The latest medical research on Cerebrovascular & Skull Base Surgery
The research magnet gathers the latest research from around the web, based on your specialty area. Below you will find a sample of some of the most recent articles from reputable medical journals about cerebrovascular & skull base surgery gathered by our medical AI research bot.
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Request AccessNatural Evolution of Incomplete Reperfusion in Patients following Endovascular Therapy after Ischemic Stroke.
StrokeA third of endovascularly treated stroke patients experience incomplete reperfusion (expanded Thrombolysis in Cerebral Infarction, eTICI<3) and the natural evolution of this incomplete reperfusion remains unknown. We systematically reviewed literature and performed a meta-analysis on the natural evolution of incomplete reperfusion after endovascular therapy.
A systematic review of MEDLINE, Embase and PubMed up until March 1, 2024 using a predefined strategy. Only full-text English written articles reporting rates of either favorable (i.e., delayed reperfusion or no new infarct) or unfavorable progression (i.e., persistent perfusion deficit or new infarct) of incompletely reperfused tissue were included. Primary outcome was the rate of delayed reperfusion and its association with functional independence (modified Rankin Scale, mRS 0-2) at 90 days post-intervention. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random-effects model.
Six studies involving 950 patients (50.7% female; median age 71, IQR 60-79) were included. Four studies assessed the evolution of incomplete reperfusion on MRI perfusion imaging, while two studies used DWI and NCCT imaging, where new infarct was used to denote unfavorable progression. Five studies defined incomplete reperfusion as eTICI2b50 or 2c. Delayed reperfusion occurred in 41% (IQR 33%-51%) of cases 24h post-intervention. Achieving delayed reperfusion was associated with higher likelihood of functional independence at 90 days (OR 2.5, 95%CI 1.9-3.4).
Nearly half of eTICI<3 patients achieve delayed reperfusion, leading to favorable clinical outcome. This subgroup may derive limited or potentially harmful effects from pursuing additional reperfusion strategies (e.g., intra-arterial lytics or secondary thrombectomy). Accurately predicting the evolution of incomplete reperfusion could optimize patient selection for adjunctive reperfusion strategies at the end of an intervention.
Cost-Effectiveness of Nonoperative Management vs Upfront Laparoscopic Appendectomy for Pediatric Uncomplicated Appendicitis Over 1 Year.
American College of SurgeonsNon-operative management (NOM) with antibiotics alone for pediatric uncomplicated appendicitis is accepted to be safe and effective. However, the relative cost-effectiveness of this approach compared to appendectomy remains unknown. We aimed to evaluate the cost-effectiveness of non-operative versus operative management for pediatric uncomplicated acute appendicitis.
A trial-based real-world economic evaluation from the healthcare sector perspective was performed using data collected from a multi-institutional non-randomized controlled trial investigating NOM versus surgery. The time horizon was 1 year, with costs in 2023 US dollars. Ratio of costs-to-charges (RCC)-based data for the initial hospitalization, readmissions, and unplanned emergency department visits were extracted from the Pediatric Health Information System (PHIS). Utility data were derived from patient-reported disability days and health-related quality-of-life scores. Multiple scenarios and one-way deterministic and probabilistic sensitivity analyses accounted for parameter uncertainty. Willingness-to-pay (WTP) threshold was set at $100,000 per quality-adjusted life year (QALY) or disability-adjusted life year (DALY). Primary outcome measures included total and incremental mean costs, QALY, DALY, and incremental cost-effectiveness ratios (ICERs).
Of 1,068 participants, 370 (35%) selected NOM and 698 (65%) selected urgent laparoscopic appendectomy. Operative management cost an average of $9,791/patient and yielded an average of 0.884 QALYs while NOM cost an average of $8,044/patient and yielded an average of 0.895 QALYs. NOM was both less costly and more effective in base case and scenario analyses using disability days and alternate methods of calculating utilities.
NOM is cost-effective compared to laparoscopic appendectomy for pediatric uncomplicated appendicitis over 1 year.
NSAID Allergy Labels Associated With Mortality and Cardiovascular Outcomes in Stroke.
StrokeMislabeled drug allergy can restrict future prescriptions and medication use, but its prevalence and impact among patients with stroke remain unknown. This study investigated the prevalence of the most commonly labeled drug allergies, their accuracy, and their impact among patients with stroke.
In this combined longitudinal and cross-sectional study, we compared the prevalence of allergy labels among the general population and patients with ischemic stroke between 2008 and 2014 from electronic health care records in Hong Kong. Outcomes between patients with stroke with or without the most prevalent labels (ie, NSAID) were compared. Rate of mislabeled NSAID allergy was confirmed by provocation testing.
Compared with the general population (n=702 966), patients with stroke had more labels (n=235) to cardiovascular and hematopoietic system (prevalence, 19.5% versus 9.2%; odds ratio [OR], 2.4 [95% CI, 1.74-3.32]; P<0.001) and radiographic and diagnostic agents (prevalence, 4.2% versus 0.9%; OR, 4.82 [95% CI, 2.56-9.08]; P<0.001). The most common labels were to NSAID (prevalence, 1.8%). Patients with NSAID allergy labels were significantly less likely to be prescribed aspirin after acute stroke (OR, 0.24 [95% CI, 0.09-0.60]; P=0.003) and on follow-up (OR, 0.22 [95% CI, 0.08-0.56]; P=0.002). The median duration of follow-up was 6.7 years (6499±2.49 patient-years). Patients with stroke with NSAID allergy labels also experienced significantly higher mortality (OR, 7.44 [95% CI, 2.44-23.18]; P<0.001), peripheral vascular disease (OR, 9.35 [95% CI, 1.95-44.86]; P=0.005), and major adverse cardiovascular events (OR, 6.09 [95% CI, 2.00-18.58]; P=0.001) in the poststroke period. Patients with NSAID allergy labels (who remained alive and could consent) were referred for allergist assessment and offered drug provocation testing. The majority (80%; 4/5) had negative provocation tests and were delabeled.
NSAID allergy labels were significantly more prevalent among patients with stroke, associated with excessive mortality, peripheral vascular disease, and major adverse cardiovascular events. Given the high rate of mislabeled allergies, multidisciplinary neuro-allergy interventions could have the potential to improve patient outcomes.
EXCELLENT Registry: A Prospective, Multicenter, Global Registry of Endovascular Stroke Treatment With the EMBOTRAP Device.
StrokeThe EXCELLENT registry aimed to evaluate the effectiveness of the EMBOTRAP Revascularization Device in an all-comer population in a real-world setting, with a focus on the composition of retrieved clots.
EXCELLENT is a prospective, global registry of patients with acute ischemic stroke treated with EMBOTRAP as the first-line mechanical thrombectomy device conducted at 34 sites (25 sites contributing clot) from September 2018 to March 2021, utilizing core imaging and central histology laboratories blinded to clinical data, independent 90-day modified Rankin Scale assessment and Clinical Events Committee.
After screening 3799 patients, a total of 997 subjects (mean age, 70.0±14.2 years; 51.8% women; 19.7% non-White) were included. The first-pass modified Treatment in Cerebral Infarction (mTICI) ≥2b rate was 64.5% (623/966), first-pass mTICI ≥2c was 39.1% (378/966), and final mTICI ≥2b was 94.5% (931/985). A total of 427/912 (46.8%) patients achieved a 90-day modified Rankin Scale of 0 to 2 or ≤baseline. Embolization to a new territory occurred in 0.2% (2/984), and symptomatic intracranial hemorrhage at 24 hours in 1.6% (16/997). The 90-day mortality was 19.1% (175/918). Device- and/or procedure-related serious adverse events occurred in 5.9% (54/912) through 90 days. The mean RBC percentage of retrieved clots was 45.62±21.372. Among patients who achieved mTICI ≥2b with the first pass, 15.7% (52/331) and 9.7% (32/331), respectively, had RBC-poor (<25%) and RBC-rich (>75%) clots. Patients with no clot retrieved in any procedural pass had a lower percentage of hyperdense or susceptibility vessel sign on baseline imaging (58.9% versus 74.7%; P<0.001), pointing to a potential preprocedure indicator of challenging clot.
The EXCELLENT registry informs real-world practices in mechanical thrombectomy and sheds light on the range of clots effectively retrieved by current technology. This is the first report of detailed patient characteristics where mechanical thrombectomy maneuvers failed to remove any clot material. Although the composition of nonretrievable clots cannot be assessed histologically, the results support the notion that no retrieval may be correlated with imaging findings suggesting clots lower in RBC.
URL: https://www.clinicaltrials.gov; Unique identifier: NCT03685578.
WMH Contributions to Cognitive Impairment: Rationale and Design of the Diverse VCID Study.
StrokeAs awareness of dementia increases, more individuals with minor cognitive complaints are requesting clinical assessment. Neuroimaging studies frequ...
Cerebral Infarct Growth: Pathophysiology, Pragmatic Assessment, and Clinical Implications.
StrokeCerebral ischemic injury occurs when blood flow drops below a critical level, resulting in an energy failure. The progressive transformation of hyp...
Neuroprotective Effects of Rapid Local Ischemic Postconditioning in Successful Endovascular Thrombectomy Patients.
StrokeWe aim to assess the efficacy of rapid local ischemic postconditioning (RL-IPostC) following successful reperfusion in patients with acute ischemic stroke with anterior circulation large vessel occlusion who underwent endovascular thrombectomy.
We conducted an ambidirectional cohort study with 78 prospectively enrolled patients with RL-IPostC and endovascular thrombectomy and 129 retrospectively enrolled patients with endovascular thrombectomy. The RL-IPostC procedure involved 5 cycles of 15-s balloon inflation and deflation in the ipsilateral internal carotid artery. The primary outcome was functional independence, defined as a modified Rankin Scale score of 0 to 2. Secondary outcomes included excellent outcomes (modified Rankin Scale score, 0-1) and early therapeutic response. Imaging outcomes involved infarct volume changes and cerebral edema measurements. Outcomes were compared with postpropensity score matching (1:1) and assessed using univariable and multivariable regression models.
In the matched cohort of 136 patients (mean age, 71±14 years; 70 men [51%]), RL-IPostC was associated with a higher rate of functional independence (adjusted odds ratio, 2.47 [95% CI, 1.10-5.68]; P=0.030). The RL-IPostC group exhibited significantly reduced infarct volumes at 24 hours (difference, -12.2 [95% CI, -23.9 to -0.53]; P=0.041) and less infarct growth (difference, -12.2 [95% CI, -23.9 to -0.45]; P=0.042). Furthermore, RL-IPostC correlated with lower increases in net water uptake (difference, -0.04 [95% CI, -0.07 to -0.01]; P=0.018), lower decrease cerebrospinal fluid volume (difference, -7.75 [95% CI, -11.7 to -3.84]; P<0.001), and reduced midline shift at 24 hours (difference, -1.39 [95% CI, -2.48 to -0.30]; P=0.013).
RL-IPostC tends to promote functional independence and reduces infarct growth and cerebral edema in patients with acute ischemic stroke post-reperfusion.
Diastolic Dysfunction and the Risk of Stroke and Major Bleeding.
StrokeLeft ventricular diastolic dysfunction (DD) is associated with adverse cardiovascular outcomes including atrial fibrillation. Whether DD is independently associated with incident stroke and transient ischemic attack (TIA) and with bleeding events is not known. We performed this observational cohort analysis to examine the impact of DD on the risk of stroke/TIA and major bleeding.
Patients who underwent at least 1 cardiac echocardiogram and were followed for at least 3 months were included in this study. Patients with a prior history of stroke, TIA, or major bleeding, as determined by International Classifications of Diseases codes, were excluded. Smart key-phrase search was applied to echocardiographic reports to classify patients into 4 groups based on the most severe DD assessment. Patients in whom the presence of DD could not be determined were excluded. The final study cohort was followed to the end point of hospital admission for stroke/TIA and major bleeding, and independent predictors of these events were evaluated using the multivariable Cox proportional hazards method.
The final study cohort (age, 56±18 years; 56% women) had 96 702 patients with no DD and 18 164, 5881, and 1340 patients with DD grades I, II, and III, respectively. Over a median follow-up of 3.4 years, 2938 (2.4%) patients were hospitalized for stroke/TIA and 5567 (4.6%) for major bleeding. After adjusting for age, the CHA2DS2-VASc score, chronic kidney disease, use of antiplatelet agents, use of anticoagulation agents, the year of echocardiographic testing, household income, and history of atrial fibrillation, DD remained a strong predictor of incident stroke/TIA (hazard ratio, 1.22 per grade increase in DD [95% CI, 1.16-1.29]; P<0.001) and major bleeding (hazard ratio, 1.20 per grade increase in DD [95% CI, 1.16-1.25]; P<0.001).
DD is independently associated with a higher risk of cerebrovascular accidents and major bleeding. DD should be considered when counseling patients regarding their risk profile and management options.
Eliminating Error in Central Line Scheduling and Placement Using Quality Improvement Methods.
American College of SurgeonsThe Joint Commission defines a sentinel event as "surgery or other invasive procedure performed at the wrong site, on the wrong patient, or that is the wrong (unintended) procedure for a patient regardless of the type of procedure or the magnitude of the outcome." At our institution, we observed a low but consistent rate of incorrect surgical line placement for pediatric patients with cancer.
Following quality improvement methodology and using the resources available on a large academic medical campus we designed and implemented a new multi-factorial process to schedule and place surgical central lines for pediatric patients with cancer. Changes included re-defining responsibilities, adding staff, and redesigning the process with workflows supported by modifications to the electronic medical record. Our primary outcome measures were incorrect central line placement or near miss event per quarter and days between these events.
After implementation the rate of incorrect line placement and near miss events was reduced to zero with 1018 days since the last incorrect line placement.
As a result of our multi-factorial quality improvement initiative in the scheduling and placement of central lines, we were able to eliminate surgical line placement sentinel events and improve care for pediatric patients with cancer.
Anti-Inflammatory Thrombolytic JX10 (TMS-007) in Late Presentation of Acute Ischemic Stroke.
StrokeContemporary thrombolytics in acute ischemic stroke are limited to administration within 4.5 hours of last known normal. JX10 (formerly TMS-007), a Stachybotrys microspora triprenyl phenol family member, may extend this therapeutic window.
In this multicenter, randomized, double-blind, placebo-controlled, dose-escalation phase 2a study, JX10 or placebo was administered as a single intravenous infusion to Japanese patients with acute ischemic stroke who were unable to receive tissue-plasminogen activator or thrombectomy within 12 hours of last known normal. Primary end point was incidence of symptomatic intracranial hemorrhage with a worsening National Institutes of Health Stroke Scale score of ≥4 points within 24 hours of drug administration (symptomatic intracranial hemorrhage incidence).
Ninety patients received either placebo (n=38; female 26.3%) or JX10 at 1, 3, or 6 mg/kg (n=6, 18, 28; female 0%, 33.3%, and 42.9%, respectively). Median age (range) and baseline median (range) National Institutes of Health Stroke Scale scores were respectively 76.5 (42-87) and 8 (6-21) for the combined JX10 cohort (JX10 Cohorts) and 75.0 (34-85) and 8 (6-22) for placebo. Median (range) dosing time since last known normal was 9.5 (5.0-12.1) and 10.0 (3.7-12.0) hours for JX10 Cohorts and placebo, respectively. Symptomatic intracranial hemorrhage incidence was 0% (0/52 [95% CI, 0.0-5.6]) for JX10 Cohorts versus 2.6% (1/38 [95% CI, 0.1-13.8]) for placebo (P=0.42). Vessel patency at 24 hours (secondary end point) in patients with baseline arterial occlusive lesion score <3 (39/90) improved in 58.3% (14/24) of patients in JX10 Cohorts versus 26.7% (4/15) for placebo (odds ratio, 4.23 [95% CI, 0.99-18.07]). In JX10 Cohorts, a significantly higher proportion of patients had modified Rankin Scale scores of 0 to 1 on day 90 (secondary end point) versus placebo (JX10: 21/52, 40.4% versus placebo: 7/38, 18.4%; P=0.03).
JX10 was well tolerated and may expand the acute ischemic stroke therapeutic window as a novel thrombolytic agent.
URL: https://rctportal.niph.go.jp/en; Unique identifier: jRCT2080223786.
Menstruation: An Important Indicator for Assessing Stroke Risk and Its Outcomes.
StrokeIn recent years, stroke incidence in older adults has declined strikingly, but stroke in younger women has become more common. Abnormalities of men...
Omitting Radiotherapy after Breast-Conserving Surgery in Luminal A Breast Cancer: The LUMINA Study.
American College of SurgeonsThe modern generation of trials evaluating the role of adjuvant radiation have turned to genomic profiling as a further risk stratification tool. T...
