Cerebral Venous Thrombosis in COVID-19: A New York Metropolitan Cohort Study.

BACKGROUND AND PURPOSE: Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infection is associated with hypercoagulability. We sought to evaluate the demographic and clinical characteristics of cerebral venous thrombosis among patients hospitalized for coronavirus disease 2019 (COVID-19) at 6 tertiary care centers in the New York City metropolitan area. MATERIALS AND METHODS: We conducted a retrospective multicenter cohort study of 13,500 consecutive patients with COVID-19 who were hospitalized between March 1 and May 30, 2020. RESULTS: Of 13,500 patients with COVID-19, twelve had imaging-proved cerebral venous thrombosis with an incidence of 8.8 per 10,000 during 3 months, which is considerably higher than the reported incidence of cerebral venous thrombosis in the general population of 5 per million annually. There was a male preponderance (8 men, 4 women) and an average age of 49 years (95% CI, 36-62 years; range, 17-95 years). Only 1 patient (8%) had a history of thromboembolic disease. Neurologic symptoms secondary to cerebral venous thrombosis occurred within 24 hours of the onset of the respiratory and constitutional symptoms in 58% of cases, and 75% had venous infarction, hemorrhage, or both on brain imaging. Management consisted of anticoagulation, endovascular thrombectomy, and surgical hematoma evacuation. The mortality rate was 25%. CONCLUSIONS: Early evidence suggests a higher-than-expected frequency of cerebral venous thrombosis among patients hospitalized for COVID-19. Cerebral venous thrombosis should be included in the differential diagnosis of neurologic syndromes associated with SARS-CoV-2 infection.

Regional intensity of neurosurgical care and integration of aneurysm coiling in the United States.

AIM: There is wide regional variability in the volume of procedures performed for similar surgical patients throughout the United States. We investigated the association of the intensity of neurosurgical care with the diffusion of the novel technology of cerebral aneurysm coiling. METHODS: We performed a retrospective cohort study involving patients who underwent any neurosurgical procedure from 2005-2010 and were registered in the National Inpatient Sample (NIS) database. A sub-cohort of patients undergoing aneurysm clipping or coiling was also created. Regression techniques were used to investigate the association of the average risk-adjusted intensity of neurosurgical care with the average rate of coiling. RESULTS: There were significant disparities in the rate of coiling among several states (ANOVA, P<0.0001). It ranged from 0.24 in Maryland, where clipping was very predominant, to 0.82 in Minnesota, where coiling was the main treatment modality used. In multivariate analysis, higher coiling rate was associated with increased age, higher income, rural hospital location, and small institution size. The Midwest was association with higher rate in comparison to the Northeast, whereas the West and the South had even lower rates. Increasing rate of coiling was associated with increasing intensity of neurosurgical care. There was a positive correlation of the average risk-adjusted intensity of neurosurgical care with the average rate of coiling per state (Pearson's ρ=0.43, P<0.001). CONCLUSION: We observed significant disparities in the rate of coiling in the United States. Increased intensity of neurosurgical care was positively associated with the integration of coiling in treatment of cerebral aneurysms.

Socioeconomic characteristics of patients undergoing ambulatory diagnostic cerebral angiography in four US States.

AIMS: Several groups have demonstrated the safety of ambulatory cerebral angiography, with no patients experiencing complications related to early discharge. Although this practice appears to be safe, the socioeconomic characteristics factoring in the selection of the patients have not been investigated. METHODS: We performed a retrospective cohort study involving 45,226 patients undergoing outpatient and 159,046 undergoing inpatient cerebral angiography, who were registered in the State Ambulatory Surgery Databases (SASD) and State Inpatient Databases (SID) respectively for 4 US States (New York, California, Florida, North Carolina). RESULTS: In a multivariate analysis of diagnostic cerebral angiography, Caucasian race (OR 1.36, 95% CI, 1.31, 1.42) and male gender (OR 1.36, 95% CI, 1.31, 1.41), were significantly associated with outpatient procedures. Higher Charlson Comorbidity Index (CCI) (OR 0.60, 95% CI, 0.54, 0.67), high income (OR 0.70, 95% CI, 0.67, 0.73), high volume hospitals (OR 0.69, 95% CI, 0.66, 0.73), and coverage by Medicare/Medicaid (OR 0.96, 95% CI, 0.92, 0.99) were associated with a decreased chance of outpatient procedures. Institutional charges were significantly less for outpatient cerebral angiography. The median charge for inpatient diagnostic cerebral angiography was $26,968 as compared to $16,151 in the outpatient setting (P < 0.0001, Student's t-test). CONCLUSION: Access to ambulatory diagnostic cerebral angiography appears to be more common for patients with private insurance and less comorbidities, in the setting of lower volume hospitals. Further investigation is needed in the direction of mapping these disparities in resource utilization.

B-mode estimate of carotid stenosis: planimetric measurements complement the velocity estimate of internal carotid stenosis.

AIM: Velocity criteria for diagnosis of carotid stenosis are subject to flow phenomenon such as contralateral stenosis or occlusion. Duplex tri-axial diameter and cross sectional area measurements are potentially more accurate because they are anatomic. METHODS: As part of a prospective study on triplanar ultrasound carotid stenosis measurements, 30 consecutive patients were studied by 3 independent operators to assess variability of the technique. PSV and EDV were recorded at the common and internal carotid arteries and Duplex B-mode long-axis and diameter views were obtained using color and/or power Doppler. Cross-sectional area (CSAS), minimal luminal diameter (MLD), and triaxial diameter measurements, based on the NASCET criteria were performed at the narrowest lumen. RESULTS: The CSAS, MLD and triaxial diameter measurements were not significantly different in the 3 measurements and that was true for the 3 operators (ANOVA, P=0.1 for both). There were 4 patients where the velocity measurements differed by one stenosis grade, when compared to diameter. The triaxial diameter stenosis correlated well with the percent area reduction for all three measurements. Other than having a very good linear relationship (R2=0.95, R2=0.96, R2=0.93). The MLD was reduced with increasing grades of stenosis and provided a clear separation between the 50-69% and 80-99% grades with only a small overlap in the 70-79% grade. CONCLUSION: The present analysis demonstrates that CSAS and triaxial diameter can be performed by experienced investigators with low variability and good reproducibility. Velocity and planimetric measurements are complimentary in the assessment of carotid artery stenosis.

Indications for treatment of recurrent carotid stenosis.

BACKGROUND: There is significant variation in the indications for intervention in patients with recurrent carotid artery stenosis. The aim of the present study was to describe these indications in a contemporary cohort of patients. METHODS: This was a systematic review of all peer-reviewed studies reporting on the indications for carotid intervention in patients with recurrent stenosis after carotid endarterectomy (CEA) or carotid artery stenting (CAS) that were published between 1990 and 2012. RESULTS: There were 50 studies reporting on a total of 3524 patients undergoing a carotid procedure; of these, 3478 underwent CEA as the initial intervention. Reintervention was by CEA in 2403 patients and by CAS in 1121. Only 54·7 per cent of the patients were treated for any symptoms and, importantly, just 444 (23·1 per cent of 1926 symptomatic patients) underwent intervention for documented ipsilateral symptoms. None of the studies reported whether the patients were evaluated for other sources of emboli. The remaining 45·3 per cent of patients had asymptomatic restenosis and in the majority of the studies were treated when the degree of stenosis exceeded 80 per cent. The time to repeat intervention was significantly longer in patients with recurrent atherosclerosis, in asymptomatic patients and in patients undergoing CEA. CONCLUSION: The reported criteria for retreatment of carotid stenosis were not rigorous and there is still significant ambiguity surrounding the indications for intervention.

Scalp arteriovenous malformation associated with a superior sagittal sinus, sinus pericranii.

Scalp arteriovenous malformations (AVMs) and sinus pericranii are two rare vascular lesions of the scalp that are part of the differential diagnosis in patients with scalp masses. The necessity of treatment of sinus pericranii, due to its risk of catastrophic hemorrhage or scalp necrosis, makes its diagnosis imperative. There are several theories on the pathogenesis of sinus pericranii with some of them stressing the importance of altered hemodynamic parameters in the affected area. An 8-year-old girl presented with a five centimeter soft, reducible scalp mass that had been present since birth. Clinical and radiographic evaluation revealed a sinus pericranii in association with a scalp AVM. She underwent resection of the sinus pericranii followed by embolization and planned separate en bloc resection of the AVM. During resection of the scalp AVM at a later date, the sinus pericranii was noted to have recurred. Concurrent treatment of all vascular anomalies associated with a sinus pericranii appears to be the key to its complete eradication.

Stroke of the posterior cerebral circulation.

AIM: Identification of stroke etiology aids in developing secondary prevention and treatment strategies for posterior circulation stroke (PCS). Studies have identified large vessel atherosclerotic disease as the predominant etiology and others have cited cardioembolism. This study was designed to describe the prevalence, outcome, and stroke mechanisms of PCS and to analyze the strengths and weaknesses of the classifications used. METHODS: A comprehensive MEDLINE search identified seven studies evaluating the etiology of PCS. Incoherent data and lack of prospective studies made performance of a thorough meta-analysis impossible. Special attention was paid to the design of trials and the classifications used. In a similar way, the limitations of each study were clearly determined. RESULTS: Seven trials encompassing 8057 patients, of which 23% were isolated PCS and 4% were combined ACS and PCS, were analyzed. Overall, large vessel atherosclerotic disease was responsible for 35% of PCS, cardioembolism for 18%, small vessel disease for 13% and undetermined etiology for 15%. Strokes of mixed and "other" etiology represented 4% and 8% of PCS respectively. Major sequelae were observed in 10.8-17.7% of patients with no sequelae noted in 7-28% of patients. Mortality ranged from 4-10% and it was directly related to stroke in 2-5%. CONCLUSION: Large vessel atherosclerotic disease was the most common stroke subtype identified. Conclusions are inconsistent between the studies, highlighting the difficulties in systematic investigations of stroke etiology and the need for a unified approach to stroke classification.