Intrathecal Nicardipine for Severe Intractable Reversible Cerebral Vasoconstriction Syndrome: A Novel Case Report.

Reversible cerebral vasoconstriction syndrome (RCVS) is a poorly understood but increasingly recognized entity, likely multifactorial in nature and characterized by diffuse cerebral vasospasm that presents as sudden, intense, and fluctuating headaches. Due to insufficient evidence, there is currently no consensus on RCVS treatment guidelines. However, nicardipine, an L-type calcium channel blocker, may prove effective in RCVS treatment because of its ability to penetrate the blood-brain barrier. We report the concomitant use of intrathecal (IT) nicardipine and continuous intraarterial (IA) nicardipine infusion via microcatheter placed in the intracranial circulation for the treatment of a 58-year-old female with severe refractory RCVS. On presentation, this patient was noted to have a non-traumatic non-aneurysmal subarachnoid hemorrhage secondary to RCVS. Initially managed with oral verapamil, she later developed refractory symptomatic vasoconstriction requiring multiple angiograms for spasmolysis via balloon angioplasty and IA nicardipine. Due to the refractory nature of her spasm despite the IA therapy, we decided to attempt intrathecal nicardipine, starting at 4 mg q12 h via an external ventricular drain. This dose was escalated to 4 mg q6 h. The patient stabilized for 24 h but again decompensated, requiring continuous IA spasmolysis via a microcatheter placed in the left middle cerebral artery and left for continuous IA nicardipine infusion (5 mg/h). The patient showed slow incremental improvement clinically and a decrease in vasospasms on imaging, ultimately suffering minimal stroke burden. This patient's hospital course demonstrates that nicardipine, administered intrathecally or intraarterially, could be beneficial in select patients with refractory RCVS as a means of minimizing repeat angiography/angioplasty. Further studies are needed to better define a treatment paradigm for these patients.

Comparison of nimodipine formulations and administration techniques via enteral feeding tubes in patients with aneurysmal subarachnoid hemorrhage: A multicenter retrospective cohort study.

BACKGROUND: Nimodipine improves outcomes following aneurysmal subarachnoid hemorrhage (aSAH) and current guidelines suggest that patients with aSAH receive nimodipine for 21 days. Patients with no difficulty swallowing will swallow the whole capsules or tablets; otherwise, nimodipine liquid must be drawn from capsules, tablets need to be crushed, or the commercially available liquid product be used to facilitate administration through an enteral feeding tube (FT). It is not clear whether these techniques are equivalent. The goal of the study was to determine if different nimodipine formulations and administration techniques were associated with the safety and effectiveness of nimodipine in aSAH. METHODS: This was a retrospective multicenter observational cohort study conducted in 21 hospitals across North America. Patients admitted with aSAH and received nimodipine by FT for ≥3 days were included. Patient demographics, disease severity, nimodipine administration, and study outcomes were collected. Safety end points included the prevalence of diarrhea and nimodipine dose reduction or discontinuation secondary to blood pressure reduction. Predictors of the study outcomes were analyzed using regression modeling. RESULTS: A total of 727 patients were included. Administration of nimodipine liquid product was independently associated with higher prevalence of diarrhea compared to other administration techniques/formulations (Odds ratio [OR] 2.28, 95% confidence interval [CI] 1.41-3.67, p-value = 0.001, OR 2.76, 95% CI 1.37-5.55, p-value = 0.005, for old and new commercially available formulations, respectively). Bedside withdrawal of liquid from nimodipine capsules prior to administration was significantly associated with higher prevalence of nimodipine dose reduction or discontinuation secondary to hypotension (OR 2.82, 95% CI 1.57-5.06, p-value = 0.001). Tablet crushing and bedside withdrawal of liquid from capsules prior to administration were associated with increased odds of delayed cerebral ischemia (OR 6.66, 95% CI 3.48-12.74, p-value <0.0001 and OR 3.92, 95% CI 2.05-7.52, p-value <0.0001, respectively). CONCLUSIONS: Our findings suggest that enteral nimodipine formulations and administration techniques might not be equivalent. This could be attributed to excipient differences, inconsistency and inaccuracy in medication administration, and altered nimodipine bioavailability. Further studies are needed.

Stroke thrombolysis given by emergency physicians: The time is here.

Emergency Medicine core clinical privileges include administration of thrombolytic therapy for myocardial infarction and stroke. However, emergency medicine providers have created their own paradigm to rely on neurology specialty consultation to treat acute stroke patients. A 2013 study supported by the American Academy of Neurology showed an 11% shortage of neurologists at that time and projected a 19% shortage by 2025. The lack of neurologists is a worldwide problem. To help ease the shortage, teleneurology and telestroke care has been implemented by neurologists, most notably for acute ischemic stroke (AIS) patients. We present a model in which an Emergency Medicine (EM) Stroke Champion (SC); an EM physician within our Neurologic Emergency Department, directs care for acute stroke patients at our comprehensive hub and primary stroke center spoke hospitals. The SCs independently treat patients with fibrinolytic therapy and provide teleneurology to fellow emergency physicians caring for acute stroke patients at spoke hospitals. Over nineteen months the SCs received 457 phone calls for patients meeting stroke alert criteria. Sixteen patients were deemed eligible for IV alteplase with one hemorrhagic conversion (6.25%). Sixty-four patients required transfer, and this was facilitated by the SCs. The concept of emergency physician SCs providing teleneurology consultation to other fellow emergency physicians was found to be feasible and safe. This model has the potential to be generalized not to just stroke champions, but to all emergency physicians to feel both confident and comfortable treating acute stroke patients.

Radiographic and clinical outcomes with particle or liquid embolic agents for middle meningeal artery embolization of nonacute subdural hematomas.

BACKGROUND: Middle meningeal artery (MMA) embolization is an apparently efficacious minimally invasive treatment for nonacute subdural hematomas (NASHs), but how different embolisates affect outcomes remains unclear. Our objective was to compare radiographic and clinical outcomes after particle or liquid MMA embolization. METHODS: Patients who had MMA embolization for NASH were retrospectively identified from a multi-institution database. The primary radiographic and clinical outcomes-50% NASH thickness reduction and need for surgical retreatment within 90 days, respectively-were compared for liquid and particle embolizations in patients treated 1) without surgical intervention (upfront), 2) after recurrence, or 3) with concomitant surgery (prophylactic). RESULTS: The upfront, recurrent, and prophylactic subgroups included 133, 59, and 16 patients, respectively. The primary radiographic outcome was observed in 61.8%, 61%, and 72.7% of particle-embolized patients and 61.3%, 55.6%, and 20% of liquid-embolized patients, respectively (p = 0.457, 0.819, 0.755). Hazard ratios comparing time to reach radiographic outcome in the particle and liquid groups or upfront, recurrent, andprophylactic timing were 1.31 (95% CI 0.78-2.18; p = 0.310), 1.09 (95% CI 0.52-2.27; p = 0.822), and 1.5 (95% CI 0.14-16.54; p = 0.74), respectively. The primary clinical outcome occurred in 8.0%, 2.4%, and 0% of patients who underwent particle embolization in the upfront, recurrent, and prophylactic groups, respectively, compared with 0%, 5.6%, and 0% who underwent liquid embolization (p = 0.197, 0.521, 1.00). CONCLUSIONS: MMA embolization with particle and liquid embolisates appears to be equally effective in treatment of NASHs as determined by the percentage who reach, and the time to reach, 50% NASH thickness reduction and the incidence of surgical reintervention within 90 days.

Isolated oculomotor nerve palsy secondary to non-aneurysmal subarachnoid hemorrhage.

We present a case series of two patients who developed unilateral cranial nerve III (CNIII) palsy following non-aneurysmal SAH (NASAH). Subarachnoid hemorrhage (SAH) can present with various signs and symptoms. Early diagnosis is paramount to determine treatment course. Thus, clinicians must be aware of the variable clinical presentations of this condition. Two patients were admitted to a single institution for SAH. Patient 1, 52-year-old male, presented with headache, left eye ptosis, and painless diplopia. A non-contrast head computed tomography (CT) demonstrated a SAH within the left sylvian fissure and blood surrounding the mesencephalon and falx. Patient 2, 70-year-old male, presented with mild headache, acute onset of blurry vision, and right eye ptosis. A non-contrast head CT demonstrated a diffuse SAH predominantly in the Sylvian and suprasellar cisterns. Patients were admitted to the neuro intensive care unit and underwent diagnostic angiograms to identify possible aneurysms. Magnetic resonance imaging and angiograms for both patients were negative. Patients were managed with best medical therapy and followed up in the outpatient setting. Unilateral CNIII palsy in the setting of NASAH was identified in both patients. Diagnostic angiograms were negative for aneurysms; therefore, SAH were determined to be spontaneous. We propose that unilateral CNIII palsy is a possible sign of NASAH.

The Use of Antiplatelet Agents and Heparin in the 24-Hour Postintravenous Alteplase Window for Neurointervention.

BACKGROUND: Intravenous (IV) alteplase with mechanical thrombectomy has been found to be superior to alteplase alone in select patients with intracranial large vessel occlusion. Current guidelines discourage the use of antiplatelet agents or heparin for 24 h following alteplase. However, their use is often necessary in certain circumstances during thrombectomy procedures. OBJECTIVE: To study the safety and outcomes in patients who received blood thinning medications for thrombectomy after IV Tissue-Type plasminogen activator (tPA). METHODS: This is a multicenter retrospective review of the use of antiplatelet agents and/or heparin in patients within 24 h following tPA administration. Patient demographics, comorbidities, bleeding complications, and discharge outcomes were collected. RESULTS: A series of 88 patients at 9 centers received antiplatelet medications and/or heparin anticoagulation following IV alteplase for revascularization procedures requiring stenting. The mean National Institutes of Health Stroke Scale (NIHSS) on admission was 14.6. Reasons for use of a stent included internal carotid artery occlusion in 74% of patients. Thrombolysis in cerebral infarction (TICI) 2b-3 revascularization was accomplished in 90% of patients. The rate of symptomatic intracranial hemorrhage (sICH) was 8%; this was not significantly different than the sICH rate for a matched group of patients not receiving antiplatelets or heparin during the same time frame. Functional independence at 90 d (modified Rankin Scale 0-2) was seen in 57.8% of patients. All-cause mortality was 12%. CONCLUSION: The use of antiplatelet agents and heparin for stroke interventions following IV alteplase appears to be safe without significant increased risk of hemorrhagic complications in this group of patients when compared to control data and randomized controlled trials.

Placement of a Pipeline Embolization Device: 2-Dimensional Operative Video.

Flow diversion has been a game-changer in the treatment of wide-neck large and giant cavernous and supraclinoid internal carotid artery (ICA) aneurysms as well as large vertebral artery aneurysms. Prior to their existence, carotid sacrifice or clipping with or without external to internal carotid artery bypass was the mainstay of treatment. Prior to flow diversion, endovascular coil embolization was often not effective as a stand-alone treatment because of the fact that many of these aneurysms present with symptoms created by mass effect on the cavernous sinus cranial nerves by the aneurysm. Packing the aneurysm with coils did nothing to alleviate the mass effect and did not prevent flow from entering the aneurysm. The continued flow causes coil compaction and aneurysm enlargement. Flow diversion addressed both these issues by diverting flow from the aneurysm while allowing the aneurysm to slowly thrombose and shrink. The video is a step-by-step account of this procedure in a 72-yr-old male with a large recurrence of a previously coiled cavernous ICA aneurysm. The procedure was performed following informed consent.

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Multi-Center Experience of 154 Consecutive Embolizations.

BACKGROUND: Middle meningeal artery (MMA) embolization has emerged as a promising treatment for chronic subdural hematoma (cSDH). OBJECTIVE: To determine the safety and efficacy of MMA embolization. METHODS: Consecutive patients who underwent MMA embolization for cSDH (primary treatment or recurrence after conventional surgery) at 15 centers were included. Clinical details and follow-up were collected prospectively. Primary clinical and radiographic outcomes were the proportion of patients requiring additional surgical treatment within 90 d after index treatment and proportion with > 50% cSDH thickness reduction on follow-up computed tomography imaging within 90 d. National Institute of Health Stroke Scale and modified Rankin Scale were also clinical outcomes. RESULTS: A total of 138 patients were included (mean age: 69.8, 29% female). A total of 15 patients underwent bilateral interventions for 154 total embolizations (66.7% primary treatment). At presentation, 30.4% and 23.9% of patients were on antiplatelet and anticoagulation therapy, respectively. Median admission cSDH thickness was 14 mm. A total of 46.1% of embolizations were performed under general anesthesia, and 97.4% of procedures were successfully completed. A total of 70.2% of embolizations used particles, and 25.3% used liquid embolics with no significant outcome difference between embolization materials (P > .05). On last follow-up (mean 94.9 d), median cSDH thickness was 4 mm (71% median thickness reduction). A total of 70.8% of patients had >50% improvement on imaging (31.9% improved clinically), and 9 patients (6.5%) required further cSDH treatment. There were 16 complications with 9 (6.5%) because of continued hematoma expansion. Mortality rate was 4.4%, mostly unrelated to the index procedure but because of underlying comorbidities. CONCLUSION: MMA embolization may provide a safe and efficacious minimally invasive alternative to conventional surgical techniques.

Middle meningeal artery embolization treatment of nonacute subdural hematomas in the elderly: a multiinstitutional experience of 151 cases.

OBJECTIVE: The incidence of already common chronic subdural hematomas (CSDHs) and other nonacute subdural hematomas (NASHs) in the elderly is expected to rise as the population ages over the coming decades. Surgical management is associated with recurrence and exposes elderly patients to perioperative and operative risks. Middle meningeal artery (MMA) embolization offers the potential for a minimally invasive, less morbid treatment in this age group. The clinical and radiographic outcomes after MMA embolization treatment for NASHs have not been adequately described in elderly patients. In this paper, the authors describe the clinical and radiographic outcomes after 151 cases of MMA embolization for NASHs among 121 elderly patients. METHODS: In a retrospective review of a prospectively maintained database across 15 US academic centers, the authors identified patients aged ≥ 65 years who underwent MMA embolization for the treatment of NASHs between November 2017 and February 2020. Patient demographics, comorbidities, clinical and radiographic factors, treatment factors, and clinical outcomes were abstracted. Subgroup analysis was performed comparing elderly (age 65-79 years) and advanced elderly (age > 80 years) patients. RESULTS: MMA embolization was successfully performed in 98% of NASHs (in 148 of 151 cases) in 121 patients. Seventy elderly patients underwent 87 embolization procedures, and 51 advanced elderly patients underwent 64 embolization procedures. Elderly and advanced elderly patients had similar rates of embolization for upfront (46% vs 61%), recurrent (39% vs 33%), and prophylactic (i.e., with concomitant surgical intervention; 15% vs 6%) NASH treatment. Transfemoral access was used in most patients, and the procedure time was approximately 1 hour in both groups. Particle embolization with supplemental coils was most common, used in 51% (44/87) and 44% (28/64) of attempts for the elderly and advanced elderly groups, respectively. NASH thickness decreased significantly from initial thickness to 6 weeks, with additional decrease in thickness observed in both groups at 90 days. At longest follow-up, the treated NASHs had stabilized or improved in 91% and 98% of the elderly and advanced elderly groups, respectively, with > 50% improvement seen in > 60% of patients for each group. Surgical rescue was necessary in 4.6% and 7.8% of cases, and the overall mortality was 8.6% and 3.9% for elderly and advanced elderly patients, respectively. CONCLUSIONS: MMA embolization can be used safely and effectively as an alternative or adjunctive minimally invasive treatment for NASHs in elderly and advanced elderly patients.

Cardiopulmonary resuscitation causing thoracolumbar hyperextension with severe spinal cord injury: A case report.

Thoracic vertebral fractures are extremely rare complications of cardiopulmonary resuscitation (CPR). A morbidly obese 79-year-old female positive for COVID-19 suffered cardiac arrest and received CPR for 18 minutes with return of spontaneous circulation. Post cardiac arrest the patient was unable to be weaned from the ventilator and had decreased lower extremity movement. A computed tomography scan of the chest/abdomen/pelvis demonstrated a widely diastatic spinal separation at the T12/L1 intervertebral disc space with L1 spinous process fracture. The patient ultimately expired from the severe spinal cord injury combined with older age, COVID-19 pneumonia, and morbid obesity. CPR can be an important life-saving procedure, but strict attention to proper technique is of paramount importance as it can have many possible complications.

Minimizing SARS-CoV-2 exposure when performing surgical interventions during the COVID-19 pandemic.

BACKGROUND: Infection from the SARS-CoV-2 virus has led to the COVID-19 pandemic. Given the large number of patients affected, healthcare personnel and facility resources are stretched to the limit; however, the need for urgent and emergent neurosurgical care continues. This article describes best practices when performing neurosurgical procedures on patients with COVID-19 based on multi-institutional experiences. METHODS: We assembled neurosurgical practitioners from 13 different health systems from across the USA, including those in hot spots, to describe their practices in managing neurosurgical emergencies within the COVID-19 environment. RESULTS: Patients presenting with neurosurgical emergencies should be considered as persons under investigation (PUI) and thus maximal personal protective equipment (PPE) should be donned during interaction and transfer. Intubations and extubations should be done with only anesthesia staff donning maximal PPE in a negative pressure environment. Operating room (OR) staff should enter the room once the air has been cleared of particulate matter. Certain OR suites should be designated as covid ORs, thus allowing for all neurosurgical cases on covid/PUI patients to be performed in these rooms, which will require a terminal clean post procedure. Each COVID OR suite should be attached to an anteroom which is a negative pressure room with a HEPA filter, thus allowing for donning and doffing of PPE without risking contamination of clean areas. CONCLUSION: Based on a multi-institutional collaborative effort, we describe best practices when providing neurosurgical treatment for patients with COVID-19 in order to optimize clinical care and minimize the exposure of patients and staff.

Delayed presentation of acute ischemic strokes during the COVID-19 crisis.

BACKGROUND: The COVID-19 pandemic has disrupted established care paths worldwide. Patient awareness of the pandemic and executive limitations imposed on public life have changed the perception of when to seek care for acute conditions in some cases. We sought to study whether there is a delay in presentation for acute ischemic stroke patients in the first month of the pandemic in the US. METHODS: The interval between last-known-well (LKW) time and presentation of 710 consecutive patients presenting with acute ischemic strokes to 12 stroke centers across the US were extracted from a prospectively maintained quality database. We analyzed the timing and severity of the presentation in the baseline period from February to March 2019 and compared results with the timeframe of February and March 2020. RESULTS: There were 320 patients in the 2-month baseline period in 2019, there was a marked decrease in patients from February to March of 2020 (227 patients in February, and 163 patients in March). There was no difference in the severity of the presentation between groups and no difference in age between the baseline and the COVID period. The mean interval from LKW to the presentation was significantly longer in the COVID period (603±1035 min) compared with the baseline period (442±435 min, P<0.02). CONCLUSION: We present data supporting an association between public awareness and limitations imposed on public life during the COVID-19 pandemic in the US and a delay in presentation for acute ischemic stroke patients to a stroke center.

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.

Common Femoral Artery Access: 2-Dimensional Operative Video.

Vascular access for cerebral angiography has traditionally been performed via the common femoral artery. It is crucial to obtain safe access to prevent complications that could lead to limb ischemia, groin hematoma, or retroperitoneal hematoma. This is especially true in neurointervention as many patients are anticoagulated or have received intravenous thrombolytics prior to their intervention. Special attention to anatomic landmarks, both grossly and radiographically, can help to assure safe access. The patient consented for this procedure. This video details rapid but safe femoral artery access in a patient undergoing emergent thrombectomy.

Carotid Artery Angioplasty and Stenting: 2-Dimensional Operative Video.

Carotid artery angioplasty and stenting (CAS) has been shown to be equally effective as carotid endarterectomy (CEA) for carotid stenosis in both symptomatic and asymptomatic disease.1 In patients who are considered high risk for endarterectomy, CAS is safe and effective.2 While this is a common procedure, proper technique is crucial to ensure that the procedure is safe with minimal risk of stroke. This patient consented to treatment. The following is a video detailing the CAS procedure in a 77-yr-old male with a symptomatic 65% carotid stenosis (by NASCET criteria3) in a patient with prior CEA.

Endovascular Coil Embolization of a Posterior Communicating Artery Aneurysm: 2-Dimensional Operative Video.

Since the International Subarachnoid Aneurysm Trial,1 endovascular treatment has been the favored treatment for appropriate ruptured intracranial aneurysms. While our endovascular technology has advanced to allow us to treat the majority of intracranial aneurysms, simple coil embolization is still the most common modality. This video demonstrates the fundamentals of aneurysm catheterization and coiling for safe treatment. In addition, the set-up and devices are detailed. This video is to add to the library of basic techniques that will aid a large number of practitioners. This patient consented to endovascular treatment. The video demonstrates endovascular coil embolization of a posterior communicating artery aneurysm in a 76-yr-old female who presented with a subarachnoid hemorrhage. Image of biplane suite in video used courtesy of Siemens Medical Solutions USA, Inc. Illustration at 5:12 reprinted from Yasargil MG, et al, Microneurosurgery IV B, p. 9, Thieme, New York, 1995.

Innovations in Care Delivery of Stroke from Emergency Medical Services to the Neurointerventional Operating Room.

Acute ischemic stroke (AIS) and its care is currently one of the most dynamic and evolving illnesses across the globe. Among the most crucial factors in providing the best care to patients are the expedient delivery of thrombolytics and endovascular intervention when indicated. Here, we review our unique model of efficient care centered in our innovative Neurological Emergency Department (Neuro ED). The Neuro ED acts as our hub for EMS communication, imaging, administration of intravenous alteplase, and transition to the Neurointerventional OR. Our structure with its enabling of shortened IV alteplase delivery times and faster door-to-needle (DTN) times may serve as an international model for stroke centers.