The impact of coronavirus disease 2019 (COVID-19) is continuing, and the most important issue facing medical staff is how to provide medical care while preventing nosocomial infections. Since acute stroke treatment, particularly mechanical thrombectomy, is urgent, infection protection measures may not always be followed, which increases the risk of infection exposure. The measures and methods for patient screening, transport, zoning, and use of personal protective equipment (PPE) employed to prevent nosocomial infections of COVID-19 at our facility are described herein.
Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SAR-CoV-2), which appeared at the end of 2019 and has spread rapidly worldwide. In Japan, the increasing number of people infected with SAR-CoV-2 is also a cause of concern for physicians managing stroke patients. From the perspective of viral transmission in the hospital, stroke physicians must determine whether patients who have been transported by emergency have confirmed or suspected COVID-19. For this reason, stroke physicians must also understand about the characteristics and accuracy of the test for COVID-19 diagnosis. This article describes the sensitivity of the clinical symptoms, imaging investigations such as chest radiography and chest CT, and accuracy of nucleic-acid amplification tests and antigen tests used in the diagnosis of COVID-19. However, it should be noted that the accuracy of specimen tests may change depending on the collection site, timing, and method, because positive results in these tested specimens depend on the viral loads. In performing medical treatment for stroke, high accuracy and rapid inspection for COVID-19 is desired, but this is not currently available. For acute stroke treatment, such as thrombectomy, we recommend that these emergency patients, who are suspected of COVID-19 by clinical symptoms and image investigations, should be treated with implementation of strict infection control against droplets, contact, and airborne transmission until the most sensitive polymerase chain reaction test result is confirmed as negative.
Objective: To examine the effectiveness of a newly developed emergency room (ER) protocol to treat patients with stroke and control the spread of SARS-CoV-2 by evaluating the door-to-picture time.
Methods: We retrospectively enrolled 126 patients who were transported to our ER by ambulance with suspected stroke between April 15 and October 31, 2020 (study group). A risk judgment system named the COVID level was introduced to classify the risk of infection as follows: level 0, no infection; I, infection unlikely; II, possible; III, probable; and IV, definite. Patients with COVID levels 0, I, or II and a Glasgow Coma Scale (GCS) score >10 were placed in a normal ER (nER) without atmospheric pressure control; the medical staff wore standard personal protective equipment (PPE) in such cases. Patients with COVID level II, III, or IV, and a GCS score of ≤10 were assigned to the negative pressure ER (NPER); the medical staff wore enhanced PPE for these cases. The validity of the protocol was assessed. The door-to-picture time of the study group was compared with that of 114 control patients who were transported with suspected stroke during the same period in 2019 (control group). The difference in the time for CT and MRI between the two groups was also compared. In the study group, the time spent in the nER and NPER was evaluated.
Results: In all, 118 patients (93.7%) were classified as level I, 6 (4.8%) as level II, and 2 (1.6%) as level III. Only five patients (4.0%) were treated with NPER. Polymerase chain reaction tests were performed on 118 out of 126 patients (93.7%) and were negative. No significant differences were observed in age, sex, neurological severity, modalities of diagnostic imaging, and diagnosis compared with the control group. The median door-to-picture time was 18 (11–27.8) min in the study group and 15 (10–25) min in the control group (p = 0.08). No delay was found on CT (15 [10–21] vs. 14 [9–21] min, p = 0.24). In contrast, there was an 8-min delay for MRI (30 [21.8–50] vs. 22 [14–30] min, p = 0.01). The median door-to-picture time was 29 min longer in patients treated with NPER than in those treated with nER, although the difference was not significant due to the small number of patients (47 [27–57] vs. 18 [11–26] min, p = 0.07).
Conclusion: Our protocol could optimize the use of medical resources with only a 3-min delay in the door-to-picture time in an area without explosive outbreak. Unfortunately, the effectiveness of the protocol in preventing infection could not be verified because of the low incidence of COVID-19. When developing and modifying an institutional protocol, recognizing the outbreak status surrounding each institution is important.
Objective: The present study investigated changes in the management of acute stroke patients between before and during the coronavirus disease 2019 (COVID-19) pandemic in several countries using a questionnaire.
Methods: A questionnaire survey was conducted at 23 stroke centers in 20 countries to examine how stroke management systems have changed from 2019 (before the COVID-19 pandemic) to 2020 (during the COVID-19 pandemic).
Results: Questionnaire responses were obtained from 14 stroke centers (61%) in 14 countries. Among the surveyed stroke centers, 36% utilized full personal protective equipment (PPE) including N95 masks in all cases. After the proper application of infection precautions and screening for COVID-19, the initial imaging modality and indications for endovascular thrombectomy (ET) for ischemic stroke remained unchanged in more than 85% of the surveyed stroke centers. The transmission of COVID-19 from stroke patients to doctors or nurses was confirmed in 29% of the surveyed stroke centers, and hospital-acquired infection from patients to other patients occurred in 25%. The number of cases undergoing ET decreased by 10–70% in 50% of stroke centers during the COVID-19 pandemic. Despite successful recanalization, 50% of patients who underwent ET died, and death was mainly attributed to COVID-19-related systemic complications.
Conclusion: No significant differences were observed in stroke management or treatment strategies between before and during the COVID-19 pandemic in most stroke centers, except for COVID-19 precautions. However, the higher proportion of hospital-acquired infections and increased morbidity rate among patients despite successful recanalization due to COVID-19-related systemic complications are important findings.
Objective: The assessment of platelet functions is necessary to prevent both thromboembolic and hemorrhagic complications under dual antiplatelet therapy (DAPT). Using the VerifyNow (Accumetrics, Inc., San Diego, CA, USA) assay, this study aimed to reveal time-dependent changes in platelet functions after carotid artery stenting (CAS).
Methods: We enrolled retrospectively 43 patients who underwent CAS under DAPT. Aspirin reaction unit (ARU) and P2Y12 reaction unit (PRU) values were determined on the day before and on days 1, 3, and 7 after the procedure. Multiple comparison tests (MCTs) were performed among ARU and PRU measurement points, and the proportions of hypo- and hyper-responses were compared.
Results: The median ARU values were 408 (interquartile range: 392–497) before CAS and 418 (405–470) on day 1, 405 (393.0–460.5) on day 3, and 402 (388.5–477.5) on day 7 (not significant in MCTs). The percentages of hypo-responses were 16.3%, 7.0%, 2.3%, and 7.0%, respectively (p = 0.11). The significantly different median PRU values were 173 (116.5–209.5), 233 (166.5–273.5), 139 (70.5–205.5), and 51 (9.0–79.5), respectively. The median PRU was before the procedure within the therapeutic range but exceeded the upper cutoff on day 1 and was below the lower cutoff on day 7. The percentages of hypo-responses were 14.0%, 51.2%, 18.6%, and 11.6%, respectively (p <0.001) and the percentages of hyper-responses were 9.3%, 2.3%, 23.3%, and 62.8%, respectively (p <0.001).
Conclusion: In the periprocedural CAS period, ARU values were stable, but PRU values showed time-dependent changes. PRU values were above the therapeutic range the day after CAS but decreased below this range on day 7.
Objective: Preoperative embolization of meningiomas induces necrosis prior to surgery and facilitates resection. Lack of contrast enhancement on postembolization MRI correlates with pathological findings of necrosis and can be used to assess embolization efficacy. This study aimed to examine clinicopathologic factors associated with tumor necrosis after embolization.
Methods: A total of 119 patients with intracranial meningioma who underwent 145 surgical resections between 2010 and 2019 at our institute were reviewed. Inclusion criteria for the study were preoperative embolization with trisacryl gelatin microspheres (Embosphere) or absorbable gelatine sponge (Gelfoam). Postembolization Gd-enhanced T1-weighted and angiographic imaging, and histopathologic examination results were reviewed to evaluate the effectiveness of embolization.
Results: In all, 66 patients satisfied the inclusion criteria. In total, 36 patients were embolized with Embosphere and 30 patients were embolized with Gelfoam. Patients embolized with Embosphere had a significantly higher necrosis rate (NR) than patients with Gelfoam (21% vs. 7.1%, P <0.01). The 36 Embosphere patients were analyzed regarding clinicopathologic factors associated with NR. Tumors in 12 patients were located in the parasagittal/falx region; these patients had a significantly lower NR compared with tumors in other locations (10.6% vs. 26.2%, P = 0.016). In all, 13 patients had feeders arising from only the middle meningeal artery (MMA), which was associated with a significantly higher NR (29.3% vs. 14.4%, P = 0.015). In total, 11 patients had meningeal feeders arising from internal carotid artery (ICA), which was associated with a significantly lower NR (9.0% vs. 26.3%, P <0.01).
Conclusion: This study showed embolization agent, tumor location, and blood supply were important factors predicting necrosis after preoperative embolization.
Objective: In patients with acute ischemic stroke (AIS), prognosis strongly depends on the onset-to-recanalization time. The Ishinomaki protocol for rapid recanalization has been used since October 2017. This protocol determines the indication for reperfusion therapy based on computed tomography (CT)/three-dimensional CT angiography (3DCTA) findings and intends to reduce the onset-to-recanalization time. We aimed to compare the outcomes before and after protocol introduction.
Methods: Our hospital is the only thrombectomy-capable center in Ishinomaki, Tome, and Kesennuma medical area. Before protocol introduction (April 2014–June 2016), both CT and magnetic resonance imaging were performed to determine the indications for intravenous (IV) recombinant tissue-plasminogen activator (rt-PA) or mechanical thrombectomy within 6 hours of disease onset. However, after protocol introduction (from October 2017), plain CT and 3DCTA were used. We collected data on patients who underwent mechanical thrombectomy and/or IV rt-PA before (n = 13) and after (n = 34) the protocol introduction. The required time from onset to door (OTD), door to needle (DTN), needle to puncture (NTP), puncture to recanalization (PTR), and door to recanalization (DTR) were compared before and after protocol introduction. Furthermore, thrombolysis in cerebral infarction (TICI) grades and modified Rankin scale (mRS) scores at discharge were compared.
Results: The outcomes before and after protocol introduction were as follows: OTD: 105 ± 73.8 (mean ± standard deviation) vs. 120 ± 68.1 min (p = 0.376, Mann–Whitney U test); DTN: 62.9 ± 15.9 vs. 41 ± 17 min (p <0.01); NTP: 112 ± 69.8 vs. 39.9 ± 33.7 min (p <0.01); PTR: 87.9 ± 45.4 vs. 52.5 ± 27.9 min (p <0.01); and DTR, 230 ± 69.9 vs. 110 ± 40.3 min (p <0.0001). Before and after protocol introduction, the proportion of patients with TICI grade 2b–3, mRS score of 0–2 at discharge, and mRS score of 5–6 were 54% vs. 50% (p = 0.815, Fisher’s exact test), 23% vs. 21% (p = 0.854), and 15% vs. 50% (p = 0.046), respectively.
Conclusion: The Ishinomaki protocol reduced the mean DTR time by 120 min. The reduction in treatment time was due to the change in CT-based recanalization and collaboration with emergency physicians and paramedics. There was no increase in good outcomes, but there was a significant increase in poor outcomes at discharge. Patients who could not be salvaged were indicated for reperfusion therapy as CT and 3DCTA cannot detect the ischemic core.
Objective: During cerebral aneurysm embolization using intracranial stents, platelet aggregation increases owing to increased wall shear stress and a loss of vascular endothelial function at the stent implantation site. Preoperative multiple antiplatelet therapy was introduced to prevent severe thromboembolic complications due to increased platelet aggregation. However, specific guidelines for the administration and pharmacological evaluation of this therapy do not exist currently. We examined the benefits of perioperative platelet aggregation monitoring in a cohort of patients.
Methods: We had 377 patients with unruptured intracranial aneurysms who underwent stent-assisted embolization at our hospital between December 2012 and November 2019. We ultimately included 181 patients in our final analysis. These patients were continuously administered aspirin (100 mg/day) and clopidogrel (75 mg/day) for more than 5 days before the procedure to the post-procedural period. Of these patients, 30 patients who underwent light transmission aggregometry (LTA) before procedure, post-procedure (3 days after procedure), and at first post-discharge clinic visit were included as the subjects. The following characteristics were studied: age; sex; presence/absence of hypertension, dyslipidemia, and/or diabetes mellitus; location of aneurysm; type/number of stent; technique for stent placement; duration of preoperative multiple antiplatelet therapy; perioperative platelet aggregation test results; and postoperative ischemic or hemorrhagic complications.
Results: Among these 30 patients, the median duration of antiplatelet therapy prior to the preoperative platelet aggregation measurements was 7 (interquartile range [IQR]: 6–8) days, and post-discharge measurement of LTA was performed at a median period of 27 (IQR: 22–35.5) days after procedure. The preoperative, postoperative, and first post-discharge clinic visit LTA values for adenosine diphosphate (ADP)-induced platelet aggregation were 50% (IQR: 44–54%), 42.5% (IQR: 36–48%), and 36% (IQR: 32–40%), respectively. These results represented gradual decrease in LTA values and a significant difference between the preoperative and post-discharge values. The LTA values for collagen aggregation showed a significant difference evident between the preoperative and post-discharge values; preoperative 38% (IQR: 27–60%), postoperative 42% (IQR: 30–58%), post-discharge 28% (IQR: 20–42%), respectively. We had one thromboembolic complication and one hemorrhagic complication. The results indicated that appropriate platelet aggregation monitoring during multiple antiplatelet therapy prevents thromboembolic complications such as stent thrombosis. However, we also found that many patients demonstrated increased postoperative platelet aggregation inhibitory effects due to the postoperative continuation of the same multiple antiplatelet therapy that was used preoperatively.
Conclusion: This study demonstrates that postoperative, continuous, oral antiplatelet therapy induces increased platelet aggregation inhibition effects, which may lead to hemorrhagic complications. Therefore, continued platelet aggregation monitoring after surgery may be important to allow for any necessary alterations to the therapeutic dose and regimen.
Objective: We report a case of spinal cord infarction following mechanical thrombectomy for acute basilar artery occlusion, and describe the pathophysiological mechanism of spinal cord infarction and its possible prevention.
Case Presentation: A 70-year-old man developed dysarthria and left-sided sensory impairment and was then diagnosed with acute basilar artery occlusion. Mechanical thrombectomy was performed using a 6-Fr guiding sheath via the left vertebral artery (VA). Complete recanalization was achieved within 1.5 hours. However, toward the end of the procedure, the guiding sheath was wedged in the distal portion of the VA. Postoperatively, left-sided flaccid paralysis and right-sided sensory deficit were observed. Cervical magnetic resonance imaging (MRI) demonstrated an acute spinal cord infarction on the left side, at the level of C3. The cause of infarction was suspected to be the wedging of the guiding sheath during the procedure.
Conclusion: Spinal cord infarction is a rare but serious complication of mechanical thrombectomy for acute basilar artery occlusion. The selection of appropriate procedure, device, and safe access route are essential for the success of a mechanical thrombectomy for acute basilar artery occlusion.
Objective: We report three patients successfully treated by emergent transvenous thrombectomy for cerebral venous sinus thrombosis (CVST).
Case Presentation: (Case 1) A 77-year-old man presented with vomiting, dizziness, and headache. CT revealed local subarachnoid hemorrhage (l-SAH), and angiography confirmed occlusion of the right transverse sigmoid sinus and superior sagittal sinus (SSS). Emergent transvenous aspiration thrombectomy using a Penumbra catheter (PC) resulted in effective reperfusion. (Case 2) A 60-year-old man developed disorientation, sensory aphasia, and right hemiparesis. MRI demonstrated extensive cerebral edema caused by venous congestion in both thalami, and angiography revealed poor opacification of the SSS, straight sinus, and bilateral transverse sinuses. Venous sinus flow was restored by catheter aspiration using a PC and topical infusion of urokinase (UK). (Case 3) A 19-year-old man developed a headache, numbness of the right upper limb, motor paralysis, and convulsions. CT revealed l-SAH and dense clot sign in the SSS. The SSS was poorly delineated on angiography. Thrombus aspiration using a PC and topical UK administration achieved partial recanalization.
Conclusion: Transvenous aspiration thrombectomy using large lumen catheters for patients with CVST is effective and safe. In particular, this method may be a better option than anti-coagulation therapy alone for patients presenting with a severe neurological condition or intracranial hemorrhage.