Acute StrokeTreatment in Children: Are Adult Guidelines Applicable?

Purpose of this Review: This article provides an overview into acute treatments in stroke which are widely studied and available for adults and their applicability in the pediatric population. Recent Findings: Arterial ischemic stroke is an important cause of morbidity and mortality in the pediatric population. Neurological deficits and etiologies are age-dependent and more challenging to diagnose than in the adult population. Advancements in imaging and treatment modalities including increased treatment windows in acute stroke have led to improvement in the diagnosis and management of pediatric arterial ischemic disease. Accordingly, hyperacute treatments, such as endovascular therapy, are becoming increasingly available in an attempt to improve outcomes in children. Summary: Significant scientific and technological advances have transformed the hyperacute treatment of stroke in the recent years, allowing for improvement in the diagnosis and treatment of cerebrovascular pathologies in children. Optimization in the approach, and validation of existing stroke pathways/protocols is expected to further advance acute stroke therapy in pediatric patient care. Given that the lifelong individual, family, and societal burden of acute stroke is likely to be greater than in adults because infants and children surviving stroke live more years with disability, we must be knowledgeable about this pathology and the medical and therapeutic options available for this unique population as detailed in this review.

Angiography suite cone-beam CT perfusion for selection of thrombectomy patients: A pilot study.

BACKGROUND AND PURPOSE: The availability of cone-beam CT perfusion (CBCTP) in angiography suites may improve large-vessel occlusion (LVO) triage and reduce reperfusion times for patients presenting during extended time window. We aim to evaluate the perfusion maps correlation and agreement between multidetector CT perfusion (MDCTP) and CBCTP when obtained sequentially in patients undergoing endovascular therapy. METHODS: This is a prospective, pilot, single-arm interventional cohort study of consecutive patients with anterior circulation LVO. All patients underwent MDCTP and CBCTP prior to endovascular therapy, generating cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time-to-maximum/time to peak contrast concentration maps. We compared the two imaging modalities using three different methods: (1) six regions of interest (ROIs) placed in the anterior circulation territory; (2) ROIs placed in all 10 Alberta Stroke Program Early CT Score regions; and (3) ROI drawn around the entire ischemic area. ROI ratios (unaffected/affected area) were compared for all sequences in each method. We used the intraclass correlation coefficient to calculate the correlation between the studies. Bland-Altman plots were also created to measure the degree of agreement. Finally, a sensitivity analysis was done comparing both modalities in patients with low infarct growth rate. RESULTS: Fourteen patients were included (median age 81 years [74-87], 50% males, median National Institutes of Health Stroke Scale 19 [14-22]). Median time between studies was 42 minutes (interquartile range 29-61). Independently of the method used, we found moderate to excellent correlation in CBF, CBV, and MTT between modalities. CBF correlation further improved in patients with low infarct growth. CONCLUSION: These results demonstrate promising accuracy of CBCTP in evaluating ischemic tissue in patients presenting with LVO ischemic stroke.

Absent hyperdense middle cerebral artery sign is associated with poor functional outcome after mechanical thrombectomy.

BACKGROUND: The hyperdense middle cerebral artery sign on computed tomography indicates proximal middle cerebral artery occlusion. Recent reports suggest an association between the hyperdense sign and successful reperfusion. The prognostic value of the hyperdense middle cerebral artery sign in patients receiving mechanical thrombectomy has not been extensively studied. AIMS: Our study aims to evaluate the association between the hyperdense middle cerebral artery sign and functional outcome in patients with M1 occlusions that had undergone mechanical thrombectomy. METHODS: We conducted a single-center retrospective observational cohort study of 102 consecutive patients presenting with acute M1 occlusions that had undergone mechanical thrombectomy. Patients were stratified into cohorts based on the presence of hyperdense middle cerebral artery sign visually assessed on computed tomography by two readers. The outcomes of interests were functional disability measured by the ordinal Modified Rankin Scale (mRS) at 90 days, mortality, reperfusion status and hemorrhagic conversion. RESULTS: Out of the 102 patients with M1 occlusions, 71 had hyperdense middle cerebral artery sign. There was no significant difference between the cohorts in age, baseline mRS, NIHSS, ASPECTS, and time to reperfusion. The absence of hyperdense middle cerebral artery sign was associated with increased odds of being dependent or dying (higher mRS) (OR: 3.24, 95% CI: 1.30-8.06, p = 0.011) after adjusting for other significant predictors, including age, female sex, hypertension, presenting serum glucose, ASPECTS, CTA collateral score, and successful reperfusion. CONCLUSION: The absence of hyperdense middle cerebral artery sign is associated with worse functional outcome in patients presenting with M1 occlusions undergoing thrombectomy.

Cerebral Venous Sinus Thrombosis Associated With Coronavirus Disease 2019: Case Report and Review of the Literature.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) is associated with significant risk of acute thrombosis. We present a case report of a patient with cerebral venous sinus thrombosis (CVST) associated with COVID-19 and performed a literature review of CVST associated with COVID-19 cases. CASE REPORT: A 38-year-old woman was admitted with severe headache and acute altered mental status a week after confirmed diagnosis of COVID-19. Magnetic resonance imaging brain showed diffuse venous sinus thrombosis involving the superficial and deep veins, and diffuse edema of bilateral thalami, basal ganglia and hippocampi because of venous infarction. Her neurological exam improved with anticoagulation (AC) and was subsequently discharged home. We identified 43 patients presenting with CVST associated with COVID-19 infection. 56% were male with mean age of 51.8±18.2 years old. The mean time of CVST diagnosis was 15.6±23.7 days after onset of COVID-19 symptoms. Most patients (87%) had thrombosis of multiple dural sinuses and parenchymal changes (79%). Almost 40% had deep cerebral venous system thrombosis. Laboratory findings revealed elevated mean D-dimer level (7.14/mL±12.23 mg/L) and mean fibrinogen level (4.71±1.93 g/L). Less than half of patients had prior thrombotic risk factors. Seventeen patients (52%) had good outcomes (mRS <=2). The mortality rate was 39% (13 patients). CONCLUSION: CVST should be in the differential diagnosis when patients present with acute neurological symptoms in this COVID pandemic. The mortality rate of CVST associated with COVID-19 can be very high, therefore, early diagnosis and prompt treatment are crucial to the outcomes of these patients.

Optimal Woven EndoBridge (WEB) Device Size Selection Using Automated Volumetric Software.

INTRODUCTION: Selecting the appropriate Woven EndoBridge (WEB) device sizing for the treatment of wide-neck bifurcation aneurysms (WNBAs) remains challenging. The aim of this study was to evaluate different volumetric-based imaging methodologies to predict an accurate WEB device size selection to result in a successful implantation. METHODS: All consecutive patients treated with WEB devices for intracranial aneurysms from January 2019 to June 2020 were included. Aneurysm dimensions to calculate aneurysm volumes were measured using three different modalities: automated three-dimensional (3D) digital subtraction angiography (DSA), manual 3D DSA, and two-dimensional (2D) DSA. The device-aneurysm volume (DAV) ratio was defined as device volume divided by the aneurysm volume. WEB volumes and the DAV ratios were used for assessing the device implantation success and follow-up angiographic outcomes at six months. Pearson correlation, Wilcoxon Rank Sum test, and density approximations were used for estimating the WEB volumes and the imaging modality volumes for successful implantation. RESULTS: A total of 41 patients with 43 aneurysms were included in the study. WEB device and aneurysm volume correlation coefficient was highest for 3D automatic (r = 0.943), followed by 3D manual (r = 0.919), and 2D DSA (r = 0.882) measurements. Measured median volumes were significantly different for 3D automatic and 2D DSA (p = 0.017). The highest rate of successful implantation (87.5%) was between 0.6 and 0.8 DAV ratio. CONCLUSION: Pre-procedural assessment of DAV ratios may increase WEB device implantation success. Our results suggest that volumetric measurements, especially using automated 3D volumes of the aneurysms, can assist in accurate WEB device size selection.

Safety and Feasibility of Symptomatic Carotid Artery Stent-Assisted Revascularization within 48 Hours after Symptoms Onset.

OBJECTIVE: We aimed to evaluate the safety and feasibility of carotid artery stenting (CAS) performed in the hyperacute period. METHODS: We analyzed a retrospective database of CAS patients from our center. We included patients with symptomatic isolated ipsilateral extracranial carotid stenosis and acute tandem occlusions who underwent CAS. Hyperacute CAS (HCAS) and acute CAS (ACAS) groups were defined as CAS within 48 hours and >48 hours to 14 days from symptoms onset, respectively. The primary outcome was a composite of any stroke, myocardial infarction, or death at 3 months of follow-up. Secondary outcomes were periprocedural complications and restenosis or occlusion rates. RESULTS: We included 97 patients, 39 with HCAS and 58 with ACAS. There was no significant difference between groups for the primary outcome (HCAS 3.3% vs. ACAS 6.1%; p = 1). There were no differences in the rate of perioperative complications between groups although a trend was observed (HCAS 15.3% vs. ACAS 3.4%; p = .057). The rate of restenosis or occlusion between groups (HCAS 8.1% vs. ACAS 9,1%; log-rank test p = .8) was similar with a median time of follow-up of 13.7 months. CONCLUSION: Based on this study, CAS may be feasible in the hyperacute period. However, there are potential higher rates of perioperative complications in the hyperacute group, primarily occurring in MT patients with acute tandem occlusion. A larger multicenter study may be needed to further corroborate our findings.

Combined Transradial and Transfemoral Approach Using a Compliant Balloon for Emboli Protection at the Vertebral Artery During Subclavian Stenosis Stenting: 2-Dimensional Operative Video.

Endovascular intervention has become the mainstay of treatment for subclavian artery stenosis in many centers, with high technical success and low complication rates.1,2 However, potential embolization during proximal subclavian artery intervention can lead to catastrophic posterior circulation ischemic complications.3-5 Although considered a rare complication, the presence of a contralateral hypoplastic vertebral artery with persisting anterograde vertebral blood flow on the affected side is likely to increase the risk of embolization.3 The use of embolic protection devices, such as filters and noncompliant balloons, has been previously described.3,6,7 However, there is still a risk of distal embolization and vessel injury with the use of these devices.7 We present a technical video of a patient in their 80s with left subclavian stenosis who underwent subclavian stent-assisted percutaneous transluminal angioplasty (SAPTA) using an anterograde-retrograde access technique with a dual-lumen compliant balloon catheter (Scepter XC; MicroVention, Aliso Viejo, California) placed at the proximal segment of the left vertebral artery. With this approach, the compliant balloon provides adequate protection while minimizing the risk of endothelial injury and distal embolization. Written informed consent was obtained for the procedure. Patient consent was waived because all health information was deidentified.

Review of current intracranial aneurysm flow diversion technology and clinical use.

Endovascular treatment of intracranial aneurysms (IAs) has evolved considerably over the past decades. The technological advances have been driven by the experience that coils fail to completely exclude all IAs from the blood circulation, the need to treat the diseased parent vessel segment leading to the aneurysm formation, and expansion of endovascular therapy to treat more complex IAs. Stents were initially developed to support the placement of coils inside wide neck aneurysms. However, early work on stent-like tubular braided structure led to a more sophisticated construct that then later was coined as a flow diverter (FD) and found its way into clinical application. Although FDs were initially used to treat wide-neck large and giant internal carotid artery aneurysms only amenable to surgical trap with or without a bypass or endovascular vessel sacrifice, its use in other types of IAs and cerebrovascular pathology promptly followed. Lately, we have witnessed an explosion in the application of FDs and subsequently their modifications leading to their ubiquitous use in endovascular therapy. In this review we aim to compile the available FD technology, evaluate the devices' peculiarities from the authors' perspective, and analyze the current literature to support initial and expanded indications, recognizing that this may be outdated soon.

Quantitative Assessment of Hyperdense Sign Measured by Hounsfield Units is Associated with Unsuccessful Mechanical Thrombectomy.

PURPOSE: Despite advancement in mechanical thrombectomy (MT) techniques, 10-30% of MT for large vessel occlusions (LVO) are unsuccessful. Current prediction models fail to address the association between patient-specific factors and reperfusion. We aimed to evaluate objective, easily reproducible, admission clinical and radiological biomarkers that predict unsuccessful MT. METHODS: We analyzed consecutive anterior LVO MT patients at two comprehensive stroke centers. The primary outcome was unsuccessful reperfusion defined by a modified thrombolysis in cerebral infarction (mTICI) score of 0-2a. We quantitatively assessed the hyperdense vessel sign by measuring Hounsfield units (HU) on admission computed tomography (CT). Receiver operating characteristic (ROC) curves were plotted to estimate the predictive value of quantitative hyperdense middle cerebral artery (MCA) measurements (delta and ratio) and of the final model for mTICI scores. We performed multivariable logistic regression to analyze associations with outcomes. RESULTS: Out of 348 patients 87 had unsuccessful MT. Smoking, difficult arch, vessel tortuosity, vessel calcification, diminutive vessels, truncal M1 occlusion, delta HU and HU ratio were significantly associated with unsuccessful MT in the univariate analysis. When we fitted two separate multivariate models including all significant variables and a HU measurement; delta HU <6 (odds ratio, OR = 2.07, 95% confidence intervals, CI 1.09-3.92) and HU ratio ≤1.1 (OR = 2.003, 95% CI 1.05-3.81) were independently associated with failed MT after adjustment for smoking, diminutive vessels, vessel tortuosity, and difficult arch. The area under the curve AUC<9 of the final model was 0.717. CONCLUSION: Novel radiological biomarkers on CT, CT angiography (CTA) and digital subtraction angiography (DSA) may help identify patients refractory to standard MT and prepare interventionalists for using additional alternative methods. Quantitative assessment of HU (delta and ratio) may be important in developing objective prediction tools for unsuccessful MT.

Retrieval of distally migrated coil using stent retriever and proximal aspiration.

Endovascular coiling has become the preferred treatment of many centers for the management of both ruptured and unruptured aneurysms. Coil migration is a rare complication that can lead to vessel occlusion in 90% of the cases. Endovascular techniques for coil retrieval have shown less complication rates than open surgery. Stent retriever devices have been successfully used for the retrieval of proximally migrated coils, however, distally migrated coils still represent a challenge with greater risk of complications. In the present technical video 1, we demonstrate the successful retrieval of a distally M3 migrated coil using a 3 mm Trevo XP ProVue stent riever (Stryker Neurovascular, Fremont, CA, USA) in combination with proximal aspiration. neurintsurg;13/9/860/V1F1V1Video 1.

Greater intraprocedural systolic blood pressure and blood pressure variability are associated with contrast-induced neurotoxicity after neurointerventional procedures.

BACKGROUND: Contrast-induced neurotoxicity (CIN) is a rare complication of neurointerventional procedures and its understanding remains limited. We evaluated the association of CIN with systemic hemodynamics in patients undergoing neuroendovascular interventions. METHODS: We conducted a 1:2 matched case-control study from a prospectively collected database of 2510 neurointerventional patients. We defined CIN as new neurological deficits presented ≤24 h post-operation after excluding other possible etiologies. We obtained demographic, clinical and imaging data, and baseline and intraprocedural blood pressures (BP) from medical records. The area between baseline and intraprocedural BP was used to measure sustained variability of BP over time. A generalized linear mixed model and generalized estimating equation were used to analyze the BP difference between groups over time. RESULTS: We evaluated 11 CIN cases and 22 controls. 2746 and 5837 min of continued BP data were analyzed for cases and controls, respectively. CIN cases had higher measurements and greater variability for: Systolic BP (SBP) [median 125 (IQR:121-147) vs. 114 (IQR:107-124) mmHg], median area above baseline [median 350 (IQR:25-1328) vs. 52 (IQR:0-293) mmHg*minutes] and mean arterial pressure (MAP) [median 85 (IQR:79-98) vs. 80 (IQR:74-89) mmHg]. CIN cases demonstrated a significant mean increase in SBP and MAP of 23.41 mmHg (p < 0.01) and 13.79 mmHg (p < 0.01) when compared to controls, respectively, over the perioperative time. CONCLUSION: Sustained hypertension and high BP variability may contribute to the pathophysiology of CIN. Acute hypertension can increase blood-brain barrier permeability and potentially allow contrast to leak into the brain parenchyma causing direct toxicity and CIN symptoms.

Combined Transradial and Transfemoral Approach With Ostial Vertebral Balloon Protection for the Treatment of Patients With Subclavian Steal Syndrome.

Background: Patients with an obstructive subclavian artery (SA) may exhibit symptoms of vertebrobasilar insufficiency known as subclavian steal syndrome (SSS). Endovascular treatment with stent assisted percutaneous transluminal angioplasty (SAPTA) demonstrates significantly lower percentage of intraoperative and postoperative complications in comparison with open surgery. There is a 1-5% risk of distal intracranial embolization through the ipsilateral vertebral artery (VA) during SAPTA. Objective: To assess the safety and feasibility of a novel technique for distal embolic protection using balloon catheters during SA revascularization with a dual transfemoral and transradial access. Methods: We describe a case series of patients with SSS who underwent SAPTA due to severe stenosis or occlusion of the SA using a combined anterograde/retrograde approach. Transfemoral access to SA was obtained using large bore guide sheaths. Ipsilateral transradial access was obtained using intermediate bore catheters. A Scepter XC balloon catheter was introduced through the transradial intermediate catheter into the ipsilateral VA at the ostium during SAPTA for distal embolic protection. Results: A total of eight patients with SSS underwent subclavian SAPTA. Four patients had the combined anterograde/retrograde approach. Successful revascularization was achieved in three of them. It was difficult to create a channel in the fourth unsuccessful case due to heavily calcified plaque burden. No peri-operative ischemic events were identified. On follow-up, we demonstrated patency of the stents with resolution of symptoms and without any adverse events. Conclusion: Subclavian stenting using a combined transradial and transfemoral access with compliant balloon catheters at the vertebral ostium for prevention of distal emboli may represent an alternative therapeutic approach for the treatment of SA stenosis and occlusions.

Overestimation of core infarct by computed tomography perfusion in the golden hour.

A nonagenarian patient developed a right middle cerebral artery syndrome during recovery after a right internal carotid artery (ICA) balloon angioplasty. Emergent head computed tomography (CT) revealed no acute ischemic changes; CT angiography (CTA) and CT perfusion (CTP) demonstrated a right ICA occlusion with a large right hemispheric predicted core infarct by cerebral blood flow thresholds and minimal mismatch volume. She underwent complete reperfusion in <45 min from symptom onset. Magnetic resonance imaging brain obtained within 48 h showed a decreased infarct volume as that estimated by CTP. This case emphasizes the limitations of estimating the ischemic core with CTP in the golden hour with ultra-early reperfusion and suggests that CTP thresholds should not be used to exclude patients from treatment in the very early time window.

In-House Anesthesia and Interventional Radiology Technologist Support Optimize Mechanical Thrombectomy Workflow after Hours.

BACKGROUND AND PURPOSE: Prior literature suggests after-hours delay leads to poor functional outcomes in stroke patients undergoing thrombectomy. We aimed to evaluate the impact of time of presentation on mechanical thrombectomy (MT) metrics and its association with long-term functional outcome in an Interventional Radiology (IR) suite equipped operating room (OR) setting. METHODS: Retrospective review of prospectively maintained database on all stroke patients undergoing mechanical thrombectomy between January 2015 and December 2018 at our CSC. Work hours were defined by official OR work hours (Monday-Friday 7 AM and 5 PM) and after-hours as between 5 PM and 7 AM during weekdays and weekends as well as official hospital holidays. Primary outcome was 90-day modified Rankin Scale (mRS). Secondary outcomes included door to groin puncture time and procedural complications. RESULTS: A total of 315 patients were included in the analyses. 209 (66.4%) received mechanical thrombectomy after hours and 106 (33.6%) during work hours. There was no difference in the shift distribution of functional outcome on the mRS at 90 days (OR: 1.14, CI: 0.72-1.78, p=0.58) and the percentage of patients achieving functional independence (mRS 0-2) at 90 days (43.1% vs. 41.3%; p=0.83) between the after hour and work hour groups respectively. Similarly, there was no difference in median door to groin times and procedural complications among both groups, with significant year on year improvement in overall time metrics. CONCLUSIONS: Our study showed that undergoing MT during off-hours had similar functional outcomes when compared to MT during working hours in an OR setting. The after-hours deleterious effect might disappear when MT is performed in a system with 24-hours in-house Anesthesia and IR tech services.

Hemorrhagic Cerebrovascular Pathology in the Pediatric Population.

Hemorrhagic cerebrovascular disease in the pediatric population can have devastating and long-term effects. Progress in the fields of genetics, neuroimaging, pharmacology, and surgical techniques has led to improved diagnosis and management of pediatric cerebrovascular diseases. In this review we discuss the current etiologies and medical and surgical treatments of hemorrhagic cerebrovascular pathology affecting infants and children. A special emphasis is placed on neuroendovascular treatment options. Increased knowledge about this unique pathology and the medical and therapeutic options will empower practitioners to more quickly and accurately identify and accurately treat hemorrhagic diseases in the pediatric population.

Patterns of Care and Clinical Outcomes in Patients with Cerebral Sinus Venous Thrombosis.

OBJECTIVES: To explore the association between rurality, transfer patterns and level of care with clinical outcomes of CVST patients in a rural Midwestern state. MATERIALS AND METHODS: CVST patients admitted to the hospitals between 2005 and 2014 were identified by inpatient diagnosis codes from statewide administrative claims dataset. Records were linked across interhospital transfers using probabilistic linkage. Rurality was defined by Rural-Urban Commuting Areas using the 2-category approximation. Driving distances were estimated using GoogleMaps Application Programming Interface. Hospital stroke certification was defined by the Joint Commission. Severity of CVST was estimated by cost of care corrected for inflation and cost-to-charge ratios. Outcome was discharge disposition and total length of stay (LOS). Wilcoxon rank-sum, Chi-square, Fisher's exact tests and linear and logistic regressions were used. RESULTS: 168 CVST patients were identified (79.8% female; median age = 32, IQR = 24.0-45.5). Median LOS was four days (IQR = 2-7) and patients traveled a median of 8.1 miles (IQR = 2.5-28.5) to the first hospital; 42% of patients were transferred to a second hospital, 5% to a third. More than half (58.3%) bypassed the nearest hospital. 86% visit a primary or comprehensive stroke center (CSC) during their acute care. Rurality was not significantly associated with LOS or discharge disposition after adjusting for age, sex and cost of care. Patients in CSC demonstrated greater likelihood of being discharged home compared to at a primary stroke center after adjusting for age and disease severity (p = 0.008). CONCLUSIONS: While rurality was not significantly associated with LOS or disposition outcome, care at a CSC increases likelihood of being discharge home.

Clinical and Imaging Features of Contrast-Induced Neurotoxicity After Neurointerventional Surgery.

BACKGROUND: Contrast-induced neurotoxicity (CIN) is an infrequent complication of endovascular procedures, and its understanding remains poor. We aimed to study and characterize the clinical and imaging features of a case series of CIN after neurointerventional surgery. METHODS: We reviewed all neuroendovascular consecutive procedures from September 2014 to November 2018. CIN was defined as new onset of neurologic deficits that occurred postoperatively after excluding other conditions. All demographic, clinical, procedural, and radiologic data were retrospectively analyzed and collected. RESULTS: Eleven cases of CIN in 1587 patients were identified out of 2510 procedures. The median age was 76 years (interquartile range [IQR], 65-81). The most common comorbidity was hypertension (82%). Median procedure time was 100 minutes (IQR, 80-130.5 minutes). All patients showed wide variability in intraprocedural blood pressure (BP) recordings with fluctuations from the baseline BP. Systolic BP ranged from 83 mm Hg below the patient baseline to 80 mm Hg above baseline. The median symptom onset was 4 hours (IQR, 0.8-9.5 hours). The CIN signs and symptoms presented gradually, initially with encephalopathy and later with focal signs. All patients had an initial computed tomography scan, which showed ipsilateral cerebral edema in 82% of patients. Two had contrast enhancement. Complete resolution of CIN symptoms was obtained in a median time of 3 days (IQR, 2.5-3 days). CONCLUSIONS: CIN should be considered in the context of the progressive onset of neurologic deficits after neuroendovascular procedures. A distinct imaging pattern of ipsilateral hemisphere edema in the absence of ischemia is usually identified. Variability in procedural BP might be a predisposing factor.

Transcirculation Approach for Mechanical Thrombectomy in Acute Ischemic Stroke: A Multicenter Study and Review of the Literature.

Background: Transcirculation approaches, which consist of primary catheterization of a target artery from the contralateral side or opposite cerebral circulation, provide alternate endovascular routes when anterograde interventions are not feasible. We aimed to assess the safety and efficacy of mechanical thrombectomy (MT) through a transcirculation route. Methods: Six centers provided retrospective data on acute ischemic stroke (AIS) patients who underwent MT via transcirculation approaches. Demographics and technical details of the endovascular intervention were collected. Recanalization rates, peri-procedural complications and clinical/angiographic outcomes immediately after the procedure and at last available follow-up were assessed. A review of the literature reporting on AIS patients whom underwent transcirculation MT was also performed. Results: Our multicenter study included 14 AIS patients treated through transcirculation routes. Mean age was 57.8 ± 11.9 years, and 10 (71.4%) were men. Mean NIHSS at admission was 18.4 (range 8-27). TICI 2b-3 recanalization was achieved in 10/14 (71.4%) patients. Three patients died after intervention: one due to late recanalization, one due to acute in-stent thrombosis, and one due to a procedure-related thromboembolic brainstem infarct. Of 11 surviving patients with follow-up available (mean 9.7 months), mRS 0-2 was achieved in 6 (54.5%) cases. Our review of the literature pooled a total of 37 transcirculation MT cases. Most common occlusions were tandem lesions (ICA + MCA = 64.9%) and BA + bilateral VA (18.9%). ACOM and PCOM were crossed in 18 (48.6%) cases each; one patient required a combined ACOM-PCOM approach. Primary recanalization technique included intra-arterial (IA) thrombolytics alone in 10 (27%), angioplasty ± stenting in 6 (16.2%), stent-retriever in 8 (21.6%), contact aspiration in 6, and combined (MT ± IA-thrombolytics) in 6 cases. Twenty-eight (75.7%) AIS patients achieved successful TIMI 2-3/TICI 2b-3 recanalization. After a mean follow-up of 6.7 months, 23/31 (74.2%) patients achieved a favorable functional outcome. Conclusions: Transcirculation approaches may be used to access the target lesion when the parent artery cannot be crossed through conventional antegrade routes. These techniques are feasible but should be reserved as a bailout maneuver when anterograde MT is not possible. Newer endovascular devices have improved neurological and angiographic outcomes in transcirculation cases.

Neuromuscular Mimics of Entrapment Neuropathies of Upper Extremities.

Introduction: Carpal tunnel syndrome and ulnar neuropathy are such common maladies affecting the upper extremties that they often become the default diagnosis when patients complain of numbness, pain, or weakness of the hands. While often correct, there are a number of other conditions that can also cause sensory or motor loss of the hands, which should be considered when appropriate, as they can mimic upper extremity entrapment syndromes. Methods: In this review, we will discuss such mimics, including Charcot-Marie-Tooth disease, multifocal motor neuropathy, hereditary neuropathy with pressure palsies, mononeuropathy multiplex, Lewis-Sumner syndrome, brachial plexitis (Parsonage-Turner syndrome), myotonic dystrophy, inclusion body myopathy, and distal myopathy of Welander. We will discuss the clinical presentation, as well as diagnostic testing, treatment (if available), and prognosis. Conclusion: The objective is to provide a differential diagnosis for those patients who do not fit well clinically or respond to usual therapy for entrapment neuropathy of the upper extremities.