Rescue therapy after thrombectomy for large vessel occlusion due to underlying atherosclerosis: review of literature.

In this review article, we summarized the current advances in rescue management for reperfusion therapy of acute ischemic stroke from large vessel occlusion due to underlying intracranial atherosclerotic stenosis (ICAS). It is estimated that 24-47% of patients with acute vertebrobasilar artery occlusion have underlying ICAS and superimposed in situ thrombosis. These patients have been found to have longer procedure times, lower recanalization rates, higher rates of reocclusion and lower rates of favorable outcomes than patients with embolic occlusion. Here, we discuss the most recent literature regarding the use of glycoprotein IIb/IIIa inhibitors, angioplasty alone, or angioplasty with stenting for rescue therapy in the setting of failed recanalization or instant/imminent reocclusion during thrombectomy. We also present a case of rescue therapy post intravenous tPA and thrombectomy with intra-arterial tirofiban and balloon angioplasty followed by oral dual antiplatelet therapy in a patient with dominant vertebral artery occlusion due to ICAS. Based on the available literature data, we conclude that glycoprotein IIb/IIIa is a reasonably safe and effective rescue therapy for patients who have had a failed thrombectomy or have residual severe intracranial stenosis. Balloon angioplasty and/or stenting may be helpful as a rescue treatment for patients who have had a failed thrombectomy or are at risk of reocclusion. The effectiveness of immediate stenting for residual stenosis after successful thrombectomy is still uncertain. Rescue therapy does not appear to increase the risk of sICH. Randomized controlled trials are warranted to prove the efficacy of rescue therapy.

Utility of video-fundoscopy and prospects of portable stereo-photography of the ocular fundus in neurological patients.

BACKGROUND: Proper evaluation of ocular fundi is an integral part of neurological examination. Unfortunately, neurology residents are increasingly uncomfortable performing fundoscopy and interpreting findings because of diminishing skills and lack of experience. This became more prominent during the COVID-19 pandemic as fundoscopy requires proximity to the patient. With the recent dramatic improvement of smartphone cameras, fundus photography using the PanOptic Ophthalmoscope (Welch Allyn, Skaneateles Falls, NY) with a smartphone adapter offered an alternative to direct fundoscopic examination. We present the first experience with our own design of a universal smartphone adapter. METHODS: This is a single-center case series, consecutive for a single user and certain presenting neurological symptoms, which is aimed to evaluate the feasibility and practicality of a new, universal PanOptic smartphone adapter. Presenting symptoms included headache, ocular symptoms, seizure, or encephalopathy. We used 3D modeling and printing techniques to create the adapter. We also developed a methodology of capturing stereoscopic images of the optic disc using a single smartphone camera, but the method was not systematically evaluated in this paper. RESULTS: Here we present our initial experience of fundus video/photography in patients, who presented with encephalopathy, headache, seizure, vision loss, and other ocular symptoms. Fundoscopic abnormalities were discovered in 11 out of 100 patients. Some were incidental findings and were unrelated to the presentation. In one case, fundoscopy played a critical role in establishing the correct diagnosis. CONCLUSIONS: Our custom-designed smartphone adapter allowed obtaining high-quality video and photo recordings using PanOptic Ophthalmoscope. The acquisition of high-quality photos enables a high-yield diagnostic tool and allows revisiting the image in the patient's chart. Improvement of smartphone cameras opens vast horizons for stereo-fundoscopy and 3D reconstruction of the ocular fundus without using sophisticated and costly equipment. Microscopic eye movements allow taking snapshots of two side-by-side photos for 3D reconstruction and stereoscopic image viewing, which is the next level of optic disc assessment.

Comparison of Outcomes in Patients Undergoing Renal Transplantation With Impaired vs Normal Left Ventricular Ejection Fraction.

BACKGROUND: Renal transplantation improves long-term outcomes in patients with end-stage renal disease (ESRD); however, patients with impaired left ventricular ejection fraction (LVEF) are less likely to be selected for renal transplantation. We sought to evaluate the effect of renal transplantation in this population. METHODS: We retrospectively evaluated 181 patients who underwent renal transplantation between 2011 and 2016. For patients with pretransplant LVEF <50% (cohort 1) and ≥50% (cohort 2), we evaluated the effect of renal transplantation on LVEF, graft failure, and mortality. RESULTS: Cohort 1 comprised 24 patients (mean age, 47 years; pretransplant LVEF 38%). Cohort 2 comprised 157 patients (mean age, 53 years; pretransplant LVEF 64%). Forty-six percent of cohort 1 experienced significant improvement in LVEF posttransplant, with mean LVEF improvement from 38% to 66%. There was no significant association between pretransplant LVEF and graft failure (hazard ratio [HR] = 2.7; 95% confidence interval [CI], 0.6-11.4; P = .1) or mortality (HR = 1.02; 95% CI, 0.3-3.6; P = .9). Coronary artery disease predicted mortality (HR = 3.12; 95% CI, 1.2-8.4; P = .02). Older age trended toward higher mortality (HR = 1.04; 95% CI, 1.0-1.1; P = .05). Younger age predicted graft failure (HR = 0.96; 95% CI, 0.8-0.9; P = .02). CONCLUSIONS: In patients with ESRD undergoing renal transplantation, there was no significant association between pretransplant LVEF and mortality or graft failure, suggesting that patients with ESRD with impaired LVEF can experience positive posttransplant outcomes.

Review of Direct Oral Anticoagulants and Guide for Effective Drug Utilization.

Direct oral anticoagulants (DOACs) have been developed as a viable and in some cases superior alternative to warfarin. These agents have overcome some of the limitations of warfarin, which has a narrow therapeutic window and many food and drug interactions. DOACs have been demonstrated to have a more predictable and reliable pharmacology and, unlike warfarin, do not require frequent monitoring of anticoagulant effect. For these reasons, the use of DOACs is increasing. Despite the many positive attributes of these agents, limitations and contraindications do exist. An understanding of the pharmacology, indications, and contraindications is therefore crucial for effective patient management. We review the available agents to aid in effective drug utilization.

Length of Stay After Transfemoral Transcatheter Aortic Valve Replacement: An Analysis of the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.

OBJECTIVES: The goal of this study was to investigate the trends, predictors, and outcomes of delayed discharge (>72 h) after transcatheter aortic valve replacement. BACKGROUND: Length of stay post-transcatheter aortic valve replacement may have significant clinical and administrative implications. METHODS: Data from the Transcatheter Valve Therapy Registry were used to identify patients undergoing nonaborted transfemoral transcatheter aortic valve replacement who survived to discharge, and data linked from the Centers for Medicare & Medicaid Services were used to provide 1-year events. Patients were categorized to early discharge (≤72 h) versus delayed discharge (>72 h). The trends, predictors, and adjusted 1-year outcomes were compared in both groups. RESULTS: From 2011 to 2015, a total of 13,389 patients (55.1%) were discharged within 72 h, whereas 10,896 patients (44.9%) were discharged beyond 72 h. There was a significant decline in rates of delayed discharge across the study period (62% vs. 34%; p < 0.01). This remained unchanged when stratified by Transcatheter Valve Therapy risk scores. Several factors were identified as independent predictors of early and delayed discharge. After adjustment for in-hospital complications, delayed discharge was an independent predictor of 1-year all-cause mortality (hazard ratio: 1.45; 95% confidence interval: 1.30 to 1.60; p < 0.01). CONCLUSIONS: Rates of delayed discharge have declined from 2011 to 2015. Delayed discharge is associated with a significant increase in mortality even after adjusting for in-hospital complications. Further work is necessary to determine if predictors of early discharge could be used to develop length of stay scores that might be instrumental in administrative, financial, or clinical policy development.

Comparison of Accuracy of Left Atrial Area and Volume by Two-dimensional Trans-thoracic Echocardiography Versus Computed Tomography.

Left atrial (LA) size is prognostic of cardiovascular events and can be quantified as diameter, area, or volume. While LA area measurement by 2-dimensional (2D) echocardiography is performed by tracing LA borders in the apical 4-chamber view, LA volume is derived from a formula that is based on geometrical assumptions. We compared LA area and volume measurements obtained by trans-thoracic echocardiography (TTE) to those obtained using multi-detector computed tomography (MDCT). Sixty-four patients with MDCT and TTE performed within a 1-week period were included in the study. End-systolic LA area was planimetered from the 4-chamber view by TTE and MDCT. LA end-systolic volume was calculated using the biplane area-length (AL) method in both TTE and MDCT. Mean LA volume measurement using MDCT was significantly larger than TTE measurement (92 ± 31 mL vs 68 ± 27 mL, p <0.001). There was moderate correlation between MDCT and TTE in both LA area (0.74, p <0.0001), and volumetric measurements (0.77, p <0.0001). Bland-Altman agreement plots demonstrated a significantly lower bias and narrower 95% confidence intervals (CI) for the 2D area (bias: -5.5; 95% CI: -14.3 to 3.3) as compared with volumetric measurements (bias: -23.7; 95% CI: -64.9 to 17.5, p <0.0001). Contrary to current guidelines for chamber quantification, 2D TTE LA area has better agreement with MDCT than volumetric measurements by TTE. LA volumetric measurements are desirable; however, they are currently less reliable than the direct LA area tracing by 2D TTE and therefore represent a suboptimal and less reproducible method to determine LA size.

The possible impact of cervical stenosis on cephalad neuronal dysfunction.

Earlier observers have speculated on the causal relationships between abnormal CSF circulation and a variety of neurological dysfunctions. Such speculations have been at least partially validated by recent evidence and inquiries contravening the traditional static viewpoint of CSF circulation. More contemporary inquiries establish a number of factors which influence both CSF production and absorption (sleep disturbance, neck position, cerebral metabolism, brain atrophy, medications, etc.). Thus, transient periods of abnormality are possibly mingled with periods of normality. Such episodic alterations suggest that the physiological arrangements which underpin CSF circulation may be in some ways likened to blood pressure alterations, in that long-standing CSF abnormalities may be both unappreciated and gradual, though virulent enough to cause substantial neurological injury. We suggest that cervical stenosis (blocking an important CSF decompressive pathway into the vertebral canal) is among the largely unappreciated causes of abnormal CSF circulation and may play a role in cephalad neuronal dysfunction. Such a blockage is correlated with age and easily assessed by cine MRI study. Indeed, episodic disturbances can diminish CSF cerebral flow circulation increasing deposition in cerebral parenchyma of contrary metabolic products (e.g. beta Amyloid), possibly having a causal influence on senile dementia. Additionally, cervical stenosis, by increasing posterior fossa cerebral pressure, could play a causal role in a number of afflictions, among them sleep apnea, concomitant respiratory and circulatory dysfunction, hypertension, chronic occipital headaches, tinnitus, etc. We further suggest that among those patients with substantial cervical stenosis (extensive enough to block CSF circulation in the cervical area as identified by cine MRI) appropriate comparative clinical studies could be undertaken to demarcate associations with presenile dementia, sleep disturbance and posterior fossa dysfunction. Additionally, we suggest that an intracranial monitoring implant be perfected to chronically monitor both intracranial pressure and CSF flow - a monitoring device comparable to the rather less invasive sphygmometric evaluation of blood pressure. If such speculations prove correct, different therapeutic regimens which might improve outcome could be imagined. Among them better sleep hygiene (to by position maximize CSF flow) and possibly more aggressive operative decompressive intervention to diminish cervical obstruction.

Preclinical Evaluation of the NeVaTM Stent Retriever: Safety and Efficacy in the Swine Thrombectomy Model.

BACKGROUND: A novel stent retriever device with an enhanced radial force profile, enlarged offset openings, and a closed distal end has been developed. OBJECTIVE: Evaluate the safety and effectiveness of the NeVaTM thrombectomy device in animal model of thrombo-occlusive disease. MATERIALS AND METHODS: Seven swine were used in safety and efficacy studies. Thrombo-occlusive disease was modeled using 4 emboli morphologies; 2 distinct models of autologous whole blood thrombi, plasma-enriched thrombi, and Onyx® emboli. A total of 35 vascular occlusions and retrievals were performed using emboli of variable sizes. Pre- and post-modified thrombolysis in cerebral ischemia (mTICI) scores, number of retrievals, and the presence of angiographic complications were recorded. In the safety study, a total of 6 clot retrievals were completed and the vascular territory examined grossly and harvested for histopathological evaluation. A semiquantitative vasospasm study was performed. Radial force testing was performed on NeVaTM and control devices for comparison. RESULTS: Near-full or full reperfusion (mTICI 2b/3) was achieved in 34/35 occlusions after a mean of 1.2 passes. Full reperfusion (TICI 3) was achieved in 17/17 of whole blood clot occlusions (ranging between 10 and 20 mm) after a mean of 1.06 passes. The rate of mTICI 2b/3 reperfusion was 10/11 (mean, 1.6 passes) and 5/5 (mean, 1.0 passes) for Onyx® and plasma-enriched clot emboli, respectively. Histopathological vessel injury and vasospasm scores were comparable to predicate studies. Radial force curves demonstrated increased expansive radial force and similar compressive radial force compared to predicate devices. CONCLUSIONS: Our preclinical results support the use of the NeVaTM device in a clinical trial to determine if this novel design improves upon current stent retriever outcomes.

Enlargement of an incidental internal carotid artery aneurysm embedded in pituitary adenoma associated with medical shrinkage of the tumor: Case report.

BACKGROUND: Currently, transsphenoidal surgery (TSS) is the preferred method for surgical treatment of intrasellar pituitary adenomas. However, it carries some risk of intraoperative arterial injuries, which is mainly attributed to direct iatrogenic rupture of the internal carotid artery (ICA). There is anecdotal evidence suggesting that intracranial aneurysms are coincidentally found significantly more frequently in the setting of pituitary adenomas than when the incidence is compared to other intracranial neoplasms. The exact cause of this discrepancy remains unclear, but it certainly raises concerns about the potential existence of an ICA aneurysm, which might be encountered during TSS and in some cases may cause hemorrhagic complications. CASE DESCRIPTION: We present a case of a patient who was found to have a growth hormone (GH)-secreting pituitary adenoma and a coexisting cavernous ICA aneurysm which was embedded within the tumor. The patient underwent medical treatment of the adenoma. However, shrinkage of the tumor was associated with enlargement of the observed aneurysm, warranting endovascular intervention. CONCLUSIONS: This case report is an illustration for physicians to be conscientious about the potential danger posed by the coexistence of an intratumoral aneurysm in the setting of a pituitary adenoma. Special attention should be given to recognition of an intrinsic flow void signal on the presurgical imaging of the tumor, and if observed, magnetic resonance angiography (MRA) should be performed for preoperative planning. If MRA is not performed routinely, detailed review of high-resolution magnetic resonance imaging is recommended to detect any flow artifacts suggestive of an aneurysm.

Prediction of revascularization after myocardial perfusion SPECT by machine learning in a large population.

OBJECTIVE: We aimed to investigate if early revascularization in patients with suspected coronary artery disease can be effectively predicted by integrating clinical data and quantitative image features derived from perfusion SPECT (MPS) by machine learning (ML) approach. METHODS: 713 rest (201)Thallium/stress (99m)Technetium MPS studies with correlating invasive angiography with 372 revascularization events (275 PCI/97 CABG) within 90 days after MPS (91% within 30 days) were considered. Transient ischemic dilation, stress combined supine/prone total perfusion deficit (TPD), supine rest and stress TPD, exercise ejection fraction, and end-systolic volume, along with clinical parameters including patient gender, history of hypertension and diabetes mellitus, ST-depression on baseline ECG, ECG and clinical response during stress, and post-ECG probability by boosted ensemble ML algorithm (LogitBoost) to predict revascularization events. These features were selected using an automated feature selection algorithm from all available clinical and quantitative data (33 parameters). Tenfold cross-validation was utilized to train and test the prediction model. The prediction of revascularization by ML algorithm was compared to standalone measures of perfusion and visual analysis by two experienced readers utilizing all imaging, quantitative, and clinical data. RESULTS: The sensitivity of machine learning (ML) (73.6% ± 4.3%) for prediction of revascularization was similar to one reader (73.9% ± 4.6%) and standalone measures of perfusion (75.5% ± 4.5%). The specificity of ML (74.7% ± 4.2%) was also better than both expert readers (67.2% ± 4.9% and 66.0% ± 5.0%, P < .05), but was similar to ischemic TPD (68.3% ± 4.9%, P < .05). The receiver operator characteristics areas under curve for ML (0.81 ± 0.02) was similar to reader 1 (0.81 ± 0.02) but superior to reader 2 (0.72 ± 0.02, P < .01) and standalone measure of perfusion (0.77 ± 0.02, P < .01). CONCLUSION: ML approach is comparable or better than experienced readers in prediction of the early revascularization after MPS, and is significantly better than standalone measures of perfusion derived from MPS.

The 'Inextricabilis Syndrome': a case with no solution.

UNLABELLED: We describe a case of a 58-year-old man with cardiogenic shock who underwent triple vessel coronary artery bypass and a left ventricular assist device (LVAD) implantation. His course was complicated by stroke, worsening mitral regurgitation, aortic regurgitation, and multiple cardiac thrombi while on the device. We provide the details of the patient's hospital course, management, and echocardiographic findings. We also discuss the utility of echocardiography before LVAD insertion and its role for continued monitoring after insertion. LEARNING POINTS: Ventricular assist devices (VADs) are used as bridge to decision, transplant, recovery, or destination therapy in patients with advanced heart failure and cardiogenic shock.VADs improve survival and the quality of life but have significant associated complications.Echocardiography plays an essential role before VAD insertion and for postoperative cardiac monitoring. Information provided by echocardiography is used in device selection, consideration for corrective surgical interventions, and device explantation.

Coronary arteriovenous malformation, as imaged with cardiac computed tomography angiography: A case series.

INTRODUCTION: Coronary Arteriovenous Malformations (AVM) can lead to various cardiovascular events. The severity of clinical manifestation depends on the degree of the malformation. The significance of major arterial shunt is that they can deprive the myocardium of the necessary amount of blood, leading to myocardial ischemia, and potentially tachycardia, left ventricular dilatation and heart failure secondary to increased stroke volume and cardiac output. Cardiac computed tomography (CCT) has proven to be a good non-invasive diagnostic tool in the detection of coronary Arteriovenous Malformations. CASE PRESENTATION: We include 4 patients, who presented with various symptoms in relation to the coronary Arteriovenous Malformations. Diagnostic confirmation was made non-invasively using multi-row detector cardiac computed tomography (MDCT). CONCLUSION: Coronary Arteriovenous Malformation is a rare congenital disease which can produce symptoms of varying severity depending on the size of the malformation. CCT angiography can help in non-invasively diagnosing the malformation along with revealing the anatomic details, which can be used for surgical planning, or for better medical management of the patients.