Physician Approaches to Imaging and Revascularization for Acutely Symptomatic Carotid Stenosis: Insights from the Hot Carotid Qualitative Study

Background Evidence informing the choice between carotid endarterectomy and carotid artery stenting for acutely symptomatic carotid stenosis (“hot carotid”) is dated and does not factor in contemporary therapies or techniques. The optimal imaging modality is also uncertain. We explored the attitudes of stroke physicians regarding imaging and revascularization of patients with acute symptomatic carotid stenosis. Methods We used a qualitative descriptive methodology to examine decision‐making approaches and opinions of physicians regarding the choice of imaging and revascularization procedures for hot carotids. We conducted semistructured interviews with purposive sampling of 22 stroke physicians from 16 centers in 6 world regions and various specialties: 11 neurologists, 3 geriatricians, 5 interventional neuroradiologists, and 3 neurovascular surgeons. Results Qualitative analysis revealed several themes regarding clinical decision‐making for hot carotids. Whereas CT angiography was favored by most participants, timely imaging availability, breadth of information gained, and surgeon/interventionalist preferences were important themes influencing the choice of imaging modality. Carotid endarterectomy was generally favored over carotid artery stenting, but participants’ choice of intervention was influenced by healthcare system factors such as use of multidisciplinary vascular teams and operating room or angiography suite availability, and patient factors like age and infarct size. Areas of uncertainty included choice of imaging modality for borderline stenosis, utility of carotid plaque imaging, timing of revascularization, and the role of intervention with borderline stenosis or intraluminal thrombus. Conclusions This qualitative study highlights practice patterns common in different centers around the world, such as the general preference for CT angiography imaging and carotid endarterectomy over carotid artery stenting but also identified important differences in availability, selection, and timing of imaging and revascularization options. To gain widespread support, future carotid trials will need to accommodate identified variations in practice patterns and address areas of uncertainty, such as optimal timing of revascularization with modern best medical management and risk‐stratification with imaging features other than just degree of stenosis.

Reversal of Intracranial Hypertension‐Related Pseudomeningocele after Venous Sinus Stenting

Postoperative pseudomeningocele is a common complication of craniotomies for tumor resection. Intracranial hypertension can hinder dural repair and potentially lead to refractory or severe cases of pseudomeningocele. We present an unconventional use of venous sinus stenosis stenting to treat postcraniotomy pseudomeningocele driven by intracranial hypertension.

Mechanical Thrombectomy Beyond 2b Reperfusion: Should We Pursue a Higher Reperfusion Grade after Achievement of 2b?

Background Extended thrombolysis in cerebral infarction (eTICI) 2c/3 reperfusion after mechanical thrombectomy (MT) is associated with better stroke outcomes than eTICI 2b. Whether additional MT attempt after achieving eTICI 2b (beyond 2b attempt) leads to better outcomes is unknown. Methods Consecutive patients with acute anterior circulation stroke who achieved eTICI 2b during MT were divided into 2 groups: those who further tried MT (beyond‐2b group) and those without (nonbeyond‐2b group). The patients who directly achieved eTICI 2c/3 without experiencing 2b (direct‐2c/3 group) were also studied. The outcomes included the reperfusion status, favorable outcome (3‐month modified Rankin scale score of 0–2), neurological improvement (a ≥10‐point decrease of the National Institutes of Health Stroke Scale score from baseline or the score of 0) at 24 hours and symptomatic intracranial hemorrhage. Results Of 308 patients, 50 were in the beyond‐2b group, 87 in the nonbeyond‐2b group, and the remaining 171 in the direct‐2c/3 group. Perfusion of middle cerebral artery branches supplying the primary motor cortex was worse in the beyond‐2b than the nonbeyond‐2b group at the time of eTICI 2b ( P =0.007). Favorable outcome was similarly common (48% for each, P =0.40). Neurological improvement was more frequent (52% versus 37%; P =0.04) and symptomatic intracranial hemorrhage tended to be more common (6% versus 1%, P =0.11) in the beyond‐2b than the nonbeyond‐2b group. Eighteen patients (36%) in the beyond‐2b group finally achieved eTICI 2c/3; 10 of these (56%) and 14 of the remaining 32 (44%) had favorable outcome ( P =0.83). The former rate was similar to that in the direct‐2c/3 group (58%; P =0.99). Conclusions Patients undergoing additional MT attempt after achieving eTICI 2b had numerically but not significantly more symptomatic intracranial hemorrhage and showed a similar level of functional outcome at 3 months than those who did not. When eTICI 2c/3 was finally achieved by additional attempts, functional outcome was similar with that of patients who directly achieved eTICI 2c/3 without experiencing 2b. Clinical Trial Registration Information URL: https://www.clinicaltrials.gov . Unique identifier: NCT02251665.

Incidence and Risk Factors for Acute Transient Contrast‐Induced Neurologic Deficit: A Systematic Review With Meta‐Analysis

BACKGROUND After MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) demonstrated that endovascular therapy improved outcomes in patients with stroke, the number of endovascular procedures has risen sharply. We describe acute transient contrast‐induced neurological deficit (ATCIND), a group of neurological syndromes associated with arterial contrast administration during angiography. Our goal is to elucidate the incidence, risk factors, outcomes, pathogenesis, and diagnostic characteristics of ATCIND. Our primary objective is to elucidate the incidence of ATCIND in the setting of coronary or cerebral angiography. Secondary outcomes include potential risk factors, demographics, treatment modalities, and patient recovery. METHODS The data that support the findings of this study are available from the corresponding author on reasonable request. The databases of the Cochrane Library, MEDLINE, Web of Science, and Embase were queried, yielding studies from 1974 to 2021. Inclusion criteria for articles were the following: (1) contrast‐induced encephalopathy, contrast‐induced neurotoxicity, or cortical blindness after contrast administration during angiography were the focus of the article; (2) incidence was reported; (3) studies included ≥3 cases; and (4) follow‐up tests were described to rule out other causes. Exclusion criteria included the following: (1) incidence was not reported; (2) unavailable in the English language; (3) abstracts and unpublished studies; and (4) did not exclude other possible causes, or findings suggested other possible causes, such as worsening ischemic injury. Of 627 articles, 7 were retained. This systematic review with meta‐analysis was performed in accordance with guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) and the Meta‐Analysis of Observational Studies in Epidemiology (MOOSE) checklists. Independent extraction by multiple reviewers was performed. Data were pooled using a random‐effects model. RESULTS The primary study outcome was incidence of ATCIND, which was formulated before data collection began. We hypothesized that the pooled incidence of ATCIND would be similar to that of individual studies. A total of 70 of 21007 patients had the diagnosis of contrast‐induced encephalopathy, contrast‐induced neurotoxicity or angiography‐associated cortical blindness, and ATCIND. The incidence rate of ATCIND is estimated to be 0.51% (CI, 0.3%–1.0%; P <0.001 [ I 2 =29.3]), or 51 per 10 000 patients. Pooled data for risk factors for contrast‐induced encephalopathy were higher contrast dose (odds ratio [OR], 1.072; 95% CI, 0.952–1.192 [ P <0.001]; I 2 =0), and prior stroke (OR, 5.153; CI 1.726–8.581 [ P =0.003]; I 2 =0). Contrast dose >150 mL was a positive, significant predictor of visual disturbance (OR, 7.083; CI, 1.1742–42.793 [ P =0.033]). Full recovery is estimated at 89.5% (95% CI, 76.9%–95.6%; P <0.001 [ I 2 =0]). CONCLUSIONS This study confirms the rare incidence of ATCIND, although it shows moderate heterogeneity, likely reflecting the type of angiography performed. Risk factors include larger contrast dose and prior stroke. Full recovery occurs in the majority of patients. It should remain in the differential diagnosis in patients with certain risk factors for blood–brain barrier compromise.

General Anesthesia Versus Conscious Sedation for Mechanical Thrombectomy in Acute Anterior Circulation Ischemic Stroke

BACKGROUND Retrospective studies suggested that general anesthesia (GA) for mechanical thrombectomy has worse outcomes compared with conscious sedation (CS). However, randomized single‐center trials suggested noninferiority of GA to CS. We investigated the impact of anesthesia techniques on thrombectomy, and hypothesized that the routine use of GA with a defined protocol would not adversely affect thrombectomy delivery or outcomes. METHODS A total of 451 consecutive patients receiving mechanical thrombectomy for anterior circulation ischemic stroke from 2016 to 2019 were identified from the local registry. Patients were divided into cohort A when both GA and CS were used, and cohort B (from October 2017) when GA became the default method. Favorable functional outcome was defined as modified Rankin scale of 0 to 2 at 3 months. Intraprocedural blood pressures were audited annually. RESULTS In cohort A, compared with patients receiving CS, patients with GA had prolonged median arrival to arterial puncture time (26 versus 18 minutes; P <0.001) and comparable favorable functional outcome at 3 months (37.7% versus 45.1%; P =0.355). In cohort B, the median arrival to arterial puncture was reduced to 10 minutes, with comparable favorable functional outcome of 46.7%, and reduced mortality compared with cohort A (14.2% versus 22.7%; P =0.024). Yearly audits demonstrated good adherence to the protocol. Binary logistic regression analysis showed only old age (odds ratio [OR], 1.04; 95% CI, 1.02–1.07 [ P =0.003]), high National Institute of Health Stroke Scale at presentation (OR, 1.17; 95% CI, 1.08–1.26 [ P <0.001]), and poor collateral status (OR, 0.29; 95% CI, 0.12–0.72 [ P =0.008]) were independent factors predicting for poor prognosis, not GA (OR, 0.71; 95% CI, 0.32–1.60 [ P =0.408]). CONCLUSIONS Patients treated under GA for mechanical thrombectomy achieved comparable functional outcome at 3 months compared with those under CS. Through practice and a defined protocol, GA for mechanical thrombectomy can achieve sustainable good functional outcomes. Large clinical trials are needed to confirm these findings.