Social Determinants of Health Attenuate the Relationship Between Race and Ethnicity and White Matter Hyperintensity Severity but not Microbleed Presence in Patients with Intracerebral Hemorrhage.

BACKGROUND: The association between race and ethnicity and microvascular disease in patients with intracerebral hemorrhage (ICH) is unclear. We hypothesized that social determinants of health (SDOHs) mediate the relationship between race and ethnicity and severity of white matter hyperintensities (WMHs) and microbleeds in patients with ICH. METHODS: We performed a retrospective observational cohort study of patients with ICH at two tertiary care hospitals between 2013 and 2020 who underwent magnetic resonance imaging of the brain. Magnetic resonance imaging scans were evaluated for the presence of microbleeds and WMH severity (defined by the Fazekas scale; moderate to severe WMH defined as Fazekas scores 3-6). We assessed for associations between sex, race and ethnicity, employment status, median household income, education level, insurance status, and imaging biomarkers of microvascular disease. A mediation analysis was used to investigate the influence of SDOHs on the associations between race and imaging features. We assessed the relationship of all variables with discharge outcomes. RESULTS: We identified 233 patients (mean age 62 [SD 16]; 48% female) with ICH. Of these, 19% were Black non-Hispanic, 32% had a high school education or less, 21% required an interpreter, 11% were unemployed, and 6% were uninsured. Moderate to severe WMH, identified in 114 (50%) patients, was associated with age, Black non-Hispanic race and ethnicity, highest level of education, insurance status, and history of hypertension, hyperlipidemia, or diabetes (p < 0.05). In the mediation analysis, the proportion of the association between Black non-Hispanic race and ethnicity and the Fazekas score that was mediated by highest level of education was 65%. Microbleeds, present in 130 (57%) patients, was associated with age, highest level of education, and history of diabetes or hypertension (p < 0.05). Age, highest level of education, insurance status, and employment status were associated with discharge modified Rankin Scale scores of 3-6, but race and ethnicity was not. CONCLUSIONS: The association between Black non-Hispanic race and ethnicity and moderate to severe WMH lost significance after we adjusted for highest level of education, suggesting that SDOHs may mediate the association between race and ethnicity and microvascular disease.

Remodeling of the Posterior Cerebral Artery P1-Segment after Pipeline Flow Diverter Treatment of Posterior Communicating Artery Aneurysms.

INTRODUCTION: Flow diverters such as the pipeline embolization device (PED) cause hemodynamic changes of the treated vessel segment. In posterior communicating artery (PcomA), aneurysms' unique anatomic consideration have to be taken in account due to the connection between the anterior and posterior circulation. We hypothesize that in conjunction with PcomA remodeling, there will also be remodeling of the ipsilateral P1 segment of the posterior cerebral artery (PCA) after PED treatment for PcomA aneurysms. METHODS: We retrospectively collected radiological as well as clinical data of PcomA aneurysm patients treated with PED including PcomA and P1 vessel diameters before and after treatment as well as patient and aneurysm characteristics. RESULTS: Overall, 14 PcomA aneurysm patients were included for analysis and PED treatment was performed without complications in all patients. In 10 out of 14 patients (71%), a decrease in PcomA diameter was observed and there was a significant mean decrease of 0.78 mm in PcomA diameter on angiographic last follow-up (LFU) (p = 0.003). In the same patient population (10 out of 14 patients), there was meanwhile a significant mean increase of 0.43 mm in the ipsilateral P1 segment diameter observed (p = 0.015). These vessel remodeling effects were in direct correlation with aneurysm occlusion since all of these patients showed aneurysm occlusion at LFU while 29% showed only partial occlusion without vessel remodeling effects. A decrease in PcomA diameter was directly associated with aneurysm occlusion (p = 0.042). There were no neurologic complications on LFU. CONCLUSION: In the treatment of PcomA aneurysms with PED, the P1 segment of the PCA increases in diameter while the PcomA diameter decreases. Our results suggest that this remodeling effect is associated with aneurysm occlusion and decrease of PcomA is hemodynamically compensated for by an increase in the ipsilateral P1 diameter.

Infection risk in endovascular neurointerventions: a comparative analysis of 549 cases with and without prophylactic antibiotic use.

OBJECTIVE: A systematic analysis on the utility of prophylactic antibiotics for neuroendovascular procedures has not been performed. At the authors' institution there is a unique setup to address this question, with some attending physicians using prophylactic antibiotics (cefazolin or vancomycin) for all of their neurointerventions while others generally do not. METHODS: The authors performed a retrospective review of the last 549 neurointerventional procedures in 484 patients at Tisch Hospital, NYU Langone Medical Center. Clinical and radiological data were collected for analysis, including presence of prophylactic antibiotic use, local or systemic infection, infection laboratory values, and treatment. Overall, 306 aneurysms, 117 arteriovenous malformations/arteriovenous fistulas, 86 tumors, and 40 vessel stenosis/dissections were treated with coiling (n = 109), Pipeline embolization device (n = 197), embolization (n = 203), or stenting (n = 40). RESULTS: Antibiotic prophylaxis was used in 265 of 549 cases (48%). There was no significant difference between patients with or without antibiotic prophylaxis in sex (p = 0.48), presence of multiple interventions (p = 0.67), diseases treated (p = 0.11), or intervention device placed (p = 0.55). The mean age of patients in the antibiotic prophylaxis group (53.4 years) was significantly lower than that of the patients without prophylaxis (57.1 years; p = 0.014). Two mild local groin infections (0.36%) and no systemic infections (0%) were identified in this cohort, with one case in each group (1/265 [0.38%] vs 1/284 [0.35%]). Both patients recovered completely with local drainage (n = 1) and oral antibiotic treatment (n = 1). CONCLUSIONS: The risk of infection associated with endovascular neurointerventions with or without prophylactic antibiotic use was very low in this cohort. The data suggest that the routine use of antibiotic prophylaxis seems unnecessary and that to prevent antibiotic resistance and reduce costs antibiotic prophylaxis should be reserved for selected patients deemed to be at increased infection risk.

Balloon-assisted tracking technique to overcome intracranial stenosis during thrombectomy for stroke.

Anatomical vessel obstacles such as an intracranial stenosis in stroke are challenging and may lead to delayed clot access for thrombectomy. We describe a simple and effective technique to overcome the step-off between the intermediate catheter and an intracranial vessel stenosis during thrombectomy. The patient presented with acute embolic left middle cerebral artery occlusion and a favorable penumbral pattern. Clot access was made challenging by focal stenosis in the ipsilateral cavernous segment. The balloon-assisted tracking technique was effective in traversing the step-off to enable TICI 3 aspiration thrombectomy. This simple and effective technique should be kept in mind during stroke procedures where a proximal stenotic obstacle complicates access to the site of occlusion.

Balloon-assisted tracking technique to overcome intracranial stenosis during thrombectomy for stroke.

Anatomical vessel obstacles such as an intracranial stenosis in stroke are challenging and may lead to delayed clot access for thrombectomy. We describe a simple and effective technique to overcome the step-off between the intermediate catheter and an intracranial vessel stenosis during thrombectomy. The patient presented with acute embolic left middle cerebral artery occlusion and a favorable penumbral pattern. Clot access was made challenging by focal stenosis in the ipsilateral cavernous segment. The balloon-assisted tracking technique was effective in traversing the step-off to enable TICI 3 aspiration thrombectomy. This simple and effective technique should be kept in mind during stroke procedures where a proximal stenotic obstacle complicates access to the site of occlusion.

Permanent Deployment of the Solitaire FR™ Device in the Basilar Artery in an Acute Stroke Scenario.

BACKGROUND: Scarce reports exist of permanent deployment of Solitaire FR™ devices for arterial steno-occlusive disease as it is primarily indicated for temporary deployment for thrombectomy in large-vessel, anterior-circulation ischemic strokes. Even more scarce are reports describing permanent deployment of the Solitaire device for posterior circulation strokes. SUMMARY: We present 2 cases where the Solitaire device was electrolytically detached to re-establish flow in an occluded or stenotic basilar artery in acutely symptomatic patients. In both cases, a 4 × 15 mm Solitaire device was positioned across the stenotic or occluded portion of the basilar artery and electrolytically detached to maintain vessel patency. Both cases had good clinical outcomes with a National Institutes of Health Stroke Scale (NIHSS) score of 1 (from 24) on 90-day follow-up and an NIHSS score of 2 (from 7) on 30-day follow-up. KEY MESSAGES: Permanent deployment of the Solitaire device may potentially be a safe and effective means of maintaining vessel patency in an occluded or stenotic basilar artery.

AVM Compartments: Do they modulate trasnidal pressures? An electrical network analysis.

BACKGROUND: Arteriovenous malformation (AVM) compartments are thought as independently fed, hemodynamically independent components of the AVM nidus. Its possible role in modulating transnidal pressures have not been investigated to our knowledge. OBJECTIVE: To investigate if AVM compartments play a role in modulating transnidal pressures by using electrical models as a method of investigation. MATERIALS AND METHODS: Monocompartmental and multicompartmental AVM models were constructed using electrical circuits- building on Dr. Guglielmi's previous work. Each compartment was fed by two feeding arteries (resistors) and had a shared draining vein with other compartments in the AVM nidus. Each compartment is composed of a series of resistors which represents the pressure gradient along the AVM (arterial, arteriolar, venular, and venous). Pressure (voltage) readings were obtained within these nidal points. RESULTS: The pressure gradient (venous-arterial) is more as there are less AVM compartments in the nidus model. The monocomparmental model had a pressure gradient of 66mmHg (V); while it was 64, 61, and 59 for the 2-, 3-, and 4-compartment models, respectively. In addition, the more the number of compartments, the greater the flow (mA) is in the whole AVM nidus, 33 ml/min for the monocompartmental AVM and 121ml/min for the 4-compartment AVM; though there was greater flow per compartment as there were less compartments, 33ml/min per compartment for the monocompartmental model versus 29ml/min for the 4-compartment model. CONCLUSION: Transnidal pressure gradients may be less the more compartments an AVM has. This electrical model represents an approach that can be used in investigating the hemodynamic contributions of AVM compartments.