Mechanical thrombectomy with Embolus Retriever with Interlinked Cages device for medium vessel occlusions: First pass results and safety profile.

BACKGROUND: Reperfusion of medium vessel occlusions is correlated with good outcomes. However, optimal techniques and medical devices are still unclear. In this study, we sought to evaluate the safety and efficacy of mechanical thrombectomy with Embolus Retriever with Interlinked Cages (ERIC™) retrieval device in patients with acute ischemic stroke due to distal medium vessel occlusions. METHODS: A retrospective review of the prospectively collected mechanical thrombectomy database revealed 50 patients who had fulfilled the inclusion criteria. The data collected includes clinical patient characteristics, procedural measures, timestamps at each stage, and patient outcomes. Intravenous thrombolytics application, pre- and post-intervention imaging findings, device-related adverse events and any type of intracranial hemorrhage were recorded. RESULTS: There were 25 men (50%) and 25 women (50%) with a median of 67 years (interquartile range (IQR) 41-84). Median presenting NIHSS was 14 (IQR, 3-23). First pass rates were: eTICI3 in 16 cases (32%), eTICI-2c in eight cases (16%), eTICI-2B67 in nine cases (10%), eTICI2B50 in three cases (6%) and mTICI 0-2A in 18 cases (36%). Final recanalization rate of mTICI 2b-3 was 90% and 2c-3 was 70%. CONCLUSION: In conclusion, the ERIC thrombectomy device offers a high rate of first-pass success along with a favorable safety profile. Larger series and multi-center studies are needed for further investigation.

The effect of metabolic syndrome and obesity on outcomes of acute ischemic stroke patients treated with systemic thrombolysis.

Metabolic syndrome (MetS) is associated with increased risk of ischemic stroke; while central obesity has controversial effects on ischemic stroke. We investigated effects of MetS and obesity on clinical courses and outcomes of patients treated with intravenous recombinant tissue-type plasminogen activator (iv rt-PA). 319 patients treated with intravenous thrombolysis were included to our study. Metabolic syndrome was determined if ≥3 of following criteria are present: elevated waist circumference; elevated triglycerides; reduced high density-lipoprotein cholesterol (HDL-C); elevated blood pressure; elevated fasting glucose. Obesity was defined as BMI≥30. Clinical features at baseline, 24th hour and 3rd month were examined. Computed tomography (CT) findings for ASPECT scores and hemorrhagic transformation were analyzed. 182 patients were MetS+; they were older (p=0.035), had similar ASPECT scores (p=0.477) and NIHSS scores (p=0.167) at admission; had significantly higher NIHSS scores at 24th hour (p<0.001) and worse outcome at 3rd month (p<0.001). Logistic regression analysis showed that either MetS, obesity or age were not independent predictors of poor outcome. Obese patients (n:72) had slight but significantly lower NIHSS scores at admission (p=0.049) compared to non-obese patients; meanwhile there was no significant difference between NIHSS scores at 24th hour (p=0.736) and 3rd month mRS scores (p=0.145). Hemorrhagic transformation and mortality rates were not affected with MetS or obesity. MetS is not an independent factor on clinical outcome but its presence may have a relationship with poor outcome; but obesity was not found to have any significant role on clinical course and outcome of patients treated with iv rt-PA.

Renal Dysfunction Is an Independent Risk Factor for Poor Outcome in Acute Ischemic Stroke Patients Treated with Intravenous Thrombolysis: A New Cutoff Value.

Objective. This study was set to assess the effect of renal dysfunction on outcome of stroke patients treated with intravenous thrombolysis (IVT). Methods. This multicenter research involved 403 patients from January 2009 to March 2015. Patients were divided into two groups: (1) control group with GFR ≥ 45 mL/min/1.73 m2 and (2) low GFR group with GFR < 45 mL/min/1.73 m2. Outcome measurements were poor outcome (mRS 3-6) and mortality at 3 months and symptomatic intracerebral hemorrhage (SICH) within the first 24-36 hours. Univariate and multivariate regression analyses were performed, and odds ratios (ORs) were determined at 95% confidence intervals (CIs). Results. Univariate analyses determined that every decrease of GFR by 10 mL/min/1.73 m2 significantly increased the risk of poor outcome (OR 1.19, 95% CI 1.09-1.30, p < 0.001) and mortality (OR 1.18, 95% CI 1.06-1.32, p = 0.002). In multivariate regression, adjusted for all variables with p value < 0.1, low GFR (GFR < 45 versus GFR equal to or more than 45) was associated with poor outcome (OR adjusted 2.15, 95% CI 1.01-4.56, p = 0.045). Conclusion. In IVT for acute stroke, renal dysfunction with GFR < 45 mL/min/1.73 m2 before treatment determined increased odds for poor outcome compared to GFR of more than 45 mL/min/1.73 m2.

Higher Insulin Resistance Level is Associated with Worse Clinical Response in Acute Ischemic Stroke Patients Treated with Intravenous Thrombolysis.

Insulin resistance is linked to atherosclerotic cardiovascular diseases and stroke. We investigated whether there is a relationship between insulin resistance and clinical findings and outcomes of acute ischemic stroke patients treated with intravenous thrombolysis. In our study, 180 acute ischemic stroke non-diabetic patients treated with intravenous recombinant tissue-type plasminogen activator (iv rt-PA) were evaluated for insulin resistance assessed by homeostasis model assessment insulin resistance (HOMA-IR). The threshold for HOMA-IR was determined as 2.7. Patients were grouped as HOMA-IR > 2.7 and HOMA-IR ≤ 2.7. Clinical features at baseline, 24th hour, and 3rd month were examined. Computed tomography (CT) findings for hemorrhagic transformation were also assessed. Patients with HOMA-IR > 2.7 had significantly higher National Institutes of Health Stroke Scale (NIHSS) scores at 24th hour (p = 0.005) and higher modified Rankin Scale (mRS) scores at 3rd month (p = 0.011). Logistic regression analysis displayed that the presence of HOMA-IR > 2.7 increases the likelihood of poor outcome 2.93 times (confidence interval [CI] 1.001-1.079) (p = 0.003). There was no statistically significant difference between baseline clinical features, hemorrhagic transformation (p = 1.000), and mortality (p = 0.350) rates. Insulin resistance at higher levels seems to be associated with poor clinical courses and outcomes in patients who received iv rt-PA.

Predictors of a Good Outcome after Endovascular Stroke Treatment with Stent Retrievers.

BACKGROUND AND PURPOSE: Successful recanalization after endovascular stroke therapy (EVT) did not translate into a good clinical outcome in randomized trials. The goal of the study was to identify the predictors of a good outcome after mechanical thrombectomy with stent retrievers. METHODS: A retrospective analysis of a prospectively collected database included consecutive patients treated with stent retrievers. We evaluated the influence of risk factors for stroke, baseline NIHSS score, Alberta Stroke Program Early CT (ASPECT) score, recanalization rate, onset-to-recanalization and onset-to-groin puncture time, and glucose levels at admission on good outcomes. The number of stent passes during procedure and symptomatic hemorrhage rate were also recorded. A modified Rankin Scale (mRS) score of 0-2 at 90 days was considered as a good outcome. RESULTS: From January 2011 to 2014, 70 consecutive patients with an acute ischemic stroke underwent EVT with stent retrievers. The absence of a medical history of diabetes was associated with good outcomes. Apart from diabetes, the baseline demographic and clinical characteristics of patients were similar between subjects with poor outcome versus those with good outcomes. Median time from onset to recanalization was significantly shorter in patients with good outcomes 245 (IQR: 216-313 min) compared with poor outcome patients (315 (IQR: 240-360 min); P = 0.023). Symptomatic intracranial hemorrhage was observed in eight (21.6%) of 37 patients with poor outcomes and no symptomatic hemorrhage was seen in patients with good outcomes (P = 0.006). In multivariate stepwise logistic regression analysis, a favorable ASPECT score (ASPECT > 7) and successful recanalization after EVT were predictors of good outcomes. Every 10-year increase was associated with a 3.60-fold decrease in the probability of a good outcome at 3 months. The probability of a good outcome decreases by 1.43-fold for each 20 mg/dL increase in the blood glucose at admission. CONCLUSION: To achieve a good outcome after EVT with stent retrievers, quick and complete recanalization and better strategies for patient selection are warranted. We need randomized trials to identify the significance of tight blood glucose control in clinical outcome during or after EVT.

Paradoxical consequence of human chorionic gonadotropin misuse.

Recombinant human chorionic gonadotropin (hCG) is commonly misused as a weight reducing or performance enhancing agent but is associated with increased risk of thromboembolic events. A 29-year-old female with a history of obesity was admitted to our center with a diagnosis of ischemic stroke. Etiologic workup revealed a large patent foramen ovale and history of recent use of hCG as part of a weight loss regimen. This report highlights the potential complications of hCG therapy, particularly when used for unapproved indications and without medical supervision.

Non-expert use of quantitative EEG displays for seizure identification in the adult neuro-intensive care unit.

Video-EEG monitoring is the ultimate way to diagnose non-convulsive status epilepticus (NCSE) in intensive care units (ICU). Usually EEG recordings are evaluated once a day by an electrophysiologist, which may lead to delay in diagnosis. Digital EEG trend analysis methods like amplitude integrated EEG (aEEG) and density spectral array (DSA) have been developed to facilitate recognition of seizures. In this study, we aimed to investigate the diagnostic utility of these methods by non-expert physicians and ICU nurses for NCSE identification in an adult neurological ICU. Ten patients with NCSE and ten control patients without seizures were included in the study. The raw EEG recordings of all subjects were converted to both aEEG and DSA and displayed simultaneously without conventional EEG. After training for seizure recognition with both methods, two physicians and two nurses analyzed the visual displays individually, and marked seizure timings. Their results were compared with those of a study epileptologist. Participants analyzed 615h of EEG data with 700 seizures. Overall, 63% of the seizures were recognized by all, 15.6% by three, 11.6% by two, 8.3% by one rater and only 1.5% were missed by all of them (sensitivity was 88-99%, and specificity was 89-95% when the ratings were assessed as 1-h epochs). False positive rates were 1 per 2h in the study and 1 per 6h in the control groups. Interrater agreement was high (κ=0.79-0.81). Bilateral independent seizures and ictal recordings with lower amplitude and shorter duration were more likely to be missed. There was no difference in performance between the rating of physicians and nurses. Our study demonstrates that bedside nurses, ICU fellows and residents can achieve acceptable level of accuracy for seizure identification using the digital EEG trend analysis methods following brief training. This may help earlier notification of the electrophysiologist who is not always available in ICUs.

Plasma 3-nitrotyrosine estimates the reperfusion-induced cerebrovascular stress, whereas matrix metalloproteinases mainly reflect plasma activity: a study in patients treated with thrombolysis or endovascular recanalization.

Cerebral reperfusion injury may account for complications of thrombolysis and endovascular recanalization. Experimental studies have shown that brain matrix metalloproteinase (MMP) activity increases during reperfusion and is correlated with oxidative/nitrative stress. Increased plasma MMP levels have been reported in stroke, but no information is available for reperfusion-induced plasma MMP and 3-nitrotyrosine (3-NT, a marker of oxidative/nitrative stress) changes immediately after recanalization. We obtained plasma from 29 patients undergoing endovascular recanalization, 12 patients treated with thrombolysis, and six control patients having diagnostic angiogram before and 1,3, and 24 h after treatment to investigate the effect of cerebral reperfusion on plasma MMP gelatinolytic activity and 3-NT level. Hypoperfusion was shown distal to the stenotic artery in endovascular treatment patients. Presence of an occluded artery and recanalization was documented in thrombolysis patients. A significant increase was detected in plasma 3-NT levels 3 and 24 h after stenting/angioplasty. Plasma MMP-9 gelatinolytic activity rose more than 50% of the pre-treatment level in 12 of 29 patients. However, this was not statistically significant and not correlated with any of the clinical or radiological correlates of reperfusion injury (e.g., hyperperfusion and hemorrhage). After thrombolysis, a significant increase in plasma MMP-9 gelatinolytic activity at 3 and 24 h and the cleaved form of MMP-9 were detected. 3-NT levels increased by 44% and 62% at 3 and 24 h, which did not achieve statistical significance, but was highly correlated with admission NIH Stroke Scale (r = 0.930 p < 0.001). No change was detected in MMP-2 in all groups. In conclusion, these data suggest that the increased plasma MMP-9 levels is not a direct measure of MMP-9 activity in the reperfused brain but rather a consequence of tissue plasminogen activator infusion, whereas plasma 3-NT levels appear to originate from the reperfused brain vasculature. The changes in 3-NT levels may therefore be useful to monitor oxygen/nitrogen radical formation during reperfusion with serial measurements.

Spinal cord infarction in congenital afibrinogenemia: a case report and review of the literature.

A 22-year-old woman with congenital afibrinogenemia presented with acute-onset rapidly progressive quadriparesis as a result of spinal cord infarction caused by vertebral artery dissection. Magnetic resonance imaging scans showed microhemorrhages in addition to edematous swelling suggesting acute ischemia throughout cervical and upper thoracic portions of the spinal cord. Fat-saturated T1-weighted magnetic resonance examination and digital subtraction angiography studies demonstrated cervical vertebral artery dissection on the right. This case provides an example of how a primary bleeding disorder could result in a severe ischemic complication caused by an occlusive vessel wall hematoma. Along with other reports, diagnostic and therapeutic aspects of this paradoxical situation were discussed in the particular setting of acute spinal cord ischemia.

Atypical reversible posterior leukoencephalopathy syndrome in thrombotic thrombocytopenic purpura.

A 32-year-old man with an atypical form of reversible leukoencephalopathy syndrome (RPLS) caused by thrombotic thrombocytopenic purpura (TTP) is reported. In this particular case, a timely diagnosis of TTP was established primarily on the clinical findings, which led to the early initiation of plasmapheresis and resulted in excellent clinical recovery. The pathophysiological aspects of the relationship between TTP and RPLS are discussed in light of the clinical and radiological features (including diffusion- and perfusion-weighted magnetic resonance imaging studies) of this case. The mechanism for TTP-associated, or TTP-induced, leukoencephalopathy is suggested to be independent of hypertension and vasoconstriction. TTP-associated endothelial injury can play a major role as the inciting mechanism for the development of RPLS.