Diagnostic Value of Vessel Wall Imaging to Determine the Timing of Extracranial‒Intracranial Bypass for Moyamoya Syndrome Associated with Active Sjögren's Syndrome: A Case Report.

BACKGROUND: Sjögren's syndrome is a chronic autoimmune disorder that predominantly affects exocrine organs. It is characterized by an organ-specific infiltration of lymphocytes. The involvement of the major cerebral arteries in Sjögren's syndrome has rarely been reported. A recent study reported a case of successful extracranial-intracranial (EC-IC) bypass without complications, even in the active inflammatory state, although the optimal timing of such a bypass remains unclear. CASE DESCRIPTION: We here report the case of a 43-year-old woman presenting with acute ischemic stroke due to progressive middle cerebral artery (MCA) occlusion and signs of primary Sjögren's syndrome. During intensive immunosuppressive therapy for active Sjögren's syndrome, the patient was monitored using contrast-enhanced magnetic resonance vessel wall imaging (MR-VWI). A couple of intravenous cyclophosphamide injections combined with a methylprednisolone pulse and antiplatelet therapy resulted in clear resolution of vessel wall enhancement, which suggested remission of inflammatory vasculitis. Nevertheless, she still experienced a transient ischemic attack (TIA) due to decreased regional cerebral blood flow by MCA occlusion, as demonstrated by the conventional time-of-flight MR angiography and single-photon emission computed tomography. Considering the increased risk of further stroke, the decision was made to perform an EC-IC bypass as a treatment for medically uncontrollable hemodynamic impairment. Her postoperative course was uneventful without further repeated TIAs, and continued immunosuppressive therapy for Sjögren's syndrome provided effective management. CONCLUSIONS: Our findings emphasize the diagnostic value of contrast-enhanced MR-VWI in monitoring the effect of immunosuppressive therapy for the major cerebral artery vasculitis and in determining the timing of EC-IC bypass as a "rescue" treatment for moyamoya syndrome associated with active Sjögren's syndrome.

Long-Term Outcomes After Stenting in Extracranial vs. Intracranial Stenosis.

Objective: The purpose of this pilot study is to explore the difference in safety and effectiveness after stenting in patients with extracranial or intracranial vertebral artery stenosis. Methods: The study involved 26 patients treated with stents for ≥70% stenosis between January 1, 2017, and September 8, 2020. The patients were divided into intracranial and extracranial groups based on the location of the target vessel stenosis. The incidence of stroke or death within 30 days, long-term recurrence of ischemic symptoms, and restenosis during follow-up were monitored. Results: Within 30 days, no stroke or death was observed in the 26 patients, During the follow-up period, the risk of recurrence of posterior circulation stroke or transient ischemic attack was 23.1% (6/26). Vascular-related complications were 5.6% vs. 12.5% (P = .529) in the intracranial vs. extracranial stenosis group. After 1 year, stroke or transient ischemic attack of posterior circulation was observed in 12.5% (1/8) vs. 16.7% (3/18) in the intracranial and extracranial stenosis group, respectively. The restenosis rate in the intracranial stenosis group was higher than the extracranial stenosis group (37.5% vs. 28.6%, P > .05). This trend was also found in the asymptomatic restenosis rate (25% vs. 7.1%, P = .527). Conclusions: The study results showed that there was no significant difference in the safety and effectiveness after stenting in extracranial and intracranial vertebral artery stenosis, but intracranial vertebral artery stenosis has a low rate of symptomatic restenosis. Symptomatic restenosis may be an important problem that limits the efficacy of extracranial vertebral artery stenting.

Extracranial-Intracranial Bypass and Risk of Stroke and Death in Patients With Symptomatic Artery Occlusion: The CMOSS Randomized Clinical Trial.

Importance: Prior trials of extracranial-intracranial (EC-IC) bypass surgery showed no benefit for stroke prevention in patients with atherosclerotic occlusion of the internal carotid artery (ICA) or middle cerebral artery (MCA), but there have been subsequent improvements in surgical techniques and patient selection. Objective: To evaluate EC-IC bypass surgery in symptomatic patients with atherosclerotic occlusion of the ICA or MCA, using refined patient and operator selection. Design, Setting, and Participants: This was a randomized, open-label, outcome assessor-blinded trial conducted at 13 centers in China. A total of 324 patients with ICA or MCA occlusion with transient ischemic attack or nondisabling ischemic stroke attributed to hemodynamic insufficiency based on computed tomography perfusion imaging were recruited between June 2013 and March 2018 (final follow-up: March 18, 2020). Interventions: EC-IC bypass surgery plus medical therapy (surgical group; n = 161) or medical therapy alone (medical group; n = 163). Medical therapy included antiplatelet therapy and stroke risk factor control. Main Outcomes and Measures: The primary outcome was a composite of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years after randomization. There were 9 secondary outcomes, including any stroke or death within 2 years and fatal stroke within 2 years. Results: Among 330 patients who were enrolled, 324 patients were confirmed eligible (median age, 52.7 years; 257 men [79.3%]) and 309 (95.4%) completed the trial. For the surgical group vs medical group, no significant difference was found for the composite primary outcome (8.6% [13/151] vs 12.3% [19/155]; incidence difference, -3.6% [95% CI, -10.1% to 2.9%]; hazard ratio [HR], 0.71 [95% CI, 0.33-1.54]; P = .39). The 30-day risk of stroke or death was 6.2% (10/161) in the surgical group and 1.8% (3/163) in the medical group, and the risk of ipsilateral ischemic stroke beyond 30 days through 2 years was 2.0% (3/151) and 10.3% (16/155), respectively. Of the 9 prespecified secondary end points, none showed a significant difference including any stroke or death within 2 years (9.9% [15/152] vs 15.3% [24/157]; incidence difference, -5.4% [95% CI, -12.5% to 1.7%]; HR, 0.69 [95% CI, 0.34-1.39]; P = .30) and fatal stroke within 2 years (2.0% [3/150] vs 0% [0/153]; incidence difference, 1.9% [95% CI, -0.2% to 4.0%]; P = .08). Conclusions and Relevance: Among patients with symptomatic ICA or MCA occlusion and hemodynamic insufficiency, the addition of bypass surgery to medical therapy did not significantly change the risk of the composite outcome of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years. Trial Registration: ClinicalTrials.gov Identifier: NCT01758614.

Diagnosis and management of acute conditions of the extracranial carotid artery.

Symptomatic carotid stenosis and carotid dissection are acute conditions of extracranial cerebrovascular vessels determining transient ischemic attack or stroke. Medical, surgical, or endovascular management are different options to treat these pathologies. This narrative review focused on the management, from symptoms to treatment, of the acute conditions of extracranial cerebrovascular vessels, including post-carotid revascularization stroke. Symptomatic carotid stenosis (> 50% according to North American Symptomatic Carotid Endarterectomy Trial criteria) with transient ischemic attack or stroke benefits from carotid revascularization-primarily with carotid endarterectomy associated with medical therapy-within 2 weeks from symptom onset to reduce the risk of stroke recurrence. Different from acute extracranial carotid dissection, medical management with antiplatelet or anticoagulant therapy can prevent new neurologic ischemic events, considering stenting only in case of symptom recurrence. Stroke after carotid revascularization can be associated with the following etiologies: carotid manipulation, plaque fragmentation, or clamping ischemia. Medical or surgical management is therefore influenced by the cause and timing of the neurologic events after carotid revascularization. Acute conditions of the extracranial cerebrovascular vessels include a heterogeneous group of pathologies and correct management can reduce symptom recurrence substantially.

Preceding transient ischemic attack was associated with functional outcome after stroke thrombectomy: A propensity score matching study.

Whether preceding transient ischemic attack (TIA) can provide neuroprotective benefits in subsequent acute ischemic stroke (AIS) caused by large vessel occlusion remains unclarified. This study aimed to investigate the association between preceding TIA and functional outcomes in AIS patients with endovascular therapy (EVT). Eligible patients were divided into TIA and non-TIA groups according to whether they experienced TIA within 96 hours prior to stroke. Two groups were balanced using propensity score matching (PSM) analysis at a 1:3 ratio. Onset stroke severity and 3-month functional independence were evaluated. A total of 887 patients were included. After PSM, 73 patients with and 217 patients without preceding TIA were well matched. Onset stroke severity was not different between the groups (p > 0.05). However, the TIA group had a lower systemic immune-inflammation index (SII) (median, 1091 versus 1358, p < 0.05). Preceding TIA was significantly associated with 3-month functional independence (adjusted odds ratio, 2.852; 95% confidence interval [CI], 1.481-5.495; adjusted p < 0.01). The effects of preceding TIA on functional independence were partially mediated by SII (average causal mediation effects 0.02; 95% CI, 0.001-0.06, p < 0.05). In AIS patients treated by EVT, preceding TIA within 96 hours was associated with three-month functional independence but not with reduced onset stroke severity.

Clinical and echocardiographic outcomes after percutaneous closure of patent foramen ovale: a single center experience.

BACKGROUND: Patent foramen ovale (PFO) has a high estimated prevalence (25% of the general population) and has been implicated in the pathogenesis of cryptogenic stroke and transient ischemic attack (TIA), as well as in the pathogenesis of migraine headache. This study evaluated the effectiveness of percutaneous transcatheter PFO closure with Amplatzer™ (Abbott Laboratories, Abbott Park, IL, USA) devices, from a large single-center experience. METHODS: From January 1998 to December 2014, 577 patients (243 males and 334 females, mean age 50 years, range 11-82 years) with documented PFO and history of at least one episode of cryptogenic stroke/TIA (N.=356) or occasional finding of previous ischemic lesions on MRI (N.=221) underwent percutaneous transcatheter closure of PFO using an Amplatzer™ Occluder (Abbott Laboratories). All the procedures were performed under general anesthesia or mild sedation and were assisted by transesophageal or intracardiac echocardiography. RESULTS: Procedural success was 100%. After a median follow-up period of 2.7 years with echocardiographic evaluations, the rate of recurrent adverse cerebral events was 0.4%. Two patients (0.4%) required a secondary procedure for significant residual shunt. Of 36 patients with minor residual shunt, 30 (83%) showed spontaneous shunt regression at follow-up. There was a consistent decrease after procedure in headache migraine, platypnea-orthodeoxia, fainting episodes, syncope, and coenesthesia phenomena. CONCLUSIONS: Transcatheter PFO closure is an effective and safe therapy for the prevention of thromboembolic events in the patients with cryptogenic stroke/TIA or an occasional finding of a positive cerebral MRI. Late follow-up shows device stability and clinical improvement in the majority of patients.

Modified Eversion Carotid Endarterectomy: A Novel Surgical Technique for Carotid Artery Stenosis Treatment.

Background: Carotid endarterectomy (CEA) has been the standard therapy for carotid artery stenosis (CAS). Modified eversion carotid endarterectomy (mECEA) was recently introduced to treat CAS. However, the short-term safety and long-term efficacy of mECEA are still controversial among studies. This systematic review aims to summarize the current literatures about safety and efficacy of mECEA in treating CAS. Methods: A systematic review of mECEA was conducted in the main bibliographic databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Clinical studies on the safety and efficacy of mECEA in treating CAS with clinical results of transient ischemic attack (TIA), stroke, death, and restenosis were included. Results: The initial search and screening found 15 references from the main databases, and 7 studies were finally included after full-text article assessment, which consisted of 3 single-arm studies and 4 comparative studies. The risks of postoperative complications including TIA, stroke, myocardial infarction (MI), and death ranged from 1.1% to 2%, 0% to 2.5%, 0% to 4.4%, and 0% to 2.32%, respectively. The mECEA was significantly related to lower risk of carotid artery occlusion, incision numbness, and shorter lengths of stay in hospital and average scar when separately compared with conventional CEA (cCEA), CEA with patch closure (pCEA), and eversion CEA (eCEA). Conclusions: The mECEA is a promising surgical option for CAS with acceptable clinical outcomes. In order to prove its safety and efficacy, future practices need to be conducted by more medical workers in more large-scale trials.

[Indications for Extracranial-Intracranial Bypass Surgery].

Previous randomized clinical trials have so far failed to establish the efficacy of extracranial-intracranial(EC-IC)bypass in the prevention of secondary ischemic strokes. For patients with a recent transient ischemic attack or ischemic stroke ipsilateral to a stenosis or occlusion of the middle cerebral or carotid artery, EC-IC bypass is not recommended as per the American heart association/American stroke association guidelines(Class III, Level of Evidence A). However, patients with severe hemodynamic impairment(misery perfusion)are at high risk of developing stroke, and EC-IC bypass is recommended as per the Japan stroke guideline 2021, provided that the patients show cerebral blood flow less than 80% from baseline and cerebral vascular reserve less than 10%. Perioperative management is also important in preventing ischemic complications and hyperperfusion. Some adjunctive drugs, including minocycline and edaravone, have been reported to be effective against brain damage from hyperperfusion. Regarding Moyamoya disease, EC-IC bypass has been established as a recommended strategy for ischemic presentation, hemorrhagic presentation, hemodynamic impairment, and choroidal anastomosis. EC-IC bypass is also necessary for specific types of aneurysms, including fusiform and thrombotic, as well as in the dissection of aneurysms that are difficult to clip.

Comparison of long-term outcomes and risk factors of aortic stenosis treatment in patients undergoing transcatheter aortic valve implantation and surgical aortic valve replacement.

BACKGROUND: Aortic stenosis (AS) is the most common valvular heart disease and untreated has a bleak prognosis. The only effective method of treatment is valve replacement, surgical (SAVR), or transcatheter (TAVI). AIMS: We decided to analyze outcomes and predictors of long-term mortality in patients undergoing TAVI and SAVR. METHODS: A retrospective analysis of 1229 patients with advanced AS, comprising TAVI (n = 211), SAVR (n = 556), SAVR, and additional procedures (n = 462), operated on from 2014 to 2018, was performed. RESULTS: No significant differences between SAVR and TAVI were found for 24-month mortality in groups of consecutive patients. Postoperative stroke or transient ischemic attack (TIA), chronic obstructive pulmonary disease (COPD), and transfusion of red blood cells (RBCs) were independent predictors of 1-year mortality after SAVR. The above-mentioned factors regarding the increased estimated surgery risk in the EuroSCORE II ( > 4%) were predictors of 2-years mortality after SAVR. Risk factors for 6- and 12-month mortality after TAVI were EuroSCORE II, new onset of atrial fibrillation (NOAF), and the increased RBC distribution width (RDW). Postoperative respiratory failure was an independent risk factor for 6-, 12- and 24-month mortality in both groups of patients. CONCLUSIONS: There were no significant differences regarding prognosis after TAVI and SAVR at the 24-month follow-up in the propensity score matching model. Independent predictive factors of late mortality after both procedures were EuroScore II and respiratory failure. Independent predictive factors of late mortality specific for TAVI were NOAF, increased RDW, and for SAVR: TIA, stroke, COPD, and RBC transfusion.

Impact of Shunting Practice Patterns During Carotid Endarterectomy for Symptomatic Carotid Stenosis.

BACKGROUND: We aimed to assess the effect of surgeons' shunting practice and shunt use on the early outcomes of carotid endarterectomy (CEA) in recently symptomatic patients. METHODS: We conducted a retrospective observational study based on a multicenter national prospective database. The Vascular Quality Initiative database (2010-2019) was queried for CEAs performed within 14 days after an ipsilateral stroke or transient ischemic attack. Surgeons were gauged as routine shunters if they shunted in >95% of CEAs, otherwise were classified as selective shunters. In-hospital stroke and death rates were compared between routine and selective shunters, stratifying by type of index event (transient ischemic attack versus stroke) and timing of CEA (≤2 versus >2 days). RESULTS: Thirteen thousand four hundred sixty-nine CEAs were performed after a transient ischemic attack (43%) or stroke (57%), 3186 (24%) by routine shunters, and 10 283 (76%) by selective shunters. Comparing routine and selective shunters, in-hospital stroke (1.9% versus 2.4%; P=0.09) and death (0.4% versus 0.5%; P=0.73) rates were similar. A lower stroke rate (1.5% versus 4.2%; P=0.02) was achieved by routine shunters for CEA performed <2 days after an ischemic stroke. Among selective shunters, a higher stroke rate occurred in case of shunt use (2.9% versus 2.3%; P<0.01), mainly due to cases presenting with stroke (3.5% versus 2.4%; P<0.01) but not transient ischemic attack (1.8% versus 1.5%; P=0.57). Awake anesthesia was adopted in 7.8% of cases by selective shunters and in 0.8% by routine shunters, without impact on the perioperative stroke rate (1.8% versus 2.3%; P=0.349). CONCLUSIONS: In this large national cohort, the overall outcomes of CEA were similar between routine and selective shunters. A lower postoperative stroke rate was achieved by routine shunters in CEA performed <2 days after an ischemic stroke. Among selective shunters, intraoperatively indicated shunting determined an increased stroke rate, likely due to intraoperative hypoperfusion. These data may guide the decision regarding timing of CEA and shunting intention in symptomatic patients.

No Evidence for Long Term Blood Pressure Differences Between Eversion and Conventional Carotid Endarterectomy in Two Independent Study Cohorts.

OBJECTIVE: Blood pressure (BP) management is a vital aspect of stroke prevention and post-stroke care. Different surgical carotid endarterectomy (CEA) techniques may impact on BP control post-operatively. Specifically, the carotid sinus nerve, which innervates the carotid baroreceptors and carotid body, is commonly left intact during conventional CEA but is routinely transected as part of eversion CEA. The aim of this study was to assess long term BP control after eversion and conventional CEA. METHODS: Patients from the International Carotid Stenting Study (ICSS cohort) and a personal series of patients from the Stroke Clinical Trials Unit at University College London (UCL cohort) were separately analysed and divided into eversion and conventional CEA groups. Mixed effect linear models were fitted and adjusted for baseline demographic data and antihypertensive treatment to test for changes in BP from baseline over a three year follow up period after the respective procedures. RESULTS: There were no differences in changes in baseline BP readings and follow up readings between eversion and conventional CEA in the ICSS or UCL cohorts. In the ICSS cohort a mild but significant systolic (-8.6 mmHg; 95% confidence interval [CI] -10.6 - -6.6) and diastolic (-4.9 mmHg; 95% CI -6.0 - -3.8) BP lowering effect was evident at discharge in the conventional group but not in the eversion CEA group. BP monitoring during follow up did not reveal any consistent BP changes with either conventional or eversion CEA vs. baseline levels. CONCLUSION: Neither conventional nor eversion CEA seem to result in clinically significant long term BP changes. Potential concerns related to either short or long term alterations in BP levels with transection of the carotid sinus nerve during eversion CEA could not be substantiated.

Patients Receiving Extracranial to Intracranial Bypass for Atherosclerotic Vessel Occlusion Today Differ Significantly From the COSS Population.

Background and Purpose: Despite the findings reported in the COSS (Carotid Occlusion Surgery Study), patients with atherosclerotic cerebrovascular disease continue to be referred for superficial temporal artery to middle cerebral artery bypass surgery. Here, we determined how today's patients differ from the population reported in COSS. Methods: We retrospectively analyzed all patients that were referred to our Department for superficial temporal artery to middle cerebral artery bypass surgery of atherosclerotic cerebrovascular disease following the publication of COSS. Results: Between 2012 and 2019, 179 patients were referred for 186 bypass surgeries. Ninety-one (51%) patients suffered atherosclerotic, unilateral internal carotid occlusion and 88 (49%) atherosclerotic multivessel disease. All patients had received intensive medical management. A single transitory ischemic attack or ischemic stroke within the last 120 days according to the inclusion criteria of COSS occurred in only 36 out of 179 (20%) patients, whereas 27 out of 179 (15%) suffered >1 transitory ischemic attack within 120 days, 109 out of 179 (61%) had recurrent minor ischemic stroke, and 7 out of 179 (4%) were hemodynamically unstable and required blood pressure maintenance. The distribution of symptoms did not differ between atherosclerotic unilateral internal carotid artery occlusion and atherosclerotic multivessel disease (P=0.376) but hemodynamic impairment was significantly greater in atherosclerotic multivessel disease (P<0.001 for atherosclerotic multivessel disease versus atherosclerotic unilateral internal carotid artery occlusion). The overall perioperative stroke rate was 4.3%. Conclusions: Patients referred for flow augmentation surgery today appear to suffer more severe symptoms and vessel occlusion patterns than patients reported in COSS. A new, carefully designed randomized controlled trial appears warranted, considering the still poor prognosis of severe atherosclerotic cerebrovascular disease.

Additional Revascularization Using Multiple Burr Holes for PCA Involvement in Moyamoya Disease.

In specific cases of moyamoya disease (MMD), posterior cerebral artery (PCA) stenosis can develop after treatment of the anterior circulation and require additional revascularization. Here, we report two cases that underwent additional posterior indirect revascularization with multiple burr holes for PCA involvement after bilateral revascularization treatment of the anterior circulation. They presented with transient ischemic attack even after bilateral superficial temporal artery-middle cerebral artery bypass, and magnetic resonance angiography (MRA) showed that PCA stenosis had worsened. Indirect revascularization with multiple burr holes using Benz-marked skin incisions was performed. After surgery, the symptoms improved without perioperative complications, and cerebral angiography showed collateral circulation via the burr hole. Indirect revascularization for MMD is often combined with direct revascularization, and there are only a few reports on the use of multiple burr hole surgery alone. In addition, there are few reports of posterior circulation, despite the emphasis on the importance of PCA involvement in MMD. Indirect revascularization with multiple burr holes alone can be performed in multiple areas and applied to patients who cannot undergo direct revascularization using the occipital artery. The procedure is simple and less invasive than traditional direct revascularization procedures. Therefore, it can be effective, especially in pediatric cases of MMD with PCA involvement.

Impact of the COVID-19 Pandemic on Emergency Department Use: Focus on Patients Requiring Urgent Revascularization.

BACKGROUND: The novel coronavirus (2019-nCOV) appeared in China and precipitously extended across the globe. As always, natural disasters or infectious disease outbreaks have the potential to cause emergency department (ED) volume changes. OBJECTIVE: We aimed to assess the influence of the Coronavirus Disease 2019 (COVID-19) pandemic on ED visits and the impact on the handling of patients requiring urgent revascularization. METHODS: We reviewed the charts of all patients presenting to the ED of Hospital Sainte Anne (Toulon, France) from March 23 to April 5, 2020 and compared them with those of the same period in 2019. Then we analyzed complementary data on acute coronary syndrome (ST-elevation myocardial infarction [STEMI] and non-ST-elevation myocardial infarction [NSTEMI]) and neurovascular emergencies (strokes and transient ischemic attacks). RESULTS: The total number of visits decreased by 47%. The number of people assessed as triage level 2 was 8% lower in 2020. There were five fewer cases of NSTEMI in 2020, but the same number of STEMI. The number of neurovascular emergencies increased (27 cases in 2019 compared with 30 in 2020). We observed a reduction in the delay between arrival at the ED and the beginning of coronary angiography for STEMI cases (27 min in 2019 and 22 min in 2020). In 2020, 7 more stroke patients were admitted. CONCLUSION: The COVID-19 pandemic probably dissuaded "non-critical" patients from coming to the hospital, whereas the same number of patients with a critical illness attended the ED as attended prior to the pandemic. There does not seem to have been any effect of the pandemic on patients requiring reperfusion therapy (STEMI and stroke).

A symptomatic atherosclerotic persistent pharyngo-hyo-stapedial artery: Treatment management and embryological considerations.

The stapedial artery (SA) is an embryonic vessel connecting the internal carotid artery (ICA) to the branches of the future external carotid artery (ECA). It passes through the primordium of the stapes that progressively develops around the SA. Normally, SA disappears during the tenth week in utero. Approximately 0.4% of the population can have a persistent SA. It can persist as four types of embryological variations, of which the pharyngo-hyo-stapedial variant has been rarely described before. We reported a case of a 61-year-old woman presented with transient ischemic attacks (TIAs). Computed tomography angiography showed an unusual "duplicated" aspect of the left ICA. Digital subtraction angiography depicted a persistent pharyngo-hyo-stapedial artery with an atherosclerotic wall and was considered the cause of the TIAs. After failure of the antiplatelet therapy in preventing recurrent TIAs, stenting of the artery was planned and successfully performed. Patient was asymptomatic during 12-month follow-up. The pharyngo-hyo-stapedial artery is a very rare variation in which the SA is supplied by the inferior tympanic (rising from the ascending pharyngeal artery) and the hyoid artery (rising from the ICA). To our knowledge, this is a unique case of a pharyngo-hyo-stapedial artery in a patient presenting associated ischemic symptoms. Radiological and embryological findings are discussed.

Endovascular Recanalization for Nonacute Intracranial Vertebral Artery Occlusion According to a New Classification.

BACKGROUND AND PURPOSE: Endovascular recanalization for patients with nonacute intracranial vertebral artery occlusion remains clinically challenging. We aim to evaluate the feasibility and safety of endovascular recanalization for nonacute intracranial vertebral artery occlusion and propose a new angiographic classification. METHODS: Fifty patients with symptomatic atherosclerotic nonacute intracranial vertebral artery occlusion from January 2015 to December 2019 were analyzed, retrospectively. The rate of recanalization, peri-procedural complications, and follow-up results were evaluated. All patients were divided into 4 groups according to an angiographic classification. RESULTS: Among the 50 patients, 38 (76%) achieved successful recanalization. Any stroke or death within 30 days was 4% (2/50). From type I to type IV, the recanalization rate gradually decreased (94.1%, 76.9%, 70%, and 50%, respectively, P=0.012), while the perioperative complication rate gradually increased (0.0%, 7.7%, 20%, and 50%, respectively, P=0.001). CONCLUSIONS: Endovascular recanalization may be feasible and safe for carefully selected patients with symptomatic atherosclerotic nonacute intracranial vertebral artery occlusion and, therefore, represents an alternative treatment, especially for type I and type II patients.

Direct versus indirect bypass procedure for the treatment of ischemic moyamoya disease: results of an individualized selection strategy.

OBJECTIVE: The only effective treatment for ischemic moyamoya disease (iMMD) is cerebral revascularization by an extracranial to intracranial bypass. The preferred revascularization method remains controversial: direct versus indirect bypass. The purpose of this study was to test the hypothesis that method choice should be personalized based on angiographic, hemodynamic, and clinical characteristics to balance the risk of perioperative major stroke against treatment efficacy. METHODS: Patients with iMMD were identified retrospectively from a prospectively maintained database. Those with mild to moderate internal carotid artery or M1 segment stenosis, preserved cerebrovascular reserve, intraoperative M4 segment anterograde flow ≥ 8 ml/min, or the absence of frequent and severe transient ischemic attacks (TIAs) or stroke had been assigned to indirect bypass. The criteria for direct bypass were severe ICA or M1 segment stenosis or occlusion, impaired cerebrovascular reserve or steal phenomenon, intraoperative M4 segment retrograde flow or anterograde flow < 8 ml/min, and the presence of frequent and severe TIAs or clinical strokes. The primary study endpoint was MRI-confirmed symptomatic stroke ≤ 7 days postoperatively resulting in a decline in the modified Rankin Scale (mRS) score from preoperatively to 6 months postoperatively. As a secondary endpoint, the authors assessed 6-month postoperative DSA-demonstrated revascularization, which was classified as < 1/3, 1/3-2/3, or > 2/3 of the middle cerebral artery territory. RESULTS: One hundred thirty-eight patients with iMMD affecting 195 hemispheres revascularized in the period from March 2016 to June 2018 were included in this analysis. One hundred thirty-three hemispheres were revascularized with direct bypass and 62 with indirect bypass. The perioperative stroke rate was 4.7% and 6.8% in the direct and indirect groups, respectively (p = 0.36). Degree of revascularization was higher in the direct bypass group (p = 0.03). The proportion of patients improving to an mRS score 0-1 (from preoperatively to 6 months postoperatively) tended to be higher in the direct bypass group, although the difference between the two bypass groups was not statistically significant (p = 0.27). CONCLUSIONS: The selective use of an indirect bypass procedure for iMMD did not decrease the perioperative stroke rate. Direct bypass provided a significantly higher degree of revascularization. The authors conclude that direct bypass is the treatment of choice for iMMD.

Increased Risk of Transient Cerebral Ischemia After Subarachnoid Hemorrhage in Patients with Premorbid Opioid Use Disorders: A Nationwide Analysis of Outcomes.

BACKGROUND: Subarachnoid hemorrhage (SAH) is the most morbid sequela of intracranial aneurysms. Although mortality from SAH has been declining, opioid use in the United States has surged, and neurosurgeons are increasingly tasked with operating on patients with opioid use disorders (OUDs). There is a deficit in the literature regarding how OUDs affect SAH outcomes, particularly transient cerebral ischemic (TCI) events. The objective of this study was to investigate the influence of clinically diagnosed OUDs on the outcomes after acute SAH, with a specific focus on the rate of symptomatic TCI. METHODS: Patients with and without a diagnosed OUD who underwent either microsurgical clipping or endovascular coiling for SAH were queried from the 2012-2014 National Inpatient Sample using International Classification of Disease codes. The primary outcome was the rate of TCI after SAH treatment. RESULTS: A total of 25,330 patients were included, 310 of whom (1.22%) also carried a diagnosis of OUD. Univariate and multivariate regression showed that patients with OUD faced significantly increased odds of TCI (P = 0.044) compared with patients without OUD. OUD status was not associated with increased odds of other adverse outcomes, including overall complication, in-hospital mortality, poor outcome by a validated National Inpatient Sample SAH Outcome Measure, nonhome discharge, or extended hospitalization. CONCLUSIONS: Patients with OUD face significantly higher odds of symptomatic TCI events producing clinical deficits during hospitalization for acute SAH. These findings suggest usefulness in screening patients for OUD to identify individuals who may benefit from a higher level of clinical scrutiny for post-SAH TCI.

Late (5-20 years) outcomes after STA-MCA anastomosis and encephalo-duro-myo-arterio-pericranial synangiosis in patients with moyamoya disease.

OBJECTIVE: Surgical revascularization is known to reduce the incidence of further ischemic and hemorrhagic events in patients with moyamoya disease, but the majority of previous studies report only short-term (< 5 years) outcomes. Therefore, in this study the authors aimed to evaluate late (5-20 years) outcomes of moyamoya patients after superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis and indirect bypass (encephalo-duro-myo-arterio-pericranial synangiosis [EDMAPS]). METHODS: Cumulative incidences of late morbidity/mortality and disease progression were evaluated among 93 patients who underwent STA-MCA anastomosis and EDMAPS. All of the patients were prospectively followed up for longer than 5 years postsurgery (10.5 ± 4.4 years). There were 35 pediatric and 58 adult patients. Initial presentation included transient ischemic attack/ischemic stroke in 80 patients and hemorrhagic stroke in 10 patients, and 3 patients were asymptomatic. Surgery was performed in a total of 141 hemispheres. Follow-up MRI/MRA was performed within a 6- or 12-month interval during the follow-up periods. RESULTS: During the follow-up periods, 92/93 patients were free from any stroke or death, but 1 patient had a recurrence of hemorrhagic stroke (0.10% per patient-year). Disease progression occurred in the territory of the contralateral carotid or posterior cerebral artery (PCA) in 19 hemispheres of 15 patients (1.5% per patient-year). The interval between initial surgery and disease progression varied widely, from 0.5 to 15 years. Repeat bypass surgery for the anterior and posterior circulation resolved ischemic attacks in all 10 patients. CONCLUSIONS: The study results indicate that STA-MCA anastomosis and EDMAPS would be the best choice to prevent further ischemic and hemorrhagic stroke for longer than 10 years on the basis of the demonstrated widespread improvement in cerebral hemodynamics in both the MCA and ACA territories in the study patients. However, after 10 years postsurgery regular follow-up is essential to detect disease progression in the territory of the contralateral carotid artery and PCA and prevent late cerebrovascular events.