Trends in Demographic and Geographic Disparities in Stroke Mortality Among Older Adults in the United States.

BACKGROUND: Stroke is a leading cause of morbidity and mortality in the United States among older adults. However, the impact of demographic and geographic risk factors remains ambiguous. A clear understanding of these associations and updated trends in stroke mortality can influence health policies and interventions. METHODS: This study characterizes stroke mortality among older adults (age ≥55) in the US from January 1999 to December 2020, sourcing data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research. Segmented regression was used to analyze trends in crude mortality rate and age-adjusted mortality rate (AAMR) per 100,000 individuals stratified by stroke subcategory, sex, ethnicity, urbanization, and state. RESULTS: A total of 3,691,305 stroke deaths occurred in older adults in the US between 1999 and 2020 (AAMR = 233.3), with an overall decrease in AAMR during these years. The highest mortality rates were seen in nonspecified stroke (AAMR = 173.5), those 85 or older (crude mortality rate1276.7), men (AAMR = 239.2), non-Hispanic African American adults (AAMR = 319.0), and noncore populations (AAMR = 276.1). Stroke mortality decreased in all states from 1999 to 2019 with the greatest and least decreases seen in California (-61.9%) and Mississippi (-35.0%), respectively. The coronavirus pandemic pandemic saw increased stroke deaths in most groups. CONCLUSIONS: While there's a decline in stroke-related deaths among US older adults, outcome disparities remain across demographic and geographic sectors. The surge in stroke deaths during coronavirus pandemic reaffirms the need for policies that address these disparities.

Venous Sinus Stenosis Treatment in Pediatric Idiopathic Intracranial Hypertension: Illustrative Case and Literature Review.

OBJECTIVE: To review the literature of venous sinus stenosis (VSS) treatment in children for idiopathic intracranial hypertension (IIH) and present our own institutional case. METHODS: A literature review was conducted using the PubMed and MEDLINE databases up to June 2020. From 134 studies that were screened, 6 studies were chosen for analysis that included patients <18 years old, a diagnosis of IIH that fit Dandy diagnostic criteria, and angiogram obtained to assess for VSS. IIH symptoms experienced in the pediatric population and efficacy of venous sinus stenting were analyzed. RESULTS: Eleven patients identified in the literature and 1 patient from our institution were included in the analysis. There was no statistically significant difference in pressure gradient response to stenting between male and female patients (P = 0.424) or patients with body mass index >90th percentile (P = 0.626). Larger decreases in pressure gradient after stent placement correlated with headache resolution (P = 0.0005). Patients who underwent unilateral stenting showed greater reduction in pressure gradient compared with patients who underwent bilateral stenting (average change 24 mm Hg vs. 5.75 mm Hg, P = 0.003). CONCLUSIONS: Our analysis showed that VSS treatment has the potential to be a safe option for IIH in pediatric patients. VSS treatment has shown similar results to traditional cerebrospinal fluid diversion procedures, with a lower complication rate and need for revision. More studies should be conducted to analyze the long-term efficacy and safety of VSS treatment in pediatric patients with IIH.

Embolization and Open Decompression of a Giant Aneurysm Involving the P2 Segment of the Posterior Cerebral Artery.

A 5-year-old girl was brought to the clinic because of chronic intermittent left-sided headaches. The patient underwent computed tomographic angiography, which demonstrated a giant aneurysm that involved the P2 segment of the left posterior cerebral artery. Before treatment proceeded, consent was obtained from the patient's legal guardian. A trapping-evacuation technique was used for proximal control and decompression so that a clip could be placed on the proximal inflow artery of the aneurysm. First, embolization was performed for aneurysm trapping and for sacrifice of the parent vessel. Two days later, the patient was taken to the operating room for open surgical decompression, clipping, and reconstruction. Heparin was administered during the embolization stage of the operation. The patient did well postoperatively and was discharged home. The 3-month follow-up evaluation demonstrated a right superior homonymous quadrantanopia and no other neurologic deficits. The patient's clinical course is summarized in Video 1.

A contralateral transventricular approach for microsurgical clip ligation of a ruptured intrathalamic aneurysm.

Intrathalamic aneurysms are a cause of patient morbidity and mortality. Aneurysms in this location can be accessed microsurgically when they cannot be accessed endovascularly. Care must be taken to avoid critical white matter tracts when approaching the thalamus microsurgically. Use of a tubular retractor can offer safe brain retraction during the approach. A 53-year-old female with a history of hypertension and cerebrovascular accidents presented with slurred speech, altered mental status, and right-sided weakness. CT demonstrated an acute parenchymal hemorrhage within the left thalamus and the internal capsule. CT angiography demonstrated a left dorsal thalamic aneurysm. Following angiography with consideration for embolization, the patient was taken to the operating room for microsurgical clip ligation with the use of minimally invasive techniques. The aneurysm was accessed using a contralateral transventricular approach with a tubular retractor for microsurgical clip ligation. Postoperative imaging demonstrated successful interval clipping of the aneurysm within the thalamus. This is the first report using our described surgical approach for treatment of a dorsal intrathalamic aneurysm. We combined the use of diffusion tensor imaging with a tubular retractor to clip a dorsal thalamic aneurysm.

PulseRider Use in Ruptured Basilar Apex Aneurysms.

BACKGROUND: The PulseRider (Pulsar Vascular, Inc, Los Gatos, California, USA) device was developed to treat wide-neck aneurysms, and the Adjunctive Neurovascular Support of Wide-neck aneurysm Embolization and Reconstruction (ANSWER) Trial showed efficacy in the treatment of unruptured wide-neck aneurysms. Our case series demonstrates the use of the PulseRider device in the treatment of ruptured wide-neck aneurysms. CASE DESCRIPTION: The 2 patients in our series presented with subarachnoid hemorrhage secondary to ruptured basilar apex aneurysms. The patients were taken to the neurointervention suite for embolization of their aneurysms with the PulseRider and platinum microcoils. CONCLUSIONS: In both cases, a Roy Raymond class III embolization was achieved. The patients recovered from their subarachnoid hemorrhage and were discharged with resolution of their symptoms. The presented cases document the safety and efficacy of treating ruptured aneurysms with the PulseRider device.

Dasatinib Reinitiation After Poststroke Thrombolysis Associated with Symptomatic Intracerebral Hemorrhage.

BACKGROUND: Dasatinib, a tyrosine kinase inhibitor commonly used in treatment of acute lymphoblastic leukemia and chronic myelogenous leukemia, is often associated with hemorrhagic complications. Safety of dasatinib after thrombolytic therapy in acute ischemic stroke is unknown. CASE DESCRIPTION: A 63-year-old man with multiple vascular risk factors and chronic myelogenous leukemia (in molecular remission) on dasatinib presented with signs and symptoms of right hemispheric stroke owing to acute intracranial internal carotid artery occlusion that was treated with intravenous thrombolysis and mechanical thrombectomy resulting in near-complete resolution of stroke symptoms. The patient developed clinical worsening (>24 hours of thrombolytic therapy) after receiving a second dose of dasatinib that was due to symptomatic intracerebral hemorrhage and necessitated decompressive hemicraniectomy. Routine coagulation profile was normal. The etiology of this hemorrhagic complication was likely secondary to primary platelet dysfunction due to dasatinib as reported in some recent in vitro and ex vivo studies. CONCLUSIONS: It is advisable to withhold dasatinib during the poststroke period owing to its associated risk of symptomatic intracerebral hemorrhage.

Mini-Pterional Craniotomy for Resection of Parasellar Meningiomas.

BACKGROUND: Surgical resection of parasellar meningiomas is a challenging operation that traditionally has been performed with a large pterional or orbitozygomatic craniotomy. In this study, we report patient outcomes and detail our surgical approach when resecting these tumors with a smaller, less invasive "mini-pterional" craniotomy. METHODS: We performed a retrospective review on all patients undergoing a mini-pterional craniotomy for resection of parasellar meningiomas from 2012 to 2016. We describe the technical aspects of the mini-pterional craniotomy and provide the outcomes of patients who received an operation with this approach. RESULTS: Twenty-four patients were treated with a mini-pterional craniotomy for resection of parasellar meningiomas. Median tumor volume was 6.2 cm3. Twenty-two of 24 (92%) patients had a World Health Organization grade I meningioma, and 2 of 24 (8%) patients had a World Health Organization grade II meningioma. Tumors were located at the medial sphenoid wing (60%), anterior clinoid (24%) and spheno-cavernous junction (12%). Nineteen of 24 (79%) patients had a Simpson Grade I resection and 5 of 24 (21%) a Simpson Grade IV resection. Median length of the operations was 242 minutes. Neurosurgical complications occurred in 2 patients who had a surgical-site infection and cerebrospinal fluid leak; one of these patients also developed postoperative hydrocephalus. In this series, no deaths, parenchymal contusions, or repeat operations occurred. CONCLUSIONS: The mini-pterional craniotomy can be used to resect parasellar meningiomas with good results and a low complication profile. This approach provides an efficacious method of resecting these tumors without sacrificing Simpson grade or patient safety.

Brainstem cavernous malformations resected via miniature craniotomies: technique and approach selection.

Brainstem cavernous malformations can cause devastating neurologic disability when they hemorrhage, which occurs at a higher rate in the brainstem than in other locations. Traditional access to these lesions requires a large craniotomy with extensive exposure and manipulation of vital structures. We present a case series of patients who underwent surgical resection of brainstem cavernous malformations using minimally invasive approaches at our institution from January 2012 to August 2014, all of whom had experienced at least one hemorrhage prior to presentation. Approach choice was determined by location of the cavernous malformation in relation to the brainstem surface. Resection occurred through our described standardized method. Postoperatively, there were three instances of transient neurologic symptoms, all of which resolved at time of last follow-up. All eight patients experienced neurologic improvement after surgery, with four patients showing no deficits at last follow-up. Approach selection rationale and technical nuances are presented on a case-by-case basis. With carefully planned keyhole approaches to cavernous malformations presenting to the brainstem surface, excellent results may be achieved without the necessity of larger conventional craniotomies. We believe the nuances presented may be of use to others in the surgical treatment of these lesions.