occlusion stroke who presented from January 2020 to August 2022 were reviewed. In May 2021, our health care system switched from alteplase to tenecteplase as the primary thrombolytic for all patients with stroke, facilitating the comparison of alteplase-versus-tenecteplase femoral access-site complication rates. Major (requiring surgery) and minor (managed conservatively) access-site complications were assessed. RESULTS: One hundred thirty-nine patients underwent transfemoral mechanical thrombectomy for large-vessel-occlusion stroke, of whom 46/139 (33.1%) received tenecteplase and 93/139 (66.9%) received alteplase. In all cases (n = 139), an 8F sheath was inserted without sonographic guidance, and vascular closure was obtained with an Angio-Seal. Baseline demographics, concomitant antithrombotic medications, and periprocedural coagulation lab findings were similar between groups. The incidence of conservatively managed groin hematomas (2.2% versus 4.3%), delayed access-site oozing requiring manual compression (6.5% versus 2.2%), and arterial occlusion requiring surgery (2.2% versus 1.1%) was similar between the tenecteplase and alteplase groups, respectively (P = not significant). No dissection, arteriovenous fistula, or retroperitoneal hematoma was observed. CONCLUSIONS: Tenecteplase compared with alteplase before mechanical thrombectomy for large-vessel-occlusion stroke is not associated with an alteration in femoral access-site complication rates.

Learning Curve for Flow Diversion of Posterior Circulation Aneurysms: A Long-Term International Multicenter Cohort Study.

BACKGROUND AND PURPOSE: Flow diversion has gradually become a standard treatment for intracranial aneurysms of the anterior circulation. Recently, the off-label use of the flow diverters to treat posterior circulation aneurysms has also increased despite initial concerns of rupture and the suboptimal results. This study aimed to explore the change in complication rates and treatment outcomes across time for posterior circulation aneurysms treated using flow diversion and to further evaluate the mechanisms and variables that could potentially explain the change and outcomes. MATERIALS AND METHODS: A retrospective review using a standardized data set at multiple international academic institutions was performed to identify patients with ruptured and unruptured posterior circulation aneurysms treated with flow diversion during a decade spanning January 2011 to January 2020. This period was then categorized into 4 intervals. RESULTS: A total of 378 procedures were performed during the study period. Across time, there was an increasing tendency to treat more vertebral artery and fewer large vertebrobasilar aneurysms (P = .05). Moreover, interventionalists have been increasingly using fewer overlapping flow diverters per aneurysm (P = .07). There was a trend toward a decrease in the rate of thromboembolic complications from 15.8% in 2011-13 to 8.9% in 2018-19 (P = .34). CONCLUSIONS: This multicenter experience revealed a trend toward treating fewer basilar aneurysms, smaller aneurysms, and increased usage of a single flow diverter, leading to a decrease in the rate of thromboembolic and hemorrhagic complications.

Outcomes of Mechanical Thrombectomy in the Early (<6-hour) and Extended (≥6-hour) Time Window Based Solely on Noncontrast CT and CT Angiography: A Propensity Score-Matched Cohort Study.

BACKGROUND AND PURPOSE: Current stroke care recommendations for patient selection for mechanical thrombectomy in the extended time window demand advanced imaging to determine the stroke core volume and hypoperfusion mismatch, which may not be available at every center. We aimed to determine outcomes in patients selected for mechanical thrombectomy solely on the basis of noncontrast CT and CTA in the early (<6-hour) and extended (≥6-hour) time windows. MATERIALS AND METHODS: Consecutive mechanical thrombectomies performed for acute large-vessel occlusion ischemic (ICA, M1, M2) stroke between February 2016 and August 2020 were retrospectively reviewed. Eligibility was based solely on demographics and noncontrast CT (ASPECTS) and CTA, due to the limited availability of perfusion imaging during the study period. Propensity score matching was performed to compare outcomes between time windows. RESULTS: Of 417 mechanical thrombectomies performed, 337 met the inclusion criteria, resulting in 205 (60.8%) and 132 (39.2%) patients in the 0- to 6- and 6- to 24-hour time windows, respectively. The ASPECTS was higher in the early time window (9; interquartile range = 8-10) than the extended time window (9; interquartile range = 7-10; P = .005). Propensity score matching yielded 112 well-matched pairs. Equal rates of TICI 2b/3 revascularization and symptomatic intracranial hemorrhage were observed. A favorable functional outcome (mRS 0-2) at 90 days was numerically more frequent in the early window (45.5% versus 33.9%, P = .091). Mortality was numerically more frequent in the early window (25.9% versus 17.0%, P = .096). CONCLUSIONS: Patients selected for mechanical thrombectomy in the extended time window solely on the basis of noncontrast CT and CTA still achieved decent rates of favorable 90-day functional outcomes, not statistically different from patients in the early time window.

Labor epidural analgesia onset time and subsequent analgesic requirements: a prospective observational single-center cohort study.

BACKGROUND: We investigated the correlation between lumbar epidural analgesia onset time and pain intensity at 60 and 120 min after initiation. METHODS: We conducted a prospective observational study of nulliparous women receiving lumbar epidural analgesia (initial bolus 15 mL bupivacaine 0.1% with fentanyl 3.33 µg/mL), followed by patient-controlled epidural analgesia (PCEA). The measured variable was lumbar epidural analgesia onset time (time to pain numerical rating score ≤3). Secondary outcomes were pain score at 60 and 120 min and at full dilatation; and analgesic requirements through the labor. RESULTS: One-hundred-and-five women were eligible for analysis. There was a significant correlation between lumbar epidural analgesia onset time and pain intensity at 60 min (Spearman's R2=0.286, P=0.003), but not at 120 min (R2=0.030, P=0.76). Women who requested more PCEA boluses during the first 120 min had a longer lumbar epidural analgesia onset time (R2=0.321, P=0.001) and reported higher pain scores at 60 min (R2=0.588, P <0.001) and at 120 min (R2=0.539, P <0.001). Women who reported higher pain scores at 60 min had more pain at 120 min (R2=0.47, P <0.001) and higher analgesic consumption during labor (R2=0.403, P <0.001). Women who were at a greater cervical dilatation at 60 and 120 min had higher pain scores at the same time point (R2=0.259, P=0.008 and R2=0.243, P=0.013 respectively). CONCLUSION: There was a correlation between the onset time of lumbar epidural analgesia during labor and the pain score 60 min later but this had disappeared by 120 min.

Neuraxial block for delivery among women with low platelet counts: a retrospective analysis.

BACKGROUND: Laboring women with low platelet counts may be denied neuraxial block due to concerns about causing a spinal-epidural hematoma. AIMS: To assess the anesthetic management, complications and outcome variables of women with low platelet counts, and to expand the existing data regarding the safety of neuraxial blocks in this patient population. METHODS: This is a retrospective analysis of anesthetic and obstetric data from women with platelet counts <100 000/µL, who were admitted to a single referral center during 2011-2014. The rate of neuraxial block and related complications were examined in relation to the platelet count and the results combined with published data to assess the risk of spinal-epidural hematoma. RESULTS: During the study period, 471 of 45 462 women (1%) had a low platelet count (<100 000/µL). The rate of neuraxial block was significantly higher in women with platelet counts of 70-99 000/µL (280/394, 71.1%) when compared to women with platelet counts of 50-69 000/µL and 0 to 49 000/µL (23/59, 38.9% and 5/18, 27.8%, respectively, P <0.0001). Women in the lower platelet count ranges had a higher risk of cesarean delivery under general anesthesia and longer hospital stay. No neuraxial hematoma were reported. CONCLUSIONS: This study contributes a substantial series of neuraxial blocks among women with low platelet counts. The findings support that the risk of hematoma is low if the platelet count is <100 000/µL, specifically between 70 and 99 000/µL. Risk assessment in the lower count ranges requires a much larger sample.

Perioperative acute kidney injury.

Perioperative acute kidney injury (AKI) is not uncommon and is associated with considerable morbidity and mortality. Recently, several definition systems for AKI were proposed, incorporating both small changes of serum creatinine and urinary output reduction as diagnostic criteria. Novel biomarkers are under investigation as fast and accurate predictors of AKI. Several special considerations regarding the risk of AKI are of note in the surgical patient. Co-morbidities are important risk factors for AKI. The surgery in itself, especially emergency and major surgery in the critically ill, is associated with a high incidence of AKI. Certain types of surgeries, such as cardiac and transplantation surgeries, require special attention because they carry higher risk of AKI. Nephrotoxic drugs, contrast dye, and diuretics are commonly used in the perioperative period and are responsible for a significant amount of in-hospital AKI. Before surgery, the anaesthetist is required to identify patients at risk of AKI, optimize anaemia, and treat hypovolaemia. During surgery, normovolaemia is of utmost importance. Additionally, the surgical and anaesthesia team is advised to use measures to reduce blood loss and avoid unnecessary blood transfusion. Hypotension should be avoided because even short periods of mean arterial pressure <55-60 mm Hg carry a risk of postoperative AKI. Higher blood pressures are probably required for hypertensive patients. Urine output can be reduced significantly during surgery and is unrelated to perioperative renal function. Thus, fluids should not be given in excess for the sole purpose of avoiding or treating oliguria. Use of hydroxyethyl starch needs to be reconsidered. Recent evidence indicates a beneficial effect of administering low-chloride solutions.

Mass casualty incident management, triage, injury distribution of casualties and rate of arrival of casualties at the hospitals: lessons from a suicide bomber attack in downtown Tel Aviv.

BACKGROUND: Terrorist attacks in Israel cause mass events with varying numbers of casualties. A study was undertaken to analyse the medical response to an event which occurred on 17 April 2006 near the central bus station, Tel Aviv, Israel. Lessons are drawn concerning the management of the event, primary triage, evacuation priorities and the rate and characteristics of casualty arrival at the nearby hospitals. METHODS: Data were collected both during and after the event in formal debriefings. Their analysis refers to medical response components, interactions and main outcomes. The event is described according to the DISAST-CIR methodology (Disastrous Incidents Systematic AnalysiS Through--Components, Interactions and Results). RESULTS: 91 casualties were reported in this event; 85 were evacuated from the scene including 3 already dead on arrival, 9 severely injured, 14 moderately injured and 59 mildly injured. Six were declared dead at the scene. Emergency medical service (EMS) vehicle accumulation was rapid. The casualties were distributed between five hospitals (three level 1 and two level 2 trauma centres). The first evacuated casualty arrived at the hospital within 20 min of the explosion and the last urgent victim was evacuated from the scene after 1 h 14 min. Evacuation occurred in two phases: the first, lasting 1 h 20 min, in which most of the patients with evident trauma were evacuated and the second, lasting 8 h 15 min, in which most patients presented with tinnitus and symptoms of somatisation. The most common injuries were upper and lower limb injuries, diagnosed in 37% of the total injuries, and stress-related disturbances (anxiety, tinnitus, somatisation) diagnosed in 41%. CONCLUSION: Rapid accumulation of EMS vehicles, effective primary triage between urgent and non-urgent casualties and primary distribution between five hospitals enabled rapid conclusion of the event, both at the scene and at the receiving hospitals.

Immunomodulation of the human prion peptide 106-126 aggregation.

Site-directed monoclonal antibodies (mAbs) may interact with their antigens, leading to stabilization, refolding, and suppression of aggregation. In the following study, we show that mAbs raised against the peptide 106-126 of human prion protein (PrP 106-126) modulate the conformational changes occurring in the peptide exposed to aggregation conditions. MAbs 3-11 and 2-40 prevent PrP 106-126's fibrillar aggregation, disaggregates already formed aggregates, and inhibits the peptide's neurotoxic effect on the PC12 cells system, while mAb 3F4 has no protective effect. We suggest that there are key positions within the PrP 106-126 molecule where unfolding is initiated and their locking with specific antibodies may maintain the prion peptide native structure, reverse the aggregated peptide conformation, and lead to rearrangements involved in the essential feature of prion diseases.

An international training program to assist with establishing emergency medicine in Ethiopia.

Ethiopia has a population of 56 million and an area of 1,110,000 km(2). Ethiopia is one of the poorest nations in the world, and its health services system reflects that poverty. Accidental injury, violence, infectious diseases, and natural and manmade disasters abound, yet emergency medicine is practically nonexistent. Poorly equipped and staff emergency "rooms" supply substandard service even in the capital. Significant work and planning are under way by a group of high-quality and dedicated local physicians and nurses with international support from Israel and the United States. A coherent plan is due at the end of the year. Much financial and professional support from outside sources will be required for significant advances in the quality of emergency care to improve. Human as well are material resources are vital.