Robert F. James

Mechanical Thrombectomy Outcomes With and Without Intravenous Thrombolysis in Stroke Patients: A Meta-Analysis

Background and Purpose— Whether prior intravenous thrombolysis provides any additional benefits to the patients undergoing mechanical thrombectomy for large vessel, acute ischemic stroke remains unclear. Methods— We conducted a meta-analysis of 13 studies obtained through PubMed and EMBASE database searches to determine whether functional outcome (modified Rankin Scale) at 90 days, successful recanalization rate, and symptomatic intracerebral hemorrhage rate differed between patients who underwent mechanical thrombectomy with (MT+IVT) and without (MT−IVT) pre-treatment with intravenous thrombolysis. Results— MT+IVT patients compared with MT−IVT patients had better functional outcomes (modified Rankin Scale score, 0–2; summary odds ratio [OR], 1.27 [95% confidence interval (CI), 1.05–1.55]; P=0.02; n=1769/1174), lower mortality (OR, 0.71 [95% CI, 0.55–0.91]; P=0.006; n=1774/1202), and higher rate of successful recanalization (OR, 1.46 [95% CI, 1.09–1.96]; P=0.01; n=1652/1216) without having increased odds of symptomatic intracerebral hemorrhage (OR, 1.11 [95% CI, 0.69–1.77]; P=0.67; n=1471/1143). A greater number of MT+IVT patients required ⩽2 passes with a neurothrombectomy device to achieve successful recanalization (OR, 2.06 [95% CI, 1.37–3.10]; P=0.0005; n=316/231). Conclusions— Our results demonstrated that MT+IVT patients had better functional outcomes, lower mortality, higher rate of successful recanalization, requiring lower number of device passes, and equal odds of symptomatic intracerebral hemorrhage compared with MT−IVT patients. The results support the current guidelines of offering intravenous thrombolysis to eligible patients even if they are being considered for mechanical thrombectomy. Because the data are compiled from studies where the 2 groups differed based on eligibility for intravenous thrombolysis, randomized trials are necessary to accurately evaluate the added value of intravenous thrombolysis in patients treated with mechanical thrombectomy.

Low-dose intravenous heparin infusion in patients with aneurysmal subarachnoid hemorrhage: a preliminary assessment

OBJECT Aneurysmal subarachnoid hemorrhage (aSAH) predisposes to delayed neurological deficits, including stroke and cognitive and neuropsychological abnormalities. Heparin is a pleiotropic drug that antagonizes many of the pathophysiological mechanisms implicated in secondary brain injury after aSAH. METHODS The authors performed a retrospective analysis in 86 consecutive patients with Fisher Grade 3 aSAH due to rupture of a supratentorial aneurysm who presented within 36 hours and were treated by surgical clipping within 48 hours of their ictus. Forty-three patients were managed postoperatively with a low-dose intravenous heparin infusion (Maryland low-dose intravenous heparin infusion protocol: 8 U/kg/hr progressing over 36 hours to 10 U/kg/hr) beginning 12 hours after surgery and continuing until Day 14 after the ictus. Forty-three control patients received conventional subcutaneous heparin twice daily as deep vein thrombosis prophylaxis. RESULTS Patients in the 2 groups were balanced in terms of baseline characteristics. In the heparin group, activated partial thromboplastin times were normal to mildly elevated; no clinically significant hemorrhages or instances of heparin-induced thrombocytopenia or deep vein thrombosis were encountered. In the control group, the incidence of clinical vasospasm requiring rescue therapy (induced hypertension, selective intraarterial verapamil, and angioplasty) was 20 (47%) of 43 patients, and 9 (21%) of 43 patients experienced a delayed infarct on CT scanning. In the heparin group, the incidence of clinical vasospasm requiring rescue therapy was 9% (4 of 43, p = 0.0002), and no patient suffered a delayed infarct (p = 0.003). CONCLUSIONS In patients with Fisher Grade 3 aSAH whose aneurysm is secured, postprocedure use of a low-dose intravenous heparin infusion may be safe and beneficial.

Systolic Blood Pressure Within 24 Hours After Thrombectomy for Acute Ischemic Stroke Correlates With Outcome

Background Current guidelines suggest treating blood pressure above 180/105 mm Hg during the first 24 hours in patients with acute ischemic stroke undergoing any form of recanalization therapy. Currently, no studies exist to guide blood pressure management in patients with stroke treated specifically with mechanical thrombectomy. We aimed to determine the association between blood pressure parameters within the first 24 hours after mechanical thrombectomy and patient outcomes. Methods and Results We retrospectively studied a consecutive sample of adult patients who underwent mechanical thrombectomy for acute ischemic stroke of the anterior cerebral circulation at 3 institutions from March 2015 to October 2016. We collected the values of maximum, minimum, and average values of systolic blood pressure, diastolic blood pressure, and mean arterial pressures in the first 24 hours after mechanical thrombectomy. Primary and secondary outcomes were patients’ functional status at 90 days measured on the modified Rankin scale and the incidence and severity of intracranial hemorrhages within 48 hours. Associations were explored using an ordered multivariable logistic regression analyses. A total of 228 patients were included (mean age 65.8±14.3; 104 males, 45.6%). Maximum systolic blood pressure independently correlated with a worse 90‐day modified Rankin scale and hemorrhagic complications within 48 hours (adjusted odds ratio=1.02 [1.01–1.03], P=0.004; 1.02 [1.01–1.04], P=0.002; respectively) in multivariable analyses, after adjusting for several possible confounders. Conclusions Higher peak values of systolic blood pressure independently correlated with worse 90‐day modified Rankin scale and a higher rate of hemorrhagic complications. Further prospective studies are warranted to identify whether systolic blood pressure is a therapeutic target to improve outcomes.

Strategic and Technical Considerations for the Endovascular Embolization of Intracranial Meningiomas

Endovascular embolization is a frequently used adjunct to operative resection of meningiomas. Embolization may decrease intraoperative blood loss, operative time, and surgical difficulty associated with resection. The specific clinical applications of this treatment have not been defined clearly. Procedural indications, preferred embolic agent, and latency until tumor resection all differ across operators. It is clear that strategic patient selection, comprehensive anatomic understanding, and sound operative technique are critical to the success of the embolization procedure. This article reviews the management and technical considerations associated with preoperative meningioma embolization.

Visual Improvement after Intra-Arterial Thrombolysis for Central Retinal Artery Occlusion Does Not Correlate with Time to Treatment.

Background: Intra-arterial thrombolysis (IAT) for the treatment of acute central retinal artery occlusion (CRAO) has demonstrated variable results for improving visual acuity and remains controversial. Despite limited evidence, time from symptom onset to thrombolysis is believed to be an important factor in predicting visual improvement after IAT. Methods: A comprehensive review of the literature was conducted and individual subject level data were extracted from relevant studies. From these, a secondary analysis was performed. Initial and final logarithm of the minimum angle of resolution (logMAR) scores were either abstracted directly from relevant studies or converted from provided Snellen chart scores. Change in logMAR scores was used to determine overall treatment efficacy. Results: Data on 118 patients undergoing IAT from five studies were evaluated. Median logMAR improvement in visual acuity was -0.400 (p < 0.001). There was no significant association between logMAR change and time to treatment when time (hours) was described as a continuous variable or described categorically [0-4, 4-8, 8-12, 12+ h; or 0-6, 6-12, 12+ h]. Conclusion: The visual improvement observed in this series had no relationship to the time from symptom onset to treatment with IAT. This suggests that patients may have the possibility for improvement even with delayed presentation to the neurointerventionalist. Other factors, such as completeness of retinal occlusion, may be more important than time to treatment. Additional studies to determine optimal patient selection criteria for the endovascular treatment of acute CRAO are needed.

Evaluation of previously embolized intracranial aneurysms: inter- and intra-rater reliability among neurosurgeons and interventional neuroradiologists

Background The angiographic evaluation of previously coiled aneurysms can be difficult yet remains critical for determining re-treatment. Objective The main objective of this study was to determine the inter-rater reliability for both the Raymond Scale and per cent embolization among a group of neurointerventionalists evaluating previously embolized aneurysms. Methods A panel of 15 neurointerventionalists examined 92 distinct cases of immediate post-coil embolization and 1 year post-embolization angiographs. Each case was presented four times throughout the study, along with alterations in demographics in order to evaluate intra-rater reliability. All respondents were asked to provide the per cent embolization (0–100%) and Raymond Scale grade (1-3) for each aneurysm. Inter-rater reliability was evaluated by computing weighted kappa values (for the Raymond Scale) and intraclass correlation coefficients (ICC) for per cent embolization. Results 10 neurosurgeons and 5 interventional neuroradiologists evaluated 368 simulated cases. The agreement among all readers employing the Raymond Scale was fair (κ=0.35) while concordance in per cent embolization was good (ICC=0.64). Clinicians with fewer than 10 years of experience demonstrated a significantly greater level of agreement than the group with greater than 10 years (κ=0.39 and ICC=0.70 vs κ=0.28 and ICC=0.58). When the same aneurysm was presented multiple times, clinicians demonstrated excellent consistency when assessing per cent embolization (ICC=0.82), but moderate agreement when employing the Raymond classification (κ=0.58). Conclusions Identifying the per cent embolization in previously coiled aneurysms resulted in good inter- and intra-rater agreement, regardless of years of experience. The strong agreement among providers employing per cent embolization may make it a valuable tool for embolization assessment in this patient population.

Copper deficiency myelopathy in the setting of advanced degenerative cervical spondylosis.

When presenting conjointly, degenerative cervical spondylosis and copper deficiency myelopathy may be difficult to differentiate providing the potential for mismanagement and unnecessary surgery. We present a case of a 69-year-old female with copper deficiency myelopathy secondary to previous bowel resection in the setting of advanced degenerative cervical spondylotic disease.

Review: propensity score methods with application to the HELP clinic clinical study

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Basic Endovascular Techniques: Direct, Balloon-Assisted, and Stent-Assisted Coil Embolization

Abstract Devices and techniques for the endovascular treatment of intracranial aneurysms have rapidly progressed since their clinical debut nearly three decades ago. However, mastery of basic embolization techniques remains the cornerstone of successful endovascular therapy. Commonly employed techniques include direct, balloon-assisted, and stent-assisted coil embolization. The neuroendovascular field continues to innovate and coil embolization may not remain at the forefront of endovascular aneurysm treatment in the future. The introduction of innovative and promising new devices that do not utilize a coil platform may diminish the future importance of coil embolization techniques leading to a new age in aneurysm embolization where the coil is no longer the dominant device. In this chapter, we will discuss the basics of coil embolization focusing on standard direct, balloon-assisted, and stent-assisted techniques as they remain the workhorse options for aneurysm embolization.

Delayed Neurological Injury Not From Large-Vessel Vasospasm

Abstract Delayed neurological injury in patients with aneurysmal subarachnoid hemorrhage has long been attributed to large-vessel vasospasm. New evidence suggests that delayed neurological injury is correlated to other pathophysiological mechanisms. Neuroinflammation is considered a hallmark feature of subarachnoid hemorrhage and is associated with release of various inflammatory molecules, believed to contribute to continued neurological injury and associated cognitive decline. Cortical spreading depolarization is an additional mechanism that could be causing microvascular ischemia and additional injury. Another cause of delayed injury associated with aneurysmal subarachnoid hemorrhage is hydrocephalus, usually treated with cerebrospinal fluid diversion. Various therapeutic interventions have been designed to target delayed injury. Unfractionated heparin, glyburide, IL-1 antagonists as well as TLR-4 antagonists target delayed neurological injury by blocking inflammatory pathways associated with long-term outcomes.