The curious case of the Zzz's.

Excessive daytime sleepiness is a common presenting symptom that may present a diagnostic challenge for the sleep medicine clinician. We present a case of an adolescent female with excessive daytime sleepiness and "sleep attacks" who was evaluated using a 2-week sleep log, wrist actigraphy, baseline polysomnogram, and Multiple Sleep Latency Test. Multiple Sleep Latency Test results noted a short mean sleep latency without sleep onset rapid eye movement periods, concerning for possible central disorders of hypersomnolence. However, actigraphy data noted a habitual bedtime of midnight or later, resulting in less than recommended total sleep time for her age on weekdays with extended sleep periods on the weekends. The most unique actigraphy finding was exposure to ambient light throughout most overnight sleep periods. When actigraphy results were discussed with the patient, she revealed recent onset of severe anxiety with fear of sleeping in the dark. This case highlights the importance of thorough clinical evaluation, and careful interpretation of objective tests, when evaluating for causes of excessive daytime sleepiness. CITATION: Dang L, Kanney ML, Hsu DP. The curious case of the Zzz's. J Clin Sleep Med. 2023;19(5):1009-1012.

Social impairment and snoring: a unique presentation of pediatric Chiari I malformation.

Symptomatic progression of Chiari malformation type 1 (CM-1) can be difficult to recognize in children because of the slow progressive nature of the disorder and highly varied neurological symptoms. We present a case of an obese 11-year-old girl seeking an evaluation of snoring. Progressive social impairment and academic difficulties were also endorsed. The past medical history was remarkable for absence seizures at an earlier age with an incidental finding of CM-1 on brain imaging. No headaches, vision changes, or swallowing dysfunction were endorsed in the acute presentation. The patient underwent a polysomnogram, which revealed the unexpected finding of severe central sleep apnea. Magnetic resonance imaging of the brain revealed further herniation of the cerebellar tonsils and a cervical syrinx, which was not present on initial imaging. Posterior fossa decompression resulted in the successful resolution of symptoms. It was postulated that the social impairment and academic problems were manifestations of CM-1. There are no current standard protocols for disease surveillance of pediatric CM-1. Annual polysomnograms may serve as a useful tool. CITATION: Kanney ML, Spear J, Hsu DP. Social impairment and snoring: a unique presentation of pediatric Chiari I malformation. J Clin Sleep Med. 2022;18(12):2867-2870.

Risk of Distal Embolization From tPA (Tissue-Type Plasminogen Activator) Administration Prior to Endovascular Stroke Treatment.

BACKGROUND AND PURPOSE: In large artery occlusion stroke, both intravenous (IV) tPA (tissue-type plasminogen activator) and endovascular stroke treatment (EST) are standard-of-care. It is unknown how often tPA causes distal embolization, in which a procedurally accessible large artery occlusion is converted to a more distal and potentially inaccessible occlusion. METHODS: We analyzed data from a decentralized stroke telemedicine program in an integrated healthcare delivery system covering 21 hospitals, with 2 high-volume EST centers. We captured all cases sent for EST and examined the relationship between IV tPA administration and the rate of distal embolization, the rate of target recanalization (modified Treatment in Cerebral Infarction scale 2b/3), clinical improvement before EST, and short-term and long-term clinical outcomes. RESULTS: Distal embolization before EST was quite common (63/314 [20.1%]) and occurred more often after IV tPA before EST (57/229 [24.9%]) than among those not receiving IV tPA (6/85 [7.1%]; P<0.001). Distal embolization was associated with an inability to attempt EST: after distal embolization, 26/63 (41.3%) could not have attempted EST because of the new clot location, while in cases without distal embolization, only 8/249 (3.2%) were unable to have attempted EST (P<0.001). Among patients who received IV tPA, 13/242 (5.4%) had sufficient symptom improvement that a catheter angiogram was not performed; 6/342 (2.5%) had improvement to within 2 points of their baseline NIHSS. At catheter angiogram, 2/229 (0.9%) of patients who had received tPA had complete recanalization without distal embolization. Both IV tPA and EST recanalization were associated with improved long-term outcome. CONCLUSIONS: IV tPA administration before EST for large artery occlusion is associated with distal embolization, which in turn may reduce the chance that EST can be attempted and recanalization achieved. At the same time, some IV tPA-treated patients show symptomatic improvement and complete recanalization. Because IV tPA is associated with both distal embolization and improved long-term clinical outcome, there is a need for prospective clinical trials testing the net benefit or harm of IV tPA before EST.

Prevalence of Pulmonary Hypertension in Pediatric Patients With Obstructive Sleep Apnea and a Cardiology Evaluation: A Retrospective Analysis.

STUDY OBJECTIVES: Pulmonary hypertension (PH) has been reported as a serious complication of obstructive sleep apnea (OSA) in children; however, estimated prevalence rates vary widely (zero to 85%). The purpose of this study is to determine the prevalence of PH in children with OSA and identify factors that may predict an increased PH risk in children with OSA. METHODS: A retrospective review of all pediatric beneficiaries (88,058) in the San Antonio Military Health System with a diagnosis of OSA and a clinical evaluation by a pediatric cardiologist. OSA severity and nadir oxygen saturation were recorded from overnight polysomnography. Reason for referral, comorbid disorders, echocardiogram results, and cardiac diagnoses were obtained from cardiology records. RESULTS: OSA was identified in 2,020 pediatric patients (2.3%). A pediatric cardiology consultation was reported for 296 patients with OSA. After excluding 95 patients for incorrect OSA diagnoses, incomplete data, or OSA treatment before cardiology evaluation, 163 patients were included in the final analysis. A diagnosis of PH was found in 3 patients with OSA (1.8%). Two of these patients had obesity, and all three had comorbid cardiac disorders. CONCLUSIONS: Prevalence of PH in pediatric patients with OSA is low and none of the patients with PH had severe OSA. Current guidelines recommend PH screening in patients with severe OSA, yet OSA severity may not accurately predict risk. Factors evaluated in this study did not demonstrate an increased PH risk; additional research is necessary to improve screening in pediatric patients with OSA. CITATION: Burns AT, Hansen SL, Turner ZS, Aden JK, Black AB, Hsu DP. Prevalence of pulmonary hypertension in pediatric patients with obstructive sleep apnea and a cardiology evaluation: a retrospective analysis. J Clin Sleep Med. 2019;15(8):1081-1087.

Predictors of Wellness Behaviors in U.S. Army Physicians.

Introduction: In 2013, the U.S. Army Surgeon General implemented the Performance Triad (P3), an educational initiative to improve health-related behaviors of soldiers throughout the U.S. Army. The components of P3 are Sleep, Activity, and Nutrition with tenet behaviors for each component. This study reports the results of the 2015 U.S. Army Medical Corps survey regarding physician knowledge and adherence to the tenet behaviors of P3. Methods: In 2015, an anonymous survey was sent to all active duty U.S. Army physicians to assess demographic information, work hours, and knowledge of and adherence to P3. The survey assessed the tenets of P3 with questions about the following topics: obtaining 8 h of sleep per day; performing at least 2 d of resistance training and 1 day of agility training per week; re-fueling 30-60 min after exercise; incorporating at least 150 min of moderate and 75 min of vigorous aerobic exercise per week; going caffeine free 6 h before bedtime; eating at least 8 servings of fruits and vegetables per day; and getting 15,000 steps per day. For each question, there were four response options which ranged from "Always" to "Never." A positive response to the questionnaire was defined as answering frequently or always. The responses were analyzed by comparison of several physician categories utilizing descriptive statistics and multivariable analysis. Results: Surveys were completed by 1,003 of approximately 4,500 U.S. Army physicians. 79.1% of the respondents were male. Staff physicians made up 834 (83.6%) of the respondents compared with 164 (16.4%) physicians in training. Overall 25% of respondents were adherent to the sleep tenet, 45% to the exercise tenet, and 38% to the nutrition tenet. Reported work hours were significantly higher in physicians in training compared with staff physicians (p < 0.001). About 28.4% of staff reported a positive response to obtaining at least 8 h of sleep per night, compared with 12.7% of residents/fellows. In multivariable analyses, better sleep was associated with being a staff physician [odds ratio 2.4 (95% confidence interval 1.40-4.13)], working fewer hours per week [1.75 (1.37-2.25)], and belief in supervisor adherence to P3 [2.04 (1.59-2.56)]. Increased exercise was associated with male gender [2.09 (1.45-3.02)], being a staff physician [1.63 (1.09-2.43)], and belief in supervisor adherence to P3 [1.43 (1.18-1.75)]. Positive response to the nutrition tenet was associated with belief in supervisor adherence to P3 [1.23 (1.01-1.49)]. Conclusion: Overall, U.S. Army physicians are most adherent to the exercise tenet and least adherent to the sleep tenet of P3; this is consistent with the military culture. Work hours seem to affect wellness behaviors. Specifically, physicians who work fewer hours are more likely to report obtaining 8 h of sleep per day and exercise on a regular basis. Importantly, belief in supervisor adherence to P3 was associated with better adherence to P3, suggesting that physician leadership has a positive effect on wellness behaviors. This suggests a role for similar wellness programs in civilian healthcare institutions. Future research should also include changes in health system policies to motivate physician wellness behaviors.

Detection of Anterior Circulation Large Artery Occlusion in Ischemic Stroke Using Noninvasive Cerebral Oximetry.

BACKGROUND AND PURPOSE: Large artery occlusion (LAO) in ischemic stroke requires recognition and triage to an endovascular stroke treatment center. Noninvasive LAO detection is needed to improve triage. METHODS: Prospective study to test whether noninvasive cerebral oximetry can detect anterior circulation LAO in acute stroke. Interhemispheric ΔBrSO2 in LAO was compared with controls. RESULTS: In LAO stroke, mean interhemispheric ΔBrSO2 was -8.3±5.8% (n=19), compared with 0.4±5.8% in small artery stroke (n=17), 0.4±6.0% in hemorrhagic stroke (n=14), and 0.2±7.5% in subjects without stroke (n=19) (P<0.001). Endovascular stroke treatment reduced the ΔBrSO2 in most LAO subjects (16/19). Discrimination of LAO at a -3% ΔBrSO2 cut had 84% sensitivity and 70% specificity. Addition of the G-FAST clinical score (gaze-face-arm-speech- time) to the BrSO2 measure had 84% sensitivity and 90% specificity. CONCLUSIONS: Noninvasive cerebral oximetry may help detect LAO in ischemic stroke, particularly when combined with a simple clinical scoring system.

Endovascular plug for internal carotid artery occlusion in the management of a cavernous pseudoaneurysm with bifrontal subdural empyema: technical note.

The authors demonstrate the use of an endovascular plug in securing a carotid artery pseudoaneurysm in an emergent setting requiring craniotomy for a concurrent subdural empyema. They describe the case of a 14-year-old boy with sinusitis and bifrontal subdural empyema who underwent transsphenoidal exploration at an outside hospital. An injury to the right cavernous segment of the ICA caused torrential epistaxis. Bleeding was successfully controlled by inflating a Foley balloon catheter within the sphenoid sinus, and the patient was transferred to the authors' institution. Emergent angiography showed a dissection of the right cavernous carotid artery, with a large pseudoaneurysm projecting into the sphenoid sinus at the site of arterial injury. The right internal carotid artery was obliterated using pushable coils distally and an endovascular plug proximally. The endovascular plug enabled the authors to successfully exclude the pseudoaneurysm from the circulation. The patient subsequently underwent an emergent bifrontal craniotomy for evacuation of a left frontotemporal subdural empyema and exenteration of both frontal sinuses. He made a complete neurological recovery. Endovascular large-vessel sacrifice, obviating the need for numerous coils and antiplatelet therapy, has a role in the setting of selected acute neurosurgical emergencies necessitating craniotomy. The endovascular plug is a useful adjunct in such circumstances as the device can be deployed rapidly, safely, and effectively.

Inhaled corticosteroid related adrenal suppression detected by poor growth and reversed with ciclesonide.

INTRODUCTION: This case series intends to highlight the association between decreased linear growth velocity and adrenal suppression in patients receiving inhaled corticosteroids for asthma. A potential treatment option is also discussed. Adrenal suppression secondary to inhaled corticosteroids has previously been reported and is often underrecognized. A decrease in linear height velocity has also been associated with inhaled corticosteroids. However, a decrease in height velocity has not been shown to predict adrenal suppression. CASE STUDY: This case series of 15 patients receiving inhaled corticosteroids for control of asthma were noted to have a decrease in linear growth velocity ultimately associated with adrenal suppression. A change in inhaled corticosteroid to ciclesonide led to recovery of adrenal function without impacting asthma control. RESULTS: Chart review from a pediatric pulmonology clinic was performed. Growth parameters and laboratory studies were recorded and analyzed. A mean decrease in height standard deviation score in the year prior to diagnosis of adrenal suppression was -0.59, -0.11, and -0.18, in pre-puberty, peri-puberty, and post-puberty patients, respectively. After ciclesonide therapy was initiated, a mean change in height standard deviation score of +0.40, +0.13, and -0.13, was noted for pre-puberty, peri-puberty, and post-puberty patients, respectively. A change in growth velocity of +5.3 cm/yr, +2.1 cm/yr, and -1.9 cm/yr, was noted for pre-puberty, peri-puberty, and post-puberty patients, respectively, after starting ciclesonide. CONCLUSIONS: Height velocity should be monitored closely during routine asthma visits to identify potential adrenal suppression associated with inhaled corticosteroids use. Ciclesonide is a good option for asthma treatment that allows for adrenal recovery.

Evaluation of a Noninvasive Hemoglobin Measurement Device to Screen for Anemia in Infancy.

OBJECTIVE: Iron deficiency is the most prevalent micronutrient deficiency worldwide and a common medical condition in the United States. The American Academy of Pediatrics has recommended universal screening for iron deficiency anemia in infants at approximately 1 year of age. This screening involves invasive venous blood sampling which increases the clinic visit time and may cause significant stress to the patient and family members. The purpose of this study was to assess the accuracy and utility of a non-invasive hemoglobin measurement device compared to standard laboratory hemoglobin measurement from venipuncture. METHODS: One hundred ten children were enrolled in the study following a well-child examination at San Antonio Military Medical Center from June 2012 to June 2014. Each child had a hemoglobin measurement obtained with the Masimo Pronto with Rainbow(®) R20L disposable sensor followed by venipuncture that was sent to the clinical laboratory for hemoglobin measurement. Paired hemoglobin results from the non-invasive device and the clinical laboratory were compared. RESULTS: Ninety-seven children successfully had hemoglobin measured by the Masimo Pronto device. Hemoglobin values obtained with the Masimo Pronto were significantly correlated with venous hemoglobin levels, with a correlation coefficient of 0.48. A hemoglobin level less than 11.5 gm/dL on the Masimo Pronto had a sensitivity of 82 % and a negative predictive value of 95 % when compared to venous hemoglobin level less than 11 gm/dL. CONCLUSIONS: for Practice Non-invasive hemoglobin testing with the Masimo Pronto device may be a useful screening tool for anemia in infants that avoids invasive testing.

Predictors and clinical relevance of hemorrhagic transformation after endovascular therapy for anterior circulation large vessel occlusion strokes: a multicenter retrospective analysis of 1122 patients.

BACKGROUND AND PURPOSE: Endovascular techniques are frequently employed to treat large artery occlusion in acute ischemic stroke (AIS). We sought to determine the predictors and clinical impact of intracranial hemorrhage (ICH) after endovascular therapy. METHODS: Retrospective analysis of consecutive patients presenting to 13 high volume stroke centers with AIS due to proximal occlusion in the anterior circulation who underwent endovascular treatment within 8 h from symptom onset. Logistic regression was performed to determine the variables associated with ICH, hemorrhagic infarction (HI), and parenchymal hematomas (PHs), as well as 90 day poor outcome (modified Rankin Scale score ≥3) and mortality. RESULTS: There were a total of 363 ICHs (overall rate 32.3%; HI=267, 24%; PH=96, 8.5%) among the 1122 study patients (mean age 67±15 years; median National Institutes of Health Stroke Scale score 17 (IQR 13-20)). Independent predictors for HI included diabetes mellitus (OR 2.27, 95% CI (1.58 to 3.26), p<0.0001), preprocedure IV tissue plasminogen activator (tPA) (1.43 (1.03 to 2.08), p<0.037), Merci thrombectomy (1.47 (1.02 to 2.12), p<0.032), and longer time to puncture (1.001 (1.00 to 1.002), p<0.026). Patients with atrial fibrillation (1.61 (1.01 to 2.55), p<0.045) had a higher risk of PH while the use of IA tPA (0.57 (0.35 to 0.90), p<0.008) was associated with lower chances of PH. Both the presence of HI (2.23 (1.53 to 3.25), p<0.0001) and PH (6.24 (3.06 to 12.75), p<0.0001) were associated with poor functional outcomes; however, only PH was associated with higher mortality (3.53 (2.19 to 5.68), p<0.0001). CONCLUSIONS: Greater understanding about the predictors and consequences of ICH post endovascular stroke therapy is essential to improve risk assessment, patient selection/clinical outcomes, and early prognostication. Our data suggest that patients with atrial fibrillation are particularly prone to severe ICH and question the 'benign' nature of HI suggested by earlier studies.

Device localization and dynamic scan plane selection using a wireless magnetic resonance imaging detector array.

PURPOSE: A prototype wireless guidance device using single sideband amplitude modulation (SSB) is presented for a 1.5T magnetic resonance imaging system. METHODS: The device contained three fiducial markers each mounted to an independent receiver coil equipped with wireless SSB technology. Acquiring orthogonal projections of these markers determined the position and orientation of the device, which was used to define the scan plane for a subsequent image acquisition. Device localization and scan plane update required approximately 30 ms, so it could be interleaved with high temporal resolution imaging. Since the wireless device is used for localization and does not require full imaging capability, the design of the SSB wireless system was simplified by allowing an asynchronous clock between the transmitter and receiver. RESULTS: When coupled to a high readout bandwidth, the error caused by the lack of a shared frequency reference was quantified to be less than one pixel (0.78 mm) in the projection acquisitions. Image guidance with the prototype was demonstrated with a phantom where a needle was successfully guided to a target and contrast was delivered. CONCLUSION: The feasibility of active tracking with a wireless detector array is demonstrated. Wireless arrays could be incorporated into devices to assist in image-guided procedures.

Palliative procedures for the interventional oncologist.

OBJECTIVE: The purpose of this article is to present our experience using multimodality interventional radiologic techniques for the treatment of cancer-related pain across a spectrum of abnormalities. CONCLUSION: Percutaneous imaging-guided thermal ablation has emerged as a safe and efficacious treatment for painful osseous metastases. The implementation of interventional thermal ablative techniques for the treatment of intractable pain secondary to malignancy can be further expanded to include transcatheter and combination procedures.

Outcome of pediatric inpatient asthma clinical pathway implementation in a military medical center.

A performance improvement project was instituted at our facility to standardize pediatric inpatient asthma care by instituting an asthma clinical pathway (ACP). Formal asthma education and standardized postdischarge follow-up plans for all asthma inpatients were initiated. Patients treated by following the ACP were compared against historically similar patients from the previous 4 years. Differences in hospital length-of-stay (LOS) for patients treated on the ACP were compared to historical LOS. Adherence to The Joint Commission's home management plan of care metric, CAC-3, was also compared. There was a 25% lower hospital LOS in the ACP group compared to historical control group, 45.8 hours versus 60.9 hours (p < 0.002). CAC-3 adherence significantly increased from 48% to 89% (p < 0.001) after initiating formal asthma education. The implementation of a pediatric asthma inpatient performance improvement project was associated with a significant decrease in hospital LOS, when compared to historic controls. It also led to a significant improvement in adherence with The Joint Commission's CAC-3 measures.

Evaluation of interpretation strategies and substantial bronchodilator response in pediatric patients with normal baseline spirometry.

BACKGROUND: Controversy exists regarding the best method to interpret pediatric spirometry. There is also controversy regarding the benefit of performing post-bronchodilator spirometry after normal baseline spirometry. This study compares the use of lower limit of normal (LLN) against percent of predicted (PP) in the interpretation of spirometry. We also investigate the occurrence of a substantial bronchodilator response for patients who received post-bronchodilator spirometry. METHODS: Spirometric tests performed in the pediatric clinic at San Antonio Military Medical Center were retrospectively reviewed. Results of spirometry were compared using LLN and PP for interpretation. Abnormal spirometry was defined as a low FEV1 or low FEV1/FVC, indicating evidence of airway obstruction. The presence of a substantial bronchodilator response was recorded and the results were analyzed. RESULTS: Of 242 tests, 212 normal and 30 abnormal tests were reported using the LLN interpretation strategy. Using the PP interpretation strategy, there was a significant difference in the number of normal (183) and abnormal (59) tests, when compared to the LLN (P < .001). No significant difference between LLN versus PP interpretation strategies was noted in the number of baseline tests, normal or abnormal, that demonstrated a substantial response to bronchodilator. Of the subjects with normal baseline spirometry, 10% (PP) and 12% (LLN) had a substantial bronchodilator response. An abnormal baseline spirometry was more likely to have a substantial response to bronchodilator, compared to normal baseline spirometry (P < .001). CONCLUSIONS: The use of LLN for interpretation is more likely to report a test as normal, when compared to the PP interpretation strategy. Although a substantial bronchodilator response is more likely to occur following abnormal baseline spirometry, 10-12% of subjects with normal baseline spirometry showed a substantial bronchodilator response. This suggests that normal baseline spirometry may miss reversible airway obstruction, which is a hallmark of asthma.

Novel use of optical coherence tomography.

Currently in use by interventional cardiology for the intravascular evaluation of coronary arteries, optical coherence tomography (OCT) has proven to be effective in the evaluation of atherosclerotic disease and further therapeutic management. We report a novel use of OCT technology in the case of a 46-year-old man with sudden onset blurred vision and greater than 70% stenosis of his left vertebral artery. To date, no detailed descriptions or case reports have previously been reported regarding the use of neuroendovascular OCT in diseased arteries.

Risk of contrast-induced nephropathy in patients undergoing endovascular treatment of acute ischemic stroke.

BACKGROUND AND PURPOSE: We report the incidence and risk factors for contrast-induced nephropathy after the use of iodinated contrast for endovascular treatment of acute ischemic stroke. METHODS: A retrospective chart review was performed in 194 consecutive patients who underwent endovascular treatment for acute ischemic stroke between January 2006 and January 2011. No patients were excluded from treatment for elevated creatinine (Cr). Each patient received approximately 150 ml intra-arterial non-ionic low-osmolar contrast agent (Optiray 320) during the endovascular procedure. Contrast-induced nephropathy (CIN) was defined according to the Acute Kidney Injury Network criteria as a relative increase of serum Cr 50% above the baseline or an absolute increase of 0.3 mg/dl at 48 h following the endovascular procedure. RESULTS: Of 194 patients (mean age 65 ± 14 years), 52% were women (n=100) and 25% (n=48) were diabetic. Baseline Cr levels for 191 patients ranged between 0.4 and 2.7 mg/dl. Three patients on chronic hemodialysis had baseline Cr levels ranging between 5.3 and 6.1 mg/dl. Cr was ≤ 1.5 mg/dl in 163 patients (84%) and ≥ 1.5 mg/dl in 31 (16%). Three of the 191 patients (1.5%) developed CIN as noted from Cr measurements between baseline and within 48 h. One patient who developed an elevated Cr level had a known history of chronic renal insufficiency (Cr > 1.5 mg/dl) and two had baseline Cr levels within the normal range. An additional CT angiogram was obtained in 44 patients, none of which developed CIN. Female gender and diabetes were not associated with a higher risk of developing CIN. CONCLUSIONS: The risk of developing CIN is low among patients with acute stroke who undergo emergency endovascular treatment. Treatment of acute stroke should be performed irrespective of Cr levels.

Cochlear implantation outcomes in patients with far advanced otosclerosis.

OBJECTIVES: To compare hearing outcomes in patients with far advanced otosclerosis (FAO) undergoing cochlear implantation to an age-matched group of controls, to describe the effects of cochlear ossification on hearing, and to review the adverse effects of implantation in patients with FAO. HYPOTHESIS: Hearing performance in patients with FAO after cochlear implantation is comparable to similarly treated postlingually deafened adults without FAO. Ossification or retrofenestral otosclerosis does not predict poor hearing outcomes. Modiolar-hugging technology reduces postoperative facial nerve stimulation. STUDY DESIGN: Retrospective chart review. SETTING: Academic neurotologic tertiary referral center. PATIENTS: Thirty patients with FAO, who metaudiological criteria for cochlear implantation, were compared to 30 age-matched controls, postlingually deafened by non-otosclerotic causes. MAIN OUTCOME MEASURES: Audiometric pre- and postoperative speech reception threshold, word, and sentence scores were analyzed. The presence of retrofenestral findings on computed tomography or intraoperative cochlear ossification were noted. RESULTS: In the FAO group, radiographic abnormalities were noted in 26.4% of patients. Intraoperative ossification requiring drillout was seen in 29.4% of patients. None developed postoperative facial nerve stimulation. There was no difference between the FAO and control groups in the mean short-term and long-term postoperative speech reception threshold, word, and sentence scores (P = .77). The presence of radiographic abnormalities did not predict hearing outcome. Intraoperative cochlear ossification was not associated with worse short-term word and sentence scores (P = .58 and 0.79, respectively), and for the long-term hearing outcome (P = .24). CONCLUSIONS: In patients with FAO, effective and safe hearing rehabilitation can be accomplished with cochlear implantation.

Standard of practice: endovascular treatment of intracranial atherosclerosis.

BACKGROUND: Symptomatic intracranial atherosclerotic disease (ICAD) worldwide represents one of the most prevalent causes of stroke. When severe, studies show that it has a very high risk for recurrent stroke, highlighting the need for effective preventative strategies. The mainstay of treatment has been medical therapy and is of critical importance in all patients with this disease. Endovascular therapy is also a possible therapeutic option but much remains to be defined in terms of best techniques and patient selection. This guideline will serve as recommendations for diagnosis and endovascular treatment of patients with ICAD. METHODS: A literature review was performed to extract published literature regarding ICAD, published from 2000 to 2011. Evidence was evaluated and classified according to American Heart Association (AHA)/American Stroke Association standard. Recommendations are made based on available evidence assessed by the Standards Committee of the Society of NeuroInterventional Surgery. The assessment was based on guidelines for evidence based medicine proposed by the American Academy of Neurology (AAN), the Stroke Council of the AHA and the University of Oxford, Centre for Evidence Based Medicine (CEBM). RESULTS: 59 publications were identified. The SAMMPRIS study is the only prospective, randomized, controlled trial available and is given an AHA level B designation, AAN class II and CEBM level 1b. The Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial arteries (SSYLVIA) trial was a prospective, non-randomized study with the outcome assessment made by a non-operator study neurologist, allowing an AHA level B, AAN class III and CEBM level 2. The remaining studies were uncontrolled or did not have objective outcome measurement, and are thus classified as AHA level C, AAN class IV and CEBM level 4. CONCLUSION: Medical management with combination aspirin and clopidogrel for 3 months and aggressive risk factor modification is the firstline therapy for patients with symptomatic ICAD. Endovascular angioplasty with or without stenting is a possible therapeutic option for selected patients with symptomatic ICAD. Further studies are necessary to define appropriate patient selection and the best therapeutic approach for various subsets of patients.