Systematic Review and Case of Thrombectomy for Pediatric Stroke Due to Myxoma Embolism.

BACKGROUND: Stroke presentation secondary to a cardiac myxoma thromboembolism is rare in the pediatric population. Because of such rarity, the reported cases in the literature are primarily case reports. Additionally, general pediatric stroke management lacks evidence-based guidelines because of its low incidence and lack of clinical trials. In pediatric strokes identified from a cardiac myxoma, the incidence favors boys with the classical presentation of unilateral weakness and aphasia. We present a pediatric patient who presented with strokelike symptoms secondary to an intracranial embolus from a previously undiagnosed cardiac myxoma. METHODS: We performed a systematic review by searching PubMed, Google Scholar, Web of Science, and Embase databases for cases of pediatric myxoma causing stroke (n = 2431) and identified 19 reported uses of surgical management in treating pediatric patients who present with stroke symptoms secondary to a cardiac myxoma thromboembolism. RESULTS: The most common imaging modality was magnetic resonance imaging in 42% of cases, computed tomography in 36.8%, followed by computed tomography angiography in 31.6% of cases. Of these 19 children treated with procedures, 36.8% of pediatric patients aged between 4 and 14 years underwent neurosurgery (n = 7). CONCLUSIONS: We describe an urgent mechanical thrombectomy and share preoperative and postoperative images and pathology slides confirming a stroke from myxoma origin. We provide added insight in the safe use of mechanical thrombectomy as treatment for pediatric strokes secondary to a thromboembolism.

Continuous direct intraarterial treatment of meningitis-induced vasospasm in a pediatric patient: illustrative case.

BACKGROUND: Bacterial meningitis-induced ischemic stroke continues to cause significant long-term complications in pediatric patients. The authors present a case of severe right internal carotid artery terminus and M1 segment vasospasm in a 9-year-old with an infected cholesteatoma, which was refractory to multiple intraarterial treatments with verapamil and milrinone. This is the first report of continuous intraarterial antispasmodic treatment in a pediatric patient as well as the first report of continuous treatment in an awake and extubated patient. OBSERVATIONS: Arterial narrowing was successfully treated by continuous direct intraarterial administration of both a calcium channel blocker (verapamil) and a phosphodiesterase-3 inhibitor (milrinone). The patient recovered remarkably well and was discharged home with no neurological deficit (National Institutes of Health Stroke Scale score 0) and ambulatory without assistance after 22 days. The authors report a promising outcome of this technique performed in a pediatric patient. LESSONS: This represents a novel treatment option for the prevention of stroke in pediatric bacterial meningitis. Continuous, direct intraarterial administration of antispasmodic medications can successfully prevent long-term neurological deficit in pediatric meningitis-associated vasospasm. The described method has the potential to significantly improve outcomes in severe pediatric meningitis-associated vasospasm.

The Enterprise stent still useful after all these years.

BACKGROUND: The Enterprise stent (Codman Neuro, Massachusetts, USA) received Food and Drug Administration (FDA) approval in 2007 for stent-assisted coiling (SAC). Since its introduction, newer stents and devices for aneurysm treatment have been developed resulting in a shift in the utilization of this stent from SAC to other off-label indications. OBJECTIVE: To describe our experience with the Enterprise stent being used for SAC and other off-label indications. METHODS: This is a multi-center retrospective review of the use of the Enterprise stent between 2018 and 2023. All patients in which the Enterprise stent was successfully deployed were included in the study. RESULTS: Our study cohort comprised of 194 patients, mostly females (n = 112, 57.7%), with a mean age of 63.2 years ± 14.3. The Enterprise stent was used for SAC in only 24 (12.4%) patients and was used for rescue stenting in stroke in 101 patients (52.1%), treatment of intracranial stenosis in 53 patients (27.3%), treatment of in-stent stenosis in 1 patient (0.5%), and for treatment of dissections in 15 patients (7.7%). From 2018 to 2023, the use of Enterprise stents for SAC significantly decreased (p < 0.0001) while the use of Enterprise stents for non-SAC purposes was insignificantly variable (p = 0.05). CONCLUSION: Our study shows that the Enterprise stent remains a reliable tool in neuroendovascular procedures, even if its original intended use has been supplanted by other devices.

Artificial intelligence improves transfer times and ischemic stroke workflow metrics.

INTRODUCTION: Rapid initiation of mechanical thrombectomy (MT) for the treatment of large-vessel occlusion (LVO) critically improves patient outcomes. Artificial intelligence algorithms aid in the identification of LVOs and improve door to puncture times as well as patient transfer times. OBJECTIVES: We aimed to determine whether the implementation of an LVO detection algorithm that provides immediate active notification to the thrombectomy team provider's cell phone would improve ischemic stroke workflow at our institution and aid in patient transfer from outlying hospitals when compared to our prior system of passive computed tomography perfusion software analysis and radiologist interpretation and notification. METHODS: A retrospective review of our institutional thrombectomy registry was performed for all patients who underwent MT between January 2020 and March 2022. Demographic, radiographic, and stroke workflow metrics and notification times were collected. Transfer times and stroke metrics were compared pre- and post-implementation of the Viz.ai (Viz.ai, San Francisco, California, USA) smartphone application. RESULTS: Two hundred sixty-two patients underwent MT during the study period. Door-to-puncture time decreased 15 min (p = 0.009) after the implementation of Viz.ai at our Comprehensive Stroke Center. Transfer time from outside hospitals that implemented Viz.ai was reduced by 37 min (p = 0.04). There was no significant change in transfer time over the same time period in outlying hospitals that did not implement the Viz.ai software. CONCLUSION: Active notification of the neurosurgical team significantly reduces patient transfer time and initiation of MT.

Post-operative weight loss in venous sinus stenting patients: A multi-center review, systematic review, and meta-analysis.

INTRODUCTION: Idiopathic intracranial hypertension (IIH) can result in headaches, pulsatile tinnitus, papilledema, and other neurological symptoms. Weight loss can alleviate some symptoms of IIH. This study aims to investigate the effect of venous sinus stenting on post-operative weight and body mass index (BMI) changes among IIH patients. The secondary objective is to investigate the relationship between post-operative weight changes and papilledema resolution. METHODS: Patients with papilledema undergoing venous sinus stenting for IIH were retrospectively reviewed from two comprehensive North American cerebrovascular centers. Patient demographics, surgical course, post-operative outcomes, and weight were analyzed. A systematic review and meta-analysis of post-operative weight in stented IIH patients was conducted. RESULTS: Twenty-eight patients with a diagnosis of IIH and papilledema who underwent venous sinus stenting were identified across two institutions. Patients had a mean pre-operative weight of 103.2 kg, which decreased to 101.5 kg at 3-month follow up (p = 0.0757). Patients at 6-month follow-up saw a weight decrease to 97.4 kg (p = 0.0066). Patients who saw papilledema resolution saw a mean greater decrease in weight (-4.5%) at 6-month follow up than those whose papilledema did not resolve (-1.7%), although this was insignificant (p = 0.1091). A total of 41 patients were included in the meta-analysis. Patients had an average of 1.1 increase in BMI at 3-month follow up. CONCLUSIONS: This study shows that venous sinus stenting leads to modest weight reduction in IIH patients, and those with resolved papilledema experience slightly greater weight loss. Further research is necessary to determine the clinical significance of these findings.

Selection of optimised ligands by fluorescence-activated bead sorting.

The chemistry of aptamers is largely limited to natural nucleotides, and although modifications of nucleic acids can enhance target aptamer affinity, there has not yet been a technology for selecting the right modifications in the right locations out of the vast number of possibilities, because enzymatic amplification does not transmit sequence-specific modification information. Here we show the first method for the selection of specific nucleoside modifications that increase aptamer binding efficacy, using the oncoprotein EGFR as a model target. Using fluorescence-activated bead sorting (FABS), we have successfully selected optimized aptamers from a library of >65 000 variations. Hits were identified by tandem mass spectrometry and validated by using an EGFR binding assay and computational docking studies. Our results provide proof of concept for this novel strategy for the selection of chemically optimised aptamers and offer a new method for rapidly synthesising and screening large aptamer libraries to accelerate diagnostic and drug discovery.

Comparison of pipeline embolization device, flow re-direction endoluminal device and surpass flow diverters in the treatment of intracerebral aneurysms.

OBJECTIVES: The use of flow diversion for the treatment of intracranial aneurysms has gained broad acceptance. Three flow-diverting stents are approved by the Food and Drug Administration for use in the United States. We sought to compare the outcomes and safety profiles between the three devices at our institution. METHODS: A retrospective review of aneurysms treated with pipeline embolization device (PED), flow re-direction endoluminal device (FRED), and SURPASS was performed for aneurysms treated between 2018 and 2022 at our institution. RESULTS: The study cohort consisted of 142 patients. Precisely, 86 aneurysms were treated with a pipeline, 33 aneurysms were treated with FRED, and 23 aneurysms were treated with SURPASS. The 1-year complete occlusion rates were 59.4%, 60%, and 65%, respectively (0.91). Linear regression models found that only adjunctive coiling predicted aneurysm occlusion at 6 months (p = 0.02), but this effect was lost at 1 year and beyond. There was no significant difference in acute thrombotic or acute hemorrhagic complications between the three cohorts. There was a higher rate of delayed hemorrhagic complications in the SURPASS cohort (10%) compared to the PED (1.3%) and FRED (0%) cohorts (p = 0.04). There was also a higher rate of in-stent stenosis in the SURPASS cohort (20%) compared to the PED (5%) and FRED (3.1%) cohorts (p < 0.01). CONCLUSIONS: Treatment with PED, FRED, and SURPASS all resulted in similar complete occlusion rates at 6 months and 1 year. SURPASS was associated with higher in-stent stenosis as well as delayed hemorrhagic complications. Additional future studies evaluating the newest generation of flow-diverting stents with long-term follow-up will be necessary to make any definitive conclusions.

Drainage, Irrigation, and Fibrinolytic Therapy (DRIFT) for Adult Intraventricular Hemorrhage Associated with Primary Hypertensive Hemorrhages Using IRRAflow Self-Irrigating Catheter: A Report of Three Cases and Prior Historical Controls.

BACKGROUND: Spontaneous primary intracerebral hemorrhage (ICH) accounts for 10%-15% of strokes and is accompanied by ventricular involvement in 10%-30% of cases. Intraventricular hemorrhage (IVH) is a poor prognostic factor and the current treatment paradigm of external ventricular drainage requires frequent flushing and replacement. Given the documented high rate of failure standard EVD catheters, we sought to determine if the use of the IRRAflow system with the addition of alteplase would be beneficial in this patient population for the treatment of IVH associated with primary hypertensive ganglionic hemorrhages. METHODS: Three patients with ganglionic hemorrhages and IVH underwent treatment with the IRRAflow system at our institution from December 2022 to January 2023. A retrospective review was then performed of patients with primary hypertensive ganglionic hemorrhages and EVD placement at our institution from January 2021 to present day. RESULTS: Three patients underwent treatment with the IRRAflow system and continuous lavage of Tissue Plasminogen Activator (tPA). The IVH was efficiently cleared in all cases and the drains were removed within 8 days in all cases. No patients required replacement of the drain and there were no hemorrhagic complications noted. In our retrospective review, 28 patients were identified who underwent placement of a standard EVD for the treatment of primary hypertensive ganglionic hemorrhages. When patients who had early withdrawal of care were excluded, the average length of EVD treatment was 11.3 days and the EVD replacement rate was 24%. CONCLUSIONS: We demonstrate here that the use of the IRRAflow system for the treatment of primary hypertensive hemorrhages with IVH results in rapid clearance of the IVH without safety concerns. Compared to historical controls there was a decrease in EVD duration, EVD replacement and, ICU LOS.

Incidence of mechanical thrombectomy among stroke patients brought directly to a comprehensive stroke center versus transfer from a primary stroke center in upstate New York.

BACKGROUND: Faster time to treatment for stroke is associated with improved outcomes. In cases of large vessel occlusion (LVO), standard of care treatment with thrombectomy can only be provided at a comprehensive stroke center (CSC). We examine the outcomes of patients who are directly brought to our center, a CSC, compared to those seen at a primary stroke center (PSC) and then transferred. METHODS: Patients with LVO presenting to our center from 1/1/2019 to 12/31/2019 were included. Cohorts of patients presenting first to a PSC and presenting first to a CSC were compared. Demographics and outcome metrics (Discharge Modified Rankin Scale (mRS) and National Institute of Health Stroke Severity Scale (NIHSS) scores) were obtained for all LVO patients. Imaging was also assessed. RESULTS: Of 864 stroke admissions, 346 had LVO (40%) with 183 (53%) transferring from a PSC and 163 (47%) presenting directly. Similar percentages of each cohort were taken for thrombectomy (25.1% transfer and 31.3% direct). However, as distance between PSC and CSC increased, likelihood of thrombectomy decreased. Transfer patients were more likely to be excluded from thrombectomy secondary to a large volume of complete stroke (p = 0.0001). Direct presenters had lower discharge mRS scores than transfer patients (p < 0.01), however, severity of stroke upon admission was similar in the two groups. CONCLUSION: Patients transferred from a PSC were more likely to have a worse outcome at time of discharge than those presenting directly to our center. Large volume of completed stroke was a frequent reason for exclusion from thrombectomy. Optimizing stroke protocols to CSC in cases of LVOs may result in better outcomes.

Use of intravenous cangrelor in the treatment of ruptured and unruptured cerebral aneurysms: an updated single-center analysis and pooled analysis of current studies.

BACKGROUND: Intracranial stent placement for the treatment of cerebral aneurysms is increasingly utilized in both ruptured and unruptured scenarios. Intravenous (IV) cangrelor is a relatively new antiplatelet agent that was initially approved for coronary interventions. In addition to our institution, five other centers have published their results using IV cangrelor in neurointerventional procedures. This article combines the aneurysm treatment data from all prior studies to provide insight into the safety and efficacy of cangrelor for intracranial aneurysm treatment. METHODS: A prospectively maintained database was reviewed to identify all cases of IV cangrelor administration during aneurysm embolization. 20 additional patients were identified who had not been previously published. In addition, a literature search was performed to identify prior publications regarding cangrelor in neurointervention. The data from these were combined with our institutional results in a pooled-analysis. RESULTS: Overall, 85 patients who received IV cangrelor during aneurysm embolization were identified, including 46 ruptured and 39 unruptured cases. The asymptomatic and symptomatic intracranial hemorrhage rates were 4% (2/46) for ruptured cases and 2.6% (1/39) for unruptured cases. The rate of retroperitoneal hematoma and gastrointestinal bleeding was 0%. There were no incidents of intraprocedural thromboembolic complication or intraprocedural in-stent thrombosis in either cohort. One subject suffered an ischemic stroke at 24 hours secondary to in-stent thrombosis in a ruptured case. CONCLUSIONS: IV cangrelor during aneurysm embolization appears to be safe, with a symptomatic intracranial hemorrhage rate of 4% in ruptured cases and 2.6% in unruptured cases. More research is needed to determine the ideal dosing regimen.

Developing a fast-track discharge protocol for patients with cerebral aneurysms treated via neuroendovascular techniques.

INTRODUCTION: As we emerge from the current pandemic, hospitals, staff, and resources will need to continue to adjust to meet ongoing healthcare demands. Lessons learned during past shortages can be used to optimize peri-procedural protocols to safely improve the utilization of hospital resources. METHODS: Retrospective review of patients who underwent elective endovascular intracranial aneurysm treatment was performed. Multivariable logistic regression was used to identify factors associated with patients who were able to be discharged within 24 h of elective procedures. Rates of complications (particularly readmission) were determined. RESULTS: 330 patients underwent elective endovascular aneurysm treatment with 86 (26.1%) discharged within 24 h. Factors associated with earlier discharge included procedure years (2019-2021) and male sex. Patients were more likely to be discharged later (after 24 h) if they underwent stent-coil embolization or flow-diversion. There was no association between discharge timing and likelihood of readmission. DISCUSSION: Our review highlights the safety of earlier discharge and allowed us to prepare a fast-track protocol for same-day discharge in these patients. This protocol will be studied prospectively in the next phase of this study. As we gain more comfort with emerging, minimally invasive endovascular therapies, we hope to safely achieve same-day discharge on a protocolized and routine basis, reducing the demand of elective aneurysm treatments on our healthcare system. CONCLUSION: We retrospectively demonstrate that early discharge following elective aneurysm treatment is safe in our cohort and provide a fast-track pathway based on these findings for other centers developing similar protocols.

Comparison of hydrogel coils versus bare platinum coils for the treatment of anterior communicating artery aneurysms.

INTRODUCTION: While endovascular coiling has been shown to be a safe treatment option for intracranial aneurysms, there remains concern regarding increased recurrence and retreatment rates. Preliminary studies evaluating hydrogel coated coils have demonstrated decreased recurrence rates compared to bare metal coils. METHODS: A retrospective chart review was done on all patients with anterior communicating artery aneurysms (ACoAAs) treated with endovascular coiling between 2014 and 2018. Treatment groups were divided into hydrogel coated coils or bare metal coils. Patients were categorized into the hydrogel group when ≥ 70% of the coil length was hydrogel coated. RESULTS: Eighty-four ACoAAs were treated with coil embolization between 2014 and 2018. Postoperative imaging was available for 68 patients. Twenty-six patients were categorized into the hydrogel treatment group. Aneurysm recurrence was seen in 7.7% (2/26) of patients treated with hydrogel coated coils compared to 33.3% (14/42) of those treated with bare metal coils (P = 0.03). Subanalysis of patients with ruptured aneurysms revealed decreased recurrence rates in patients treated with hydrogel coated coils at 5.9% (1/17) compared to patients treated with bare metal coils at 39.4% (13/33) (P = 0.01). CONCLUSIONS: Hydrogel-coated coils may reduce recurrence rates in the treatment of both ruptured and unruptured ACoAAs.

Does Pre-existing Anticoagulation or Antiplatelet Therapy Increase the Risk of Traumatic Subarachnoid Hemorrhage Progression?

BACKGROUND: Isolated traumatic subarachnoid hemorrhage (tSAH) is a common finding in mild traumatic brain injury that often results in transfer to a tertiary center. Patients prescribed blood-thinning medications (BTs) are believed to be at higher risk of clinical or radiographic worsening. OBJECTIVE: To compare the rates of radiographic progression and need for neurosurgical intervention in patients with tSAH who are on anticoagulation (AC) and antiplatelet (AP) therapies with those who are not. METHODS: Analysis using a retrospective cohort design identified patients older than 18 years with isolated tSAH and a Glasgow Coma Scale of 15 on admission. Clinical information including use of BTs, administration of reversal agents, radiographic progression, and need for neurosurgical intervention was collected. Patients on BTs were divided into AP, AC, and AP/AC groups based on drug type. RESULTS: Three hundred eighty-four patients were included with 203 in the non-BT group and 181 in the BT group. Overall, 2.1% had worsening scans, and none required operative intervention. There was no difference in radiographic worsening between the non-BT and BT groups (2.4% vs 1.6%; P = 1.00). Crosswise comparison revealed no difference between the non-BT group and each BT subtype (AP, AP/AC, or AC). The non-BT group was more likely to have radiographic improvement than the BT group (45.8% vs 30.9%; P = .002). CONCLUSION: Neurologically intact patients on BTs with isolated tSAH are not at increased risk of radiographic progression or neurosurgical intervention. The presence of BTs should not influence management decisions for increased surveillance.

Characterization of antiplatelet response to low-dose cangrelor utilizing platelet function testing in neuroendovascular patients.

STUDY OBJECTIVES: The optimal antiplatelet therapy for emergent neuroendovascular stenting is uncertain. Cangrelor is an intravenous P2Y12 inhibitor that is an attractive option due its favorable pharmacokinetic profile and ease of measurability but optimal dosing remains unclear. The primary objective of this study is to characterize the dose response of low dose cangrelor (<2 mcg/kg/min) with the utilization of platelet function testing (PFT). DESIGN: A retrospective review of all patients treated with cangrelor for either procedural stenting or bridging was conducted between January 1st, 2019 and October 31st, 2020. Seventy-two patients met inclusion criteria. An in-depth analysis of dose response to low dose cangrelor based on PFT was performed. PATIENTS: Neuroendovascular patients treated with cangrelor. SETTING: Albany Medical Center Hospital. INTERVENTION AND MAIN RESULTS: Patients who underwent procedural stenting were given a bolus of 5 mcg/kg and an initial infusion rate of either 0.75 mcg/kg/min or 1 mcg/kg/min. Patients who were bridged with cangrelor were administered an initial infusion rate of 0.75 mcg/kg/min or 1 mcg/kg/min. Twelve patient's doses were titrated to achieve a platelet reactivity unit (PRU) between 50-150; three patient's doses were titrated multiple times. Based on initial PFT results, utilizing the 1 mcg/kg/min maintenance dose resulted in more patients being in the acceptable (10-180) and desired (50-150) PRU range than the 0.75 mcg/kg/min dose (47% vs 56% and 70% vs 80%, respectively). Final recorded PRU results showed that 64% of patients had PRUs in the optimal range (50-150) and 88% of patients had PRUs in the desire range (10-180). CONCLUSIONS: Utilizing low doses of cangrelor with platelet function testing is an option during emergent neuroendovascular stenting and bridging. Cangrelor demonstrates significant variability in response at low doses and exhibits a dose response relationship when PFT is utilized.

The Role of Gender in Neurosurgical Residency Applicants' Letters of Recommendation.

BACKGROUND: Letters of recommendation (LORs) are one of the most important components of the neurosurgical residency application. Studies in other fields and surgical subspecialties have found gender bias. OBJECTIVE: To determine whether neurosurgical LORs contain significant linguistic gendered differences. METHODS: We performed a retrospective review and linguistic analysis of all LORs submitted on behalf of applicants offered an interview invitation to a single neurosurgical residency program at an academic medical center between 2015-2016 and 2018-2019. RESULTS: A total of 599 letters from 156 applicants (120 males and 36 females) were included. Background demographics, including United States Medical Licensing Examination (USMLE) Step 1 score and publications, were not significantly different between applicants. Male faculty authored 93% of all letters. Female faculty were more likely to write letters for female applicants than male applicants (12.1% vs 5.5%, P < .001). Letters for women were significantly longer (334 words vs 277 words, P < .001). Overall, 1754 agentic terms and 854 communal terms were coded. Letters for men contained significantly fewer agentic terms (10.7 vs 13.1, per applicant, P < .01) and communal terms (5.2 vs 6.4, P < .034). This difference, however, is nonsignificant when word count was used as a covariate. Female applicants were more significantly likely to be labeled "Outstanding" (2.4 vs 1.6 mentions per applicant). CONCLUSION: Overall, there are more similarities than differences between genders in LORs for neurosurgical applicants. This finding is at odds with what has previously been reported in most other surgical specialties.

Use of intravenous cangrelor and stenting in acute ischemic stroke interventions: a new single center analysis and pooled-analysis of current studies.

INTRODUCTION: Emergent stenting of both extra- and intracranial occlusions during acute ischemic stroke procedures is complicated by the need for immediate platelet inhibition to prevent thromboembolic complications. IV cangrelor is a relatively new antiplatelet that was initially approved for coronary interventions. Five prior case series have been published evaluating the results of IV cangrelor in neurointerventional procedures. We sought to combine the data from all prior studies and analyze only ischemic stroke interventions. METHODS: A prospectively maintained database was reviewed to identify all cases of IV cangrelor administration during acute ischemic stroke intervention. Nine additional patients were identified who have not been previously published. In addition, a literature search was performed to identify five prior publications of cangrelor in neurointervention. The data from these was combined with our institution in a pooled-analysis. RESULTS: Overall, 129 patients who received IV cangrelor during an acute ischemic stroke intervention were identified. The asymptomatic intracranial hemorrhage rate was 12.6%(11/87). The symptomatic intracranial hemorrhage rate was 6.2% (8/129). The rate of retroperitoneal hematoma and gastrointestinal bleeding were also low (1.5% and 0.8%, 2/129 and 1/129). There was one case of intraprocedural thromboembolic complication (0.8%) and no cases of intraprocedural in-stent thrombosis(0%). CONCLUSIONS: IV cangrelor during acute ischemic stroke intervention appears to be safe, with a symptomatic intracranial hemorrhage rate of 6.2%. More research is needed to determine the ideal dosing regimen.

Cangrelor dose titration using platelet function testing during cerebrovascular stent placement.

BACKGROUND: Optimal antiplatelet inhibition is vital during cerebrovascular stenting procedures, yet no standardized recommendation exists for antithrombotic therapy in these scenarios. Cangrelor is an intravenous P2Y12 inhibitor with a favorable pharmacokinetic profile for use during neuroendovascular stenting. METHODS: A retrospective review of all neuroendovascular patients who underwent stenting between 1 January 2019 and 22 March 2020 and were treated with cangrelor was conducted. Thirty-seven patients met inclusion criteria. RESULTS: All patients were administered a bolus of 5 mcg/kg of cangrelor followed by a maintenance infusion. Antiplatelet effects of cangrelor were monitored using platelet reactivity units (PRU). Based on the initial PRU, seven patients' doses were adjusted with subsequent PRUs in or near the goal range of 50-150. One patient experienced an acute intraprocedural occlusion likely related to a subtherapeutic PRU which subsequently resolved with cangrelor dose adjustment and intra-arterial tirofiban administration, and one patient experienced a post-procedure stent occlusion which required a thrombectomy and intra-arterial tirofiban administration. No hemorrhagic complications occurred. DISCUSSION: Cangrelor utilization during neuroendovascular stenting with maintenance doses of <2 mcg/kg/min with dose adjustments based on platelet function testing has not been previously described. Cangrelor presents many advantages compared to standard therapy in patients undergoing stent placement related to its pharmacokinetic profile, rapid onset of action, ease of transition to oral P2Y12 antiplatelet agents, and measurability. CONCLUSION: Cangrelor is a promising alternative to currently available therapies, especially in patients with a high hemorrhagic risk.

Simultaneous revascularization of the occluded internal carotid artery using the Solitaire as a workhorse wire during acute ischemic stroke intervention.

INTRODUCTION: Tandem lesions involving a large vessel occlusion intracranially with concomitant cervical carotid critical stenosis or occlusion are a common presentation of acute ischemic stroke. These lesions are both challenging and time-consuming but can be extremely beneficial for patients when successful. We present a technique utilizing the pusher wire of the stent retriever used for intracranial thrombectomy as the workhorse wire for carotid intervention using a monorail system to perform cervical carotid angioplasty. METHODS: We reviewed four successive patients who presented with a tandem occlusion and underwent thrombectomy and simultaneous carotid artery intervention using this technique. RESULTS: All four patients had radiographically successful intracranial thrombectomy and cervical carotid revascularization. Time from groin puncture to intracranial stent retriever deployment was 63 min on average. Then, using the pusher wire as a monorail workhorse, time from stent retriever deployment to carotid angioplasty was on average 6 min. DISCUSSION: This technique allows for cervical carotid revascularization to begin during the recommended 5-min wait time after stent retriever deployment, allowing for rapid near-simultaneous revascularization across both lesions. This technique has been reported briefly in the past for management of a cervical dissection. There is continued debate regarding the management of tandem occlusions, as to which lesion should be managed first. CONCLUSION: As the management paradigms of tandem occlusions continue to evolve, this technique may improve outcomes by expediting endovascular intervention. Using the stent retriever wire provides a method of expediting the management of the proximal lesion after addressing the more distal intracranial occlusion first.