Endovascular Thrombectomy after Large-Vessel Ischemic Stroke: Utilization, Outcomes, and Readmissions across the United States.

Background Following publication of trials demonstrating the efficacy of thrombectomy, societal guidelines were revised in 2015 to recommend this procedure for large-vessel stroke. Purpose To evaluate real-world thrombectomy rates, adverse events, outcomes, and readmissions across the United States in the 2 years after large-scale adoption of thrombectomy for acute stroke. Materials and Methods In this retrospective study, the authors queried the National Inpatient Sample and Nationwide Readmissions Database for patients undergoing thrombectomy between 2016 and 2017. Thrombectomy rates were compared by using the χ2 test. Adjusted risk ratios (aRRs) were obtained for factors affecting routine discharge, mortality, and readmission by using multivariable Poisson regression with clustering at the hospital level. Results There were 290 460 admissions (mean age, 70.5 years ± 14.2 [standard deviation]; 148 620 women) for internal carotid or middle cerebral artery stroke; 30 835 (10.6%) of these patients underwent thrombectomy. Thrombectomy rates were lower in patients aged 90 years or older (1815 of 24 090 patients, 7.5%), Black patients (4280 of 43 365 patients, 9.9%), patients with the lowest income (8520 of 85 905 patients, 9.9%), and those treated in West South Central division hospitals (2695 of 34 355 patients, 7.8%) (P < .001 for all). The inpatient mortality rate was 12.1% (3740 of 30 835 patients), and 19.1% of patients (5900 of 30 835) were discharged to home. In adjusted analyses, routine discharge was less likely in patients aged 90 years or older (aRR: 0.12; 95% CI: 0.09, 0.16; P < .001) and octogenarians (aRR: 0.37; 95% CI: 0.33, 0.41; P < .001). Patients aged 90 years or older (aRR: 1.78; 95% CI: 1.48, 2.14; P < .001), octogenarians (aRR: 1.76; 95% CI: 1.51, 2.06; P < .001), Asians and/or Pacific Islanders (aRR: 1.21; 95% CI: 1.06, 1.39; P = .005), and those treated in teaching (aRR: 1.20; 95% CI: 1.07, 1.34; P = .001) or West South Central division (aRR: 1.35; 95% CI: 1.14, 1.60; P < .001) hospitals had a higher risk of death. Following discharge, 18.9% of patients (3449 of 18 274) were readmitted within 90 days. Conclusion Rates and outcomes of thrombectomy are affected by demographic, socioeconomic, and hospital-related factors. Fewer than one-fifth of patients are discharged to home, nearly one-fifth are readmitted within 90 days, and mortality and outcomes may be less favorable than in published trials. © RSNA, 2021 Online supplemental material is available for this article.

Analysis of Mechanical Thrombectomy for Acute Ischemic Stroke on Nights and Weekends Versus Weekdays at Comprehensive Stroke Centers.

OBJECTIVE: The "weekend effect" has been shown to affect outcomes in acute ischemic stroke. We sought to compare metrics and outcomes of emergent stroke thrombectomy at three affiliated comprehensive stroke centers on weekdays versus nights/weekends for a three-year period beginning in 2015, when thrombectomy became common practice for large vessel occlusion acute ischemic stroke. METHODS: We performed a retrospective analysis of all stroke thrombectomy patients treated from 2015 to 2018 to compare standard thrombectomy metrics and outcomes in patients presenting during weekdays or nights/weekends. RESULTS: Two hundred-sixteen mechanical thrombectomy cases were evaluated, with 50.9% of patients presenting on weekdays and 49.1% presenting on nights/weekends. There were no statistical differences in baseline characteristics in demographics, stroke risk factors, or stroke severity, but patients presenting on nights/weekends had longer times from last known normal to presentation (130 versus 72.5 minutes, p=0.03). Door-to-groin times were delayed in patients presenting on nights/weekends compared to weekdays (median 104.5 versus 86 minutes, respectively; p=0.007) but groin-to-reperfusion times were similar (51.5 versus 48 minutes, respectively; p=0.4). Successful reperfusion was similar in both groups (90.6% nights/weekends versus 90% weekdays; p=1.0) as were the incidence of symptomatic intracerebral hemorrhage (10.4% nights/weekend versus 7.3% weekdays; p=0.48) and 90-day good functional outcomes based on the modified Rankin Scale did not differ between the two groups in a shift analysis (p=0.545). CONCLUSIONS: Despite delays in door-to-groin puncture times in acute ischemic stroke patients presenting on nights/weekends compared to weekdays, we did not identify significant differences in successful reperfusion or functional outcomes in this cohort. Further studies are warranted to continue to evaluate differences in stroke care on nights/weekends versus weekdays.

Spinal neurovascular complications with anterior thoracolumbar spine surgery: a systematic review and review of thoracolumbar vascular anatomy.

OBJECTIVE: Spinal cord infarction due to interruption of the spinal vascular supply during anterior thoracolumbar surgery is a rare but devastating complication. Here, the authors sought to summarize the data on this complication in terms of its incidence, risk factors, and operative considerations. They also sought to summarize the relevant spinal vascular anatomy. METHODS: They performed a systematic literature review of the PubMed, Scopus, and Embase databases to identify reports of spinal cord vascular injury related to anterior thoracolumbar spine procedures as well as operative adjuncts and considerations related to management of the segmental artery ligation during such anterior procedures. Titles and abstracts were screened, and studies meeting inclusion criteria were reviewed in full. RESULTS: Of 1200 articles identified on the initial screening, 16 met the inclusion criteria and consisted of 2 prospective cohort studies, 10 retrospective cohort studies, and 4 case reports. Four studies reported on the incidence of spinal cord ischemia with anterior thoracolumbar surgery, which ranged from 0% to 0.75%. Eight studies presented patient-level data for 13 cases of spinal cord ischemia after anterior thoracolumbar spine surgery. Proposed risk factors for vasculogenic spinal injury with anterior thoracolumbar surgery included hyperkyphosis, prior spinal deformity surgery, combined anterior-posterior procedures, left-sided approaches, operating on the concavity side of a scoliotic curve, and intra- or postoperative hypotension. In addition, eight studies analyzed operative considerations to reduce spinal cord ischemic complications in anterior thoracolumbar surgery, including intraoperative neuromonitoring and preoperative spinal angiography. CONCLUSIONS: While spinal cord infarction related to anterior thoracolumbar surgery is rare, it warrants proper consideration in the pre-, intra-, and postoperative periods. The spine surgeon must be aware of the relevant risk factors as well as the pre- and intraoperative adjuncts that can minimize these risks. Most importantly, an understanding of the relevant spinal vascular anatomy is critical to minimizing the risks associated with anterior thoracolumbar spine surgery.

Standardized Evaluation of Cerebral Arteriovenous Malformations Using Flow Distribution Network Graphs and Dual-venc 4D Flow MRI.

BACKGROUND: Cerebral arteriovenous malformations (AVMs) are pathological connections between arteries and veins. Dual-venc 4D flow MRI, an extended 4D flow MRI method with improved velocity dynamic range, provides time-resolved 3D cerebral hemodynamics. PURPOSE: To optimize dual-venc 4D flow imaging parameters for AVM; to assess the relationship between spatial resolution, acceleration, and flow quantification accuracy; and to introduce and apply the flow distribution network graph (FDNG) paradigm for storing and analyzing complex neurovascular 4D flow data. STUDY TYPE: Retrospective cohort study. SUBJECTS/PHANTOM: Scans were performed in a specialized flow phantom: 26 healthy subjects (age 41 ± 17 years) and five AVM patients (age 27-68 years). FIELD STRENGTH/SEQUENCE: Dual-venc 4D flow with varying spatial resolution and acceleration factors were performed at 3T field strength. ASSESSMENT: Quantification accuracy was assessed in vitro by direct comparison to measured flow. FDNGs were used to quantify and compare flow, peak velocity (PV), and pulsatility index (PI) between healthy controls with various Circle of Willis (CoW) anatomy and AVM patients. STATISTICAL TESTS: In vitro measurements were compared to ground truth with Student's t-test. In vivo groups were compared with Wilcoxon rank-sum test and Kruskal-Wallis test. RESULTS: Flow was overestimated in all in vitro experiments, by an average 7.1 ± 1.4% for all measurement conditions. Error in flow measurement was significantly correlated with number of voxels across the channel (P = 3.11 × 10-28 ) but not with acceleration factor (P = 0.74). For the venous-arterial PV and PI ratios, a significant difference was found between AVM nidal and extranidal circulation (P = 0.008 and 0.05, respectively), and between AVM nidal and healthy control circulation (P = 0.005 and 0.003, respectively). DATA CONCLUSION: Dual-venc 4D flow MRI and standardized FDNG analysis might be feasible in clinical applications. Venous-arterial ratios of PV and PI are proposed as network-based biomarkers characterizing AVM nidal hemodynamics. LEVEL OF EVIDENCE: 3 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2019;50:1718-1730.

Three-dimensional hemodynamics in intracranial aneurysms: influence of size and morphology.

PURPOSE: To use four-dimensional (4D)-flow MRI for the comprehensive in vivo analysis of hemodynamics and its relationship to size and morphology of different intracranial aneurysms (IA). We hypothesize that different IA groups, defined by size and morphology, exhibit different velocity fields, wall shear stress, and vorticity. MATERIALS AND METHODS: The 4D-flow MRI (spatial resolution = 0.99-1.8 × 0.78-1.46 × 1.2-1.4 mm(3) , temporal resolution = 44-48 ms) was performed in 19 IAs (18 patients, age = 55.4 ± 13.8 years) with saccular (n = 16) and fusiform (n = 3) morphology and different sizes ranging from small (n = 8; largest dimension = 6.2 ± 0.4 mm) to large and giant (n = 11; 25 ± 7 mm). Analysis included quantification of volumetric spatial-temporal velocity distribution, vorticity, and wall shear stress (WSS) along the aneurysm's 3D surface. RESULTS: The 4D-flow MRI revealed distinct hemodynamic patterns for large/giant saccular aneurysms (Group 1), small saccular aneurysms (Group 2), and large/giant fusiform aneurysms (Group 3). Saccular IA (Groups 1, 2) demonstrated significantly higher peak velocities (P < 0.002) and WSS (P < 0.001) compared with fusiform aneurysms. Although intra-aneurysmal 3D velocity distributions were similar for Group 1 and 2, vorticity and WSS was significantly (P < 0.001) different (increased in Group 1 by 54%) indicating a relationship between IA size and hemodynamics. Group 3 showed reduced velocities (P < 0.001) and WSS (P < 0.001). CONCLUSION: The 4D-flow MRI demonstrated the influence of lesion size and morphology on aneurysm hemodynamics suggesting the potential of 4D-flow MRI to assist in the classification of individual aneurysms.

Early Infantile Diagnosis of Hereditary Hemorrhagic Telangiectasia Complicated by Child Abuse.

We report a rare case of hereditary hemorrhagic telangiectasia (HHT) in a 4-month-old female infant with findings of child abuse. She presented with poor feeding, vomiting, and irritability after a short fall from the bed. Initial evaluation found subdural hematomas, persistent hypoxia, failure to thrive, a frenulum tear, facial lacerations, and bruising. The patient was admitted, and an extensive workup led to the diagnosis of brain and pulmonary arteriovenous malformations and finally the diagnosis of HHT. The subdural hematomas, cutaneous injuries, and oral injury were highly suspicious for child abuse and were reported to Child Protective Services and law enforcement for investigation simultaneous to the medical work-up. Her hospital course was complicated by progressive hypoxemia with radiographic evidence of several large pulmonary arteriovenous malformations, for which she underwent successful embolization. Her head injury was indeterminate for physical abuse in the setting of a medical condition predisposing to intracranial hemorrhage. A few weeks later, she was readmitted with repeat abusive injuries in the form of femur fractures. This case demonstrates the unique diagnostic dilemma when 2 diagnoses are occurring simultaneously-HHT and child abuse-and showcases the importance of a detailed family history, genetic testing, strong multidisciplinary collaboration with a holistic approach and medically informed Child Protective Services systems to ensure accurate diagnoses and safe disposition.

Endovascular Embolization of Traumatic Vessel Injury Using N-butyl Cyanoacrylate: A Case Series.

There is limited evidence of N-butyl cyanoacrylate (n-BCA) use in endovascular embolization of traumatic face and neck vessel injuries. We investigated the safety and effectiveness of n-BCA for this purpose. We retrospectively analyzed consecutive patients presenting to a Level 1 trauma center between April 2021 and July 2022. We included patients aged ≥ 18 years old with any vessel injury in the face and neck circulation requiring n-BCA embolization. The primary endpoint was n-BCA effectiveness defined as immediate control of active bleeding post-embolization. In total, 13 patients met the inclusion criteria. The median decade of life was 3 (IQR 3 - 5) with a male predominance (n = 11, 84.6%). Median Glasgow Coma Scale score on presentation was 15 (IQR 3-15). Eleven patients suffered gunshot wound injuries; two patients suffered blunt injuries. Injured vessels included facial artery (n = 6, 46.2%), buccal branch artery (n = 3, 23.1%), internal maxillary (n = 5, 38.5%), cervical internal carotid artery (n = 1, 7.7%), and vertebral artery (n = 1, 7.7%). All patients were treated with 1:2 n-BCA to ethiodol mixture with immediate extravasation control. No bleeding recurrence or need for retreatment occurred. One patient died in-hospital (7.7%). Patients were discharged to home (n = 8, 61.5%), day rehabilitation (n = 1, 7.7%), or acute rehabilitation (n = 3, 23.1%). One patient developed a right posterior cerebral artery infarct with hemorrhagic transformation. To our knowledge, this is the first study demonstrating the safety and effectiveness of n-BCA liquid embolism in traumatic vessel injuries, especially penetrating gunshot wounds.

Early single-center experience with middle meningeal artery embolization using Zoom™ 45 Catheter.

BACKGROUND: Middle meningeal artery (MMA) embolization for subdural hematomas (SDH) and dural arteriovenous fistulas (dAVFs) has gained momentum in the neuroendovascular space. However, there is variability in the technique for safe and effective embolization. The aim of this report is to describe the technical feasibility and clinical performance of using Zoom™ 45 catheter for MMA access to facilitate embolization. METHODS: We analyzed all cases of MMA embolization in which the Zoom™ 45 catheter was used and performed in our institution from February 2021 to March 2023 for SDH and dAVFs. RESULTS: A total of 32 patients were included. Mean age was 64.0 ± 18.0 years, 75.0% (4/32) were male, and 56.7% (17/30), were black. The technical success was achieved in 93.8% (30/32) of cases, with selective embolization utilizing microcatheter directly into frontal and parietal branches for most patients (96.9%, 31/32). Identification of dangerous collaterals, such as lacrimal and petrous branches, prior to embolization, was achieved in most patients (96.9%, 31/32). Bilateral MMA embolization was done in 50.0% (16/32) of patients. The transradial approach and transfemoral approach were used in 53.1% (17/32) and 46.9% (15/32) of patients, respectively. The most common embolization material was n-butyl cyanoacrylate (84.4%, 27/32). There were no access site complications or complications related to the MMA embolization procedures and used devices. CONCLUSIONS: The use of Zoom™ 45 Catheter seems to be technically feasible, safe, and effective for facilitating MMA access for embolization in the context of SDH and dAVFs.

Cerebral arteriovenous malformation: complex 3D hemodynamics and 3D blood flow alterations during staged embolization.

Complex hemodynamics in cerebral arteriovenous malformations (AVM) are thought to play a key role in their pathophysiology. We applied 4D flow magnetic resonance imaging (MRI) for the detailed evaluation of AVM function at baseline and to investigate the impact of staged embolization on AVM hemodynamics in a patient with a Spetzler-Martin grade III AVM. The patient underwent three embolization procedures resulting in >50% nidal casting and obliteration of several arteriovenous fistulae. 4D flow MRI demonstrated highly complex 3D hemodynamics at baseline and revealed intricate arterial feeding, a large vascularized nidus with high variability in regional blood flow velocities, and clearly visible venous drainage with high flow velocities above 50 cm/s. 3D blood flow visualization and quantification during follow-up illustrated the systemic impact of focal embolization on cerebral hemodynamics resulting in compaction of the AVM, redistribution of blood flow velocities, and altered peak flow velocities and blood flow in multiple vascular territories. 4D flow MRI may offer a useful noninvasive tool to help to identify subtleties and nuances of the quantitative hemodynamic alterations in AVM vascular architecture as a supplement to established imaging modalities.

Correction for arterial-tissue delay and dispersion in absolute quantitative cerebral perfusion DSC MR imaging.

The singular value decomposition deconvolution of cerebral tissue concentration-time curves with the arterial input function is commonly used in dynamic susceptibility contrast cerebral perfusion MR imaging. However, it is sensitive to the time discrepancy between the arrival of the bolus in the tissue concentration-time curve and the arterial input function signal. This normally causes inaccuracy in the quantitative perfusion maps due to delay and dispersion effects. A comprehensive correction algorithm has been achieved through slice-dependent time-shifting of the arterial input function, and a delay-dependent dispersion correction model. The correction algorithm was tested in 11 healthy subjects and three ischemic stroke patients scanned with a quantitative perfusion pulse sequence at 1.5 T. A validation study was performed on five patients with confirmed cerebrovascular occlusive disease scanned with MRI and positron emission tomography at 3.0 T. A significant effect (P < 0.05) was reported on the quantitative cerebral blood flow and mean transit time measurements (up to 50%). There was no statistically significant effect on the quantitative cerebral blood volume values. The in vivo results were in agreement with the simulation results, as well as previous literature. This minimizes the bias in patient diagnosis due to the existing errors and artifacts in dynamic susceptibility contrast imaging.

Quantitative computed tomographic predictors of compressive optic neuropathy in patients with thyroid orbitopathy: a volumetric analysis.

PURPOSE: To evaluate the relationship between orbital bony geometry and the volume of the intraorbital structures in predicting compressive dysthyroid optic neuropathy (DON). DESIGN: Retrospective, consecutive case series. PARTICIPANTS: Images of 198 orbits from 99 patients suffering from thyroid-related orbitopathy were reviewed. METHODS: Clinical examination and computed tomography of the orbits, including volumetric analysis, were performed on all patients. MAIN OUTCOME MEASURES: Clinical and radiologic predictors of DON. RESULTS: Significant volumetric univariate predictors of compressive optic neuropathy included medial rectus volume (P = 0.005), lateral rectus volume (P = 0.011), superior muscle group volume (P = 0.04), and total rectus muscle volume (P = 0.015). Inferior rectus muscle volume, orbital volume, bony orbital apex angle, globe diameter, and bony medial wall contour were not associated with optic neuropathy. Multivariate modeling found medial rectus volume the only independently significant predictor. Univariate modeling of simple rectus diameter measurements found medial rectus axial diameter (P = 0.003) and total recti diameter (P = 0.016) predictive of optic neuropathy. Lateral rectus, superior rectus, and inferior rectus diameters were not predictive. Multivariate modeling found only medial rectus diameter to be a significant independent predictor of optic neuropathy. The area under the receiver operating characteristic curve was not different between the volumetric and rectus diameter curves. CONCLUSIONS: Medial rectus size was found to be the most important quantifiable predictor of compressive optic neuropathy in patients with optic neuropathy. In this study, simple maximum medial rectus diameter, as measured on axial scans, was equally predictive of compressive optic neuropathy as the more involved volumetric calculation. Assessment of orbital geometry, including bowing of the medial wall, orbital apex angle, globe diameter, and orbital volume, were not found to be predictive of DON.

Magnetization spoiling in radial FLASH contrast-enhanced MR digital subtraction angiography.

PURPOSE: To increase the in-plane spatial resolution and image update rates of 2D magnetic resonance (MR) digital subtraction angiography (DSA) pulse sequences to 0.57 × 0.57 mm and 6 frames/sec, respectively, for intracranial vascular disease applications by developing a radial FLASH protocol and to characterize a new artifact, not previously described in the literature, which arises in the presence of such pulse sequences. MATERIALS AND METHODS: The pulse sequence was optimized and artifacts were characterized using simulation and phantom studies. With Institutional Review Board (IRB) approval, the pulse sequence was used to acquire time-resolved images from healthy human volunteers and patients with x-ray DSA-confirmed intracranial vascular disease. RESULTS: Artifacts were shown to derive from inhomogeneous spoiling due to the nature of radial waveforms. Gradient spoiling strategies were proposed to eliminate the observed artifact by balancing gradient moments across TR intervals. The resulting radial 2D MR DSA sequence (2.6 sec temporal footprint, 6 frames/sec with sliding window factor 16, 0.57 × 0.57 mm in-plane) demonstrated small vessel detail and corroborated x-ray DSA findings in intracranial vascular imaging studies. CONCLUSION: Appropriate gradient spoiling in radial 2D MR DSA pulse sequences improves intracranial vascular depiction by eliminating circular banding artifacts. The proposed pulse sequence may provide a useful addition to clinically applied 2D MR DSA scans.

Continued Dominance of Carotid Endarterectomy over Stenting in the United States: Volumes, Outcomes, and Complications from the National Inpatient Sample (1997-2015).

BACKGROUND: The introduction of carotid stenting (CAS) has led to numerous comparative trials with carotid endarterectomy (CEA). OBJECTIVE: The objective of the study was to review real-world volumes, outcomes, and complications following CEA versus CAS over an extended period to identify durable changes in practice. METHODS: Data were extracted from the National Inpatient Sample. Trends were assessed by annual percent change (APC), and adjusted risk ratios were calculated across the last 5 years of the study period. RESULTS: During 1997-2015, 199,330 symptomatic and 1,995,637 asymptomatic patients underwent carotid revascularization. In symptomatic patients, CEA declined (1997-2004; APC = -7.68%, P < 0.001) and CAS rose (1997-2008; APC = 15.48%, P < 0.001) during the first decade, subsequently becoming more muted. In asymptomatic patients, CEA decreased, whereas CAS initially increased (1997-2006; APC = 20.27%, P < 0.001) and then decreased (2007-2015; APC = -4.52%, P < 0.001). Routine discharge after symptomatic revascularization declined in CEA after 2003 and in CAS after 2006 (APC = -1.72% and -3.11%, respectively, P < 0.001 for both), corresponding to increasing patient comorbidity; similar trends were seen in asymptomatic patients. Death decreased after CEA (symptomatic and asymptomatic; APC = -4.85% and -3.53%, respectively, P < 0.001 for both) and CAS (asymptomatic only, APC = -2.53%, P = 0.04). CAS remained associated with a higher adjusted risk ratio for death, venous thromboembolism, and seizures in all patients and stroke and nonroutine discharge in symptomatic patients, during the last 5 years of the study period. CONCLUSIONS: Mortality has improved, but routine discharge has decreased following both CEA and CAS, congruent with increasing patient comorbidity. Trends in volumes, outcomes, and complication rates continue to favor CEA in real-world practice.

Endovascular stroke therapy: a single-center retrospective review.

OBJECT: Endovascular treatment of acute ischemic stroke delivers direct therapy at the site of an occluded cerebral artery and can be employed beyond the 3-4.5-hour window limit set for intravenous recombinant tissue plasminogen activator. In this paper, the authors report their experience with various endovascular therapies in acute ischemic stroke. METHODS: The authors conducted a retrospective review of their clinical database for acute ischemic stroke in large-vessel cerebral territories that underwent endovascular treatment between May 2005 and February 2009. Endovascular treatment was defined as pharmacological and/or mechanical intervention, angioplasty, stenting, or a combination of these methods. Admission National Institutes of Health Stroke Scale and the modified Rankin Scale scores were recorded. Thrombolysis in Myocardial Infarction (TIMI) scores of 0, 1, 2A, 2B, and 3 were used to define recanalization. RESULTS: Forty procedures were performed in 39 patients, with 1 patient having sequential bilateral strokes. Nine patients were lost to follow-up after discharge. Strokes in the carotid artery circulation occurred in 82.5% of cases, and those in the vertebral-basilar territory occurred in 17.5%. The Merci device was used in 22 (55%) of 40 procedures, and the Penumbra device in 9 (22.5%) of 40. Angioplasty was performed in 15 (37.5%) of 40 procedures, and intraarterial recombinant tissue plasminogen activator was administered in 23 (57.5%) of 40 procedures. In 23 (57.5%) of 40 cases, multiple recanalization methods were used. The recanalization rate for all methods was 60%. The recanalization rate from TIMI Score 0/1 occlusions was 71.4% (20 of 28). An estimated modified Rankin Scale score of ≤ 2 was obtained in 11 (36.7%) of 30 cases. The overall mortality rate was 26.7% (8 of 30). Intracerebral hemorrhage at 24 hours postprocedure was noted in 17 (42.5%) of 40 cases, 3 (7.5%) of which were symptomatic. CONCLUSIONS: The authors' institution performs endovascular stroke treatment with a safety and efficacy profile comparable to those of other major endovascular stroke therapy studies. Recanalization was associated with an improved clinical outcome. Protocols to maximize efficient triage of patients and better documentation of stroke treatments can assist in further studies.

Direct percutaneous transcarotid approach for embolization of dural sinus malformation in a premature neonate: A case report.

CONCLUSIONS: Direct percutaneous TCAA can be a feasible access for intracranial interventions in neonates with LBW and unavailable UA access.

Follow-up neutrophil-lymphocyte ratio after stroke thrombectomy is an independent biomarker of clinical outcome.

BACKGROUND: Admission neutrophil-lymphocyte ratio (NLR) is significantly correlated to clinical outcomes in acute ischemic stroke (AIS). We investigated follow-up NLR and temporal changes in NLR after endovascular thrombectomy (EVT) with respect to successful revascularization, clinical outcomes, symptomatic intracranial hemorrhage (sICH) and mortality. METHODS: Retrospective analysis of EVT for anterior circulation emergent LVO was performed with both admission (NLR1) and 3-7 day follow-up NLR (NLR2) laboratory data. Patient demographics, National Institutes of Health Stroke Scale (NIHSS) presentations, reperfusion efficacy (modified Thrombolysis in Cerebral Infarction (mTICI) score), sICH, and clinical outcomes (modified Rankin Scale (mRS)) at 90 days were studied. Univariate analyses correlated NLR1, NLR2, and temporal change in NLR (NLR2-NLR1) with successful reperfusion (mTICI ≥2b), favorable outcomes (mRS ≤2), sICH, and mortality. Multivariable logistic regression model evaluated the independent effects of NLR2 on favorable outcomes. RESULTS: 142 AIS patients with median NIHSS 17 underwent EVT within 24 hours, and met NLR laboratory inclusion criteria. Lower follow-up NLR2 and less temporal change in NLR over 3-7 days, but not admission NLR1, inversely correlated with successful reperfusion (p<0.05) and favorable clinical outcomes (p<0.001). Higher follow-up NLR2 and greater temporal change in NLR was significantly associated with sICH and mortality (p≤0.05). In multivariable logistic regression, lower follow-up NLR2 remained a predictor of favorable outcomes (OR 0.785, p=0.001), independent of age or successful reperfusion. CONCLUSIONS: Follow-up NLR is a readily available and modifiable biomarker that correlates with the degree of reperfusion after mechanical stroke thrombectomy. Lower follow-up NLR2 at 3-7 days is associated with successful reperfusion and an independent predictor of favorable clinical outcomes, with reduced risk for sICH and mortality.

Case Report: Anterior Spinal Cord Ischemia Following Embolization of Cerebellar Arteriovenous Malformation: An Illustrative Case and Review of Spinal Cord Vascular Anatomy.

Spinal cord ischemia (SCI) is a rare entity with high mortality and morbidity which can arise from causes such as atherosclerosis, aortic dissection or aneurysm, thromboembolic events or systemic hypotension, and is a potential complication of spinal surgery. Published literature contains very few reports of SCI as a complication of intracranial interventions, highlighting the uncommon nature of SCI in these circumstances. We report the occurrence of anterior SCI in a 69-year-old patient following successful embolization of a cerebellar arteriovenous malformation (AVM), marked by upper extremity weakness, lower extremity paraplegia, loss of bladder and bowel control, and hypercapnic respiratory failure requiring mechanical ventilation. Magnetic resonance imaging (MRI) demonstrated upper cervical diffusion restriction and T2/STIR hyperintensity. Unusually, SCI occurred in this case without intraprocedural catheter wedging or obvious flow limitation, prolonged procedure time, hypercoagulable state, or general hypotension. We review previous cases in the literature as well as spinal cord vascular anatomy, and discuss the possible etiologies of this complication. Spinal cord ischemia could be a very rare complication of neuroendovascular procedures even in the absence of warning signs and should be carefully evaluated in patients with suspected neurologic symptoms after such procedures.

Pipeline embolization of cerebral aneurysms in pediatric patients: combined systematic review of patient-level data and multicenter retrospective review.

OBJECTIVE: Cerebral aneurysms in the pediatric population are rare and optimal treatment strategies are not as well characterized as in adults. The Pipeline embolization device (PED) is an endoluminal flow diverter that is commonly used to treat aneurysms in adults, but experience with this device in children is limited. The authors sought to further characterize PED use and outcomes in this specific population by performing both a systematic review of patient-level data from studies reporting the use of the PED to treat pediatric aneurysms and a retrospective review of their experience. METHODS: A systematic review of the PubMed, Embase, and Scopus databases was performed to identify studies reporting the use of the PED in pediatric patients (age ≤ 18 years). Disaggregated data regarding demographics, aneurysm characteristics, treatment, and outcomes were collected. Retrospective data from the authors' two institutions were also included. RESULTS: Thirty studies comprising patient-level data on 43 pediatric patients with 47 aneurysms were identified. An additional 9 patients with 9 aneurysms were included from the authors' institutions for a total of 52 patients with 56 aneurysms. The mean patient age was 11.1 years. Presentations included aneurysm rupture (17.3%) and symptomatic mass effect (23.1%). Aneurysms were located in the anterior circulation in 55.4% of cases, and 73.2% were described as nonsaccular. Imaging follow-up was available for 89.3% with a mean follow-up of 13.3 months. Aneurysm occlusion was reported in 75%, with 1 case each (1.8%) demonstrating significant in-stent stenosis and parent vessel occlusion. Clinical follow-up was reported in 90.4% with a mean follow-up of 14.7 months. Good functional outcomes (modified Rankin Scale score of 0-1 or Glasgow Outcome Scale score of 5) were reported in 65.4% of the total population. Two major complications were reported, including 1 death. CONCLUSIONS: Despite substantial differences in aneurysm location and type between published pediatric and adult patient populations treated with the PED, the use of the PED in the pediatric population appears to be safe. While the short-term effectiveness is also similar to that of adults, additional studies are needed to further characterize the long-term outcomes and better define the use of this device in pediatric patients.

Radiotherapy-induced common carotid pseudoaneurysm presenting with initially occult upper airway hemorrhage and successfully treated by endovascular stent graft.

Radiation induced carotid vasculopathy may present as steno-occlusive disease or less commonly as a pseudoaneurysm. The latter most often presents with a pulsatile mass but is a potential cause of life threatening hemorrhage. We present a case of a small common carotid artery (CCA) pseudoaneurysm that was initially dismissed as the cause of the patients presenting epistaxis given its small size and location. After standard bilateral internal maxillary artery embolizations failed to prevent significant subsequent pharyngeal and tracheal blood loss and serial imaging demonstrated a progressive enlargement of the pseudoaneurysm, a stent graft was successfully placed across the lesion. At five months post stenting, follow-up imaging of the neck showed a stable obliteration of the pseudoaneurysm, good arterial patency, and the patient remained free of recurrent hemorrhage. This case demonstrates that even a small carotid pseudoaneurysm, can present with pharyngeal hemorrhage and should be treated aggressively--with endovascular stent grafting being a preferred treatment modality for arterial lesions in the irradiated neck.