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Purpose: Stroke patients are excluded from expeditious thrombectomy in regions lacking neurointerventional specialists. An audiovisual online streaming system was tested, allowing a neurointerventional specialist located at a neurovascular center to supervise and instruct a thrombectomy performed at a distant hospital without being physically present (remote streaming support [RESS])., Methods: In total, 36 thrombectomy procedures were performed on a Mentice endovascular simulator by six radiologists not specialized in neurointerventions. Each radiologist was challenged with six different endovascular simulation scenarios under alternating conventional local support (specialist inside the room [LOS]) and RESS, which was performed using an advanced live streaming platform., Results: Both support modes led to a median of 2 attempts (interquartile range [IQR] 2.0-2.0 each) until successful recanalization. There was no statistically significant difference in time from first catheter insertion to recanalization between LOS (median 24.9 min, IQR 21.0-31.5 min) and RESS (23.9 min, IQR 21.7-28.7 min, p = 0.89). The percentage of thrombi covered by the stent-retriever and average speed when retrieving the stent-retriever (3.7 mm/s, IQR 3.25-5.35 mm/s vs. 3.6 mm/sec, IQR 2.5-4.7) were similar in both groups. Fluoroscopy time did not differ (19.0 min, IQR 16.9-23.5 min vs. 19.9 min, IQR 15.9-23.5 min) with a trend towards increased median amounts of contrast medium used under RESS (62.9 ml vs. 43.1 ml; p = 0.055)., Conclusion: This study confirmed the feasibility of RESS for thrombectomy procedures in a simulated environment. This serves as basis for future studies planned to analyze the effectiveness of RESS in a real-world environment and to test if it improves the learning curve of interventionalists with limited thrombectomy experience in remote areas.

Background: Endovascular procedures are paramount in the treatment of cerebrovascular diseases, e.g. thrombectomy for stroke. The continuous further development of the devices used for these procedures (e.g. catheters and stents) requires permanent learning by the treating physician., Objective: Technical support options for new neuroendovascular procedures., Methods: Integration of streaming technologies into the training concept for neuroradiologists., Results: The transmission of angiographic images to a remote computer workstation in real time is possible independent of location by means of specific streaming technology. This approach enables a neuroendovascular specialist to advise geographically distant interventionalists when performing catheter interventions of the brain, to oversee the handling of the materials used and to instruct them if necessary (remote proctoring)., Conclusion: Especially during emergency interventions and during travel restrictions, patient safety can be increased by connecting to another neuroendovascular specialist via live streaming.

Background: To satisfy the increasing demand of mechanical thrombectomy (MT) for acute ischemic stroke treatment, new organizational concepts for patient care are required. This study evaluates time intervals of acute stroke management in two stroke care models, including one based on transportation of the interventionalist from a comprehensive stroke center (CSC) to treat patients in two primary stroke centers (PSC). We hypothesized that time intervals were not inferior for the 'drip-and-drive' concept compared with the traditional 'drip-and-ship' concept., Methods: Patients treated with MT at the PSC ('drip-and-drive', 'D+D group') were compared with patients transferred from PSC to CSC for MT ('drip-and-ship', 'D+S group') with regard to time delays. Time intervals assessed were: symptom onset to initial CT, to angiography, and to recanalization; time from initial CT to telephone call activation, to arrival, and to angiography; and time from telephone call activation to arrival and from arrival to angiography., Results: 42 patients were treated at the PSC after transfer of the interventionalist, and 32 patients were transferred to the CSC for MT. The groups did not differ with regard to median Onset-CT and CT-Phone times. Significant differences between the groups were found for the primary outcome measure CT-Arrival time ('D+D group': median 121 (IQR 108-134) min vs 181 (157-219) min for the 'D+S group'; P<0.001). Time difference between the groups increased to more than 2 hours for median CT-Angio times (median 123 (IQR 93-147) min vs 252 (228-275) min; P<0.001)., Conclusion: Time intervals for the 'D+D group' were not inferior to those of the 'D+S group'. Moreover, under certain conditions, the 'drip-and-drive' concept might even be superior., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Carotid stenting carries a risk of periprocedural stroke. We aimed at determining predictors of cerebral ischemic events associated with stenting for symptomatic carotid stenosis., Methods: 127 patients who had been studied by diffusion-weighted MR imaging (DWI) before and on the day after carotid stenting were included. Six clinical variables and 5 variables characterizing the target carotid artery and aortic atherosclerosis were analyzed as potential risk factors for new ipsilateral DWI lesions after stenting., Results: Among all variables assessed, only age, length of stenosis and carotid intima-media thickness (IMT) significantly modified the risk of new lesions after stenting. Age ≥68 years, stenosis ≥15 mm and IMT ≥1.3 mm were identified as the best thresholds to predict new lesions. In the subgroup of patients ≥68 years with carotid stenosis ≥15 mm in length and IMT ≥1.3 mm, the risk of new lesions was markedly higher than in patients to whom no more than two of these factors applied (odds ratio 7.250, 95% CI 1.612-34.513, p = 0.005). The use of this simple predictive model correctly identified patients who had new lesions after stenting with high specificity (0.96) and a negative predictive value (0.83), while the positive predictive value was moderate (0.60) and sensitivity was low (0.23)., Conclusions: The risk of stenting for symptomatic carotid stenosis may vary with clinical and morphological patient characteristics. Further research is needed to validate these results and to evaluate the safety of stenting versus endarterectomy in specific patient subgroups., (Copyright © 2011 S. Karger AG, Basel.)