Symptomatic Hemorrhage Research Articles

Zabramski classification in predicting the occurrence of symptomatic intracerebral hemorrhage in sporadic cerebral cavernous malformations.

The authors aimed to investigate the evolutionary characteristics of the Zabramski classification of cerebral cavernous malformations (CCMs) and the value of the Zabramski classification in predicting clinical outcome in patients with sporadic CCM. This retrospective study consecutively included cases of sporadic CCM that had been untreated from January 2001 through December 2021. Baseline and follow-up patient information was recorded. The evolution of the Zabramski classification of a sporadic CCM was defined as the initial lesion type changing into another type for the first time on MRI follow-up. The primary outcome was the occurrence of a hemorrhage event, which was defined as a symptomatic event with radiological evidence of overt intracerebral hemorrhage. Among the 255 included cases, 55 (21.6%) were classified as type I CCM, 129 (50.6%) as type II CCM, and 71 (27.8%) as type III CCM, based on initial MRI. During a mean follow-up of 58.8 ± 33.6 months, 51 (20.0%) patients had lesion classification transformation, whereas 204 (80.0%) patients maintained their initial type. Among the 51 transformed lesions, 29 (56.9%) were type I, 11 (21.6%) were type II, and 11 (21.6%) were type III. Based on all follow-up imaging, of the initial 55 type I lesions, 26 (47.3%) remained type I and 27 (49.1%) regressed to type III because of hematoma absorption; 91.5% of type II and 84.5% of type III lesions maintained their initial type during MRI follow-up. The classification change rate of type I lesions was statistically significantly higher than those of type II and III lesions. After a total follow-up of 1157.7 patient-years, new clinical hemorrhage events occurred in 40 (15.7%) patients. The annual cumulative incidence rate for symptomatic hemorrhage in all patients was 3.4 (95% CI 2.5-4.7) per 100 person-years. Kaplan-Meier survival analysis showed that the annual cumulative incidence rate for symptomatic hemorrhage of type I CCM (15.3 per 100 patient-years) was significantly higher than those of type II (0.6 per 100 patient-years) and type III (2.3 per 100 patient-years). This study suggests that the Zabramski classification is helpful in estimating clinical outcome and can assist with surgical decision-making in patients with sporadic CCM.

Cerebral microbleeds and risk of symptomatic hemorrhagic transformation following mechanical thrombectomy for large vessel ischemic stroke.

In patients with acute ischemic stroke (AIS) treated with endovascular therapy (EVT), the association of pre-existing cerebral small vessel disease (cSVD) with symptomatic intracerebral hemorrhage (sICH) remains controversial. We tested the hypothesis that the presence of cerebral microbleeds (CMBs) and their burden would be associated with sICH after EVT of AIS. We conducted a retrospective study combining cohorts of patients that underwent EVT between January 1st 2015 and January 1st 2020. CMB presence, burden, and other cSVD markers were assessed on a pre-treatment MRI, evaluated independently by two observers. Primary outcome was the occurrence of sICH. 445 patients with pretreatment MRI were included, of which 70 (15.7%) demonstrated CMBs on baseline MRI. sICH occurred in 36 (7.6%) of all patients. Univariate analysis did not demonstrate an association between CMB and the occurrence of sICH (7.5% in CMB+ group vs 8.6% in CMB group, p = 0.805). In multivariable models, CMBs' presence was not significantly associated with increased odds for sICH (-aOR- 1.19; 95% CI [0.43-3.27], p = 0.73). Only ASPECTs (aOR 0.71 per point increase; 95% CI [0.60-0.85], p < 0.001) and collaterals status (aOR 0.22 for adequate versus poor collaterals; 95% CI [0.06-0.93], p 0.019) were independently associated with sICH. CMB presence and burden is not associated with increased occurrence of sICH after EVT. This result incites not to exclude patients with CMBs from EVT. The risk of sICH after EVT in patients with more than10 CMBs will require further investigation. Registration-URL: http://www. gov ; Unique identifier: NCT01062698.

Abstract WP177: Hemorrhagic Transformation in the Thrombectomy Era: Clinical Predictors, Subtypes and Symptomatic Outcomes

Background: Hemorrhagic transformation (HT) is the principal adverse event of thrombectomy. Definitions of symptomatic HT developed during the intravenous thrombolysis (IVT) era are outdated in the endovascular thrombectomy (EVT) era but continue to be widely used. Symptomatic intracerebral hemorrhage (sICH) underestimation may result due to failure to categorize: 1) as sICH-causing hemorrhage types common with EVT but not IVT, such as SAH, IVH; and 2) as sICH-qualifying clinical deterioration patterns common with EVT but not IVT, such as moderate worsening after dramatic initial improvement. Methods: Retrospective, blinded, core lab (2 independent imaging readers), single-center analysis of 149 consecutive thrombectomy patients. Clinical characteristics, technical considerations associated with thrombectomy, severity and subtypes of HT (Heidelberg) and clinical outcomes were analyzed. Results: HT was adjudicated present in 70 out of 149 (47.0%) consecutive thrombectomy patients. Radiologic subtypes were: hemorrhagic infarction (HI-1) (51.4%), HI-2 (25.7%), parenchymal hematoma (PH-1) (4.3%), PH-2 (4.3%), subarachnoid hemorrhage (SAH) (34.3%), intraventricular hemorrhage (IVH) (12.8%), and subdural hemorrhage (SDH) (0%). Coexisting subtypes were present in 27.1 % of HT cases. A total of 8 patients had sICH (5.4% of all patients and 11.4% of patients with HT), conservatively defined by a decline in NIHSS of at least 4 points from baseline to 24 hours post thrombectomy. Only 25% of sICH patients were classified as PH-2, while 62.5% had SAH and 12.5% PH-1. Conclusion: Assessment of HT in EVT requires adoption of later-generation, thrombectomy appropriate classification systems. Multiple, co-existing, radiologic subtypes were present in 1 in 4 EVT patients, making single anatomic categorizations infeasible. Symptomatic hemorrhages were due to subarachnoid hemorrhage in more than half and PH-2 in only one-quarter of symptomatic hemorrhages in this EVT series.

Abstract TP12: Changes in Plasma Metabolites Reflect Lesional Iron Content and Permeability Imaging as Monitoring Biomarkers of Hemorrhage in Cavernous Angiomas

Background: Increase in mean lesional iron content (≥6%) measurement by QSM and vascular permeability (≥ 40%) assessed by DCEQP MRI have been associated with new bleeding in cavernous angiomas (CA), and are used as monitoring biomarkers in clinical trial of pharmacotherapy in CAs with symptomatic hemorrhage (SH). Plasma metabolites have been associated with CA in unsupervised discovery, and linked mechanistically to the permissive microbiome and angiogenic and inflammatory mechanisms in CAs. To date, their levels change has not been compared to lesional QSM and DCEQP change during prospective monitoring. Methods: Fifty-nine paired plasma samples and MRI sequences were simultaneously acquired in 46 subjects at beginning and end of 1-year epochs in prospective follow-up of cases with CA enrolled in clinical trial after SH. Plasma levels of 14 metabolites previously associated with CA were assayed by liquid-chromatography mass spectrometry, and their changes were compared to changes in mean lesional QSM and DCEQP during the same epochs. Univariate correlations were followed by multivariate analyses combining multiple metabolites levels to minimize Akaike Information Criterion (AIC) or increase R 2 . Accuracy (AUC on receiver operating curves) and sum of squared error (SSE) are reported for associations achieving statistical significance with FDR correction. Results: Aceltyl.L.carnitine absolute change was correlated with QSM absolute change (p=0.01). Highest accuracy for lesional ΔθΣμ ινχρεασε ≥6% was reported for the absolute change of Arachidonic Acid + LPE.18.0 (AUC 99.7%; SD 0.003; p0.01). Relative change of Arachidonic Acid + Hypoxanthine + Piperine, and absolute change of LPE.18.0 + Pipecolic Acid + Piperine had the highest accuracy (AUC 99.1%; SD 0.008 and 98.0%; 0.013) for lesional DCEQP increase of ≥40%. Relative change in Phenylacetylglutamine and LPE.18.0+Piperine reported the lowest SSE (9.77; 438.33) with respective QSM and DCEQP relative change Conclusion: Changes in circulating metabolites accurately reflect changes in lesional iron content and permeability in CASH during yearly follow-up. Results are a proof of concept that blood tests could replace more complex and costly imaging biomarkers in monitoring CA hemorrhage.

Abstract WMP7: Impact of Telestroke Access in a Rural Setting

Background: Despite decades long adoption as the standard-of-care for ischemic stroke, the majority of eligible patients do not receive intravenous thrombolysis (IVT), with underutilization especially pronounced in rural areas. Telestroke, however, may help alleviate this geographical healthcare disparity. The current study aims to identify the impact of implementing a mature telestroke network within a rural setting. Methods: Retrospective review of a prospectively maintained telestroke database from a large rural tertiary care comprehensive stroke center covering 31 spoke hospitals spanning critical access hospitals to primary stroke centers between 10/2021-02/2023. Data was compared to a previous review period (01/2016-12/2018; comprised of 8 spokes) and the statewide IVT rates recorded in GWTG. Data analysis conducted via descriptive statistics and Fisher’s (two-tailed) exact test. Results: 1801 telestroke consults were performed; 41.4% (746/1801) were ineligible for acute stroke intervention. 39% (410/1055) of eligible patients were treated with IVT (vs. 33% [317/959] previously, p = 0.068), representing 58% (410/708; vs 24% [107/448] previously, p &lt; 0.001) of statewide total IVT administration. Symptomatic hemorrhage (sICH) was 3.0%, overall 30-day mortality was 5.6%, and sICH mortality was 1.0%. IVT deferred most commonly: low NIH (44%), mimics (21%), coagulopathy (8%), followed by other. 22% (396/1801) of total consults were transferred from the originating site (vs. 34% [305/890] previously, p &lt; 0.0001) of which 10% (42/396) underwent EVT. Discussion: The impact of expanding a rural telestroke network continued to produce high IVT rates (nearly double the national average) with safety outcomes (sICH, mortality) at or below national standards. Additionally, a large network has significantly increased the proportion of patients remaining at originating sites, optimizing both tertiary and local centers’ resources. The value of a regional telestroke hub is further underscored by the significant increase in statewide IVT attributed to network consults. However, further strategies are needed to better educate rural providers on acute stroke to reduce the rate of ineligible consults and streamline use of telestroke services.

Abstract TP112: Clinical Consequences of Tenecteplase Substitution for Alteplase at a Large Hub-Spoke Care Model

Introduction: Tenecteplase (TNK) is becoming the preferred thrombolytic for acute brain ischemia. We report a system-wide transition using intentional change management of a hub-spoke delivery model annually providing about 300 intravenous thrombolytic administrations to 3000 stroke alerts from alteplase to TNK. Methods: By 2021, evidence supported transition to TNK from alteplase to treat acute ischemic stroke at 0.25mg/kg (maximum 25mg). We began by gathering opinions from key stakeholders regarding TNK’s clinical merit to gauge support. We subsequently educated constituents including nursing, pharmacy, technical and clinical staff. A six-month lead-in, six-month introductory, and one-year transition period began in April 2021 using an intentional change method. Median door-to-needle (DTN), door-to-puncture (DTP), thrombolytic utilization and symptomatic hemorrhage rates were recorded at five primary (P) and a comprehensive stroke center (C). Results: During lead-in to TNK, DTN were 60(P), 26(C) minutes with 10%(P), 19%(C) utilization. DTP was 73 minutes. Symptomatic hemorrhage occurred in 0.0%(P), 4.9%(C) of alteplase-treated patients. During TNK’s 6-month introductory period DTN were 60(P), 20(C) minutes with 10%(P), 19%(C) utilization. DTP was 71 minutes. Symptomatic hemorrhage occurred in 0.0%(P), 4.9%(C) of TNK patients. During the subsequent one-year transition period, DTN was 53(P) and 23(C) minutes with 8%(P),16%(C) utilization. DTP was 78 minutes. Symptomatic hemorrhage occurred in 1.5%(P) and 3.0%(C). Conclusions: Hub-spoke delivery systems can safely transition to TNK using intentional process change reducing DTN and hemorrhagic complications with stable utilization. Substitution may not reduce DTP if thrombolytic administration is not the rate-limiting step. Intentional process change provides smooth transition when stakeholder education precedes, and pathway adherence follows implementation.

Abstract 41: Conventional vs Advanced Imaging for the Selection of Stroke Therapy in the Extended Window (VESTA Study)

Background: The optimal imaging modality for treatment selection in the extended stroke window is uncertain. VESTA study (NCT05299034) compared conventional imaging (noncontrast CT + CT angiography) with advanced imaging (adding perfusion) in extended window stroke patients, focusing on EVT selection rate, safety and functional outcome. Methods: From the prospective Catalan Stroke Registry (CICAT, 29 centers) ischemic stroke patients within 6-24h of symptom onset and NIHSS ≥6 (Jan 2019 -Dec 2021) were selected. Imaging modality was decided according to the local site protocol. Images were re-evaluated by a central core lab with full access to each patient’s images. LVO was defined as intracranial ICA, M1 or proximal M2 occlusion. Blinded investigators centrally assessed 90-day functional independence, defined as mRS≤2. We employed a propensity score matching algorithm to adjust for age, sex, NIHSS, established infarct, and time from onset to arrival. Results: We included 1405 patients in the analysis (median age 76y, median NIHSS 11; 48% women). Conventional imaging was performed in 48% of patients, while 52% received advanced imaging. Patients receiving conventional vs. advanced imaging showed lower NIHSS (11 vs. 12, p=0.006), and lower rates of LVO (45% vs. 58%, p&lt;0.001) and EVT indication (33% vs. 41%, p=0.01). Demographics and time metrics were comparable between techniques. The matched adjusted analysis showed no differences between modalities in 90-day functional independence (OR=0.9 [0.7;1.2]), mortality (1.18 [0.9;1.6]), or symptomatic hemorrhage (OR=1.35 [0.47;3.8]). The figure displays subgroup analysis for patients arriving at a comprehensive stroke center and for patients with anterior LVO. Conclusions: Advanced imaging allowed the identification of more occlusions and the selection of more patients for EVT; however, patients undergoing either conventional or advanced imaging had similar clinical outcomes at 90 days.

Abstract WP192: Impact of Second Line Thrombectomy Technique Following Failed First Pass Thrombectomy for Anterior Circulation Stroke: To Switch or Not to Switch?

Introduction: Despite comparable outcomes for different frontline techniques in mechanical thrombectomy (MT) for acute ischemic stroke (AIS), there are sparse data regarding if and when to switch techniques if the first pass is unsuccessful. We aimed to investigate the impact of converting from one MT technique to another on the second MT attempt for AIS among patients with large vessel occlusion (LVO). Methods: This was a retrospective observational study using data from the large multicenter international Stroke Thrombectomy and Aneurysm Registry (STAR). Data from 29 stroke centers for 10,229 AIS patients treated with MT for LVO between January 2010 and December 2022 was investigated. The primary outcome measure was successful recanalization defined as modified Thrombolysis in Cerebral Ischemia (mTICI) score of 2b or higher. 90-day modified Rankin score (mRS) 0-2, mortality and symptomatic hemorrhage were used as secondary outcomes. Clinical and technical outcomes after the second MT attempt were compared between those with or without technique conversion. Results: Among 10,229 AIS patients, 1,797 AIS patients with LVO failed first pass recanalization and were included in this retrospective analysis. 927 patients were female (52%) and median (interquartile range) age was 72 (61-81) years. Converting to alternative techniques following a first failed attempt was more likely to be associated with successful recanalization at the second attempt (adjusted odds ratio 2.30, 95% CI: 1.37-3.86, P = 0.002) and 90-day good clinical outcome (adjusted odds ratio 2.10, 95% CI: 1.15-3.85, P = 0.02) after multivariate adjustment. Conclusions: This study demonstrates better clinical and technical outcomes with conversion of MT technique for the second attempt in AIS patients with LVO who failed first pass recanalization.

Abstract WMP102: Risk Factors for MACE and Major Bleeding in Patients With Atrial Fibrillation Undergoing Elective Surgery: Insights From the BRIDGE Randomized Trial

Introduction: Atrial fibrillation (AF) patients undergoing elective procedures are at risk for Major Adverse Cardiovascular Events (MACE) and major bleeding. This study aimed to identify risk factors to guide risk stratification and perioperative management. Methods: We performed a post-hoc analysis of the BRIDGE randomized trial. Patients who were randomized into the study with outcome follow-ups were included in the analysis. The primary outcome was MACE (stroke, myocardial infarction, and cardiovascular death) and clinically symptomatic major bleeding. Statistical techniques included standard univariate analysis, logistic stepwise regression, and Cox regression models with Schoenfeld residual test to validate proportional hazard assumption. Additional interaction analyses were performed to assess interactions between low-molecular-weight heparin bridge therapy with identified risk factors. Results: A total of 1,813 participants met inclusion criteria: mean age 71.6±8.8, 73.3% male. MACE occurred in 25 (1.4%) individuals, with pre-procedure clopidogrel use (adjusted hazard ratio [aHR] 7.73, 95% CI 2.63-22.72, p&lt;0.001) and high CHA 2 DS 2 -VASc score (≥ 5; aHR 2.89, 95% CI 1.26-6.63, p=0.012) identified as risk factors. Major bleeding occurred in 41 (2.3%) individuals, with bridge therapy (aHR 2.53, 95% CI 1.29-4.96, p=0.007), history of renal disease (aHR 3.12, 95% CI 1.56-6.24, p=0.001), post-procedure aspirin use (aHR 3.02, 95% CI 1.61-5.68, p=0.001), post-procedure NSAID use (aHR 3.90, 95% CI 1.20-12.70, p=0.024), and major surgery (aHR 2.17, 95% CI 1.05-4.46, p=0.036) identified as risk factors. The interactions between above risk factors and bridge therapy for MACE and major bleeding outcomes were not significant (p&gt;0.05). Conclusion: The importance of perioperative assessment in AF patients is underscored by our findings, which identify distinct predictors for MACE and major bleeding. Guided by these insights, clinicians may generally avoid bridging and concomitant post-operative aspirin and NSAID use, thereby optimizing perioperative management to minimize the risk of adverse outcomes.

Early and late basilar artery thrombectomy time window outcomes.

Stroke-to-recanalization time is a strong predictor of outcomes in anterior circulation large-vessel occlusion (LVO). The authors aimed to evaluate functional outcomes in early (<6 h) vs. late (6-24 h) time windows for thrombectomy-treated basilar artery occlusions. Patients were derived from the Posterior Circulation Ischemic Stroke Evaluation: Analyzing Radiographic and Intra-procedural Predictors of Mechanical Thrombectomy (PC-SEARCH) Registry and retrospectively analyzed early and late basilar artery thrombectomy time windows cohorts. Patients were dichotomized based on the last known well and correlated to 90-day functional outcomes (mRS 0-3). A multiple logistic regression analysis was performed. A total of 405 patients were included in this study: 216 and 189 patients in the early and late time windows, respectively. Baseline demographic, stroke, radiographic, and intraprocedural characteristics were similar between the groups. A total of 99 (46%) and 79 (42%) patients in the early and late time windows, respectively, achieved favorable functional outcomes at 90 days (p = 0.41), and multiple logistic regression analysis did not reveal differences between cohorts (OR: 0.74; 95% CI: 0.46-1.19; p = 0.22). Symptomatic hemorrhage (7% vs. 5%; p = 0.69) and neurological complications (8% vs. 9%; p = 0.83) were similar between the groups; however, hospital complications were more common in the early time window cohort (22% vs. 13%; p = 0.01). The early and late thrombectomy time windows can achieve similar rates of 90-day favorable functional outcomes. However, timely thrombectomy influences the likelihood of achieving excellent functional outcomes (mRS ≤ 2) within the early time window.

Safety Profile of Intra-Arterial Tirofiban as a Rescue Therapy during Mechanical Thrombectomy in Acute Ischemic Stroke

Abstract Purpose This article studies the safety profile and role of intra-arterial (IA) tirofiban as a rescue therapy in acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy. Methods This is a retrospective observational study conducted among AIS patients with large vessel occlusion (LVO) eligible for endovascular revascularization and in whom IA tirofiban is given as rescue therapy. If the target vessel shows reocclusion following initial recanalization, flow limiting or significant residual stenosis after thrombectomy, or requires balloon angioplasty or stenting, IA tirofiban at a dose of 0.4 μg/kg/min was administered through the microcatheter in the target vessel followed by intravenous infusion of 0.1 μg/kg/min. The primary safety measure of the study was the incidence of symptomatic hemorrhage. Results The total number of patients in the study group was 82, 36 were in the tirofiban group and 46 were in the non-tirofiban group. Immediate successful reperfusion was achieved in 31 patients (86.1%) and 41 patients (89%) in the tirofiban and non-tirofiban groups, respectively. Note that 19.4 and 25% of patients in the tirofiban group required adjunct techniques of angioplasty and stenting, respectively. Also, 2.7% patient in the tirofiban group had a symptomatic hemorrhage, while 8.7% in the non-tirofiban group had symptomatic intracranial hemorrhage. On multinomial logistic regression, history of transient ischemic attack, truncal occlusion and watershed infarct pattern predicted the usage of IA tirofiban during mechanical thrombectomy. Conclusion Usage of IA tirofiban with or without adjunct techniques as a rescue therapy during mechanical thrombectomy in LVO improved recanalization rates without increasing the risk of symptomatic hemorrhage.

Surgical management of Rathke cleft cysts in pediatric patients: a single institution experience

ObjectiveRathke cleft cysts (RCCs) are benign, epithelial-lined sellar lesions that arise from remnants of the craniopharyngeal duct. Due to their rarity in the pediatric population, data are limited regarding the natural history and optimal management of growing or symptomatic RCCs. We present our institutional experience with the surgical management of RCCs.MethodsWe performed a retrospective study of consecutive RCC patients ≤ 18 years old treated surgically at our institution between 2006 and 2022.ResultsOverall, 567 patients with a diagnosis of pituitary mass or cyst were identified. Of these, 31 had a histopathological diagnosis of RCC, 58% female and 42% male. The mean age was 13.2 ± 4.2 years. Presenting symptoms included headache (58%), visual changes (32%), and endocrinopathies or growth delay (26%); 13% were identified incidentally and subsequently demonstrated growth on serial imaging. Six percent presented with symptomatic intralesional hemorrhage. Surgical approach was transsphenoidal for 90% of patients and orbitozygomatic for 10%. Preoperative headaches resolved in 61% of patients and preoperative visual deficits improvement in 55% after surgery. New pituitary axis deficits were seen in 9.7% of patients. Only two complications occurred from a first-time surgery: one cerebrospinal fluid leak requiring lumbar drain placement, and one case of epistaxis requiring cauterization. No patients experienced new visual or neurological deficits. Patients were followed postoperatively with serial imaging at a mean follow-up was 62.9 ± 58.4 months. Recurrence requiring reoperation occurred in 32% of patients. Five-year progression-free survival was 47.9%. Except for one patient with multiple neurological deficits from a concurrent tectal glioma, all patients had a modified Rankin Scale score of 0 or 1 (good outcome) at last follow-up.ConclusionDue to their secretory epithelium, pediatric RCCs may demonstrate rapid growth and can cause symptoms due to local mass effect. Surgical management of symptomatic or growing pediatric RCCs via cyst fenestration or partial resection of the cyst wall can be performed safely, with good neurologic outcomes. There is a nontrivial risk of endocrinologic injury, and long-term follow up is needed due to high recurrence rates.

Single-center outcomes of Onyx Frontier™ and Resolute Onyx™ drug-eluting balloon-mounted stents for rescue stenting for acute large vessel occlusion.

In cases where mechanical thrombectomy (MT) fails, rescue stenting may be necessary to achieve reperfusion; however, the lack of standardized techniques or devices poses a challenge. This series aims to present our early experience with the Onyx Frontier™ and Resolute Onyx™ balloon-mounted drug-eluting stents for rescue stenting. A retrospective chart review was performed of all patients who underwent rescue stenting, in the setting of failed MT, using Onyx Frontier™ or Resolute Onyx™ stents at a single institution. Technical details, procedural complications, and patient outcomes were recorded for each case. Twenty-two Onyx Frontier™ and Resolute Onyx™ stents were deployed in 18 patients undergoing rescue stenting. Stent locations included the middle cerebral artery (36.4%), internal carotid artery (18.2%), vertebral artery (22.7%), and basilar artery (22.7%). The average National Institutes of Health Stroke Scale score before MT was 13.8 (range 0-31). The median initial modified Rankin Scale (mRS) score was zero, while the median mRS score at follow-up was three. Successful reperfusion, as assessed by TICI scores, was achieved in 43.8% of patients for TICI 3, 43.8% for TICI 2C, and 12.5% for TICI 2B. Post-revascularization, 16.7% of patients experienced hemorrhage, of which one patient (5.6%) had symptomatic hemorrhage. Onyx Frontier™ and Resolute Onyx™ stents are well suited for rescue stenting in cases of failed MT. These balloon-mounted drug-eluting stents exhibit excellent navigability, rendering them appropriate for rescue revascularization procedures. Our findings demonstrate that these stents confer a high degree of technical success.

Direct superficial temporal artery access for middle meningeal artery embolization.

Middle meningeal artery embolization has become an important option in the management of subdural hemorrhages with multiple prospective studies demonstrating efficacy and randomized controlled trial data on the way. Access to the middle meningeal artery is usually achieved via the external carotid artery to the internal maxillary artery, then the middle meningeal artery. We report a case where a patient with symptomatic left-sided chronic subdural hemorrhage also had an external carotid artery occlusion. Direct puncture of the superficial temporal artery allowed retrograde access to the internal maxillary artery and thus the middle meningeal artery. Successful embolization of the vessel with 1:9 nBCA was performed with near total resorption of the subdural collection by 1 month postprocedure.

Trial Readiness of Cavernous Malformations With Symptomatic Hemorrhage, Part II: Biomarkers and Trial Modeling.

Quantitative susceptibility mapping (QSM) and dynamic contrast-enhanced quantitative perfusion (DCEQP) magnetic resonance imaging sequences assessing iron deposition and vascular permeability were previously correlated with new hemorrhage in cerebral cavernous malformations. We assessed their prospective changes in a multisite trial-readiness project. Patients with cavernous malformation and symptomatic hemorrhage (SH) in the prior year, without prior or planned lesion resection or irradiation were enrolled. Mean QSM and DCEQP of the SH lesion were acquired at baseline and at 1- and 2-year follow-ups. Sensitivity and specificity of biomarker changes were analyzed in relation to predefined criteria for recurrent SH or asymptomatic change. Sample size calculations for hypothesized therapeutic effects were conducted. We logged 143 QSM and 130 DCEQP paired annual assessments. Annual QSM change was greater in cases with SH than in cases without SH (P=0.019). Annual QSM increase by ≥6% occurred in 7 of 7 cases (100%) with recurrent SH and in 7 of 10 cases (70%) with asymptomatic change during the same epoch and 3.82× more frequently than clinical events. DCEQP change had lower sensitivity for SH and asymptomatic change than QSM change and greater variance. A trial with the smallest sample size would detect a 30% difference in QSM annual change during 2 years of follow-up in 34 or 42 subjects (1 and 2 tailed, respectively); power, 0.8, α=0.05. Assessment of QSM change is feasible and sensitive to recurrent bleeding in cavernous malformations. Evaluation of an intervention on QSM percent change may be used as a time-averaged difference between 2 arms using a repeated measures analysis. DCEQP change is associated with lesser sensitivity and higher variability than QSM. These results are the basis of an application for certification by the US Food and Drug Administration of QSM as a biomarker of drug effect on bleeding in cavernous malformations. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03652181.

A comparison of conscious sedation and local anesthesia for thrombectomy in acute ischemic stroke: a multicenter study.

Ischemic cerebrovascular disease (ICVD) is a serious health problem in which brain tissue suffers from hypoxic damage due to obstruction in cerebral vessels. Mechanical thrombectomy is a commonly used method in the treatment of these patients. However, the effects of local anesthesia (LA) and conscious sedation (CS) during thrombectomy are still unclear. We evaluated whether there was a relationship between the two anesthesia regimens in terms of 90-day modified Rankin Scale (mRS) scores. In this study, a retrospective observational study was conducted to evaluate the effects of LA and CS used during mechanical thrombectomy in four comprehensive stroke centers among ICVD patients. Patients were divided into the LA group and the CS group. Statistical analysis was performed before and after 1:1 matching under propensity score matching (PSM) analysis. The primary outcome measure was an mRS score of 0-2 at 90 days. Secondary outcomes were procedure times, recanalization rates, symptomatic and asymptomatic hemorrhage rates, and procedural complications. A total of 193 patients (118 patients with LA and 75 patients with CS) were included in the final analysis before PSM. After 1:1 PSM, 98 patients-49 patients from each group-were included in the study. There was no difference in clinical outcomes between the LA- and CS-applied groups (p = 0.543). When blood pressure (BP) values at follow-up after endovascular treatment (EVT) were compared, the lowest systolic and lowest diastolic BP were found to be lower in the CS group (p = 0.001 and p = 0.009). There was no significant difference between the two groups in terms of recanalization rates, symptomatic intracranial hemorrhage (sICH) rates, 90-day mRS, and procedure-related complication rates (p = 0.617, p = 0.274, p = 0.543, and p = 1.000). This study did not reveal the superiority of CS applied during EVT on 90-day mRS, sICH, recanalization rates, or procedural complications. However, the risk of developing hypotension during the CS application was found to be high.

Oral Rivaroxaban Versus Warfarin After inferior Vena cava Filter Implantation: A Retrospective Cohort Study.

To assess the efficacy and safety of rivaroxaban compared to warfarin after inferior vena cava (IVC) filter implantation. This retrospective analysis includes data from 100 patients with deep vein thrombosis (DVT) who underwent IVC filter implantation due to a free-floating thrombus (n = 64), thrombus propagation (n = 8), or acute bleeding (n = 8) on therapeutic anticoagulation, catheter-directed thrombolysis (n = 8), or had previously implanted filter with DVT recurrence. Patients were treated with warfarin (n = 41) or rivaroxaban (n = 59) for 3-12 months. Symptomatic venous thromboembolism (VTE) recurrence and bleeding events were assessed at 12 months follow-up. Three (7.3%) cases of VTE recurrence without IVC filter occlusion occurred on warfarin and none on rivaroxaban. The only (2.4%) major bleeding occurred on warfarin. Three (5.1%) clinically relevant non-major bleedings were detected on rivaroxaban. No significant differences existed between groups when full and propensity scores matched datasets were compared. Rivaroxaban seems not less effective and safe than warfarin after IVC filter implantation.

Cerebellar Cavernous Angioma With Symptomatic Hemorrhage Mimicking Different Sequential Peripheral Vestibular Disorders.

Cerebellar Cavernous Angioma With Symptomatic Hemorrhage Mimicking Different Sequential Peripheral Vestibular Disorders.

Effect of General Anesthesia Versus Conscious Sedation/Local Anesthesia on the Outcome of Patients with Minor Stroke and Isolated M2 Occlusion Undergoing Immediate Thrombectomy: A Retrospective Multicenter Matched Analysis

BackgroundThis study investigates the impact of general anesthesia (GA) versus conscious sedation/local anesthesia (CS/LA) on the outcome of patients with minor stroke and isolated M2 occlusion undergoing immediate mechanical thrombectomy (iMT). MethodsThe databases of 16 comprehensive stroke centers were retrospectively screened for consecutive patients with isolated M2 occlusion and a baseline National Institute of Health Stroke Scale score ≤ 5 who received iMT. Propensity score matching (PSM) was used to estimate the effect of GA versus CS/LA on clinical outcome and procedure-related adverse events. Primary outcome measure was a 90-day modified Rankin Scale (mRS) score 0-1. Secondary outcome measures were 90-day mRS score 0-2 and all-cause mortality, successful reperfusion, procedural-related symptomatic subarachnoid hemorrhage (sSAH), intraprocedural dissections and new territory embolism. ResultsOf the 172 patients that were selected, 55 received GA and 117 CS/LA. After PSM, 47 pairs of patients were available for analysis. We found no significant differences in clinical outcome, rates of efficient reperfusion and procedural-related complications between patients receiving GA or LA/CS. (mRS 0-1: p=0.815; mRS 0-2: p=0.401; all-cause mortality: p=0.408; modified Treatment In Cerebral Infarction score 2b-3: p=0.374; sSAH: p=0.082; intraprocedural dissection: p=0.408; new territory embolism: p=0.462) ConclusionsIn patients with minor stroke and isolated M2 occlusion undergoing iMT, the type of anesthesia does not affect clinical outcome or the rate of procedural-related complications. Our results agree with recent data showing no benefit of one specific anesthesiologic procedure over the other and confirm their generalizability also to patients with minor baseline symptoms.

Efficacy and safety of apixaban compared to warfarin for nonvalvular atrial fibrillation in end-stage renal disease on hemodialysis

BackgroundThis study compared the efficacy and safety of apixaban and warfarin in patients with nonvalvular atrial fibrillation (NVAF) and end-stage renal disease (ESRD) on hemodialysis (HD). Apixaban decreased incidence of stroke and bleeding compared with warfarin in major clinical trials that excluded patients with severe renal dysfunction. Apixaban is no longer contraindicated in patients with ESRD on HD with NVAF based on pharmacokinetic studies. Limited clinical data exist for patients with ESRD on HD on apixaban. MethodsA retrospective chart review was performed on patients with a diagnosis of NVAF and ESRD on HD who were prescribed apixaban or warfarin for stroke prevention in the years 2018 through 2019. Patients’ charts were reviewed for up to a 2-year period. Patients on renal replacement therapy other than HD, those using anticoagulation for reasons other than NVAF, patients with Child-Pugh Class C cirrhosis, and those with severe mitral valve stenosis were excluded. The primary outcome was emergency department visits or hospital admissions for ischemic stroke or transient ischemic attack. Secondary outcomes included major or minor bleeding and adverse effects. ResultsA total of 181 patients were screened; 110 patients met eligibility criteria and were included in the analysis. Four patients (7.5%) in the apixaban group and 6 patients (10.5%) in the warfarin group met the primary outcome of hospitalization or emergency department visit for stroke (P = 0.742). Symptomatic bleeding occurred in 39.6% of patients in the apixaban group and 36.8% in the warfarin group (P = 0.918). A trend in major bleeding occurred more often in the warfarin group, 52.4% versus 49.2% (P = 0.758). ConclusionsThere were no statistically significant differences in efficacy and safety outcomes between apixaban and warfarin in patients with NVAF and ESRD on HD in the intention-to-treat analysis of our study. Larger trials are needed to further analyze this patient population.