A Rare Complication of Fine-Needle Aspiration of Neck Structures

Fine-needle aspiration (FNA) is a generally accepted tool for safe diagnostic evaluation in the workup of lesions and masses. Aside from the commonly discussed risks of infection and minor bleeding related to skin puncture, other more serious complications have been reported sparingly. We present two cases of pneumothorax from FNA of neck structures, which have been theorized but not previously reported to our knowledge. Discussion of cases of this complication rather than solely a theoretical understanding of it will aid in diagnosis and management of this complication.

Abstract 1122‐000096: Transradial Results in Faster Recanalization in Left Anterior Circulation Stroke and Bovine Arch

Introduction : We compared technical and clinical outcomes of transradial (TRA) versus transfemoral (TFA) access for mechanical thrombectomy (MT) of acute ischemic stroke (AIS) due to large vessel occlusion (LVO) in the left anterior cerebral circulation of bovine origin. Methods : A single‐center retrospective review of a prospectively maintained neuro‐interventional database from a large volume service in a tertiary academic center. Procedural metrics, technical, and clinical outcomes data were collected and analyzed for patients who underwent MT presenting with AIS and LVO in the left anterior circulation of bovine origin. Primary outcomes included the average number of passes, single first effective pass, rate of successful recanalization (thrombolysis in cerebral infarction (TICI) score ≥ 2b), 3‐month disability modified Rankin Scale (mRS) score ≤2, time from skin puncture to microcatheter placement and recanalization. Results : Between January 2018 and January 2021, 26 patients (TRA = 13, TFA = 13) underwent MT. The TRA cohort had a significantly shorter time in minutes for skin puncture to microcatheter placement (TRA: 17.0± 5.8 vs TFA: 35.4± 20.5, P = 0.0001), shorter skin puncture to recanalization (TRA: 34.0± 15.6 vs TFA: 58.1± 34.6, P = 0.01), and shorter total fluoroscopy time (TRA: 13.8±9.4 vs TFA: 29.5±18.0, P = 0.03). The 3‐month mRS score of 0–1 was higher in the TRA group (38.5% vs 7.69%, P = 0.06). Conclusions : In patients with LVO in the left anterior cerebral circulation of bovine origin, right TRA access permits more direct navigation and provides a stable platform resulting in shorter procedure times and faster recanalization with the potential to improve functional outcomes.

Event-related potentials evoked by skin puncture reflect activation of Aβ fibers: comparison with intraepidermal and transcutaneous electrical stimulations

Background Recently, event-related potentials (ERPs) evoked by skin puncture, commonly used for blood sampling, have received attention as a pain assessment tool in neonates. However, their latency appears to be far shorter than the latency of ERPs evoked by intraepidermal electrical stimulation (IES), which selectively activates nociceptive Aδ and C fibers. To clarify this important issue, we examined whether ERPs evoked by skin puncture appropriately reflect central nociceptive processing, as is the case with IES. Methods In Experiment 1, we recorded evoked potentials to the click sound produced by a lance device (click-only), lance stimulation with the click sound (click+lance), or lance stimulation with white noise (WN+lance) in eight healthy adults to investigate the effect of the click sound on the ERP evoked by skin puncture. In Experiment 2, we tested 18 heathy adults and recorded evoked potentials to shallow lance stimulation (SL) with a blade that did not reach the dermis (0.1 mm insertion depth); normal lance stimulation (CL) (1 mm depth); transcutaneous electrical stimulation (ES), which mainly activates Aβ fibers; and IES, which selectively activates Aδ fibers when low stimulation current intensities are applied. White noise was continuously presented during the experiments. The stimulations were applied to the hand dorsum. In the SL, the lance device did not touch the skin and the blade was inserted to a depth of 0.1 mm into the epidermis, where the free nerve endings of Aδ fibers are located, which minimized the tactile sensation caused by the device touching the skin and the activation of Aβ fibers by the blade reaching the dermis. In the CL, as in clinical use, the lance device touched the skin and the blade reached a depth of 1 mm from the skin surface, i.e., the depth of the dermis at which the Aβ fibers are located. Results The ERP N2 latencies for click-only (122 ± 2.9 ms) and click+lance (121 ± 6.5 ms) were significantly shorter than that for WN+lance (154 ± 7.1 ms). The ERP P2 latency for click-only (191 ± 11.3 ms) was significantly shorter than those for click+lance (249 ± 18.6 ms) and WN+lance (253 ± 11.2 ms). This suggests that the click sound shortens the N2 latency of the ERP evoked by skin puncture. The ERP N2 latencies for SL, CL, ES, and IES were 146 ± 8.3, 149 ± 9.9, 148 ± 13.1, and 197 ± 21.2 ms, respectively. The ERP P2 latencies were 250 ± 18.2, 251 ± 14.1, 237 ± 26.3, and 294 ± 30.0 ms, respectively. The ERP latency for SL was significantly shorter than that for IES and was similar to that for ES. This suggests that the penetration force generated by the blade of the lance device activates the Aβ fibers, consequently shortening the ERP latency. Conclusions Lance ERP may reflect the activation of Aβ fibers rather than Aδ fibers. A pain index that correctly and reliably reflects nociceptive processing must be developed to improve pain assessment and management in neonates.

A study to compare effects of shoulder position on infraclavicular central venous catheterization in critically ill patients.

Objectives: Aim of this study was to compare the effects of two different shoulder positions on infraclavicular subclavian venous catheterization in critically ill patients. Study Design: Prospective Comparative study. Setting: Sheikh Zayed Medical College Rahim Yar Khan Pakistan. Period: 1st July 2017 to 30th June 2018. Material & Methods: Enrolling 100 patients thru convenient sampling, divided into two groups, Group A & Group B, 50 in each group. In group A patients were put in supine position, with head turned to contra lateral side and caudal pull was applied on ipsilateral shoulder. While in group B patients were lying supine, head turned to contra lateral side and shoulders were retracted by placing a small pillow vertically under the chest between the scapulae. In both groups, subclavian vein was approached through infra clavicular route. Number of attempts of venous punctures (1st attempt / 2nd attempt), total time spent on procedure (from 1st skin puncture to CVC insertion), complications (arterial puncture, pneumothorax, hydrothorax, malpositioning), any hemodynamic irregularity (ECG changes), radiographic findings to confirm successful CVC insertion was recorded. Results: Number of successful subclavian venous catheterizations was same in both groups (94% vs. 94%) with no significant difference (p= 1.000). 1st attempt success was more in group A as compared to group B, though statistically this was not significant (p= 0.275). Total time spent on CVC insertion (from 1st skin puncture to catheter insertion) was less than 05 mints in 84% patient in group A and 82% in group B. While more than 05 mints were spent on 16% vs. 18% patients in group A vs. B. This was also not statistically significant (p=0.790). In group A 2/50 (4%) while in group B 1/50 (2%) cases were recorded as malpositioning on post-CVC radiograph. Other complications were not encountered in either group. Conclusion: Lowered shoulder and retracted shoulder positions are equally effective for SVC insertion in terms of success, 1st attempt success, total time spent and number of complications.

Abstract TP387: Development of a Single System Activation Process to Reduce Time From Arrival to Skin Puncture in Endovascular Treatment

Background and Issues: Timely recanalization of intracerebral artery occlusions is a strong predictor of functional independence and reduced mortality in acute ischemic stroke patients. Our current stroke alert process did not address a way to assemble the neuro-interventional team rapidly for these emergent cases, resulting in lengthy times from arrival to skin puncture. In an effort to improve these times, with an ultimate goal of 90 minutes or less, we created a single system pager titled “Neuro IR 911”. With one phone call, we can now simultaneously activate the entire team. Purpose: The purpose of this project was to improve arrival to skin puncture times by eliminating overlap of multiple staff working separately to assemble the neuro-interventional team. Methods: We captured arrival to skin puncture times in 29 emergency department patients with a discharge diagnosis of ischemic stroke. Descriptive statistics (mean, standard deviation, median, 25 th and 75 th percentiles, minimum and maximum values for continuous variables) were calculated separately by group (pre-intervention and post-intervention). These two groups were compared using the Mann Whitney test for continuous data. A result was considered statistically significant at the p<0.05 level of significance. Results: There was a reduction in arrival to skin puncture times but no statistical significance between pre-intervention and post-intervention groups was determined (126 minutes vs. 107 minutes respectively, p<0.4785). Conclusions: Streamlining the activation process using a single system pager can reduce arrival to skin puncture times, but statistical significance remains to be determined.

Abstract WP459: Advanced Practice Providers versus Neurology Residents: Similar Stroke Code Quality Metrics and Functional Outcomes

Background: Advanced Practice Providers (APPs) are important members of stroke code teams. However, the impact of APP involvement on quality metrics and functional outcomes is unclear. We sought to evaluate if APPs perform similarly to neurology residents for stroke code quality metrics and functional outcome at 90 days. Methods: We retrospectively analyzed data of consecutive patients who underwent thrombectomy in a single center cohort. Demographics, National Institute of Health Stroke Scale (NIHSS), last known normal (LKN) to emergency department (ED) presentation time, ED door to skin puncture time, recanalization (mTICI IIb/III) rates, and modified rankin scale (mRS) at 90 days were compared between neurology residents and APPs. A multiple logistic regression was used to determine factors independently associated with a favorable mRS at 90 days. Results: A total of 172 patients were included in the study of which 80 (47%) were managed by neurology residents. Both groups (residents vs. APPs) were balanced for age ( p =0.87), NIHSS ( p =0.18), LKN to ED Door time ( p =0.19), ED door to skin puncture time ( p =0.08), recanalization rate ( p =0.28), and favorable outcome (mRS 0-2) ( p =0.27). The multiple logistic regression model found patients with recanalization were 8.9 times more likely to have a favorable outcome. Age and initial NIHSS were found to be negative predictors of mRS (Table 1). Resident or APP involvement in the stroke code process did not impact outcome ( p =0.08). Conclusion: APPs achieve similar acute stroke code metrics and functional outcomes when compared to neurology residents. Further studies are needed to confirm our findings.

Abstract WP37: Endovascular Thrombectomy Practice Pattern Across the Nihss Spectrum

Background: Endovascular thrombectomy (EVT) after Ischemic Stroke (AIS) has shown to improve outcomes in multiple large clinical trials. However, most guidelines recommend EVT for patients with NIHSS greater than 5 and caution EVT in severe stroke. We analyzed data from a stroke registry to learn about ‘real-world’ use of EVT across stroke serverity. Most clinical trials focus on academic medical centers. Our analysis reports on data from all centers within a region. Methods: The San Diego County EMS Stroke Registry represents data from 10 EVT ready centers. We included all AIS cases with NIHSS between 0 and 42 from July 2016 through December 2018. Patients were grouped into three categories: 1) NIHSS 0-5, 2) 6-25, 3) 26-42. We analyzed frequency of EVT use, last known normal (LKN) to skin puncture time, admission NIHSS in EVT cases, and hospital discharge dispositon of EVT cases. Results: Of 7,050 AIS cases, 662 (9.4%) received EVT from July 2016 to December 2018. Group (G) 1: 80 of 4184 cases received EVT (1.9%), G2: 470 of 2502 cases received EVT (18.8%), G3: 112 of 364 cases received EVT (30.8%). Rate of EVT in all AIS and for each NIHSS group did not change (all AIS: p=.24, G1: p=.59, G2: p=.15, G3: p=.57). Mean (±SD) NIHSS among all AIS was 7.4 (±8.5); among EVT cases it was 17.2 (±8.6). Mean (±SD) LKN to skin puncture (hours) was G1: 9.2 (±12.1), G2: 5.8 (±5.8), G3: 5.5 (±5.3) (p=.000001). Mean (±SD) age (years) of EVT cases was G1: 65.5 (±15.4); G2: 71.9 (±15.6); , G3: 77.1 (±14.0) (p=.00001). Discharge to home among EVT cases was Group 1: 50.0%; 2) 26.5%; 3) 9.8%; to a non-acute health care facility: G1) 28.8%, 2) 39.5%, 3) 44.6%); in-hospital death 1) 10.0%, 2) 13.6%, 3) 25.0%. Conclusion: Patients with mild and severe stroke present a significant subpopulation of patients undergoing EVT in this sample. Overall, one in three stroke patients with NIHSS above 25 underwent EVT; less than one in five stroke patients with low NIHSS underwent EVT. Over time there has been no change in the number of patients receiving EVT and no change in EVT use within NIHSS groups. Half of patients with low NIHSS were discharged home; one in four patients with high NIHSS expired in hospital. As hospitals embraced EVT, the use of the procedure among patients with low or high NIHSS has remained consistent.