XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

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

Methods We randomly assigned eligible patients to either intraarterial treatment plus usual care or usual care alone. Eligible patients had a proximal arterial occlusion in the anterior cerebral circulation that was confirmed on vessel imaging and that could be treated intraarterially within 6 hours after symptom onset. The primary outcome was the modified Rankin scale score at 90 days; this categorical scale measures functional outcome, with scores ranging from 0 (no symptoms) to 6 (death). The treatment effect was estimated with ordinal logistic regression as a common odds ratio, adjusted for prespecified prognostic factors. The adjusted common odds ratio measured the likelihood that intraarterial treatment would lead to lower modified Rankin scores, as compared with usual care alone (shift analysis). Results We enrolled 500 patients at 16 medical centers in the Netherlands (233 assigned to intraarterial treatment and 267 to usual care alone). The mean age was 65 years (range, 23 to 96), and 445 patients (89.0%) were treated with intravenous alteplase before randomization. Retrievable stents were used in 190 of the 233 patients (81.5%) assigned to intraarterial treatment. The adjusted common odds ratio was 1.67 (95% confidence interval [CI], 1.21 to 2.30). There was an absolute difference of 13.5 percentage points (95% CI, 5.9 to 21.2) in the rate of functional independence (modified Rankin score, 0 to 2) in favor of the intervention (32.6% vs. 19.1%). There were no significant differences in mortality or the occurrence of symptomatic intracerebral hemorrhage. Conclusions In patients with acute ischemic stroke caused by a proximal intracranial occlusion of the anterior circulation, intraarterial treatment administered within 6 hours after stroke onset was effective and safe. (Funded by the Dutch Heart Foundation and others; MR CLEAN Netherlands Trial Registry number, NTR1804, and Current Controlled Trials number, ISRCTN10888758.)

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A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)00163-X.pdf

Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials

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

Aneurysms are regarded as “complex” when they are challenging to treat using conventional surgical or endovascular approaches. Complexity is typically associated with very large or giant size, dysplastic or fusiform morphology, recurrence after prior surgical or endovascular treatment, and other anatomical features making conventional surgical or endovascular treatment challenging or impossible. Flow-diverting stents may allow a constructive, technically feasible, definitive, and durable treatment option in many of these cases that were previously deemed “complex” or “untreatable” in the past.

Flow-Diverting Stents in the Treatment of Intracranial Aneurysms

While recent major trials have demonstrated the efficacy of thrombectomy for the treatment of emergent large vessel occlusion (ELVO), major technical aspects of the endovascular procedure used to achieve revascularization vary significantly. Balloon-guide catheters (BGCs) were initially brought into use as a means of temporarily arresting antegrade flow to improve the ability of the operator to extract clot from the intracranial vessels. In addition, BGCs limit embolization to new territories (ENT), as during the clot extraction, portions of the thrombus may break off and travel distally, potentially resulting in re-occlusion of the target artery or occlusion of previously unaffected vessels. For proximal internal carotid (and sometimes middle cerebral) artery occlusions, BGCs can serve as a standalone mechanism for thrombectomy when coupled with aspiration. This concept of “remote aspiration,” in which the inflated BGC arrests flow and then direct aspiration of the BGC functions to reverse flow, is a technically straightforward technique, which, when effective, results in prompt and efficient revascularization without the need of and potential risks associated with distal intracranial catheter manipulation.

Thrombectomy Techniques: Remote Aspiration

<h3>Background</h3> The INSIGHT Registry, a multicentered ‘multi-omic’ analysis of thrombi associated with acute hemorrhagic and ischemic stroke is currently enrolling, with over 300 subjects already enrolled. Through this effort, we can evaluate ischemic stroke thrombi in the setting of concurrent medical conditions. While it has been reported that COVID positivity can affect clotting mechanisms, there is a paucity of data on histopathology of stroke clot in this setting. <h3>Aim</h3> Our aim in this analysis was to study the relationship between COVID positivity and clot histopathology in large vessel occlusive stroke. <h3>Methods</h3> Patients, aged ≥18 years, treated frontline with the Penumbra System<sup>®</sup> for thrombectomy are included in this analysis. Patient demographics, medical history, radiographic, and procedural information are collected in conjunction with extracted clot and concurrent extracranial arterial blood. While the protocol includes analysis for proteomics and transcriptomics, for this analysis we used histopathological evaluation of the thrombi. <h3>Results/Conclusion</h3> Of 230 patients included in this interim analysis across 24 centers in the United States, between 02/2021 and 01/2022, 16 patients had a history of COVID. Comparing COVID-positive to non-positive, patients with COVID were younger (median 66.5 years vs 71.5 years, p 0.042), and had more intracranial clot by weight (median 101.0 mg vs 42.0 mg, p 0.047). There was a trend toward COVID positive patients to have more clot volume (median 180 cc vs 77.5 cc p 0.08), suggesting the difference was a higher clot burden instead of more density to the thrombus. These results suggest different histopathological characteristics in clot formation in COVID patients with large vessel occlusive stroke. <h3>Disclosures</h3> <b>J. Fraser:</b> 1; C; University of Kentucky, American Heart Association. 2; C; Stream Biomedical, Penumbra, Medtronic. 4; C; Fawkes Biotechnology, Cerelux. <b>A. Dabney:</b> None. <b>J. Vicari:</b> None. <b>D. Rivet:</b> None. <b>B. Woodward:</b> None. <b>A. Nanda:</b> None. <b>D. Fiorella:</b> None. <b>S. Baltan:</b> None. <b>F. Sohrabji:</b> None. <b>K. Pennypacker:</b> None. <b>C. Kellner:</b> None. 

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E-096 COVID status is related to clot burden during thrombectomy in acute stroke patients

BACKGROUND
Flow diverters carry the risk of thromboembolic complications (TEC). We tested a coating with covalently bound heparin that activates antithrombin to address TEC by locally downregulating the coagulation cascade. We hypothesized that the neuroimaging evidence of TEC would be reduced by the coating.


METHODS
16 dogs were implanted with overlapping flow diverters in the basilar artery, separated into two groups: heparin-coated (n=9) and uncoated (n=7). Following implantation, high-frequency optical coherence tomography (HF-OCT) was acquired to quantify acute thrombus (AT) formation on the flow diverters. MRI was performed postoperatively and repeated at 1, 2, 3, 4, and 8 weeks, consisting of T1-weighted imaging, time-0f-flight (ToF), diffusion weighted imaging (DWI), susceptibility weighted imaging (SWI), and fluid attenuated inversion recovery (FLAIR) sequences. Neurological examinations were performed throughout the 8-week duration of the study.


RESULTS
The mean AT volume on coated devices was lower than uncoated (0.014 vs 0.018 mm3); however, this was not significant (P=0.3). The mean number of foci of magnetic susceptibility artifacts (MSAs) on SWI was significantly different between the uncoated and coated groups at the 1-week follow-up (P<0.02), and remained statistically different throughout the duration of the study. The AT volume showed a direct linear correlation with the MSA count and 80% of the variance in the MSA could be explained by the AT volume (P<0.001). Pathological analysis showed evidence of ischemic injury at locations of MSA.


CONCLUSIONS
Heparin-coated flow diverters significantly reduced the number of new MSAs after 1 week follow-up, showing the potential to reduce TEC.

David Fiorella

Papers

Flow-Diverting Stents in the Treatment of Intracranial Aneurysms

Thrombectomy Techniques: Remote Aspiration

E-096 COVID status is related to clot burden during thrombectomy in acute stroke patients

Active drug-coated flow diverter in a preclinical model of intracranial stenting.