The WOVEN trial: Wingspan One-year Vascular Events and Neurologic Outcomes.

BACKGROUND: Prior studies evaluating the Wingspan stent for treatment of symptomatic intracranial atherosclerotic disease have included patients with a spectrum of both on-label and off-label indications for the stent. The WEAVE trial assessed 152 patients stented with the Wingspan stent strictly by its current on-label indication and found a 2.6% periprocedural stroke and death rate. OBJECTIVE: This WOVEN study assesses the 1-year follow-up from this cohort. METHODS: Twelve of the original 24 sites enrolling patients in the WEAVE trial performed follow-up chart review and imaging analysis up to 1 year after stenting. Assessment of delayed stroke and death was made in 129 patients, as well as vascular imaging follow-up to assess for in-stent re-stenosis. RESULTS: In the 1-year follow-up period, seven patients had a stroke (six minor, one major). Subsequent to the periprocedural period, no deaths were recorded in the cohort. Including the four patients who had periprocedural events in the WEAVE study, there were 11 strokes or deaths of the 129 patients (8.5%) at the 1-year follow-up. CONCLUSIONS: The WOVEN study provides the 1-year follow-up on a cohort of 129 patients who were stented according to the current on-label use. It provides a more homogeneous patient group for analysis than prior studies, and demonstrates a relatively low 8.5% 1-year stroke and death rate in stented patients.

Real-World Impact of Retrievable Stents for Acute Ischemic Stroke on Disability Utilizing the National Inpatient Sample.

PURPOSE: We assess the impact of retrievable stent (RS) compared to first-generation devices on in-hospital mortality and disability in patients with acute ischemic stroke (AIS). METHODS: Using the National Inpatient Sample, data were obtained for patients with a primary diagnosis of AIS who underwent mechanical thrombectomy (MT) and were admitted to US hospitals between 2010 and 2014. Two time periods were compared: 2010-2012 (pre-RS Food and Drug Administration [FDA] approval) and 2013-2014 (post-RS FDA approval). Disability level was used to classify outcomes as minimal disability, moderate to severe disability, or in-hospital mortality. Weighted, multivariable logistic regression was used to assess the association between MT device type and disability. RESULTS: A total of 2,443,713 weighted patients admitted with AIS were identified; 148,923 (4.9%) of these received intravenous tissue plasminogen activator; and 23,719 (0.8%) underwent MT. In multivariable logistic regression analysis, the odds of in-hospital mortality decreased (OR 0.69, 95% CI 0.59-0.82) in the post-RS time-period compared with pre-RS time. The odds of moderate-to-severe disability decreased (OR 0.88, 95% CI 0.73-1.06) compared with minimal disability. In-hospital mortality rates decreased successively over the 4 years in the MT-treated patients (p < 0.001). CONCLUSIONS: The FDA approval of RS technology after 2012 was associated with decreased in-hospital mortality when compared with the 3-year interval prior. These findings provide an indication that the RCT data on the efficacy of RS technology are translating into improved real-world outcomes.

First Pass Effect in Patients Treated With the Trevo Stent-Retriever: A TRACK Registry Study Analysis.

Background and Objective: The first pass effect (FPE; achieving complete recanalization with a single thrombectomy device pass) has been shown to be associated with higher rates of good clinical outcomes in patients with acute ischemic stroke. Here, we investigate clinical and radiographic factors associated with FPE in a large U.S. post-marketing registry (TRACK, Trevo Stent-Retriever Acute Stroke). Methods: We analyzed the TRACK database (multicenter registry of 634 patients from 23 centers from March 2013 through August 2015), which 609 patients were included in the final analysis. FPE was defined as a single pass/use of device, TICI 2c/3 recanalization, and no use of rescue therapy. Analysis of individual patient data from TRACK were performed to analyze clinical and radiographic characteristics associated with FPE as well-compared clinical outcomes defined as modified Rankin Scale (mRS) score at 30 and 90 days from hospital discharge to the non-FPE group. Results: The rate of FPE in TRACK was 23% (140/609). There was no association between patient demographics and FPE, including age (p = 0.36), sex (p = 0.50), race (p = 0.50), location of occlusion (p = 0.26), baseline NIHSS (p = 0.62), or past medical history. There was no difference in the use of a balloon-guide catheter or general anesthesia (49 and 57% with FPE vs. 47 and 64%, p = 0.63 and p = 0.14, respectively). Clinical outcomes were significantly associated with FPE; 63 vs. 44% in non-FPE patients achieved mRS 0-2 at 90 days (p = 0.0004). Conclusion: Our study showed that achieving complete recanalization with a single thrombectomy pass using the Trevo device was highly beneficial. The most common clinical factors that are used to determine eligibility for endovascular therapy, such as NIHSS severity, location of occlusion or patient age were not predictive of the ability to achieve FPE.

Site Experience and Outcomes in the Trevo Acute Ischemic Stroke (TRACK) Multicenter Registry.

Background and Purpose- It remains unclear how experience influences outcomes after the advent of stent retriever technology. We studied the relationship between site experience and outcomes in the Trevo Acute Ischemic Stroke multicenter registry. Methods- The 24 sites that enrolled patients in the Trevo Acute Ischemic Stroke registry were trichotomized into low-volume (<2 cases/month), medium-volume (2-4 cases/month), and high-volume centers (>4 cases/month). Baseline features, imaging, and clinical outcomes were compared across the 3 volume strata. A multivariable analysis was performed to assess whether outcomes were influenced by site volumes. Results- A total of 624 patients were included and distributed as low- (n=188 patients, 30.1%), medium- (n=175, 28.1%), and high-volume (n=261, 41.8%) centers. There were no significant differences in terms of age (mean, 66±16 versus 67±14 versus 65±15; P=0.2), baseline National Institutes of Health Stroke Scale (mean, 17.6±6.5 versus 16.8±6.5 versus 17.6±6.9; P=0.43), or occlusion site across the 3 groups. Median (interquartile range) times from stroke onset to groin puncture were 266 (181.8-442.5), 239 (175-389), and 336.5 (221.3-466.5) minutes in low-, medium-, and high-volume centers, respectively (P=0.004). Higher efficiency and better outcomes were seen in higher volume sites as demonstrated by shorter procedural times (median, 97 versus 67 versus 69 minutes; P<0.001), higher balloon guide catheter use (40% versus 36% versus 59%; P≤0.0001), and higher rates of good outcome (90-day modified Rankin Scale [mRS], ≤2; 39% versus 50% versus 53.4%; P=0.02). There were no appreciable differences in symptomatic intracranial hemorrhage or 90-day mortality. After adjustments in the multivariable analysis, there were significantly higher chances of achieving a good outcome in high- versus low-volume (odds ratio, 1.67; 95% CI, 1.03-2.7; P=0.04) and medium- versus low-volume (odds ratio, 1.75; 95% CI, 1.1-2.9; P=0.03) centers, but there were no significant differences between high- and medium-volume centers (P=0.86). Conclusions- Stroke center volumes significantly influence efficiency and outcomes in mechanical thrombectomy.

TARGET® Intracranial Aneurysm Coiling Prospective Multicenter Registry: Final Analysis of Peri-Procedural and Long-Term Safety and Efficacy Results.

Background and Purpose: To describe the final results of the TARGET Registry, a multicenter, real-world study of patients with intracranial aneurysms treated with new generation TARGET Coils. Methods: The TARGET Registry is a prospective, single-arm study with independent medical event monitoring and core-lab adjudication. Patients with de novo intracranial aneurysms were embolized with either TARGET-360° or helical coils in 12 US centers. The primary outcome was aneurysm packing density (PD), which was assessed immediately post-procedure. The secondary outcomes were immediate and long-term aneurysm occlusion rate using the Raymond Scale, and independent functional outcome using the modified Rankin Scale (mRS). A secondary analysis investigated the influence of the use of 100% 360-complex coils on clinical and angiographic outcomes. Results: 148 patients with 157 aneurysms met the inclusion and exclusion criteria. 58 (39.2%) patients with ruptured and 90 (61.8%) with unruptured aneurysms were treated using TARGET 360°, helical Coils, or both. Median age was 58.3 (IQR 48.1-67.4), 73% female, and 71.6% were Caucasian. Median follow-up time was 5.9 (IQR 4.0-6.9) months. The majority were treated with TARGET 360-coils (63.7%), followed by mixed and helical coils only. Peri-procedural morbidity and mortality was seen in 2.7% of patients. A good outcome at discharge (mRS 0-2) was seen in 89.9% of the full cohort, and in 84.5 and 93.3% in the ruptured and unruptured patients, respectively. The median packing density was 28.8% (IQR 20.3-41.1). Long-term complete and near complete occlusion rate was seen in 90.4% of aneurysms and complete obliteration was seen in 66.2% of the aneurysms. No significant difference in clinical and angiographic outcomes were noted between the pure 360-complex coiling vs. mixed 360-complex/Helical coiling strategies. In a multivariate analysis, predictors for long-term aneurysm occlusion were aneurysm location, immediate occlusion grade, and aneurysm size. The long-term independent functional outcome was achieved in 128/135 (94.8%) patients and all-cause mortality was seen in 3/148 (2%) patients. Conclusion: In the multicenter TARGET Registry, two-thirds of aneurysms achieved long-term complete occlusion and 91.0% achieved complete or near complete occlusion with excellent independent functional outcome. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT01748903.

Effect of balloon guide catheter on clinical outcomes and reperfusion in Trevo thrombectomy.

INTRODUCTION: The Solitaire stent retriever registry showed improved reperfusion, faster procedure times, and better outcome in acute stroke patients with large vessel occlusion treated with a balloon guide catheter (BGC) and Solitaire stent retriever compared with a conventional guide catheter. The goal of this study was to evaluate whether use of a BGC with the Trevo stent retriever improves outcomes compared with a conventional guide catheter. METHODS: The TRACK registry recruited 23 sites to submit demographic, clinical, and site adjudicated angiographic and outcome data on consecutive patients treated with the Trevo stent retriever. BGC use was at the discretion of the physician. RESULTS: 536 anterior circulation patients (of whom 279 (52.1%) had BGC placement) were included in this analysis. Baseline characteristics were notable for younger patients in the BGC group (65.4±15.3 vs 68.1±13.6, P=0.03) and lower rate of hypertension (72% vs 79%, P=0.06). Mean time from symptom onset to groin puncture was longer in the BGC group (357 vs 319 min, P=0.06).Thrombolysis in Cerebral Infarction 2b/3 scores were higher in the BGC cohort (84% vs 75.5%, P=0.01). There was no difference in reperfusion time, first pass effect, number of passes, or rescue therapy. Good clinical outcome at 3 months was superior in patients with BGC (57% vs 40%; P=0.0004) with a lower mortality rate (13% vs 23%, P=0.008). Multivariate analysis demonstrated that BGC use was an independent predictor of good clinical outcome (OR 2; 95% CI 1.3 to 3.1, P=0.001). CONCLUSIONS: In acute stroke patients presenting with anterior circulation large vessel occlusion, use of a BGC with the Trevo stent retriever resulted in improved reperfusion, improved clinical outcome, and lower mortality.

Association of Blood Glucose and Clinical Outcome after Mechanical Thrombectomy for Acute Ischemic Stroke.

BACKGROUND: Elevated blood glucose levels following acute ischemic stroke have been associated with adverse clinical outcomes in thrombolytic and nonthrombolytic treated patients. The current study examined multiple blood glucose parameters and their association with modified Rankin Scale (mRS) score at 3 months following mechanical thrombectomy and hospital discharge. METHODS: Acute ischemic stroke patients undergoing mechanical thrombectomy with a retrievable stent at two stroke centers were studied. Admission blood glucose level, maximum blood glucose during the hospital stay, and serial blood glucose measurements within the first 24 h of hospital admission were recorded. Variability in blood glucose level was represented by the standard deviation of the serial measurements within the first 24 h. The following demographic and clinical data was also collected: age, sex, baseline NIHSS score, onset-to-reperfusion times, hemoglobin A1c, and stroke mechanism. RESULTS: 79 patients were identified; at 3 months, 35 patients had an mRS score of 0-2 and 44 had had an mRS of 3-6. Among the blood glucose variables, standard deviation of blood glucose in the first 24 h following admission and maximum blood glucose during hospital stay were significantly higher in the mRS 3-6 group. In multivariate logistic regression analysis, only the standard deviation of blood glucose remained significant (OR = 1.07, 95% CI = 1.02-1.11, p = 0.003) in a model that adjusted for admission NIHSS score (p = 0.016) and number of stent retriever passes (p = 0.042). CONCLUSIONS: Greater blood glucose variability following acute ischemic stroke is associated with worse clinical outcome in patients undergoing mechanical thrombectomy.

TREVO stent-retriever mechanical thrombectomy for acute ischemic stroke secondary to large vessel occlusion registry.

BACKGROUND: Recent randomized clinical trials (RCTs) demonstrated the efficacy of mechanical thrombectomy using stent-retrievers in patients with acute ischemic stroke (AIS) with large vessel occlusions; however, it remains unclear if these results translate to a real-world setting. The TREVO Stent-Retriever Acute Stroke (TRACK) multicenter Registry aimed to evaluate the use of the Trevo device in everyday clinical practice. METHODS: Twenty-three centers enrolled consecutive AIS patients treated from March 2013 through August 2015 with the Trevo device. The primary outcome was defined as achieving a Thrombolysis in Cerebral Infarction (TICI) score of ≥2b. Secondary outcomes included 90-day modified Rankin Scale (mRS), mortality, and symptomatic intracranial hemorrhage (sICH). RESULTS: A total of 634patients were included. Mean age was 66.1±14.8 years and mean baseline NIH Stroke Scale (NIHSS) score was 17.4±6.7; 86.7% had an anterior circulation occlusion. Mean time from symptom onset to puncture and time to revascularization were 363.1±264.5 min and 78.8±49.6 min, respectively. 80.3% achieved TICI ≥2b. 90-day mRS ≤2 was achieved in 47.9%, compared with 51.4% when restricting the analysis to the anterior circulation and within 6 hours (similar to recent AHA/ASA guidelines), and 54.3% for those who achieved complete revascularization. The 90-day mortality rate was 19.8%. Independent predictors of clinical outcome included age, baseline NIHSS, use of balloon guide catheter, revascularization, and sICH. CONCLUSION: The TRACK Registry results demonstrate the generalizability of the recent thrombectomy RCTs in real-world clinical practice. No differences in clinical and angiographic outcomes were shown between patients treated within the AHA/ASA guidelines and those treated outside the recommendations.

Treatment of cerebral aneurysms in children: analysis of the Kids' Inpatient Database.

UNLABELLED: OBJECT.: Endovascular coiling and surgical clipping are viable treatment options of cerebral aneurysms. Outcome data of these treatments in children are limited. The objective of this study was to determine hospital mortality and complication rates associated with surgical clipping and coil embolization of cerebral aneurysms in children, and to evaluate the trend of hospitals' use of these treatments. METHODS: The authors identified a cohort of children admitted with the diagnoses of cerebral aneurysms and aneurysmal subarachnoid hemorrhage from the Kids' Inpatient Database for the years 1998 through 2009. Hospital-associated complications and in-hospital mortality were compared between the treatment groups and stratified by aneurysmal rupture status. A multivariate regression analysis was used to identify independent variables associated with in-hospital mortality. The Cochrane-Armitage test was used to assess the trend of hospital use of these operations. RESULTS: A total of 1120 children were included in this analysis; 200 (18%) underwent aneurysmal clipping and 920 (82%) underwent endovascular coiling. Overall in-hospital mortality was higher in the surgical clipping group compared with the coil embolization group (6.09% vs 1.65%, respectively; adjusted odds ratio [OR] 2.52, 95% CI 0.97-6.53, p = 0.05). The risk of postoperative stroke or hemorrhage was similar between the two treatment groups (p = 0.86). Pulmonary complications and systemic infection were higher in the surgical clipping population (p < 0.05). The rate of US hospitals' use of endovascular coiling has significantly increased over the years included in this study (p < 0.0001). Teaching hospitals were associated with a lower risk of death (OR 0.13, 95% CI 0.03-0.46; p = 0.001). CONCLUSIONS: Although both treatments are valid, endovascular coiling was associated with fewer deaths and shorter hospital stays than clip placement. The trend of hospitals' use of coiling operations has increased in recent years.

Broken heart syndrome during myasthenic crisis.

OBJECTIVES: Myocardial pathology is rarely associated with myasthenia gravis (MG). We describe a case of newly diagnosed MG with decompensated heart failure [stress-induced cardiomyopathy (SICM)] that occurred during the crisis phase. METHODS: Case report and review of literature. RESULTS: A 42-year-old woman underwent chemotherapy followed by a transsternal resection of a malignant epithelioid thymoma invading the pericardium. A month after surgical resection, she developed progressive oropharyngeal symptoms with respiratory distress requiring tracheal intubation. Cardiac evaluation on the day of admission showed a normal ejection fraction, which rapidly decreased to 15% on the second hospital day and recovered to 45% after 1 week. Review of the literature revealed 4 myasthenic patients who developed SICM in the crisis phase; all improved with treatment. CONCLUSIONS: SICM may occur in MG crisis, especially in the presence of malignant thymoma. All previous cases including our patient had improved myocardial function and clinical outcomes.

Traumatic carotid-rosenthal fistula treated with Jostent Graftmaster.

Traumatic injuries of the carotid artery may result in severe morbidity and mortality. The most common location of carotid artery injury is the cavernous segment, which may result in fistulous connection to the cavernous sinus and ophthalmic veins, which in turn lead to pressure symptoms in the ipsilateral orbit. Unlike the commonly reported direct traumatic carotid-cavernous fistula, we describe an unusual case of a 38-year-old man presented with a traumatic brain injury led to a fistula connection between the cavernous carotid artery and the ipsilateral basal vein of Rosenthal, with eventual drainage to the straight and transverse sinuses. The basal vein of Rosenthal is usually formed from confluence of anterior and middle cerebral veins deep in the Sylvian fissure and drain the insular cortex and the cerebral peduncles to the vein of Galen. Immediate endovascular deployment of a covered stent in the cavernous carotid artery allowed sealing the laceration site. Three months follow up showed a non-focal neurological examination and healed carotid laceration over the covered stent.

Stroke mimics under the drip-and-ship paradigm.

BACKGROUND: Recent reports suggested better outcomes associated with the drip-and-ship paradigm for acute ischemic stroke (AIS) treated with thrombolysis. We hypothesized that a higher rate of stroke mimics (SM) among AIS treated in nonspecialized stroke centers that are transferred to comprehensive centers is responsible for such outcomes. METHODS: Consecutive patients treated with thrombolysis according to the admission criteria were reviewed in a single comprehensive stroke center over 1 academic year (July 1, 2011 to June 30, 2012). Information on the basic demographic, hospital complications, psychiatric diagnoses, and discharge disposition was collected. We identified those patients who were treated at a facility and then transferred to the tertiary center (ie, drip-and-ship paradigm). In addition to comparative and adjusted analysis to identify predictors for SM, a stratified analysis by the drip-and-ship status was performed. RESULTS: One hundred twenty patients were treated with thrombolysis for AIS included in this analysis; 20 (16.7%) were discharged with the final diagnosis of SM; 14 of those had conversion syndrome and 6 patients had other syndromes (seizures, migraine, and hypoglycemia). Patients with SM were younger (55.6 ± 15.0 versus 69.4 ± 14.9, P = .0003) and more likely to harbor psychiatric diagnoses (45% versus 9%; P ≤ .0001). Eighteen of 20 SM patients (90%) had the drip-and-ship treatment paradigm compared with 65% of those with AIS (P = .02). None of the SM had hemorrhagic complications, and all were discharged to home. Predictors of SM on adjusted analysis included the drip-and-ship paradigm (odds ratio [OR] 12.8, 95% confidence interval [CI] 1.78, 92.1) and history of any psychiatric illness (OR 12.08; 95% CI 3.14, 46.4). Eighteen of 83 drip-and-ship patients (21.7%) were diagnosed with SM compared with 2 of 37 patients (5.4%) presented directly to the hub hospital (P = .02). CONCLUSION: The drip-and-ship paradigm and any psychiatric history predict the diagnosis of SM. None of the SM had thrombolysis-related complications, and all were discharged to home. These findings may explain the superior outcomes associated with the drip-and-ship paradigm in the treatment for AIS.

Hospital mortality associated with stroke in southern iran.

BACKGROUND: Unlike the western hemisphere, information about stroke epidemiology in southern Iran is scarce. The aim of this study was to determine the main epidemiological characteristics of patients with stroke and its mortality rate in southern Iran. METHODS: A retrospective, single-center, hospital-based longitudinal study was performed at Nemazee Hospital in Shiraz, Southern Iran. Patients with a diagnosis of hemorrhagic and ischemic strokes were identified based on the International Classification of Diseases, 9th and 10th editions, for the period between 2001 and 2010. Demographics including age, sex, area of residence, socioeconomic status, length of hospital stay, and discharge destinations were analyzed in association with mortality. RESULTS: 16351 patients with a mean age of 63.4 years (95% CI: 63.1, 63.6) were included in this analysis. Men were slightly predominant (53.6% vs. 46.4%). Forty-seven percent of the total sample was older than 65,17% were younger than 45, and 2.6% were children younger than 18. The mean hospital stay was 6.3 days (95% CI: 6.2, 6.4). Among all types of strokes, the overall hospital mortality was 20.5%. Multiple logistic regression revealed significantly higher in-hospital mortality in women and children (P<0.001) but not in patients with low socioeconomic status or from rural areas. During the study period, the mortality proportions increased from 17.8% to 22.2%. CONCLUSION: In comparison to western countries, a larger proportion of our patients were young adults and the mortality rate was higher.

Thrombolysis for children with acute ischemic stroke: a perspective from the kids' inpatient database.

BACKGROUND: Thrombolysis for acute ischemic stroke (AIS) in children is yet to be proven efficacious, and there is limited information about its safety in large pediatric samples. Here we evaluate the safety outcomes associated with thrombolysis in children as well as the trend of hospital utilization over the past decade in the United States. METHODS: A cohort of children with acute ischemic stroke was identified from the Kids' Inpatient Database for the years 1998-2009. Acute ischemic stroke was identified by the International Classification of Diseases-9 clinical classification software codes (109 and 110). Multivariate logistic regression analyses were used to assess covariates associated with outcomes of hospital mortality and intracerebral hemorrhage. The Cochran-Armitage test was employed for linear trend of discrete variables. RESULTS: In this analysis, 9257 children were admitted with the diagnosis of acute ischemic stroke; only 67 (0.7%) received thrombolysis. Thrombolysis-treated children were older than the rest of the cohort (13.1 ± 7.3 vs 8.18 ± 7.5; P < 0.0001) and they had a longer hospital stay (median 11 vs 6 days; P < 0.0001). Gender, race, and family income approximated by postal code were similar among the treated and untreated children. Unadjusted analysis showed higher hospital mortality (10.45% vs 6.14%; P = 0.06) and intracerebral hemorrhage (2.99% vs 0.77%; P = 0.08) in the thrombolysis group. Adjusted analysis showed that intracerebral hemorrhage is predictive of a higher hospital mortality (odds ratio 3.43; 95% confidence interval 1.89-6.22), whereas thrombolysis was not (odds ratio 1.78; 95% confidence interval 0.86-3.64). The overall rate of thrombolysis per 3 years intervals had increased from 5.2 to 9.7 per 1000 children with acute ischemic stroke (P = 0.02). This increase was mainly seen in non-children hospitals (P = 0.01). CONCLUSION: Thrombolysis for acute ischemic stroke is infrequently used in children. There is a trend toward higher risks of intracerebral hemorrhage and hospital mortality, although these risks are as low as those reported in adult population. The hospitals' utilization of thrombolysis in children has increased during the study period.

A long-term follow-up study using IPMSSG criteria in children with CNS demyelination.

OBJECTIVE: To evaluate the practical application of International Pediatrics Multiple Sclerosis study group definitions in children with inflammatory demyelination of the central nervous system and to identify predictors of multiple sclerosis. METHODS: Baseline data on 123 children with a first episode of acute central nervous system demyelination were collected. The initial diagnosis according to the International Pediatrics Multiple Sclerosis study group was recorded and compared with final diagnosis. RESULTS: Forty-seven (38.2%) children met International Pediatrics Multiple Sclerosis study group criteria for acute disseminated encephalomyelitis and 67 (54.4%) had clinically isolated syndrome at the initial presentation. Four (3.2%) had the diagnosis of neuromyelitis optica and five (4%) did not meet any specific diagnosis per the study group criteria. Clinical follow-up was available on 118 of 123 children (95.9%), with a median of 61.5 months (quartile range 23, 110 months). Conversion from clinically isolated syndrome to multiple sclerosis occurred in 26 of 67 children (38.8%); acute disseminated encephalomyelitis to multiple sclerosis occurred in 4 of 47 children (8.5%). Adjusted multivariate logistic regression analysis for an outcome of future development of multiple sclerosis showed the following predictors: female gender (odds ratio 12.44; 95% confidence interval 1.03-149.3); initial diagnosis of monofocal brain stem or hemispheric dysfunction (odds ratio 24.57; 95% confidence interval 3.06-196.78); and Callen magnetic resonance imaging criteria if met (odds ratio 122.45; 95% confidence interval 16.57-904.57). CONCLUSION: International Pediatrics Multiple Sclerosis study group criteria affirm that children with initial clinically isolated syndrome are more likely to develop future multiple sclerosis compared with those with an acute disseminated encephalomyelitis initial diagnosis. In addition, female gender, brain stem or hemispheric involvement, and Callen magnetic resonance imaging criteria predict the diagnosis of multiple sclerosis.

How Safe is Eptifibatide during Urgent Carotid Artery Stenting?

BACKGROUND: Glycoprotein IIB/IIIA inhibitors are occasionally utilized during carotid artery stenting (CAS) in the presence or absence of a visualized intra-operative thrombus. OBJECTIVE: We assess the hemorrhagic and clinical outcomes associated with the use of eptifibatide during CAS. METHODS: A retrospective analysis of prospectively collected data on patients with the diagnosis of carotid artery stenosis underwent CAS in a single center. We identified those who received intravenous eptifibatide intra-operatively and compared to the rest of the cohort. Hemorrhagic outcomes included intracerebral hemorrhage (ICH) or groin hematoma that occurred during the hospital stay. RESULTS: In this analysis, 81 patients had CAS during a 3-year span; 16 of those had received 15 mg of intravenous eptifibatide intra-operatively. The mean age of the treated and untreated patients was similar (65.6 ± 13.4 versus 65.4 ± 10.2; P = 0.13). One patient (1.2%) in this series had ICH in the perioperative period that occurred in the non-eptifibatide group. Five patients (6.2%) in this series had groin hematoma; only one in the non-eptifibatide group required surgical repair. No mortality was reported and clinical outcomes including discharge modified Rankin scale, NIH stroke scale, as well as discharge destination were similar in both groups. A stratified analysis among those who underwent an urgent CAS showed no significant differences in the risks of hemorrhages or any clinical outcome (P > 0.05). CONCLUSION: The use of eptifibatide during CAS is safe. The risk of any hemorrhagic complication is rare in this series; however, a prospective study to validate this observation will be helpful.

Age-associated vasospasm in aneurysmal subarachnoid hemorrhage.

The relationship between age and vasospasm caused by subarachnoid hemorrhage (SAH) is controversial. We evaluated this relationship in a contemporary sample from a single institution. In a retrospective study design, we included patients with SAH caused by ruptured intracranial aneurysms. All patients underwent an evaluation that included head imaging, cerebral angiography, and treatment for the underlying aneurysm. Vasospasm was classified as absent, any vasospasm, or symptomatic vasospasm. Age was classified into 2 categories with a cutoff of 50 years, and also was stratified by decade. All patients had received preventative and therapeutic measures for vasospasm. Logistic regression analysis was used to assess the association between age and the occurrence of vasospasm. A total of 108 patients were included in this analysis, 67 of whom were age ≥50 years. The older patients had a higher incidence of vascular risk factors, and the younger patients had a higher incidence of smoking and illicit substance abuse. The mean age of the patients with any vasospasm (n = 41) was 48.51 ± 11.23 years, compared with 59.67 ± 13.30 years in those without vasospasm (P < .0001). Adjusted analysis found a greater risk of vasospasm in the younger patients compared with the older patients (odds ratio, 5.83; 95% confidence interval, 2.41-14.12 for any vasospasm; odds ratio, 2.66; 95% confidence interval, 1.008-7.052 for symptomatic vasospasm). This risk of vasospasm decreased with advanced age (P < .0001). Our findings suggest that patients age <50 years are at 5-fold greater risk of any vasospasm compared with older patients, and that age-adjusted prevention protocols may need to be considered.

Endovascular therapy of a craniocervical pial AVF fed by the anterior spinal artery.

Though pial arteriovenous fistulae (PAVF) are an uncommon cerebrovascular disorder, their presentation with subarachnoid hemorrhage (SAH) is not rare. PAVF near the craniocervical junction are rare and may have a worse outcome. These fistulae are often fed from either the carotid and/or the vertebrobasilar systems, but are rarely fed by the anterior spinal artery. We report the case of a young man presenting with SAH. Cerebral angiography revealed 2 AVF, a symptomatic PAVF located at the craniocervical junction and fed from the anterior spinal artery and incidental dural AVF (DAVF) originate from the left occipital and middle meningeal arteries. These fistulae were treated with different endovascular techniques, including Onyx and platinum coil embolization into the feeding arteries of the DAVF and PAVF, respectively.

Multicenter study of safety in stenting for symptomatic vertebral artery origin stenosis: results from the Society of Vascular and Interventional Neurology Research Consortium.

PURPOSE: To assess the safety and efficacy of vertebral artery origin angioplasty and stenting for stroke prevention in a multicenter clinical experience. METHODS: Patients with symptomatic vertebral artery origin stenosis (VAOS) were gathered from the Society of Vascular and Interventional Neurology Research Consortium. Demographic, clinical, and procedural data were collected. The main outcome measure was procedural and peri-procedural risks of stroke, transient ischemic attack (TIA), or death at 1 and 3 months. Logistic regression analysis was used to assess covariates associated with future restenosis. RESULTS: A total of 148 patients were included with mean age of 66.2 ± 11.5; 74% men and 77% Caucasian. One patient (.8%) had a stroke at 1 month and 5 of 96 (5.2%) patients had TIA at 3 months. There were no immediate procedural events or deaths. The mean angiographic pre-treatment stenosis was 80.5 ± 12.7%, which was reduced to 5.3 ± 9.1% after stent deployment. Follow-up angiography showed 15.5% of patients had significant restenosis (≥50%). Predictors of restenosis included age (OR 3.08; 95% CI 1.01, 9.41) and smoking (OR 3.10; 95% CI 1.12, 8.64). CONCLUSIONS: Endovascular intervention of VAOS is associated with low peri-procedural complication rates. Restenosis remains a concern; age and smoking predicted future restenosis.