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Background Minimally invasive surgery procedures, including stereotactic catheter aspiration and clearance of intracerebral hemorrhage (ICH) with recombinant tissue plasminogen activator hold a promise to improve outcome of supratentorial brain hemorrhage, a morbid and disabling type of stroke. A recently completed Phase III randomized trial showed improved mortality but was neutral on the primary outcome (modified Rankin scale score 0 to 3 at 1 yr). Objective To assess surgical performance and its impact on the extent of ICH evacuation and functional outcomes. Methods Univariate and multivariate models were used to assess the extent of hematoma evacuation efficacy in relation to mRS 0 to 3 outcome and postulated factors related to patient, disease, and protocol adherence in the surgical arm (n = 242) of the MISTIE trial. Results Greater ICH reduction has a higher likelihood of achieving mRS of 0 to 3 with a minimum evacuation threshold of ≤15 mL end of treatment ICH volume or ≥70% volume reduction when controlling for disease severity factors. Mortality benefit was achieved at ≤30 mL end of treatment ICH volume, or >53% volume reduction. Initial hematoma volume, history of hypertension, irregular-shaped hematoma, number of alteplase doses given, surgical protocol deviations, and catheter manipulation problems were significant factors in failing to achieve ≤15 mL goal evacuation. Greater surgeon/site experiences were associated with avoiding poor hematoma evacuation. Conclusion This is the first surgical trial reporting thresholds for reduction of ICH volume correlating with improved mortality and functional outcomes. To realize the benefit of surgery, protocol objectives, surgeon education, technical enhancements, and case selection should be focused on this goal.

Acute stroke due to supratentorial intracerebral haemorrhage is associated with high morbidity and mortality. Open craniotomy haematoma evacuation has not been found to have any benefit in large randomised trials. We assessed whether minimally invasive catheter evacuation followed by thrombolysis (MISTIE), with the aim of decreasing clot size to 15 mL or less, would improve functional outcome in patients with intracerebral haemorrhage. MISTIE III was an open-label, blinded endpoint, phase 3 trial done at 78 hospitals in the USA, Canada, Europe, Australia, and Asia. We enrolled patients aged 18 years or older with spontaneous, non-traumatic, supratentorial intracerebral haemorrhage of 30 mL or more. We used a computer-generated number sequence with a block size of four or six to centrally randomise patients to image-guided MISTIE treatment (1·0 mg alteplase every 8 h for up to nine doses) or standard medical care. Primary outcome was good functional outcome, defined as the proportion of patients who achieved a modified Rankin Scale (mRS) score of 0-3 at 365 days, adjusted for group differences in prespecified baseline covariates (stability intracerebral haemorrhage size, age, Glasgow Coma Scale, stability intraventricular haemorrhage size, and clot location). Analysis of the primary efficacy outcome was done in the modified intention-to-treat (mITT) population, which included all eligible, randomly assigned patients who were exposed to treatment. All randomly assigned patients were included in the safety analysis. This study is registered with ClinicalTrials.gov, number NCT01827046. Between Dec 30, 2013, and Aug 15, 2017, 506 patients were randomly allocated: 255 (50%) to the MISTIE group and 251 (50%) to standard medical care. 499 patients (n=250 in the MISTIE group; n=249 in the standard medical care group) received treatment and were included in the mITT analysis set. The mITT primary adjusted efficacy analysis estimated that 45% of patients in the MISTIE group and 41% patients in the standard medical care group had achieved an mRS score of 0-3 at 365 days (adjusted risk difference 4% [95% CI -4 to 12]; p=0·33). Sensitivity analyses of 365-day mRS using generalised ordered logistic regression models adjusted for baseline variables showed that the estimated odds ratios comparing MISTIE with standard medical care for mRS scores higher than 5 versus 5 or less, higher than 4 versus 4 or less, higher than 3 versus 3 or less, and higher than 2 versus 2 or less were 0·60 (p=0·03), 0·84 (p=0·42), 0·87 (p=0·49), and 0·82 (p=0·44), respectively. At 7 days, two (1%) of 255 patients in the MISTIE group and ten (4%) of 251 patients in the standard medical care group had died (p=0·02) and at 30 days, 24 (9%) patients in the MISTIE group and 37 (15%) patients in the standard medical care group had died (p=0·07). The number of patients with symptomatic bleeding and brain bacterial infections was similar between the MISTIE and standard medical care groups (six [2%] of 255 patients vs three [1%] of 251 patients; p=0·33 for symptomatic bleeding; two [1%] of 255 patients vs 0 [0%] of 251 patients; p=0·16 for brain bacterial infections). At 30 days, 76 (30%) of 255 patients in the MISTIE group and 84 (33%) of 251 patients in the standard medical care group had one or more serious adverse event, and the difference in number of serious adverse events between the groups was statistically significant (p=0·012). For moderate to large intracerebral haemorrhage, MISTIE did not improve the proportion of patients who achieved a good response 365 days after intracerebral haemorrhage. The procedure was safely adopted by our sample of surgeons. National Institute of Neurological Disorders and Stroke and Genentech. [Abstract copyright: Copyright © 2019 Elsevier Ltd. All rights reserved.]

Pulmonary barotrauma can cause cerebral arterial gas embolism (CAGE) from pulmonary overdistension of alveoli forcing gas into the pulmonary vasculature. We report a case of CAGE in a man found to have occult pulmonary arteriovenous malformation (PAVM) and undiagnosed obstructive sleep apnea (OSA). A 46-year-old man was admitted to the hospital for an acute seizure and left-sided weakness, with telangiectasias on his lower lip and tongue. Brain-computed tomography (CT) showed gas emboli in the right hemisphere. Chest CT revealed a 1.8-cm PAVM in the posterior right costophrenic sulcus. A transthoracic echocardiogram showed no intracardiac shunt or patent foramen ovale. He was treated with phenytoin, lidocaine and hyperbaric oxygen. The PAVM was occluded with a detachable balloon followed by coil embolization. Polysomnography revealed severe obstructive sleep apnea, which was treated with CPAP. Seven years later, the patient was functioning at his pre-event baseline. We propose the CAGE was caused by high negative intrathoracic pressures while breathing against an obstructed upper airway, with air entrainment into the PAVM and subsequent arterialization.

To assess whether direct comparative feedback changes stroke physician behavior to improve Emergency Department (ED) page-to-stroke physician arrival, ED page-to-needle and door-to-needle (DTN) times in thrombolytic therapy for acute ischemic stroke. Background: Rapid thrombolytic therapy improves stroke outcomes. Interplay between ED processes and stroke physician behavior influences treatment times. We noted a broad range of intervals between times the physician was paged, to arrival and treatment among 4 Board-certified Vascular Neurologists at two affiliated Primary Stroke Centers. Method: In January 2013 a physician report card was implemented, comparing each physician to the group’s mean and median time points for all 2012 stroke treatment cases. Report cards were then provided quarterly. The pre-implementation (2012) and post-implementation (2013) intervals for overall and individual median page-to- physician arrival, page-to-needle and DTN times were compared using a Mann-Whitney U test. Included in this analysis were all treatment cases that did not have a documented reason for delay (per Target Stroke criteria). Results: Between the pre and post implementation period, the overall median physician page-to-response time decreased by 8.0 minutes (p=0.001). The range of median difference for individual physician page-to-response time was 3-11 minutes. The overall median physician page-to-needle time decreased by 8.0 minutes (p=0.004). The range for the median difference for individual physician page-to-needle time was 5.5-11 minutes. The overall median door-to-needle time decreased by 5 minutes (p=0.104), however, this was not significant. The range for change in individual physician median door-to-needle times was -1 to 9 minutes. Conclusion: The results show that direct, personal and comparative feedback to stroke physicians influences their page-to-response, page-to-needle times and may affect DTN times. There was a clear trend overall, and the page-to-response and page-to-needle times showed significant improvement. Though our numbers were too small to detect statistical significance for individuals, the benefit of improved treatment times is likely clinically significant.

Background and Issues: ASA guidelines support early mobilization of less severely affected stroke patients, with bedrest until they are clinically stable. However, there is no standard for assessing clinical stability of patients regardless of severity. Also, therapy resources may be limited, delaying mobility even in appropriate patients. Purpose: Our goal was to develop, implement, and assess a protocol for nursing staff to assess mobility readiness and advance activity in all stroke patients, within hours of admission. Methods: Stroke nurses, occupational/physical therapists (OT/PT), and a stroke neurologist, teamed to review mobility literature, then develop an assessment protocol with progressive, monitored levels of activity, usable by nursing and OT/PT. Barriers to implementation were identified and overcome. Adherence to protocol was audited by chart review. Safety was monitored via unusual occurrence reports. Nursing satisfaction was assessed by verbal feedback. Results: A progressive mobility assessment protocol was developed with staff feedback. Identified obstacles to implementation included: staff protocol awareness, mobility assessment inexperience, work routine alteration, patient safety concern, and lack of a charting system. Educational in-services, posters, emails, and one-on-one training emphasized expected benefits of the program for patients and staff. Meal vouchers were offered as rewards for compliance. Compliance was 18% with a paper charting form, but improved to 85-100% with a revised computer charting system. Patient safety was not compromised, and nursing workflow improved with earlier patient mobilization. Therapists are able to build on previous nursing assessments, enhancing efficiency. Nursing participation in protocol development promoted ownership of the protocol, based on verbal feedback. Conclusion: Our inter-disciplinary team successfully developed and safely implemented a new mobility practice protocol. This protocol benefits patients, nursing and rehab teams allowing safe and expedited patient activity, and improving efficiency on the stroke unit.