scholarly journals P.100 Endovascular Thrombectomy (EVT) for stroke: experience in a Canadian teaching hospital

2018 ◽  
Vol 45 (s2) ◽  
pp. S42-S42
Author(s):  
S Hu ◽  
K Virani ◽  
S Phillips ◽  
J Shankar
Keyword(s):  
Nova Scotia ◽  
Cerebral Infarction ◽  
Teaching Hospital ◽  
Standard Of Care ◽  
Escape Trial ◽  
Process Measures ◽  
Endovascular Thrombectomy ◽  
Imaging Characteristics

Background: EVT is now recommended as standard of care for stroke in Canada, but its implementation still poses challenges. We studied the delivery of EVT in our hospital, a participanting site in the ESCAPE trial, which serves the province of Nova Scotia. Methods: Patients who underwent EVT December 2011 – December 2016 were identified prospectively. Demographics, process measures, imaging characteristics (Alberta Stroke Program Early CT Score [ASPECTS], collateral score, Thrombolysis in Cerebral Infarction [TICI] score), and outcomes, including modified Rankin score [mRS] ~ 90 days post-EVT, were collected retrospectively. Effectiveness was assessed by comparison with outcomes in the ESCAPE trial. Results: 91 patients (M:F= 48:43; mean age 64 years) presented to hospital after 194 min ± 230 min from last seen normal. In 58%, the ASPECTS was >7. 80% had good/intermediate collaterals. Alteplase was administered to 72% (75% in ESCAPE, p=0.97). EVT mean duration was 70 min ± 62 min. Successful recanalization (≥TICI 2b) was achieved in 76% (vs 72.4% in ESCAPE, p= 0.97). Among the 54 patients recanalized, mRS scores of 0-2, 3-5 and 6 were seen in 57.4, 24.1 and 14.8% respectively; ESCAPE comparators 53, 37 and 10%, p=0.96, 0.86 and 0.91. Conclusions: EVT at our hospital yielded results similar to the ESCAPE trial.

Lessons Learned Over More than 500 Stroke Thrombectomies Using ADAPT With Increasing Aspiration Catheter Size

Neurosurgery ◽  
2018 ◽  
Author(s):  
Ali Alawieh ◽  
A Rano Chatterjee ◽  
Jan Vargas ◽  
M Imran Chaudry ◽  
Jonathan Lena ◽  
...  
Keyword(s):  
South Carolina ◽  
Standard Of Care ◽  
Multivariate Regression Analysis ◽  
Lessons Learned ◽  
Stent Retriever ◽  
Complication Rates ◽  
Procedure Time ◽  
University Of South Carolina ◽  
Endovascular Thrombectomy ◽  
The Impact

Abstract BACKGROUND Endovascular thrombectomy is currently the standard of care for acute ischemic stroke (AIS). Although earlier trials on endovascular thrombectomy were performed using stent retrievers, recently completed the contact aspiration vs stent retriever for successful revascularization (ASTER) and a comparison of direct aspiration versus stent retriever as a first approach (COMPASS) trials have shown the noninferiority of direct aspiration. OBJECTIVE To report the largest experience with ADAPT thrombectomy and compare the impact of advancement in reperfusion catheter technologies on outcomes. METHODS We reviewed a retrospective database of AIS patients who underwent ADAPT thrombectomy between January 2013 and November 2017 at the Medical University of South Carolina. Demographics and baseline characteristics, technical variables, and radiological and clinical outcomes were reviewed. RESULTS Among 510 patients (mean age: 67.7, 50.6% females), successful recanalization at first pass was achieved in 61.8%, and with aspiration only in 77.5%. Mean procedure time was 27.4 min, and the rate of good outcomes (mRS 0-2) at 90 d was 42.9%. The rate of recanalization with aspiration only was significantly higher, and procedure time was significantly lower in patients treated with larger catheters (ACE 064 and ACE 068) compared to smaller catheters (5 MAX and ACE, P < .05). There were no differences in complication rates or postoperative parenchymal hemorrhage across groups (P > .05); however, use of ACE 068 was an independent predictor of good outcomes at 90 d on multivariate regression analysis (odds ratio = 1.6, P < .05). CONCLUSION Refinement of ADAPT thrombectomy by incorporating reperfusion catheters with higher inner diameters and thus higher aspiration forces is associated with better outcomes, shorter procedure times, and lower likelihood of using additional devices without impacting complication rates.

Accurate Placement of Central Venous Catheters Using a 16-cm Catheter

1996 ◽  
Vol 11 (1) ◽  
pp. 19-22 ◽  
Author(s):  
William T. McGee ◽  
Kevin P. Moriarty
Keyword(s):  
Prospective Study ◽  
Teaching Hospital ◽  
Subclavian Vein ◽  
Standard Of Care ◽  
Central Venous Catheters ◽  
Central Venous ◽  
A Prospective Study ◽  
Relationship Of ◽  
Community Teaching ◽  
Central Circulation

We determine if use of 16-cm central venous catheters (CVC) minimizes dangerous intracardiac catheter placements. We conducted a prospective study in a large community teaching hospital. Consecutive patients (n = 127) who required a CVC via either the internal jugular (IJV) or the subclavian vein (SCV) were assessed using 16 (n = 102) or 20-cm (n = 25) catheters. The main outcome measurements were (1) intracardiac placement of central venous catheters, and (2) relationship of right- or left-sided internal jugular or subclavian vein insertions to intracardiac catheter placement. Use of a 20-cm CVC resulted in 14 of 25 (56%) intracardiac placements compared with 11 of 102 (11%) using a 16-cm catheter ( p < 0.0001). All intracardiac placements with the 16-cm CVC were from right-sided approaches: IJV 7 of 38 (16%), SCV 4 of 18 (18%). Use of a 16-cm CVC to access the central circulation from either the SCV or the IJV results in a significantly greater proportion of safe catheter placements than using longer CVCs, and it should become the standard of care.

scholarly journals A multimodality test to guide the management of patients with a pancreatic cyst

2019 ◽  
Vol 11 (501) ◽  
pp. eaav4772 ◽  
Author(s):  
Simeon Springer ◽  
David L. Masica ◽  
Marco Dal Molin ◽  
Christopher Douville ◽  
Christopher J. Thoburn ◽  
...  
Keyword(s):  
Management Practices ◽  
Pancreatic Cyst ◽  
Standard Of Care ◽  
Supervised Machine Learning ◽  
Machine Learning Techniques ◽  
Pancreatic Cysts ◽  
Current Standard ◽  
Imaging Characteristics ◽  
Using Data ◽  
Multimodality Test

Pancreatic cysts are common and often pose a management dilemma, because some cysts are precancerous, whereas others have little risk of developing into invasive cancers. We used supervised machine learning techniques to develop a comprehensive test, CompCyst, to guide the management of patients with pancreatic cysts. The test is based on selected clinical features, imaging characteristics, and cyst fluid genetic and biochemical markers. Using data from 436 patients with pancreatic cysts, we trained CompCyst to classify patients as those who required surgery, those who should be routinely monitored, and those who did not require further surveillance. We then tested CompCyst in an independent cohort of 426 patients, with histopathology used as the gold standard. We found that clinical management informed by the CompCyst test was more accurate than the management dictated by conventional clinical and imaging criteria alone. Application of the CompCyst test would have spared surgery in more than half of the patients who underwent unnecessary resection of their cysts. CompCyst therefore has the potential to reduce the patient morbidity and economic costs associated with current standard-of-care pancreatic cyst management practices.

Onset to Reperfusion Time Was Not Important in Mechanical Thrombectomy for Elderly Patients: A Retrospective Multicenter Study in Tama Area, Tokyo

2018 ◽  
Vol 46 (1-2) ◽  
pp. 89-96 ◽  
Author(s):  
Satoshi Koizumi ◽  
Takahiro Ota ◽  
Keigo Shigeta ◽  
Tatsuo Amano ◽  
Masayuki Ueda ◽  
...  
Keyword(s):  
Elderly Patients ◽  
Scale Score ◽  
Mechanical Thrombectomy ◽  
Treatment Strategies ◽  
Onset Time ◽  
Standard Of Care ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Factors Affecting ◽  
Good Outcome

Background: Mechanical thrombectomy (MT) has become the standard of care for acute ischemic stroke with large vessel occlusion; however, evidence remains insufficient for MT for elderly patients, especially with respect to factors affecting their outcomes. Methods: This study was a retrospective analysis of a multicenter registry of MT, called Tama Registry of Acute Endovascular Thrombectomy. Patients were divided by their age into 2 groups: Nonelderly (NE; < 80) and elderly (E; ≥80). Factors related to a good outcome (modified Rankin scale score ≤2) were examined in each group. Onset to reperfusion time (OTR) was stratified into 4 categories: category 1, 0 – ≤180 min; category 2, > 180 – ≤360 min; category 3, > 360 min or onset time not identified; and category 4, effective recanalization not achievable. Results: 143 NE patients and 78 E patients were included in this study. The E group had less chance of achieving a good outcome (NE group 51%, E group 35%; p = 0.024). In the NE group, lower OTR category was an independent prognostic factor for good outcome (p = 0.037, OR = 1.09). However, in the E group, OTR category was not a significant predictor on multivariate analysis. Instead, effective recanalization (p = 0.0081, OR 1.40) and lower National Institute of Health Stroke Scale score at presentation (p = 0.0032, OR 1.02) were the independent predictors. Conclusions: In MT for elderly patients, effective recanalization improved the patients’ outcome but OTR affected less. Further studies are warranted to establish the appropriate patient selection and treatment strategies.

Abstract TP279: Evaluation of Exclusions for Endovascular Intervention to Identify Clinical Practice Patterns

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Michele Patterson ◽  
Lee Birnbaum ◽  
Deb Motz ◽  
Tracy Moore ◽  
Dicky Huey ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Symptom Onset ◽  
Practice Patterns ◽  
Retrospective Chart Review ◽  
Rapid Improvement ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Clinical Practice Patterns ◽  
Imaging Characteristics ◽  
Elevated Creatinine

Background: Our five-hospital Comprehensive Stroke Program utilizes a standardized large vessel occlusion (LVO) triage that includes NIHSS >10 and last known well <6 hours. When these criteria are met, the ED Physician and Neuro-interventionalist determine endovascular thrombectomy (ET) eligibility. If ET is not performed, standardized exclusion criteria is documented Purpose: To evaluate patterns in exclusions for ET and identify opportunities to expand treatments. Methods: A retrospective chart review of patients who arrived within 6 hours of symptom onset over a 4- month period was conducted. Patients were divided into two groups: those who received ET and those who did not. Documented exclusions were evaluated to identify clinical practice patterns. Results: Of the 52 patients who arrived within 6 hours of symptom onset, 81% (n=42) did not receive ET. Fifty-seven percent (n=24) were excluded due to deficits too mild (NIHSS < 10) and 43% (n=18) had NIHSS > 10 with documented exclusions. Exclusions included 1) Lack of LVO 56% (n=10); 2) Rapid improvement or mild symptoms 6% (n=1); 3) Refusal by the patient/family 11% (n=2); 4) Other reasons documented by the physician 27% (n=4). Other reasons included CTP findings of complete infarct (1), poor collaterals with large clot extension (1), unable to access common carotid occlusion (2). None of the patients were excluded due to elevated creatinine or advanced age. Exclusions were documented by 1) Neuro-interventionalist 72% (n=13;) 2) ED Physician 6% (n=1;) 3) Primary Care 6% (n=1); 4) Radiology CTA report 16% (n=3). Conclusions: The most common reasons for ET exclusion in our cohort are non-modifiable: absence of LVO and unfavorable imaging characteristics. We identified patient/family refusal as a less common exclusion reason but one that may warrant education. Continued data collection is needed to further understand exclusion patterns and improve identification of patients that could benefit from ET.

scholarly journals Update in the Early Management and Reperfusion Strategies of Patients with Acute Ischemic Stroke

2018 ◽  
Vol 2018 ◽  
pp. 1-15 ◽  
Author(s):  
Aldo A. Mendez ◽  
Edgar A. Samaniego ◽  
Sunil A. Sheth ◽  
Sudeepta Dandapat ◽  
David M. Hasan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Time Window ◽  
Prehospital Care ◽  
Standard Of Care ◽  
Ongoing Research ◽  
Early Management ◽  
Endovascular Thrombectomy

Acute ischemic stroke (AIS) remains a leading cause of death and long-term disability. The paradigms on prehospital care, reperfusion therapies, and postreperfusion management of patients with AIS continue to evolve. After the publication of pivotal clinical trials, endovascular thrombectomy has become part of the standard of care in selected cases of AIS since 2015. New stroke guidelines have been recently published, and the time window for mechanical thrombectomy has now been extended up to 24 hours. This review aims to provide a focused up-to-date review for the early management of adult patients with AIS and introduce the new upcoming areas of ongoing research.

Rapid Endovascular Treatment of Acute Ischemic Stroke: What a General Radiologist Should Know

2017 ◽  
Vol 68 (2) ◽  
pp. 154-160 ◽  
Author(s):  
Elizabeth H.Y. Du ◽  
Jai J.S. Shankar
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Standard Of Care ◽  
Stroke Care ◽  
Large Vessel ◽  
Anterior Circulation ◽  
Endovascular Thrombectomy ◽  
Disability Adjusted Life ◽  
Life Years ◽  
Workflow Efficiency

Stroke is the second leading cause of mortality and the third leading cause of disability-adjusted life-years worldwide. For each minute of an ischemic stroke, an estimated 1.9 million brain cells die. The year 2015 saw the unprecedented publication of 5 multicentre, randomized, controlled trials. These studies showed that patients with acute ischemic stroke caused by large-vessel thrombus occlusion of the proximal anterior circulation had significantly reduced disability at 90 days when treated with endovascular thrombectomy and usual stroke care compared to usual stroke care alone. As a result, endovascular thrombectomy is now the new North American and European standard of care for suitable patients with acute ischemic stroke caused by large-vessel proximal anterior circulation occlusion. We review key take-home messages in this paradigm shift for radiologists, including the importance of time and workflow efficiency, what currently constitutes appropriate preimaging patient selection and imaging criteria, the use of newer generation thrombectomy devices, safety outcomes, as well as further areas still in need of elucidation.

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