White Papers

• The Impact of the Endovascular Treatment of Cerebral Aneurysms on Headaches

  November 2017 by The Neurologist

  Objective: The co-occurrence of headaches and cerebral aneurysms is common in clinical practice, although a clear causal relationship has not been ascertained. We aimed to investigate the impact of endovascular obliteration of aneurysms on headaches using a cross-sectional, prospective, open-label protocol. We also sought to characterize the preexisting headaches in patients harboring cerebral aneurysms using the International Classification of Headache Disorders criteria.

  Methods: A total of 33 patients were recruited into the study and underwent endovascular treatment for obliteration of their aneurysms. A standardized survey was administered before and 3 to 6 months after the procedure, documenting the HIT-6 scores as well as the headache frequency.

  Results: The study cohort included 25 women and 8 men. In 61% of cases, the aneurysms were located in the posterior circulation. We achieved grade 0 or 1 obliteration of aneurysms in 100% of cases and there were no complications. The mean for HIT-6 scores were 52.3 at baseline and 49.6 post procedure (student t test, P < 0.047). The headache frequency measured as total headache days per month did not demonstrate statistical significance. Our data indicated that more than half of our cohort had preexisting headaches which fulfilled the criteria for a primary headache disorder. These individuals showed a more robust response to the intervention compared with the remainder of the group, although the P-value per se was not considered statistically significant due to the small sample size.

  Conclusions: Endovascular treatment of the aneurysms mitigates the headache-related disability.

  Key Words: cerebral aneurysms, headache, endovascular coiling of aneurysms

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• Carotid Artery Angioplasty and Stenting Without Distal Embolic Protection Devices

  January 2017 by Neurosurgery-Online

  BACKGROUND: Embolic protection devices are used during carotid artery stenting procedures to reduce risk of distal embolization. Although this is a standard procedural recommendation, no studies have shown superiority of these devices over unprotected stenting procedures.

  OBJECTIVE: To assess the periprocedural outcome and durability of carotid artery stenting without embolic protection devices and poststent angioplasty.

  METHODS: We performed a retrospective chart review of 174 carotid angioplasty stent procedures performed at our institution. One hundred sixty-six patients underwent angioplasty and stenting without distal protection devices or poststent angioplasty. Complications related to stenting, including procedural complications, postoperative stroke and/or myocardial infarction, and stent restenosis were analyzed.

  RESULTS: One hundred thirty-five stents (78%) were performed in symptomatic patients, whereas 22% of stents were placed for asymptomatic internal carotid artery stenosis. The degree of stenosis was 80% or greater in 75% of patients and 90% or greater in 55% of patients. Following the stenting procedure, the 24-hour and 30-day rate of transient ischemic attack, intracranial hemorrhage, or ischemic stroke was 0. Three (2%) patients had a perioperative, non-ST elevation myocardial infarction. Five patients (2.8%) required treatment for restenosis (>50% stenosis from baseline), 1 of which was symptomatic.

  CONCLUSION: Our data show that carotid artery stenting without the use of embolic protection devices and without postangioplasty stenting, in experienced hands, can be performed safely. Furthermore, this technique does not result in a higher degree of in-stent restenosis than series in which poststenting angioplasty is performed.

  KEYWORDS: Angioplasty, Carotid artery, Embolic protection device, Stenting

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• Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct

  November 11, 2017 by The New England Journal of Medicine

  BACKGROUND: The effect of endovascular thrombectomy that is performed more than 6 hours after the onset of ischemic stroke is uncertain. Patients with a clinical deficit that is disproportionately severe relative to the infarct volume may benefit from late thrombectomy.

  METHODS: We enrolled patients with occlusion of the intracranial internal carotid artery or proximal middle cerebral artery who had last been known to be well 6 to 24 hours earlier and who had a mismatch between the severity of the clinical deficit and the infarct volume, with mismatch criteria defined according to age (<80 years or ≥80 years). Patients were randomly assigned to thrombectomy plus standard care (the thrombectomy group) or to standard care alone (the control group). The coprimary end points were the mean score for disability on the utility-weighted modified Rankin scale (which ranges from 0 [death] to 10 [no symptoms or disability]) and the rate of functional independence (a score of 0, 1, or 2 on the modified Rankin scale, which ranges from 0 to 6, with higher scores indicating more severe disability) at 90 days.

  RESULTS: A total of 206 patients were enrolled; 107 were assigned to the thrombectomy group and 99 to the control group. At 31 months, enrollment in the trial was stopped because of the results of a prespecified interim analysis. The mean score on the utility-weighted modified Rankin scale at 90 days was 5.5 in the thrombectomy group as compared with 3.4 in the control group (adjusted difference [Bayesian analysis], 2.0 points; 95% credible interval, 1.1 to 3.0; posterior probability of superiority, >0.999), and the rate of functional independence at 90 days was 49% in the thrombectomy group as compared with 13% in the control group (adjusted difference, 33 percentage points; 95% credible interval, 24 to 44; posterior probability of superiority, >0.999). The rate of symptomatic intracranial hemorrhage did not differ significantly between the two groups (6% in the thrombectomy group and 3% in the control group, P = 0.50), nor did 90-day mortality (19% and 18%, respectively; P = 1.00).

  CONCLUSIONS: Among patients with acute stroke who had last been known to be well 6 to 24 hours earlier and who had a mismatch between clinical deficit and infarct, outcomes for disability at 90 days were better with thrombectomy plus standard care than with standard care alone. (Funded by Stryker Neurovascular; DAWN ClinicalTrials.gov number, NCT02142283.)

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• Can Emergency Department Physicians Safely Discharge Patients Presenting with TIA? Assessing the TIA Rapid Assessment (TIARA) Protocol

  July 25, 2016 by Matthews Journal of Emergency Medicine

  Objectives: Among discharged patients with TIA, we hypothesize that rates of recurrent stroke within 90 days will be similar to that of an admitted population reported in the current literature.

  Methods: Beginning in 2011 a comprehensive stroke center’s neurological emergency department (Neuro ED) implemented a protocol named TIA rapid assessment (TIARA). All patients presenting with an acute neurologic syndrome are triaged based on this system. This protocol enables Neuro ED physicians to admit high-risk patients and discharge low-risk patients based on ABCD2 scores in conjunction with advanced neuroimaging. The discharged patients are provided with expedited work-up and neurology follow-up within 48 hours. Eligible participants were identified by physicians in the Neuro ED and consented at their 48-hour follow-up appointment. The TIARA protocol served as the intervention in our study. Rate of stroke recurrence at 90 days was the main outcome used to evaluate this new standard of care.

  Results: At 90 days, 29 out of 37 patients discharge with TIA were successfully contacted by phone. One patient had a stroke in this time frame, yielding a recurrence rate of 3.4%. The overall risk of stroke reported in the literature currentlyis 11-17%.

  Conclusions: While this study did not directly compare stroke recurrence rate to an admitted population, we were able to compare with rates in the literature. Our markedly low stroke recurrence rate at 90 days suggests that ED physicians can safely discharge patients with TIA provided they receive neurology follow-up in 48 hours.

  KEYWORDS: Cerebrovascular Disease/Stroke; Transient Ischemic Attack; Magnetic Resonance Imaging; Emergency Care.

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• Clinical and Procedural Predictors of Outcomes From the Endovascular Treatment of Posterior Circulation Strokes

  March 2016 by the American Heart Association

  Background and Purpose: Patients with posterior circulation strokes have been excluded from recent randomized endovascular stroke trials. We reviewed the recent multicenter experience with endovascular treatment of posterior circulation strokes to identify the clinical, radiographic, and procedural predictors of successful recanalization and good neurological outcomes.

  Methods: We performed a multicenter retrospective analysis of consecutive patients with posterior circulation strokes, who underwent thrombectomy with stent retrievers or primary aspiration thrombectomy (including A Direct Aspiration First Pass Technique [ADAPT] approach). We correlated clinical and radiographic outcomes with demographic, clinical, and technical characteristics.

  Results: A total of 100 patients were included in the final analysis (mean age, 63.5±14.2 years; mean admission National Institutes of Health Stroke Scale score, 19.2±8.2). Favorable clinical outcome at 3 months (modified Rankin Scale score ≤2) was achieved in 35% of patients. Successful recanalization and shorter time from stroke onset to the start of the procedure were significant predictors of favorable clinical outcome at 90 days. Stent retriever and aspiration thrombectomy as primary treatment approaches showed comparable procedural and clinical outcomes. None of the baseline advanced imaging modalities (magnetic resonance imaging, computed tomographic perfusion, or computed tomography angiography assessment of collaterals) showed superiority in selecting patients for thrombectomy.

  Conclusions: Time to the start of the procedure is an important predictor of clinical success after thrombectomy in patients with posterior circulation strokes. Both stent retriever and aspiration thrombectomy as primary treatment approaches are effective in achieving successful recanalization.

  Key Words: endovascular procedures, magnetic resonance imaging, stents, stroke, thrombectomy

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• Change Takes Time: EMS as the Spark Plug for Faster Acute Ischemic Stroke Care

  June 27, 2017 by Matthews Journal of Emergency Medicine

  Introduction: It is well documented that a Prehospital Stroke Alert (PHSA) protocol leads to decreased treatment times for stroke patients. Outcomes measured typically include Door to Physician (DTP), Door to CT (DTCT), and Door to Needle (DNT) times. Our comprehensive stroke center’s PHSA system has been in place since 2012. This study evaluates 3 specific endpoints. First, Emergency Medical Services (EMS) improve their recognition of stroke symptoms as they gain experience with PHSA. Second, a PHSA protocol decreases treatment times of DTP, DTCT, and DNT over a study period of 3 years compared to times recorded prior to implementation of the PHSA system. Third, when patients present to our Neurologic Emergency Department (Neuro ED) as a PHSA, rather than a non-PHSA, the treatment times are markedly decreased, and acute ischemic stroke care is significantly expedited.

  Methods: A retrospective chart review was conducted for patients who presented to our hospital with an admitting diagnosis of stroke from 2012, 2013 and the first half of 2014. Patients were screened for presentation to the Neuro ED and further stratified based on whether a PHSA was called. PHSA was called if EMS deemed the patient’s Cincinnati Stroke Scale score as positive, and symptom onset was within 6 hours. We recorded DTP, DTCT, and DTN times over the years for all patients meeting these inclusion criteria.

  Results: Three hundred and five patients with an admission diagnosis of stroke were seen in the Neuro ED (Hours are 0700- 1800, 7 days a week) from 2012 through the first half of 2014, 128 of which presented as PHSAs. EMS responders accurately diagnosed stroke in 72% of cases. When EMS diagnosis was combined with Neuro ED physician expertise, accuracy improved to 85%. Previously, EMS assessment of stroke was accurate only 66% of the time. PHSA patients had decreased DTP, DTCT, and DTN times over the two and a half year period. When comparing the PHSA group to non-PHSA group, statistically significant differences were found in DTP and DTCT times within each year (p ≤ 0.0001).

  Discussion: In conclusion, gaining experience with a PHSA protocol did in fact lead to EMS better recognizing stroke symptoms, reduction in the times of delivery of care for acute ischemic stroke patients over the years 2012-2014, and a markedly statistically significant difference in treatment times if patients were seen as a PHSA as opposed to a non-PHSA.

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• An Analysis of Transient Ischemic Attack Practices: Does Hospital Admission Improve Patient Outcomes?

  September 2016 by Journal of Stroke and Cerebrovascular Diseases

  Introduction: Immediate treatment has been shown to decrease the recurrence of cerebrovascular accidents following transient ischemic attacks (TIA), prompting the use of a specialized neurologic emergency department (Neuro ED) to triage patients. Despite these findings, there is little evidence supporting the notion that hospital admission improves post-TIA outcomes. Through the lens of a Neuro ED, this retrospective chart review of TIA patients examines whether hospital admission improves 90-day outcomes.

  Materials and Methods: Two hundred sixty charts of patients discharged with TIA diagnosis were reviewed. These charts encompassed patients with TIA who presented to a main emergency department (ED) or Neuro ED from January 2014 to April 2015. Demographic information, admission ABCD2 scores, admission National Institutes of Health Stroke Scale scores, and admission Modified Rankin Scale, and reason for any return visits within 90 days were collected.

  Results: This review shows that patients triaged by the Neuro ED were admitted at a lower rate than those seen by the standard ED. Further, patients triaged by the Neuro ED experienced lower readmission and recurrence of stroke or TIA within 90 days.

  Conclusions: These results provide preliminary support for the notion that discharging appropriate TIA patients, with adequate follow-up, will not adversely affect the recurrence of TIA or stroke within 90 days.

  Key Words: Transient ischemic attack, stroke, cerebrovascular accident, emergency department.

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• Unilateral Symptomatic Hypertrophic Olivary Degeneration Secondary to Midline Brainstem Cavernous Angioma: A Case Report and Review of the Literature

  World Neurosurgery

  Background: Hypertrophic olivary degeneration (HOD) is a rare phenomenon in the dento-rubroolivary pathway due to lesion or disruption of the fibers of the Guillain-Mollaret Triangle. Hemorrhage of pontine and midbrain cavernous angiomas rarely can lead to hypertrophic olivary degeneration (HOD) portending neurological deterioration and possible concomitant lifethreatening complications; for this reason, it may define a poignant consideration in planning intervention.

  Case Description: 57-year-old female with known midbrain-pontine cavernous angioma. For several years, the lesion was stable, as demonstrated by imaging follow-up until 10 months prior to presentation with falls, dysarthria and headache. Imaging demonstrated some decrease in size as well as blood product around the cavernous angioma suggesting interim period hemorrhage and interval development of unilateral hypertrophic olivary degeneration.

  Conclusions: Herein, the literature regarding imaging recommendations for stable cavernous angioma in the midbrain-pontine junction is reviewed. The implication of hypertrophic olivary degeneration for patient outcome is discussed and a comment is made on how the development of HOD may impact management of the cavernous angioma.

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• Training Standards in Neuroendovascular Surgery Program Accreditation and Practitioner Certification

  August 2017 by the American Heart Association

  Background and Purpose: Neuroendovascular surgery is a medical subspecialty that uses minimally invasive catheterbased technology and radiological imaging to diagnose and treat diseases of the central nervous system, head, neck, spine, and their vasculature. To perform these procedures, the practitioner needs an extensive knowledge of the anatomy of the nervous system, vasculature, and pathological conditions that affect their physiology. A working knowledge of radiation biology and safety is essential. Similarly, a sufficient volume of clinical and interventional experience, first as a trainee and then as a practitioner, is required so that these treatments can be delivered safely and effectively.

  Methods: This document has been prepared under the aegis of the Society of Neurological Surgeons and its Committee for Advanced Subspecialty Training in conjunction with the Joint Section of Cerebrovascular Surgery for the American Association of Neurological Surgeons and Congress of Neurological Surgeons, the Society of NeuroInterventional Surgery, and the Society of Vascular and Interventional Neurology.

  Results: The material herein outlines the requirements for institutional accreditation of training programs in neuroendovascular surgery, as well as those needed to obtain individual subspecialty certification, as agreed on by Committee for Advanced Subspecialty Training, the Society of Neurological Surgeons, and the aforementioned Societies. This document also clarifies the pathway to certification through an advanced practice track mechanism for those current practitioners of this subspecialty who trained before Committee for Advanced Subspecialty Training standards were formulated.

  Conclusions: Representing neuroendovascular surgery physicians from neurosurgery, neuroradiology, and neurology, the above mentioned societies seek to standardize neuroendovascular surgery training to ensure the highest quality delivery of this subspecialty within the United States.

  Key Words: cerebrovascular disorders, certification, education, neurosurgery, stroke

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• TREVO stent-retriever mechanical thrombectomy for acute ischemic stroke secondary to large vessel occlusion registry

  November 20, 2017 by BMJ

  Background: Recent randomized clinical trials (RCTs) demonstrated the efficacy of mechanical thrombectomy using stent-retrievers in patients with acute ischemic stroke (AIS) with large vessel occlusions; however, it remains unclear if these results translate to a real-world setting. The TREVO Stent-Retriever Acute Stroke (TRAC K) multicenter Registry aimed to evaluate the use of the Trevo device in everyday clinical practice.

  Methods: Twenty-three centers enrolled consecutive AIS patients treated from March 2013 through August 2015 with the Trevo device. The primary outcome was defined as achieving a Thrombolysis in Cerebral Infarction (TICI) score of ≥2b. Secondary outcomes included 90-day modified Rankin Scale (mRS), mortality, and symptomatic intracranial hemorrhage (sICH).

  Results: A total of 634patients were included. Mean age was 66.1±14.8 years and mean baseline NIH Stroke Scale (NIHSS) score was 17.4±6.7; 86.7% had an anterior circulation occlusion. Mean time from symptom onset to puncture and time to revascularization were 363.1±264.5 min and 78.8±49.6 min, respectively. 80.3% achieved TICI ≥2b. 90-day mRS ≤2 was achieved in 47.9%, compared with 51.4% when restricting the analysis to the anterior circulation and within 6 hours (similar to recent AHA/ASA guidelines), and 54.3% for those who achieved complete revascularization. The 90- day mortality rate was 19.8%. Independent predictors of clinical outcome included age, baseline NIHSS, use of balloon guide catheter, revascularization, and sICH.

  Conclusion: The TRAC K Registry results demonstrate the generalizability of the recent thrombectomy RCTs in real-world clinical practice. No differences in clinical and angiographic outcomes were shown between patients treated within the AHA/ASA guidelines and those treated outside the recommendations.

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News Articles

• Critical Procedure Available for More Stroke Victims

  By John Kopp, PhillyVoice

  September 13, 2018

  Brain surgeons have been removing blood clots from stroke victims for nearly two decades. Previous research suggested those extractions needed to occur within six hours of stroke onset, a time restriction that eliminated the treatment possibility for many stroke victims – particularly those who experienced onset in their sleep.

  But the DAWN clinical trials determined stroke outcomes can improve when blood clots are removed within 6 to 24 hours after symptoms first develop.

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• Brain Trust: The Brains Behind a Neurologic ED

  By Marcolini, Evie MD

  Emergency Medicine News: March 2018 - Volume 40 - Issue 3 - p 9

  I had the privilege recently to interview Karen Greenberg, DO, who holds a unique position as the director of the neurologic emergency department at the Global Neurosciences Institute of Crozer-Chester Medical Center in Chester, PA. She is one of a kind, but we may be seeing more in her position with the recent progress in stroke and neurology and the collaboration of the two fields in primary and comprehensive stroke centers.

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• Walk while counting backward to diagnose this type of dementia

  By Susan Scutti, CNN

  Updated 4:00 PM ET, Wed February 21, 2018

  (CNN) – Simple walking tests can accurately diagnose a type of dementia that may sometimes be reversed when identified early and quickly treated, a study published Wednesday in the journal Neurology found.

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• Crozer-Keystone Health System Partners with Global Neurosciences Institute to Develop Comprehensive Neurosciences Program

  By Global Neurosciences Institute

  Published on January 10, 2018

  Crozer-Keystone Health System today announced it has entered into a partnership with Global Neurosciences Institute (GNI) to develop a comprehensive neurosciences institute focused on delivering clinically advanced brain and spine care services. This patient-focused institute will use the latest research and state-of-the-art technologies to diagnose and treat patients with a full range of neurological conditions including stroke, aneurysm, brain tumor, concussion, spine treatments, epilepsy, Multiple Sclerosis, Parkinson’s disease and movement disorders, Alzheimer’s disease and cognitive disorders, pain management, and behavioral health conditions.

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• Delco health system forms partnership to create a neurosciences institute

  By John George – Senior Reporter, Philadelphia Business Journal

  Jan 10, 2018, 3:59pm

  Crozer-Keystone Health System has entered into a partnership with the Global Neurosciences Institute to provide Delaware County patients with “clinically advanced” brain and spine care services.

  The Global Neurosciences Institute (GNI) is a group of neurosurgeon, neurologists and researchers in Pennsylvania and New Jersey led by Dr. Erol Veznedaroglu, director of the Drexel Neurosciences Institute in Philadelphia.

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