Showing papers by "J Mocco published in 2022"

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma Using N-Butyl Cyanoacrylate With D5W Push Technique

Abstract: BACKGROUND: Middle meningeal artery (MMA) embolization has been recognized as a promising treatment for patients with subdural hematoma (SDH). OBJECTIVE: To present the technical feasibility and efficacy of n-butyl cyanoacrylate (n-BCA) embolization in the largest consecutive cohort to date. METHODS: We retrospectively reviewed our consecutive cases of recurrent SDH treated with MMA embolization using diluted n-BCA with the “sugar rush” technique. In brief, a 2.1-Fr microcatheter was used to selectively catheterize the frontal and posterior branches of the MMA. 5% dextrose in water (D5W) was injected through an intermediate catheter while injecting n-BCA through the microcatheter. Complete obliteration of MMA and lack of SDH recurrence in a 3–6 months follow-up computed tomography scan were defined as efficacy outcomes. Cranial nerve palsy, vision loss, transient neurological deficit, and stroke were defined as safety outcomes. RESULTS: A total of 61 patients were identified with a mean (±standard deviation) age of 62.5 ± 9 years. In 6 patients (10%), coil embolization of the origin of the frontal or posterior branch was performed because super-selective catheterization of the branch was unsuccessful because of tortuous anatomy. Complete obliteration of frontal and posterior branches was achieved in 100% of the cases. Recurrent SDH was seen in 3 patients (5%). No incidence of cranial nerve palsy, vision loss, or stroke occurred. One patient suffered a transient neurological deficit. CONCLUSION: MMA embolization using diluted n-BCA with concomitant D5W injection is associated with a high degree of distal penetration and complete branch occlusion and minimal risk of cranial nerve palsy or other thromboembolic complications.

Portable stroke detection devices: a systematic scoping review of prehospital applications

Abstract: Abstract Background The worldwide burden of stroke remains high, with increasing time-to-treatment correlated with worse outcomes. Yet stroke subtype determination, most importantly between stroke/non-stroke and ischemic/hemorrhagic stroke, is not confirmed until hospital CT diagnosis, resulting in suboptimal prehospital triage and delayed treatment. In this study, we survey portable, non-invasive diagnostic technologies that could streamline triage by making this initial determination of stroke type, thereby reducing time-to-treatment. Methods Following PRISMA guidelines, we performed a scoping review of portable stroke diagnostic devices. The search was executed in PubMed and Scopus, and all studies testing technology for the detection of stroke or intracranial hemorrhage were eligible for inclusion. Extracted data included type of technology, location, feasibility, time to results, and diagnostic accuracy. Results After a screening of 296 studies, 16 papers were selected for inclusion. Studied devices utilized various types of diagnostic technology, including near-infrared spectroscopy (6), ultrasound (4), electroencephalography (4), microwave technology (1), and volumetric impedance spectroscopy (1). Three devices were tested prior to hospital arrival, 6 were tested in the emergency department, and 7 were tested in unspecified hospital settings. Median measurement time was 3 minutes (IQR: 3 minutes to 5.6 minutes). Several technologies showed high diagnostic accuracy in severe stroke and intracranial hematoma detection. Conclusion Numerous emerging portable technologies have been reported to detect and stratify stroke to potentially improve prehospital triage. However, the majority of these current technologies are still in development and utilize a variety of accuracy metrics, making inter-technology comparisons difficult. Standardizing evaluation of diagnostic accuracy may be helpful in further optimizing portable stroke detection technology for clinical use.

Predictors of early neurologic deterioration (END) following stroke thrombectomy

Abstract: Background Early neurologic deterioration (END) following ischemic stroke is a serious event and is associated with poor outcomes. However, the incidence and predictors of END after stroke thrombectomy for emergent large vessel occlusion are largely unknown. Methods The baseline characteristics of patients enrolled in the COMPASS trial (NCT02466893) were analyzed. The primary outcome was worsening of ≥4 National Institutes of Health Stroke Scale (NIHSS) points 24 hours post thrombectomy (4+ END24) and the secondary outcome was deterioration of ≥2 points (2+ END24). Results Among 270 patients, 27 (10%) developed 4+ END24 and 42 (16%) had 2+ END24. Those with 4+ END24 were older (76.4±12.9 vs 70.9±12.9 years; p=0.04), had a higher prevalence of hypertension (96% vs 69%; p=0.003), diabetes (41% vs 27%; p=0.13) and higher pretreatment systolic blood pressure (SBP) (170.4±32.6 vs 157.6±28.1 mmHg; p=0.03). More 4+ END24 patients had failed reperfusion: Thrombolysis in Cerebral Infarction ≤2a (26% vs 8%; p=0.003). In unadjusted analysis, older patients and those with hypertension, diabetes, elevated SBP and failed reperfusion had higher odds of 4+ END24. In adjusted analysis, age increase by 5 years led to an increase in 4+ END24 of 28%, diabetes increased odds of 2.6 and failed reperfusion increased odds of 4.5. In the multivariable analysis for the secondary outcome, age (OR 1.33; 95% CI 1.109 to 1.593), diabetes (OR 2.7; 95% CI 1.247 to 5.764) and failed reperfusion (OR 7.2; 95% CI 0.055 to 0.349) were also significant predictors of 2+ END24. Conclusions Older patients with acute ischemic stroke who have a history of diabetes or hypertension, with elevated pretreatment SBP and failed reperfusion are at a higher risk of END following stroke thrombectomy for emergent large vessel occlusion.

Long-term functional independence after minimally invasive endoscopic intracerebral hemorrhage evacuation.

Abstract: OBJECTIVE Intracerebral hemorrhage (ICH) is a devastating form of stroke with no proven treatment. However, minimally invasive endoscopic evacuation is a promising potential therapeutic option for ICH. Herein, the authors examine factors associated with long-term functional independence (modified Rankin Scale [mRS] score ≤ 2) in patients with spontaneous ICH who underwent minimally invasive endoscopic evacuation. METHODS Patients with spontaneous supratentorial ICH who had presented to a large urban healthcare system from December 2015 to October 2018 were triaged to a central hospital for minimally invasive endoscopic evacuation. Inclusion criteria for this study included age ≥ 18 years, hematoma volume ≥ 15 ml, National Institutes of Health Stroke Scale (NIHSS) score ≥ 6, premorbid mRS score ≤ 3, and time from ictus ≤ 72 hours. Demographic, clinical, and radiographic factors previously shown to impact functional outcome in ICH were included in a retrospective univariate analysis with patients dichotomized into independent (mRS score ≤ 2) and dependent (mRS score ≥ 3) outcome groups, according to 6-month mRS scores. Factors that reached a threshold of p < 0.05 in a univariate analysis were included in a multivariate logistic regression. RESULTS A total of 90 patients met the study inclusion criteria. The median preoperative hematoma volume was 41 (IQR 27-65) ml and the median postoperative volume was 1.2 (0.3-7.5) ml, resulting in a median evacuation percentage of 97% (85%-99%). The median hospital length of stay was 17 (IQR 9-25) days, and 8 (9%) patients died within 30 days of surgery. Twenty-four (27%) patients had attained functional independence by 6 months. Factors independently associated with long-term functional independence included lower NIHSS score at presentation (OR per point 0.78, 95% CI 0.67-0.91, p = 0.002), lack of intraventricular hemorrhage (IVH; OR 0.20, 95% CI 0.05-0.77, p = 0.02), and shorter time to evacuation (OR per hour 0.95, 95% CI 0.91-0.99, p = 0.007). Specifically, patients who had undergone evacuation within 24 hours of ictus demonstrated an mRS score ≤ 2 rate of 36% and were associated with an increased likelihood of long-term independence (OR 17.7, 95% CI 1.90-164, p = 0.01) as compared to those who had undergone evacuation after 48 hours. CONCLUSIONS In a single-center minimally invasive endoscopic ICH evacuation cohort, NIHSS score on presentation, lack of IVH, and shorter time to evacuation were independently associated with functional independence at 6 months. Factors associated with functional independence may help to better predict populations suitable for minimally invasive endoscopic evacuation and guide protocols for future clinical trials.

Multicenter investigation of technical and clinical outcomes after thrombectomy for distal vessel occlusion by frontline technique

Abstract: Background Endovascular thrombectomy (EVT) is the standard-of-care for proximal large vessel occlusion (LVO) stroke. Data on technical and clinical outcomes in distal vessel occlusions (DVOs) remain limited. Methods This was a retrospective study of patients undergoing EVT for stroke at 32 international centers. Patients were divided into LVOs (internal carotid artery/M1/vertebrobasilar), medium vessel occlusions (M2/A1/P1) and isolated DVOs (M3/M4/A2/A3/P2/P3) and categorized by thrombectomy technique. Primary outcome was a good functional outcome (modified Rankin Scale ≤2) at 90 days. Secondary outcomes included recanalization, procedure-time, thrombectomy attempts, hemorrhage, and mortality. Multivariate logistic regressions were used to evaluate the impact of technical variables. Propensity score matching was used to compare outcome in patients with DVO treated with aspiration versus stent retriever Results We included 7477 patients including 213 DVOs. Distal location did not independently predict good functional outcome at 90 days compared with proximal (p=0.467). In distal occlusions, successful recanalization was an independent predictor of good outcome (adjusted odds ratio (aOR) 5.11, p<0.05) irrespective of technique. Younger age, bridging therapy, and lower admission National Institutes of Health Stroke Scale (NIHSS) were also predictors of good outcome. Procedure time ≤1 hour or ≤3 thrombectomy attempts were independent predictors of good outcomes in DVOs irrespective of technique (aOR 4.5 and 2.3, respectively, p<0.05). There were no differences in outcomes in a DVO matched cohort of aspiration versus stent retriever. Rates of hemorrhage and good outcome showed an exponential relationship to procedural metrics, and were more dependent on time in the aspiration group and attempts in the stent retriever group. Conclusions Outcomes following EVT for DVO are comparable to LVO with similar results between techniques. Techniques may exhibit different futility metrics; stent retriever thrombectomy was influenced by attempts whereas aspiration was more dependent on procedure time.

Stroke thrombectomy volume, rather than stroke center accreditation status of hospitals, is associated with mortality and discharge disposition

Abstract: Background Few studies have explored the association between stroke thrombectomy (ST) volume and hospital accreditation with clinical outcomes. Objective To assess the association of ST case volume and accreditation status with in-hospital mortality and home discharge disposition using the national Medicare Provider Analysis and Review (MEDPAR) database. Methods Rates of hospital mortality, home discharge disposition, and hospital stay were compared between accredited and non-accredited hospitals using 2017–2018 MEDPAR data. The association of annual ST case volume with mortality and home disposition was determined using Pearson’s correlation. Median rate of mortality and number of ST cases at hospitals within the central quartiles were estimated. Results A total of 29 355 cases were performed over 2 years at 847 US centers. Of these, 354 were accredited. There were no significant differences between accredited and non-accredited centers for hospital mortality (14.8% vs 14.5%, p=0.34) and home discharge (12.1% vs 12.0%, p=0.78). A significant positive correlation was observed between thrombectomy volume and home discharge (r=0.88; 95% CI 0.58 to 0.97, p=0.001). A significant negative relationship was found between thrombectomy volume and mortality (r=−0.86; 95% CI −0.97 to −0.49, p=0.002). Within the central quartiles, the median number of ST cases at hospitals with mortality was 24/year, and the median number of ST cases at hospitals with home discharge rate was 23/year. Conclusion A higher volume of ST cases was associated with lower mortality and higher home discharge rate. No significant differences in mortality and discharge disposition were found between accredited and non-accredited hospitals.

Differential Subsampling with Cartesian Ordering–MRA for Classifying Residual Treated Aneurysms

Abstract: BACKGROUND AND PURPOSE: Differential Subsampling with Cartesian Ordering (DISCO), an ultrafast high-spatial-resolution head MRA, has been introduced. We aimed to determine the diagnostic performance of DISCO-MRA in grading residual aneurysm in comparison with TOF-MRA in patients with treated intracranial aneurysms. MATERIALS AND METHODS: Patients with endovascular treatment and having undergone DISCO-MRA, TOF-MRA, and DSA were included for review. The voxel size and acquisition time were 0.75 × 0.75 × 1 mm3/6 seconds for DISCO-MRA and 0.6 × 0.6 × 1 mm3/6 minutes for TOF-MRA. Residual aneurysms were determined using the Modified Raymond-Roy Classification on TOF-MRA and DISCO-MRA by 2 neuroradiologists independently and were compared against DSA as the reference standard. Statistical analysis was performed using the κ statistic and the χ2 test. RESULTS: Sixty-eight treated intracranial aneurysms were included. The intermodality agreement was κ = 0.82 (95% CI, 0.67–0.97) between DISCO and DSA and 0.44 (95% CI, 0.28–0.61) between TOF and DSA. Modified Raymond-Roy Classification scores matched DSA scores in 60/68 cases (88%; χ2 = 144.4, P < .001 for DISCO and 46/68 cases (68%; χ2 = 65.0, P < .001) for TOF. The diagnostic accuracy for the detection of aneurysm remnants was higher for DISCO (0.96; 95% CI, 0.88–0.99) than for TOF (0.79; 95% CI, 0.68–0.88). CONCLUSIONS: In patients with endovascularly treated intracranial aneurysms, DISCO-MRA provides superior diagnostic performance in comparison with TOF-MRA in delineating residual aneurysms in a fraction of the time.

Endovascular Therapy vs Medical Management for Patients With Acute Stroke With Medium Vessel Occlusion in the Anterior Circulation

Abstract: Key Points Question In patients with acute ischemic stroke and primary distal, medium vessel occlusion (DMVO) in anterior circulation, is endovascular therapy (EVT) associated with improved outcomes at 90 days when compared with patients treated with medical therapy alone? Findings In this multicenter cohort study of 286 patients with acute stroke and primary DMVO treated with EVT vs medical therapy alone, no significant difference was found in 90-day functional independence (modified Rankin Scale scores, 0-2), whereas EVT was associated with slightly improved 90-day excellent outcome (modified Rankin Scale scores, 0-1). Meaning These findings suggest that EVT may be beneficial in selected patients with primary DMVO.

Pilot Deployment of Viz–Intracranial Hemorrhage for Intracranial Hemorrhage Detection: Real-World Performance in a Stroke Code Cohort

Abstract: ntracranial hemorrhage (ICH) is associated with a high disease burden and poor outcomes. During the workup of stroke codes, it is essential that ICH is excluded. In this study, we report the real-life performance of Viz ICH, in a prospective consecutive series of stroke code patients. The Figure depicts the main processing steps of the algorithm. and September 2020. The NCCT impressions served as the clinical reference standard test, while Viz ICH served as the index test. Although Viz ICH offers a volumetric segmentation result, in instances where ICH was detected, this output was translated into a qualita-tive, binary (positive or negative) characterization. Exclusion criteria included contrast contamination (eg, if NCCT was performed following CT angiography), nondiagnostic NCCTs (due to motion artifact), and metal artifact. A patient workflow is provided (Figure S1).

Initial Experience With the NICO Myriad Device for Minimally Invasive Endoscopic Evacuation of Intracerebral Hemorrhage

Abstract: BACKGROUND: Intracerebral hemorrhage (ICH) is a devastating form of stroke for which there is no consensus treatment. Although open craniotomy has been explored as a surgical treatment option, multiple minimally invasive (MIS) techniques have been developed including endoscopic evacuation. An adjunctive aspiration device can be used through the working channel to provide an additional degree of freedom and increased functionality regarding clot manipulation and morcellation. OBJECTIVE: To report our single-center technical experience with the Myriad device used as an adjunctive aspiration device during endoscopic ICH evacuation in an exploratory case series. METHODS: Demographic, clinical, and radiographic data were collected on patients who underwent MIS endoscopic ICH evacuation using the Myriad aspiration device from December 2018 to March 2019. RESULTS: Eight patients underwent ICH evacuation with the Myriad aspiration device. Bleeding was confined to the cortex in 4 patients, subcortical region in 2 patients, and the cerebellum in 2 patients. One of the cerebellar cases also underwent suboccipital craniotomy. The mean preoperative hematoma volume was 65.1 ± 68.9 mL, and the median postoperative volume was 7.6 ± 9.0 mL, for an average evacuation percentage of 88.1% ± 12.1%. In 75% of the cases, a bleeding vessel was identified and treated with either cautery or irrigation alone. There was no hemorrhagic recurrence or mortality within 30 days. CONCLUSION: Data from this initial experience suggest that MIS endoscopic ICH evacuation with the NICO Myriad aspiration device is feasible and technically effective. Multicenter exposure is necessary to verify broader applicability.

Intracranial Aneurysm Wall Displacement Predicts Instability

Abstract: Ruptured intracranial aneurysms (IAs) are catastrophic events associated with a high mortality rate. An estimation of 6 million people in the United States have reported IAs, raising a pressing need for diagnostic tools to assess IAs rupture risks. Current population-based guidelines are imperfect, hence the need for new quantifiable variables and imaging markers. Aneurysm wall motion has been identified as a potential marker of high risk aneurysms, but conventional imaging techniques are challenged by small IAs sizes and limited spatial resolution. Recently, amplified Flow (aFlow) has been introduced as an algorithm which allows visualization and quantification of aneurysm wall motion based on amplification of 4D flow MRI data. In this work, we used aFlow to assess IAs wall motion in patients with growing aneurysms. The results were compared with a patient cohort with stable aneurysms. Among 118 patients with unruptured IAs who underwent sequential surveillance imaging, 10 patients with growing IAs who had baseline 3D TOF-MRA and 4D flow MR imaging were identified and matched with another cohort of patients with stable IAs based on IAs size and location. aFlow was then applied to the 4D flow MR data to amplify the aneurysm wall displacement. Voxel-based values of displacement were extracted for each aneurysm and normalized with respect to the reference parent artery. Following histogram analysis, the highest and lowest IAs displacements were calculated, together with their standard deviation and interquartile ranges. A paired-wise analysis was adopted to assess the differences among clinical variables, demographic data, morphological features, and aFlow parameters between patients with stable versus growing aneurysm. Results demonstrated higher wall motion and higher variability of deformation for the growing aneurysms, possibly due to inhomogeneities of the mechanical characteristics of the vessels walls or to underlying hemodynamics. Computational Fluid Dynamic simulation was also conducted for a subset of 6 stable and 6 growing aneurysms to examine the correlation between hemodynamic parameters, wall motion, and aneurysm stability. The magnitude and variance of directional wall shear stress gradient, in addition to area of colocation of elevated oscillatory shear stress and high variance in pressure, were highly correlated with both wall motion and aneurysm stability. We demonstrated here that the measurement and amplification of the aneurysm wall motion achieved with our method has the potential to differentiate stable from growing aneurysms, and potentially act as a substitute for in depth computational fluid dynamic analysis.

Blood pressure management through application-based telehealth platforms: a systematic review and meta-analysis

Abstract: Background and objectives: Hypertension management has several challenges, including poor compliance with medications and patients being lost to follow-up. Recently, remote patient monitoring and telehealth technologies have emerged as promising methods of blood pressure management. We aimed to investigate the role of application-based telehealth programs in optimizing blood pressure management. Methods: Searches were performed in December 2020 using three databases: Cochrane Central Register of Controlled Trials, Embase and Ovid MEDLINE. All randomized controlled trials that included remote blood pressure management programmes were eligible for inclusion. Studies were included if blood pressure data were available for both the intervention and control groups. Following PRISMA guidelines, data were independently collected by two reviewers. Data were pooled using a random-effects model. The primary study outcomes were mean SBP and DBP changes for the intervention and control groups. Results: Eight hundred and seventy-nine distinct articles were identified and 18 satisfied inclusion and exclusion criteria. Overall, a mean weighted decrease of 7.07 points (SBP) and 5.07 points (DBP) was found for the intervention group, compared with 3.11 point (SBP) and 3.13 point (DBP) decreases in the control group. Forest plots were constructed and effect sizes were also calculated. Mean change effect sizes of 1.1 (SBP) and 0.98 (DBP) were found, representing 86 and 85% of the intervention group having greater SBP or DBP changes, respectively, when compared with the control group. Discussion: Remote patient monitoring technologies may represent a promising avenue for hypertension management. Future research is needed to evaluate the benefits in different disease-based patient subgroups.

359 The Cost of Illness of an Aneurysm Rupture: A Prospective Study to Quantity the Unseen Cost of Aneurysmal Subarachnoid Hemorrhage

Abstract: INTRODUCTION: Subarachnoid hemorrhage (SAH) is a devastating neurological event affecting 1/10,000 adults globally with a mortality of more than 30%. SAH is financially straining for both the patient and caretaker due to its high morbidity, prolonged hospital stay, intensive treatments, and involved recovery. In this prospective study, we aim to quantify the total direct and indirect costs of SAH throughout the acute and subacute care periods. METHODS: Patients and their self-reported primary caregivers were prospectively followed for up to a year after the ictus hemorrhagic event, and queried monthly about expenses related to the recovery process. Additional clinical and cost information was obtained from the hospital finance department and directly from patient/caregiver follow-up interviews. RESULTS: Thirty-three patients were enrolled in this prospective study including 28 females (85%) and 5 males (15%) with a median (quartile range) age of 58 (47-66). Thirty-nine designated caregivers were also enrolled. The median ICU and hospital length of stay were 14 (11-19) and 19 (15-23) days, respectively. The median total cost for these patients was $135,568 ($38,082 - $644,688) and the median direct cost was $73,161 ($55,138 - $91,596) with a median expected patient payment of $114,453 ($70,772 -$204,855). The median percentage of direct costs attributed to the ICU was 40% (32-45). Patients with Medicare had smaller ranges of costs. Additionally indirect hospital costs reported were for travel related costs (hotels, ride shares, metro cards), toiletries, home modifications and medications ranging from $0 to $1000 a day. CONCLUSION: SAH is consistently a devastating neurological event affecting active members of society and their social networks. Its complicated course and recovery process can leave patients confined to a hospital for extended periods of time. As providers, we must investigate avenues to mitigate the costs and burdens patients and their support networks face.

Consensus recommendations on therapeutic hypothermia after minimally invasive intracerebral hemorrhage evacuation from the hypothermia for intracerebral hemorrhage (HICH) working group

Abstract: Background and purpose Therapeutic hypothermia (TH), or targeted temperature management (TTM), is a classic treatment option for reducing inflammation and potentially other destructive processes across a wide range of pathologies, and has been successfully used in numerous disease states. The ability for TH to improve neurological outcomes seems promising for inflammatory injuries but has yet to demonstrate clinical benefit in the intracerebral hemorrhage (ICH) patient population. Minimally invasive ICH evacuation also presents a promising option for ICH treatment with strong preclinical data but has yet to demonstrate functional improvement in large randomized trials. The biochemical mechanisms of action of ICH evacuation and TH appear to be synergistic, and thus combining hematoma evacuation with cooling therapy could provide synergistic benefits. The purpose of this working group was to develop consensus recommendations on optimal clinical trial design and outcomes for the use of therapeutic hypothermia in ICH in conjunction with minimally invasive ICH evacuation. Methods An international panel of experts on the intersection of critical-care TH and ICH was convened to analyze available evidence and form a consensus on critical elements of a focal cooling protocol and clinical trial design. Three focused sessions and three full-group meetings were held virtually from December 2020 to February 2021. Each meeting focused on a specific subtopic, allowing for guided, open discussion. Results These recommendations detail key elements of a clinical cooling protocol and an outline for the roll-out of clinical trials to test and validate the use of TH in conjunction with hematoma evacuation as well as late-stage protocols to improve the cooling approach. The combined use of systemic normothermia and localized moderate (33.5°C) hypothermia was identified as the most promising treatment strategy. Conclusions These recommendations provide a general outline for the use of TH after minimally invasive ICH evacuation. More research is needed to further refine the use and combination of these promising treatment paradigms for this patient population.

LB004 Combined results of pre-market and post-market core lab adjudicated evaluation of the nautilus intrasaccular neck cover

Abstract:

Introduction

The Nautilus is a novel, CE-marked, self-conforming intrasaccular neck cover.

Aim of Studies

To combine pre- and post-market core lab adjudicated outcome data in order to assess the probable efficacy of the Nautilus for patients undergoing coil embolization of wide-neck cerebral aneurysms.

Methods

Patients were enrolled in one pre-, or one post-, market approval clinical studies. Core lab adjudicated rate of adequate occlusion, (Raymond Roy grade I/II) after 3-6 months, was collected. Additionally, all device related adverse events were collected.

Results

Thirty-eight patients with ruptured (37%) and unruptured (63%) aneurysms were enrolled. Three ruptured patients passed away in delayed fashion secondary to the course of their disease, in a manner unrelated to the aneurysm treatment itself. Thirty-five patients underwent delayed follow up imaging. Thirty-three (94%) of patients demonstrated core-lab adjudicated successful aneurysm occlusion at follow-up. There were no device-related serious adverse events, and no patients required the use of adjunctive bridging devices or retreatment.

Conclusions

In these pre- and post-market cohorts of ruptured and unruptured aneurysms, the Nautilus appears to be effective in treating wide-neck aneurysms.

Disclosures

J. Mocco: 2; C; EndoStream Medical Ltd. T. Shigematsu: None. N. Sakai: 2; C; EndoStream Medical Ltd. S. Sirakov: None.

Oh, the places we’ll go

Abstract: The first percutaneous coronary angioplasty was performed in September 1977 in Zurich, Switzerland. Less than 10 years later, intraarterial stents were introduced as a viable treatment for coronary artery disease, and by 1994 coronary stenting was an established standard of care for percutaneous coronary intervention. 4 This rapid growth and the resulting lives saved are impressive. However, interventional cardiology has grown into a field much broader and more complex than the opening of clogged arteries. It is now well accepted that an appropriately trained interventional cardiologist can replace leaky cardiac valves, close a patent foramen ovale, seal off atrial appendages, place electric leads to record the heart—or even defibrillate it, and completely alter a heart’s electrophysiological pathways with targeted ablation. The modern interventional cardiologist is not only a plumber, but also an electrician, and a carpenter. Which begs the question ... what job titles might we consider for the future neurointerventionalist? Given the brain and spine’s complexity, neurointervention has the potential to be an exceedingly diverse environment. While much of neurointervention’s foundation is rooted in the advent and growth of aneurysm coil embolization, we have also been pioneers in developing advanced technologies and techniques to treat other vascular lesions, such as arteriovenous malformations and dural arteriovenous fistula. And yes, we have opened clogged pipes as well. In fact, we have identified increasingly expansive patient cohorts that may benefit from thrombectomy, 16 as well as demonstrating that clogged drains (veins) can be opened like arteries. 18 Not bad, not bad at all. But there is so much more to the future of this field. As we became comfortable removing clots from the venous system, we discovered that the robust network of veins can also serve as a route for therapy and a source of pathology. Transvenous access has expanded traditional embolization techniques to facilitate the cure of complex vascular lesions, sometimes with the assistance of cardiologists. We have even seen the venous vasculature be a roadway to biopsy neoplastic lesions. We then realized that the veins are often contributory to patients’ actual pathology. We have now shown that sinus manipulation can alter intracranial pressure, correct intracranial hypotension, improve idiopathic intracranial hypertension symptoms, and cure pulsatile tinnitus. It is likely that the larger venous system may provide the first opportunities for ‘structural brain’ to evolve, akin to the concept of ‘structural heart’. For instance, we have recently seen the advent of transvenous placement of a mechanical biomimetic valve to return cerebrospinal fluid (CSF) drainage to normal and alleviate hydrocephalus. Not surprisingly, larger catheters that can access the intracranial space to support delivery of larger intracranial devices, on the arterial or venous sides, are becoming more common. Furthermore, while the frontier of ‘structural brain’ is just on our horizon, we should not forget that neurointerventionalists are already performing, and advancing, ‘structural spine’. 28 While the reality of a world wherein we can seal CSF leaks, reconstruct sinuses, replace valves (an appropriate term whether referring to arachnoid cysts, or ventriculoperitoneal shunts), and repair the spine is very exciting, we are also entering an era where we can alter disease basic pathophysiology. There are now three ongoing prospective randomized trials evaluating embolization’s exciting potential to halt the pathological cascades that have long made chronic subdurals a challenging disease. Transarterial chemotherapy has become an accepted standard of care for pediatric retinoblastoma treatment, revolutionizing that disease’s care paradigm, and other potential tumor modification efforts are ongoing. We have even begun to explore the value of altering the pathophysiology of chronic headaches through endovascular means. We are also learning about pathology manipulation outside the arteries and veins. For instance, chemotherapeutic treatments have become a mainstay to ablate lymphatic lesions, dramatically altering the course of this disfiguring pathology. Perhaps most futuristic of all, neurointervention is bridging the chasm between mind and machine. The first ever report of the transvascular brain computer interface was published last year. There are already animal studies suggesting that brain stimulation is also possible, using similar transvascular techniques. 32 The entire idea becomes even more fantastical when we realize it may be completed by robots, as the past 2 years have seen an explosion of science and actual in vivo application of robotic neurointervention. It is almost the stuff of science fiction, and yet it is just on the horizon. One could imagine a very near future wherein the neurointerventionalist regularly treats hydrocephalus, neoplasms, chronic pain, and seizures, as well as curing patients of their functional paralysis with motor neuron prostheses. We have made tremendous strides over the past few decades, but I sincerely wonder if the coming decade will quickly out pace our prior achievements and expand our field into areas previously considered unimaginable. At the 1964 World’s Fair in Queens, New York, Walt Disney teamed up with General Electric to create an attraction called ‘Progressland’, which modern Disney World visitors would recognize as the ‘Carousel of Progress’ (yep, they moved it from NYC to California and then to Florida). The Sherman Brothers created a song for the animatronic theatrical show that includes the refrain, ‘There’s a great big beautiful tomorrow, and tomorrow is just a dream away’. I can think of no better jingle to sum up the promise that is neurointerventional surgery.

Multicenter investigation of technical and clinical outcomes after thrombectomy for Proximal Medium Vessel Occlusion (pMeVO) by frontline technique.

Abstract: BACKGROUND Endovascular thrombectomy(EVT) is the standard of care for large vessel occlusion(LVO) stroke. Data on technical and clinical outcome in proximal medium vessel occlusions(pMeVOs) comparing frontline techniques remain limited. METHODS We report an international multicenter retrospective study of patients undergoing EVT for stroke at 32 centers between 2015-2021. Patients were divided into LVOs(ICA/M1/Vertebrobasilar) or pMeVOs(M2/A1/P1) and categorized by thrombectomy technique. Primary outcome was 90-day good functional outcome(mRS ≤ 2). Multivariate logistic regressions were used to evaluate the impact of technical variables on clinical outcomes. Propensity score matching was used to compare outcome in patients with pMeVO treated with aspiration versus stent-retriever. RESULTS In the cohort of 5977 LVO and 1287 pMeVO patients, pMeVO did not independently predict good-outcome(p = 0.55). In pMeVO patients, successful recanalization irrespective of frontline technique(aOR = 3.2,p < 0.05), procedure time ≤ 1-h(aOR = 2.2,p < 0.05), and thrombectomy attempts ≤ 4(aOR = 2.8,p < 0.05) were independent predictors of good-outcomes.In a propensity-matched cohort of aspiration versus stent-retriever pMeVO patients, there was no difference in good-outcomes. The rates of hemorrhage were higher(9%vs.4%,p < 0.01) and procedure time longer(51-min vs. 33-min,p < 0.01) with stent-retriever, while the number of attempts was higher with aspiration(2.5vs.2,p < 0.01). Rates of hemorrhage and good-outcome showed an exponential relationship to procedural metrics, and were more dependent on time in the aspiration group compared to attempts in the stent-retriever group. CONCLUSIONS Clinical outcomes following EVT for pMeVO are comparable to those in LVOs. The golden hour or 3-pass rules in LVO thrombectomy still apply to pMeVO thrombectomy. Different techniques may exhibit different futility metrics; SR thrombectomy was more influenced by attempts whereas aspiration was more dependent on procedure time.

Time trends in the risk of delayed cerebral ischemia after subarachnoid hemorrhage: a meta-analysis of randomized controlled trials.

Abstract: OBJECTIVE Delayed cerebral ischemia (DCI) contributes to morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Continuous improvement in the management of these patients, such as neurocritical care and aneurysm repair, may decrease the prevalence of DCI. In this study, the authors aimed to investigate potential time trends in the prevalence of DCI in clinical studies of DCI within the last 20 years. METHODS PubMed, Embase, and the Cochrane library were searched from 2000 to 2020. Randomized controlled trials that reported clinical (and radiological) DCI in patients with aSAH who were randomized to a control group receiving standard care were included. DCI prevalence was estimated by means of random-effects meta-analysis, and subgroup analyses were performed for the DCI sum score, Fisher grade, clinical grade on admission, and aneurysm treatment method. Time trends were evaluated by meta-regression. RESULTS The search strategy yielded 5931 records, of which 58 randomized controlled trials were included. A total of 4424 patients in the control arm were included. The overall prevalence of DCI was 0.29 (95% CI 0.26-0.32). The event rate for prevalence of DCI among the high-quality studies was 0.30 (95% CI 0.25-0.34) and did not decrease over time (0.25% decline per year; 95% CI -2.49% to 1.99%, p = 0.819). DCI prevalence was higher in studies that included only higher clinical or Fisher grades, and in studies that included only clipping as the treatment modality. CONCLUSIONS Overall DCI prevalence in patients with aSAH was 0.29 (95% CI 0.26-0.32) and did not decrease over time in the control groups of the included randomized controlled trials.

Intraoperative imaging reveals spot sign with surgical correlate during early endoscopic ICH evacuation.

Abstract: Intracerebral hemorrhage (ICH) is the most devastating form of stroke. Intraoperative imaging and management of intracavity bleeding during early endoscopic ICH evacuation may mitigate rebleeding, hematoma expansion, and neurological worsening. Here we document a case of intraoperative spot sign, detected in the angio suite using cone beam CT with contrast protocol, in a patient with spontaneous supratentorial ICH undergoing evacuation 13 hours after last known well. The spot sign was detected after endoscopic evaluation of the evacuated hematoma cavity demonstrated sufficient hemostasis, but before completion of the case and skin closure, prompting second-pass hematoma evacuation as well as identification and cauterization of the specific correlating bleeding vessel, resulting in near-complete evacuation of the hematoma. Spot sign detection on intraoperative cone beam CT followed by endoscopic ICH evacuation may provide an opportunity to specifically target and treat active bleeding and mitigate impending expansion and neurologic worsening, especially in high-risk patients, including those undergoing early ICH evacuation.

E-265 Thrombosis of two or more venous sinuses in cerebral venous thrombosis

Abstract:

Introduction

Cerebral venous thrombosis (CVT) is commonly treated through antithrombotic therapy, in addition to drugs targeting associated symptoms (such as seizure or papilledema). In medically refractory cases, though rarely required, mechanical thrombectomy (MT) may be employed. Here, we describe associations among the extent of thrombosis, geographical location of the thrombosis, and an outcome of complete recanalization in a CVT cohort treated with MT.

Methods

CVT cases treated with MT between June 2016 and August 2021 were pulled from our neuroendovascular database. 30 cases were selected for detailed review.

Results

Of the 30 patients in our cohort, 26 (86.7%) were found to have extensive venous thrombosis within two or more sinuses. In particular, CVT cases involving the transverse sinus (26/30) were significantly more likely to be concurrent with thrombosis in another venous sinus (25/26, p<0.01). CVT cases involving the sigmoid sinus (18/30) showed a similar, but stronger association with thrombosis in more than two sinuses (18/18, p<0.01). In addition to this general association, we found that 100% of all sigmoid sinus thrombosis cases also demonstrated thrombosis of the transverse sinus (p<0.01). Complete recanalization, which occurred in 13/30 cases overall, was found to negatively associate with the presence of thrombosis in two or more sinuses (p<0.01). Indeed, 17/26 (65.4%) cases with thrombosis in more than two sinuses failed to achieve complete recanalization. Interestingly, no association was found between complete recanalization and either transverse sinus thrombosis or sigmoid sinus thrombosis alone.

Conclusion

Thrombosis in more than two sinuses shows a strong correlation with thrombosis of the transverse sinus and thrombosis in the sigmoid sinus. Moreover, concurrent thrombosis in these sinuses shows a strong correlation within our cohort of medically refractory CVT cases. Finally, thrombosis in two or more sinuses was highly predictive of complete recanalization failure as an outcome.

Disclosures

M. Bazil: None. J. Scaggiante: None. J. Mocco: None. C. Kellner: None.

Updated New York City Emergency Medical Services Acute Stroke Triage Protocol Reduces Interfacility Transfers and Time to Endovascular Thrombectomy for Emergent Large Vessel Occlusion Stroke Patients

Abstract: Jacob R. Morey, Brian D. Kim, Michael Redlener, Xiangnan Zhang, Naoum Fares Marayati, Stavros Matsoukas, Emily Fiano, Laura K. Stein, J Mocco, Johanna T. Fifi Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA

Machine Learning–Based Identification of Target Groups for Thrombectomy in Acute Stroke

Abstract: Whether endovascular thrombectomy (EVT) improves functional outcome in patients with large-vessel occlusion (LVO) stroke that do not comply with inclusion criteria of randomized controlled trials (RCTs) but that are considered for EVT in clinical practice is uncertain. We aimed to systematically identify patients with LVO stroke underrepresented in RCTs who might benefit from EVT. Following the premises that (i) patients without reperfusion after EVT represent a non-treated control group and (ii) the level of reperfusion affects outcome in patients with benefit from EVT but not in patients without treatment benefit, we systematically assessed the importance of reperfusion level on functional outcome prediction using machine learning in patients with LVO stroke treated with EVT in clinical practice (N = 5235, German-Stroke-Registry) and in patients treated with EVT or best medical management from RCTs (N = 1488, Virtual-International-Stroke-Trials-Archive). The importance of reperfusion level on outcome prediction in an RCT-like real-world cohort equaled the importance of EVT treatment allocation for outcome prediction in RCT data and was higher compared to an unselected real-world population. The importance of reperfusion level was magnified in patient groups underrepresented in RCTs, including patients with lower NIHSS scores (0-10), M2 occlusions, and lower ASPECTS (0-5 and 6-8). Reperfusion level was equally important in patients with vertebrobasilar as with anterior LVO stroke. The importance of reperfusion level for outcome prediction identifies patient target groups who likely benefit from EVT, including vertebrobasilar stroke patients and among patients underrepresented in RCT patients with low NIHSS scores, low ASPECTS, and M2 occlusions.

E-100 New or developing intracranial hemorrhage after mechanical thrombectomy

Abstract:

Introduction

Mechanical thrombectomy (MT) serves as an alternative measure to medically refractory cases of cerebral venous thrombosis (CVT). Here we describe new or increased intracerebral hemorrhage (ICH) as a periprocedural complication to MT for CVT and its correlative factors.

Methods

A retrospective review of all CVT cases treated with venous thrombectomy between June 2016 and August 2021 was performed within our institutional, neuroendovascular database.

Results

Peri-procedural new or increased ICH was identified in 8/30 (26.7%) of patients overall. In all of these patients, new or increased ICH was identified post-MT. Presence of stupor or coma was identified in 10/30 (33.3%) of patients. Among these, 5/10 (50%) experienced new or increased ICH. Partial recanalization after MT occurred in 13/30 (43.3%) of patients. Among these, 6/13 (46.1%) experienced new or increased ICH. Among the 17 who did not achieve partial recanalization (13 with complete and 4 with none), 15/17 (88.2%) did not experience new or increased ICH (p<0.01). Internal jugular (IJ) sinus occlusion was identified in 9/30 (30%) of our CVT cohort. A strong negative correlation was identified between IJ thrombosis and development of new or increased ICH (0/9, p<0.01).

Conclusion

Periprocedural new or increased ICH showed a strong positive correlation with presence of stupor/coma, partial recanalization, and a negative correlation with IJ thrombosis. The association with partial recanalization will be incorporated in future studies with a larger cohort to determine if incomplete MT may be predictive of other outcomes as well.

Disclosures

J. Scaggiante: None. M. Bazil: None. J. Mocco: None. C. Kellner: None.