Nationwide trends in intensive care unit utilization in the elective endovascular treatment of unruptured intracranial aneurysms.

OBJECTIVE: Multiple studies suggest routine post-operative intensive care unit (ICU) stays after endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs) is unnecessary, though rates of ICU utilization nationwide are unknown. We aim to evaluate rates and characteristics of ICU utilization in patients undergoing elective endovascular repair of UIAs. METHODS: This is a retrospective cohort study utilizing a nationwide private-payer database in the United States to evaluate the ICU utilization in patients undergoing elective endovascular repair of UIAs between 2005 and 2019. Demographics and pre-operative comorbidities as well as post-procedural complications and discharge status were compared. An analysis of charges and costs was also performed. RESULTS: Among 6218 patients who underwent elective EVT of a UIA, 4890 (78.6%) were admitted to the ICU post-operatively. There were no differences in age, sex, or Charlson comorbidity scores in patients admitted to the ICU post-operatively compared to those admitted elsewhere. ICU utilization was more common in urban locations compared to rural. 12.7% of patients had ICU-specific needs sufficient to be billed by a critical care provider. Total provider costs were significantly higher in patients utilizing the ICU post-operatively, even among uncomplicated patients with routine discharges. CONCLUSION: Most patients undergoing elective endovascular UIA repair in the United States are admitted to the ICU postoperatively. Only 12.7% have ICU needs, and these patients are predictable from pre-operative characteristics or peri-operative complications. Reducing ICU use in this subgroup of patients may be an important target to improve healthcare value in this patient population.

Safety and efficacy of endovascular versus microsurgical treatment of unruptured wide-necked middle cerebral artery aneurysms: a propensity score-matched analysis of the NeuroVascular Quality Initiative Quality Outcomes Database Cerebral Aneurysm Registry.

OBJECTIVE: Unruptured, wide-necked middle cerebral artery (WN-MCA) aneurysms have traditionally been considered ideal candidates for microsurgery (MS), although endovascular treatment (EVT) has dramatically increased in popularity with the advent of novel devices such as intrasaccular flow disruptors. The purpose of this study was to evaluate the safety and efficacy of MS versus EVT for unruptured WN-MCA aneurysms. METHODS: The NeuroVascular Quality Initiative Quality Outcomes Database (NVQI-QOD) Cerebral Aneurysm Registry, a multiinstitutional, prospectively collected procedural database, was queried for cases of unruptured WN-MCA aneurysms treated with MS or EVT between 2015 and 2022. A wide neck was defined as an aneurysm neck ≥ 4 mm or a dome/neck ratio ≤ 2. Demographics and aneurysm characteristics were queried. Propensity score matching (PSM) was utilized to match aneurysm size, number of aneurysms treated, patient age, and aneurysm status. Safety outcomes were evaluated including intraoperative and postoperative complication rates. Aneurysm occlusion status and clinical outcomes using the modified Rankin Scale (mRS) score at discharge and the last follow-up were also assessed. RESULTS: Of 671 unruptured MCA aneurysms, 319 were wide necked. Thirty cases were excluded, as the aneurysm had been previously treated. Two hundred eighty-nine operations (203 EVT, 86 MS) in 282 patients satisfied inclusion criteria. After PSM, there were 86 operations in each group for analysis. The mean aneurysm width was 5.0 (EVT) versus 4.9 mm (MS; p = 0.285). Safety data showed similar intraoperative (7.0% EVT vs 3.5% MS, p = 0.496) and postoperative (4.7% vs 7%, p = 0.746) complication rates. The MS patients were more likely to have complete aneurysm occlusion at discharge (90.4% vs 58.8%, p < 0.001). In a limited subset of patients (52.9%) for whom outcome data were available, the EVT patients were more likely to have an mRS score 0 at discharge (50/59 [84.7%] vs 29/54 [53.7%], p < 0.0003] and at the last follow-up (36/55 [65.5%] vs 13/36 [36.1%], p = 0.006). CONCLUSIONS: This study describes a large, modern cohort of propensity score-matched patients who underwent treatment of unruptured WN-MCA aneurysms. Safety data on intraoperative and postoperative complication rates were similar in both treatment groups. MS was more likely to result in complete aneurysm occlusion at discharge. In a subset of patients with available outcome data, EVT was associated with better functional outcomes at discharge and the last follow-up. Given the lack of complete follow-up data and rates of retreatment, these results should be interpreted cautiously.

Conscious sedation by sedation-trained interventionalists versus anesthesia providers in patients with acute ischemic stroke undergoing endovascular thrombectomy: A propensity score-matched analysis.

BACKGROUND: The appropriate choice of perioperative sedation during endovascular thrombectomy for ischemic stroke is unknown. Few studies have evaluated the role of nursing-administered conscious sedation supervised by a trained interventionalist. OBJECTIVE: To compare the safety and efficacy of endovascular thrombectomy for ischemic stroke performed with nursing-administered conscious sedation supervised by a trained interventionalist with monitored anesthesia care supervised by an anesthesiologist. METHODS: A retrospective review of a prospectively collected stroke registry was performed. The primary outcome was functional independence at 90 days, defined as a modified Rankin score of 0-2. Propensity score matching was performed to control for known confounders including patient comorbidities, access type, and direct-to-suite transfers. RESULTS: A total of 355 patients underwent endovascular thrombectomy for large vessel occlusion between 2018 and 2022. Thirty five patients were excluded as they arrived at the endovascular suite intubated. Three hundred and twenty patients were included in our study, 155 who underwent endovascular thrombectomy with nursing-administered conscious sedation and 165 who underwent endovascular thrombectomy with monitored anesthesia care. After propensity score matching, there were 111 patients in each group. There was no difference in modified Rankin score 0-2 at 90 days (26.1% vs 35.1%, p = 0.190). Patients undergoing monitored anesthesia care received significantly more vasoactive medications (23.4% vs 49.5%, p < 0.001) and had a lower intraoperative minimum systolic blood pressure (134 vs 123 mmHg, p < 0.046). There was no difference in procedural efficacy, safety, intubation rates, and postoperative complications. CONCLUSION: Perioperative sedation with nursing-administered conscious sedation may be safe and effective in patients undergoing endovascular thrombectomy for ischemic stroke.

Common Mutation in the HFE Gene Modifies Recovery After Intracerebral Hemorrhage.

BACKGROUND: Intracerebral hemorrhage (ICH) is characterized by bleeding into the brain parenchyma. During an ICH, iron released from the breakdown of hemoglobin creates a cytotoxic environment in the brain through increased oxidative stress. Interestingly, the loss of iron homeostasis is associated with the pathological process of other neurological diseases. However, we have previously shown that the H63D mutation in the homeostatic iron regulatory (HFE) gene, prevalent in 28% of the White population in the United States, acts as a disease modifier by limiting oxidative stress. The following study aims to examine the effects of the murine homolog, H67D HFE, on ICH. METHODS: An autologous blood infusion model was utilized to create an ICH in the right striatum of H67D and wild-type mice. The motor recovery of each animal was assessed by rotarod. Neurodegeneration was measured using fluorojade-B and mitochondrial damage was assessed by immunofluorescent numbers of CytC+ (cytochrome C) neurons and CytC+ astrocytes. Finally, the molecular antioxidant response to ICH was quantified by measuring Nrf2 (nuclear factor-erythroid 2 related factor), GPX4 (glutathione peroxidase 4), and FTH1 (H-ferritin) levels in the ICH-affected and nonaffected hemispheres via immunoblotting. RESULTS: At 3 days post-ICH, H67D mice demonstrated enhanced performance on rotarod compared with wild-type animals despite no differences in lesion size. Additionally, H67D mice displayed higher levels of Nrf2, GPX4, and FTH1 in the ICH-affected hemisphere; however, these levels were not different in the contralateral, non-ICH-affected hemisphere. Furthermore, H67D mice showed decreased degenerated neurons, CytC+ Neurons, and CytC+ astrocytes in the perihematomal area. CONCLUSIONS: Our data suggest that the H67D mutation induces a robust antioxidant response 3 days following ICH through Nrf2, GPX4, and FTH1 activation. This activation could explain the decrease in degenerated neurons, CytC+ neurons, and CytC+ astrocytes in the perihematomal region, leading to the improved motor recovery. Based on this study, further investigation into the mechanisms of this neuroprotective response and the effects of the H63D HFE mutation in a population of patients with ICH is warranted.

Variation in Carotid Artery Stenosis Measurements Among Facilities Seeking Carotid Stenting Facility Accreditation.

BACKGROUND: Based on the inclusion criteria of clinical trials, the degree of cervical carotid artery stenosis is often used as an indication for stent placement in the setting of extracranial carotid atherosclerotic disease. However, the rigor and consistency with which stenosis is measured outside of clinical trials are unclear. In an agreement study using a cross-sectional sample, we compared the percent stenosis as measured by real-world physician operators to that measured by independent expert reviewers. METHODS: As part of the carotid stenting facility accreditation review, images were obtained from 68 cases of patients who underwent carotid stent placement. Data collected included demographics, stroke severity measures, and the documented degree of stenosis, termed operator-reported stenosis (ORS), by 34 operators from 14 clinical sites. The ORS was compared with reviewer-measured stenosis (RMS) as assessed by 5 clinicians experienced in treating carotid artery disease. RESULTS: The median ORS was 90.0% (interquartile range, 80.0%-90.0%) versus a median RMS of 61.1% (interquartile range, 49.8%-73.6%), with a median difference of 21.8% (interquartile range, 13.7%-34.4%), P<0.001. The median difference in ORS and RMS for asymptomatic versus symptomatic patients was not statistically different (24.6% versus 19.6%; P=0.406). The median difference between ORS and RMS for facilities granted initial accreditation was smaller compared with facilities whose accreditation was delayed (17.9% versus 25.5%, P=0.035). The intraclass correlation between ORS and RMS was 0.16, indicating poor agreement. If RMS measurements were used, 72% of symptomatic patients and 10% of asymptomatic patients in the population examined would meet the Centers for Medicare and Medicaid Services criteria for stent placement. CONCLUSIONS: Real-world operators tend to overestimate carotid artery stenosis compared with external expert reviewers. Measurements from facilities granted initial accreditation were closer to expert measurements than those from facilities whose accreditation was delayed. Since decisions regarding carotid revascularization are often based on percent stenosis, such measuring discrepancies likely lead to increased procedural utilization.

Modeling flow in an in vitro anatomical cerebrovascular model with experimental validation.

Acute ischemic stroke (AIS) is a leading cause of mortality that occurs when an embolus becomes lodged in the cerebral vasculature and obstructs blood flow in the brain. The severity of AIS is determined by the location and how extensively emboli become lodged, which are dictated in large part by the cerebral flow and the dynamics of embolus migration which are difficult to measure in vivo in AIS patients. Computational fluid dynamics (CFD) can be used to predict the patient-specific hemodynamics and embolus migration and lodging in the cerebral vasculature to better understand the underlying mechanics of AIS. To be relied upon, however, the computational simulations must be verified and validated. In this study, a realistic in vitro experimental model and a corresponding computational model of the cerebral vasculature are established that can be used to investigate flow and embolus migration and lodging in the brain. First, the in vitro anatomical model is described, including how the flow distribution in the model is tuned to match physiological measurements from the literature. Measurements of pressure and flow rate for both normal and stroke conditions were acquired and corresponding CFD simulations were performed and compared with the experiments to validate the flow predictions. Overall, the CFD simulations were in relatively close agreement with the experiments, to within ±7% of the mean experimental data with many of the CFD predictions within the uncertainty of the experimental measurement. This work provides an in vitro benchmark data set for flow in a realistic cerebrovascular model and is a first step towards validating a computational model of AIS.

Modeling Flow in an In Vitro Anatomical Cerebrovascular Model with Experimental Validation.

Acute ischemic stroke (AIS) is a leading cause of mortality that occurs when an embolus becomes lodged in the cerebral vasculature and obstructs blood flow in the brain. The severity of AIS is determined by the location and how extensively emboli become lodged, which are dictated in large part by the cerebral flow and the dynamics of embolus migration which are difficult to measure in vivo in AIS patients. Computational fluid dynamics (CFD) can be used to predict the patient-specific hemodynamics and embolus migration and lodging in the cerebral vasculature to better understand the underlying mechanics of AIS. To be relied upon, however, the computational simulations must be verified and validated. In this study, a realistic in vitro experimental model and a corresponding computational model of the cerebral vasculature are established that can be used to investigate flow and embolus migration and lodging in the brain. First, the in vitro anatomical model is described, including how the flow distribution in the model is tuned to match physiological measurements from the literature. Measurements of pressure and flow rate for both normal and stroke conditions were acquired and corresponding CFD simulations were performed and compared with the experiments to validate the flow predictions. Overall, the CFD simulations were in relatively close agreement with the experiments, to within ±7% of the mean experimental data with many of the CFD predictions within the uncertainty of the experimental measurement. This work provides an in vitro benchmark data set for flow in a realistic cerebrovascular model and is a first step towards validating a computational model of AIS.

Minimally Invasive Ventriculo-Cholecystic Shunt Placement Utilizing Combined Ultrasound and Fluoroscopic Guidance.

For the management of hydrocephalus with ventricular cerebrospinal fluid (CSF) shunting, multiple therapeutic options are available. Among these routes, the most commonly used are ventriculo-peritoneal, ventriculo-atrial, and ventriculo-pleural, while ventriculo-cholecystic is a less common option. Although ventriculo-peritoneal is accepted as the first option, ventriculo-cholecystic shunting may be performed in patients who are poor candidates for other routes of shunt placement. Open cholecystic shunt placement may be contraindicated in patients who have undergone previous surgeries or other comorbidities. Here, we present the case of a 25-year-old female with a complex medical history who presented with a posterior fossa intraparenchymal hemorrhage and subsequent hydrocephalus. She was unable to undergo a ventriculo-peritoneal, atrial, or pleural shunt placement, and thus, a cholecystic shunt placement was chosen. Due to a history of previous surgeries and comorbidities as well as a large volume of idiopathic and recurrent ascites, open placement was contraindicated in this patient. To the best of our knowledge, we present the first successful adult case of a minimally invasive ventriculo-cholecystic shunt placement under ultrasound and fluoroscopic guidance.

Risk Factors Associated with ICU-Specific Care in Patients Undergoing Endovascular Treatment of Unruptured Intracranial Aneurysms.

BACKGROUND: Multiple studies suggest routine postoperative intensive care unit (ICUs) stays in presumed high-risk neurosurgical procedures may be unnecessary. Our objective was to evaluate the risk factors associated with ICU-specific needs in patients undergoing elective endovascular treatment of unruptured intracranial aneurysms. METHODS: A retrospective review of consecutive patients undergoing elective endovascular treatment of unruptured aneurysms was performed between January 2010 and January 2020 in a single academic medical center. Patient demographic information, aneurysm and treatment characteristics, intraoperative and postoperative complications, as well as ICU-specific needs, were abstracted. The primary outcome was ICU-specific needs. RESULTS: A total of 382 patient encounters in 344 unique patients were abstracted. 13.6% (52 of 382) of patient encounters had an ICU-specific need. Multivariate analysis revealed that age [adjusted odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.07, p = 0.03], procedure duration greater 200 min (adjusted OR 2.75, 95% CI 1.34-5.88, p = 0.007), and any intraoperative complication (adjusted OR 20.41, CI 7.97-56.57, p < 0.001) were independent predictors of postoperative ICU-specific needs. The majority of ICU-specific needs (94%, 49 of 52) occurred within 6 h of surgery. CONCLUSIONS: Our results show that age, procedure duration greater than or equal to 200 min, and intraoperative complication were independent predictors of postoperative ICU-specific needs in patients presenting for elective endovascular treatment of unruptured intracranial aneurysms. The majority of ICU-specific needs and associated complications occurred in the immediate postoperative period. This data can be used to help decide the appropriate postoperative level of care in this patient population.

Balloon-Assisted Roadmap Technique to Enable Flow Diversion of a High-Flow Direct Carotid-Cavernous Fistula.

BACKGROUND: The use of flow diverters as a first-line treatment for direct carotid cavernous fistula (CCF) is a relatively new approach in the neurointerventional field which allows obliteration of the fistula with less mass effect from coils in the cavernous sinus. Safe and successful deployment of a flow diverter requires adequate imaging of the parent vessel, which may be challenging in the setting of high-flow CCF without antegrade flow. OBJECTIVE: To facilitate adequate parent vessel imaging in the setting of high-flow CCF to enable the safe development of a flow diverter device. METHODS: Here we present the case of a patient with delayed presentation of post-traumatic direct CCF after a motor vehicle accident, with no antegrade flow past the fistulous connection. We used temporary balloon occlusion of the fistulous connection to enable road-map imaging of the parent vessel and flow-diverter placement. "Drag and drop" device opening in the middle cerebral artery facilitated better deployment of the flow-diverter against retrograde cavernous flow through the fistula. RESULTS: Temporary balloon occlusion of the fistulous connection was used to acquire a roadmap to facilitate safe deployment of a flow diverter and subsequent treatment of the CCF with transvenous coil embolization, with complete resolution of symptoms. CONCLUSION: Balloon-assisted roadmap use is a novel means of visualizing the parent vessel in direct CCF to facilitate safe flow diverter deployment.

Management of neurophysiological monitoring changes during carotid endarterectomy exposure.

BACKGROUND: Carotid endarterectomy (CEA) is a safe and effective operation in the management of carotid stenosis. Intraoperative neurophysiologic monitoring (IONM) changes during carotid clamping has been well studied, but there is scant evidence detailing IONM changes during carotid exposure. OBJECTIVE: We analyzed our experience with IONM changes during CEA exposure to determine whether multimodal IONM changes during exposure predict outcomes and how best to manage this challenging clinical scenario. METHODS: We reviewed all CEAs performed at our medical center between January 2015 and June 2020 and identified patients with multimodal IONM changes during exposure of the carotid artery. Our primary outcomes were perioperative stroke and functional outcomes. Functional outcomes were measured by modified Rankin scale (mRS), with good functional outcome defined at mRS scores 0-3. We also reviewed our intraoperative IONM change management strategies. RESULTS: Five patients (4 males, 1 female) with an average age of 67 ± 12 years had intraoperative IONM changes during carotid exposure. Among these, three patients were discharged with good functional outcome, and four patients had a good functional outcome at last follow-up. Two patients had perioperative stroke, half of which resulted in significant disability. One patient was transferred to the neuroendovascular suite intraoperatively for evaluation for thromboembolism followed by angioplasty and stenting with distal protection. CONCLUSION: Intraoperative IONM changes during carotid exposure predict outcomes in CEA. We propose that transition to the neuroendovascular suite following significant IONM changes during carotid exposure may be a useful strategy for management of this challenging clinical scenario. This approach provides the opportunity to evaluate and treat thromboembolism and still complete carotid revascularization when appropriate. This algorithm may be particularly useful in the era of dual trained vascular neurosurgeons.

Management of Internal Carotid Artery and Intracranial Anterior Circulation Tandem Occlusion with Stenting versus No Stenting: A Multicenter Study.

BACKGROUND: Tandem occlusion (TO) describes not only occlusion of the middle cerebral artery but a contemporaneous occlusion of the cervical internal carotid artery. There is a paucity of data over whether mechanical thrombectomy (MT) alone, MT with angioplasty, or MT with carotid artery stent placement is superior. We aim to address a gap in the literature comparing carotid stenting with mechanical thrombectomy (CSMT) and carotid angioplasty with mechanical thrombectomy (CAMT) in patients presenting with acute anterior circulation TOs. METHODS: This is a multicenter, retrospective study from 2012 to 2020 comparing CSMT and CAMT presenting with acute anterior circulation TOs. Primary outcomes of interest were functional status, perioperative stroke, mortality, and symptomatic intracranial hemorrhage (sICH). A total of 92 patients (66 vs. 26 in CSMT and CAMT, respectively) met inclusion criteria for analysis. RESULTS: There was no statistically significant difference in functional outcomes at 90-day follow-up (adjusted odds ratio [aOR] 0.82; 95% confidence interval [CI] 0.20-3.5; P = 0.46). In addition, there was no statistically significant difference in 90-day mortality (aOR 0.361; 95% CI 0.016-2.92; P = 0.532) and perioperative stroke rate (aOR 1.76; 95% CI 0.160-15.6; P = 0.613). However, sICH risk was significantly greater in the stent-treated cohort (aOR 3.94; 95% CI 0.529-37.4; P = 0.003). CONCLUSIONS: Functional outcomes, mortality, and perioperative stroke rates do not significantly differ in CSMT and CAMT procedures in the acute setting. However, CSMT-treated patients do appear to have an increased risk of sICH, potentially due to the use of additional antiplatelet agents following stent placement.

A Systematic Review and Meta-Analysis of Antiepileptic Prophylaxis in Spontaneous Intracerebral Hemorrhage.

BACKGROUND: Frequency of clinical seizures may be as high as 16% in patients with spontaneous intracerebral hemorrhage (ICH). Current guidelines recommend against antiepileptic drug (AED) prophylaxis, but this recommendation is based on older trials, and the effect of newer AEDs is uncertain. The aim of this review was to study effects of AEDs on seizure occurrence and outcome in patients with spontaneous ICH. METHODS: We searched key databases using combinations of the following terms: "levetiracetam," "prophylaxis," "ICH," "intracerebral hemorrhage," "intraparenchymal hemorrhage." Selected studies were reviewed for level of evidence and overall quality of data using Grading of Recommendations, Assessment, Development and Evaluations criteria. A meta-analysis was performed to evaluate seizure prevention, functional outcome, and mortality in patients with seizure prophylaxis compared with no prophylaxis following spontaneous ICH. RESULTS: Seven articles met inclusion criteria and were graded level III studies. Administration of AEDs was not associated with reduced seizure risk (odds ratio 1.14, 95% confidence interval 0.47-2.77, P = 0.77). There was an association between AED prophylaxis and poor functional outcome (odds ratio 1.65, 95% confidence interval 1.17-2.31, P = 0.004) but not mortality (odds ratio 1.04, 95% confidence interval 0.62-1.72, P = 0.89). The overall quality of evidence using Grading of Recommendations, Assessment, Development and Evaluations criteria was low. CONCLUSIONS: This systematic review and meta-analysis including recent studies focusing on newer AEDs supports the 2015 guidelines regarding AED use in spontaneous ICH. There are some important caveats, including a possible confounding association between AED use and higher ICH score and the overall poor quality of the available data. A randomized clinical trial may be helpful.

An Assessment of Neurosurgery Resident Clinical and Socioeconomic Training: The 2013 Council of State Neurosurgical Societies Postresidency Survey Results.

OBJECTIVE: The Council of State Neurosurgical Societies surveyed neurosurgeons applying for oral board certification in 2008 to assess their preparedness to practice. This survey was repeated in 2013 for a subsequent group of board applicants to evaluate the quality of neurosurgery training and identify opportunities for improvement. METHODS: Applicants for the American Board of Neurological Surgeons oral examination from 2008 to 2013 were provided an anonymous survey focused on clinical and socioeconomic skills. Survey responses were compared with the published results of a similar survey using an inferential statistical analysis. RESULTS: In total, 110 of 655 neurosurgeons responded (response rate 16.8%). Significantly more respondents from the 2013 survey felt prepared to perform the following techniques: angiography, endoscopic surgery, anterior lumbar interbody fusion, posterior lumbar interbody fusion, transforaminal lumbar interbody fusion, kyphoplasty, and deep brain stimulation. Significantly more respondents in 2013 attested to receiving appropriate education on Health Insurance Portability and Accountability Act and pay-for-performance practice models of health care. However, significantly fewer respondents in 2013 felt prepared in open vascular neurosurgery techniques. In both surveys, fewer than 35% of respondents felt adequately prepared in endovascular neurosurgery techniques, medical coding, negotiating an employment contract, and issues regarding practice management and the economics of neurosurgery. CONCLUSIONS: The 2013 survey suggests that candidates for board certification in neurosurgery perceive themselves to be adequately prepared to independently perform nearly all neurosurgical procedures. However, additional work is required to optimize neurosurgery training in endovascular procedures and the socioeconomic aspects of neurosurgery practice.

Effect of Blood Pressure Management Strategies on Outcomes in Patients with Acute Ischemic Stroke After Successful Mechanical Thrombectomy.

BACKGROUND: Variability, with no general consensus, exists in how patients' blood pressure should be managed after successful mechanical thrombectomy (MT) for large vessel ischemic stroke. We examined whether exceeding the systolic blood pressure (SBP) targets in patients during the first 24 hours after successful MT led to worse outcomes. METHODS: We retrospectively studied a consecutive sample of adult patients who had undergone MT. We collected SBP data for the first 24 hours after MT and categorized the patients into 3 groups according to cases of the SBP exceeding 140, 160, or 180 mm Hg. The primary and secondary outcomes were the modified Rankin scale score at discharge and 90 days of follow-up, the incidence of symptomatic intracranial hemorrhage, malignant cerebral edema, and hemicraniectomy, mortality within 90 days, and discharge disposition. RESULTS: A total of 117 patients were included (mean age, 65 ± 13.12 years; 53% female). The occurrence of ≥1 instance of SBP ≥180 mm Hg was significantly associated with poor functional outcomes at discharge (adjusted odds ratio [OR], 5.83; 95% confidence interval [CI], 1.41-32.9; P = 0.025) but not at 90 days of follow-up. The occurrence of SBP ≥160 mm Hg resulted in an independently increased odds of malignant cerebral edema (adjusted OR, 17.07; 95% CI, 2.56-174.4; P = 0.01), with a trend toward increased odds of symptomatic intracranial hemorrhage (adjusted OR, 4.42; 95% CI, 1.03-21.2; P = 0.0503). CONCLUSIONS: These results suggest that individual instances of SBP elevation alone after successful MT, rather than a necessarily prolonged increased blood pressure as reflected by the mean or median SBP values, can significantly affect the clinical outcomes after successful MT.

Impact of COVID-19 Pandemic on the Incidence, Prehospital Evaluation, and Presentation of Ischemic Stroke at a Nonurban Comprehensive Stroke Center.

INTRODUCTION: Many reports have described a decrease in the numbers of patients seeking medical attention for typical emergencies during the COVID-19 pandemic. These reports primarily relate to urban areas with widespread community transmission. The impact of COVID-19 on nonurban areas with minimal community transmission is less well understood. METHODS: Using a prospectively maintained prehospital quality improvement database, we reviewed our hospital EMS transports with a diagnosis of stroke from January to April 2019 (baseline) and January to April 2020 (pandemic). We compared the volume of patients, transport/presentation times, severity of presenting symptoms, and final diagnosis. RESULTS: In January, February, March, and April 2019, 10, 11, 17, and 19 patients, respectively, were transported in comparison to 19, 14, 10, and 8 during the same months in 2020. From January through April 2019, there was a 53% increase in transports, compared to a 42% decrease during the same months in 2020, constituting significantly different trend-line slopes (3.30; 95% CI 0.48-6.12 versus -3.70; 95% CI -5.76--1.64, p = 0.001). Patient demographics, comorbidities, and symptom severity were mostly similar over the two time periods, and the number of patients with a final diagnosis of stroke was also similar. However, the median interval from EMS dispatch to ED arrival for patients with a final diagnosis of stroke was significantly longer in January to April 2020 (50 ± 11.7 min) compared to the same time period in 2019 (42 ± 8.2 min, p = 0.01). Discussion/Conclusion. Our data indicate a decrease in patient transport volumes and longer intervals to EMS activation for suspected stroke care. These results suggest that even in a nonurban location without widespread community transmission, patients may be delaying or avoiding care for severe illnesses such as stroke. Clinicians and public health officials should not ignore the potential impact of pandemic-like illnesses even in areas of relatively low disease prevalence.

Hydrodynamics in Acute Ischemic Stroke Catheters Under Static and Cyclic Aspiration Conditions.

PURPOSE: Previous studies have suggested improved recanalization efficiency by using cyclic aspiration as opposed to static aspiration for mechanical thrombectomy in the treatment of acute ischemic stroke (AIS). However, there has not been an investigation into which parameters optimize this theoretical approach. Therefore, this study was designed to investigate the application of static and cyclic pressure in AIS aspiration catheters. METHODS: An experimental flow system was designed to apply and measure both static and cyclic aspiration pressures in four commercial aspiration catheters. A medical aspirator and solenoid-valve were used to generate a range of applied pump pressures and cyclic valve frequencies. The measured mean and oscillatory pressure amplitudes were analyzed and compared across catheters and operating conditions. RESULTS: The greatest mean pressures and forces were achieved under contact-aspiration conditions using the largest diameter catheter, while the largest oscillating pressure (ΔP) and force (ΔF) values were generated in the least compliant catheter, determined to be proportional to both its inner radius and wall thickness. Furthermore, lower frequency cyclic aspiration was able to generate the largest values of ΔP and ΔF. CONCLUSION: For future investigations of cyclic aspiration AIS therapy, the best options are to use large inner diameter and low compliance catheters operating at lower cyclic frequencies to generate the greatest mean and oscillating forces on lodged thromboemboli.

Temporal augmentation with poly methyl methacrylate at the time of autologous cranioplasty.

Patients undergoing decompressive hemicraniectomy often have temporal wasting. We present a technique to manage temporalis wasting at the time of cranioplasty. Using poly methyl methacrylate, a small temporal implant is placed during cranioplasty. This is both a simple and cost effective technique for temporal augmentation at the time of cranioplasty.

Impact of an External Ventricular Drain Placement and Handling Protocol on Infection Rates: A Meta-Analysis and Single Institution Experience.

BACKGROUND: Numerous studies have examined the impact of initiating an external ventricular drain (EVD) placement and handling protocol on the infection rate dating back to the early 2000s. METHODS: We report a quantitative systematic review of the published literature, described our own protocol (including a mandatory checklist), and present our single institution experience. Search terms "external ventricular drain protocol" or "external ventricular drain placement protocol" or "preventing infections in external ventricular drains" or "external ventricular drain infections" were entered into standard search engines in a systematic fashion. Articles were reviewed and graded independently for class of evidence. There were 10 relevant class IV articles and no discrepancies among article ratings (i.e., κ = 1). The published evidence was reviewed and evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. RESULTS: Our meta-analysis revealed a statistically significant drop in rates of EVD infection after initiation of the protocol, although the overall quality of the body of evidence according to the GRADE criteria was "very poor". Preimplementation and postimplementation infection rates were collected and analyzed in combination with the results from our literature review. The EVD infection rate in our institution was 12% in the 8 months before protocol initiation (January 2015 to August 2015), and dropped to 0% in the 7 months after initiation. CONCLUSIONS: Although the quality of the literature supporting EVD placement protocols is poor, all published studies show a consistent and substantial benefit, and this effect was recapitulated in our own meta-analysis-based prospective EVD protocol experience.