Russell Cerejo

High-Resolution MRI Vessel Wall Imaging: Spatial and Temporal Patterns of Reversible Cerebral Vasoconstriction Syndrome and Central Nervous System Vasculitis

BACKGROUND AND PURPOSE: High-resolution MR imaging is an emerging tool for evaluating intracranial artery disease. It has an advantage of defining vessel wall characteristics of intracranial vascular diseases. We investigated high-resolution MR imaging arterial wall characteristics of CNS vasculitis and reversible cerebral vasoconstriction syndrome to determine wall pattern changes during a follow-up period. MATERIALS AND METHODS: We retrospectively reviewed 3T-high-resolution MR imaging vessel wall studies performed on 26 patients with a confirmed diagnosis of CNS vasculitis and reversible cerebral vasoconstriction syndrome during a follow-up period. Vessel wall imaging protocol included black-blood contrast-enhanced T1-weighted sequences with fat suppression and a saturation band, and time-of-flight MRA of the circle of Willis. Vessel wall characteristics including enhancement, wall thickening, and lumen narrowing were collected. RESULTS: Thirteen patients with CNS vasculitis and 13 patients with reversible cerebral vasoconstriction syndrome were included. In the CNS vasculitis group, 9 patients showed smooth, concentric wall enhancement and thickening; 3 patients had smooth, eccentric wall enhancement and thickening; and 1 patient was without wall enhancement and thickening. Six of 13 patients had follow-up imaging; 4 patients showed stable smooth, concentric enhancement and thickening; and 2 patients had resoluton of initial imaging findings. In the reversible cerebral vasoconstriction syndrome group, 10 patients showed diffuse, uniform wall thickening with negligible-to-mild enhancement. Nine patients had follow-up imaging, with 8 patients showing complete resolution of the initial findings. CONCLUSIONS: Postgadolinium 3T-high-resolution MR imaging appears to be a feasible tool in differentiating vessel wall patterns of CNS vasculitis and reversible cerebral vasoconstriction syndrome changes during a follow-up period.

Telemedicine in Prehospital Stroke Evaluation and Thrombolysis: Taking Stroke Treatment to the Doorstep

IMPORTANCE Mobile stroke treatment units (MSTUs) with on-site treatment teams that include a vascular neurologist can provide thrombolysis in the prehospital setting faster than treatment in the hospital. These units can be made more resource efficient if the need for an on-site neurologist can be eliminated by relying solely on telemedicine for physician presence. OBJECTIVE To test whether telemedicine is reliable and remote physician presence is adequate for acute stroke treatment using an MSTU. DESIGN, SETTING, AND PARTICIPANTS Prospective observational study conducted between July 18 and November 1, 2014. The dates of the study analysis were November 1, 2014, to March 30, 2015. The setting was a community-based study assessing telemedicine success of the MSTU in Cleveland, Ohio. Participants were the first 100 residents of Cleveland who had an acute onset of stroke-like symptoms between 8 am and 8 pm and were evaluated by the MSTU after the implementation of the MSTU program at the Cleveland Clinic. A vascular neurologist evaluated the first 100 patients via telemedicine, and a neuroradiologist remotely assessed images obtained by mobile computed tomography (CT). Data were entered into the medical record and a prospective registry. MAIN OUTCOMES AND MEASURES The study compared the evaluation and treatment of patients on the MSTU with a control group of patients brought to the emergency department via ambulance during the same year. Process times were measured from the time the patient entered the door of the MSTU or emergency department, and any problems encountered during his or her evaluation were recorded. RESULTS Ninety-nine of 100 patients were evaluated successfully. The median duration of telemedicine evaluation was 20 minutes (interquartile range [IQR], 14-27 minutes). One connection failure was due to crew error, and the patient was transported to the nearest emergency department. There were 6 telemedicine disconnections, none of which lasted longer than 60 seconds or affected clinical care. Times from the door to CT completion (13 minutes [IQR, 9-21 minutes]) and from the door to intravenous thrombolysis (32 minutes [IQR, 24-47 minutes]) were significantly shorter in the MSTU group compared with the control group (18 minutes [IQR, 12-26 minutes] and 58 minutes [IQR, 53-68 minutes], respectively). Times to CT interpretation did not differ significantly between the groups. CONCLUSIONS AND RELEVANCE An MSTU using telemedicine is feasible, with a low rate of technical failure, and may provide an avenue for reducing the high cost of such systems.

A Mobile Stroke Treatment Unit for Field Triage of Patients for Intraarterial Revascularization Therapy.

Favorable outcomes in intraarterial therapy (IAT) for acute ischemic stroke (AIS) are related to early vessel recanalization. The mobile stroke treatment unit (MSTU) is an on‐site, prehospital, treatment team, laboratory, and CT scanner that reduces time to treatment for intravenous thrombolysis and may also shorten time to IAT.

Performance of CT Angiography on a Mobile Stroke Treatment Unit: Implications for Triage.

There is a strong inverse relationship between outcome in patients with acute ischemic stroke from emergent large vessel occlusion (ELVO), and time to reperfusion from intra‐arterial therapy. Delay in transferring patients to thrombectomy‐capable centers is currently a major limitation. The mobile stroke unit (MSU) concept with onboard portable computed tomography (CT) scanner enables rapid performance of CT angiography (CTA) of the intracranial vessels to detect ELVO in the field, and allows for rapid triage of patients to interventional‐capable centers.

Brain Imaging Using Mobile CT: Current Status and Future Prospects

Computed tomography (CT) is an invaluable tool in the diagnosis of many clinical conditions. Several advancements in biomedical engineering have achieved increase in speed, improvements in low‐contrast detectability and image quality, and lower radiation. Portable or mobile CT constituted one such important advancement. It is especially useful in evaluating critically ill, intensive care unit patients by scanning them at bedside. A paradigm shift in utilization of mobile CT was its installation in ambulances for the management of acute stroke. Given the time sensitive nature of acute ischemic stroke, Mobile stroke units (MSU) were developed in Germany consisting of an ambulance equipped with a CT scanner, point of care laboratory system, along with teleradiological support. In a radical reconfiguration of stroke care, the MSU would bring the CT scanner to the stroke patient, without waiting for the patient at the emergency room. Two separate MSU projects in Saarland and Berlin demonstrated the safety and feasibility of this concept for prehospital stroke care, showing increased rate of intravenous thrombolysis and significant reduction in time to treatment compared to conventional care. MSU also improved the triage of patients to appropriate and specialized hospitals. Although multiple issues remain yet unanswered with the MSU concept including clinical outcome and cost‐effectiveness, the MSU venture is visionary and enables delivery of life‐saving and enhancing treatment for ischemic and hemorrhagic stroke. In this review, we discuss the development of mobile CT and its applications, with specific focus on its use in MSUs along with our institutions MSU experience.

Reversible cerebral vasoconstriction syndrome: Is it more than just cerebral vasoconstriction?

Background Systemic vascular alterations have not been described in reversible cerebral vasoconstriction syndrome (RCVS). We present a case series of RCVS patients having cardiac dysfunction during ictus, with a subset showing complete resolution of cardiomyopathy. Methods Retrospective case-series: Cardiac left ventricular ejection fraction (LVEF) and wall motion abnormalities (WMA) visualized on transthoracic echocardiography (TTE), performed during RCVS ictus and follow-up was analyzed. Results Of 68 patients, 18 (26%) had a TTE performed around ictus. Three of 18 (17%) patients demonstrated WMA on initial TTE. All three patients were female without previous coronary artery disease or heart failure, and were asymptomatic from the cardiac dysfunction. WMA resolved completely on follow-up in Patients 1 and 2. Global LV dysfunction persisted for at least 90 days in Patient 3. Conclusion Although the exact pathophysiology of the cardiomyopathy is uncertain, it may be related to localized coronary vasoconstriction causing myocardial ischemia/infarction. Vasoconstriction may not be limited to the cerebral vasculature and may involve extracerebral organs. Cardiac ventricular abnormalities may be a part of the RCVS spectrum.

Reduction in time to treatment in prehospital telemedicine evaluation and thrombolysis

Objective: To compare the times to evaluation and thrombolytic treatment of patients treated with a telemedicine-enabled mobile stroke treatment unit (MSTU) vs those among patients brought to the emergency department (ED) via a traditional ambulance. Methods: We implemented a MSTU with telemedicine at our institution starting July 18, 2014. A vascular neurologist evaluated each patient via telemedicine and a neuroradiologist and vascular neurologist remotely assessed images obtained by the MSTU CT. Data were entered in a prospective registry. The evaluation and treatment of the first 100 MSTU patients (July 18, 2014–November 1, 2014) was compared to a control group of 53 patients brought to the ED via a traditional ambulance in 2014. Times were expressed as medians with their interquartile ranges. Results: Patient and stroke severity characteristics were similar between 100 MSTU and 53 ED control patients (initial NIH Stroke Scale score 6 vs 7, p = 0.679). There was a significant reduction of median alarm-to-CT scan completion times (33 minutes MSTU vs 56 minutes controls, p < 0.0001), median alarm-to-thrombolysis times (55.5 minutes MSTU vs 94 minutes controls, p < 0.0001), median door-to-thrombolysis times (31.5 minutes MSTU vs 58 minutes controls, p = 0.0012), and symptom-onset-to-thrombolysis times (97 minutes MSTU vs 122.5 minutes controls, p = 0.0485). Sixteen patients evaluated on MSTU received thrombolysis, 25% of whom received it within 60 minutes of symptom onset. Conclusion: Compared with the traditional ambulance model, telemedicine-enabled ambulance-based thrombolysis resulted in significantly decreased time to imaging and treatment.

Emergent mechanical thrombectomy for acute stroke using the Mindframe Capture LP system: initial single-center experience.

Background Mechanical thrombectomy using stentrievers is the standard of care for emergent large vessel occlusion stroke. Data on the use of stentrievers in smaller caliber vessels are sparse. Objective To present our initial experience with the Mindframe Capture LP device, which was designed for mechanical thrombectomy in small cerebral arteries. Methods A retrospective chart review was conducted of patients who underwent Mindframe device assisted emergent thrombectomy. Clinical, imaging, procedural and early follow-up data were obtained. Results Nine patients met inclusion criteria (5 men, median age 62 years). Median National Institute of Health Stroke Scale (NIHSS) score was 18 (IQR 9–22), and 6 patients received intravenous tissue plasminogen activator. Six patients had M2 segment occlusions, and 2 patients had distal M1 segment occlusions of the middle cerebral artery. One had distal basilar artery occlusion. Median vessel diameter at the thrombus was 1.7 mm (IQR 1.5–2.5). In all 9 patients the Mindframe device was used together with manual aspiration, with median groin puncture to recanalization time of 35 min (IQR 27–54), and median procedural time of 67 min (IQR 51–91). Final Thrombolysis in Cerebral Infarction score was 3 and 2b in 4 patients each (89% total), and 2a in 1 patient. No patient had any postprocedural complications or symptomatic intracerebral hemorrhage. Median postprocedure and discharge NIHSS were 4 and 1, respectively. Conclusions Our data suggest that the Mindframe device is safe and effective for rapid treatment of acute strokes involving small caliber intracranial vessels. Further study in a larger cohort is warranted.

Flow diverter treatment of intracranial vertebral artery dissecting pseudoaneurysms

Introduction Intracranial vertebral dissecting pseudoaneurysms are a rare, but increasingly recognized, cause of subarachnoid hemorrhage and ischemic stroke. The risks of aneurysm re-rupture and associated morbidity are high. The use of flow diverter stents for the treatment of these aneurysms has not been well studied. Objective To report our data and provide a summarized review of literature using flow diverter stents for the treatment of intracranial vertebral artery dissecting pseudoaneurysms. Methods We performed a retrospective analysis of flow diverter stents used for the treatment of intracranial vertebral artery dissecting pseudoaneurysms. Clinical, imaging, procedural, and follow-up data were collected. Results We identified eight vertebral dissecting pseudoaneurysms in seven patients (5 (71.4%) female; median age 47 years (IQR 46–52)) who had undergone treatment with flow diverter stents. In 4/7 patients (57.1%) the aneurysm had ruptured; however, only one was treated in the acute phase. Median size of the largest diameter of the aneurysm was 6.3 mm (IQR 4.2–8.8), and 7/8 aneurysms (87.5%) were treated with a single flow diverter device. Three aneurysms were concurrently coiled. Angiographic complete occlusion was seen in 6/8 (75%) aneurysms at a median follow-up of 14 months (IQR 7.7–20.2). Two patients had periprocedural strokes with transient neurologic deficits. All patients had a good clinical outcome (modified Rankin Scale score ≤2). There were no re-treatments or aneurysm ruptures during the follow-up period. Conclusions Our experience suggests that flow diverter stent treatment of intracranial vertebral artery dissecting pseudoaneurysms is safe, and associated with good occlusion rates and favorable clinical outcomes.

Predictors of Functional and Quality of Life Outcomes following Deep Brain Stimulation Surgery in Parkinson’s Disease Patients: Disease, Patient, and Surgical Factors

Objective The primary objective was to evaluate predictors of quality of life (QOL) and functional outcomes following deep brain stimulation (DBS) in Parkinsons disease (PD) patients. The secondary objective was to identify predictors of global improvement. Methods PD patients who underwent DBS at our Center from 2006 to 2011 were evaluated by chart review and email/phone survey. Postoperative UPDRS II and EQ-5D were analyzed using simple linear regression adjusting for preoperative score. For global outcomes, we utilized the Patient Global Impression of Change Scale (PGIS) and the Clinician Global Impression of Change Scale (CGIS). Results There were 130 patients in the dataset. Preoperative and postoperative UPDRS II and EQ-5D were available for 45 patients, PGIS for 67 patients, and CGIS for 116 patients. Patients with falls/postural instability had 6-month functional scores and 1-year QOL scores that were significantly worse than patients without falls/postural instability. For every 1-point increase in preoperative UPDRS III and for every 1-unit increase in body mass index (BMI), the 6-month functional scores significantly worsened. Patients with tremors, without dyskinesia, and without gait-freezing were more likely to have “much” or “very much” improved CGIS. Conclusions Presence of postural instability, high BMI, and worse baseline motor scores were the greatest predictors of poorer functional and QOL outcomes after DBS.