A Critical Assessment of the Golden Hour and the Impact of Procedural Timing in Stroke Thrombectomy

BACKGROUND AND PURPOSE

Previous studies in acute ischemic stroke have demonstrated the importance of minimizing delays to endovascular treatment and keeping thrombectomy procedural times at <30-60 minutes. The purpose of this study was to investigate the impact of thrombectomy procedural times on clinical outcomes.

MATERIALS AND METHODS

We retrospectively compared 319 patients having undergone thrombectomy according to procedural time (<30 minutes, 30-60 minutes, and >60 minutes) and time from stroke onset to endovascular therapy (≤6 or >6 hours). Clinical characteristics of patients with postprocedural intracranial hemorrhage were also assessed. Logistic regression was used to determine independent predictors of poor outcome at 90 days (mRS ≥3).

RESULTS

Greater age (OR, 1.03; 95% CI, 1.01-1.06; P = .016), higher admission NIHSS score (OR, 1.10; 95% CI, 1.04-1.16; P = .001), history of diabetes mellitus (OR, 1.96; 95% CI, 1.05-3.65; P = .034), and postprocedural intracranial hemorrhage were independently associated with greater odds of poor outcome. Modified TICI scale scores of 2c (OR, 0.11; 95% CI, 0.04-0.28; P < .001) and 3 (OR, 0.15; 95% CI, 0.06-0.38; P < .001) were associated with reduced odds of poor outcome. Although not statistically significant on univariate analysis, onset to endovascular therapy of >6 hours was independently associated with increased odds of poor outcome (OR, 2.20; 95% CI, 1.11-4.36; P = .024) in the final multivariate model (area under the curve = 0.820). Procedural time was not independently associated with clinical outcome in the final multivariate model (P > .05).

CONCLUSIONS

Thrombectomy procedural times beyond 60 minutes are associated with lower revascularization rates and worse 90-day outcomes. Procedural time itself was not an independent predictor of outcome. While stroke thrombectomy procedures should be performed rapidly, our study emphasizes the significance of achieving revascularization despite the requisite procedural time. However, the potential for revascularization must be weighed against the risks associated with multiple thrombectomy attempts.

Pipeline Diameter Significantly Impacts the Long-Term Fate of Jailed Side Branches during Treatment of Intracranial Aneurysms

BACKGROUND AND PURPOSE

Although covered side branches typically remain patent acutely following Pipeline Embolization Device embolization of intracranial aneurysms, the long-term fate of these vessels remains uncertain. We therefore elected to investigate factors that may influence the long-term patency of these covered side branches.

MATERIALS AND METHODS

We retrospectively evaluated the long-term patency of side branches covered by the Pipeline Embolization Device at our institution during treatment of intracranial aneurysms with at least 6 months of conventional angiography follow-up. Procedural and anatomic factors that might influence the fate of covered side branches were explored.

RESULTS

One hundred forty-eight Pipeline Embolization Device treatments in 137 patients met the inclusion criteria. In 217 covered side branches, 29 (13.4%) were occluded on follow-up, and 40 (18.4%) were stenotic. All stenoses and occlusions were asymptomatic. In the entire cohort and in the largest subset of ophthalmic arteries, a smaller Pipeline Embolization Device diameter was associated with branch vessel occlusion (P = .001, P = .013). When we considered stenotic and occluded side branches together, smaller Pipeline Embolization Device size (P = .029) and administration of intraprocedural abciximab (P = .03) predicted side branch stenosis/occlusion, while anterior choroidal branch type (P = .003) was a predictor of gross side branch patency.

CONCLUSIONS

A smaller Pipeline Embolization Device diameter is associated with delayed side branch stenosis/occlusion following Pipeline Embolization Device treatment, likely due to the higher metal density of smaller caliber devices. Although hemodynamic factors, including the potential for collateral flow, are still paramount in determining the fate of covered side branches, the amount of metal coverage at the side branch orifice also plays an important role.

Analysis of epsilon-N-2-furoylmethyl-L-lysine (furosine) in dried milk by capillary electrophoresis with controlled electroosmotic flow using N,N,N',N'-tetramethyl-1,3-butanediamine in the running electrolyte solution

The electrophoresis of epsilon-N-2-furoylmethyl-L-lysine (furosine) was studied in an attempt to develop a method for the identification and quantitation of this compound in processed food. The effect of pH and composition of electrolyte solution on both the electrophoretic migration of furosine and the electroosmotic flow in a bare fused-silica capillary of 75 mu m internal diameter was investigated. We demonstrate that the addition, to the running electrolyte solution, of N,N,N',N'-tetramethyl-1,3-butanediamine (TMBD) at concentrations ranging from 20 to 80 mM improves peak efficiency and can be used to modulate the migration time of furosine by controlling the electroosmotic flow which is reversed from cathodic to anodic. In a sample of dried milk subjected to a long period of storage under controlled conditions, furosine could be efficiently and reproducibly separated and quantitated by employing as the running electrolyte 60 mM TMBD titrated to pH 2.5. Capillary electrophoresis is a promising technique for the rapid identification and quantitation of furosine in processed food.

N,N,N',N'-tetramethyl-1,3-butanediamine as effective running electrolyte additive for efficient electrophoretic separation of basic proteins in bare fused-silica capillaries

The effect of N,N,N',N'-tetramethyl-1,3-butanediamine (TMBD) in the running electrolyte on the electroosmotic flow and the migration behavior of four standard basic proteins in bare fused-silica capillaries was examined at pH 4.0, 5.5, and 6.5. Depending on the electrolyte pH and additive concentration the electroosmotic flow was either cathodic or anodic. A similar Langmuirian-type dependence of the electroosmotic flow on the concentration of TMBD in the running electrolyte was found at the three experimented pH values, which may be indicative of the specific adsorption of the additive in the immobilized region of the electric double layer at the interface between the capillary wall and the electrolyte solution. Electrophoretic separations of the four standard basic proteins performed at the three above pH values, showed well-resolved, efficient and symmetric peaks, demonstrating the utility of this additive for protein electrophoresis in bare fused-silica capillaries. The variations in separation efficiency, peak capacity, resolution and reproducibility of migration times as a function of the additive concentration at pH 6.5 were also examined.