The Management of Persistent Distal Occlusions after Mechanical Thrombectomy and Thrombolysis: An Inter- and Intrarater Agreement Study.

BACKGROUND AND PURPOSE: The best management of patients with persistent distal occlusion after mechanical thrombectomy with or without IV thrombolysis remains unknown. We sought to evaluate the variability and agreement in decision-making for persistent distal occlusions. MATERIALS AND METHODS: A portfolio of 60 cases was sent to clinicians with varying backgrounds and experience. Responders were asked whether they considered conservative management or rescue therapy (stent retriever, aspiration, or intra-arterial thrombolytics) a treatment option as well as their willingness to enroll patients in a randomized trial. Agreement was assessed using κ statistics. RESULTS: The electronic survey was answered by 31 physicians (8 vascular neurologists and 23 interventional neuroradiologists). Decisions for rescue therapies were more frequent (n = 1116/1860, 60%) than for conservative management (n = 744/1860, 40%; P < .001). Interrater agreement regarding the final management decision was "slight" (κ = 0.12; 95% CI, 0.09-0.14) and did not improve when subgroups of clinicians were studied according to background, experience, and specialty or when cases were grouped according to the level of occlusion. On delayed re-questioning, 23 of 29 respondents (79.3%) disagreed with themselves on at least 20% of cases. Respondents were willing to offer trial participation in 1295 of 1860 (69.6%) cases. CONCLUSIONS: Individuals did not agree regarding the best management of patients with persistent distal occlusion after mechanical thrombectomy and IV thrombolysis. There is sufficient uncertainty to justify a dedicated randomized trial.

Prospective observational study of stroke in Cayenne, Tours and Besançon: The BECATOUR study.

BACKGROUND: Stroke is a major public health issue. Its epidemiology is still poorly known in French Guiana. METHOD: We conducted a prospective observational study including 100 consecutive patients hospitalized for stroke in Cayenne (in French Guiana), and Tours and Besançon (in metropolitan France). We compared their age, medical history, cardiovascular risk factors, pre-admission Rankin score, Glasgow and NIHSS scores, usual treatments, acute phase management, type of stroke, duration of hospitalization, mechanism of stroke according to TOAST classification, NIHSS and Rankin scores at discharge, discharge treatments, and mode of discharge. RESULTS: In French Guiana, the average age of patients was 7years lower (62 y), patients were more frequently affected by hypertension (75%) and diabetes (31%). Lacunar strokes were overrepresented (16.1%), and infarctions of cardioembolic origin were underrepresented (12%). NIHSS entry and Glasgow scores were similar between French Guiana and mainland France. Acute management was different: thrombolysis rate (9.3%) was 3 to 4 times lower, thrombectomy was not available. Fewer patients were transferred to rehabilitation centers and more patients were transferred to home hospitalization. DISCUSSION: In Tours and Besançon, patients eligible for thrombectomy were overrepresented. This bias explains the overrepresentation of more severe infarctions and probably the overrepresentation of strokes of cardioembolic origin. Infarctions of undetermined origin were more numerous in French Guiana because patients were often discharged from hospital with an incomplete cardiological workup. CONCLUSION: Despite some caveats, the profile of patients admitted for stroke in French Guiana is different from mainland France. The establishment of a stroke unit and an information campaign on the symptoms of stroke would allow better management.

Surgical or Endovascular Treatment of MCA Aneurysms: An Agreement Study.

BACKGROUND AND PURPOSE: MCA aneurysms are still commonly clipped surgically despite the recent development of a number of endovascular tools and techniques. We measured clinical uncertainty by studying the reliability of decisions made for patients with middle cerebral artery (MCA) aneurysms. MATERIALS AND METHODS: A portfolio of 60 MCA aneurysms was presented to surgical and endovascular specialists who were asked whether they considered surgery or endovascular treatment to be an option, whether they would consider recruitment of the patient in a randomized trial, and whether they would provide their final management recommendation. Agreement was studied using κ statistics. Intrarater reliability was assessed with the same, permuted portfolio of cases of MCA aneurysm sent to the same specialists 1 month later. RESULTS: Surgical management was the preferred option for neurosurgeons (n = 844/1320; [64%] responses/22 raters), while endovascular treatment was more commonly chosen by interventional neuroradiologists (1149/1500 [76.6%] responses/25 raters). Interrater agreement was only "slight" for all cases and all judges (κ = 0.094; 95% CI, 0.068-0.130). Agreement was no better within specialties or with more experience. On delayed requestioning, 11 of 35 raters (31%) disagreed with themselves on at least 20% of cases. Surgical management and endovascular treatment were always judged to be a treatment option, for all patients. Trial participation was offered to patients 65% of the time. CONCLUSIONS: Individual clinicians did not agree regarding the best management of patients with MCA aneurysms. A randomized trial comparing endovascular with surgical management of patients with MCA aneurysms is in order.

From mothership to drip-and-ship: Effects of staff shortages at a comprehensive stroke center.

BACKGROUND: Mechanical thrombectomy (MT) has been shown to be effective in the acute phase of ischemic stroke. Current data suggests that the drip-and-ship and mothership telestroke models are equally effective for its administration. We describe the consequences of changing the telestroke model due to staff shortages in a comprehensive stroke center (Besançon), which was replaced by a more distant one (Dijon). METHODS: We conducted a retrospective analysis of all patients referred for MT from January 2015 to December 2018. We analyzed the time between symptom onset and arrival in the angiography suite. We also calculated number of thrombectomies divided by number of days on call, and rate of thrombectomies relative to the number of strokes in each group. RESULTS: In Besançon, 205 patients underwent an MT procedure, versus 43 patients in Dijon. A further four patients were transferred to Dijon but not treated. The time from symptom onset to arrival in the angiography suite was longer for Dijon; 334min versus 281min for Besançon (p<0.001). The percentage of thrombectomies performed per day on call was higher for Besançon: 18.6% versus 13.2% in Dijon (p=0.026). CONCLUSIONS: Over the study period, the time from symptom onset to angiography suite was longer for patients who were transferred to Dijon. The period in which the Besançon hospital experienced the greatest lack of personnel corresponded to a decrease in the number of MTs performed.

Results of a four-year multi-channel regional program for monitoring stroke survivors in Franche-Comté, France.

INTRODUCTION: Clinical monitoring of stroke survivors after hospital discharge was initiated in France in 2012 and funding for its model began in 2016. A regional program in Franche-Comté relying on various assessment methods including telehealth was initiated. The objective of this study was to describe the implementation and quality of the program. METHODS: A retrospective observational study was conducted from 1st January 2016 to 31st December 2019. Patients were included if they were adults, hospitalized for stroke or transient ischemic attack in one of the six public hospitals in the region and discharged alive. There were five types of monitoring methods: physical consultation, day hospital, nurse-led phone consultation, postal mail or medical record analysis. Characteristics, method of monitoring and discharge delay were described. RESULTS: In total, 7166 patients were identified; male gender predominated (52.9%); mean age was 72.2years. Monitoring coverage increased from 89.2% to 92% within the period. Most patients had ischemic stroke (68.5%, n=4912) and were at home at the time of monitoring (71.6%, n=5130). The main method was nurse-led phone consultations (40.8%, n=2921) followed by physical consultation (16%, n=1143). Day hospital monitoring increased (1.5% to 14.4%) while the postal mail method decreased (18.7% to 8.1%). The average delay decreased from 240.3 to 148.6days. Monitoring period of less than four months was 46.2% in 2019 and 75.3% for thrombolysis. In 2019, 99.3% of patients were being monitored at one year. Mortality decreased from 10% to 6.3%. DISCUSSION: The program improved over time with an increase in the number of patients and reduction in delays and mortality rate.

Safeguard pressure assisted device for local femoral hemostasis in neuroendovascular procedures: A single center study of 879 patients.

BACKGROUND: Various vascular closure devices (VCDs) are available for local hemostasis after percutaneous transfemoral approach for neuroendovascular procedures but they have been associated with an increased complication rate and limitations to a re-puncture of the artery. We evaluated the safety and efficacy of Safeguard® 24 cm pressure assisted device (Merit Medical, West Jordan, UT, USA) and the associated complications. METHODS: From September 2016 to December 2019, 879 patients underwent neuroendovascular procedures via transfemoral approach using an introducer sheath ranging from 4 to 6-French and they were included in a prospective database. We registered the demographic characteristics and procedural factors. We evaluated the device failure and associated complications. RESULTS: The Safeguard® was successful in 862 cases (98.1 %) with post-procedural local bleeding in 17 patients (1.9%). On univariate analysis, an association with local bleeding was observed with age >60 years (Odds ratio [OR] = 3.2, P = 0.04) and the use of an introducer sheath >4 F ([OR] = 3.1, P = 0.007). Female gender, antithrombotic medication and type of procedure (diagnostic or interventional) were not associated with local bleeding. On binary logistic regression analysis, there was association only for age >60 years ([OR] = 3, P = 0.04). CONCLUSION: The Safeguard® 24 cm is safe and efficient. It is simple to use and it can be applied independently from vessel anatomic characteristics. It should though be used with caution in case of a femoral introducer sheath larger than 4 Fr and patients older than 60 years.

OLOGRAM: Determining significance of total overlap length between genomic regions sets.

MOTIVATION: Various bioinformatics analyses provide sets of genomic coordinates of interest. Whether two such sets possess a functional relation is a frequent question. This is often determined by interpreting the statistical significance of their overlaps. However, only few existing methods consider the lengths of the overlap, and they do not provide a resolutive p-value. RESULTS: Here, we introduce OLOGRAM, which performs overlap statistics between sets of genomic regions described in BEDs or GTF. It uses Monte Carlo simulation, taking into account both the distributions of region and inter-region lengths, to fit a negative binomial model of the total overlap length. Exclusion of user-defined genomic areas during the shuffling is supported. AVAILABILITY: This tool is available through the command line interface of the pygtftk toolkit. It has been tested on Linux and OSX and is available on Bioconda and from https://github.com/dputhier/pygtftk under the GNU GPL license. SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online.

Explore, edit and leverage genomic annotations using Python GTF toolkit.

MOTIVATION: While Python has become very popular in bioinformatics, a limited number of libraries exist for fast manipulation of gene coordinates in Ensembl GTF format. RESULTS: We have developed the GTF toolkit Python package (pygtftk), which aims at providing easy and powerful manipulation of gene coordinates in GTF format. For optimal performances, the core engine of pygtftk is a C dynamic library (libgtftk) while the Python API provides usability and readability for developing scripts. Based on this Python package, we have developed the gtftk command line interface that contains 57 sub-commands (v0.9.10) to ease handling of GTF files. These commands may be used to (i) perform basic tasks (e.g. selections, insertions, updates or deletions of features/keys), (ii) select genes/transcripts based on various criteria (e.g. size, exon number, transcription start site location, intron length, GO terms) or (iii) carry out more advanced operations such as coverage analyses of genomic features using bigWig files to create faceted read-coverage diagrams. In conclusion, the pygtftk package greatly simplifies the annotation of GTF files with external information while providing advance tools to perform gene analyses. AVAILABILITY AND IMPLEMENTATION: pygtftk and gtftk have been tested on Linux and MacOSX and are available from https://github.com/dputhier/pygtftk under the MIT license. The libgtftk dynamic library written in C is available from https://github.com/dputhier/libgtftk.