Access-site complications in ultrasound-guided endovascular thrombectomy: a single-institution retrospective cohort study.

OBJECTIVE: Mechanical endovascular thrombectomy (EVT) is an increasingly relied-on treatment for clot retrieval in the context of ischemic strokes, which otherwise are associated with significant morbidity and mortality. Despite several known risks associated with this procedure, there is a high degree of technical heterogeneity across both centers and operators. The most common procedural complications occur at the point of transfemoral access (the common femoral artery), and include access-site hematomas, dissections, and pseudoaneurysms. Other interventional fields have previously popularized the use of ultrasound to enhance the anatomical localization of structures relevant to vascular access and thereby reducing access-site complications. In this study, the authors aimed to describe the ultrasound-guided EVT technique performed at a large, quaternary neurovascular referral center, and to characterize the effects of ultrasound guidance on access-site complications. METHODS: A retrospective chart review of all patients treated with EVT at a single center between January 2013 and August 2020 was performed. Patients in this cohort were treated using a universal, unique, ultrasound-guided, single-wall puncture technique, which bears several theoretical advantages over the standard technique of arterial puncture via palpation. RESULTS: There were 479 patients treated with EVT within the study period. Twenty patients in the cohort were identified as having experienced some form of access-site complication. Eight (1.67%) of these patients experienced minor access-site complications, all of which were groin hematomas and none of which were clinically significant, as defined by requiring surgical or interventional management or transfusion. The remaining 12 patients experienced arterial dissection (n = 5), arterial pseudoaneurysm (n = 4), retroperitoneal hematoma (n = 2), or arterial occlusion (n = 1), with only 1.04% (5/479) requiring surgical or interventional management or transfusion. CONCLUSIONS: The authors found an overall reduction in total access-site complications as well as minor access-site complications in the study cohort compared with previously published randomized controlled trials and observational studies in the recent literature. The findings suggested that there may be a role for routine use of ultrasound-guided puncture techniques in EVT to decrease rates of complications.

Cervical Spine Chondrosarcoma in an Adult with a History of Wilms Tumor.

INTRODUCTION: We report the first case of cervical spine chondrosarcoma in a Wilms tumor survivor. CASE DESCRIPTION: A 52-year-old female patient presented with myelopathic symptoms including poor balance, difficulty walking, and numbness of both feet. A magnetic resonance imaging of the spine showed a mass at the right C7-T1 foramen causing significant cord compression. The patient's symptoms improved after posterior decompression and fusion with excision of the tumor. CONCLUSION: Through our experience with this case, we would like to suggest a possible unknown genetic syndrome predisposing patients with Wilms tumor to chondrosarcoma as secondary neoplasms. We would also like to re-emphasize the need for vigilance when assessing patients with a history of Wilms tumor.

Neurointerventional Procedural Complications in a Growing Canadian Regional Stroke Center: Single Hospital Experience Analysis in the Context of Recommended Case Volumes.

BACKGROUND: Evidence continues to emerge regarding the inverse relationship between high neurointerventional case volume and complication rates, leading several medical/surgical societies to recommend minimum volumes for specific procedures. Recent data suggest few centers are meeting these requirements. We report a single center's neurointerventional complication rates with associated case volumes, along with a review of the literature. METHODS: A retrospective cohort review of all consecutive patients undergoing diagnostic catheter cerebral angiography and/or neurointerventional procedures between January 1, 2013, and March 1, 2018, was undertaken. No diagnostic or interventional procedures were excluded. All major and minor complications were recorded. RESULTS: A total of 1000 procedures (463 diagnostic cerebral angiograms and 537 neurointerventional procedures) were completed. Of the neurointerventional procedures, 216 (40%) were endovascular thrombectomy, 170 (32%) were aneurysmal embolization, and 48 (9%) were carotid stenting. The mean and median age was 60 years. There were 460 women and 540 men. The total number of major complications for diagnostic angiography, endovascular thrombectomy, ruptured aneurysm embolization, unruptured aneurysm embolization, and carotid artery stenting were 4 (0.9%), 4 (1.9%), 10 (11%), 4 (5.4%), and 3 (6.3%), respectively. CONCLUSIONS: We provided a single-center experience of the relationship between neurointerventional procedural case volume and complication rates in the growth phase of our center's establishment. We demonstrated that as our center was being developed, specific procedural staffing measures allowed proficiency maintenance, acquisition of new techniques, and complication avoidance, whereas specific case volumes crossed the suggested thresholds as defined in the literature.

The importance of preoperative tissue sampling for mobile spine chordomas: literature review and report of two cases.

INTRODUCTION: Pre-operative biopsy and diagnosis of chordomas of the mobile spine is indicated as en bloc resections improve outcomes. This review of the management of mobile spine chordomas includes two cases of unexpected mobile spine chordomas where a preoperative tissue diagnosis was decided against and may have altered surgical decision-making. CASE PRESENTATION: Two lumbar spine chordomas thought to be metastatic and primary bony lesions preoperatively were not biopsied before surgery and eventual pathology revealed chordoma. Preoperative diagnoses were questioned during surgery after an intraoperative tissue diagnosis of chordoma in one case and unclear pathology with non-characteristic tumor morphology in the other. The surgical plan was altered in these cases to maximize resection as en bloc resection reduces the risk of local recurrence in chordoma. DISCUSSION: Mobile spine chordomas are rare and en bloc resection is recommended, contrary to the usual approach to more common spine tumors. Since en bloc resection of spine chordomas improves disease free survival, it has been recommended that tissue diagnosis be obtained preoperatively when chordoma is considered in the differential diagnosis, in order to guide surgical planning. We present two cases where a preoperative biopsy was considered but not obtained after neuroradiology consultation and imaging review, which may have been managed differently if the diagnosis of spine chordomas were known pre-operatively.

Impact of Smartphone Applications on Timing of Endovascular Therapy for Ischemic Stroke: A Preliminary Study.

BACKGROUND: The metrics of imaging-to-puncture and imaging-to-reperfusion were recently found to be associated with the clinical outcomes of endovascular thrombectomy for acute ischemic stroke. However, measures for improving workflow within hospitals to achieve better timing results are largely unexplored for endovascular therapy. The aim of this study was to examine our experience with a novel smartphone application developed in house to improve our timing metrics for endovascular treatment. METHODS: We developed an encrypted smartphone application connecting all stroke team members to expedite conversations and to provide synchronized real-time updates on the time window from stroke onset to imaging and to puncture. The effects of the application on the timing of endovascular therapy were evaluated with a secondary analysis of our single-center cohort. Our primary outcome was imaging-to-puncture time. We assessed the outcomes with nonparametric tests of statistical significance. RESULTS: Forty-five patients met our criteria for analysis among 66 consecutive patients with acute ischemic stroke who received endovascular therapy at our institution. After the implementation of the smartphone application, imaging-to-puncture time was significantly reduced (preapplication median time, 127 minutes; postapplication time, 69 minutes; P < 0.001). Puncture-to-reperfusion time was not affected by the application use (42 minutes vs. 36 minutes). CONCLUSION: The use of smartphone applications may reduce treatment times for endovascular therapy in acute ischemic stroke. Further studies are needed to confirm our findings.

Failure of aneurysm occlusion by flow diverter: a role for surgical bypass and parent artery occlusion.

Flow diverters represent a paradigm shift in the treatment of aneurysms. However, unusual and poorly understood complications are being reported. We present a case of a giant internal carotid artery terminus aneurysm treated with flow diversion that progressively and symptomatically enlarged despite a reduction in the filling portion. Complete occlusion of the aneurysm and reduction in mass effect occurred through superficial temporal artery- middle cerebral artery bypass and parent artery occlusion. Incomplete aneurysm occlusion following flow diversion has been reported, but mechanisms and predisposing factors are speculative and definitive solutions have not been described. This case illustrates a potential solution.

Wait times for carotid endarterectomy, London Ontario 2006-2007.

OBJECTIVE: To examine time delays and identify factors that affect wait times from index neurological event to carotid endarterectomy in patients with symptomatic carotid stenosis treated at a regional neurosurgical referral centre. METHODS: We performed a retrospective audit over two years of all patients who underwent a carotid endarterectomy at University Hospital, London, Ontario. The number of days was calculated from first neurological event through until surgery. RESULTS: Eighty-nine carotid endarterectomies (CEAs) were performed by four surgeons during the years 2006 and 2007. From the first neurological event, the median wait time for surgery was 111 days, while from the last event the median wait time was 83 days. There was 19 days' wait between specialist / TIA clinic appointment and the receipt of neurosurgical referral. Median wait time for diagnostic imaging was eight days for carotid Doppler ultrasound and 15 days for CT or MR angiography. There was a 44 day wait from receipt of neurosurgical referral to the date of surgery. Only three patients (4%) received CEA within two weeks of their last neurological event. There was a trend towards a difference in wait times between inpatients and outpatients, but no difference between females compared with males, or between patients presenting with stroke versus TIA. DISCUSSION: Median wait times for CEA after first neurological event was over three months at our center, reflecting the diagnostic workup required in TIA as well as the lack of a systematic approach. This is the subject of continued study at our institution.