Treatment and Outcomes of Cervical Artery Dissection in Adults: A Scientific Statement From the American Heart Association.

Cervical artery dissection is an important cause of stroke, particularly in young adults. Data conflict on the diagnostic evaluation and treatment of patients with suspected cervical artery dissection, leading to variability in practice. We aim to provide an overview of cervical artery dissection in the setting of minor or no reported mechanical trigger with a focus on summarizing the available evidence and providing suggestions on the diagnostic evaluation, treatment approaches, and outcomes. Writing group members drafted their sections using a literature search focused on publications between January 1, 1990, and December 31, 2022, and included randomized controlled trials, prospective and retrospective observational studies, meta-analyses, opinion papers, case series, and case reports. The writing group chair and vice chair compiled the manuscript and obtained writing group members' approval. Cervical artery dissection occurs as a result of the interplay among risk factors, minor trauma, anatomic and congenital abnormalities, and genetic predisposition. The diagnosis can be challenging both clinically and radiologically. In patients with acute ischemic stroke attributable to cervical artery dissection, acute treatment strategies such as thrombolysis and mechanical thrombectomy are reasonable in otherwise eligible patients. We suggest that the antithrombotic therapy choice be individualized and continued for at least 3 to 6 months. The risk of recurrent dissection is low, and preventive measures may be considered early after the diagnosis and continued in high-risk patients. Ongoing longitudinal and population-based observational studies are needed to close the present gaps on preferred antithrombotic regimens considering clinical and radiographic prognosticators of cervical artery dissection.

Emergent Large Vessel Occlusion due to Intracranial Stenosis: Identification, Management, Challenges, and Future Directions.

This comprehensive literature review focuses on acute stroke related to intracranial atherosclerotic stenosis (ICAS), with an emphasis on ICAS-large vessel occlusion. ICAS is the leading cause of stroke globally, with high recurrence risk, especially in Asian, Black, and Hispanic populations. Various risk factors, including hypertension, diabetes, hyperlipidemia, smoking, and advanced age lead to ICAS, which in turn results in stroke through different mechanisms. Recurrent stroke risk in patients with ICAS with hemodynamic failure is particularly high, even with aggressive medical management. Developments in advanced imaging have improved our understanding of ICAS and ability to identify high-risk patients who could benefit from intervention. Herein, we focus on current management strategies for ICAS-large vessel occlusion discussed, including the use of perfusion imaging, endovascular therapy, and stenting. In addition, we focus on strategies that aim at identifying subjects at higher risk for early recurrent risk who could benefit from early endovascular intervention The review underscores the need for further research to optimize ICAS-large vessel occlusion treatment strategies, a traditionally understudied topic.

Acute Coiling With Delayed Flow Diversion for Posterior Communicating Segment Internal Carotid Artery Aneurysms: A Multicenter Case Series.

BACKGROUND AND OBJECTIVES: In ruptured posterior communicating artery (PcomA) aneurysms, the protection of the aneurysm dome alone with initial subtotal coiling decreases the risk of rerupture in the acute setting but does not provide durable/definitive long-term protection against delayed rupture. Delayed flow diverter (FD) placement can be a potential alternative to definitively secure these aneurysms without increasing the risk of complications and PComA occlusion. We analyzed PComA aneurysms treated with a planned delayed FD after primary coiling and assess radiographic and clinical outcomes. METHODS: We performed a retrospective study of prospectively collected data for intracranial aneurysms treated with planned FD at 2 institutions from 2013 to 2022. PComA aneurysms that underwent primary coiling and delayed FD placement were included for analysis. RESULTS: There were 29 PComA aneurysms identified that were included in the analysis. Patients were mostly female (79.3%), with a median age of 60 years. The mean aneurysm maximum diameter was 7.2 mm ± (5.3). Immediate Raymond-Roy occlusion grade after primary coiling was I in 48.3%, II in 41.4%, and III in 10.3% of aneurysms. The median time from initial coiling to planned delayed FD placement was 6.3 months (3.2-18.6). A total of 21 (72.4%) aneurysms underwent follow-up radiological imaging. Complete and near-complete occlusion status was achieved in 76.2% of the evaluated aneurysms. There were no retreatments and no evidence of delayed aneurysm rupture. One case (3.5%) presented thromboembolic complications and 1 (3.5%) intracranial hemorrhagic complication after FD placement, which was associated with mortality. Most patients (90.5%) had a modified Rankin scale of ≤2 on the last follow-up. CONCLUSION: Primary coiling with planned staged FD placement is effective for treating ruptured PComA aneurysms with high occlusion rates and low complications.

Endovascular Treatment of Small Anterior Communicating Artery Aneurysms: Safety and Efficacy in a Contemporary Cohort.

BACKGROUND AND OBJECTIVES: Endovascular treatment (EVT) of small anterior communicating artery (ACoA) aneurysms accompanies a high risk of intraprocedural rupture (IR) because of anatomic location and aneurysm orientation. In this study, we aimed to investigate the safety and efficacy of EVT for small ACoA aneurysms in a contemporary cohort. METHODS: ACoA aneurysms treated at the Medical University of South Carolina between April 2012 and March 2022 were retrospectively analyzed. Periprocedural baseline characteristics, aneurysm size, and clinical and radiological outcomes were collected. Aneurysms were dichotomized into <4 and ≥4 mm in maximum size. The IR rate, favorable occlusion rate (Raymond-Roy I and II), and the favorable outcome defined as modified Rankin Scale 0-2 were compared. RESULTS: A total of 174 patients were identified, of whom 111 (63.8%) were female, and the median age was 57.7 (interquartile range 50.6-69.6) years. 98 (56.3%) aneurysms were ruptured, and 53 (30.5%) were <4 mm. IR was not observed in unruptured ACoA aneurysms, and there was no significant difference in the IR rates between <4 mm and ≥4 mm ruptured aneurysms (6.5% vs 4.5%, P = .65). Favorable occlusion rate and favorable outcome were observed in 94.7% and 78.2% of patients, respectively. CONCLUSION: EVT of small ACoA aneurysms is safe and effective.

Outcomes Associated With Intracranial Aneurysm Treatments Reported as Safe, Effective, or Durable: A Systematic Review and Meta-Analysis.

Importance: Testing new medical devices or procedures in terms of safety, effectiveness, and durability should follow the strictest methodological rigor before implementation. Objectives: To review and analyze studies investigating devices and procedures used in intracranial aneurysm (IA) treatment for methods and completeness of reporting and to compare the results of studies with positive, uncertain, and negative conclusions. Data Sources: Embase, MEDLINE, Web of Science, and The Cochrane Central Register of Clinical Trials were searched for studies on IA treatment published between January 1, 1995, and the October 1, 2022. Grey literature was retrieved from Google Scholar. Study Selection: All studies making any kind of claims of safety, effectiveness, or durability in the field of IA treatment were included. Data Extraction and Synthesis: Using a predefined data dictionary and analysis plan, variables ranging from patient and aneurysm characteristics to the results of treatment were extracted, as were details pertaining to study methods and completeness of reporting. Extraction was performed by 10 independent reviewers. A blinded academic neuro-linguist without involvement in IA research evaluated the conclusion of each study as either positive, uncertain, or negative. The study followed Preferring Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Main Outcomes and Measures: The incidence of domain-specific outcomes between studies with positive, uncertain, or negative conclusions regarding safety, effectiveness, or durability were compared. The number of studies that provided a definition of safety, effectiveness, or durability and the incidence of incomplete reporting of domain-specific outcomes were evaluated. Results: Overall, 12 954 studies were screened, and 1356 studies were included, comprising a total of 410 993 treated patients. There was no difference in the proportion of patients with poor outcome or in-hospital mortality between studies claiming a technique was safe, uncertain, or not safe. Similarly, there was no difference in the proportion of IAs completely occluded at last follow-up between studies claiming a technique was effective, uncertain, or noneffective. Less than 2% of studies provided any definition of safety, effectiveness, or durability, and only 1 of the 1356 studies provided a threshold under which the technique would be considered unsafe. Incomplete reporting was found in 546 reports (40%). Conclusions and Relevance: In this systematic review and meta-analysis of IA treatment literature, studies claiming safety, effectiveness, or durability of IA treatment had methodological flaws and incomplete reporting of relevant outcomes supporting these claims.

Failed mechanical thrombectomy: prevalence, etiology, and predictors.

OBJECTIVE: Despite advances in endovascular techniques, mechanical thrombectomy (MT) fails to achieve successful reperfusion in approximately 20% of patients. This study aimed to identify common etiologies and predictors of failed thrombectomy in a contemporary series. METHODS: A prospectively maintained database of MT patients between January 2013 and August 2021 was interrogated. Failed MT was defined as a final modified Thrombolysis in Cerebral Infarction score < 2b. Demographic data, procedural details, stroke etiology, and anatomical data in patients who underwent MT with subsequent failed reperfusion were collected. RESULTS: Of a total 1010 MT procedures, 120 (11.9%) were unsuccessful. The mean patient age was 66.8 years; 51.5% of patients were male, and 61.1% were White. The most common failure location was intracranial (93.3%) followed by failure at the arch (3.3%) and neck (3.3%). Among patients with intracranial failure, underlying intracranial atherosclerosis (ICAS) was the cause of failure in 84 patients (70%). Compared with patients with successful MT, patients with failed MT had a longer onset to puncture time (p = 0.012) and onset to groin time (p = 0.04). Rescue stenting was performed in 45 cases: 39 patients (4.4%) with successful MT and 6 (5.0%) with MT failure (p = 0.765). Multivariate analysis demonstrated that diabetes mellitus (p = 0.009) was independently associated with unsuccessful reperfusion. CONCLUSIONS: Failed MT was encountered in approximately 12% of MT procedures. The most common cause of failed MT was underlying ICAS. Further studies to evaluate better ways of early identification and treatment of ICAS-related large-vessel occlusion are warranted.

Contrast conservation measures during the global iohexol contrast shortage crisis did not affect stroke thrombectomy outcomes.

BACKGROUND: The current global shortage in iohexol contrast material (Omnipaque) used in performing CT-based triage images and mechanical thrombectomy (MT) represents a challenge to the healthcare system. A study was undertaken to assess the safety and feasibility of implementing protocol-based changes in pre-MT and MT workflow at a comprehensive stroke center. METHODS: A retrospective cohort study was undertaken of all patients with stroke who underwent MT during a 3-week period before implementing the contrast shortage protocol and for 3 weeks while implementing the protocol. The contrast shortage protocol included not performing perfusion images for MT selection and using diluted iohexol (50% contrast mixed with 50% heparinized saline) during the MT procedure. Procedural variables were compared between the two groups. RESULTS: A total of 27 patients underwent MT during the study period, 12 pre-contrast shortage and 15 post-contrast shortage. The average contrast volume used during the MT procedure was reduced from 83 mL to 68 mL after implementing the contrast shortage protocol (p=0.04). No difference was noted in the rate of successful reperfusion (11/15 vs 10/12), average time to recanalization (21 vs 23 min), average radiation dose (1143 vs 1117mGy) and time under fluoroscopy (20.7 vs 20.5 min) in the pre- and post-contrast shortage groups. A favorable discharge outcome was observed in 3/12 patients and 4/15 patients in the pre- and post-shortage periods, respectively (p=0.92). CONCLUSIONS: Modifying stroke workflow to adapt to the current global shortage in iohexol is feasible. Using diluted iohexol (50% contrast mixed with 50% heparinized saline) did not affect MT outcomes.

Case-Control Study Design in Neurological Surgery.

The hallmark of case-control study design involves dividing groups based on outcome and looking back at exposures to determine associations. Case-control studies are ideal for scenarios when outcomes are rare, making them well suited to the infrequent events often found among neurosurgical diseases. It is also a favorable design for scenarios when it would be infeasible or unethical to assign treatment groups as is necessary for a randomized controlled trial. Case-control studies are powerful but often misapplied and mislabeled. This article provides an overview of case-control study design along with discussion of a real-world example of an effectively executed case-control study.

Impact of Increasing Aspiration Catheter Size and Refinement of Technique: Experience of Over 1000 Strokes Treated With ADAPT.

BACKGROUND: We present longitudinal data regarding the outcomes and evolution of mechanical thrombectomy (MT) using a direct aspiration first pass technique. OBJECTIVE: To evaluate the impact of increasing aspiration catheter size. METHODS: This is a planned analysis of a prospective cohort study that enrolled all patients who underwent a direct aspiration first pass technique MT in a comprehensive stroke center from January 2013 to December 2020. We did exploratory analysis of the characteristics and outcomes of patients who had intracranial internal carotid artery or M1 segment of middle cerebral artery occlusion based on the aspiration catheter bore size (small [041, 054, 058, and 060 inch] vs medium [0.064 and 0.068 inch] and medium vs large [0.071, 0.072, and 0.074 inch]). RESULTS: During the 8-year study period, a total of 1004 patients were included. Median age was 69 years, 49% were female patients, and 60.6% were White. Symptomatic hemorrhagic transformation was observed in 47 patients (4.7%), and 366 patients (36.5%) achieved the modified Rankin scale of 0 to 2 at 90 days after the stroke. For patients with intracranial internal carotid artery or M1 occlusion, medium-bore aspiration catheters were more likely to achieve successful recanalization after first aspiration attempt (63.9% vs 51.4%, P = .015) and had a faster groin-to-reperfusion time (16 vs 20 minutes, P = .001) when compared with small-bore catheters. However, these differences were not significant when comparing medium-bore with large-bore catheters. CONCLUSION: Medium-bore catheters had better performance measures compared with small-bore catheters. However, large-bore catheters did not show significantly better performance results that suggest a plateau effect.

Cigarette smoking and risk of intracranial aneurysms in middle-aged women.

BACKGROUND AND PURPOSE: We previously reported a single-centre study demonstrating that smoking confers a six-fold increased risk for having an unruptured intracranial aneurysm (UIA) in women aged between 30 and 60 years and this risk was higher if the patient had chronic hypertension. There are no data with greater generalisability evaluating this association. We aimed to validate our previous findings in women from a multicentre study. METHODS: A multicentre case-control study on women aged between 30 and 60 years, that had magnetic resonance angiography (MRA) during the period 2016-2018. Cases were those with an incidental UIA, and these were matched to controls based on age and ethnicity. A multivariable conditional logistic regression was conducted to evaluate smoking status and hypertension differences between cases and controls. RESULTS: From 545 eligible patients, 113 aneurysm patients were matched to 113 controls. The most common reason for imaging was due to chronic headaches in 62.5% of cases and 44.3% of controls. A positive smoking history was encountered in 57.5% of cases and in 37.2% of controls. A multivariable analysis demonstrated a significant association between positive smoking history (OR 3.7, 95%CI 1.61 to 8.50), hypertension (OR 3.16, 95% CI 1.17 to 8.52) and both factors combined with a diagnosis of an incidental UIA (OR 6.9, 95% CI 2.49 to 19.24). CONCLUSIONS: Women aged between 30 and 60 years with a positive smoking history have a four-fold increased risk for having an UIA, and a seven-fold increased risk if they have underlying chronic hypertension. These findings indicate that women aged between 30 and 60 years with a positive smoking history might benefit from a screening recommendation.

Women With First-Hand Tobacco Smoke Exposure Have a Higher Likelihood of Having an Unruptured Intracranial Aneurysm Than Nonsmokers: A Nested Case-Control Study.

BACKGROUND: The prevalence of unruptured intracranial aneurysms (UIA) in females who smoke cigarettes and the association between smoking and hypertension with purely incidental UIAs have been unexplored. OBJECTIVE: To obtain the prevalence of UIA among females and to assess the relationship between smoking and hypertension with a diagnosis of incidental UIAs. METHODS: A nested case-control study from a cohort of female patients aged between 30 and 60 yr with a brain magnetic resonance angiography (MRA) between 2016 and 2018. Incidental UIAs were compared to patients with normal MRAs. Smoking was characterized as never or former/current smokers. A logistic regression was used to evaluate the association between smoking, hypertension, or both, with a diagnosis of incidental UIAs. RESULTS: A total of 1977 patients had a brain MRA between 2016 and 2018. From 1572 nonsmoker patients, we encountered 30 with an UIA (prevalence: 1.9%). There were 405 patients with a positive smoking history, and 77 patients harbored an UIA (prevalence: 19%). Of 64 aneurysm patients and 130 random controls eligible for the case control, aneurysm patients were more likely to have a positive smoking history and hypertension compared with healthy controls (60% vs 18%, P ≤ .001; 44% vs 14%, P ≤ .001). A multivariable analysis demonstrated a significant association between a smoking history, hypertension, or both factors with an incidental UIA (odds ratio [OR] 5.8 CI 1.22-11.70; OR 3.8 CI 2.31-14.78; OR 12.6 CI 4.38-36.26; respectively). CONCLUSION: Females who smoke cigarettes have a higher prevalence of UIAs than the general population. Smoking confers a higher risk for having a silent UIA, aggravated by hypertension. This population is an ideal target for potential screening.

Role of aspirin and statin therapy in patients with cerebral cavernous malformations.

Stagnant blood flow and organizing thrombus are intralesional components of patients with cerebral cavernous malformations (CCM). Stasis and inflammation are mechanisms of growth, lesional instability and acute hemorrhages with or w/o symptoms. We evaluate the association of pre-diagnostic aspirin and/or statin use with acute hemorrhages at diagnosis. Patients with a CCM diagnosis were identified and categorized according to their medications on admission into four groups (no therapy, statin, aspirin, combined). The primary outcome was an acute hemorrhage (with or w/o symptoms) at diagnosis reported in a standardized manner from the T2 weighted magnetic resonance image. A multivariate generalized linear mixed models (GLMM) was utilized to conduct per-lesion analysis. We identified 446 patients with 635 lesions. An acute hemorrhage at diagnosis was observed in 31% of the patients. There were 328 patients without statin or aspirin therapy, 34% of whom presented with acute hemorrhage. Of patients on aspirin therapy at diagnosis, 25% presented with hemorrhage. Of patients on statin therapy, 26% had a hemorrhage at diagnosis. Combined therapy in 44 patients demonstrated a lower proportion of patients with acute hemorrhages (7 patients, 16% incidence). A GLMM showed that patients in the combined therapy group to have significantly lower odds of having an acute hemorrhage at diagnosis compared to the reference group of no therapy (OR 0.24; 95% CI 0.09-0.59; P = 0.002). Patients with a CCM receiving therapy with both aspirin and statins were less likely to present at diagnosis with acute hemorrhage.

Symptomatic Hemorrhage From Cerebral Cavernous Malformations: Evidence from a Cohort Study.

OBJECTIVE: Patients with a cerebral cavernous malformation (CCM) can have intracranial hemorrhages ranging from insignificant and chronic microbleeds to life-threatening hemorrhage. Management decisions and patient counseling are based on a heterogeneous body of evidence. We sought to improve the literature by providing our results based on the standardized definitions and aimed to delineate differences in the symptomatic burden for CCMs, based on their anatomic location and presence of developmental venous anomalies. This evidence will aid in clinical decision making and patient counseling. METHODS: A retrospective cohort analysis between 1990 and 2018 was performed, including patients with a diagnosis of a CCM. The primary outcome was acute symptomatic hemorrhages. RESULTS: We identified 438 patients harboring 632 CCMs. Mean age at diagnosis was 50 years (standard deviation ±17 years). Median follow-up was 26 months (interquartile range, 7-72 hours). Multiple lesions were encountered in 64 patients (15%). An initial symptomatic presentation was observed in 64% of the patients. There were 438 supratentorial lesions (69%) and 194 infratentorial lesions (31%). A symptomatic hemorrhage was observed in 25% of the supratentorial lesions and 29% of the infratentorial lesions (P < 0.001). A linear mixed-effects regression model showed a significant difference in developing a symptomatic hemorrhage at diagnosis or follow-up between CCMs with an infratentorial location and those with a supratentorial location (odds ratio, 1.81; 95% confidence interval, 1.17-2.81; P = 0.008). CONCLUSIONS: Infratentorial cavernous malformations are more likely to present with symptomatic hemorrhages at diagnosis or during follow-up when accounting for size differences between lesions.

Flow Diversion for Treatment of Partially Thrombosed Aneurysms: A Multicenter Cohort.

BACKGROUND: Partially thrombosed intracranial aneurysms (PTIA) represent a unique subset of intracranial aneurysms with an ill-defined natural history, posing challenges to standard management strategies. This study aims to assess the efficacy of flow diversion in the treatment of this pathology. METHODS: A retrospective review of patients with flow-diverted PTIA at 6 cerebrovascular centers was performed. Clinical and radiographic data were collected from the medical records, with the primary outcome of aneurysmal occlusion and secondary outcomes of clinical status and complications. RESULTS: Fifty patients with 51 PTIA treated with flow diversion were included. Median age was 56.5 years. Thirty-three (64.7%) aneurysms were saccular and 16 (31.4%) were fusiform/dolichoectatic. The most common location was the internal carotid artery (54.9%) followed by the vertebral and basilar arteries (17.7% and 17.7%, respectively). Last imaging follow-up was performed at a median of 25.1 (interquartile range, 12.8-43) months. Complete occlusion at last radiographic follow-up was achieved in 37 (77.1%) aneurysms. Pretreatment aneurysm thrombosis of >50% was associated with a significantly lower rate of complete aneurysm occlusion (58.8 vs. 87.1%, P = 0.026) with a trend toward better functional outcome (modified Rankin scale <2) at last follow-up in patients with <50% pretreatment aneurysm thrombosis (96.8 vs. 82.4; P = 0.08). Ischemic complications occurred in 5 (9.8%) patients, producing symptoms in 4 (7.8%) and resultant mortality in 2 (4.2%) patients. CONCLUSIONS: Flow diversion treatment of PTIA has adequate efficacy along with a reasonable safety profile. Aneurysms harboring large amounts of pretreatment thrombus were associated with lower rates of complete occlusion.

Coil Embolization of a Carotid-Cavernous Fistula Through Superior Ophthalmic Venous Access via External Jugular Vein Puncture Approach.

Carotid-cavernous fistulas are vascular malformations that pose a risk for intracranial hemorrhage when there is documented cortical venous drainage. When possible, treatment with transvenous embolization has become the technique of choice since the late 1990s.1,2 We present a case of a patient with a carotid-cavernous fistula treated with venous coil embolization via a jugular venous approach. The patient was a 59-year-old female with a history of intense headaches. Initial magnetic resonance imaging showed congestion in the right cavernous sinus, and a diagnostic angiogram revealed a cavernous carotid fistula Thomas type 4.3,4 Given the presence of retrograde cortical venous drainage, we decided to treat the lesion. A femoral route for endovascular treatment was attempted, but it was unsuccessful in traversing the external jugular vein due to venous valves. We accessed the fistula through a direct puncture direct proximal approach,5 from the external jugular vein making our trajectory through the facial-angular-supraorbital vein, ultimately reaching the cavernous sinus. We then filled the sinus with coils to obliterate the fistula. The patient awakened neurologically intact, and a postoperative angiogram demonstrated complete occlusion of the lesion. The patient was discharged at postoperative day 1 without complications. In this video, we narrate the important details of this alternative when a traditional route is inaccessible (Video 1). Informed consent was obtained for the case illustrated; however, neither Institutional Review Board nor patient consent is required for the report of a single case in which no identifiable patient information is shared.

Role of the Neurosurgeon in Acute Ischemic Stroke Treatment From Triage to Intensive Care Unit.

As ischemic stroke care advances with more patients eligible for mechanical thrombectomy, so too does the role of the neurosurgeon in these patients. Neurosurgeons are an important member of the team from triage through the intensive care unit. This paper explores current research and insights on the contributions of neurosurgeons in care of acute ischemic stroke patients in the acute setting.