Reuben Grech

Functional outcomes and recanalization rates of stent retrievers in acute ischaemic stroke: A systematic review and meta-analysis

Background and purpose Intra-arterial therapy for acute ischaemic stroke has evolved rapidly in the last few years. Stent retrievers have now replaced ‘first-generation’ devices, which have been the principle devices tested in stroke trials. Our aims were to determine the rates of successful recanalization and functional independence in acute stroke patients treated with stent retrievers. We also sought to assess the safety outcomes of stent retrievers by assessing the rates of mortality and intra-cranial haemorrhage. Materials and methods We conducted a systematic review and meta-analysis of studies which utilized stent retrievers as sole treatment or as part of a multi-modal approach in acute ischaemic stroke. Results We identified 20 eligible studies: 17 on Solitaire (ev3/Covidien, Irvine, California, USA) (n = 762) and three on Trevo (Stryker, Kalamazoo, Michigan, USA) (n = 210). The mean age of participants was 66.8 (range 62.1–73.0) years and the M:F ratio was 1.1:1. The average stroke severity score (National Institutes of Health Stroke Scale (NIHSS)) at presentation was 17.2. The weighted mean symptom onset to arterial puncture and procedural duration were 265.4 minutes and 54.8 minutes, respectively. Successful recanalization was achieved in 84.5% of patients with a weighted mean of 2.0 stent retriever passes. Independent functional outcome was achieved in 51.2% and the mortality rate was 16.8%. Conclusion Stent retrievers have the potential to achieve a high rate of recanalization and functional independence whilst being relatively safe. They should be assessed in well-designed randomized controlled trials to determine their efficacy and assess whether they compare favourably with ‘standard treatment’ in stroke.

Outcome Prediction in Acute Stroke Patients Considered for Endovascular Treatment: a Novel Tool

Functional outcome following emergent intra-arterial thrombectomy is variable and likely reflects the heterogeneous characteristics of acute stroke patients. The aims of our study were (1) to study which pre-treatment variables correlate with functional outcome and (2) to devise a tool which would reliably predict outcome. Prospective data of patients treated with intra-arterial mechanical thrombectomy in our institution between 2010 and 2012 were collected. A preliminary univariate analysis of baseline variables was performed and data outliers were identified by constructing scatter and box plots. Systematic bivariate analysis was then carried out using a linear regression model and the individual contributing weights of the variables to outcome calculated. The B and constant values from the regression were used to construct a predictive formula. Fifty-seven patients, 35 males (61.4%) and 22 females (38.6%) with a mean age of 62.3 years (range 26–87) were included in the cohort. Statistical correlations of baseline variables and functional outcome showed that age, National Institutes of Health Stroke Scale at presentation and CT leptomeningeal collaterals were strongly correlated (p<0.01), and were later included in the linear regression model. A tool was devised from the regression formula combining weighted inputs of the three variables. Regression statistics and residual analysis were then performed to assess the accuracy and reliability of the proposed tool. The proposed tool is easy to use and reliably predicts functional outcome prior to endovascular therapy. It may help clinical decision-making in the acute setting and offers ‘tailor-made’ outcome expectations.

Imaging of Adult Ocular and Orbital Pathology - a Pictorial Review

Orbital pathology often presents a diagnostic challenge to the reporting radiologist. The aetiology is protean, and clinical input is therefore often necessary to narrow the differential diagnosis. With this manuscript, we provide a pictorial review of adult ocular and orbital pathology.

An efficacy and safety comparison between different stentriever designs in acute ischaemic stroke: a systematic review and meta-analysis.

AIM To assess the recanalisation rates and long-term functional outcomes of the Solitaire and Trevo devices; to compare these results to those from the Solitaire With the Intention For Thrombectomy (SWIFT) trial and TREVO 2 studies; and to assess for statistical differences in the outcomes between the two devices. MATERIALS AND METHODS A systematic review and meta-analysis of studies that utilised stentrievers in the treatment of acute ischaemic stroke was conducted. The results were compared to those of the SWIFT and TREVO 2 trials and outcome differences between Trevo (Stryker, Kalamazoo, Michigan, USA) and Solitaire (ev3/Covidien, Irvine, California, USA) were analysed statistically. RESULTS Solitaire had a lower mortality rate compared to Trevo (16.2% [95% confidence interval {CI}: 13.1%, 19.8%] versus 22.2% [95% CI: 10.8%, 40.2%]) and achieved a higher rate of functional independence (52.1% [95% CI: 46.3%, 57.8%] versus 47.6% [95% CI: 36.7%, 58.8%]). Statistical tests, however, failed to demonstrate significant differences in either functional outcomes or 3-month mortality rates. No significant differences were noted in weighted mean recanalisation rates between the Solitaire and Trevo groups. CONCLUSION Stentrievers achieve a high rate of recanalisation and functional independence in acute ischaemic stroke and have a relatively good safety profile. No significant differences in functional outcomes, mortality, and symptomatic intra-cranial haemorrhage could be demonstrated between two popular stentrievers designs, namely Trevo and Solitaire.

Intracranial calcifications. A pictorial review.

Brain calcifications are a common radiographic finding. The pathogenesis is diverse and ranges from benign physiological calcifications to a variety of pathological disorders. Whereas certain calcifications are considered an incidental finding, their presence can sometimes be crucial in making a specific diagnosis. Several pathological conditions affecting the brain parenchyma are associated with calcifications and their recognition and location might help in narrowing the differential. Knowledge of physiological calcifications is essential to avoid misinterpretation. This review illustrates a broad spectrum of CNS disorders associated with calcifications, and tries to highlight the salient radiological findings.

Teaching NeuroImages: Chordoma

A 30-year-old man presented with recurrent headaches. CT head revealed a clival chordoma (figure 1A). Chordomas originate from the embryonic remnants of the notochord and account for 2%–4% of all malignant bone tumors. They have a predilection for the axial skeleton, with 35% affecting the spheno-occipital region. The incidence peaks at ages 20–40 years. Male patients are affected twice as commonly as female patients.1 Clinical symptoms often result from local mass effect. On imaging, the tumor appears as a midline lesion and can contain heterogeneous calcifications. MRI demonstrates high signal on T2-weighted sequences and heterogeneous enhancement with a honeycomb appearance (figure 1).2 Indenting of the pons results in the characteristic thumb sign (figure 2). Differential diagnosis based on imaging appearance includes chondrosarcoma and metastasis.

Adult colorectal intussusception.

### Case report A 30-year-old woman presented with severe lower, colicky abdominal pain and difficulty in passing flatus. Clinical examination revealed suprapubic tenderness. An abdominal CT was performed which revealed a soft-tissue mass in the pelvis demonstrating ‘a target sign’ appearance confirming the diagnosis of intussusception (figure 1). The effect of the intussusceptum within the intussuscipiens creates a layered appearance. There is loss of gas within the rectum, instead, this is replaced by a soft-tissue mass of fat density (Hounsfield units −10) (figure 2). A …

Stent-based thrombectomy versus intravenous tissue plasminogen activator in acute ischaemic stroke: A systematic review and meta-analysis.

Purpose To date only a few studies have compared the effectiveness and functional outcomes of stent retrievers versus intravenous thrombolysis in acute ischaemic stoke. Our aim was to identify and collate all the available data and to assess for statistical differences in patient outcomes between the two treatments. Materials and methods We performed a systematic review and meta-analysis of studies with a randomised controlled design which utilised stentrievers and intravenous thrombolysis in acute ischaemic stroke. Results Five randomised controlled studies published in 2015 were identified. Second-generation thrombectomy devices constituted at least 80% of thrombectomy devices in the included studies, namely MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME and REVASCAT. No significant heterogeneity was seen in the included studies and the five trials were therefore included in the meta-analysis. A total of 46.10% of patients treated with stentrievers achieved an independent functional outcome (mRS < 2) at 90 days compared with 26.46% of those treated with intravenous thrombolysis with an odds ratio of 2.40 (p < 0.001). The weighted recanalisation mean in the thrombectomy arms was 76.02%. A lower mortality rate was observed with stentrievers compared to intravenous thrombolysis (15.33% vs 18.74%; OR 0.81, p = 0.15). Stentrievers were also associated with a lower risk of symptomatic intracranial haemorrhage (7.86% vs 8.64%; OR 1.02, p = 0.93). The differences in the secondary/safety outcomes were not statistically significant. Conclusion Stentrievers can achieve a high rate of recanalisation and functional independence in acute ischaemic stroke and have a relatively good safety profile. Our meta-analysis demonstrates a clear benefit of an intra-arterial mechanical approach vs standard treatment.

Tullio phenomenon in superior semicircular canal dehiscence (SSCD)

A 68-year-old woman presented with worsening sound-induced vertigo (Tullio phenomenon) and left-sided hearing loss. Webers test lateralised to the affected ear and audiography confirmed mild conductive hearing loss. Neurological assessment was remarkable for torsional/vertical noise and vibration-induced nystagmus. The patient demonstrated low threshold cervical vestibular-evoked myogenic potential responses, and superior semicircular canal dehiscence was suspected. Otoscopy, tympanography and stapedial reflexes were normal bilaterally. High-resolution CT of …

Not just another thunderclap headache: a case of isolated cortical vein thrombosis and subarachnoid haemorrhage

A 63-year-old woman presented with a severe frontal thunderclap headache associated with transient blurring of vision. No significant medical history other than blood hypertension was noted. On examination, there was no neck stiffness or fever, however, her blood pressure was 160/90 mm Hg. Ophthalmoscopic assessment excluded papilloedema and neurological examination was unremarkable. A non-contrast CT scan showed a small subarachnoid haemorrhage (SAH) in the frontal region bilaterally (figure 1A). A cerebral CT angiogram failed to reveal any aneurysms. She proceeded to have an MRI. The fluid-attenuated inversion recovery sequence confirmed the subarachnoid bleed (figure 1 …