Highly Visible Wall-Timer to Reduce Endovascular Treatment Time for Stroke.

BACKGROUND: Endovascular therapy for acute ischemic stroke has revolutionized clinical care for patients with stroke and large vessel occlusion, but treatment remains time sensitive. At our stroke center, up to half of the door-to-groin time is accounted for after the patient arrives in the angio-suite. Here, we apply the concept of a highly visible timer in the angio-suite to quantify the impact on endovascular treatment time. METHODS: This was a single-center prospective pseudorandomized study conducted over a 32-week period. Pseudorandomization was achieved by turning the timer on and off in 2-week intervals. The primary outcome was angio-suite-to-groin time, and secondary outcomes were angio-suite-to-intubation time, groin-to-recanalization time, and 90-day modified Rankin scale. A stratified analysis was performed based on type of anesthesia (ie, endotracheal intubation versus not). RESULTS: During the 32-week study period, 97 mechanical thrombectomies were performed. The timer was on and off for 38 and 59 cases, respectively. The timer resulted in faster angio-suite-to-groin time (28 versus 33 minutes; P=0.02). The 5-minute reduction in angio-suite-to-groin was maintained after adjusting for intubation status in a multivariate regression (P=0.02). There was no difference in the 90-day modified Rankin scale between groups. The timer impact was consistent across the 32-week study period. CONCLUSIONS: A highly visible timer in the angio-suite achieved a meaningful, albeit modest, reduction in endovascular treatment time for patients with stroke. Given the lack of risk and low cost, it is reasonable for stroke centers to consider a highly visible timer in the angio-suite to improve treatment times.

Computed tomography-guided transforaminal lumbar puncture using local anesthesia and a straight 22-gauge spinal needle for intrathecal nusinersen in adults: Findings in 77 procedures.

BACKGROUND: Intrathecal nusinersen is the first Food and Drug Administration-approved treatment for spinal muscular atrophy. Reliable intrathecal access is critical for initial and maintenance therapy; however, this can be challenging in older patients with spinal muscular atrophy many of whom have had prior lumbar instrumentation and osseous fusion. Transforaminal lumbar punctures have emerged as a technique for intrathecal access that avoids the hazards of cervical punctures. We describe our technique for transforaminal lumbar punctures under computed tomography guidance using local anesthesia and a straight 22-gauge needle. METHODS: Following local institutional review board approval, medical records of all patients undergoing computed tomography-guided transforaminal lumbar puncture for intrathecal nusinersen injection were obtained and analyzed. The rate of technical success and immediate complications were recorded. Any delayed complications noted in a 3-day follow-up phone call and future office visit were also recorded. Data collation and analysis were performed using Excel. RESULTS: A total of 77 transforaminal lumbar punctures were performed with intrathecal administration of nusinersen, for a 100% technical success rate. Local anesthesia was used in 76 cases, with conscious sedation used in one case. General anesthesia was not used in any case. There were no major complications. One patient had a postdural puncture headache that resolved completely after a transforaminal epidural blood patch performed 4 days later. CONCLUSIONS: Intrathecal administration of nusinersen is critical for treatment of patients with spinal muscular atrophy. Our described technique allows for reliable access to the intrathecal space using local anesthesia and a straight 22-gauge spinal needle under computed tomography guidance, and is easily reproducible.

Artery of Davidoff and Schechter: A Large Angiographic Case Series of Dural AV Fistulas.

The artery of Davidoff and Schechter (ADS) is the only meningeal branch of the posterior cerebral artery (PCA), supplying the medial tentorial margin and posterior portions of the falx. Given its small size, it is rarely identified on angiographic studies, unless enlarged in pathologies such as dural arteriovenous fistulas (DAVFs) or vascularized masses. This artery was first described by Wollschlaeger and Wollschlaeger in 1965, and to date, only a few reports have described its significance. The objective of this study is to report our experience with the ADS in dural fistulas from 2 tertiary medical centers and to emphasize the importance of recognizing this artery during angiographic examination of vascular tentorial and posterior fossa lesions. To our knowledge, this report demonstrates the largest angiographic case series published to date, recognizing a total of 7 patients with ADS arising secondary to a posterior fossa or tentorial DAVF and one of the largest reported series of DAVFs supplied by the ADS treated by endovascular and surgical techniques. Our cases validate the importance of prompt identification of the ADS for the diagnosis as well as endovascular treatment of vascular malformations in the posterior fossa and tentorial region.

Impact of carotid tortuosity on outcome after endovascular thrombectomy.

BACKGROUND AND OBJECTIVES: Endovascular thrombectomy (EVT) is efficacious in patients with large vessel occlusion stroke (LVO). We explored whether internal carotid (ICA) tortuosity increases the technical difficulty of EVT thereby lowering the chances of successful recanalization and favorable outcomes. PATIENTS AND METHODS: Consecutive patients with LVO and patent ICAs who underwent EVT were included. Carotid tortuosity was determined on pre-EVT CTA and classified by raters blinded to outcomes into: type 1-straight ICA trunk and type 2-severe tortuosity potentially impeding adequate catheter placement. Thrombolysis in cerebral infarction (TICI) 2b-3 was considered successful recanalization, and 90-day-modified Rankin Scale ≤ 2 was considered favorable functional outcome. RESULTS: Among 302 patients (mean age 70 ± 15, median NIHSS 17), 53% had type 1, and 47% type 2 tortuosity. Overall, 85% had successful recanalization. Patients with type 2 tortuosity were significantly older (p < 0.0001) and less frequently achieved successful recanalization (80% vs. 90%; p = 0.019) but had similar outcomes compared with those without tortuosity. On regression analysis, marked tortuosity was associated with lower chances of successful recanalization (OR 0.43 95% CI 0.20-0.92) but had no effect on clinical outcomes. CONCLUSIONS: Carotid tortuosity does not appear to impact the likelihood of favorable functional outcome but may influence recanalization.

Neuroendovascular Treatment of Acute Stroke During COVID-19: A Guide From the Frontlines.

Since the initial reports surfaced of a novel coronavirus causing illness and loss of life in Wuhan, China, COVID-19 has rapidly spread across the globe, infecting millions and leaving hundreds and thousands dead. As hospitals cope with the influx of patients with COVID-19, new challenges have arisen as health-care systems care for patients with COVID-19 while still providing essential emergency care for patients with acute strokes and acute myocardial infarction. Adding to this complex scenario are new reports that patients with COVID-19 are at increased risk of thromboembolic complications including strokes. In this article, we detail our experience caring for acute stroke patients and provide some insight into neurointerventional workflow modifications that have helped us adapt to the COVID-19 era.

Type V Dural Arteriovenous Fistula Supplied by the Artery of Wollschlaeger and Wollschlaeger Causing Cervical Myelopathy and Quadriparesis.

BACKGROUND: The artery of Wollschlaeger and Wollschlaeger is a tentorial branch of the superior cerebellar artery that is usually not visualized on conventional cerebral angiography, unless it is pathologically enlarged. It can be recruited as part of the blood supply to tentorial dural arteriovenous fistulas (AVFs), although this occurs infrequently. CASE DESCRIPTION: Here we report the clinico-radiologic evaluation and treatment of a 48-year-old man referred to our institution for hitherto workup negative progressive, relapsing quadriparesis. This represents the first reported case of cervical myelopathy caused by venous congestion from a type V dural AVF supplied by the artery of Wollschlaeger and Wollschlaeger. CONCLUSIONS: The anatomic discrepancy between the symptomatic spinal cord lesion and the etiologic intracranial fistula frequently results in delayed care in cases of myelopathy due to intracranial dural AVFs. Familiarity with these disorders and of their pathophysiologic mechanisms is important to avoid unnecessary diagnostic delays.

Lymphoma Metastasis to Vertebral Body Hemangioma: Collision Tumor Causing Cord Compression.

BACKGROUND: Collision tumors of the spine are extremely uncommon. Prior reports have detailed intracranial collision tumors comprising meningiomas and astrocytomas, as well as metastases to meningiomas. Spinal collision tumors are even rarer, with only 5 cases in the literature, none involving the osseous spine. In this report, we highlight the salient features of a case of lymphoma metastasis to a preexisting benign osseous hemangioma, resulting in cord compression. CASE DESCRIPTION: An 81-year-old woman with a known typical T8 vertebral body hemangioma stable for over 6 years was evaluated for increasing back pain, new gait instability, and urinary retention. Magnetic resonance imaging showed a change in the appearance of the T8 hemangioma, with marrow replacement and new associated epidural soft tissue causing cord compression. A biopsy was performed, which showed diffuse large B-cell lymphoma within blood elements, consistent with lymphoma metastasis to a vertebral body hemangioma. The patient was treated with intravenous steroids and radiation therapy. CONCLUSIONS: Collision tumors of the spine are extremely rare. New or increasingly aggressive appearance of a previously benign spinal osseous lesion should prompt consideration for a collision tumor or malignant transformation of the benign tumor. Biopsy of the lesion should be strongly pursued whenever feasible, as the treatment strategy may vary depending on the histology of the tumor.

Readmissions After Mechanical Thrombectomy for Acute Ischemic Stroke in the United States: A Nationwide Analysis.

OBJECTIVE: Mechanical thrombectomy after acute ischemic stroke has been shown to improve clinical outcomes. Data on short-term hospitalization outcomes after thrombectomy are needed. Our objective was to quantify 30- and 90-day readmissions after thrombectomy and identify factors associated with readmissions. METHODS: Retrospective observational analysis of adult patients hospitalized between January and November 2014, using data from the 2014 Nationwide Readmissions Database. Readmission rates were calculated and examined according to patient, clinical, and hospital characteristics using descriptive statistics. Weighted unconditional logistic regression models estimated the odds of readmission and examine the associations between select characteristics and readmission. RESULTS: 4850 individuals who underwent mechanical thrombectomy for acute ischemic stroke in 2014 were eligible for 30-day readmissions analyses. The nonelective readmission rate was 12.5% at 30 days, 20.7% at 90 days. Sepsis and stroke were the most common reasons for readmission. Female sex (adjusted odds ratio [AOR] 1.34, 1.02-1.77 at 30 days), discharge to inpatient postacute care facility (AOR 1.61, 1.07-2.41 at 30 days, AOR 1.99, 1.47-2.69 at 90 days), and longer initial length of stay (AOR 1.52, 1.04-2.23 at 30 days, AOR 1.67, 1.14-2.43 at 90 days) were associated with a higher likelihood of readmission. Thrombectomy complications were rare and not associated with readmission. CONCLUSIONS: 1 in 8 thrombectomy patients had a short-term readmission in 2014. Characteristics suggestive of a complicated hospital course or greater physical disability were the primary predictors of readmission. This study provides preliminary data for evaluations of the public health impact of mechanical thrombectomy in real world settings.

Recanalization after Extracranial Dissection: Effect of Antiplatelet Compared with Anticoagulant Therapy.

BACKGROUND: Cervical arterial dissection is a leading cause of stroke in young patients, yet optimal management remains controversial. Existing studies focusing on recurrent stroke were underpowered to demonstrate differences between antithrombotic strategies. Vessel recanalization is a more prevalent outcome and is potentially clinically important. We aimed to assess recanalization rates with anticoagulation compared with antiplatelet therapy. METHODS: We studied a single-center retrospective cohort of patients with extracranial carotid or vertebral artery dissection. Subjects with baseline and follow-up imaging between 1999 and 2013 were included. Stenosis was measured using North American Symptomatic Carotid Endarterectomy Trial methodology. Univariate and multivariable analyses were performed to determine factors associated with recanalization, defined as ≥50% relative improvement in stenosis from baseline to follow-up imaging. Secondary analyses assessed absolute and relative stenosis change and limited the cohort to >50% stenosis at diagnosis. RESULTS: We identified 75 patients with 84 dissections, mean age 47 years, 43% female, 39% non-white. Patients treated with anticoagulation had worse stenosis at baseline (median 99% versus 50%, P = .02). Comparing anticoagulation with antiplatelet therapy in the first month, there were no differences in the rates of ≥50% relative improvement in stenosis (50% versus 48%, P = .84) nor in absolute (median 16% versus 7%, P = .34) or relative (median 48% versus 43%, P = .92) change in stenosis from baseline to follow-up. In multivariable analysis, anticoagulation was not associated with recanalization (odds ratio [OR] 1.41, 95% confidence interval [CI]: .5-4.1, P = .52), whereas hypertension was negatively associated (OR .26, 95% CI: .09-.72, P = .009). CONCLUSIONS: Anticoagulation was not associated with greater likelihood of recanalization compared with antiplatelet medication therapy.

Carotid Artery Stenting Versus Endarterectomy for Stroke Prevention: A Meta-Analysis of Clinical Trials.

BACKGROUND: Data conflict regarding the relative effectiveness of carotid artery stenting (CAS) and carotid artery endarterectomy (CEA) for the prevention of stroke due to carotid artery stenosis. OBJECTIVES: The authors performed an updated meta-analysis evaluating the efficacy and safety of CAS versus CEA, given recently published clinical trial data. METHODS: Databases were searched through April 30, 2016. Randomized trials with ≥50 patients, that had exclusive use of embolic-protection devices, and that compared CAS against CEA for the treatment of carotid artery stenosis were selected. We calculated summary odds ratios (ORs) and 95% confidence intervals (CIs) using a random-effects model. RESULTS: We analyzed 6,526 patients from 5 trials with a mean follow-up of 5.3 years. The composite outcome of periprocedural death, stroke, myocardial infarction (MI), or nonperiprocedural ipsilateral stroke was not significantly different between therapies (OR: 1.22; 95% CI: 0.94 to 1.59). The risk of any periprocedural stroke plus nonperiprocedural ipsilateral stroke was higher with CAS (OR: 1.50; 95% CI: 1.22 to 1.84). The risk of higher stroke with CAS was mostly attributed to periprocedural minor stroke (OR: 2.43; 95% CI: 1.71 to 3.46). CAS was associated with significantly lower risk of periprocedural MI (OR: 0.45; 95% CI: 0.27 to 0.75); cranial nerve palsy (OR: 0.07; 95% CI: 0.04 to 0.14); and the composite outcome of death, stroke, MI, or cranial nerve palsy during the periprocedural period (OR: 0.75; 95% CI: 0.60 to 0.93). CONCLUSIONS: CAS and CEA were associated with similar rates of a composite of periprocedural death, stroke, MI, or nonperiprocedural ipsilateral stroke. The risk of long-term overall stroke was significantly higher with CAS, and was mostly attributed to periprocedural minor stroke. CAS was associated with lower rates of periprocedural MI and cranial nerve palsy than CEA.

Thromboelastography Parameter Predicts Outcome After Subarachnoid Hemorrhage: An Exploratory Analysis.

OBJECTIVE: Hypercoagulability after subarachnoid hemorrhage (SAH) is well described and may be platelet mediated. Thromboelastography (TEG) provides a global assessment of coagulation. We sought to determine whether the maximum amplitude (MA) parameter of TEG, a measure of platelet strength and function, is associated with outcome after SAH. METHODS: One hundred ten TEG analyses were performed for patients with moderate-to-severe SAH and compared with 6 healthy age- and sex-matched controls. TEG indices included MA, G value (G), alpha angle, and thrombus generation and were correlated to functional outcomes and laboratory tests including complete blood count, erythrocyte sedimentation rate, high sensitivity C-reactive protein, fibrinogen, and d-dimer, obtained on post-bleed days (PBDs) 1, 3, 5, 7, and 10. RESULTS: MA was significantly elevated compared with controls on PBD 3 (70.0 mm ± 4.5 mm vs. 64.1 mm ± 6.5 mm; P = 0.02), PBD 5 (72.6 mm ± 5.3 mm vs. 64.1 mm ± 6.5 mm; P = 0.003), PBD 7 (73.0 mm ± 5.4 mm vs. 64.1 mm ± 6.5 mm; P = 0.003), and PBD 10 (73.4 mm ± 6.0 mm vs. 64.1 mm ± 6.5 mm; P = 0.005). G was significantly elevated compared with controls on PBD 3 (P = 0.03), PBD 5 (P = 0.01), PBD 7 (P = 0.01), and PBD 10 (P = 0.02). The only biomarker associated with poor outcome was CRP. Multivariate logistic regression demonstrated an association between elevated MA and outcome (odds ratio 39.1, P = 0.006) independent of CRP, age, Hunt Hess grade, and transfusion. CONCLUSIONS: TEG indices are associated with poor outcome after SAH and may identify a platelet-mediated hypercoagulable state. The association between MA and outcome was stronger than that between traditional biomarkers and was independent of age and Hunt Hess grade.

Proximal versus distal embolic protection for carotid artery stenting: a national cardiovascular data registry analysis.

OBJECTIVES: The aim of this study was to compare the stroke/death rates between proximal embolic protection devices (P-EPDs) and distal filter embolic protection devices (F-EPDs) in elective carotid artery stenting (CAS). BACKGROUND: P-EPDs have theoretical advantages that may make them superior to F-EPDs for stroke prevention during CAS. METHODS: We examined 10,246 consecutive elective CAS procedures performed with embolic protection in the NCDR CARE registry between January 2009 and March 2013. We analyzed crude and propensity-matched rates of in-hospital combined death/stroke in patients treated with P-EPDs versus F-EPDs. Secondary analyses included 30-day adverse event rates and stroke rates by the involved cerebrovascular territory. RESULTS: P-EPDs were used in 590 of 10,246 cases (5.8%). Patients treated with P-EPDs had higher rates of symptomatic lesion status (46.8% vs. 39.7%, p<0.001), atrial fibrillation/flutter (16.1% vs. 13.0%, p=0.03), and history of a neurological event (51.2% vs. 46.6%, p=0.03). In unadjusted and propensity-matched analyses, differences in in-hospital stroke/death between P-EPD and F-EPD cohorts were nonsignificant (1.5% vs. 2.4%, p=0.16 and 1.6% vs. 2.0%, p=0.56, respectively). For patients with available data (n=7,693, 75.1%), 30-day adverse events rates were similar for P-EPDs and F-EPDs before (2.5% vs. 4.2%, p=0.07) and after (2.7% vs. 4.0%, p=0.22) propensity matching. CONCLUSIONS: Use of a P-EPD during CAS was associated with low rates of in-hospital stroke/death similar to those with an F-EPD in the first comparative effectiveness study of the devices. An adequately powered randomized trial comparing clinical outcomes between these devices is unlikely to be feasible.

Septo-temporal gradients of neurogenesis and activity in 13-month-old rats.

Recent studies suggest that hippocampal function is partially dissociable along its septo-temporal axis: the septal hippocampus is more critical for spatial processing, while the temporal hippocampus may be more important for non-spatial-related behavior. In young adults, water maze training specifically activates new neurons in the temporal hippocampus, but it is unknown whether subregional differences are maintained in older animals, which have reduced neurogenesis levels. We therefore examined gradients of activity-related Fos expression and neurogenesis in 13-month-old rats and found that neurogenesis occurs relatively evenly throughout the dentate gyrus. Water maze experience significantly increased Fos expression in the suprapyramidal blade and Fos was highest in the septal pole of the dentate gyrus whether the animal learned a platform location, swam in the absence of a platform or remained in their cage. No Fos+ young neurons were found using typical markers of immature neurons. However, Fos expression in the subgranular zone, where adult-born neurons predominate, was disproportionally high in the temporal dentate gyrus. These findings indicate that adult-born neurons in the temporal hippocampus are preferentially activated compared with older neurons.