International controlled study of revascularization and outcomes following COVID-positive mechanical thrombectomy.

BACKGROUND AND PURPOSE: Previous studies suggest that mechanisms and outcomes in patients with COVID-19-associated stroke differ from those in patients with non-COVID-19-associated strokes, but there is limited comparative evidence focusing on these populations. The aim of this study, therefore, was to determine if a significant association exists between COVID-19 status with revascularization and functional outcomes following thrombectomy for large vessel occlusion (LVO), after adjustment for potential confounding factors. METHODS: A cross-sectional, international multicenter retrospective study was conducted in consecutively admitted COVID-19 patients with concomitant acute LVO, compared to a control group without COVID-19. Data collected included age, gender, comorbidities, clinical characteristics, details of the involved vessels, procedural technique, and various outcomes. A multivariable-adjusted analysis was conducted. RESULTS: In this cohort of 697 patients with acute LVO, 302 had COVID-19 while 395 patients did not. There was a significant difference (p < 0.001) in the mean age (in years) and gender of patients, with younger patients and more males in the COVID-19 group. In terms of favorable revascularization (modified Thrombolysis in Cerebral Infarction [mTICI] grade 3), COVID-19 was associated with lower odds of complete revascularization (odds ratio 0.33, 95% confidence interval [CI] 0.23-0.48; p < 0.001), which persisted on multivariable modeling with adjustment for other predictors (adjusted odds ratio 0.30, 95% CI 0.12-0.77; p = 0.012). Moreover, endovascular complications, in-hospital mortality, and length of hospital stay were significantly higher among COVID-19 patients (p < 0.001). CONCLUSION: COVID-19 was an independent predictor of incomplete revascularization and poor functional outcome in patients with stroke due to LVO. Furthermore, COVID-19 patients with LVO were more often younger and had higher morbidity/mortality rates.

Characteristics of a COVID-19 Cohort With Large Vessel Occlusion: A Multicenter International Study.

BACKGROUND: The mechanisms and outcomes in coronavirus disease (COVID-19)-associated stroke are unique from those of non-COVID-19 stroke. OBJECTIVE: To describe the efficacy and outcomes of acute revascularization of large vessel occlusion (LVO) in the setting of COVID-19 in an international cohort. METHODS: We conducted an international multicenter retrospective study of consecutively admitted patients with COVID-19 with concomitant acute LVO across 50 comprehensive stroke centers. Our control group constituted historical controls of patients presenting with LVO and receiving a mechanical thrombectomy between January 2018 and December 2020. RESULTS: The total cohort was 575 patients with acute LVO; 194 patients had COVID-19 while 381 patients did not. Patients in the COVID-19 group were younger (62.5 vs 71.2; P < .001) and lacked vascular risk factors (49, 25.3% vs 54, 14.2%; P = .001). Modified thrombolysis in cerebral infarction 3 revascularization was less common in the COVID-19 group (74, 39.2% vs 252, 67.2%; P < .001). Poor functional outcome at discharge (defined as modified Ranklin Scale 3-6) was more common in the COVID-19 group (150, 79.8% vs 132, 66.7%; P = .004). COVID-19 was independently associated with a lower likelihood of achieving modified thrombolysis in cerebral infarction 3 (odds ratio [OR]: 0.4, 95% CI: 0.2-0.7; P < .001) and unfavorable outcomes (OR: 2.5, 95% CI: 1.4-4.5; P = .002). CONCLUSION: COVID-19 was an independent predictor of incomplete revascularization and poor outcomes in patients with stroke due to LVO. Patients with COVID-19 with LVO were younger, had fewer cerebrovascular risk factors, and suffered from higher morbidity/mortality rates.

Quantification of pial collateral pressure in acute large vessel occlusion stroke: basic concept with patient outcomes.

PURPOSE: Pial collateral perfusion to the ischemic penumbra plays a critical role in determining patient outcomes in acute stroke. We aimed to assess the validity and reliability of an intra-procedural technique for measuring and quantifying the pial collateral pressure (QPCP) to ischemic brain tissue during acute stroke secondary to LVO. QPCP measurements were correlated with standard computed tomography angiography (CTA) and digital subtraction angiography imaging assessments of pial collateral perfusion and outcomes after mechanical endovascular revascularization (MER). METHODS: This prospective cohort study included 60 consecutive patients with middle cerebral artery (MCA)-M1 and proximal M2 occlusions. QPCP measurements were obtained during MER. The validity of QPCP measurements was evaluated using four widely accepted collateral grading scales. QPCP measurements were also analyzed as a predictor of patient outcomes utilizing National Institute of Health Stroke Scale reduction at 24 h and modified Rankin Scale (mRS) scores at 30 days. RESULTS: QPCP measurements and QPCP ratio (QPCP/systemic mean arterial blood pressure) showed a statistically significant association with single-phase pretreatment CTA Maas and American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology binary grading scales. Patient outcomes demonstrated for every 10-unit increase in QPCP, the odds of mRS 0-2 at 30 days increased by 76% (p = 0.019). CONCLUSION: QPCP measurements related best with the pretreatment CTA Maas collateral grading scale but were more strongly associated with patient outcomes than any of the four widely accepted collateral grading scales. Greater QPCP was significantly associated with better overall patient outcomes as defined by mRS at 30 days.

Cranial angiomatoid fibrous histiocytoma: A case report and review of literature.

BACKGROUND: Angiomatoid fibrous histiocytoma (AFH) is a rare low-grade soft-tissue tumor that typically arises from the deep dermal and subcutaneous tissue of the extremities in children and young adults. Intracranial AFH is exceedingly rare, and only four cases of primary AFH tumors have been reported to date. CASE DESCRIPTION: A 43-year-old male presented to our hospital with headaches, vision changes, and a known brain tumor suspected to be an atypical meningioma. After undergoing craniotomy for resection of the mass, the immunomorphologic features of the resected tumor showed typical features of AFH with ESWR1 (exon7) - ATF1 (exon 5) fusion. CONCLUSION: AFH is a difficult tumor to diagnose with imaging and histologic studies. Thus, further knowledge is necessary - particularly of intracranial cases - to aid clinicians in its diagnosis and management.

Anterior Cerebral Artery: Variant Anatomy and Pathology.

The anterior cerebral artery (ACA) contains anatomical variants that are closely related to its embryology and development. In this study, the authors reviewed the most commonly encountered variants of the ACA and anterior communicating artery. They also reviewed the embryological origins of these variants as well as a variety of associated pathologies. Several variants are described and highlighted with illustrations including: (1) the aberrant origin of the ACA from the internal carotid artery and its developmental association with the ophthalmic artery; (2) the persistent olfactory artery; (3) the azygous ACA; (4) the triplicated ACA; and (5) multiple anterior communicating arteries. The formation of aneurysms is associated with such variants, thus their knowledge and the embryology behind their development are crucial to prevent injury to the patient.

Moyamoya vasculopathy with anti-SCL-70 antibodies: A case report and review of the literature.

Moyamoya disease and syndrome constitute two distinct pathological entities with a primary finding of progressive distal internal carotid artery occlusion, which results in either an ischemic or hemorrhagic sequela. While the disease entity stands as a primary arterial vasculopathy, moyamoya syndrome represents a secondary vasculopathy associated with a systemic inflammatory process. We describe a patient with an ischemic stroke and angiographic findings of moyamoya in the setting of positive antinuclear antibodies and anti-Scl-70 antibodies with clinical features of scleroderma on exam. A review of current literature identified three similar cases where immunosuppression in addition to secondary stroke prevention led to reduced frequency of neurological sequelae. These cases plus our own demonstrate that patients with moyamoya vasculopathy in association with anti-Scl 70 antibodies exist on a spectrum with either predominant scleroderma features or neurological symptoms. There are a limited number of cases reported of moyamoya vasculopathy in association with anti-Scl 70 antibodies. This case report demonstrates that not only may the association be more common than we think, but that it exists on a dynamic spectrum with variable clinical presentation and course.

Intracranial Hemorrhage in Patients with a Left Ventricular Assist Device.

BACKGROUND: There is a dearth of literature regarding management and outcomes of patients with a left ventricular assist device (LVAD) for advanced heart failure who develop intracranial hemorrhage (ICH). We conducted a case series from 2 centers highlighting patient outcomes and prognostic factors to help clinicians better understand and care for these high-risk patients. METHODS: A case series from 2 large-volume institutions (defined as large by the Nationwide Inpatient Sample hospital size, i.e., >500 beds both with Departments of Neurosurgery and Advanced Heart Failure-Cardiology) was conducted to clarify the prognosis of patients with an LVAD and ICH. We included patients who were being treated with an LVAD who developed ICH. Patient-specific demographics and data regarding heart failure and intracranial hemorrhage characteristics were collected and analyzed to determine which factors contributed to overall survival. RESULTS: We analyzed 59 unique ICHs in patients being treated with an LVAD for heart failure. Initial Glasgow Coma Scale score, presence of midline shift, and ICH size were factors found to be predictive of mortality. One institution had a sicker patient population including patients with ICH with lower Glasgow Coma Scale score, presence of midline shift, and greater hemorrhage size, which led to overall higher mortality compared with the second institution. CONCLUSIONS: Patients being treated with an LVAD who develop ICH have poor outcomes. Predictive factors for same-admission mortality are lower initial Glasgow Coma Scale score, presence of midline shift, and greater ICH volume.

Development of De Novo Arteriovenous Malformation Following Ischemic Stroke: Case Report and Review of Current Literature.

BACKGROUND: Arteriovenous malformations (AVMs) are hypothesized to be static, congenital lesions developing as early as 4 weeks of fetal life. New literature has shown that AVMs may represent dynamic and reactive vascular lesions arising from cerebral infarction, inflammation, or trauma. A literature search reveals 17 previously reported cases of new AVM formation after previous negative imaging studies. This reactive development or "second hit" theory suggests that at a molecular level, growth factors may play a vital role in aberrant angiogenesis and maturation of an arteriovenous fistula into an AVM. CASE DESCRIPTION: A 52-year-old female presented with a ruptured left frontal AVM demonstrated by computed tomography angiography and digital subtraction angiography. The patient had suffered an acute ischemic stroke in the similar cerebral vascular territory 8 years prior due to left internal carotid artery occlusion. Detailed neuroimaging at that time failed to reveal any vascular malformation, suggesting that the AVM might have developed in response to initial vascular insult. CONCLUSIONS: We believe that there might exist a subset of AVMs that display dynamic characteristics and could potentially appear, grow, or resolve spontaneously without intervention, especially in the presence of local growth factors and molecular signaling cascades. When combined with a previous cerebral insult such as stroke, trauma, or inflammation, de novo AVM formation may represent a "second hit" with abnormal angiogenesis and vessel formation.

Therapeutic hypothermia and ischemic stroke: A literature review.

BACKGROUND: Ischemic stroke is the fifth leading cause of death in the US. Clinical techniques aimed at helping to reduce the morbidity associated with stroke have been studied extensively, including therapeutic hypothermia. In this study, the authors review the literature regarding the role of therapeutic hypothermia in ischemic stroke to appreciate the evolution of hypothermia technology over several decades and to critically analyze several early clinical studies to validate its use in ischemic stroke. METHODS: A comprehensive literature search was performed using PubMed and Google Scholar databases. Search terms included "hypothermia and ischemic stroke" and "therapeutic hypothermia." A comprehensive search of the current clinical trials using clinicaltrials.gov was conducted using the keywords "stroke and hypothermia" to evaluate early and ongoing clinical trials utilizing hypothermia in ischemic stroke. RESULTS: A comprehensive review of the evolution of hypothermia in stroke and the current status of this treatment was performed. Clinical studies were critically analyzed to appreciate their strengths and pitfalls. Ongoing and future registered clinical studies were highlighted and analyzed compared to the reported results of previous trials. CONCLUSION: Although hypothermia has been used for various purposes over several decades, its efficacy in the treatment of ischemic stroke is debatable. Several trials have proven its safety and feasibility; however, more robust, randomized clinical trials with large volumes of patients are needed to fully establish its utility in the clinical setting.