Effects of an Infection Control Protocol for Coronavirus Disease in Emergency Mechanical Thrombectomy

Objective

Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, neurointerventionists have been increasingly concerned regarding the prevention of infection and time delay in performing emergency thrombectomy procedures in patients with acute stroke. This study aimed to analyze the effects of changes in mechanical thrombectomy protocol before and after the COVID-19 pandemic on procedure time and patient outcomes and to identify factors that significantly impact procedure time.

Methods

The last-normal-to-door, first-abnormal-to-door, door-to-imaging, door-to-puncture, and puncture-to-recanalization times of 88 patients (45 treated with conventional pre-COVID-19 protocol and 43 with COVID-19 protection protocol) were retrospectively analyzed. The recanalization time, success rate of mechanical thrombectomy, and modified Rankin score of patients at discharge were assessed. A multivariate analysis was conducted to identify variables that significantly influenced the time delay in the door-to-puncture time and total procedure time.

Results

The door-to-imaging time significantly increased under the COVID-19 protection protocol (p=0.0257) compared to that with the conventional pre-COVID-19 protocol. This increase was even more pronounced in patients who were suspected to be COVID-19-positive than in those who were negative. The door-to-puncture time showed no statistical difference between the conventional and COVID-19 protocol groups (p=0.5042). However, in the multivariate analysis, the last-normal-to-door time and door-to-imaging time were shown to affect the door-to-puncture time (p=0.0068 and 0.0097). The total procedure time was affected by the occlusion site, last-normal-to-door time, door-to-imaging time, and type of anesthesia (p=0.0001, 0.0231, 0.0103, and 0.0207, respectively).

Conclusion

The COVID-19 protection protocol significantly impacted the door-to-imaging time. Shortening the door-to-imaging time and performing the procedure under local anesthesia, if possible, may be required to reduce the door-to-puncture and door-to-recanalization times. The effect of various aspects of the protection protocol on emergency thrombectomy should be further studied.

Selection of an Appropriate Surgical Method for the Management of Chronic Subdural Hematoma in a Patient with Poor Physical Status

Physical status is an important factor to consider when treating patients with chronic subdural hematomas. Surgical treatment of chronic subdural hematoma is mainly by burr hole trephination. However, operative methods must be selected after careful consideration of mortality, morbidity, and recurrence rates. In the case presented here, a chronic subdural hematoma was noted in a 65-year-old patient with several comorbidities; therefore, minimally invasive burr hole trephination was performed. After thrice repetition of the burr hole trephination procedure, a craniectomy for hematoma removal and middle meningeal artery embolization was finally conducted, followed by cranioplasty to treat a subsequent epidural hemorrhage. In the case discussed here, we review the options for the treatment of chronic subdural hematoma and evaluate the factors that should be considered in determining the appropriate surgical course. Despite poor patient physical status, minimally invasive operation may not always be the best option. If the patient is at high risk for recurrent subdural hematoma, craniotomy with hematoma removal may be a better choice.

Clinical outcomes of 201 neonates born to mothers with COVID-19: a systematic review

OBJECTIVE

To evaluate the clinical manifestations and outcomes of neonates born to women who had Coronavirus Disease 2019 (COVID-19) during pregnancy.

MATERIALS AND METHODS

A systematic literature search was conducted on PubMed and Embase till April 15, 2020, by combining the terms (COVID-19, Severe Acute Respiratory Syndrome Coronavirus 2, SARS-CoV-2, Novel Coronavirus, 2019-nCov, Wuhan pneumonia) and (pregnancy, pregnant women, mother, fetus, neonate, newborn, infant).

RESULTS

We included 16 case series and 12 case reports describing a total of 223 pregnant women and 201 infants. Four newborns born to mothers affected by COVID-19 were reported to have laboratory-confirmed Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection within 48 hours after birth. However, Reverse Transcription-Polymerase Chain Reaction tests of the breast milk, placenta, amniotic fluids, and cord blood and maternal vaginal secretions were all negative for SARS-CoV-2 in the reported cases. Fetal death was reported in two cases, and 48 of 185 newborns (25.9%) were born prematurely. Infants born small for gestational age and low birth weight (< 2,500 g) accounted for 8.3% and 15.6% of reported cases, respectively. Birth asphyxia and respiratory distress syndrome were observed in 1.8% and 6.4% of neonates, respectively. There was one neonatal death due to intractable gastric bleeding among the SARS-CoV-2-negative infants.

CONCLUSIONS

Current evidence suggests that COVID-19 during pregnancy rarely affects fetal and neonatal mortality, but can be associated with adverse neonatal morbidities. Vertical transmission has not been observed in the majority of the reported cases. The infants born to mothers with COVID-19 are carefully monitored for accompanying complication, and quarantine of infected mothers is warranted.

Bypass surgery versus medical treatment for symptomatic moyamoya disease in adults

OBJECTIVE

In this study the authors evaluated whether extracranial-intracranial bypass surgery can prevent stroke occurrence and decrease mortality in adult patients with symptomatic moyamoya disease (MMD).

METHODS

The medical records of 249 consecutive adult patients with symptomatic MMD that was confirmed by digital subtraction angiography between 2002 and 2011 at 8 institutions were retrospectively reviewed. The study outcomes of stroke recurrence as a primary event and death during the 6-year follow-up and perioperative complications within 30 days as secondary events were compared between the bypass and medical treatment groups.

RESULTS

The bypass group comprised 158 (63.5%) patients, and the medical treatment group comprised 91 (36.5%) patients. For 249 adult patients with MMD, bypass surgery showed an HR of 0.48 (95% CI 0.27–0.86, p = 0.014) for stroke recurrence calculated by Cox regression analysis. However, for the 153 patients with ischemic MMD, the HR of bypass surgery for stroke recurrence was 1.07 (95% CI 0.43–2.66, p = 0.887). For the 96 patients with hemorrhagic MMD, the multivariable adjusted HR of bypass surgery for stroke recurrence was 0.18 (95% CI 0.06–0.49, p = 0.001). For the treatment modality, indirect bypass and direct bypass (or combined bypass) did not show any significant difference for stroke recurrence, perioperative stroke, or mortality (log rank; p = 0.524, p = 0.828, and p = 0.616, respectively).

CONCLUSIONS

During the treatment of symptomatic MMD in adults, bypass surgery reduces stroke recurrence for the hemorrhagic type, but it does not do so for the ischemic type. The best choice of bypass methods in adult patients with MMD is uncertain. In adult ischemic MMD, a prospective randomized study to evaluate the effectiveness and safety of bypass surgery to prevent recurrent stroke is necessary.

Abstract TMP37: Adult Moyamoya Disease : Clinical Presentation, Treatment Outcome and Prognostic Factor

Background and Purpose: This study was aimed to investigate treatment results and outcome predictors in adult patients with moyamoya disease.

Methods: During the period from 2000 to 2011, a clinical database of adult patients with definite moyamoya disease were collected retrospectively from 8 participating centers in Korea during the period from 2000 to 2011. Among total 399 elligible patients, 355 cases were evaluated about clinical and radiological outcomes through medical records. Stroke-free survival rate and prognostic factors for stroke recurrence were measured by Kaplan-Meier and Cox regression methods. Neurologic outcome was assessed according to surgical revascularization and conservative observation.

Results: The mean age of symptom onset was 39.4 ( ± 13.8) years. Male to female ratio was 1 to 2.16. Presenting symptoms were ischemia in 197 (55.5%), hemorrhage in 118 (33.2%), and asymptomatic in 40 (11.3%) patients. The median follow-up was 34.3 months (range 0.4 to 284.8). One hundred thirty seven (38.6%) of the 355 patients received observational conservative management. The remaining 218 (61.4%) patients underwent one of direct, indirect or combined revascularization. In the total adult moyamoya patients, 5 year stroke-free survival rate of surgery and observation group was 82.8% vs 73.4%, respectively. In the ischemic moyamoya cases, 5 year stroke-free survival rate of surgery and observation group was 80.9% vs 76.2%, respectively. In the hemorrhagic moyamoya cases, 5 year stroke-free survival rate of surgery and observation group was 83.7% vs 70.1%, respectively. In the asymptomatic cases, 5 year stroke-free survival rate of surgery and observation group was 95.3% vs 83.1%. There was no significant difference between surgical and observation group in Kaplan Meier Survival analysis. Angiographic stage was only a significant factor for stroke recurrence (HR 3.275, 95% CI; 1.251-8.575, P=0.016). Neurologic outcome tended to be better in the surgical group than the observation group (88.5% vs 81.8%, P=0.074)

Conclusions: In adult moyamoya patients, the long-term prognosis of surgical treatment may be better than that of conservative observation under real-world setting. Angiographic stage is a predictor of future stroke

Abstract TP158: Angiographic Feature And Stroke Presentation Of Adult Moyamoya Disease

Background and Purpose: Adult moyamoya disease (MMD) has a different clinical presentation compared as pediatric MMD. The present study was conducted to elucidate the correlation of angiographic characteristics and stroke presentation in adult MMD patients.

Methods: We conducted a retrospective analysis of radiologic features of 315 adult patients with definite moyamoya disease which was proved by digital subtraction angiography according to the guidelines of the Research Committee on Spontaneous Occlusion of the Circle of Willis (MMD) of the Ministry of Health and Welfare in 1997. Comparison of angiographic stage and stroke patterns for 630 hemispheres was performed according to stroke presentation.

Results: The mean age of diagnosis was 41.5 ( ± 11.7) years. Male to female ratio was 1 to 1.85. One hundred eighty five patients (57.8%) experienced the acute stroke at diagnosis. There was stroke episode prior to diagnosis in 139 patients (43.4%). Among 63 patients (19.7%) who had not experienced any stroke, there was TIA in 44 (13.7%) and no symptoms in 19 (5.9%). Angiographic stage was 50 in 1 (7.8%), 170 in 2 (26.6%), 221 in 3 (35.5%), 129 in 4 (20.2%), 61 in 5 (9.5%) and 9 in 6 (1.4%). Stroke rates were significantly different according to angiographic stage (P=0.041). The occlusion of middle cerebral artery was a significant association with ipsilateral acute stroke (P=0.01). The occlusion of anterior cerebral artery (ACA), middle cerebral artery (MCA), fetal-type posterior cerebral artery was significantly associated with stroke type (P=0.001, 0.002, 0.018). Cerebral blood flow and cerebral vascular reactivity were also strongly associated with ipsilateral acute stroke (P<0.001).

Conclusions: In adult moyamoya disease, angiographic stage, MCA occlusion and hemodynamic status are associating factors with stroke development. Occlusion patterns of major arteries are different according to stroke type.

Clinical experience of the brushite calcium phosphate cement for the repair and augmentation of surgically induced cranial defects following the pterional craniotomy

OBJECTIVE

To prevent temporal depression after the pterional craniotomy, this study was designed to examine the safety and aesthetic efficacy of the brushite calcium phosphate cement (CPC) in the repair and augmentation of bone defects following the pterional craniotomy.

METHODS

The brushite CPC was used for the repair of surgically induced cranial defects, with or without augmentation, in 17 cases of pterional approach between March, 2005 and December, 2006. The average follow-up month was 20 with range of 12-36 months. In the first 5 cases, bone defects were repaired with only brushite CPC following the contour of the original bone. In the next 12 cases, bone defects were augmented with the brushite CPC rather than original bone contour. For a stability monitoring of the implanted brushite CPC, post-implantation evaluations including serial X-ray, repeated physical examination for aesthetic efficacy, and three-dimensional computed tomography (3D-CT) were taken 1 year after the implantation.

RESULTS

The brushite CPC paste provided precise and easy contouring in restoration of the bony defect site. No adverse effects such as infection or inflammation were noticed during the follow-up periods from all patients. 3D-CT was taken 1 year subsequent to implantation showed good preservation of the brushite CPC restoration material. In the cases of the augmentation group, aesthetic outcomes were superior compared to the simple repair group.

CONCLUSION

The results of this clinical study indicate that the brushite CPC is a biocompatible alloplastic material, which is useful for prevention of temporal depression after pterional craniotomy. Additional study is required to determine the long-term stability and effectiveness of the brushite calcium phosphate cement for the replacement of bone.

Cervical schwannoma presenting with acute intracranial subarachnoid hemorrhage

A subarachnoid hemorrhage (SAH) associated with negative finding on four-vessel angiography is seen in 5 to 30% of patients with intracranial SAH. A previously silent lesion in the spinal canal may be responsible for the angiographically negative finding for cause of intracranial SAH. We report a case of upper cervical (C1-2) intradural schwannoma presenting with acute intracranial SAH. Repeated cerebral angiographic studies were negative, but cervical magnetic resonance imaging study and tissue pathology revealed a intradural-extramedullary schwannoma in C1-2 level. This case illustrates the importance of a high index of clinical suspicion for spinal disease in angiographically negative intracranial SAH patients.

Infraoptic course of both anterior cerebral arteries

A 28-year-old woman was referred to our hospital with a sudden, very severe headache. Brain computed tomographic angiography showed a saccular cerebral aneurysm at the bifurcation of the left middle cerebral artery and infraoptic courses of both anterior cerebral arteries. The anterior cerebral arteries were seen to arise from the ipsilateral internal cerebral arteries at the level of the origin of the ophthalmic artery, passed underneath the ipsilateral optic nerve, and turned upward at ventral portion of the optic chiasm.Infraoptic course of the proximal anterior cerebral artery is an extremely rare anomaly and is often associated with cerebral aneurysms. We report the clinical features, radiological findings, and possible genesis of this anomaly with a literature review.

Vinorelbine-associated myelopathy in a patient who previously received paclitaxel: a case report

Vinorelbine seems to cause less neurotoxicity than other vinca alkaloids because of its selective activity on mitotic cells over axonal microtubules. Clinical trials report very mild peripheral neurotoxicity with distal paresthesiae and there are no reports of myelopathy in these series of patients. The authors describe a patient who developed a rare event of myelopathy while on vinorelbine for non-small-cell lung cancer.

Cephalometric appraisal of posttreatment vertical changes in adult orthodontic patients

The purpose of this study was to evaluate vertical facial changes in adult orthodontic patients and to evaluate the stability of these changes. Thirty-three patients (8 males and 25 females) were examined. The patients had been treated with full fixed edgewise appliance mechanics and exhibited at least 1.0 degrees of clockwise rotation of the mandible during treatment. Mandibular rotation was determined by the angular change in the Y-axis to the Frankfort plane. Twelve angular and 14 linear skeletal and dental measurements and 3 skeletal ratios were derived from pretreatment (T1), posttreatment (T2), and postretention (T3) cephalometric radiographs. Paired t tests were used to compare vertical changes that occurred as a result of orthodontic treatment and their stability or relapse tendency during the retention and postretention periods. Twenty-five percent (P <.001) of the opening rotation of the mandible recovered during the posttreatment period, resulting in a significant overall rotation that was maintained. Both treatment and posttreatment changes in the Y-axis angle showed a high correlation with the horizontal position of pogonion (r = -0.797 and -0.889, respectively). Only overjet showed a low correlation between treatment changes and posttreatment changes in the Y-axis angle. Stepwise regression analysis of pretreatment variables and treatment changes failed to predict the behavior of the Y-axis angle change.

Biomechanical considerations in distraction of the osteotomized dentomaxillary complex

The completely osteotomized dentomaxillary complex is essentially a free body constrained only by its soft tissue attachments. Therefore the line of action and point of application of any protractive force(s) used during distraction osteogenesis must be considered relative to its center of mass. This is in contrast to the nonsurgically separated dentomaxillary complex, which is a constrained body, and therefore the application of protractive force(s) must be considered relative to its center of resistance. These two centers are not coincident. With knowledge of the location of the center of mass, predictable protraction of the dentomaxillary complex can be achieved. In this study, the center of mass of an adult maxillary specimen osteotomized to emulate a Le Fort I osteotomy was determined. Protractive force(s) through the center of mass will produce linear advancement along its line of action. Protractive movement of the dentomaxillary complex can be adjusted downward and forward or upward and forward by locating the protractive force(s) line of action superior or inferior to the center of mass. A cleft patient is described wherein the surgically separated dentomaxillary complex is protracted downward and forward with a force vector superior to its approximate center of mass. This results in a predictable increase in overbite and overjet with negligible mandibular rotation.

Trauma-induced isomorphic lesions in morphea--a brief case report

We describe a case of morphea which presented further typical lesions of the disease at the sites of mechanical trauma. It can be suggested that cutaneous lesions of morphea may be locally developed due to physical stimuli as an isomorphic response in patients or subclinical cases of the disease.