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Background and purpose There is still much debate whether bridging-therapy [intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MT)] might be beneficial compared to MT alone. We investigated the effect of IVT on size and histological composition of the clots retrieved from patients undergoing bridging-therapy or MT alone. Methods We collected mechanically extracted thrombi from 1000 acute ischemic stroke (AIS) patients included in RESTORE registry. Patients were grouped according to the administration (or not) of IVT before thrombectomy. Gross photos of each clot were taken and Extracted Clot Area (ECA) was measured using ImageJ software. Martius Scarlett Blue stain was used to characterize the main histological clot components [red blood cells (RBCs), fibrin (FIB), platelets/other (PTL)] and Orbit Image Analysis was used for quantification. Additionally, we calculated the area of each main component by multiplying the component percent by ECA. Chi-squared and Kruskal–Wallis tests were used for statistical analysis. Results 451 patients (45%) were treated with bridging-therapy while 549 (55%) underwent MT alone. When considering only percent histological composition, we did not find any difference in RBC% (P = 0.895), FIB% (P = 0.458) and PTL% (P = 0.905). However, bridging-therapy clots were significantly smaller than MT-alone clots [32.7 (14.8–64.9) versus 36.8 (20.1–79.8) mm2, N = 1000, H1 = 7.679, P = 0.006*]. A further analysis expressing components per clot area showed that clots retrieved from bridging-therapy cases contained less RBCs [13.25 (4.29–32.06) versus 14.97 (4.93–39.80) mm2, H1 = 3.637, P = 0.056] and significantly less fibrin [9.10 (4.62–17.98) versus 10.54 (5.57–22.48) mm2, H1 = 7.920, P = 0.005*] and platelets/other [5.04 (2.26–11.32) versus 6.54 (2.94–13.79) mm2, H1 = 9.380, P = 0.002*] than MT-alone clots. Conclusions Our results suggest that previous IVT administration significantly reduces thrombus size, proportionally releasing all the main histological components.

This paper provides evidence on the impact of European Banking Union (BU) and the associated Single Supervisory Mechanism (SSM) on the risk disclosure practices of European banks. The onset of BU and the associated rules are considered as an exogenous shock that provides the setting for a natural experiment to analyze the effects of the new supervisory arrangements on bank risk disclosure practices. A Difference-in-Differences approach is adopted, building evidence from the disclosure practices of systemically important banks supervised by the European Central Bank (ECB) and other banks supervised by national regulators over the period 2012–2017. The main findings are that bank risk disclosure increased overall following BU but there was a weakening of disclosure by SSM-supervised banks relative to banks supervised by national authorities. We also find that the overall positive effect of the BU on bank disclosure is stronger for less profitable banks and in the most troubled economies of the Eurozone (GIPSI countries), while the negative effect on centrally supervised banks is stronger if bank CEOs act also as chairmen (CEO duality). We interpret these findings in light of the fact that the new institutional arrangements for bank supervision under which the ECB relies on local supervisors to collect the information necessary to act gives rise to inefficiencies with respect to the speed and completeness of the information flow between SSM supervised banks and the ECB, which are reflected in bank disclosure practices.

An approach to producing hierarchical multi-scale porous ultra-high temperature ceramics (zirconium diboride, ZrB2) using 3D printing has been developed. Porous ceramic filaments can be 3D printed via Direct Ink Writing (DIW) (paste extrusion). Millimeter scale porosity is created by the 3D printed scaffold filaments. We introduce 20-micron-scale porosity into the scaffold filaments with the addition of oil to produce capillary suspension paste inks. Micron-scale porosity is also developed by partial sintering of the ceramic. The rheological (flow) properties of the capillary suspension paste inks suitable for printing by extrusion through the needle of the 3D printer have been characterized. The samples are strengthened by partial sintering at high temperatures. Complex-shaped components can be printed and sintered into crack-free components, but distortion during drying and sintering lead to poor shape and tolerance control. X-ray tomography is used to characterize the internal structure of the printed components. Printed test bars measured in 4-point bend testing exhibit high strength to density ratio. Such materials potentially have applications as insulation near very high-temperature surfaces in aerospace applications.

Background and purpose: Endovascular treatment (EVT) is a powerful treatment for large vessel occlusion (LVO) stroke if reperfusion can be achieved, while in cases with failed reperfusion, EVT may cause harm, as procedure-related complications may occur. We hypothesized that EVT with failed recanalization does not result in worse outcomes compared to best medical management and compared clinical outcomes of LVO stroke patients who underwent EVT with failed reperfusion to those who were treated with best medical management. Methods: We included patients with failed reperfusion from the control (EVT-only) arm of the ESCAPE-NA1 trial and the EVT arm of the ESCAPE trial and patients of the ESCAPE control arm who were treated with best medical management. Failed reperfusion following EVT was defined as modified thrombolysis in cerebral infarction score 0–2a. Proportions of good outcome (modified Rankin scale 0–2) were compared between patients who did and did not undergo EVT, and adjusted effect size estimates for EVT on outcomes were obtained. Results: We included 260 patients (110 failed EVT and 150 non-EVT patients). Proportions of good outcome were 38/110 (34.6%) with failed EVT vs.43/147 (29.3%) without EVT (adjusted odds ratio[aOR]: 1.48 [95%CI: 0.81–2.68]). Mortality and proportions of sICH in the failed EVT group vs. patients treated with best medical management were 26/110 (23.6%) vs. 28/147 (19.1%), aOR: 1.12 (95%CI: 0.56–2.24), and 7/110 (6.4%) vs. 4/150 (2.7%), aOR: 2.34 (95%CI: 0.00–22.97). Conclusion: Clinical outcomes of EVT patients with failed reperfusion did not differ significantly from patients treated with best medical management.

International guidelines emphasise the importance of securing ruptured cerebral aneurysms within 48–72 h of ictus. We assessed the timing of treatment of patients with aneurysmal subarachnoid haemorrhage (aSAH) referred to a national neurosurgical centre. Analysis of a prospective database of patients with aSAH admitted between 1st of February 2016 and 29th of February 2020 was performed. The timing to treatment was expressed in days and analysed in three ways: ictus to treatment, ictus to referral and referral to treatment. ORs with 95% CI were calculated for aneurysm treatment within 24, 48 and 72 h for good grade (WFSN 1–3) and poor grade (WFNS 4–5) cohorts separately. Of a total of 538 patients with aSAH, the aneurysm was secured in 312 (58%) within 24 h and in 398 (74%) within 48 h of ictus. Securing the aneurysm within 48 h of ictus was achieved in 89% (395/444) of patients who were referred within 24 h of ictus, but in only 3.2% (3/94) who were referred > 24 h after ictus. Poor grade patients (WFNS 4–5) were more likely than good grade patients (WFNS 1–3) to be referred to neurosurgery within 48 h of ictus (OR 22.87, 95% CI 3.14–166.49, p = 0.0020) and for their aneurysm to be secured within 48 h (OR 1.78, 95% CI 1.06–2.98, p = 0.0297) of ictus. Ictus to referral delay was highest in WFNS grade 1 patients. In centres with 7 day per week provision of interventional neuroradiology and vascular neurosurgery, the majority of patients with aSAH can be treated within the timeframes recommended by international guidelines and this applies to all grades of aSAH. However, delays still occur in a significant proportion of patients and this particularly applies to delays in presentation and diagnosis in good grade patients.

Background: During the Randomized Assessment of Rapid Endovascular Treatment (EVT) of Ischemic Stroke (ESCAPE) trial, patient-level micro-costing data were collected. We report a cost-effectiveness analysis of EVT, using ESCAPE trial data and Markov simulation, from a universal, single-payer system using a societal perspective over a patient’s lifetime. Methods: Primary data collection alongside the ESCAPE trial provided a 3-month trial-specific, non-model, based cost per quality-adjusted life year (QALY). A Markov model utilizing ongoing lifetime costs and life expectancy from the literature was built to simulate the cost per QALY adopting a lifetime horizon. Health states were defined using the modified Rankin Scale (mRS) scores. Uncertainty was explored using scenario analysis and probabilistic sensitivity analysis. Results: The 3-month trial-based analysis resulted in a cost per QALY of $201,243 of EVT compared to the best standard of care. In the model-based analysis, using a societal perspective and a lifetime horizon, EVT dominated the standard of care; EVT was both more effective and less costly than the standard of care (−$91). When the time horizon was shortened to 1 year, EVT remains cost savings compared to standard of care (∼$15,376 per QALY gained with EVT). However, if the estimate of clinical effectiveness is 4% less than that demonstrated in ESCAPE, EVT is no longer cost savings compared to standard of care. Conclusions: Results support the adoption of EVT as a treatment option for acute ischemic stroke, as the increase in costs associated with caring for EVT patients was recouped within the first year of stroke, and continued to provide cost savings over a patient’s lifetime. Clinical Trial Registration: NCT01778335

BackgroundInitial studies investigating correlations between stroke etiology and clot composition are conflicting and do not account for clot size as determined by area. Radiological studies have shown that cardioembolic strokes are associated with shorter clot lengths and lower clot burden than non-cardioembolic clots.ObjectiveTo report the relationship between stroke etiology, extracted clot area, and histological composition at each procedural pass.MethodsAs part of the multi-institutional RESTORE Registry, the Martius Scarlett Blue stained histological composition and extracted clot area of 612 per-pass clots retrieved from 441 patients during mechanical thrombectomy procedures were quantified. Correlations with clinical and procedural details were investigated.ResultsClot composition varied significantly with procedural passes; clots retrieved in earlier passes had higher red blood cell content (H4=11.644, p=0.020) and larger extracted clot area (H4=10.730, p=0.030). Later passes were associated with significantly higher fibrin (H4=12.935, p=0.012) and platelets/other (H4=15.977, p=0.003) content and smaller extracted clot area. Large artery atherosclerotic (LAA) clots were significantly larger in the extracted clot area and more red blood cell-rich than other etiologies in passes 1–3. Cardioembolic and cryptogenic clots had similar histological composition and extracted clot area across all procedural passes.ConclusionLAA clots are larger and associated with a large red blood cell-rich extracted clot area, suggesting soft thrombus material. Cardioembolic clots are smaller in the extracted clot area, consistent in composition and area across passes, and have higher fibrin and platelets/other content than LAA clots, making them stiffer clots. The per-pass histological composition and extracted clot area of cryptogenic clots are similar to those of cardioembolic clots, suggesting similar formation mechanisms.

Background Some patients with ischemic stroke have poor outcomes despite small infarcts after endovascular thrombectomy, while others with large infarcts sometimes fare better. Aims We explored factors associated with such discrepancies between post-treatment infarct volume (PIV) and functional outcome. Methods We identified patients with small PIV (volume ≤ 25th percentile) and large PIV (volume ≥ 75th percentile) on 24–48-h CT/MRI in the ESCAPE randomized-controlled trial. Demographics, comorbidities, baseline, and 24–48-h stroke severity (NIHSS), stroke location, treatment type, post-stroke complications, and other outcome scales like Barthel Index, and EQ-5D were compared between “discrepant cases” – those with 90-day modified Rankin Scale(mRS) ≤ 2 despite large PIV or mRS ≥ 3 despite small PIV – and “non-discrepant cases”. Multi-variable logistic regression was used to identify pre-treatment and post-treatment factors associated with small-PIV/mRS ≥ 3 and large-PIV/mRS ≤ 2. Sensitivity analyses used different definitions of small/large PIV and good/poor outcome. Results Among 315 patients, median PIV was 21 mL; 27/79 (34.2%) patients with PIV ≤ 7 mL (25th percentile) had mRS ≥ 3; 12/80 (15.0%) with PIV ≥ 72 mL (75th percentile) had mRS ≤ 2. Discrepant cases did not differ by CT versus MRI-based PIV ascertainment, or right versus left-hemisphere involvement ( p = 0.39, p = 0.81, respectively, for PIV ≤ 7 mL/mRS ≥ 3). Pre-treatment factors independently associated with small-PIV/mRS ≥ 3 included older age ( p = 0.010), cancer, and vascular risk-factors; post-treatment factors included 48-h NIHSS ( p = 0.007) and post-stroke complications ( p = 0.026). Absence of vascular risk-factors ( p = 0.004), CT-based lentiform nucleus sparing ( p = 0.002), lower 24-hour NIHSS ( p = 0.001), and absence of complications ( p = 0.013) were associated with large-PIV/mRS ≤ 2. Sensitivity analyses yielded similar results. Conclusions Discrepancies between functional ability and PIV are likely explained by differences in age, comorbidities, and post-stroke complications, emphasizing the need for high-quality post-thrombectomy stroke care. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT01778335 .

We examine whether environmental, social and governance (ESG) scores of European banks impact on their risk-taking behavior and on bank value. We find that high ESG scores are associated with a modest reduction in risk-taking for banks that are high or low risk-takers, and that the impact is conditional on executive board characteristics. These findings are consistent with the “stakeholder” view of ESG activities. However, high ESG scores are also associated with a reduction in bank value consistent with the “overinvestment” view of ESG whereby scare resources are diverted from investment. The decline in bank value occurs notwithstanding a positive indirect link between ESG scores and bank value through their impact on risk taking. Our results are robust to different measures of risk and value and to alternative estimation methodologies, and the key results hold for each of the sub-components of the ESG score. We conclude that there is a trade-off between reducing bank risk-taking and a more stable financial system on the one hand and bank value on the other.

Electrical switching of ferroelectric domains and subsequent domain wall motion promotes strong piezoelectric activity; however, light scatters at refractive index discontinuities such as those found at domain wall boundaries. Thus, simultaneously achieving large piezoelectric effect and high optical transmissivity is generally deemed infeasible. Here, it is demonstrated that the ferroelectric domains in perovskite Pb(In1/2 Nb1/2 )O3 Pb(Mg1/3 Nb2/3 )O3 -PbTiO3 domain-engineered crystals can be manipulated by electrical field and mechanical stress to reversibly and repeatably, with small hysteresis, transform the opaque poly-domain structure into a highly transparent mono-domain state. This control of optical properties can be achieved at very low electric fields (less than 1.5 kV cm-1 ) and is accompanied by a large (>10000 pm V-1 ) piezoelectric coefficient that is superior to that of linear state-of-the-art materials by a factor of three or more. The coexistence of tunable optical transmissivity and high piezoelectricity paves the way for a new class of photonic devices. This article is protected by copyright. All rights reserved.

To determine the experience of a regional stroke referral centre of external referrals for endovascular thrombectomy (EVT) in patients with symptoms of acute ischaemic stroke (AIS) and large vessel occlusion (LVO).Data were collected prospectively over two 4-month periods (2017-2018) on consecutive external referrals for EVT. Baseline demographics, imaging findings, and key time parameters were recorded. Reasons for not transferring patients and for not performing EVT were recorded. Key time intervals were calculated and compared between the transferred and non-transferred group with and without intracranial occlusion and between the transferred patients who underwent thrombectomy and those who did not.Two hundred and sixty-two patients were referred. Sixty-one percent (n=159) were accepted and transferred for treatment. Of those transferred, 86% (n=136) had EVT. Fourteen percent (n=23) were unsuitable for EVT on arrival due to no vessel occlusion (48% n=11), poor Alberta Stroke Program Early CT Score (ASPECTS)/established infarct (30%, n=7) haemorrhage (9%, n=2), and clinical recovery (13% n=3). One hundred and three patients (39%) were ineligible for EVT following phone discussion due to absence of intracranial occlusion (59%, n=61), low ASPECTS (22%, n=23), distal occlusion (4%, n=4), low/improving National Institutes of Health Stroke Scale (NIHSS; 10.7%, n=11), and poor modified Rankin Scale (mRS) at baseline (3%, n=3). Patients with LVO but not transferred had longer onset to hospital arrival time compared with those transferred 151.5 versus 91 minutes (p0.005), with a trend also toward a longer door to CT/CTA 40 minutes versus 30 minutes (p=0.142).These data provide valuable insights into the service provision of a comprehensive stroke network. The present rates of EVT and futile transfers are modest compared to published data. Access to neuroradiology and specialised stroke assessment is crucial to optimise time to treatment.

Background and aimsPlatelets and von Willebrand factor (vWF) are key factors in thrombosis and thus are likely key components of acute ischemic stroke (AIS) emboli. We aimed to characterize platelet and vWF levels in AIS emboli and to assess associations between their expression levels and clinical and procedural information.Materials and methodHistopathological and immunohistochemical analysis of emboli collected as part of the multi-institutional RESTORE registry was performed. The composition of the emboli was quantified using Orbit Image Analysis machine learning software. Correlations between clot components and clinical and procedural information were assessed using the χ2 test.ResultsNinety-one emboli samples retrieved from 63 patients were analyzed in the study. The mean platelet (CD42b) content of the clots was 33.9% and the mean vWF content of the clots was 29.8%. There was a positive correlation between platelet and vWF levels (ρ=0.564, p2=5.856, p=0.016).ConclusionPlatelet and vWF levels in AIS emboli correlate with each other and both have an inverse relationship with RBC composition. Patients with platelet-rich clots have poorer revascularization outcomes.

Background and Purpose— Mechanical thrombectomy may involve multiple attempts to retrieve the occluding thrombus. This study examined the composition of thrombus fragments retrieved with each pass of a device during the thrombectomy procedure. Second, the per-pass composition was compared with procedural and clinical data including angiographic outcome and stroke etiology. Methods— Thrombi were retrieved from 60 patients with acute ischemic stroke, where thrombus fragments retrieved in each pass were segregated as individual samples and maintained throughout the histological analysis as independent samples. All samples were stained with hematoxylin and eosin and Martius Scarlet Blue. The relative composition of red blood cells, fibrin, and white blood cells in thrombus fragments from each pass was quantified. Results— Over the 60 cases, thrombus material was retrieved in 106 of 138 passes. The number of passes required to complete the cases ranged from 1 to 6 passes. The analysis of thrombus fragments retrieved in each pass provided a greater insight into the thrombectomy procedure progression than the overall thrombus composition; the red blood cell content of thrombus fragments retrieved in passes 1 and 2 was significantly higher than that retrieved in passes 3 to 6. The removal of thrombus material in a total of 1, 2, or 3 passes was associated with the highest percentage of final modified Thrombolysis in Cerebral Infarction score of 2c-3. There was no association between modified Thrombolysis in Cerebral Infarction score and per-pass thrombus composition. Conclusions— The differentiation achieved through the per-pass analysis of acute ischemic stroke thrombi provides a greater insight into the thrombectomy procedure progression than the combined per-case thrombus analysis. Insights gained may be a useful consideration in determining the treatment strategy as a case evolves and may be useful for the development of new devices to increase rates of 1-pass recanalization.

BackgroundMechanical thrombectomy is the standard of care for acute ischemic strokes with proximal intracranial occlusion. Arterial access is commonly achieved with femoral artery puncture, although this is not always possible. In this case series, we describe 11 cases of anterior circulation stroke where direct carotid puncture was used to obtain vascular access.Methods and materialsA review of a prospectively maintained thrombectomy database over a 2-year period (August 2016 – August 2018) was undertaken to identify cases where direct carotid access was performed. CT and angiographic imaging were reviewed. Indications for carotid access, techniques used, technical success of procedure, recanalization rates, procedure-related complications, and patient outcomes were assessed.ResultsEleven patients out of 498 overall thrombectomy procedures (2.2% thrombectomies) underwent direct carotid access. Median National Institutes of Health Stroke Scale was 20. Seventy three percent of patients received intravenous thrombolysis. The direct carotid approach was performed following the failed femoral approach due to unfavorable aortic arch anatomy, vessel tortuosity, and severe atherosclerotic disease. Direct carotid puncture was successful in 10 patients, and unsuccessful in one. Successful recanalization (TICI 2b–3) was achieved in eight patients. One patient had spontaneously recanalized on angiography. There was failed recanalization in one patient with tandem ICA and M1 occlusion. Carotid access complications included one patient with both neck hematoma and asymptomatic ICA dissection, and one of delayed central retinal artery occlusion.ConclusionThis case series highlights direct carotid puncture as a successful alternative when the femoral approach is not possible, allowing thrombectomy in patients who would otherwise be unsuitable.

Objectives Most clots retrieved from patients with acute ischemic stroke are ‘red’ in color. ‘White’ clots represent a less common entity and their histological composition is less known. Our aim was to investigate the composition, imaging and procedural characteristics of ‘white’ clots retrieved by mechanical thrombectomy. Materials and methods Seventy five ‘white’ thrombi were selected by visual inspection from a cohort of 760 clots collected as part of the RESTORE registry. Clots were evaluated histopathologically. Results Quantification of Martius Scarlett Blue stain identified platelets/other as the major component in ‘white’ clots’ (mean of 55% of clot overall composition) followed by fibrin (31%), red blood cells (6%) and white blood cells (3%). ‘White’ clots contained significantly more platelets/other (p

Introduction Various mechanical thrombectomy devices and techniques including Stentrievers and Aspiration Catheters are used in the treatment of acute ischemic stroke.1Balloon Guide Catheters (BGC) are commonly used to achieve flow control. A new generation of ‘Super-bore’ 088’’ catheters are currently being tested clinically.2 3 Objective/Aim We evaluated the in-vitro revascularization performance of current and novel thrombectomy approaches. Methods National University of Ireland Galway Research Ethics Committee approved the study. Clot analogues from human blood were used to create ICA (20 mm) and MCA (10 mm) occlusions in an In-vitro thrombectomy model. Thrombectomy setups tested were; ADAPT: Millipede 088, SOFIA, SOFIA+BGC and Combination; Millipede 088+Solitaire, SOFIA+BGC+Solitaire, SOFIA+Solitaire. 10 replicates of each test were performed. Endpoints were First Pass Effect (FPE), Second and Third-pass success and procedural-related distal emboli from 50–1000µm. Results The Millipede 088 catheter achieved the highest rate of FPE in both ICA (60%) and MCA (100%) occlusions and had the lowest number of procedural-related emboli compared to all other device setups, followed by the Millipede 088+Solitaire technique. Of the currently used techniques, the use of a Solitaire in combination with a SOFIA lead to a higher rate of FPE in ICA occlusions (40% vs 20%, SOFIA+BGC+Solitaire vs SOFIA+BGC), but a lower rate of FPE in MCA occlusions (50% vs 60%, SOFIA+BGC+Solitaire vs SOFIA+BGC). Conclusions The novel 0.088’’ aspiration catheter achieves the best FPE rates in both ICA and MCA occlusions. In terms of existing techniques, ADAPT is more effective in the MCA, while the stentrievers provide a benefit in the ICA. References Hafeez MU, Kan P, Srivatsan A, Moore S, Jafari M, DeLaGarza C, et al. Comparison of first-pass efficacy among four mechanical thrombectomy techniques: a single-center experience. World Neurosurgery 2020;144:e533–e40. Gershon BS, Bageac DV, Shigematsu T, Majidi S, De Leacy R. Republished: first clinical report of aspiration through a novel 0.088-inch catheter positioned in the M1 middle cerebral artery for ELVO thrombectomy. Journal of NeuroInterventional Surgery 2021;13(4):e4–e. Nogueira RG, Mohammaden MH, Al-Bayati AR, Frankel MR, Haussen DC. Preliminary experience with 088 large bore intracranial catheters during stroke thrombectomy. Interventional Neuroradiology 2020:1591019920982219. Disclosure Sean Fitzgerald received research funding from Enterprise Ireland that is co-funded by Perfuze Ltd. Liam Mullins declares the following competing interest; Perfuze (stock options). John Thornton declares the following competing interests; Perfuze (Physician Advisory Board, stock options); Consultancy fees: Microvention, Johnson and Johnsons. Raul G. Nogueira declares the following competing interests: consulting fees for advisory roles with Anaconda, Biogen, Cerenovus, Genentech, Imperative Care, Medtronic, Phenox, Prolong Pharmaceuticals, Stryker Neurovascular and stock options for advisory roles with Astrocyte, Brainomix, Cerebrotech, Ceretrieve, Corindus Vascular Robotics, Vesalio, Viz-AI, and Perfuze.

Introduction Emerging data show an association between increased mechanical thrombectomy (MT) passes and poor outcomes in ischemic stroke. Clots that require ≥3 passes are more often tough, fibrin-rich thrombi than those retrieved within two passes. Aims To assess the clinical and economic burden of number of MT passes, we evaluated the odds of achieving successful reperfusion and functional independence in first pass, or 2–3 passes, compared to ≥4 passes. Methods A retrospective observational study was conducted on 857 cases treated with MT from the Irish National Thrombectomy database. Outcomes were 90-day functional independence (mRS 0–2) and successful reperfusion (mTICI 2b-3) stratified by number of passes (1; 2–3; and ≥4) with multivariable regression to adjust for confounding variables. A decision-tree economic model was informed by 90-day mRS: independent (0–2), dependent (3–5), or dead, with literature-derived annual healthcare costs by mRS. Results The odds of achieving successful reperfusion were significantly higher for 1 vs. ≥4 passes (OR 7.19, p Conclusion Odds of achieving good outcomes decline with MT passes, while care costs increase. Thrombectomy devices that improve interaction with tough clots for rapid and complete retrieval in fewer passes may improve clinical and economic outcomes. References Yoo AJ. Journal of Stroke 2017;19(2):121. Douglas A. JNIS 2020;12(6):557–562. Liebeskind DS. Stroke 2011;42(5):1237–1243. Abbasi M. Interventional Neuroradiology 2021;202115910199211009119. Siddiqui AH. Stroke 2021;52(Suppl_1):AP14–AP14. Garcia-Tornel A. Stroke 2019;50(7):1781–1788. Shireman TI. Stroke 2017;48(2):379–387. Disclosure Dr. Jack Alderson, Radiology, Beaumont Hospital. Prof. Dr. John Thornton, Neuroradiology, Beaumont Hospital. Consultancy for Johnson & Johnson, Perfuze and Microvention. Shareholder Perfuze. Cindy Tong and Shelly Ikeme are employees of Johnson & Johnson. Heather Cameron is an employee of EVERSANA, a consultant for Johnson & Johnson. This research is funded by Cerenovus – a company of Johnson & Johnson

Introduction We assessed the correlation between thrombus size before and after mechanical thrombectomy, measured as length by Computed Tomography Angiography/Non-Contrast Computed Tomography (CTA/NCCT) and Extracted Clot Area, ECA, respectively. We also assessed the influence of thrombus size on the number of passes required for clot removal and final recanalization outcome. Materials and methods Acute ischaemic stroke (AIS) thrombi retrieved by mechanical thrombectomy from 500 patients and data of clot length by CTA/NCCT were collected from three hospitals in Europe. ECA was obtained by measuring the area of the extracted clot. Non-parametric tests were used for data analysis. Results A strong positive correlation was found between clot length on CTA/NCCT and ECA (rho = 0.619,N = 500,P

Background and purpose Aspiration is a successful technique used in thrombectomy for acute stroke. It is contingent upon the appropriate position of the aspiration catheter, so that it is in contact with the thrombus. However, navigating the craniocervical vasculature is challenging is some patients. The wedge microcatheter (MicroVention®) is designed to reduce the gap between the microcatheter and the SofiaPlus 6F catheter for ease of advancement. The purpose of this study is to describe our initial experience with the wedge microcatheter. Materials and Methods A retrospective review of 38 consecutive patients in whom the wedge microcatheter was used during thrombectomy was performed to determine whether the wedge microcatheter was successful in delivering the Sofia catheter to the desired location. Results We have found this device to be successful in delivering the aspiration catheter to the correct position in 97% ( N = 37) of cases. It was used predominantly to pass the origin of branching vessels and also to navigate the tortuous cavernous and petrous segments of the ICA. Conclusion The wedge microcatheter is a successful tool in delivering the aspiration catheter to the desired vessel for revascularisation.

Introduction Recent advances in stroke management and care have resulted in improved survival and outcomes. However, providing equitable access to acute care, rehabilitation and longer-term stroke care is challenging. Recent Irish evidence indicates variation in stroke outcomes across hospitals, and a need for continuous audit of stroke care to support quality improvement. The aim of this project is to develop a core minimum dataset for use in the new Irish National Audit of Stroke (INAS), which aims to improve the standard of stroke care in Ireland. This paper outlines the protocol for conducting a scoping review of international practice and guidelines in auditing acute and non-acute stroke care. Objective Identify data items that are currently collected by stroke audits internationally, and identify audit guidelines that exist for recommending inclusion of content in stroke audit datasets. Methods and analysis This scoping review will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews (PRISMA-ScR). We will search the following databases: Medline Ovid; Embase; CINAHL EBSCOHost. Grey literature will also be searched for relevant materials, as will relevant websites. Study selection and review will be carried out independently by two researchers, with discrepancies resolved by a third. Data charting and synthesis will involve sub-dividing relevant sources of evidence, and synthesising data into three categories: i) acute stroke care; ii) non-acute stroke care; and iii) audit data collection procedures and resourcing. Data will be charted using a standardised form specific to each category. Consultation with knowledge users will be conducted at all stages of the scoping review. Discussion This scoping review will contribute to a larger project aimed at developing an internationally benchmarked stroke audit tool that will be used prospectively to collect data on all stroke admissions in Ireland, encompassing both acute and non-acute data items.

BackgroundDuring the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study’s objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines.MethodsWe conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March–31 May 2020. The prior 1-year control period (1 March–31 May 2019) was obtained to account for seasonal variation.FindingsThere was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI −24.3% to −20.7%, pInterpretationThere was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction.

We examine the link between the genetic diversities of executive board members and bank financial misconduct. The premise is that genetic diversity results in different perspectives, skills, and abilities that impact on the effectiveness of executive board guidance and monitoring, including with respect to misconduct. Employing a panel of US banks over 1998-2019 we find that adding directors from countries with different levels of genetic diversity is negatively associated with financial misconduct as measured by enforcements and class action litigation against banks by the main regulatory agencies. In addition, the relation between genetic diversity and misconduct is hump-shaped, suggesting that there a trade-off between the beneficial and detrimental effects of genetic diversity on board monitoring and guidance. These results are robust to controlling for bank specific variables, including other board characteristics, and to the use of instrumental variables.

Background No currently approved intervention counteracts airway metaplasia and mucus hypersecretion of chronic bronchitis in COPD. However, metered cryospray (MCS) delivering liquid nitrogen to the tracheobronchial airways ablates abnormal epithelium and facilitates healthy mucosal regeneration. The objective of this study was to evaluate the feasibility, efficacy and safety of MCS in chronic bronchitis. Methods Patients with a forced expiratory volume in 1 s of 30–80% predicted who were taking optimal medication were recruited. Primary outcomes were feasibility (completion of treatments), efficacy (3-month change in St George's Respiratory Questionnaire (SGRQ)) and safety (incidence of adverse events). Secondary outcomes were lung function, exercise capacity and additional patient-reported outcomes. Results 35 patients, 19 male/16 female, aged 47–76 years, Global Initiative for Chronic Obstructive Lung Disease grade I (n=3), II (n=10) and III (n=22), underwent staggered liquid nitrogen treatments to the tracheobronchial tree. 34 patients completed three treatments, each lasting 34.3±12.1 min, separated by 4–6 weeks; one withdrew after the first treatment. ∼1800 doses of MCS were delivered. Clinically meaningful improvements in patient-reported outcomes were observed at 3 months: change in SGRQ −6.4 (95% CI −11.4 to −1.3; p=0.01), COPD Assessment Test (CAT) −3.8 (95% CI −6.4 to −1.3; p, RejuvenAir system treatment for individuals with chronic bronchitis in COPD is safe, feasible, well tolerated, and resulted in clinically meaningful improvements in multidimensional measures of cough, sputum production, breathlessness and quality of life https://bit.ly/30KBfPs

In a panel of 121 developed and developing economies, financial development promotes income equality in upper-middle income countries and inequality in low- and high-income countries. Finance impacts on income inequality through both the financial institutions and financial markets channels, though the impact of the financial institutions channel is relatively larger.

Both intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are evidence-based treatments for acute ischemic stroke (AIS) in selected cases. Recanalization may occur following IVT without the necessity of further interventions or requiring a subsequent MT procedure. IVT prior to MT (bridging-therapy) may be associated with benefits or hazards. We studied the retrieved clot area and degree of recanalization in patients undergoing MT or bridging-therapy for whom it was possible to collect thrombus material. We collected mechanically extracted thrombi from 550 AIS patients from four International stroke centers. Patients were grouped according to the administration (or not) of IVT before thrombectomy and the mechanical thrombectomy approach used. We assessed the number of passes for clot removal and the mTICI (modified Treatment In Cerebral Ischemia) score to define revascularization outcome. Gross photos of each clot were taken and the clot area was measured with ImageJ software. The non-parametric Kruskal-Wallis test was used for statistical analysis. 255 patients (46.4%) were treated with bridging-therapy while 295 (53.6%) underwent MT alone. By analysing retrieved clot area, we found that clots from patients treated with bridging-therapy were significantly smaller compared to those from patients that underwent MT alone (H-1 = 10.155 p = 0.001*). There was no difference between bridging-therapy and MT alone in terms of number of passes or final mTICI score. Bridging-therapy was associated with significantly smaller retrieved clot area compared to MT alone but it did not influence revascularization outcome. This publication has emanated from research conducted with the financial support of Science Foundation Ireland (SFI) and is co-funded under the European Regional Development Fund under Grant Number 13/RC/2073. Furthermore, it was supported by Cerenovus. peer-reviewed

Introduction/Purpose Larger lumen catheters are associated with improved reperfusion using aspiration for the treatment of stroke. Significant scope remains to improve the rate of first pass effect, which has been associated with significantly improved clinical outcomes. To date, the degree of tortuosity encountered during neurovascular procedures has limited the ability of larger lumen catheters to navigate distally to the target vessels. Perfuze Ltd (Galway, Ireland) have developed a novel aspiration catheter (Millipede 088) which has an 8F OD and 0.088’’ ID. The purpose of this study was to evaluate the navigability of Millipede 088 to the M1 segment of the MCA in a fresh-frozen cadaver model. Methods In total six cadavers were investigated, allowing evaluation of navigation to twelve MCAs. Commercially available 6F aspiration catheters (Terumo Sofia Plus, Penumbra ACE 64 and 68) were used as a control for baseline comparison. Slow perfusion using warm water was maintained throughout the procedure. The study was conducted at MERI, Memphis, TN, USA, using Siemens Artis Pheno for imaging. Control A Penumbra Neuron Max was placed at the petrous segment of the ICA. The 6F aspiration catheter was navigated triaxially over a microcatheter and microwire. Initially, 2.1F microcatheters and 0.014’’ microwires were used for support. Where additional support was required, microcatheters of up 2.7F or Penumbra 3Max and/or a 0.016’’ microwire were used. Test: Via femoral access, an 80 cm long sheath Super Arrow-Flex (Teleflex) or Flexor Shuttle (Cook) was placed in the proximal ICA. Various combinations of internal support were investigated 1) 2.1F microcatheters and 0.014’’ microwire, 2) 6F aspiration catheters. Where additional support was required to cross the ophthalmic artery, microcatheters of up 2.7F or Penumbra 3Max and/or a 0.016’’ microwire were used. Results Varying tortuosity was encountered; aortic-arch (Type I-III, bovine), cervical (s-shaped); siphon (U, C, S, o). In 11/12 instances it was possible to navigate to the distal M1 using test (Millipede 088) and control (6F aspiration catheters) devices. In the instance of unsuccessful navigation, both Millipede 088 and the 6F aspiration catheters were unable to cross the ophthalmic artery. In general, navigation of Millipede 088 to the M1 was facilitated by the support of a 6F aspiration catheter. Conclusions Navigation of the Millipede 088 catheter to the M1 is feasible in a cadaver model. The ophthalmic artery can represent a challenge which in the majority of cases can be overcome using the support of standard neurovascular devices. Disclosures R. Nogueira: 2; C; Perfuze Ltd. 4; C; Perfuze. L. Mullins: 4; C; Perfuze Ltd. 5; C; Perfuze Ltd. D. Finneran: 4; C; Perfuze Ltd. 5; C; Perfuze Ltd. W. Allen: 4; C; Perfuze Ltd. 5; C; Perfuze Ltd. J. Thornton: 2; C; Perfuze Ltd. 4; C; Perfuze Ltd.

Introduction/Purpose Achieving complete reperfusion from a single mechanical thrombectomy attempt, termed First Pass Effect (FPE), is associated with significantly improved outcomes. Increasing the lumen of aspiration catheters to 6Fr has previously been shown to increase the reperfusion rates in comparison to smaller lumen catheters. We evaluated the performance of a novel large bore (0.088’’ ID) 8Fr aspiration catheter (Millipede 088, Perfuze Ltd.) and compared its performance against current industry standard 6Fr aspiration catheters (ACE68, Penumbra and SOFIA Plus, Microvention) in an in-vitro human vasculature model. Methods Following National University of Ireland Research Ethics committee approval human whole blood and platelet donations were obtained from the Irish Blood Transfusion Service. Three clot analogue phenotypes representative of clots retrieved from patients were created; Red Blood Cell-Rich, Mixed and Fibrin/Platelet-Rich. Histopathological analysis was performed using Martius Scarlet Blue (MSB) staining to confirm clot composition. The in-vitro model comprised a peristaltic pump, aortic arch and circle of Willis. Flow rates and pressure were controlled to replicate in-vivo conditions. Clot analogues of each phenotype were inserted into the ICA and lodged under pulsatile flow. Clot volume was optimized to mimic the clinical scenario; 10 mm clots reliably lead to a Distal M1+MCA Bifurcation Occlusion and 20 mm clots reliably lead to an ICA-T + Proximal M1 occlusion covering both the Posterior Communicating Artery and Anterior Cerebral Artery. Five replicates of each test were performed. Endpoints were FPE and Second Pass Reperfusion Success (>90% Retrieved). Results Histological composition was confirmed as RBC-Rich (RBCs:92.9%, WBCs:0.1%, Fibrin/Platelets:7.0%), Mixed (RBCs:79.7%, WBCs:0.3%, Fibrin/Platelets:20.0%) and Fibrin/Platelet-Rich (RBCs:51.8%, WBCs:0.3%, Fibrin/Platelets:47.9%). The 8Fr (Millipede 088) catheter performed better for each clot phenotype and in both occlusion locations (ICA-T & M1) compared to the 6Fr (0.068’’ & 0.070’’ ID) devices. In 10 mm M1+Bifurcation occlusions the 8Fr catheter achieved 100% FPE compared to an average of 40% in 6Fr devices (p>0.001*). In longer 20 mm ICA-T+Proximal M1 occlusions the Millipede 088 achieved 100% removal success within two passes in each clot phenotype compared to an average of 27% in the 6Fr devices (p>0.001*). Conclusions A novel 8Fr aspiration catheter demonstrates superiority over 6Fr aspiration catheters for each clot phenotype at the most common sites of occlusion in an in-vitro model. Disclosures S. Fitzgerald: 1; C; Perfuze Ltd. D. Ryan: None. L. Mullins: 4; C; Perfuze Ltd. 5; C; Perfuze Ltd. J. Thornton: 2; C; Perfuze Ltd. 4; C; Perfuze Ltd. R. Nogueira: 2; C; Perfuze Ltd. 4; C; Perfuze Ltd.

Background and purpose The goal of the analysis of revascularisation in ischaemic stroke with EmboTrap study (ARISE I) was to demonstrate the effectiveness of EmboTrap. Methods ARISE I was an open label, single arm, multicentre, prospective study for the treatment of acute stroke due to large vessel occlusion. The primary outcome was revascularisation of the target vessel as measured by the modified thrombolysis in cerebrovascular infarction (mTICI) score of at least 2b following thrombectomy with EmboTrap. For comparison of the ARISE I results a meta-analysis of eight randomised controlled trials was performed. Results ARISE I enrolled 40 patients. Their baseline characteristics that are predictors of stroke outcome and procedure timings in ARISE I were similar to those reported in recent randomised controlled trials. The primary outcome, good revascularisation rates (mTICI 2b/3 scores) after three or fewer passes with EmboTrap were 75% (95% confidence interval (CI) 62–88%), which is the same as 74% found in randomised controlled trials (difference of 0.8%, P = 0.95). After additional EmboTrap passes or the use of another device mTICI 2b/3 scores rose to 85% (95% CI 74–96%), which was also similar to the randomised controlled trials (difference 11%, P = 0.38). The high revascularisation rates in ARISE I converted into 64% good clinical outcomes (modified Rankin scale ≤2) compared to 50% in randomised controlled trials (difference 14%; 95% CI –13.7–41.7%; P = 0.32). Conclusions ARISE I demonstrates that thrombectomy using the EmboTrap stent retriever yields similar results to devices that were used in recent randomised controlled trials for the treatment of stroke due to large vessel occlusions. ClinicalTrials.gov identifier NCT02190552

In a sample of European banks, we find that credit default swaps (CDS) are used for regulatory arbitrage to lower capital requirements and facilitate greater risk taking. Moreover, CDS-using banks generate higher returns on capital from the lower risk weighted assets they hold relative to banks that do not use CDS.

We test for a link between CEO tenure and misconduct by US banks. We find that banks are more likely to commit misconduct when CEOs have a relatively long tenure and banks have relatively poor balance sheets. Large and independent corporate boards can mitigate but not prevent misconduct.

Introduction In ischaemic stroke care, fast reperfusion is essential for disability free survival. It is unknown if bypassing thrombolysis centres in favour of endovascular thrombectomy (mothership) outweighs transport to the nearest thrombolysis centre for alteplase and then transfer for endovascular thrombectomy (drip-and-ship). We use conditional probability modelling to determine the impact of treatment times on transport decision-making for acute ischaemic stroke. Materials and methods Probability of good outcome was modelled using a previously published framework, data from the Irish National Stroke Register, and an endovascular thrombectomy registry at a tertiary referral centre in Ireland. Ireland was divided into 139 regions, transport times between each region and hospital were estimated using Google’s Distance Matrix Application Program Interface. Results were mapped using ArcGIS 10.3. Results Using current treatment times, drip-and-ship rarely predicts best outcomes. However, if door to needle times are reduced to 30 min, drip-and-ship becomes more favourable; even more so if turnaround time (time from thrombolysis to departure for the endovascular thrombectomy centre) is also reduced. Reducing door to groin puncture times predicts better outcomes with the mothership model. Discussion This is the first case study modelling pre-hospital transport for ischaemic stroke utilising real treatment times in a defined geographic area. A moderate improvement in treatment times results in significant predicted changes to the optimisation of a national acute stroke patient transport strategy. Conclusions Modelling patient transport for system-level planning is sensitive to treatment times at both thrombolysis and thrombectomy centres and has important implications for the future planning of thrombectomy services.

Objective Selection of patients with acute ischemic stroke for endovascular thrombectomy (EVT) is complex and time-critical. Benefits of EVT are well established for patients with small core infarcts. The aim of this study was to compare clinical outcomes of EVT in patients with larger established infarcts (Alberta Stroke Programme Early CT Score [ASPECTS] ≤6) with patients with smaller infarcts (ASPECTS 7–10). Methods The study included 355 patients with acute ischemic stroke due to large vessel occlusion who underwent EVT. ASPECTS was assigned to baseline noncontrast computed tomography, and collateral perfusion scores were assigned to multiphase computed tomography angiography. Baseline stroke severity, collateral grading, and clinical outcome data (complication rate, symptomatic intracranial hemorrhage and 90-day modified Rankin Scale score) were compared between patients with borderline (≤6) and high (7–10) ASPECTS. Results There were 34 (10%) patients with borderline ASPECTS. There was no difference in rate of good clinical outcome (37% vs. 46%, P = 0.852), symptomatic intracerebral hemorrhage (9% vs. 9%, P = 0.984), or mortality (20% vs. 22%, P = 0.818) between patients with borderline ASPECTS and high ASPECTS at 90 days. Moreover, there was no significant difference in collateral perfusion grade. Conclusions This study identifies similar clinical benefit of EVT in patients with acute large vessel occlusion stroke with borderline ASPECTS and high ASPECTS.

We test for a link between CEO power and risk taking in US banks. Banks are more likely to take risks if they have powerful CEOs and relatively poor balance sheets. There is little evidence that executive board size and independence have a dampening effect on the channels through which powerful CEOs influence risk-taking and some evidence that institutional investors reinforce the risk-taking preferences of powerful CEOs.

In a large sample of sovereign debt issues, we show that a personal connection between senior executives in credit rating agencies and leading politicians in the sovereign results in an improved rating. A test on bond yields suggest that the personal connection reflects a favorable treatment of the issuer.

We use heterogeneous panel cointegration techniques to examine the long-run effect of financial development on income inequality in a panel of 119 countries from 1980 to 2015. We include real GDP per capita in the cointegration relation and explicitly deal with cross-sectional dependence in the data that arises due to unobserved common factors. On average, financial development reduces income inequality in the long-run, with the result robust to different measures of finance and across country income groups.

Background: No current medication counteracts the excessive mucus secretion or reverses the airway metaplasia of Chronic Bronchitis (CB) in COPD. Metered Cryospray (RejuvenAir® System) is a novel procedure delivering liquid N2 to the bronchial airways to target mucus overproduction, ablate abnormal epithelium, reduce chronic airway inflammation and promote regeneration of a healthy mucosal lining. Methods: This is a prospective, multicenter single-arm study of CB patients with an FEV1 of 30-80% predicted. Primary outcomes were safety and feasibility; secondary outcomes, SGRQ and 6MWT, were measured. Results: We included 35 subjects with Gold Grade II (31.4%) and III (68.6%) COPD (mean age 67.2+7.0 years, FEV1% 50.2±14.5, 54% male). Full treatment was accomplished of intended lobes with median times of 34 (right lower), 30 (left lower) and 41 minutes (upper lobes + trachea) during 3 separate outpatient visits. Approximately 1800 doses of MCS were delivered without inducing pneumothorax or unanticipated device-related serious adverse events (SAEs). Efficacy data showed clinically meaningful improvements of SGRQ-symptom score of -9.5±22.0 (95% CI; -17.7 to -1.3; p=0.025), SGRQ-impact score of -10.2±19.4 (95% CI: -17.5 to -3.0; p=0.007) and SGRQ-total score of -7.9±16.8 (95% CI: -14.2 to -1.6; p=0.008); most pronounced when baseline SGRQ-total ≥50 points (n=19). 6MWT significantly improved by 28 meters (95% CI: 3.0 to 62.0; Wilcoxon signed rank, p=0.034; n=25). Conclusions: These data indicate MCS treatment is safe, feasible and associated with clinically significant improvements in health-related quality of life in COPD patients with CB over 9 months.

BACKGROUND AND PURPOSE: Direct aspiration is a recognized technique for revascularization in large-vessel ischemic strokes. There is ongoing debate regarding its efficacy compared with stent retrievers. Every delay in achieving revascularization and a decrease in reperfusion rates reduces the likelihood of patients achieving functional independence. We propose a standardized setup technique for aspiration-first for all anterior circulation thrombectomy procedures for increasing speed and recanalization rates. MATERIALS AND METHODS: We analyzed 127 consecutive patients treated by a standardized approach to thrombectomy with an intention to perform aspiration-first compared with 127 consecutive patients treated with a stent retriever–first approach. Key time metrics evaluated included groin to first angiogram, first angiogram to reperfusion, groin to first reperfusion, and length of the procedure. The degree of successful recanalization (TICI 2b–3) and the number of passes were compared between the 2 groups. RESULTS: In 127 patients who underwent the standardized technique, the median time from groin puncture to first reperfusion was 18 minutes compared with 26 minutes (P < .001). The duration of the procedure was shorter compared with the stent retriever group (26 minutes in the aspiration first group versus 47 minutes, P < .001) and required fewer passes (mean, 2.4 versus 3.1; P < .05). A higher proportion of patients had a TICI score of 2b–3 in the aspiration-first group compared with stent retriever group (96.1% versus 85.8%, P < .005). CONCLUSIONS: Our study highlights the increasing speed and recanalization rates achieved with fewer passes in a standardized approach to thrombectomy with an intention to attempt aspiration-first. Any attempt to reduce revascularization time and increase successful recanalization should be used.

Since 2012, seven central banks have sought additional monetary policy accommodation through the adoption of negative policy interest rates (NPIR). The policy resulted in a significant reduction in exchange rate volatility and weaker exchange rates in NPIR--adopter countries relative countries that did not adopt the policy.

BackgroundRapid access to thrombectomy for patients with large vessel occlusion (LVO) acute ischemic stroke (AIS) is critical for improving outcome. A major challenge for the ‘drip and ship’ model is reducing the door-in-door-out time (DIDO). We propose a new protocol with the aim of reducing DIDO, without adversely affecting emergency service usage time.MethodsConsecutive patients with suspected LVO AIS admitted to a Primary Stroke Center (PSC) from October 2018 to January 2021 were included. On arrival, the ambulance crew remained with the patient. Following immediate clinical and radiological evaluation, patients were transferred to the Comprehensive Stroke Center (CSC) by the same waiting crew. Key time metrics were collected and compared with historical data prior to the new protocol.Results27 patients had an LVO amenable for mechanical thrombectomy during the time period. There was a significant reduction in the DIDO times compared with the historical group (median 45 min vs 96 min; pConclusionOur data show a significant reduction in the DIDO for patients transferred for thrombectomy, with no adverse effects on ambulance usage time.

Alcohol is one of the most commonly abused substances worldwide. It results in a wide range of diseases and disorders affecting many organ systems. Alcohol-related nutritional deficiencies and electrolyte disturbance leave chronic abusers at risk of a range of demyelinating conditions to which the radiologist and clinician should always be alert. These include Wernicke's encephalopathy, Korsakoff's syndrome, Marchiafava-Bignami disease and osmotic demyelination. Cerebral volume loss is also a commonly encountered neuroimaging phenomenon in chronic alcohol abusers. Neuroimaging with CT and MR, with a focus on FLAIR and diffusion-weighted MR sequences, play an important role in the diagnosis and often monitoring of these conditions. We present an educational review of these entities in terms of their clinical features, neuropathology and imaging features along with a case example of each condition.

Background— The Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial used innovative imaging and aggressive target time metrics to demonstrate the benefit of endovascular treatment in patients with acute ischemic stroke. We analyze the impact of time on clinical outcome and the effect of patient, hospital, and health system characteristics on workflow within the trial. Methods and Results— Relationship between outcome (modified Rankin Scale) and interval times was modeled by using logistic regression. Association between time intervals (stroke onset to arrival in endovascular-capable hospital, to qualifying computed tomography, to groin puncture, and to reperfusion) and patient, hospital, and health system characteristics were modeled by using negative binomial regression. Every 30-minute increase in computed tomography-to-reperfusion time reduced the probability of achieving a functionally independent outcome (90-day modified Rankin Scale 0–2) by 8.3% ( P =0.006). Symptom onset-to-imaging time was not associated with outcome ( P >0.05). Onset-to-endovascular hospital arrival time was 42% (34 minutes) longer among patients receiving intravenous alteplase at the referring hospital (drip and ship) versus direct transfer (mothership). Computed tomography-to-groin puncture time was 15% (8 minutes) shorter among patients presenting during work hours versus off hours, 41% (24 minutes) shorter in drip-ship patients versus mothership, and 43% (22 minutes) longer when general anesthesia was administered. The use of a balloon guide catheter during endovascular procedures shortened puncture-to-reperfusion time by 21% (8 minutes). Conclusions— Imaging-to-reperfusion time is a significant predictor of outcome in the ESCAPE trial. Inefficiencies in triaging, off-hour presentation, intravenous alteplase administration, use of general anesthesia, and endovascular techniques offer major opportunities for improvement in workflow. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01778335.

We show that price-cost margins for European banks are countercyclical after controlling for monetary policy, interest rate risk, and several banking industry and bank-specific factors. Our results support the existence of a “financial accelerator” at work in European economies.

We examine the link between bank capital and earning assets in five European countries during 1989–2012 using panel cointegration techniques. We find that higher bank capital is associated with a higher volume of earning assets, including bank loans. However, we also find some evidence that bank capitalization would impact negatively on the growth of bank lending at capital-to-asset ratios above 15%, which is below the ratio mandated for some UK-headquartered banks in the UK's 2013 Bank Reform Act.

Objectives There is a paucity of knowledge in the literature relating to the extent of clot burden and stroke etiology. In this study, we measured the Extracted Clot Area (ECA) retrieved during endovascular treatment (EVT) and investigated relationships with suspected etiology, administration of intravenous thrombolysis and recanalization. Materials and Methods As part of the multi-institutional RESTORE registry, the ECA retrieved during mechanical thrombectomy was quantified using ImageJ. The effect of stroke etiology (Large-artery atherosclerosis (LAA), Cardioembolism, Cryptogenic and other) and recombinant tissue plasminogen activator (rtPA) on ECA and recanalization outcome (mTICI) was assessed. Successful recanalization was described as mTICI 2c-3. Results A total of 550 patients who underwent EVT with any clot retrieved were included in the study. The ECA was significantly larger in the LAA group compared to all other etiologies. The average ECA size of each etiology was; LAA=109 mm2, Cardioembolic=52 mm2, Cryptogenic=47 mm2 and Other=52 mm2 (p=0.014*). LAA patients also had a significantly poorer rate of successful recanalization (mTICI 2c-3) compared to all other etiologies (p=0.003*). The administration of tPA was associated with a smaller ECA in both LAA (p=0.007*) and cardioembolic (p=0.035*) groups. Conclusion The ECA of LAA clots was double the size of all other etiologies and this is associated with a lower rate of successful recanalization in LAA stroke subtype. rtPA administration prior to thrombectomy was associated with reduced ECA in LAA and CE clots. This work was supported by the European Regional Development Fund and Science Foundation Ireland grant number (13/RC/2073). R01 funding to the Brinjikji lab is also acknowledged (1R01NS105853). peer-reviewed

We examine whether the effect of bank capital on credit growth differs depending upon the level of liquidity in a panel of up to 521 banks from 21 European countries. We find that the effect of an increase in bank capital is positively associated with the level of bank liquidity, suggesting that capital exerts a significantly positive effect on European banks’ credit growth after they retain sufficient liquid funds.

Rationale: Targeted lung denervation (TLD) is a bronchoscopic radiofrequency ablation therapy for chronic obstructive pulmonary disease (COPD), which durably disrupts parasympathetic pulmonary nerves to decrease airway resistance and mucus hypersecretion.Objectives: To determine the safety and impact of TLD on respiratory adverse events.Methods: We conducted a multicenter, randomized, sham bronchoscopy-controlled, double-blind trial in patients with symptomatic (modified Medical Research Council dyspnea scale score, ≥2; or COPD Assessment Test score, ≥10) COPD (FEV1, 30-60% predicted). The primary endpoint was the rate of respiratory adverse events between 3 and 6.5 months after randomization (defined as COPD exacerbation, tachypnea, wheezing, worsening bronchitis, worsening dyspnea, influenza, pneumonia, other respiratory infections, respiratory failure, or airway effects requiring therapeutic intervention). Blinding was maintained through 12.5 months.Measurements and Main Results: Eighty-two patients (50% female; mean ± SD: age, 63.7 ± 6.8 yr; FEV1, 41.6 ± 7.3% predicted; modified Medical Research Council dyspnea scale score, 2.2 ± 0.7; COPD Assessment Test score, 18.4 ± 6.1) were randomized 1:1. During the predefined 3- to 6.5-month window, patients in the TLD group experienced significantly fewer respiratory adverse events than those in the sham group (32% vs. 71%, P = 0.008; odds ratio, 0.19; 95% confidence interval, 0.0750-0.4923, P = 0.0006). Between 0 and 12.5 months, these findings were not different (83% vs. 90%; P = 0.52). The risk of COPD exacerbation requiring hospitalization in the 0- to 12.5-month window was significantly lower in the TLD group than in the sham group (hazard ratio, 0.35; 95% confidence interval, 0.13-0.99; P = 0.039). There was no statistical difference in the time to first moderate or severe COPD exacerbation, patient-reported symptoms, or other physiologic measures over the 12.5 months of follow-up.Conclusions: Patients with symptomatic COPD treated with TLD combined with optimal pharmacotherapy had fewer study-defined respiratory adverse events, including hospitalizations for COPD exacerbation.Clinical trial registered with www.clinicaltrials.gov (NCT02058459).

Background and purposeHealthcare systems are challenged to provide access to thrombectomy in acute stroke patients. Either the “drip and ship” or “mothership” models result in increased numbers of patients in the endovascular stroke centre (ESC). We describe our approach for a “drip, ship, retrieve and leave” model repatriating patients immediately or within 24 hours of thrombectomy.MethodsWe included consecutive patients who underwent thrombectomy from January 2016 to June 2018. Patients from local region primary stroke centres (PSC) are immediately repatriated and those from remote region PSCs are admitted for 24 hours before repatriation. Key parameters recorded included clinical, radiological and timeline data as well as 90-day modified Rankin Scale (mRS). Patients who stayed beyond the intended time period in the ESC were analysed.ResultsFrom January 2016 to June 2018, 435 patients were transferred, with 352 patients in the local region group and 83 in the remote region group. The median NIHSS was 16 with a median ASPECTS of 9. Good functional outcome was seen in 47% of patients with a mortality rate of 19%. The local region group that were repatriated at the intended time period had a 90-day mRS 0–2 of 47% compared with 20% of those admitted to the ESC (P=0.006). Mortality rates were 20% and 27% respectively (P=0.377). The remote region group, repatriated at 24 hours' post-emergency endovascular thrombectomy had 90-day mRS 0–2 of 65% compared with 41% in the group admitted (P=0.042). Mortality rates were 4% and 22% respectively (P=0.007).ConclusionThis model enables the treatment of large numbers of patients with large vessel occlusion acute ischaemic stroke with thrombectomy within a national stroke service and system of care which would not otherwise be facilitated.