Abstract In-stent stenosis has a reported prevalence of 14% to 19% at 1-yr follow-up after carotid stenting and is associated with an increased risk of acute ischemic stroke. 1,2 Risk factors include female sex, diabetes, and dyslipidemia. Cutting balloon angioplasty is a safe and effective treatment modality for the treatment of carotid in-stent stenosis, and alternative treatment options include observation with medical management and placement of another stent. 3,4 The authors present the case of a 61-yr-old man with carotid in-stent restenosis and progressive worsening on serial imaging with ultrasound. The patient had a history of carotid stenting for symptomatic stenosis 6 mo prior and was maintained on aspirin and clopidogrel. In light of the progressive worsening, the in-stent stenosis was confirmed on computed tomography (CT) angiogram. The options were discussed with the patient and he consented for treatment with cutting balloon angioplasty. Final angiogram showed improvement of the luminal diameter with a residual stenosis of 15%. The patient tolerated the procedure well and was discharged home on postoperative day 1. Follow-up ultrasound demonstrated moderate improvement in peak systolic velocities, and the plan is to continue observation with a clinical follow-up and repeat carotid Dopplers at 3 mo.
To the Editor: COVID-19 syndrome, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, most commonly presents with upper respiratory infectious symptoms and may lead to hypoxemic failure, the most common cause of ventilation support.1-5 There may be a hypercoagulable state during SARS-CoV-2 infections that could lead to an increased vascular thrombotic phenomenon and a potential need for neurointerventional procedures.6-8 We aim to outline practices to be considered when managing COVID-19 patients requiring neurointerventional care. GENERAL PLANNING Given the number of SARS-CoV-2 infections within the community, patients presenting with neurological emergencies needing immediate interventional therapy will not be able to be tested in time, and thus such patients should be considered as persons under investigation (PUIs) for SARS-CoV-2 viral infection.4 Care of such patients should be performed with maximal personal protective equipment (PPE), including N95 masks.9,10 All patients needing emergent neurointerventional procedures should be considered PUIs. Maximal PPE should be employed when performing emergent neurointerventional procedures on COVID-19 or PUI patients. Personnel It is ideal to minimize the number of neurointerventional radiology (NIR) attendings, fellows, nurses, and technologists who are in-house at any one time to minimize personnel exposure to SARS-CoV-2.11 This is feasible with a general trend towards canceling elective procedures during the pandemic. Members of the NIR team need to be appropriately fitted with the N95 mask and be aware as to how to obtain all appropriate PPE as N95s may be stored in secure environments. Those who have facial hair or cannot tolerate an N95 must be trained to use a powered air purifying respirator (PAPR) or follow alternative institutional protocols. One can reuse the N95 for up to 8 h without an outer cover; however, when a face mask is worn over the N95 to prevent gross contamination, its reuse can be extended. During cases it is imperative that team members within the NIR suite restrict their movement and not enter clean areas until the procedure is completed and they have doffed their PPEs appropriately. This will necessitate that a member of the team be placed in the clean control room to obtain the equipment necessary during the procedure. The number of NIR personnel within the hospital setting should be minimal. All team members must be fitted appropriately with N95 masks. An outer standard surgical mask should be worn over the N95 to prolong the shelf life of the N95. NIR personnel should be divided as such to prevent the movement of NIR suite personnel to clean areas. NIR Suite and Control Room NIR suites are typically positive-pressure areas to minimize outside infectious contaminants and prevent procedure-related infections; however, this also increases the risk of spreading aerosolized respiratory secretions from COVID-19 patients. Reports from Singapore and New York University share the idea of converting COVID-designated NIR suites into negative-pressure areas with high efficiency particulate air (HEPA) filters, thus reducing the risk of contaminating air flow systems and minimizing the exposure of clean areas to infectious particulate matter. While there may be a theoretical risk of increasing surgical site infections (SSIs) in a negative-pressure environment, this may be outweighed by the benefits of minimizing the exposure of clean areas to infectious matter.12 If a facility has 2 NIR suites, one should become the designated suite for COVID+/PUI patients and the other for documented COVID-19-negative patients. The inventory in the COVID-19-designated suite should remain in closed storage closets at all times, or a barrier such as plastic sheets could be secured to cover the inventory. Infrequently used inventory should be removed from the suite and could be stored in the control room or an adjacent anteroom. In addition, you must determine if the control room attached to the COVID NIR suite can be maintained as a clean environment. This can be done if the pressure of the control room can be changed to be higher than that of the NIR suite. If this can be achieved, then portable material within the NIR suite can be moved to the control room. If the control room cannot be maintained as a clean environment, then it is ideal to move nonessential portable equipment from the control room, as it also may require a terminal clean. All COVID-contaminated areas (NIR suite and possibly the control room) will need terminal cleaning from ceiling to floor, including the lights and air ducts. Designate one NIR suite as COVID NIR and remove all portable equipment that may get contaminated. Predetermine supplies needed for the NIR case and take those to COVID NIR. Keep the clean control room entrance to the COVID NIR room closed at all times during the procedure. Maintain 1 team member in the NIR control room to seek needed supplies. Anteroom An anteroom serves as a gateway from the COVID-designated NIR suite to the halls, preventing infectious particulate matter from reaching the halls.13 The anteroom is a small area outside of the NIR suite under negative pressure and fitted with a HEPA filter allowing for personnel to remove their PPE and wash hands before entering a clean area. The negative pressure within the anteroom prevents contaminated particulate matter from traveling to other parts of the hospital. Most NIR suites may not have an attached anteroom, thus engineering staff should be contacted to build a portable anteroom for the COVID NIR suite. Build an anteroom attached to the COVID-NIR suite to prevent contamination of adjacent clean areas. PREOPERATIVE, OPERATIVE, AND POSTOPERATIVE BEST PRACTICES Transfer from emergency department (ED) to NIR Room All nonintubated patients being transported should have a face mask in place. For an intubated patient, it is safest to maintain a closed circuit until after the procedure is concluded. If that is not possible, extreme caution must be taken while clamping the tube when transferring from bagging to ventilator, or ideally the patient may remain on a single ventilator from ED until after treatment, when the ventilator can be changed in a negative-pressure setting. All personnel working with COVID-19 patients should have maximal PPE. A face mask should be placed on all nonintubated patients during transport. Endotracheal tubes should be clamped before transferring to ventilator. Intubation and Procedure With most NIR emergencies (subarachnoid hemorrhage, carotid blow out, epistaxis, etc), intubation becomes essential for the protection of the airway; however, with large vessel occlusion (LVO)-related ischemic stroke, there continues to be a lack of guidance for the best practice. If intubation is to be performed, it should ideally be performed in a negative-pressure environment to minimize the contamination of adjacent areas and personnel, and hypotension should be avoided in stroke patients.14 If intubation must be performed in the NIR suite, then only anesthesia staff donning appropriate PPE should be present within the room, and postintubation a barrier around the patient's face should be applied to contain aerosolization.15 Before entering the NIR suite, you should wait for a period of time (determined by your engineering team) to minimize aerosolized particulate matter within the NIR environment; however, such delays will not be ideal in cases of LVO-related stroke patients. If a negative-pressure room is available, full recirculation time is typically around 3 min, so staff may re-enter the room within 5 min. Other centers have not changed their anesthesia/intubation paradigms secondary to the COVID status. In these circumstances, patients remain on nasal cannula O2 with a face mask, and there is not a need to extubate, which is the largest producer of aerosolized matter. Thus, performing thrombectomies without intubation allows for the avoidance of intubation and extubation (highest risk of aerosolization), risk of patient continuing to be intubated and requiring ventilator and intensive care unit (ICU) room, and prolonged recovery times. Intubation and extubation lead to maximal aerosolization and contamination. Intubation and extubation should ideally be performed in negative-pressure rooms. NIR personnel should not be present for intubations/extubations. NIR should enter with appropriate PPE once airway is secure and patient face barrier is in place. Extubation and Transfer to Final Destination While it is ideal if resources allow for the transport of an intubated patient into a negative-pressure room to extubate, this may be unlikely given the rise in the COVID patient population requiring critical care services and negative-pressure rooms. Thus, if possible, extubate the patient within the NIR environment under the same conditions as described for intubation. Once the patient is extubated and has stopped coughing, it is ideal to transport to the final destination rather than an intermediary stop within the postanesthesia care unit (PACU). This will minimize contamination during transport and minimize the number of healthcare personnel exposed. For those patients not intubated, extubation is avoided; however, they should also be transported to the final destination with a face mask and without stopping in a PACU environment. Flat-panel detector computed tomography (CT) scanning capabilities of modern angiographic equipment may also reduce the need to transport to postprocedure CT. Extubate with a minimal number of surrounding personnel (must use N95s). Transfer the patient to the final destination rather than an intermediary location (PACU). Terminal clean the COVID NIR suite. CONCLUSION The COVID-19 pandemic is affecting most regions of the United States, necessitating a change in our practice patterns. We have outlined general principles to be taken into consideration as neurointerventional teams look to care for their patients while preventing the exposure of other patients as well as healthcare personnel. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
A 40-yr-old male with no significant past medical history presented with sudden onset right-sided retro-orbital headache associated with vision loss after a session of strenuous exercise. Initial assessment with noncontrast head computed tomography at the local emergency department revealed a right sided occipital intracranial hemorrhage (ICH). On arrival the patient ad a left quadrantopsia with Glasgow Coma Scale of 15 and an ICH score of 0. A computed tomographic angiography showed a high density 6 × 9 mm vascular lesion associated with 2 tortuous vessels. Cerebral angiography revealed a right sided dural arteriovenous fistula, Cognard Type IV, with arterial feeders arising from dural branches of the right vertebral artery, the posterior division of the right middle meningeal artery and meningeal branches distal to the neuromeningeal trunk of the left ascending pharyngeal artery.1 Four days after the ICH event the patient was treated with endovascular Onyx embolization of the fistula, through a transradial approach. Immediate angiographic assessment showed complete obliteration of the dAVF. The patient was discharged home and recovered his visual field deficit over 3 mo. The following operative video includes a discussion of the endovascular technique and treatment nuances associated with the transarterial management of a dural arteriovenous fistula. Patient consent was given prior to the procedure and consent and approval for this operative video was waived due to the retrospective nature of this manuscript and the anonymized video material.
OBJECTIVE The incidence of already common chronic subdural hematomas (CSDHs) and other nonacute subdural hematomas (NASHs) in the elderly is expected to rise as the population ages over the coming decades. Surgical management is associated with recurrence and exposes elderly patients to perioperative and operative risks. Middle meningeal artery (MMA) embolization offers the potential for a minimally invasive, less morbid treatment in this age group. The clinical and radiographic outcomes after MMA embolization treatment for NASHs have not been adequately described in elderly patients. In this paper, the authors describe the clinical and radiographic outcomes after 151 cases of MMA embolization for NASHs among 121 elderly patients. METHODS In a retrospective review of a prospectively maintained database across 15 US academic centers, the authors identified patients aged ≥ 65 years who underwent MMA embolization for the treatment of NASHs between November 2017 and February 2020. Patient demographics, comorbidities, clinical and radiographic factors, treatment factors, and clinical outcomes were abstracted. Subgroup analysis was performed comparing elderly (age 65–79 years) and advanced elderly (age > 80 years) patients. RESULTS MMA embolization was successfully performed in 98% of NASHs (in 148 of 151 cases) in 121 patients. Seventy elderly patients underwent 87 embolization procedures, and 51 advanced elderly patients underwent 64 embolization procedures. Elderly and advanced elderly patients had similar rates of embolization for upfront (46% vs 61%), recurrent (39% vs 33%), and prophylactic (i.e., with concomitant surgical intervention; 15% vs 6%) NASH treatment. Transfemoral access was used in most patients, and the procedure time was approximately 1 hour in both groups. Particle embolization with supplemental coils was most common, used in 51% (44/87) and 44% (28/64) of attempts for the elderly and advanced elderly groups, respectively. NASH thickness decreased significantly from initial thickness to 6 weeks, with additional decrease in thickness observed in both groups at 90 days. At longest follow-up, the treated NASHs had stabilized or improved in 91% and 98% of the elderly and advanced elderly groups, respectively, with > 50% improvement seen in > 60% of patients for each group. Surgical rescue was necessary in 4.6% and 7.8% of cases, and the overall mortality was 8.6% and 3.9% for elderly and advanced elderly patients, respectively. CONCLUSIONS MMA embolization can be used safely and effectively as an alternative or adjunctive minimally invasive treatment for NASHs in elderly and advanced elderly patients.
Infection from the SARS-CoV-2 virus has led to the COVID-19 pandemic. Given the large number of patients affected, healthcare personnel and facility resources are stretched to the limit; however, the need for urgent and emergent neurosurgical care continues. This article describes best practices when performing neurosurgical procedures on patients with COVID-19 based on multi-institutional experiences.We assembled neurosurgical practitioners from 13 different health systems from across the USA, including those in hot spots, to describe their practices in managing neurosurgical emergencies within the COVID-19 environment.Patients presenting with neurosurgical emergencies should be considered as persons under investigation (PUI) and thus maximal personal protective equipment (PPE) should be donned during interaction and transfer. Intubations and extubations should be done with only anesthesia staff donning maximal PPE in a negative pressure environment. Operating room (OR) staff should enter the room once the air has been cleared of particulate matter. Certain OR suites should be designated as covid ORs, thus allowing for all neurosurgical cases on covid/PUI patients to be performed in these rooms, which will require a terminal clean post procedure. Each COVID OR suite should be attached to an anteroom which is a negative pressure room with a HEPA filter, thus allowing for donning and doffing of PPE without risking contamination of clean areas.Based on a multi-institutional collaborative effort, we describe best practices when providing neurosurgical treatment for patients with COVID-19 in order to optimize clinical care and minimize the exposure of patients and staff.
Survivors of aneurysmal subarachnoid hemorrhage (SAH) are faced with a complicated recovery, which typically includes surgery, prolonged monitoring in the intensive care unit, and treatment focusing on the prevention of complications.The purpose of this study was to determine the safety and feasibility of an early mobilization program for patients with aneurysmal SAH.This study was a retrospective analysis.Twenty-five patients received early mobilization by a physical therapist or an occupational therapist, or both, which focused on functional training and therapeutic exercise in more progressively upright positions. Participation criteria focused on neurologic and physiologic stability prior to the initiation of early mobilization program sessions.Patients met the criteria for participation in 86.1% of the early mobilization program sessions attempted. Patients did not meet criteria for the following reasons: Lindegaard ratio >3.0 or middle cerebral artery (MCA) mean flow velocity (MFV) >120 cm/s (8.1%), mean arterial pressure (MAP) <80 mm Hg (1.8%), intracranial pressure (ICP) >15 mm Hg (1.8%), unable to open eyes in response to voice (0.9%), respiratory rate >40 breaths/min (0.6%), MAP >110 mm Hg (0.3%), and heart rate <40 bpm (0.3%). Adverse events occurred in 5.9% of early mobilization program sessions for the following reasons: MAP <70 mm Hg (3.1%) or >120 mm Hg (2.4%) and heart rate >130 bpm (0.3%). The 30-day mortality rate for all patients was 0%. Participation in the early mobilization program began a mean of 3.2 days (SD=1.3) after aneurysmal SAH, and patients received an average of 11.4 sessions (SD=4.3). Patients required a mean of 5.4 days (SD=4.2) to participate in out-of-bed activity and a mean of 10.7 days (SD=6.2) to walk ≥15.24 m (50 ft).The results of this study suggest that an early mobilization program for patients with aneurysmal SAH is safe and feasible.
Kan, Peter MD, MPH, FRCS; Maragkos, Georgios A MD; Srivatsan, Aditya MS; Srinivasan, Visish MD; Johnson, Jeremiah MD; Burkhardt, Jan-Karl MD; Robinson, Timothy M MD; Salem, Mohamed M MD; Chen, Stephen MD; Riina, Howard A MD; Tanweer, Omar MD; Levy, Elad I MD; Spiotta, Alejandro M MD; Kasab, Sami Al MD; Lena, Jonathan MD; Gross, Bradley A MD; Cherian, Jacob MD; Cawley, C Michael MD; Howard, Brian M MD; Khalessi, Alexander A MD; Pandey, Aditya S MD; Ringer, Andrew J MD; Hanel, Ricardo MD, PhD; Ortiz, Rafael A MD; Langer, David MD; Kelly, Cory M MS; Jankowitz, Brian T MD; Ogilvy, Christopher S MD; Moore, Justin M MD, PhD; Levitt, Michael R MD; Binning, Mandy MD; Grandhi, Ramesh MDMS; Siddiq, Farhan MD; Thomas, Ajith J MD
Current randomized trials demonstrating superiority of mechanical thrombectomy for the treatment of acute ischemic stroke for anterior circulation large vessel occlusion. These trials included patients up to 6 hours from symptom onset. The Trevo Registry is designed to assess real world outcomes of the Trevo Retriever in patients experiencing acute ischemic stroke within any timeframe. This is the largest prospective study for acute stroke intervention that has currently enrolled 718 (1431 with 90 day outcomes) patients. Enrollment is expected to reach 2000 subjects at up to 100 sites. A subgroup analysis of the number of stent-retriever passes and need for adjuvant devices was studied as a function of time last seen normal as well as etiology of stroke.
Methods
The study design is a prospective, open-label, consecutive enrollment, multi-center, global registry of all patients who undergo mechanical thrombectomy for acute stroke using the Trevo stent retriever as the initial device. Subgroup analysis of enrolled patients with 90 day follow-up was performed.
Results
As of March, 24, 2017, a total of 1846 patients were enrolled. The median NIHSS at admission was 15.5 (IQR 11–20). Most patients (67.4%) were treated at 6 hours or less from last known normal with a median procedure time of 50 min (8–286 min). Subgroup analysis of patients presenting within 6 hours of symptom onset and those presenting beyond 6 hours showed no significant difference in patient demographics or medical comorbidities. In addition, there was no difference in complication rate or 90 day outcome between the two groups. The time last seen normal to arterial puncture was 0–3 hours in 23.3%, 3–6 hours 44.1%, 6–8 hours 11.3% and >8 hours in 21. 2% of patients. The mean time last known well to arterial puncture was 7.2±22.8 hours. The mean number of passes with any thrombectomy device, including Trevo, was 1.92±1.37 with a range of 1 to 12 passes. The mean number of passes with the Trevo device was 1.68±1.07 with a range of 1 to 10 passes. Adjunctive devices were use at site of thrombus in 23.6% of patients with aspiration catheter being most frequent (8.9%) and typically associated with worse outcomes in multivariate analyses ( OR 0.61 [0.46–0.82, p<0.001). We see slightly more cardo embolic etiology in the <6 hour group (57.5% vs 50.6, p=0.008) We see slightly fewer passes in the <6 vs >6 cohort (1.6 vs 1.8, p=0.02). Despite differences in TLSW, age, or admission NIHSS, an increased number of device passes (>3) was associated with significantly worse recanalization (OR, 0.287 [0.169–0.488], p<0.0001) and worse mRS outcome (OR, 0.335 [0.206–0.547], p<0.0001).
Conclusions
The Trevo Retriever Registry represents the first look at real world data with stent retriever use in the era of clinical trials showing the overwhelming benefit of stent retrievers to treat acute ischemic stroke. This data represents real world use of the Trevo Retriever in regards to the typical number of passes and devices required for recanalization.
Disclosures
M. Binning: None. E. Veznedaroglu: 2; C; stryker. B. Baxter: None. J. English: None. R. Budzik: None. B. Bartolini: None. D. Liebeskind: None. A. Krajina: None. R. Gupta: None. R. Nogueira: None.
✓Optic pathway gliomas represent approximately 3–5% of childhood intracranial tumors. They usually occur in children during the first decade of life and are seen in 11–30% of patients with neurofibromatosis Type 1 (NF1). Although these tumors are typically low-grade gliomas, the clinical course and natural history are highly variable, making treatment paradigms difficult. Overall, however, they are often indolent tumors that can be observed over time for progression without initial treatment, especially in patients with NF1. Chemotherapy is the first-line treatment for progressive tumors, and radiation therapy is reserved for patients with progressive disease who are older than 5–7 years. Surgery is reserved for large tumors causing mass effect or hydrocephalus and tumors confined to the orbit or unilateral optic nerve.
'%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)