Effect of anesthetic strategies on distal stroke thrombectomy in the anterior and posterior cerebral artery.

BACKGROUND: Numerous questions regarding procedural details of distal stroke thrombectomy remain unanswered. This study assesses the effect of anesthetic strategies on procedural, clinical and safety outcomes following thrombectomy for distal medium vessel occlusions (DMVOs). METHODS: Patients with isolated DMVO stroke from the TOPMOST registry were analyzed with regard to anesthetic strategies (ie, conscious sedation (CS), local (LA) or general anesthesia (GA)). Occlusions were in the P2/P3 or A2-A4 segments of the posterior and anterior cerebral arteries (PCA and ACA), respectively. The primary endpoint was the rate of complete reperfusion (modified Thrombolysis in Cerebral Infarction score 3) and the secondary endpoint was the rate of modified Rankin Scale score 0-1. Safety endpoints were the occurrence of symptomatic intracranial hemorrhage and mortality. RESULTS: Overall, 233 patients were included. The median age was 75 years (range 64-82), 50.6% (n=118) were female, and the baseline National Institutes of Health Stroke Scale score was 8 (IQR 4-12). DMVOs were in the PCA in 59.7% (n=139) and in the ACA in 40.3% (n=94). Thrombectomy was performed under LA±CS (51.1%, n=119) and GA (48.9%, n=114). Complete reperfusion was reached in 73.9% (n=88) and 71.9% (n=82) in the LA±CS and GA groups, respectively (P=0.729). In subgroup analysis, thrombectomy for ACA DMVO favored GA over LA±CS (aOR 3.07, 95% CI 1.24 to 7.57, P=0.015). Rates of secondary and safety outcomes were similar in the LA±CS and GA groups. CONCLUSION: LA±CS compared with GA resulted in similar reperfusion rates after thrombectomy for DMVO stroke of the ACA and PCA. GA may facilitate achieving complete reperfusion in DMVO stroke of the ACA. Safety and functional long-term outcomes were comparable in both groups.

Neutrophil-Lymphocyte ratio is associated with poor clinical outcome after mechanical thrombectomy in stroke in patients with COVID-19.

BACKGROUND: The neutrophil-lymphocyte ratio (NLR) is emerging as an important biomarker of acute physiologic stress in a myriad of medical conditions, and is a confirmed poor prognostic indicator in COVID-19. OBJECTIVE: We sought to describe the role of NLR in predicting poor outcome in COVID-19 patients undergoing mechanical thrombectomy for acute ischemic stroke. METHODS: We analyzed NLR in COVID-19 patients with large vessel occlusion (LVO) strokes enrolled into an international 12-center retrospective study of laboratory-confirmed COVID-19, consecutively admitted between March 1, 2020 and May 1, 2020. Increased NLR was defined as ≥7.2. Logistic regression models were generated. RESULTS: Incidence of LVO stroke was 38/6698 (.57%). Mean age of patients was 62 years (range 27-87), and mortality rate was 30%. Age, sex, and ethnicity were not predictive of mortality. Elevated NLR and poor vessel recanalization (Thrombolysis in Cerebral Infarction (TICI) score of 1 or 2a) synergistically predicted poor outcome (likelihood ratio 11.65, p = .003). Patients with NLR > 7.2 were 6.8 times more likely to die (OR 6.8, CI95% 1.2-38.6, p = .03) and almost 8 times more likely to require prolonged invasive mechanical ventilation (OR 7.8, CI95% 1.2-52.4, p = .03). In a multivariate analysis, NLR > 7.2 predicted poor outcome even when controlling for the effect of low TICI score on poor outcome (NLR p = .043, TICI p = .070). CONCLUSIONS: We show elevated NLR in LVO patients with COVID-19 portends significantly worse outcomes and increased mortality regardless of recanalization status. Severe neuro-inflammatory stress response related to COVID-19 may negate the potential benefits of successful thrombectomy.

Rescue Maneuver of Migrated Coil Using the ERIC Device after Previous Attempts with Conventional Stentrievers.

Coil prolapse or migration is a rare but potentially serious complication that may occur during aneurysm embolization, with no standard management currently described. Here we describe our experience with the Embolus Retriever with Interlinked Cages (ERIC) device® (Microvention, Aliso Viejo, CA, USA) for the retrieval of prolapsed or migrated coils in a case series and Flow-Model analysis. First, a retrospective review was performed using our institution database for patients in which coil prolapse or migration occurred during aneurysm embolization, and data was collected and analyzed. Second, an in vitro Flow-Model analysis was performed comparing the ERIC device® with other stent retrievers for coil retrieval. In 2 cases, the ERIC device® successfully retrieved the displaced coil from intracranial circulation in 1 pass, after failure with other devices. In the Flow-Model, again the ERIC device® achieved success for retrieving a detached coil, whereas 2 other different stent retrievers failed to capture the coil after 2 attempts. The ERIC device® appears to be a safe and effective tool for retrieving a prolapsed or migrated coil from the intracranial circulation.

First multicenter experience using the Silk Vista flow diverter in 60 consecutive intracranial aneurysms: technical aspects.

BACKGROUND: The aim of this study was to assess the technical success and procedural safety of the new Silk Vista device (SV) by evaluating the intraprocedural and periprocedural complication rate after its use in several institutions worldwide. METHODS: The study involved a retrospective review of multicenter data regarding a consecutive series of patients with intracranial aneurysms, treated with the SV between September 2020 and January 2021. Clinical, intra/periprocedural and angiographic data, including approach, materials used, aneurysm size and location, device/s, technical details and initial angiographic aneurysm occlusion, were analyzed. RESULTS: 60 aneurysms were treated with SV in 57 procedures. 66 devices were used, 3 removed and 63 implanted. The devices opened instantaneously in 60 out of 66 (91%) cases and complete wall apposition was achieved in 58 out of 63 (92%) devices implanted. In 4 out of 66 (6%) devices a partial opening of the distal end occurred, and in 5 (8%) devices incomplete apposition was reported. There were 3 (5%) intraprocedural thromboembolic events managed successfully with no permanent neurological morbidity, and 4 (7%) postprocedural events. There was no mortality in this study. The initial occlusion rates in the 60 aneurysms were as follows: O'Kelly-Marotta (OKM) A in 34 (57%) cases, OKM B in 15 (25%) cases, OKM C in 6 (10%) cases, and OKM D in 5 (8%) cases. CONCLUSIONS: Our study demonstrated that the use of the new flow diverter Silk Vista for the treatment of intracranial aneurysms is feasible and technically safe.

Incidence, Characteristics and Outcomes of Large Vessel Stroke in COVID-19 Cohort: An International Multicenter Study.

BACKGROUND: While there are reports of acute ischemic stroke (AIS) in coronavirus disease 2019 (COVID-19) patients, the overall incidence of AIS and clinical characteristics of large vessel occlusion (LVO) remain unclear. OBJECTIVE: To attempt to establish incidence of AIS in COVID-19 patients in an international cohort. METHODS: A cross-sectional retrospective, multicenter study of consecutive patients admitted with AIS and COVID-19 was undertaken from March 1 to May 1, 2020 at 12 stroke centers from 4 countries. Out of those 12 centers, 9 centers admitted all types of strokes and data from those were used to calculate the incidence rate of AIS. Three centers exclusively transferred LVO stroke (LVOs) patients and were excluded only for the purposes of calculating the incidence of AIS. Detailed data were collected on consecutive LVOs in hospitalized patients who underwent mechanical thrombectomy (MT) across all 12 centers. RESULTS: Out of 6698 COVID-19 patients admitted to 9 stroke centers, the incidence of stroke was found to be 1.3% (interquartile range [IQR] 0.75%-1.7%). The median age of LVOs patients was 51 yr (IQR 50-75 yr), and in the US centers, African Americans comprised 28% of patients. Out of 66 LVOs, 10 patients (16%) were less than 50 yr of age. Among the LVOs eligible for MT, the average time from symptom onset to presentation was 558 min (IQR 82-695 min). A total of 21 (50%) patients were either discharged to home or discharged to acute rehabilitation facilities. CONCLUSION: LVO was predominant in patients with AIS and COVID-19 across 2 continents, occurring at a significantly younger age and affecting African Americans disproportionately in the USA.

Upper extremity transvenous access for neuroendovascular procedures: an international multicenter case series.

BACKGROUND: Radial artery access for transarterial procedures has gained recent traction in neurointerventional due to decreased patient morbidity, technical feasibility, and improved patient satisfaction. Upper extremity transvenous access (UETV) has recently emerged as an alternative strategy for the neurointerventionalist, but data are limited. Our objective was to quantify the use of UETV access in neurointerventions and to measure failure and complication rates. METHODS: An international multicenter retrospective review of medical records for patients undergoing UETV neurointerventions or diagnostic procedures was performed. We also present our institutional protocol for obtaining UETV and review the existing literature. RESULTS: One hundred and thirteen patients underwent a total of 147 attempted UETV procedures at 13 centers. The most common site of entry was the right basilic vein. There were 21 repeat puncture events into the same vein following the primary diagnostic procedure for secondary interventional procedures without difficulty. There were two minor complications (1.4%) and five failures (ie, conversion to femoral vein access) (3.4%). CONCLUSIONS: UETV is safe and technically feasible for diagnostic and neurointerventional procedures. Further studies are needed to determine the benefit over alternative venous access sites and the effect on patient satisfaction.

Arm-only access for combined transarterial and transvenous neurointerventional procedures.

A simultaneous arterial and venous approach has been widely described for the endovascular treatment of dural arteriovenous fistula (DAVFs) and recently for arteriovenous malformation (AVMs). Conventional venous approaches are performed by direct internal jugular puncture or by femoral access. Although complication rates are low, there are potential life-threatening complications that should be avoided. The advantages of radial artery access have been widely proven, nevertheless the use of upper limb veins in neurointervention are rarely reported. We present five cases of the simultaneous arteriovenous approach through the radial artery and superficial veins of the forearm for the treatment of intracranial neurovascular diseases.

Transcirculation Silk Vista Baby-assisted coiling in half-T configuration for the treatment of posterior communicating artery aneurysms associated with a fetal posterior circulation: An alternative flow diversion strategy.

Flow diverter devices have become a routine first-line option for treatment of an increasing population of intracranial aneurysms at many neurovascular centers. Despite the promising results of flow diverter stents on anterior circulation, incomplete occlusion on the presence of fetal posterior circulation has been described on several reports. Here we describe a novel technical alternative to conventional flow diversion approach for this specific subgroup of aneurysms using the low-profile flow diverter, Silk Vista Baby. The device was selectively placed into the fetal type posterior cerebral artery in half-T configuration for the treatment of a posterior communicating aneurysm using a transcirculation approach through the anterior communicating artery. This represents a useful and effective technique and should be considered when encountering the above-described situation.

Estudio de las gestantes de edad avanzada en el Hospital Universitario de Caracas / Advanced maternal age studies in the Hospital Universitario de Caracas

Se realizó un estudio retrospectivo, descriptivo, comparativo en 436 pacientes embarazadas atendidas en el Servicio de Obstetricia del Hospital Universitario de Caracas, durante el período comprendido entre enero de 2000 y diciembre de 2003. Fueron distribuidas en dos grupos, el grupo "A" constituido por 212 embarazadas de 35 años o más, atendidas en la consulta de alto riesgo obstétrico y el grupo "B" conformado por 224 embarazadas menores de 35 años atendidas en la consulta prenatal de bajo riesgo. Los objetivos del estudio fueron determinar si es cierto que la edad materna avanzada es un factor de alto riesgo y determinar si el control prenatal, el control del parto y el puerperio hecho en la gestante de edad avanzada disminuye el grado de riesgo materno - fetal haciendo que su pronóstico sea similar al de las gestantes de menor edad con menos riesgo. En el grupo estudio hubo mayor porcentaje de complicaciones prenatales, destacándose la hipertensión. La cesárea tuvo una proporción del 45,29 por ciento, siendo más frecuentes las de emergencia. Las cifras de amenaza de parto pretérmino fueron semejantes en ambos grupos. El puerperio fue de evolución satisfactoria con un número menor de casos para el grupo estudio. No hubo muertes maternas en ambos grupos. El peso de los recién nacidos fue adecuado muestra en ambos grupos con un porcentaje mayor de recién nacidos macrosómicos en el grupo estudio. La evolución neonatal tuvo un porcentaje mayor de casos no satisfactorios en las gestantes de edad avanzada. Se concluye que a pesar de ser las gestantes de edad avanzada un grupo de alto riesgo, el control adecuado y frecuente para la detección oportuna de las complicaciones y una conducta más intervencionista en la resolución de los casos y a una mayor atención de las madres en el posparto, así como de sus hijos en forma inmediata, hacen que los índices de morbimortalidad perinatal no muestren diferencias significativas con respecto al grupo control catalogado.

A retrospective, comparative study control case was performed in 436 pregnant women assisted on the Hospital Universitario de Caracas, between January 2000 and December 2003. They were distributed in two groups, group "A" with 212 pregnant women 35 or more old years, assisted on Obstetrical High Risk Consultation and group "B" conformed by 224 pregnant women minor 35 year old. The objective was to determine if true than advanced age in pregnant women is a high risk factor; and the prenatal control, intrapartum and puerperal care in the pregnant women 35 or more years old minimizes the risk, making it similar to control group. In study group there were a larger percentage of prenatal complications, principally hypertension. Cesarean section was done a in 45.29 percent, often as emergencies. The premature delivery threat numbers were similar in both groups. Puerperal evolution was satisfactory with fewer cases for the study group. There were not maternal deaths in both groups. Weight of newborns showed in both groups a large percentage with standard weight, with a double incidence for macrosomics in the study group. Neonatal evolution had more unsatisfactory cases for the patients with advanced maternal age. We conclude that advanced age in pregnant patients is a high risk factor. Pregnant women with good health and an adequate prenatal care can reduce risks, resulting in a good maternal-fetal prognostic similar to the low risk group.