Search

Regenerating Family Member 3 Alpha (REG3A) is an antimicrobial protein secreted by the intestine and pancreas with additional immunomodulatory properties. Previously, we published that REG3A expression in ischemic stroke patient systemic blood, during mechanical thrombectomy (MT), is significantly associated with inflammatory cytokines and patient function on admission. This paper, however, did not investigate post-acute death rates. Therefore, we investigated plasma REG3A protein expression, during MT, in patients (n = 141) that survived or died within the end of the follow-up after MT. Subjects who died had significantly higher systemic plasma REG3A levels at the time of MT compared to survivors (p = 0.001). Age, sex, time from last known normal, and admission NIHSS were included as predictors to control for confounding variables and were all examined to determine their association in patient mortality. Logistic regression was used to demonstrate that higher odds of death were associated with increased REG3A levels (p = 0.002). REG3A demonstrated acceptable discrimination (AUC (95% CI): 0.669 (0.566–0.772) in predicting mortality. The overall model with age, sex, time from last known normal, and admission NIHSS discriminated well between survivors and those who died (AUC (95% CI): 0.784 (0.703–0.864)). In conclusion, REG3A could be promising as a biomarker to prognosticate stroke outcomes and stratify high-risk groups following acute ischemic stroke. [ABSTRACT FROM AUTHOR]

The last 10 years have seen a major shift in management of large vessel ischemic stroke with changes towards ever-expanding use of reperfusion therapies (intravenous thrombolysis and mechanical thrombectomy). These strategies 'open the door' to acute therapeutics for ischemic tissue, and we should investigate novel therapeutic approaches to enhance survival of recently reperfused brain. Key insights into new approaches have been provided through translational research models and preclinical paradigms, and through detailed research on ischemic mechanisms. Additional recent clinical trials offer exciting salvos into this new strategy of pairing reperfusion with neuroprotective therapy. This pairing strategy can be employed using drugs that have shown neuroprotective efficacy; neurointerventionalists can administer these during or immediately after reperfusion therapy. This represents a crucial moment when we emphasize reperfusion, and have the technological capability along with the clinical trial experience to lead the way in multiprong approaches to stroke treatment. [ABSTRACT FROM AUTHOR]

• Webinar increased insight into neurosurgery and the path to become a neurosurgeon. • There is a substantial appetite for virtual content related to neurosurgery. • USMSs, IMSs, and undergraduates have different motivations for webinar attendance. • Webinar format may effectively provide international exposure to neurosurgery. During the COVID-19 pandemic, the American Association of Neurological Surgeons (AANS) Young Neurosurgeons Committee (YNC) and Neurosurgery Research & Education Foundation (NREF) launched the YNC-NREF Webinar Series to provide young and aspiring neurosurgeons with timely information, education, and inspiration in the absence of in-person programming. Five 90-minute Zoom webinars were evaluated, each including 1–2 keynote speakers, a panel discussion, and an audience question-and-answer section. Topics included overviews of neurosurgery, the match, subspecialties, and inspirational career stories. Optional pre- and post-webinar surveys with 11-point Likert-type scores were distributed to attendees. We compared groups using chi-squared and Kruskal-Willis tests, and perceptions pre- and post-webinar using Mann-Whitney tests. The webinars were live using Zoom, and the recordings were published on NREF's YouTube channel. The webinar series targeted young neurosurgeons. The first five episodes had a particular focus on medical students and undergraduates. A total of 673 unique participants attended the webinar series; 257 (38%) and 78 (11%) attendees completed the pre- and post-webinar survey, respectively. Respondents had high baseline interest in neurosurgery and were motivated to learn about the match and training in the US, understand neurosurgeons' day-to-day lives, and ask questions. There were significant differences in perceptions between USMSs, IMSs, and undergraduate students. The webinar improved attendees' knowledge about neurosurgical specialties, the match, and US neurosurgery training. The YNC and NREF effectively engaged a large, diverse audience through an online webinar series, building a foundation for future virtual programming by organized neurosurgery. ACGME competencies. 1. Medical Knowledge. 2. Professionalism. 3. Interpersonal Skills and Communication. [ABSTRACT FROM AUTHOR]

Background: Emergent Large Vessel Occlusion (ELVO) stroke causes devastating vascular events which can lead to significant cognitive decline and dementia. In the subset of ELVO subjects treated with mechanical thrombectomy (MT) at our institution, we aimed to identify systemic and intracranial proteins predictive of cognitive function at time of discharge and at 90-days. These proteomic biomarkers may serve as prognostic indicators of recovery, as well as potential targets for novel/existing therapeutics to be delivered during the subacute stage of stroke recovery. Methods: At the University of Kentucky Center for Advanced Translational Stroke Sciences, the BACTRAC tissue registry (clinicaltrials.gov; NCT 03153683) of human biospecimens acquired during ELVO stroke by MT is utilized for research. Clinical data are collected on each enrolled subject who meets inclusion criteria. Blood samples obtained during thrombectomy were sent to Olink Proteomics for proteomic expression values. Montreal Cognitive Assessments (MoCA) were evaluated with categorical variables using ANOVA and t-tests, and continuous variables using Pearson correlations. Results: There were n = 52 subjects with discharge MoCA scores and n = 28 subjects with 90-day MoCA scores. Several systemic and intracranial proteins were identified as having significant correlations to discharge MoCA scores as well as 90-day MoCA scores. Highlighted proteins included s-DPP4, CCL11, IGFBP3, DNER, NRP1, MCP1, and COMP. Conclusion: We set out to identify proteomic predictors and potential therapeutic targets related to cognitive outcomes in ELVO subjects undergoing MT. Here, we identify several proteins which predicted MoCA after MT, which may serve as therapeutic targets to lessen post-stroke cognitive decline. [ABSTRACT FROM AUTHOR]

Background Emergent large vessel occlusion (ELVO) acute ischemic stroke is a time- sensitive disease. Objective To describe our experience with artificial intelligence (AI) for automated ELVO detection and its impact on stroke workflow. Methods We conducted a retrospective chart review of code stroke cases in which VizAI was used for automated ELVO detection. Patients with ELVO identified by VizAI were compared with patients with ELVO identified by usual care. Details of treatment, CT angiography (CTA) interpretation by blinded neuroradiologists, and stroke workflow metrics were collected. Univariate statistical comparisons and linear regression analysis were performed to quantify time savings for stroke metrics. Results Six hundred and eighty consecutive code strokes were evaluated by AI; 104 patients were diagnosed with ELVO during the study period. Forty-five patients with ELVO were identified by AI and 59 by usual care. Sixty-nine mechanical thrombectomies were performed. Median time from CTA to team notification was shorter for AI ELVOs (7 vs 26 min; p<0.001). Door to arterial puncture was faster for transfer patients with ELVO detected by AI versus usual care transfer patients (141 vs 185 min; p=0.027). AI yielded a time savings of 22 min for team notification and a 23 min reduction in door to arterial puncture for transfer patients. Conclusions AI automated alerts can be incorporated into a comprehensive stroke center hub and spoke system of care. The use of AI to detect ELVO improves clinically meaningful stroke workflow metrics, resulting in faster treatment times for mechanical thrombectomy. [ABSTRACT FROM AUTHOR]

Evidence is growing to support minimally invasive surgical evacuation of intraparenchymal hematomas, particularly those with minimal residual hematoma volumes following evacuation. To maximize the potential for neurologic recovery, it is imperative that the trajectory for access to the hematoma minimizes disruption of normal parenchyma. Flat panel detector CT-based navigation and needle guidance software provides a platform that uses flat panel detector CT imaging obtained on the angiography table to aid reliable and safe access to the hematoma. In addition to providing a high degree of accuracy, this method also allows convenient and rapid re-imaging to assess navigation accuracy and the degree of hematoma evacuation prior to procedural completion. We provide a practical review of the syngo iGuide needle guidance software and the methodology for incorporating its use, and the software of other vendors, in a variety of minimally invasive methods for evacuation of intraparenchymal hematomas. [ABSTRACT FROM AUTHOR]

Background and Purpose: Quantitative electroencephalogram (QEEG) parameters have been previously utilized in prognosis following acute ischemic stroke (AIS). However, the use and interpretation of QEEG parameters remain scarce following endovascular treatment (EVT) of AIS. Methods: AIS patients were prospectively enrolled following EVT, and 24-hour EEG monitoring was conducted. Global delta/alpha ratio (DAR), (delta + theta)/(alpha + beta) ratio (DTABR), and relative band power were analyzed. Primary outcome was a poor outcome (modified Rankin Scale ≥4 at 90-day follow-up). Multivariate logistic regression and diagnostic analyses were performed. Results: Poor outcome was seen in 35.5% (11/31) of enrolled patients. Multivariable logistic regression identified that higher DAR (OR 1.10, 95% CI 1.02–1.18, p = 0.02) and higher DTABR (OR 1.13, 95% CI 1.01–1.27, p = 0.02) were associated with poor outcome. DAR ≥14.3 demonstrated high sensitivity (90.9%), specificity (90.0%) and accuracy (90.3%) for poor outcome. Conclusions: Early evidence of elevated DAR and DTABR on quantitative EEG was associated with poor outcome at 90 days following EVT for AIS. [ABSTRACT FROM AUTHOR]

Intravenous thrombolysis elevates the prognostic level of acute ischemic stroke (AIS) patients. Normobaric hyperoxia (NBO) delays the progression of the infarct core and promotes neurological recovery. However, it is uncertain whether NBO can further raise the prognostic level of AIS patients based on intravenous thrombolysis. To explore the efficacy and safety of NBO combined with intravenous thrombolysis on AIS patients. This observational study included anterior circulation stroke patients who received intravenous thrombolysis within 4.5 h after stroke onset. These patients were divided into two groups based on whether or not they received NBO therapy. The baseline data and the prognosis of the two groups were compared. The primary outcome was the proportion of functional independence (modified Rankin Scale 0–2) at 90 days post discharge. A total of 227 patients were included in this study. 125 patients received NBO therapy combined with intravenous thrombolysis, while 102 patients received intravenous thrombolysis only. Overall, the rate of recanalization was 83.3%. Consequently, 101 patients (80.8%) who received NBO combined with intravenous thrombolysis and 63 patients (61.8%) in the control group achieved functional independence (P = 0.002). Multivariable logistic regression analysis showed that NBO combined with intravenous thrombolysis over intravenous thrombolysis alone was associated with 90-day functional independence (OR: 2.318; 95% CI: 1.226–4.381; P = 0.01). This study verified the efficacy and safety of NBO combined with intravenous thrombolysis in AIS patients. Prospective study is needed to further substantiate these findings. [ABSTRACT FROM AUTHOR]

Cerebral cortical vein thrombosis (CCVT) is often misdiagnosed because of its non-specific diagnostic symptoms. Here, we analyzed a cohort of patients with CCVT in hopes of improving understandings and treatments of the disease. A total of 23 patients with CCVT (confirmed with high-resolution imaging), who had been diagnosed between 2017 and 2019, were enrolled in this cohort study. Baseline demographics, clinical manifestations, laboratory data, radiological findings, treatment, and outcomes were collected and analyzed. Fourteen females and nine males were enrolled (mean age: 32.7 ± 11.9 years), presenting in the acute (within 7 days, n = 9), subacute (8–30 days, n = 7), and chronic (over 1 month, n = 7) stages. Headaches (65.2%) and seizures (39.1%) were the most common symptoms. Abnormally elevated plasma D-dimers were observed in the majority of acute stage patients (87.5%). The diagnostic accuracy of contrast-enhanced magnetic resonance venography (CE-MRV) and high-resolution magnetic resonance black-blood thrombus imaging (HR-MRBTI) in detecting CCVT were 57.1 and 100.0%, respectively. All patients had good functional outcomes after 6-month of standard anticoagulation (mRS 0–1) treatment. However, four CCVT patients that had cases involving multiple veins showed symptom relief after batroxobin therapy (p = 0.030). HR-MRBTI may be a fast and accurate tool for non-invasive CCVT diagnosis. HR-MRBTI combined with D-dimer can also precisely identify the pathological stage of CCVT. Batroxobin may safely accelerate cortical venous recanalization in combination with anticoagulation. Follow-up studies with larger sample sizes are suggested to evaluate the safety and efficacy of batroxobin for treating CCVT. [ABSTRACT FROM AUTHOR]

Background To evaluate anatomical and clinical factors that make trans- radial cerebral angiography more difficult. Methods A total of 52 trans- radial diagnostic angiograms were evaluated in a tertiary care stroke center from December 2019 until March 2020. We analyzed a number of anatomical variables to evaluate for correlation to outcome measures of angiography difficulty. Results The presence of a proximal radial loop had a higher conversion to femoral access (p<0.03). The presence of a large diameter aortic arch (p<0.01), double subclavian innominate curve (p<0.01), left proximal common carotid artery (CCA) loop (p<0.001), acute subclavian vertebral angle (p<0.01), and absence of bovine aortic arch anatomy (p=0.03) were associated with more difficult trans- radial cerebral angiography and increased fluoroscopy time-per-vessel. Conclusion The presence of a proximal radial loop, large diameter aortic arch, double subclavian innominate curve, proximal left CCA loop, acute subclavian vertebral angle, and absence of bovine aortic arch anatomy were associated with more difficult trans- radial cerebral angiography. We also introduce a novel grading scale for diagnostic trans- radial angiography. [ABSTRACT FROM AUTHOR]

• Anatomic risk factors increased post-operative stroke and MI risk. • Contralateral ICA stenosis increased post-operative stroke and MI risk. • Physiologic risk factors increased post-operative MI and arrhythmia risk. • Severe contralateral ICA stenosis increased postoperative carotid restenosis rate. Carotid artery stenosis accounts for up to 20% of ischemic strokes. Since the 1950 s, one of the primary surgical treatment for this condition is carotid endarterectomy (CEA). Because of improvement of medical therapy for carotid artery atherosclerosis and the increased use of carotid artery stents, CEA is indicated if the risk of stroke and death are low. The goal of this study is to characterize the impact of pre-operative stroke and stroke risk factors on post-operative CEA patient outcomes, using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Vascular Module on CEA. Using the Targeted Vascular Module of the ACS-NSQIP, 22,116 patients who underwent CEA were identified from 2011 to 2016. Univariate analysis and multivariable logistic regression analyses were conducted to identify significant risk factors that predispose patients to stroke. Patients with pre-operative stroke comprise 42.1% of the group, with post-operative stroke being the second most common complication (2.1%). Pre-operative stroke patients were also at a higher risk for transient ischemic attacks, post-operative restenosis, post-operative distal embolization, and other complications. Patients with pre-operative risk factors, including stroke or stroke-like symptoms, high risk physiologic factors, high risk anatomic factors, and contralateral internal carotid artery stenosis were at a higher risk of developing post-operative stroke and other complications. Patients with these pre-operative risk factors should be closely monitored for post-operative complications in an effort to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Inadvertent arterial placement of central venous catheters carries serious sequelae, including pseudoaneurysm development and stroke. Although numerous strategies for therapeutic repair after arterial injury have been employed, no treatment provides a definitive standard of care. All articles published between January 2000 and July 2018 involving the placement of central venous catheters in the brachiocephalic or subclavian arteries, carotid artery, vertebral artery, and aortic arch and subsequent treatment were systematically reviewed. Arterial repair consisted of manual pressure, endovascular techniques (balloon tamponade, percutaneous closure devices, and covered stent placement), and open surgery. Success rates favored endovascular techniques and surgery over manual compression. [ABSTRACT FROM AUTHOR]

Provided certain anatomic considerations, stent-assisted coiling of basilar apex aneurysms can be performed using a single stent placed in a horizontal T-configuration across the aneurysm neck prior to coil deployment, although this has predominantly been described using older-generation stents. The development of the Low-profile Visualized Intraluminal Support (LVIS Jr) device has provided greater versatility than previous stents, including use in smaller vessels, the ability to be resheathed, and improved flow diversion properties. To our knowledge, we report the first use of the LVIS Jr device in a horizontal T-configuration across the aneurysm neck prior to coil deployment in 2 patients for the treatment of basilar apex aneurysms. This technique requires robust posterior communicating artery aneurysms and a second site of vascular access. Both patients demonstrated good outcomes following the procedure with no adverse sequelae. One patient required retreatment for recurrence after 1 year and was able to undergo further coiling without difficulty. Use of the LVIS Jr device allows greater versatility in horizontal T-configuration stent-assisted coil embolization, when compared with other available intracranial stents. This provides another tool to treat basilar apex aneurysms with improved coil occlusion and a theoretically decreased risk of thromboembolic events. [ABSTRACT FROM AUTHOR]

Myelopathy of the dorsal columns is a rare complication of intrathecal (IT) chemotherapy that occurs most frequently with IT methotrexate and cytarabine. This diagnosis is made with a combination of magnetic resonance imaging, somatosensory evoked potentials, and elevated cerebrospinal fluid (CSF) protein levels, particularly myelin basic protein. A 73-year-old man with blastic plasmacytoid dendritic cell neoplasm and known central nervous system involvement underwent standard treatment, including 5 doses of IT cytosine arabinoside. Following this, he had documented CSF clearance of disease. One year later, he developed progressive lower extremity weakness, numbness, and bowel/bladder dysfunction. Magnetic resonance imaging and repeat CSF analysis demonstrated recurrence, and he underwent further IT administration of methotrexate and cytarabine. CSF clearance of malignant cells was again established. However, weakness progressed to quadriplegia; loss of bowel/bladder control; and severe sensory loss, particularly vibration and proprioception. Repeat magnetic resonance imaging demonstrated high signal intensity in bilateral posterior columns. A lower thoracic spine dorsal column biopsy revealed cord destruction and diffuse macrophage infiltration with profound destruction of the neuropil. Although dorsal column myelopathy has previously been described in association with IT chemotherapy, this has solely been diagnosed on the basis of clinical examination, electrodiagnostic criteria, radiographic findings, and CSF analysis. This case provides a pathologic evaluation of an antemortem obtained specimen revealing diffuse macrophage infiltration and profound destruction of the neuropil. Whereas the mechanism underlying spinal cord toxicity following IT chemotherapy remains largely unknown, this case demonstrates a potentially macrophage-mediated process. [ABSTRACT FROM AUTHOR]

Objectives:Fractional flow reserve (FFR) accurately predicts the degree of stenosis and is now widely used to identify clinically significant severe coronary artery lesions. In the current study, we utilized a similar indicator, fractional flow (FF), to determine the hemodynamic impact of symptomatic intracranial atherosclerotic stenosis (ICAS) and to assess the correlation of FF with the severity of stenosis and collateral circulation. Methods:Patients with symptomatic ICAS (70–99% stenosis) confirmed on digital subtraction angiography (DSA) were consecutively recruited. FF was obtained during DSA examination with the use of pressure sensors and was measured as a ratio, comparing measurements distal to an ICAS lesion (Pd) and within the aorta (Pa). The degree of leptomeningeal collateralization was graded from zero (absent) to four (complete compensatory). The correlation between FF, anatomical stenosis, and collateral status was then analyzed. Results:Twenty-five patients with a mean age of 55.6 years were analyzed. The median percentage of stenosis and median FF were 82.3 and 0.68%, respectively. Eleven patients were found to have poor collateralization (grade 0-2), and fourteen patients were identified with good collateral circulation (grade 3-4). Overall, the hemodynamic impact of an atherosclerotic lesions worsened (decreased FF) as the percentage of stenosis increased, although this did not reach statistical significance (r = −0.398,p = 0.06). However, the status of collateralization significantly altered this correlation, worsening the hemodynamic impact in patients with poor collateral circulation (r = −0.677,p = 0.032). There was no difference in patients with good collateral circulation (r = −0.279,p = 0.356). Conclusion:An anatomically severe (70–99%) symptomatic ICAS lesion may generate significant hemodynamic stress downstream as assessed by the indicator FF, particularly in patients with poor collateral circulation. Further, good collateralization may mitigate this hemodynamic impact, partially explaining the protective effect of collateral circulation against recurrent stroke in such patients. [ABSTRACT FROM PUBLISHER]

Ischemic stroke is a major cause of morbidity and mortality, incurring significant cost. Intracranial atherosclerotic disease (ICAD) accounts for 10-15% of ischemic stroke in Western societies, but is an underlying pathology in up to 54% of ischemic strokes in Asian populations. ICAD has largely been treated with medical management, although a few studies have examined outcomes following endovascular treatment. Our objective was to summarize the major trials that have been performed thus far in regard to the endovascular treatment of ICAD and to provide direction for future management of this disease process. Systematic review of the literature from 1966 to 2015, was conducted in regard to intracranial angioplasty and stenting. Studies were analyzed from PubMed, American Heart Association and Society of Neurointerventional Surgery databases. SAMMPRIS and VISSIT are the only randomized controlled trials from which Western guidelines of intracranial stenting have been derived, which have displayed the superiority of medical management. However, pooled reviews of smaller studies and other nonrandomized trials have shown better outcomes with endovascular therapy in select patient subsets, such as intracranial vertebrobasilar stenosis or in the presence of robust collaterals. Suboptimal cases, including longer lesions, bifurcations and significant tortuosity tend to fair better with medical management. Medical management has been shown to be more efficacious with less adverse outcomes than endovascular therapy. However, the majority of studies on endovascular management included a diverse patient population without ideal selection criteria, resulting in higher adverse outcomes. Population analyses and selective utilization of endovascular therapy have shown that the treatment may be superior to other management in select patients. [ABSTRACT FROM AUTHOR]

In this review, we briefly introduce recent developments and updates in neurocritical care in the treatment of stroke, including both ischemic and hemorrhagic stroke. Time to recanalization remains the major rate limiting step in the treatment of acute ischemic stroke as only a minority of patients arrive within a timeframe appropriate for treatment. Whether caring for a patient following ischemic or hemorrhagic stroke, the principle focus of neurocritical care for acute brain catastrophes is the identification and prevention of secondary brain injury. While much advancement is still needed for optimum care of patients suffering from ischemic or hemorrhagic stroke, the field continues to evolve in ways that promote improved patient outcomes. [ABSTRACT FROM AUTHOR]

Background and Objective: Hypothermia has shown promise as a neuroprotective strategy for stroke. The use of whole body hypothermia has limited clinical utility due to many severe side effects. Selective brain cooling, or local brain hypothermia, has been previously proposed as an alternative treatment strategy. This study investigated the safety, feasibility, and efficacy of selective brain hypothermia induced by local infusion of ice-cold lactated Ringer's solution in rhesus monkeys. Methods: Eight male rhesus monkeys were used in this study. Brain temperature in the territory supplied by middle cerebral artery (MCA) was reduced by infusing 100 mL of ice-cold (0 °C) lactated Ringer's solution over 20 min via a micro-catheter placed in the proximal MCA (n = 4). Vital signs and the temperature of the brain and rectum were monitored before and after infusion. Transcranial Doppler, Magnetic resonance imaging (MRI), and digital subtraction angiography (DSA) were used to evaluate cerebral blood flow, cerebrovascular reactivity (CVR), cerebral edema, and vasospasm. Another cohort of rhesus monkeys (n = 4) were used as systemic cooling controls. Results: Oxygen saturation, blood pressure, heart rate, and hematologic analysis of the two groups remained within the normal range after infusion. Mild cerebral hypothermia (<35 °C) was achieved in 10 min (0.3 °C/min) and was maintained for 20 min in local cortex and striatum following local infusion. The average lowest cerebral temperature in the locally cooled animals was 33.9 ± 0.3 °C in the striatum following 20-min infusion. This was not observed in animals cooled by systemic infusion. The decreases in the rectal temperature for local and systemic infusion were 0.5 ± 0.2 °C and 0.5 ± 0.3 °C, respectively. Selective brain cooling did not cause any cerebral edema as determined by MRI or vasospasm in the perfused vessel based on DSA. Selective cerebral hypothermia did not significantly alter CVR. Conclusion: Local infusion of ice-cold lactated Ringer's solution via micro-catheter is a safe and effective method for selective cerebral hypothermia. This cooling method could potentially be developed as a new treatment in acute ischemic stroke. [ABSTRACT FROM AUTHOR]

Objectives: To determine the protective effects of remote post-conditioning on ischemic brain lesions caused by middle cerebral artery (MCA) occlusion in rats. Methods: A total of 54 animals were used in this present study. An ischemic stroke model was generated by 90-minute occlusion of right MCA (n = 42). Twelve rats were used as control for studying edema and blood-brain barrier (BBB) integrity. Remote post-conditioning was conducted immediately after MCA occlusion in the bilateral lower limb by occluding and releasing the femoral artery for three cycles; each occlusion and release lasted for 10 minutes. After 24 hours of reperfusion, the cerebral infarct volumes were quantified by 2,3,4-triphenytetrazolium-chloride, brain water content was determined by dry/wet weight method, and damage to the BBB was determined by Evans blue extravasation. Results: Remote post-conditioning significantly reduced brain infarct damage (P<0·0001). Brain edema was significantly (P<0·01) reduced after stroke in the remote post-conditioning group. BBB leakage was significantly reduced in the remote post-conditioning group when compared to the control ischemic groups (P<0·05). Conclusion: These results provide evidence that remote post-conditioning, which was initiated after ischemia and before reperfusion, protects against brain injury in experimental ischemic stroke. [ABSTRACT FROM AUTHOR]

Objective: To investigate the characteristics of transcranial Doppler variables in the acute stage of intracerebral hemorrhage (ICH) and its relationship with 14-day death and outcomes at 90 day after onset. Methods: Ninety first-time supratentorial nontraumatic ICH patients were prospectively included. Computed tomography and transcranial Doppler examinations were performed on the first, third, seventh, and fourteenth day after onset. Transcranial Doppler variables were obtained from bilateral middle cerebral arteries. The relationship between ICH outcome and the following variables were analyzed: systolic (Vs), diastolic (Vd), mean (Vm) velocities, and pulsatiliy index (PI) from affected and unaffected hemispheres. Results: Fourteen (15·6%) patients died within 14 days after onset of ICH. The stepwise logistic regression analyses proved presence of intraventricular hemorrhage (OR: 11·91; 95%CI: 1·62-87·42) and PI from unaffected hemisphere (OR: 1·64; 95%CI: 1·19-2·25) to be independent predictors of 14-day death. Forty-eight of the 90 ICH patients performed the transcranial Doppler monitoring at all four time points. Vm from both hemispheres decreased gradually within 14 days after onset. Among the 48 patients, 22 patients were dependent (modified Rankin Scale&ges;3) at 90 days after onset. Compared with patients who were independent at 90 days, Vd (F = 4·98, P = 0·03) and Vm (F = 7·30, P<0·01) from unaffected hemisphere were significantly lower, while the PI was significantly higher in patients who were dependent (F = 9·84, P<0·01). Conclusions: Presence of intraventricular hemorrhage and PI from unaffected hemisphere proved to be independent predictors of 14-day death. Sustained persistent decreases in Vd and Vm and increases in PI from the unaffected hemisphere during the acute stage may be related with dependency at 90 days. [ABSTRACT FROM AUTHOR]

Objectives: Conduction aphasia is usually considered a result of damage of the arcuate fasciculus, which is subjacent to the parietal portion of the supra-marginal gyrus and the upper part of the insula. It is important to stress that many features of conduction aphasia relate to a cortical deficit, more than a pure disconnection mechanism. In this study, we explore the mechanism of Broca-like and Wernicke-like conduction aphasia by using diffusion tensor imaging (DTI) and diffusion tensor imaging-fibre tractograph (DT-FT). Methods: We enrolled five Broca-like conduction aphasia cases, five Wernicke-like aphasia conduction cases and 10 healthy volunteers residing in Beijing and speaking Mandarin. All are right handed. We analyzed the arcuate fasciculus, Broca's areas and Wernicke's areas by DTI and measured fractional anisotrogy (FA). The results of left and right hemispheres were compared in both conduction aphasia cases and volunteers. Then the results of the conduction aphasia cases were compared with those of volunteers. The fibre construction of Broca's and Wernicke's areas was also compared by DTI-FT. Results: The FA occupied by the identified connective pathways (Broca's area, Wernicke's area and the arcuate fasciculus) in the left hemisphere was larger than that in the right hemisphere in the control group (P<0·05). Among Broca-like conduction aphasia cases, the FA of the left Broca's area was smaller than that of the right mirror side (P<0·05), and the FA of the left anterior segment of the arcuate fasciculus was smaller than that of right mirror side (P<0·05). On the other hand, among Wernicke-like conduction aphasia patients, the FA of the left Wernicke's area was smaller than that of right mirror side (P<0·05), and the FA of left posterior segment of arcuate fasciculus was smaller than that of right mirror side (P<0·05). Conclusions: Conduction aphasia results from not only arcuate fasciculus destruction, but also from disruption of the associated cortical areas. Along different segments of the arcuate fasciculus, the characteristics of language disorders of conduction aphasia were different. A lesion involving Broca's area and the anterior segments of the arcuate fasciculus would lead to Broca-like conduction aphasia, whereas a lesion involved Wernicke's area and posterior segments of the arcuate fasciculus would lead to Wernicke-like conduction aphasia. [ABSTRACT FROM AUTHOR]

Small ruptured aneurysms present a unique problem to endovascular therapy. We report a case in which a patient presented with subarachnoid hemorrhage and a very small ruptured ophthalmic artery aneurysm, for which endovascular therapy was preferred secondary to severe cardiac comorbidities. Due to the aneurysm size, a small 1.5 mm coil was needed, but presented a significant risk of migration. Conventional stent assisted coiling was considered suboptimal as the small coil could have easily migrated through the strut. We present a novel technique of flow diverter assisted coil embolization in which a coil was placed within the aneurysm and a pipeline embolization device was then partially deployed, jailing the microcatheter and coil mass. Once in place, the coil was detached, securing the aneurysm, and preventing coil migration. Through the use of a flow diverter, some degree of aneurysm protection would still be expected in the event of coil migration toward the ophthalmic artery origin. [ABSTRACT FROM AUTHOR]

Small ruptured aneurysms present a unique problem to endovascular therapy. We report a case in which a patient presented with subarachnoid hemorrhage and a very small ruptured ophthalmic artery aneurysm, for which endovascular therapy was preferred secondary to severe cardiac comorbidities. Due to the aneurysm size, a small 1.5 mm coil was needed, but presented a significant risk of migration. Conventional stent assisted coiling was considered suboptimal as the small coil could have easily migrated through the strut. We present a novel technique of flow diverter assisted coil embolization in which a coil was placed within the aneurysm and a pipeline embolization device was then partially deployed, jailing the microcatheter and coil mass. Once in place, the coil was detached, securing the aneurysm, and preventing coil migration. Through the use of a flow diverter, some degree of aneurysm protection would still be expected in the event of coil migration toward the ophthalmic artery origin. [ABSTRACT FROM AUTHOR]

Brain arteriovenous malformations (AVMs) are complex vascular lesions composed of abnormal arteries directly connected to veins without the typical intervening angioarchitecture. Rupture rates range from 2% to 4%, with that risk increasing to 4.5% per year for those presenting with hemorrhage. Mortality ranges from 12% to 66.7% after rupture, and up to 40% of survivors suffer from permanent neurologic sequelae. Treatment commonly includes a multimodality approach consisting of a combination of microsurgery, embolization, and radiosurgery. Typically, preoperative embolization is undertaken in a staged manner several days to weeks prior to microsurgical resection. We describe a series of 5 pediatric patients harboring intracranial AVMs who underwent embolization and resection in the same anesthetic event, an approach that has not yet been described in the literature. Three patients presented symptomatically, whereas 2 AVMs were discovered incidentally, and average Spetzler−Martin grade was 1.6. Average anesthesia length was 580.8 minutes, and intraoperative angiography revealed complete resection in all cases. All patients were extubated at the end of the case and were discharged and followed up with a modified Rankin Scale score of 0. We describe a novel approach to treatment of pediatric intracranial AVMs that is shown to be safe and feasible. A single anesthesia event allows for aggressive preoperative embolization without increasing the risk of hemorrhage in the waiting period until resection. A single anesthesia event also prevents the patients from undergoing another intubation and anesthesia and decreases the risk associated with another anesthesia in a relatively short time frame. [ABSTRACT FROM AUTHOR]

Background Bow hunter's syndrome (BHS) or rotational vertebral artery occlusion is a rare syndrome of vertebrobasilar insufficiency due to compression or occlusion of the contralateral vertebral artery with cervical axial rotation. Compression at the C2-C3 level, the junction between the axial and subaxial spine, has not been described. Management can include medical treatment with antiplatelet medications, surgical fusion, or vertebral artery decompression. Case Description The patient presented with dizziness and loss of consciousness with axial head rotation to the left. Dynamic digital subtraction angiography revealed occlusion of the right vertebral artery with the head turning to the left, with concurrent symptom onset. The left vertebral artery largely ended in the posterior inferior cerebellar artery. The patient underwent C2-C3 anterior cervical discectomy and fusion without vertebral artery decompression. His postoperative course was uneventful, with complete symptom resolution. Follow-up dynamic angiography demonstrated a patent right vertebral artery with axial head rotation to the left. Conclusions This case report demonstrates that even high cervical etiology for BHS can be successfully managed from an anterior approach. At present, no consensus has been reached for the treatment of BHS. A review of the current data demonstrated that anterior approaches without decompression are slightly safer than posterior approaches, with a smaller risk of vertebral artery injury. Depending on the anatomic variant and the pathophysiology of vertebral compression, an anterior approach without decompression provides a feasible alternative for the treatment of symptomatic BHS. Highlights • We have described BHS at the C2-C3 level, which has not been previously reported. • We treated our patient with ACDF without transverse foramen decompression. • Anterior approaches might be safer for preventing iatrogenic vertebral artery injury. [ABSTRACT FROM AUTHOR]

Carole A. Miller, M.D., was born (May 7, 1939) and raised in Kalamazoo, Michigan. She obtained her undergraduate and medical degrees at the Ohio State University. She went on to complete her neurosurgical training at the Ohio State University Medical Center. After her first faculty role at the University of Michigan (1971), she returned to the Ohio State University Medical Center (1975) where she spent nearly 4 decades. She thrived in the specialty, achieving in every facet of academic practice including scientific contributions, graduate medical education, clinical care, and leadership roles within her academic department, locally, and at the national level of organized neurosurgery. Dr. Miller passed away peacefully, on October 28, 2015, after a courageous battle with cancer. Based on her essential programmatic and specialty-related contributions, she is remembered as the 'founding mother' of neurosurgery at the Ohio State University. [ABSTRACT FROM AUTHOR]

Background: Cerebral venous sinus thrombosis (CVST) is a rare but potentially morbid disease in the pediatric population, and the optimal treatment is not fully understood. Endovascular intervention for this condition has been rarely reported.Methods: The Stroke Thrombectomy and Aneurysm Registry was queried for patients aged less than or equal to 18 years undergoing endovascular treatment for CVST in the past 10 years. Clinical charts and radiographic data were retrospectively reviewed. Modified Rankin Score (mRS) at 90 days postprocedure was determined as the primary outcome.Results: A total of seven patients across five pediatric centers ranging from 7 to 16 years of age were identified with a mean follow-up of 28 months. All had underlying conditions predisposing to CVST. Endovascular intervention was undertaken due to neurological deterioration despite systemic anticoagulation; venous infarct was evident preoperatively in six of seven patients. Mechanical venous thrombectomy was attempted in all individuals, and intrasinus thrombolytic therapy was also performed in three cases. Six patients had favorable outcome with mRS 0 or 1 at 90 days postprocedure; one remained neurologically devastated.Conclusions: Endovascular treatment by an experienced interventionalist may be safe and effective in severe cases of CVST in children failing frontline therapy. Children with radiographic or clinical progression despite anticoagulation may be considered for endovascular intervention in a timely manner. [ABSTRACT FROM AUTHOR]

The rapid processing of perfusion and diffusion (RAPID) system for automating perfusion and diffusion data from head computed tomography has improved acute ischemic stroke treatment by quickly and accurately identifying those patients who may benefit from thrombectomy. Collateral scoring (CS) of cerebral arteries using computed tomography angiography (CTA) has proven useful in predicting postintervention infarct volumes and functional outcomes in ischemic stroke patients. Here we evaluate the relationship between CS and RAPID software in an effort to augment triage and provide improved predictability of functional outcomes in ischemic stroke patients. A retrospective review of 77 mechanical thrombectomy patients from January 2017 to October 2018 with large vessel occlusions of the anterior circulation who underwent RAPID and CTA imaging was performed. Baseline characteristics, RAPID data, CS, modified Rankin Scale score, and procedural data were collected. magnetic resonance imaging was used to calculate the postintervention stroke volume. CS inversely correlates with the volume of RAPID cerebral blood flow <30% (β= –18.131, 95% confidence interval [CI] –24.384 to –11.879, P < 0.001), RAPID Tmax >6s (β= –22.205, 95% CI –39.125 to –5.285, P = 0.011), postintervention stroke volume (β= –30.637, 95% CI –41.554 to –19.720, P < 0.001), and discharge National Institutes of Health Stroke Scale score (β= –1.922, 95% CI –3.575 to –0.269, P = 0.023). CS on CTA may be a useful way to identify patients who would benefit from mechanical thrombectomy and predict functional outcomes postintervention. CS may allow the stroke team to optimize the care of patients who may not be able to obtain RAPID analysis. [ABSTRACT FROM AUTHOR]

Although multidisciplinary teams have been shown to decrease in-hospital mortality for patient with infectious endocarditis, most studies have focused on the inpatient role of these teams, and are primarily based at European tertiary care centers. There is limited literature available on the optimal longitudinal care of this patient population. Here we outline our experience developing an interdisciplinary endocarditis program at the University of Kentucky, which cares for patients from their index hospitalization into the outpatient setting, while also coordinating transfers from regional hospitals and offering education to regional providers. • Multidisciplinary endocarditis teams have been demonstrated to decrease short-term mortality for patients with infectious endocarditis. • Additional support is required for patients after their index hospitalization, particularly for patients with substance use disorder and those undergoing delayed surgery. • A comprehensive interdisciplinary endocarditis program with participation from multiple specialties and providers can provide long-term care for this patient population. [ABSTRACT FROM AUTHOR]

Stroke is a major cause of death and disability in the United States. Mechanical thrombectomy (MT) and tissue plasminogen activator are the current treatments for ischemic stroke, which have improved clinical outcomes. Despite these treatments, functional and cognitive deficits still occur demonstrating a need for predictive biomarkers for beneficial clinical outcomes which can be used as therapeutic targets for pharmacotherapy. The aim of this study compares the proteomic expression of systemic arterial blood collected at the time of MT to those from a matched cerebrovascular disease (CVD) control cohort. The Blood And Clot Thrombectomy Registry And Collaboration (BACTRAC) (clinicaltrials.gov NCT03153683) collects and banks arterial blood, both distal and proximal to the thrombus, from ischemic stroke subjects undergoing MT. Arterial blood from patients undergoing a diagnostic angiogram was also collected and banked as CVD controls. Changes in cardiometabolic and inflammatory proteins between stroke and CVD controls were analyzed via Olink Proteomics. Proteins including ARTN, TWEAK, HGF, CCL28, FGF-5, CXCL9, TRANCE and GDNF were found to be decreased in stroke subjects when compared to CVD controls. CXCL1, CCL5, OSM, GP1BA, IL6, MMP-1, and CXCL5 were increased in stroke subjects when compared to CVD controls. These proteins were also significantly correlated to stroke outcome metrics such as NIHSS, infarct volume and MoCA scoring. Overall, acute stroke patients had an increase in inflammatory proteins with a decrease in trophic proteins systemically compared to matched CVD controls. Using our CVD controls, proteins of interest were directly compared to stroke patients with the same cerebrovascular risk factors instead of statistically controlling for comorbidities. The novel methodology of matching an arterial blood CVD control group to a stroke group, as well as controlling for age and comorbid status add to the literature on prognostic stroke biomarkers, which are specific targets for future therapeutics. • Large vessel ischemic stroke is a deadly and debilitating disease. • We utilized novel arterial blood from cerebrovascular disease patients. • Proinflammatory proteins are increased during stroke. • Proteins related to growth and survival decreased during stroke. • Stroke biomarkers can be used as prognostic indicators and therapeutic targets. [ABSTRACT FROM AUTHOR]

Background: Currently, there are no large-scale studies in the neurointerventional literature comparing safety between transradial (TRA) and transfemoral (TFA) approaches for flow diversion procedures. This study aims to assess complication rates in a large multicenter registry for TRA versus TFA flow diversion., Methods: We retrospectively analyzed flow diversion cases for cerebral aneurysms from 14 institutions from 2010 to 2019. Pooled analysis of proportions was calculated using weighted analysis with 95% CI to account for results from multiple centers. Access site complication rate and overall complication rate were compared between the two approaches., Results: A total of 2,285 patients who underwent flow diversion were analyzed, with 134 (5.86%) treated with TRA and 2151 (94.14%) via TFA. The two groups shared similar patient and aneurysm characteristics. Crossover from TRA to TFA was documented in 12 (8.63%) patients. There were no access site complications in the TRA group. There was a significantly higher access site complication rate in the TFA cohort as compared with TRA (2.48%, 95% CI 2.40% to 2.57%, vs 0%; p=0.039). One death resulted from a femoral access site complication. The overall complications rate was also higher in the TFA group (9.02%, 95% CI 8.15% to 9.89%) compared with the TRA group (3.73%, 95% CI 3.13% to 4.28%; p=0.035)., Conclusion: TRA may be a safer approach for flow diversion to treat cerebral aneurysms at a wide range of locations. Both access site complication rate and overall complication rate were lower for TRA flow diversion compared with TFA in this large series., Competing Interests: Competing interests: RMS research is supported by the NREF, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, and by National Institute of Health (R01NS111119-01A1) and (UL1TR002736, KL2TR002737) through the Miami Clinical and Translational Science Institute, from the National Center for Advancing Translational Sciences and the National Institute on Minority Health and Health Disparities. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. RMS has consulting and teaching agreements with Penumbra, Abbott, Medtronic, InNeuroCo and Cerenovus. DRY: Medtronic Neurovascular: Consultant, Cerenovus: Consultant, Rapid Medical and Neuralanalytics: consultant. ECP: Stryker Neurovascular: Consultant, Penumbra: Consultant, RIST Neurovascular: Stockholder, Medtronic Neurovascular: Consultant, Cerenovus: Consultant. MRL: Grants: National Institutes of Health (R01NS105692, R01NS088072, U24NS100654); American Heart Association (18CDA34110295); The Aneurysm and AVM Foundation. Unrestricted educational grants: Stryker Neurovascular, Medtronic, Philips Volcano. Equity interest: eLoupes Inc, Cerebrotech, Synchron. AS: Penumbra: consulting, research support, Stryker: consulting, Cerenovus: consulting. CMS: NTI stockholder, AANS honoraria. ASA: Consultant for Johnson and Johnson, Medtronic, Microvention, Penumbra, Scientia, Siemens, Stryker. Research support from Balt, Cerenovus, Medtronic, Microvention, Penumbra, Siemens, and Stryker. Shareholder in Bendit, Cerebrotech, Endostream, Magneto, Marblehead, Neurogami, Serenity, Synchron, Triad Medical, Vascular Simulations. JWO: Disclosures: consultant for Terumo, Medtronic, Microvention. Royalties: Caeli Vascular, inc., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)