Education Research: Challenges Faced by Neurology Trainees in a Neuro-Intervention Career Track

ObjectiveThe widespread adoption of endovascular therapy (EVT) for emergent large vessel occlusion has led to increased nationwide demand for neurointerventionalists, heightened interest among neurology residents to pursue neurointervention as a career, and increased importance of neurointervention exposure for all neurologists who care for patients with acute ischemic stroke. Exposure to neurointervention and its career path are not well-defined for neurology trainees.MethodsThe Society for Vascular and Interventional Neurology (SVIN) Education Committee conducted a multicenter electronic survey directed towards neurology residents and vascular neurology (VN), neurocritical care (NCC), and neurointervention fellows in June 2018. A total of 250 programs were invited to participate; 76 trainees completed the survey.ResultsRespondents self-identified as 22% postgraduate year (PGY)2, 40% PGY3/4, 30% VN fellows, and 8% neurointervention or NCC fellows. Eighty-seven percent of trainees had more than 2 months exposure to VN during residency, 41% to NCC, and only 3% to neurointervention. Sixty-eight percent of respondents had no exposure to neurointervention during residency. Whereas 72% believed that a background in neurology was good preparation for neurointervention, only 41% agreed that fellowship training pathway in neurointervention is well-structured for neurology residents when compared to other subspecialties.ConclusionIn this survey, respondents identified lack of exposure to neurointervention and a well-defined training pathway as obstacles towards pursuing neurointervention as a career. These obstacles must be addressed for the continued development of neurointervention as a subspecialty of neurology.

Download Full-text

Abstract 3314: The Role of Bridging with Intravenous Thrombolysis in Endovascular Therapy of Acute Ischemic Stroke.

Stroke ◽

10.1161/str.43.suppl_1.a3314 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Omar Kass-Hout ◽

Tareq Kass-Hout ◽

Maxim Mokin ◽

David Orion ◽

Shadi Jahshan ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Combined Therapy ◽

Large Vessel ◽

P Value ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Nihss Score

Background: Large vessel occlusions with a high clot burden are less likely to improve with the FDA-approved IV strategy. Endovascular therapy within the first 3 h of stroke symptom onset provides an effective alternative treatment in patients with large vessel occlusion. It is not clear if combination of IV thrombolysis and endovascular approach is superior to endovascular treatment alone. Methods: We retrospectively reviewed all cases of acute ischemic stroke with large vessel occlusion treated within the first 3 h stroke onset during the 2005-2010 period. First group received endovascular therapy within the first 3 h of stroke onset. Second group consisted of patients who received IV thrombolysis within the first 3 h followed by endovascular therapy. We compared the following outcomes: revascularization rates, NIHSS score at discharge, mRS at discharge and 3months, symptomatic hemorrhage rates and mortality. Results: Among 104 patients identified, 42 received combined therapy, and 62 received endovascular therapy only. The two groups had similar demographic (age and sex distribution) and vascular risk factors distribution, as well as NIHSS score on admission (14.8±4.7 and 16.0±5.3; p=0.23). We found no difference in TIMI recanalization rates (Thrombolysis in Myocardial Infarction scale score of 2 or 3) following combined or endovascular therapy alone (83.3% and 79.0%; p=0.59). A preferred outcome, defined as a mRS of 2 or less at 90 days also did not differ between the combined therapy group and the endovascular only group (37.5% and 34.5%; p=0.76). There was no difference in mortality rate (22.5% and 31.0%; p=0.36) and the rate of symptomatic intracranial hemorrhage (9.5% and 8.1%; p=0.73). There was a significant difference in mean time from symptom onset to endovascular treatment between the combined group (227±88 min) and endovascular only group (125±40 min; p<0.0001).Patients with good TIMI recanalization rate of 2 or 3 showed a trend of having a better mRS at 90 days in both bridging (16.67% vs. 41.18%, p-value: 0.3813) and endovascular groups (25% vs. 34.78%, p-value: 0.7326).When analyzing the correlation of mRS at 90 days with the site of occlusion, patients in the bridging group showed a trend of a better outcome when the site of occlusion was ICA (33.3% vs 30%) and MCA (66.67% vs. 27.59%) and worse outcome when the site of occlusion was in the posterior circulation (26.32% vs. 50%), however, these results were not statistically significant (p-values: 0.1735& 0.5366). Conclusion: Combining IV thrombolysis and endovascular therapy achieves similar rates of clinical outcomes, revascularization rates, complications and mortality rates, when compared with endovascular treatment alone. The combined therapy, however, significantly delays initiation of endovascular treatment. A randomized prospective trial comparing both treatment strategies in acute ischemic stroke is warranted

Download Full-text

Abstract 3183: Prognosis of Mild Ischemic Stroke with Large Vessel Occlusion

Stroke ◽

10.1161/str.43.suppl_1.a3183 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Esteban Cheng-Ching ◽

Russell Cerejo ◽

Ken Uchino ◽

Muhammad S Hussain ◽

Gabor Toth

Keyword(s):

Ischemic Stroke ◽

Endovascular Therapy ◽

Time Window ◽

Optimal Treatment ◽

Large Vessel ◽

Stroke Severity ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Nihss Score ◽

Mild Stroke

Background and purpose Large vessel occlusion (LVO) in acute ischemic stroke has been reported to be an independent predictor of unfavorable clinical outcome. However, the prognosis and optimal treatment of patients with only mild neurologic deficits due to LVO are not known. Methods We performed a retrospective chart review from a database of stroke patients admitted to our large academic medical center between July 1, 2010 and June 30 , 2011. Inclusion criteria were acute stroke or TIA, presentation within 9 hours from symptom onset, large vessel occlusion as a culprit of ischemic symptoms, and mild stroke severity with initial NIH Stroke Scale (NIHSS) score <8. Results We identified 59 patients with mild ischemic stroke or TIA, who were evaluated within 9 hours from onset. Of these, 13 (22%) had culprit large vessel occlusions. Five were female, 1 had diabetes, 12 had hypertension, 7 had hyperlipidemia, 2 had atrial fibrillation and 7 were smokers. The median NIHSS score was 5. The location of arterial occlusions were 5 in M1 segment of the middle cerebral artery (MCA), 6 in M2 segment of MCA, 1 each in posterior cerebral and vertebral arteries. Two patients received acute therapy, 1 with intravenous thrombolysis and 1 with endovascular therapy. Reasons for withholding thrombolytic therapy were time window in 8, mild stroke severity in 2, and atypical presentations in 2. Reasons for withholding acute endovascular therapy were mild stroke severity in 7, imaging finding in 2, technical considerations in 2, and lack of consent in 1. From hospital admission to discharge, 10 (77%) patients had symptom improvement, 2 had worsening, and one was unchanged. At 30 days, 5 (38%) had good outcome with a modified Rankin Scale (mRS) of 0-1. Three (23%) had mRS of 2, one (8%) patient had mRS of 3. Outcomes for 4 patients were unknown. Conclusions A significant proportion of patients presenting with mild ischemic symptoms has large vessel occlusion. Acute treatment in this population is frequently withheld due to mild severity or thrombolytic time window. Despite mild symptoms at presentation, some patients are left with moderate disability. Optimal treatment options for this population should be further evaluated in a larger group of patients.

Download Full-text

Abstract TP43: Is Unintended Hypothermia After Endovascular Therapy Associated With Improved Functional Outcome of Patients With Acute Ischemic Stroke?

Stroke ◽

10.1161/str.51.suppl_1.tp43 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Christian Hartmann ◽

Simon Winzer ◽

Timo Siepmann ◽

Lars-Peder Pallesen ◽

Alexandra Prakapenia ◽

...

Keyword(s):

Ischemic Stroke ◽

Venous Thromboembolism ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Endovascular Therapy ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Good Outcome ◽

Risk Ratios

Introduction: Hypothermia may be neuroprotective in acute ischemic stroke. Stroke patients with anterior circulation large vessel occlusion (acLVO) who receive endovascular therapy (EVT) are frequently hypothermic after the procedure. We sought to analyze whether this unintended hypothermia was associated with improved functional outcome. Methods: We extracted data of consecutive patients (01/2016-04/2019) from our prospective EVT database that includes all patients screened for EVT at our center. We included patients with acLVO who received EVT and analyzed recanalization (mTICI 2b-3) and complications (i.e., pneumonia, bradyarrhythmia, venous thromboembolism) during the hospital course. We assessed functional outcome at 3 months and analyzed risk ratios (RR) for good outcome (mRS scores 0-2) and mortality of patients who were hypothermic (<36°C) compared to patients who were normothermic ( > 36°C) after EVT. We compared the frequency of complications and calculated RRs for good outcome and mortality in the subgroup with recanalization. Results: Among 674 patients with anterior circulation ischemic stroke, 372 patients received EVT for acLVO (178 [47%] male, age 77 years [65-82], NIHSS score 16 [12 - 20]). Of these, 186 patients (50%) were hypothermic (median [IQR] temperature 35.2°C [34.7-35.6]) and 186 patients were normothermic (media temperature 36.4 [36.2-36.8]) after EVT. At 3 months, 54 of 186 (29.0%) hypothermic patients compared with 65 of 186 (35.0%) normothermic patients had a good outcome (RR, 0.83; 95%CI 0.62-1.12) and 52 of 186 (27.9%) hypothermic patients compared with 46 of 186 (24.7%) normothermic patients had died (RR, 1.13; 95%CI 0.8-1.59). This relation was consistent in 307 patients (82.5% of all EVTs) with successful recanalization (good outcome: RR, 0.85; 95%CI 0.63-1.14.; mortality: RR, 1.05; 95%CI 0.7-1.57). More hypothermic patients suffered pneumonia (37.8% vs. 24.7%; p=0.003) or bradyarrhythmia (55.6% vs. 18.3%; p<0.001). Venous thromboembolism was distributed similarly (5.4% vs. 6.5%; p=0.42). Conclusion: Unintended hypothermia following EVT for acLVO was not associated with improved functional outcome or reduced mortality but an increased complication rate in patients with acute ischemic stroke.

Download Full-text

E-033 The smoking-thrombolysis paradox in large vessel occlusion acute ischemic stroke after endovascular therapy

10.1136/neurintsurg-2017-snis.105 ◽

2017 ◽

Author(s):

J Grossberg ◽

M Bouslama ◽

L Rebello ◽

D Haussen ◽

M Frankel ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion

Download Full-text

Endovascular Therapy for Acute Ischemic Stroke in Patients with Large-Vessel Occlusion due to Atherosclerotic Stenosis

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2021.105960 ◽

2021 ◽

Vol 30 (10) ◽

pp. 105960

Author(s):

Manabu Shirakawa ◽

Hidetoshi Matsukawa ◽

Nobuyuki Sakai ◽

Hiroshi Yamagami ◽

Kanta Tanaka ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Atherosclerotic Stenosis

Download Full-text

Abstract TMP5: The Smoking-Thrombolysis Paradox in Large Vessel Occlusion Acute Ischemic Stroke Undergoing Endovascular Therapy

Stroke ◽

10.1161/str.48.suppl_1.tmp5 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Mehdi Bouslama ◽

Leticia C Rebello ◽

Diogo C Haussen ◽

Jonathan A Grossberg ◽

Shannon Doppelheuer ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Univariate Analysis ◽

Tertiary Care ◽

Posterior Circulation ◽

Large Vessel ◽

Stroke Severity ◽

Large Vessel Occlusion ◽

Vessel Occlusion

Background and Purpose: The smoking-thrombolysis paradox has been well described in myocardial infarction. However, its existence in the stroke population remains elusive. In the past decade, several studies have investigated the phenomenon with mixed results. We sought to determine whether clinical outcomes differ between smokers and non-smokers with acute ischemic stroke undergoing endovascular therapy. Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution. All patients who underwent endovascular therapy for acute large vessel occlusion acute ischemic stroke were categorized into current smokers and non-smokers. Baseline characteristics, procedural radiological as well as outcome parameters where compared. Results: A total of 968 patients qualified for the study of which 189 (19.5%) were current smokers. Smokers were younger (60.78±11.95 vs. 66.41±15.05 years, p<0.001), had higher rates of dyslipidemia (49.7% vs 31.7%, p<0.001) and posterior circulation strokes (13.2% vs 7.8%, p=0.02,) and lower rates of atrial fibrillation (21.1% vs 37.9%, p<0.001). There were no statistically significant differences between groups in terms of stroke severity (as assessed by NIHSS), baseline CT perfusion core and hypoperfusion volumes, CT angiogram collateral scores as well as procedural variables. On univariate analysis, smokers had higher rates of good outcomes at 90 days (modified Rankin scale, mRS 0-2: 53.8% vs 42.8%, p=0.01) and similar rates of successful reperfusion (mTICI 2b-3) (92.1% vs 87.7%, p=0.09), parenchymal hematomas (4.2% vs 4%, p=0.84) and mortality at 90 days (20.2% vs 25.7%, p=0.14). Multivariate analysis showed that smoking was not independently associated with good outcomes. Stratifying for (1) stroke etiology and (2) anterior vs. posterior circulation topology yielded similar results. Conclusion: In stroke patients treated with mechanical thrombectomy, smoking does not seem to be associated with outcomes regardless of stroke subtype or location.

Download Full-text