Mechanical Thrombectomy for Acute Ischemic Stroke Patients Aged 80 Years or Older.

BACKGROUND: There are limited data about the prognostic factors predicting outcomes after mechanical thrombectomy with stent retrievers for the elderly. Here, we evaluated outcomes in elderly patients in a real-world setting. METHODS: Between April 2015 and January 2017, 80 patients with anterior intracranial acute large vessel occlusion, who had lived independently before ictus, were treated with mechanical thrombectomy using a stent retriever at our institute. We compared outcomes between patients ≥80 years old (n = 36) and those <80 years old (n = 44), and assessed prognostic factors for favorable outcomes (modified Rankin Scale score 0-2) at 90 days in all patients. RESULTS: There was no significant difference in baseline National Institutes of Health Stroke Scale score and Alberta Stroke Program Early Computed Tomography Score between the 2 groups. Successful revascularization (modified Thrombolysis in Cerebral Infarction [mTICI] scores 2b/3) (83% versus 93%, P = .286), complete recanalization (mTICI 3) (47% versus 50%, P = .826), and favorable outcomes (42% versus 57%, P = .261) were achieved more often in those <80 years old, but differences did not reach statistical significance. Multivariate regression analysis showed that baseline National Institutes of Health Stroke Scale (P = .013) and mTICI scores of 3 (P = .006) were significant predictive factors, but being ≥80 years old and baseline Alberta Stroke Program Early Computed Tomography Score were not. In those ≥80 years old, mTICI score of 3 was an influential factor for favorable outcome (P = .017). CONCLUSIONS: Being aged 80 years or older was not a significant predictor for outcomes after mechanical thrombectomy, whereas complete recanalization was an influential predictor of outcome in the elderly.

Efficacy of damage control surgery and staged endoscopic pancreatic ductal double stenting therapy for severe pancreatic head injury: a case report.

BACKGROUND: A high-grade pancreatic injury is a life-threatening injury that is associated with high mortality and morbidity. It is currently unclear which treatment strategy results in good clinical outcomes. CASE PRESENTATION: A 23-year-old Japanese woman sustained severe injury in a motor vehicle accident. Abdominal computed tomography revealed severe pancreatic head injury with extravasation of contrast media. Since it was not possible to insert an endoscopic pancreatic stenting tube into the main pancreatic duct, damage control surgery was performed. On day 3, we could insert the endoscopic pancreatic stenting tube from the ampulla of Vater and an endoscopic nasopancreatic drainage tube in the distal pancreatic duct from the accessory ampulla before the second operation. Drainage tubes were placed around the pancreatic head in the second operation. The endoscopic nasopancreatic drainage tube tube was converted to endoscopic pancreatic stenting tube on day 9. On day 51, the patient was discharged on foot from our hospital without serious complications. CONCLUSION: Early and effective hemostasis, staged pancreatic duct drainage with stenting, and surgical external drainage around the pancreas in combination with an endoscopic procedure and damage control surgery were considered appropriate therapeutic strategy for high-grade pancreatic injury.

Intubation during a medevac flight: safety and effect on total prehospital time in the helicopter emergency medical service system.

INTRODUCTION: The Helicopter Emergency Medical Service (HEMS) commonly intubates patients who require advanced airway support prior to takeoff. In-flight intubation (IFI) is avoided because it is considered difficult due to limited space, difficulty communicating, and vibration in flight. However, IFI may shorten the total prehospital time. We tested whether IFI can be performed safely by the HEMS. METHODS: We conducted a retrospective cohort study in adult patients transported from 2010 to 2017 who received prehospital, non-emergent intubation from a single HEMS. We divided the cohort in two groups, patients intubated during flight (flight group, FG) and patients intubated before takeoff (ground group, GG). The primary outcome was the proportion of successful intubations. Secondary outcomes included total prehospital time and the incidence of complications. RESULTS: We analyzed 376 patients transported during the study period, 192 patients in the FG and 184 patients in the GG. The intubation success rate did not differ between the two groups (FG 189/192 [98.4%] vs. GG 179/184 [97.3%], p = 0.50). There were also no differences in hypoxia (FG 4/117 [3.4%] vs. GG 4/95 [4.2%], p = 1.00) or hypotension (FG 6/117 [5.1%] vs. GG 5/95 [5.3%], p = 1.00) between the two groups. Scene time and total prehospital time were shorter in the FG (scene time 7 min vs. 14 min, p <  0.001; total prehospital time 33.5 min vs. 40.0 min, p <  0.001). CONCLUSIONS: IFI was safely performed with high success rates, similar to intubation on the ground, without increasing the risk of hypoxia or hypotension. IFI by experienced providers shortened transportation time, which may improve patient outcomes.

Field Assessment of Critical Stroke by Emergency Services for Acute Delivery to a Comprehensive Stroke Center: FACE2AD.

Patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) should be triaged to an endovascular-capable hospital by the emergency medical service (EMS). We designed a prehospital LVO prediction scale based on EMS assessments. In the derivation cohort, 1157 patients transferred to our hospital by the EMS because of suspected stroke within 24 h of onset were retrospectively examined. Factors associated with AIS due to LVO were identified based on the EMS assessment, and a prehospital scale identifying LVO was developed. The accuracy of this scale was validated in 502 consecutive patients who were transferred to 4 stroke centers, and its accuracy was compared with those of 4 previously reported scales. AIS due to LVO was diagnosed in 149 of 1157 patients (13%) in the derivation cohort. One point each was assigned for facial palsy, arm weakness, consciousness impairment (cannot say his/her name), atrial fibrillation, and diastolic blood pressure ≤ 85 mmHg, with two points for conjugate eye deviation (FACE2AD scale). In the derivation cohort, with the optimal cut-point of FACE2AD ≥ 3 determined by the area under the curve (AUC; 0.88; 95% confidence interval 0.87-0.90), sensitivity, specificity, positive predictive value, and negative predictive value for FACE2AD to predict LVO were 0.85, 0.80, 0.39, and 0.97, respectively. In the validation cohort, the FACE2AD scale had higher accuracy, with an AUC value of 0.84 for predicting LVO compared with the other scales (all p < 0.01). The FACE2AD scale is a simple, reliable tool for identifying AIS due to LVO by the EMS.

Impact of introducing endovascular treatment on acute ischemic stroke outcomes: A shift from an era of medical management to thrombectomy in Japan.

BACKGROUND: Endovascular treatment (EVT) has increasingly become the standard treatment of acute cerebral large vessel occlusion (LVO). We evaluated the impact of introducing EVT on LVO therapy in a single center where intravenous thrombolysis (IVT) had been the only recanalization therapy. MATERIALS AND METHODS: Between April 2013 and March 2017, 354 consecutive patients with LVO admitted to our institution were analyzed. We compared outcomes between two chronological groups before (Pre-EVT group) and after (Post-EVT group) introducing EVT in April 2015. We assessed prognostic factors for favorable outcomes (modified Rankin scale score ≤2 at 90 days). RESULTS: In the Pre-EVT group, all 140 patients were treated medically, including 30 patients (21%) undergoing IVT. In the Post-EVT group, 118 patients (55%) underwent EVT, and the remaining 96 patients treated medically, including six patients (3%) undergoing IVT. The proportion undergoing recanalization therapy with IVT or EVT significantly increased after introducing EVT (21% versus 58%, p < 0.001). The rate of patients achieving favorable outcomes also significantly increased (14% versus 31%, p < 0.001). In multivariate regression analysis, introducing EVT was an independent predictive factor after adjusting for age, stroke severity and extent, and time (p = 0.005). The arrival time in patients with helicopter transport was significantly shorter than that with ground ambulance for a distance of more than 10 km (p < 0.001). CONCLUSIONS: This study demonstrated that the introduction of EVT improved outcomes of acute LVO patients, increasing the opportunity to receive recanalization therapy. Further efforts to establish medical systems to provide EVT are required throughout the country.

Stent Expansion and In-Stent Thrombus Sign in the Trevo Stent Retriever Predict Recanalization and Possible Etiology During Mechanical Thrombectomy: A Case Series of 50 Patients with Acute Middle Cerebral Artery Occlusion.

BACKGROUND: Interaction between the stent retriever and clot is a key factor for recanalization during mechanical thrombectomy. The aim of this study was to evaluate the association between radiographically apparent features during thrombectomy and angiographic outcomes using the Trevo stent retriever with a fully radiopaque strut. METHODS: We retrospectively reviewed 50 patients with acute middle cerebral artery occlusion who were treated with the Trevo. Patients were divided into groups that achieved (first-pass recanalization group, n = 21) or did not achieve (non-first-pass recanalization group, n = 29) a modified Thrombolysis in Cerebral Ischemia score of 2b or 3 with the first-pass procedure. Patients were also divided into a thromboembolic (n = 39) and atherosclerotic (n = 11) group by occlusion etiology. We evaluated radiographic findings of the Trevo's strut (e.g., degree of stent expansion and filling defect of the thrombus in the strut [in-stent thrombus sign]) during the first-pass procedure. RESULTS: Median stent expansion was significantly greater in the first-pass recanalization group than in the non-first-pass recanalization group (60% vs. 34%; P < 0.01) and in the thromboembolic group than in the atherosclerotic group (45% vs. 31%; P < 0.01). The receiver operator characteristic curve showed moderate capacity for prediction of recanalization and etiology, with an area under the curve of 0.83 and 0.73, respectively. In-stent thrombus sign was significantly more common in the thromboembolic group than in the atherosclerotic group (86% vs. 10%; P < 0.01). CONCLUSIONS: Greater stent expansion was associated with recanalization after thrombectomy. The in-stent thrombus sign may be useful for etiology prediction. These radiographic findings could provide useful real-time feedback during procedures, reflecting clot-stent interaction.

[A case of bacterial pneumonia caused by Streptococcus dysgalactiae subsp. equisimilis, showing patchy consolidations resembling organizing pneumonia].

In December, 2001, a 67-year-old woman was given a diagnosis of having systemic sclerosis and organizing pneumonia. Steroid treatment improved her condition, and she received no further medication for approximately three years thereafter. In October 2005, she visited Kurume University Hospital because of cough and fever. Chest X-ray film and high-resolution computed tomography (HRCT) showed bilateral patchy consolidation with air-bronchogram sign and ground-glass opacities, predominantly in the right lower lung field, suggesting relapse of organizing pneumonia. However, bronchoalveolar lavage fluid (BALF) analysis showed an increase of neutrophils (79%) and the CD4/CD8 ratio (4.04). Streptococcus dysgalactiae subsp. equisimilis (beta-hemolytic, Lancefield group G) was detected by bacterial culture of the BALF. Treatment with sulbactam sodium/ampicillin sodium (SBT/ ABPC) rapidly improved her symptoms. The patchy consolidations on chest X-ray and HRCT also disappeared after the treatment. On the basis of these clinical and bacteriological findings, we diagnosed the patient as having bacterial pneumonia caused by Streptococcus dysgalactiae subsp. equisimilis.

Mechanical Thrombectomy Using the Trevo ProVue in 50 Consecutive Patients with Anterior Circulation Stroke: A Single-Center Experience after Approval of the Stent Retriever in Japan.

Mechanical thrombectomy using the stent retriever has been proven to be effective for select patients with acute ischemic stroke. We evaluated our early experience using the device after its approval in 2014 in Japan, with a special emphasis on the occlusion site. Fifty consecutive endovascular revascularization procedures for treating anterior acute large vessel occlusion were performed using the Trevo ProVue as the first-line device at our institute between April 2015 and March 2016. Focusing on the involvement of the M1-M2 bifurcation with deployment or retrieval of the stent retriever, we regarded the middle cerebral artery M1 mid-portion as the boundary and divided the cases into proximal (n = 26) and distal (n = 24) groups. We assessed the overall clinical outcome and compared the outcome between the two groups. Among 50 patients (median age, 80 years; National Institutes of Health Stroke Scale score (NIHSS) score, 20), successful (modified Thrombolysis in Cerebral Infarction score (TICI) 2b or 3) or complete revascularization (TICI 3) was achieved in 41 patients (82%; 88% in the proximal group vs 75% in the distal group, P = 0.28) and in 27 patients (54%; 73% vs 33%, P = 0.01), respectively. Symptomatic intracranial hemorrhage occurred in three patients (6%; 4% vs 8%, P = 0.60). A good outcome (mRS score 0 to 2) was obtained in 25 patients at 90 days (50%; 54% vs 46%, P = 0.78). Mechanical thrombectomy using the Trevo ProVue was safe and effective in patients with acute cerebral artery occlusion, especially for proximal occlusions. The efficacy of the procedure for distal occlusions was somewhat inferior to those for proximal occlusions, which might be resolved by next generation devices.