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.

Predictors of aneurysm occlusion following treatment with the WEB device: systematic review and case series.

The Woven EndoBridge (WEB) device is becoming increasingly popular for treatment of wide-neck aneurysms. As experience with this device grows, it is important to identify factors associated with occlusion following WEB treatment to guide decision making and screen patients at high risk for recurrence. The aim of this study was to identify factors associated with adequate aneurysm occlusion following WEB device treatment in the neurosurgical literature and in our case series. A systematic review of the present literature was conducted to identify studies related to the prediction of WEB device occlusion. In addition, a retrospective review of our institutional data for patients treated with the WEB device was performed. Demographics, aneurysm characteristics, procedural variables, and 6-month follow-up angiographic outcomes were recorded. Seven articles totaling 450 patients with 456 aneurysms fit our criteria. Factors in the literature associated with inadequate occlusion included larger size, increased neck width, partial intrasaccular thrombosis, irregular shape, and tobacco use. Our retrospective review identified 43 patients with 45 aneurysms. A total of 91.1% of our patients achieved adequate occlusion at a mean follow-up time of 7.32 months. Increasing degree of contrast stasis after WEB placement on the post-deployment angiogram was significantly associated with adequate occlusion on follow-up angiogram (p = 0.005) and with Raymond-Roy classification (p = 0.048), but not with retreatment (p = 0.617). In our systematic review and case series totaling 450 patients with 456 aneurysms, contrast stasis on post-deployment angiogram was identified as a predictor of adequate aneurysm occlusion, while morphological characteristics such as larger size and wide neck negatively impact occlusion.

Quantification of pial collateral pressure in acute large vessel occlusion stroke: basic concept with patient outcomes.

PURPOSE: Pial collateral perfusion to the ischemic penumbra plays a critical role in determining patient outcomes in acute stroke. We aimed to assess the validity and reliability of an intra-procedural technique for measuring and quantifying the pial collateral pressure (QPCP) to ischemic brain tissue during acute stroke secondary to LVO. QPCP measurements were correlated with standard computed tomography angiography (CTA) and digital subtraction angiography imaging assessments of pial collateral perfusion and outcomes after mechanical endovascular revascularization (MER). METHODS: This prospective cohort study included 60 consecutive patients with middle cerebral artery (MCA)-M1 and proximal M2 occlusions. QPCP measurements were obtained during MER. The validity of QPCP measurements was evaluated using four widely accepted collateral grading scales. QPCP measurements were also analyzed as a predictor of patient outcomes utilizing National Institute of Health Stroke Scale reduction at 24 h and modified Rankin Scale (mRS) scores at 30 days. RESULTS: QPCP measurements and QPCP ratio (QPCP/systemic mean arterial blood pressure) showed a statistically significant association with single-phase pretreatment CTA Maas and American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology binary grading scales. Patient outcomes demonstrated for every 10-unit increase in QPCP, the odds of mRS 0-2 at 30 days increased by 76% (p = 0.019). CONCLUSION: QPCP measurements related best with the pretreatment CTA Maas collateral grading scale but were more strongly associated with patient outcomes than any of the four widely accepted collateral grading scales. Greater QPCP was significantly associated with better overall patient outcomes as defined by mRS at 30 days.

M2 segment thrombectomy is not associated with increased complication risk compared to M1 segment: A meta-analysis of recent literature.

INTRODUCTION: Recent clinical comparisons of M1 and M2 segment endovascular thrombectomy have reached incongruous results in rates of complication and functional outcomes. This study aims to clarify the controversy surrounding this rapidly advancing technique through literature review and meta-analysis. METHODS: A Pubmed search was performed (January 2015-September 2019) using the following keywords: "M2 AND ("stroke" OR "occlusion") AND ("thrombectomy" OR "endovascular")". Safety and clinical outcomes were compared between segments via weighted Student's t-test, Chi-square and odds ratio while study heterogeneity was analyzed using Cochran Q and I2 tests. RESULTS: Pubmed identified 208 articles and eleven studies were included after full-text analysis, comprising 2,548 M1 and 758 M2 mechanical thrombectomy segment cases. Baseline National Institutes of Health Stroke Scale scores were comparatively lower in patients experiencing an M2 occlusion (16 ± 1.25 vs 13.6 ± 0.96, p < 0.01). Patients who underwent M2 mechanical thrombectomy were more likely to experience both good clinical outcomes (modified Rankin Scale 0-2) (48.6% vs 43.5% respectively, OR 1.24; CI 1.05-1.47, p = 0.01) and excellent clinical outcomes (modified Rankin Scale 0-1) (34.7% vs. 26.5%%, OR 1.6; CI 1.28-1.99, p < 0.01) at 90 days compared to M1 mechanical thrombectomy. Neither recanalization rates (75.3% vs 72.8%, OR 0.92, CI 0.75-1.13, p = 0.44) nor symptomatic intracranial hemorrhage rates (5.6% vs 4.9%, OR 0.92; CI 0.61-1.39, p= 0.7) were significantly different between M1 and M2 cohorts. Mortality was less frequent in the M2 cohort compared to M1 (16.3% vs 20.7%, OR 0.73; CI 0.57-0.94, p = 0.01). M1 and M2 cohorts did not differ in symptom onset-to-puncture (238.1 ± 46.7 vs 239.8 ± 43.9 min respectively, p=0.488) nor symptom onset-to recanalization times (318.7 ± 46.6 vs 317.7 ± 71.1 min respectively, p = 0.772), though mean operative duration was shorter in the M2 cohort (61.8 ± 25.5 vs 54.6 ± 24 min, p < 0.01). CONCLUSIONS: Patients who underwent M2 mechanical thrombectomy had a higher prevalence of good and excellent clinical outcomes compared to the M1 mechanical thrombectomy cohorts. Additionally, our data suggest lower mortality rates in the M2 cohort and symptomatic intracranial hemorrhage rates that are similar to the M1 cohort. Therefore, M2 segment thrombectomy likely does not pose a significantly elevated operative risk and may have a positive impact on patient outcomes.

Predicting symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage with an artificial neural network in a pediatric population.

PURPOSE: Artificial neural networks (ANN) are increasingly applied to complex medical problem solving algorithms because their outcome prediction performance is superior to existing multiple regression models. ANN can successfully identify symptomatic cerebral vasospasm (SCV) in adults presenting after aneurysmal subarachnoid hemorrhage (aSAH). Although SCV is unusual in children with aSAH, the clinical consequences are severe. Consequently, reliable tools to predict patients at greatest risk for SCV may have significant value. We applied ANN modeling to a consecutive cohort of pediatric aSAH cases to assess its ability to predict SCV. METHODS: A retrospective chart review was conducted to identify patients < 21 years of age who presented with spontaneously ruptured, non-traumatic, non-mycotic, non-flow-related intracranial arterial aneurysms to our institution between January 2002 and January 2015. Demographics, clinical, radiographic, and outcome data were analyzed using an adapted ANN model using learned value nodes from the adult aneurysmal SAH dataset previously reported. The strength of the ANN prediction was measured between - 1 and 1 with - 1 representing no likelihood of SCV and 1 representing high likelihood of SCV. RESULTS: Sixteen patients met study inclusion criteria. The median age for aSAH patients was 15 years. Ten underwent surgical clipping and 6 underwent endovascular coiling for definitive treatment. One patient experienced SCV and 15 did not. The ANN applied here was able to accurately predict all 16 outcomes. The mean strength of prediction for those who did not exhibit SCV was - 0.86. The strength for the one patient who did exhibit SCV was 0.93. CONCLUSIONS: Adult-derived aneurysmal SAH value nodes can be applied to a simple AAN model to accurately predict SCV in children presenting with aSAH. Further work is needed to determine if ANN models can prospectively predict SCV in the pediatric aSAH population in toto; adapted to include mycotic, traumatic, and flow-related origins as well.

Long-term seizure and psychosocial outcomes after resective surgery for intractable epilepsy.

Resective surgery is considered an effective treatment for refractory localization-related epilepsy. Most studies have reported seizure and psychosocial outcomes of 2-5 years postsurgery and a few up to 10 years. Our study aimed to assess long-term (up to 15 years) postsurgical seizure and psychosocial outcomes at our epilepsy center. The Henry Ford Health System Corporate Data Store was accessed to identify patients who had undergone surgical resection for localization-related epilepsy from 1993 to 2011. Demographics including age at epilepsy onset and surgery, seizure frequency before surgery, and pathology were gathered from electronic medical records. Phone surveys were conducted from May 2012 to January 2013 to determine patients' current seizure frequency and psychosocial metrics including driving and employment status and use of antidepressants. Surgical outcomes were based on Engel's classification (classes I and II=favorable outcomes). McNemar's tests, chi-square tests, two sample t-tests, and Wilcoxon two sample tests were used to analyze the relationships of psychosocial and surgical outcomes with demographic and surgical characteristics. A total of 470 patients had resective epilepsy surgery, and of those, 50 (11%) had died since surgery. Of the remaining, 253 (60%) were contacted with mean follow-up of 10.6±5.0years (27% of patients had follow-up of 15 years or longer). Of the patients surveyed, 32% were seizure-free and 75% had a favorable outcome (classes I and II). Favorable outcomes had significant associations with temporal resection (78% temporal vs 58% extratemporal, p=0.01) and when surgery was performed after scalp EEG only (85% vs 65%, p<0.001). Most importantly, favorable and seizure-free outcome rates remained stable after surgery over long-term follow-up [i.e., <5 years (77%, 41%), 5-10 years (67%, 29%), 10-15 years (78%, 38%), and >15 years (78%, 26%)]. Compared to before surgery, patients at the time of the survey were more likely to be driving (51% vs 35%, p<0.001) and using antidepressants (30% vs 22%, p=0.013) but less likely to be working full-time (23% vs 42%, p<0.001). A large majority of patients (92%) considered epilepsy surgery worthwhile regardless of the resection site, and this was associated with favorable outcomes (favorable=98% vs unfavorable=74%, p<0.001). The findings suggest that resective epilepsy surgery yields favorable long-term postoperative seizure and psychosocial outcomes.

Development of Sustainable Hydrophilic Azadirachta indica Loaded PVA Nanomembranes for Cosmetic Facemask Applications.

Nanofiber-based facial masks have attracted the attention of modern cosmetic applications due to their controlled drug release, biocompatibility, and better efficiency. In this work, Azadirachta indica extract (AI) incorporated electrospun polyvinyl alcohol (PVA) nanofiber membrane was prepared to obtain a sustainable and hydrophilic facial mask. The electrospun AI incorporated PVA nanofiber membranes were characterized by scanning electron microscope, Ultraviolet-visible spectroscopy (UV-Vis) drug release, water absorption analysis, 2,2-diphenyl-1-picrylhydrazyl (DPPH) scavenging, and antibacterial activity (qualitative and quantitative) at different PVA and AI concentrations. The optimized nanofiber of 376 ± 75 nm diameter was obtained at 8 wt/wt% PVA concentration and 100% AI extract. The AI nanoparticles of size range 50~250 nm in the extract were examined through a zeta sizer. The water absorption rate of ~660% and 17.24° water contact angle shows good hydrophilic nature and water absorbency of the nanofiber membrane. The UV-Vis also analyzed fast drug release of >70% in 5 min. The prepared membrane also exhibits 99.9% antibacterial activity against Staphylococcus aureus and has 79% antioxidant activity. Moreover, the membrane also had good mechanical properties (tensile strength 1.67 N, elongation 48%) and breathability (air permeability 15.24 mm/s). AI-incorporated nanofiber membrane can effectively be used for facial mask application.

Nano-Silica Bubbled Structure Based Durable and Flexible Superhydrophobic Electrospun Nanofibrous Membrane for Extensive Functional Applications.

Nanoscale surface roughness has conventionally been induced by using complicated approaches; however, the homogeneity of superhydrophobic surface and hazardous pollutants continue to have existing challenges that require a solution. As a prospective solution, a novel bubbled-structured silica nanoparticle (SiO2) decorated electrospun polyurethane (PU) nanofibrous membrane (SiO2@PU-NFs) was prepared through a synchronized electrospinning and electrospraying process. The SiO2@PU-NFs nanofibrous membrane exhibited a nanoscale hierarchical surface roughness, attributed to excellent superhydrophobicity. The SiO2@PU-NFs membrane had an optimized fiber diameter of 394 ± 105 nm and was fabricated with a 25 kV applied voltage, 18% PU concentration, 20 cm spinning distance, and 6% SiO2 nanoparticles. The resulting membrane exhibited a water contact angle of 155.23°. Moreover, the developed membrane attributed excellent mechanical properties (14.22 MPa tensile modulus, 134.5% elongation, and 57.12 kPa hydrostatic pressure). The composite nanofibrous membrane also offered good breathability characteristics (with an air permeability of 70.63 mm/s and a water vapor permeability of 4167 g/m2/day). In addition, the proposed composite nanofibrous membrane showed a significant water/oil separation efficiency of 99.98, 99.97, and 99.98% against the water/xylene, water/n-hexane, and water/toluene mixers. When exposed to severe mechanical stresses and chemicals, the composite nanofibrous membrane sustained its superhydrophobic quality (WCA greater than 155.23°) up to 50 abrasion, bending, and stretching cycles. Consequently, this composite structure could be a good alternative for various functional applications.

Effects of assessing the productivity of faculty in academic medical centres: a systematic review.

BACKGROUND: Many academic medical centres have introduced strategies to assess the productivity of faculty as part of compensation schemes. We conducted a systematic review of the effects of such strategies on faculty productivity. METHODS: We searched the MEDLINE, Healthstar, Embase and PsycInfo databases from their date of inception up to October 2011. We included studies that assessed academic productivity in clinical, research, teaching and administrative activities, as well as compensation, promotion processes and satisfaction. RESULTS: Of 531 full-text articles assessed for eligibility, we included 9 articles reporting on eight studies. The introduction of strategies for assessing academic productivity as part of compensation schemes resulted in increases in clinical productivity (in six of six studies) in terms of clinical revenue, the work component of relative-value units (these units are nonmonetary standard units of measure used to indicate the value of services provided), patient satisfaction and other departmentally used standards. Increases in research productivity were noted (in five of six studies) in terms of funding and publications. There was no change in teaching productivity (in two of five studies) in terms of educational output. Such strategies also resulted in increases in compensation at both individual and group levels (in three studies), with two studies reporting a change in distribution of compensation in favour of junior faculty. None of the studies assessed effects on administrative productivity or promotion processes. The overall quality of evidence was low. INTERPRETATION: Strategies introduced to assess productivity as part of a compensation scheme appeared to improve productivity in research activities and possibly improved clinical productivity, but they had no effect in the area of teaching. Compensation increased at both group and individual levels, particularly among junior faculty. Higher quality evidence about the benefits and harms of such assessment strategies is needed.

The Woven EndoBridge (WEB) device: feasibility, techniques, and outcomes after FDA approval.

OBJECTIVE: Wide-neck bifurcation cerebral aneurysms have historically required either clip ligation or stent- or balloon-assisted coil embolization. This predicament led to the development of the Woven EndoBridge (WEB) aneurysm embolization system, a self-expanding mesh device that achieves intrasaccular flow disruption and does not require antithrombotic medications. The authors report their operative experience and 6-month follow-up occlusion outcomes with the first 115 aneurysms they treated via WEB embolization. METHODS: The authors reviewed the first 115 cerebral aneurysms they treated by WEB embolization after FDA approval of the WEB embolization device (from February 2019 to January 2021). Data were collected on patient demographics and clinical presentation, aneurysm characteristics, procedural details, postembolization angiographic contrast stasis, and functional outcomes. RESULTS: A total of 110 patients and 115 aneurysms were included in our study (34 ruptured and 81 unruptured aneurysms). WEB embolization was successful in 106 (92.2%) aneurysms, with a complication occurring in 6 (5.5%) patients. Contrast clearance was seen in the arterial phase in 14 (12.2%) aneurysms, in the capillary phase in 16 (13.9%), in the venous phase in 63 (54.8%), and no contrast was seen in 13 (11.3%) of the aneurysms studied. Follow-up angiography was performed on 60 (52.6%) of the aneurysms, with complete occlusion in 38 (63.3%), neck remnant in 14 (23.3%), and aneurysmal remnant in 8 (13.3%). Six (5.5%) patients required re-treatment for persistent aneurysmal residual on follow-up angiography. CONCLUSIONS: The WEB device has been successfully used for the treatment of both unruptured and ruptured wide-neck bifurcation aneurysms by achieving intrasaccular flow diversion. Here, the authors have shared their experience with its unique technical considerations and device size selection, as well as critically reviewed complications and aneurysm occlusion rates.

Nonwoven/Nanomembrane Composite Functional Sweat Pads.

Sweat is a natural body excretion produced by skin glands, and the body cools itself by releasing salty sweat. Wetness in the underarms and feet for long durations causes itchiness and an unpleasant smell. Skin-friendly reusable sweat pads could be used to absorb sweat. Transportation of moisture and functionality is the current challenge that many researchers are working on. This study aims to develop a functional and breathable sweat pad with antimicrobial and quick drying performance. Three layered functional sweat pads (FSP) are prepared in which the inner layer is made of an optimized needle-punched coolmax/polypropylene nonwoven blend. This layer is then dipped in antimicrobial ZnO solution (2, 4, and 6 wt.%), and super absorbent polymer (SAP) is embedded, and this is called a functional nonwoven (FNW1) sheet. Electrospun nanofiber-based nanomembranes of polyamide-6 are optimized for bead-free fibers. They are used as a middle layer to enhance the pad's functionality, and the third layer is again made of needle-punched optimized coolmax/polypropylene nonwoven sheets. A simple nonwoven-based sweat pad (SSP) is also prepared for comparison purposes. Nonwoven sheets are optimized based on better comfort properties, including air/water vapor permeability and moisture management (MMT). Nonwoven webs having a higher proportion of coolmax show better air permeability and moisture transfer from the inner to the outer layer. Antimicrobial activity of the functional nonwoven layer showed 8 mm of bacterial growth, but SSP and FSP showed only 6 mm of growth against Staphylococcus aureus. FSP showed superior comfort and antibacterial properties. This study could be a footstone toward highly functional sweat pads with remarkable comfort properties.

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.

Simultaneous bilateral mechanical thrombectomy in a patient with COVID-19.

Owing to systemic inflammation and widespread vessel endotheliopathy, SARS-CoV-2 has been shown to confer an increased risk of cryptogenic stroke, particularly in patients without any traditional risk factors. In this report, we present a case of a 67-year-old female who presented with acute stroke from bilateral anterior circulation large vessel occlusions, and was incidentally found to be COVID-positive on routine hospital admission screening. The patient had a large area of penumbra bilaterally, and the decision was made to pursue bilateral simultaneous thrombectomy, with two endovascular neurosurgeons working on each side to achieve a faster time to recanalization. Our study highlights the utility and efficacy of simultaneous bilateral thrombectomy, and this treatment paradigm should be considered for use in patients who present with multifocal large vessel occlusions.

Cranial angiomatoid fibrous histiocytoma: A case report and review of literature.

BACKGROUND: Angiomatoid fibrous histiocytoma (AFH) is a rare low-grade soft-tissue tumor that typically arises from the deep dermal and subcutaneous tissue of the extremities in children and young adults. Intracranial AFH is exceedingly rare, and only four cases of primary AFH tumors have been reported to date. CASE DESCRIPTION: A 43-year-old male presented to our hospital with headaches, vision changes, and a known brain tumor suspected to be an atypical meningioma. After undergoing craniotomy for resection of the mass, the immunomorphologic features of the resected tumor showed typical features of AFH with ESWR1 (exon7) - ATF1 (exon 5) fusion. CONCLUSION: AFH is a difficult tumor to diagnose with imaging and histologic studies. Thus, further knowledge is necessary - particularly of intracranial cases - to aid clinicians in its diagnosis and management.

Anterior Cerebral Artery: Variant Anatomy and Pathology.

The anterior cerebral artery (ACA) contains anatomical variants that are closely related to its embryology and development. In this study, the authors reviewed the most commonly encountered variants of the ACA and anterior communicating artery. They also reviewed the embryological origins of these variants as well as a variety of associated pathologies. Several variants are described and highlighted with illustrations including: (1) the aberrant origin of the ACA from the internal carotid artery and its developmental association with the ophthalmic artery; (2) the persistent olfactory artery; (3) the azygous ACA; (4) the triplicated ACA; and (5) multiple anterior communicating arteries. The formation of aneurysms is associated with such variants, thus their knowledge and the embryology behind their development are crucial to prevent injury to the patient.

Cost of hospitalization for aneurysmal subarachnoid hemorrhage in the United States.

OBJECTIVE: Recent large-scale studies describing hospitalization cost trends secondary to aneurysmal subarachnoid hemorrhage (aSAH) in the United States are lacking. We sought to discover the impact of aSAH-related factors upon its hospitalization cost. PATIENTS AND METHODS: Patients with a primary diagnosis of aSAH were selected utilizing the National Inpatient Sample. Regression analyses were used to evaluate the impact of aSAH-related factors on hospitalization costs. RESULTS: From 2002-2014, 22,831 cases of aSAH were identified. The inflation-adjusted mean cost of hospitalization was $82,514 (standard deviation ± $54,983). The proportion of males was lower (31%), but a higher cost of $3385 (± $685; p < .001) remained compared to females. Median length of hospitalization was 16 days (interquartile range 11-23) and each day increase in hospitalization was associated with a cost increase of $3228 (± $19; p < .001). There was no difference in cost between patients undergoing aneurysmal coiling or clipping. When compared to patients < 40 years old, the increase in cost for patients 40-59 years old was $3829 (± $914; p < .001), and $4573 (± $1033; p < .001) for patients 60-79 years old; however, for patients ≥ 80 years old, there was a decrease in cost of $8124 (± $1722; p < .001). Several central nervous system complications were also associated with increased cost. CONCLUSION: aSAH is a significant financial burden on the United States healthcare system. We were able to identify many important factors associated with higher costs, and these results may help us understand resource utilization and develop future cost-reduction strategies.

Usefulness of Cardiac Resynchronization Therapy in Patients With Continuous Flow Left Ventricular Assist Devices.

The benefit of cardiac resynchronization therapy in patients supported by a left ventricular assist device (LVAD) is unknown. There are currently no guidelines regarding the continuation, discontinuation or pacemaker (PM) settings post-LVAD implant. The aim of the study was to assess the hemodynamic benefit of biventricular (BiV) pacing in LVAD patients. We studied 22 patients supported by LVADs (age 62 ± 9, 21 males) who had received a BiV PM before LVAD implant. A total of 123 complete sets of hemodynamics were obtained during BiV pacing (n = 54), right ventricular (RV) pacing (n = 54), and intrinsic rhythm (n = 15). There were no significant differences in right atrial (RA) pressure, mean pulmonary artery pressure (mPA), PCWP, cardiac output, PA saturation (PASat) and right ventricular stroke work index between BiV and RV pacing. Hemodynamics obtained during intrinsic rhythm in 15 non-PM-dependent patients were not significantly different compared with those obtained during BiV or RV pacing. Furthermore, hemodynamics were similar at different heart rates ranging 50 to 110 beats/min. Right ventricular stroke work index was significantly lower at the highest heart rate compared with baseline and lowest heart rates suggesting decreased RV performance at higher heart rate. In conclusion, BiV pacing does not have any acute hemodynamic benefit compared with RV pacing or intrinsic rhythm in LVAD patients. A lower heart rate may confer better RV performance.

Moyamoya vasculopathy with anti-SCL-70 antibodies: A case report and review of the literature.

Moyamoya disease and syndrome constitute two distinct pathological entities with a primary finding of progressive distal internal carotid artery occlusion, which results in either an ischemic or hemorrhagic sequela. While the disease entity stands as a primary arterial vasculopathy, moyamoya syndrome represents a secondary vasculopathy associated with a systemic inflammatory process. We describe a patient with an ischemic stroke and angiographic findings of moyamoya in the setting of positive antinuclear antibodies and anti-Scl-70 antibodies with clinical features of scleroderma on exam. A review of current literature identified three similar cases where immunosuppression in addition to secondary stroke prevention led to reduced frequency of neurological sequelae. These cases plus our own demonstrate that patients with moyamoya vasculopathy in association with anti-Scl 70 antibodies exist on a spectrum with either predominant scleroderma features or neurological symptoms. There are a limited number of cases reported of moyamoya vasculopathy in association with anti-Scl 70 antibodies. This case report demonstrates that not only may the association be more common than we think, but that it exists on a dynamic spectrum with variable clinical presentation and course.

Ruptured Distal Superior Cerebellar Artery Dissecting Aneurysm Treated with a Flow-diverting Device: Case Report and Review of Literature.

Distal fusiform aneurysms of the superior cerebellar artery (SCA) are rare and present several challenges to clinicians, especially when ruptured. While several treatment options are available, including surgical clipping and endovascular coiling, numerous challenges still remain due to the presence of vital neighboring neurovascular structures. In addition, the complications that arise due to the compromise of brainstem perforators make these aneurysms difficult to treat. This case report demonstrates the successful treatment of a ruptured fusiform aneurysm of the SCA with a flow-diverting device. We also conducted a literature review of the use of flow-diverting devices for treating such aneurysms. When choosing a treatment modality for a ruptured aneurysm, clinicians must consider both the patient-specific variables as well as aneurysm morphology. Treatment options including microsurgical clipping, endovascular coiling, and flow diversion carry risks. Therefore, the clinician must decide which option best fits each situation.

Man-in-the-barrel syndrome: Case report of ventral epidural abscess and review of the literature.

BACKGROUND: Man-in-the-barrel syndrome (MBS) is an uncommon clinical condition for which patients present with bilateral brachial diplegia but intact lower extremity strength. This syndrome is typically attributed to a cranial/cortical injury rather than a spinal pathology. CASE DESCRIPTION: A 62-year-old diabetic male presented with bilateral upper extremity paresis attributed to a ventral cervical epidural abscess diagnosed on magnetic resonance imaging. Emergent cervical decompression resulted in slight improvement of upper extremity strength. However, he later expired due to sepsis and respiratory compromise. CONCLUSION: Establishing the correct diagnosis via clinical examination and proceeding with appropriate management of MBS attributed to a cervical epidural abscess is critical to achieve a good outcome.