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1.
J Neurointerv Surg ; 12(11): 1049-1052, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32998982

RESUMO

BACKGROUND: Academic physicians aim to provide clinical and surgical care to their patients while actively contributing to a growing body of scientific literature. The coronavirus disease 2019 (COVID-19) pandemic has resulted in procedural-based specialties across the United States witnessing a sharp decline in their clinical volume and surgical cases. OBJECTIVE: To assess the impact of COVID-19 on neurosurgical, stroke neurology, and neurointerventional academic productivity. METHODS: The study compared the neurosurgical, stroke neurology, and neurointerventional academic output during the pandemic lockdown with the same time period in previous years. Editors from a sample of neurosurgical, stroke neurology, and neurointerventional journals provided the total number of original manuscript submissions, broken down by months, from the year 2016 to 2020. Manuscript submission was used as a surrogate metric for academic productivity. RESULTS: 8 journals were represented. The aggregated data from all eight journals as a whole showed that a combined average increase of 42.3% was observed on original submissions for 2020. As the average yearly percent increase using the 2016-2019 data for each journal exhibited a combined average increase of 11.2%, the rise in the yearly increase for 2020 in comparison was nearly fourfold. For the same journals in the same time period, the average percent of COVID-19 related publications from January to June of 2020 was 6.87%. CONCLUSION: There was a momentous increase in the number of original submissions for the year 2020, and its effects were uniformly experienced across all of our represented journals.


Assuntos
Infecções por Coronavirus , Eficiência , Neurologia/estatística & dados numéricos , Neurocirurgia/estatística & dados numéricos , Pandemias , Pneumonia Viral , Pesquisa/estatística & dados numéricos , Acidente Vascular Cerebral/fisiopatologia , Acidente Vascular Cerebral/cirurgia , Universidades/estatística & dados numéricos , Humanos , Neurocirurgia/tendências , Publicações Periódicas como Assunto , Editoração , Quarentena/estatística & dados numéricos , Pesquisa/tendências , Universidades/tendências
2.
J Neurointerv Surg ; 12(11): 1045-1048, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32989032

RESUMO

BACKGROUND: We aimed to compare the outcome of acute ischemic stroke (AIS) patients who received endovascular thrombectomy (EVT) with confirmed COVID-19 to those without. METHODS: We performed a retrospective analysis using the Vizient Clinical Data Base and included hospital discharges from April 1 to July 31 2020 with ICD-10 codes for AIS and EVT. The primary outcome was in-hospital death and the secondary outcome was favorable discharge, defined as discharge home or to acute rehabilitation. We compared patients with laboratory-confirmed COVID-19 to those without. As a sensitivity analysis, we compared COVID-19 AIS patients who did not undergo EVT to those who did, to balance potential adverse events inherent to COVID-19 infection. RESULTS: We identified 3165 AIS patients who received EVT during April to July 2020, in which COVID-19 was confirmed in 104 (3.3%). Comorbid COVID-19 infection was associated with younger age, male sex, diabetes, black race, Hispanic ethnicity, intubation, acute coronary syndrome, acute renal failure, and longer hospital and intensive care unit length of stay. The rate of in-hospital death was 12.4% without COVID-19 vs 29.8% with COVID-19 (P<0.001). In mixed-effects logistic regression that accounted for patient clustering by hospital, comorbid COVID-19 increased the odds of in-hospital death over four-fold (OR 4.48, 95% CI 3.02 to 6.165). Comorbid COVID-19 was also associated with lower odds of a favorable discharge (OR 0.43, 95% CI 0.30 to 0.61). In the sensitivity analysis, comparing AIS patients with COVID-19 who did not undergo EVT (n=2139) to the AIS EVT patients with COVID-19, there was no difference in the rate of in-hospital death (30.6% vs 29.8%, P=0.868), and AIS EVT patients had a higher rate of favorable discharge (32.4% vs 47.1%, P=0.002). CONCLUSION: In AIS patients treated with EVT, comorbid COVID-19 infection was associated with in-hospital death and a lower odds of favorable discharge compared with patients without COVID-19, but not compared with AIS patients with COVID-19 who did not undergo EVT. AIS EVT patients with COVID-19 were younger, more likely to be male, have systemic complications, and almost twice as likely to be black and over three times as likely to be Hispanic.


Assuntos
Isquemia Encefálica/complicações , Isquemia Encefálica/cirurgia , Infecções por Coronavirus/complicações , Procedimentos Endovasculares/estatística & dados numéricos , Pneumonia Viral/complicações , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/cirurgia , Trombectomia/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Procedimentos Endovasculares/métodos , Grupos Étnicos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Estudos Retrospectivos , Fatores Sexuais , Fatores Socioeconômicos , Reabilitação do Acidente Vascular Cerebral/estatística & dados numéricos , Trombectomia/métodos , Resultado do Tratamento , Adulto Jovem
4.
Anesth Analg ; 131(4): 1124-1134, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925333

RESUMO

Acute ischemic stroke is a neurological emergency with a high likelihood of morbidity, mortality, and long-term disability. Modern stroke care involves multidisciplinary management by neurologists, radiologists, neurosurgeons, and anesthesiologists. Current American Heart Association/American Stroke Association (AHA/ASA) guidelines recommend thrombolytic therapy with intravenous (IV) alteplase within the first 3-4.5 hours of initial stroke symptoms and endovascular mechanical thrombectomy within the first 16-24 hours depending on specific inclusion criteria. The anesthesia and critical care provider may become involved for airway management due to worsening neurologic status or to enable computerized tomography (CT) or magnetic resonance imaging (MRI) scanning, to facilitate mechanical thrombectomy, or to manage critical care of stroke patients. Existing data are unclear whether the mechanical thrombectomy procedure is best performed under general anesthesia or sedation. Retrospective cohort trials favor sedation over general anesthesia, but recent randomized controlled trials (RCT) neither suggest superiority nor inferiority of sedation over general anesthesia. Regardless of anesthesia type, a critical element of intraprocedural stroke care is tight blood pressure management. At different phases of stroke care, different blood pressure targets are recommended. This narrative review will focus on the anesthesia and critical care providers' roles in the management of both perioperative stroke and acute ischemic stroke with a focus on anesthetic management for mechanical thrombectomy.


Assuntos
Anestesia , Isquemia Encefálica/cirurgia , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Humanos , Assistência Perioperatória
5.
Stroke ; 51(10): 2951-2959, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32895016

RESUMO

BACKGROUND AND PURPOSE: The best anesthetic management for mechanical thrombectomy of large vessel occlusion strokes is still uncertain and could impact the quality of reperfusion and clinical outcome. We aimed to compare the efficacy and safety outcomes between local anesthesia (LA) and conscious sedation in a large cohort of acute ischemic stroke patients with anterior circulation large vessel occlusion strokes treated with mechanical thrombectomy in current, everyday clinical practice. METHODS: Patients undergoing mechanical thrombectomy for anterior large vessel occlusion strokes at 4 comprehensive stroke centers in France between January 1, 2018, and December 31, 2018, were pooled from the ongoing prospective multicenter observational Endovascular Treatment in Ischemic Stroke Registry in France. Intention-to-treat and per-protocol analyses were used. RESULTS: Among the included 1034 patients, 762 were included in the conscious sedation group and 272 were included in the LA group. In the propensity score matched cohort, the rate of favorable outcome (90-day modified Rankin Scale score 0-2) was significantly lower in the LA group than in the conscious sedation group (40.0% versus 52.0%, matched relative risk=0.76 [95% CI, 0.60-0.97]), as well as the rate of successful reperfusion (modified Thrombolysis in Cerebral Infarction grade 2b-3; 76.6% versus 87.1%; matched relative risk=0.88 [95% CI, 0.79-0.98]). There was no difference in procedure time between the 2 groups. In the inverse probability of treatment weighting-propensity score-adjusted cohort, similar significant differences were found for favorable outcomes and successful reperfusion. In inverse probability of treatment weighting-propensity score-adjusted cohort, a higher rate of 90-day mortality and a lower parenchymal hematoma were observed after LA. The sensitivity analysis restricted to our per-protocol sample provided similar results in the matched- and inverse probability of treatment weighting-propensity cohorts. CONCLUSIONS: In the Endovascular Treatment in Ischemic Stroke registry mainly included patients in early time window (<6 hours), LA was associated with lower odds of favorable outcome, successful reperfusion, and higher odds of mortality compared with conscious sedation for mechanical thrombectomy of large vessel occlusion.


Assuntos
Anestesia Local , Isquemia Encefálica/cirurgia , Sedação Consciente/métodos , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Resultado do Tratamento
6.
Stroke ; 51(10): 3174-3181, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32912096

RESUMO

The use of mechanical thrombectomy for the treatment of acute childhood arterial ischemic stroke with large vessel occlusion is increasing, with mounting evidence for its feasibility and safety. Despite this emerging evidence, clear guidelines for patient selection, thrombectomy technique, and postprocedure care do not exist for the pediatric population. Due to unique features of stroke in children, neurologists and interventionalists must consider differences in patient size, anatomy, collateral vessels, imaging parameters, and expected outcomes that may impact appropriate patient selection and timing criteria. In addition, different causes of stroke and comorbidities in children must be considered and may alter the safety and efficacy of thrombectomy. To optimize the success of endovascular intervention in children, a multidisciplinary team should take into account these nuanced considerations when determining patient eligibility, developing a procedural approach, and formulating a postprocedure neurological monitoring and therapeutic plan.


Assuntos
Isquemia Encefálica/cirurgia , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Isquemia Encefálica/diagnóstico por imagem , Criança , Humanos , Imagem por Ressonância Magnética , Seleção de Pacientes , Acidente Vascular Cerebral/diagnóstico por imagem , Resultado do Tratamento
7.
Stroke ; 51(10): 2925-2933, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32933416

RESUMO

BACKGROUND AND PURPOSE: This study aimed to evaluate the treatment effect of intraarterial versus intravenous tirofiban during endovascular thrombectomy in acute ischemic stroke. METHODS: This study retrospectively examined 503 patients with acute ischemic stroke with large vessel occlusion who received endovascular thrombectomy within 24 hours of stroke onset. Patients were divided into 3 groups: no tirofiban (n=354), intraarterial tirofiban (n=79), and intravenous tirofiban (n=70). The 3 groups were compared in terms of recanalization rate, symptomatic intracerebral hemorrhage, in-hospital death rate, 3-month death, and 3-month outcomes measured by modified Rankin Scale score (good clinical outcome of 0-2, poor outcome of 5-6). The comparison was statistically assessed by propensity score matching, followed by Freidman rank-sum test and pairwise Wilcoxon signed-rank test with Bonferroni correction. RESULTS: The propensity score matching resulted in 92 matched triplets. Compared with the no-tirofiban group, the intravenous tirofiban group showed significantly increased recanalization (96.7% versus 64.1%, P<0.001), an increased rate of 3-month good outcome (69.5% versus 51.2%, P=0.034), and a lower rate of 3-month poor outcome (12.2% versus 41.4%, P<0.001). There was no significant difference between the tirofiban intravenous and no-tirofiban groups in terms of symptomatic intracerebral hemorrhage (2.2% versus 0%, P=1.000). However, symptomatic intracerebral hemorrhage was significantly increased in the intraarterial-tirofiban group compared with the no-tirofiban group (19.1% versus 0%, P<0.001), with an increased rate of in-hospital death (23.6% versus 0% P<0.001), and increased rate of 3-month death (26.8% versus 11.1%, P=0.021). The intraarterial-tirofiban and no-tirofiban group showed no significant difference in recanalization rate (66.3% versus 64.1%, P=1.000). CONCLUSIONS: As an adjunct to endovascular thrombectomy, intravenous tirofiban is associated with high recanalization rate and good outcome, whereas intraarterial tirofiban is associated with high hemorrhagic rate and death rate.


Assuntos
Isquemia Encefálica/terapia , Procedimentos Endovasculares , Fibrinolíticos/uso terapêutico , Acidente Vascular Cerebral/terapia , Trombectomia , Tirofibana/uso terapêutico , Idoso , Isquemia Encefálica/tratamento farmacológico , Isquemia Encefálica/cirurgia , Terapia Combinada , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Infusões Intra-Arteriais , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/cirurgia , Tirofibana/administração & dosagem , Resultado do Tratamento
8.
Stroke ; 51(10): 2934-2942, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32933420

RESUMO

BACKGROUND AND PURPOSE: Post hoc analyses of randomized controlled clinical trials evaluating mechanical thrombectomy have suggested that admission-to-groin-puncture (ATG) delays are associated with reduced reperfusion rates. Purpose of this analysis was to validate this association in a real-world cohort and to find associated factors and confounders for prolonged ATG intervals. METHODS: Patients included into the BEYOND-SWIFT cohort (Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the Solitaire FR With the Intention for Thrombectomy; https://www.clinicaltrials.gov; Unique identifier: NCT03496064) were analyzed (n=2386). Association between baseline characteristics and ATG was evaluated using mixed linear regression analysis. The effect of increasing symptom-onset-to-admission and ATG intervals on successful reperfusion (defined as Thrombolysis in Cerebral Infarction [TICI] 2b-3) was evaluated using logistic regression analysis adjusting for potential confounders. RESULTS: Median ATG was 73 minutes. Prolonged ATG intervals were associated with the use of magnetic resonance imaging (+19.1 [95% CI, +9.1 to +29.1] minutes), general anesthesia (+12.1 [95% CI, +3.7 to +20.4] minutes), and borderline indication criteria, such as lower National Institutes of Health Stroke Scale, late presentations, or not meeting top-tier early time window eligibility criteria (+13.8 [95% CI, +6.1 to +21.6] minutes). There was a 13% relative odds reduction for TICI 2b-3 (adjusted odds ratio [aOR], 0.87 [95% CI, 0.79-0.96]) and TICI 2c/3 (aOR, 0.87 [95% CI, 0.79-0.95]) per hour ATG delay, while the reduction of TICI 2b-3 per hour increase symptom-onset-to-admission was minor (aOR, 0.97 [95% CI, 0.94-0.99]) and inconsistent regarding TICI 2c/3 (aOR, 0.99 [95% CI, 0.97-1.02]). After adjusting for identified factors associated with prolonged ATG intervals, the association of ATG delay and lower rates of TICI 2b-3 remained tangible (aOR, 0.87 [95% CI, 0.76-0.99]). CONCLUSIONS: There is a great potential to reduce ATG, and potential targets for improvement can be deduced from observational data. The association between in-hospital delay and reduced reperfusion rates is evident in real-world clinical data, underscoring the need to optimize in-hospital workflows. Given the only minor association between symptom-onset-to-admission intervals and reperfusion rates, the causal relationship of this association warrants further research. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064.


Assuntos
Isquemia Encefálica/cirurgia , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico por imagem , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Acidente Vascular Cerebral/diagnóstico por imagem , Fatores de Tempo , Tempo para o Tratamento , Resultado do Tratamento
10.
PLoS One ; 15(9): e0238640, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32915843

RESUMO

We developed a prediction model of long-term risk after percutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO) based on pre-procedural clinical information. A total of 4,139 eligible patients, who underwent CTO-PCI at 52 Japanese centers were included. Specifically, 1,909 patients with 1-year data were randomly divided into the derivation (n = 1,273) and validation (n = 636) groups. Major adverse cardiac and cardiovascular event (MACCE) was the primary endpoint, including death, stroke, revascularization, and non-fatal myocardial infarction. We assessed the performance of our model using the area under the receiver operating characteristic curve (AUC) and assigned a simplified point-scoring system. One-hundred-thirty-eight (10.8%) patients experienced MACCE in the derivation cohort with hemodialysis (HD: odds ratio [OR] = 2.55), left ventricular ejection fractions (LVEF) <35% (OR = 2.23), in-stent occlusions (ISO: OR = 2.27), and diabetes mellitus (DM: OR = 1.72). The AUC of the derivation model was 0.650. The model's performance was similar in the validation cohort (AUC, 0.610). When assigned a point for each associated factor (HD = 3, LVEF <35%, ISO = 2, and DM = 1 point), the average predicted versus the observed MACCE probability using the Japan-CTO extension score for the low, moderate, high, and very high risk groups was 8.1% vs. 7.3%, 16.9% vs. 15.9%, 22.0% vs. 26.1%, and 56.2% vs. 44.4%, respectively. This novel risk model may allow for the estimation of long-term risk and be useful in disseminating appropriate revascularization procedures.


Assuntos
Oclusão Coronária/epidemiologia , Coração/fisiopatologia , Infarto do Miocárdio/epidemiologia , Intervenção Coronária Percutânea/efeitos adversos , Acidente Vascular Cerebral/epidemiologia , Idoso , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte de Artéria Coronária/métodos , Oclusão Coronária/fisiopatologia , Oclusão Coronária/cirurgia , Morte , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/fisiopatologia , Infarto do Miocárdio/cirurgia , Revascularização Miocárdica/efeitos adversos , Curva ROC , Diálise Renal/métodos , Fatores de Risco , Acidente Vascular Cerebral/fisiopatologia , Acidente Vascular Cerebral/cirurgia
11.
BMC Neurol ; 20(1): 358, 2020 Sep 24.
Artigo em Inglês | MEDLINE | ID: mdl-32972381

RESUMO

BACKGROUND: The novel coronavirus (COVID-19) global pandemic is associated with an increased incidence of acute ischemic stroke (AIS) secondary to large vessel occlusion (LVO). The treatment of these patients poses unique and significant challenges to health care providers requiring changes in existing protocols. CASE PRESENTATION: A 54-year-old COVID-19 positive patient developed sudden onset left hemiparesis secondary to an acute right middle cerebral artery occlusion (National Institutes of Health Stroke Scale (NIHSS) score = 11). Mechanical thrombectomy (MT) was performed under a new protocol specifically designed to maximize protective measures for the team involved in the care of the patient. Mechanical Thrombectomy was performed successfully under general anesthesia resulting in TICI 3 recanalization. With regards to time metrics, time from door to reperfusion was 60 mins. The 24-h NIHSS score decreased to 2. Patient was discharged after 19 days after improvement of her pulmonary status with modified Rankin Scale = 1. CONCLUSION: Patients infected by COVID-19 can develop LVO that is multifactorial in etiology. Mechanical thrombectomy in a COVID-19 confirmed patient presenting with AIS due to LVO is feasible with current mechanical thrombectomy devices. A change in stroke workflow and protocols is now necessary in order to deliver the appropriate life-saving therapy for COVID-19 positive patients while protecting medical providers.


Assuntos
Infecções por Coronavirus/complicações , Procedimentos Endovasculares/métodos , Infarto da Artéria Cerebral Média/cirurgia , Equipamento de Proteção Individual , Pneumonia Viral/complicações , Trombectomia/métodos , Betacoronavirus , Isquemia Encefálica/complicações , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/cirurgia , Angiografia Cerebral , Angiografia por Tomografia Computadorizada , Serviços Médicos de Emergência , Feminino , Humanos , Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Intubação Intratraqueal , Pessoa de Meia-Idade , Pandemias , Reperfusão , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Tempo para o Tratamento , Resultado do Tratamento
13.
Curr Opin Anaesthesiol ; 33(5): 651-654, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32796168

RESUMO

PURPOSE OF REVIEW: With the aging of the population, there are increasing number of aged patients who require surgical interventions. Perioperative covert stroke is emerging as an important health threat and social burden that could affect patients' long-term neurological outcomes. RECENT FINDINGS: Recent findings of the association between perioperative covert stroke with long-term cognitive declines of surgical patients highlighted the significance of the silent cognitive function killer-perioperative covert stroke. Considering the devastating long-term consequence of the asymptomatic covert stroke, early diagnosis and prevention are turning out as crucial problems to tackle. The evolving brain imaging techniques, such as multimodel MRI sequences are not only able to detect early, small and subtle injuries of the acute ischemic lesions, but also quite advantageous in capturing the preexisting brain vascular diseases that are considered as important risk factors of covert stroke. However, effective predictive markers are still lacking to identify high risk patients for perioperative covert stroke, rendering an unmet need of investigations in this regard. SUMMARY: The present review will summarize recent findings in perioperative covert stroke and highlight future perspectives of its early diagnosis and the impact of postoperative cognitive impairments.


Assuntos
Cognição/fisiologia , Disfunção Cognitiva/etiologia , Complicações Pós-Operatórias , Acidente Vascular Cerebral/cirurgia , Humanos , Imagem por Ressonância Magnética , Período Perioperatório , Fatores de Risco , Acidente Vascular Cerebral/complicações
14.
AJNR Am J Neuroradiol ; 41(10): 1849-1855, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32819897

RESUMO

BACKGROUND AND PURPOSE: Chest CT is a rapid, useful additional screening tool for coronavirus disease 2019 (COVID-19) in emergent procedures. We describe the feasibility and interim outcome of implementing a modified imaging algorithm for COVID-19 risk stratification across a regional network of primary stroke centers in the work-up of acute ischemic stroke referrals for time-critical mechanical thrombectomy. MATERIALS AND METHODS: We undertook a retrospective review of 49 patients referred to the regional neuroscience unit for consideration of mechanical thrombectomy between April 14, 2020, and May 21, 2020. During this time, all referring units followed a standard imaging protocol that included a chest CT in addition to a head CT and CT angiogram to identify Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infective pulmonary changes. RESULTS: Overall, 2 patients had typical COVID-19 radiologic features and tested positive, while 7 patients had indeterminate imaging findings and tested negative. The others had normal or atypical changes and were not diagnosed with or suspected of having COVID-19. There was an overall sensitivity of 100%, specificity of 74.1%, negative predictive value of 100%, and positive predictive value of 22.2% when using chest CT to diagnose COVID-19 in comparison with the real-time reverse transcriptase-polymerase chain reaction test. The mean additional time and radiation dose incurred for the chest CT were 184 ± 65.5 seconds and 2.47 ± 1.03 mSv. Multiple cardiovascular and pulmonary incidental findings of clinical relevance were identified in our patient population. CONCLUSIONS: Chest CT provides a pragmatic, rapid additional tool for COVID-19 risk stratification among patients referred for mechanical thrombectomy. Its inclusion in a standardized regional stroke imaging protocol has enabled efficient use of hospital resources with minimal compromise or delay to the overall patient treatment schedule.


Assuntos
Betacoronavirus , Isquemia Encefálica/diagnóstico por imagem , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/etiologia , Isquemia Encefálica/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Estudos Retrospectivos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/cirurgia , Trombectomia , Tomografia Computadorizada por Raios X
15.
PLoS One ; 15(8): e0236956, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32790766

RESUMO

OBJECTIVES: Stroke triage using CT perfusion (CTP) or MRI gained importance after successful application in recent trials on late-window thrombectomy but is often unavailable and time-consuming. We tested the clinical value of software-based analysis of cerebral attenuation on Single-phase CT angiography source images (CTASI) as CTP surrogate in stroke patients. METHODS: Software-based automated segmentation and Hounsfield unit (HU) measurements for all regions of the Alberta Stroke Program Early CT Score (ASPECTS) on CTASI were performed in patients with large vessel occlusion stroke who underwent thrombectomy. To normalize values, we calculated relative HU (rHU) as ratio of affected to unaffected hemisphere. Ischemic regions, regional ischemic core and final infarction were determined on simultaneously acquired CTP and follow-up imaging as ground truth. Receiver operating characteristics analysis was performed to calculate the area-under-the-curve (AUC). Resulting cut-off values were used for comparison with visual analysis and to calculate an 11-point automated CTASI ASPECTS. RESULTS: Seventy-nine patients were included. rHU values enabled significant classification of ischemic involvement on CTP in all ten regions of the ASPECTS (each p<0.001, except M4-cortex p = 0.002). Classification of ischemic core and prediction of final infarction had best results in subcortical regions but produced lower AUC values with significant classification for all regions except M1, M3 and M5. Relative total hemispheric attenuation provided strong linear correlation with CTP total ischemic volume. Automated classification of regional ischemia on CTASI was significantly more accurate in most regions and provided better agreement with CTP cerebral blood flow ASPECTS than visual assessment. CONCLUSIONS: Automated attenuation measurements on CTASI provide excellent performance in detecting acute ischemia as identified on CTP with improved accuracy compared to visual analysis. However, value for the approximation of ischemic core and morphologic outcome in large vessel occlusion stroke after thrombectomy was regionally dependent and limited. This technique has the potential to facilitate stroke imaging as sensitive surrogate for CTP-based ischemia.


Assuntos
Isquemia Encefálica/diagnóstico por imagem , Angiografia por Tomografia Computadorizada/métodos , Interpretação de Imagem Radiográfica Assistida por Computador/métodos , Acidente Vascular Cerebral/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/cirurgia , Angiografia por Tomografia Computadorizada/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Interpretação de Imagem Radiográfica Assistida por Computador/estatística & dados numéricos , Estudos Retrospectivos , Acidente Vascular Cerebral/cirurgia , Trombectomia , Resultado do Tratamento
16.
J Neuroimaging ; 30(5): 555-561, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32776617

RESUMO

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as the name suggests was initially thought to only cause a respiratory illness. However, several reports have been published of patients with ischemic strokes in the setting of coronavirus disease 2019 (COVID-19). The mechanisms of how SARS-CoV-2 results in blood clots and large vessel strokes need to be defined as it has therapeutic implications. SARS-CoV-2 enters the blood stream by breaching the blood-air barrier via the lung capillary adjacent to the alveolus, and then attaches to the angiotensin-converting enzyme II receptors on the endothelial cells. Once SARS-CoV-2 enters the blood stream, a cascade of events (Steps 1-8) unfolds including accumulation of angiotensin II, reactive oxygen species, endothelial dysfunction, oxidation of beta 2 glycoprotein 1, formation of antiphospholipid antibody complexes promoting platelet aggregation, coagulation cascade, and formation of cross-linked fibrin blood clots, leading to pulmonary emboli (PE) and large vessel strokes seen on angiographic imaging studies. There is emerging evidence for COVID-19 being a blood clotting disorder and SARS-CoV-2 using the respiratory route to enter the blood stream. As the blood-air barrier is breached, varying degrees of collateral damage occur. Although antiviral and immune therapies are studied, the role of blood thinners in the prevention, and management of blood clots in Covid-19 need evaluation. In addition to ventilators and blood thinners, continuous aspiration and clot retrieval devices (approved in Europe, cleared in the United States) or cyclical aspiration devices (approved in Europe) need to be considered for the emergent management of life-threatening clots including PE and large vessel strokes.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Acidente Vascular Cerebral/etiologia , Coagulação Sanguínea , Células Endoteliais , Humanos , Pandemias , Acidente Vascular Cerebral/cirurgia , Trombectomia
17.
Stroke ; 51(9): 2697-2704, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32757749

RESUMO

BACKGROUND AND PURPOSE: In large artery occlusion stroke, both intravenous (IV) tPA (tissue-type plasminogen activator) and endovascular stroke treatment (EST) are standard-of-care. It is unknown how often tPA causes distal embolization, in which a procedurally accessible large artery occlusion is converted to a more distal and potentially inaccessible occlusion. METHODS: We analyzed data from a decentralized stroke telemedicine program in an integrated healthcare delivery system covering 21 hospitals, with 2 high-volume EST centers. We captured all cases sent for EST and examined the relationship between IV tPA administration and the rate of distal embolization, the rate of target recanalization (modified Treatment in Cerebral Infarction scale 2b/3), clinical improvement before EST, and short-term and long-term clinical outcomes. RESULTS: Distal embolization before EST was quite common (63/314 [20.1%]) and occurred more often after IV tPA before EST (57/229 [24.9%]) than among those not receiving IV tPA (6/85 [7.1%]; P<0.001). Distal embolization was associated with an inability to attempt EST: after distal embolization, 26/63 (41.3%) could not have attempted EST because of the new clot location, while in cases without distal embolization, only 8/249 (3.2%) were unable to have attempted EST (P<0.001). Among patients who received IV tPA, 13/242 (5.4%) had sufficient symptom improvement that a catheter angiogram was not performed; 6/342 (2.5%) had improvement to within 2 points of their baseline NIHSS. At catheter angiogram, 2/229 (0.9%) of patients who had received tPA had complete recanalization without distal embolization. Both IV tPA and EST recanalization were associated with improved long-term outcome. CONCLUSIONS: IV tPA administration before EST for large artery occlusion is associated with distal embolization, which in turn may reduce the chance that EST can be attempted and recanalization achieved. At the same time, some IV tPA-treated patients show symptomatic improvement and complete recanalization. Because IV tPA is associated with both distal embolization and improved long-term clinical outcome, there is a need for prospective clinical trials testing the net benefit or harm of IV tPA before EST.


Assuntos
Embolização Terapêutica/efeitos adversos , Procedimentos Endovasculares/métodos , Fibrinolíticos/efeitos adversos , Acidente Vascular Cerebral/cirurgia , Ativador de Plasminogênio Tecidual/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Angiografia , Arteriopatias Oclusivas/complicações , Infarto Cerebral/cirurgia , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Medição de Risco , Ativador de Plasminogênio Tecidual/uso terapêutico , Tomografia Computadorizada por Raios X , Resultado do Tratamento
19.
Stroke ; 51(9): 2630-2638, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32772684

RESUMO

BACKGROUND AND PURPOSE: To quantify workflow metrics in patients receiving stroke imaging (noncontrast-enhanced computed tomography [CT] and CT-angiography) in either a computed-tomography scanner suite (CT-Transit [CTT]) or an angio-suite (direct transfer to angio-suite-[DTAS]-using flat-panel CT) before undergoing mechanical thrombectomy. METHODS: Prospective, single-center investigator initiated randomized controlled trial in a comprehensive stroke center focusing on time from imaging to groin puncture (primary end point) and time from hospital admission to final angiographic result (secondary end point) in patients receiving mechanical thrombectomy for anterior circulation large vessel occlusion after randomization to the CTT or DTAS pathway. RESULTS: The trial was stopped early after the enrollment of n=60 patients (CTT: n=34/60 [56.7 %]; DTAS: n=26/60 [43.3%]) of n=110 planned patients because of a preplanned interim analysis. Time from imaging to groin puncture was shorter in DTAS-patients (in minutes, median [interquartile range]: CTT: 26 [23-32]; DTAS: 19 [15-23]; P value: 0.001). Time from hospital admission to stroke imaging was shorter in patients randomized to DTAS (CTT: 12 (7-18); DTAS: 21 (15-25), P value: 0.007). Time from hospital admission to final angiographic reperfusion was comparable between patient groups (CTT: 78 [58-92], DTAS: 80 [66-118]; P value: 0.067). CONCLUSIONS: This trial showed a reduction in time from imaging to groin-puncture when patients are transferred directly to the angiosuite for advanced stroke-imaging compared with imaging in a CT scanner suite. This time saving was outweighed by a longer admission to imaging time and could not translate into a shorter time to final angiographic reperfusion in this trial.


Assuntos
Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/cirurgia , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/cirurgia , Angiografia por Tomografia Computadorizada , Determinação de Ponto Final , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transferência de Pacientes , Estudos Prospectivos , Reperfusão , Tempo para o Tratamento , Tomografia Computadorizada por Raios X , Fluxo de Trabalho
20.
Stroke ; 51(9): 2742-2751, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32811382

RESUMO

BACKGROUND AND PURPOSE: We aimed to evaluate the impact of cortical microinfarcts (CMIs) on functional outcome after endovascular treatment in patients with acute ischemic stroke. METHODS: In a multicenter registration study for RESCUE-RE (a registration study for Critical Care of Acute Ischemic Stroke After Recanalization), eligible patients with large vessel occlusion stroke receiving endovascular treatment, who had undergone 3T magnetic resonance imaging on admission or within 24 hours after endovascular treatment were analyzed. We evaluated the presence and numbers of CMIs with assessment of axial T1, T2-weighted images, and fluid-attenuated inversion recovery images. The primary outcome was functional dependence or death defined as modified Rankin Scale scores of 3 to 6 at 90 days. Secondary outcomes included early neurological improvement, any intracranial hemorrhage, symptomatic intracranial hemorrhage, and mortality. We investigated the independent associations of CMIs with the outcomes using multivariable logistic regression in overall patients and in subgroups. RESULTS: Among 414 patients (enrolled from July 2018 to May 2019) included in the analyses, 96 (23.2%) patients had at least one CMI (maximum 6). Patients with CMI(s) were more likely to be functionally dependent or dead at 90 days, compared with those without (55.2% versus 37.4%; P<0.01). In multivariable logistic regression analyses, presence of CMI(s) (adjusted odds ratio, 1.78 [95% CI, 1.04-3.07]; P=0.04) and multiple CMIs (CMIs ≥2; adjusted odds ratio, 7.41 [95% CI, 2.48-22.17]; P<0.001) were independently, significantly associated with the primary outcome. There was no significant difference between subgroups in the associations between CMI presence and the primary outcome. CONCLUSIONS: Acute large vessel occlusion stroke patients receiving endovascular treatment with CMI(s) were more likely to have a poor functional outcome at 90 days, independent of patients' characteristics. Such associations may be dose-dependent. Registration: URL: http://www.chictr.org.cn; Unique identifier: ChiCTR1900022154.


Assuntos
Isquemia Encefálica/complicações , Isquemia Encefálica/cirurgia , Córtex Cerebral , Infarto Cerebral/complicações , Procedimentos Endovasculares/métodos , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Arteriopatias Oclusivas/complicações , Arteriopatias Oclusivas/cirurgia , Isquemia Encefálica/diagnóstico por imagem , Córtex Cerebral/diagnóstico por imagem , Infarto Cerebral/diagnóstico por imagem , Infarto Cerebral/mortalidade , Feminino , Humanos , Hemorragias Intracranianas/etiologia , Angiografia por Ressonância Magnética , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sistema de Registros , Acidente Vascular Cerebral/diagnóstico por imagem , Resultado do Tratamento
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