Mechanical thrombectomy - is time still brain? The DAWN of a new era.

PURPOSE: The purpose of this study is to review the history of treatments for acute ischemic stroke, examine developments in endovascular therapy, and discuss the future of the management of acute ischemic stroke. METHODS: A selective review of recent clinical trials for the treatment of acute ischemic stroke was conducted. RESULTS: We reviewed completed trials of the management of acute ischemic stroke including intravenous thrombolytics, intraarterial thrombolytics, and thrombectomy. We also assessed the future direction of research by reviewing ongoing clinical trials. CONCLUSIONS: The advancement of endovascular treatment for stroke has led to improved morbidity and mortality for patients. Future challenges include delivering these treatments to stroke centers worldwide.

Identifying the Sylvian Triangle on CT angiography: A technique for detecting distal middle cerebral artery occlusions.

Medium vessel occlusions (MeVOs), defined as occlusion of the M2/M3 and A2/A3 segments of the middle cerebral artery (MCA) and anterior cerebral artery, can be challenging to visualize on CT angiography (CTA) and MR angiography (MRA), given the anatomic complexity of the mid- and distal intracranial vasculature and smaller vessel caliber (Leary MC, Kidwell CS, Villablanca JP, et al. Validation of computed tomographic MCA "dot" sign: an angiographic correlation study. Stroke 2003; 34: 2636-2640; Luijten SPR, Wolff L, Duvekot MHC, et al. Diagnostic performance of an algorithm for automated large vessel occlusion (LVO) detection on CTA. J Neurointerv Surg 2022; 14: 794-798). In turn, the appearance of a sudden vessel cutoff in these vascular distributions on CTA or MRA is not always straightforward and may represent true occlusion, variant anatomy, and/or artifact (Leary MC, Kidwell CS, Villablanca JP, et al. Validation of computed tomographic MCA "dot" sign: an angiographic correlation study. Stroke 2003; 34: 2636-2640; Luijten SPR, Wolff L, Duvekot MHC, et al. Diagnostic performance of an algorithm for automated LVO detection on CTA. J Neurointerv Surg 2022; 14: 794-798). Given the importance of rapidly establishing an accurate diagnosis in the setting of stroke, combined with recent clinical trials and movements promoting the efficacy of endovascular therapeutic approaches to treat MeVOs, it remains imperative to detect such occlusions accurately and quickly on imaging. In turn, we present five imaging patterns of the Sylvian Triangle on sagittal reformatted images from CTA Head examinations, which our practice has utilized to assess patency of the M2 and M3 divisions. This approach is rapidly deployable and can be utilized by radiology and non-radiology healthcare providers alike, thus facilitating rapid and accurate diagnosis of MeVO, timely evaluation of candidacy for endovascular therapy, and ultimately supporting favorable door-to-intervention time and successful patient outcomes.

Educating Radiology Stakeholders on Relevant Health Issues and Terminology Regarding LGBTQIA+ Patients in 2023.

RATIONALE AND OBJECTIVES: Over 20% of the Lesbian, Gay, Bisexual, Queer or Questioning, Intersex, Asexual or Ally, and more (LGBTQIA+) community reports experiencing discrimination upon accessing health care, causing many to defer access to care and resulting in poorer outcomes. While members of this community routinely undergo imaging studies, little formal education exists within the field of radiology to review the unique health care needs of this population and the specific relevance to imaging, in addition to actionable methods to promote inclusion. MATERIALS AND METHODS: A 1-hour educational conference was held for a cohort of radiology resident physicians at our institution, in which topics including LGBTQIA+ health care disparities, clinical nuances relevant to the field of radiology, and actionable suggestions that both academic and private-practice centers can adopt to foster inclusion were presented. All attendees were required to complete a 12-question, multiple-choice preconference and postconference examination. RESULTS: Median prelecture and postlecture quiz scores for four first-year radiology residents were 29% and 75%, for two second-year radiology residents were 29% and 63%, for two third-year radiology residents were 17% and 71%, and for three fourth-year radiology residents were 42% and 80%. CONCLUSION: Multiple areas of opportunity to foster LGBTQIA+ inclusion at the provider and administration levels currently exist throughout the field of radiology. A radiology-focused education module regarding clinical nuances, health care inequities, and ways to foster an inclusive environment with the LGBTQIA+ community is an effective way to promote learner knowledge.

Strategies for managing periodontal inflammation.

Most of the tissue destruction in periodontal disease is caused by the patient's inflammatory response. Classical approaches to controlling inflammation rely on attempts to eliminate pathogenic bacteria that incite the inflammatory response through mechanical or chemical means. This approach still has a place in treating periodontal inflammation today. Emerging and future approaches will rely more on modifying the inflammatory response itself, by limiting the activity of proinflammatory pathways and by amplifying pathways that resolve inflammation.

Endovascular Management of Intracranial Vertebral Artery Dissection: Technical Nuances for the Preservation of Posterior Inferior Cerebellar Artery and Basilar Artery.

BACKGROUND: The treatment of intracranial vertebral artery dissection (VAD) can be challenging. OBJECTIVE: To evaluate the clinical presentation, endovascular treatment techniques, and prognostic outcome of patients diagnosed with intracranial VAD at our institution. METHODS: A retrospective analysis of 35 patients who were diagnosed with VAD at our institution over 17-yr period (2001-2017) is presented. A total of 27 patients with a total of 30 affected arteries underwent endovascular treatment, and their outcome was evaluated. RESULTS: Of the 35 total patients with VAD, 15 presented with headache, 12 with focal neurological deficits, 2 with neck pain, 2 with dizziness, 1 with syncope, and 3 after trauma. Of the 30 dissected arteries, 18 were treated with deconstruction and 12 were treated with stent reconstruction. Treatment method was determined by the dominance of the affected artery and location relative to the ipsilateral posterior inferior cerebellar artery (PICA) and the basilar artery. Deconstructive techniques were utilized in all cases of hypoplastic artery dissection and the majority of codominant artery dissections, whereas reconstruction was performed on the majority of dominant artery dissections. Rupture did not impact treatment technique. Four patients demonstrated post-treatment infarcts, and another 1 patient died because of intraparenchymal bleed. The remaining 22 patients demonstrated favorable clinical outcome. None of the patients developed recanalization or needed retreatment till the last follow-up. CONCLUSION: This study suggests that endovascular treatment of intracranial VAD with deconstruction or stent reconstruction based on the patients anatomy, particularly vessel dominance and location with respect to PICA, is feasible and effective though the revascularization procedures still has its role in selected cases.

Neuroendovascular Cerebral Sinus Stenting in Idiopathic Intracranial Hypertension.

Idiopathic intracranial hypertension (IIH) is a rare, ill-understood disease of significant morbidity. Because the pathophysiology is poorly understood, treatment protocols are not uniform and are directed towards alleviating the most common symptoms: headache and visual loss. In this review, we analyze 25 case series, all of which included IIH patients (n = 408) who were treated with placement of a venous sinus stent. Among 342 patients who had headache, 240 patients (70.2%) had improvement or resolution of headache after the stent insertion. Of the 217 patients documented to have visual problems, visual acuity was improved or stabilized in 161 patients (74.2%). Of the 304 patients with papilledema, 257 showed resolution or improved (84.5%). Of the 124 patients who presented with pulsatile tinnitus, it was resolved in 110 patients (88.7%) after stent placement. Endovascular management of dural sinus stenosis is therefore clinically efficacious in patients with IIH who have failed medical and surgical therapy.

Updates in the Management of Cerebral Infarctions and Subarachnoid Hemorrhage Secondary to Intracranial Arterial Dissection: A Systematic Review.

OBJECTIVE: Intracranial arterial dissection (IAD) is a rare cerebrovascular disease that is likely underdiagnosed because of the inherent difficulty of visualizing the subtle radiographic signs of the pathologic small intracranial arteries. No widespread consensus exists on the treatment of IAD, and thus it is often managed empirically because of the absence of major randomized controlled trials. In this study, we conducted a systematic review to evaluate the management and treatment options for IAD. METHODS: We performed a systematic review in accordance with the PRISMA guidelines using the following databases: MEDLINE (PubMed) and Cochrane Library. Included studies were limited to human patients with dissections in intracranial vessels only. RESULTS: A total of 82 studies were included in this systematic review. The most common complications of IAD were cerebral infarction and subarachnoid hemorrhage, and thus, patients with IAD can be subdivided into those presenting with either ischemia or hemorrhage, respectively. Those with ischemia were predominantly managed with antiplatelet therapy, whereas patients presenting with hemorrhage often were amenable to treatment with endovascular techniques. CONCLUSIONS: Given these findings, clinicians should prescribe antiplatelet therapy for patients with IAD presenting with ischemia and consider endovascular treatment for those presenting with hemorrhage. However, further investigation is required given the heterogeneity of methods and reporting outcomes in the investigated studies.

The art and science of periodontal prognosis.

In this paper, periodontal literature related to making a periodontal prognosis is reviewed. Factors that can influence both an overall and tooth-specific prognosis are enumerated. Factors influencing the overall periodontal prognosis include age, genetics, oral hygiene, systemic conditions, and tobacco use. Tooth-specific influences include the amount of attachment loss, crown:root ratio, position in the arch, and presence or absence of furcation invasions. These factors are then synthesized into a scheme for determining a periodontal prognosis.

Endovascular treatment of a ruptured giant serpentine aneurysm of the superior cerebellar artery in a patient with a Chiari II malformation.

We present a case of a ruptured giant serpentine aneurysm (GSA) of the superior cerebellar artery in a patient with a Chiari II malformation. The fusiform aneurysm was successfully treated with endovascular parent artery occlusion of the GSA by using detachable coils.

Using community-based protocols to prevent dental disease in people with special needs: periodontal prevention and intervention.

This paper discusses preventing and treating periodontal diseases in people with special needs.