Blood Pressure Management Before, During, and After Endovascular Thrombectomy for Acute Ischemic Stroke.

There is an absence of specific evidence or guideline recommendations on blood pressure management for large vessel occlusion stroke patients. Until randomized data are available, the periprocedural blood pressure management of patients undergoing endovascular thrombectomy can be viewed in two phases relative to the achievement of recanalization. In the hyperacute phase, prior to recanalization, hypotension should be avoided to maintain adequate penumbral perfusion. The American Heart Association guidelines should be followed for the upper end of prethrombectomy blood pressure: ≤185/110 mm Hg, unless post-tissue plasminogen activator administration when the goal is <180/105 mm Hg. After successful recanalization (thrombolysis in cerebral infarction [TICI]: 2b-3), we recommend a target of a maximum systolic blood pressure of < 160 mm Hg, while the persistently occluded patients (TICI < 2b) may require more permissive goals up to <180/105 mm Hg. Future research should focus on generating randomized data on optimal blood pressure management both before and after endovascular thrombectomy, to optimize patient outcomes for these divergent clinical scenarios.

Diurnal Variations in the First 24/7 Mobile Stroke Unit.

Background and Purpose- Mobile Stroke Units (MSUs) provide innovative prehospital stroke care but their 24/7 operation has not been studied. Our study investigates 24/7 MSU diurnal variations related to transport frequency, patient characteristics, and stroke treatments. Methods- We compared transportation frequency, demographics, thrombolytic and mechanical thrombectomy administration, and treatment metrics across 8-hour shifts (morning, evening, and nocturnal) from our 24/7 MSU in Northwest Ohio prospective database. Results- One hundred ninety-five patients were transported by the MSU. Most transports occurred during the morning shift (52.3%) followed by evening shift (35.8%) and nocturnal shift (11.9%; Ptrend<0.001). Twenty-three patients (11.9%) received intravenous thrombolytic in the MSU, most frequently in the morning shift (56.5%). No cases of mechanical thrombectomy were performed on MSU patients in the nocturnal shift. Conclusions- Morning and evening shifts account for the majority of our MSU transports (88.1%) and therapeutic interventions. Understanding temporal variations in a resource-intensive MSU is critical to its worldwide implementation.

SEIMLESS: Simultaneous Extracranial, Intracranial Management of (tandem) LESsions in Stroke.

BACKGROUND: Pooled individual data from the landmark stroke trials of 2015 conclude that the benefit of endovascular thrombectomy for patients with intracranial arterial occlusion also extends to patients with concomitant (so-called 'tandem') occlusions of proximal vessels. However, there is heterogeneity and debate in the management of these patients, without a clear standard of care. In particular, there is contention regarding whether the proximal or distal lesion should be treated first. We present a case control study and describe the Simultaneous Extracranial, Intracranial Management of (tandem) LESsions in Stroke (SEIMLESS) technique, an efficient approach to the acute ischemic stroke (AIS) patient who presents with tandem lesions (TLs). METHODS: We describe 5 patients, presenting with AIS and TLs between 2015 and 2017, who we treated with SEIMLESS. Cases were reviewed for clinical data, including arterial puncture to intracranial reperfusion, total fluoroscopy time, amount of contrast, age, and gender. Our series was matched to 5 patients treated with the standard 'sequential' approach (angioplasty followed by thrombectomy) in the same time period by the same operator. RESULTS: Arterial access to intracranial recanalization time was significantly shorter in patients treated with SEIMLESS versus those who had angioplasty followed by thrombectomy (39.6±5.9 min vs 85.2±20.6 min; P=0.014). Patients treated 'seimlessly' also received significantly less iodinated contrast (117±13.5 mL vs 213±48.9 mL; P=0.005) and significantly less fluoroscopy time (21.1±5.2 min vs 55.9±17.8 min; P=0.003). There was no difference in the post-procedural Thrombolysis in Cerebral Infarction score for patients treated with SEIMLESS versus the sequential method (p=0.658). CONCLUSION: SEIMLESS is an efficient procedural method that simultaneously treats a distal intracranial occlusion and a more proximal one. Our small case controlled study finds that this technique is feasible and can lead to faster intracranial recanalization compared with the standard 'sequential' method, utilizing less contrast and radiation in the process. Larger studies are needed to verify our findings.

A Serpiginous Pericallosal Anterior Cerebral Artery.

The anterior cerebral artery (ACA) is a unique artery with many important variations with substantial clinical significance. Tortuous intracranial arteries usually occur in basilar, communicating, anterior, posterior cerebral arteries and in the white matter arterioles. This could happen for many reasons including but not limited to ageing, hypertension, patients with Moyamoya disease, congenital malformation, or increased flow associated with elastin degradation. While dolichoectasia of the ACA has been described even in children, to our knowledge, a serpiginous ACA without ectasia has not been reported, especially in the pediatric population.

Endovascular Treatment of Acute Ischemic Stroke Under General Anesthesia: Predictors of Good Outcome.

BACKGROUND: The choice of anesthetic technique, general anesthesia (GA) versus Monitored Anesthesia Care, may impact the outcome of patients undergoing endovascular treatment of acute ischemic stroke (AIS). The aim of this study was to identify the factors associated with good discharge outcome in patients receiving GA for AIS. MATERIALS AND METHODS: Electronic medical records of patients above 18 years old who underwent endovascular treatment of AIS under GA at a Comprehensive Stroke Center from 2010 to 2014 were reviewed. Good outcome was defined as discharge modified Rankin Score 0 to 2 and poor outcome as modified Rankin Score 3 to 6; logistic regression analysis was performed to examine the association between the clinical characteristics and the outcome. RESULTS: In total, 88 patients (56 males), aged 63±15 years with median National Institute of Health Stroke Scale (NIHSS) score 16 (range, 4 to 38) were included. Nineteen (22%) patients had good outcome and 78 (88%) had systolic blood pressure below the guideline recommended 140 mm Hg under GA. After adjusting for age and NIHSS score, the independent predictors of good discharge outcomes were higher maximum end-tidal carbon dioxide (odds ratio [OR], 1.14; confidence interval [CI], 1.02-1.28; P=0.02) and extubation after endovascular treatment (OR, 26.31; CI, 4.80-144.12; P<0.0001). A secondary analysis was performed after excluding 25 patients emergently intubated in the Emergency Department for airway protection. In the logistic regression analysis controlling for age and NIHSS score, postprocedure extubation was still associated with higher odds of good outcomes (OR, 13.35; CI, 2.58-68.90; P=0.002). CONCLUSIONS: These findings indicate the importance of ventilation management and extubation after endovascular intervention under GA in patients with AIS.

Anterior Communicating Artery Aneurysm Treatment with the Pipeline Embolization Device: A Single-Center Experience with Long-Term Follow-Up.

INTRODUCTION: The pipeline embolization device (PED) is increasingly used in the endovascular management of cerebral aneurysms. Longitudinal data regarding safety and benefit of the PED in anterior communicating (ACOM) artery aneurysms are limited and particularly lacking in residual ACOM artery aneurysms. We report the use of the PED in 3 patients with ACOM artery aneurysms who were previously coiled. METHODS: Three patients with ACOM artery aneurysms, all previously treated with coiling and with recurrence of the aneurysm neck, were treated with the PED. All obtained follow-up diagnostic cerebral angiograms at either 3 or 6 months. RESULTS: Mean age of patients was 59 years. All patients received cerebral angiograms at a minimum of 3 months after treatment with the PED. Follow-up angiography was performed up to a mean of 10 months at which time point all cases demonstrated complete aneurysm occlusion, without any stenosis in the parent artery. CONCLUSION: The PED can be safely used for the treatment of ACOM artery aneurysms. Complete aneurysm obliteration can be achieved in cases refractory to endovascular coiling. These findings warrant replication in a larger data set.

Cross-circulation thrombectomy with use of a stent retriever: A case report.

Introduction The efficacy of the endovascular treatment of acute ischemic stroke has been substantiated by several recent randomized clinical trials. While intra-arterial therapy has significantly evolved in recent years, anatomic cerebrovascular variants and disease burden can present challenges to timely recanalization. We present the first reported case of anterior-to-posterior mechanical clot retrieval with use of a stent retriever. Case description A 53-year-old man presented with basilar artery thrombosis. Endovascular mechanical clot retrieval was performed. The typical, antegrade, access to the basilar artery thrombus was precluded by the findings of a hypoplastic left vertebral artery and an occluded proximal right vertebral artery. Given a number of factors including the patient's worsening symptoms and the high morbidity and mortality associated with basilar stroke, cross-circulation-anterior-to-posterior-intra-arterial therapy was performed. Thrombectomy of the basilar thrombus was achieved via the right internal carotid artery and right posterior communicating artery. Conclusion To our knowledge, we report the first case of cross-circulation, anterior-to-posterior thrombectomy, with the use of a stent-retriever device. Cross-circulation stroke treatment may be beneficial in cases of proximal vessel occlusion or anatomical constraints. Larger studies will need to evaluate the safety and efficacy of these approaches.

Nonstenotic Culprit Plaque: The Utility of High-Resolution Vessel Wall MRI of Intracranial Vessels after Ischemic Stroke.

Intracranial atherosclerotic disease (ICAD) accounts for 9-15% of ischemic stroke in the United States. Although highly stenotic ICAD accounts for most of the strokes, it is assumed that nonstenotic ICAD (nICAD) can result in stroke, despite being missed on standard luminal imaging modalities. We describe a patient with nICAD who suffered recurrent thromboembolic stroke and TIA but had a negative conventional stroke workup. As a result, they were referred for high-resolution magnetic resonance imaging (HR-MRI) of the arterial vessel wall, which identified a nonstenotic plaque with multiple high-risk features, identifying it as the etiology of the patient's thromboembolic events. The diagnosis resulted in a transition from anticoagulation to antiplatelet therapy, after which the patient's clinical events resolved. HR-MRI is an imaging technique that has the potential to guide medical management for patients with ischemic stroke, particularly in cryptogenic stroke.

Ischemic stroke patients with active malignancy or extracardiac shunts are more likely to have a right-to-left shunt found by TCD than echocardiogram.

Although the association between patent foramen ovale and ischemic stroke is controversial, the evaluation for a right-to-left shunt remains part of the standard workup for cryptogenic stroke. Transthoracic and transesophageal echocardiogram (TTE and TEE) are the screening test and gold standard to evaluate for right-to-left shunt, respectively. Studies comparing TTE or TEE to transcranial Doppler (TCD) have shown that 15-25 % of patients test positive for right-to-left shunt on TCD but are negative on TTE or TEE. We sought to further explore this phenomenon in patients with recent ischemic stroke. Between 2011 and 2013, 109 ischemic stroke patients had both a TCD and TTE or TEE bubble study. We abstracted 12 comorbid medical conditions and stroke subtype according to the TOAST classification. The majority of TCD and TTE or TEE showed agreement on right-to-left shunt status (80/109, 73 %). Two percent (2/109) of patients were negative on TCD and positive on TTE or TEE, while 25 % (27/109) had a positive TCD and negative TTE or TEE (TCD+Echo-). The TCD+Echo- patients were more likely to have active malignancy and the delayed arrival of contrast bubbles than the remainder of the cohort (15 vs. 2 %, p = 0.032; 51 vs. 18 %, p = 0.001). Our results confirm previous reports that TCD is superior to echocardiography in the detection of right-to-left shunt. The TCD+Echo- patients were more likely to have active malignancy and findings suggestive of an extracardiac shunt. These results could lead to more comprehensive evaluation for occult malignancy or a pulmonary arteriovenous malformation, both potentially treatable etiologies of ischemic stroke.

Development of regional stroke programs.

The organization of stroke care has undergone a dramatic evolution in the USA over the last two decades. Beginning with the recommendation for Primary Stroke Centers (PSCs) in 1994, there has been a concerted effort by physicians, the American Heart Association/American Stroke Association (AHA/ASA), National Institutes of Health (NIH), and state legislatures to advance an evidence-based system of care with several tiers of stroke centers. At the apex of this structure are Regional Stroke Centers (RSCs), which do not have official recognition like PSCs and Comprehensive Stroke Centers (CSCs), but their existence as a hub for the many disparate spokes of stroke care in their region is increasingly necessary. Observational evidence suggests that this approach is improving the delivery of stroke care and reducing costs in the USA. Similar efforts are being made in Europe and Asia with encouraging results. The RSC model has the potential to lead to more uniform evidence-based stroke medicine, but many challenges exist.