Day 1 :
- Stroke and Cerebrovascular Diseases
Vickie and Jack Farber Institute for Neuroscience Thomas Jefferson University Hospital, United States
Hekmat Zarzour is a Assistant Professor of Neurological Surgery Vickie and Jack Farber Institute for Neuroscience Thomas Jefferson University Hospital, United States
Objective: To present intraoperative observations that when recognized may facilitate the identification of patients at high risk of MT recanalization failure. We illustrate 4 cases of successful recanalization via rescue treatment with balloon angioplasty and/or stenting when such observations were noted. We also discuss the role of intracranial atherosclerotic disease in recanalization failure. Patients and Methods: We conducted a retrospective review of a prospectively maintained database for 450 stroke patients and identified 122 patients who underwent MT that failed to achieve recanalization. Operative notes were reviewed, and intraoperative nuances were discussed amongst neurointerventionalists.
Results: Intraoperative observations that may suggest a high risk of MT recanalization failure include resistance to microwire advancement, significant resistance to microcatheter advancement, temporary antegrade flow upon stent retriever (SR) deployment, temporary retrograde flow upon SR deployment with simultaneous aspiration, restricted SR expansion (“pinched device”), moderate resistance to total impedance of SR removal causing vessel/SR stretch on angiographic roadmap, and minimal recanalization after > 3 device passes.
Conclusion: Intraoperative observations may facilitate early recognition of patients at high risk of MT recanalization failure. We suggest considering rescue treatment when such observations are noted to avoid prolonged procedure times, futile reperfusion, and reocclusion post-MT. Intracranial balloon angioplasty and/or stenting may be a safe and effective treatment in this patient subgroup. Stent placement may be considered depending on the patient’s antiplatelet status, angioplasty success, and concern for intracranial hemorrhage. Further studies amongst larger patient cohorts are needed.
Keywords: Endovascular therapy; intracranial atherosclerotic disease; mechanical thrombectomy; multiple device passes; recanalization failure; ischemic stroke
Calcutta National Medical College, Kolkata, India
Dr. Payoz Pandey has completed his M.B.B.S from Manipal University and General surgical Training from Kolkata. He is currently pursuing his Post-Doctoral Training in Neurosurgery at Calcutta National Medical College. He has presented papers at various national level conferences and has been awarded best paper award at twice. He has special interest in Neuro-Endoscopic and Neuro-Vascular surgery .He is currently playing an active role in planning and organization of 2020 Neurosurgical society of India conference.
Supratentorial Hypertensive hematomas are the most common form of intracerebral hematomas. Inspite of various surgical modalities to treat this problem, there is still no consensus on the definitive technique. Resource limited low middle income country setup like in India, require most optimal utilization of resources.. Aim of our study was to analyze results of surgical modalities available to us to provide a rational advice regarding treatment of Supratentorial hypertensive hemorrhages in similar setups. We have retrospectively compared results of Neuroendoscopic vs Decompressive craniectomy with clot evacuation in treatment of Supratentorial hypertensive ICH conducted at our hospital in 72 patients over past 1 year(May2018-April 2019).We utilized readily available silicone tube as tubular sheath which provided excellent visualization. In the endoscopy group M:F Ratio was 1.22:1,Average age was 52.1years,Average Pre-op hematoma volume was 42.3 cc and average GCS was 8.4 while in Craniectomy Group, M:F ratio was 1:1,Average age 51.4 years, Average Pre-op Hematoma volume was 44.5 and pre-OP GCS was 8.1. In the Neuroendoscopy group, we found statiscally significant reduction in operative time (72.65 mins vs 137mins in craniectomy), less blood loss (198.25 ml vs 704.13 ml in craniectomy group and a better Hematoma Removal ratio (87.98 vs 80.38). The Average ICU stay (6d vs 8.1 day in open) was shorter. No statistically significant reduction in Mortality or GCS improvement was found. Lesser post-operative edema was noted in the Neuro-endoscopy group. We hereby conclude that Neuro-Endoscopy for management of Supratentorial Hypertensive ICH provides a better Intra-operative visualization, reduces brain trauma, better ICH evacuation and Shorter ICU stay.
- Ischemic Stroke and Transient Ischemic Attack
Lebanese International University, Beirut, Lebanon
Diana has completed her Masters in epidemiology and clinical pharmacy from the Lebanese University and received her board certification (BCPS). She is a full time professor at the Lebanese International University and has worked as the chair of PharmD department at the university. She has published 25 articles in different medical topics.
Background: Early seizures (ES) have been recognized as serious complications of acute strokes where the data is limited among Lebanese patients. The aim of our study is to determine the incidence and risk factors of ES post-stroke and determine the effect of ES on functional outcome among Lebanese stroke patients.
Methods: The study was conducted between January 2017 and March 2020 on patients with acute ischemic and hemorrhagic strokes at three tertiary hospitals in Lebanon. Data were collected from patients’ medical records at each site through a well-designed data collection sheet. ES were defined as seizures occurring within 7-14 days after acute stroke. Functional outcome was assessed at discharge, according to modified Rankin scale.
Results: Of 152 enrolled patients, 140 had an ischemic stroke (92%) and 12 had a hemorrhagic stroke (8%). ES developed in 18 patients (11.8%) with mean age of 64.50 ± 13.47 years and 11 (61%) were females. Independent risk factors for ES development were female gender, hemorrhagic stroke, and cortical involvement. Moreover, ES development was not associated with higher disability and mortality.
Conclusion: The findings of the study highlight that ES occurred more commonly in patients with hemorrhagic stroke type, cortical involvement, and female gender. In addition, ES did not impair functional outcome in our study, however; further studies are needed to predict patients at risk of ES so that appropriate prevention and treatment strategies can be implemented promptly.
Lebanese International University, Beirut, Lebanon
Hiba has completed her doctorate of pharmacy (pharmD) at the age of 23 from the Lebanese International University.
Stroke, the most common neurologic disorder and the major cause of disability and death after heart disease causing 11.8% of the total deaths worldwide, is defined as rapidly developing clinical signs of focal disturbance of cerebral function lasting more than 24h. This study aims to assess appropriateness of hypertension treatment in acute stroke and its adherence with the choice of medications tailored according to blood pressure readings. This pilot study was performed in Lebanese hospitals where medical records of ischemic stroke patients were used to collect required data. Patients 18 years or older were enrolled following admission to intensive care unit or internal medicine department. Patients with hemorrhagic stroke were excluded. A total of 146 patients were included in the analysis. At baseline, patients had a mean ± standard deviation SBP of 160.6 (±31.3) and a mean DBP of 85.5. Labetalol and amlodipine were administered to patients with significantly higher baseline blood pressure. Change in SBP from baseline after 2h of drug administration was significantly higher with labetalol, amlodipine, and nitroglycerine. As for the change in SBP after 24h, it was significantly higher with labetalol in patients not eligible for reperfusion, and amlodipine. As for change in DBP, it was significantly lower after 24h with labetalol administration to patients not eligible for reperfusion and it was also lower 2h after administration of ramipril and 24h. This study reveals the gap between American Stroke Association guideline recommendations and clinical practice and states the impact of this difference on patients’ health.
- Cardiovascular and Stroke Nursing
Faculty of Medicine, Universitas Brawijaya, Malang, East Java - Indonesia
Rachmawati Wardani, MD, Faculty of Medicine, Universitas Brawijaya, Malang, East Java - Indonesia. Rachmawati has completed her MD at the age of 24 years from Universitas Brawijaya. She had actively participated in local and national medical students’ organizations focusing on medical education, public health, reproductive health, human rights and peace as well as research and professional exchange, including facilitated training on global health and intercultural learning and took a part in Asian Para Games 2018 as a Medical & Doping Control Team. She is having an interest in the Neurology department and willing to learn new things from this conference.
Aim: Patients with history of stroke have higher risk of recurrence within early weeks and months, making the first year relatively risky. We wished to determine the effectiveness of physical activity through Prolanis [chronic disease management program launched by Indonesia’s Universal Health Coverage aiming to prevent ongoing complications, especially hypertension and type 2 diabetes mellitus, which are known to be the risk factor for stroke] in preventing stroke recurrence in Mutiara Sehat PHC, East Java, Indonesia.
Methods: This is a descriptive study conducted in Mutiara Sehat PHC using 10 participants with history of stroke who involved in Prolanis activities. Moderate intensity aerobic is held routinely every Friday for 30 minutes throughout 12 months (September 2018 - 2019).
Results: No participant was found to develop stroke recurrence during the period September 2018 - 2019.
Conclusion: Physical activity with moderate intensity aerobic turns out to play a major role in preventing stroke recurrence at Mutiara Sehat PHC. However, participants are encouraged to carry out physical activity at least three days a week for about 30 minutes, in accordance with AHA recommendation. But, due to the limited sample size and the numerous factors that can affect stroke recurrence, further research is needed in this area.
- Neurology and Neurosurgery
University of Massachusetts Medical School, United States
The author Stanlies D’Souza MD, FRCA, FCARCSI is an Associate Professor in Anesthesiology at the University of Massachusetts Medical School (UMMS) and at the Tufts University School of Medicine, USA. He is also the chief of neuroanesthesiology division at UMMS, Baystate Medical Center, MA, USA. In addition he has been appointed as national neuroanesthesia committee member of the American Society of Anesthesiologists (ASA). He is active at the ASA with multiple problem based learning discussions (PBLD) sessions and poster presentations over the past 9 years. He is also moderating poster sessions at the ASA. Most importantly his article on “Aneurysmal Subarachnoid Hemorrhage” published in the Journal of Neurosurgical Anesthesia is the most viewed article since its publication in 2015. This is the only neurosurgical anesthesia journal in the world and the official journal of neurosurgical anesthesia societies of several countries across the world.
- Lower limit of of mean arterial pressure(MAP) in neurosurgical patients: current concepts
- Pathophysiology of systemic hypertension as per current literature
- Pathophysiology of systemic cardiovascular and pulmonary events as current literature
- Status of cerebral autoregulation and blood brain integrity following an intracranial event
- Management of systemic hypertension: Choice of pharmacological agents as per current concepts
- Reasons for avoiding vasodilator agents to treat systemic hypertension
- Role of routine cardiac evaluation in a patient with acute intracranial pathology
- Role of perioperative prophylactic beta blockers to treat systemic hypertension and cardiac pathology in a patient with intracranial pathology
- Laboratory monitoring of hypertensive response following intracranial event as per current evidence.
Target blood Traumatic Brain Injury (TBI)
- Definition of hypotension in TBI and why the lower limit of hypotension was increased from 90 to 110 mm Hg as per 2016 Brain Trauma Foundation(BTF) guidelines
- Target cerebral perfusion Pressure (CPP) as per recent BTF guidelines and why the target CPP is narrowed in recent BTF guidelines. Definition of lower and upper limit of CPP in TBI.
- Method of calculation of target MAP in the absence of ICP monitor for an emergent TBI patient coming craniotomy. Discussion about lower and upper level of MAP.
- Harmful effects of the rise and fall of CPP above and below this narrow range of CPP.
Target BP in acute ischemic stroke(AIS)
- Review of literature of target systolic BP range prior to reperfusion therapy in AIS.
Target BP in spontaneous intracerebral hemorrhage
- Review of INTERACT 2 and ATTACH2 trials.
- Target BP based on above 2 trials as per neurological outcome
Target BP in aneurysmal subarachnoid hemorrhage (aSAH)
- Historical target for BP in aSAH.
- Review of Neurocritical care society consensus statement 2011 on target BP for patients presenting clipping, coiling or endovascular flow diversion for techniques.
- Review of the American Stroke Association (ASA) of the American Heart Association(AHA) guidelines for aSAH blood pressure targets.
- Extrapolation of results of spontaneous ICH trials to spontaneous aSAH.
- Target BP during application of a temporary clip.
- Target BP during induced hypotension for permanent clip.
- Target BP for induced hypertension for DCI. afteraSAH.
Target BP for Deep Brain stimulation electrode implantation
- Target BP range during permanent macroelectrode and microelectrode implantation
- Reasons for this blood pressure target as per current evidence
- Which antihypertensive agents should be avoided during permanent Deep Brain Stimulation electrodes ?Why?