Endovascular Therapy in Mild Ischemic Strokes Presenting Under 6 hours: An International Survey.

BACKGROUND: Endovascular therapy (EVT) for patients with mild ischemic stroke (NIHSS ≤5) and visible intracranial occlusion remains controversial, including within 6 hours of symptom onset. We conducted a survey to evaluate global practice patterns of EVT in this population. METHODS: Vascular stroke clinicians and neurointerventionalists were invited to participate through professional stroke listservs. The survey consisted of six clinical vignettes of mild stroke patients with intracranial occlusion. Cases varied by NIHSS, neurological symptoms and occlusion site. All had the same risk factors, time from symptom onset (5h) and unremarkable head CT. Advanced imaging data was available upon request. We explored independent case and responder specific factors associated with advanced imaging request and EVT decision. RESULTS: A total of 482/492 responders had analyzable data ([median age 44 (IQR 11.25)], 22.7% women, 77% attending, 22% interventionalist). Participants were from USA (45%), Europe (32%), Australia (12%), Canada (6%), and Latin America (5%). EVT was offered in 48% (84% M1, 29% M2 and 19% A2) and decision was made without advanced imaging in 66% of cases. In multivariable analysis, proximal occlusion (M1 vs. M2 or A2, p<0.001), higher NIHSS (p<0.001) and fellow level training (vs. attending; p=0.001) were positive predictors of EVT. Distal occlusions (M2 and A2) and higher age of responders were independently associated with increased advanced imaging requests. Compared to US and Australian responders, Canadians were less likely to offer EVT, while those in Europe and Latin America were more likely (p<0.05). CONCLUSIONS: Treatment patterns of EVT in mild stroke vary globally. Our data suggest wide equipoise exists in current treatment of this important subset of mild stroke.

Spinal epidural tuberculoma with osseous involvement: illustrative case.

BACKGROUND: A tuberculosis infection of the central nervous system can present as a localized, intraspinal tuberculoma. These lesions may cause spinal cord compression requiring early identification and surgical decompression to limit deleterious neurological sequelae. OBSERVATIONS: A 28-year-old female with a history of opioid use disorder presented with low-back pain in the setting of trauma with progressive bilateral lower extremity radiculopathy and paraparesis. T1- and T2-weighted magnetic resonance imaging sequences of the spine demonstrated a heterogeneously hyperintense extra-axial epidural mass at T11 with mass effect. Biopsy of the lesion revealed benign soft tissue with necrosis and caseating granulomatous inflammation consistent with tuberculoma. The patient underwent laminectomy and debulking of mass for decompression and was subsequently began antitubercular treatment with good neurological outcome. LESSONS: To the best of the authors' knowledge, there are only a handful of microbiologically and radiographically confirmed cases of spinal epidural tuberculoma in English literature. These lesions are rare and difficult to clinically and radiographically characterize in the absence of systemic pulmonary TB symptoms. Tuberculoma is an important differential for a spinal epidural mass, particularly because resection with systemic antitubercular treatment results in symptom resolution.