Citations

Introduction: The selection of acute ischemic stroke patients relies on the interpretation of radiological studies, commonly including noncontrast CT (ASPECTS score), CTA, and in some circumstances, CT perfusion (CTP) scans. Hypothesis: The interrater reliability between readers of noncontrast head CT will be moderate and not as good as that between readers of CT perfusion scans. Methods: Retrospective study of consecutive ischemic stroke patients who were considered for endovascular stroke therapy at an academic medical center from April 2010 - November 2014. All patients underwent CT, CTA, and CTP. Images were independently reviewed by four readers (A, B, C, D) in total (2 experienced neuroradiologists, one experienced neurointensivist, and one neuroradiology fellow). Each rated half of the cohort. All readers performed online training in ASPECTS. Moderate-to-good collateral circulation was defined as filling of 50% or more of the middle cerebral artery pial arterial territory on CTA, as in ESCAPE trial. An “acceptable core” on CTP was defined as in EXTEND-IA trial with core volume < 70 mL, mismatch ratio >1.2, and absolute mismatch volume >10 mL but was qualitatively estimated. Interrater agreement was assessed for total ASPECTS, dichotomized ASPECTS (≥6 vs <6), evaluation of collaterals, and evaluation of core. Agreement was assessed using kappa statistic, which was weighted for the total ASPECTS analysis. Results: Our cohort included 119 patients with acute stroke and large vessel occlusion. Interrater agreement for total ASPECTS was very good between readers C and D (' 0.70) and good between A and B (' 0.55). For dichotomized ASPECTS, agreement was fair-to-good (' 0.30 for C/D; ' 0.41 for A/B). Agreement for grading collaterals on CTA was good to very good (' 0.64 for C /D; ' 0.54 for A/B). Agreement for rating core on CTP was very good (' 0.78 for C/D; ' 0.62 for A/D). Conclusions: Interrater reliability is good to very good for total ASPECTS score, dichotomous grading of collaterals on CTA, and subjective estimation of core size on CTP. Agreement is only fair to good for dichotomized ASPECTS.

Objective: Controversy exists as to whether platelet inhibition testing is necessary prior to aneurysm treatment in patients premedicated with antiplatelet agents. Using the IntrePED ( Int ernational Re trospective Study of P ipeline E mbolization D evice) registry, we studied complication rates in platelet-testing and non-platelet testing groups to determine if platelet testing is associated with improved outcomes. Materials and Methods: Patients with unruptured intracranial aneurysms from the INTREPED registry were divided into those who received platelet testing (testing group) and those who did not (nontesting group). Morbidity, mortality and thrombotic and hemorrhagic complication rates were studied. Comparisons between groups for continuous variables were evaluated using t -tests and Fisher’s exact test or Pearson’s chi-square for binary categorical variables. Multivariate logistic regression analysis was performed to determine if platelet function testing was independently associated with poor outcomes adjusting for age, number of devices, aneurysm location, size, and use of multiple exchange wires. Results: When compared to the non-testing group, the platelet testing group suffered higher rates of ipsilateral intracranial hemorrhage (12/511, 2.3% versus 0/187, 0.0%, P=0.04), neurological morbidity (42/511, 8.2% versus 4/187, 2.1%, P=0.01), and combined neurological morbidity and mortality (45/511, 8.8% versus 6/187, 3.2%, P=0.01). More patients in the testing group were treated with multiple PEDs (228 patients, 38.1% versus 57 patients, 28.4%, P=0.01). On multivariate analysis, the platelet testing group had a higher odds of total major morbidity (OR=3.80, 95%CI=1.30=11.08, P=0.01) and total major morbidity and neurological mortality (OR=2.74, 95%CI=1.11-6.79). Conclusion: Our findings caution against blind acceptance of platelet testing in Pipeline patients. Further prospective studies are needed to determine if and when platelet testing in Pipeline patients is appropriate.

Background and Purpose: The HydroSoft coil was developed to be placed along the aneurysm neck to enhance intracranial aneurysm healing. In order to better understand the safety and efficacy of Hydrosoft coils in treating the aneurysm neck, the GEL THE NEC multicenter registry was developed. We report immediate angiographic and clinical results of this prospective registry. Methods: The GEL THE NEC study was undertaken at 30 centers in 5 countries. Patients aged 21-90 years with a ruptured or unruptured aneurysm 3-15 mm in size were eligible for enrollment. For each patient the following data were obtained: demographics and comorbidities, aneurysm geometry, use of adjunctive devices, immediate angiographic outcomes, and early (<30 days) adverse events. Postoperative anatomic results were graded by on-site neuroradiologists using the Modified Raymond Scale (Raymond 1=complete obliteration of aneurysm including the neck, Raymond 2=contrast filling the neck of the aneurysm without opacification of the aneurysm sac, Raymond 3=contrast filling the sac of the aneurysm). Predictors of good angiographic outcome were studied using chi-squared and t-tests. Results: A total of 571 patients with 571 aneurysms have been treated thus far in the study (196 ruptured, 375 unruptured). HydroSoft coils were successfully deployed in 549 (96.3%) of these patients. Adjunctive devices were used in 307 cases (53.8%) (212 balloon assistance, 89 stent). Aneurysmal occlusion rates were the following: 261 patients (47.3%) exhibited Raymond 1 occlusion, 257 patients (47.0%) had Raymond 2, and 29 patients (5.3%) had Raymond 3. Early post-operative stroke occurred in 10 patients (1.8%). Aneurysm perforation occurred in 11 patients (1.9%). Coil prolapse/migration occurred in 8 patients (1.4%). Early post-operative death occurred in 3 patients, all of whom presented with SAH (0.5%). Small aneurysm neck size was a significant predictor of good angiographic outcome (P=0.0003). Conclusions: Endovascular treatment of intracranial aneurysms with HydroSoft coils resulted in high rates of satisfactory occlusion (94.3%) and low rates of major clinical complications. Aneurysm neck size was a significant predictor of angiographic outcomes.

Objective: To determine trends in tPA utilization, treatment outcomes and predictors of mortality for pediatric patients with acute ischemic stroke. Materials and Methods: Using the Nationwide Inpatient Sample (NIS) from 2001-2010, pediatric patients (age < 18 years) with the primary diagnosis of ischemic stroke were identified. We studied time trends of utilization of intravenous rtPA and outcomes after thrombolysis. We also analyzed the associations of demographic factors, comorbidities, and complications of acute ischemic stroke with in-hospital mortality. Results: A total of 7,379 patients were included in this study. In-hospital mortality was 4.5%. The co-morbidities associated with the highest rates of in-hospital mortality were mitochondrial disorders (19.5%, P<0.0001) and hypercoagulable states (10.9%, p<0.0001). The main complications associated with increased mortality were intracranial hemorrhage (19.9%, p<0.0001), sepsis (13.2%, p<0.0001) and pneumonia (9.3%, p=0.0007). tPA utilization rate was 1.3% (99 patients). tPA utilization increased from 0.9% of patients in 2001-2005 to 1.9% of patients in 2006-2010 (P<0.0001). While patients who received tPA did not have higher mortality rates than non-tPA patients (0.0% versus 5.5%, P=0.06), there was an increased discharge-to-long-term-facilities rate in the tPA group (50.8% versus 12.1%, P<0.0001). Conclusion: Acute ischemic stroke in the pediatric population is associated with a higher mortality rate when related to mitochondriopathies or hypercoagulability. Patients suffering complications such as intracranial hemorrhage, sepsis and pneumonia have higher mortality. rtPA utilization is increasing in pediatric patients with acute ischemic stroke. Pediatric patients receiving tPA have a low risk of fatal hemorrhage. Although patients receiving rtPA have higher rates of morbidity, this may be related to worse stroke severity in these cases.

Background and Purpose- IV rt-PA has become a widely accepted treatment for a select group of patients with acute ischemic stroke. Quantifying the costs of hospitalization is important for understanding the economic impact of these patients on the hospitals that care for them. We evaluated recent data to determine costs associated with hospitalization for acute ischemic stroke patients treated with intravenous thrombolysis, including subgroup analysis to determine the effects of age and discharge status on hospital costs. Methods- Using the National Inpatient Sample, we evaluated the costs for hospitalization for patients treated with intravenous thrombolysis for acute ischemic stroke in the United States from 2001-2008. The primary endpoint examined in this study was total hospital costs, and these were correlated with clinical outcome. Costs were compared with 2008 Medicare reimbursement for intravenous thrombolysis without complication, and intravenous thrombolysis with major complication. Results- A total of 63472 patients received intravenous thrombolysis for acute ischemic stroke. 24094 patients were <65 years old and 40780 patients were ≥65 years old. Median hospital costs in 2008 dollars were $14102 (IQR $9987-$20819) for patients with good outcome, $18856 (IQR $13145-$30423) for patients with severe disability, and $19129 (IQR $11966-$30781) for patients with mortality. Average 2008 Medicare payments were $10,098 for intravenous thrombolysis without complication and $13,835 for intravenous thrombolysis with major complication. Conclusions- Our study of the NIS shows that hospitalization costs in the United States for ischemic stroke patients treated with intravenous thrombolysis are rather high. Medicare payments have not been adequate reimbursement for these hospitalizations. Hopefully, future reconciliation of costs with payments will be feasible, so that hospitals can afford to provide proper care for ischemic stroke patients treated with intravenous thrombolysis.

Object We sought to determine the safety and efficacy in secondary stroke prevention of carotid endarterectomy (CEA) in patients with symptomatic non-stenotic carotid artery disease (SyNC). Methods This was a single-centre retrospective case series. All patients who underwent CEA for unilateral anterior circulation cerebrovascular events with ipsilateral <50% carotid stenosis from 2002 to 2020 were included. Imaging hallmarks including the degree of luminal stenosis and the presence of various vulnerable plaque characteristics (eg, intraplaque haemorrhage (IPH) on MR angiography, ulceration or low-density plaque on CT angiography) were assessed. The presence of vulnerable plaque characteristics was compared between arteries ipsilateral to the ischaemic event and contralateral arteries. The prevalence of perioperative/intraoperative complications, as well as recurrent ischaemic events at follow-up was determined. Results Thirty-two patients were included in the analysis, of which 25.0% were female. Carotid arteries ipsilateral to an ischaemic event had a significantly higher prevalence of IPH when compared with contralateral arteries (80.0% vs 0.0%; p<0.001). There were no intraoperative complications. One patient (3.1%) developed symptoms of transient ipsilateral ischaemia 1 day following CEA which resolved without treatment. In a median follow-up of 18.0 months (IQR 5.0–36.0), only one patient (3.1%) experienced a transient neurologic deficit with complete resolution (annualised rate of recurrent stroke after CEA of 1.5% for a total follow-up of 788 patient-months following CEA). All other patients (31/32, 96.9%) were free of recurrent ischaemic events. Conclusion CEA appears to be safe and well-tolerated in patients with SyNC. Additional studies with larger cohorts and longer follow-up intervals are needed in order to determine the role of CEA in this patient population.

Background Endovascular thrombectomy (EVT) is an effective treatment for acute ischemic stroke attributable to the anterior circulation large‐vessel occlusion. Randomized trials of patients with posterior circulation large‐vessel occlusion (PC‐LVO) have failed to show a benefit of EVT over medical therapy (MEDT). We performed a systematic review and meta‐analysis to understand better whether EVT is beneficial for PC‐LVO. Methods Using the Nested Knowledge AutoLit living review platform, we identified randomized control trials and prospective studies that reported functional outcomes in patients with PC‐LVO treated with EVT versus MEDT. The primary outcome variable was 90‐day modified Rankin scale score of 0 to 3, and secondary outcome variables included 90‐day modified Rankin scale score of 0 to 2, 90‐day mortality, and rate of symptomatic intracranial hemorrhage. A separate random effects model was fit for each outcome measure to calculate pooled odds ratios. Results Three studies with 1248 patients, 860 in the EVT arm and 388 in the MEDT arm, were included in the meta‐analysis. The favorable outcome rate (modified Rankin scale score of 0–3) in patients undergoing EVT was 39.9% (95% CI, 30.6%–50.1%) versus 24.5% in patients undergoing MEDT (95% CI, 9.6%–49.8%). Patients undergoing EVT had higher modified Rankin scale score of 0 to 2 rates (31.8% [95% CI, 25.7%–38.5%] versus 19.7% [95% CI, 7.4%–42.7%]) and lower mortality (42.1% [95% CI, 35.9%–48.6%] versus 52.8% [95% CI, 33.3%–71.5%]) compared with patients undergoing MEDT, but neither result was statistically significant. Patients undergoing EVT were more likely to develop symptomatic intracranial hemorrhage (odds ratio, 10.36; 95% CI, 3.92–27.40). Conclusions EVT treatment of PC‐LVO trended toward superior functional outcomes and reduced mortality compared with MEDT despite a trend toward increased symptomatic intracranial hemorrhage in patients undergoing EVT. Existing randomized and prospective studies are insufficiently powered to demonstrate a benefit of EVT over MEDT in patients with PC‐LVO.

Introduction: Mechanical thrombectomy (MT) has become the standard of care for acute ischemic stroke (AIS) patients due to large vessel occlusion (LVO). Clinical outcome of successful recanalization (mTICI 2b or higher) varies greatly and is associated with some baseline characteristics. Many studies have reported the relation of thrombus composition with MT outcomes however the association of thrombus composition with the prognosis of successful recanalization remains to be elucidated. Hypothesis: thrombi retrieved from patients with good clinical outcome may have different compositions compared to that of patients with poor clinical outcome. Methods: Thrombi retrieved from AIS-LVO patients with successful recanalization were included. Patients were divided according to modified Rankin Scale at 90 days (mRS-90days) into good clinical outcome (mRS-90days 0-2) and poor clinical outcome (mRS-90 days 3-6). Representative slide for each thrombus was stained with Martius Scarlet Blue (MSB) for red blood cells (RBCs), white blood cells (WBCs), fibrin (FIB), and platelet (PLT). Immunohistochemistry (IHC) was also performed for NETs (anti-citrullinated H3; CitH3) and vWF in thrombi. The overall mean value of each thrombus composition was calculated. Thrombus was considered rich in given composition if that composition was higher than its overall mean. We compared the thrombus composition and type between patients with good and poor clinical outcomes. Results: A total of 94 patients were included. Fifty-six patients had good clinical outcome. The overall average percentage of RBCs, WBCs, fibrin, platelet, NETs (CitH3), and vWF components in thrombi were 44.3%, 3.6%, 29.3%, 22.8%, 20.3% and 12.5% respectively. There was no association between thrombus type (including RBC-rich, FIB-rich, PLT-rich, vWF-rich, and NETs-rich) and clinical outcomes (P values>0.05). Multivariate logistic regression analysis showed no association between thrombus composition and clinical outcome (good vs poor) while adjusting for age, initial NIHSS score, ASPECT score, pre-MT IV-tPA, and MT technique and number of the device passes. Conclusion: we found no association between thrombus composition and clinical outcome after successful recanalization.