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Background Emergence delirium (ED) is a common phenomenon occurring in the recovery period. The aim of this study was to investigate the incidence, risk factors, and consequences of ED in adults after elective brain tumor resection. Methods We retrospectively analyzed the data of a prospective cohort performed in a tertiary university hospital. Adult patients admitted to the intensive care unit (ICU) immediately after elective brain tumor resection were consecutively enrolled. Level of consciousness was assessed using the Richmond Agitation–Sedation Scale and ED was assessed using the Confusion Assessment Method for the ICU. Risk factors for ED were determined by multivariable logistic regression. Results A total of 659 patients met the inclusion criteria, of which 41 patients with coma were excluded. Among the remaining 618 patients, 131 (21.2%) developed ED. Independent risk factors for ED were: age, education level, use of anticholinergic and mannitol, Glasgow Coma Score and arterial partial pressure of oxygen postoperatively, postoperative pain, malignant tumor, and frontal approach craniotomy. ED was associated with increased postoperative delirium, longer length of hospital stay, and higher hospitalization costs. There was no significant difference in the neurological function deficits (modified Rankin Scale score) between ED and non-ED groups. Conclusions ED has a high incidence and is associated with poor outcomes in adults after elective brain tumor resection. Early screening and prevention for ED should be established in perioperative management of this population.

Background The osteosclerotic skeletal dysplasias (OSSDs) are a heterogeneous group of disorders characterized by systemic bone sclerosis. Little is known about OSSDs because of their rarity. We conducted a cross-sectional nationwide survey of OSSDs and examined the incidence, epidemiology, and therapeutic interventions on these disorders. Methods This study consisted of a two-step survey. The number of patients with OSSDs who had visited medical institutions between April 2017 and March 2018 was reported from a total of 341 facilities (1364 departments from pediatrics, orthopaedic surgery, neurosurgery, and otolaryngology in each facility) by the first questionnaire. In the secondary survey, their clinical features were assessed by collecting demographic data, diagnostic details, current status, family histories, therapeutic interventions, histories of bone fracture and osteomyelitis, severity assessed by the modified Rankin Scale (mRS) and recent lifestyle conditions of the patient by the EQ-5D. Results In the first survey, 51 facilities (56 departments) reported one or more OSSDs patients, including 50 patients with osteopetrosis and 57 patients of other OSSDs. Among 87 patients eligible for inclusion in the analysis in the secondary survey, we investigated detailed information on the 42 patients with osteopetrosis. The number of initial visits of osteopetrosis patients during the surveillance period was five per year, indicating that the estimated incidence of osteopetrosis seemed to be 0.6 per 100,000 live births. Eighty-six bone fractures were reported in 22 patients (52%), and interventions of pseudarthrosis were conducted in five patients. Nine patients (23%) showed significant disabilities with the mRS of grade 3 or higher. Neurological complications and severe anemia were the factors that deteriorate patients’ quality of life. Conclusions This is the first study to examine the detailed epidemiology of OSSDs in Japan. We demonstrated that the incidence of OSSDs is extremely rare. Bone fragility and delayed fracture healing seem to be important orthopaedic problems for patients with osteopetrosis.

Background/Purpose Whilst much is known about the survival outcomes of patients that suffer an in-hospital cardiac arrest (IHCA) in Australia very little is known about the functional outcomes of survivors. This study aimed to describe the functional outcomes of a cohort of patients that suffered an in-hospital cardiac arrest (IHCA) and survived to hospital discharge in a regional Australian hospital. Methods This is a single-centre retrospective observational cohort study conducted in a regional Australian hospital. All adult patients that had an IHCA in the study hospital between 1 Jan 2017 and 31 Dec 2019 and survived to hospital discharge were included in the study. Functional outcomes were reported using the Modified Rankin Scale (mRS), a six-point scale for which increasing scores represent increasing disability. Scores were assigned through a retrospective review of medical notes. Results Overall, 102 adult patients had an IHCA during the study period, of whom 50 survived to hospital discharge. The median age of survivors was 68 years, and a third had a shockable initial arrest rhythm. Of survivors, 47 were able to be assigned both mRS scores. At discharge, 81% of patients achieved a favourable functional outcome (mRS 0–3 or equivalent function at discharge equal to admission). Conclusions Most survivors to hospital discharge following an IHCA have a favourable functional outcome and are discharged home. Although these results are promising, larger studies across multiple hospitals are required to further inform what is known about functional outcomes in Australian IHCA survivors.

BACKGROUND: Nimodipine improves outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, the impact of alternative dosing strategies on outcome remains unclear. METHODS: We performed a retrospective cohort study of consecutive patients admitted with aSAH to an academic referral center from 2016 to 2019. Patients with a confirmed aneurysm cause who received nimodipine were included; patients who died or had withdrawal of life-sustaining treatment within 24 hours of admission were excluded. Univariable and multivariable modified Poisson regression models were used to identify predictors of using modified nimodipine dosing (30 mg every 2 hours) versus standard dosing (60 mg every 4 hours). Inverse probability weighted and modified Poisson regression models were used to estimate adjusted risk ratios (RRs) for outcome measures, with poor outcome defined as modified Rankin Scale score 4–6 at 3 months. RESULTS: We identified 175 patients with aSAH who met eligibility criteria (mean [SD] age = 57 [13.2] years, 62% female, 73% White); 49% (n = 86) received modified nimodipine dosing. A modified dose was used more frequently in women (RR 2.08, 95% confidence interval [CI] 1.11–3.89, P = 0.02), patients with vasospasm (RR 3.47, 95% CI 1.84–6.51, P < 0.001), and patients who required vasopressors (RR 1.73, 95% CI 1.3–2.32, P < 0.001). Modified dosing was not associated with poor functional outcome (inverse probability weighted RR 1.1, 95% CI 0.8–1.4, P = 0.65). CONCLUSIONS: Modified dosing of nimodipine is well tolerated and may not be associated with worse functional outcome. Prospective studies are needed to better assess the relationship between nimodipine dosing and outcomes in patients with aSAH.

Background Chronic subdural hematoma (CSDH) is a neurologic condition characterized as a hematoma in the subdural space with a period >3 weeks that primarily affects the elderly. Glucocorticoid, especially dexamethasone, either alone or combined with surgery, has been used to manage CSDH. We aimed to perform an updated systematic review and meta-analysis of the literature regarding the role of steroids in CSDH. Methods We searched the electronic databases PubMed, PubMed Central, Scopus, and Embase for relevant articles until December 2020. Study characteristics, quality, and end points were extracted, and analysis was performed by RevMan 5.4. Results The odds for subdural hematoma recurrence were decreased by 61% in the steroid group (odds ratio [OR], 0.39; confidence interval [CI], 0.19–0.79) compared with the control group. There was no significant difference in mortality during the study period (OR, 0.66; CI, 0.20–2.18), modified Rankin Scale score 0–3 (OR, 0.87; CI, 0.31–2.40), and modified Rankin Scale score 4–6 (OR, 1.15; CI, 0.42–3.18) between the 2 groups. However, pooling data from 3 studies showed 2.7 times higher odds of occurring adverse effects in steroid groups using the fixed-effect model (OR, 2.70; CI, 1.71–4.28). The treatment success was similar between the steroid and control groups (OR, 2.39; CI, 0.94–6.04). Conclusions Treatment with steroids was associated with a lesser recurrence of CSDH. However, there was no benefit of steroid treatment in CSDH compared with nonsteroid treatment in terms of mortality and treatment success and some but significantly increased risk of adverse events.

Background Idiopathic normal pressure hydrocephalus (iNPH) is a chronic neurologic syndrome that affects the elderly population in a context of concomitant medical conditions. The aim of this study was to understand the significance of comorbidities using 4 validated and specific clinical scores: Cumulative Illness Rating Scale (CIRS), American Society of Anesthesiologists (ASA) score, Comorbidity Index (CMI), and Charlson Comorbidity Index (CCI). Methods From 2015 until 2019, the Bologna PRO-Hydro multidisciplinary team selected 63 patients for shunt surgery. All comorbidity scores were collected during preoperative anesthesia evaluation. Positive shunt response was defined as an improvement in overall disability (assessed with modified Rankin Scale [mRS]), in risk of fall (assessed with Tinetti Permormance Orientated Mobility Assessment, Tinetti) and in INPH specific symptoms (assessed with INPH Grading Scale, INPHGS). Results Patients with elevated values of CIRS had worse performance in gait and balance at Tinetti scale, both before (P = 0.039) and after surgery (P = 0.005); patients with high values of CMI had inferior values of Tinetti at baseline (P = 0.027) and higher mRS after surgery (P = 0.009); ASA 2 patients had better postoperative Tinetti scores than ASA 3 patients (P = 0.027). A positive or negative shunt response was not significantly correlated with patients' preoperative comorbidity scores. Conclusions Patients with multiple comorbidities have a worse preoperative condition compared to patients with less concomitant diseases, and the proposed comorbidity scores, CIRS in particular, are useful clinical tools for the anesthesiologist. Comorbidities, though, do not impact overall postoperative outcome.

Objective To explore the association between early neutrophil-to-lymphocyte ratio (ENLR) and prognosis of anterior circulation large-vessel occlusion stroke (LVOS) after patients undergo endovascular treatment (EVT) with successful revascularization. Methods Patients who experienced acute anterior circulation LVOS and underwent EVT at Changzhou Second People's Hospital Affiliated to Nanjing Medical University between May 2017 and May 2020 were included in this retrospective study. We collected information about patients' baseline characteristics, medical history, laboratory test results, imaging data, and endovascular treatment outcomes, as well as data from follow-up at 3 months. Univariate and multivariate logistic regression models were used to evaluate the association between ENLR and functional disease prognosis. A piecewise linear regression model was also applied to compute the threshold effect of ENLR on poor prognosis (defined as modified Rankin Scale score 3–6) at 3 months using a smoothing plot. Results Of 224 patients who received EVT during the study period, 160 patients were included in the analysis. After adjustments were made for potential confounders, multivariate analysis demonstrated a significant association between ENLR and poor prognosis at 3 months (odds radio 1.19; 95% confidence interval 1.07–1.32; P = 0.0016). An ENLR ≥9.75 was found to be significantly associated with poor prognosis at 3 months (odds ratio 1.54; 95% confidence interval 1.19–2.00; P = 0.0119). Conclusions Increased ENLR after successful revascularization is independently associated with poor prognosis. These findings suggest that ENLR could be used to inform treatment strategies for patients who experience anterior circulation LVOS.

Trials examining the benefit of thrombectomy in anterior circulation proximal large vessel occlusion stroke have enrolled patients considered to have salvageable brain tissue, who were randomly assigned beyond 6 h and (depending on study protocol) up to 24 h from time last seen well. We aimed to estimate the benefit of thrombectomy overall and in prespecified subgroups through individual patient data meta-analysis.We did a systematic review and individual patient data meta-analysis between Jan 1, 2010, and March 1, 2021, of randomised controlled trials of endovascular stroke therapy. In the Analysis Of Pooled Data From Randomized Studies Of Thrombectomy More Than 6 Hours After Last Known Well (AURORA) collaboration, the primary outcome was disability on the modified Rankin Scale (mRS) at 90 days, analysed by ordinal logistic regression. Key safety outcomes were symptomatic intracerebral haemorrhage and mortality within 90 days.Patient level data from 505 individuals (n=266 intervention, n=239 control; mean age 68·6 years [SD 13·7], 259 [51·3%] women) were included from six trials that met inclusion criteria of 17 screened published randomised trials. Primary outcome analysis showed a benefit of thrombectomy with an unadjusted common odds ratio (OR) of 2·42 (95% CI 1·76-3·33; p0·0001) and an adjusted common OR (for age, gender, baseline stroke severity, extent of infarction on baseline head CT, and time from onset to random assignment) of 2·54 (1·83-3·54; p0·0001). Thrombectomy was associated with higher rates of independence in activities of daily living (mRS 0-2) than best medical therapy alone (122 [45·9%] of 266 vs 46 [19·3%] of 238; p0·0001). No significant difference between intervention and control groups was found when analysing either 90-day mortality (44 [16·5%] of 266 vs 46 [19·3%] of 238) or symptomatic intracerebral haemorrhage (14 [5·3%] of 266 vs eight [3·3%] of 239). No heterogeneity of treatment effect was noted across subgroups defined by age, gender, baseline stroke severity, vessel occlusion site, baseline Alberta Stroke Program Early CT Score, and mode of presentation; treatment effect was stronger in patients randomly assigned within 12-24 h (common OR 5·86 [95% CI 3·14-10·94]) than those randomly assigned within 6-12 h (1·76 [1·18-2·62]; pThese findings strengthen the evidence for benefit of endovascular thrombectomy in patients with evidence of reversible cerebral ischaemia across the 6-24 h time window and are relevant to clinical practice. Our findings suggest that in these patients, thrombectomy should not be withheld on the basis of mode of presentation or of the point in time of presentation within the 6-24 h time window.Stryker Neurovascular.

AIM To explore the association between haemorrhagic transformation (HT) subtypes and functional outcome in acute ischaemic stroke (AIS) patients with successful recanalization treated by endovascular thrombectomy (EVT). MATERIALS and METHODS Consecutive patients with AIS due to large-vessel occlusion in the anterior circulation, who were treated between January 2015 and June 2019 and achieved successful EVT, were enrolled in this retrospective study. HT was categorized according to the Heidelberg Bleeding Classification. Functional outcome was evaluated using the 90-day modified Rankin Scale (mRS) after stroke onset. Ordinal logistic regression analysis was performed to determine the association of HT subtypes with functional outcomes. RESULTS A total of 243 patients were included for further analysis. Among them, 121 (49.8%) had HT. Ten (4.1%) patients were classified as haemorrhagic infarction (HI) subtype 1, 61 (25.1%) as HI subtype 2, 17 (7.0%) as parenchymal haematoma (PH) subtype 1, and 33 (13.6%) as PH subtype 2. Ordinal logistic regression analysis suggested that HI subtype 2 (adjusted common OR 0.357, 95% CI: 0.192–0.667), PH1 (adjusted common OR 0.254, 95% CI: 0.093–0.696) and PH subtype 2 (adjusted common OR 0.017, 95% CI: 0.006–0.051) were significantly associated with poor functional outcomes. CONCLUSION The present study shows that HI subtype 2, PH subtype 1, and PH subtype 2 are independently associated with poor clinical outcomes in AIS patients with successful recanalization after EVT.

Background Triggering receptor expressed on myeloid cells-1 (TREM-1) participates in neuroinflammation. We intended to ascertain whether serum soluble TREM-1 (sTREM-1) could be utilized as a biomarker of inflammation, severity, early neurologic deterioration (END) and outcome after primary intracerebral hemorrhage (ICH). Methods Serum sTREM-1 levels were gauged in 104 ICH patients and 104 healthy controls. END was diagnosed when the National Institutes of Health Stroke Scale (NIHSS) score increased ≥ 4 points or death between admission and 24 h after admission. Patients with a modified Rankin scale score of > 2 at 3 months were considered to have poor outcome. Results As compared to controls, patients exhibited significantly elevated serum sTREM-1 levels (median: 309.0 vs 67.9 pg/ml). Serum sTREM-1 concentrations were intimately correlated with NIHSS score (r = 0.574), hematoma volume (r = 0.554), blood leukocyte count (r = 0.529) and serum C-reactive protein concentrations (r = 0.509). Serum sTREM-1 concentrations > 309.0 pg/ml independently predicted END and poor outcome with odds ratio values of 4.054 and 4.721 respectively. Serum sTREM-1 concentrations distinguished END and poor outcome with areas under receiver operating characteristic curve of 0.789 and 0.813 respectively. Conclusion Serum sTREM-1 may represent a promising inflammatory biomarker for assessment of severity and prediction of END and poor outcome after ICH.

Introduction Evidence of the intravenous tissue plasminogen activator (tPA) efficacy beyond the 4.5 hours window is emerging. We aim to study the factors affecting the outcome of delayed thrombolysis in patients of clear onset acute ischemic stroke (AIS). Methods Data of patients with AIS who received intravenous thrombolytic after 4.5 hours were reviewed including: demographics, risk factors, clinical, laboratory, investigational and radiological data, evidence of mismatch, treatment type and onset, National Institutes of Health Stroke Scale (NIHSS) score at baseline, 24 hours, 7 days after thrombolysis and before discharge, and 3 months follow-up modified Rankin Scale (mRS). Results We report 136 patients treated by intravenous tPA between 4.53 and 19.75 hours with average duration of 5.7 h. The ASPECT score of our patients was ≥ 7. Sixty-four cases showed intracranial arterial occlusion . Perfusion mismatch was detected in 117 (84.6%) patients, while clinical imaging mismatch was detected in 19 (15.4%). Early neurological improvement after 24 hours occurred in 114 (83.8%) patients. At 90 days, 91 patients (67%) achieved good outcome (mRS 0–2), while 45 (33%) had bad outcome (mRS 3–6). Age, endovascular treatment, NIHSS, AF , and HT were significantly higher in the bad outcome group. Age ( P = 0.001, OR: 1.099, 95% CI: 1.042–1.160) and baseline NIHSS were predictive of the poor outcome (P = 0.002, OR: 1.151, 95% CI: 1.055–1.256). The best cutoff value of age was 72.5 with AUC of 0.76, sensitivity 73.3% and specificity 60.4%. While for NIHSS at admission, the cutoff value of 7 showed the best results with AUC of 0.73, sensitivity 71.1% and specificity 63.7%. Combination of age and admission NIHSS raised the sensitivity and specificity to 84.4% and 63.7%, respectively. Conclusion Increased age and admission NIHSS may adversely affect the outcome of delayed thrombolysis and narrow the eligibility criteria. Age and baseline NIHSS based stratification of the patients may provide further evidence as regards the efficacy of the delayed thrombolysis.

Treatment of acute ischemic stroke (AIS) with intravenous alteplase within 4.5 h of symptom onset is associated with neurologic improvement. High baseline blood pressure (BP) and BP variability during the first 24 h of AIS is associated with increased early adverse events and death. The purpose of this study is to characterize the incidence of poor neurologic outcome in patients treated with alteplase for AIS who received antihypertensive medications prior to and within the first 24 h following alteplase administration compared with patients who did not.This was a multicenter, retrospective cohort of patients18 years diagnosed with AIS from January 1, 2011 through December 31, 2015 who received one or more antihypertensive medication in the first 24 h of AIS in patients receiving alteplase compared to controls. The primary endpoint was poor neurologic outcome at 90 days, according to modified Rankin Scale ≥3. Univariate analysis was conducted using Chi-square, Fisher's exact test, or Mann-Whitney U test. Multivariable logistic regression was conducted to determine independent predictors of poor outcome.Of the 587 patients evaluated, 351 (59.7%) were included, of which 127 (36.2%) received antihypertensive(s). More patients in the antihypertensive treatment group had a history of hypertension (88.2% vs. 69.6%, p0.01), diabetes (37% vs. 25.5%, p = 0.03) and chronic kidney disease (19.7% vs. 8.5%, p0.01). Intravenous push labetalol was most commonly administered (81.2%), followed by nicardipine (44.1%), and hydralazine (22%). More patients in the antihypertensive treatment group experienced poor neurologic outcome at 90 days (53.5% vs. 38.8%, p0.01), however, this finding was not observed after multivariable logistic regression.Antihypertensive treatment in the first 24 h of AIS was associated with poor neurologic outcomes at 90 days. However, after controlling for other clinical factors in a multivariable logistic regression, this association was no longer observed.

Background and purpose Triggering receptors expressed on myeloid cells 1 and 2 (TREM-1 and TREM-2) are cell surface receptors important for modulation of microglia immune response. In this study, we evaluate serum levels of TREM-1 and TREM-2 as potential biomarkers in acute ischemic stroke (AIS). Material and methods Prospective cohort study of 50 patients with AIS admitted at our hospital. Serum TREM-1 and TREM-2 was evaluated within 24 h of the acute event and on the third and fifth days after the stroke. Neurological stroke severity and global disability were determined with the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at the same three times and at the time of hospital discharge. Results TREM-1 and TREM-2 levels were elevated in stroke. TREM-1, but not TREM-2, exhibited correlations with NIHSS and mRS within 24 h (NIHSS and TREM-1: rS = 0.31, p = 0.029; mRS and TREM-1: rS = 0.32, p = 0.023). The serum level of TREM-1 within 24 h correlated with the neurological outcomes at hospital discharge (NIHSS and TREM-1: p = 0.021; mRS and TREM-1: p = 0.049). The serum concentrations of TREM-1 protein within 24 h after stroke was significantly higher in patients with poor outcome (mRS > 2) at hospital discharge (p = 0.021). After Exact Logistic Regression, large segmental stroke (O.R. = 4.14; 95CI = 1.07–16.09; p = 0.040) and initial sTREM levels (O.R. = 1.02; 95CI 1.00–1.04; p = 0.045) remained independent prognostic factors for AIS poor outcome (mRS > 2). Conclusion In our study, TREM-1 and TREM-2 were significantly increased in AIS. Early elevation of TREM-1 correlated with stroke severity and it was an independent prognostic factor for stroke outcome.

The authors sought to evaluate whether initial intracranial pressure was associated with functional outcomes following aneurysmal subarachnoid hemorrhage. This retrospective analysis consisted of 54 consecutive patients with aneurysmal subarachnoid hemorrhage and acute symptomatic hydrocephalus requiring emergent placement of an external ventricular drain. Patient demographics, clinical data, intracranial pressure parameters, and radiographic imaging were collected. Functional outcomes were evaluated at 3 months using the modified Rankin Scale and dichotomized as favorable (modified Rankin Scale 0-2) or unfavorable (modified Rankin Scale 3-6). Univariate and multivariate logistic regression analyses were performed to investigate parameters independently associated with functional outcomes. In an adjusted multivariate logistic regression model, initial intracranial pressure (OR: 1.371, 95% CI: 1.119-1.679; p = 0.002) was found to be an independent predictor of unfavorable functional outcomes at 3 months. Receiver operating characteristic curve analysis for the prediction of unfavorable functional outcomes demonstrated that initial intracranial pressure exhibited an acceptable area under the curve (AUC = 0.901, 95% CI: 0.818-0.985; p 0.001). The optimal predictive threshold to distinguish between favorable and unfavorable functional outcomes was identified at an initial intracranial pressure of 25 mmHg.

Background Intraparenchymal hemorrhage (IPH), possibly due to reperfusion, after evacuation of a cranial chronic subdural hematoma (cSDH) is a known phenomenon. However, it is sparingly reported and not well understood. Methods An illustrative case series is presented. A literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to identify all previously reported cases. Results A total of 48 cases were analyzed. Males were 85.4% of the population, and the mean age was 67.5 years. Pre-existing head trauma and hypertension were the most common comorbidities. Headache was a presenting symptom in 60.4% of cases. Midline shift was explicitly stated in 54.2% of cases. Initial burr hole alone was performed 75.0% of the time, whereas craniotomy alone was performed in 16.7% of cases. Any initial craniotomy patients were associated with a modified Rankin Scale score of 5 (P = 0.03). The IPH was located in the cerebral hemisphere in 62.5% of cases and more likely to occur ipsilateral to a unilateral cSDH (P = 0.02). The IPH occurred a mean 1.9 days after surgery, and 50.0% occurred within 24 hours of initial intervention. The median modified Rankin Scale at discharge was 2. The mortality rate was 25%. Lastly, a multifactorial reperfusion pathophysiology was proposed. Conclusion IPH after cSDH evacuation is associated with significant morbidity and mortality. Prompt recognition, regulating blood pressure, controlling the amount and rate of extra-axial fluid drained, and a meticulous surgical technique are critical to optimize the care of patients with cSDH and reduce the rate of postoperative IPH.

International audience; OBJECTIVES: Patients waking up with stroke symptoms are often excluded from intravenous thrombolysis with alteplase (IV-tpa). The WAKE-UP trial, a European multicenter randomized controlled trial, proved the clinical effectiveness of magnetic resonance imaging-guided IV-tpa for these patients. This analysis aimed to assess the cost-effectiveness of the intervention compared to placebo. METHODS: A Markov model was designed to analyze the cost-effectiveness over a 25-year time horizon. The model consisted of an inpatient acute care phase and a rest-of-life phase. Health states were defined by the modified Rankin Scale (mRS). Initial transition probabilities to mRS scores were based on WAKE-UP data and health state utilities on literature search. Costs were based on data from the University Medical Center Hamburg-Eppendorf, literature, and expert opinion. Incremental costs and effects over the patients' lifetime were estimated. The analysis was conducted from a formal German healthcare perspective. Univariate and probabilistic sensitivity analyses were performed. RESULTS: Treatment with IV-tpa resulted in cost savings of €51 009 and 1.30 incremental gains in quality-adjusted life-years at a 5% discount rate. Univariate sensitivity analysis revealed incremental cost-effectiveness ratio being sensitive to the relative risk of favorable outcome on mRS for placebo patients after stroke, the costs of long-term care for patients with mRS 4, and patient age at initial stroke event. In all cases, IV-tpa remained cost-effective. Probabilistic sensitivity analysis proved IV-tpa cost-effective in \textgreater95% of the simulations results. CONCLUSIONS: Magnetic resonance imaging-guided IV-tpa compared to placebo is cost-effective in patients with ischemic stroke with unknown time of onset.

Endovascular treatment (EVT) is less effective for intracranial atherosclerosis-induced emergent large vessel occlusion. Extracranial-intracranial (EC-IC) bypass surgery is a possible treatment option to augment cerebral blood flow in the perfusion defect area. We compared the efficacy and safety of EC-IC bypass surgery with those of EVT and maximal medical treatment for acute ischemic stroke.The data from 39 patients, for whom vessel revascularization had failed despite mechanical thrombectomy, were retrospectively analyzed. Of the 39 patients, 22 had undergone percutaneous transluminal angioplasty or intracranial stenting (PTA/S), 10 had undergone emergency EC-IC bypass surgery within 24 hours of symptom onset, and 7 had received maximal medical treatment (MMT) only. The patency, perfusion status, and postoperative infarct volume were evaluated. The clinical outcomes were assessed at 6 months postoperatively using the modified Rankin scale.The mean reperfusion time was significantly longer for the EC-IC bypass group (14.9 hours) compared with that in the PTA/S group (4.1 hours) and MMT group (7.5 hours; P0.05). The postoperative infarct volume on diffusion-weighted magnetic resonance imaging was significantly lower in the emergency EC-IC bypass group (11.3 cmEmergency EC-IC bypass surgery is an effective and safe treatment option for intracranial atherosclerosis-induced acute ischemic stroke for which EVT is inadequate.

Purpose To compare the evaluation of collaterals on multiphase computed tomography (CT) angiography using the score proposed by the reference study by Menon et al. and the Alberta Stroke Program Early CT (ASPECT) score for the prediction of favorable clinical outcome in patients with anterior ischemic stroke (IS). Materials and methods Retrospective single center study including 199 patients with anterior ischemic stroke and evaluated using multiphase CT angiography. Collaterals were assessed using the reference score and ASPECT score. The early clinical outcome [National Institute of Health Stroke Score (NIHSS) over day 1] and later clinical outcome [90-day modified Rankin Scale (mRS)] were collected. The primary analysis related to the association between collateral scores and clinical outcome. Results Collaterals are an independent predictive factor of favorable clinical outcome with the two scores, ranging from an odds ratio (OR) [95% confidence interval (CI)] = 1.84 [1.23; 2.76], P = 0.003 for the reference score to an OR [95% CI] = 2.63 [1.21; 5.73], p = 0.015 for the phase 3 ASPECT score. The phase 3 ASPECT score offers better sensitivity (Se) for the prediction of a favorable clinical outcome [Se = 95%, specificity (Sp) = 37% for a threshold of 7/7] than the reference score (Se = 83%, Sp = 47% for a threshold of 4/5). Conclusion This study demonstrates the value of the ASPECT score in analyzing collaterals using multiphase CT angiography for the prediction of clinical outcome.

Deep-seated intracranial arteriovenous malformations (AVMs) represent a subset of AVMs characterized by variably reported outcomes regarding the risk of hemorrhage, microsurgical complications, and response to stereotactic radiosurgery (SRS). We aimed to compare outcomes of microsurgery, SRS, endovascular therapy, and conservative follow-up in deep-seated AVMs. A prospectively maintained database of AVM patients (1990-2017) was queried to identify patients with ruptured and unruptured deep-seated AVMs (extension into thalamus, basal ganglia, or brainstem). Comparisons of hemorrhage-free survival and poor functional outcome (modified Rankin scale [mRS] 2) were performed between conservative management, microsurgery (±pre-procedural embolization), SRS (±pre-procedural embolization), and embolization utilizing multivariable Cox and logistic regression analyses controlling for univariable factors with p 0.05. Of 789 AVM patients, 102 had deep-seated AVMs (conservative: 34; microsurgery: 6; SRS: 54; embolization: 8). Mean follow-up time was 6.1 years and did not differ significantly between management groups (p = 0.393). Complete obliteration was achieved in 49% of SRS patients. Upon multivariable analysis controlling for baseline rupture with conservative management as a reference group, embolization was associated with an increased hazard of hemorrhage (HR = 6.2, 95%CI [1.1-40.0], p = 0.037), while microsurgery (p = 0.118) and SRS (p = 0.167) provided no significant protection from hemorrhage. Controlling for baseline mRS, microsurgery was associated with an increased risk of poor outcome (OR = 9.2[1.2-68.3], p = 0.030), while SRS (p = 0.557) and embolization (p = 0.541) did not differ significantly from conservative management. Deep AVMs harbor a high risk of hemorrhage, but the benefit from intervention Remains uncertain. SRS may be a relatively more effective approach if interventional therapy is indicated.

Introduction Distal anterior cerebral artery aneurysms (DACAA) are a rare and difficult entity to manage. Endovascular treatment has evolved for safe and durable treatment of these lesions. The objective of this study is to report the safety, efficacy, and outcomes of endovascular treatment of DACAA. Methods A retrospective review of DACAA endovascularly treated at 5 different institutions was performed. Data included demographics, rupture status, radiographic features, endovascular technique, complication rates, and long-term angiographic and clinical outcomes. A primary endpoint was a good clinical outcome (modified Rankin scale 0–2). Secondary endpoints included complications and radiographic occlusion at follow-up. Results A total of 84 patients were reviewed. The mean age was 56, and 64 (71.4%) were female. Fifty-two (61.9%) aneurysms were ruptured. A good functional outcome was achieved in 59 patients (85.5%). Sixty (71.4%) aneurysms were treated with primary coiling, and the remaining 24 were treated with flow diversion. Adequate occlusion was achieved in 41 (95.3%) aneurysms treated with coiling, and 17 (89.5%) with flow diversion. There were total 11 (13%) complications. In the flow diversion category, there were 2, both related to femoral access. In the coiling category, there were 9: 5 thromboembolic, 3 ruptures, and 1 related to femoral access. Conclusion Endovascular treatment, and in particular, flow diversion for DACAA, is safe, feasible, and associated with good long-term angiographic and clinical outcomes.

Introduction: Moyamoya disease (MD) is a progressive, occlusive disease of the arteries of the anterior cerebral circulation that may cause ischaemia or haemorrhage. Patient management aims to prevent new cerebrovascular events through surgical revascularisation and/or pharmacological treatment. Materials and methods: We studied a series of 17 patients with MD (n = 14) or moyamoya syndrome (MS; n = 3), who were evaluated between January 1989 and December 2016; 11 patients were women and 6 were men. Thirteen patients had definitive MD (76%), one had unilateral MD (5.2%), and 3 had MS (18%). The condition manifested as intraparenchymal haemorrhage (in 35.2% of patients), brain ischaemia (29.4%), subarachnoid haemorrhage (17.6%), seizures (11.7%), and headache with no associated haemorrhage (1 patient). Results: Ten patients (58.8%) underwent revascularisation and 7 (41.2%) received pharmacological treatment. All patients were evaluated with the modified Rankin Scale (mRs) at admission and at the last consultation; mRs scores were significantly lower in the group undergoing surgery (P

Inflammation plays a pivotal role in acute ischemic stroke, and various inflammatory markers are known to predict prognosis of acute ischemic stroke. This study aimed to evaluate the prognostic value of systemic inflammation response index (SIRI) and systemic immune-inflammation index (SII) after mechanical thrombectomy (MT) for acute ischemic stroke caused by large artery occlusion.The study enrolled 440 patients who underwent MT for large artery occlusion. SIRI and SII were calculated using laboratory data on admission. Prognosis was estimated with modified Rankin Scale at 3 months, and favorable clinical outcome was defined by a modified Rankin Scale score of 0-2. Receiver operating characteristic analysis was used to calculate the optimal cutoff values of SIRI and SII for predicting clinical outcome. Multivariate analysis was used to assess the relationship of SIRI and SII with clinical outcome.In receiver operating characteristic analysis, the optimal cutoff values for SIRI and SII were 2.9 and 853, respectively (area under the curve 0.799, 95% confidence interval [CI] 0.756-0.843, P0.001 and area under the curve 0.679, 95% CI 0.643-0.745, P0.001, respectively). Multivariate analysis revealed that SIRI2.9 (odds ratio 2.27, 95% CI 1.29-5.17, P = 0.019) and SII853 (OR 1.82, 95% CI 1.16-3.10, P = 0.031) were independent predictors of favorable clinical outcome after MT.Decreased SIRI and SII were associated with favorable clinical outcome after MT. SIRI and SII represent potential prognostic factors in patients undergoing MT for large artery occlusion.

Summary Background Non-immunogenic staphylokinase is modified recombinant staphylokinase with low immunogenicity, high thrombolytic activity, and selectivity to fibrin. We aimed to assess the safety and efficacy of a single intravenous bolus of non-immunogenic staphylokinase compared with alteplase in patients with acute ischaemic stroke within 4·5 h after symptom onset. Methods We did a randomised, open-label, multicentre, parallel-group, non-inferiority trial in 18 clinical sites in Russia. We included patients aged 18 years and older with a diagnosis of acute ischaemic stroke (up to 25 points on the National Institutes of Health Stroke Scale). The study drug had to be administered within 4·5 h after the onset of symptoms. Patients were randomly assigned to receive either non-immunogenic staphylokinase (10 mg) or alteplase (0·9 mg/kg, maximum 90 mg), both administered intravenously. The randomisation sequence was created by an independent biostatistician using computer-generated random numbers. 84 blocks (block size of four) of opaque sealed envelopes were numbered sequentially from 1 to 336 and were opened in numerical order. Patients were unaware of their assigned treatment and were assessed by the study investigators who were also unaware of the treatment assignment on all trial days. Emergency department staff, who administered the assigned drug and opened the envelopes, were not masked to treatment. The primary efficacy endpoint was a favourable outcome, defined as a modified Rankin scale (mRS) score of 0–1 on day 90. The margin of non-inferiority was established as 16% for the difference in mRS score of 0–1 on day 90. Non-inferiority was tested using Welch's t-test for the primary outcome only. Endpoints were analysed in the per-protocol population, which comprised all randomly assigned patients who completed treatment without any protocol violations; this population was identical to the intention-to-treat population. This trial is completed and registered at ClinicalTrials.gov , NCT03151993 . Findings Of 385 patients recruited from March 18, 2017, to March 23, 2019, 336 (87%) were included in the trial. 168 (50%) patients were randomly assigned to receive non-immunogenic staphylokinase and 168 (50%) to receive alteplase. The median duration of follow-up was 89 days (IQR 89–89). 84 (50%) of 168 patients in the non-immunogenic staphylokinase group had a favourable outcome at day 90 compared with 68 (40%) of 168 patients in the alteplase group (odds ratio [OR] 1·47, 95% CI 0·93 to 2·32; p=0·10). The difference in the rate of favourable outcome at day 90 was 9·5% (95% CI –1·7 to 20·7) and the lower limit did not cross the margin of non-inferiority (pnon-inferiority Interpretation Non-immunogenic staphylokinase was non-inferior to alteplase for patients with acute ischaemic stroke. Mortality, symptomatic intracranial haemorrhage, and serious adverse events did not differ significantly between groups. Future studies are needed to continue to assess the safety and efficacy of non-immunogenic staphylokinase in patients with acute ischaemic stroke within the 4·5 h time window, and to assess the drug in patients with acute ischaemic stroke outside this time window with reperfusion CT or magnetic resonance angiography followed by thrombectomy if necessary. Funding The Russian Academy of Sciences.

Objective To assess the effects of high-intensity interval training (HIIT) on physical, mental, and cognitive functioning after stroke. Design The HIIT Stroke Study was a single-blind, multicenter, parallel-group randomized controlled trial. Setting Specialized rehabilitation units at 3 Norwegian hospitals. Participants Adult stroke survivors (N=70) 3 months to 5 years after a first-ever stroke. Mean age was 57.6±9.2 years and 58.7±9.2 years in the intervention and control groups, respectively. Interventions Participants were randomized to standard care in combination with 4×4 minutes of treadmill HIIT at 85%-95% of peak heart rate or standard care only. Outcomes Outcomes were measured using physical, mental, and cognitive tests and the FIM and Stroke Impact Scale. Linear mixed models were used to analyze differences between groups at posttest and 12-month follow-up. Results The intervention group showed a significant treatment effect (95% confidence interval [CI]) from baseline to posttest on a 6-minute walk test of 28.3 (CI, 2.80-53.77) meters (P=.030); Berg Balance Scale 1.27 (CI, 0.17-2.28) points (P=.025); and Trail Making Test Part B (TMT-B; −24.16 [CI, −46.35 to −1.98] s, P=.033). The intervention group showed significantly greater improvement on TMT-B at the 12-month follow-up (25.44 [CI, −49.01 to −1.87] s, P=.035). The control group showed significantly greater improvement in total Functional Independence Measure score with a treatment effect of −2.37 (CI, −4.30 to −0.44) points (P=.016) at 12-month follow-up. No significant differences were identified between groups on other outcomes at any time point. Conclusions HIIT combined with standard care improved walking distance, balance, and executive function immediately after the intervention compared with standard care only. However, only TMT-B remained significant at the 12-month follow-up.

Background aims Mesenchymal stromal cells (MSCs) are characterized by paracrine and immunomodulatory functions capable of changing the microenvironment of damaged brain tissue toward a more regenerative and less inflammatory milieu. The authors conducted a phase 2, single-center, assessor-blinded randomized controlled trial to investigate the safety and efficacy of intravenous autologous bone marrow-derived MSCs (BMMSCs) in patients with subacute middle cerebral artery (MCA) infarct. Methods Patients aged 30–75 years who had severe ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] score of 10–35) involving the MCA territory were recruited within 2 months of stroke onset. Using permuted block randomization, patients were assigned to receive 2 million BMMSCs per kilogram of body weight (treatment group) or standard medical care (control group). The primary outcomes were the NIHSS, modified Rankin Scale (mRS), Barthel Index (BI) and total infarct volume on brain magnetic resonance imaging (MRI) at 12 months. All outcome assessments were performed by blinded assessors. Per protocol, analyses were performed for between-group comparisons. Results Seventeen patients were recruited. Nine were assigned to the treatment group, and eight were controls. All patients were severely disabled following their MCA infarct (median mRS = 4.0 [4.0–5.0], BI = 5.0 [5.0–25.0], NIHSS = 16.0 [11.5–21.0]). The baseline infarct volume on the MRI was larger in the treatment group (median, 71.7 [30.5–101.7] mL versus 26.7 [12.9–75.3] mL, P = 0.10). There were no between-group differences in median NIHSS score (7.0 versus 6.0, P = 0.96), mRS (2.0 versus 3.0, P = 0.38) or BI (95.0 versus 67.5, P = 0.33) at 12 months. At 12 months, there was significant improvement in absolute change in median infarct volume, but not in total infarct volume, from baseline in the treatment group (P = 0.027). No treatment-related adverse effects occurred in the BMMSC group. Conclusions Intravenous infusion of BMMSCs in patients with subacute MCA infarct was safe and well tolerated. Although there was no neurological recovery or functional outcome improvement at 12 months, there was improvement in absolute change in median infarct volume in the treatment group. Larger, well-designed studies are warranted to confirm this and the efficacy of BMMSCs in ischemic stroke.

Objective This study aimed to investigate the safety and efficacy of endovascular embolization for very small ruptured anterior communicating artery (AcomA) aneurysms. Methods From August 2015 to June 2020, 81 patients with very small (≤3 mm) ruptured AcomA aneurysms treated endovascularly were enrolled in this study. Clinical and radiographic data were analyzed retrospectively, including the aneurysm occlusion rate, complications, and clinical outcome. Results Among 81 patients, simple coiling embolization was performed in 52 cases and stent-assisted embolization in 29 cases. Immediate angiography demonstrated complete occlusion in 59 (72.8%) aneurysms, residual neck in 20 (24.7%) aneurysms, and residual lumen in 2 (2.5%). Procedure-related complications rate was 2.5% (2 of 81), all of which were transient thromboembolic events. Angiographic follow-up outcomes of 60 patients (mean: 6.8 ± 3.2 months) revealed complete occlusion in 91.7% (55 of 60), with recurrence in 1 patient. The mean clinical follow-up time was 22.6 ± 11.4 months and good prognosis rates (6-month modified Rankin Scale score: 0–2) reached 90.2% (73 of 81). The differences in aneurysm occlusion and procedure-related complications between the simple coiling group and the stent-assisted coiling group were not statistically significant. Conclusions Coiling with or without stent-assisted technique for the treatment of very small ruptured AcomA aneurysms was safe and effective.

Purpose Hyperactive delirium is common after subarachnoid hemorrhage (SAH). We aimed to identify risk factors for delirium and to evaluate its impact on outcome. Methods We collected daily Richmond Agitation Sedation Scale (RASS) and Intensive Care Delirium Screening Checklist (ICDSC) scores in 276 SAH patients. Hyperactive delirium was defined as ICDSC ≥4 when RASS was >0. We investigated risk factors for delirium and its association with 3-month functional outcome using generalized linear models. Results Patients were 56 (IQR 47–67) years old and had a HuntH 95%-CI = 1.89–10.56; p = 0.001), the detection of an aneurysm (adjOR = 4.38; 95%-CI = 1.48–12.97; p = 0.008), a lower HH 95%-CI = 0.48–0.83; p = 0.001) and a pre-treated psychiatric disorder (adjOR = 3.17; 95%-CI = 1.14–8.83; p = 0.027) were associated with the development of delirium. Overall, delirium was not associated with worse outcome (p = 0.119). Interestingly, patients with delirium more often had a modified Rankin Scale Score (mRS) of 1–3 (77%) compared to an mRS of 0 (14%) or 4–6 (9%). Conclusion Our data indicate that hyperactive delirium is common after SAH patients and requires a certain degree of brain connectivity based ono the highest prevalence found in SAH patients with intermediate outcomes.

Background Mechanical thrombectomy is a proven treatment for large-vessel ischemic stroke with improved functional outcomes compared with intravenous thrombolytics. Access to thrombectomy-capable sites varies greatly by geography, often necessitating interhospital transfer of patients who first present to hospitals unable to provide thrombectomy. The purpose of this meta-analysis was to examine the impact of interhospital transportation on patient outcomes to better inform recommendations for prehospital protocols. Methods A meta-analysis was performed following systematic literature searches. Outcomes of interest included successful reperfusion, symptomatic intracranial hemorrhage, 90-day modified Rankin Scale score 0–2, 90-day mortality, onset-to-puncture times, and door-to-puncture times. Results Pooled analysis comprised >27,000 patients. Door-to-puncture time was 35.6 minutes shorter among transferred patients; however, symptom onset-to-puncture time was 91.6 minutes longer. Rate of reperfusion or symptomatic intracranial hemorrhage as well as 90-day mortality did not differ significantly between transferred and directly admitted patients. While the proportion of patients achieving good functional outcome at 90 days with modified Rankin Scale score 0–2 did not differ by admission type, when modified Rankin Scale score was narrowed to 0–1, direct transport showed 20% greater probability of achieving excellent functional outcome (P Conclusions This meta-analysis represents the largest pooled population examined to date to assess how interfacility transportation to thrombectomy-capable sites affects patient outcomes. Our results indicate that direct admission is a significant predictor of excellent functional outcome. The findings presented here can be used to better inform quality improvement projects to streamline access to facilities providing endovascular mechanical thrombectomy capabilities.

Introduction Anterior odontoid screw fixation is a valid surgical option for unstable odontoid fractures, as type II Anderson D’Alonzo fractures. Grauer further divided type II fractures in subtypes according to the fracture line, providing recommendations for implementation of screw fixation techniques. Objective Primary endpoint of our study is to evaluate the postoperative results of minimally invasive odontoid screw insertion in terms of outcome, fusion rate and stability of cranio-cervical junction. Secondary endpoint was to investigate the influence of age or fractures’ features on outcome and fusion rate. Materials and methods We report the clinical and radiological features of 32 patients harbouring unstable type II fractures operated by a minimally invasive odontoid screw insertion technique. All patients underwent a high resolution multiplanar CT in order to assess fracture features according to Grauer's classification; the integrity of ligaments was investigated by MRI. In addition, a preoperative neurological performance (modified Rankin Scale, mRS) was evaluated for patients either directly or interviewing their families. Follow-up at one, three and six months and 1 year have been performed (averaging 13.5 months) by cervical CT (fusion rate and stability) and mRS update. In order to investigate the influence of age on postoperative neurological performance, two groups (≤ 50 yrs, 9 pts/ > 50 yrs, 23 pts) were separately considered and analysed. Overall, we observed no surgery related complications. We also analysed the fusion rate and its correlation with patient age and Grauer's subtype of fracture. Results At last available clinical follow-up, the preoperative performance was preserved (mRS 0/1: 24, 75%; mRS 2–4: 9, 15%) although with slight reduction of intact patients (mRS 0: 22 vs. 19; 71.8 vs. 59.3%). Younger patients (≤ 50 yrs) fared significantly better than older ones, achieving a good clinical outcome (mRS 0/1) in 100% vs. 69.5% (9/9 vs. 16/23 pts). Statistical analysis showed a fair correlation between age and outcome. Other factors such as sex and Grauer's type did not influence significantly the clinical outcome. Nine patients did not complete a full radiological follow-up and were therefore excluded from analysis of radiological outcome. Among the remaining 23 patients, only 25% of those who were followed three months or less showed fusion; conversely, all patients who have been examined from 6 to 48 months fused. Among the non-union patients, two underwent a second surgery by posterior approach. Conclusions In our recent experience, the minimally invasive AOSF proved safe and effective in treating odontoid peg fractures. Selection based on Grauer's type is mandatory to achieve best results. While in the elderly, an anterior approach is well accepted as the first choice treatment, we recommend that this option should be offered as a suitable alternative to Halo or orthosis also in younger patients since it provides prompt, excellent clinical outcome and high fusion rate especially in this age group.

Made available in DSpace on 2022-05-01T05:29:34Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-07-01 Background: The aim of this study was to determine whether muscle strength of the lower limb and trunk during the acute phase after stroke are predictors of motor function and disability 90 days after hospital discharge. Methods: This prospective study used a nonconcurrent design to evaluate stroke patients at two time points: a) first 72 h: hip abduction and ankle dorsiflexion (HAAD) score, trunk sitting control, clinical evaluation, demographic profile, and stroke severity using the National Institutes of Health Stroke Scale (NIHSS); b) 90 days after hospital discharge: modified Rankin scale (mRS). The participants were divided into two groups: good outcome (mRS 0–2) and worse outcome (mRS>2), and the differences between them were assessed statistically. Clinical and demographic variables were included in the multiple logistic regression analysis. The ROC curve was used to illustrate the clinical sensitivity and specificity of the HAAD score cutoff for the outcomes. Results: Thirty-seven patients were included: 16 with mRS≤2 and 21 with mRS>2. Patients in the worse outcome group were older (p = 0.02) and presented with higher NIHSS scores (p = 0.002), lower HAAD scores (p < 0.001), higher pain sensation (p = 0.04), greater altered perception (p = 0.008), and no trunk control in the sitting position (p = 0.004). A lower HAAD score (OR = 0.09; 95%CI: 0.14–0.53; p < 0.001) and the absence of trunk control in the sitting position (OR = 0.55; 95%CI:0.54–0.95; p < 0.001) were associated with unsatisfactory outcomes. Conclusion: A HAAD score

Background An increasing white blood cell (WBC) count in early course of aneurysmal subarachnoid hemorrhage (SAH) can indicate a systemic inflammatory state triggered by the initial insult. We sought to determine the significance of the early WBC trend as a potential predictor of outcomes. Methods We analyzed a cohort of consecutive patients with aneurysmal SAH. The WBC values in first 5 days of admission, plus relevant clinical and imaging data, and modified Rankin Scale (mRS) at 3 months after hospital discharge were retrieved and analyzed. Favorable outcome was defined as mRS 0–3. The association between WBC counts and outcomes including mRS and delayed cerebral ischemia (DCI) was determined using binary logistic regression models. We used receiver operating characteristic curve analysis to assess accuracy of WBC in predicting outcomes. Results We included 167 patients in final analysis. Mean age was 56.4 (standard deviation [SD] 14.8) years, and 65% (109) of patients were female. Peak WBC was greater in patients with poor functional outcome (mean 17 × 109 cells/L, SD 6.4 vs. 13.5 × 109 cells/L SD 4.7). Combining peak WBC with modified Fisher scale slightly increased accuracy in predicting DCI (area under the curve 0.670, 95% confidence interval 0.586–0.755) compared with each component alone. Conclusions WBC count in the early course of SAH may have prognostic values in predicting DCI and functional outcome. WBC count monitoring may be used in conjunction with other clinical and radiographic tools to stratify patients with SAH into high- and low-risk groups to tailor neuromonitoring and treatment strategies.

Effective anticoagulation status may determine the recanalization and outcome of cerebral venous thrombosis (CVT). We report impact of anticoagulation status on recanalization and outcome of CVT. This is a retrospective study on 126 patients with CVT diagnosed on magnetic resonance venography (MRV). Their clinical features and risk factors were noted. The data were retrieved from a prospectively maintained registry, and international normalized ratio (INR) was noted after discharge till 3 months. All the patients were on acenocoumarol. Based on INR value, patients were categorized as Group A (effective anticoagulation INR within the therapeutic range or above) and Group B (ineffective anticoagulation INR > 50% below the therapeutic range). A repeat MRV at 3 months was done for recanalization. Outcome at 3 months was evaluated using modified Rankin Scale (mRS), and categorized as good (mRS ≤ 2) and poor (mRS 2 or more ) 101(80.2%) patients were in group A and 25(19.8%) in group B. Their demographic, risk factors, magnetic resonance imaging (MRI) and MRV findings were comparable. On repeat MRV, recanalization occurred in 22/24(91.7%); 15(88%) in group A and 7(100%) in group B. Recanalization was independent of coagulation status. Seven (5.6%) patients died and 107(84.9%) had good outcome; 85(84.2%) in group A and 22(88%) in group B. Kaplan Meier analysis also did not reveal survival or good outcome benefits between the groups. In CVT, outcome and recanalization at 3 months are not dependent on coagulation status. Further prospective studies are needed regarding duration of anticoagulant and its impact on recanalization and outcome.

The effect of emergency department length of stay (EDLOS) on outcomes of patients with acute ischemic stroke (AIS) remains largely unexamined. We aimed to investigate the association between EDLOS and outcomes in AIS patients.618 AIS patients were enrolled. Baseline demographics, vascular risk factors, ED admission information, hyperacute treatment of AIS and stroke severity were collected. Stroke progression was defined as any new neurological symptoms/signs or any neurological worsening within 7 days after stroke onset and poor prognosis was defined as modified Rankin Scale(mRS) scores2 at 30 day. The effect of EDLOS on stroke progression and prognosis was assessed.The median EDLOS was 2.5 h (1.4-6.9 h). On multivariable linear regression, presentation month between Apr. and Jun., admission at the ED between 7 am to 3 pm(P = 0.036), transferring to stroke unit, receiving endovascular interventional treatment, onset on holidays, and progressive stroke were associated with shorter EDLOS(all P 0.05). A shorter EDLOS was significantly associated with an increased risk of stroke progression (P = 0.007). Patients with the lowest EDLOS (≤1.35 h) were 2-3 fold more likely to have stroke progression, compared with those with the highest EDLOS (6.93 h) (OR, 2.52; 95% CI, 1.29-4.93; P = 0.043). However, no significant association between EDLOS and stroke prognosis was revealed.In AIS patients, shorter EDLOS was associated with the increased risk of stroke progression, possibly reflecting prioritized admission of more severely affected patients at high risk of stroke progression. EDLOS alone might be an insufficient indicator of stroke care in the ED.

Background Mechanical thrombectomy (MT) is the standard of care for the treatment of proximal anterior circulation large vessel occlusions. However, little is known about its efficacy and safety in the treatment of distal intracranial occlusions. Methods This is a multicenter retrospective study of patients treated with MT at 15 comprehensive centers between January 2015 and December 2018. The study cohort was divided into 2 groups based on the location of occlusion (proximal vs. distal). Distal occlusion was defined as occlusion of M3 segment of the middle cerebral artery, any segment of the anterior cerebral artery, or any segment of the posterior cerebral artery. Only isolated distal occlusion was included. Good outcome was defined as 90-day modified Rankin scale score 0–2. Results A total of 4710 patients were included in this study, of whom 189 (4%) had MT for distal occlusions. Compared with the proximal occlusion group, distal occlusion group had a higher rate of good outcome (45% vs. 36%; P = 0.03) and a lower rate of successful reperfusion (78% vs. 84%; P = 0.04). However, the differences did not retain significance in adjusted models. Otherwise there was no difference in the rate of hemorrhagic complications, mortality, or procedure-related complications between the 2 groups. Successful reperfusion, age, and admission stroke severity emerged as predictors of good functional outcome in the distal occlusion group. Conclusions Thrombectomies of distal vessels achieve high rate of successful reperfusion with similar safety profile to those in more proximal locations.

Unruptured intracranial aneurysms (UIAs) are commonly acquired vascular lesions that form an outpouching of the arterial wall due to wall thinning. The prevalence of UIAs in the general population is 3.2%. In contrast, an intracranial aneurysm may be manifested after rupture with classic presentation of a thunderclap headache suggesting aneurysmal subarachnoid hemorrhage (SAH). Previous consensus suggests that although small intracranial aneurysms (

Surgical treatment of idiopathic normal pressure hydrocephalus (iNPH) by ventriculoperitoneal (VP) or lumboperitoneal (LP) shunting can achieve long-term recovery of activities of daily living; however, in a subset of patients, maintenance of independence lasted for6 months. This study examined positive preoperative predictive factors of short-term outcome for shunted iNPH patients.Over a 9-year period, consecutive patients from multiple centers diagnosed with probable iNPH underwent either VP or LP shunt surgery. Preoperative variables of age, symptom duration, iNPH severity, tap test response, and magnetic resonance imaging findings of disproportionately enlarged subarachnoid space hydrocephalus (DESH) or incomplete DESH were retrospectively evaluated in relation to 1-year postoperative outcome.Outcome for 154 shunt patients (12 VP, 142 LP) as measured by postoperative disability modified Rankin Scale (mRS) and iNPH-gait disturbance (GD) was the same regardless of age. Symptom duration was inversely correlated with both iNPH severity (P0.0001) and postoperative improvement at 1 year (P = 0.0015). Severity also correlated inversely with postoperative improvement at 1 year (P0.0001). Age was not significantly correlated with the degree of postoperative improvement (mRS: P = 0.487; iNPH grading scale [GD]: P = 0.725). Outcome at 1 year (mRS, gait domain, and activities of daily living significantly improved in patients with a good response to the tap test (P0.0001) Preoperative DESH correlated with improvement in mRS and GD (P0.0001).Mild preoperative iNPH severity, shorter preoperative symptom duration, good tap test response, and complete DESH were associated with good short-term postoperative outcome at 1 year. These positive factors may be useful for prediction of short-term surgical outcome in iNPH patients.

Long-term data on neurological and radiological outcome after aneurysmal subarachnoid hemorrhage (aSAH) are scarce. The aim of this study was to report neurological and radiological outcome15 years after aSAH.Patients with aSAH who were randomly assigned to endovascular treatment (EVT) or microsurgical treatment (MST) during 1997-2001 were included. Main end points were neurological outcome assessed by modified Rankin Scale, fatigue assessed by mental fatigue scale, and radiological outcome assessed by magnetic resonance angiography. Results for mental fatigue scale were compared with a control group.After 15-21 years, 46 (62.2%) of the 74 survivors replied to a questionnaire. Of these patients, 18 received MST, and 28 received EVT. Modified Rankin Scale score of 0-2 was found in 100% of patients in the EVT group and 88.8% of patients in the MST group. Moderate or severe mental fatigue was found in 7/28 patients (25%) in the EVT group and 7/18 patients (38.8%) in the MST group (P0.05), whereas moderate or severe mental fatigue was observed in 3/34 patients (8.9%) in the control group. Magnetic resonance angiography was performed in 29 patients. In the EVT group, new neck remnants were found in 2/16 patients (12.5%), and de novo aneurysm was found in 2/16 patients (12.5%). In the MST group, de novo aneurysm was found in 1/13 patients (7.7%).Neurological outcome at long-term follow-up after aSAH was good; however, mental fatigue was overrepresented in patients compared with healthy control subjects regardless of treatment modality. Residual or de novo aneurysm was found in 17% of patients warranting radiological long-term follow-up.

The prevalence of headache in stroke has been reported between 8% and 34%. Determining the preva-lence, features, and effects on prognosis of cerebellar ischemic strokes that presented with headache solely and/or with other cerebellar signs were the aims of our study. All patients diagnosed with cerebel-lar ischemia were included. Electronic medical records were reviewed. Patients have been followed up for 6th month. Descriptive statistics were generated. A total of 4763 patients were evaluated retrospectively, 200 patients had cerebellar ischemia and 22 patients of these cerebellar ischemias (11%) had a headache at initial presentation. Ataxia, dysarthria, dysmetria were the most common neurological findings. There was no significant difference whether ischemic lesion single or multiple and whether above or below 1.5 cm diameter. Ischemic lesions generally were in cortical/ juxtacortical layer. According to vascular perfusion areas, 54.5% patients & rsquo; ischemia was located in PICA (posterior inferior cerebellar artery) terri-tory. Patients presenting with a headache, predominantly had left hemispheric (vermian > hemispheric > pedincular) involvement. Although these patients generally had high modified Rankin Scale scores at the first evaluation, they had low NIHSS (National Institutes of Health Stroke Scale) scores (0 & ndash;5), and nearly all patients recovered, with low mRS at the 6-month follow-up. Cerebellar ischemic strokes with headache presentation are significantly prevalent in patients with left hemispheric, cortical/juxtacortical, PICA perfusion territory ischemias and are associated with low morbidity unless there was a conscious disorder. We believe this is one of the first studies that evaluated the clinical and radiological parameters of cerebellar stroke patients with headache.

To investigate death-related factors in patients with electroencephalographic (EEG) periodic discharges (PDs) and to construct a model for death prediction.This case-control study enrolled a total of 80 severe neurological disease patients with EEG PDs within 72 h of admission to the neuroscience intensive care unit (NICU). According to modified Rankin scale (mRS) scores half a year after discharge, patients were divided into a survival group (6 points) and a death group (6 points). Their relevant clinical and biochemical indicators as well as EEG characteristics were retrospectively analyzed. Logistic regression analysis was used to identify the risk factors associated with the death of patients with EEG PDs. A death risk prediction model and an individualized nomogram prediction model were constructed, and the prediction performance and concordance of the models were evaluated.Multivariate logistic regression analysis showed that the involvement of both gray and white matter in imaging, disappearance of EEG reactivity, occurrence of stimulus-induced rhythmic, periodic, or ictal discharges (SIRPIDs), and an interval time of 0.5-4 s were independent risk factors for death. A regression model was established according to the multivariate logistic regression analysis, and the area under the curve of this model was 0.9135. The accuracy of the model was 87.01%, the sensitivity was 87.17%, and the specificity was 89.17%. A nomogram model was constructed, and a concordance index of 0.914 was obtained after internal validation.The regression model based on risk factors has high accuracy in predicting the risk of death of patients with EEG PDs.This model can help clinicians in the early assessment of the prognosis of severe neurological disease patients with EEG PDs.

Objective To investigate the effect of superficial temporal artery–posterior cerebral artery (STA-PCA) bypass on chronic basilar artery occlusion (CBAO). Methods A total of 4 patients who underwent STA-PCA bypass between January 2018 and October 2019 were enrolled in this study. Cerebral blood perfusion, ischemic events, STA diameter and blood flow changes, modified Rankin scale score (mRS), and National Institutes of Health Stroke Scale (NIHSS) score changes were recorded before and after bypass surgery. Results The average time from basilar artery occlusion (confirmed by cerebral angiography or computed tomography angiography) to operation was 76 ± 38.89 days (range: 30–120 days). Average scores on the NIHSS were 6.8 ± 1.26 (5–8) and 5.2 ± 2.06 (3–7) before and after treatment, respectively. mRS scores averaged 1.8 ± 0.5 (1–2) and 1.5 ± 0.58 (1–2) points, respectively. There were no obvious complications or further stroke during the follow-up. The STA diameter and flow rate were significantly increased at 12 months after operation (P Conclusions STA-PCA bypass can improve cerebral blood flow perfusion in CBAO patients. The diameter and flow of the superficial temporal artery can be increased to meet the demand of blood supply.

Objective The present study aimed to perform a comprehensive data analysis of 47 consecutive patients treated in 8 years and to observe how clinical, radiologic, and surgical factors affect early and long-term outcomes, recurrence rate, and survival. Methods Clinical, radiologic, and surgical data were collected retrospectively from the review of a prospectively collected database. The neurologic disability was evaluated according to the modified Rankin Scale (mRS). Radiologic data were obtained by direct measurement performed on magnetic resonance imaging (MRI). Univariate and multivariate statistical analysis was performed. Results From 2008 to 2016, 47 consecutive patients underwent microsurgical resection of intramedullary lesions (28 males and 19 females; mean age, 41.2 years). Ependymoma (53.2%), astrocytoma (14.9%), hemangioblastoma (14.9%), and cavernous angioma (6.4%) were the most frequent tumor histology. The mean follow-up duration was 69.3 months. Gross total tumor resection was performed in 80.8% of cases. Forty-two patients (89.4%) were alive at last follow-up. Five-year overall survival and recurrence-free survival were 92% and 82%, respectively. Conclusions Among the examined variables, age seemed to strongly correlate with outcomes; better chances of recovery and a good postoperative outcome were observed in younger patients. Surfacing lesions had a better early functional outcome than did intramedullary located lesions. Patients' preoperative neurologic and functional status (mRS score ≤2) had a significant impact on late neurologic outcome. Progression-free survival correlated with the extent of tumor resection. Surgery should probably be performed before patients' neurologic decline, aiming to achieve maximal resection without compromising patients' quality of life.

Objective We describe the clinical features and outcomes of anti-N-methyl- d -aspartate receptor (NMDAR) encephalitis in infants and toddlers. Methods This was a single-center retrospective study. Infants and toddlers who met the diagnostic criteria for anti-NMDAR encephalitis were recruited for the study. Data on clinical features, treatment, and long-term outcomes were collected retrospectively. Results A total of 41 patients (age range: six to 34 months; median age: 23 months; female: 19) were enrolled in this study. Nineteen (46%) patients exhibited classical anti-NMDAR encephalitis, whereas 22 (54%) patients exhibited anti-NMDAR encephalitis after viral encephalitis. There was a high presentation of movement disorders (100%), developmental regression (90%), abnormal behaviors (90%). All patients were administered first-line therapy, with only 17% of them being administered second-line immunotherapy. Two patients succumbed to the disease, whereas none of them relapsed. At the long-term follow-up (more than one year), 20 of 35 (57%) exhibited satisfactory outcomes (modified Rankin Scale ≤2). Compared with patients with classical anti-NMDAR encephalitis (n = 18), patients after viral encephalitis (n = 17) were more likely to have worse clinical outcomes. They exhibited a higher modified Rankin Scale/Pediatric Cerebral Performance Category score and more frequent seizures. A predictor of poor outcome was presentation after viral encephalitis (odds ratio 35.7, 95% confidence interval 4.64 to 275.03, P = 0.001). Conclusion Anti-NMDAR encephalitis in infants and toddlers clinically presents with movement disorders, developmental regression, and abnormal behaviors. Interestingly, this group had a higher proportion of patients after viral encephalitis, which is regarded as the only risk factor for poor outcomes.

Background Severe intraventricular hemorrhage (IVH) is associated with a high mortality rate and poor functional outcome, even with recent neurosurgical developments. IVH requires emergent surgery to save the patient's life, but the optimal surgical strategy remains controversial. We assessed the results obtained with our tailor-made endoscopic surgical strategy for severe IVH with obstructive hydrocephalus. Methods Consecutive patients with severe IVH owing to intracerebral hemorrhage who were treated with endoscopic surgery in the acute phase were retrospectively reviewed. Both rigid and flexible endoscopes were used for removal of hematoma in the whole ventricular system. Endoscopic third ventriculostomy and septostomy were performed as appropriate in each individual case. Results Eight patients met the inclusion criteria and were included in the analysis. Sufficient IVH removal without neglecting the fourth ventricle was achieved with our technique in 6 of 8 cases (75.0%). Endoscopic third ventriculostomy and septostomy were added in 4 cases each (50.0%). Four patients (50.0%) had a marked recovery and a good outcome (modified Rankin Scale score ≤2) despite disease severity at onset. The procedure was completed successfully in all cases, and there were no surgery-related complications. Conclusions This study showed that our tailor-made endoscopic surgical strategy for severe IVH with obstructive hydrocephalus may be beneficial.

Objective The Sofia catheter is a new large-bore aspiration catheter that allows easy access and good reperfusion. In this study, we analyzed the efficacy and safety of the Sofia catheter in comparison with stent retrievers as a contact aspiration thrombectomy (CAT) tool for large vessel occlusion. Methods We enrolled patients with acute ischemic stroke who underwent endovascular thrombectomy from April 2017 and April 2020 in our hospital. Patients were retrospectively reviewed and divided into the stent retriever group (SR), the Sofia group, and all cases group. Results A total of 114 patients were treated during the study period, including 27 in the stent retriever group and 15 in the Sofia group. Higher rates of the first-pass effect (FPE) (37% vs. 47%, P = 0.12) and significantly higher modified FPE (44% vs. 67%, P = 0.001) were observed in patients with SR and Sofia, respectively. Functional independence (modified Rankin Scale ≤2) at 30 days after onset was observed in 30% versus 47% (P = 0.47) of SR and Sofia, respectively. Conclusions The Sofia Plus is a large-bore aspiration catheter with high FPE and good accessibility. Use of this catheter resulted better angiographic outcome compared with the stent retriever, but there was no difference in clinical outcomes in this study. Further studies are needed to compare in new generation aspiration catheters.

BACKGROUND: Different treatment options have been proposed for obstructive hydrocephalus associated with pineal lesions. We discuss the obstructive hydrocephalus management associated with pineal region tumors and cysts in Helsinki Neurosurgery. METHODS: In this article, hydrocephalus treatment by tumor-cyst removal (n = 40), shunt surgery (n = 25), and endoscopic ventriculostomies (n = 3) is evaluated in 68 patients with obstructive hydrocephalus among 136 patients with pineal region tumor and cyst. Multivariate statistical analysis was followed by univariate and multivariate regression models of last functional status, last tumor-free imaging, and disease-specific mortality of the study population. RESULTS: Preoperative hydrocephalus was linked to higher World Health Organization tumor grades, poor functional status, higher mortality, and incomplete resection of pineal region cysts and tumors. Preoperative hydrocephalus remained a predictor of poor last functional status after multivariate regression. Pineal lesion removal with the posterior third ventricle opening as primary hydrocephalus treatment resulted in better last functional status, fewer postoperative shunts, fewer hydrocephalus related procedures, and fewer postoperative infections than in the shunt-treatment group. Multivariate regression analysis linked higher World Health Organization tumor & nbsp;grade, poor immediate functional status, postoperative complications, and incomplete surgical resection as independent predictors of disease mortality in patients with hydrocephalus. Same variables (except immediate modified Rankin Scale score) and higher number of shunt surgeries became independent predictors of poor last functional status at multivariate analysis. Incomplete resection was the only independent predictor of tumor-free magnetic resonance imaging at the last evaluation. CONCLUSIONS: Direct removal of pineal lesions with the opening of the posterior third ventricle could represent effective and reliable management of the associated obstructive hydrocephalus. Further research is required to generalize our inferences.

Objective Although intracranial aneurysms are increasingly treated endovascularly, microsurgical clipping has been the standard approach for middle cerebral artery (MCA) aneurysms. We compared microsurgical clipping and state-of-the-art endovascular treatment of unruptured MCA bifurcation aneurysms treated at a neurovascular center following a “coil-first” policy. Methods This single-center study included 148 patients treated for 160 unruptured MCA bifurcation aneurysms. Technical success, complications, clinical outcome, and angiographic results were retrospectively compared. Results Microsurgical clipping was performed for 120 MCA aneurysms (75%) and endovascular treatment for 40 (25%; conventional coiling: 8, stent-assisted coiling: 16, balloon-assisted coiling: 3, and flow-disruption: 13). Technical treatment success was higher in the clipping group (100%) than in the endovascular group (92.5%, P = 0.015). Overall, complications occurred in 16.7% for clipping and in 20.0% for endovascular treatment (P = 0.631). Major ischemic stroke rates were 4.2% in the clipping group and 7.5% in the endovascular group (P = 0.414). At 6 months, a favorable outcome was obtained by 99.2% after clipping and 95.0% after endovascular treatment (P = 0.154). The 6-month complete aneurysm occlusion rates were by trend higher in the clipping group (89.2%) than in the endovascular group (75.9%, P = 0.078). Conclusions Microsurgical clipping was associated with a higher technical success rate and tendentially higher complete occlusion than endovascular treatment, with no additional morbidity and similar clinical outcome. On the basis of these results, clipping proves to be the standard treatment option for MCA bifurcation aneurysms. However, endovascular treatment represents a safe and efficient alternative treatment option for patients.

Objective It is challenging to safely treat blood blister–like aneurysms (BBAs) of the internal carotid artery. Endovascular surgery has been reported, but the optimal strategy is yet to be established. We report our endovascular treatment strategy using the Low-profile Visualized Intraluminal Support (LVIS) stent. Methods Twelve patients with ruptured BBAs including 1 patient with 2 separate aneurysmal bulges were treated from December 2017 to January 2020. Single LVIS stent-assisted coil embolization was performed as the initial treatment. If the coil could not be placed in the aneurysm, or follow-up angiography showed persistent filling or regrowth of the aneurysm, a second LVIS stent was deployed as an overlapping stent. Clinical characteristics, treatment details, and clinical outcomes were retrospectively examined. Results Single stent-assisted coiling was performed in 8 patients (69%), 2 overlapping stents with coiling in 1 (8%), a single stent in 2 (15%), and 2 overlapping stents in 2 (15%). Three patients with persistent filling or regrowth of the aneurysm were re-treated with overlapping stents. Follow-up angiography confirmed complete occlusion in 12 aneurysms (92%). No re-rupture occurred. Postoperative symptomatic ischemia was confirmed in 4 patients (33%), and all 4 patients suffered severe subarachnoid hemorrhage. Modified Rankin scale was 0–2 in 8 patients (67%). Conclusions LVIS stent-assisted coil embolization is effective in preventing re-rupture of BBAs. However, the morphology of the aneurysm may change within a short period, so careful angiographic follow-up is needed. Appropriate preoperative antiplatelet administration and optimal timing of the treatment may reduce the risk of postoperative ischemic complication.

Summary Background and aims Malnutrition is prevalent among individuals with acute ischaemic stroke (AIS) and may worsen clinical outcomes. There is no consensus on the best tool for nutritional screening in this population. The present study compared four screening tools and one diagnostic tool in terms of their prognostic significance in predicting short-term and long-term outcomes in AIS patients. Methods We included patients admitted to five major hospitals in Wenzhou and diagnosed with a primary diagnosis of AIS from October 1 to December 31, 2018. The Controlling Nutritional Status (CONUT) score, the Geriatric Nutritional Risk Index (GNRI), the Malnutrition Universal Screening Tool (MUST), the Nutritional Risk Screening Tool 2002 (NRS-2002) and the European Society for Clinical Nutrition and Metabolism diagnostic criteria for malnutrition (ESPEN-DCM) were assessed at admission. The clinical outcomes were evaluated by the modified Rankin Scale (mRS) and mortality at 3 months and 12 months after discharge. Results Five hundred and ninety-three patients were included in our prospective study. The mean age was 67.3 ± 12.0 years. Based on the mRS score, 125 patients exhibited poor functional recovery (an mRS ≥3) at 3 months after discharge. Seventeen patients died during the 3-month follow-up period, and the other 25 did not survive 12 months. Multivariate binary logistic regression revealed that inadequate nutritional status at admission, as determined by the CONUT, GNRI, MUST, NRS-2002 and ESPEN-DCM, were independently associated with poor outcomes in AIS patients 3 months after discharge. Both MUST ≥2 and NRS-2002 ≥ 3 showed significant associations with poor outcomes at 12-month post-discharge. Further analysis with the receiver operator characteristic (ROC) curve showed similar results, where all the tools predicted the poor outcomes at 3 months while only the NRS-2002 and MUST scores were significantly associated with the mRS at 12 months post-discharge. Moreover, the area under the curve (AUC) of MUST and NRS-2002 were significantly larger than those for the other tools. The optimal cut-off values of the MUST and NRS-2002 to predict poor outcomes were scores of ≥2 and ≥ 3 points, respectively. Conclusions Our data supported a deleterious effect of inadequate nutrition, as evidenced by the nutrition screening tools or ESPEN-DCM, on clinical outcomes during and beyond the acute phase of AIS. We recommended the use of the MUST and NRS-2002 in guiding nutritional support in AIS patients, as they have higher predictive power and can predict both short-term and long-term outcomes.

BACKGROUND: Lost to follow-up (LTF) represents an understudied barrier to effective management of chronic subdural hematoma (cSDH). Understanding the factors associated with LTF after surgical treatment of cSDH could uncover pathways for quality improvement efforts and modify discharge planning. We sought to identify the demographic and clinical factors associated with patient LTF. METHODS: A single-institution, retrospective cohort study of patients treated surgically for convexity cSDH from 2009 to 2019 was conducted. The primary outcome was LTF, with neurosurgical readmission as the secondary outcome. Univariate analysis was conducted using the student-t test and χ(2) test. Multivariate logistic regression was performed to identify the factors associated with LTF and neurosurgical readmission. RESULTS: A total of 139 patients were included, 29% of whom were LTF. The mean first postoperative follow-up duration was 60 days. On univariate analysis, uninsured/Medicaid coverage was associated with increased LTF compared with private insurance/Medicare coverage (62.5% vs. 41.4%; P = 0.039). A higher discharge modified Rankin scale score was also associated with LTF (3.7 vs. 3.5; P < 0.001). On multivariate analysis, uninsured/Medicaid patients had a significantly greater risk of LTF compared with private insurance/Medicare patients (odds ratio, 2.44; 95% confidence interval, 1.13–5.23; P = 0.022). LTF was independently associated with an increased risk of neurosurgical readmission (odds ratio, 1.94; 95% confidence interval, 1.17–3.24; P = 0.011). CONCLUSIONS: Uninsured and Medicaid patients had a greater likelihood of LTF compared with private insurance and Medicare patients. LTF was further associated with an increased risk of neurosurgical readmission. The results from the present study emphasize the need to address barriers to follow-up to reduce readmission after surgery for cSDH. These findings could inform improved discharge planning, such as predischarge repeat imaging studies and postdischarge contact.

Background Some reports suggest the efficacy of mechanical thrombectomy (MT) for acute vertebrobasilar artery (VBA) occlusion. The major causes of VBA occlusion include cardioembolism (CE) and large-artery atherosclerosis (LAA). However, the clinical characteristics of each cause remain unclear, and they might be important for decision making related to the indications and strategy of MT. Objective This study aimed to compare functional outcomes and factors affecting outcomes between patients with CE and LAA with acute VBA occlusion. Methods This was a retrospective and prospective observational study using data from TREAT (Tokyo-Tama-Registry of Acute Endovascular Thrombectomy), a multicenter registry of MT for acute large-vessel occlusion in the Tokyo metropolitan area. Patients with VBA occlusion classified into CE and LAA groups were analyzed. The primary outcome was a modified Rankin Scale score of 0–2 at 90 days. Results Seventy-nine patients (57 with CE and 22 with LAA) were eligible from January 2015 to March 2020. Despite significantly shorter puncture-to-recanalization and onset-or-last-well-known-to-recanalization times in the CE group, the primary outcome was not significantly different between the 2 groups (CE, 31.6% vs. LAA, 45.5%; P = 0.248). In the subgroup analysis, patients with CE had worse clinical outcomes in the onset-or-last-well-known-to-door time ≥180 minutes, onset-or-last-well-known-to-door time ≥300 minutes, and low posterior circulation Alberta Stroke Program Early CT Score (≤7) subgroups. Conclusions Functional outcomes of VBA occlusion were not significantly different between CE and LAA. Based on the subgroup analysis, patients with CE might have poorer collateral status than do patients with LAA, and earlier recanalization might therefore be desired.