Endovascular Thrombectomy for Stroke Effectiveness Study-An Audit From a Small Tertiary Care Center.

PURPOSE: Endovascular thrombectomy (EVT) treatment for acute ischemic stroke is now recommended as a standard of care. However, implementing EVT in routine clinical practice poses many challenges, even in countries with advanced health-care systems. The aim of the current study is to delineate if EVT at our institution is an effective treatment for acute ischemic stroke. METHODS: All patients who underwent EVT at our institution between December 2011 and July 2017 were retrospectively assessed from our prospective registry. Clinical and imaging (including the Alberta Stroke Program Early CT [ASPECT] score, single-phase computed tomography angiography, and computed tomography perfusion) criteria were utilized to determine EVT suitability. Primary outcomes included modified Rankin score (mRS) at 90 days and recanalization determined by the modified Treatment in Cerebral Infarction score. Effectiveness was assessed by comparing our cohort with patients receiving EVT in the ESCAPE (Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke) trial. RESULTS: Eighty-eight patients presented to our hospital after a median of 87 minutes last seen normal. Of these, median ASPECT score was 9. A majority (72%) also received intravenous alteplase. Successful recanalization (≥TICI 2b) was achieved in 79%. At 90 days, 48% (36/75) were functionally independent (mRS score of 0-2) and 28% (21/75) were disabled (mRS score of 3-5); 24% (18/75) died (mRS of 6) within 90 days. CONCLUSIONS: An audit of our initial experience with EVT for the treatment of acute ischemic stroke in a small tertiary care center yielded similar results compared to the ESCAPE trial, which is encouraging for implementing this treatment in routine clinical practice.

Admission Perfusion CT for Classifying Early In-Hospital Mortality of Patients With Severe Traumatic Brain Injury: A Pilot Study.

OBJECTIVE. The purposes of this study were to assess the feasibility and safety of perfusion CT of patients with severe traumatic brain injury (TBI) at hospital admission and to examine whether early in-hospital mortality could be characterized with perfusion CT (PCT). The hypothesis was that PCT can be used to characterize brain death, when present, in patients with severe TBI at hospital admission. SUBJECTS AND METHODS. In this prospective cohort pilot study, PCT was performed on patients with severe TBI at first imaging workup at hospital admission. PCT images were processed at the end of the study and assessed for features of brain death. The PCT features were then compared with the clinical outcome of in-hospital mortality. RESULTS. A total of 19 patients (13 men [68.4%]; six women [31.6%]; mean age, 36.4 years; median, 27.5 years) had a mean hospital stay longer than 1 month. No complications of PCT were found. In the first 48 hours after admission, four patients (21%) died. Admission PCT changes suggesting brainstem death were sensitive (75%) and specific (100%) and had high positive (100%) and negative (93.75%) predictive value for correct classification early in-hospital mortality. CONCLUSION. Admission PCT of patients with severe TBI was feasible and safe. Admission PCT findings helped in correctly classifying early in-hospital mortality in the first 48 hours of hospital admission.

Case-Control Study of Endovascular Thrombectomy in a Canadian Stroke Center.

BACKGROUND: Although the efficacy of endovascular thrombectomy (EVT) for acute ischemic stroke caused by intracranial anterior circulation large vessel occlusion (LVO) is proven, demonstration of local effectiveness is critical for health system planning and resource allocation because of the complexity and cost of this treatment. METHODS: Using our prospective registry, we identified all patients who underwent EVT for out-of-hospital LVO stroke from February 1, 2013 through January 31, 2017 (n = 44), and matched them 1:1 in a hierarchical fashion with control patients not treated with EVT based on age (±5 years), prehospital functional status, stroke syndrome, severity, and thrombolysis administration. Demographics, in-hospital mortality, discharge disposition from acute care, length of hospitalization, and functional status at discharge from acute care and at follow-up were compared between cases and controls. RESULTS: For EVT-treated patients (median age 66, 50% women), the median onset-to-recanalization interval was 247 min, and successful recanalization was achieved in 30/44 (91%). Alteplase was administered in 75% of cases and 57% of controls (p = 0.07). In-hospital mortality was 11% among the cases and 36% in the control group (p = 0.006); this survival benefit persisted during follow-up (p = 0.014). More EVT patients were discharged home from acute care (50% vs. 18%, p = 0.002). Among survivors, there were nonsignificant trends in favor of EVT for median length of hospitalization (14 vs. 41 days, p = 0.11) and functional independence at follow-up (51% vs. 32%, p = 0.079). CONCLUSION: EVT improved survival and decreased disability. This demonstration of single-center effectiveness may help facilitate expansion of EVT services in similar health-care jurisdictions.

Étude cas-témoin portant sur la thrombectomie endovasculaire dans un centre canadien de prise en charge des AVC. Contexte : Bien qu'on ait prouvé l'efficacité de la thrombectomie endovasculaire dans le cas d'accidents ischémiques cérébraux aigus causés par l'occlusion de grosses artères affectant la circulation antérieure intracrânienne, la démonstration de son efficacité sur le terrain est essentielle à la planification du réseau la santé et à l'allocation des ressources en raison de la complexité de ce traitement et des coûts qui y sont associés. Méthodes : À l'aide d'un registre prospectif, nous avons identifié tous les patients ayant bénéficié (n = 44), du 1er février 2013 au 31 janvier 2017, d'une thrombectomie endovasculaire à la suite d'un AVC survenu en dehors d'un établissement de la santé, AVC causé par l'occlusion de grosses artères. De manière hiérarchique, nous avons fait correspondre nos patients dans un rapport de 1 à 1 à nos témoins non traités par thrombectomie endovasculaire, et ce, en nous basant sur leur âge (± 5 ans), sur leur situation fonctionnelle avant d'être admis, sur les signes cliniques et la gravité de leur AVC, et sur l'administration d'un traitement thrombolytique. Nous avons également comparé leurs caractéristiques démographiques, leur taux de mortalité hospitalière, les modalités d'obtention d'un congé des soins intensifs, la durée de leur hospitalisation et leur situation fonctionnelle au moment de quitter les soins intensifs et à l'occasion d'un suivi. Résultats : Dans le cas de nos patients traités par thrombectomie endovasculaire (âge médian : 66 ans ; 50 % de femmes), l'intervalle médian entre les premiers signes d'un AVC et la recanalisation a été de 247 minutes. Fait à souligner, une recanalisation réussie a été accomplie dans 30 cas sur 44 (91 %). L'altéplase a été administré dans 75 % des cas et chez 57 % des témoins (p = 0,07). En ce qui concerne le taux de mortalité hospitalière, il a été de 11 % parmi tous nos cas et de 36 % chez nos témoins (p = 0,006) ; À noter que cet avantage en termes de survie a persisté au moment des suivis (p = 0,014). Plus de patients traités par thrombectomie endovasculaire ont obtenu leur congé des soins intensifs et sont revenus à la maison (50 % contre 18 % ; p = 0,002). Parmi les survivants à ces AVC, on a noté des tendances non significatives en faveur des patients traités par thrombectomie endovasculaire pour ce qui est de la durée médiane d'hospitalisation (14 jours contre 41 jours ; p = 0,11) et de l'autonomie fonctionnelle au moment des suivis (51 % contre 32 % ; p = 0,079). Conclusion : En somme, la thrombectomie endovasculaire a permis d'améliorer le taux de survie des patients ainsi que leur niveau d'autonomie fonctionnelle. Effectuée dans un seul établissement hospitalier, cette démonstration de l'efficacité de ce traitement pourrait contribuer à faciliter l'essor des traitements de thrombectomie endovasculaire dans d'autres systèmes de santé similaires.

A Cost-Utility Analysis of Endovascular Thrombectomy in a Real-World Setting.

OBJECTIVE: Endovascular thrombectomy (EVT) is efficacious for ischemic stroke caused by proximal intracranial large-vessel occlusion involving the anterior cerebral circulation. However, evidence of its cost-effectiveness, especially in a real-world setting, is limited. We assessed whether EVT ± tissue plasminogen activator (tPA) was cost-effective when compared with standard care ± tPA at our center. METHOD: We identified patients treated with EVT ± tPA after the Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing computed tomography to recanalization times trial from our prospective stroke registry from February 1, 2013 to January 31, 2017. Patients admitted before February 2013 and treated with standard care ± tPA constitute the controls. The sample size was 88. Cost-effectiveness was assessed using the net monetary benefit (NMB). Differences in average costs and quality-adjusted life years (QALYs) were estimated using the augmented inverse probability weighted estimator. We accounted for sampling and methodological uncertainty in sensitivity analyses. RESULTS: Patients treated with EVT ± tPA had a net gain of 2.89 [95% confidence interval (CI): 0.93-4.99] QALYs at an additional cost of $22,200 (95% CI: -28,902-78,244) per patient compared with the standard care ± tPA group. The NMB was $122,300 (95% CI: -4777-253,133) with a 0.85 probability of being cost-effective. The expected savings to the healthcare system would amount to $321,334 per year. CONCLUSION: EVT ± tPA had higher costs and higher QALYs compared with the control, and is likely to be cost-effective at a willingness-to-pay threshold of $50,000 per QALY.

Analyse coût-efficacité de la thrombectomie endovasculaire dans un contexte réel. Objectif : La thrombectomie endovasculaire (TE) est efficace dans le cas d'accidents ischémiques cérébraux (AIC) causés par une occlusion proximale de l'artère cérébrale antérieure. Toutefois, les preuves d'un bon rapport coût-efficacité, particulièrement dans le cadre d'une pratique réelle, demeurent limitées. Nous avons ainsi évalué au sein de notre établissement dans quelle mesure la thrombectomie endovasculaire jumelée à un traitement au moyen d'un activateur tissulaire du plasminogène (t-PA) étaient davantage rentables en comparaison avec des soins usuels également jumelés à un traitement de t-PA. Méthodes : En consultant nos registres prospectifs, nous avons identifié des patients traités par une thrombectomie endovasculaire jumelée à un traitement de t-PA après avoir subi, du 1er février 2013 au 31 janvier 2017, un traitement endovasculaire destiné à un petit AVC central et ischémique à occlusion proximale avec un accent mis sur la minimisation du temps de recanalisation par tomodensitométrie. Les patients hospitalisés avant février 2013 et auxquels des soins usuels avaient été prodigués de concert avec l'administration d'un t-PA ont fait partie de notre groupe témoin. Au total, notre échantillon était formé de 88 patients. Nous avons évalué le rapport coût-efficacité au moyen du concept d'avantage monétaire net (AMN). Nous avons également estimé les différences en ce qui concerne les coûts moyens et l'indicateur QALY (quality-adjusted life years) en faisant appel à un estimateur pondéré par l'inverse de la probabilité inverse (augmented inverse probability weighted estimator). Enfin, nous avons tenu compte de l'incertitude de notre échantillonnage et de nos choix méthodologiques dans nos analyses de sensibilité. Résultats : Les patients traités par thrombectomie endovasculaire et l'administration d'un t-PA ont donné à voir un gain net de 2,89 années selon l'indicateur QALY (IC 95 % : 0,93 ­ 4,99) pour un coût additionnel de 22 200 $ (IC 95 % : −28,902 ­ 78,244) par patient si on les compare à notre groupe témoin. L'AMN s'est quant à lui élevé à 122 300 $ (IC 95 % : −4 777 ­ 253 133), sa probabilité d'être rentable atteignant 0,85. À cet égard, les économies annuelles pour le système de soins de santé pourraient atteindre les 321 334 $. Conclusion : Il appert que la thrombectomie endovasculaire jumelée à un traitement de t-PA entraînent des coûts plus élevés et un meilleur indicateur QALY en comparaison avec notre groupe témoin. Il est probable qu'une telle approche soit rentable en vertu d'un seuil de disposition à payer (willingness-to-pay threshold) avoisinant les 50 000 $ par année selon le QALY.

Is the emotion recognition deficit associated with frontotemporal dementia caused by selective inattention to diagnostic facial features?

Frontotemporal dementia (FTD) is a debilitating neurodegenerative disorder characterized by severely impaired social and emotional behaviour, including emotion recognition deficits. Though fear recognition impairments seen in particular neurological and developmental disorders can be ameliorated by reallocating attention to critical facial features, the possibility that similar benefits can be conferred to patients with FTD has yet to be explored. In the current study, we examined the impact of presenting distinct regions of the face (whole face, eyes-only, and eyes-removed) on the ability to recognize expressions of anger, fear, disgust, and happiness in 24 patients with FTD and 24 healthy controls. A recognition deficit was demonstrated across emotions by patients with FTD relative to controls. Crucially, removal of diagnostic facial features resulted in an appropriate decline in performance for both groups; furthermore, patients with FTD demonstrated a lack of disproportionate improvement in emotion recognition accuracy as a result of isolating critical facial features relative to controls. Thus, unlike some neurological and developmental disorders featuring amygdala dysfunction, the emotion recognition deficit observed in FTD is not likely driven by selective inattention to critical facial features. Patients with FTD also mislabelled negative facial expressions as happy more often than controls, providing further evidence for abnormalities in the representation of positive affect in FTD. This work suggests that the emotional expression recognition deficit associated with FTD is unlikely to be rectified by adjusting selective attention to diagnostic features, as has proven useful in other select disorders.

Individual differences in the anterior insula are associated with the likelihood of financially helping versus harming others.

The neural basis of individual differences in positive and negative social decisions and behaviors in healthy populations is yet undetermined. Recent work has focused on the potential role of the anterior insula in guiding social and nonsocial decision making, but the specific nature of its activation during such decision making remains unclear. To identify the neural regions mediating individual differences in helpful and harmful decisions and to assess the nature of insula activation during such decisions, in the present study we used a novel fMRI task featuring intentional and unintentional decisions to financially harm or help persons in need. Based on a whole-brain, unbiased approach, our findings indicate that individual differences in dorsal anterior insula, anterior cingulate cortex (ACC), and right temporo-parietal junction activation are associated with behavioral tendencies to financially harm or help another. Furthermore, activity in the dorsal anterior insula and ACC was greatest during unintended outcomes, whether these were gains or losses for a charity or for oneself, supporting models of the role of these regions in salience prediction error signaling. Together, the results suggest that individual differences in risk anticipation, as reflected in the dorsal anterior insula and dorsal ACC, guide social decisions to refrain from harming others.

Functional neural correlates of emotional expression processing deficits in behavioural variant frontotemporal dementia.

BACKGROUND: Frontotemporal dementia (FTD) is a neurodegenerative disorder resulting in social-cognitive deficits partially attributed to abnormalities processing social cues, such as facial expressions. However, to our knowledge, the functional neuroanatomy of deficient social cue processing in individuals with FTD has not been examined. The objective of this study was to delineate the functional abnormalities under lying altered facial expression processing in individuals with FTD using functional magnetic resonance imaging (fMRI). METHODS: Patients meeting Neary criteria for behavioural variant FTD (bvFTD) with supportive neuroimaging and 18 age-matched healthy controls completed an implicit facial expression task during fMRI. We conducted volumetric brain morphometry to correct functional imaging data for volume differences. RESULTS: We included 20 patients with bvFTD and 18 controls in our study. The results demonstrate emotion-specific functional abnormalities in frontal and limbic regions in patients with bvFTD. Patients also showed decreased activity in posterior ventral visual regions, specifically the fusiform cortex, possibly reflecting reduced afferent input from limbic regions. Finally, bvFTD was associated with increased activity in posterior regions, including the inferior parietal cortex. LIMITATIONS: Autopsy validation of frontotemporal dementia is not yet available for this cohort. CONCLUSION: Together, these findings suggest that fMRI combined with tasks targeting social-cognitive deficits is a powerful technique to objectively measure neural systems involved in emotion processing in individuals with bvFTD. As viewing emotional expressions is known to engage many of the same neural systems that are active when experiencing the emotion itself, fMRI during expression processing provides a novel window into the emotions of patients with FTD.