Holly Battenhouse

ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy.

Background The development of new revascularization devices has improved recanalization rates and time, but not clinical outcomes. We report a prospectively collected clinical experience with a new technique utilizing a direct aspiration first pass technique with large bore aspiration catheter as the primary method for vessel recanalization. Methods 98 prospectively identified acute ischemic stroke patients with 100 occluded large cerebral vessels at six institutions were included in the study. The ADAPT technique was utilized in all patients. Procedural and clinical data were captured for analysis. Results The aspiration component of the ADAPT technique alone was successful in achieving Thrombolysis in Cerebral Infarction (TICI) 2b or 3 revascularization in 78% of cases. The additional use of stent retrievers improved the TICI 2b/3 revascularization rate to 95%. The average time from groin puncture to at least TICI 2b recanalization was 37 min. A 5MAX demonstrated similar success to a 5MAX ACE in achieving TICI 2b/3 revascularization alone (75% vs 82%, p=0.43). Patients presented with an admitting median National Institutes of Health Stroke Scale (NIHSS) score of 17.0 (12.0–21.0) and improved to a median NIHSS score at discharge of 7.3 (1.0–11.0). Ninety day functional outcomes were 40% (modified Rankin Scale (mRS) 0–2) and 20% (mRS 6). There were two procedural complications and no symptomatic intracerebral hemorrhages. Discussion The ADAPT technique is a fast, safe, simple, and effective method that has facilitated our approach to acute ischemic stroke thrombectomy by utilizing the latest generation of large bore aspiration catheters to achieve previously unparalleled angiographic outcomes.

Platelet-oriented inhibition in new TIA and minor ischemic stroke (POINT) trial: rationale and design.

Background Ischemic stroke and other vascular outcomes occur in 10–20% of patients in the three-months following a transient ischemic attack or minor ischemic stroke, and many are disabling. The highest risk period for these outcomes is the early hours and days immediately following the ischemic event. Aspirin is the most common antithrombotic treatment used for these patients. Aim The aim of POINT is to determine whether clopidogrel plus aspirin taken <12 h after transient ischemic attack or minor ischemic stroke symptom onset is more effective in preventing major ischemic vascular events at 90 days in the high-risk, and acceptably safe, compared with aspirin alone. Design POINT is a prospective, randomized, double-blind, multicenter trial in patients with transient ischemic attack or minor ischemic stroke. Subjects are randomized to clopidogrel (600 mg loading dose followed by 75 mg/day) or matching placebo, and all will receive open-label aspirin 50–325 mg/day, with a dose of 162 mg daily for five-days followed by 81 mg daily strongly recommended. Study Outcomes The primary efficacy outcome is the composite of new ischemic vascular events — ischemic stroke, myocardial infarction, or ischemic vascular death — by 90 days. The primary safety outcome is major hemorrhage, which includes symptomatic intracranial hemorrhage. Discussion Aspirin is the most common antithrombotic given to patients with a stroke or transient ischemic attack, as it reduces the risk of subsequent stroke. This trial expects to determine whether more aggressive antithrombotic therapy with clopidogrel plus aspirin, initiated acutely, is more effective than aspirin alone.

Comparison of endovascular treatment approaches for acute ischemic stroke: cost effectiveness, technical success, and clinical outcomes

Introduction The use of mechanical thrombectomy for the treatment of acute ischemic stroke has significantly advanced over the last 5 years. Few data are available comparing the cost and clinical and angiographic outcomes associated with available techniques. The aim of this study is to compare the cost and efficacy of current endovascular stroke therapies. Methods A single-center retrospective review was performed of the medical record and hospital financial database of all ischemic stroke cases admitted from 2009 to 2013. Three discrete treatment methodologies used during this time were compared: traditional Penumbra System (PS), stent retriever with local aspiration (SRLA) and A Direct Aspiration first Pass Technique (ADAPT). Statistical analyses of clinical and angiographic outcomes and costs for each group were performed. Results 222 patients (45% men) underwent mechanical thrombectomy. Successful revascularization was defined as Thrombolysis In Cerebral Infarction (TICI) 2b/3 flow, which was achieved in 79% of cases with PS, 83% of cases with SRLA, and 95% of cases with ADAPT. The average total cost of hospitalization for patients was

Detection of anti‐isoniazid and anti–cytochrome P450 antibodies in patients with isoniazid‐induced liver failure

51 599 with PS,

Outcomes and complications of intracranial pressure monitoring in acute liver failure: a retrospective cohort study.

54 700 with SRLA, and

Therapeutic hypothermia in acute liver failure: A multicenter retrospective cohort analysis

33 611 with ADAPT (p<0.0001). Average times to recanalization were 88 min with PS, 47 min with SRLA, and 37 min with ADAPT (p<0.0001). Similar rates of good functional outcomes were seen in the three groups (PS 36% vs SRLA 43% vs ADAPT 47%; p=0.4). Conclusions The ADAPT technique represents the most technically successful yet cost-effective approach to revascularization of large vessel intracranial occlusions.

The golden hour of stroke intervention: effect of thrombectomy procedural time in acute ischemic stroke on outcome

Isoniazid (INH)‐induced hepatotoxicity remains one of the most common causes of drug‐induced idiosyncratic liver injury and liver failure. This form of liver injury is not believed to be immune‐mediated because it is not usually associated with fever or rash, does not recur more rapidly on rechallenge, and previous studies have failed to identify anti‐INH antibodies (Abs). In this study, we found Abs present in sera of 15 of 19 cases of INH‐induced liver failure. Anti‐INH Abs were present in 8 sera; 11 had anti–cytochrome P450 (CYP)2E1 Abs, 14 had Abs against CYP2E1 modified by INH, 14 had anti‐CYP3A4 antibodies, and 10 had anti‐CYP2C9 Abs. INH was found to form covalent adducts with CYP2E1, CYP3A4, and CYP2C9. None of these Abs were detected in sera from INH‐treated controls without significant liver injury. The presence of a range of antidrug and autoAbs has been observed in other drug‐induced liver injury that is presumed to be immune mediated. Conclusion: These data provide strong evidence that INH induces an immune response that causes INH‐induced liver injury. (Hepatology 2014;59:1084–1093)

An investigation of the cost and benefit of mechanical thrombectomy for endovascular treatment of acute ischemic stroke

Objective:To determine if intracranial pressure monitor placement in patients with acute liver failure is associated with significant clinical outcomes. Design:Retrospective multicenter cohort study. Setting:Academic liver transplant centers comprising the U.S. Acute Liver Failure Study Group. Patients:Adult critically ill patients with acute liver failure presenting with grade III/IV hepatic encephalopathy (n = 629) prospectively enrolled between March 2004 and August 2011. Intervention:Intracranial pressure monitored (n = 140) versus nonmonitored controls (n = 489). Measurements and Main Results:Intracranial pressure monitored patients were younger than controls (35 vs 43 yr, p < 0.001) and more likely to be on renal replacement therapy (52% vs 38%, p = 0.003). Of 87 intracranial pressure monitored patients with detailed information, 44 (51%) had evidence of intracranial hypertension (intracranial pressure > 25 mm Hg) and overall 21-day mortality was higher in patients with intracranial hypertension (43% vs 23%, p = 0.05). During the first 7 days, intracranial pressure monitored patients received more intracranial hypertension–directed therapies (mannitol, 56% vs 21%; hypertonic saline, 14% vs 7%; hypothermia, 24% vs 10%; p < 0.03 for each). Forty-one percent of intracranial pressure monitored patients received liver transplant (vs 18% controls; p < 0.001). Overall 21-day mortality was similar (intracranial pressure monitored 33% vs controls 38%, p = 0.24). Where data were available, hemorrhagic complications were rare in intracranial pressure monitored patients (4 of 56 [7%]; three died). When stratifying by acetaminophen status and adjusting for confounders, intracranial pressure monitor placement did not impact 21-day mortality in acetaminophen patients (p = 0.89). However, intracranial pressure monitor was associated with increased 21-day mortality in nonacetaminophen patients (odds ratio, ~ 3.04; p = 0.014). Conclusions:In intracranial pressure monitored patients with acute liver failure, intracranial hypertension is commonly observed. The use of intracranial pressure monitor in acetaminophen acute liver failure did not confer a significant 21-day mortality benefit, whereas in nonacetaminophen acute liver failure, it may be associated with worse outcomes. Hemorrhagic complications from intracranial pressure monitor placement were uncommon and cannot account for mortality trends. Although our results cannot conclusively confirm or refute the utility of intracranial pressure monitoring in patients with acute liver failure, patient selection and ancillary assessments of cerebral blood flow likely have a significant role. Prospective studies would be required to conclusively account for confounding by illness severity and transplant.

Hounsfield unit value and clot length in the acutely occluded vessel and time required to achieve thrombectomy, complications and outcome

The benefit of therapeutic hypothermia (TH) in acute liver failure (ALF) has not been previously demonstrated in a controlled fashion. This study sought to determine the impact of TH on 21‐day survival and complications in ALF patients at high risk for cerebral edema. This was a retrospective cohort study of ALF patients in the US Acute Liver Failure Study Group with grade III or IV hepatic encephalopathy. TH (32°C‐35°C) was used in 97 patients (8%); 1135 (92%) who were not cooled were controls. Intracranial pressure was monitored in 38 TH ALF patients (39.2% versus 22% of controls, P < 0.001). Rates of bleeding (12% for both) and bloodstream (17% versus 18%) and tracheal infections (21% versus 23%, P > 0.5 for all) were similar. Unadjusted 21‐day overall (62% versus 60%) and transplant‐free survival rates (45% versus 39%, P > 0.4 for both) were similar. Multivariate models were created for acetaminophen (APAP) patients (n = 582) and non‐APAP patients (n = 613). For APAP patients, the Model for End‐Stage Liver Disease [MELD; odds ratio (OR) = 0.91 per increment, 95% confidence interval (CI) = 0.89‐0.94, P < 0.001] and vasopressors (OR = 0.16, 95% CI = 0.11‐0.24, P < 0.001) were associated with decreased 21‐day spontaneous survival. Survival was improved with TH in APAP patients who were <25 years old (age of 25 years: OR = 2.735, 95% CI = 1.001‐7.467) but worsened for APAP patients who were 64 years old or older (age of 64 years: OR = 0.167, 95% CI = 0.028‐0.999). For non‐APAP patients, MELD (OR = 0.93 per increment, 95% CI = 0.91‐0.95, P < 0.001) and vasopressors (OR = 0.60, 95% CI = 0.40‐0.90, P = 0.01) were associated with worse outcomes, whereas TH had no impact (P = 0.93). In conclusion, TH in ALF was not associated with increased bleeding or infections. Although young APAP ALF patients may benefit, TH did not consistently affect 21‐day survival. A prospective trial is required to clarify the utility of TH in ALF patients. Liver Transpl 21:4‐12, 2015.

Impact of the ASPECT scores and distribution on outcome among patients undergoing thrombectomy for acute ischemic stroke

Introduction Outcome studies in acute ischemic stroke (AIS) have focused on time from symptom onset to treatment. The purpose of this study was to investigate whether time to achieve vessel recanalization from groin puncture affects outcomes. Methods We studied all AIS cases that underwent intra-arterial therapy between May 2008 and October 2012 at a high volume center for anterior circulation occlusions. Candidacy for thrombectomy is determined by CT perfusion imaging, irrespective of time of onset. Patients were then dichotomized into two groups: ‘Early recan’ assigned in which recanalization was achieved in ≤60 min from groin puncture and ‘Delayed recan’ in which procedures extended beyond 60 min. Time to recanalize was also studied as a continuous variable. Results 159 patients (53.5% women, mean age 66.4±15.2 years) were identified. The mean National Institutes of Health Stroke Scale (NIHSS) score was similar between ‘Early recan’ patients (16.8±6.1) compared with ‘Delayed recan’ patients (15.4±5.8, p=0.149). Among the ‘Early recan’ patients, recanalization was achieved in 40.7±13.6 min compared with 101.7±32.5 min in the ‘Delayed recan’ patients (p<0.0001). The likelihood of achieving a good outcome (modified Rankin Scale score 0–2) was higher in the ‘Early recan’ group (53.6%) compared with the ‘Late recan’ group (30.8%; p=0.009). On logistic regression analysis, time to recanalization from groin puncture, baseline NIHSS, revascularization, diabetes, and hemorrhages were found to significantly impact on outcome at 90 days, as measured by the modified Rankin Scale. Conclusions Our findings suggest that extending mechanical thrombectomy procedure times beyond 60 min increases complications and device cost rates while worsening outcomes. These findings can serve as a time frame of when it is prudent to abort a failed thrombectomy case.