Intracerebral hemorrhage (ICH) is associated with devastating outcomes. Admission to the intensive care unit has been the only proven course to improve outcomes. All other treatment modalities have failed so far. The majority of patients presenting with ICH have an elevated blood pressure (BP). Initial data on the safety and efficacy of BP treatment in acute ICH have been conflicting. This has led to large prospective and randomized clinical trials to assess the safety and efficacy of early BP lowering in acute ICH. These trials showed safety and a tendency toward improved functional outcomes. In fact, the results of three subsequent meta-analyses also showed safety and possible efficacy of early lowering of BP in ICH. Based on the results of the published clinical trials and meta-analyses, the American Heart Association and the European Stroke Association concluded that early intensive treatment of BP in acute ICH is safe and might improve functional outcome. The authors advocate that-pending additional data from ongoing trials-health care professionals should maintain the SBp < 140 mm Hg in patients presenting with acute ICH.
Objective: To determine the 5 year risk of new intracranial hemorrhage, second procedure, and all-cause mortality in elderly patients with unruptured intracranial aneurysms who underwent either surgical or endovascular treatment. Methods: The study included a representative sample of fee-for-service Medicare beneficiaries aged 65 years or older who underwent endovascular or surgical treatment for unruptured intracranial aneurysms between 1999 through 2010. The Medicare Provider Analysis and Review files were linked to the Center for Medicaid and Medicare Services denominator files for 2000-2010 to ascertain any new admission or mortality. Cox proportional hazards and Kaplan Meir survival analyses were used to assess the relative risk of all-cause mortality, new intracranial hemorrhage, or second procedure for patients treated with endovascular treatment compared with those treated with surgical treatment after adjusting for potential confounders. Results: A total of 1005 patients with unruptured intracranial aneurysms were treated with either endovascular (n=569) or surgical treatment (n=436) with post-procedure follow-up available for 4.64 (±2.98) years. The rate of immediate post-procedural neurological complications (8.7% vs. 3.2%, p<0.0001) and requirement for intraventricular catheter (2.8% vs. 0.7%, p=0.019) was higher among patients treated with surgery compared with those treated with endovascular treatment. The estimated 5 year survival was 93.6% and 95.8% in patients treated with surgical and endovascular treatments, respectively. After adjusting for age, gender, and race/ethnicity, relative risks of all-cause mortality (RR 0.5, 95% CI 0.3-0.9) and new intracranial hemorrhage (RR 0.4, 95% CI 0.2-0.8) were significantly lower with endovascular treatment. Conclusions: In elderly patients with unruptured intracranial aneurysms, endovascular treatment was associated with lower rates of acute adverse events, long-term all-cause mortality and new intracranial hemorrhages.
Introduction: Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) results, published in 2010, showed no difference in composite outcome (stroke, myocardial infarction, or death) between carotid artery stent placement (CAS) and carotid endarterectomy (CEA). The impact of these results on the pre-existing practices has not been studied. The aim of our study is to determine whether any change in utilization and outcomes of CAS and CEA subsequent to the CREST results. Methods: We estimated the frequency of CAS and CEA procedures in the years 2009 (pre-CREST period) and 2011 (post-CREST period), using data from the National In-patient Sample (NIS). Pre- and post-CREST CAS and post-CREST CEA rates and outcomes were compared with pre-CREST CEA (reference). Results: A total of 225,191 patients underwent CEA or CAS in pre- and post-CREST period. The frequency of CAS did not change after CREST publication. In the pre-CREST period, CAS group (compared with CEA) were younger .Neurological complications, and in-hospital mortality was higher in the CAS group compared to CEA group in the pre-CREST analysis (p=0.008, 0.0003, 0.0004, respectively. In the post-CREST period, the frequency of CAS has remained unchanged in comparison to CEA. Neurological complications were more frequently reported in the post-CREST group (p<0.0001 and 0.005, respectively). Post-procedure cardiac complications were not different in both pre and post CREST CAS group when compared with reference CEA group (p=0.8 and 0.6, respectively). After adjusting for age, gender and risk factors, the Odds ratio (OR) for moderate to severe disability was 1.0 (95% CI 0.8-1.2) in the pre-CREST CAS group and 0.7 (95%CI 0.6-0.9) in the post-CREST CAS group compared with the reference. Adjusted OR for neurological complications in the pre-CREST CAS group was 0.6 (95%CI 0.6-0.9) and 0.7 (95%CI 0.5-0.9) in the post-CREST CAS group. Conclusion: The frequency of CAS and CEA for carotid artery stenosis has not changed after the publication of CREST trial. The demographics, pre-treatment co-morbidity profile and in-hospital complications remain unchanged during the two time periods. CAS continues to have higher risk of post-operative neurological complications as reported in CREST trial.
Percutaneous transluminal angioplasty and stent placement (PTAS) has become a treatment option for selected patients with symptomatic intracranial arterial stenosis.[1][1] The Stent Placement versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS)
To investigate the role that intravascular thrombus volume plays in mechanical thrombectomy and dose-titrated algorithms using pharmaceutical thrombolytic therapies.The angiographic studies of 33 consecutive patients (19 women; mean age 66+/-11 years) who underwent endovascular treatment for acute ischemic stroke were reviewed. A double-injection technique was utilized that involved 2 catheters for simultaneous injection of contrast proximal and distal to the thrombus to delineate its boundaries. The thrombus volume was calculated using the formula for cylindrical objects after measuring its length and diameter.The volume of the 36 thrombi measured in the study group was 46+/-59 mm3. The mean length and diameter were 10+/-6 and 2+/-1 mm, respectively. The time between symptom onset and acquisition of angiographic images ranged from 167 to 589 minutes (mean 336+/-109). In a multivariate analysis, thrombus volume was not associated with any recanalization (odds ratio 2.4, 95% CI 0.02-191) after adjusting for initial occlusion grade, time between symptom onset and angiography, and previous intravenous use of thrombolytic agents. Volume capacities for retrieval devices to retain 50% and 75% of the thrombi were estimated as 29.2 mm3 and 55.3 mm3, respectively.The large variation in thrombi volume must be considered in designing retrieval devices to optimize their performance.
Background and Purpose: Chronic hypoperfusion associated with high grade intracranial atherosclerosis may results in regional atrophy. This study was performed to determine the effect of intracranial stenosis on ipsilateral regional cerebral volume. Methods: We included patients with intracranial stenosis >50% in the anterior circulation who underwent brain magnetic resonance image (MRI) who were admitted to a University hospital. The severity of intracranial atherosclerosis was evaluated by angiography and degree of stenosis was calculated using the WASID criteria. MRI images were acquired with a 1.5-T MR scanner and fluid attenuated inversion recovery (FLAIR) images were used for volumetric analysis. Volumetric analysis was performed by a single observer with the ANALYZE 9.0 software package. Hemispheric supratentorial volume was defined as hemispheric volume (HV) and included a cumulative value of grey and white matter volumes in frontal, parietal, and occipital lobes. Results: A total 42 hemispheres in 21 patients (12 men, mean age±standard deviation 56.4±16.2 years) with intracranial stenosis were studied. There was no statistical difference of HV in between non-stenotic and stenotic side (491.7±62.6 vs 486.7±57.8 cm3, p=0.3953, t-test). There was no statistical difference of HV in between moderate stenosis (50∼75%) and severe stenosis (>75%) (480.6±56.7 vs 490.5±60.4 cm3, p=0.3657, t-test). However, in regression analysis, difference between both HV (non stenotic-side - stenotic side HV) within individuals significantly correlated with degree of stenosis (R2=0.27, P=0.0152). Conclusion: The patients with intracranial stenosis of anterior circulation appear to have an asymmetry in regional cerebral volume directly related to the severity of stenosis. This observation supports the concept that regional cerebral atrophy may be seen with intracranial stenosis.
Background: Induced hypertension is feasible, likely safe and can improve neurologic deficits in patients who are not candidates for thrombolysis. The safety of inducing hypertension in post-thrombolytic patients with suboptimal recanalization after endovascular thrombolysis is not currently known. Objective: To determine the feasibility and safety of inducing hypertension in patients in the acute post thrombolytic phase. Methods: We analyzed retrospectively collected data from a database of patients who presented with acute ischemic stroke and who received endovascular treatment with or without intravenous (IV) r-tPA . Patients with suboptimal recanalization after endovascular thrombolysis underwent induction of hypertension (systolic blood pressure [SBP] target 140-180 mmHg) for a 24 hour period after an immediate post-procedure CT scan did not demonstrate any intracerebral hemorrhage (ICH). We determined the rate of symptomatic ICH (sICH), and outcome based on modified Rankin score (mRS) at the time of discharge and compared these data to those observed in patients with non-induced hypertension and normotension. Multivariate logistic regression analysis was used to identify the odds ratio of neurological worsening and/or death after adjusting for initial National Institute of Health Stroke Scale (NIHSS) score and success of hypertension induction, which was defined as a sustained mean BP of ≥ 30% above the admission BP over the first 24 hours. Results: A total of 16 patients (12%, mean age 66) underwent post-thrombolytic induced hypertension among 138 patients who were treated with endovascular treatment. The mean age (± standard deviation [SD]) of treated patients was 68 (± 15.3) years and 52 (46%) were women. Hypertension was induced using intravenous phenylephrine or norepinephrine infusion in 9 and 7 patients, respectively. The mean (±SD) increase in SBP was 140 (±16.4) mmHg. In multivariate analysis, patients with post-thrombolytic induced hypertension had similar risk of sICH (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.11-8.55) and similar discharge mRS (OR 1.85, 95% CI 0.50-6.84). Conclusion: There was no observed increase in sICH or poor outcomes associated with induced hypertension in patients with suboptimal recanalization after endovascular thrombolysis supporting safety. Further trials directed towards assessing efficacy of this approach are needed.
Introduction: Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) results, published in 2010, showed no difference in outcome between carotid artery stenting (CAS) and carotid endarterectomy (CEA). We aim to determine whether there has been any change in utilization or outcomes of CAS and CEA after CREST results. Methods: We determined the frequency of CAS and CEA procedures performed in the state of Minnesota, in the years 2009 (pre-CREST period) and 2011 (post-CREST period), using data from the Minnesota Hospital Association. Pre- and post-CREST CAS and post-CREST CEA rates and outcomes were compared with pre-CREST CEA (reference). In-hospital outcomes were analyzed after adjusting for potential confounders using multivariate analysis. Results: A total of 2,718 patients underwent CEA or CAS in pre- and post-CREST period. The frequency of CAS increased from 8.2% to 11.5% of the total patients treated (p=0.004). In the pre-CREST period, CAS group (compared with CEA) were younger, had higher rate of diabetes mellitus and congestive heart failure, in-hospital occurrence of urinary tract infection, sepsis, and myocardial infarction. In the post-CREST period, CAS group did not differ from CEA group in demographics, medical co morbidities, or in-hospital complications except UTI. Hospital stay and hospital charges were greater with CAS compared to CEA, however, the differences in 2011 were less than in 2009. After adjusting for age, sex, relevant risk factors and hospital complications, compared with pre-CREST CEA, pre-CREST CAS was associated with higher neurological complications (odds ratio [OR] 3.3; 95% confidence interval [CI] 1.1-10; p=0.03), cardiovascular complications (OR 5.0; 95% CI 1.8-14; p=0.001), and composite outcome of neurological complications, cardiovascular complications, or death (OR 4.0; 95% CI 1.8-8.6; p=0.0007). There was no difference in outcomes or procedure-related complications between post-CREST CAS and either pre- or post-CREST CEA. Conclusion: There has been a significant increase in the number and improvement in outcome of CAS procedures performed after publication of CREST results in state of Minnesota, presumably due to higher rates of CAS performance in average surgical risk patients.
Background: The off label use of FDA approved drugs and devices in neuroendovascular procedures is common. However, the frequency and characteristics of such use in the endovascular treatment of cerebrovascular diseases is not well defined. Methods: We reviewed 100 consecutive endovascular procedures and ascertained off label use with either drugs or devices. The off label uses were categorized as I or II if the drug or device had been evaluated as primary or ancillary intervention in prospective trial/registry of neuro-endovascular procedures and III if evaluated in case series. Category IV use was based on evaluation as primary or ancillary intervention in prospective trial/registry of non neuro-endovascular procedures. Results: Of the 100 consecutive endovascular procedures reviewed, all the procedures were performed under heparin infusion (category II off label use); intra-arterial (IA) nicardipine or verapamil (category III) in 31 cases; dual anti platelet therapy (category II) in 24 cases; IA thrombolytics (category I) in 13 cases; stent assisted embolization of intracranial aneurysms (category I) in 3 cases; stent placement of intracranial stenosis (category I) in 4 cases; angioplasty alone of intracranial stenosis (category III) in 3 cases; 5 cases had stent placement of carotid or vertebral dissections (category III); the intravascular ultrasound (IVUS) catheter system were used in 3 cases (category III); and PVA embolization of the internal maxillary artery (category III) in 2 cases. Conclusions: The off label use of FDA approved drugs and devices for endovascular treatment of cerebrovascular diseases is highly prevalent. However, physicians have the responsibility to be well informed about the product, in order to base its use on firm scientific rationale and to maintain awareness of the product’s use and effects.
'%3e%3cpath fill='%23012169' d='M0 0v30h60V0z'/%3e%3cpath stroke='%23fff' stroke-width='6' d='m0 0 60 30m0-30L0 30'/%3e%3cpath stroke='%23C8102E' stroke-width='4' d='m0 0 60 30m0-30L0 30' clip-path='url(%23b)'/%3e%3cpath stroke='%23fff' stroke-width='10' d='M30 0v30M0 15h60'/%3e%3cpath stroke='%23C8102E' stroke-width='6' d='M30 0v30M0 15h60'/%3e%3c/g%3e%3c/svg%3e)