Racial and Ethnic Disparities in the Utilization of Thrombectomy for Acute Stroke.

Background and Purpose- Racial and ethnic disparities in the access to mechanical thrombectomy (MT) for treatment of acute ischemic stroke (AIS) secondary to large vessel occlusion have been previously described. The effect of recent randomized trials validating MT as an effective therapy for AIS secondary to large vessel occlusion on such disparities has not been investigated. Methods- Information on admissions for AIS to endovascular centers occurring between January 2016 and September 2018 was obtained from a national database. The number of patients receiving IV-tPA (intravenous tissue-type plasminogen activator) and MT at each institution was determined, and patient demographics were characterized according to age, sex, race/ethnicity, and insurance status. Comparisons of patients who did and did not undergo MT and between patients of different racial and ethnic backgrounds were performed. Demographic variables independently associated with the utilization of MT were identified using multivariate linear regression analysis. Results- There were 206 853 admissions to 173 endovascular centers during the time period of interest. The overall utilization of MT was 8.4%. The utilization of MT for black/Hispanic patients was lower than that among white/non-Hispanic patients (7.0% versus 9.8%; P<0.001). Black/Hispanic patients were also less likely to receive IV-tPA (16.2% versus 20.5%; P<0.001) and to be admitted to the endovascular center after transfer from a different hospital (20.0% versus 30.1%; P<0.001). On multivariate linear regression analysis, increasing institutional proportions of patients with female sex (ß=-0.601; P<0.001), insurance with Medicaid or uninsured status (ß=-0.153; P=0.029), and black/Hispanic race/ethnicity (ß=-0.062; P=0.046) were independently associated with lower institutional utilization of MT. Conclusions- Despite the mainstream acceptance of MT for the treatment of AIS secondary to large vessel occlusion, racial and ethnic disparities in the utilization of MT persist.

Pipeline Embolization Device for Treatment of Extracranial Internal Carotid Artery Pseudoaneurysms: A Multicenter Evaluation of Safety and Efficacy.

BACKGROUND: There is a paucity of literature regarding treatment options for extracranial pseudoaneurysms of the internal carotid artery (ICA). To date, Pipeline Embolization Device (PED; Medtronic Inc) use for the treatment of extracranial pseudoaneurysms of the ICA has only been reported from single-center case series. OBJECTIVE: To evaluate the safety and efficacy of PED for the treatment of extracranial ICA pseudoaneurysms. METHODS: This is a multicenter retrospective study involving 6 high-volume tertiary academic institutions in the United States. We analyzed patients with extracranial ICA pseudoaneurysms treated with PED between January 1, 2011, and January 1, 2019. Clinical assessment was performed pre- and postintervention using the modified Rankin Scale (mRS) and National Institution of Health Stroke Scale (NIHSS) at a minimum of 4-mo follow-up. RESULTS: A total of 28 pseudoaneurysms with a mean diameter of 17.7 mm (range: 4.1-52.5 mm) were treated with PED in 24 patients at 6 participating centers. The mean age was 52.1 yr (17-73) ± 14.3 with 14 females and 10 males. At a mean of 21-mo (range 4-66 mo) follow-up, complete occlusion was achieved in 89% (n = 25/28), with near-complete occlusion (>90% occlusion) in the remainder. There were no periprocedural complications. Postprocedure NIHSS was 0 in 88% (n = 21/24) and 1 in 12% (n = 3/24) of patients, and mRS was 0 in 83% (n = 20/24) and 1 in 17% (n = 4/24) of patients. CONCLUSION: The treatment of extracranial ICA pseudoaneurysms with PED is safe and effective in selected patients. Randomized controlled trials and prospective cohort studies are needed to establish the role of flow diversion for ICA pseudoaneurysms.

Ruptured Posterior Inferior Cerebellar Artery Dural Fistula After Vestibular Schwannoma Resection.

A 50-year-old man with a history of left-sided retrosigmoid craniotomy for vestibular schwannoma (VS) resection 19 years prior presented with severe headache and left cerebellopontine angle subarachnoid hemorrhage (SAH). Digital subtraction angiography demonstrated a dissected, nonfunctional left posterior inferior cerebellar artery with direct fistulization at the left transverse sinus (Video 1). The lesion was treated with endovascular Onyx embolization. The patient recovered without neurologic deficit. Five additional cases of new dural arteriovenous fistula arising after VS resection have been described; we report the first such case presenting with SAH, suggesting that postoperative magnetic resonance angiography may be of value in long-term VS follow-up imaging protocols.

Effect of Fetal Posterior Circulation on Efficacy of Flow Diversion for Treatment of Posterior Communicating Artery Aneurysms: A Multi-Institutional Study.

BACKGROUND: Flow diversion (FD) has emerged as an effective treatment modality for aneurysms of the posterior communicating artery (PCOM). Whether or not a fetal posterior circulation (FPC) affects PCOM aneurysm occlusion rates after FD remains undetermined. METHODS: We performed a retrospective cohort study in which treatment outcomes for FD of PCOM aneurysms from multiple institutions were reviewed. The primary outcome of interest was complete aneurysm occlusion at last follow-up. The presence of a FPC, defined as a PCOM diameter larger than that of the P1 segment, was noted and its relationship to complete aneurysm occlusion was investigated using a Cox proportional hazards model. RESULTS: There were 49 patients with 49 PCOM aneurysms treated with FD who met inclusion criteria for analysis. A FPC was present in 16 patients (32.7%). Complete aneurysm occlusion was observed in 34 patients (69.4%). Complete occlusion was less common for patients with a FPC (43.7% vs. 81.8%; P = 0.007). For patients with and without a FPC, median time to occlusion was 51 and 6 months, respectively (P = 0.002). Using a multivariable Cox proportional hazards model, a FPC was associated with reduced odds of complete occlusion on last follow-up (risk ratio 0.35, 95% confidence interval 0.14-0.89; P = 0.029). CONCLUSIONS: Our results indicate reduced efficacy of FD for the treatment of PCOM aneurysms associated with a FPC. These findings may influence treatment selection for aneurysms at this location.