Clinical presentation and treatment of 26 spinal epidural arteriovenous fistulas: a single-center experience.

BACKGROUND: Spinal epidural arteriovenous fistulas (SEDAVFs) are rarely diagnosed vascular malformations that can cause spinal cord compression and congestive myelopathy. METHODS: This is a single-center, retrospective case series of patients with SEDAVFs who underwent observation or treatment at UCLA medical center between 1993 and 2023. RESULTS: Between 1993 and 2023 a total of 26 patients at UCLA were found to have a SEDAVF. The median age at treatment was 59 years (range 4 months to 91 years). Compared with sacral, lumbar, and thoracic SEDAVFs, patients with cervical SEDAVF were younger (41 years vs 63 years, P=0.016) and more likely to be female (66.7% vs 14.3%, P=0.006). Possible triggers for development of SEDAVFs may be prior spinal surgery or trauma (n=4), turning the neck (n=1), lifting a heavy box (n=1), a prolonged period of bending over (n=1), and neurofibromatosis type 1 (n=1). Of the 22 patients treated endovascularly, 18 (82%) were angiographically cured on the first attempt without complications. One patient underwent surgical treatment alone and had a failed surgery on the first attempt, and developed a surgical site infection after the second successful attempt at treatment. Of the 16 patients with adequate clinical follow-up, 11 (69%) demonstrated early improved clinical outcome (eg, improved strength on examination, absent bruit). CONCLUSIONS: SEDAVFs are a rarely diagnosed disease that can be treated effectively and safely with endovascular embolization in most cases. Patients with sacral, lumbar, and thoracic SEDAVFs were older and more often male compared to patients with cervical SEDAVFs.

In vitro comparison of manual and robotic endovascular thrombectomy for acute ischemic stroke.

BACKGROUND: Robotic endovascular systems have the potential to reduce radiation exposure to physicians and expand timely neurointerventional access to patients in remote areas. The goal of the study was to determine the feasibility of robotic endovascular thrombectomy (EVT) in an in vitro model. METHODS: In vitro procedures were conducted manually and robotically using the Corpath GRX robotic system in a human vascular simulator with an elastic ovine clot in the M1 segment of the left middle cerebral artery. Due to the limited device compatibility of the CorPath GRX, a simple technique with a stent retriever and guiding catheter without a balloon was used in the study. Seven robotic EVT and manual EVT were carried out in each group. Metrics including procedural time, success rate, and radiation dose were compared between the two groups. RESULTS: In robotic EVT, the mean total preparation and procedural time was 892 s, which was significantly longer than manual operation at 357 (p = 0.0001). There was no significant difference in the success rate between the two approaches (robotic: 28.6% vs. manual 42.9%, p = 0.577). The mean radiation exposure to operating physicians was significantly lower during robotic operation compared to manual operation (0.02 µSv vs. 0.22 µSv, p < 0.0001). CONCLUSIONS: Robotic EVT was feasible in our human vascular simulator with significantly reduced radiation exposure to the operating physicians, despite an increased length of procedure when compared to manual procedures. Future technological advancement is warranted for reducing procedural length using endovascular robotic techniques.

Robotic Diagnostic Cerebral Angiography: A Multicenter Experience of 113 Patients.

BACKGROUND: Neurointerventional robotic systems have potential to reduce occupational radiation, improve procedural precision, and allow for future remote teleoperation. A limited number of single institution case reports and series have been published outlining the safety and feasibility of robot-assisted diagnostic cerebral angiography. METHODS: This is a multicenter, retrospective case series of patients undergoing diagnostic cerebral angiography at three separate institutions - University of California, Davis (UCD); University of California, Los Angeles (UCLA); and University of California, San Francisco (UCSF). The equipment used was the CorPath GRX Robotic System (Corindus, Waltham, MA). RESULTS: A total of 113 cases were analyzed who underwent robot-assisted diagnostic cerebral angiography from September 28, 2020 to October 27, 2022. There were no significant complications related to use of the robotic system including stroke, arterial dissection, bleeding, or pseudoaneurysm formation at the access site. Using the robotic system, 88 of 113 (77.9%) cases were completed successfully without unplanned manual conversion. The principal causes for unplanned manual conversion included challenging anatomy, technical difficulty with the bedside robotic cassette, and hubbing out of the robotic system due to limited working length. For robotic operation, average fluoroscopy time was 13.2 min (interquartile range (IQR), 9.3 to 16.8 min) and average cumulative air kerma was 975.8 mGY (IQR, 350.8 to 1073.5 mGy). CONCLUSIONS: Robotic cerebral angiography with the CorPath GRX Robotic System is safe and easily learned by novice users without much prior manual experience. However, there are technical limitations such as a short working length and an inability to support 0.035" wires which may limit its widespread adoption in clinical practice.

Modeling optimal patient transport in a stroke network capable of remote telerobotic endovascular therapy.

BACKGROUND: Telerobotic endovascular therapy (EVT) has the potential to decrease time to treatment and expand existing networks of care to more rural populations. It is currently unclear how its implementation would impact existing stroke networks. METHODS: Conditional probability models were generated to predict the probability of excellent outcome for patients with suspected large vessel occlusion (LVO). A baseline stroke network was created for California using existing intravenous thrombolysis (IVT) centers and comprehensive stroke centers (CSCs) capable of IVT and EVT. Optimal transport decisions and catchment areas were generated for the baseline model and three hypothetical scenarios through conversion of IVT centers at various distances from a CSC into centers capable of telerobotic EVT [i.e., hospitals ≥15 and <50 miles from a CSC were converted (Scenario 1), ≥50 and <100 miles (Scenario 2), and ≥100 miles (Scenario 3)]. Procedural times and success rates were varied systematically. RESULTS: Telerobotic EVT centers decreased median travel time for LVO patients in all three scenarios. The estimated number of robotically treated LVOs per year in Scenarios 1, 2, and 3 were 2,172, 740, and 212, respectively. Scenario 1 (15-50 miles) was the most sensitive to robotic time delay and success rate, but all three scenarios were more sensitive to decreases in procedural success rate compared to time delay. CONCLUSIONS: Telerobotic EVT has the potential to improve care for stroke patients outside of major urban centers. Compared to procedural time delays in robotic EVT, a decrease in procedural success rate would not be well tolerated.

Complete robotic intervention for acute epistaxis in a patient with COVID-19 pneumonia: technical considerations and device selection tips.

The use of robot-assisted technology is expanding in interventional laboratories with an increasing number of reports of effective treatment delivery in neurointerventional procedures. Here we report the feasibility of complete robot-assisted neurointervention including the guide catheter and microcatheter manipulations with subsequent embolization of the arterial source of hemorrhage in a patient hospitalized with severe COVID-19 complicated by acute epistaxis.

Cerebral Microbleeds, Cerebral Amyloid Angiopathy, and Their Relationships to Quantitative Markers of Neurodegeneration.

BACKGROUND AND OBJECTIVES: Age-related cognitive impairment is driven by the complex interplay of neurovascular and neurodegenerative disease. There is a strong relationship between cerebral microbleeds (CMBs), cerebral amyloid angiopathy (CAA), and the cognitive decline observed in conditions such as Alzheimer disease. However, in the early, preclinical phase of cognitive impairment, the extent to which CMBs and underlying CAA affect volumetric changes in the brain related to neurodegenerative disease remains unclear. METHODS: We performed cross-sectional analyses from 3 large cohorts: The Northern Manhattan Study (NOMAS), Alzheimer's Disease Neuroimaging Initiative (ADNI), and the Epidemiology of Dementia in Singapore study (EDIS). We conducted a confirmatory analysis of 82 autopsied cases from the Brain Arterial Remodeling Study (BARS). We implemented multivariate regression analyses to study the association between 2 related markers of cerebrovascular disease-MRI-based CMBs and autopsy-based CAA-as independent variables and volumetric markers of neurodegeneration as dependent variables. NOMAS included mostly dementia-free participants age 55 years or older from northern Manhattan. ADNI included participants living in the United States age 55-90 years with a range of cognitive status. EDIS included community-based participants living in Singapore age 60 years and older with a range of cognitive status. BARS included postmortem pathologic samples. RESULTS: We included 2,657 participants with available MRI data and 82 autopsy cases from BARS. In a meta-analysis of NOMAS, ADNI, and EDIS, superficial CMBs were associated with larger gray matter (ß = 4.49 ± 1.13, p = 0.04) and white matter (ß = 4.72 ± 2.1, p = 0.03) volumes. The association between superficial CMBs and larger white matter volume was more evident in participants with 1 CMB (ß = 5.17 ± 2.47, p = 0.04) than in those with ≥2 CMBs (ß = 1.97 ± 3.41, p = 0.56). In BARS, CAA was associated with increased cortical thickness (ß = 6.5 ± 2.3, p = 0.016) but not with increased brain weight (ß = 1.54 ± 1.29, p = 0.26). DISCUSSION: Superficial CMBs are associated with larger morphometric brain measures, specifically white matter volume. This association is strongest in brains with fewer CMBs, suggesting that the CMB/CAA contribution to neurodegeneration may not relate to tissue loss, at least in early stages of disease.

A technical guide to robotic catheter angiography with the Corindus CorPath GRX system.

Robotic catheter angiography is an emerging technology with the opportunity to increase procedural precision and decrease occupational hazards.1-5 In this video, we present our initial experiences with the CorPath GRX Robotic System (Corindus, a Seimens Healthineers Company, Waltham, Massachusetts, USA), including various technical considerations such as set-up, operation, and recommended tools (video 1). We demonstrate that the robotic system can be used to reformat catheters and select cervical arteries without the need for manual conversion. Lastly, we discuss the commonly encountered robot-specific operational challenges, along with strategies to overcome them. neurintsurg;14/12/1284/V1F1V1Video 1Video 1.

Impacts of ABO-incompatible platelet transfusions on platelet recovery and outcomes after intracerebral hemorrhage.

Acute platelet transfusion after intracerebral hemorrhage (ICH) given in efforts to reverse antiplatelet medication effects and prevent ongoing bleeding does not appear to improve outcome and may be associated with harm. Although the underlying mechanisms are unclear, the influence of ABO-incompatible platelet transfusions on ICH outcomes has not been investigated. We hypothesized that patients with ICH who receive ABO-incompatible platelet transfusions would have worse platelet recovery (using absolute count increment [ACI]) and neurological outcomes (mortality and poor modified Rankin Scale [mRS 4-6]) than those receiving ABO-compatible transfusions. In a single-center cohort of consecutively admitted patients with ICH, we identified 125 patients receiving acute platelet transfusions, of whom 47 (38%) received an ABO-incompatible transfusion. Using quantile regression, we identified an association of ABO-incompatible platelet transfusion with lower platelet recovery (ACI, 2 × 103cells per µL vs 15 × 103cells per µL; adjusted coefficient ß, -19; 95% confidence interval [CI], -35.55 to -4.44; P = .01). ABO-incompatible platelet transfusion was also associated with increased odds of mortality (adjusted odds ratio [OR], 2.59; 95% CI, 1.00-6.73; P = .05) and poor mRS (adjusted OR, 3.61; 95% CI, 0.97-13.42; P = .06); however, these estimates were imprecise. Together, these findings suggest the importance of ABO compatibility for platelet transfusions for ICH, but further investigation into the mechanism(s) underlying these observations is required.

Cortical response states for enhanced sensory discrimination.

Brain activity during wakefulness is characterized by rapid fluctuations in neuronal responses. Whether these fluctuations play any role in modulating the accuracy of behavioral responses is poorly understood. Here, we investigated whether and how trial changes in the population response impact sensory coding in monkey V1 and perceptual performance. Although the responses of individual neurons varied widely across trials, many cells tended to covary with the local population. When population activity was in a 'low' state, neurons had lower evoked responses and correlated variability, yet higher probability to predict perceptual accuracy. The impact of firing rate fluctuations on network and perceptual accuracy was strongest 200 ms before stimulus presentation, and it greatly diminished when the number of cells used to measure the state of the population was decreased. These findings indicate that enhanced perceptual discrimination occurs when population activity is in a 'silent' response mode in which neurons increase information extraction.

Sensory coding accuracy and perceptual performance are improved during the desynchronized cortical state.

Cortical activity changes continuously during the course of the day. At a global scale, population activity varies between the 'synchronized' state during sleep and 'desynchronized' state during waking. However, whether local fluctuations in population synchrony during wakefulness modulate the accuracy of sensory encoding and behavioral performance is poorly understood. Here, we show that populations of cells in monkey visual cortex exhibit rapid fluctuations in synchrony ranging from desynchronized responses, indicative of high alertness, to highly synchronized responses. These fluctuations are local and control the trial variability in population coding accuracy and behavioral performance in a discrimination task. When local population activity is desynchronized, the correlated variability between neurons is reduced, and network and behavioral performance are enhanced. These findings demonstrate that the structure of variability in local cortical populations is not noise but rather controls how sensory information is optimally integrated with ongoing processes to guide network coding and behavior.

Focal Changes to Human Electrocorticography With Drowsiness: A Novel Measure of Local Sleep.

Drowsiness may be defined as the progressive loss of cortical processing efficiency that occurs with time passing while awake. This loss of cortical processing efficiency is reflected in focal changes to the electroencephalogram, including islands of increased delta power concurrent with drop-offs in neuronal activity (i.e., focal cortical inactivity). The authors hypothesized that these focal changes are evidenced at individual electrodes by combination of increased instantaneous amplitude in delta band and decreased instantaneous frequency in theta-alpha band, permitting their categorization as "active" and "inactive." An analysis of records from six patients with refractory epilepsy undergoing video-electrocorticographic monitoring was conducted. Feature extraction and state classification on multiple recordings revealed focal changes consistent with the hypothesis, as well as progressively increased numbers of inactive electrodes with time awake. The implications of these findings on the study of sleep, and particularly local sleep, are discussed.

Spontaneous Fluctuations in Visual Cortical Responses Influence Population Coding Accuracy.

Information processing in the cerebral cortex depends not only on the nature of incoming stimuli, but also on the state of neuronal networks at the time of stimulation. That is, the same stimulus will be processed differently depending on the neuronal context in which it is received. A major factor that could influence neuronal context is the background, or ongoing neuronal activity before stimulation. In visual cortex, ongoing activity is known to play a critical role in the development of local circuits, yet whether it influences the coding of visual features in adult cortex is unclear. Here, we investigate whether and how the information encoded by individual neurons and populations in primary visual cortex (V1) depends on the ongoing activity before stimulus presentation. We report that when individual neurons are in a "low" prestimulus state, they have a higher capacity to discriminate stimulus features, such as orientation, despite their reduction in evoked responses. By measuring the distribution of prestimulus activity across a population of neurons, we found that network discrimination accuracy is improved in the low prestimulus state. Thus, the distribution of ongoing activity states across the network creates an "internal context" that dynamically filters incoming stimuli to modulate the accuracy of sensory coding. The modulation of stimulus coding by ongoing activity state is consistent with recurrent network models in which ongoing activity dynamically controls the balanced background excitation and inhibition to individual neurons.

A simple confined impingement jets mixer for flash nanoprecipitation.

Johnson and Prud'homme (2003. AICHE J 49:2264-2282) introduced the confined impingement jets (CIJ) mixer to prepare nanoparticles loaded with hydrophobic compounds (e.g., drugs, inks, fragrances, or pheromones) via flash nanoprecipitation (FNP). We have modified the original CIJ design to allow hand operation, eliminating the need for a syringe pump, and we added a second antisolvent dilution stage. Impingement mixing requires equal flow momentum from two opposing jets, one containing the drug in organic solvent and the other containing an antisolvent, typically water. The subsequent dilution step in the new design allows rapid quenching with high antisolvent concentration that enhances nanoparticle stability. This new CIJ with dilution (CIJ-D) mixer is a simple, cheap, and efficient device to produce nanoparticles. We have made 55 nm diameter ß-carotene nanoparticles using the CIJ-D mixer. They are stable and reproducible in terms of particle size and distribution. We have also compared the performance of our CIJ-D mixer with the vortex mixer, which can operate at unequal flow rates (Liu et al., 2008. Chem Eng Sci 63:2829-2842), to make ß-carotene-containing particles over a series of turbulent conditions. On the basis of dynamic light scattering measurements, the new CIJ-D mixer produces stable particles of a size similar to the vortex mixer. Our CIJ-D design requires less volume and provides an easily operated and inexpensive tool to produce nanoparticles via FNP and to evaluate new nanoparticle formulation.