Basilar artery fenestration and ischaemic stroke: cause, sieve, or both?

This is a case of a young male patient with no known prior risk factors who presented for acute-onset right-sided neurological deficits suspicious for stroke, and magnetic resonance angiography (MRA) identified the development of an occlusion at the level of a basilar artery (BA) fenestration in the setting of right vertebral artery occlusion. The patient was treated with dual-antiplatelet therapy in the hospital and was able to return to work shortly after discharge. The case provides insights into several possibilities for the clinical significance of BA fenestration and its potential causal or contributory relationship with ischaemic stroke of the brainstem.

Stroke Code From EMS to Thrombectomy: An Interdisciplinary In Situ Simulation for Prompt Management of Acute Ischemic Stroke.

INTRODUCTION: Treatment of acute ischemic stroke is challenging because it requires prompt management, interdisciplinary collaboration, and adherence to specific guidelines. This resource addresses these challenges by providing in situ simulated practice with stroke codes by practicing clinicians at unannounced times. METHODS: An emergency department team was presented with a 55-year-old simulated patient with speech difficulty and right-sided weakness. The team had to assess her efficiently and appropriately, including activating the stroke team via the hospital paging system. The stroke team responded to collaboratively coordinate evaluation, obtain appropriate imaging, administer thrombolytic therapy, and recognize the need for thrombectomy. Learners moved through the actual steps in the real clinical environment, using real hospital equipment. Upon simulation completion, debriefing was utilized to review the case and team performance. Latent safety threats were recorded, if present. Participants completed an evaluation to gauge the simulation's effectiveness. RESULTS: Six simulations involving 40 total participants were conducted and debriefed across New York City Health + Hospitals. One hundred percent of teams correctly identified the presenting condition and assessed eligibility for thrombolytic and endovascular therapy. Evaluations indicated that 100% of learners found the simulation to be an effective clinical, teamwork, and communication teaching tool. Debriefing captured several latent safety threats, which were rectified by collaboration with hospital leadership. DISCUSSION: Impromptu, in situ simulation helps develop interdisciplinary teamwork and clinical knowledge and is useful for reviewing crucial times and processes required for best-practice patient care. It is particularly useful when timely management is essential, as with acute ischemic stroke.

Staffing Up For The Surge: Expanding The New York City Public Hospital Workforce During The COVID-19 Pandemic.

Confronted with the coronavirus disease 2019 (COVID-19) pandemic, New York City Health + Hospitals, the city's public health care system, rapidly expanded capacity across its eleven acute care hospitals and three new field hospitals. To meet the unprecedented demand for patient care, NYC Health + Hospitals redeployed staff to the areas of greatest need and redesigned recruiting, onboarding, and training processes. The hospital system engaged private staffing agencies, partnered with the Department of Defense, and recruited volunteers throughout the country. A centralized onboarding team created a single-source portal for medical care providers requiring credentialing and established new staff positions to increase efficiency. Using new educational tools focused on COVID-19 content, the hospital system trained twenty thousand staff members, including nearly nine thousand nurses, within a two-month period. Creation of multidisciplinary teams, frequent enterprisewide communication, willingness to shift direction in response to changing needs, and innovative use of technology were the key factors that enabled the hospital system to meet its goals.

CT angiography-source image hypoattenuation predicts clinical outcome in posterior circulation strokes treated with intra-arterial therapy.

BACKGROUND AND PURPOSE: The aim of this study was to correlate CT angiography-source image (CTA-SI) parenchymal hypoattenuation with clinical outcome in patients with vertebrobasilar occlusion treated with intra-arterial thrombolysis. METHODS: In 16 patients with vertebrobasilar occlusion treated with intra-arterial thrombolysis, we graded CTA-SI parenchymal hypoattenuation in the medulla, pons, midbrain, thalamus, cerebellum, occipital lobe, inferior parietal lobe, and medial temporal lobe. The grading scale was: 0, no hypoattenuation; 1, <50% hypoattenuation; and 2, >50% hypoattenuation. On CTA, we assessed clot location and length and collaterals. Outcome was measured with modified Rankin score. RESULTS: Mean patient age was 68.3 years (range, 47 to 86 years), National Institutes of Health Stroke Scale was 28 (range, 11 to 40), time to CTA was 5.2 hours (range, 0.69 to 15.32), and time from CTA to intra-arterial thrombolysis was 5 hours (range, 2.25 to 10.38 hours). There were 4 basilar, 2 vertebral, and 10 combined occlusions. Eleven patients had near complete, 4 had partial, and one had no recanalization. Independent outcome predictors measured as modified Rankin score at 3 months were CTA-SI pons and midbrain scores(cumulative r=0.81, P<0.001). For outcome dichotomized into death versus survival, the CTA-SI pons score (P=0.0037) was the only independent predictor. CONCLUSIONS: Hypoattenuation in the pons and midbrain on pretreatment CTA-SI correlates highly with clinical outcome in patients with vertebrobasilar occlusion treated with intra-arterial thrombolysis.

A ventriculoperitoneal shunt incidentally found in the stomach.

We report a case of a ventriculoperitoneal shunt incidentally found within the stomach while the patient was undergoing a percutaneous endoscopic gastrostomy (PEG) tube placement. Among the complications of ventriculoperitoneal shunt placement, bowel perforation is rare a complication found in 0.01%-0.07% of cases, and typically occurs in premature infants and neonates [1]. To date, less than 100 such cases have been recorded of which only a few have appeared in the radiological literature. Here we discuss the current literature, the radiological features, clinical presentations and the management.

Temporal evolution of vasospasm and clinical outcome after intra-arterial vasodilator therapy in patients with aneurysmal subarachnoid hemorrhage.

Intra-arterial (IA) vasodilator therapy is one of the recommended treatments to minimize the impact of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm refractory to standard management. However, its usefulness and efficacy is not well established. We evaluated the effect IA vasodilator therapy on middle cerebral artery blood flow and on discharge outcome. We reviewed records for 115 adults admitted to Neurointensive Care Unit to test whether there was a difference in clinical outcome (discharge mRS) in those who received IA infusions. In a subset of 19 patients (33 vessels) treated using IA therapy, we tested whether therapy was effective in reversing the trends in blood flow. All measures of MCA blood flow increased from day -2 to -1 before infusion (maximum Peak Systolic Velocity (PSV) 232.2±9.4 to 262.4±12.5 cm/s [p = 0.02]; average PSV 202.1±8.5 to 229.9±10.9 [p = 0.02]; highest Mean Flow Velocity (MFV) 154.3±8.3 to 172.9±10.5 [p = 0.10]; average MFV 125.5±6.3 to 147.8±9.5 cm/s, [p = 0.02]) but not post-infusion (maximum PSV 261.2±14.6 cm/s [p = .89]; average PSV 223.4±11.4 [p = 0.56]; highest MFV 182.9±12.4 cm/s [p = 0.38]; average MFV 153.0±10.2 cm/s [p = 0.54]). After IA therapy, flow velocities were consistently reduced (day X infusion interaction p<0.01 for all measures). However, discharge mRS was higher in IA infusion group, even after adjusting for sex, age, and admission grades. Thus, while IA vasodilator therapy was effective in reversing the vasospasm-mediated deterioration in blood flow, clinical outcomes in the treated group were worse than the untreated group. There is need for a prospective randomized controlled trial to avoid potential confounding effect of selection bias.

Low neurologic intensive care unit hemoglobin as a predictor for intra-arterial vasospasm therapy and poor discharge modified Rankin Scale in aneurysmal subarachnoid haemorrhage-induced cerebral vasospasm.

BACKGROUND: Intra-arterial vasospasm therapy (IAVT) with vasodilators, balloon angioplasty, and cerebral blood flow augmentation devices are therapies for aneurysmal subarachnoid hemorrhage-induced symptomatic cerebral vasospasm refractory to maximal medical management. Our aim was to identify clinical factors predictive of IAVT and/or poor outcome. METHODS: A cross-sectional retrospective analysis was performed of 130 patients with aneurysmal subarachnoid hemorrhage including patients without and with symptomatic cerebral vasospasm requiring IAVT. The data were analysed by Student t test, univariate analysis and binary logistic regression. RESULTS: The mean±SD patient age was 54±12.2 years, admission hemoglobin was 13.6±1.5 g/dL, and neurologic intensive care unit (NICU) hemoglobin 11±1.4 g/dL. The median Hunt and Hess grade was 2 (range 1,4), Fisher grade 3 (range 3,3), and discharge modified Rankin Scale (mRS) 0.5 (range 0,2). Lower mean NICU hemoglobin was found in patients receiving IAVT than in those not receiving IAVT (M=10.4±0.9 g/dL vs M=11.2±1.4 g/dL, t(115)=-2.52, p=0.01). Further, lower mean NICU hemoglobin was associated with increased IAVT (ρ=-0.3, p<0.01) and higher discharge mRS (ρ=-0.5, p<0.01). In binary logistic regression, lower mean NICU hemoglobin was an independent predictor of IAVT (OR 0.6, 95% CI 0.4 to 0.9, p<0.05) as well as poor discharge mRS (OR 0.6, 95% CI 0.4 to 0.9, p<0.05). Hunt and Hess grade was also an independent predictor of these outcomes. CONCLUSIONS: Lower mean hemoglobin during the acute phase of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm is an independent predictor of IAVT and poor discharge mRS. This relationship warrants further evaluation.

Clinical presentation and treatment considerations of a ruptured posterior spinal artery pseudoaneurysm.

Spinal artery pseudoaneurysms are rare vascular lesions with poorly defined natural history, diagnostic paradigms, and treatment strategies. We present a 68-year-old woman with severe back pain and left lower extremity weakness with spinal subarachnoid hemorrhage due to a ruptured T5 region posterior spinal artery pseudoaneurysm, and review issues related to radiologic diagnosis and endovascular and open neurosurgical interventions.

Reducing door-to-puncture times for intra-arterial stroke therapy: a pilot quality improvement project.

BACKGROUND: Delays to intra-arterial therapy (IAT) lead to worse outcomes in stroke patients with proximal occlusions. Little is known regarding the magnitude of, and reasons for, these delays. In a pilot quality improvement (QI) project, we sought to examine and improve our door-puncture times. METHODS AND RESULTS: For anterior-circulation stroke patients who underwent IAT, we retrospectively calculated in-hospital time delays associated with various phases from patient arrival to groin puncture. We formulated and then implemented a process change targeted to the phase with the greatest delay. We examined the impact on time to treatment by comparing the pre- and post-QI cohorts. One hundred forty-six patients (93 pre- vs. 51 post-QI) were analyzed. In the pre-QI cohort (ie, sequential process), the greatest delay occurred from imaging to the neurointerventional (NI) suite ("picture-suite": median, 62 minutes; interquartile range [IQR], 40 to 82). A QI measure was instituted so that the NI team and anesthesiologist were assembled and the suite set up in parallel with completion of imaging and decision making. The post-QI (ie, parallel process) median picture-to-suite time was 29 minutes (IQR, 21 to 41; P<0.0001). There was a 36-minute reduction in median door-to-puncture time (143 vs. 107 minutes; P<0.0001). Parallel workflow and presentation during work hours were independent predictors of shorter door-puncture times. CONCLUSIONS: In-hospital delays are a major obstacle to timely IAT. A simple approach for achieving substantial time savings is to mobilize the NI and anesthesia teams during patient evaluation and treatment decision making. This parallel workflow resulted in a >30-minute (25%) reduction in median door-to-puncture times.