Surgical intervention ≤ 24 hours versus > 24 hours after injury for the management of acute traumatic central cord syndrome: a systematic review and meta-analysis.

OBJECTIVE: The objective was to evaluate the efficacy, outcomes, and complications of surgical intervention performed within 24 hours (≤ 24 hours) versus after 24 hours (> 24 hours) in managing acute traumatic central cord syndrome (ATCCS). METHODS: Articles pertinent to the study were retrieved from PubMed, Scopus, Web of Science, and Cochrane. The authors performed a systematic review and meta-analysis of treatment procedures and outcomes according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) guidelines. RESULTS: Seven articles comprising 488 patients were included, with 188 (38.5%) patients in the ≤ 24-hour group and 300 (61.5%) in the > 24-hour group. Significant differences were not found between groups in terms of demographic characteristics, injury mechanism, spinal cord compression level, neuroimaging features, and the American Spinal Injury Association (ASIA) motor score at admission. Both groups had a similar approach to surgery and steroid administration. The surgical complication rate was significantly higher in the > 24-hour group (4.5%) compared to the ≤ 24-hour group (1.2%) (p = 0.05). Clinical follow-up duration was similar at 12 months (interquartile range 3-36) for both groups (p > 0.99). The ≤ 24-hour group demonstrated a not statistically significant greater improvement in ASIA motor score, with a mean difference of 12 (95% CI -20.7 to 44.6) compared to the > 24-hour group. CONCLUSIONS: The present study indicates potential advantages of early (≤ 24 hours) surgery in ATCCS patients, specifically in terms of lower complication rates. However, further research is needed to confirm these findings and their clinical implications.

The Utility of Transcranial Electrical Stimulation Motor Evoked Potential Monitoring in Predicting Postoperative Supplementary Motor Area Syndrome and Motor Function Recovery.

BACKGROUND: Postoperative hemiparesis following frontal lobe lesion resection is alarming, and predicting motor function recovery is challenging. Supplementary motor area (SMA) syndrome following resection of frontal lobe lesions is often indistinguishable from postoperative motor deficit due to surgical injury of motor tracts. We aimed to describe the use of intraoperative transcranial electrical stimulation (TES) with motor evoked potential monitoring data as a diagnostic tool to distinguish between SMA syndrome and permanent motor deficit (PMD). METHODS: A retrospective analysis of 235 patients undergoing craniotomy and resection with TES-MEP monitoring for a frontal lobe lesion was performed. Patients who developed immediate postoperative motor deficit were included. Motor deficit and TES-MEP findings were categorized by muscle group as left upper extremity, left lower extremity, right upper extremity, or right lower extremity. Statistical analysis was performed to determine the predictive value of stable TES-MEP for SMA syndrome versus PMD. RESULTS: This study included 20 patients comprising 29 cases of immediate postoperative motor deficit by muscle group. Of these, 27 cases resolved and were diagnosed as SMA syndrome, and 2 cases progressed to PMD. TES-MEP stability was significantly associated with diagnosis of SMA syndrome (P = 0.015). TES-MEP showed excellent diagnostic utility with a sensitivity and positive predictive value of 100% and 92.6%, respectively. Negative predictive value was 100%. CONCLUSIONS: Temporary SMA syndrome is difficult to distinguish from PMD immediately postoperatively. TES-MEP may be a useful intraoperative adjunct that may aid in distinguishing SMA syndrome from PMD secondary to surgical injury.

Subarachnoid Hemorrhage Outcomes in an Endovascular Right of First Refusal Neurosurgical Environment.

BACKGROUND: Randomized controlled trials demonstrate that endovascular techniques yield improved outcomes compared with microsurgical approaches. However, not all patients are suitable candidates for endovascular management. This study aimed to determine if healthy patients managed microsurgically could achieve functional outcomes comparable to patients managed endovascularly. METHODS: Patients treated for ruptured aneurysmal subarachnoid hemorrhage at 2 level 1 stroke centers from January 2012 through December 2020 were retrospectively reviewed. All cases were evaluated in an endovascular right of first refusal neurosurgical environment. We collected relevant clinical and follow-up data and created a generalized linear model to identify differences between patients treated endovascularly versus microsurgically. A propensity score model accounting for these differences was used to predict patient outcomes. Functional outcomes were independently assessed using the modified Rankin Scale (mRS) with good functional outcome defined as modified Rankin Scale score <3. RESULTS: The study included 588 patients (211 microsurgical, 377 endovascular); median age was 58 years (interquartile range: 40-86 years); in-hospital mortality was 13%. Age, aneurysm size, and aneurysm location significantly predicted treatment modality (all P < 0.05). After greedy-type matching (210 microsurgical, 210 endovascular), patients managed microsurgically were less likely to be discharged home (odds ratio = 0.6, 95% confidence interval 0.4-0.9, P = 0.01). Functional differences disappeared over time; patients in the 2 treatment arms had similar functional outcomes at 3 months (odds ratio = 1.1, 95% confidence interval 0.7-1.8, P = 0.66) and 1 year after subarachnoid hemorrhage (odds ratio = 1.3, 95% confidence interval 0.8-2.1, P = 0.38). CONCLUSIONS: In an endovascular right of first refusal neurosurgical environment, practitioners can treat patients who are not good endovascular candidates microsurgically and achieve functional outcomes comparable to patients managed endovascularly.

Patterns in Follow-Up Imaging Usage for Pediatric Patients with Whiplash-Associated Disorder.

BACKGROUND: A clinical concern exists that pediatric patients with whiplash-associated disorder (WAD) might have missed structural injuries or, alternatively, subsequently develop structural injuries over time, despite initially negative imaging findings. The primary objective of this study is to assess follow-up imaging usage for pediatric patients presenting with WAD. METHODS: A retrospective review of 444 pediatric patients presenting to a level 1 pediatric trauma hospital from January 1, 2010 to December 31, 2019 was performed. Imaging was reviewed at the initial encounter and the 3- and 6-month follow-up appointments. RESULTS: At the initial evaluation, children aged <6 years were more likely to receive radiographs (P = 0.007) and magnetic resonance imaging (P = 0.048) than were children aged 6-11 and 12-18 years. At the 3- and 6-month follow-up appointments, persistent neck pain was rare, representing <15% of patients at either time. Regardless of pain persistence, 80.2% of patients seen at the 3-month follow-up and 100% of patients at the 6-month follow-up underwent additional imaging studies. At the 3-month follow-up, children with persistent neck pain were more likely to undergo magnetic resonance imaging than were patients without persistent pain (P < 0.001). Also, patients with persistent neck pain were also more likely to not undergo any imaging evaluation (P = 0.002). Follow-up imaging studies did not reveal new structural injuries at either time point. CONCLUSIONS: Follow-up imaging for pediatric patients with low-grade WAD did not identify new structural pathology-in patients with or without persistent neck pain.

Intraoperative Imaging and Optical Visualization Techniques for Brain Tumor Resection: A Narrative Review.

Advancements in intraoperative visualization and imaging techniques are increasingly central to the success and safety of brain tumor surgery, leading to transformative improvements in patient outcomes. This comprehensive review intricately describes the evolution of conventional and emerging technologies for intraoperative imaging, encompassing the surgical microscope, exoscope, Raman spectroscopy, confocal microscopy, fluorescence-guided surgery, intraoperative ultrasound, magnetic resonance imaging, and computed tomography. We detail how each of these imaging modalities contributes uniquely to the precision, safety, and efficacy of neurosurgical procedures. Despite their substantial benefits, these technologies share common challenges, including difficulties in image interpretation and steep learning curves. Looking forward, innovations in this field are poised to incorporate artificial intelligence, integrated multimodal imaging approaches, and augmented and virtual reality technologies. This rapidly evolving landscape represents fertile ground for future research and technological development, aiming to further elevate surgical precision, safety, and, most critically, patient outcomes in the management of brain tumors.

Clopidogrel Is Associated with Reduced Likelihood of Aneurysmal Subarachnoid Hemorrhage: a Multi-Center Matched Retrospective Analysis.

Maladaptive inflammation underlies the formation and rupture of human intracranial aneurysms. There is a growing body of evidence that anti-inflammatory pharmaceuticals may beneficially modulate this process. Clopidogrel (Plavix) is a commonly used irreversible P2Y12 receptor antagonist with anti-inflammatory activity. In this paper, we investigate whether clopidogrel is associated with the likelihood of aneurysm rupture in a multi-institutional propensity-matched cohort analysis. Patients presenting for endovascular treatment of their unruptured intracranial aneurysms and those presenting with aneurysm rupture between 2015 and 2019 were prospectively identified at two quaternary referral centers. Patient demographics, comorbidities, and medication usage at the time of presentation were collected. Patients taking clopidogrel or not taking clopidogrel were matched in a 1:1 fashion with respect to location, age, smoking status, aneurysm size, aspirin usage, and hypertension. A total of 1048 patients with electively treated aneurysms or subarachnoid hemorrhages were prospectively identified. Nine hundred twenty-one patients were confirmed to harbor aneurysms during catheter-based diagnostic angiography. A total of 172/921 (19%) patients were actively taking clopidogrel at the time of presentation. Three hundred thirty-two patients were matched in a 1:1 fashion. A smaller proportion of patients taking clopidogrel at presentation had ruptured aneurysms than those who were not taking clopidogrel (6.6% vs 23.5%, p < .0001). Estimated treatment effect analysis demonstrated that clopidogrel usage decreased aneurysm rupture risk by 15%. We present, to the best of our knowledge, the first large-scale multi-institutional analysis suggesting clopidogrel use is protective against intracranial aneurysm rupture. It is our hope that these data will guide future investigation, revealing the pathophysiologic underpinning of this association.

Increased prevalence of blister aneurysm formation during the COVID-19 pandemic.

BACKGROUND: Intracranial blister aneurysms are a rare and an historically difficult to treat subset of aneurysms. They are distinct from typical saccular aneurysms with different pathophysiology and treatment options. METHODS: A prospectively maintained database of subarachnoid hemorrhage patients was queried for those presenting prior to the pandemic (2017-2019), and those presenting during the height of the pandemic in our locality (2021). Aneurysm characteristics and patient demographics associated with rupture risk/formation were collected. RESULTS: 334 aneurysmal subarachnoid hemorrhage patients were reviewed. 86 of these patients presented in 2021, with a statistically significant increase in the proportion of ruptured ICA blister aneurysms as compared to 2017-2019 (7/86, 8% vs 5/248, p = .02). Mean patient age, presenting grade, other aneurysm location proportions, aneurysm size, and incidence of delayed cerebral ischemia were not different between the groups. CONCLUSIONS: Patients presenting with SAH during the height of the SARS-CoV-2 pandemic in 2021 were more likely to have ICA blister type aneurysms.

Combined exploratory laparotomy, transpsoas, and thoracic approach to resection of a giant spinal ganglioneuroma: illustrative case.

BACKGROUND: Ganglioneuromas are rare peripheral nervous system tumors of neural crest origin. Most are often asymptomatic and incidentally found, but large tumors can cause mass effect. Herein, the authors report a case of a giant ganglioneuroma that arose from the lumbar foramina into the retroperitoneal and thoracic cavities. OBSERVATIONS: A 62-year-old female presented with low back pain, left lower extremity swelling, and increased sensation of an abdominal mass. Surgical treatment options were reviewed with the patient and coordinated care was planned by surgical oncological specialists. The patient opted for multistage exploratory laparotomy for abdominal mobilization, diaphragm resection, and en bloc resection with neuromonitoring. After surgery, the patient experienced significant improvement in symptoms. LESSONS: A combined surgical exposure involving gastrointestinal, thoracic, and neurological surgeons can be important in the safe resection of ganglioneuromas that span multiple body cavities. Hence, a thorough preoperative assessment could help plan surgery accordingly.

National reduction in cerebral arteriovenous malformation treatment correlated with increased rupture incidence.

BACKGROUND: Recently, there has been a shift in management of unruptured cerebral arteriovenous malformations (AVMs) following studies suggesting that medical management alone was superior to interventional therapy. OBJECTIVE: To evaluate the influence of contemporary AVM management on AVM rupture patterns in the United States. METHODS: 154 297 AVM admissions were identified between 2003 and 2017 in the National Inpatient Sample. Annual AVM intervention and rupture rates were computed and multivariable logistic regression assessed the likelihood of AVM intervention pre- and post-2014. Segmented regression identified significant change points and fitted segmented linear models for annual intervention and rupture rates. Correlation coefficients assessed the relationship between annual AVM intervention and rupture rates. RESULTS: For unruptured AVMs, intervention likelihood and proportion decreased after 2014 (28.1% to 22.3%, p<0.0001; adjusted OR=0.857, 95% CI 0.751 to 0.977, p=0.02). Ruptured AVM admissions increased from 14.7% to 18.6% after 2014 (p<0.0001). Between 2003 and 2017, segmented linear regression identified one significant change point in intervention rate between 2014 and 2015. Average annual percent change for rupture incidence and intervention rate increased by 0.49% (p=0.0001) and decreased by 1.17% (p=0.0001), respectively. Annual AVM intervention rates were inversely correlated with annual AVM rupture incidence (Pearson coefficient=-0.82, p=0.0002). In 2017, the annual AVM rupture rate (20.6%) surpassed the annual AVM intervention rate (19.7%). CONCLUSIONS: After 2014, the likelihood of intervention for unruptured AVMs decreased while the incidence of ruptured AVMs increased. These findings suggest that fewer unruptured AVM treatments may lead to increases in AVM rupture incidence.

Brain Arteriovenous Malformations: Status of Open Surgery after A Randomized Trial of Unruptured Brain Arteriovenous Malformations.

The results of "A Randomized Trial of Unruptured Brain Arteriovenous Malformations" (ARUBA) suggested that observation alone resulted in less morbidity and mortality than intervention for these lesions. These findings generated significant controversy throughout the cerebrovascular community and resulted in several subsequent studies investigating the role of microsurgical resection on ARUBA-eligible patients. Herein, we provide a brief overview of the ARUBA trial, its subsequent criticisms, the resultant publications challenging the findings in ARUBA, and discuss the available data regarding the effect ARUBA has had on arteriovenous malformation (AVM) treatments.

Radial Access Techniques.

Transradial access (TRA) has gained traction in neurointerventions as studies continue to demonstrate improved access site safety and equivalent end artery effectiveness when compared with traditional transfemoral techniques. Herein, we describe the technical nuances of obtaining TRA with a focus on distal TRA, left TRA, and sheathless TRA using larger bore catheters. We also discuss various strategies to avoid access site conversion if radial artery spasm or radial anomalies are encountered and offer some solutions for forming the Simmons catheter especially when it cannot be performed in the descending aorta. Lastly, we provide some insights regarding contraindications to TRA.

Trends in mechanical thrombectomy and decompressive hemicraniectomy for stroke: A multicenter study.

BACKGROUND AND PURPOSE: Acute ischemic stroke has increasingly become a procedural disease following the demonstrated benefit of mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) on clinical outcomes and tissue salvage in randomized trials. Given these data and anecdotal experience of decreased numbers of decompressive hemicraniectomies (DHCs) performed for malignant cerebral edema, we sought to correlate the numbers of strokes, thrombectomies, and DHCs performed over the timeline of the 2013 failed thrombolysis/thrombectomy trials, to the 2015 modern randomized MT trials, to post-DAWN and DEFUSE 3. MATERIALS AND METHODS: This is a multicenter retrospective compilation of patients who presented with ELVO in 11 US high-volume comprehensive stroke centers. Rates of tissue plasminogen activator (tPA), thrombectomy, and DHC were determined by current procedural terminology code, and specificity to acute ischemic stroke confirmed by each institution. Endpoints included the incidence of stroke, thrombectomy, and DHC and rates of change over time. RESULTS: Between 2013 and 2018, there were 55,247 stroke admissions across 11 participating centers. Of these, 6145 received tPA, 4122 underwent thrombectomy, and 662 patients underwent hemicraniectomy. The trajectories of procedure rates over time were modeled and there was a significant change in MT rate (p = 0.002) without a concomitant change in the total number of stroke admissions, tPA administration rate, or rate of DHC. CONCLUSIONS: This real-world study confirms an increase in thrombectomy performed for ELVO while demonstrating stable rates of stroke admission, tPA administration and DHC. Unlike prior studies, increasing thrombectomy rates were not associated with decreased utilization of hemicraniectomy.

Onyx embolization for dural arteriovenous fistulas: a multi-institutional study.

BACKGROUND: Although the liquid embolic agent, Onyx, is often the preferred embolic treatment for cerebral dural arteriovenous fistulas (DAVFs), there have only been a limited number of single-center studies to evaluate its performance. OBJECTIVE: To carry out a multicenter study to determine the predictors of complications, obliteration, and functional outcomes associated with primary Onyx embolization of DAVFs. METHODS: From the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database, we identified patients who were treated for DAVF with Onyx-only embolization as the primary treatment between 2000 and 2013. Obliteration rate after initial embolization was determined based on the final angiographic run. Factors predictive of complete obliteration, complications, and functional independence were evaluated with multivariate logistic regression models. RESULTS: A total 146 patients with DAVFs were primarily embolized with Onyx. Mean follow-up was 29 months (range 0-129 months). Complete obliteration was achieved in 80 (55%) patients after initial embolization. Major cerebral complications occurred in six patients (4.1%). At last follow-up, 84% patients were functionally independent. Presence of flow symptoms, age over 65, presence of an occipital artery feeder, and preprocedural home anticoagulation use were predictive of non-obliteration. The transverse-sigmoid sinus junction location was associated with fewer complications, whereas the tentorial location was predictive of poor functional outcomes. CONCLUSIONS: In this multicenter study, we report satisfactory performance of Onyx as a primary DAVF embolic agent. The tentorium remains a more challenging location for DAVF embolization, whereas DAVFs located at the transverse-sigmoid sinus junction are associated with fewer complications.

Incidence and Clinical Outcomes of Hypothyroidism in Patients Undergoing Spinal Fusion.

Background Hypothyroidism has been independently associated with the development of several comorbidities and is known to increase complication rates in non-spinal surgeries. However, there are limited data regarding the effects of hypothyroidism in major spine surgery. Therefore, we present the largest retrospective analysis evaluating outcomes in hypothyroid patients undergoing spinal fusion. Methods A retrospective review of the National Inpatient Sample (NIS) from 2004-2014 was performed. Patients with an International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) procedure code indicating spinal fusion (81.04-81.08, 81.34-81.38, 81.0x, 81.3x) were included. Patients with an ICD-9-CM diagnosis code indicating hypothyroidism (244.x) were compared to those without. Cervical and lumbar fusions were evaluated independently. Significant covariates in univariable logistic regression were utilized to construct multivariable models to analyze the effect of hypothyroidism on perioperative morbidity and mortality. Results A total of 4,149,125 patients were identified, of which 9.4% were hypothyroid. Although, hypothyroid patients had a higher risk of hematologic complications (lumbar - odds ratio [OR] 1.176, p < 0.0001; cervical - OR 1.162, p < 0.0001), they exhibited decreased in-hospital mortality (lumbar - OR .643, p < 0.0001; cervical - OR .606, p < 0.0001). Hypothyroid lumbar fusion patients also demonstrated decreased rates of perioperative myocardial infarction (MI) (OR .851, p < 0.0001). All these results were independent of patient gender. Conclusions Hypothyroid patients undergoing spinal fusion demonstrated lower rates of inpatient mortality and, in lumbar fusions, also had lower rates of acute MI when compared to their euthyroid counterparts. This suggests that hypothyroidism may offer protection against all-cause mortality and may be cardioprotective in the postoperative period for lumbar spinal fusions independent of patient gender.

Navigating radial artery loops in neurointerventions.

BACKGROUND: Although studies continue to demonstrate lower complications in neurointerventions using transradial access (TRA) compared with transfemoral approaches, anatomic radial variants can be difficult to navigate and remain one of the frequent causes of access site conversion. OBJECTIVE: To evaluate predictors of TRA failure in neuroendovascular patients with radial loops and suggest a protocol for managing these anomalies. METHODS: A prospective collection of patients undergoing TRA at participating institutions from July 2018 to September 2020 was reviewed. Patients with a radial loop were identified. Patient demographics and procedural characteristics were evaluated to determine predictors of both TRA failure and successful reduction of the radial loop. RESULTS: We identified 32 transradial neurointerventions in which patients had radial loops. Twenty-two (68.8%) were identified by diagnostic angiography, and the majority were performed for evaluation or treatment of an aneurysm (56.3%). TRA failure occurred in 13 (40.6%) of the cohort and happened more frequently in patients over 60 years of age (p=0.01) and those with recurrent radial artery diameters ≤2 mm (p=0.02). Of the 19 patients who had successful TRA, 12 (63.2%) procedures were performed through the recurrent radial artery. CONCLUSION: Although radial loops are associated with high transradial failure rates, our results suggest that the presence of a loop is not an absolute contraindication to TRA. Therefore, we recommend attempting loop navigation using our protocol. Patient age, vascular tortuosity, and recurrent radial artery size should help dictate when to convert to an alternative access site.

Implementation of a radial long sheath protocol for radial artery spasm reduces access site conversions in neurointerventions.

BACKGROUND: Many neurointerventionalists have transitioned to transradial access (TRA) as the preferred approach for neurointerventions as studies continue to demonstrate fewer access site complications than transfemoral access. However, radial artery spasm (RAS) remains one of the most commonly cited reasons for access site conversions. We discuss the benefits, techniques, and indications for using the long radial sheath in RAS and present our experience after implementing a protocol for routine use. METHODS: A retrospective review of all patients undergoing neurointerventions via TRA at our institution from July 2018 to April 2020 was performed. In November 2019, we implemented a long radial sheath protocol to address RAS. Patient demographics, RAS rates, radial artery diameter, and access site conversions were compared before and after the introduction of the protocol. RESULTS: 747 diagnostic cerebral angiograms and neurointerventional procedures in which TRA was attempted as the primary access site were identified; 247 were performed after the introduction of the long radial sheath protocol. No significant differences in age, gender, procedure type, sheath sizes, and radial artery diameter were seen between the two cohorts. Radial anomalies and small radial diameters were more frequently seen in patients with RAS. Patients with clinically significant RAS more often required access site conversion (p<0.0001), and in our multivariable model use of the long sheath was the only covariate protective against radial failure (OR 0.061, 95% CI 0.007 to 0.517; p=0.0103). CONCLUSION: In our experience, we have found that the use of long radial sheaths significantly reduces the need for access site conversions in patients with RAS during cerebral angiography and neurointerventions.

Impact of off-hour endovascular therapy on outcomes for acute ischemic stroke: insights from STAR.

BACKGROUND: The off-hour effect has been observed in the medical care of acute ischemic stroke. However, it remains unclear if time of arrival affects revascularization rates and outcomes after endovascular therapy (EVT) for emergent large vessel occlusion (ELVO). We aimed to investigate the clinical outcomes of EVT between on-hour and off-hour admissions. METHODS: Patients who underwent EVT for ELVO from January 2013 to June 2019 from the STAR Registry were included. Patients were grouped based on time of groin puncture: on-hour period (Monday through Friday, 7:00 am-4:59 pm) and off-hour period (overnight 5:00pm-6:59am and the weekends). Primary outcome was final modified Rankin Scale (mRS) at 90 days on mRS-shift analysis. RESULTS: A total of 1919 patients were included in the study from six centers. The majority of patients (1169, 60.9%) of patients presented during the off-hour period. The mean age was 68.1 years and 50.5% were women. Successful reperfusion, as defined by a Thrombolysis In Cerebral Infarction (TICI) score of ≥2B, was achieved in 88.8% in the on-hour group and 88.0% in the off-hour group. Good clinical outcome (mRS 0-2) was obtained in 34.4% of off-hour patients and 37.7% of on-hour patients. On multivariable ordinal logistic regression analysis, time of presentation was not associated with worsened outcome (OR 1.150; 95% CI 0.96 to 1.37; P=0.122). Age, admission National Institutes of Health Stroke Scale (NIHSS), baseline mRS, and final TICI score were significantly associated with worse outcomes. CONCLUSION: There is no statistical difference in functional outcome in acute ischemic stroke patients who underwent EVT during on-hours versus off-hours.

More expansive horizons: a review of endovascular therapy for patients with low NIHSS scores.

While the landmark 2015 stroke trials demonstrated that endovascular therapy (EVT) was superior to medical management for the treatment of acute ischemic stroke due to large vessel occlusion, the efficacy of EVT for patients presenting with a low NIHSS score remains undetermined. We conducted a review of the EVT low National Institutes of Health Stroke Scale (NIHSS) stroke literature, identifying 24 quantitative and six qualitative publications. Details of study designs and outcome were extracted and critically discussed.All identified qualitative studies were retrospective. There was significant study design heterogeneity, with 18 unique study designs between the 24 identified quantitative manuscripts. Study investigations included low NIHSS EVT feasibility (n=6), EVT versus best medical management (BMM; n=10), EVT versus intravenous therapy (IVT, n=3), and low NIHSS score versus high NIHSS score (n=3). From single-arm EVT feasibility studies, the reported ranges of modified Thrombolysis in Cerebral Infarction and symptomatic intracranial hemorrhage were 78-97% and 0-10%, respectively. The EVT versus BMM literature had heterogeneous results with 40% reporting benefit with EVT and 60% reporting neutral findings. None of the studies comparing EVT with IVT reported a difference between the two revascularization therapies. The four identified meta-analyses had incongruent inclusion criteria and conflicting results. Two randomized trials are currently investigating EVT in patients with a low NIHSS score. Selected meta-analyses do suggest a potential benefit of EVT over BMM; however, current and future randomized clinical trials will better elucidate the efficacy of EVT in this patient population.

Thrombectomy Technique Predicts Outcome in Posterior Circulation Stroke-Insights from the STAR Collaboration.

BACKGROUND: Randomized controlled trials evaluating mechanical thrombectomy (MT) for acute ischemic stroke predominantly studied anterior circulation patients. Both procedural and clinical predictors of outcome in posterior circulation patients have not been evaluated in large cohort studies. OBJECTIVE: To investigate technical and clinical predictors of functional independence after posterior circulation MT while comparing different frontline thrombectomy techniques. METHODS: In a retrospective multicenter international study of 3045 patients undergoing MT for stroke between 06/2014 and 12/2018, 345 patients had posterior circulation strokes. MT was performed using aspiration, stent retriever, or combined approach. Functional outcomes were assessed using the 90-d modified Rankin score dichotomized into good (0-2) and poor outcomes (3-6). RESULTS: We included 2700 patients with anterior circulation and 345 patients with posterior circulation strokes. Posterior patients (age: 60 ± 14, 46% females) presented with mainly basilar occlusion (80%) and were treated using contact aspiration or ADAPT (39%), stent retriever (31%) or combined approach (19%). Compared to anterior strokes, posterior strokes had delayed treatment (500 vs 340 min, P < .001), higher national institute of health stroke scale (NIHSS) (17.1 vs 15.7, P < .01) and lower rates of good outcomes (31% vs 43%, P < .01). In posterior MT, diabetes (OR = 0.28, 95%CI: 0.12-0.65), admission NIHSS (OR = 0.9, 95%CI: 0.86-0.94), and use of stent retriever (OR = 0.26, 95%CI: 0.11-0.62) or combined approach (OR = 0.35, 95%CI: 0.12-1.01) vs ADAPT were associated with lower odds of good outcome. Stent retriever use was associated with lower odds of good outcomes compared to ADAPT even when including patients with only basilar occlusion or with successful recanalization only. CONCLUSION: Despite similar safety profiles, use of ADAPT is associated with higher rates of functional independence after posterior circulation thrombectomy compared to stent retriever or combined approach in large "real-world" retrospective study.

Treatment and diagnosis of cerebral aneurysms in the post-International Subarachnoid Aneurysm Trial (ISAT) era: trends and outcomes.

BACKGROUND: Following publication of the International Subarachnoid Aneurysm Trial (ISAT), treatment paradigms for cerebral aneurysms (CAs) shifted from open surgical clipping to endovascular embolization as primary therapy in a majority of cases. However, comprehensive analyses evaluating more recent CA diagnosis patterns, patient populations and outcomes as a function of treatment modality remain rare. METHODS: The National Inpatient Sample from 2004 to 2014 was reviewed. Aneurysmal subarachnoid hemorrhages (aSAHs) and unruptured intracranial aneurysms (UIAs) with a treatment of surgical clipping or endovascular therapy (EVT) were identified. Time trend series plots were created. Linear and logistic regressions were utilized to quantify treatment changes. RESULTS: 114 137 aSAHs and 122 916 UIAs were reviewed. aSAH (+732/year, p=0.014) and UIA (+2550/year, p<0.0001) discharges increased annually. The annual caseload of surgical clippings for aSAH decreased (-264/year, p=0.0002) while EVT increased (+366/year, p=0.0003). For UIAs, the annual caseload for surgical clipping remained stable but increased for EVT (+615/year, p<0.0001). The rate of incidentally diagnosed UIAs increased annually (+1987/year; p<0.0001). Inpatient mortality decreased for clipping (p<0.0001) and EVT in aSAH (p<0.0001) (2004 vs 2014-clipping 13% vs 11.7%, EVT 15.8% vs 12.7%). Mortality rates for clipped UIAs decreased over time (p<0.0001) and remained stable for EVT (2004 vs 2014-clipping 1.57% vs 0.40%, EVT 0.59% vs 0.52%). CONCLUSION: Ruptured and unruptured CAs are increasingly being treated with EVT over clipping. Incidental unruptured aneurysm diagnoses are increasing dramatically. Mortality rates of ruptured aneurysms are improving regardless of treatment modality, whereas mortality in unruptured aneurysms is only improving for surgical clipping.