A Novel Case of Deep Temporal Artery (DTA) Embolization for Recurrent Subacute-Chronic Subdural Hematoma.

Subdural hemorrhage (SDH) is a common neurological disease. In past, SDHs were managed either conservatively (non-surgically) or with surgical evacuation (burr hole versus craniotomy) depending on the severity. Surgical evacuation has major challenges including high recurrence rate, stoppage and reversal of antiplatelet or anticoagulation agents, risk of general anesthesia and surgery in elderly patients with multiple comorbidities. Given the above challenges, embolization of the distal branches of the middle meningeal artery (MMA) has recently emerged as an excellent alternate to surgical evacuation or conservative management. To the best of our knowledge, there is no literature on the embolization of the deep temporal artery (DTA) for subacute-chronic SDH. We report the first case of recurrent subdural hematoma post MMA embolization that was successfully treated with embolization of DTA.

Retrieval of Migrated Coils From Distal Cerebral Vasculature Using Stent Retriever: A Case Series.

The incidence of coil dislocation during an endovascular embolization of intracranial aneurysm is low but it can lead to serious thrombo-embolic complications. Therefore, coil displacement/migration often requires either retrieval or fixation of the errant coil with a stent. There are no standard recommended methods of coil retrieval. We present a series of three cases in which off-label application of a stent retriever allowed successful retrieval of herniated coils.

Internal Carotid Artery Agenesis: A Rare Entity.

Congenital absence of the internal carotid artery (ICA) is an extremely rare entity that occurs due to insult during the embryonic development of the ICA. Various intracranial collateral pathways develop to compensate for the ICA agenesis. Patients can present with aneurysmal subarachnoid hemorrhage, stroke-like symptoms, or other neurological symptoms due to compression of brain structures from enlarged collateral pathways/aneurysms. We present two cases of ICA agenesis along with an extensive review of the literature. A 67-year-old man presented with fluctuating right-sided hemiparesis and aphasia, found to have left ICA agenesis. The left middle cerebral artery (MCA) is supplied by the basilar artery through the well-developed posterior communicating artery (PCOM). Left ophthalmic artery coming from the proximal left MCA. A 44-year-old woman presented with severe headaches, found to have right ICA agenesis with bilateral MCAs and anterior cerebral arteries (ACA) supplied by left ICA. A 17-mm anterior communicating artery (ACOM) aneurysm was discovered.

Long-term Anticoagulation with Apixaban in Patients with Cerebral Venous Thrombosis.

Introduction: Cerebral venous thrombosis (CVT) is a life-threatening neurological condition. There is limited evidence for the use of direct oral anticoagulants (DOAC) for long-term anticoagulation in this patient population. We report a case series of patients treated with apixaban and their clinical course. Methods: This was a retrospective cohort study. Patients diagnosed with CVT in a defined time period at our institution were screened for long-term anticoagulation and patients who were treated with apixaban were included in this study. Results: A total of nine patients were included in this study. The mean age was 36 years and 56% of the patients included were women. All received initial anticoagulation with unfractionated heparin (UFH) infusion for at least twenty-four hours, except for one patient who had anti-thrombin III deficiency and was treated with argatroban infusion. For long-term anticoagulation, 56% of patients received apixaban 10 mg twice daily for the first five to seven days followed by 5 mg twice daily, while the remaining 44% were transitioned from IV anticoagulation to apixaban 5 mg twice daily. There were no adverse events reported, except for one patient who developed anemia after 7 months of treatment and required a blood transfusion. Complete recanalization was achieved in 78% while 22% had partial recanalization. Follow-up time ranged from six to twenty-three months. Conclusion: The use of apixaban for long-term anticoagulation in CVT resulted in recanalization in all of the patients in this case series without any major side effects. This case series adds to the emerging studies demonstrating the utility of apixaban for CVT.

Changes in Neuroendovascular Procedural Volume During the COVID-19 Pandemic: An International Multicenter Study.

BACKGROUND AND PURPOSE: The effect of coronavirus disease 2019 (COVID-19) pandemic on performance of neuroendovascular procedures has not been quantified. METHODS: We performed an audit of performance of neuroendovascular procedures at 18 institutions (seven countries) for two periods; January-April 2019 and 2020, to identify changes in various core procedures. We divided the region where the hospital was located based on the median value of total number of COVID-19 cases per 100,00 population-into high and low prevalent regions. RESULTS: Between 2019 and 2020, there was a reduction in number of cerebral angiograms (30.9% reduction), mechanical thrombectomy (8% reduction), carotid artery stent placement for symptomatic (22.7% reduction) and asymptomatic (43.4% reduction) stenoses, intracranial angioplasty and/or stent placement (45% reduction), and endovascular treatment of unruptured intracranial aneurysms (44.6% reduction) and ruptured (22.9% reduction) and unruptured brain arteriovenous malformations (66.4% reduction). There was an increase in the treatment of ruptured intracranial aneurysms (10% increase) and other neuroendovascular procedures (34.9% increase). There was no relationship between procedural volume change and intuitional location in high or low COVID-19 prevalent regions. The procedural volume reduction was mainly observed in March-April 2020. CONCLUSIONS: We provided an international multicenter view of changes in neuroendovascular practices to better understand the gaps in provision of care and identify individual procedures, which are susceptible to change.

Safety and Clinical Outcomes after Transverse Venous Sinus Stenting for Treatment of Refractory Idiopathic Intracranial Hypertension: Single Center Experience.

BACKGROUND: Idiopathic intracranial hypertension (IIH) is a syndrome of elevated intracranial pressure of unknown etiology. Unilateral or bilateral transverse sinus (TS) or transverse-sigmoid junction stenosis is present in about 30%-93% of these patients. There is an ongoing debate on whether venous sinus stenosis is the cause of IIH or a result of it. The subset of IIH patients who continue to have clinical deterioration despite maximum medical therapy is termed as "refractory IIH." Traditionally, cerebrospinal fluid diversion surgeries (ventriculoperitoneal shunt and lumboperitoneal shunt) and optic nerve sheath fenestration (ONSF) were the mainstays of treatment for refractory IIH. In the last decade, venous sinus stenting (VSS) has emerged as a safe and effective option for treating refractory IIH patients with venous sinus stenosis. Through this study, we want to share our experience with venous stenting in refractory IIH patients with venous sinus stenosis associated with a significant pressure gradient (≥10 mm Hg). METHODS: Retrospective chart review of all the patients diagnosed with refractory IIH who underwent VSS or angioplasty at our comprehensive stroke center from November 2016 to March 2019. RESULTS: A total of seven refractory IIH patients underwent VSS or angioplasty within the specified period. The mean age was 39 years. Eighty-five percent of the patients were women (n = 6). The mean body mass index (BMI) was 37 kg/m2. Headache was the most common symptom (85%, n = 6) followed by transient visual obscurations (71%, n = 5) and pulsatile tinnitus (57%; n = 4). All patients had papilledema. Fifty-seven percent of patients (n = 4) had impaired visual field. Mean lumbar opening pressure was 40.6 cm H2O (SD = 9.66; 95% CI = 33.5-47.7). All patients were on maximum doses of acetazolamide ± furosemide. Six patients (85%) had dominant right transverse-sigmoid sinus. Fifty-seven percent of the patients had severe right transverse ± sigmoid sinus stenosis (n = 4) and the rest (43%) had bilateral TS stenosis (n = 3). Prestenting mean trans-stenosis pressure gradient was 18 mm Hg (SD = 6.16; 95% CI = 13.43-22.57). Six patients (85%) were treated with TS stenting and one (15%) with only angioplasty. Poststenting mean trans-stenosis pressure gradient was 4.8 mm Hg (SD = 6.6; 95% CI = -0.1-9.7). All patients were able to come off their medications with significant improvement in neurological and ophthalmological signs and symptoms. No procedure-related complications occurred. CONCLUSION: TS stenting ± angioplasty is a safe and effective means of treating refractory IIH with venous sinus stenosis associated with a significant pressure gradient (≥10 mm Hg).

Safety and Efficacy of a 3-Dimensional Stent Retriever With Aspiration-Based Thrombectomy vs Aspiration-Based Thrombectomy Alone in Acute Ischemic Stroke Intervention: A Randomized Clinical Trial.

Importance: The treatment effects of individual mechanical thrombectomy devices in large-vessel acute ischemic stroke (AIS) remain unclear. Objective: To determine whether the novel 3-dimensional (3-D) stent retriever used in conjunction with an aspiration-based mechanical thrombectomy device (Penumbra System; Penumbra) is noninferior to aspiration-based thrombectomy alone in AIS. Design, Setting, and Participants: This randomized, noninferiority clinical trial enrolled patients at 25 North American centers from May 19, 2012, through November 19, 2015, with follow-up for 90 days. Adjudicators of the primary end points were masked to treatment allocation. Patients with large-vessel intracranial occlusion AIS presenting with a National Institutes of Health Stroke Scale (NIHSS) score of at least 8 within 8 hours of onset underwent 1:1 randomization to 3-D stent retriever with aspiration or aspiration alone. The primary analyses were conducted in the intention-to-treat population. Interventions: Mechanical thrombectomy using intracranial aspiration with or without the 3-D stent retriever. Main Outcomes and Measures: The primary effectiveness end point was the rate of a modified Thrombolysis in Cerebral Infarction (mTICI) grade of 2 to 3 with a 15% noninferiority margin. Device- and procedure-related serious adverse events at 24 hours were the primary safety end points. Results: Of 8082 patients screened, 198 patients were enrolled (111 women [56.1%] and 87 men [43.9%]; mean [SD] age, 66.9 [13.0] years) and randomized, including 98 in the 3-D stent retriever with aspiration group and 100 in the aspiration alone group; an additional 238 patients were eligible but not enrolled. The median baseline NIHSS score was 18.0 (interquartile range, 14.0-23.0). Eighty-two of 94 patients in the 3-D stent retriever and aspiration group (87.2%) had an mTICI grade of 2 to 3 compared with 79 of 96 in the aspiration alone group (82.3%; difference, 4.9%; 90% CI, -3.6% to 13.5%). None of the other measures were significantly different between the 2 groups. Device-related serious adverse events were reported by 4 of 98 patients in the 3-D stent retriever with aspiration group (4.1%) vs 5 of 100 patients in the aspiration only group (5.0%); procedure-related serious adverse events, 10 of 98 (10.2%) vs 14 of 100 (14.0%). A 90-day modified Rankin Scale score of 0 to 2 was reported by 39 of 86 patients in the 3-D stent retriever with aspiration group (45.3%) vs 44 of 96 patients in the aspiration only group (45.8%). Conclusions and Relevance: The present study provides class 1 evidence for the noninferiority of the 3-D stent retriever with aspiration vs aspiration alone in AIS. Future trials should evaluate whether these results can be generalized to other stent retrievers. Trial Registration: clinicaltrials.gov Identifier: NCT01584609.

Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct.

BACKGROUND: The effect of endovascular thrombectomy that is performed more than 6 hours after the onset of ischemic stroke is uncertain. Patients with a clinical deficit that is disproportionately severe relative to the infarct volume may benefit from late thrombectomy. METHODS: We enrolled patients with occlusion of the intracranial internal carotid artery or proximal middle cerebral artery who had last been known to be well 6 to 24 hours earlier and who had a mismatch between the severity of the clinical deficit and the infarct volume, with mismatch criteria defined according to age (<80 years or ≥80 years). Patients were randomly assigned to thrombectomy plus standard care (the thrombectomy group) or to standard care alone (the control group). The coprimary end points were the mean score for disability on the utility-weighted modified Rankin scale (which ranges from 0 [death] to 10 [no symptoms or disability]) and the rate of functional independence (a score of 0, 1, or 2 on the modified Rankin scale, which ranges from 0 to 6, with higher scores indicating more severe disability) at 90 days. RESULTS: A total of 206 patients were enrolled; 107 were assigned to the thrombectomy group and 99 to the control group. At 31 months, enrollment in the trial was stopped because of the results of a prespecified interim analysis. The mean score on the utility-weighted modified Rankin scale at 90 days was 5.5 in the thrombectomy group as compared with 3.4 in the control group (adjusted difference [Bayesian analysis], 2.0 points; 95% credible interval, 1.1 to 3.0; posterior probability of superiority, >0.999), and the rate of functional independence at 90 days was 49% in the thrombectomy group as compared with 13% in the control group (adjusted difference, 33 percentage points; 95% credible interval, 24 to 44; posterior probability of superiority, >0.999). The rate of symptomatic intracranial hemorrhage did not differ significantly between the two groups (6% in the thrombectomy group and 3% in the control group, P=0.50), nor did 90-day mortality (19% and 18%, respectively; P=1.00). CONCLUSIONS: Among patients with acute stroke who had last been known to be well 6 to 24 hours earlier and who had a mismatch between clinical deficit and infarct, outcomes for disability at 90 days were better with thrombectomy plus standard care than with standard care alone. (Funded by Stryker Neurovascular; DAWN ClinicalTrials.gov number, NCT02142283 .).

Phantom-based standardization of CT angiography images for spot sign detection.

PURPOSE: The CT angiography (CTA) spot sign is a strong predictor of hematoma expansion in intracerebral hemorrhage (ICH). However, CTA parameters vary widely across centers and may negatively impact spot sign accuracy in predicting ICH expansion. We developed a CT iodine calibration phantom that was scanned at different institutions in a large multicenter ICH clinical trial to determine the effect of image standardization on spot sign detection and performance. METHODS: A custom phantom containing known concentrations of iodine was designed and scanned using the stroke CT protocol at each institution. Custom software was developed to read the CT volume datasets and calculate the Hounsfield unit as a function of iodine concentration for each phantom scan. CTA images obtained within 8 h from symptom onset were analyzed by two trained readers comparing the calibrated vs. uncalibrated density cutoffs for spot sign identification. ICH expansion was defined as hematoma volume growth >33%. RESULTS: A total of 90 subjects qualified for the study, of whom 17/83 (20.5%) experienced ICH expansion. The number of spot sign positive scans was higher in the calibrated analysis (67.8 vs 38.9% p < 0.001). All spot signs identified in the non-calibrated analysis remained positive after calibration. Calibrated CTA images had higher sensitivity for ICH expansion (76 vs 52%) but inferior specificity (35 vs 63%) compared with uncalibrated images. CONCLUSION: Normalization of CTA images using phantom data is a feasible strategy to obtain consistent image quantification for spot sign analysis across different sites and may improve sensitivity for identification of ICH expansion.

Systematic Review and Pooled Analyses of Recent Neurointerventional Randomized Controlled Trials: Setting a New Standard of Care for Acute Ischemic Stroke Treatment after 20 Years.

BACKGROUND: Recent advances in the treatment of ischemic stroke have focused on revascularization and led to better clinical and functional outcomes. A systematic review and pooled analyses of 6 recent multicentered prospective randomized controlled trials (MPRCT) were performed to compare intravenous tissue plasminogen activator (IV tPA) and endovascular therapy (intervention) with IV tPA alone (control) for anterior circulation ischemic stroke (AIS) secondary to large vessel occlusion (LVO). OBJECTIVES: Six MPRCTs (MR CLEAN, ESCAPE, EXTEND IA, SWIFT PRIME, REVASCAT and THERAPY) incorporating image-based LVO AIS were selected for assessing the following: (1) prespecified primary clinical outcomes of AIS patients in intervention and control arms: good outcomes were defined by a modified Rankin Scale score of 0-2 at 90 days; (2) secondary clinical outcomes were: (a) revascularization rates [favorable outcomes defined as modified Thrombolysis in Cerebral Infarction scale (mTICI) score of 2b/3]; (b) symptomatic intracranial hemorrhage (sICH) rates and mortality; (c) derivation of number needed to harm (NNH), number needed to treat (NNT), and relative percent difference (RPD) between intervention and control groups, and (d) random effects model to determine overall significance (forest and funnel plots). RESULTS: A total of 1,386 patients were included. Good outcomes at 90 days were seen in 46% of patients in the intervention (p < 0.00001) and in 27% of patients in the control groups (p < 0.00002). An mTICI score of 2b/3 was achieved in 70.2% of patients in the intervention arm. The sICH and mortality in the intervention arm compared with the control arm were 4.7 and 14.3% versus 7.9 and 17.8%, respectively. The NNT and NNH in the intervention and control groups were 5.3 and 9.1, respectively. Patients in the intervention arm had a 50.1% (RPD) better chance of achieving a good 90-day outcome as compared to controls. CONCLUSIONS: Endovascular therapy combined with IV tPA (in appropriately selected patients) for LVO-related AIS is superior to IV tPA alone. These results support establishing an endovascular therapy in addition to IV tPA as the standard of care for AIS secondary to LVO.

Mechanical Thrombectomy-Ready Comprehensive Stroke Center Requirements and Endovascular Stroke Systems of Care: Recommendations from the Endovascular Stroke Standards Committee of the Society of Vascular and Interventional Neurology (SVIN).

Five landmark multicenter, prospective, randomized, open-label, blinded end point clinical trials have recently demonstrated significant clinical benefit of endovascular therapy with mechanical thrombectomy in acute ischemic stroke (AIS) patients presenting with proximal intracranial large vessel occlusions. The Society of Vascular and Interventional Neurology (SVIN) appointed an expert writing committee to summarize this new evidence and make recommendations on how these data should guide emergency endovascular therapy for AIS patients.

Intravenous thrombolysis in a patient using factor Xa inhibitor.

UNLABELLED: Until recently, only warfarin was approved for the prevention of stroke in patients with AF. Patients on warfarin with ischemic stroke were considered candidates for IV tPA as long as their PT/INR was not prolonged. Now, there are several new agents approved for stroke prevention in patients with non-valvular AF. The newer agents include direct thrombin inhibitors, like dabigatran, and factor Xa inhibitors, like rivaroxaban and apixaban. The coagulation profile of patients on direct thrombin inhibitors is more predictable than that of patients on factor Xa inhibitors, and the usage of IV tPA in patients on dabigatran has been previously reported. To our knowledge, there are no prior reports of IV tPA in a patient on a factor Xa inhibitor. We report a case of a 71-year-old man on rivaroxaban who improved with IV tPA after presenting with acute onset of aphasia and right-sided weakness. ABBREVIATIONS: AFAtrial fibrillationIV tPAIntravenous tissue plasminogen activatorINRInternational normalized ratioPTTPartial thromboplastin timeNIHNational Institute of HealthPTProthrombin timeCTComputed tomographyMCAMiddle cerebral arteryMRIMagnetic resonance imaging.

Possible role of Eptifibatide drip in-patient with aneurysmal subarachnoid hemorrhage in vasospasm prevention.

OBJECTIVE: Approximately 18,000 patients suffer from a subarachnoid hemorrhage (SAH) in the United States annually. SAH is a form of stroke and comprises 1%-5% of all strokes. Nearly 50% of all SAH cases end in fatality within 30 days of presentation; one of eight patients die before reaching a hospital. Those who survive often have neurological or cognitive impairment. METHODS: This case report describes the course of two patients who presented to the emergency department with aneurismal subarachnoid hemorrhage and received external ventricular drainage and endovascular treatment of their aneurysm. RESULTS: Both patients required treatment with Eptifibatide drip after endovascular approach and their SAH in the basal cisterns resolved by day 5. Neither patient developed signs of clinical or subclinical vasospasm. COMMENTS: Eptifibatide drip facilitated resolution of the thick clot in the subarachnoid space early enough to eliminate the direct toxicity of oxyhemoglobin on the cerebral arteries and arachnoid granulations, thus preventing vasospasm and eliminating the necessity for a long-term shunt.

Endovascular treatment for acute ischemic stroke patients: implications and interpretation of IMS III, MR RESCUE, and SYNTHESIS EXPANSION trials: A report from the Working Group of International Congress of Interventional Neurology.

OBJECTIVE: The results of Interventional Management of Stroke (IMS) III, Magnetic Resonance and REcanalization of Stroke Clots Using Embolectomy (MR RESCUE), and SYNTHESIS EXPANSION trials are expected to affect the practice of endovascular treatment for acute ischemic stroke. The purpose of this report is to review the components of the designs and methods of these trials and to describe the influence of those components on the interpretation of trial results. METHODS: A critical review of trial design and conduct of IMS III, MR RESCUE, and SYNTHESIS EXPANSION is performed with emphasis on patient selection, shortcomings in procedural aspects, and methodology of data ascertainment and analysis. The influence of each component is estimated based on published literature including multicenter clinical trials reporting on endovascular treatment for acute ischemic stroke and myocardial infarction. RESULTS: We critically examined the time interval between symptom onset and treatment and rates of angiographic recanalization to differentiate between "endovascular treatment" and "parameter optimized endovascular treatment" as it relates to the IMS III, MR RESCUE, and SYNTHESIS EXPANSION trials. All the three trials failed to effectively test "parameter optimized endovascular treatment" due to the delay between symptom onset and treatment and less than optimal rates of recanalization. In all the three trials, the magnitude of benefit with endovascular treatment required to reject the null hypothesis was larger than could be expected based on previous studies. The IMS III and SYNTHESIS EXPANSION trials demonstrated that rates of symptomatic intracerebral hemorrhages subsequent to treatment are similar between IV thrombolytics and endovascular treatment in matched acute ischemic stroke patients. The trials also indirectly validated the superiority/equivalence of IV thrombolytics (compared with endovascular treatment) in patients with minor neurological deficits and those without large vessel occlusion on computed tomographic/magnetic resonance angiography. CONCLUSIONS: The results do not support a large magnitude benefit of endovascular treatment in subjects randomized in all the three trials. The possibility that benefits of a smaller magnitude exist in certain patient populations cannot be excluded. Large magnitude benefits can be expected with implementation of "parameter optimized endovascular treatment" in patients with ischemic stroke who are candidates for IV thrombolytics.

Increased brain volume among good grade patients with intracerebral hemorrhage. Results from the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) study.

BACKGROUND: We ascertained the occurrence of global cerebral edema manifesting as increased brain volume in subjects with intracerebral hemorrhage (ICH) and explored the relationship between subject characteristics and three month outcomes. METHODS: A post-hoc analysis of a multicenter prospective study that recruited patients with ICH, elevated SBP ≥170 mm Hg, and Glasgow Coma Scale (GCS) score ≥8, who presented within 6 h of symptom onset was performed. Computed tomographic (CT) scans at baseline and 24 h, submitted to a core image laboratory, were analyzed to measure total brain, hematoma, and perihematoma edema volumes from baseline and 24-h CT scans using image analysis software. The increased brain volume was determined by subtracting the hematoma and perihematomal edema volumes from the total brain volume. RESULTS: A total of 18 (44 %) of 41 subjects had increased brain volume that developed between initial CT scan and 24-h CT scan. The median increase in brain volume among the 18 subjects was 35 cc ranging from 0.12 to 296 cc. The median baseline GCS score was 15 in both groups of subjects who experienced increased brain volume and those who did not, and the median hematoma volume was 10.18 and 6.73, respectively. Three of the 18 subjects with increased brain volume underwent concurrent neurological deterioration and one subject died during hospitalization. CONCLUSIONS: We found preliminary evidence of increased cerebral brain volume in subjects with good grade and small ICHs, which may be suggestive of global cerebral edema.