Impact of demographic and clinical factors on in-hospital delays in acute ischemic stroke treatment.

BACKGROUND: Delays in reperfusion treatment, both intravenous thrombolysis (IVT) and endovascular treatment (EVT), adversely affect outcomes in patients with acute ischemic stroke (AIS). To alleviate these delays, it is essential to comprehend how patients' baseline and stroke characteristics impact in-hospital reperfusion delays. While demographic and socioeconomic factors affect stroke outcomes, their impact on in-hospital delays remains unclear. METHOD: This is retrospective analysis at a tertiary stroke center, encompassing AIS patients receiving IVT and / or EVT between 2019 and 2022 (re-canalization cohort). Outcomes of interest were time intervals of admission to CT and admission to recanalization. Univariable analyses explored age, gender, baseline functional status, socioeconomic status (SES), ethnicity, vascular risk factors, and stroke characteristics. Subsequently, multivariable logistic regression analyses were performed. RESULTS: Altogether, 313 patients treated with IVT and 293 with EVT were included in the re-canalization cohort. No demographic variables were found to be associated with stroke treatment time intervals. Following multivariable analysis, stroke severity (low NIHSS, p < 0.01), arrival to the hospital by other means than ambulance (p < 0.01), and atypical stroke symptoms (p < 0.01), were associated with in-hospital delays, both in the EVT and the IVT groups. CONCLUSION: Our findings indicate that patients with a more severe ischemic stroke, typical stroke symptoms, and arrival by ambulance have shorter stroke treatment time intervals. These results emphasize that, in atypical cases, even a lower suspicion of stroke should promote urgent workup for stroke diagnosis. Our findings do not indicate any influence of demographic or SES on in-hospital reperfusion delays.

Effect of Radiological Tumor Thickness on Prognosis of Early Glottic-Squamous Cell Carcinoma Treated With Radiation.

OBJECTIVES: Tumor depth of invasion is a known prognostic factor in several head and neck cancers, but data on early laryngeal squamous cell carcinoma (SCC) are sparse. In this study, we aim to determine whether radiological tumor thickness serves as a prognostic factor in early SCC of the glottis treated with radiation. METHODS: One hundred thirty-two adult patients (age >18 years) underwent pretreatment computed tomography (CT) and were treated with radiation for pathologically proven early stage (T1 or T2) glottic SCC. Thirty-eight were excluded because the tumor could not be correctly identified on the CT scan, and an additional three patients because of insufficient data. RESULTS: The final cohort consisted of 91 patients, 84 (90.3%) men and 7 (9.7%) women aged 39.86-86.53 (mean 65.55 ± 12.76) years. Mean tumor thickness was 0.59 ± 0.19 cm in patients with T1 tumors and 0.79 ± 0.21 cm in patients with T2 tumors. The optimal cutoff value for 5-year disease-free survival (DFS), using the Youden index (sensitivity: 81.2%, specificity 65.3%), was 0.7 cm. A significant advantage in 5-year overall survival (OAS) and 5-year DFS for tumor thickness of <0.7 cm (P = 0.01 and P < 0.01, respectively) was found, these findings were consistent also when each stage was examined separately (T1 vs T2). CONCLUSION: Radiological tumor thickness appears to significantly predict OAS and DFS in early glottic SCC patients. IMPLICATION FOR PRACTICE: Tumor thickness may be considered as an auxiliary aid in deciding follow-up time and frequency, proper treatment, and determining prognosis.

Impact of dementia status on intravenous thrombolysis and endovascular treatment for acute ischemic stroke: Retrospective study.

INTRODUCTION: Individuals with dementia are underrepresented in interventional studies for acute ischemic stroke (AIS). This research gap creates a bias against their treatment in clinical practice. Our goal was to compare the safety and efficacy of intravenous-thrombolysis (t-PA) and endovascular treatment (EVT) in individuals with or without pre-AIS dementia. METHOD: A retrospective study of AIS patients receiving t-PA or EVT between 2019 and 2022. Patients were classified as dementia on a case-by-case review of baseline assessment. Additional variables included demographic, vascular risk factors, AIS severity and treatment. Outcomes of interest were intracerebral hemorrhage, mortality in 90-days, and the difference in modified rankin scale (mRS) before AIS and in 90-days follow-up. Outcomes were compared across non-matched groups and following propensity-score matching. RESULTS: Altogether, 628 patients were included, of which 68 had pre-AIS dementia. Compared to non-dementia group, dementia group were older, had a higher rate of vascular risk factors, higher pre-stroke mRS and higher baseline NIHSS. Individuals with dementia had higher rates of mortality (25% vs.11%,p < 0.01) on non-matched comparison. All cohort and restricted t-PA EVT matched analysis showed no difference in any outcome. Regression analysis confirmed that AIS severity at presentation and its treatment, not dementia, were the chief contributors to patients' outcomes. DISCUSSION: Our results indicate that pre-AIS dementia does not impact the efficacy or safety of EVT or t-PA for AIS. We thus call for more inclusive research on stroke therapy with regards to baseline cognitive status. Such studies are urgently required to inform stroke guidelines and enhance care.

Intracranial stenting for large vessel intracranial atherosclerotic disease: Retrospective study.

BACKGROUND: Intracranial atherosclerotic disease (ICAD) is a common cause for stroke and can be defined as symptomatic (stroke) or asymptomatic. Current guidelines recommend against intracranial stenting (ICS) for patients with ICAD; treatment of patients who failed the best medical therapy is still debatable. METHODS: We introduce a preliminary retrospective analysis of our tertiary stroke center during 2018-2022 of patients that were treated with ICS either in acute phase or elective (eICS). Study endpoints were stroke, functional outcome (modified Rankin Score [mRS] at 3 months), and serious adverse events. RESULTS: Thirty-three stents were implanted, 21 in acute group and 12 in the eICS group. Most patients (75%) were treated with a new generation self-expandible stent. One patient had peri-procedural stroke and four patients had transient ischemic event or stroke during follow-up. There were eight cases of death (all acute group patients, seven of which occurred in the posterior circulation). Fifteen patients (62%) had favorable clinical outcomes (mRS 0-2 for pre-stroke), of which 10/10 (100%) in the eICS, the other two eICS patients had pre-morbid mRS 3 with no clinical change. CONCLUSIONS: The evolution of new devices for ICS and the accumulating interventional experience might open a new era. As no other effective alternative treatment options exist for preventing recurrent stroke, stenting is still common practice in many tertiary centers either urgently or as elective procedure for refractory cases.

Effect of time delay in inter-hospital transfer on outcomes of endovascular treatment of acute ischemic stroke.

Background: Endovascular treatment (EVT) with mechanical thrombectomy is the standard of care for large vessel occlusion (LVO) in acute ischemic stroke (AIS). The most common approach today is to perform EVT in a comprehensive stroke center (CSC) and transfer relevant patients for EVT from a primary stroke center (PSC). Rapid and efficient treatment of LVO is a key factor in achieving a good clinical outcome. Methods: We present our retrospective cohort of patients who underwent EVT between 2018 and 2021, including direct admissions and patients transferred from PSC. Primary endpoints were time intervals (door-to-puncture, onset-to-puncture, door-to-door) and favorable outcome (mRS ≤ 2) at 90 days. Secondary outcomes were successful recanalization, mortality rate, and symptomatic intracranial hemorrhage (sICH). Additional analysis was performed for transferred patients not treated with EVT; endpoints were time intervals, favorable outcomes, and reason for exclusion of EVT. Results: Among a total of 405 patients, 272 were admitted directly to our EVT center and 133 were transferred; there was no significant difference between groups in the occluded vascular territory, baseline NIHSS, wake-up strokes, or thrombolysis rate. Directly admitted patients had a shorter door-to-puncture time than transferred patients (190 min vs. 293 min, p < 0.001). The median door-to-door shift time was 204 min. We found no significant difference in functional independence, successful recanalization rates, or sICH rates. The most common reason to exclude transferred patients from EVT was clinical or angiographic improvement (55.6% of patients). Conclusion: Our results show that transferring patients to the EVT center does not affect clinical outcomes, despite the expected delay in EVT. Reassessment of patients upon arrival at the CSC is crucial, and patient selection should be done based on both time and tissue window.

Polyglycolide/polylactide-coated platinum coils for patients with ruptured and unruptured cerebral aneurysms: a single-center experience.

BACKGROUND AND PURPOSE: Recanalization of cerebral aneurysm is a limitation of bare platinum coils (BPCs). In a swine aneurysm model, polyglycolide/polylactide (a polymer)-coated platinum coils (Matrix) accelerated clot fibrosis and reduced recanalization rate and aneurysmal volume. We aimed to evaluate the safety of Matrix coils in patients with intracranial aneurysm. METHODS: This is a single-center, prospective study of patients with intracranial aneurysms treated with Matrix alone or in combination with BPCs. Follow-up evaluation included a 1-month clinical evaluation and a 6- and 12-month clinical and angiographic examination. Primary adverse events included death, stroke, and permanent neurological deficits. RESULTS: Between May 2002 and January 2004, 52 patients (range 34 to 79 years of age; 38 females) were treated for 54 aneurysms (size 7.9+/-4.6 mm; neck 3.9+/-1.5 mm; 26 ruptured). Matrix alone was used in 13 aneurysms. In 39, we used a combination of Matrix and BPCs. Twenty-one aneurysms had a 6-month follow-up examination (11 Matrix; 10 Matrix combined with bare platinum), and 11 completed the 12-month follow-up evaluation (Matrix only). Adverse events not related to the procedure were 2 deaths (ruptured basilar aneurysms) and 1 stroke at day 10 postcoiling secondary to vasospasm. Procedure-related adverse events were 2 strokes. At 6-month follow-up (n=21) evaluation, 2 of 3 recanalizations needed retreatment. At 12-month follow-up (n=11), there was no recanalization in patients treated with Matrix alone and no significant reduction in aneurysmal size. CONCLUSIONS: Polyglycolide/polylactide-coated coils had a satisfactory safety profile. Significant aneurysmal size reduction after coiling was not observed.

Transvenous n-butyl-cyanoacrylate infusion for complex dural carotid cavernous fistulas: technical considerations and clinical outcome.

BACKGROUND AND PURPOSE: Endovascular transvenous embolization has been advocated as the treatment technique for dural carotid cavernous fistulas (dCCFs). Most centers use platinum coils primarily. The purpose of this study was to evaluate the technical aspects, efficacy, and safety of transvenous n-butyl cyanoacrylate (n-BCA) infusion in dCCFs as a primary alternative or adjunct to coil embolization. METHODS: We retrospectively evaluated 14 patients with dCCFs who were treated at this institution from 1999 to 2004 by using n-BCA infusion alone or in combination with coils. The efficacy of treatment and safety aspects were studied in dCCFs of Barrow type B (4/14), C (2/14), and D (8/14). Six patients were treated with transvenous n-BCA infusion alone in the cavernous sinus, 7 with a combination of transvenous n-BCA and coil embolization, and one with transvenous n-BCA combined with transarterial polyvinyl alcohol (PVA)-particle embolization of the feeding arteries. RESULTS: An angiographic obliteration and clinical cure was achieved in all patients. Technical complications were nonsymptomatic and included spillage of an n-BCA droplet into a middle cerebral artery branch retrograde through the arteriovenous fistulas in one patient and perforation of the inferior petrosal sinus during microcatheter placement in another. A third patient developed temporary palsy of the sixth cranial nerve a few days after the treatment. CONCLUSION: In this small series, the use of n-BCA either alone or in conjunction with detachable coils was a safe and effective technique for the treatment of symptomatic patients presenting with complex dCCFs.

High incidence of chest malignancy detected by FDG PET in patients suspected of recurrent squamous cell carcinoma of the upper aerodigestive tract.

OBJECTIVE: To determine the incidence of chest neoplasms detected by FDG PET in patients with previously treated squamous cell head and neck cancer (HNC), being evaluated for possible recurrent disease. METHODS: This is a retrospective review of 41 patients (M = 29, F = 12: average age = 58 years) with previously treated HNC who underwent FDG PET of the neck and chest as part of routine evaluation for locoregional and/or distant recurrence. Thirty-four of 41 patients had advanced stage III or IV HNC. All FDG PET studies were reviewed by dedicated nuclear medicine physicians, including evaluation for abnormal uptake in the chest. The chest FDG findings were correlated with serial chest radiographs or chest CT. The occurrence rate of incidental chest malignancy was determined and based on characteristic imaging findings, biopsy, and/or clinical course. RESULTS: Twelve of 41 patients had abnormal FDG uptake in the lungs and/or mediastinum. Ten of 12 patients were found to have neoplasms that could represent either metastases or a new lung primary. Five of these 10 were unsuspected neoplasms prior to FDG PET. The other 2/12 FDG PET scans in the chest were false positive. There was one false-negative FDG PET, with subsequent PET and CT demonstrating pulmonary metastases. Overall, there was a 27% incidence of chest malignancies in patients with advanced HNC being evaluated for possible recurrence. CONCLUSION: Our study demonstrated a chest malignancy in 1 out of 4 patients with advanced HNC being evaluated for locoregional and/or distant spread. Fifty percent were unsuspected prior to FDG PET. This result suggests that FDG PET of the lungs should be routinely included in the evaluation of high-risk patients.