This was a retrospective single operator experience of aneurysm coiling at the Ochsner Clinic, comparing the Penumbra coil 400 with the other most commonly used coil types, Orbit and Galaxy.40 aneurysms treated exclusively with Orbit or Galaxy coils and 18 aneurysms treated only with Penumbra coils from 2010 to February 2012 were compared. Measurements included packing density, number of coils per unit aneurysm volume, and total coil length per unit aneurysm volume.Mean packing density of 33.7% using Penumbra coils was significantly greater than 24.4% for Orbit/Galaxy coils. The number of coils per aneurysm volume of 0.026 coils/mm(3) for the Penumbra coil was significantly lower than 0.114 coils/mm(3) for the Orbit/Galaxy coils. Aneurysm occlusion rates were similar in both groups.Compared with the Orbit/Galaxy coils, our analysis suggests that the Penumbra coil is more efficient and cost effective in the treatment of intracranial aneurysms.
Background: Endovascular mechanical thrombectomy (EVT) for large vessel occlusions has had a dramatic impact on the management of acute ischemic stroke. Extended use of EVT beyond American Heart Association guidelines has been successful in carefully selected cases. Case Report: A 71-year-old male presented to our comprehensive stroke center upon awakening with mild left hemiparesis. He was found to have a chronic occlusion of the right supraclinoid segment of the internal carotid artery. Angiography demonstrated large vessel occlusion of the contralateral A1-A2 junction that was successfully recanalized. Imaging at 24 hours displayed no evidence of infarct, the patient rapidly improved during hospitalization, and he was discharged on postoperative day 7 with a National Institutes of Health Stroke Scale score of zero. Conclusion: We describe successful EVT of a patient presenting with false-localizing symptoms consistent with a right hemispheric acute ischemic stroke secondary to left A1-A2 junction large vessel occlusion. This case demonstrates the importance of a high index of suspicion when evaluating atypical stroke presentations and the effectiveness of EVT in the treatment of distal small-caliber vessels.
Major trials assessing the clinical efficacy of mechanical thrombectomy show some unexpected variability in statistically significant variables.1-4 This abstract will assess the underlying variability of National Institute of Health stroke scale (NIHSS) subscores, and provide proof of concept for its effect on major clinical trials.
Methods
300 consecutive patients evaluated with CT perfusion for stroke were retrospectively analyzed. Patients were included if thrombectomy was attempted and excluded if the pre-intervention dataset was incompletely documented, including incomplete documentation of NIHSS. 53 patients were included in the study. Principal component analysis was performed on the NIHSS subscores for feature reduction with retention of 95% of variance. Three models were made, using composite score (CS), individual subscores (IS), and principal components (PC). Using data available prior to the decision to intervene, whole data logistic regression models were produced to analyze effect of NIHSS on discharge outcome as assessed by modified rankin scale. Discharge location was also assessed. Backward stepwise elimination was used to reduce included variables, with a p-value threshold of 0.1 used for inclusion. Furthermore sampling with repletion was used to divide the data into training and testing subsets, with a 0.8 sampling ratio. Logistic regression models were built on the training data using composite score, individual subscores, and principal components. T-testing with Bonferroni multiple testing correction compared models for accuracy and receiver operating characteristic curves area under the curve (AUC) based on testing data.
Results
Predictive model analysis of mRS, PC based models (accuracy 61.79+/-9.90 AUC.704+/-0.111) outperformed IS (accuracy 60.88+/-10.42 AUC 0.605+/-0.130) and composite score (accuracy 59.23+/-10.49, AUC 0.632+/-0.132) with a p value<0.001 for AUC. For accuracy PC also showed a statistically significant improvement in accuracy over CS with p<0.02. Similar results were seen for discharge location, with statistically significant improvement of PC models over CS models in AUC and accuracy. For both discharge location and mRS, analytic handling of NIHSS subscores produces variation in what factors are statistically significant, altering included variables and their p values.
Conclusions
NIHSS composite score is a suboptimal predictor for assessed patient outcomes. Principal component analysis improves predictive value of assessment with a statistically significant effect for pre-intervention patient outcomes analysis. Statistically significant variables are heavily dependent of NIHSS subscores, and variation in the distribution of these subscore may represent a significant source of bias.
References
. OA Berkhemer, et al. MR CLEAN, a multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands: new england journal of med 372;1 nejm.org january 1, 2015. . Campbell BCV, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009–1018. . Ciccone A, et al. Endovascular treatment for acute ischemic stroke. N Engl J Med2013;368:904–913 . Linfante I, et al. Predictors of poor outcome despite recanalization: a multiple regression analysis of the NASA registry. J Neurointerv Surg. 2016;8:224–229.
Disclosures
S. Arndt: None. A. Albar: None. G. Bennett: None. J. Lavie: None. P. Gulotta: None. J. Milburn: None.
PURPOSE: To determine the value of arterial sheaths in diagnostic neuroangiography in a randomized controlled trial. MATERIALS AND METHODS: A total of 842 patients (411 men, 431 women; mean age, 59.4 years; age range, 29.5–94.3 years) undergoing diagnostic neuroangiography were randomly assigned to groups in which a sheath was introduced immediately after puncture of the femoral artery (sheath group) or in which a diagnostic catheter was introduced without a sheath (control group). Two hundred twenty-four (26.7%) of 839 patients were receiving anticoagulants immediately prior to the procedure. RESULTS: Complications (mostly small hematomas of the groin) occurred in 106 (12.6%) of 842 patients, with no difference between groups (53 [12.6%] of 421 patients in both; P > .99). Ease of catheter manipulation was greater in the sheath group than in the control group. Incidence of bleeding at the femoral puncture site during the procedure was less in the sheath group (seven [1.7%] of 421 patients) versus the control group (150 [35.6%] of 421 patients), with a P value less than .001. Because of bleeding, sheath insertion was necessary in 165 (39.2%) of 421 patients in the control group. This crossover group also had a higher rate of local complications (28 [17.0%] of 165 patients) than the sheath and control groups. Serious complications, such as stroke (one [0.12%] of 842 patients) and transient ischemic attacks (five [0.60%] of 842 patients), occurred with equal frequency in both the sheath and control groups. CONCLUSION: Use of arterial sheaths lessens the incidence of intraprocedural bleeding at the femoral puncture site and increases ease of catheter manipulation without increasing the number of groin complications.
Burnout takes a heavy toll on healthcare providers. We sought to assess the prevalence and risk factors for burnout among neurointerventional (NI) non-physician procedural staff (nurses and technologists) given increasing thrombectomy demands.
Materials and Methods
A 41 question online survey containing questions including the Maslach Burnout Inventory-Human Services Survey for Medical Personnel was distributed to NI nurses and radiology technologists at 20 U.S. endovascular capable stroke centers.
Results
244 responses were received (64% response rate). Median (inter-quartile range) composite scores for emotional exhaustion were 25 (15–35), depersonalization 6 (2–11) and personal accomplishment 39 (35–43). Fifty-one percent of respondents met established criteria for burnout. There was no significant relationship between hospital thrombectomy volume, call frequency, call cases covered, or length of commute. On multiple logistic regression analysis, feeling under-appreciated by hospital leadership (OR 4.1; P<0.001) and working with difficult/unpleasant physicians (OR 1.2; P=0.05) were strongly associated with burnout. At participating centers, nurse and technologist attrition was 25% over the last year. Over 50% of respondents indicated they had strongly considered leaving their position over the last 2 years.
Conclusion
This survey of United States NI non-physician procedural staff demonstrates a self-reported burnout prevalence of 51%. This was driven more by interaction with leadership and physician staff than by thrombectomy procedural volume and stroke call. Attrition among NI non-physician procedural staff is high.
Disclosures
K. Fargen: None. S. Ansari: None. A. Spiotta: None. G. Dabus: None. M. Mokin: None. P. Brown: None. S. Wolfe: None. C. Kittel: None. P. Kan: None. B. Baxter: None. R. de Leacy: None. J. Milburn: None. S. Munich: None. A. Ducruet: None. A. Reeves: None. J. Fraser: None. R. Starke: None. A. Jadhav: None. W. Mack: None. A. Arthur: None. G. Pride: None. S. Sheth: None. T. Leslie-Mazwi: None. J. Hirsch: None.
We describe the case of a patient with aneurysmal subarachnoid hemorrhage who was transferred to our hospital for treatment. She developed spontaneous rebleeding from her aneurysm that was depicted on her computed tomography (CT) angiogram (CTA) obtained in the emergency department (ED).
A 68-year-
Modern aspiration catheters have revolutionized thrombectomy outcomes. The Zoom System is series of catheters, with ID's of 0.045, 0.055, 0.071, and 0.088, that are advertised as being designed to support superior stroke thrombectomy performance. We aimed to preliminarily evaluate such claims by retrospectively assessing technical outcomes in a consecutive series of M1 ELVOs in which aspiration was the first line approach.
Methods
We performed a retrospective multicenter analysis of consecutive ELVO patients with M1 occlusion treated within 24 hours from the time of last known well. Patients were divided into two cohorts: those in whom the Zoom 088 or 071 was the initial technology used to attempt reperfusion and those in whom any other aspiration catheter was used for initial reperfusion attempt. The primary outcome was excellent reperfusion (TICI≥2C) on first pass. Secondary outcomes included the rate of excellent reperfusion and successful reperfusion (TICI≥2B), access to successful reperfusion time, and occurrence of downstream emboli. All data was self-adjudicated. No outside funding was provided for this analysis.
Results
Total of 660 patients with acute M1 occlusion who underwent thrombectomy were identified. Zoom System catheters (088 or 071) were used as primary aspiration catheter in 172 patients, while 488 patients were treated with other aspiration catheters (ranging from 064 to 074). The baseline mRS score, admission NIHSS score, the rate of intravenous thrombolytic therapy, symptom onset to hospital arrival, and use of anesthesia were not different between the cohorts. The primary outcome, first pass excellent reperfusion, was significantly higher in the Zoom System cohort (51% vs 41%, p=0.02). The rate of excellent reperfusion was significantly higher in the Zoom cohort (68% vs 59%, p=0.04), however, there was no difference in the rate of successful reperfusion (96% vs 94%, p=0.78). Access time to final reperfusion was significantly faster in the Zoom cohort (27 vs 35 minutes, p<.0001). After adjusting for confounding factors (age, thrombectomy technique, use of secondary aspiration catheter), access time to TICI 2B (30 vs 35 minutes, p=0.028) and final recanalization (25 vs 31 minutes, p=0.018) were significantly shorter in the Zoom System cohort.
Conclusion
This retrospective, multicenter, consecutive real-world experience suggests that using Zoom 088 or 071 as primary aspiration catheter may demonstrate superior technical outcomes for M1 thrombectomy.
Disclosures
S. Majidi: None. J. Vargas: 2; C; Cerenovus, Medtronic. 4; C; Truvic. H. Hawk: None. S. Nimjee: None. A. Zakeri: None. M. Mokin: 2; C; Medtronic, Cerenovus. R. Kellogg: None. R. DeLeacy: None. G. Cortez: None. A. Aghaebrahmin: None. E. Sauvageau: None. R. Hanel: 1; C; Microvention, Stryker. 2; C; Medtronic, Microvention, Stryker, Balt, Cerenovus, Q'Apel. A. Siddiqui: 2; C; Imperitive Care, Medtronic, Microvention, Penumbra, Q'Apel, Stryker. 4; C; Imperitive Care, Q'Apel, Truvic, RiSt. M. Oselkin: None. E. Marlin: None. A. Turk: 2; C; Impertive care, stryker, medtronic, penumbra, balt, cerenovus. 4; C; imperitive care. R. Turner: 2; C; Q'Apel, Cerenovus, Medtronic, Siemens. 4; C; Q'Apel. I. Chaudry: 2; C; Medtronic, Microvention, Q'Apel. 4; C; Q'Apel. J. Milburn: None.
The WHO European Region has faced high rates of external and internal migration in recent years, with concerns that this is contributing to the burden of tuberculosis (TB), multidrug-resistant TB (MDR-TB) and TB/HIV coinfection in some countries. This report examines evidence of effective and efficient service packages for the prevention, diagnosis and treatment of TB to inform strategies to address the TB burden in refugee and migrant populations. Significant regional variations were identified in both migration levels and TB burden in refugees and migrants, as well as in approaches to TB control, with low quality of evidence in many cases. While it is unlikely that a single strategy/package will be effective for all situations, the evidence highlights some common approaches that could guide policy-making and service development. TB elimination targets for the Region will not be met unless inequalities in access to screening and treatment for migrants are addressed, alongside efforts to tackle TB globally.
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