The Tezpur Model of Physician-based Stroke Unit implementation

 Is it truly a successful experience if you are not measuring or even attempting 100% recovery? Unless your tyranny of low expectations is so fucking low that you are trying to emulate  first world countries. First world countries should not be emulated because they don't know what the fuck they are doing for stroke.

The Tezpur Model of Physician-based Stroke Unit implementation

The Baptist Christian Mission Hospital is located in rural Northeast India; Tezpur, Assam. Despite high burden of stroke in India, very few hospitals have stroke units. The team in Tezpur set out to create and evaluate a stroke unit at their hospital.

Lydia John¹, Akanksha William²,  Dimple Dawar²,  Himani Khatter²,  Pratibha Singh¹, Anjana Andrias¹, Christina Mochahari¹, Peter Langhrne³, and Jeyaraj Pandian².

¹Department of Medicine, Baptist Christian Hospital, Tezpur, Assam, India
²Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
³Institute of Cardiovascular and Medical Sciences, Royal Infirmary Hospital, Glasgow, UK

Recently, John et al. (2021)¹ published a paper in the Journal of Neurosciences of Rural Practice, detailing their model, and successful experience, of implementing a physician-based stroke unit at the Baptist Christian Mission Hospital, in rural Northeast India; Tezpur, Assam.

The team looked at stroke care and 1 month recovery outcomes both before and after the introduction of stroke unit care, in 250 stroke patients from January 2015 to December 2017.

Stroke Unit care was introduced to the hospital through training of the local physicians on key aspects of stroke care, such as: how to identify stroke, assessment of symptoms, localisation of lesions and rehabilitation of patients. These trained physicians then went on to train their teams in this knowledge and establish stroke care protocols and pathways.

Recently, John et al. (2021)¹ published a paper in the Journal of Neurosciences of Rural Practice, detailing their model, and successful experience, of implementing a physician-based stroke unit at the Baptist Christian Mission Hospital, in rural Northeast India; Tezpur, Assam.

The team looked at stroke care and 1 month recovery outcomes both before and after the introduction of stroke unit care, in 250 stroke patients from January 2015 to December 2017.

Stroke Unit care was introduced to the hospital through training of the local physicians on key aspects of stroke care, such as: how to identify stroke, assessment of symptoms, localisation of lesions and rehabilitation of patients. These trained physicians then went on to train their teams in this knowledge and establish stroke care protocols and pathways.

The multidisciplinary aspect was very important to the team, which was made up of physiotherapists, occupational therapists and nurses. Working together, they completed team meetings to discuss each patient’s care and rehabilitation to ensure good outcomes.(You don't mention 100% recovery so you didn't achieve good outcomes.)

John et al (2021)¹ found that after creation of the stroke unit, their patients showed a reduction in hospital stay and an increase in secondary prevention drugs.

One of the limitations pointed out by the team is the number of patients lost to follow up. The team propose that the rate of lost to follow up is quite high due to the rural location of many patients, which makes 1 month follow up tricky to complete. This is certainly something to consider for future studies being carried out in rural areas.

In the paper, the team emphasise that this model of Stroke Unit implementation is particularly important as it utilises existing infrastructure rather than relying on the creation of new roles and resources. This is especially important in low and middle income countries that often do not have the infrastructure to implement new units.¹ Dr Richard I Lindley, of Sydney Medical School, New South Wales, highlights in his editorial² that John et al’s (2021)¹ model of stroke unit introduction is a great example of disseminating knowledge and expertise.

 

Make sure to read the papers referenced below for more information on this study!

References

¹ John L, William A, Dawar D et al.Implementation of a physician-based stroke unit in a remote hospital of North-East India—Tezpur model. J Neurosci Rural Pract. 2021;12(02):356–361.

² Lindley RI. Providing Stroke Expertise across India. J Neurosci Rural Pract. 2021;12(2):226-227. doi:10.1055/s-0041-1726664

 

Blood Pressure Management After Endovascular Therapy: An Ongoing Debate

When the hell are we going to get a protocol? While you dither stroke survivors continue to get disabled due to your lack of protocols.  Isn't it your job to deliver stroke recovery protocols?

Blood Pressure Management After Endovascular Therapy: An Ongoing Debate

 

Mohammad Anadani

,

Adam de Havenon

,

Eva Mistry

,

Craig S. Anderson

Originally published18 May 2021https://doi.org/10.1161/STROKEAHA.121.034995Stroke. 2021;52:e263–e265

 

Fatigue Following Pediatric Arterial Ischemic Stroke: Prevalence and Associated Factors

Useless, you describe a problem. Offer NO SOLUTION, I'd have you fired in a split second. 

Fatigue Following Pediatric Arterial Ischemic Stroke: Prevalence and Associated Factors

Mardee Greenham

,

Anne L. Gordon

,

Anna Cooper

,

Stephen Hearps

,

Michael Ditchfield

,

Lee Coleman

,

Rod W. Hunt

,

Mark T. Mackay

,

Paul Monagle

,

Vicki Anderson

Originally published28 Jun 2021https://doi.org/10.1161/STROKEAHA.120.033000Stroke. ;0:STROKEAHA.120.033000

Abstract

Background and Purpose:

The aims of this study were to assess the prevalence of multidimensional fatigue symptoms 5 years after pediatric arterial ischemic stroke and identify factors associated with fatigue.

Methods:

Thirty-one children (19 males) with pediatric arterial ischemic stroke, participating in a larger prospective, longitudinal study, were recruited to this study at 5 years poststroke. Parent- and self-rated PedsQL Multidimensional Fatigue Scale scores were compared with published normative data. Associations between parent-rated PedsQL Multidimensional Fatigue Scale, demographics, stroke characteristics, and concurrent outcomes were examined.

Results:

Parent-rated total, general and cognitive fatigue were significantly poorer than population norms, with more than half of all parents reporting fatigue symptoms in their children. One-third of children also reported experiencing fatigue symptoms, but their ratings did not differ significantly from normative expectations, as such, all further analyses were on parent ratings of fatigue. Older age at stroke and larger lesion size predicted greater general fatigue; older age, female sex, and higher social risk predicted more sleep/rest fatigue. No significant predictors of cognitive fatigue were identified and only older age at stroke predicted total fatigue. Greater fatigue was associated with poorer adaptive functioning, motor skills, participation, quality of life, and behavior problems but not attention.

Conclusions:

Fatigue is a common problem following pediatric arterial ischemic stroke and is associated with the functional difficulties often seen in this population. This study highlights the importance of long-term monitoring(Are you that blitheringly stupid? Monitoring does nothing to solve the fatigue problem.) following pediatric arterial ischemic stroke and the need for effective interventions to treat fatigue in children.

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Healthcare costs of post-stroke oropharyngeal dysphagia and its complications: malnutrition and respiratory infections

 REALLY? You think survivors care about costs rather than recovery? I'd have all involved fired for not working on the only goal in stroke. 100% RECOVERY.

Healthcare costs of post-stroke oropharyngeal dysphagia and its complications: malnutrition and respiratory infections

Sergio Marin, Mateu Serra-Prat, Omar Ortega, Monica Audouard Fericgla, Jordi Valls, Elisabet Palomera, Ramon Cunillera, Ernest Palomeras, Josep Maria Ibàñez, Pere Clavé

First published: 27 June 2021

https://doi.org/10.1111/ene.14998

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi:10.1111/ene.14998

Abstract

Background

The healthcare economic costs of post-stroke oropharyngeal dysphagia (OD) are not fully understood. The purpose of this study is to assess the acute, sub-acute and long-term costs related to post-stroke OD and its main complications (malnutrition and respiratory infections).

Methods

A cost of illness study of patients admitted to Mataró Hospital (Catalonia, Spain) from May 2010 to September 2014 with a stroke diagnosis was performed. OD, malnutrition and respiratory infections were assessed during hospitalization and follow-up (3 and 12 months). Hospitalization and long-term costs were measured from hospital and health care system perspectives. Multivariate linear regression analysis was performed to assess the independent effect of OD, malnutrition, and respiratory infections on healthcare costs during hospitalization, and at 3- and 12-month follow-up.

Results

395 patients were included of which 178 had OD at admission. Patients with OD concurred major total in-hospital costs (5,357.67±3,391.62 vs. 3,976.30±1,992.58 euros, p<0.0001), 3 months costs (8,242.0±5,376.0 vs. 5,320.0±4,053.0 euros, p<0.0001) and 12 months costs (11,617.58±12,033.58 vs. 7,242.78±7,402.55 euros, p<0.0001). OD was independently associated with a cost increase of 789.68 euros (p=0.011) during hospitalization and of 873.5 euros (p=0.084) at 3 months but not at 12 months. However, patients with OD, who were at risk of malnutrition or malnourished and suffered respiratory infections concurred major mean costs compared with those patients without OD (19,817.58±13,724.83 vs. 7,242.8±7,402.6 euros, p<0.0004) at 12-months follow-up.

Conclusion

OD causes significant high economic costs during hospitalization that strongly and significantly increase with the development of malnutrition and respiratory infections at long-term follow-up.

 

Two Inflammatory Proteins Linked With Slower Cognitive Decline

How will your doctor use this to recover your  5 lost years of brain cognition?

Two Inflammatory Proteins Linked With Slower Cognitive Decline

Surprise finding ties plasma cytokine levels with Alzheimer's biomarkers and cognition

by Judy George, Senior Staff Writer, MedPage Today June 23, 2021

In a surprising finding, elevated levels of two inflammatory proteins were associated with slower cognitive decline in older adults.

Higher plasma levels of pro-inflammatory cytokine interleukin-12 p70 (IL-12p70) were associated with less cognitive decline in people with a significant burden of amyloid-beta, reported Rudolph Tanzi, PhD, of Massachusetts General Hospital and Harvard Medical School in Boston, and colleagues. Elevated IL-12p70 levels also were associated with fewer tau tangles in these people.

Moreover, higher levels of another pro-inflammatory cytokine, interferon-gamma (IFN-γ), were associated with slower cognitive decline independently of amyloid burden, they wrote in Alzheimer's & Dementia.

"These are totally unexpected results," Tanzi said in a statement.

Previous meta-analyses of case-control and prospective cohort studies showed that cytokines and inflammatory markers -- like interleukin-6 (IL-6), C-reactive protein (CRP), and others -- are elevated in Alzheimer's dementia cases and predicted incident all-cause dementia.

While it seems counterintuitive that people with high levels of inflammation-inducing proteins are protected against cognitive decline, it may be that their immune systems are better primed to fight infection, Tanzi observed.

This would fit with the antimicrobial protection hypothesis of Alzheimer's that Tanzi helped developed, which postulates that amyloid-beta aggregation can be triggered by subacute microbial infection in the brain. Having high levels of IL-12 and IFN-γ "may nip infections in the bud, before they can leak into the brain and induce Alzheimer's pathology," he said.

Tanzi and colleagues measured nine cytokines in the baseline plasma of 298 older adults who were cognitively unimpaired and followed longitudinally in the Harvard Aging Brain Study. Mean baseline age was 72; 62% were female and 81% were white. Participants were followed an average of 4.3 years.

The researchers first looked to see whether the cytokines were associated with cognitive decline -- alone or synergistically with amyloid-beta -- then examined associations between cytokine levels and neuroimaging biomarkers of amyloid, tau, and neurodegeneration.

Neither IL-12p70 nor IFN-γ was associated with age, sex, or APOE4 carrier status (all P>0.05). Immunosuppressant medication use did not affect baseline IL-12p70 or IFN-γ levels. Concentrations of IL-12p70 and IFN-γ from the same individual remained stable on repeat measures up to several years apart.

Higher IL-12p70 was associated with slower cognitive decline in the setting of higher amyloid-beta (false discovery rate=0.0023). Higher IFN-γ was associated with slower cognitive decline independent of amyloid burden (false discovery rate=0.013).

Higher IL-12p70 was associated with less neocortical tau on PET and hippocampal neurodegeneration in people with a higher amyloid-beta burden. IFN-γ was not correlated with tau or neurodegeneration.

"Greater IL-12/IFN-γ axis activation may be protective against cognitive decline and early-stage Alzheimer's disease progression," Tanzi and colleagues wrote.

The study had several limitations, the researchers acknowledged. Associations between IL-12p70 and neuroimaging markers of tau and neurodegeneration were cross-sectional, not longitudinal. The study enrolled cognitively unimpaired people who mainly were white and findings may not extend to other older adults.

Moreover, the effect sizes of IL-12 and IFN-γ in predicting cognitive decline were statistically significant, but small. "These cytokines should be considered ancillary biomarkers rather than stand-alone prognostic indicators," Tanzi and colleagues wrote. Further validation and mechanistic studies are needed to translate the findings into clinical use.

• Judy George covers neurology and neuroscience news for MedPage Today, writing about brain aging, Alzheimer’s, dementia, MS, rare diseases, epilepsy, autism, headache, stroke, Parkinson’s, ALS, concussion, CTE, sleep, pain, and more. Follow

Disclosures

The study was supported by the NIH, the Cure Alzheimer's Fund, and the Doris Duke Charitable Foundation.

Primary Source

Alzheimer's & Dementia

Source Reference: Yang H-S, et al "Plasma IL-12/IFN-γ axis predicts cognitive trajectories in cognitively unimpaired older adults" Alzheimer's Dement 2021; DOI:10.1002/alz.12399.

 

Cerebral hyperperfusion syndrome after mechanical thrombectomy

Is your doctor prepared for treating Cerebral hyperperfusion syndrome if needed?

 Cerebral hyperperfusion syndrome after mechanical thrombectomy

1. http://orcid.org/0000-0002-6334-9432Markus Kneihsl1,
2. Christian Enzinger1,2,
3. Thomas Gattringer1,2

1. Correspondence to Dr Markus Kneihsl, Department of Neurology, Medical University of Graz, Graz 8036, Austria; markus.kneihsl@medunigraz.at

http://dx.doi.org/10.1136/neurintsurg-2021-017693

Case summary

A male patient in his late 50s who had untreated atrial fibrillation received mechanical thrombectomy for right middle cerebral artery occlusion (MCA), with complete recanalization. After initial neurological improvement, he developed headache and altered vigilance 2 days post-thrombectomy. Transcranial duplex sonography (TCD) showed increased blood flow velocities in the entire ipsilateral (recanalized) MCA-M1 segment.1 2 Brain MRI with angiography excluded focal stenosis and showed vasogenic edema, hemorrhagic transformation of the ischemic infarct, and cerebral hyperperfusion in the right MCA territory (figure 1). Because of this finding, the patient underwent intense blood pressure (BP) control (systolic BP target …

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Footnotes

• Contributors MK: case report design, acquisition and interpretation of data, manuscript preparation. CE: critical revision of the manuscript content. TG: case report concept and design, interpretation of data, manuscript preparation, critical revision of the manuscript content.

• Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

• Competing interests None declared.

• Provenance and peer review Not commissioned; externally peer reviewed.

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Fluid-Attenuated Inversion Recovery May Serve As a Tissue Clock in Patients Treated With Endovascular Thrombectomy

 What are you doing after this to get to 100% recovery?  THAT IS THE ONLY GOAL IN STROKE!

Fluid-Attenuated Inversion Recovery May Serve As a Tissue Clock in Patients Treated With Endovascular Thrombectomy

Junya Aoki

,

Yuki Sakamoto

,

Kentaro Suzuki

,

Yuji Nishi

,

Akihito Kutsuna

,

Yukako Takei

,

Kazutaka Sawada

,

Takuya Kanamaru

,

Arata Abe

,

Takehiro Katano

,

Yuho Takeshi

,

Toru Nakagami

, … See all authors

Originally published7 May 2021https://doi.org/10.1161/STROKEAHA.120.033374Stroke. 2021;52:2232–2240

• is related to

Abstract

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Background and Purpose:

We investigated whether the signal change on fluid-attenuated inversion recovery (FLAIR) can serve as a tissue clock that predicts the clinical outcome after endovascular thrombectomy (EVT), independently of the onset-to-admission time.

Methods:

Consecutive patients with acute stroke treated with EVT between September 2014 and December 2018 were enrolled. Based on the parenchymal signal change on FLAIR, patients were classified into FLAIR-negative and FLAIR-positive groups. The clinical characteristics, imaging findings, EVT parameters, and the intracranial hemorrhage defined as Heidelberg Bleeding Classification ≥1c hemorrhage (parenchymal hemorrhage, intraventricular hemorrhage, subarachnoid hemorrhage, and/or subdural hemorrhage) were compared between the 2 groups. A modified Rankin Scale score 0 to 1 at 3 months was considered to represent a good outcome.

Results:

Of the 227 patients with EVT during the study period, 140 patients (62%) were classified into the FLAIR-negative group and 87 (38%) were classified into the FLAIR-positive group. In the FLAIR-negative group, the patients were older (P=0.011), the onset-to-image time was shorter (P<0.001), the frequency of cardioembolic stroke was higher (P=0.006), and the rate of intravenous thrombolysis was higher (P<0.001) in comparison to the FLAIR-positive group. Although the rate of complete recanalization after EVT did not differ between the 2 groups (P=0.173), the frequency of both any-intracranial hemorrhage and Heidelberg Bleeding Classification ≥1c hemorrhage were higher in the FLAIR-positive group (P=0.004 and 0.011). At 3 months, the percentage of patients with a good outcome (FLAIR-negative, 41%; FLAIR-positive, 27%) was significantly related to the FLAIR signal change (P=0.047), while the onset-to-image time was not significant (P=0.271). A multivariate regression analysis showed that a FLAIR-negative status was independently associated with a good outcome (odds ratio, 2.10 [95% CI, 1.02–4.31], P=0.044).

Conclusions:

A FLAIR-negative status may predict the clinical outcome more accurately than the onset-to-admission time, which may support the role of FLAIR as a tissue clock.

 

Transcranial electrostimulation with special waveforms enhances upper-limb motor function in patients with chronic stroke: a pilot randomized controlled trial

 If you're chronic, good luck getting your insurance to pay for this.

Transcranial electrostimulation with special waveforms enhances upper-limb motor function in patients with chronic stroke: a pilot randomized controlled trial

• Shih-Ching Chen,
• Ling-Yu Yang,
• Muhammad Adeel,
• Chien-Hung Lai &
• Chih-Wei Peng 

Journal of NeuroEngineering and Rehabilitation volume 18, Article number: 106 (2021) Cite this article

Abstract

Background

Transcranial direct current stimulation (tDCS) and intermittent theta burst stimulation (iTBS) were both demonstrated to have therapeutic potentials to rapidly induce neuroplastic effects in various rehabilitation training regimens. Recently, we developed a novel transcranial electrostimulation device that can flexibly output an electrical current with combined tDCS and iTBS waveforms. However, limited studies have determined the therapeutic effects of this special waveform combination on clinical rehabilitation. Herein, we investigated brain stimulation effects of tDCS-iTBS on upper-limb motor function in chronic stroke patients.

Methods

Twenty-four subjects with a chronic stroke were randomly assigned to a real non-invasive brain stimulation (NIBS; who received the real tDCS + iTBS output) group or a sham NIBS (who received sham tDCS + iTBS output) group. All subjects underwent 18 treatment sessions of 1 h of a conventional rehabilitation program (3 days a week for 6 weeks), where a 20-min NIBS intervention was simultaneously applied during conventional rehabilitation. Outcome measures were assessed before and immediately after the intervention period: Fugl-Meyer Assessment-Upper Extremity (FMA-UE), Jebsen-Taylor Hand Function Test (JTT), and Finger-to-Nose Test (FNT).

Results

Both groups showed improvements in FMA-UE, JTT, and FNT scores after the 6-week rehabilitation program. Notably, the real NIBS group had greater improvements in the JTT (p = 0. 016) and FNT (p = 0. 037) scores than the sham NIBS group, as determined by the Mann–Whitney rank-sum test.

Conclusions

Patients who underwent the combined ipsilesional tDCS-iTBS stimulation with conventional rehabilitation exhibited greater impacts than did patients who underwent sham stimulation-conventional rehabilitation in statistically significant clinical responses of the total JTT time and FNT after the stroke. Preliminary results of upper-limb functional recovery suggest that tDCS-iTBS combined with a conventional rehabilitation intervention may be a promising strategy to enhance therapeutic benefits in future clinical settings.

Trial registration: ClinicalTrials.gov Identifier: NCT04369235. Registered on 30 April 2020.

Introduction

Neuromodulation is an evolving therapy for rehabilitation after a stroke and is also used to improve motor function in the lesioned cortex. Recently, studies indicated that neuromodulation could enhance neuroplasticity, the ability of the brain to reorganize or relearn in response to a new stimulus, resulting in facilitation of motor sensory recovery in stroke patients [1,2,3]. Transcranial direct current stimulation (tDCS), a non-invasive brain stimulation (NIBS) technique, is contemporarily important as it can modulate neuroplasticity in advanced rehabilitation medicine, such as pain, depression and, addictive diseases [4,5,6]. tDCS can selectively change the excitability of the regional cortex non-invasively and safely [7]. In addition, tDCS has been explored as a treatment option for stroke, particularly for upper/lower-limb motor function [8,9,10,11]. However, studies reported only 10% ~ 30% improvement in forearm motor function after stroke rehabilitation. Optimal stimulation strategies of tDCS to improve plasticity and enhance motor learning need to be determined.

Recovery as a result of traditional stroke rehabilitation often has poor outcomes and long rehabilitation times. Therefore, developing a more-effective therapeutic device is an important issue for stroke rehabilitation. To develop an optimal tDCS protocol to improve motor function, we designed and implemented a prototype of a novel transcranial electrostimulation device that can flexibly output an electrical current waveform by combining DC and theta burst waveforms [12]. Theta burst stimulation (TBS) was originally a novel waveform of repetitive transcranial magnetic stimulation (rTMS) that is more rapid and efficacious than rTMS [13]. Numerous studies determined that TBS has more advantages than other traditional waveforms of rTMS, such as long-lasting effects on motor-evoked potentials (MEPs) and neuronal excitability after a shorter stimulation duration [14,15,16], and it was associated with fewer adverse events [17]. It is well known that the most widely used TBS patterns are intermittent (i)TBS and continuous (c)TBS. iTBS consists of a 2-s train of TBS repeated every 10 s for a total of 190 s which produces long-term potentiation (LTP)-like effects, whereas cTBS consists of three-pulse bursts at 50 Hz repeated every 200 ms for 40 s, which induces long-term depression (LTD)-like cortical plasticity [14, 18,19,20].

Use of an rTMS protocol with iTBS in chronic stroke patients was shown to significantly increase ipsilesional M₁ excitability, enhanced MEP amplitudes, and improve upper-limb motor functions [15, 21,22,23]. One recent meta-analysis showed that the standardized mean difference (SMD) of iTBS was 0.60 (p = 0.018), whereas that for cTBS was 0.35 (p = 0.138) for the recovery of upper-limb motor outcomes in stroke patients, indicating that iTBS was more beneficial than cTBS in motor recovery after a stroke [24]. Therefore, modulation of cortical plasticity induced by iTBS may have therapeutic potential for patients with post-stroke motor disorders.

Both rTMS and tDCS can cause physiological effects and indirectly modulate deep-brain locations via neural circuits [25, 26]. In general, rTMS therapy is usually applied before undertaking occupational therapy for patients with motor function deficits, due to the bulky size of the rTMS device. On the contrary, the lightweight, portable tDCS device can be directly worn on a patient's head during active rehabilitation exercises, which was associated with augmentation of synaptic plasticity [27,28,29]. However, most traditional transcranial stimulators have only a DC waveform mode at present. Thus, our novel transcranial burst electrostimulator was designed to develop an effective and optimal therapeutic system for patients who need rehabilitation therapy. We previously demonstrated that compared to conventional anodal tDCS, the combined DC-iTBS electrostimulator induced LTP-like plasticity as evident from significantly enhanced MEP amplitudes for at least 30 min in animal experiments [12].

With the excellent efficacy of previously combined stimulation, we report a pilot randomized controlled study to examine the combined effects of DC-iTBS and conventional rehabilitation (CR) on upper-limb motor function as measured by the Fugl-Meyer Assessment upper extremity (FMA-UE), Finger-to-Nose test (FNT), and Jebsen-Taylor hand function test (JTT) in patients with chronic stroke compared to a sham intervention. To our knowledge, this is the first randomized controlled trial (RCT) to apply tDCS with iTBS to facilitate upper-limb motor function in chronic stroke patients. We also expected that the novel DC-iTBS stimulation combined with rehabilitation of the upper extremities would result in greater improvements and have potential to become a routine treatment strategy for stroke patients at hospitals and residential rehabilitation facilities.

More at link.

 

Flow Diversion for Reconstruction of Intradural Vertebral Artery Dissecting Aneurysms Causing Subarachnoid Hemorrhage—A Retrospective Study From Four Neurovascular Centers

More information for your doctor to explain to you if this applies.

Flow Diversion for Reconstruction of Intradural Vertebral Artery Dissecting Aneurysms Causing Subarachnoid Hemorrhage—A Retrospective Study From Four Neurovascular Centers

Jens Maybaum¹, Hans Henkes², Marta Aguilar-Pérez², Victoria Hellstern², Georg Alexander Gihr², Wolfgang Härtig³, André Reisberg⁴, Dirk Mucha⁵, Marie-Sophie Schüngel¹, Richard Brill⁶, Ulf Quäschling¹, Karl-Titus Hoffmann¹ and Stefan Schob^6*

• ¹Institute of Neuroradiology, University Hospital Leipzig, Leipzig, Germany
• ²Neuroradiological Clinic, Katharinenhospital Stuttgart, Stuttgart, Germany
• ³Paul Flechsig Institute for Brain Research, University of Leipzig, Leipzig, Germany
• ⁴Department of Diagnostic Imaging and Interventional Radiology, Bergbau-Berufsgenossenschaft Hospital Bergmannstrost Halle, Halle, Germany
• ⁵Department of Radiology, Interventional Radiology and Neuroradiology, Heinrich-Braun-Klinikum, Zwickau, Germany
• ⁶Department of Neuroradiology, Radiology and Policlinic of Radiology, University Hospital Halle (Saale), Halle, Germany

Objective: 

Dissecting aneurysms (DAs) of the vertebrobasilar territory manifesting with subarachnoid hemorrhage (SAH) are associated with significant morbi-mortality, especially in the case of re-hemorrhage. Sufficient reconstruction of the affected vessel is paramount, in particular, if a dominant vertebral artery (VA) is impacted. Reconstructive options include stent-assisted coiling and flow diversion (FD). The latter is technically less challenging and does not require catheterization of the fragile aneurysm. Our study aims to report a multicentric experience with FD for reconstruction of DA in acute SAH.

Materials and Methods: 

This retrospective study investigated 31 patients (age: 30–78 years, mean 55.5 years) who had suffered from SAH due to a DA of the dominant VA. The patients were treated between 2010 and 2020 in one of the following German neurovascular centers: University Hospital Leipzig, Katharinenhospital Stuttgart, BG Hospital Bergmannstrost Halle/Saale, and Heinrich-Braun-Klinikum Zwickau. Clinical history, imaging, implanted devices, and outcomes were reviewed for the study.

Results: 

Reconstruction with flow-diverting stents was performed in all cases. The p64 was implanted in 14 patients; one of them required an additional balloon-expandable stent to reconstruct severe stenosis in the target segment. One case demanded additional liquid embolization after procedural rupture, and in one case, p64 was combined with a PED. Further 13 patients were treated exclusively with the PED. The p48MW-HPC was used in two patients, one in combination with two additional Silk Vista Baby (SVB). Moreover, one patient was treated with a single SVB, one with a SILK+. Six patients died [Glasgow Outcome Scale (GOS) 1]. Causes of death were periprocedural re-hemorrhage, thrombotic occlusion of the main pulmonary artery, and delayed parenchymal hemorrhage. The remaining three patients died in the acute–subacute phase related to the severity of the initial hemorrhage and associated comorbidities. One patient became apallic (GOS 2), whereas two patients had severe disability (GOS 3) and four had moderate disability (GOS 4). Eighteen patients showed a complete recovery (GOS 5).

Conclusion: 

Reconstruction of VA-DA in acute SAH with flow-diverting stents is a promising approach. However, the severity of the condition is reflected by high overall morbi-mortality, even despite technically successful endovascular treatment.

Introduction

Intracranial dissections of the vertebral artery (VA) represent rare but potentially critical cerebrovascular lesions associated with a significant variety of unspecific symptoms (1). The dissection of an intracranial VA may remain clinically silent but more frequently manifests with posterior circulation stroke, subarachnoid hemorrhage (SAH), or, less frequently, spinal ischemia (2, 3). More than 80% of patients with intracranial VA dissections of the steno-occlusive type develop posterior circulation stroke. However, the majority of those improve without the imperative for endovascular treatment (4, 5).

Ruptured dissecting aneurysms of the intracranial VA are associated with worse outcomes. Between 24 and 72 h after the segmental vascular injury, frequently indicated by a characteristic occipital and nuchal headache, severe SAH manifests in almost every case (6). Subsequently, re-hemorrhage occurs in more than 70% of patients, culminating in mortality rates of ~50% (7). As a consequence, early and sufficient therapy of ruptured dissecting aneurysms of the intracranial VA is mandatory.

Depending on the hemodynamic situation in the posterior circulation and the localization of the ruptured dissecting aneurysm, different endovascular approaches must be considered (8, 9). In case the rupture site is associated with a hypoplastic VA, segmental sacrifice, ideally sparing the posterior inferior cerebellar artery (PICA) orifice, has shown promising results (8, 10). However, segmental sacrifice and proximal VA occlusion carry significant risk for ischemia and, in some cases, re-bleeding (11).

In particular, if the ruptured dissecting aneurysm arises from a dominant VA or involves the PICA origin, a reconstructive technique is recommendable (11, 12). Reconstruction can be achieved with different approaches, for example, stent-in-stent implantation, stent-assisted coiling, and flow-diverting stents (12–16). However, related to the rarity of the condition, only retrospective reports on the different strategies exist, and the most suitable treatment remains to be determined (17).

Flow-diverting stents offer several advantages over the alternative endovascular techniques; most importantly, they allow the reconstruction of the vessel without primary catheterization of the highly fragile dissecting aneurysm, and their increased surface coverage provides a superior seal of the potentially extensive intimal tear in comparison to conventional, low-porosity laser-cut stents. However, reports on flow diversion (FD) in this specific context are lacking.

This study, therefore, aims to report our multicenter experience of FD for the reconstruction of acutely ruptured, dissecting aneurysms of the dominant intracranial VA, including clinical and procedural aspects as well as follow-up data in order to present feasibility, safety, and effectiveness of this approach.

 More at link.

Flow redirection endoluminal device (FRED) for treatment of intracranial aneurysms: A systematic review

After your doctor reviews the pros and cons of this device you can decide what to do. Ask your doctor the chances of your aneurysm rupturing and the likely damage from that.  With all that information presented you can make an informed decision.

Flow redirection endoluminal device (FRED) for treatment of intracranial aneurysms: A systematic review 

Show all authors

Muhammad Waqas, Rimal H Dossani, Modhi Alkhaldi, ...

First Published June 30, 2021 Research Article 

https://doi.org/10.1177/15910199211027991

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Abstract

Introduction

The Flow Redirection Endoluminal Device (FRED; MicroVention) is a dual-layered flow diverter used for the treatment of intracranial aneurysms. The objective of this systematic review was to compile device-related safety and effectiveness data.

Methods

The literature from January 1, 2013 to April 30, 2021 was searched for studies describing use of the FRED for intracranial aneurysm treatment irrespective of aneurysm location and morphology. The review included anterior and posterior circulation ruptured and unruptured saccular, fusiform or dissection, and blister aneurysms. MeSH terms related to “flow re-direction endoluminal device” and “FRED for aneurysms” were used. Data related to indication, complications, and rates of aneurysm occlusion were retrieved and analyzed.

Results

Twenty-two studies with 1729 intracranial aneurysms were included in this review. Overall reported morbidity was 3.9% (range 0–20%). Overall procedure-related mortality was 1.4% (range 0–6%). Complication rates fell into 5 categories: technical (3.6%), ischemic (3.8%), thrombotic or stenotic (6%), hemorrhagic (1.5%), and non-neurological (0.8%). The aneurysm occlusion rate between 0 and 3 months (reported in 11 studies) was 47.8%. The occlusion rate between 4 and 6 months (reported in 14 studies) was 73.8%. Occlusion rates continued to increase to 75.1% at 7–12 months (reported in 10 studies) and 86.6% for follow-up beyond 1 year (reported in 10 studies).

Conclusion

This review indicated that the FRED is a safe and effective for the treatment of intracranial aneurysms. Future studies should directly compare the FRED with other flow diverters for a better understanding of comparative safety and effectiveness among the different devices.

Keywords

Flow diversion, Flow Redirection Endoluminal Device (FRED), Intracranial aneurysms

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EXPRESS: What is the Median Volume of Intracerebral Hemorrhage and is it Changing?

 How is anything here going to get survivors better recovery? Nothing? Then useless research. That is the criteria for all stroke research.

EXPRESS: What is the Median Volume of Intracerebral Hemorrhage and is it Changing?

 

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David Robinson, Carson Van Sanford, Soo Young Kwon, , , , , , , , , , , , , , , ...

First Published June 30, 2021 Research Article 

https://doi.org/10.1177/17474930211032594

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Abstract

Objectives: 

Population-level estimates of the median intracerebral hemorrhage (ICH) volume would allow for the evaluation of clinical trial external validity and determination of temporal trends. We previously reported the median ICH volume in 1988. However, differences in risk factor management, neuroimaging and demographics may have affected ICH volumes. The goal of this study was to determine the median volume of ICH within a population-based cross-sectional study, including whether it has changed over time.

Methods: 

The Genetic and Environmental Risk Factors for Hemorrhagic Stroke study was a population-based study of ICH among residents of the Greater Cincinnati/Northern Kentucky region from 2008 through 2012. The current study utilizes those data and compares with ICH cases from the same region in 1988. Initial CT images of the head were reviewed, and ICH volumes were calculated using consistent methodology.

Results: 

From 2008 through 2012, we identified 1117 cases of ICH. The median volume of ICH was 14.0 mL and was lower in black (11.6) than in white (15.5) patients. Median volumes of lobar and deep ICH were 28·8 mL and 9.8 mL, respectively. Median ICH volume changed significantly from 1988 to 2008-2012, with age-and-race adjusted volume decreasing from 18.3 mL to 13.76 mL (p=0.025).

Conclusions: 

Median volume of ICH was 13.76 mL, and this should be considered in clinical trial design(How precisely are you going to accomplish that, this paper is not enough.) Median ICH volume has apparently decreased from 1988 to 2008-2012.

Keywords

Acute, Cerebral hemorrhage, Epidemiology, Hemorrhage, Intracerebral hemorrahage, Radiology

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