Pomona Valley Hospital Medical Center

Introduction Preclinical animal experiments and initial feasibility studies in humans have shown encouraging outcomes using the novel Saccular Endovascular Aneurysm Lattice (SEAL™) system for the treatment of both ruptured and unruptured wide‐neck intracranial aneurysms (IAs). The SEAL™ Interventional Pivotal IDE PMA Trial (SEAL™ IT) is designed to assess the safety and efficacy of the SEAL™ in patients with saccular IAs. This ongoing, prospective, multicenter trial includes three study arms and will enroll a total of 279 participants with wide‐neck bifurcation (WNBA), sidewall (SW), or acutely ruptured IAs across 50 U.S. sites. Methods Eligibility requirements include patients aged 20‐80 years with a wide‐neck saccular intracranial aneurysm (2‐19 mm) deemed suitable for treatment with the SEAL™ Intrasaccular Device (SID). Participants receive treatment using the SEAL™ device (Galaxy Therapeutics Inc.) and are monitored at discharge, and again at 3, 6, and 12 months, followed by yearly assessments for up to 5 years. The primary efficacy outcome is defined as complete aneurysm occlusion at 12 months without evidence of parent vessel stenosis or the need for retreatment, as determined by an independent core laboratory. Key safety outcomes include neurological death within 12 months, stroke occurring within the first 30 days, and ipsilateral stroke between 30 days and 1 year. Results As of submission, 163 WNBA, 58 WNSW, and 33 ruptured for a total of 254 patients (76.3% female; mean age 61.7 ± 11.3) have been enrolled at 50 sites. Mean aneurysm width was 5.2 ± 2.1, neck size of 3.7 ± 1.4, and neck‐to‐dome ratio of 1.4 ± 0.32. SEAL Arc was used in 63.6% and SEAL Base in 36.4%. Technical device success rate is 100% for WNBA, 94.8% WNSW, and 97.0% ruptured. The interim complete occlusion rate for the primary group is 84.5% at most recent date based on available imaging. Conclusion Preliminary data for the SEAL™ intrasaccular device is promising; Safety and effectiveness updates will be presented at the SVIN Conference.

IntroductionThyroid storm is a rare, life-threatening emergency with a 3.6–17% mortality rate despite proper management. Elevated levels of circulating thyroid hormones can increase metabolic demand, leading to adverse effects on multiple organ systems, particularly critical cardiovascular complications such as cardiomyopathy, myocardial infarction, ventricular arrhythmias, or coronary vasospasm. Precipitating factors can include infection, surgery, or trauma, with infection being the most common. The potential for cardiovascular mortality is high. While beta blockers are key for treatment, they can potentially reduce necessary cardiac output, risking hemodynamic collapse. Traditionally, propranolol has been recommended. We report a rare case of an adolescent experiencing cardiac arrest after propranolol administration in thyroid storm and acute appendicitis.Case ReportA 17-year-old female with a history of Grave disease, non-adherent to methimazole, underwent evaluation and treatment of thyroid storm and concomitant acute appendicitis. Aggressive initial treatment measures were started, including intravenous and oral propranolol. She went into cardiac arrest approximately six hours after initial medication administration, with subsequent return of spontaneous circulation achieved. The patient underwent aggressive resuscitation and multidisciplinary management. She had a prolonged course in the intensive care unit and was ultimately discharged from the hospital approximately three weeks later.ConclusionBeta-blocker use in the management of thyrotoxicosis can potentially cause cardiovascular collapse. We suggest consideration of shorter acting beta blockers, such as esmolol or landiolol.

BackgroundTandem lesions pose unique challenges in the endovascular treatment of acute ischemic stroke. We aimed to compare the clinical and procedural outcomes of patients with tandem lesions and extracranial internal carotid artery (ICA) complete occlusion versus those with moderate to severe stenosis.MethodsThis is a subanalysis of a multicenter cohort of patients with acute anterior circulation tandem lesions treated with intracranial mechanical thrombectomy and carotid artery stenting, between January 2015 and December 2020. The patients were categorized into 2 groups: extracranial ICA stenosis >70% to 99% and complete occlusion. Outcomes included successful and excellent recanalization, functional independence, symptomatic intracranial hemorrhage, and puncture‐to‐recanalization time. Sensitivity analyses were conducted based on varying degrees of stenosis, and we explored interactions with age, Alberta Stroke Program Early CT [Computed Tomography] Score, National Institutes of Health Stroke Scale, procedural antiplatelets, ICA treatment approach, ICA lesion etiology, Intravenous thrombolysis, and use of a balloon‐guide catheter.ResultsThe study included 323 patients; 166 (51.4%) of whom presented with ICA occlusion and 157 (48.6%) with severe stenosis. Patients with ICA occlusion had significantly higher rates of previous stroke/transient ischemic attack, and antegrade ICA treatment approach. The comparison between both groups in univariable and multivariable analysis revealed no significant differences in the rates of successful and excellent recanalization, functional independence, symptomatic intracranial hemorrhage, and additional outcomes. The median puncture‐to‐recanalization time was longer in the occlusion group (adjusted coefficient, 1.21 [95% CI 1.01–1.46], P = 0.05). When categorized into 3 groups (occlusion, severe, and moderate stenosis), median puncture‐to‐recanalization time was significantly higher in patients with occlusion (adjusted coefficient, 1.34 [95% CI, 1.04–1.71], P = 0.022), and a trend toward statistical significance was observed in patients with severe stenosis (adjusted coefficient, 1.29 [95% CI, 0.98–1.71], P = 0.068), compared with patients with moderate stenosis. Interaction analysis did not yield significant differences.ConclusionIn patients with tandem lesions, those with ICA occlusion presented longer puncture‐to‐recanalization time than patients with cervical stenosis. This observation might be linked to higher rates of an antegrade approach in patients with ICA occlusion.

In Reply: We thank Dr. Horgan and colleagues for their interest in our Narrative Review in the April 2024 issue.1 It is important to emphasize that the soluble fms-like tyrosine kinase 1/placental growth factor (sFlt-1) assay should be used along with other laboratory tests and clinical assessments and should not be used in isolation to make clinical decisions. We stand by our algorithm, which was evidence-based and developed in conjunction with society guidelines, peer-reviewed trials, and the U.S. Food and Drug Administration label. As with all new tests, the value of the sFlt-1 assay needs to be determined for each community. For those health care professionals who find our algorithm useful, they are welcome to incorporate it into their practices. Others may elect not to use our approach, and we encourage them to develop a protocol for sFlt-1/PlGF testing in their population. It is important that all health care professionals, regardless of their approach, evaluate implementation of the sFlt-1/PlGF test over time to be certain that patient outcomes are favorable. Adjustments should be made as necessary if new information arises.

IntroductionRecent studies have shown beneficial effects of Carotid artery stenting (CAS) in acute ischemic stroke patients with tandem lesions (TL). However, stent placement requires the use of antiplatelet medications to prevent in‐stent thrombosis and re‐occlusion of the artery. This must be balanced with the risk of intracerebral hemorrhage. In this multicenter study, we aimed to investigate the safety and feasibility of using antiplatelet regimens in patients with anterior circulation stroke with TLs.MethodsPatient level data were pooled from 17 centers and included patients with intracranial occlusion of ICA or M1/M2 segment of MCA with a concomitant extracranial ICA occlusion or stenosis ≥ 50%. Inclusion criteria were; age ≥ 18 years, EVT for intracranial occlusion, and underwent treatment for extracranial ICA lesions demonstrated on CTA and/or DSA. Patients were divided into groups according to the number of antiplatelets administered at the time of endovascular therapy (EVT) procedure into four groups including; 1) no antiplatelets, 2) single oral antiplatelet, 3) dual antiplatelets, and 4) intravenous antiplatelets (in combination of single or dual antiplatelets). Multivariable logistic regression models with multiple imputations were built to assess the association of primary outcome; symptomatic intracranial hemorrhage (sICH), and secondary outcomes including; modified Rankin Score (mRS) 0–2 at 90 days, and successful reperfusion (mTICI score ≥ 2b).ResultsA total of 682 patients were included. Of these, 138 (20.2%) did not receive any antiplatelet therapy, while 143 (20.97%) were treated with single oral, 207 (30.35%) with dual oral, and 194 (28.5%) with intravenous combined with single or dual antiplatelets. The rate of favorable outcome was non‐significantly higher in the dual (53%) and IV‐combination (54.4%) antiplatelets, as compared with single (38.9%) and without antiplatelet (38.6%) medications. In the multivariable model, after adjusting, there was no significant differences in the sICH (single: aOR: 1.07, CI: 0.62‐1.84, p = 0.8, dual: aOR: 1.18, CI: 0.70‐1.99, p = 0.55, IV‐combination: aOR: 1.01, CI: 0.57‐1.78, p = 0.98) and functional outcome at 90 days (single: aOR: 1.15, CI: 0.63‐2.12, p = 0.64, dual: aOR: 1.03, CI: 0.55‐1.9, p = 0.9, IV‐combination: aOR: 0.83, CI: 0.42‐1.64, p = 0.59) among the study groups. Interestingly, successful reperfusion (mTICI score ≥ 2b) was significantly higher in dual oral and IV‐combination antiplatelets (single: aOR: 1.14, CI: 0.61‐2.14, p = 0.69, dual: aOR: 4.82, CI: 2.23‐10.42, p = < 0.001, IV‐combination: aOR: 3.65, CI: 1.71‐7.79, p = 0.001).ConclusionsAdministration of antiplatelet medications during EVT was associated with successful reperfusion without increasing the rate of symptomatic hemorrhage in patients with anterior circulation LVO with TLs. Further large‐scale randomized studies are warranted to validate the optimal antiplatelet regimens during acute carotid artery stenting in patients with TLs.