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ObjectiveThe 2020 coronavirus disease 2019 (COVID-19) pandemic resulted in state-specific quarantine protocols and introduced the concept of social distancing into modern parlance. We assess the impact of the COVID-19 pandemic on neurotrauma presentations in the first 3 months after shutdown throughout Pennsylvania.MethodsThe Pennsylvania Trauma Systems Foundation was queried for registry data from the Pennsylvania Trauma Outcomes Study between March 12 and June 5 in each year from 2017 to2020.ResultsAfter the COVID-19 shutdown, there was a 27% reduction in neurotrauma volume, from 2680 cases in 2017 to 2018 cases in 2020, and a 28.8% reduction in traumatic brain injury volume. There was no significant difference in neurotrauma phenotype incurred relative to total cases. Injury mechanism was less likely to be motor vehicle collision and more likely caused by falls, gunshot wound, and recreational vehicle accidents (P < 0.05). Location of injury was less likely on roads and public locations and more likely atindoor private locations (P < 0.05). The proportion of patients with neurotrauma with blood alcohol concentration >0.08 g/dL was reduced in 2020 (11.4% vs. 9.0%; P < 0.05). Mortality was higher during 2020 compared with pre-COVID years (7.7% vs. 6.4%; P < 0.05).ConclusionsDuring statewide shutdown, neurotrauma volume and alcohol-related trauma decreased and low-impact traumas and gunshot wounds increased, with a shift toward injuries occurring in private, indoor locations. These changes increased mortality. However, there was not a change in the types of injuries sustained.

Background Lung carcinoma metastasizing to a skull base meningioma remains an extremely rare phenomenon, with only 3 studies reported. Furthermore, no documented cases have been reported in the petroclival region. Thus, we have presented the first 2 cases of tumor-to-tumor metastasis (TTM) in which a petroclival lesion, initially thought to be purely meningioma, was also found to contain metastatic lung adenocarcinoma. Case Description We present the cases of 2 patients with a known history of lung adenocarcinoma and stable petroclival meningioma who had presented with new-onset neurologic deficits. Repeat imaging studies for both patients found an increased lesion size and peritumoral enhancement; thus, both patients underwent emergent craniotomy for complete lesion resection. Intraoperatively, both lesions had zones of markedly different tumoral texture. On histologic analysis, both lesions showed metastatic lung adenocarcinoma contained within the primary petroclival meningioma. Conclusion Skull base TTM is a rare entity for which no specific management guidelines have been created. Therefore, even if the imaging characteristics suggest a more benign process, skull base TTM should remain high on the differential diagnosis for patients with a known primary cancer and new-onset, rapidly progressive, neurologic deficits. Close clinical follow-up with short-interval repeat imaging in this subset of patients might prevent misdiagnosis and facilitate prompt treatment.

Background Transradial access (TRA) has recently gained traction as the preferred approach in a variety of neurointerventions after studies have demonstrated equivalent outcomes with fewer complications than transfemoral access (TFA). However, multiple access sites are occasionally necessary when simultaneous selective catheterization of 2 vessels is required. We present the first cases detailing bilateral TRA for complex posterior circulation interventions. Case Descriptions All neuroendovascular cases in which bilateral TRA was obtained at the University of Miami/Jackson Health System were reviewed. Two patients, each with complex left vertebral artery aneurysms, were identified. In each case, bilateral TRA was chosen because 1) left vertebral artery catheterization via right TRA can be technically challenging; 2) simultaneous catheterization of both vertebral arteries was felt to be necessary; 3) prior angiograms had demonstrated that the subclavian arteries would provide the most direct, anatomically feasible access route; and 4) the primary surgeon preferred to avoid TFA. Right TRA and left distal transradial access via the anatomic snuffbox were obtained in both cases to allow both arms to sit on the operator side of the table. Neither patient experienced any perioperative complications. Conclusions Bilateral TRA can be an effective method for catheterizing both vertebral arteries during complex posterior circulation interventions and obviates the need for TFA when multiple arterial access sites are required. Furthermore, distal transradial access allows the left hand to remain more anatomically neutral while being positioned on the right side of the table so that both access sites remain ergonomically favorable for the interventionalist.

Background Intracranial pseudoaneurysms (PSAs) are associated with high rupture and mortality rates and have traditionally been treated by parent vessel sacrifice. There has been recent interest in using flow-diverting devices for treatment of these complex lesions while preserving flow through the parent artery. The objective of this study is to examine the safety and efficacy of these devices in the treatment of intracranial PSA. Methods We performed a multi-institutional retrospective study of intracranial PSAs treated with the Pipeline Embolization Device (PED) between 2014 and 2017 at 7 institutions. Complications and clinical and radiographic outcomes were reviewed. Results A total of 19 patients underwent PED placement for intracranial PSA. Iatrogenic injury and trauma comprised most etiologies in our series. The mean pseudoaneurysm diameter was 8.8 mm, and 18 of 19 PSAs (95%) involved the internal carotid artery (ICA). Multiple PEDs were deployed in a telescoping fashion in 7 patients (37%). Of the 18 patients with follow up imaging, 14 (78%) achieved complete pseudoaneurysm obliteration and 2 achieved near-complete obliteration (11%). Two patients (11%) were found to have significant pseudoaneurysm progression on short-term follow-up and required ICA sacrifice. No patients experienced new neurologic deficits or deterioration secondary to PED placement. No patients experienced bleeding or rebleeding from PSA. Conclusions In well-selected patients, the use of flow-diverting stents may be a feasible alternative to parent vessel sacrifice. Given the high morbidity and mortality associated with PSA, we recommend short- and long-term radiographic follow-up for patients treated with flow-diverting stents.

Shorter hospital stays have been associated with decreased complication rates, fewer hospital-acquired infections, and lower costs. We evaluated an optimized treatment paradigm for patients undergoing craniotomy allowing for postoperative day 1 (POD1) discharge if the criteria were met. We compared the complication and readmission rates between the POD1 patients and those with longer stays, and examined the patient and surgical variables for predictors of POD1 discharge.We performed a retrospective review of craniotomies performed for tumor from 2011 to 2015. Craniotomies for tumors were included, and laser ablations and biopsies were excluded.A total 424 of patients were included, 132 (31%) of whom had been discharged on POD1. The mean length of stay was 6 days. The POD1 patients had had significantly better preoperative Karnofsky performance scale scores (P0.0001) and modified Rankin scale scores (P0.0001). Patient frailty, measured using the modified frailty index, was negatively predictive of POD1 discharge (P = 0.0183). Surgical factors predictive of early discharge were awake surgery (P0.0001) and supratentorial location (P0.0001). No POD1 patients experienced deep venous thrombosis (DVT), pulmonary embolus (PE), or urinary tract infections. However, of the patients with a length of stay1 day, 4.4% and 2.7% developed DVT or PE (P = 0.0119) and urinary tract infections (P = 0.0202), respectively. Multivariate regression identified patient factors (male gender, low preoperative modified Rankin scale score), tumor factors (right-sided, supratentorial, smaller size), lower modified frailty index score, and operative factors (lack of a cerebrospinal fluid drain, awake surgery) as independent predictors of successful early discharge.Patients with good functional status can be safely discharged on POD1 after tumor craniotomy if the appropriate postoperative criteria have been met. Patients with early discharge had lower 30-day readmission and DVT/PE rates, likely owing to better baseline health status.

Background The distal transradial approach (dTRA) is being widely adopted by interventional cardiologists, primarily owing to reduced morbidity and mortality from access site complications. The distal radial artery has advantages over standard radial access in relation to procedural positioning and radial artery preservation, particularly in patients who may require multiple angiograms. One disadvantage is the smaller diameter of the artery with more challenging puncture of a smaller, weaker artery. We demonstrate the feasibility of dTRA in 2 patients who underwent successful diagnostic angiography and mechanical thrombectomy. Case Description Two patients underwent dTRA for neurointerventions. In patient 1, a 5-F Glidesheath Slender and a Sim2 catheter were used for a 6-vessel cerebral angiogram. In patient 2, an 0.88-inch sheathless guide catheter was used to perform a mechanical thrombectomy. Successful hemostasis in both cases was achieved with a Safeguard Radial Compression Device; no complications were observed. Conclusions Neurovascular access via dTRA is feasible, and further exploration is warranted.

Background Acute ischemic stroke in pregnancy is a cause of maternal and fetal morbidity. Optimal treatment strategies for stroke in this population are undefined. Thrombolysis is recommended by guidelines should the benefit outweigh uterine bleeding risk. Alternately, data regarding mechanical thrombectomy (MT) is extremely limited. We present a 37-year-old woman in the first trimester that developed recurrent proximal middle cerebral artery (MCA) occlusion after previous thrombolysis and underwent MT via transradial access. This report of transradial MT represents the first case performed through an extrafemoral route for large vessel occlusion in early pregnancy found in the literature. Case Description A 37-year-old gravida 8 para 7 at 9 weeks' gestation presented with left-sided hemiplegia and right gaze preference and underwent successful thrombolysis for a right MCA occlusion. Two days later, she exhibited the same symptoms, and a reoccluded right MCA was identified. Because thrombolysis was unavailable given the recent stroke, the patient underwent emergent MT via radial access (to minimize fetal radiation exposure) and achieved thrombolysis in cerebral infarction 2b revascularization without complication to her or her child. At 2-month follow-up, the patient is on anticoagulation and has a healthy pregnancy with only minor left-sided facial weakness. Conclusions When thrombolysis is contraindicated, thrombectomy should be considered and weighed against risks of fetal radiation exposure and contrast load, especially in early pregnancy. Transradial MT is safe, feasible, and mitigates pelvic radiation. A multidisciplinary approach with obstetrics, stroke teams, and neurointerventionalists is vital for successful therapy.

Background Reperfusion time influences patient outcome in mechanical thrombectomy for large vessel occlusion. We analyzed anatomic features that could be used to make preoperative and intraoperative decisions to minimize revascularization time. Methods We reviewed a prospectively maintained database for patients with stroke evaluated from February 2015 to July 2016. Patients received a score based on bovine arch, aortic arch, and internal carotid artery dolichoarteriopathy (B.A.D. score), which we correlated with procedural times and outcomes. Univariate analysis was performed to identify predictors of procedural times, revascularization, complications, and outcome. Relevant variables were assessed via multivariate regression. Results We identified 61 patients (31 men) who underwent transfemoral thrombectomy. Mean puncture to reperfusion time was 46 minutes. Age >75 years (odds ratio [OR] = 3.98; 95% confidence interval [CI], 1.17–13.54; P = 0.027) and high B.A.D. score (OR = 2.55; 95% CI, 1.17–5.57; P = 0.019) were significant predictors of puncture to reperfusion time >40 minutes. Mean puncture to first-pass time was 24 ± 14.2 minutes. Age >65 years (OR = 4.68; 95% CI, 1.07–20.55; P = 0.041) and high B.A.D. score (OR = 2.84; 95% CI, 1.18–6.85; P = 0.020) were independently predictive of time to first pass >20 minutes. Lower scores predicted higher Thrombolysis In Cerebral Infarction score (OR = 0.07; 95% CI, 0.01–0.81; P = 0.033). Higher scores predicted hemorrhagic transformation (OR = 4.8; 95% CI, 1.19–12.29; P = 0.024) and modified Rankin Scale score >4 (OR = 3.0; 95% CI, 1.15–7.92; P = 0.025) after thrombectomy. Conclusions Bovine variation, aortic arch type, and internal carotid artery dolichoarteriopathy are associated with increased revascularization time and poor outcomes in thrombectomy. We developed the B.A.D. score to predict reperfusion time and outcomes, demonstrating need for preoperative anatomic evaluation to guide treatment.

Obesity is an established risk factor for the development of acute ischemic stroke. However, its effect on clinical outcomes after acute ischemic stroke has remained controversial. In the present study, we evaluated the association of body mass index (BMI) on outcomes after mechanical thrombectomy (MT) for large vessel occlusion acute ischemic stroke (LVOS).We reviewed our prospective endovascular database for patients who had undergone MT for LVOS from 2015 to 2018. The BMI was analyzed as a continuous and categorical variable, with the latter defined as BMI,18.5 kg/mA total of 335 patients had undergone MT, with 7 (2.1%) classified as underweight, 107 (31.9%) normal, 141 (42.1%) overweight, and 80 (23.9%) obese. The procedural times, techniques, and reperfusion success (treatment in cerebral infarction score2b) were not significantly different among the BMI categories. A significant inverse linear correlation was found between the BMI and symptomatic hemorrhagic. For patients with successful reperfusion (treatment in cerebral infarction score2b), we also found a significant bell-shaped relationship between the BMI and functional independence (modified Rankin scale score3), with high and low BMIs associated with worse outcomes. For patients without post-MT symptomatic hemorrhage, a significant linear correlation was found between BMI and inpatient mortality.For LVOS patients treated with MT, a high BMI will not affect procedural success. However, it was independently associated with lower rates of functional independence in recanalized patients. Thus, the obesity paradox does not appear to pertain to MT, although larger prospective studies are necessary.

Treatment for surgically inaccessible medically refractory cerebral radiation necrosis (RN) has remained limited. Recently, laser interstitial thermal therapy (LITT) has gained traction as an effective means of treating these lesions but limited data are available regarding the effect of ablation size on patient outcome. Therefore, this study analyzed various outcome measures as a function of ablation volume/diameter for a series of 20 patients with surgically inaccessible biopsy-proven RN.Twenty patients with biopsy-proven RN treated with LITT from 2013 to 2018 at our institution were retrospectively reviewed. Local progression-free survival (PFS), overall survival, and steroid dependence were analyzed with Kaplan-Meier and Cox regression analysis for ablation volume/diameter. Comparison of preoperative and postoperative Karnofsky Performance Status was conducted with a matched paired t test.Patients with subtotal ablation (100% increase in pre-LITT lesion volume or0 mm increase in pre-LITT lesion diameter) had higher risk of local disease progression (hazard ratio, 12.4; P = 0.004) compared with patients with total ablations. Patients who received radical ablations (200% increase in pre-LITT lesion volume or2 mm increase in pre-LITT lesion diameter) showed the most favorable PFS (P0.0458 and P0.0378, respectively). There was no difference in post-LITT Karnofsky Performance Status and time to steroid freedom between ablation groups. Overall survival increased with radical diametric ablation (P = 0.0401).Although LITT has proved to be an effective salvage therapy for patients with RN, detailed volumetric studies have not been explored. Our results suggest that radical ablations have the potential to increase PFS.