Hisham Salahuddin

Stroke care: initial data from a county-based bypass protocol for patients with acute stroke

Background Early identification and transfer of patients with acute stroke to a primary or comprehensive stroke center results in favorable outcomes. Objective To describe implementation and results of an emergency medical service (EMS)-driven stroke protocol in Lucas County, Ohio. Method All county EMS personnel (N=464) underwent training in the Rapid Arterial oCclusion Evaluation (RACE) score. The RACE Alert (RA) protocol, whereby patients with stroke and a RACE score ≥5 were taken to a facility that offered advanced therapy, was implemented in July 2015. During the 6-month study period, 109 RAs were activated. Time efficiencies, diagnostic accuracy, and mechanical thrombectomy (MT) outcomes were compared with standard ‘stroke-alert’ (N=142) patients from the preceding 6 months. Results An increased treatment rate (25.6% vs 12.6%, p<0.05) and improved time efficiency (median door-to-CT 10 vs 28 min, p<0.05; door-to-needle 46 vs 75 min, p<0.05) of IV tissue plasminogen activator within the RA cohort was achieved. The rate of MT (20.1% vs 7.7%, p=0.06) increased and treatment times improved, including median arrival-to-puncture (68 vs 128 min, p=0.04) and arrival-to-recanalization times (101 vs 205 min, p=0.001) in favor of the RA cohort. A non-significant trend towards improved outcome (50% vs 36.4%, p=0.3) in the RA cohort was noted. The RA protocol also showed improved diagnostic specificity for ischemic stroke (52.3% vs 30.1%, p<0.05). Conclusions Our results indicate that EMS adaptation of the RA protocol within Lucas County is feasible and effective for early triage and treatment of patients with stroke. Using this protocol, we can significantly improve treatment times for both systemic thrombolysis and MT.

Conservative Management of Spinal Tuberculosis: Initial Series from Pakistan

Study Design A prospective study on spinal tuberculosis (TB) at a tertiary care hospital in an endemic region. Purpose The aim of the study is to reiterate the importance of conservative management of spinal TB. Overview of Literature Spinal tuberculosis can present with wide spectrum of symptoms, with back pain being the most common symptom. It is the leading cause of non-traumatic paraplegia in developing countries. There is an emerging trend to operate on patients early with spinal TB. Methods Forty-seven (M=14, F=33) patients were enrolled in the study during the four year study period. Initially, all the patients were subjected to computed tomography guided percutaneous needle aspiration (PCNA) followed by antituberculous therapy (ATT) for 12 months. Indications for surgery included patients with moderate to severe symptoms in which PCNA either failed, was impossible to carry out, or produced minimal improvement within 48 hours. Results Presenting complaints included pain (95.7%), weakness (85.1%) and sphincter involvement (12.8%). On the magnetic resonance imaging, a paravertebral abscess was seen in 37 (78.7%), disc and body destruction in 29 (61.7%), and an epidural abscess in 12 (25.9%) patients. Of the 47 patients, 9 (19.1%) required surgery, 4 of whom had failed PCNA attempts and 5 demonstrated indications despite successful PCNA. Conclusions The results of conservative treatment consisting of PCNA and ATT for at least 12 months in compliant patients are excellent. A combined approach using clinical staging, PCNA, and ATT can minimize surgical intervention in most patients. However, ATT remains to be the cornerstone of management of spinal TB.

Mechanical thrombectomy of M1 and M2 middle cerebral artery occlusions

Background Over half of patients who receive intravenous tissue plasminogen activator for middle cerebral artery division (MCA-M2) occlusion do not recanalize, leaving a large percentage of patients who may need mechanical thrombectomy (MT). However, the outcomes of MT for M2 occlusion have not been well characterized. Objective To determine if MT of M2 occlusion is as safe and efficacious as current standard-of-care MT for M1 occlusions. Methods With institutional review board approval, we retrospectively reviewed records of 212 patients undergoing MT for isolated MCA M1 or M2 occlusions during a 36-month period (Sept 2013 to Sept 2016) at two centres. Treatment variables, clinical outcomes, and complications in each group were recorded. Results There were 153 M1 MCA occlusions and 59 M2 MCA occlusions. No statistically significant difference was found in the rate of mortality (20% in M1 vs 13.6% in M2, p=0.32), excellent (34.5% vs 37.3%, p=0.75) or good (51% vs 55.9%, p=0.54) clinical outcomes between the two groups. Infarct volumes (48.4 mL vs 46.2 mL, p=0.62) were comparable between the two groups, as were the rates of hemorrhagic (3.3% vs 3.4%, p=1.0) and procedural complications (3.3% vs 5.1%, p=0.69). Conclusion Our data on MT targeting M2 occlusions demonstrates reasonable safety and functional outcomes. Further randomized clinical trials are needed to clarify which patients may benefit from MT for M2 occlusions.

Emergent carotid endarterectomy versus stenting in acute stroke patients with tandem occlusion

Objective: Acute stroke due to tandem cervical internal carotid artery (ICA) and intracranial large‐vessel occlusion (ILVO) has a high rate of morbidity and mortality. The most appropriate treatment strategy for the extracranial culprit lesion remains unclear. In this study, we report our institutional outcomes with two approaches: emergent carotid endarterectomy (CEA) and carotid artery stenting (CAS). Methods: Patients with tandem ICA‐ILVO were identified in a prospective mechanical thrombectomy (MT) database between July 2012 and April 2016. Patients had a concomitant complete ICA origin occlusion and occlusion of the intracranial ICA or M1 or M2 middle cerebral artery segment. Baseline characteristics, procedural data, and treatment times were reviewed. End points included good recanalization of both ICA and ILVO, symptomatic intracerebral hemorrhage (defined by clinical decline of >4 points on the National Institutes of Health Stroke Scale), and functional outcome at 90 days. Results: Forty‐five patients had tandem ICA‐ILVO occlusion; 27 patients underwent emergent CAS and 12 patients underwent emergent CEA after MT. Successful Thrombolysis in Cerebral Infarction grade 2B/3 recanalization was achieved in 92% of the CEA and 96% of the CAS patients (P = .53). Three CAS patients (11%) and none of the CEA patients had symptomatic intracerebral hemorrhage (P = .54). At 90 days, 75% (9/12) of the CEA patients were functionally independent compared with 70% (19/27) in the CAS group (P = 1.0). No deaths were noted in the CEA group compared with five (18.5%) in the CAS arm (P = .30). Conclusions: Our study indicates that early recanalization with MT followed by emergent CEA is safe and feasible, which suggests that both CAS and CEA should be considered in the emergent treatment of patients with tandem occlusion.

Bacterial Endocarditis Complicated by Leukocytoclastic Vasculitis

A 29-year-old woman who underwent dental extraction 1 month before her presentation with painful purpuric skin lesions that progressed to necrotic ulcers over the buttocks and lower extremities (Figure 1A). Physical examination demonstrated new pansystolic murmur grade IV/VI at the apex of the heart and splinter hemorrhages. Initial laboratory testing was pertinent for elevated inflammatory markers, low C3 and C4 levels, positive Rheumatoid factor, positive p-ANCA (titer 1:5120) and positive anti-serine proteinase 3. Blood cultures grew Staphylococcus epidermidis. A transesophageal echocardiogram confirmed the presence of large vegetation on the mitral valve associated with severe mitral regurgitation (Figure 1B). Skin biopsy demonstrated smalland medium-sized vessels with reactive endothelium and surrounding acute inflammatory cells as depicted between the arrows in Figure 1C, on background of fibrinoid necrosis and focal extravasated red blood cells and nuclear dust, all suggestive of leukocytoclastic vasculitis. Endocarditis is one of the vasculitis mimickers that should remain in the differential diagnosis of systemic vasculitis because clinically and pathologically it may be hard to differentiate between the 2 entities, as both diseases can present with peripheral ischemic/embolic phenomena, splinter hemorrhages, low complements and positive rheumatoid factor. Moreover, positive testing for ANCA, anti-proteinase 3 and/ or anti-myeloperoxidase is not uncommon in endocarditis, which further complicates the clinical picture. Although the treatment for vasculitis is immunosuppressive therapy, the treatment for vasculitis driven by infective endocarditis is eradication of the infection. Therefore, it is important to recognize and distinguish vasculitis mimickers from true vasculitis to avoid unnecessary treatment with immunosuppressive agents.

Ischemic Stroke After Plasmapheresis

&NA; Plasmapheresis involves the separation of all cellular elements of blood with the help of an extracorporeal semipermeable membrane. Even though plasmapheresis is generally considered safe, there have been anecdotal reports of thrombosis related to this exchange. We present 2 cases of healthy young males developing ischemic strokes within 24 hours of plasmapheresis. Patient A was a 24‐year‐old man with a family history of Factor V Leiden mutation presented with right‐sided weakness 1 hour after donating plasma. A hypercoagulable work‐up revealed elevations in Factor II. Patient B was a 42‐year‐old man who presented with a right facial droop, expressive aphasia and right arm weakness. He had donated plasma 18 hours before his presentation. A hypercoagulable work‐up revealed elevated levels of von Willebrand factor antigen and high sensitivity C‐reactive protein. A procoagulant state induced by plasmapheresis likely increases the risk for symptomatic thrombosis when an underlying thrombophilic state is present in the donor.

Ischemic stroke due to retrograde thromboembolism during arteriovenous graft thrombectomy

Complications of arteriovenous graft thrombectomy (AVGT) are uncommon and may rarely result in ischemic stroke via paradoxical emboli. The introduction of new thrombectomy devices and techniques may result in complications via mechanisms not frequently encountered. A 50-year-old right-handed woman with a history of stage 5 chronic kidney disease on hemodialysis underwent a leftarm brachiobasilic AVGT. A direct micropuncture was used to access the graft, and fluoroscopic study showed thrombus in the graft’s arterial portion. The rheolytic Angiojet® Thrombectomy System (rATS) was employed for 30 seconds with 31 mL of saline injected. Patient suddenly became unresponsive, hypertensive (197/128) and tachycardic (101). Neurological examination revealed a National Institutes of Health Stroke Scale (NIHSS) score of 27. A CT brain demonstrated a hyperdense basilar artery sign and the patient was taken for mechanical thrombectomy. Digital subtraction angiogram confirmed complete occlusion of the proximal basilar artery with reconstitution at the basilar tip via the posterior communicating artery (Fig. 1). Complete recanalization was achieved within 110 minutes from onset of symptoms (Fig. 2). MRI brain post-thrombectomy revealed an acute infarct involving the left and lateral right superior cerebellum. Stroke work-up including a transthoracic and trans-esophageal echocardiogram, and CT chest with contrast were unremarkable. The patient was discharged to a short-term rehabilitation facility and her modified Rankin Scale was zero at three months. Five cases have been reported in the past where paradoxical emboli during AV fistula/graft thrombectomies caused stroke (1-5). The absence of intracardiac shunts on transthoracic and trans-esophageal echocardiograms (combined sensitivity ≥96% (6, 7) and lack of pulmonary arteriovenous malformations on contrast enhanced CT chest indicate that a paradoxical embolus was unlikely the cause of stroke in this case. The rATS is a percutaneous thrombectomy device that uses the Bernoulli effect to aid in thrombus retrieval. Streams of high-velocity heparinized saline jets directed in a retrograde manner lead to local pressure of less than -600 mmHg to pull thrombi proximally towards the device. This is the fourth reported case of an embolic stroke from retrograde flow of thrombus along the arterial system (8, 9). Gaan et al (8) reported that a minimum of 7 mL of fluid was required for a detached clot to reach the origin of the vertebral artery from the brachial artery based on the velocity of fluid being injected using a syringe; speeds of 360 mph are used in the rATS. The use of the Angiojet for 30 seconds with 31 mL of fluid likely pulled the arterial thrombus towards the device. We suspect further propulsion up the arterial circulation into the Fig. 1 Pre-thrombectomy cerebral angiogram revealing occlusion of the basilar artery.

Mechanical Thrombectomy in Elderly Stroke Patients with Mild-to-Moderate Baseline Disability

Background: The number of elderly patients suffering from ischemic stroke is rising. Randomized trials of mechanical thrombectomy (MT) generally exclude patients over the age of 80 years with baseline disability. The aim of this study was to understand the efficacy and safety of MT in elderly patients, many of whom may have baseline impairment. Methods: Between January 2015 and April 2017, 96 patients ≥80 years old who underwent MT for stroke were selected for a chart review. The data included baseline characteristics, time to treatment, the rate of revascularization, procedural complications, mortality, and 90-day good outcome defined as a modified Rankin Scale (mRS) score of 0–2 or return to baseline. Results: Of the 96 patients, 50 had mild baseline disability (mRS score 0–1) and 46 had moderate disability (mRS score 2–4). Recanalization was achieved in 84% of the patients, and the rate of symptomatic hemorrhage was 6%. At 90 days, 34% of the patients had a good outcome. There were no significant differences in good outcome between those with mild and those with moderate baseline disability (43 vs. 24%, p = 0.08), between those aged ≤85 and those aged > 85 years (40.8 vs. 26.1%, p = 0.19), and between those treated within and those treated beyond 8 h (39 vs. 20%, p = 0.1). The mortality rate was 38.5% at 90 days. The Alberta Stroke Program Early CT Score (ASPECTS) and the National Institutes of Health Stroke Scale (NIHSS) predicted good outcome regardless of baseline disability (p < 0.001 and p = 0.009, respectively). Conclusion: Advanced age, baseline disability, and delayed treatment are associated with suboptimal outcomes after MT. However, redefining good outcome to include return to baseline functioning demonstrates that one-third of this patient population benefits from MT, suggesting the real-life utility of this treatment.

Mechanical Thrombectomy for Middle Cerebral Artery Division Occlusions: A Systematic Review and Meta-Analysis

Background: Middle cerebral artery division (M2) occlusion was significantly underrepresented in recent mechanical thrombectomy (MT) randomized controlled trials, and the approach to this disease remains heterogeneous. Objective: To conduct a systematic review and meta-analysis of outcomes at 90 days among patients undergoing MT for M2 middle cerebral artery (MCA) occlusions. Methods: Five clinical databases were searched from inception through September 2016. Observational studies reporting 90-day modified Rankin Scale scores for patients undergoing MT for M2 MCA occlusions with an M1 MCA control group were selected. The primary outcome of interest was good clinical outcome 90 days after MT of an M1 or M2 MCA occlusion. Secondary outcomes of interest included mortality and excellent clinical outcome, recanalization rates, significant intracerebral hemorrhage, and procedural complications. Results: A total of 323 publications were identified, and 237 potentially relevant articles were screened. Six studies were included in the analysis (M1 = 1,203, M2 = 258; total n = 1,461). We found no significant differences in good clinical outcomes (1.10 [95% CI, 0.83-1.44]), excellent clinical outcomes (1.07 [0.65-1.79]), mortality at 3 months (0.85 [0.58-1.24]), recanalization rates (1.06 [0.32-3.48]), and significant intracranial hemorrhage (1.19 [0.61-2.30]). Conclusions: MT of M2 MCA occlusions is as safe as that of main trunk MCA occlusions, and comparable in terms of clinical outcomes and hemorrhagic complications. Randomized clinical trials are needed to assess the impact of MT in patients with M2 occlusions, given that M1 MCA occlusions have different natural histories than M2 occlusions.