Neurointerventional Physicians Research Articles

CASSH Registry: Rationale and Study Design

BACKGROUND Carotid artery disease, a major cause of strokes, often results from carotid atherosclerotic stenosis. Although carotid endarterectomy has long been the standard treatment, carotid artery stenting (CAS) emerged as an alternative for high‐risk surgical patients. Operator experience plays a crucial role in reducing complications, with neurointerventional specialists demonstrating proficiency in CAS. However, they are often underrepresented in CAS studies. The CASSH (Carotid Artery Stenting Outcomes in Comprehensive Stroke Hospitals) registry aims to provide comprehensive insights into CAS outcomes, particularly when performed by neurointerventionalists at comprehensive stroke centers. METHODS The CASSH is a multicenter, prospective, observational study currently enrolling patients with carotid artery stenosis undergoing CAS performed by neurointerventional physicians. All the participating sites will screen and report cases that meet inclusion criteria, on a monthly basis. The decision of whether to use CAS is at the discretion of the interventionalist. RESULTS We will collect patients’ baseline clinical, demographic, and radiographic data. In addition, we plan to collect procedure variables and postoperative clinical and imaging data. Outcomes include the rate of postoperative symptomatic stroke (hemorrhagic/ischemic), access site complications, in‐stent thrombosis, and mortality. CONCLUSION Current literature underrepresents neurointerventionalists in CAS studies, especially as it pertains to procedural expertise and outcomes. CASSH is a prospective observational study that will enhance our understanding of CAS management and outcomes, emphasizing the benefits of neurointerventional expertise within comprehensive stroke centers.

Patterns of Care in the Diagnosis and Management of Intracranial Atherosclerosis‐Related Large‐Vessel Occlusion: The Rescue‐LVO Survey

Background We aimed to determine the current practice patterns among neurointerventional practitioners frequently involved in treating intracranial atherosclerosis‐related large‐vessel occlusion (ICAS‐LVO) during mechanical thrombectomy. Methods We conducted an international online survey of neurointerventionalist members of the Society of Vascular and Interventional Neurology and Society of Neurointerventional Surgery. The 28‐question poll evaluated the preferences on diagnosis, treatment, and endovascular approach to ICAS‐LVO. Results A total of 184 individual survey responses were obtained from practicing neurointerventional physicians. Overall, 38.3% reported an incidence of 6% to 10% of ICAS‐LVO during mechanical thrombectomy. Most neurointerventionalists (91%) diagnose ICAS‐LVO after a continued or recurrent occlusion or by the presence of fixed focal stenosis after multiple mechanical thrombectomy attempts. Most respondents (86%) preferred acute treatment of ICAS‐LVO with rescue stenting (RS)±angioplasty. However, in patients who achieved recanalization with a severe fixed focal stenosis, most (58%) recommended primary medical management. The preferred medication during acute RS was intravenous antiplatelet therapy (65%), and after acute RS, it was dual oral antiplatelet therapy (65%). Fear of hemorrhagic complications (74%) was the most compelling reason not to perform RS±angioplasty. Of respondents, 24% were hesitant to randomize patients to acute RS versus medical therapy in a future randomized trial because of the lack of sensitive and specific biomarkers to diagnose ICAS‐LVO before mechanical thrombectomy treatment. Conclusions The findings of this survey highlight the variations in practice in the medical and endovascular management of ICAS‐LVO. In addition, it informs the situation of equipoise in the treatment decision in ICAS‐LVO, which can then be incorporated into the design of future randomized clinical trials.

Abstract 056: Patterns of Care in the Management of Intracranial Atherosclerosis‐related Large Vessel Occlusion–the RESCUE‐LVO survey

Introduction Intracranial atherosclerosis‐related large vessel occlusion (ICAS‐LVO) is a common cause of failed mechanical thrombectomy (MT) in acute ischemic stroke (AIS) [1]. Treatment of ICAS‐LVO with rescue stenting and/or angioplasty has shown promising outcomes, but diagnosing ICAS‐LVO during MT can be challenging [2, 3]. There are uncertainties regarding optimal approaches, techniques, and timing for treating ICAS‐LVO. To understand current practice patterns and address these uncertainties, we conducted a survey among neurointerventional practitioners experienced in ICAS‐LVO management during MT. Methods We conducted an international online survey of neurointerventionalist members of the Society of Neurointerventional Surgery (SNIS) and the Society of Vascular and Interventional Neurology (SVIN). The 28‐question poll evaluated the preferences on diagnosis, treatment, and endovascular approach to ICAS‐LVO. Results 168 individual survey responses were obtained from practicing neurointerventional physicians. Overall, 40.6% reported an incidence of 6–10% of ICAS‐LVO during MT. Most neurointerventionalists (91%) diagnose ICAS‐LVO after a continued or recurrent occlusion or by the presence of fixed focal stenosis (FFS) after multiple MT attempts. Most respondents (86%) preferred acute treatment of ICAS‐LVO with rescue stenting (RS) +/‐ angioplasty. However, in patients who achieved recanalization with a severe FFS, the majority (44%) recommended maximal medical management only. The preferred medication during acute RS was intravenous antiplatelet therapy (69%), and after acute RS was dual oral antiplatelet therapy (58%). Fear of hemorrhagic complications (70%) was the most compelling reason not to perform RS +/‐ angioplasty. Twenty‐five percent of respondents were hesitant to randomize patients to acute RS versus medical therapy in a future randomized trial because of the lack of sensitive and specific biomarkers to diagnose ICAS‐LVO before MT treatment. Conclusion Our survey highlights the significant variability and uncertainty in the diagnosis and management of ICAS‐LVO during MT among neurointerventional practitioners. There is no equipoise regarding the optimal treatment strategy, and the fear of hemorrhagic complications associated with antithrombotic medications contributes to the variation in practice. Our survey underscores the need for future research and randomized clinical trials to address the uncertainties in the management of ICAS‐LVO during MT. Improved imaging biomarkers and consensus guidelines are essential to guide clinical decision‐making and optimize patient outcomes in this challenging population of AIS patients.

Commentary on “Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists versus Neurointerventional Physicians”

The article “Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists versus Neurointerventional Physicians” addresses an important and controversial issue of whether nonneuroscience interventional physicians should be performing stroke thrombectomy ( 1 Sacks D. Dhand S. Hegg R. et al. Outcomes of stroke thrombectomy performed by interventional radiologists versus neurointerventional physicians. J Vasc Interv Radiol. 2022; 33: 619-626 Google Scholar ). There is convincing evidence that stroke thrombectomy improves the clinical outcomes of large vessel occlusion (LVO) anterior circulation strokes and that it is cost effective ( 2 Powers W.J. Rabinstein A.A. Ackerson T. et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019; 50: e344-e418 Crossref PubMed Scopus (1847) Google Scholar , 3 Bulwa Z. Chen M. Stroke center designations, neurointerventionalist demand, and the finances of stroke thrombectomy in the United States. Neurology. 2021; 97: S17-S24 Crossref PubMed Scopus (2) Google Scholar ). This article provides data to support the position that interventional radiology (IR) physicians with additional training can achieve technical and clinical outcomes similar to those obtained by neurointerventional (NI) physicians. We do not take sides in this controversy. The purposes of this commentary are to appraise the current article critically, to examine its potential implications, and to provide an update on the issues of the supply of, demand for, and access to stroke thrombectomy. Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists versus Neurointerventional PhysiciansJournal of Vascular and Interventional RadiologyVol. 33Issue 6PreviewTo test the hypothesis that interventional radiologists (IRs) and neurointerventional (NI) physicians have similar outcomes of endovascular stroke thrombectomy (EVT), which could be used to improve the availability of thrombectomy. Full-Text PDF

Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists versus Neurointerventional Physicians

PurposeTo test the hypothesis that interventional radiologists (IRs) and neurointerventional (NI) physicians have similar outcomes of endovascular stroke thrombectomy (EVT), which could be used to improve the availability of thrombectomy. Materials and MethodsEight hospitals providing EVT performed by IRs and NI physicians at the same institution submitted sequential retrospective data limited to the era of modern devices. Good clinical outcomes (a 90-day modified Rankin score [mRS] of 0–2) and technically successful revascularization (a modified thrombolysis in cerebral infarction score of ≥2b) were compared between the specialties after adjusting for treating hospital, patient age, stroke severity, Alberta stroke program early computed tomography score, time from symptom onset to door, and clot location. Propensity score matching was used to compare the outcomes. A total of 1,009 patients were evaluated (622 treated by IRs and 387 treated by NI physicians). ResultsThe median time from stroke onset to puncture was 245 versus 253 minutes (P = .49), the technically successful revascularization rate was 81.8% versus 82.4% (P = .81), and the good clinical outcome rate was 45.5% versus 50.1% (P = .16). After adjusting, the physician specialty was not a significant predictor of good clinical outcomes (odds ratio, 1.028; 95% confidence interval, 0.760–1.390; P = .86). After matching, an mRS of 0–2 was present in 47.7% of IR treated patients and 51.1% of NI treated patients (P = .366). ConclusionsThere were no significant differences in the successful revascularization rate and good clinical outcomes between IRs and NI physicians. The outcomes of EVT performed by IRs were similar to those of EVT performed by NI physicians, as determined using previously published trials and registries. This may be useful for addressing coverage and access to stroke interventions.

International Survey of Mechanical Thrombectomy Stroke Systems of Care During COVID-19 Pandemic

BackgroundThe COVID-19 pandemic has strained the healthcare systems across the world but its impact on acute stroke care is just being elucidated. We hypothesized a major global impact of COVID-19 not only on stroke volumes but also on various aspects of thrombectomy systems. AimsWe conducted a convenience electronic survey with a 21-item questionnaire aimed to identify the changes in stroke admission volumes and thrombectomy treatment practices seen during a specified time period of the COVID-19 pandemic. MethodsThe survey was designed using Qualtrics software and sent to stroke and neuro-interventional physicians around the world who are part of the Global Executive Committee (GEC) of Mission Thrombectomy 2020, a global coalition under the aegis of Society of Vascular and Interventional Neurology, between April 5th and May 15th, 2020. ResultsThere were 113 responses to the survey across 25 countries with a response rate of 31% among the GEC members. Globally there was a median 33% decrease in stroke admissions and a 25% decrease in mechanical thrombectomy (MT) procedures during the COVID-19 pandemic period until May 15th, 2020 compared to pre-pandemic months. The intubation policy for MT procedures during the pandemic was highly variable across participating centers: 44% preferred intubating all patients, including 25% of centers that changed their policy to preferred-intubation (PI) from preferred non-intubation (PNI). On the other hand, 56% centers preferred not intubating patients undergoing MT, which included 27% centers that changed their policy from PI to PNI. There was no significant difference in rate of COVID-19 infection between PI versus PNI centers (p=0.60) or if intubation policy was changed in either direction (p=1.00). Low-volume (<10 stroke/month) compared with high-volume stroke centers (>20 strokes/month) were less likely to have neurointerventional suite specific written personal protective equipment protocols (74% vs 88%) and if present, these centers were more likely to report them to be inadequate (58% vs 92%). ConclusionOur data provides a comprehensive snapshot of the impact on acute stroke care observed worldwide during the pandemic. Overall, respondents reported decreased stroke admissions as well as decreased cases of MT with no clear preponderance in intubation policy during MT. Data access statementThe corresponding author will consider requests for sharing survey data. The study was exempt from institutional review board approval as it did not involve patient level data.

Abstract P141: Global Impact of Covid-19 Pandemic on Acute Stroke and Mechanical Thrombectomy - An International Survey

Introduction: The COVID-19 pandemic has strained the healthcare systems across the world but its impact on acute stroke care is just being elucidated. We hypothesized a major global impact of COVID-19 not only on stroke volumes but also on thrombectomy practice. Methods: A 19-item questionnaire survey aimed to identify the changes in stroke volumes and treatment practices seen during COVID-19 pandemic was designed using Qualtrics software. It was sent to stroke and neuro-interventional physicians around the world who are part of the executive committee of a global coalition, Mission Thrombectomy 2020 (MT2020) between April 5 th to May 15 th , 2020. Results: There were 113 responses across 25 countries. Globally there was a median 33% decrease in stroke admissions and a 25% decrease in mechanical thrombectomy (MT) procedures during COVID-19 pandemic compared to immediately preceding months (Figure 1A-B). This overall median decrease was despite a median increase in stroke volume in 4 European countries which diverted all stroke patients to only a few selected centers during the pandemic. The intubation policy during the pandemic for patients undergoing MT was highly variable across participating centers: 44% preferred intubating all patients, including 25% centers that changed their policy to preferred-intubation (PI) vs 27% centers that switched to preferred-conscious-sedation (PCS). There was no significant difference in rate of COVID-19 infection between PI vs PCS (p=0.6) or if intubation policy was changed in either direction (p=1). Low-volume (&lt;10 stroke/month) compared with high-volume stroke centers (&gt;20 strokes/month) are less likely to have neurointerventional suite specific written personal protective equipment protocols (74% vs 88%) and if present, these centers are more likely to report them to be inadequate (58% vs 92%). Conclusion: Our data provides a comprehensive snapshot of the impact on acute stroke care observed worldwide during the pandemic.

Prevention and control of COVID-19 in neurointerventional surgery: expert consensus from the Chinese Federation of Interventional and Therapeutic Neuroradiology (CFITN) and the International Society for Neurovascular Disease (ISNVD)

Coronavirus Disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been spreading in many countries, and this coronavirus epidemic has been labeled a world...

A survey of burnout and professional satisfaction among United States neurointerventionalists

BackgroundThe toll of burnout on healthcare is significant and associated with physician depression and medical errors.ObjectiveTo assess the prevalence and risk factors for burnout among neurointerventionalists.MethodsA 39-question online survey containing...

Functional Independence After Stroke Thrombectomy Using Thrombolysis In Cerebral Infarction Grade 2c: A New Aim of Successful Revascularization

Within the Thrombolysis In Cerebral Infarction (TICI) classification, TICI 2b has been historically considered successful recanalization. However, TICI 2b may result in worse functional outcomes compared with TICI 3 or a proposed TICI 2c revascularization grade. The aim of this study was to evaluate differences in functional independence at 90 days between TICI 2b, 2c, and 3 grades. A retrospective review of 185 consecutive patients with anterior cerebral circulation occlusions was performed; 33 patients who were treated >8 hours after onset were excluded. Patient angiograms were graded by 2 experienced neurointerventional physicians. Baseline demographics and functional independence at 90 days were compared. Of 152 patients included in the study, 113 patients achieved TICI grade 2b (n= 37), 2c (n= 34), or 3 (n= 42). A significant difference in functional independence at 90 days was observed between TICI 2b and 2c/3 (P= 0.0008), between 2b and 2c (P= 0.0005), and between 2b and 3 (P= 0.01). There was no significant difference in functional independence between 2c and 3 (P= 0.24). TICI 2c revascularization is associated with significantly improved outcomes compared with TICI 2b revascularization and similar outcomes compared with TICI 3 revascularization. Using a TICI grading system that includes an additional TICI 2c grade or expands the current definition of TICI 3 allows for refined prediction of functional independence. Achieving TICI 2c/3 reperfusion should be considered during stroke thrombectomy.

Current status of training environments in neuro-interventional practice: are animal models still contemporary?

PurposeSeveral different training environments for practicing neurointerventional procedures have been realized in silico, in vitro, and in vivo. We seek to replace animal-based training with suitable alternatives. In an effort...

The burden of neurothrombectomy call: a multicenter prospective study

IntroductionNeurothrombectomy frequency is increasing, and a better understanding of the neurothrombectomy call burden is needed.MethodsNeurointerventional physicians at nine participating stroke centers prospectively recorded time requirements for all neurothrombectomy (NT) consultations...

Abstract 050: Improvements in Door to Groin Puncture Time for Surgical Stroke After Quality Protocol Interventions at the University of California, San Diego

Introduction: Delays in door to groin puncture time (DGPT) for patients with ischemic stroke caused by acute large vessel occlusion (LVO) correlate with worse clinical outcomes. Stroke centers aim to minimize DGPT to facilitate prompt intervention and limit ischemic brain injury. In this study, we present the results of a comprehensive quality assessment at the University of California, San Diego (UCSD). From 2015 to 2016, institutional implementation of a quality improvement protocol significantly reduced DGPT. Materials and Methods: Beginning July 2015, the UCSD interdisciplinary stroke team implemented a series of quality improvement measures to decrease DGPT, with a target of 90 minutes or less. After each case, areas of inefficiency were identified and changes were implemented based on direct feedback from neurointerventional physicians and ancillary staff. Changes included: 1) creation of a pager group notification system to activate the entire neurointerventional team simultaneously, 2) consistently involving anesthesia with each neurointervention, 3) streamlining communication between the vascular neurology and neurointervention teams, and 4) structuring parallel workflows to enhance mobilization speed. R statistical software was utilized to compare DGPT before and after implementation of these process improvements. Patients were divided into three groups based on the date of their intervention as follows: 23 patients treated from July-December 2015, 24 patients treated from January-July 2016, and 14 patients treated from July 2016-December 2016. A multivariable univariate binary logistic regression model was constructed to capture predictors of compliance with our target DGPT (&lt;90 min). Variables analyzed included: date of intervention, mode of patient admission (i.e. transfer, direct admit from ED, inpatient), hospital location, age, and gender. Results: 61 patients underwent mechanical thrombectomy for treatment of acute LVO from July 2015 to December 2016. In our analysis, date of intervention—as a proxy for implementation of process improvement protocols—and mode of admission were predictive of compliance with target DGPT. Patients who were treated from July 2016 to December 2016—after full implementation of process improvements— were 9.5 times more likely to meet or exceed the target DGPT compared to patients treated July 2015 to December 2015 (p=0.01). Additionally, arrival via transfer from an outside hospital was determined to be an independent predictor of meeting DGPT goals. (p=0.02). Conclusion: UCSD’s quality improvement process effected dramatic, statistically significant improvement in DGPT. This analysis demonstrates the utility of a formal quality improvement system at a large, academic comprehensive stroke center.

Periprocedural management of acute ischemic stroke patients undergoing endovascular therapy

The physiologic derangements in acute stroke victims are dynamic. As noted extensively in the literature, there is mounting evidence to support that patients with large strokes, measured clinically through NIH Stroke Scale (NIHSS)1 or by radiologic methods,2 have increased mortality and are severely ill. Endovascular treatment of ischemic strokes inherently imposes a host of physiologic changes. Changes in cerebral perfusion and cerebral autoregulation need adequate hemodynamic support. Unintentionally induced changes during general anesthesia and potential hyperperfusion injury after revascularization may cause adverse outcomes. The loss of blood–brain barrier integrity poses additional challenges to antiplatelet and anticoagulant regimen. The primary goal of critical care management is to cater to the constantly changing cerebral perfusion in the background of loss of cerebral autoregulation. The practice remains varied in the community, administered by intensivists, anesthesiologists, and sometimes neurointerventional physicians. The individual and collective merits and demerits of current practice are unknown and have to be evaluated systematically. Admittedly, there exists no Class Ia evidence, and it is difficult …

Development of an emergency department response to acute stroke (“Code stroke”)

Minimizing delays is a crucial step in improving outcomes with acute stroke therapies whose efficacy is clearly time dependent. Logistic and human barriers to rapid stroke care can be overcome with a systematic "Code Stroke" approach provided by a structured multidisciplinary acute stroke response team. Such teams should include Emergency Medical Services providers, neurologists, neurosurgeons, diagnostic radiologists, nurses, radiology technicians, laboratory personnel, hospital administrators, and emergency medicine, intensive care, and neurointerventional physicians. An acute stroke team improves treatment practices and provides a gratifying experience for patients, families, and referring physicians. On the other hand, maintaining proficiency of the team's operation is time consuming and personally onerous for team responders. Successful maintenance requires strong departmental and institutional commitment.