Per-region interobserver agreement of Alberta Stroke Program Early CT Scores (ASPECTS).

BACKGROUND AND PURPOSE: The Alberta Stroke Program Early CT Score (ASPECTS) is a commonly used scoring system to select patients with stroke for endovascular treatment (EVT). However, the inter- and intra-reader variability is high. OBJECTIVE: To determine whether the inter- and intra-reader variability is different for various regions of the ASPECTS scoring system by evaluating the interobserver variability of ASPECTS between different readers in a per-region analysis. MATERIALS AND METHODS: All patients with acute ischemic stroke who proceeded to EVT in our institutions over a 4-year period were retrospectively identified from a prospectively maintained database. Images were reviewed by two experienced neuroradiologists, who recalculated the ASPECTS independently. We examined each region of the ASPECTS system to evaluate agreement between the raters in each area. RESULTS: 375 patients were included. The median total ASPECTS was 9 (IQR 8-9). The most common region showing ischemic change was the insula, with the M6 region being least commonly affected. Overall interobserver agreement for ASPECTS using Cohen's κ was 0.56 (95% CI 0.51 to 0.61). The region with the highest agreement was the insula (κ=0.56; 0.48 to 0.64). The region with the lowest agreement was M3 (κ=0.34; 0.12 to 0.56). Agreement was relatively good when ASPECTS were dichotomized into 0-5 versus 6-10 (κ=0.66; 0.49 to 0.84). CONCLUSIONS: Substantial interobserver variability is found when calculating ASPECTS. This variability is region dependent, and practitioners should take this into account when using ASPECTS for treatment decisions in patients with acute stroke.

Flow-diverter Stents for Internal Carotid Artery Reconstruction Following Spontaneous Dissection: A Technical Report.

BACKGROUND AND PURPOSE: Extracranial internal carotid artery (ICA) dissection is an important cause of ischemic stroke in younger adults. The optimal medical and surgical strategies for managing these lesions have not been well established. We report a case series of extracranial ICA reconstruction using overlapping flow-diverter stents as a rescue therapy for the treatment of symptomatic ICA dissection in patients presenting with recurrent ischemic stroke and/or severe hemispheric hypoperfusion who failed medical management. MATERIALS AND METHODS: Consecutive patients undergoing endovascular reconstruction of either occluded or severely narrowed ICA due to dissection and presenting with symptoms of recurrent cerebral ischemia or cerebral hypoperfusion were included. Data were collected on demographic characteristics, antiplatelet management, clinical presentation, imaging findings, treatment characteristics, complications and stroke recurrence rates. RESULTS: A total of 7 patients were included. The mean age was 47 years, 4 patients were male and 3 were female. All patients were symptomatic presenting with ipsilateral recurrent ischemia with or without cerebral hemodynamic compromise and necessitated reconstructive treatment. Patients were placed on dual antiplatelet therapy with aspirin and either ticagrelor or clopidogrel prior to the procedure. In cases where patients were not preloaded with dual antiplatelets intravenous abciximab was used as a bridging therapy. Post-stenting angioplasty was performed if deemed necessary. There were no symptomatic ischemic or hemorrhagic complications. No patients had recurrent ischemic events. CONCLUSION: Reconstruction of the ICA as a rescue strategy for extracranial carotid dissection using flow-diverter stents is feasible and was performed without adverse events in this small series.

#Fake news: a systematic review of mechanical thrombectomy results among neurointerventional stroke surgeons on Twitter.

OBJECTIVE: Twitter is a popular social media platform among physicians. Neurointerventionalists frequently document their lifesaving mechanical thrombectomy cases on Twitter with very favorable results. We fear that there may be some social media publication bias to tweeted mechanical thrombectomy cases with neurointerventionalists being more likely to tweet cases with favorable outcomes. We used these publicly documented cases to analyze post-intervention Twitter-reported outcomes and compared these outcomes with the data provided in the gold standard literature. METHODS: Two reviewers performed a search of Twitter for tweeted cases of acute ischemic strokes treated with mechanical thrombectomy. Data were abstracted from each tweet regarding baseline characteristics and outcomes. Twitter-reported outcomes were compared with the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke (HERMES) trial individual patient meta-analysis. RESULTS: When comparing the tweeted results to HERMES, tweeted cases had a higher post-intervention rate of modified Thrombolysis In Cerebral Infarction (mTICI) scale score of 2c/3 (94% vs 71%, respectively; p<0.0001) and rate of National Institutes of Health Stroke Scale (NIHSS) score ≤2 (81% vs 21%, respectively; p<0.0001). There were no reported complications; thus, tweeted cases also had significantly lower rates of complications, including symptomatic intracerebral hemorrhage (0% vs 4.4%, respectively; p<0.0001), type 2 parenchymal hemorrhage (0% vs 5.1%, respectively; p<0.0001), and mortality (0% vs 15.3%, respectively; p<0.0001). CONCLUSIONS: There is a significant difference between social media and reality even within the 'MedTwitter' sphere, which is likely due to a strong publication bias in Twitter-reported cases. Content on 'MedTwitter', as with most social media, should be accepted cautiously.

Venous sinus stenting for idiopathic intracranial hypertension: a systematic review and meta-analysis.

BACKGROUND: Stenting of the intracranial venous sinuses is used as a treatment in certain cases of idiopathic intracranial hypertension (IIH). Interest in, and experience of, this technique is growing, particularly in recent years. We sought to provide an updated systematic review and meta-analysis of the use of venous stenting in these patients, examining clinical outcomes. METHODS: A literature search of venous stenting in IIH patients was performed. Using random-effects meta-analysis, we evaluated the following outcomes: clinical resolution of papilledema; headaches and pulsatile tinnitus; recurrence of symptoms after stenting; and complications. RESULTS: Twenty articles from 18 different centers were included. In a total of 474 patients. 418 were female (88%). The mean age of the patients was 35, while the mean body mass index (BMI) was 35 kg/m2. Median follow-up was 18 months. The overall rate of improvement in papilloedema was 93.7% (95% CI 90.5% to 96.9%), while the overall rate of improvement or resolution of headache was 79.6% (95% CI 73.3% to 85.9%). Pulsatile tinnitus resolved in 90.3% (95% CI 83.8% to 96.70%), while the overall rate of recurrence of IIH symptoms after stenting was 9.8% (95% CI 6.7% to 13%). The rate of major complications was 1.9% (95% CI 0.07% to 3.1%). CONCLUSIONS: Venous sinus stenting in patients with IIH who are refractory to medical therapy appears to have an excellent safety profile and is associated with significant improvements in headaches, pulsatile tinnitus, and papilledema.

Presentation and outcomes of patients with thoracic and lumbosacral spinal epidural arteriovenous fistulas: a systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Thoracolumbar and sacral spinal epidural arteriovenous fistulas (SEDAVFs) are an increasingly recognized form of spinal vascular malformation. The purpose of this study was to perform a systematic review of the demographics, clinical presentation and treatment results of thoracolumbar SEDAVFs. MATERIALS AND METHODS: Pubmed, Scopus and Web of Science databases were searched from January 2000 to January 2018 for articles on treatment of SEDAVFs. Pooled data of individual patients were analyzed for demographic and clinical features of SEDAVFs as well as treatment outcomes. RESULTS: There were 125 patients from 11 studies included. Mean age was 63.5 years. There was a male sex predilection (69.6%). Sensory symptoms including pain or numbness were the most frequently presenting symptoms. Fistula location was the lumbosacral spine in 79.2% and the thoracic spine in 20.8%. Involvement of intradural venous drainage was more common than extradural venous drainage only (89.6% vs 10.4%). Of the 123 treated patients, endovascular therapy was performed in 67.5% of patients, microsurgery in 23.6%, and combined treatment in 8.9%. The overall complete obliteration rate was 83.5% and did not differ between groups. Clinical symptoms improved in 70.7% of patients, were stable in 25%, and worsened in 1.7% with no difference between treatment modalities. CONCLUSIONS: Thoracic and lumbosacral SEDAVFs often present with symptoms secondary to congestive myelopathy or compressive symptoms. Both endovascular and microsurgical treatments were associated with high obliteration rates and good clinical outcomes.

Vessel Wall Imaging of Intracranial Aneurysms: Systematic Review and Meta-analysis.

Vessel wall imaging (VWI) is emerging as a novel imaging tool for the management and risk stratification of patients with intracranial saccular aneurysms. Our objective was to compare the rates of wall enhancement in unstable (ruptured, growing, or symptomatic) and stable aneurysms and assess the ability of VWI with high-resolution magnetic resonance imaging to distinguish between these 2 entities. This study was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, and eligible studies were identified through a comprehensive literature review. A meta-analysis was conducted to examine the association between aneurysm wall enhancement and aneurysm instability with the use of a random effects model. The I2 statistic was used to assess for heterogeneity. Six studies comprising 505 saccular aneurysms were included. Aneurysms that showed vessel wall enhancement had statistically significant higher odds of being unstable (odds ratio [OR]: 20; 95% confidence interval [CI]: 6.4-62.1; I2: 63.1%). The sensitivity, specificity, positive predictive value, and negative predictive value of VWI in identifying unstable aneurysms were 95.0% (90.4-97.8), 62.7% (57.1-67.9), 55.8% (52.2-59.4), and 96.2% (92.8-98.0), respectively. There is a statistically significant association between vessel wall enhancement and aneurysm instability. Importantly, the lack of wall enhancement is a strong predictor of aneurysm stability. VWI could potentially provide new insights in the management of intracranial aneurysms.

Remote multifocal bleeding points producing a Sylvian subpial hematoma during endovascular coiling of an acutely ruptured cerebral aneurysm.

Subpial hematoma is a rare type of intracranial hemorrhage with a poor prognosis. A new mechanism to explain subpial Sylvian hematoma formation in acute post-aneurysmal subarachnoid hemorrhage (SAH) was observed during coiling of a posterior communicating artery aneurysm. Multiple small bleeding points from pial branches of the left middle cerebral artery, which were remote from the ruptured aneurysm, were observed on conventional angiography. This bleeding led to the formation of a large expanding subpial Sylvian hematoma. Similar observations have been recently demonstrated on 4D CT angiography (4D CTA). We present a case that adds evidence to the literature in support of a new mechanism of subpial hematoma formation in the setting of acute SAH. This may advocate the early use of 4D CTA and conveys a poor prognosis, which might influence treatment decisions.

Remote multifocal bleeding points producing a Sylvian subpial hematoma during endovascular coiling of an acutely ruptured cerebral aneurysm.

Subpial hematoma is a rare type of intracranial hemorrhage with a poor prognosis. A new mechanism to explain subpial Sylvian hematoma formation in acute post-aneurysmal subarachnoid hemorrhage (SAH) was observed during coiling of a posterior communicating artery aneurysm. Multiple small bleeding points from pial branches of the left middle cerebral artery, which were remote from the ruptured aneurysm, were observed on conventional angiography. This bleeding led to the formation of a large expanding subpial Sylvian hematoma. Similar observations have been recently demonstrated on 4D CT angiography (4D CTA). We present a case that adds evidence to the literature in support of a new mechanism of subpial hematoma formation in the setting of acute SAH. This may advocate the early use of 4D CTA and conveys a poor prognosis, which might influence treatment decisions.