Thrombectomy With the pRESET vs Solitaire Stent Retrievers as First-Line Large Vessel Occlusion Stroke Treatment: A Randomized Clinical Trial

Importance

Stent retriever-based thrombectomy is highly beneficial in large vessel occlusion (LVO) strokes. Many stent retriever designs are currently available, but comparison of these technologies in well-conducted studies is lacking.

Objective

To determine whether thrombectomy for LVO stroke with the pRESET stent retriever is noninferior to treatment with the Solitaire stent retriever.

Design, Setting, and Participants

This study was a multicenter, prospective, randomized, controlled, open-label, adaptive, noninferiority trial with blinded primary end point evaluation. Between October 2019 and February 2022, multicenter participation occurred across 19 research hospitals and/or universities in the US and 5 in Germany. Patients with LVO stroke were enrolled and included up to 8 hours after symptom onset.

Interventions

Patients underwent 1:1 randomization to thrombectomy with the pRESET or Solitaire stent retriever.

Main Outcomes and Measures

The primary outcome was the difference in the rate of 90-day functional independence across the 2 devices, using a -12.5% noninferiority margin for the lower bound of the 1-sided 95% CI of the difference between pRESET and Solitaire retrievers.

Results

Of 340 randomized patients, 170 (50.0%) were female, and the median (IQR) age was 73.0 (64.0-82.0) years. The study procedure was completed in 322 of the 340 randomized patients. The primary end point of 90-day functional independence was achieved by 95 patients (54.9%; 95% CI, 48.7-61.1) in the pRESET group and in 96 (57.5%; 95% CI, 51.2-63.8) in the Solitaire group (absolute difference, -2.57%; 95% CI, -11.42 to 6.28). As the lower bound of the 95% CI was greater than -12.5%, the pRESET retriever was deemed noninferior to the Solitaire retriever. The noninferiority of pRESET over Solitaire was also observed in the secondary clinical end point (90-day shift in modified Rankin Scale score) and in both angiographic end points (Expanded Treatment in Cerebral Infarction [eTICI] score of 2b50 or greater within 3 passes: 146 of 173 [84.4%] vs 149 of 167 [89.2%]; absolute difference, -4.83%; 95% CI, -10.84 to 1.19; eTICI of 2c or greater following the first pass: 76 of 173 [43.7%] vs 74 of 167 [44.3%]; absolute difference, -0.63%; 95% CI, -9.48 to 8.21). Symptomatic intracranial hemorrhage occurred in 0 patients in the pRESET group and 2 (1.2%) in the Solitaire group. Mortality occurred in 25 (14.5%) in the pRESET group and in 24 (14.4%) in the Solitaire group at 90 days. Findings of the per-protocol and as-treated analyses were in concordance with findings of the intention-to-treat analysis.

Conclusions and Relevance

In this study, among patients with LVO stroke, thrombectomy with the pRESET stent retriever was noninferior to thrombectomy with the Solitaire stent retriever. Findings suggest that pRESET offers a safe and effective option for flow restoration and disability reduction in patients with LVO stroke.

Tau filaments are tethered within brain extracellular vesicles in Alzheimer's disease

The abnormal assembly of tau protein in neurons is the pathological hallmark of multiple neurodegenerative diseases, including Alzheimer's disease (AD). In addition, assembled tau associates with extracellular vesicles (EVs) in the central nervous system of patients with AD, which is linked to its clearance and prion-like propagation between neurons. However, the identities of the assembled tau species and the EVs, as well as how they associate, are not known. Here, we combined quantitative mass spectrometry, cryo-electron tomography and single-particle cryo-electron microscopy to study brain EVs from AD patients. We found filaments of truncated tau enclosed within EVs enriched in endo-lysosomal proteins. We observed multiple filament interactions, including with molecules that tethered filaments to the EV limiting membrane, suggesting selective packaging. Our findings will guide studies into the molecular mechanisms of EV-mediated secretion of assembled tau and inform the targeting of EV-associated tau as potential therapeutic and biomarker strategies for AD.

Abstract WP148: The M1-2 MCA Angle And Reperfusion During Thrombectomy

Introduction: Mechanical thrombectomy with stent retrievers has been demonstrated to improve outcomes in patients with large vessel occlusion. M2 MCA occlusions pose a challenge when M2 branch takeoff has an acute angulation. Acute angles reduce the efficacy of interaction of the device with the clot as the force may be diminished in the vector of the clot. We sought to determine if the Tiger device is affected by an acute angle at the M1-2 MCA junction.

Methods: The Tiger retriever trial was a prospective single-arm multicenter trial to assess efficacy of the Tiger-21 and Tiger-17 devices. A total of 160 patients were enrolled, including 37 with a M2 MCA occlusion. The core lab independently measured the angle on AP projection of the M1-M2 junction blinded to the clinical and radiographic outcomes. Patients were compared for successful reperfusion and if a hemorrhage occurred to assess if angulation was associated with these outcome measures.

Results: A total of 37 patients suffered a M2 MCA occlusion with a mean age 67±16 years and a median NIHSS of 14. The overall rate of first pass TICI 2C/3 was 15/37(40.5%) with 11/37(29.7%) suffering an asymptomatic hemorrhage and no patients noted to have a symptomatic hemorrhage. The final reperfusion of TICI 2b/3 was achieved in 32/37(86.5%) of patients. Patients with excellent M2 TICI 2C/3 reperfusion had a more obtuse angle (113±25 degrees. vs. 92±35 degrees, p<0.03). Patients who suffered an asymptomatic intracranial hemorrhage had a trend towards more acute angulation of the M1-M2 MCA (89±34 degrees vs. 108±31 degrees, p< 0.11). Three patients had an angle <45 degrees all of which suffered asymptomatic subarachnoid hemorrhages. Patients who had an angle <90 degrees also were noted to require more passes to achieve reperfusion compared to patients with angles >90 degrees (3±2.6 vs. 1.8±1.1, p< 0.04).

Conclusions: In the TIGER study, an acute angle at M1-M2 MCA branch point was associated with a reduced rate and need for more passes to achieve successful reperfusion. The acuity of the angle makes catheterization difficult with the force vector diminished along the axis of the clot. The current study identifies an opportunity for technological advancements to overcome this anatomical challenge in M2 MCA thrombectomy.

Spatial variation of plastic debris on important turtle nesting beaches of the remote Chagos Archipelago, Indian Ocean

We report Anthropogenic Marine Debris (AMD) in Chagos Archipelago in the Indian Ocean, globally amongst the most isolated island groups. AMD on 14 island beaches in five atolls were surveyed in 2019 using two techniques: Marine Debris Tracker (MDT) along littoral vegetation and photoquadrats in open beach. Over 60 % of AMD in both beach zones was composed of plastics, especially bottles and fragments (mean = 44.9 %, 27.2 %, range = 16.5-73.2 %, 4.8-55.9 % respectively in vegetation; mean = 28.7 %, 31.5 %, range = 17.7-40.7 %, 11.6-60.0 % respectively in open beach). The density of plastic debris in littoral vegetation (MDT data: 1995 bottles, 3328 fragments per 100 m²) was 10-fold greater than in open beach (photoquadrat data: 184 bottles, 106 fragments per 100 m²). Significant latitudinal variation in vegetation AMD occurred (8-fold greater in southern atolls, p = 0.006). AMD varied within island zones: most debris observed on oceanside beaches (oceanside vs lagoon, W = 365, p < 0.001; ocean vs island tip, W = 107, p = 0.034). Standardisation of surveys using the open-source MDT App is recommended. Debris accumulation hotspots overlapped with sea turtle nesting habitat, guiding future beach clean-up prioritisation.

Acoustic signalling and behaviour of Antarctic minke whales (Balaenoptera bonaerensis)

Acoustic signalling is the predominant form of communication among cetaceans. Understanding the behavioural state of calling individuals can provide insights into the specific function of sound production; in turn, this information can aid the evaluation of passive monitoring datasets to estimate species presence, density, and behaviour. Antarctic minke whales are the most numerous baleen whale species in the Southern Ocean. However, our knowledge of their vocal behaviour is limited. Using, to our knowledge, the first animal-borne audio-video documentation of underwater behaviour in this species, we characterize Antarctic minke whale sound production and evaluate the association between acoustic behaviour, foraging behaviour, diel patterns and the presence of close conspecifics. In addition to the previously described downsweep call, we find evidence of three novel calls not previously described in their vocal repertoire. Overall, these signals displayed peak frequencies between 90 and 175 Hz and ranged from 0.2 to 0.8 s on average (90% duration). Additionally, each of the four call types was associated with measured behavioural and environmental parameters. Our results represent a significant advancement in understanding of the life history of this species and improve our capacity to acoustically monitor minke whales in a rapidly changing Antarctic region.

QT interval prolongation is a novel predictor of one year morality in patients with coronavirus disease-19 infection

Funding Acknowledgements

Type of funding sources: None.

Background

QT interval prolongation is common in critically ill patients and is associated with increased mortality. However, the predictive value of a prolonged corrected QT interval (QTc) for myocardial injury and long-term mortality among patients hospitalized with COVID-19 infection is not well known.

Purpose

To evaluate the association of prolonged QTc with myocardial injury and with 1-year mortality among patients hospitalized with COVID-19 infection.

Methods

A total of 335 consecutive patients hospitalized with COVID-19 infection were prospectively studied. All patients underwent a comprehensive echocardiographic evaluation within 48 hours from admission. Using the Bazett formula, the QTc interval was calculated from the first ECG tracing recorded at the ER. QTc ≥440 msec in males and ≥450 msec in females was considered prolonged. Patients with elevated cardiac biomarkers and/or echocardiographic signs of myocardial dysfunction were considered to have myocardial injury. The predictive value of QTc prolongation for myocardial injury was calculated using a multivariate binary regression model. One-year mortality rate of patients with and without QTc prolongation was compared using the log-rank test, and a multivariate Cox regression model adjusting for multiple covariates was performed to evaluate the 1-year mortality risk.

Results

One-hundred and nine (32.5%) patients had a prolonged QTc. Compared to patients without QTc prolongation, patients with prolonged QTc were older (70±14.4 vs 62.7±16.6, p &lt;0.001), had more comorbidities, and presented with a more severe disease. Prolonged QTc was an independent predictor for myocardial injury (adjusted HR 2.07, 95% CI 1.22-3.5; p=0.007). One-year mortality of patients with prolonged QTc was higher than those with no QTc prolongation (40.7% vs 16.9; p &lt;0.001, adjusted HR 1.85[1.2-2.84]; p=0.005). Compared to patient without QTc prolongation and no myocardial injury, the adjusted 1-year mortality risk was highest in patients with prolonged QTc and myocardial injury (HR 6.63, 95% CI 2.28-19.3; p=0.001), followed by patients with QTc prolongation without myocardial injury (HR 6.12 95% CI 1.83-20.49; p=0.003), and patients with myocardial injury without QTc prolongation (HR 4.95 95% CI 1.83-20.49.; p=0.003).

Conclusion

Prolonged QTc is an independent risk factor for both myocardial injury and 1-year mortality among patients hospitalized with COVID-19 infection.

Retreatment of Residual and Recurrent Aneurysms After Embolization With the Woven EndoBridge Device: Multicenter Case Series

BACKGROUND

The Woven EndoBridge (WEB) device (Terumno Corp. [parent company of Microvention]) was approved by the U.S. Food and Drug Administration as the first intrasaccular device for intracranial aneurysm treatment in December 2018. Its use has become more common since then, but both trial results and postmarket experiences have raised questions about the efficacy in achieving complete aneurysm obliteration. Retreatment after WEB embolization has not been extensively discussed.

OBJECTIVE

To discuss the incidence and retreatment of aneurysms after initial WEB embolization.

METHODS

Retrospective review across 13 institutions identified all occurrences of WEB retreatment within neurovascular databases. Details regarding demographics, aneurysm characteristics, treatment considerations, clinical outcomes, and aneurysm occlusion were obtained and analyzed.

RESULTS

Thirty aneurysms were retreated in 30 patients in a cohort of 342 WEB-treated aneurysms. The retreatment rate was 8.8%. Endovascular methods were used for 23 cases, and 7 were treated surgically. Two aneurysms presented with rehemorrhage after initial WEB embolization. Endovascular treatments included stent-assisted coiling (12), flow diversion (7), coiling (2), PulseRider (Johnson & Johnson)-assisted coiling (1), and additional WEB placement (1). Surgical treatments included primary clipping (6) and Hunterian ligation (1). There were no major complications within the study group.

CONCLUSION

WEB retreatments were successfully performed by a variety of techniques, including stent-assisted coiling, clipping, and flow diversion as the most common. These procedures were performed safely with subsequent obliteration of most aneurysms. The potential need for retreatment of aneurysms should be considered during primary WEB treatments.

Use of patient specific 3D printed neurovascular phantoms to simulate mechanical thrombectomy

BACKGROUND

The ability of the patient specific 3D printed neurovascular phantoms to accurately replicate the anatomy and hemodynamics of the chronic neurovascular diseases has been demonstrated by many studies. Acute occurrences, however, may still require further development and investigation and therefore we studied acute ischemic stroke (AIS). The efficacy of endovascular procedures such as mechanical thrombectomy (MT) for the treatment of large vessel occlusion (LVO), can be improved by testing the performance of thrombectomy devices and techniques using patient specific 3D printed neurovascular models.

METHODS

3D printed phantoms were connected to a flow loop with physiologically relevant flow conditions, including input flow rate and fluid temperature. A simulated blood clot was introduced into the model and placed in the proximal Middle Cerebral Artery (MCA) region. Clot location, composition, length, and arterial angulation were varied and MTs were simulated using stent retrievers. Device placement relative to the clot and the outcome of the thrombectomy were recorded for each situation. Digital subtraction angiograms (DSA) were captured before and after LVO simulation. Recanalization outcome was evaluated using DSA as either 'no recanalization' or 'recanalization'. Forty-two 3DP neurovascular phantom benchtop experiments were performed.

RESULTS

Clot angulation within the MCA region had the most significant impact on the MT outcome, with a p-value of 0.016. Other factors such as clot location, clot composition, and clot length correlated weakly with the MT outcome.

CONCLUSIONS

This project allowed us to gain knowledge of how such characteristics influence thrombectomy success and can be used in making clinical decisions when planning the procedure and selecting specific thrombectomy tools and approaches.

Factors Associated With Decreased Accuracy of Modified Thrombolysis in Cerebral Infarct Scoring Among Neurointerventionalists During Thrombectomy

Background and Purpose

The modified Thrombolysis in Cerebral Infarct (mTICI) score is used to grade angiographic outcome after endovascular thrombectomy. We sought to identify factors that decrease the accuracy of intraprocedural mTICI.

Methods

We performed a 2-center retrospective cohort study comparing operator (n=6) mTICI scores to consensus scores from blinded adjudicators. Groups were also assessed by dichotomizing mTICI scores to 0–2a versus 2b–3.

Results

One hundred thirty endovascular thrombectomy procedures were included. Operators and adjudicators had a pairwise agreement in 96 cases (73.8%). Krippendorff α was 0.712. Multivariate analysis showed endovascular thrombectomy overnight (odds ratio [OR]=3.84 [95% CI, 1.22–12.1]), lacking frontal (OR, 5.66 [95 CI, 1.36–23.6]), or occipital (OR, 7.18 [95 CI, 2.12–24.3]) region reperfusion, and higher operator mTICI scores (OR, 2.16 [95 CI, 1.16–4.01]) were predictive of incorrectly scoring mTICI intraprocedurally. With dichotomized mTICI scores, increasing number of passes was associated with increased risk of operator error (OR, 1.93 [95 CI, 1.22–3.05]).

Conclusions

In our study, mTICI disagreement between operator and adjudicators was observed in 26.2% of cases. Interventions that took place between 22:30 and 4:00, featured frontal or occipital region nonperfusion, higher operator mTICI scores, and increased number of passes had higher odds of intraprocedural mTICI inaccuracy.

Next-generation gene panel testing in adolescents and adults in a medical neuropsychiatric genetics clinic

Intellectual disability (ID) encompasses a clinically and genetically heterogeneous group of neurodevelopmental disorders that may present with psychiatric illness in up to 40% of cases. Despite the evidence for clinical utility of genetic panels in pediatrics, there are no published studies in adolescents/adults with ID or autism spectrum disorder (ASD). This study was approved by our institutional research ethics board. We retrospectively reviewed the medical charts of all patients evaluated between January 2017 and December 2019 in our adult neuropsychiatric genetics clinic at the McGill University Health Centre (MUHC), who had undergone a comprehensive ID/ASD gene panel. Thirty-four patients aged > 16 years, affected by ID/ASD and/or other neuropsychiatric/behavioral disorders, were identified. Pathogenic or likely pathogenic variants were identified in one-third of our cohort (32%): 8 single-nucleotide variants in 8 genes (CASK, SHANK3, IQSEC2, CHD2, ZBTB20, TREX1, SON, and TUBB2A) and 3 copy number variants (17p13.3, 16p13.12p13.11, and 9p24.3p24.1). The presence of psychiatric/behavioral disorders, regardless of the co-occurrence of ID, and, at a borderline level, the presence of ID alone were associated with positive genetic findings (p = 0.024 and p = 0.054, respectively). Moreover, seizures were associated with positive genetic results (p = 0.024). One-third of individuals presenting with psychiatric illness who met our red flags for Mendelian diseases have pathogenic or likely pathogenic variants which can be identified using a comprehensive ID/ASD gene panel (~ 2500 genes) performed on an exome backbone.

Brain Atrophy and Leukoaraiosis Correlate with Futile Stroke Thrombectomy

INTRODUCTION

Although mechanical thrombectomy (MT) is a proven therapy for acute large vessel occlusion strokes, futile recanalization in the elderly is common and costly. Strategies to minimize futile recanalization may reduce unnecessary thrombectomy transfers and procedures. We evaluated whether a simple and rapid visual assessment of brain atrophy and leukoaraiosis on a plain head CT correlates with futile stroke recanalization in the elderly.

METHODS

Consecutive stroke patients admitted for thrombectomy, older than 65 years of age, all with TICI 2b/3 recanalization rates were retrospectively studied from multiple comprehensive stroke centers. Brain atrophy and leukoaraiosis were visually analyzed from pre-intervention plain head CTs using a simplified scheme based on validated scales. Baseline demographics were collected and the primary outcome measure was 90-day modified Rankin score (mRS). Cochran-Armitage trend test was applied in analyzing the association of the severity of brain atrophy and leukoaraiosis with 90-day mRS.

RESULTS

Between 2017 and 2019, 175 patients > 65 years who underwent thrombectomy with TICI 2b/3 recanalization from two comprehensive stroke centers were evaluated. The median age was 77 years. IV-tPA was given in 59% of patients, average initial NIHSS was 19, average baseline mRS was 0.77 and median time to recanalization was 300 minutes. Age and severity of atrophy/leukoaraiosis was categorized into three groups of increasing severity and associated with 90 day mRS 0-3 rates of 62%, 49% and 41% (p=0.037) respectively.

CONCLUSIONS

A simplified, visual assessment of the degree of brain atrophy and leukoaraiosis measured on plain head CT correlates with futile recanalization in patients age >65 years. Although additional validation is needed, these findings suggest that brain atrophy and leukoaraiosis may have value as a surrogate marker of prestroke functional status. In doing so, simplified visual plain head CT grading scales may minimize elderly futile recanalization.

The Use of Antiplatelet Agents and Heparin in the 24-Hour Postintravenous Alteplase Window for Neurointervention

BACKGROUND

Intravenous (IV) alteplase with mechanical thrombectomy has been found to be superior to alteplase alone in select patients with intracranial large vessel occlusion. Current guidelines discourage the use of antiplatelet agents or heparin for 24 h following alteplase. However, their use is often necessary in certain circumstances during thrombectomy procedures.

OBJECTIVE

To study the safety and outcomes in patients who received blood thinning medications for thrombectomy after IV Tissue-Type plasminogen activator (tPA).

METHODS

This is a multicenter retrospective review of the use of antiplatelet agents and/or heparin in patients within 24 h following tPA administration. Patient demographics, comorbidities, bleeding complications, and discharge outcomes were collected.

RESULTS

A series of 88 patients at 9 centers received antiplatelet medications and/or heparin anticoagulation following IV alteplase for revascularization procedures requiring stenting. The mean National Institutes of Health Stroke Scale (NIHSS) on admission was 14.6. Reasons for use of a stent included internal carotid artery occlusion in 74% of patients. Thrombolysis in cerebral infarction (TICI) 2b-3 revascularization was accomplished in 90% of patients. The rate of symptomatic intracranial hemorrhage (sICH) was 8%; this was not significantly different than the sICH rate for a matched group of patients not receiving antiplatelets or heparin during the same time frame. Functional independence at 90 d (modified Rankin Scale 0-2) was seen in 57.8% of patients. All-cause mortality was 12%.

CONCLUSION

The use of antiplatelet agents and heparin for stroke interventions following IV alteplase appears to be safe without significant increased risk of hemorrhagic complications in this group of patients when compared to control data and randomized controlled trials.

Postmarket American Experience With Woven EndoBridge Device: Adjudicated Multicenter Case Series

BACKGROUND

The Woven EndoBridge (WEB) device was granted premarket approval in the United States following results of the Woven EndoBridge Intrasaccular Therapy (WEB-IT) study. WEB-IT reported excellent adequate angiographic occlusion of treated aneurysms with a high safety profile. These results were achieved, however, in the context of a prospective study with strict inclusion criteria and rigorous training support.

OBJECTIVE

To review early as-practiced clinical experience with the WEB device in the United States.

METHODS

Retrospective review across 6 institutions identified 91 patients undergoing 92 treatment sessions for WEB device placement in treatment of 91 intracranial aneurysms. Details regarding demographics, aneurysm characteristics, treatment considerations, clinical outcomes, and aneurysm occlusion were obtained and analyzed in a multicenter database. Angiograms from the index procedure and follow-up studies were reviewed by a blinded and independent adjudicator.

RESULTS

The middle cerebral, anterior communicating, and basilar artery complexes were the commonly treated locations. Eight patients presented with ruptured aneurysms. A mean of 1.2 devices were introduced per case. Technical failure without deployment of a WEB device occurred in 2% (2/92) of sessions. Complete aneurysm occlusion for patients with imaging follow-up was 49% (mean follow-up of 8 mo). Four aneurysms were retreated. 90% of patients had modified Rankin Scale ≤ 2 at last clinical follow-up with no mortalities.

CONCLUSION

Immediate postmarket experience with the WEB device, newly introduced at American centers, confirms safe procedural use, but long-term efficacy remains unclear. Early challenges include accurate sizing and device selection.

New Class of Radially Adjustable Stentrievers for Acute Ischemic Stroke: Primary Results of the Multicenter TIGER Trial

Supplemental Digital Content is available in the text.

Background and Purpose:

The Tigertriever is a novel, radially adjustable, fully visible, stentriever that permits the operator to align radial expansion with target vessel diameters. This multicenter trial compared the Tigertriever’s effectiveness and safety compared with established stent retrievers.

Methods:

Single arm, prospective, multicenter trial comparing the Tigertriever to efficacy and safety performance goals derived from outcomes in 6 recent pivotal studies evaluating the Solitaire and Trevo stent-retriever devices with a lead-in and a main-study phase. Patients were enrolled if they had acute ischemic stroke with National Institutes of Health Stroke Scale score ≥8 due to large vessel occlusion within 8 hours of onset. The primary efficacy end point was successful reperfusion, defined as core laboratory-adjudicated modified Thrombolysis in Cerebral Ischemia score 2b-3 within 3 passes of the Tigertriever. The primary safety end point was a composite of 90-day all-cause mortality and symptomatic intracranial hemorrhage. Secondary efficacy end points included 3-month good clinical outcome (modified Rankin Scale score 0–2) and first-pass successful reperfusion.

Results:

Between May 2018 and March 2020, 160 patients (43 lead-in, 117 main phase) at 17 centers were enrolled and treated with the Tigertriever. The primary efficacy end point was achieved in 84.6% in the main-study phase group compared with the 63.4% performance goal and the 73.4% historical rate (noninferiority P<0.0001; superiority P<0.01). The first pass successful reperfusion rate was 57.8%. After all interventions, successful reperfusion (modified Thrombolysis in Cerebral Ischemia score ≥2b) was achieved in 95.7% and excellent reperfusion (modified Thrombolysis in Cerebral Ischemia score 2c-3) in 71.8%. The primary safety composite end point rate of mortality and symptomatic intracranial hemorrhage was 18.1% compared with the 30.4% performance goal and the 20.4% historical rate (noninferiority P=0.004; superiority P=0.57). Good clinical outcome was achieved in 58% at 90 days.

Conclusions:

The Tigertriever device was shown to be highly effective and safe compared with Trevo and Solitaire devices to remove thrombus in patients with large-vessel occlusive stroke eligible for mechanical thrombectomy.

Registration:

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03474549.

Abstract P496: Clot Characteristics in Mechanical Thrombectomy: Interim Analysis of the EXCELLENT Registry

Introduction: Red blood cell (RBC) rich vs fibrin rich clots have different mechanical properties and greater knowledge about clot composition in the context of clinical, imaging, and procedural factors in mechanical thrombectomy (MT) may help with procedural optimization. The EXCELLENT Registry (NCT03685578) is a prospective, global, multi-center, observational registry of EmboTrap as the first line MT device for large vessel occlusion (LVO). We present an interim analysis of clot collected per pass in the registry.

Methods: Five hundred thirty-three clot specimens from 376 subjects were collected by 20 sites and sent for analysis by independent Central Labs under standardized protocol. Analysis was interrupted by COVID-19, but the labs were fully operational as of June 2020 and on track to deliver results for 300 subjects in Q4. At the time of abstract submission, composition data for 234 clots from 163 subjects was available. All available data will be presented at the time of the conference.

Results: Cardioembolic etiology (n=100) was associated with lower RBC (40.2 vs 47.2%) and higher fibrin content (31.7 vs 26.7%) compared to large artery disease (n=12). Hyperdense/vessel susceptibility sign (78+, 24-, per independent imaging core lab) corresponded to higher mean RBC content (44.4 vs 34.9%). Treatment with IV tPA (60+, 91-) had no clear impact on clot composition (42.3 vs 40.6% RBC; 30.4 vs 30.0% fibrin). Notably, clots retrieved with the first 2 passes of were more RBC rich (42.1 vs 28.0%) and clots retrieved in higher passes had a higher average fibrin content (35.5 vs 29.6%) suggesting that higher fibrin content leads to greater refractoriness.

Conclusions: Clot density/susceptibility on baseline imaging, stroke etiology and number of thrombectomy passes were associated with differential clot composition. These findings may have potential implications for the development of better MT strategies.

Abstract P14: Per Pass Clot Retrieval Technique: Interim Analysis of the Excellent Registry

Background: EXCELLENT (NCT03685578) is a large, prospective, single-arm, multicenter, international registry of mechanical thrombectomy (MT) with EmboTrap as the first attempted device in routine clinical practice. The study collects per pass data on procedural and technical details that are based on interventionalists’ preference, providing an opportunity to assess current practices in MT across multiple international high-volume stroke centers.

Methods: Subjects treated according to standard of care were eligible for inclusion in the study if EmboTrap was used in the first MT pass. Interim analysis focusing on procedural details and per pass clot retrieval technique was performed based on 689 subjects enrolled by 79 physicians across 26 international sites (US, Belgium, Germany, France) between Sept 2018 and Jul 2020.

Results: Mean #passes was 2.1 (median=1, max=10), 50.3% subjects had only 1 pass and 84.8% had 3 or fewer. Per pass use of stent retriever, aspiration, balloon guide, intermediate catheter and long sheath catheter, along with technique details (e.g. incubation time, device positioning, co-aspiration) are summarized in Table 1. Rates and reasons for device changes are also given.

Conclusion: Interim analysis of the ongoing EXCELLENT registry informs on current practice patterns in MT. This is the first report of detailed per pass clot retrieval strategies in a large international multicenter cohort.

Efficacy of prayer in inducing immediate physiological changes: a systematic analysis of objective experiments

OBJECTIVES

To assess the immediate impact of prayer on physiological state by systematically reviewing objective, controlled experimental studies in the literature.

CONTENT

Experimental studies measuring objective physiological changes induced by prayer. Studies containing the keyword, "Prayer" anywhere in the title or abstract were curated from the following databases: Public/Publisher Medline (PubMed), Excerpta Medica Database (EMBASE) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) in May 2019. Titles and abstracts were screened with the remaining 30 articles analyzed for inclusion. Only experimental studies were included.

SUMMARY

Eight experimental studies were identified of which five investigated neurocognitive changes and three investigated systemic physiological changes during prayer. The five studies focusing on neuroactivity used functional MRI (fMRI), electroencephalography or SPECT imaging to obtain measurements. The remaining three studies analyzed an array of systemic physiological metrics, including blood pressure, heart rate, respiratory rate, peripheral resistance, baroreceptor sensitivity and/or cardiovascular rhythm variability during prayer. All studies aside from one saw objective changes during prayer. Neurocognitive changes were mainly associated with improved mental functioning, control and pain tolerance. Prayer was found to slow down physiological functions in two of the three vital-based studies, with the third reporting no change in physiological status. None of the studies measured blood marker changes.

OUTLOOK

Experimental studies show prayer to induce healthy neurocognitive and physiological changes. Additional studies exploring objective measures from prayer are encouraged to provide practitioners with a more nuanced, scientific perspective when it comes to prescribing prayer as a complementary and alternative medicine (CAM) therapy.

Profilicollis chasmagnathi (Acanthocephala) parasitizing freshwater fishes: paratenicity and an exception to the phylogenetic conservatism of the genus?

Polymorphid acanthocephalans are parasites of marine mammals, waterfowl and ichthyophagous birds. Among these, the genus Profilicollis is known to use exclusively decapods as intermediate hosts. Here, we report the first record of living cystacanths of Profilicollis parasitizing the body cavity of a fish host, Oligosarcus jenynsii, inhabiting the freshwater section of an estuarial system, Mar Chiquita coastal lagoon, in south-east Buenos Aires Province, Argentina. In this environment, cystacanths of Profilicollis chasmagnathi have been previously recorded infecting decapod crabs and as transient accidental infections in the gut of some carcinophagous fishes. In the present study, larvae from the crab Neohelice granulata, from the intestine of the estuarine fish Odontesthes argentinensis and from the body cavity of O. jenynsii were morphologically and genetically compared, confirming their identity as P. chasmagnathi, a species characteristic of estuaries and marine coasts along Argentina, Uruguay and Chile. These findings can be interpreted as a possible case of incipient paratenicity for Profilicollis, and a colonization event of freshwater habitats, probably promoted by the highly variable conditions, typical of ecotonal environments. In addition, cystacanths of the genus Polymorphus were also found in O. jenynsii, representing the first record of this genus in Oligosarcus from Argentina.

Nuisance bleeding complications in patients with cerebral aneurysm treated with Pipeline embolization device

BACKGROUND

Patients with cerebral aneurysms treated with the Pipeline embolization device (PED) are maintained on dual antiplatelet therapy (DAPT) to prevent thromboembolic complications. Rates of minor, "nuisance" bleeding in these patients remain unknown. We sought to evaluate the frequency and factors associated with this bleeding and its effect on DAPT compliance.

METHODS

We performed a multicenter retrospective cohort study on consecutive cases of intracranial aneurysms treated with PED. Patient characteristics, aneurysm characteristics, and bleeding complications were analyzed. Severity of bleeding was defined according to a previously published classification defining nuisance bleeding as easy bruising, bleeding from small cuts, petechia, and ecchymosis.

RESULTS

245 PED aneurysm procedures on 243 patients were retrospectively collected from three academic centers over a 4.25-year period. Sixty-seven patients (27%) had nuisance bleeds. Patients with a higher risk of nuisance bleeding were older (59.1±3.4 vs . 54.7±2.2, P=0.032). Patients with nuisance bleeds were more likely to have their DAPT regimen changed or dose lowered (29% vs 8.3%, P<0.001), were on DAPT for less time (10.0 months±2.60 vs. 14.6 months±1.95, P=0.005) and were more likely to have aneurysm occlusion at 6 months (P<0.001). Stepwise logistic regression found age predictive of a nuisance bleed (OR=1.033) CONCLUSIONS: Nuisance bleeding was a common complaint of PED-treated aneurysm patients maintained on DAPT. Increasing age and aneurysmal occlusion at 6 months were the only factors predictive of nuisance bleeds. Clinicians were more likely to adjust antiplatelet regimens or stop DAPT early given a nuisance bleed.

Pipeline Embolization Device for Treatment of Extracranial Internal Carotid Artery Pseudoaneurysms: A Multicenter Evaluation of Safety and Efficacy

BACKGROUND

There is a paucity of literature regarding treatment options for extracranial pseudoaneurysms of the internal carotid artery (ICA). To date, Pipeline Embolization Device (PED; Medtronic Inc) use for the treatment of extracranial pseudoaneurysms of the ICA has only been reported from single-center case series.

OBJECTIVE

To evaluate the safety and efficacy of PED for the treatment of extracranial ICA pseudoaneurysms.

METHODS

This is a multicenter retrospective study involving 6 high-volume tertiary academic institutions in the United States. We analyzed patients with extracranial ICA pseudoaneurysms treated with PED between January 1, 2011, and January 1, 2019. Clinical assessment was performed pre- and postintervention using the modified Rankin Scale (mRS) and National Institution of Health Stroke Scale (NIHSS) at a minimum of 4-mo follow-up.

RESULTS

A total of 28 pseudoaneurysms with a mean diameter of 17.7 mm (range: 4.1-52.5 mm) were treated with PED in 24 patients at 6 participating centers. The mean age was 52.1 yr (17-73) ± 14.3 with 14 females and 10 males. At a mean of 21-mo (range 4-66 mo) follow-up, complete occlusion was achieved in 89% (n = 25/28), with near-complete occlusion (&gt;90% occlusion) in the remainder. There were no periprocedural complications. Postprocedure NIHSS was 0 in 88% (n = 21/24) and 1 in 12% (n = 3/24) of patients, and mRS was 0 in 83% (n = 20/24) and 1 in 17% (n = 4/24) of patients.

CONCLUSION

The treatment of extracranial ICA pseudoaneurysms with PED is safe and effective in selected patients. Randomized controlled trials and prospective cohort studies are needed to establish the role of flow diversion for ICA pseudoaneurysms.

Feasibility study for use of angiographic parametric imaging and deep neural networks for intracranial aneurysm occlusion prediction

Background

Angiographic parametric imaging (API), based on digital subtraction angiography (DSA), is a quantitative imaging tool that may be used to extract contrast flow parameters related to hemodynamic conditions in abnormal pathologies such as intracranial aneurysms (IAs).

Objective

To investigate the feasibility of using deep neural networks (DNNs) and API to predict IA occlusion using pre- and post-intervention DSAs.

Methods

We analyzed DSA images of IAs pre- and post-treatment to extract API parameters in the IA dome and the corresponding main artery (un-normalized data). We implemented a two-step correction to account for injection variability (normalized data) and projection foreshortening (relative data). A DNN was trained to predict a binary IA occlusion outcome: occluded/unoccluded. Network performance was assessed with area under the receiver operating characteristic curve (AUROC) and classification accuracy. To evaluate the effect of the proposed corrections, prediction accuracy analysis was performed after each normalization step.

Results

The study included 190 IAs. The mean and median duration between treatment and follow-up was 9.8 and 8.0 months, respectively. For the un-normalized, normalized, and relative subgroups, the DNN average prediction accuracies for IA occlusion were 62.5% (95% CI 60.5% to 64.4%), 70.8% (95% CI 68.2% to 73.4%), and 77.9% (95% CI 76.2% to 79.6%). The average AUROCs for the same subgroups were 0.48 (0.44–0.52), 0.67 (0.61–0.73), and 0.77 (0.74–0.80).

Conclusions

The study demonstrated the feasibility of using API and DNNs to predict IA occlusion using only pre- and post-intervention angiographic information.

Acylated Ghrelin and The Regulation of Lipid Metabolism in The Intestine

Acylated ghrelin (AG) is a gastrointestinal (GI) peptide mainly secreted by the stomach that promotes cytosolic lipid droplets (CLD) hypertrophy in adipose tissues and liver. However, the role of AG in the regulation of lipid metabolism in the intestine remains unexplored. This study aimed at determining whether AG influences CLD production and chylomicron (CM) secretion in the intestine. The effects of AG and oleic acid on CLD accumulation and CM secretion were first investigated in cultured Caco-2/15 enterocytes. Intestinal lipid metabolism was also studied in Syrian Golden Hamsters submitted to conventional (CD) or Western (WD) diets for 8 weeks and continuously administered with AG or physiological saline for the ultimate 2 weeks. In cultured Caco-2/15 enterocytes, CLD accumulation influenced CM secretion while AG reduced fatty acid uptake. In WD hamsters, continuous AG treatment amplified chylomicron output while reducing postprandial CLD accumulation in the intestine. The present study supports the intimate relationship between CLD accumulation and CM secretion in the intestine and it underlines the importance of further characterizing the mechanisms through which AG exerts its effects on lipid metabolism in the intestine.

Undernutrition in childhood: Clinically based assessment tools and biological markers: Where are we and where should we go?

Despite its association with poor clinical outcomes and increased hospital costs, as of today undernutrition still goes undetected in paediatric hospitals. The reported prevalence of undernutrition in paediatric patients varies considerably. This disparity is partly due to the diversity of methods for its detection and assessment, as well as to the lack of consensus regarding its definition. Several methods, based on varied combinations of morphology characteristics, estimated nutritional intakes and medical conditions have been developed during the last 25 years. However, these tools suffer from poor sensitivity and selectivity particularly in acute conditions. Also while having their own merit, these tools mainly view malnutrition from the energy standpoint, disregarding assessment of specific micronutrients such as minerals and vitamins. In this position paper we make the point that in the era of personalized medicine, present technology offers the possibility of going beyond the traditional nutritional tools for assessing patients' status, and propose the measurement of selected micronutrients and allied metabolic markers in nutritional workup schemes adapted to each clinical condition.

Is there a relationship between vitamin D nutritional status and metabolic syndrome in childhood acute lymphoblastic leukemia survivors? A PETALE study

BACKGROUND

Treatment of childhood acute lymphoblastic leukemia (cALL) has reached unprecedented success leading to survival rates reaching 90%. This is regrettably linked to increased risk of developing long-term health-related sequels into early adulthood.

OBJECTIVE

This study aims at assessing the relationship between the vitamin D status and metabolic biomarkers in PETALE, a well-characterized cohort of cALL survivors.

RESULTS

We demonstrate that 15.9% of the study participants exhibited 3 or more metabolic syndrome (MetS) risk factors. We also show a direct relationship between s25OHD₃ and plasma HDL-Cholesterol concentrations in female but not male participants.

CONCLUSION

Our data, from a metabolically well-described cohort, support a modest role for vitamin D in lipid metabolism in childhood leukemia survivors. The major outcome of this study is the strong association between HDL-Cholesterol concentration and s25OHD₃ only in female subjects, thereby conveying vitamin D a gender-specific cardio-protective effect. cALL survivors represent a population at higher risk for secondary diseases. For this reason thorough nutritional evaluation, including vitamin D should be part of the regular follow-up.

Thymosin beta 4 induces significant changes in the plasma miRNA profile following severe traumatic brain injury in the rat lateral fluid percussion injury model

OBJECTIVES

Thymosin beta 4 (Tβ4) has demonstrated neuroprotective potential in models of neurlogical injury. The neuroprotective potential of Tβ4 has been associated with increased miR-200a and miR-200b within the brain following stroke. Here we tested the hypothesis that Tβ4 treatment could also alter miRNA profiles within the plasma following severe traumatic brain injury (TBI).

METHODS

We used the rat lateral fluid percusion injury model of severe TBI to test this hypothesis. Highly sensitive and quantitative droplet digital polymerase chain reaction (ddPCR) was used to measure the plasma concentrations of miR-200 family members. In addition, we conducted RNAseq analysis of plasma miRNA to further identify changes associated with TBI and treatment with Tβ4.

RESULTS

ddPCR demonstrated that miR-200a-3p andmiR-200b-3p were both significantly increased in plasma following treatment with Tβ4 after severe TBI. RNAseq analysis suggested that miR-300-3p and miR-598-3p increased while miR-450-3p and miR-194-5p significantly decreased following TBI. In contrast, miR-194-5p significantly increased in Tβ4 treated rats following TBI. In addition, we identified nine plasma miRNAs whose expression significantly changed following treatment with Tβ4.

CONCLUSIONS

Tβ4 treatment significantly increased plasma levels of miR-200a-3p and miR-200b-3p, while RNAseq analysis identified miR-194-5p as a candidate miRNA that may be critical for neuroprotection.

Gastrointestinal factors regulating lipid droplet formation in the intestine

Cytoplasmic lipid droplets (CLD) are considered as neutral lipid reservoirs, which protect cells from lipotoxicity. It became clear that these fascinating dynamic organelles play a role not only in energy storage and metabolism, but also in cellular lipid and protein handling, inter-organelle communication, and signaling among diverse functions. Their dysregulation is associated with multiple disorders, including obesity, liver steatosis and cardiovascular diseases. The central aim of this review is to highlight the link between intra-enterocyte CLD dynamics and the formation of chylomicrons, the main intestinal dietary lipid vehicle, after overviewing the morphology, molecular composition, biogenesis and functions of CLD.

Erratum: (1) Pediatric Obesity and Cardiometabolic Disorders: Risk Factors and Biomarkers

[This corrects the article on p. 6 in vol. 28, PMID: 28439216.].

Revealing the Topology of Quasicrystals with a Diffraction Experiment

Topological properties of crystals and quasicrystals is a subject of recent and growing interest. This Letter reports an experiment where, for certain quasicrystals, these properties can be directly retrieved from diffraction. We directly observe, using an interferometric approach, all of the topological invariants of finite-length Fibonacci chains in their diffraction pattern. We also quantitatively demonstrate the stability of these topological invariants with respect to structural disorder.

Microcatheter contrast injection in stent retriever neurothrombectomy is safe and useful: insights from SWIFT PRIME

Microcatheter contrast injection (MCI) prior to stent retriever deployment for the treatment of acute ischemic stroke may be useful for evaluation of distal anatomy and flow patterns beyond the occlusion. However, prior data from intra-arterialthrombolysis suggested that MCI increases the risk of intracranial hemorrhage (ICH). The safety and utility of MCI has not been investigated in the setting of thrombectomy.

Methods

We analyzed the Solitaire With the Intention For Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME) trial to correlate pre-intervention MCI flow with collateral flow, and to investigate its impact on ICH and clinical outcome after thrombectomy with the Solitaire device.

Results

MCI was noted in 52% (n=51) of patients with a prevalence for the M2 location of 71% (n=36). Dichotomized correlation demonstrated a strong inverse relationship for partial collaterals with good MCI flow (p=0.004; OR 8.25). None of the MCI variables (presence, number, or grades) correlated with ICH and clinical outcome. The most significant predictors of non-disabled outcome were higher Alberta Stroke Program early CT Score (ASPECTS) (OR 1.61; p=0.0361) and younger age (OR 0.922; p = 0.0109). Higher ASPECTS was also a strong predictor of lower ICH risk (OR 0.501, p=0.0078).

Conclusions

Collateral flow inversely correlated with MCI flow in the endovascular arm of the SWIFT PRIME trial. This finding warrants further validation in larger cohorts as MCI may be influenced by individual operator’s technique and choice of syringe size. Evaluation of flow and distal anatomy with MCI prior to stent retriever deployment is safe with no evidence of an impact on ICH or clinical outcome.

Clinical trial registration

NCT01657461: Post- results

Results of the ANSWER Trial Using the PulseRider for the Treatment of Broad-Necked, Bifurcation Aneurysms

BACKGROUND: The safety and probable benefit of the PulseRider (Pulsar Vascular, Los Gatos, California) for the treatment of broad-necked, bifurcation aneurysms was studied in the context of the prospective, nonrandomized, single arm clinical trial—the Adjunctive Neurovascular Support of Wide-neck aneurysm Embolization and Reconstruction (ANSWER) Trial.

OBJECTIVE: To present the results of the United States cases employing the PulseRider device as part of the ANSWER clinical trial.

METHODS: Aneurysms treated with the PulseRider device among sites enrolling in the ANSWER trial were prospectively studied and the results are summarized. Aneurysms arising at either the carotid terminus or basilar apex that were relatively broad necked were considered candidates for inclusion into the ANSWER study.

RESULTS: Thirty-four patients were enrolled (29 female and 5 male) with a mean age of 60.9 years (27 basilar apex and 7 carotid terminus). Mean aneurysm height ranged from 2.4 to 15.9 mm with a mean neck size of 5.2 mm (range 2.3-11.6 mm). In all patients, the device was delivered and deployed. Immediate Raymond I or II occlusion was achieved in 82.4% and progressed to 87.9% at 6-month follow-up. A modified Rankin Score of 2 or less was seen in 94% of patients at 6 months.

CONCLUSION: The results from the ANSWER trial demonstrate that the PulseRider device is safe and offers probable benefit as for the treatment of bifurcation aneurysms arising at the basilar apex or carotid terminus. As such, it represents a useful addition to the armamentarium of the neuroendovascular specialist.

Pediatric Obesity and Cardiometabolic Disorders: Risk Factors and Biomarkers

Obesity remains the most prevailing disorder in childhood males and females worldwide. Its high prevalence markedly predisposes children to insulin resistance, hypertension, hyperlipidemia and liver disorders while enhancing the risk of type 2 diabetes and cardiovascular diseases. In this review, the relationship of obesity with genetic and environmental factors will be described and the underlined causes will briefly be reported. As obesity in children constitutes an increasingly health concern, important potential biomarkers have been discussed for the diagnosis, treatment and follow-up of the wide range of overweight-related complications. Awareness about the applicability and limitations of these preventive and predictive biomarkers will intensify the research and medical efforts for new developments in order to efficiently struggle against childhood obesity.

GEL THE NEC: a prospective registry evaluating the safety, ease of use, and efficacy of the HydroSoft coil as a finishing device

Background and purpose

The HydroSoft coil was developed as a finishing coil, ideally to be placed along the aneurysm neck to enhance intracranial aneurysm healing. The GEL THE NEC (Gaining Efficacy Long Term: Hydrosoft, an Emerging, New, Embolic Coil) multicenter registry was developed to assess the safety and efficacy of HydroSoft coils in treating intracranial aneurysms. We report angiographic and clinical results of this prospective registry.

Materials and methods

GEL THE NEC was performed at 27 centers in five countries. Patients aged 21–90 years with a ruptured or unruptured aneurysm 3–15 mm in size were eligible for enrollment. The following variables were obtained: demographics/comorbidities, aneurysm geometry, adjunctive devices used, proportion of patients in whom HydroSoft coils were successfully placed, and long-term angiographic outcomes (graded by an independent core laboratory using the Modified Raymond Scale), and procedure-related adverse events. Predictors of good angiographic outcome were studied using χ2 and t-tests.

Results

A total of 599 patients with 599 aneurysms were included in this study. HydroSoft coils were successfully deployed in 577 (96.4%) patients. Procedure-related major morbidity and mortality were 0.5% (3/599) and 1.3% (8/599), respectively. The most common perioperative complications were iatrogenic vasospasm (30/599, 5.0%), thromboemboli (27/599, 4.5%), and aneurysm perforation (16/599, 2.7%). At last angiographic follow-up (mean 9.0±6.3 months), the complete occlusion rate was 63.2% (280/442) and near complete occlusion rate was 25.2% (107/442). The core laboratory read recanalization rate was 10.8% (46/425) and the retreatment rate was 3.4% (20/599).

Conclusions

Endovascular treatment of intracranial aneurysms with HydroSoft coils resulted in complete/near complete occlusion rates of 88% and a major complication rate of 1.8%.

Trial registration number

NCT01000675.