Charles J. Prestigiacomo

Neuroendovascular management of emergent large vessel occlusion: update on the technical aspects and standards of practice by the Standards and Guidelines Committee of the Society of NeuroInterventional Surgery

Acute ischemic stroke (AIS) is the fifthxa0leading cause of death, and remains the leading cause of disability in the USA.1 There are an estimated 680u2009000 new strokes per year in the USA, with a mortality rate ofxa053–94%, and with an even greater morbidity.2 It is estimated that 3–22% of these patients are candidates for endovascular therapy.3–6 In addition to baseline stroke severity, emergent large vessel occlusion (ELVO) has been shown to be an independent predictor of poor outcome at 6 months.3 4 While intravenous recombinant tissue plasminogen activator (IV r-tPA) has proven efficacious predominantly for small cerebral vessel occlusions, endovascular therapies, including stent retriever based, aspirationxa0based mechanical thrombectomy techniques, and intra-arterial administration of thrombolytic agents, have been shown to achieve higher rates of recanalization in patients with ELVO.7–10 The purpose of this document is to provide an update and critical assessment of technical aspects of the mechanical thrombectomy procedure.nnThis document was prepared by the Standards and Guidelines Committee of the Society of NeuroInterventional Surgeryxa0(SNIS), a multidisciplinary society representing the leaders in the field of endovascular therapy for cerebrovascular disease. A review of the English language literature published between January 1998 and March 2016 was conducted using search terms that included: ‘stroke,’ ‘ischemic stroke,’ ‘large vessel occlusion,’ ‘thrombectomy,’ ‘mechanical thrombectomy,’ ‘neurointerventional,’ ‘tPA,’ and ‘technique.’ Additionally, we incorporated already existing guidelines published by the American Heart Association (AHA) and thexa0SNIS.11–15 The strength of the evidence supporting each recommendation was summarized using a scale previously described by the AHA guideline panels, and by the University of Oxford, Centre for Evidence Based Medicine .13 15–18nnMuch of our current practice in mechanical thrombectomy derives from recent randomized controlled trials (RCTs) which provide a foundation for treatment goals.xa0Thexa0onlinexa0supplementary tables 1-3 provide details of these thrombectomy trials, …

Effect of Bone Flap Surface Area on Outcomes in Decompressive Hemicraniectomy for Traumatic Brain Injury

BACKGROUNDnDecompressive hemicraniectomy to control medically refractory intracranial hypertension and cerebral edema and evacuate mass lesions in traumatic brain injury is a widely accepted treatment paradigm. However, the critical specifications of the bone flap size necessary to control the intracranial pressure (ICP) and provide improved patient outcomes is unknown. We assessed the effect of craniectomy size on the outcomes in surgical decompression for traumatic brain injury.nnnMETHODSnFrom 2003 to 2011, 58 cases of decompressive hemicraniectomy were performed for evacuation of hematoma and treatment of refractory ICP in adult patients with traumatic brain injury. The surface area of the decompressive bone flaps was calculated from the postoperative computed tomography scans and correlated with the ICP and Glasgow Coma Scale scores immediately postoperatively and during long-term follow-up.nnnRESULTSnDecompressive craniectomy led to a statistically significant continued reduction in the preoperative ICP values (24.5 mm Hg; range, 5-30 mm Hg) compared with the postoperative ICP (16.7 mm Hg; range, 1-30; Pxa0= 0.006). However, no significant improvement in the preoperative Glasgow Coma Scale (7.47 mm Hg; range, 3-15; vs. 7.50 mm Hg; range, 3-15; Pxa0= 0.96) was observed with hemicraniectomy.nnnCONCLUSIONnFor surface areas of 7000-16,000 mm2, size was an independent factor in ICP reduction but not for the overall neurologic outcome.