Medical Education 4.0: A Neurology Perspective.

Medical education faces a difficult challenge today; an exponential increase in knowledge and the rise and rise of disruptive technologies are making traditional education obsolete. As the world nears the era of Industry and Healthcare 4.0, the medical community needs to keep up and prepare physicians for a hyper-connected digital world. Virtual neurological care is poised to be at the forefront of care delivery claims, yet the virtual communication of neurological knowledge is still in its infancy. This increasing digitalization of care and education is both an opportunity and a challenge. With this paper, the authors aim to bridge the gap between technology and neurological education. After a thorough review of recent literature and assessing current trends, the authors propose that contemporary medical education must adhere to the following tenets: Hybrid, Mobile, Mixed-reality, Open Access, Collaborative, Peer-reviewed, Intelligent, Game-based, and Global. We identify and align education objectives with the needs of future digital neurologists. The authors also discuss real-world advances that are aligned to serve the next generation of patients and providers.

Artificial intelligence assisted acute patient journey.

Artificial intelligence is taking the world by storm and soon will be aiding patients in their journey at the hospital. The trials and tribulations of the healthcare system during the COVID-19 pandemic have set the stage for shifting healthcare from a physical to a cyber-physical space. A physician can now remotely monitor a patient, admitting them only if they meet certain thresholds, thereby reducing the total number of admissions at the hospital. Coordination, communication, and resource management have been core issues for any industry. However, it is most accurate in healthcare. Both systems and providers are exhausted under the burden of increasing data and complexity of care delivery, increasing costs, and financial burden. Simultaneously, there is a digital transformation of healthcare in the making. This transformation provides an opportunity to create systems of care that are artificial intelligence-enabled. Healthcare resources can be utilized more justly. The wastage of financial and intellectual resources in an overcrowded healthcare system can be avoided by implementing IoT, telehealth, and AI/ML-based algorithms. It is imperative to consider the design principles of the patient's journey while simultaneously prioritizing a better user experience to alleviate physician concerns. This paper discusses the entire blueprint of the AI/ML-assisted patient journey and its impact on healthcare provision.

Implementing Virtual Care in Neurology - Challenges and Pitfalls.

Virtual care is here to stay. The explosive expansion of telehealth caused by the SARS-CoV-2 pandemic is more than a necessary measure of protection. The key drivers of this transition in healthcare delivery to a virtual setting are changes in patient behavior and expectations and societal attitudes, and prevailing technologies that are impossible to ignore. The younger population - Generation Z - is increasingly connected and mobile-first. We are heading to a world where we expect to see healthcare in general and neurology, in particular, delivered virtually. The medical community should prepare for this overhaul; proper implementation of virtual care from the ground up is the need of the hour. In an era of virtualization, it is up to the medical community to ensure a well-informed patient population, overcome cultural differences and build digital infrastructure with enhanced access and equity in care delivery, especially for the aging neurological patient population, which is not technologically savvy. Virtual care is a continuum of care that needs deeper integration at systematic levels. The design principles of a patient's journey need to be incorporated while simultaneously placing physician satisfaction with a better user experience at the center of implementation. In this paper, we discuss common challenges and pitfalls of virtual care implementation in neurology - logistical, technical, medicolegal, and those faced in incorporating health and medical education into virtual care - intending to provide solutions and strategies.

Role of Artificial Intelligence in Unruptured Intracranial Aneurysm: An Overview.

Intracranial aneurysms (IAs) are a significant public health concern. In populations without comorbidity and a mean age of 50 years, their prevalence is up to 3.2%. An efficient method for identifying subjects at high risk of an IA is warranted to provide adequate radiological screening guidelines and effectively allocate medical resources. Artificial intelligence (AI) has received worldwide attention for its impressive performance in image-based tasks. It can serve as an adjunct to physicians in clinical settings, improving diagnostic accuracy while reducing physicians' workload. AI can perform tasks such as pattern recognition, object identification, and problem resolution with human-like intelligence. Based on the data collected for training, AI can assist in decisions in a semi-autonomous manner. Similarly, AI can identify a likely diagnosis and also, select a suitable treatment based on health records or imaging data without any explicit programming (instruction set). Aneurysm rupture prediction is the holy grail of prediction modeling. AI can significantly improve rupture prediction, saving lives and limbs in the process. Nowadays, deep learning (DL) has shown significant potential in accurately detecting lesions on medical imaging and has reached, or perhaps surpassed, an expert-level of diagnosis. This is the first step to accurately diagnose UIAs with increased computational radiomicis. This will not only allow diagnosis but also suggest a treatment course. In the future, we will see an increasing role of AI in both the diagnosis and management of IAs.

Role of Artificial Intelligence in TeleStroke: An Overview.

Teleneurology has provided access to neurological expertise and state-of-the-art stroke care where previously they have been inaccessible. The use of Artificial Intelligence with machine learning to assist telestroke care can be revolutionary. This includes more rapid and more reliable diagnosis through imaging analysis as well as prediction of hospital course and 3-month prognosis. Intelligent Electronic Medical Records can search free text and provide decision assistance by analyzing patient charts. Speech recognition has advanced enough to be reliable and highly convenient. Smart contextually aware communication and alert programs can enhance efficiency of patient flow and improve outcomes. Automated data collection and analysis can make quality improvement and research projects quicker and much less burdensome. Despite current challenges, these synergistic technologies hold immense promise in enhancing the clinician experience, helping to reduce physician burnout while improving patient health outcomes at a lower cost. This brief overview discusses the multifaceted potential of AI use in telestroke.

Correlation of Noninvasive Blood Pressure and Invasive Intra-arterial Blood Pressure in Patients Treated with Vasoactive Medications in a Neurocritical Care Unit.

BACKGROUND: The correlation between noninvasive (oscillometric) blood pressure (NBP) and intra-arterial blood pressure (IAP) in critically ill patients receiving vasoactive medications in a Neurocritical Care Unit has not been systematically studied. The purpose of this study is to examine the relationship between simultaneously measured NBP and IAP recordings in these patients. METHODS: Prospective observational study of patients (N = 70) admitted to a neurocritical care unit receiving continuous vasopressor or antihypertensive infusions. Paired NBP/IAP observations along with covariate and demographic data were abstracted via chart audit. Analysis was performed using SAS v9.4. RESULTS: A total of 2177 paired NBP/IAP observations from 70 subjects (49% male, 63% white, mean age 59 years) receiving vasopressors (n = 21) or antihypertensive agents (n = 49) were collected. Paired t test analysis showed significant differences between NBP versus IAP readings: ([systolic blood pressure (SBP): mean = 136 vs. 140 mmHg; p < 0.0001], [diastolic blood pressure (DBP): mean = 70 vs. 68 mmHg, p < 0.0001], [mean arterial blood pressure (MAP): mean = 86 vs. 90 mmHg, p < 0.0001]). Bland-Altman plots for MAP, SBP, and DBP demonstrate good inter-method agreement between paired measures (excluding outliers) and demonstrate NBP-IAP SBP differences at extremes of blood pressures. Pearson correlation coefficients show strong positive correlations for paired MAP (r = 0.82), SBP (r = 0.84), and DBP (r = 0.73) recordings. An absolute NBP-IAP SBP difference of > 20 mmHg was seen in ~ 20% of observations of nicardipine, ~ 25% of observations of norepinephrine, and ~ 35% of observations of phenylephrine. For MAP, the corresponding numbers were ~ 10, 15, and 25% for nicardipine, norepinephrine, and phenylephrine, respectively. CONCLUSION: Despite overall strong positive correlations between paired NBP and IAP readings of MAP and SBP, clinically relevant differences in blood pressure are frequent. When treating with vasoactive infusions targeted to a specific BP goal, it is important to keep in mind that NBP and IAP values are not interchangeable.

Safety and outcomes of simultaneous vasospasm and endovascular aneurysm treatment (SVAT) in subarachnoid hemorrhage.

BACKGROUND: Simultaneous vasospasm and endovascular aneurysm treatment (SVAT) has been shown to be effective with good clinical outcomes in small series, but these studies have not examined predictive factors for clinical outcome after treatment. OBJECTIVE: To identify the safety and efficacy of SVAT in a large multicenter patient cohort and evaluate prognostic markers of clinical outcome following SVAT. METHODS: This study retrospectively enrolled 50 consecutive patients undergoing SVAT at 11 different centers. We analyzed Hunt and Hess and Fisher grades, aneurysm location, angiographic vasospasm grade, Glasgow Outcome Scale (GOS) at discharge, and 90-day modified Rankin Scale (mRS) scores. RESULTS: A total of 50 patients undergoing SVAT between the years 2003 and 2009 were identified. Patients presented, on average, 6.48±4.45 days after subarachnoid hemorrhage. Hunt and Hess and Fisher grades were 1 (n=7), 2 (n=12), 3 (n=14), 4 (n=15), 5 (n=2), and 3 and 4 (n=33), respectively. Aneurysm location was distributed as follows: anterior (n=32), posterior (n=16), anterior and posterior (n=2). Patients with good clinical condition (Hunt and Hess score 1-3) had significantly higher odds of surviving (OR=17.5, 95% CI 1.9 to 161.5), favorable GOS (OR=4.2, 95% CI 1.2 to 14.8), and favorable 90-day mRS (OR=4.2, 95% CI 1.2 to 14.8). CONCLUSIONS: SVAT is safe, with the majority of patients achieving good clinical outcome. Patients with lower Hunt and Hess grades have higher odds of surviving and favorable clinical prognosis.

Idiopathic Inflammatory Myopathies: Clinical Approach and Management.

Idiopathic inflammatory myopathies (IIM) are a group of chronic, autoimmune conditions affecting primarily the proximal muscles. The most common types are dermatomyositis (DM), polymyositis (PM), necrotizing autoimmune myopathy (NAM), and sporadic inclusion body myositis (sIBM). Patients typically present with sub-acute to chronic onset of proximal weakness manifested by difficulty with rising from a chair, climbing stairs, lifting objects, and combing hair. They are uniquely identified by their clinical presentation consisting of muscular and extramuscular manifestations. Laboratory investigations, including increased serum creatine kinase (CK) and myositis specific antibodies (MSA) may help in differentiating clinical phenotype and to confirm the diagnosis. However, muscle biopsy remains the gold standard for diagnosis. These disorders are potentially treatable with proper diagnosis and initiation of therapy. Goals of treatment are to eliminate inflammation, restore muscle performance, reduce morbidity, and improve quality of life. This review aims to provide a basic diagnostic approach to patients with suspected IIM, summarize current therapeutic strategies, and provide an insight into future prospective therapies.

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.

Stenting and angioplasty of small cerebral arteries in symptomatic intracranial atherosclerotic disease.

BACKGROUND: Intracranial atherosclerotic disease (ICAD) is a common cause of stroke with a poor natural history despite medical therapy. Few studies have investigated endovascular therapies for the treatment of symptomatic ICAD in distal intracranial arteries. Here, we present the feasibility and safety of balloon angioplasty with and without stenting in patients with medically refractory small artery symptomatic ICAD. METHOD: Personal logs were reviewed to identify patients who were treated for small artery ICAD (stenosis > 50%) using angioplasty ± stenting. Small cerebral arteries were defined by a diameter ≤ 2 mm or any branch distal to a large intracranial vessel (i.e. distal to ICA, M1, A1, Vertebrobasilar trunk). Patient characteristics, clinical manifestations, treatment, hospital course, and follow up data was collected and analyzed. RESULTS: Ten patients (12 arteries) were treated with either primary balloon angioplasty (58.3%) or angioplasty with stenting (41.6 %) with 100% technical success rate. Mean pre-treatment stenosis was 79.9% while mean post-treatment stenosis was 19.0%. There were no major peri-procedural complications including symptomatic intracranial hemorrhage or mortality; three cases were complicated by groin hematoma. Patients were followed for a mean total of 18.6 months with only one symptomatic restenosis which was re-treated successfully. All patients had good functional outcome with a mRS of either 0 (80%) or 1 (20%) on follow up. CONCLUSION: In our case series, treatment of symptomatic small artery ICAD with angioplasty ± stenting was safe and effective. These interventions should be considered as an alternative treatment for ICAD patients refractory to medical therapy.

Clinical trial design for endovascular ischemic stroke intervention.

BACKGROUND: Randomized, double-blinded, placebo-controlled trials have significant impact on clinical practice. The ultimate goal of a clinical trial of therapy for acute ischemic stroke (AIS) is to compare 2 interventions. Challenges may include interventional therapy standardization, enrollment rate, patient selection, biases, data and safety monitoring, reporting, and financial and logistical support. METHOD: Selected randomized and single-arm prospective AIS trial designs. Clinical trial elements and their challenges are reviewed. Innovative designs and proposed recommendations to overcome some of the specific challenges and limitations are discussed. RESULTS: AIS therapy trials have specific challenges related to ethical issues, enrollment rate, outcome measures, limited time to treatment, efficacy, safety, and limited or variable operator experience with complex technology in a delicate end organ. Proposed suggestions for improving trial design include the following: incorporation of a lead-in phase; careful patient and outcome measure selection; historical, concurrent, or hybrid controls; open data access; and a Bayesian approach. An open data paradigm may facilitate creation of computerized prediction models for future trials (minimizing cost by decreasing sample size or providing futility analyses and directing resources to other trials). Collaborative, consortium, and network infrastructures may allow more effective and efficient study completion. Self-learning, self-correcting trials with intrinsic flexibility to adapt may help future clinical trial design in AIS. CONCLUSION: The randomized clinical trial design in AIS endovascular therapy is challenging. Lead-in phases, careful patient selection, use of innovative outcome measures, control groups, and newer clinical trial design may enhance conduct of future trials, their validity, and their results.

Multicenter analysis of stenting in symptomatic intracranial atherosclerosis.

BACKGROUND: Stenting for symptomatic intracranial atherosclerotic disease is a therapeutic option in patients in whom medical therapy fails. OBJECTIVE: To determine the periprocedural complication rates and mid-term restenosis rates in patients treated with balloon-expandable stents (BESs) compared with self-expanding stents (SESs). METHODS: A retrospective review of consecutive patients treated with intracranial stents at 5 institutions was performed. Predictors of 30-day stroke and death as well as mid-term restenosis rates were analyzed. RESULTS: A total of 670 lesions were treated in 637 patients with a mean age of 57 ± 13 years. A total of 454 lesions (68%) were treated with BESs and 216 lesions (32%) with SESs. The overall 30-day periprocedural complication rate was 6.1%, without any difference noted between the 2 groups. Patients treated within 24 hours of the index event were significantly more likely to have experienced a periprocedural complication (odds ratio [OR], 4.0; 95% confidence interval [CI]: 1.7-6.7; P < .007), whereas focal lesions were less likely to have a complication (OR, 0.31; 95% CI: 0.13-0.72; P < .001). Midterm restenosis was less likely in patients with a lower percentage of posttreatment stenosis (OR, 0.97; 95% CI: 0.95-0.99; P < .006), which was more common in BES-treated patients and focal concentric lesions (OR, 0.33; 95% CI: 0.23-0.55; P < .0001). CONCLUSION: BESs have periprocedural complication rates similar to those of SESs. Less posttreatment stenosis was associated with lower rates of mid-term restenosis. Future randomized trials comparing BESs and SESs may help to identify the stent type that is safest and most durable.

Prediction of adverse outcomes by blood glucose level after endovascular therapy for acute ischemic stroke.

OBJECT: The authors evaluated the prognostic significance of blood glucose level at admission (BGA) and change in blood glucose at 48 hours from the baseline value (CG48) in nondiabetic and diabetic patients before and after endovascular therapy for acute ischemic stroke (AIS). METHODS: The BGA and CG48 data were analyzed in 614 patients with AIS who received endovascular therapy at 7 US centers between 2006 and 2009. Data reviewed included demographics, stroke risk factors, diabetic status, National Institutes of Health Stroke Scale (NIHSS) score at presentation, recanalization grade, intracranial hemorrhage (ICH) rate, and 90-day outcomes (mortality rate and modified Rankin Scale score of 3-6 [defined as poor outcome]). Variables with p values < 0.2 in univariate analysis were included in a binary logistic regression model for independent predictors of 90-day outcomes. RESULTS: The mean patient age was 67.3 years, the median NIHSS score was 16, and 27% of patients had diabetes. In nondiabetic patients, BGA ≥ 116 mg/dl (≥ 6.4 mmol/L) and failure of glucose level to drop > 30 mg/dl (> 1.7 mmol/L) from the admission value were both significant predictors of 90-day poor outcome and death (p < 0.001). In patients with diabetes, BGA ≥ 116 mg/dl (≥ 6.4 mmol/L) was an independent predictor of poor outcome (p = 0.001). The CG48 was not a predictor of outcome in diabetic patients. A simplified 6-point scale including BGA, Thrombolysis in Myocardial Infarction (TIMI) Grade 2-3 Reperfusion, Age, presentation NIHSS score, CG48, and symptomatic ICH (BRANCH) corresponded with poor outcomes at 90 days; the area under the curve value was > 0.79. CONCLUSIONS: Failure of blood glucose values to decrease in the first 48 hours after AIS intervention correlated with poor 90-day outcomes in nondiabetic patients. The BRANCH scale shows promise as a simple prognostication tool after endovascular therapy for AIS, and it merits prospective validation.

Intra-arterial thrombolysis or stent placement during endovascular treatment for acute ischemic stroke leads to the highest recanalization rate: results of a multicenter retrospective study.

BACKGROUND: Reperfusion therapy for acute ischemic stroke (AIS) is rapidly evolving, with the development of multiple endovascular modalities that can be used alone or in combination. OBJECTIVE: To determine which pharmacologic or mechanical modality may be associated with increased rates of recanalization. METHODS: A cohort of 1122 patients with AIS involving the anterior circulation treated at 13 stroke centers underwent intra-arterial (IA) therapy within 8 hours of symptom onset. Demographic information, admission National Institutes of Health Stroke Scale (NIHSS), mechanical and pharmacologic treatments used, recanalization grade, and hemorrhagic complications were recorded. RESULTS: The mean age was 67 ± 16 years and the median NIHSS was 17. The sites of arterial occlusion before treatment were M1 middle cerebral artery (MCA) in 561 (50%) patients, carotid terminus in 214 (19%) patients, M2 MCA in 171 (15%) patients, tandem occlusions in 141 (13%) patients, and isolated extracranial internal carotid artery occlusion in 35 (3%) patients. Therapeutic interventions included multimodal therapy in 584 (52%) patients, pharmacologic therapy only in 264 (24%) patients, and mechanical therapy only in 274 (24%) patients. Patients treated with multimodal therapy had a significantly higher Thrombolysis in Myocardial Infarction 2 or 3 recanalization rate (435 patients [74%]) compared with pharmacologic therapy only (160 patients, [61%]) or mechanical only therapy (173 patients [63%]), P<.001. In binary logistic regression modeling, independent predictors of Thrombolysis in Myocardial Infarction 2 or 3 recanalization were use of IA thrombolytic OR 1.58 (1.21-2.08), P<.001 and stent deployment 1.91 (1.23-2.96), P<.001. CONCLUSION: Multimodal therapy has significantly higher recanalization rates compared with pharmacologic or mechanical therapy. Among the individual treatment modalities, stent deployment or IA thrombolytics increase the chance of recanalization.

Balloon angioplasty for intracranial atherosclerotic disease: periprocedural risks and short-term outcomes in a multicenter study.

BACKGROUND AND PURPOSE: whether stenting is superior to angioplasty in the treatment of intracranial atherosclerotic disease is unknown. Dissections, vessel rupture, and lesion recoil observed with primary angioplasty using balloon catheters designed for coronary arteries have undermined the role of primary angioplasty as a preferred treatment for intracranial atherosclerotic disease. The goal of this study is to report the immediate and 3-month outcomes of treating patients with intracranial atherosclerotic disease with angioplasty balloon catheters in a multicenter study. METHODS: this is a retrospective review of 74 patients from 4 institutions treated with primary angioplasty for intracranial atherosclerotic disease over a 6-year time period. Technical success (residual stenosis ≤ 50%), periprocedural success (no vascular complication within 72 hours), and 3-month outcomes are reported. RESULTS: the mean degree of stenosis pretreatment was 79% ± 14% and reduced to 34% ± 18% after angioplasty. Technical success was achieved in 68 (92%; 95% CI, 83% to 97%) of the 74 patients. Periprocedural success was achieved in 65 (88%; 95% CI, 78% to 94%) of the 74 patients. There were 4 (5%; 95% CI, 1.5% to 13%) major procedure-related strokes, 2 of which resulted in death within 6 hours of the procedure. The 30-day stroke/death rate was 5% (4 of 74; CI, 1.5% to 13%). Three-month follow-up was available in 71 patients. In this interval, 2 patients had new stroke, 1 in the ipsilateral territory and the other in the contralateral territory. The 3-month stroke or death rate was 8.5% (6 of 71; CI, 3.1% to 17.5%); the retreatment rate was 2.8% (2 of 71; CI, 0.3% to 10%). CONCLUSIONS: balloon angioplasty is a relatively safe alternative treatment for intracranial atherosclerotic disease. Its role in the long-term secondary prevention of recurrent stroke as compared with intracranial stenting and medical therapy remains to be determined, preferably in a randomized study.

Anesthesia and Sedation Practices Among Neurointerventionalists during Acute Ischemic Stroke Endovascular Therapy.

BACKGROUND AND PURPOSE: Intra-arterial reperfusion therapies are expanding frontiers in acute ischemic stroke (AIS) management but there is considerable variability in clinical practice. The use of general anesthesia (GA) is one example. We aimed to better understand sedation practices in AIS. METHODS: An online survey was distributed to the 68 active members of the Society of Vascular and Interventional Neurology (SVIN). Survey development was based on discussions at the SVIN Endovascular Stroke Round Table Meeting (Chicago, IL, 2008). The final survey contained 12 questions. Questions were developed as single and multiple-item responses; with an option for a free-text response. RESULTS: There was a 72% survey response rate (N = 49/68). Respondents were interventional neurologists in practice 1-5 years (71.4%, N = 35). The mean (±SD) AIS interventions performed per year at the respondents' institutions was 42.5 ± 25, median 35.0 (IQR 20, 60). The most frequent anesthesia type used was GA (anesthesia team), then conscious sedation (nurse administered), monitored anesthesia care (anesthesia team), and finally local analgesia alone. There was a preference for GA because of eliminating movement (65.3% of respondents; N = 32/49), perceived procedural safety (59.2%, N = 29/49), and improved procedural efficacy (42.9%, N = 21/49). However, cited limitations to GA included risk of time delay (69.4%, N = 34), of propagating cerebral ischemia due to hypoperfusion or other complications (28.6%, N = 14), and lack of adequate anesthesia workforce (20.4%, N = 7). CONCLUSIONS: The most frequent type of anesthesia used by Neurointerventionalists for AIS interventions is GA. Prior to making GA standard of care during AIS intervention, more data are needed about effects on clinical outcomes.

Conscious sedation versus general anesthesia during endovascular therapy for acute anterior circulation stroke: preliminary results from a retrospective, multicenter study.

BACKGROUND AND PURPOSE: Patients undergoing intra-arterial therapy (IAT) for acute ischemic stroke receive either general anesthesia (GA) or conscious sedation. GA may delay time to treatment, whereas conscious sedation may result in patient movement and compromise the safety of the procedure. We sought to determine whether there were differences in safety and outcomes in GA patients before initiation of IAT. METHODS: A cohort of 980 patients at 12 stroke centers underwent IAT for acute stroke between 2005 and 2009. Only patients with anterior circulation strokes due to large-vessel occlusion were included in the study. A binary logistic-regression model was used to determine independent predictors of good outcome and death. RESULTS: The mean age was 66+/-15 years and median National Institutes of Health Stroke Scale score was 17 (interquartile range, 13-20). The overall recanalization rate was 68% and the symptomatic hemorrhage rate was 9.2%. GA was used in 44% of patients with no differences in intracranial hemorrhage rates when compared with the conscious sedation group. The use of GA was associated with poorer neurologic outcome at 90 days (odds ratio=2.33; 95% CI, 1.63-3.44; P<0.0001) and higher mortality (odds ratio=1.68; 95% CI, 1.23-2.30; P<0.0001) compared with conscious sedation. CONCLUSIONS: Patients placed under GA during IAT for anterior circulation stroke appear to have a higher chance of poor neurologic outcome and mortality. There do not appear to be differences in hemorrhagic complications between the 2 groups. Future clinical trials with IAT can help elucidate the etiology of the differences in outcomes.

Limb-shaking transient ischemic attack masquerading as lumbar radiculopathy from pericallosal artery stenosis treated successfully with intracranial angioplasty and stenting.

The pericallosal artery is rarely associated with intracranial atherosclerotic disease and, until recently, was usually not amenable to endovascular therapy with balloon angioplasty and stenting. We present an elderly patient with postural left leg-shaking episodes secondary to pericallosal artery stenosis, which was treated initially with primary intracranial balloon angioplasty, and subsequently, angioplasty and stenting as a result of recurrent stenosis. Both procedures were preformed without complications, and the patient remained free of symptoms on 6-month follow-up. This case demonstrates unique clinical and neuroendovascular aspects; the isolated postural leg-shaking transient ischemic attacks, initially mistaken for radiculopathy and local joint etiology, were found later to be cerebrovascular ischemic in origin. Moreover, the correlation between the findings of computed tomography perfusion and angiography localized the lesion into the medial frontal lobe and pericallosal artery territory. In addition, the technical aspect provides insight into the current state of neuroendovascular techniques, addressing the difficulty of access into very small and distal intracranial arteries affected by stenosis.