Background and Purpose—The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audienc...

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Guidelines for the Early Management of Patients With Acute Ischemic Stroke A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines.

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Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

https://www.healthcare.uiowa.edu/familymedicine/fpinfo/Docs/Chest%20Rx%20VTE%20Feb%202016.pdf

Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report

Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

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.

The American Society for Testing and Materials (ASTM) is an independent organization devoted to the development of standards.

American Society for Testing and Materials

accompaNyiNg article DOI: 10.3171/2014.11.JNS141030. iNclude wheN citiNg Published online August 14, 2015; DOI: 10.3171/2015.1.JNS142795. Physicians from several different disciplines currently perform endovascular treatment of cerebral aneurysms, i.e., neurosurgery, radiology, and neurology. Early studies using administrative databases showed that better outcomes could be achieved with endovascular techniques compared with surgical clipping for both ruptured and unruptured aneurysms, and that higher volume centers had better outcomes as compared to lower volume centers.5,8 In 2002, the International Subarachnoid Aneurysm Trial (ISAT) demonstrated the relative benefit of endovascular coil occlusion of ruptured aneurysms compared with surgical clipping.12 Since that time, endovascular treatment has become the preferred approach at most centers throughout the world. Presently, neurosurgeons and radiologists comprise the majority of physicians treating cerebral aneurysms, but neurologists are now training in greater numbers and comprise a growing segment of neurointerventional specialists. Does the training background of the operating physician matter? Fennell et al. suggest that it does.2 Using the University HealthSystem Consortium (UHC) database, the authors examined the rate of complications incurred in the treatment of ruptured and unruptured cerebral aneurysms. These authors suggest that neurosurgeons achieve better clinical outcomes, especially when compared with neurologists, and to a lesser degree, compared with radiologists. These are strong assertions. Like any accusation, it is important to have substantial evidence to support the claim. If the article had meaningful evidence, then it could potentially represent a serious indictment. Unfortunately, the UHC database does not provide conclusive information, and therefore the assertions in this paper are weak. As Fennell et al. dutifully note, specific deficiencies of this study include: 1) the UHC database is self-reporting (i.e., not objective); 2) the UHC database does not readily provide individual patient characteristics or demographics under its current reporting structure; 3) there could be significant differences in patient profiles with potentially disparate impact on outcomes due to patient selection; and 4) differences could also be attributed to the overall cerebrovascular volume of the treating center as well as the treating physician.2 Therefore, it is not possible using the UHC database to know whether a complication occurred before, during, or after treatment. In addition, it is also not possible to compare preoperative morbidity of patients within the 3 physician groups, and this single factor alone could represent an impactful and confounding factor in outcomes and results. Other “potential” conclusions that could just as easily be reached from the data set include the possibility that neurosurgery physicians and hospitals are “underreporting” their true complication rates or that neurology and radiology physicians are treating more difficult and complex patients with aneurysms at centers where open cerebrovascular surgery is not readily available, and that neurosurgeons are simply treating less difficult and less complex cases, and having more complex cases undergo surgical clip placement. Each of these arguments could lead to incorrect assertions, as exemplified by the article by Fennell et al., because the data upon which it is referenced is insufficient to draw a meaningful conclusion. Comorbidities have long confounded studies to assess treatment effect, particularly for ruptured aneurysms. Simply selecting out patients with Hunt and Hess Grade I– III subarachnoid hemorrhage for endovascular treatment, while excluding patients with Hunt and Hess Grades IV and V, will influence good outcomes favoring specialists and hospitals. Nevertheless, all physicians should strive to editorial Discipline and training

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Editorial: Discipline and training.

Preoperative Embolization of Meningiomas

Introduction The Pipeline Embolization Device (PED, eV3 Neurovascular, Irvine, California) has increased the ability of the neurointerventionalist to treat progressively more difficult cerebrovascular pathology. We sought to determine the efficacy of the PED in the treatment of the most recalcitrant of aneurysms, those aneurysms recurring after previous treatments. Materials and methods We retrospectively queried a prospectively maintained endovascular database for previously treated cerebral aneurysms undergoing intervention with the PED from May 2011 to the present time. Twenty-two patients (4 male, 18 female; age range 30–78 yrs, average 59.3 yrs) were treated for 23 aneurysms (average size 11.9 mm, SD 8.5 mm) requiring 29 PED (average 1.3 PED/pt) during the study period. Fourteen patients were originally treated with neuro-interventional procedures (6 coil Embolization, 7 stent assisted coil Embolization, 1 stent only), whereas, eight patients were originally treated with open surgery (7 clipping, 1 wrapping). Of the eight clip recurrences, two patients had an additional neuro-interventional treatment with subsequent recurrence prior to PED use. Average length of follow-up was 8.5 months. Results The overwhelming majority of all patients in our cohorts had their final angiographic outcomes rated as improved (20 Better, 2 Same, 0 Worse) compared to the pre-procedure state. Furthermore, 11 patients had final Raymond scores of 1 and 11 patients had final Raymond scores of 2. There were no final Raymond 3 angiographic results in the series. Those patients who recurred following initial endovascular treatment had better final Raymond scores when compared to the open surgery cohort (9 of 14 Raymond 1 scores versus 2 of 8 Raymond 1 scores). Conclusions In our single center series, PED use for the treatment of recurrent aneurysms is an effective means of treating this difficult subset of patients. We observed that the vast majority of these patients will go on to have excellent angiographic outcomes following PED placement. Further investigations are needed to better elucidate the role of the PED in this cohort. Disclosures M. Park: None. M. Nanaszko: None. M. Sanborn: None. K. Moon: None. C. McDougall: None. F. Albuquerque: None.

E-002 Efficacy of the Pipeline Embolization Device in the Treatment of Previously-treated Aneurysms

We read with interest “Rate and Prognosis of Patients under Conscious Sedation Requiring Emergent Intubation during Neuroendovascular Procedures”[1][1] and appreciate the effort of Hassan et al to address the complicated, controversial issue of conscious sedation versus general anesthesia for

http://www.ajnr.org/content/ajnr/34/7/E83.full.pdf

Regarding "rate and prognosis of patients under conscious sedation requiring emergent intubation during neuroendovascular procedures".

Interventional neurovascular treatment of giant intracranial aneurysms is now being performed in selected cases utilizing detachable balloons, microcoils, and electrolytic detachable coils. Of the 321 cases treated by interventional techniques by our group, 95 (29.6%) were giant aneurysms, > 2.5 cm in diameter. In 74 cases, the aneurysm was on the anterior circulation, and in 21 involved the posterior circulation. The patients presented with mass effect in 81 cases (85.3%), subarachnoid hemorrhage in 11 (11.6%), and thromboemboli in 3 (3.1 %). In 64 cases (67.4%), the aneurysm was treated by parent vessel occlusion, and in 31 (32.6%), direct treatment of the aneurysm with preservation of the parent artery was attained. Complications related to treatment included 11 cases (11.6%) of stroke, transient cerebral ischemia in 6 (6.3%), and 9 deaths (9.5%). Treating giant intracranial aneurysm is technically feasible by interventional techniques. Continued advances in endovascular therapy should expand the indications and decrease associated morbidity.

Cameron G. McDougall

Papers

Editorial: Discipline and training.

Preoperative Embolization of Meningiomas

E-002 Efficacy of the Pipeline Embolization Device in the Treatment of Previously-treated Aneurysms

Regarding "rate and prognosis of patients under conscious sedation requiring emergent intubation during neuroendovascular procedures".

Interventional neurovascular treatment of giant intracranial aneurysms