International controlled study of revascularization and outcomes following COVID-positive mechanical thrombectomy.

BACKGROUND AND PURPOSE: Previous studies suggest that mechanisms and outcomes in patients with COVID-19-associated stroke differ from those in patients with non-COVID-19-associated strokes, but there is limited comparative evidence focusing on these populations. The aim of this study, therefore, was to determine if a significant association exists between COVID-19 status with revascularization and functional outcomes following thrombectomy for large vessel occlusion (LVO), after adjustment for potential confounding factors. METHODS: A cross-sectional, international multicenter retrospective study was conducted in consecutively admitted COVID-19 patients with concomitant acute LVO, compared to a control group without COVID-19. Data collected included age, gender, comorbidities, clinical characteristics, details of the involved vessels, procedural technique, and various outcomes. A multivariable-adjusted analysis was conducted. RESULTS: In this cohort of 697 patients with acute LVO, 302 had COVID-19 while 395 patients did not. There was a significant difference (p < 0.001) in the mean age (in years) and gender of patients, with younger patients and more males in the COVID-19 group. In terms of favorable revascularization (modified Thrombolysis in Cerebral Infarction [mTICI] grade 3), COVID-19 was associated with lower odds of complete revascularization (odds ratio 0.33, 95% confidence interval [CI] 0.23-0.48; p < 0.001), which persisted on multivariable modeling with adjustment for other predictors (adjusted odds ratio 0.30, 95% CI 0.12-0.77; p = 0.012). Moreover, endovascular complications, in-hospital mortality, and length of hospital stay were significantly higher among COVID-19 patients (p < 0.001). CONCLUSION: COVID-19 was an independent predictor of incomplete revascularization and poor functional outcome in patients with stroke due to LVO. Furthermore, COVID-19 patients with LVO were more often younger and had higher morbidity/mortality rates.

Management of tandem occlusions in patients who receive rtPA.

BACKGROUND: Tandem occlusions exist in 17-32% of large vessel occlusion (LVO) strokes. A significant concern is bleeding when carotid stenting is performed in tandem with thrombectomy due the administration of antiplatelet agents such as glycoprotein IIb/IIIa inhibitors (GP2b3aI) after receiving rtPA, but data are limited in this setting. METHODS: A mutlicenter, retrospective chart review was conducted at two comprehensive stroke centers to assess the safety and efficacy of using GP2b3aI to facilitate carotid stent placement simultaneously with endovascular thrombectomy in patients who have received rtPA. RESULTS: Overall, 32 patients were included in this study, with average age of 66.3 ± 10.4 years and predominantly male (87.5%). The cause of stroke was mostly large artery atherosclerosis (59.4%) and the thrombectomy target vessels were typically first- or second segment middle cerebral artery (37.5% and 31.3%). Time from symptom onset to rtPA bolus was 1.8 h [interquartile range (IQR) 1.5-2.7], rtPA bolus to first pass was 2 h [IQR 1.5-3.1], rtPA bolus to GP2b3aI bolus was 2 h [IQR 1.6-3.5], and rtPA bolus to aspirin and clopidogrel administration was 4.3 h [IQR 2.6-8.9] and 6.6 h [IQR 4.5-11.6] respectively. No patients had acute in-stent thrombosis or post-op bleeding from the access site. Two patients (6.3%) had significant hemorrhagic conversion. CONCLUSION: The use of GP2b3aI in the setting of tandem occlusions that required emergent stent placement post-rtPA appears safe and effective. Given the small sample size, these findings should be interpreted cautiously, and need to be confirmed in a larger patient population.

Pipeline embolization device for recurrence of previously treated aneurysms.

OBJECTIVE The utilization of the Pipeline embolization device (PED) has increased significantly since its inception and original approval for use in large, broad-necked aneurysms of the internal carotid artery. While microsurgical clipping and advances in endovascular techniques have improved overall efficacy in achieving complete occlusion, recurrences still occur, and the best modality for retreatment remains controversial. Despite its efficacy in this setting, the role of PED utilization in the setting of recurrent aneurysms has not yet been well defined. This study was designed to assess the safety and efficacy of PED in the recurrence of previously treated aneurysms. METHODS The authors reviewed a total of 13 cases in which patients underwent secondary placement of a PED for aneurysm recurrence following prior treatment with another modality. The PEDs were used to treat aneurysm recurrence or residual following endovascular coiling in 7 cases, flow diversion in 2, and microsurgical clipping in 4. The mean time between initial treatment and retreatment with a PED was 28.1 months, 12 months, and 88.7 months, respectively. Clinical outcomes, including complications and modified Rankin Scale (mRS) scores, and angiographic evidence of complete occlusion were tabulated for each treatment group. RESULTS All PEDs were successfully placed without periprocedural complications. The rate of complete occlusion was 80% at 6 months after PED placement and 100% at 12 months in these patients who underwent PED placement following failed endovascular coiling; there were no adverse clinical sequelae at a mean follow-up of 26.1 months. In the 2 cases in which PEDs were placed for treatment of residual aneurysms following prior flow diversion, 1 patient demonstrated asymptomatic vessel occlusion at 6 months, and the other exhibited complete aneurysm occlusion at 12 months. In patients with aneurysm recurrence following prior microsurgical clipping, the rate of complete occlusion was 100% at 6 and 12 months, with no adverse sequelae noted at a mean clinical follow-up of 27.7 months. CONCLUSIONS The treatment of recurrent aneurysms with the PED following previous endovascular coiling, flow diversion, or microsurgical clipping is associated with a high rate of complete occlusion and minimal morbidity.

High mobility group box protein-1 promotes cerebral edema after traumatic brain injury via activation of toll-like receptor 4.

Traumatic brain injury (TBI) is a major cause of mortality and morbidity worldwide. Cerebral edema, a life-threatening medical complication, contributes to elevated intracranial pressure (ICP) and a poor clinical prognosis after TBI. Unfortunately, treatment options to reduce post-traumatic edema remain suboptimal, due in part, to a dearth of viable therapeutic targets. Herein, we tested the hypothesis that cerebral innate immune responses contribute to edema development after TBI. Our results demonstrate that high-mobility group box protein 1 (HMGB1) was released from necrotic neurons via a NR2B-mediated mechanism. HMGB1 was clinically associated with elevated ICP in patients and functionally promoted cerebral edema after TBI in mice. The detrimental effects of HMGB1 were mediated, at least in part, via activation of microglial toll-like receptor 4 (TLR4) and the subsequent expression of the astrocytic water channel, aquaporin-4 (AQP4). Genetic or pharmacological (VGX-1027) TLR4 inhibition attenuated the neuroinflammatory response and limited post-traumatic edema with a delayed, clinically implementable therapeutic window. Human and rodent tissue culture studies further defined the cellular mechanisms demonstrating neuronal HMGB1 initiates the microglial release of interleukin-6 (IL-6) in a TLR4 dependent mechanism. In turn, microglial IL-6 increased the astrocytic expression of AQP4. Taken together, these data implicate microglia as key mediators of post-traumatic brain edema and suggest HMGB1-TLR4 signaling promotes neurovascular dysfunction after TBI.

Endovascular intervention for carotid blowout syndrome and predictors of recurrence: A retrospective and multicenter cohort study.

INTRODUCTION: Carotid blowout syndrome (CBS) is a potentially life-threatening complication of head and neck cancer and associated treatment. In this study, we assess the safety and efficacy of deconstructive and reconstructive procedures with a focus on CBS recurrence. METHODS: We conducted a multicenter retrospective analysis of a prospectively maintained database and identified 80 consecutive neurointerventions for CBS from 2016 to 2020. Patients were divided into 2 groups: deconstructive embolization (68 patients) and reconstructive stenting (12 patients). A comparative analysis was performed between the two groups. RESULTS: The CBS recurrence rate was 23.8 % with 84.2 % of recurrences occurring within 90 days of the primary event. The median time to rebleeding was 8.0 days (IQR: 2.0 - 28.5) with a mortality rate of 26.3 %. There was no significant difference in rates of peri-operative ischemic stroke (1.5 % vs. 0 %, p=0.672) or peri-operative mortality (1.5 % vs. 0 %, p=0.670). CBS recurrence was significantly higher in the reconstructive group (58.3 % vs. 17.6 %, p=0.002). On multivariate analysis, reconstructive stenting independently predicted rebleeding (adjusted hazard ratio 8.31, 95 % CI: 2.34-29.59, p=0.001). There was no significant association between CBS recurrence and pre-operative (p=0.600) or post-operative (p=0.275) anticoagulant/antiplatelet use. CONCLUSION: CBS remains a challenging and potentially catastrophic complication of head and neck cancers. Reconstructive procedures, including stenting, predicted CBS recurrence independent of bleeding site or tumor invasion. Postoperative surveillance based on time intervals to CBS recurrence and engineering advancements including improved vessel reconstruction devices have the potential to reduce rehemorrhage rates and improve patient outcomes. Further clinical investigations amongst larger cohorts are needed.

Factors Affecting Selection of TraineE for Neurointervention (FASTEN).

BACKGROUND AND IMPORTANCE: Neurointervention is a very competitive specialty in the United States due to the limited number of training spots and the larger pool of applicants. The training standards are continuously updated to ensure solid training experiences. Factors affecting candidate(s) selection have not been fully established yet. Our study aims to investigate the factors influencing the selection process. METHODS: A 52-question survey was distributed to 93 program directors (PDs). The survey consisted of six categories: (a) Program characteristics, (b) Candidate demographics, (c) Educational credentials, (d) Personal traits, (e) Research and extracurricular activities, and (f) Overall final set of characteristics. The response rate was 59.1%. As per the programs' characteristics, neurosurgery was the most involved specialty in running the training programs (69%). Regarding demographics, the need for visa sponsorship held the greatest prominence with a mean score of 5.9 [standard deviation (SD) 2.9]. For the educational credentials, being a graduate from a neurosurgical residency and the institution where the candidate's residency training is/was scored the highest [5.4 (SD = 2.9), 5.4 (SD = 2.5), respectively]. Regarding the personal traits, assessment by faculty members achieved the highest score [8.9 (SD = 1)]. In terms of research/extracurricular activities, fluency in English had the highest score [7.2 (SD = 1.9)] followed by peer-reviewed/PubMed-indexed publications [6.4 (SD = 2.2)]. CONCLUSION: Our survey investigated the factors influencing the final decision when choosing the future neurointerventional trainee, including demographic, educational, research, and extracurricular activities, which might serve as valuable guidance for both applicants and programs to refine the selection process.

Successful thrombectomy in a pediatric patient with large vessel occlusion and COVID-19 related multisystem inflammatory syndrome.

This is a case report of a child with multisystem inflammatory syndrome in children (MIS-C) complicated by an acute ischemic stroke with right M1 occlusion and large penumbra who underwent thrombectomy with TICI 3 recanalization. There were no complications and the patient had improvement in the pediatric NIHSS from 16 to 3 in the subsequent days. This is the first known report of successful mechanical thrombectomy performed in a pediatric patient with MIS-C associated with COVID-19.

Middle Meningeal Artery Embolization for Membranous Versus Nonmembranous Subdural Hematomas: A Retrospective and Multicenter Cohort Study.

BACKGROUND: Middle meningeal artery (MMA) embolization is a treatment option for chronic subdural hematomas (SDHs). The theorized mechanism of MMA embolization is devascularization of membranes that contribute to recurrence. In the present study, we aimed to determine whether MMA embolization is more efficacious for SDHs with radiographically visible membranes. METHODS: A multicenter, retrospective cohort study was performed of patients with SDHs who underwent MMA embolization alone or with burr hole drainage. The SDHs were categorized as membranous or nonmembranous according to the radiographic appearance. The patient characteristics and outcomes were compared between the 2 groups. RESULTS: A total of 99 patients with 117 MMA embolization procedures were included. Of the 99 patients, 73.7% with a membranous SDH and 61.0% with a nonmembranous SDH underwent MMA embolization alone. The remaining patients underwent MMA embolization in conjunction with burr hole evacuation. The overall recurrence rate was 10.7%. No significant differences were found in complications (P = 0.417), recurrence (P = 0.898), or retreatment (P = 0.999) among the membranous and nonmembranous groups. CONCLUSIONS: To the best of our knowledge, this is the first multicenter study evaluating the effect of membrane presence in SDHs undergoing embolization. Membrane presence in patients undergoing MMA embolization did not correlate with recurrence or retreatment, suggesting that membrane presence should not be used as the sole selection criterion for MMA embolization. Although prospective studies of larger cohorts are needed, the results from the present study provide information on the potential implications of membranes in determining the optimal treatment paradigm for SDHs.

Neoadjuvant Arterial Embolization of Spine Metastases Associated With Improved Local Control in Patients Receiving Surgical Decompression and Stereotactic Body Radiotherapy.

BACKGROUND: Spine metastases often cause significant pain, instability, and/or neurological morbidity. Local control (LC) of spine metastases has been augmented with advances in systemic therapies, radiation, and surgical technique. Prior reports suggest an association between preoperative arterial embolization and improved LC and palliative pain control. OBJECTIVE: To further elucidate the role of neoadjuvant embolization on LC of spine metastases and the potential for improved pain control in patients receiving surgery and stereotactic body radiotherapy (SBRT). METHOD: A retrospective single-center review between 2012 and 2020 identified 117 patients with spinal metastases from various solid tumor malignancies managed with surgery and adjuvant SBRT with or without preoperative spinal arterial embolization. Demographic information, radiographic studies, treatment characteristics, Karnofsky Performance Score, Defensive Veterans Pain Rating Scale, and mean daily doses of analgesic medications were reviewed. LC was assessed using magnetic resonance imaging obtained at a median 3-month interval and defined as progression at the surgically treated vertebral level. RESULTS: Of 117 patients, 47 (40.2%) underwent preoperative embolization, followed by surgery and SBRT and 70 (59.8%) underwent surgery and SBRT alone. Within the embolization cohort, the median LC was 14.2 months compared with 6.3 months among the nonembolization cohort ( P = .0434). Receiver operating characteristic analysis suggests ≥82.5% embolization predicted significantly improved LC (area under the curve = 0.808; P < .0001). Defensive Veterans Pain Rating Scale mean and maximum scores significantly decreased immediately after embolization ( P < .001). CONCLUSION: Preoperative embolization was associated with improved LC and pain control suggesting a novel role for its use. Additional prospective study is warranted.

Predictors of survival following carotid blowout syndrome.

OBJECTIVES: Carotid blowout syndrome (CBS) is a rare, life-threatening complication for patients with head and neck cancer (HNC). The primary objective was to identify factors associated with survival following CBS. MATERIALS AND METHODS: A retrospective analysis of HNC patients treated at a single tertiary care hospital with CBS between 2016 and 2020 was performed. A multivariate Cox proportional-hazards model identified independent predictors of survival. A p value of <0.05 was considered significant. Kaplan-Meier survival analysis was performed. RESULTS: 45 patients were identified. The majority were male (80.0%) with a mean age of 64 years at time of blowout. Oropharynx was the most common primary site (48.9%) and 73.3% of patients had stage IV disease. 35 (77.7%) patients had active tumor at time of CBS. 93.3% of patients previously received RT with a mean total dose of 62.5 ± 14.8 Gy. Threatened/type I, impending/type II, and acute/type III CBS occurred in 6.7%, 62.2%, and 31.1% of cases, respectively. Patients underwent either embolization (80.0%) or endovascular stent placement (20.0%). The 30-day and 1-year OS rates were 70.1% and 32.0%, respectively. Primary oropharyngeal tumors (adjusted hazard ratio [aHR], 4.31 [1.30-15.15 95% confidence interval]), active tumor at time of CBS (aHR 8.21 [2.10-54.95]), ICA or CCA rupture (aHR 5.81 [1.63-21.50]), and acute/type III CBS (aHR 2.98 [1.08-7.98]) were independent predictors of survival. CONCLUSION: Primary oropharyngeal tumors, active tumor at time of CBS, ICA or CCA rupture, and acute/type III hemorrhage were independent predictors of survival. Multidisciplinary management and prompt, protocol-directed intervention may improve outcomes following CBS.

Utility of the novel guide catheter in mechanical thrombectomy for emergent large vessel occlusion stroke.

BACKGROUND: A number of large bore guide catheters are currently available for use in neuroendovascular surgery. This study represents a multi-institutional retrospective series of patients undergoing mechanical thrombectomy with the use of a TracStar Large Distal Platform (LDP) guide catheter and assessed its performance in vivo in 107 patients. OBJECTIVE: To review a multi-institutional initial experience with the TracStar LDP guide catheter during mechanical thrombectomy for emergent large vessel occlusion (ELVO). METHODS: A retrospective review was performed at two level one stroke centres to include all patients who underwent mechanical thrombectomy and had the TracStar LDP guide catheter used during the intervention. RESULTS: The TracStar LDP guide catheter was successfully used in 107 mechanical thrombectomies. In anterior circulation ELVO, the guide catheter advanced into the cavernous segment of the internal carotid artery in 62.6% (62/99) of cases. In posterior circulation cases, the guide catheter advanced to the basilar artery in 87.5% (7/8) of cases. A thrombolysis in cerebral infarction 2b or greater reperfusion was obtained in 90.7% (97/107). No complications occurred related to the TracStar LDP guide catheter. Three complications occurred with aspiration catheters including a small dissection that did not require further intervention and fracturing of the AXS Catalyst 6 catheter tip in two cases. No thromboembolic events occurred. CONCLUSIONS: The TracStar LDP large bore guide catheter is safe and effective at navigating the tortuous vascular anatomy often encountered during mechanical thrombectomy for stroke. The flexible distal and stiffer proximal components provide a good combination of navigability and support for use in neuroendovascular interventions.

Characteristics of a COVID-19 Cohort With Large Vessel Occlusion: A Multicenter International Study.

BACKGROUND: The mechanisms and outcomes in coronavirus disease (COVID-19)-associated stroke are unique from those of non-COVID-19 stroke. OBJECTIVE: To describe the efficacy and outcomes of acute revascularization of large vessel occlusion (LVO) in the setting of COVID-19 in an international cohort. METHODS: We conducted an international multicenter retrospective study of consecutively admitted patients with COVID-19 with concomitant acute LVO across 50 comprehensive stroke centers. Our control group constituted historical controls of patients presenting with LVO and receiving a mechanical thrombectomy between January 2018 and December 2020. RESULTS: The total cohort was 575 patients with acute LVO; 194 patients had COVID-19 while 381 patients did not. Patients in the COVID-19 group were younger (62.5 vs 71.2; P < .001) and lacked vascular risk factors (49, 25.3% vs 54, 14.2%; P = .001). Modified thrombolysis in cerebral infarction 3 revascularization was less common in the COVID-19 group (74, 39.2% vs 252, 67.2%; P < .001). Poor functional outcome at discharge (defined as modified Ranklin Scale 3-6) was more common in the COVID-19 group (150, 79.8% vs 132, 66.7%; P = .004). COVID-19 was independently associated with a lower likelihood of achieving modified thrombolysis in cerebral infarction 3 (odds ratio [OR]: 0.4, 95% CI: 0.2-0.7; P < .001) and unfavorable outcomes (OR: 2.5, 95% CI: 1.4-4.5; P = .002). CONCLUSION: COVID-19 was an independent predictor of incomplete revascularization and poor outcomes in patients with stroke due to LVO. Patients with COVID-19 with LVO were younger, had fewer cerebrovascular risk factors, and suffered from higher morbidity/mortality rates.

Venous infarction secondary to congestive encephalopathy from central venous occlusive disease in a chronic hemodialysis patient: A case report.

Central venous occlusive disease secondary to chronic hemodialysis catheterization rarely progresses to encephalopathy, cerebral infarction, and/or hemorrhage. A 59-year-old male with 15 years of haemodialysis-dependent end-stage renal disease presented with acutely altered mental status, extensor rigidity with left hemiparesis and equal, but small and nonreactive pupils. Magnetic resonance imaging demonstrated infarction and cerebral edema. Cranial angiogram through right brachial artery injection revealed right subclavian vein opacification via a patent AV-fistula and retrograde flow to the right internal jugular vein and superior sagittal sinus secondary to occlusion of the brachiocephalic vein. All cerebral and right upper extremity venous drainage occurred via the contralateral venous outflow tract. Internal carotid artery injections revealed significant venous congestion. Despite successful angioplasty with stenting and resolution of venous flow reversal, the patient failed to recover neurologically. The devastating nature of the presented case emphasizes the need for frequent neurologic evaluation of such patients to avoid catastrophic cerebrovascular injury.

Woven EndoBridge (WEB) device in the treatment of ruptured aneurysms.

BACKGROUND: Wide-necked bifurcation aneurysms (WNBAs) present unique challenges for endovascular treatment. The Woven EndoBridge (WEB) device is an intrasaccular braided device, recently approved by the FDA for treatment of WNBAs. While treatment of intracranial aneurysms with the WEB device has been shown to yield an adequate occlusion rate of 85% at 1 year, few data have been published for patients with ruptured aneurysms. OBJECTIVE: To present a multi-institutional series depicting the safety and efficacy of using the WEB device as the primary treatment modality in ruptured intracranial aneurysms. METHODS: A multi-institutional retrospective analysis was conducted, assessing patients presenting with aneurysmal subarachnoid hemorrhage treated with the WEB between January 2014 and April 2020. Baseline demographics, aneurysm characteristics, adverse events, and long-term outcomes (occlusion, re-treatment, functional status) were collected. A descriptive analysis was performed, and variables potentially associated with aneurysm recurrence or re-treatment were assessed. RESULTS: Forty-eight patients were included. Anterior communicating artery aneurysms were the most common (35.4%) location for treatment, followed by middle cerebral artery (20.8%) and basilar apex (16.7%). Procedural success was noted in 95.8% of patients, and clinically significant periprocedural adverse events occurred in 12.5%. After a median follow-up of 5.5 months, 54.2% of patients had follow-up angiographic imaging. Complete occlusion was seen in 61.5% of cases with adequate occlusion in 92.3%. Re-treatment was required in only 4.2% of patients during the study period. Tobacco use was significantly higher in patients with aneurysm recurrence (88.9% vs 35.7%; p=0.012). No other characteristics were associated with recurrence/re-treatment. At 30 days, 81.1% were functionally independent (modified Rankin Scale score ≤2). CONCLUSION: Treatment of acutely ruptured aneurysms with the WEB device demonstrates both safety and efficacy on par with rates of conventional treatment strategies.

Elucidating novel mechanisms of brain injury following subarachnoid hemorrhage: an emerging role for neuroproteomics.

Subarachnoid hemorrhage (SAH) is a devastating neurological injury associated with significant patient morbidity and death. Since the first demonstration of cerebral vasospasm nearly 60 years ago, the preponderance of research has focused on strategies to limit arterial narrowing and delayed cerebral ischemia following SAH. However, recent clinical and preclinical data indicate a functional dissociation between cerebral vasospasm and neurological outcome, signaling the need for a paradigm shift in the study of brain injury following SAH. Early brain injury may contribute to poor outcome and early death following SAH. However, elucidation of the complex cellular mechanisms underlying early brain injury remains a major challenge. The advent of modern neuroproteomics has rapidly advanced scientific discovery by allowing proteome-wide screening in an objective, nonbiased manner, providing novel mechanisms of brain physiology and injury. In the context of neurosurgery, proteomic analysis of patient-derived CSF will permit the identification of biomarkers and/or novel drug targets that may not be intuitively linked with any particular disease. In the present report, the authors discuss the utility of neuroproteomics with a focus on the roles for this technology in understanding SAH. The authors also provide data from our laboratory that identifies high-mobility group box protein-1 as a potential biomarker of neurological outcome following SAH in humans.

Spinal dural arteriovenous fistula masquerading as subdural hematoma.

BACKGROUND: This case highlights an angiographically occult spinal dural AVF presenting with a spinal subdural hematoma. While rare, it is important that clinicians be aware of this potential etiology of subdural hematomas before evacuation. CASE DESCRIPTION: A 79-year-old female presented with acute lumbar pain, paraparesis, and a T10 sensory level loss. The MRI showed lower cord displacement due to curvilinear/triangular enhancement along the right side of the canal at the T12-L1 level. The lumbar MRA, craniospinal CTA, and multivessel spinal angiogram were unremarkable. A decompressive exploratory laminectomy revealed a subdural hematoma that contained blood products of different ages, and a large arterialized vein exiting near the right L1 nerve root sheath. The fistula was coagulated and sectioned. Postoperatively, the patient regained normal function. CONCLUSION: Symptomatic subdural thoracolumbar hemorrhages from SDAVF are very rare. Here, we report a patient with an acute paraparesis and T10 sensory level attributed to an SDAVF and subdural hematoma. Despite negative diagnostic studies, even including spinal angiography, the patient underwent surgical intervention and successful occlusion of the SDAVF.

Scoring of Middle Cerebral Artery Collaterals Predicts RAPID CT-Perfusion Analysis and Short-Term Outcomes in Acute Ischemic Stroke Patients Undergoing Thrombectomy.

OBJECTIVE: The rapid processing of perfusion and diffusion (RAPID) system for automating perfusion and diffusion data from head computed tomography has improved acute ischemic stroke treatment by quickly and accurately identifying those patients who may benefit from thrombectomy. Collateral scoring (CS) of cerebral arteries using computed tomography angiography (CTA) has proven useful in predicting postintervention infarct volumes and functional outcomes in ischemic stroke patients. Here we evaluate the relationship between CS and RAPID software in an effort to augment triage and provide improved predictability of functional outcomes in ischemic stroke patients. METHODS: A retrospective review of 77 mechanical thrombectomy patients from January 2017 to October 2018 with large vessel occlusions of the anterior circulation who underwent RAPID and CTA imaging was performed. Baseline characteristics, RAPID data, CS, modified Rankin Scale score, and procedural data were collected. magnetic resonance imaging was used to calculate the postintervention stroke volume. RESULTS: CS inversely correlates with the volume of RAPID cerebral blood flow <30% (ß= -18.131, 95% confidence interval [CI] -24.384 to -11.879, P < 0.001), RAPID Tmax >6s (ß= -22.205, 95% CI -39.125 to -5.285, P = 0.011), postintervention stroke volume (ß= -30.637, 95% CI -41.554 to -19.720, P < 0.001), and discharge National Institutes of Health Stroke Scale score (ß= -1.922, 95% CI -3.575 to -0.269, P = 0.023). CONCLUSIONS: CS on CTA may be a useful way to identify patients who would benefit from mechanical thrombectomy and predict functional outcomes postintervention. CS may allow the stroke team to optimize the care of patients who may not be able to obtain RAPID analysis.

Early neurologic decline in acute ischemic stroke patients receiving thrombolysis with large vessel occlusion and mild deficits.

BACKGROUND: We sought to determine the rate of early neurologic decline (END) in patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) who presented with mild deficits and received intravenous tissue plasminogen activator (IVtPA). METHODS: Among 1022 patients with AIS who received IVtPA from 2014 to 2019, we identified 313 (30.6%) with LVO, of which 94 (30%) presented with National Institute of Health Stroke Scale (NIHSS) score ≤7. Thirteen patients were excluded, leaving 81 for analysis. END was defined as NIHSS worsening of ≥4 points within 24 hours. RESULTS: Among 81 patients with LVO and low NIHSS score, the mean age was 65.8 years (range 25-93) and 41% were female. The mean time to IVtPA from last known well was 2.5 hours (range 0.8-7). LVO sites were as follows: 5 (6%) carotid, 23 (28%) M1, and 53 (65%) M2 occlusions. Among the 81 patients, 28 (34.6%) had END, and these patients were older (70.8 vs 63.2 years, p=0.036). The mean change in NIHSS score at 24 hours in those with END was 10.4 (range 4-22). Patients with END were less likely to be discharged home (25% vs 66%, p=0.004). CONCLUSIONS: Among patients with LVO AIS who received IVtPA, 30% presented with initial mild deficits. END occurred in one-third of LVO patients with initial mild deficits despite receiving IVtPA. Clinicians should be aware that the natural history of LVO with initial mild deficits is not benign and these patients are eligible for rescue thrombectomy in the 24-hour window if they deteriorate.

T-Configuration Horizontal Low-Profile Visualized Intraluminal Support (LVIS Jr) Device-Assisted Coiling for Treatment of Basilar Tip Aneurysms: A Technical Note.

BACKGROUND: Provided certain anatomic considerations, stent-assisted coiling of basilar apex aneurysms can be performed using a single stent placed in a horizontal T-configuration across the aneurysm neck prior to coil deployment, although this has predominantly been described using older-generation stents. The development of the Low-profile Visualized Intraluminal Support (LVIS Jr) device has provided greater versatility than previous stents, including use in smaller vessels, the ability to be resheathed, and improved flow diversion properties. METHODS: To our knowledge, we report the first use of the LVIS Jr device in a horizontal T-configuration across the aneurysm neck prior to coil deployment in 2 patients for the treatment of basilar apex aneurysms. This technique requires robust posterior communicating artery aneurysms and a second site of vascular access. RESULTS: Both patients demonstrated good outcomes following the procedure with no adverse sequelae. One patient required retreatment for recurrence after 1 year and was able to undergo further coiling without difficulty. CONCLUSIONS: Use of the LVIS Jr device allows greater versatility in horizontal T-configuration stent-assisted coil embolization, when compared with other available intracranial stents. This provides another tool to treat basilar apex aneurysms with improved coil occlusion and a theoretically decreased risk of thromboembolic events.

One and Done: Multimodal Treatment of Pediatric Cerebral Arteriovenous Malformations in a Single Anesthesia Event.

BACKGROUND: Brain arteriovenous malformations (AVMs) are complex vascular lesions composed of abnormal arteries directly connected to veins without the typical intervening angioarchitecture. Rupture rates range from 2% to 4%, with that risk increasing to 4.5% per year for those presenting with hemorrhage. Mortality ranges from 12% to 66.7% after rupture, and up to 40% of survivors suffer from permanent neurologic sequelae. Treatment commonly includes a multimodality approach consisting of a combination of microsurgery, embolization, and radiosurgery. Typically, preoperative embolization is undertaken in a staged manner several days to weeks prior to microsurgical resection. METHODS: We describe a series of 5 pediatric patients harboring intracranial AVMs who underwent embolization and resection in the same anesthetic event, an approach that has not yet been described in the literature. RESULTS: Three patients presented symptomatically, whereas 2 AVMs were discovered incidentally, and average Spetzler-Martin grade was 1.6. Average anesthesia length was 580.8 minutes, and intraoperative angiography revealed complete resection in all cases. All patients were extubated at the end of the case and were discharged and followed up with a modified Rankin Scale score of 0. CONCLUSIONS: We describe a novel approach to treatment of pediatric intracranial AVMs that is shown to be safe and feasible. A single anesthesia event allows for aggressive preoperative embolization without increasing the risk of hemorrhage in the waiting period until resection. A single anesthesia event also prevents the patients from undergoing another intubation and anesthesia and decreases the risk associated with another anesthesia in a relatively short time frame.