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1.
Neurologist ; 26(2): 62-65, 2021 Mar 04.
Artigo em Inglês | MEDLINE | ID: mdl-33646991

RESUMO

BACKGROUND: Dural arteriovenous fistulas (DAVFs) are pathologic vascular connections that shunt dural arterial flow directly to dural venous drainage. Only a few isolated case reports describe syncope on presentation. We report the first case of DAVF causing recurrent, progressive syncope in an otherwise asymptomatic patient. CASE REPORT: A female in her late 20s presented with a 9-year history of syncopal episodes and was found to have a DAVF. Syncopal episodes were exacerbated by positional changes, strenuous activity and emotional stressors. Symptoms occurred upon wakening and lasted for 2 to 3 hours before she was able to regain functionality. Physical examination revealed no abnormalities. Magnetic resonance imaging of the brain showed no irregularities. Magnetic resonance angiography revealed abnormal serpiginous structures in the left jugular foramen which communicated with the ascending pharyngeal branch of the left external carotid artery. Cerebral angiogram disclosed a left jugular bulb DAVF supplied by the left ascending pharyngeal and left occipital arteries. The DAVF was successfully managed by progressive endovascular embolization with coils and Onyx 34. On clinical follow-up evaluation, the patient had no further episodes of dizziness or syncope. CONCLUSION: We present an atypical case of DAVF in a patient presenting with recurrent syncope. Only 4 cases of DAVF causing syncope have been reported, all in combination with other neurological symptoms. In comparison, we report a unique case of DAVF presenting solely with recurrent syncope, a previously undocumented finding in the literature. Our case adds to other reports of nonspecific DAVF presentations and highlights the importance of considering this etiology.

2.
Neurosurgery ; 2021 Feb 13.
Artigo em Inglês | MEDLINE | ID: mdl-33582776

RESUMO

BACKGROUND: Low-grade intracranial dural arteriovenous fistulas (dAVF) have a benign natural history in the majority of cases. The benefit from treatment of these lesions is controversial. OBJECTIVE: To compare the outcomes of observation versus intervention for low-grade dAVFs. METHODS: We retrospectively reviewed dAVF patients from institutions participating in the CONsortium for Dural arteriovenous fistula Outcomes Research (CONDOR). Patients with low-grade (Borden type I) dAVFs were included and categorized into intervention or observation cohorts. The intervention and observation cohorts were matched in a 1:1 ratio using propensity scores. Primary outcome was modified Rankin Scale (mRS) at final follow-up. Secondary outcomes were excellent (mRS 0-1) and good (mRS 0-2) outcomes, symptomatic improvement, mortality, and obliteration at final follow-up. RESULTS: The intervention and observation cohorts comprised 230 and 125 patients, respectively. We found no differences in primary or secondary outcomes between the 2 unmatched cohorts at last follow-up (mean duration 36 mo), except obliteration rate was higher in the intervention cohort (78.5% vs 24.1%, P < .001). The matched intervention and observation cohorts each comprised 78 patients. We also found no differences in primary or secondary outcomes between the matched cohorts except obliteration was also more likely in the matched intervention cohort (P < .001). Procedural complication rates in the unmatched and matched intervention cohorts were 15.4% and 19.2%, respectively. CONCLUSION: Intervention for low-grade intracranial dAVFs achieves superior obliteration rates compared to conservative management, but it fails to improve neurological or functional outcomes. Our findings do not support the routine treatment of low-grade dAVFs.

3.
Artigo em Inglês | MEDLINE | ID: mdl-33571372

RESUMO

BACKGROUND: The transradial access (TRA) is rapidly gaining popularity for neuroendovascular procedures as there is strong evidence for its benefits compared to the traditional transfemoral access (TFA). However, the transition to TRA bears some challenges including optimization of the interventional suite set-up and workflow as well as its impact on fellowship training. OBJECTIVE: To compare the learning curves of TFA and TRA for diagnostic cerebral angiograms in neuroendovascular fellowship training. METHODS: We prospectively collected diagnostic angiogram procedural data on the performance of 2 neuroendovascular fellows with no prior endovascular experience who trained at our institution from July 2018 until June 2019. Metrics for operator proficiency were minutes of fluoroscopy time, procedure time, and volume of contrast used. RESULTS: A total of 293 diagnostic angiograms were included in the analysis. Of those, 57.7% were TRA and 42.3% were TFA. The median contrast dose was 60 cc, and the median radiation dose was 14 000 µGy. The overall complication rate was 1.4% consisting of 2 groin hematomas, 1 wrist hematoma, and 1 access-site infection using TFA. The crossover rate to TFA was 2.1%. Proficiency was achieved after 60 femoral and 95 radial cases based on fluoroscopy time, 52 femoral and 77 radial cases based on procedure time, and 53 femoral and 64 radial cases based on contrast volume. CONCLUSION: Our study demonstrates that the use of TRA can be safely incorporated into neuroendovascular training without causing an increase in complications or significantly prolonging procedure time or contrast use.

4.
J Neurointerv Surg ; 2021 Feb 16.
Artigo em Inglês | MEDLINE | ID: mdl-33593799

RESUMO

BACKGROUND: Using data from the SMART registry, we report on periprocedural safety of the Penumbra SMART Coil System for endovascular coil embolization of saccular intracranial aneurysms. METHODS: The SMART registry was a prospective, multi-center registry of site standard of care endovascular coiling procedures performed using at least 75% Penumbra SMART Coil, PC400, and/or POD coils. This subset analysis reports on the periprocedural safety outcomes of the saccular intracranial aneurysm cohort. Predictors of rupture/re-rupture or perforation (RRP), thromboembolic complications, and device- or procedure-related adverse events (AEs) were determined in univariate and multivariate analysis. RESULTS: Between June 2016 and August 2018, 851 saccular aneurysm patients (31.0%, 264/851 ruptured) were enrolled across 66 North American centers. Clinically significant (ie, a serious adverse event) RRP occurred in 2.0% (17/851) of cases - 1.9% (5/264) for the ruptured cohort and 2.0% (12/587) for the un-ruptured cohort. Clinically significant thromboembolic events occurred in 3.1% (26/851) of cases - 5.3% (14/264) for the ruptured cohort and 2.0% (12/587) for the un-ruptured cohort. Multivariate predictors of periprocedural RRP were increased packing density and adjunctive treatment with a balloon. For periprocedural thromboembolic events, multivariate predictors were bifurcation location and ruptured status. For device- or procedure-related AEs, multivariate predictors were bifurcation location and adjunctive treatment with stent or balloon. CONCLUSION: The low rates of thromboembolic complications and RRP events demonstrate the adequate safety profile of the SMART Coil System to treat cerebral aneurysms in routine clinical practice. TRIAL REGISTRATION NUMBER: NCT02729740.

5.
J Neurointerv Surg ; 2021 Feb 16.
Artigo em Inglês | MEDLINE | ID: mdl-33593801

RESUMO

BACKGROUND: Radial artery access for transarterial procedures has gained recent traction in neurointerventional due to decreased patient morbidity, technical feasibility, and improved patient satisfaction. Upper extremity transvenous access (UETV) has recently emerged as an alternative strategy for the neurointerventionalist, but data are limited. Our objective was to quantify the use of UETV access in neurointerventions and to measure failure and complication rates. METHODS: An international multicenter retrospective review of medical records for patients undergoing UETV neurointerventions or diagnostic procedures was performed. We also present our institutional protocol for obtaining UETV and review the existing literature. RESULTS: One hundred and thirteen patients underwent a total of 147 attempted UETV procedures at 13 centers. The most common site of entry was the right basilic vein. There were 21 repeat puncture events into the same vein following the primary diagnostic procedure for secondary interventional procedures without difficulty. There were two minor complications (1.4%) and five failures (ie, conversion to femoral vein access) (3.4%). CONCLUSIONS: UETV is safe and technically feasible for diagnostic and neurointerventional procedures. Further studies are needed to determine the benefit over alternative venous access sites and the effect on patient satisfaction.

6.
J Neurointerv Surg ; 2021 Feb 16.
Artigo em Inglês | MEDLINE | ID: mdl-33593800

RESUMO

BACKGROUND: The benefit of complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 3) over near-complete reperfusion (≥90%, mTICI 2c) remains unclear. The goal of this study is to compare clinical outcomes between mechanical thrombectomy (MT)-treated stroke patients with mTICI 2c versus 3. METHODS: This is a retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) comprising 33 centers. Adults with anterior circulation arterial vessel occlusion who underwent MT yielding mTICI 2c or mTICI 3 reperfusion were included. Patients were categorized based on reperfusion grade achieved. Primary outcome was modified Rankin Scale (mRS) 0-2 at 90 days. Secondary outcomes were mRS scores at discharge and 90 days, National Institutes of Health Stroke Scale score at discharge, procedure-related complications, and symptomatic intracerebral hemorrhage. RESULTS: The unmatched mTICI 2c and mTICI 3 cohorts comprised 519 and 1923 patients, respectively. There was no difference in primary (42.4% vs 45.1%; p=0.264) or secondary outcomes between the unmatched cohorts. Reperfusion status (mTICI 2c vs 3) was also not predictive of the primary outcome in non-imputed and imputed multivariable models. The matched cohorts each comprised 191 patients. Primary (39.8% vs 47.6%; p=0.122) and secondary outcomes were also similar between the matched cohorts, except the 90-day mRS which was lower in the matched mTICI 3 cohort (p=0.049). There were increased odds of the primary outcome with mTICI 3 in patients with baseline mRS ≥2 (36% vs 7.7%; p=0.011; pinteraction=0.014) and a history of stroke (42.3% vs 15.4%; p=0.027; pinteraction=0.041). CONCLUSIONS: Complete and near-complete reperfusion after MT appear to confer comparable outcomes in patients with acute stroke.

7.
J Neurointerv Surg ; 2021 Feb 25.
Artigo em Inglês | MEDLINE | ID: mdl-33632883

RESUMO

BACKGROUND: Although the liquid embolic agent, Onyx, is often the preferred embolic treatment for cerebral dural arteriovenous fistulas (DAVFs), there have only been a limited number of single-center studies to evaluate its performance. OBJECTIVE: To carry out a multicenter study to determine the predictors of complications, obliteration, and functional outcomes associated with primary Onyx embolization of DAVFs. METHODS: From the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database, we identified patients who were treated for DAVF with Onyx-only embolization as the primary treatment between 2000 and 2013. Obliteration rate after initial embolization was determined based on the final angiographic run. Factors predictive of complete obliteration, complications, and functional independence were evaluated with multivariate logistic regression models. RESULTS: A total 146 patients with DAVFs were primarily embolized with Onyx. Mean follow-up was 29 months (range 0-129 months). Complete obliteration was achieved in 80 (55%) patients after initial embolization. Major cerebral complications occurred in six patients (4.1%). At last follow-up, 84% patients were functionally independent. Presence of flow symptoms, age over 65, presence of an occipital artery feeder, and preprocedural home anticoagulation use were predictive of non-obliteration. The transverse-sigmoid sinus junction location was associated with fewer complications, whereas the tentorial location was predictive of poor functional outcomes. CONCLUSIONS: In this multicenter study, we report satisfactory performance of Onyx as a primary DAVF embolic agent. The tentorium remains a more challenging location for DAVF embolization, whereas DAVFs located at the transverse-sigmoid sinus junction are associated with fewer complications.

8.
J Neurointerv Surg ; 2021 Jan 06.
Artigo em Inglês | MEDLINE | ID: mdl-33408256

RESUMO

BACKGROUND: The coronavirus disease (COVID-19) pandemic has affected stroke care globally. In this study, we aim to evaluate the impact of the current pandemic on racial disparities among stroke patients receiving mechanical thrombectomy (MT). METHODS: We used the prospectively collected data in the Stroke Thrombectomy and Aneurysm Registry from 12 thrombectomy-capable stroke centers in the US and Europe. We included acute stroke patients who underwent MT between January 2017 and May 2020. We compared baseline features, vascular risk factors, location of occlusion, procedural metrics, complications, and discharge outcomes between patients presenting before (before February 2020) and those who presented during the pandemic (February to May 2020). RESULTS: We identified 2083 stroke patients: of those 235 (11.3%) underwent MT during the COVID-19 pandemic. Compared with pre-pandemic, stroke patients who received MT during the pandemic had longer procedure duration (44 vs 38 min, P=0.006), longer length of hospitalization (6 vs 4 days, P<0.001), and higher in-hospital mortality (18.7% vs 11%, P<0.001). Importantly, there was a lower number of African American patients undergoing MT during the COVID-19 pandemic (609 (32.9%) vs 56 (23.8%); P=0.004). CONCLUSION: The COVID-19 pandemic has affected the care process for stroke patients receiving MT globally. There is a significant decline in the number of African American patients receiving MT, which mandates further investigation.

9.
World Neurosurg ; 2020 Dec 17.
Artigo em Inglês | MEDLINE | ID: mdl-33346049

RESUMO

OBJECTIVE: Transradial access has been used increasingly for diagnostic cerebral angiography and neurointerventions. This requires development of a new skillset. Forming the Simmons catheter to catheterize the cerebral vessels is the most fundamental. Patient anatomy can complicate the formation of the Simmons catheter and the success of the procedure. The aim of this paper is to identify and describe the techniques that can be used transradially to facilitate the formation of the Simmons catheter for catheterization of the cerebral vessels. METHODS: We reviewed our series of 85 cerebral angiograms performed via a transradial approach at our institution between 2018 and 2019. We identified the techniques employed to form the Simmons catheter and compiled operative videos demonstrating each technique and its nuances. RESULTS: We have identified 7 techniques used to form the Simmons catheter from a right radial approach: in the ascending aorta, in the descending aorta, in the aortic arch, by deflecting the catheter off of the aortic valve with the glidewire in the common carotid artery, by deflecting the catheter off of the aortic valve with the glidewire in the descending aorta, and directly in the right or left common carotid arteries. We have identified that formation of the Simmons catheter from a left radial approach is most easily done in the descending aorta. CONCLUSIONS: Transradial artery access has become increasingly common in cerebral angiography and neurointerventions. We describe techniques used for the formation of the Simmons catheter, a fundamental skill necessary for transradial cerebral angiogram or neurointervention.

10.
J Neurointerv Surg ; 2020 Dec 14.
Artigo em Inglês | MEDLINE | ID: mdl-33318066

RESUMO

BACKGROUND: Atrial fibrillation (AF) associated ischemic stroke has worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Limited data exist about the effect of AF on procedural and clinical outcomes after mechanical thrombectomy (MT). OBJECTIVE: To determine whether recanalization efficacy, procedural speed, and clinical outcomes differ in AF associated stroke treated with MT. METHODS: We performed a retrospective cohort study of the Stroke Thrombectomy and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4169 patients who underwent MT for an anterior circulation stroke, 1517 (36.4 %) of whom had comorbid AF. Prospectively defined baseline characteristics, procedural outcomes, and clinical outcomes were reported and compared. RESULTS: AF predicted faster procedural times, fewer passes, and higher rates of first pass success on multivariate analysis (p<0.01). AF had no effect on intracranial hemorrhage (aOR 0.69, 95% CI 0.43 to 1.12) or 90-day functional outcomes (aOR 1.17, 95% CI 0.91 to 1.50) after MT, although patients with AF were less likely to receive IVT (46% vs 54%, p<0.0001). CONCLUSIONS: In patients treated with MT, comorbid AF is associated with faster procedural time, fewer passes, and increased rates of first pass success without increased risk of intracranial hemorrhage or worse functional outcomes. These results are in contrast to the increased hemorrhage rates and worse functional outcomes observed in AF associated stroke treated with supportive care and or IVT. These data suggest that MT negates the AF penalty in ischemic stroke.

11.
J Neurointerv Surg ; 2020 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-33239307

RESUMO

OBJECTIVE: The goal of this article is to provide a succinct review of the key components of a NIH grant application and the NIH reviewprocess for the early career neurointerventionalist. METHODS: The authors reviewed NIH rules and regulations and also reflected on their own collective experiencein writing NIH grant proposals in the area of cerebrovascular disease andneurointerventional surgery. RESULTS: Key components of theresearch strategy include specific aims, significance, innovation and approach.The specific aims page is the most important page of the application and should be written first. The NIH review isbased on these key components along with an assessment of the appropriatenessof the investigators and environment for the research. CONCLUSION: Detailed knowledge ofthe key components of the research grant is critical to a successful application.The information in the article may aid in the grant writing for early careerneurointerventionalists.

12.
J Neurointerv Surg ; 2020 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-33239308

RESUMO

OBJECTIVE: The goal of this article is to provide recommendations for the early career neurointerventionalist in writing a successful grant application to the National Institutes of Health (NIH) and similar funding agencies. METHODS: The authors reviewed NIH rules and regulations and also reflected on their own collective experience in writing NIH grant proposals in the area of cerebrovascular disease and neurointerventional surgery. RESULTS: A strong proposal should address an important scientific problem where there is a gap in knowledge. The solution offered needs to be innovative but at the same time based on a strong scientific premise. The proposed research must be feasible to implement and investigate in the researcher's environment. CONCLUSION: Successful grant writing is critical in funding and enhancing research. The information in the article may aid in the preparation stage of grant writing for early career neurointerventionalists.

13.
J Neurointerv Surg ; 2020 Oct 07.
Artigo em Inglês | MEDLINE | ID: mdl-33028674

RESUMO

While the landmark 2015 stroke trials demonstrated that endovascular therapy (EVT) was superior to medical management for the treatment of acute ischemic stroke due to large vessel occlusion, the efficacy of EVT for patients presenting with a low NIHSS score remains undetermined. We conducted a review of the EVT low National Institutes of Health Stroke Scale (NIHSS) stroke literature, identifying 24 quantitative and six qualitative publications. Details of study designs and outcome were extracted and critically discussed.All identified qualitative studies were retrospective. There was significant study design heterogeneity, with 18 unique study designs between the 24 identified quantitative manuscripts. Study investigations included low NIHSS EVT feasibility (n=6), EVT versus best medical management (BMM; n=10), EVT versus intravenous therapy (IVT, n=3), and low NIHSS score versus high NIHSS score (n=3). From single-arm EVT feasibility studies, the reported ranges of modified Thrombolysis in Cerebral Infarction and symptomatic intracranial hemorrhage were 78-97% and 0-10%, respectively. The EVT versus BMM literature had heterogeneous results with 40% reporting benefit with EVT and 60% reporting neutral findings. None of the studies comparing EVT with IVT reported a difference between the two revascularization therapies. The four identified meta-analyses had incongruent inclusion criteria and conflicting results. Two randomized trials are currently investigating EVT in patients with a low NIHSS score. Selected meta-analyses do suggest a potential benefit of EVT over BMM; however, current and future randomized clinical trials will better elucidate the efficacy of EVT in this patient population.

14.
J Neurol Sci ; 419: 117165, 2020 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-33059298

RESUMO

BACKGROUND AND PURPOSE: There has been an increasing prevalence of Moyamoya disorder (MMD) reported from recent US literature. There is a paucity of data available regarding trends of prevalence and epidemiological factors in the United States. To goal of this study was to test the hypotheses that racial-, sex-specific MMD hospitalizations and epidemiological factors have been increasing in the United States over the last decade. METHODS: In this retrospective observational study, using the National Inpatient Sample (NIS) database from 2005 to 2016, MMD-related hospitalizations in patients aged ≥18 years were identified. Trends of epidemiological factors were analyzed over time using the linear regression model with the significance of differences in trend over time assessed using the Wald test. Sex- and race-specific burden of MMD were calculated using the annual US Census data. Joinpoint regression model was used to evaluate trends of hospitalizations over time. RESULTS: A total of 24,484 adult hospitalizations were identified from January 2005 to September 2015 after excluding <18 years. Among them, approximately ~90% were aged ≤60 years, and 73.5% were females. The most common vascular and non-vascular presentations were ischemic stroke (17.3%) and seizures (21%), respectively. The trend of antithrombotic therapy has increased, while extracranial-intracranial bypass has remained stagnant. The actual average hospitalizations of MMD was 10.4 cases/ million population/year (range 4.1-17.9) and varied significantly by sex (females 14.7 [range 6.2-23.6] and males 5.9 [range 1.8-11.9]) over the 2005 to 2016 study period. The burden of hospitalizations also differed by race (African Americans 40.6 [range 32.8-63.7], Asians 24.8 [15.4-34.8], Non-Hispanic Whites 8.1 [range 6.4-11.5], and Hispanics 8.4 [2.8-12.8]) over the 2010 to 2016 study period. Joinpoint regression analysis showed an increasing overall MMD trend across the study period (+11.7%; P < 0.001), which was higher in males (+14.5% vs. +10.7%; P < 0.001). The Hispanic group had significantly increased hospitalizations over the years (+20.2%; P < 0.001). CONCLUSION: Although overall more prevalent in females, MMD-related hospitalizations are increasing more rapidly in males. Among the racial subpopulations, African Americans had the highest MMD-related hospitalizations, even higher than Asian Americans. MMD-related hospitalizations have increased quicker in Hispanics than in any other racial group.

15.
J Neurointerv Surg ; 2020 Sep 08.
Artigo em Inglês | MEDLINE | ID: mdl-32900909

RESUMO

BACKGROUND: The off-hour effect has been observed in the medical care of acute ischemic stroke. However, it remains unclear if time of arrival affects revascularization rates and outcomes after endovascular therapy (EVT) for emergent large vessel occlusion (ELVO). We aimed to investigate the clinical outcomes of EVT between on-hour and off-hour admissions. METHODS: Patients who underwent EVT for ELVO from January 2013 to June 2019 from the STAR Registry were included. Patients were grouped based on time of groin puncture: on-hour period (Monday through Friday, 7:00 am-4:59 pm) and off-hour period (overnight 5:00pm-6:59am and the weekends). Primary outcome was final modified Rankin Scale (mRS) at 90 days on mRS-shift analysis. RESULTS: A total of 1919 patients were included in the study from six centers. The majority of patients (1169, 60.9%) of patients presented during the off-hour period. The mean age was 68.1 years and 50.5% were women. Successful reperfusion, as defined by a Thrombolysis In Cerebral Infarction (TICI) score of ≥2B, was achieved in 88.8% in the on-hour group and 88.0% in the off-hour group. Good clinical outcome (mRS 0-2) was obtained in 34.4% of off-hour patients and 37.7% of on-hour patients. On multivariable ordinal logistic regression analysis, time of presentation was not associated with worsened outcome (OR 1.150; 95% CI 0.96 to 1.37; P=0.122). Age, admission National Institutes of Health Stroke Scale (NIHSS), baseline mRS, and final TICI score were significantly associated with worse outcomes. CONCLUSION: There is no statistical difference in functional outcome in acute ischemic stroke patients who underwent EVT during on-hours versus off-hours.

17.
J Neurol ; 2020 Sep 07.
Artigo em Inglês | MEDLINE | ID: mdl-32894331

RESUMO

BACKGROUND AND PURPOSE: Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by recurrent thunderclap headaches associated with segmental vasoconstriction of cerebral arteries, which may result in intracranial hemorrhage (ICH). There is a lack of contemporary data available regarding the ICH burden in RCVS cohort. Our aim of the study is to assess the ICH burden, associated risk factors, and discharge outcome of ICH in patients with RCVS. METHODS: All patients diagnosed with RCVS in the 2016 Nationwide Readmission Database were identified using ICD-10 code after excluding patients with the concurrent diagnosis of primary angiitis. ICH was defined as both intraparenchymal (IPH), subarachnoid hemorrhage (SAH), and subdural hematoma (SDH). Categorical and continuous variables were assessed by the Rao-Scott Chi-square test and the Wilcoxon signed-rank sum test respectively. We used a multivariable survey-weighted logistic model to determine the association between ICH and RCVS patient-level characteristics. FINDINGS: A total of 799 patients were identified with RCVS. Total hospitalization of ICH was 43.4% [(95% CI 36.4-50.4%); (n = 346)] including SAH 35.9% [(95% CI 29.7-42.1%); (n = 287)], IPH 13.1% [(95% CI 9.5-16.7%); (n = 105)] and SDH 3.6% [(95% CI 1.5-5.6%); (n = 28)]. Patients with hemorrhagic RCVS (H-RCVS) had a mean age (years ± SE) of 47.4 ± 1.1 vs. 45.5 ± 1.2 years in R-RCVS (p = 0.247); and were predominantly female (84.0% vs. 68.8%; p = 0.001); with longer inpatient stays (10.9 vs. 6.8 days; p = 0.016); and a higher inpatient cost ($44,300 vs. $21,350; p < 0.001). On multivariable analyses, higher odds of ICH were female sex 2.57 (95% CI 1.45-4.55; p = 0.001), middle age-group (45-64 years) 1.87 (CI: 1.11-3.15; p = 0.018) and older age group (> 64 years) 3.72 (CI: 1.15-12.03; p = 0.029). About 67.0% of all H-RCVS patients were discharged home, with no observed inpatient mortality. INTERPRETATION: Intracerebral hemorrhage is the most common vascular complication in hospitalized RCVS patients, resulting in longer hospitalizations with more invasive procedures and higher healthcare expenditure. However, overall outcomes are excellent regardless of types of ICH, with no inpatient mortality observed in patients with hemorrhagic RCVS. Female sex and middle to older age-group are associated with higher odds of ICH.

18.
J Stroke Cerebrovasc Dis ; 29(12): 105330, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32992185

RESUMO

INTRODUCTION: Cocaine through multifactorial pathogenetic mechanisms causes small and large vessel occlusions (LVO) leading to acute ischemic stroke. The optimal treatment for cocaine related LVO remains unknown. Mechanical thrombectomy (MT) poses a unique challenge, and successful MT are not widely reported. MATERIAL AND METHODS: We report three patients with no other risk factors and a common history of cocaine metabolites found on presentation drug screen who underwent MT for MCA occlusions with subsequent failed recanalization or vessel re-occlusion due to persistent thrombosis and severe vasospasm.Two patients initially had good revascularization but then developed severe vasospasm and reoccluded, and the remaining patient had persistent severe distal vasospasm. Rescue therapy either with balloon angioplasty with stent placement or intraarterial vasodilator was used in all patients and was ineffective. All patient had large hemispheric strokes and developed malignant cerebral edema requiring hemicraniectomy in two of them. We also did literature review and summarized previously reported cases of cocaine associated vasospasm in MT and other endovascular procedures. CONCLUSION: In this case series, cocaine induced vasospasm contributed to unsuccessful recanalization and reocclusion in patients undergoing MT with poor outcomes. Further studies are needed to ascertain strategies for improved outcomes in patients with LVO related to cocaine use.

19.
Clin Neurol Neurosurg ; 197: 106199, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32916397

RESUMO

The prediction of outcome after mechanical thrombectomy (MT) of basilar artery occlusion (BAO) remains an area of investigation. The objective of this study was to evaluate the prognostic role of presenting National Institute Health of Stroke Scale (NIHSS) scores in predicting favorable 90-day functional outcome. A survey of 7 electronic databases from inception to May 2020 was conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Multivariate odds ratios (ORs) for favorable 90-day function outcome (modified Rankin Score 0-2) were extracted and pooled by meta-analysis of proportions with random effects modeling. A total of 10 individual studies satisfied criteria for selection and described a total of 941 BAO patients managed by MT. Analysis revealed 590 (63%) males with a mean age of 66.6 years. The median presenting NIHSS was 19, and 316 (34%) patients were reported to have a favorable functional status 90-days after treatment. Lower presenting NIHSS scores independently and significantly predicted favorable 90-day functional outcome in BAO patients with a pooled OR of 0.89 (95% CI, 0.87-0.92; I2 = 18%; P-heterogeneity = 0.28). Meta-regression did not detect any clinical parameter that influenced this trend direction or its significance, and bias assessments were unremarkable. We confirm in this study via a consensus within the literature that the presenting NIHSS score predicts 90-day functional outcome in BAO patients treated by MT. Further, its standardized use allows more meaningful comparisons between interventions and anatomical locations.

20.
J Neurointerv Surg ; 2020 Aug 25.
Artigo em Inglês | MEDLINE | ID: mdl-32843358

RESUMO

BACKGROUND: Many neurointerventionalists have transitioned to transradial access (TRA) as the preferred approach for neurointerventions as studies continue to demonstrate fewer access site complications than transfemoral access. However, radial artery spasm (RAS) remains one of the most commonly cited reasons for access site conversions. We discuss the benefits, techniques, and indications for using the long radial sheath in RAS and present our experience after implementing a protocol for routine use. METHODS: A retrospective review of all patients undergoing neurointerventions via TRA at our institution from July 2018 to April 2020 was performed. In November 2019, we implemented a long radial sheath protocol to address RAS. Patient demographics, RAS rates, radial artery diameter, and access site conversions were compared before and after the introduction of the protocol. RESULTS: 747 diagnostic cerebral angiograms and neurointerventional procedures in which TRA was attempted as the primary access site were identified; 247 were performed after the introduction of the long radial sheath protocol. No significant differences in age, gender, procedure type, sheath sizes, and radial artery diameter were seen between the two cohorts. Radial anomalies and small radial diameters were more frequently seen in patients with RAS. Patients with clinically significant RAS more often required access site conversion (p<0.0001), and in our multivariable model use of the long sheath was the only covariate protective against radial failure (OR 0.061, 95% CI 0.007 to 0.517; p=0.0103). CONCLUSION: In our experience, we have found that the use of long radial sheaths significantly reduces the need for access site conversions in patients with RAS during cerebral angiography and neurointerventions.

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