Endovascular and medical management strategies for carotid-cavernous fistulas: A safety and efficacy analysis.

BACKGROUND: Carotid-cavernous fistulas (CCFs) are complex arteriovenous shunting lesions of the cavernous sinus with diverse clinical presentations. This study aimed to analyze clinical outcomes and differentiate patients treated with conservative observation versus those needing endovascular intervention. METHODS: A retrospective analysis of 84 patients with angiographically confirmed CCF was conducted from 2000 to 2022. Endovascular treatment decisions were made at the discretion of neurointerventionalists. Clinical and angiographic data were collected, including Barrow CCF classification and treatment outcomes. RESULTS: Patients managed conservatively (n = 17) had longer symptom duration (165 vs 42 days) and more indirect CCF (100% vs 68%) compared to those treated with endovascular embolization (n = 67). High-risk clinical symptoms, including proptosis, diplopia, decreased visual acuity, and chemosis, were more common in the embolization group. Cortical venous reflux and ophthalmic venous reflux were more prevalent in the embolization group (39% and 91%, respectively). Overall, 31% of embolized CCFs required retreatment, mainly Barrow type D lesions (65%). Transvenous coil embolization was the primary technique used (78%), followed by feeder artery embolization (16%), and internal carotid artery flow diversion (8%). CONCLUSION: In selected CCF patients without high-risk symptoms or angiographic features, conservative observation is a safe and effective alternative to endovascular embolization. High-risk symptoms and angiographic features favor endovascular intervention. Complications were rare, and most were transient, emphasizing the safety of endovascular management. Longitudinal angiographic and ophthalmologic surveillance is essential for monitoring fistula persistence or recurrence.

Predictors of favorable functional outcomes for elderly patients undergoing endovascular thrombectomy for acute ischemic stroke.

PURPOSE: The aim of this study was to identify factors that predict favorable functional outcomes in elderly patients with large-vessel occlusion acute ischemic stroke (LVO-AIS) who underwent mechanical thrombectomy (MT). METHODS: We conducted a retrospective observational study using the prospectively maintained Bigdata Observatory for Stroke of China (BOSC) to identify eligible patients who underwent MT for LVO-AIS at four comprehensive stroke centers between August 2019 and February 2022. Inclusion criteria included patients aged 80 years or older with a baseline modified Rankin Scale (mRS) 0-2, baseline National Institutes of Health Stroke Scale (NIHSS) > 6, baseline Alberta Stroke Program Early CT Score (ASPECTS) > 6 who received treatment within 24 h from symptom onset. Pertinent demographic, clinical, and procedural variables were collected. Multivariable regression analyses were performed to identify predictors of favorable long-term functional outcomes, defined as mRS 0-2 at 90 days. RESULTS: A total of 63 patients were included in the study with a mean age of 83 years. Patients with previous diagnosis of atrial fibrillation were more likely to have a favorable functional outcome (OR 2.09, 95% CI 2.09-407.33, p = 0.012), while a higher baseline NIHSS was associated with a less favorable functional outcome (OR 0.64, 95% CI 0.46-0.89, p = 0.007). In addition, there was an observed trend suggesting an association between higher baseline ASPECTS and favorable functional outcomes. This association did not reach statistical significance (OR 2.49, 95% CI 0.94-6.54, p = 0.065). CONCLUSION: In this study, we identified factors that predicted a favorable functional outcome in elderly LVO-AIS patients undergoing MT. A higher baseline NIHSS decreased the odds of mRS 0-2 at 90 days, whereas a history of atrial fibrillation increased the odds of a favorable functional outcome. These results emphasize the complex relationship between clinical factors and functional recovery in this vulnerable population.

Characterizing coma in large vessel occlusion stroke.

BACKGROUND: Coma is an unresponsive state of disordered consciousness characterized by impaired arousal and awareness. The epidemiology and pathophysiology of coma in ischemic stroke has been underexplored. We sought to characterize the incidence and clinical features of coma as a presentation of large vessel occlusion (LVO) stroke. METHODS: Individuals who presented with LVO were retrospectively identified from July 2018 to December 2020. Coma was defined as an unresponsive state of impaired arousal and awareness, operationalized as a score of 3 on NIHSS item 1a. RESULTS: 28/637 (4.4%) patients with LVO stroke were identified as presenting with coma. The median NIHSS was 32 (IQR 29-34) for those with coma versus 11 (5-18) for those without (p < 0.0001). In coma, occlusion locations included basilar (13), vertebral (2), internal carotid (5), and middle cerebral (9) arteries. 8/28 were treated with endovascular thrombectomy (EVT), and 20/28 died during the admission. 65% of patients not treated with EVT had delayed presentations or large established infarcts. In models accounting for pre-stroke mRS, basilar occlusion location, intravenous thrombolysis, and EVT, coma independently increased the odds of transitioning to comfort care during admission (aOR 6.75; 95% CI 2.87,15.84; p < 0.001) and decreased the odds of 90-day mRS 0-2 (aOR 0.12; 95% CI 0.03,0.55; p = 0.007). CONCLUSIONS: It is not uncommon for patients with LVO to present with coma, and delayed recognition of LVO can lead to poor outcomes, emphasizing the need for maintaining a high index of suspicion. While more commonly thought to result from posterior LVO, coma in our cohort was similarly likely to result from anterior LVO. Efforts to improve early diagnosis and care of patients with LVO presenting with coma are crucial.