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Implantable vagus nerve stimulation, paired with high-dose occupational therapy, has been shown to be effective in improving upper limb function among patients with stroke and received regulatory approval from the US Food and Drug Administration and the Centers for Medicare & Medicaid Services. Combining nonsurgical and surgical approaches of vagus nerve stimulation in recent meta-analyses has resulted in misleading reports on the efficacy of each type of stimulation among patients with stroke. This article aims to clarify the confusion surrounding implantable vagus nerve stimulation as a poststroke treatment option, highlighting the importance of distinguishing between transcutaneous auricular vagus nerve stimulation and implantable vagus nerve stimulation. Recent meta-analyses on vagus nerve stimulation have inappropriately combined studies of fundamentally different interventions, outcome measures, and participant selection, which do not conform to methodological best practices and, hence, cannot be used to deduce the relative efficacy of the different types of vagus nerve stimulation for stroke rehabilitation. Health care providers, patients, and insurers should rely on appropriately designed research to guide well-informed decisions.

Assuntos

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BACKGROUND: Machine learning algorithms depend on accurate and representative datasets for training in order to become valuable clinical tools that are widely generalizable to a varied population. We aim to conduct a review of machine learning uses in stroke literature to assess the geographic distribution of datasets and patient cohorts used to train these models and compare them to stroke distribution to evaluate for disparities. AIMS: 582 studies were identified on initial searching of the PubMed database. Of these studies, 106 full texts were assessed after title and abstract screening which resulted in 489 papers excluded. Of these 106 studies, 79 were excluded due to using cohorts from outside the United States or being review articles or editorials. 27 studies were thus included in this analysis. SUMMARY OF REVIEW: Of the 27 studies included, 7 (25.9%) used patient data from California, 6 (22.2%) were multicenter, 3 (11.1%) were in Massachusetts, 2 (7.4%) each in Illinois, Missouri, and New York, and 1 (3.7%) each from South Carolina, Washington, West Virginia, and Wisconsin. 1 (3.7%) study used data from Utah and Texas. These were qualitatively compared to a CDC study showing the highest distribution of stroke in Mississippi (4.3%) followed by Oklahoma (3.4%), Washington D.C. (3.4%), Louisiana (3.3%), and Alabama (3.2%) while the prevalence in California was 2.6%. CONCLUSIONS: It is clear that a strong disconnect exists between the datasets and patient cohorts used in training machine learning algorithms in clinical research and the stroke distribution in which clinical tools using these algorithms will be implemented. In order to ensure a lack of bias and increase generalizability and accuracy in future machine learning studies, datasets using a varied patient population that reflects the unequal distribution of stroke risk factors would greatly benefit the usability of these tools and ensure accuracy on a nationwide scale.

Assuntos

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Background and Purpose- Radial artery catheterization is an alternate route of access that has started to gain more widespread use for neuroendovascular procedures, and there have been few studies that describe its safety and efficacy. We present our institution's experience in performing neuroendovascular interventions via a transradial approach, with excellent clinical outcomes and patient satisfaction measures. Methods- We conducted a retrospective analysis and identified 223 patients who underwent 233 consecutive neuroendovascular interventions via radial artery access at our institution. The incidence of perioperative and postprocedural complications was investigated. We identified a subset of 98 patients who have undergone both transradial and transfemoral cerebral angiograms and compared clinical outcomes and patient satisfaction measures between the 2 groups. Results- The overall incidence of complications was low across all procedures performed via transradial access. Peri-procedurally, only 2 patients had symptomatic radial artery spasm, and there were no instances of iatrogenic complications (vessel dissection, stroke, and hemorrhage). In 10 cases (4.3%), the intended procedure could not be completed via a transradial approach, and, thus, femoral artery access had to be pursued instead. Ten patients complained of minor postprocedural complications, although none required therapeutic intervention. The mean procedure time was shorter for diagnostic angiograms performed via transradial versus transfemoral access (18.8±15.8 versus 39.5±31.1 minutes; P=0.025). Patients overall reported shorter recovery times with transradial access, and the majority of patients (94%) would elect to have subsequent procedures performed via this route. Conclusions- Radial artery catheterization is a safe and durable alternative to perform a wide range of neuroendovascular procedures, with a low rate of complications. On the whole, patients prefer transradial compared with transfemoral access.

Assuntos

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BACKGROUND: Small intracranial aneurysms pose significant challenges to endovascular therapy. Surgical clipping is considered by many to be the preferred treatment for these lesions. We present the results of the first study comparing the 2 treatment modalities in small ruptured aneurysms. METHODS AND RESULTS: Between 2004 and 2011, 151 patients with small ruptured aneurysms (≤3 mm) were treated in our institution: 91 (60.3%) with endovascular therapy and 60 (39.7%) with surgical clipping. The surgical and endovascular groups were generally comparable with regard to baseline demographics, with the exception of larger mean aneurysm size in the endovascular group versus the surgical group (2.8 versus 2.5 mm, respectively; P<0.001) and a higher proportion of posterior circulation aneurysms in the endovascular group. Endovascular treatment failed in 9.9% of patients. Procedure-related complications occurred in 23.3% of surgical patients versus 9.8% of endovascular patients (P=0.01). Only 3.7% of patients undergoing endovascular therapy experienced an intraprocedural aneurysm rupture. There were no procedural deaths or rehemorrhages in either group. The rates of aneurysm recanalization and retreatment after endovascular therapy were 18.2% and 12.7%, respectively. Favorable outcomes (moderate, mild, or no disability) were not statistically different between the endovascular (67.1%) and surgical (56.7%) groups (P=0.3). CONCLUSIONS: Surgical clipping was associated with a higher rate of periprocedural complications, but overall disability outcomes were similar. Endovascular therapy, if technically feasible, might be a preferred option in this setting. Inclusion of patients with small aneurysms in randomized controlled trials seems feasible and will be needed to provide definitive information on the best therapeutic approach. (J Am Heart Assoc. 2012;1:e002865 doi: 10.1161/JAHA.112.002865.).