Derivo embolization device for intracranial aneurysms: a Spanish multicenter retrospective study

BACKGROUND

Flow diverters have emerged in recent years as a safe and effective treatment for intracranial aneurysms, with expanding indications. The Derivo embolization device (DED) is a second-generation flow diverter with a surface finish that may reduce thrombogenicity. We report our multicenter experience evaluating its safety and efficacy.

METHODS

We retrospectively analyzed all patients treated with the DED in eight centers in Spain between 2016 and 2020. Demographics, clinical data, procedural complications, morbidity and aneurysm occlusion rates were collected.

RESULTS

A total of 209 patients with 250 aneurysms were treated (77.5% women). The majority of aneurysms were located in the internal carotid artery (86.8%) and most (69.2%) were small (<10 mm) with a median maximum diameter of 5.85 mm and median neck size of 4 mm. DED deployment was successful in all cases, despite two malfunctioning devices (1%). Major complications occurred in nine patients (4.3%), while mild neurologic clinical events were registered in 23 (11%); four patients died (1.9%). A total of 194 aneurysms had an angiographic follow-up at 6 months and showed complete aneurysm occlusion in 75% of cases. Twelve-month follow-up was available for 112 of the treated aneurysms, with a total occlusion rate of 83%.

CONCLUSION

The DED is a second-generation surface-modified flow diverter that presents an option for treatment of intracranial aneurysms with comparable safety and efficacy to other available flow diverter devices. Nonetheless, risks are not negligible, and must be balanced against the natural history risk of cerebral aneurysms, considering the tendency to widen indications for treatment of smaller and less complex lesions in day-to-day use.

Correlation Between Computed Tomography-Based Tissue Net Water Uptake and Volumetric Measures of Cerebral Edema After Reperfusion Therapy

BACKGROUND

Cerebral edema after large hemispheric infarction is associated with poor functional outcome and mortality. Net water uptake (NWU) quantifies the degree of hypoattenuation on unenhanced-computed tomography (CT) and is increasingly used to measure cerebral edema in stroke research. Hemorrhagic transformation and parenchymal contrast staining after thrombectomy may confound NWU measurements. We investigated the correlation of NWU measured postthrombectomy with volumetric markers of cerebral edema and association with functional outcomes.

METHODS

In a pooled individual patient level analysis of patients presenting with anterior circulation large hemispheric infarction (core 80-300 mL or Alberta Stroke Program Early CT Score ≤5) in the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke trials) data set, cerebral edema was defined as the volumetric expansion of the ischemic hemisphere expressed as a ratio to the contralateral hemisphere(rHV). NWU and midline-shift were compared with rHV as the reference standard on 24-hour follow-up CT, adjusted for hemorrhagic transformation and the use of thrombectomy. Association between edema markers and day 90 functional outcomes (modified Rankin Scale) was assessed using ordinal logistic regression.

RESULTS

Overall (n=144), there was no correlation between NWU and rHV (r_s=0.055, P=0.51). In sub-group analyses, a weak correlation between NWU with rHV was observed after excluding patients with any degree of hemorrhagic transformation (r_s=0.211, P=0.015), which further improved after excluding thrombectomy patients (r_s=0.453, P=0.001). Midline-shift correlated strongly with rHV in all sub-group analyses (r_s>0.753, P=0.001). Functional outcome at 90 days was negatively associated with rHV (adjusted common odds ratio, 0.46 [95% CI, 0.32-0.65]; P<0.001) and midline-shift (adjusted common odds ratio, 0.85 [95% CI, 0.78-0.92]; P<0.001) but not NWU (adjusted common odds ratio, 1.00 [95% CI, 0.97-1.03]; P=0.84), adjusted for age, baseline National Institutes of Health Stroke Scale, and thrombectomy. Prognostic performance of NWU improved after excluding patients with hemorrhagic transformation and thrombectomy (adjusted odds ratio, 0.90 [95% CI, 0.80-1.02]; P=0.10).

CONCLUSIONS

NWU correlated poorly with conventional markers of cerebral edema and was not associated with clinical outcome in the presence of hemorrhagic transformation and thrombectomy. Measuring NWU postthrombectomy requires validation before implementation into clinical research. At present, the use of NWU should be limited to baseline CT, or follow-up CT only in patients without hemorrhagic transformation or treatment with thrombectomy.

Binding Energy of Triplet Excitons in Nonfullerene Acceptors: The Effects of Fluorination and Chlorination

One strategy to improve the photovoltaic properties of nonfullerene acceptors (NFAs), employed in state-of-art organic solar cells, is the rational fluorination or chlorination of these molecules. Although this modification improves important acceptor properties, little is known about the effects on the triplet states. Here, we combine the polarizable continuum model with an optimally tuned range-separated hybrid functional to investigate this issue. We find that fluorination or chlorination of NFAs decreases the degree of the highest occupied molecular orbital-lowest unoccupied molecular orbital (HOMO-LUMO) overlap along these molecules. Consequently, the energy gap between T₁ and S₁ states, ΔE_ST = E_S1 - E_T1, also decreases. This effect reduces the binding energy of triplet excitons, which favors their dissociation into free charges. Furthermore, the reduction of ΔE_ST can contribute to mitigating the losses produced by the nonradiative deactivation of the T₁ excitons. Interestingly, although Cl has a lower electronegativity than F, chlorination is more effective to reduce ΔE_ST. Since the chlorination of NFAs is easier than fluorination, Cl substitution can be a useful approach to enhance solar energy harvesting using triplet excitons.

Cerebral Aneurysm Occlusion at 12-Month Follow-Up After Flow-Diverter Treatment: Statistical Modeling for V&V With Real-World Data

Background: Flow-Diverter (FD) porosity has been pointed as a critical factor in the occlusion of cerebral aneurysms after treatment.

Objective: Verification and Validation of computational models in terms of predictive capacity, relating FD porosity and occlusion after cerebral aneurysms treatment.

Methods: Sixty-four aneurysms, with pre-treatment and follow-up images, were considered. Patient demographics and aneurysm morphological information were collected. The computational simulation provided by ANKYRAS provided FD porosity, expansion, and mesh angle. FD occlusion was assessed and recorded from follow-up images. Multiple regression Logit and analysis of covariance (ANCOVA) models were used to model the data with both categorical and continuous models.

Results: Occlusion of the aneurysm after 12 months was affected by aneurysm morphology but not by FD mesh morphology. A Time-To-Occlusion (TTO) of 6.92 months on average was observed with an SE of 0.24 months in the aneurysm population surveyed. TTO was estimated with statistical significance from the resulting model for the data examined and was capable of explaining 92% of the data variation.

Conclusions: Porosity was found to have the most correction power when assessing TTO, proving its importance in the process of aneurysm occlusion. Still, further Verification and Validation (V&V) of treatment simulation in more extensive, multi-center, and randomized databases is required.

Venous tortuosity as a novel biomarker of rupture risk in arteriovenous malformations: ARI score

BACKGROUND

Risk of rupture in arteriovenous malformations (AVMs) varies considerably among series. Hemodynamic factors, especially within the venous side of the circuit, seem to be responsible but are not yet well defined. We analyzed tortuosity in the draining vein as a potential new marker of rupture in AVMs, and propose a simple index to predict AVM bleeding.

METHODS

A retrospective analysis of the venous angioarchitecture of brain AVMs was carried out at our center from 2013 to 2021, with special attention to venous tortuosity. After univariate analysis, the features of interest were combined to construct several predictive models using multivariate logistic regression. The best model proposed was the new AVM rupture index (ARI), which was then validated in an independent cohort.

RESULTS

68 AVMs were included in the first step and 32 in the validation cohort. Venous tortuosity, expressed as at least one curve >180°, was a significant predictor of rupture (p=0.023). The proposed bleeding index consisted of: venous tortuosity (any curve of >180°), single draining vein, and paraventricular/infratentorial location. It seems to be a robust evaluation tool, with an area under the receiver operating characteristic (AUROC) curve of 0.806 (95% CI 0.714 to 0.899), consistently replicated in the independent sample (AUROC 0.759 (95% CI 0.607 to 0.911)), and with an inter-rater kappa coefficient of 0.81 .

CONCLUSIONS

Venous tortuosity may serve as a predictor of bleeding in AVMs that warrants further investigation. This likely new marker was one of the three elements of the proposed ARI. ARI outperformed the predictive accuracy of previous scores, and remained consistent in an independent cohort.

Stent-retriever alone versus combined use of stent-retriever and contact aspiration technique for middle cerebral artery M2 occlusions: a propensity score analysis

BACKGROUND

The optimal endovascular treatment (EVT) technique for middle cerebral artery (MCA) M2 segment occlusions remains unknown. We aim to analyze whether reperfusion rate, procedure times, procedure-related complications, and clinical outcome differed between patients with isolated M2 occlusions who underwent stent-retriever (SR) alone versus combined SR and contact aspiration (CA) as a front-line EVT.

METHODS

Patients who underwent EVT for isolated MCA-M2 occlusion were recruited from the prospectively ongoing ROSSETTI registry. Patients were divided regarding the EVT approach into SR alone versus SR+CA and propensity score matching was used to achieve baseline balance. Demographic, procedural, safety, and clinical outcomes were compared between groups. Multivariable logistic regression analysis was performed to identify independent predictors of first-pass effect (FPE) and 90-day modified Rankin scale (mRS) 0-2.

RESULTS

214 patients underwent EVT for M2 occlusion, 125 treated with SR alone and 89 with SR+CA. Propensity score matchnig analysis selected 134 matched patients. The rates of FPE (42% vs 40%, p=1.000) and 90-day mRS 0-2 (60% vs 51%, p=0.281) were comparable between groups. Patients treated with SR alone had lower need of rescue therapy (p=0.006), faster times to reperfusion (p<0.001), and lower procedure-related complications (p=0.031). Higher initial Alberta Stroke Program Early CT Score was an independent predictor of FPE. Age, baseline National Institutes of Health Stroke Scale score, and procedure duration were significant predictors of good clinical outcome at 3 months.

CONCLUSIONS

As front-line modality in M2 occlusions, the SR alone approach results in similar rates of reperfusion and good clinical outcomes to combined SR+CA and might be advantageous due to faster reperfusion times and fewer adverse events.

Addition of intracranial aspiration to balloon guide catheter does not improve outcomes in large vessel occlusion anterior circulation stent retriever based thrombectomy for acute stroke

BACKGROUND

Balloon guide catheter (BGC) in stent retriever based thrombectomy (BGC+SR) for patients with large vessel occlusion strokes (LVOS) improves outcomes. It is conceivable that the addition of a large bore distal access catheter (DAC) to BGC+SR leads to higher efficacy. We aimed to investigate whether the combined BGC+DAC+SR approach improves angiographic and clinical outcomes compared with BGC+SR alone for thrombectomy in anterior circulation LVOS.

METHODS

Consecutive patients with anterior circulation LVOS from June 2019 to November 2020 were recruited from the ROSSETTI registry. Demographic, clinical, angiographic, and outcome data were compared between patients treated with BGC+SR alone versus BGC+DAC+SR. The primary outcome was first pass effect (FPE) rate, defined as near complete/complete revascularization (modified Thrombolysis in Cerebral Infarction (mTICI) 2c-3) after single device pass.

RESULTS

We included 401 patients (BGC+SR alone, 273 (66.6%) patients). Patients treated with BGC+SR alone were older (median age 79 (IQR 68-85) vs 73.5 (65-82) years; p=0.033) and had shorter procedural times (puncture to revascularization 24 (14-46) vs 37 (24.5-63.5) min, p<0.001) than the BGC+DAC+SR group. Both approaches had a similar FPE rate (52% in BGC+SR alone vs 46.9% in BGC+DAC+SR, p=0.337). Although the BGC+SR alone group showed higher rates for final successful reperfusion (mTICI ≥2b (86.8% vs 74.2%, p=0.002) and excellent reperfusion, mTICI ≥2 c (76.2% vs 55.5%, p<0.001)), there were no significant differences in 24 hour National Institutes of Health Stroke Scale score or rates of good functional outcome (modified Rankin Scale score of 0-2) at 3 months across these techniques.

CONCLUSIONS

Our data showed that addition of distal intracranial aspiration catheters to BGC+SR based thrombectomy in patients with acute anterior circulation LVO did not provide higher rates of FPE or improved clinical outcomes.

Cerebral Edema in Patients With Large Hemispheric Infarct Undergoing Reperfusion Treatment: A HERMES Meta-Analysis

BACKGROUND AND PURPOSE

Whether reperfusion into infarcted tissue exacerbates cerebral edema has treatment implications in patients presenting with extensive irreversible injury. We investigated the effects of endovascular thrombectomy and reperfusion on cerebral edema in patients presenting with radiological evidence of large hemispheric infarction at baseline.

METHODS

In a systematic review and individual patient-level meta-analysis of 7 randomized controlled trials comparing thrombectomy versus medical therapy in anterior circulation ischemic stroke published between January 1, 2010, and May 31, 2017 (Highly Effective Reperfusion Using Multiple Endovascular Devices collaboration), we analyzed the association between thrombectomy and reperfusion with maximal midline shift (MLS) on follow-up imaging as a measure of the space-occupying effect of cerebral edema in patients with large hemispheric infarction on pretreatment imaging, defined as diffusion-magnetic resonance imaging or computed tomography (CT)-perfusion ischemic core 80 to 300 mL or noncontrast CT-Alberta Stroke Program Early CT Score ≤5. Risk of bias was assessed using the Cochrane tool.

RESULTS

Among 1764 patients, 177 presented with large hemispheric infarction. Thrombectomy and reperfusion were associated with functional improvement (thrombectomy common odds ratio =2.30 [95% CI, 1.32-4.00]; reperfusion common odds ratio =4.73 [95% CI, 1.66-13.52]) but not MLS (thrombectomy β=-0.27 [95% CI, -1.52 to 0.98]; reperfusion β=-0.78 [95% CI, -3.07 to 1.50]) when adjusting for age, National Institutes of Health Stroke Score, glucose, and time-to-follow-up imaging. In an exploratory analysis of patients presenting with core volume >130 mL or CT-Alberta Stroke Program Early CT Score ≤3 (n=76), thrombectomy was associated with greater MLS after adjusting for age and National Institutes of Health Stroke Score (β=2.76 [95% CI, 0.33-5.20]) but not functional improvement (odds ratio, 1.71 [95% CI, 0.24-12.08]).

CONCLUSIONS

In patients presenting with large hemispheric infarction, thrombectomy and reperfusion were not associated with MLS, except in the subgroup with very large core volume (>130 mL) in whom thrombectomy was associated with increased MLS due to space-occupying ischemic edema. Mitigating cerebral edema-mediated secondary injury in patients with very large infarcts may further improve outcomes after reperfusion therapies.

Abstract P75: Cerebrovascular Events and Outcomes in Hospitalized Patients With Covid-19: The Society of Vascular and Interventional Neurology Multinational Registry

Background: Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients.

Aims: To summarize the findings of a multinational observational cohort of patients with SARS-CoV-2 and cerebrovascular disease.

Methods: Retrospective observational cohort of consecutive adults evaluated in the emergency department and/or admitted with coronavirus disease 2019 (COVID-19) across 31 hospitals in 4 countries (2/1/2020 - 06/16/2020). The primary outcome was the incidence rate of cerebrovascular events, inclusive of acute ischemic stroke, intracranial hemorrhages (ICH), and cortical vein and/or sinus thrombosis (CVST).

Results: Of the 14,483 patients with laboratory-confirmed SARS-CoV-2, 172 were diagnosed with an acute cerebrovascular event (1.13% of cohort; 1130/100,000 patients, 95%CI 970-1320/100,000), 68/171 (40.5%) of whom were female and 96/172 (55.8%) were between the ages 60-79 years. Of these, 156 had acute ischemic stroke (1.08%; 1080/100,000 95%CI 920-1260/100,000), 28 ICH (0.19%; 190/100,000 95%CI 130 - 280/100,000) and 3 with CVST (0.02%; 20/100,000, 95%CI 4-60/100,000). The in-hospital mortality rate for SARS-CoV-2-associated stroke was 38.1% and for ICH 58.3%. After adjusting for clustering by site and age, baseline stroke severity, and all predictors of in-hospital mortality found in univariate regression (p<0.1: male sex, tobacco use, arrival by emergency medical services, lower platelet and lymphocyte counts, and intracranial occlusion), cryptogenic stroke mechanism (aOR 5.01, 95%CI 1.63-15.44, p<0.01), older age (aOR 1.78, 95%CI 1.07-2.94, p=0.03), and lower lymphocyte count on admission (aOR 0.58, 95%CI 0.34-0.98 p=0.04) were the only independent predictors of mortality among patients with stroke and COVID-19.

Conclusions: COVID-19 is associated with a small but significant risk of clinically relevant cerebrovascular events, particularly ischemic stroke. The mortality rate is high for COVID-19 associated cerebrovascular complications, therefore aggressive monitoring and early intervention should be pursued to mitigate poor outcomes.

Balloon guide catheter improvements in thrombectomy outcomes persist despite advances in intracranial aspiration technology

BACKGROUND

First-pass effect (FPE) has been established as a key metric for technical success and strongly correlates with better clinical outcomes. Most data supporting improved outcomes with the use of a balloon guide catheter (BGC) predate the advent of last-generation large-bore intracranial aspiration catheters. We aim to evaluate the impact of BGC in FPE and clinical outcomes in a large cohort of patients treated with contemporary technology.

METHODS

Patients were recruited from the prospectively ongoing ROSSETTI registry. This registry includes all consecutive patients with anterior circulation large-vessel occlusion (LVO) from 10 comprehensive stroke centers in Spain. Demographic, clinical, angiographic, and clinical outcome data were compared between BGC and non-BGC groups. FPE was defined as the achievement of mTICI2c-3 after a single device pass.

RESULTS

426 patients were included out of which 271 (63.62%) used BCG. BGC-treated patients had higher FPE rate (45.8% vs 27.7%; P<0.001), higher final mTICI ≥2 c recanalization rate (76.8% vs 50.3%, respectively; P<0.001), shorter procedural time [median (IQR), 30 (19-58) vs 43 (33-71) min; P<0.001], higher NIHSS difference from admission to 24 hours [median (IQR), 8 (2-12) vs 3 (0-10); P=0.001], and lower mortality rate (17.6% vs 29.8%, P=0.026) compared with non-BGC patients. BGC use was an independent predictor of FPE (OR 2.197, 95% CI 1.436 to 3.361; P<0.001), and excellent clinical outcome at 3 months (OR 0.34, 95% CI 0.17 to 0.68; P=0.002).

CONCLUSIONS

Our results support the benefit of BGC use on angiographic and clinical outcomes in anterior circulation LVO ischemic stroke remain significant even when considering recent improvements in intracranial aspiration technology.

Comparison of aspiration-first versus stentriever-first techniques in performing mechanical thrombectomy for large vessel occlusions

BACKGROUND

Both stentriever and direct-aspiration thrombectomy effectively treat large-vessel occlusions. However, data are limited comparing clinical outcomes after aspiration-first versus stentriever-assisted aspiration for thrombectomy.

METHODS

A retrospective cohort study compared procedure times and radiographic outcomes after two mechanical thrombectomy techniques (aspiration first or stentriever). To minimize bias and variability inherent to multi-operator series, we assessed consecutive patients with cerebrovascular occlusions treated by a single surgeon during a 1 year period at two stroke centers. Expanded Thrombolysis in Cerebral Infarction (eTICI) grades were assessed by an investigator blinded to treatment.

RESULTS

Data from 93 patients (median age 70 years) were analyzed: 73 patients (78.5%) were treated with a strentriever-first strategy and 20 (21.5%) were treated with aspiration first, with stentriever rescue therapy required in only three of these cases following unsuccessful aspiration. There were no significant differences in patient demographics, sites of occlusion, or rates of tandem occlusions between aspiration-first and stentriever-assisted groups (p≥0.36). The rate of first-pass eTICI ≥2b was 75.0% (15/20) for aspiration-first and 52.1% (38/73) for strentriever-first groups (p=0.07), while the rate of final eTICI ≥2b was 100% (20/20) and 82.2% (60/72), respectively (p=0.04). The aspiration-first technique was associated with procedural times ≤25 min in a multivariable analysis (adjusted OR 4.77, 95% CI 1.15 to 18.39; p=0.03).

CONCLUSIONS

In this single-surgeon series, an aspiration-first technique was associated with a statistically significant improvement in eTICI outcomes and faster procedure times compared with stentriever-assisted aspiration. Further prospective studies are necessary to minimize selection bias inherent in this study design.

Effect of age and baseline ASPECTS on outcomes in large-vessel occlusion stroke: results from the HERMES collaboration

BACKGROUND

Patient age and baseline Alberta Stroke Program Early CT score (ASPECTS) are both independent predictors of outcome in acute ischemic stroke patients treated with endovascular therapy (EVT). We assessed the combined effect of age and ASEPCTS on clinical outcome in acute ischemic stroke patients with LVO with and without EVT, and EVT treatment effect in different age/ASPECTS subgroups.

METHODS

The HERMES collaboration pooled data of seven randomized controlled trials that tested the efficacy of EVT. Adjusted logistic regression was performed to test for multiplicative interaction of age and ASPECTS with the primary outcome (ordinal mRS) and secondary outcomes (mRS 0-2/0-1/0-3) in the EVT and control arms. Patients were then stratified by age (<75 vs ≥ 75 years) and ASPECTS (0-5/6-7/8-10), and adjusted effect-size estimates for the association of EVT were derived for the six age/ASPECTS subgroups.

RESULTS

1735 patients were included in the analysis. There was no multiplicative interaction between age and ASPECTS on clinical outcomes. In the exploratory subgroup analysis, we found a nominally negative point estimate for the association of EVT with clinical outcome in the ASPECTS 0-5/age ≥75, subgroup (acOR 0.36, 95% CI 0.07 to 1.89). The point estimate for moderate outcome (mRS0-3) nominally favored EVT (aOR 1.24, 95% CI 0.16 to 9.84). In all other subgroups, effect size-estimates consistently favored EVT.

CONCLUSION

There was no multiplicative interaction of age and ASPECTS on clinical outcomes in EVT or control arm patients. Outcomes in patients ≥75 years with ASPECTS 0-5 were poor, irrespective of treatment. Further investigation to define the role of EVT and range of acceptable outcomes in this subgroup is warranted.

Association of Time From Stroke Onset to Groin Puncture With Quality of Reperfusion After Mechanical Thrombectomy: A Meta-analysis of Individual Patient Data From 7 Randomized Clinical Trials

Importance

Reperfusion is a key factor for clinical outcome in patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT) for large-vessel intracranial occlusion. However, data are scarce on the association between the time from onset and reperfusion results.

Objective

To analyze the rate of reperfusion after EVT started at different intervals after symptom onset in patients with AIS.

Design, Setting, and Participants

We conducted a meta-analysis of individual patient data from 7 randomized trials of the Highly Effective Reperfusion Using Multiple Endovascular Devices (HERMES) group. This is a multicenter cohort study of the intervention arm of randomized clinical trials included in the HERMES group. Patients with anterior circulation AIS who underwent EVT for M1/M2 or intracranial carotid artery occlusion were included. Each trial enrolled patients according to its specific inclusion and exclusion criteria. Data on patients eligible but not enrolled (eg, refusals or exclusions) were not available. All analyses were performed by the HERMES biostatistical core laboratory using the pooled database. Data were analyzed between December 2010 and April 2015.

Main Outcomes and Measures

Successful reperfusion was defined as a modified thrombolysis in cerebral infarction score of 2b/3 at the end of the EVT procedure adjusted for age, occlusion location, pretreatment intravenous thrombolysis, and clot burden score and was analyzed in relation to different intervals (onset, emergency department arrival, imaging, and puncture) using mixed-methods logistic regression.

Results

Among the 728 included patients, with a mean (SD) age of 65.4 (13.5) years and of whom 345 were female (47.4%), decreases in rates of successful reperfusion defined as a thrombolysis in cerebral infarction score of 2b/3 were observed with increasing time from admission or first imaging to groin puncture. The magnitude of effect was a 22% relative reduction (odds ratio, 0.78; 95% CI, 0.64-0.95) per additional hour between admission and puncture and a 26% relative reduction (odds ratio, 0.74; 95% CI, 0.59-0.93) per additional hour between imaging and puncture.

Conclusions and Relevance

Because the probability of reperfusion declined significantly with time between hospital arrival and groin puncture, we provide additional arguments for minimizing the intervals after symptom onset in anterior circulation acute ischemic stroke.

Religious support buffers the indirect negative psychological effects of mass shooting in church-affiliated individuals

OBJECTIVE

Religion has been shown to protect against the negative effects of traumatic events. The current pilot study explored the extent to which religious support (i.e., sense of comfort and support from the Sacred, religious leaders, and fellow faith participants) buffered against the indirect negative psychological symptoms (i.e., religious/spiritual struggle, depression, anxiety, posttraumatic stress disorder [PTSD]) following the 2015 mass shooting on the campus of Umpqua Community College in Roseburg, Oregon.

METHOD

The study examined 34 individuals (12 male, 22 female) that were indirectly affected by the mass shooting (i.e., did not directly witness the shooting and were not physically harmed by the shooting), recruited from the surrounding religious community. Participants completed measures of resource loss, religious support, religious and spiritual struggle, depression, anxiety, and PTSD symptoms.

RESULTS

Religious support buffered the relationship between resource loss and negative psychological symptoms for religious and spiritual struggle, depression, and PTSD symptoms but not anxiety.

CONCLUSIONS

Religious and spiritual support may be an important factor for helping church-affiliated individuals cope with the negative effects of resource loss that occur when a community is affected by a mass shooting. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Early Results in Flow Diverter Sizing by Computational Simulation: Quantification of Size Change and Simulation Error Assessment

BACKGROUND

Sizing of flow diverters (FDs) stent in the treatment of intracranial aneurysms is a challenging task due to the change of stent length after implantation.

OBJECTIVE

To quantify the size change and assess the error in length prediction in 82 simulated FD deployments.

METHODS

Eighty-two consecutive patients treated with FDs were retrospectively analyzed. Implanted FD length was measured from angiographic images and compared to the nominal sizes of the implanted device. Length change was obtained by subtracting the nominal length from the real length and dividing by the nominal length. Implanted devices were simulated on 3-dimensional models of each patient. Simulation error was obtained by subtracting real length from simulated length and dividing by the real length of the FD. Subanalysis was done using ANOVA. Statistical significance was set to P < .05, and bootstrap resampling was used.

RESULTS

When assessing the length change of the FD after implantation, changes of 30% in average and up to 80% with reference to the nominal length of the device were observed. The simulation results showed a lower error of 3.52% in average with a maximum of 30%. Paired t-test showed nonsignificant differences between measured and real length (P = .07, with the mean of differences at 0.45 mm, 95% confidence interval [-0.950 0.038]).

CONCLUSION

Nominal length is not an accurate sizing metric when choosing the size of an FD irrespective of the brand and manufacturer. Good estimation of the final length of the stent after deployment as expressed by an error of 3.5% in average.

Association of follow-up infarct volume with functional outcome in acute ischemic stroke: a pooled analysis of seven randomized trials

Background

Follow-up infarct volume (FIV) has been recommended as an early indicator of treatment efficacy in patients with acute ischemic stroke. Questions remain about the optimal imaging approach for FIV measurement.

Objective

To examine the association of FIV with 90-day modified Rankin Scale (mRS) score and investigate its dependency on acquisition time and modality.

Methods

Data of seven trials were pooled. FIV was assessed on follow-up (12 hours to 2 weeks) CT or MRI. Infarct location was defined as laterality and involvement of the Alberta Stroke Program Early CT Score regions. Relative quality and strength of multivariable regression models of the association between FIV and functional outcome were assessed. Dependency of imaging modality and acquisition time (≤48 hours vs >48 hours) was evaluated.

Results

Of 1665 included patients, 83% were imaged with CT. Median FIV was 41 mL (IQR 14–120). A large FIV was associated with worse functional outcome (OR=0.88(95% CI 0.87 to 0.89) per 10 mL) in adjusted analysis. A model including FIV, location, and hemorrhage type best predicted mRS score. FIV of ≥133 mL was highly specific for unfavorable outcome. FIV was equally strongly associated with mRS score for assessment on CT and MRI, even though large differences in volume were present (48 mL (IQR 15–131) vs 22 mL (IQR 8–71), respectively). Associations of both early and late FIV assessments with outcome were similar in strength (ρ=0.60(95% CI 0.56 to 0.64) and ρ=0.55(95% CI 0.50 to 0.60), respectively).

Conclusions

In patients with an acute ischemic stroke due to a proximal intracranial occlusion of the anterior circulation, FIV is a strong independent predictor of functional outcome and can be assessed before 48 hours, oneither CT or MRI.

Abstract WP17: Effect of Solitaire Retriever-predominant Thrombectomy in Acute Ischemic Stroke: a Pooled, Individual Patient Data, Systematic Analysis

Introduction: Endovascular thrombectomy predominantly with the Solitaire stent retriever results in better outcomes among ischemic stroke patients with proximal, anterior circulation occlusions. The overall effect size and benefit in important subgroups are best estimated using pooled, individual participant-level data meta-analysis.

Methods: The SEER consortium pooled individual patient-level data from the 4 major randomized trials in which Solitaire retrievable stents were the predominant endovascular device, ESCAPE, SWIFT-PRIME, REVASCAT, and EXTEND-IA. A formal statistical analysis plan was pre-specified. The primary outcome is the modified Rankin Score at 90 days. Secondary outcomes include functional independence (mRS 0-2) and mortality at 90 days. Clinical sub-groups assessed are age, sex, NIHSS score, and target occlusion location. Full results will be presented at the meeting.

Results: Among 777 patients randomized (400 intervention, 377 control), mean age was 68 (sd 13), 51% were female, pretreatment NIHSS was median 17 (iqr 7), median ASPECTS score was 8 (iqr 2). More favorable outcomes over the entire mRS were observed with thrombectomy, CMH test p <0.001. Treatment benefit was homogenous across all subgroups of age, sex, baseline NIHSS, and target occlusion location. The rate of functional independence (mRS 0-2) at 90d was 55.0% endovascular vs. 31.5% control (RR = 1.7 CI95 1.4-2.1). The risk of death trended lower in the endovascular group (RR = 0.75 CI95 0.5-1.1). Among 128 patients ≥ 80 years of age, 37.8% (endovascular) vs. 18.5% (control) achieved an independent outcome (RR 2.0 CI95 1.1-3.8). Among 206 subjects with ICA occlusion, 45.9% (endovascular) vs. 18.9% (control) achieved an independent outcome (RR 2.4 CI95 1.5-3.8). Among 561 with MCA occlusions, 58.6% (endovascular) and 38.9% (control) achieved an independent outcome (RR 1.6 CI95 1.3-2.0).

Conclusions: Endovascular treatment for anterior circulation, large vessel occlusion ischemic stroke is a robust therapy in old and young, men and women, more and less severe deficits, and both ICA and MCA occlusions. The magnitude of benefit is large and consistent across trials; overall, 1 of every 4 treated patients achieves functional independence as a result of therapy.

Abstract WP27: Endovascular Treatment Improves Executive Functioning in Acute Ischemic Stroke

Background: Endovascular treatment has demonstrated benefit in functional outcomes after acute stroke but the effect on cognitive outcomes has not been explored yet.

Hypothesis: Our hypothesis is that endovascular treatment is associated with better cognitive outcome after ischemic stroke.

Methods: REVASCAT (Randomized Trial of Revascularization with Solitaire FR Device versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting within Eight Hours of Symptom Onset) enrolled 206 patients with stroke of anterior circulation<8h and without cognitive impairment at onset that were randomized to receive thrombectomy or best medical treatment. Executive function was measured by means of Trail Making tests (TM-A and B) at 90 day. Time of completion of each test and number of errors were recorded.

Results: Excluding deaths, 120 patients were able to complete TM-A in due time (less than 5 min), 61 in thrombectomy and 59 controls (p=NS), and 65 patients could complete TM-B, 39 in thrombectomy and 26 controls (p=0.026). Time required to complete TM-A was not different between groups but controls needed more time (unadjusted Beta,1.0; 95%CI, 0.15-1.84) than thrombectomy patients to complete TM-B.

Conclusion: Patients treated with thrombectomy showed more frequently preserved and faster executive functioning compared to controls 3 months after stroke.

Computation of the change in length of a braided device when deployed in realistic vessel models

PURPOSE

An important issue in the deployment of braided stents, such as flow diverters, is the change in length, also known as foreshortening, underwent by the device when is released from the catheter into a blood vessel. The position of the distal end is controlled by the interventionist, but knowing a priori the position of the proximal end of the device is not trivial. In this work, we assess and validate a novel computer method to predict the length that a braided stent will adopt inside a silicon model of an anatomically accurate vessel.

METHODS

Three-dimensional rotational angiography images of aneurysmatic patients were used to generate surface models of the vessels (3D meshes) and then create accurate silicon models from them. A braided stent was deployed into each silicon model to measure its length. The same stents deployed on the silicon models were virtually deployed on the 3D meshes using the method being evaluated.

RESULTS

The method was applied to five stent placements on three different silicon models. The length adopted by the real braided device in the silicon models varies between 15 and 30% from the stent length specified by the manufacturer. The final length predicted by the method was within the estimated error of the measured real stent length.

CONCLUSIONS

The method provides, in a few seconds, the length of a braided stent deployed inside a vessel, showing an accurate estimation of the final length for the cases studied. This technique could provide useful information for planning the intervention and improve endovascular treatment of intracranial aneurysms in the future.

REVASCAT: a randomized trial of revascularization with SOLITAIRE FR device vs. best medical therapy in the treatment of acute stroke due to anterior circulation large vessel occlusion presenting within eight-hours of symptom onset

REVASCAT is a prospective, multicenter, randomized trial seeking to establish whether subjects meeting following main inclusion criteria: age 18-80, baseline National Institutes of Health Stroke Scale ≥6, evidence of intracranial internal carotid artery or proximal (M1 segment) middle cerebral artery occlusion, Alberta Stroke Program Early Computed Tomography score of >7 on non-contrast CT or >6 on diffusion-weighted magnetic resonance imaging , ineligible for or with persistent occlusion after intravenous alteplase and procedure start within 8 hours from symptom onset, have higher rates of favorable outcome when treated with the Solitaire FR embolectomy device compared to standard medical therapy alone The primary end-point, based on intention-to-treat criteria is the distribution of modified Rankin Scale scores at 90 days. Projected sample size is 690 patients. Estimated common odds ratio is 1●615. Randomization is performed under a minimization process using age, baseline NIHSS, therapeutic window, occlusion location and investigational center. The study follows a sequential analysis (triangular model) with the first approach to test efficacy at 174 patients and subsequent analyses (if necessary) at 346, 518, and 690 subjects. Secondary end-points are infarct volume evaluated on CT at 24 h, dramatic early favorable response, defined as NIHSS of 0-2 or NIHSS improvement ≥8 points at 24 h and successful recanalization in the Solitaire arm according to the thrombolysis in cerebral infarction (TICI) classification defined as TICI 2b or 3. Safety variables are mortality at 90 days, symptomatic intracranial haemorrhage rates at 24 hours and procedure related complications.

Effect of vertebroplasty on pain relief, quality of life, and the incidence of new vertebral fractures: a 12-month randomized follow-up, controlled trial

Uncertainty regarding the benefits of vertebroplasty (VP) for the treatment of acute osteoporotic vertebral fractures has recently arisen. A prospective, controlled, randomized single-center trial (ClinicalTrials.gov registration number NCT00994032) was designed to compare the effects of VP versus conservative treatment on the quality of life and pain in patients with painful osteoporotic vertebral fractures, new fractures and secondary adverse effects were also analyzed during a 12-month follow-up period. A total of 125 patients were randomly assigned to receive conservative treatment or VP. The primary end point was to compare the evolution of the quality of life (Quality of Life Questionnaire of the European Foundation for Osteoporosis [Qualeffo-41] and pain (Visual Analogue Scale [VAS]) during a 12 month follow-up. Secondary outcomes included comparison of analgesic consumption, clinical complications, and radiological vertebral fractures at the same time points. Both arms showed significant improvement in VAS scores at all time points, with greater improvement (p = 0.035) in the VP group at the 2-month follow-up. Significant improvement in Qualeffo total score was seen in the VP group throughout the study, whereas this was not seen in the conservative treatment arm until the 6-month follow-up. VP treatment was associated with a significantly increased incidence of vertebral fractures (odds ratio [OR], 2 · 78; 95% confidence interval [CI], 1.02-7.62, p = 0.0462). VP and conservative treatment are both associated with significant improvement in pain and quality of life in patients with painful osteoporotic vertebral fractures over a 1-year follow-up period. VP achieved faster pain relief with significant improvement in the pain score at the 2-month follow-up but was associated with a higher incidence in vertebral fractures.

Three-dimensional morphological analysis of intracranial aneurysms: a fully automated method for aneurysm sac isolation and quantification

PURPOSE

Morphological descriptors are practical and essential biomarkers for diagnosis and treatment selection for intracranial aneurysm management according to the current guidelines in use. Nevertheless, relatively little work has been dedicated to improve the three-dimensional quantification of aneurysmal morphology, to automate the analysis, and hence to reduce the inherent intra and interobserver variability of manual analysis. In this paper we propose a methodology for the automated isolation and morphological quantification of saccular intracranial aneurysms based on a 3D representation of the vascular anatomy.

METHOD

This methodology is based on the analysis of the vasculature skeleton's topology and the subsequent application of concepts from deformable cylinders. These are expanded inside the parent vessel to identify different regions and discriminate the aneurysm sac from the parent vessel wall. The method renders as output the surface representation of the isolated aneurysm sac, which can then be quantified automatically. The proposed method provides the means for identifying the aneurysm neck in a deterministic way. The results obtained by the method were assessed in two ways: they were compared to manual measurements obtained by three independent clinicians as normally done during diagnosis and to automated measurements from manually isolated aneurysms by three independent operators, nonclinicians, experts in vascular image analysis. All the measurements were obtained using in-house tools. The results were qualitatively and quantitatively compared for a set of the saccular intracranial aneurysms (n = 26).

RESULTS

Measurements performed on a synthetic phantom showed that the automated measurements obtained from manually isolated aneurysms where the most accurate. The differences between the measurements obtained by the clinicians and the manually isolated sacs were statistically significant (neck width: p <0.001, sac height: p = 0.002). When comparing clinicians' measurements to automatically isolated sacs, only the differences for the neck width were significant (neck width: p <0.001, sac height: p = 0.95). However, the correlation and agreement between the measurements obtained from manually and automatically isolated aneurysms for the neck width: p = 0.43 and sac height: p = 0.95 where found.

CONCLUSIONS

The proposed method allows the automated isolation of intracranial aneurysms, eliminating the interobserver variability. In average, the computational cost of the automated method (2 min 36 s) was similar to the time required by a manual operator (measurement by clinicians: 2 min 51 s, manual isolation: 2 min 21 s) but eliminating human interaction. The automated measurements are irrespective of the viewing angle, eliminating any bias or difference between the observer criteria. Finally, the qualitative assessment of the results showed acceptable agreement between manually and automatically isolated aneurysms.

Does Thrombolysis Benefit Patients with Lacunar Syndrome?

The efficacy of thrombolysis in clinical stroke subtypes is unclear. We compared the benefit of intravenous rt-PA in 11 patients with lacunar syndrome with that in 33 patients with a non-lacunar syndrome. Patients were matched by NIHSS score and time to treatment. Although no statistically significant differences were detected in outcome, the benefit was greater in the non- lacunar syndrome group.

Electrochemically deposited poly(3-methylthiophene) performance in single layer photovoltaic devices

Photovoltaic devices based on electrochemically synthesized poly(3-methylthiophene) PMeT were constructed and characterized. The charge mobility for positive carriers of this polymer is quite high, 4 x 10(-4) cm2/Vs, being attractive for optoelectronic devices. In single layer photovoltaic devices with PMeT active layer electrochemically deposited onto indium-tin oxide substrate with aluminum as top electrode we have obtained short-circuit current density of 0.31 A/m2, open-circuit voltage of 1 V and power conversion efficiency of 0.14% at 100 W/m2 white light irradiance.

Insecticidal neolignans from Piper decurrens

2,3-Dihydro-2-(4'-hydroxyphenyl)-3-methyl-5(E)-propenylbenzofuran (conocarpan) (1), 2-(4'-hydroxy-3'-methoxyphenyl)-3-methyl-5(E)- propenylbenzofuran (eupomatenoid-5) (2), and 2-(4'- hydroxyphenyl)-3-methyl-5(E)-propenylbenzofuran (eupomatenoid-6) (3), three known neolignans found for the first time in a species of the Piperaceae, were isolated from Piper decurrens via insecticidal bioassay-guided fractionation, along with a small quantity of a new related compound, 2,3-dihydro-5-formyl-2-(4'-hydroxyphenyl)-3-methylbenzofuran (decurrenal) (4), and 3,7,11,15-tetramethyl-2(E)-hexadecen-1-ol (trans-phytol).