Determining the effects of targeted high-definition transcranial direct current stimulation on reducing post-stroke upper limb motor impairments-a randomized cross-over study.

BACKGROUND: Stroke is one of the leading causes of death in the USA and is a major cause of serious disability for adults. This randomized crossover study examines the effect of targeted high-definition transcranial direct current transcranial brain stimulation (tDCS) on upper extremity motor recovery in patients in the post-acute phase of stroke recovery. METHODS: This randomized double-blinded cross-over study includes four intervention arms: anodal, cathodal, and bilateral brain stimulation, as well as a placebo stimulation. Participants receive each intervention in a randomized order, with a 2-week washout period between each intervention. The primary outcome measure is change in Motor Evoked Potential. Secondary outcome measures include the Fugl-Meyer Upper Extremity (FM-UE) score, a subset of FM-UE (A), related to the muscle synergies, and the Modified Ashworth Scale. DISCUSSION: We hypothesize that anodal stimulation to the ipsilesional primary motor cortex will increase the excitability of the damaged cortico-spinal tract, reducing the UE flexion synergy and enhancing UE motor function. We further hypothesize that targeted cathodal stimulation to the contralesional premotor cortex will decrease activation of the cortico-reticulospinal tract (CRST) and the expression of the upper extremity (UE) flexion synergy and spasticity. Finally, we hypothesize bilateral stimulation will achieve both results simultaneously. Results from this study could improve understanding of the mechanism behind motor impairment and recovery in stroke and perfect the targeting of tDCS as a potential stroke intervention. With the use of appropriate screening, we anticipate no ethical or safety concerns. We plan to disseminate these research results to journals related to stroke recovery, engineering, and medicine. TRIAL REGISTRATION: ClinicalTrials.gov NCT05479006 . Registered on 26 July 2022.

Initial clinical experience with the ADAPT technique: A direct aspiration first pass technique for stroke thrombectomy.

BACKGROUND: The development of new revascularization devices has improved recanalization rates and time but not clinical outcomes. We report our initial results with a new technique utilizing a direct aspiration first pass technique with a large bore aspiration catheter as the primary method for vessel recanalization. METHODS: A retrospective evaluation of a prospectively captured database of 37 patients at six institutions was performed on patients where the ADAPT technique was utilized. The data represent the initial experience with this technique. RESULTS: The ADAPT technique alone was successful in 28 of 37 (75%) cases although six cases had large downstream emboli that required additional aspiration. Nine cases required the additional use of a stent retriever and one case required the addition of a Penumbra aspiration separator to achieve recanalization. The average time from groin puncture to at least Thrombolysis in Cerebral Ischemia (TICI) 2b recanalization was 28.1 min, and all cases were successfully revascularized. TICI 3 recanalization was achieved 65% of the time. On average, patients presented with an admitting National Institutes of Health Stroke Scale (NIHSS) score of 16.3 and improved to an NIHSS score of 4.2 by the time of hospital discharge. There was one procedural complication. DISCUSSION: This initial experience highlights the fact that the importance of the technique with which new stroke thrombectomy devices are used may be as crucial as the device itself. The ADAPT technique is a simple and effective approach to acute ischemic stroke thrombectomy. Utilizing the latest generation of large bore aspiration catheters in this fashion has allowed us to achieve excellent clinical and angiographic outcomes.

Endovascular management of cerebral septic embolism: three recent cases and review of the literature.

Endovascular management of acute ischemic stroke secondary to septic emboli from bacterial endocarditis is case-specific and outside established guidelines. We report three new cases of an acute ischemic stroke secondary to septic embolus from two different centers. All cases reported here were large vessel occlusions of the middle cerebral artery in anticoagulated patients. In one case the embolus was noted to be firm and aspiration thrombectomy was attempted in lieu of stent retrieval. Thrombolysis in Cerebral Ischemia (TICI) 3 recanalization was achieved and the patient experienced a good outcome with resolution of deficits. In this case, pathologic analysis of the embolus was available. These additional three cases from two centers add to the small but growing literature for interventional management of acute ischemic stroke in bacterial endocarditis.

Anticoagulation Reversal Strategies for Left Ventricular Assist Device Patients Presenting with Acute Intracranial Hemorrhage.

The safety of alternative vitamin K antagonist (VKA) reversal strategies in patients with left ventricular assist devices (LVAD's) who present with intracranial hemorrhage (ICH) are not well known. A review of LVAD patients with ICH from May 2008 to 2015 was conducted, comparing the safety and efficacy of 4-factor prothrombin complex concentrate-assisted VKA reversal (4F-PCC group, n = 10) to reversal with traditional agents alone (no-PCC group, n = 10). An analysis of a no-reversal strategy in selected patients (n = 11) with ICH was additionally performed. Thirty-one cases of ICH on LVAD support were reviewed. The rate of post reversal thromboembolic events was not significantly different between 4F-PCC and no-PCC patients (0% vs. 10%, p = 1.0); however, the time to VKA reversal was shorter (474 vs. 945 minutes, p = 0.02) and fresh frozen plasma (FFP) requirements lower (1.9 vs. 3.6 units, p = 0.05) in 4F-PCC patients, with no difference in mortality between groups (p = 1.0). Eleven patients (mean ICH volume: 0.4 cm) were successfully managed without active VKA reversal, with no increased hemorrhage noted on neuroimaging. These results suggest that 4F-PCC-assisted reversal in LVAD patients is safe and may improve the efficacy of VKA reversal. Our findings also indicate that carefully selected patients with small ICH volumes may be safely managed by discontinuing anticoagulation and allowing the international normalized ratio (INR) to normalize physiologically.

Neurosurgery clinical registry data collection utilizing Informatics for Integrating Biology and the Bedside and electronic health records at the University of Rochester.

In a population health-driven health care system, data collection through the use of clinical registries is becoming imperative to continue to drive effective and efficient patient care. Clinical registries rely on a department's ability to collect high-quality and accurate data. Currently, however, data are collected manually with a high risk for error. The University of Rochester's Department of Neurosurgery in conjunction with the university's Clinical and Translational Science Institute has implemented the integrated use of the Informatics for Integrating Biology and the Bedside (i2b2) informatics framework with the Research Electronic Data Capture (REDCap) databases.

Initial clinical experience with the ADAPT technique: a direct aspiration first pass technique for stroke thrombectomy.

BACKGROUND: The development of new revascularization devices has improved recanalization rates and time but not clinical outcomes. We report our initial results with a new technique utilizing a direct aspiration first pass technique with a large bore aspiration catheter as the primary method for vessel recanalization. METHODS: A retrospective evaluation of a prospectively captured database of 37 patients at six institutions was performed on patients where the ADAPT technique was utilized. The data represent the initial experience with this technique. RESULTS: The ADAPT technique alone was successful in 28 of 37 (75%) cases although six cases had large downstream emboli that required additional aspiration. Nine cases required the additional use of a stent retriever and one case required the addition of a Penumbra aspiration separator to achieve recanalization. The average time from groin puncture to at least Thrombolysis in Cerebral Ischemia (TICI) 2b recanalization was 28.1 min, and all cases were successfully revascularized. TICI 3 recanalization was achieved 65% of the time. On average, patients presented with an admitting National Institutes of Health Stroke Scale (NIHSS) score of 16.3 and improved to an NIHSS score of 4.2 by the time of hospital discharge. There was one procedural complication. DISCUSSION: This initial experience highlights the fact that the importance of the technique with which new stroke thrombectomy devices are used may be as crucial as the device itself. The ADAPT technique is a simple and effective approach to acute ischemic stroke thrombectomy. Utilizing the latest generation of large bore aspiration catheters in this fashion has allowed us to achieve excellent clinical and angiographic outcomes.

Balloon augmented Onyx embolization utilizing a dual lumen balloon catheter: utility in the treatment of a variety of head and neck lesions.

INTRODUCTION: Endovascular embolization for tumors and vascular malformations has emerged as an important preoperative adjunct prior to resection. We describe the advantages of utilizing a recently released dual lumen balloon catheter for ethylene vinyl alcohol copolymer, also known as Onyx (ev3, Irvine, California, USA), embolization for a variety of head and neck pathologies. METHODS: A retrospective review of all cases utilizing the Scepter C balloon catheter (MicroVention Inc, Tustin, California, USA) for use in balloon augmented embolization was performed over a 4 month period from October 2012 to February 2013 at the Medical University of South Carolina, Charleston, South Carolina, USA. Charts and angiographic images were reviewed. Representative cases involving diverse pathologies are summarized and illustrate the observed advantages of balloon augmented Onyx embolization with a dual lumen balloon catheter. CASE ILLUSTRATIONS: Balloon augmented Onyx embolization utilizing a novel dual lumen balloon catheter was employed to treat both ruptured and unruptured arteriovenous malformations, intracranial dural arteriovenous fistulae, intracranial neoplasms, carotid body tumors, a thyroid mass, and an extracranial arteriovenous fistula. CONCLUSIONS: The dual lumen balloon catheter has several advantages for use with Onyx embolization over older devices, including more efficient proximal plug formation and enhanced navigability for placement deep within the pedicles. The balloon augmented Onyx embolization technique represents a valuable tool to add to the armamentarium of the neurointerventionalist to address a variety of head and neck lesions.

Neuroangiography simulation using a silicone model in the angiography suite improves trainee skills.

PURPOSE: Simulation techniques in neurosurgical training are becoming more important. The purpose of this study was to determine whether silicone vascular models used in the angiography suite can render improvement in trainee performance and safety in neuroendovascular procedures. METHODS: 10 residents from neurosurgery and radiology training programs were asked to perform a diagnostic angiogram on a silicone based vascular model (United Biologics, Tustin, USA). This was done in the angiography suite with the full biplane fluoroscopy machine (Siemens, Munich, Germany). On their first attempt, they were coached by a faculty member trained in endovascular neurosurgery; on their second attempt, they received coaching only if the procedure had stalled. Technique was scored on multiple criteria by the faculty, and total time and fluoroscopy time were recorded on both attempts. RESULTS: In this group of 10 residents, overall procedure time significantly decreased from 51 to 42 min (p=0.01), and total fluoro time significantly decreased from 12 to 9 min (p=0.002) between the first attempt and the second attempt. Technical skill increased significantly in navigation, vessel selection, projection setup, and road map usage. CONCLUSIONS: Silicone vascular models used in the angiography suite, with the clinical working tools and biplane fluoroscopy, provide a valuable experience for training residents in diagnostic angiography, and improved performance and safety.

Demographic, circadian, and climatic factors in non-aneurysmal versus aneursymal subarachnoid hemorrhage.

BACKGROUND: Although, the relationship of spontaneous subarachnoid hemorrhage (SAH) to climatic or circadian factors has been widely studied, epidemiologic, circardian and climatic factors in non-aneurysmal SAH (naSAH), particularly perimesencephalic SAH (PMH), has not been reported before. OBJECTIVE: For the first time, demographic, climatic, and circadian variables are examined together as possible contributing factors comparing aSAH and naSAH. METHODS: We reviewed records for 384 patients admitted to University of Wisconsin Neurosurgery Service from January 2005 to December 2010 with spontaneous non-traumatic SAH. Patients were grouped as aSAH (n=338) or naSAH (n=46) on clinical and radiological criteria. PMH (n=32) was identified as a subgroup of naSAH based on radiological criteria. We logged demographic data, time of SAH, temperature at onset and atmospheric pressure at onset. The three subgroups were compared. RESULTS: Aneurysmal SAH occurred most often from 6am to 12pm (p<0.001); this correlation was not found in naSAH or PMH subgroups. Demographic analysis demonstrated predominance of female gender (p=0.008) and smoking (p=0.002) in aSAH, with predominance of hypercholesterolemia in naSAH (p=0.033). Atmospheric pressure, correlated with aSAH in the main county referral area, where we had detailed weather data (p<0.05); however, there was no weather correlation in the entire referral region taken together. Multivariate analysis supported a statistical difference only in smoking status between aSAH and naSAH groups (p=0.0159). CONCLUSION: Statistical differences in gender, smoking status, and history of hypercholesterolemia support a clinical distinction between aSAH and naSAH. Furthermore, circadian patterning of aSAH is not reproduced in naSAH, supporting pathophysiologic differences. Only smoking status provides a robust difference in aSAH and naSAH groups. Our data prompt further investigation into the relationship between aSAH and atmospheric pressure.

Balloon remodeling for aneurysm coil embolization with the coaxial lumen Scepter C balloon catheter: initial experience at a high volume center.

INTRODUCTION: The use of balloon remodeling allows for the treatment of aneurysms that were previously considered to be poor candidates for coil embolization. The Scepter C (Microvention, Tustin, California, USA) is a novel temporary occlusion balloon system with a dual coaxial lumen catheter. The design accommodates a more steerable 0.014 inch guidewire with improved control for delivery to the target lesion. We describe our initial experience with the use of this device for balloon remodeling to assist during aneurysm coil embolization. METHODS: All aneurysms that were treated with balloon remodeling employing the Scepter C balloon at a single institution (Medical University of South Carolina) from the time it was available in October 2011 to July 2012 were evaluated. Patient demographics, aneurysm characteristics, procedural success, and adverse events were assessed. RESULTS: 52 aneurysms were treated in 48 patients (45 women, three men) with a mean age of 59.3 ± 11 years (mean ± SD). Mean aneurysm height was 5.9 ± 3 mm, width 4.4 ± 2 mm with a 3.1 ± 2 mm broad neck. A variety of aneurysms were treated. The most commonly utilized size was the 4 mm × 10 mm (n=33) balloon. A Raymond 1 (complete occlusion) was achieved in the majority (n=44; 84.6%) of aneurysms, Raymond 2 (residual neck) in five, and Raymond 3 (residual aneurysm) in five. There was one complication (1.9%) attributed directly to balloon use. CONCLUSIONS: Our initial experience with the dual coaxial lumen Scepter C occlusion balloon catheter demonstrates its feasibility for use in balloon remodeling for aneurysm coil embolization. A variety of aneurysms at different locations were treated with satisfactory initial angiographic results and adverse event rates.

Combined balloon stent technique with the Scepter C balloon and low-profile visualized intraluminal stent for the treatment of intracranial aneurysms.

BACKGROUND: The 'balloon-then-stent' method involves stent placement after completion of a balloon-assisted embolization. The drawback to this technique is that the coil mass achieved during balloon remodeling must be crossed prior to stent deployment. This additional maneuver introduces the potential risk of coil disruption. We describe the first report of a novel technique employing the 'balloon-then-stent' method. METHODS: A 51-year-old patient with an unruptured right middle cerebral artery bifurcation aneurysm was treated with balloon remodeling employing a 4 × 10 mm Scepter C balloon catheter. Following coil embolization, a low-profile visualized intraluminal stent (LVIS) Jr 2.5 mm × 16 mm was delivered via the coaxial balloon catheter and deployed across the aneurysm neck. RESULTS: Follow-up angiograms demonstrated that the coil mass was well-seated within the aneurysm sac and the parent vessel was widely patent with satisfactory vessel wall apposition by the stent. CONCLUSIONS: We describe a technique for balloon remodeling followed by stenting for aneurysm coil embolization that incorporates the use of a coaxial dual-lumen balloon catheter system through which a novel self-expanding stent can be deployed. In the case described, we found this technique to be safe and feasible, reducing both the number of steps involved in this technique and the opportunities for mechanical coil-related complications.

Upper cervical intramedullary spinal metastasis of ovarian carcinoma: a case report and review of the literature.

INTRODUCTION: Currently there is no generalized approach to treating patients with intra-medullary spinal metastasis. High cervical spinal cord lesions can be particularly challenging cases, and may even be considered inoperable by some. CASE REPORT: We present what is, to the best of our knowledge, the first reported case of ovarian carcinoma (managed primarily with surgery) in a 65-year-old Caucasian woman metastasizing to the upper cervical spinal cord; we also review the relevant literature and discuss management strategies. CONCLUSIONS: Due to improving systemic cancer therapies, patients with cancer now often survive longer and are more likely to develop central nervous system metastases. Therefore, neurosurgical oncologists are often challenged with difficult decisions about how to surgically manage these patients. We recommend individualized multidisciplinary management based on patient functional status, the need for definitive diagnosis for possible additional adjuvant therapies, and consideration of extent of systemic disease impacting on desirable quality and length of survival.

Focal cerebral ischemia model by endovascular suture occlusion of the middle cerebral artery in the rat.

Stroke is the leading cause of disability and the third leading cause of death in adults worldwide. In human stroke, there exists a highly variable clinical state; in the development of animal models of focal ischemia, however, achieving reproducibility of experimentally induced infarct volume is essential. The rat is a widely used animal model for stroke due to its relatively low animal husbandry costs and to the similarity of its cranial circulation to that of humans. In humans, the middle cerebral artery (MCA) is most commonly affected in stroke syndromes and multiple methods of MCA occlusion (MCAO) have been described to mimic this clinical syndrome in animal models. Because recanalization commonly occurs following an acute stroke in the human, reperfusion after a period of occlusion has been included in many of these models. In this video, we demonstrate the transient endovascular suture MCAO model in the spontaneously hypertensive rat (SHR). A filament with a silicon tip coating is placed intraluminally at the MCA origin for 60 minutes, followed by reperfusion. Note that the optimal occlusion period may vary in other rat strains, such as Wistar or Sprague-Dawley. Several behavioral indicators of stroke in the rat are shown. Focal ischemia is confirmed using T2-weighted magnetic resonance images and by staining brain sections with 2,3,5-triphenyltetrazolium chloride (TTC) 24 hours after MCAO.