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

Objective Obesity has become a public health crisis and continues to be on the rise. An elevated BMI has been linked to higher rates of spinal degenerative disease requiring surgical intervention. Limited studies exist that evaluate the effects of obesity on peri-operative complications in patients undergoing anterior cervical discectomy and fusion (ACDF). Our study aims to determine the incidence of obesity in the ACDF population and the effects it may have on postoperative in-patient complications. Methods The National Inpatient Sample was evaluated from 2004 to 2014 and discharges with International Classification of Diseases procedure codes indicating ACDF were identified. This cohort was stratified into patients with diagnosis codes indicating obesity. Separate univariable followed by multivariable logistic regression analysis were performed for the likelihood of peri-operative inpatient outcomes among the patients with obesity. Results From 2004 to 2014 an estimated 1,212,475 ACDFs were identified in which 9.2% of the patients were obese. The incidence of obesity amongst ACDF patients has risen dramatically during those years from 5.8% to 13.4%. Obese ACDF patients had higher inpatient likelihood of dysphagia, neurological, respiratory, and hematologic complications as well as pulmonary emboli, and intraoperative durotomy. Conclusion Obesity is a well-established modifiable comorbidity that leads to increased perioperative complications in various surgical specialties. We present one of the largest retrospective analyses evaluating the effects of obesity on inpatient complications following ACDF. Our data suggests that the number of obese patients undergoing ACDF is steadily increasing and had a higher inpatient likelihood of developing peri-operative complications.

Objective Anterior cervical discectomy and fusion (ACDF) is the most common performed surgery in the cervical spine. Dysphagia is one of the most frequent complications following ACDF. Several studies have identified certain demographic and perioperative risk factors associated with increased dysphagia rates, but few have reported recent trends. Our study aims to report current trends and factors associated with the development of inpatient postoperative dysphagia after ACDF. Methods The National Inpatient Sample was evaluated from 2004 to 2014 and discharges with International Classification of Diseases procedure codes indicating ACDF were selected. Time trend series plots were created for the yearly treatment trends for each fusion level by dysphagia outcome. Separate univariable followed by multivariable logistic regression analyses were performed to evaluate predictors of dysphagia. Results A total of 1,212,475 ACDFs were identified in which 3.3% experienced postoperative dysphagia. A significant increase in annual dysphagia rates was observed from 2004-2014. Frailty, intraoperative neuromonitoring, 4 or more level fusions, African American race, fluid/electrolyte disorders, blood loss, and coagulopathy were all identified as significant independent risk factors for the development of postoperative dysphagia following ACDF. Conclusion Postoperative dysphagia is a well-known postsurgical complication associated with ACDF. Our cohort showed a significant increase in the annual dysphagia rates independent of levels fused. We identified several risk factors associated with the development of postoperative dysphagia after ACDF.

BackgroundAlthough studies continue to demonstrate lower complications in neurointerventions using transradial access (TRA) compared with transfemoral approaches, anatomic radial variants can be difficult to navigate and remain one of the frequent causes of access site conversion.ObjectiveTo evaluate predictors of TRA failure in neuroendovascular patients with radial loops and suggest a protocol for managing these anomalies.MethodsA prospective collection of patients undergoing TRA at participating institutions from July 2018 to September 2020 was reviewed. Patients with a radial loop were identified. Patient demographics and procedural characteristics were evaluated to determine predictors of both TRA failure and successful reduction of the radial loop.ResultsWe identified 32 transradial neurointerventions in which patients had radial loops. Twenty-two (68.8%) were identified by diagnostic angiography, and the majority were performed for evaluation or treatment of an aneurysm (56.3%). TRA failure occurred in 13 (40.6%) of the cohort and happened more frequently in patients over 60 years of age (p=0.01) and those with recurrent radial artery diameters ≤2 mm (p=0.02). Of the 19 patients who had successful TRA, 12 (63.2%) procedures were performed through the recurrent radial artery.ConclusionAlthough radial loops are associated with high transradial failure rates, our results suggest that the presence of a loop is not an absolute contraindication to TRA. Therefore, we recommend attempting loop navigation using our protocol. Patient age, vascular tortuosity, and recurrent radial artery size should help dictate when to convert to an alternative access site.

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

BackgroundRecently, there has been a shift in management of unruptured cerebral arteriovenous malformations (AVMs) following studies suggesting that medical management alone was superior to interventional therapy.ObjectiveTo evaluate the influence of contemporary AVM management on AVM rupture patterns in the United States.Methods154 297 AVM admissions were identified between 2003 and 2017 in the National Inpatient Sample. Annual AVM intervention and rupture rates were computed and multivariable logistic regression assessed the likelihood of AVM intervention pre- and post-2014. Segmented regression identified significant change points and fitted segmented linear models for annual intervention and rupture rates. Correlation coefficients assessed the relationship between annual AVM intervention and rupture rates.ResultsFor unruptured AVMs, intervention likelihood and proportion decreased after 2014 (28.1% to 22.3%, pConclusionsAfter 2014, the likelihood of intervention for unruptured AVMs decreased while the incidence of ruptured AVMs increased. These findings suggest that fewer unruptured AVM treatments may lead to increases in AVM rupture incidence.

Transradial access (TRA) has gained traction in neurointerventions as studies continue to demonstrate improved access site safety and equivalent end artery effectiveness when compared with traditional transfemoral techniques. Herein, we describe the technical nuances of obtaining TRA with a focus on distal TRA, left TRA, and sheathless TRA using larger bore catheters. We also discuss various strategies to avoid access site conversion if radial artery spasm or radial anomalies are encountered and offer some solutions for forming the Simmons catheter especially when it cannot be performed in the descending aorta. Lastly, we provide some insights regarding contraindications to TRA.

While the landmark 2015 stroke trials demonstrated that endovascular therapy (EVT) was superior to medical management for the treatment of acute ischemic stroke due to large vessel occlusion, the efficacy of EVT for patients presenting with a low NIHSS score remains undetermined. We conducted a review of the EVT low National Institutes of Health Stroke Scale (NIHSS) stroke literature, identifying 24 quantitative and six qualitative publications. Details of study designs and outcome were extracted and critically discussed.All identified qualitative studies were retrospective. There was significant study design heterogeneity, with 18 unique study designs between the 24 identified quantitative manuscripts. Study investigations included low NIHSS EVT feasibility (n=6), EVT versus best medical management (BMM; n=10), EVT versus intravenous therapy (IVT, n=3), and low NIHSS score versus high NIHSS score (n=3). From single-arm EVT feasibility studies, the reported ranges of modified Thrombolysis in Cerebral Infarction and symptomatic intracranial hemorrhage were 78–97% and 0–10%, respectively. The EVT versus BMM literature had heterogeneous results with 40% reporting benefit with EVT and 60% reporting neutral findings. None of the studies comparing EVT with IVT reported a difference between the two revascularization therapies. The four identified meta-analyses had incongruent inclusion criteria and conflicting results. Two randomized trials are currently investigating EVT in patients with a low NIHSS score. Selected meta-analyses do suggest a potential benefit of EVT over BMM; however, current and future randomized clinical trials will better elucidate the efficacy of EVT in this patient population.

BackgroundMany neurointerventionalists have transitioned to transradial access (TRA) as the preferred approach for neurointerventions as studies continue to demonstrate fewer access site complications than transfemoral access. However, radial artery spasm (RAS) remains one of the most commonly cited reasons for access site conversions. We discuss the benefits, techniques, and indications for using the long radial sheath in RAS and present our experience after implementing a protocol for routine use.MethodsA retrospective review of all patients undergoing neurointerventions via TRA at our institution from July 2018 to April 2020 was performed. In November 2019, we implemented a long radial sheath protocol to address RAS. Patient demographics, RAS rates, radial artery diameter, and access site conversions were compared before and after the introduction of the protocol.Results747 diagnostic cerebral angiograms and neurointerventional procedures in which TRA was attempted as the primary access site were identified; 247 were performed after the introduction of the long radial sheath protocol. No significant differences in age, gender, procedure type, sheath sizes, and radial artery diameter were seen between the two cohorts. Radial anomalies and small radial diameters were more frequently seen in patients with RAS. Patients with clinically significant RAS more often required access site conversion (pConclusionIn our experience, we have found that the use of long radial sheaths significantly reduces the need for access site conversions in patients with RAS during cerebral angiography and neurointerventions.

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

Hair-sparing techniques in cranial neurosurgery have gained traction in recent years and previous studies have shown no difference in infection rates, yet limited data exists evaluating the specific closure techniques utilized during hair-sparing craniotomies. Therefore, it was the intention of this study to evaluate the rate of surgical site infections (SSIs) and perioperative complications associated with using an absorbable intradermal barbed suture for skin closure in hair-sparing supratentorial craniotomies for tumor in order to prove non-inferiority to traditional methods. A retrospective review of supratentorial craniotomies for tumor by a single surgeon from 2011 to 2017 was performed. All perioperative adverse events and wound complications, defined as a postoperative infection, wound dehiscence, or CSF leak, were compared between three different groups: (1) hair shaving craniotomies + transdermal polypropylene suture/staples for scalp closure, (2) hair-sparing craniotomies + transdermal polypropylene suture/staples for scalp closure, and (3) hair-sparing craniotomies + absorbable intradermal barbed suture for scalp closure. Two hundred sixty-three patients underwent hair shaving + transdermal polypropylene suture/staples, 83 underwent hair sparing + transdermal polypropylene suture/staples, and 100 underwent hair sparing + absorbable intradermal barbed suture. Overall, 2.9% of patients experienced a perioperative complication and 4.3% developed a wound complication. In multivariable analysis, the use of a barbed suture for scalp closure and hair-sparing techniques was not predictive of any complication or 30-day readmission. Furthermore, the absorbable intradermal barbed suture cohort had the lowest overall rate of wound complications (4%). Hair-sparing techniques using absorbable intradermal barbed suture for scalp closure are safe and do not result in higher rates of infection, readmission, or reoperation when compared with traditional methods.

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

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

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

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

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

Background Laser interstitial thermal therapy (LITT) for posterior fossa lesions remains rare as the small size of the infratentorial compartment, proximity to the brainstem, and thickness/angulation of the occipital bone creates barriers to procedural success. Furthermore, evaluation of the effect of ablation volume on outcomes is limited. Objective To analyze our institutional experience with LITT in the posterior fossa stratifying perioperative and long-term outcomes by ablation volumes. Methods Seventeen patients with posterior fossa lesions treated with LITT from 2013 to 2020 were identified. Local progression-free survival (PFS), overall survival, steroid dependence, and edema reduction were evaluated with Kaplan-Meier analysis grouped by ablation volume. Preoperative, postoperative, and last known Karnofsky Performance Status (KPS) were compared using a matched paired t test. Results No differences in pathology, preoperative KPS, or preoperative lesion volume were found between patients with total (100%-200% increase in pre-LITT lesion volume) versus radical (>200% increase in pre-LITT lesion volume) ablations. Patients who underwent radical ablation had a higher postoperative KPS (93 vs 82, P = .02) and higher KPS (94 vs 87, P = .04) and greater reduction in perilesional edema at last follow-up (P = .01). Median follow-up was 80.8 wk. Conclusion Despite obvious anatomical challenges, our results demonstrate that radical ablations are both feasible and safe in the posterior fossa. Furthermore, radical ablations may lead to greater decreases in perilesional edema and improved functional status both immediately after surgery and at last follow-up. Thus, LITT should be considered for patients with otherwise unresectable or radioresistant posterior fossa lesions.

BackgroundAlthough the liquid embolic agent, Onyx, is often the preferred embolic treatment for cerebral dural arteriovenous fistulas (DAVFs), there have only been a limited number of single-center studies to evaluate its performance.ObjectiveTo carry out a multicenter study to determine the predictors of complications, obliteration, and functional outcomes associated with primary Onyx embolization of DAVFs.MethodsFrom the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database, we identified patients who were treated for DAVF with Onyx-only embolization as the primary treatment between 2000 and 2013. Obliteration rate after initial embolization was determined based on the final angiographic run. Factors predictive of complete obliteration, complications, and functional independence were evaluated with multivariate logistic regression models.ResultsA total 146 patients with DAVFs were primarily embolized with Onyx. Mean follow-up was 29 months (range 0–129 months). Complete obliteration was achieved in 80 (55%) patients after initial embolization. Major cerebral complications occurred in six patients (4.1%). At last follow-up, 84% patients were functionally independent. Presence of flow symptoms, age over 65, presence of an occipital artery feeder, and preprocedural home anticoagulation use were predictive of non-obliteration. The transverse-sigmoid sinus junction location was associated with fewer complications, whereas the tentorial location was predictive of poor functional outcomes.ConclusionsIn this multicenter study, we report satisfactory performance of Onyx as a primary DAVF embolic agent. The tentorium remains a more challenging location for DAVF embolization, whereas DAVFs located at the transverse-sigmoid sinus junction are associated with fewer complications.

Purpose: The preoperative medical clearance process is well established to screen for medical comorbidities and therefore must be thorough. However, screening for potential cervical spine disease is often overlooked. In older surgical candidates, the presence of cervical spondylosis can increase risk of iatrogenic cervical spine injury during prolonged neck extension in non-spinal surgeries. We present a standard protocol for cervical spine clearance and a novel sustained neck extension maneuver through a retrospective case series. Methods: Sixty-three consecutive cases that underwent preoperative cervical clearance between April 2012 and December 2019 were reviewed. Referral for clearance occurred through the department of anesthesiology after concerning radiographic or physical exam findings were noted. A standard preoperative screening protocol with a sustained one-minute neck extension maneuver was implemented. Recommendations were made for standard neck precautions with or without neuromonitoring or for cervical spine decompression surgery prior to the planned procedure. Results: There were 25 patients with symptoms of myelopathy, 11 with radiculopathy and 13 with neck pain at baseline. Cervical spondylosis was observed in 51 patients, cervical canal stenosis in 29 and cervical myelomalacia in six. Fifty-seven patients underwent neck extension exam and 25 exhibited new or worsening symptoms. Myelopathic symptoms and radicular pain at baseline and positive Hoffman’s and Spurling’s sign, independently, were significantly associated with a positive neck extension exam (p

International audience; Abstract BACKGROUND Randomized controlled trials evaluating mechanical thrombectomy (MT) for acute ischemic stroke predominantly studied anterior circulation patients. Both procedural and clinical predictors of outcome in posterior circulation patients have not been evaluated in large cohort studies. OBJECTIVE To investigate technical and clinical predictors of functional independence after posterior circulation MT while comparing different frontline thrombectomy techniques. METHODS In a retrospective multicenter international study of 3045 patients undergoing MT for stroke between 06/2014 and 12/2018, 345 patients had posterior circulation strokes. MT was performed using aspiration, stent retriever, or combined approach. Functional outcomes were assessed using the 90-d modified Rankin score dichotomized into good (0-2) and poor outcomes (3-6). RESULTS We included 2700 patients with anterior circulation and 345 patients with posterior circulation strokes. Posterior patients (age: 60 ± 14, 46% females) presented with mainly basilar occlusion (80%) and were treated using contact aspiration or ADAPT (39%), stent retriever (31%) or combined approach (19%). Compared to anterior strokes, posterior strokes had delayed treatment (500 vs 340 min, P

Laser interstitial thermal therapy is a minimally invasive surgical alternative to craniotomy that uses laser light through a fiber optic probe placed within a target lesion to create thermal tissue damage, resulting in cellular death. It is used in neuro-oncology to treat inaccessible lesions and obviate morbidity in high-risk patients. Overall complication rates and outcome measures are comparable with those seen in radiation and/or craniotomy. Laser interstitial thermal therapy can be an effective option for recurrent brain metastases. Prospective, randomized trials must be performed to evaluate the efficacy of laser interstitial thermal therapy as a primary treatment for brain metastases.

BackgroundThe off-hour effect has been observed in the medical care of acute ischemic stroke. However, it remains unclear if time of arrival affects revascularization rates and outcomes after endovascular therapy (EVT) for emergent large vessel occlusion (ELVO). We aimed to investigate the clinical outcomes of EVT between on-hour and off-hour admissions.MethodsPatients who underwent EVT for ELVO from January 2013 to June 2019 from the STAR Registry were included. Patients were grouped based on time of groin puncture: on-hour period (Monday through Friday, 7:00 am–4:59 pm) and off-hour period (overnight 5:00pm–6:59am and the weekends). Primary outcome was final modified Rankin Scale (mRS) at 90 days on mRS-shift analysis.ResultsA total of 1919 patients were included in the study from six centers. The majority of patients (1169, 60.9%) of patients presented during the off-hour period. The mean age was 68.1 years and 50.5% were women. Successful reperfusion, as defined by a Thrombolysis In Cerebral Infarction (TICI) score of ≥2B, was achieved in 88.8% in the on-hour group and 88.0% in the off-hour group. Good clinical outcome (mRS 0–2) was obtained in 34.4% of off-hour patients and 37.7% of on-hour patients. On multivariable ordinal logistic regression analysis, time of presentation was not associated with worsened outcome (OR 1.150; 95% CI 0.96 to 1.37; P=0.122). Age, admission National Institutes of Health Stroke Scale (NIHSS), baseline mRS, and final TICI score were significantly associated with worse outcomes.ConclusionThere is no statistical difference in functional outcome in acute ischemic stroke patients who underwent EVT during on-hours versus off-hours.

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

Background: Standard mechanical thrombectomy (MT) techniques utilized include aspiration thrombectomy (ADAPT), stent retriever (SR), and a combination of both (Solumbra). Many studies compare outcomes between ADAPT and SR; however, there has yet to be a large multicenter investigation comparing ADAPT and SR to Solumbra. Methods: All patients from the participating STAR collaboration who underwent MT from 2015-2019 were included. Patients were analyzed by first MT technique utilized (ADAPT, SR, or Solumbra). Univariable and multivariable linear regression was utilized to analyze the MT technique association to number of thrombectomy attempts and procedure time. Univariable and multivariable logistic regression was utilized to determine the association between MT technique and the following outcomes: recanalization, symptomatic hemorrhage, 90-day functional independence, or 90-day mortality. P value less than 0.5 was considered significant. Results: A total of 2515 MT for stroke were identified: 1155 (46%) ADAPT, 735 (29%) SR, 625 (25%) Solumbra. Patients who received Solumbra MT were older (p Conclusion: Compared to standard ADAPT and SR thrombectomy, the Solumbra technique for MT is a longer procedure that results in an increased likelihood of hemorrhage and 90-day mortality.

Introduction: Radiological hemorrhagic transformation (rHT) and symptomatic intracranial hemorrhage (sICH) remain a major complication of mechanical thrombectomy (MT) in acute stroke. Our aim is to identify independent predictors of rHT and sICH. Methods: A retrospective multicenter international study across the US and Europe included 2499 patients, 18 years or older, who underwent EVT for acute stroke from 2015-2019. rHT is defined as any intracranial hemorrhage post MT and subgrouped per ECASS II as petechial (HI), parenchymal hematoma without (PH1) and with mass effect (PH2) and subarachnoid hemorrhage (SAH). sICH was defined as presence of PH2 or SAH. Functional outcomes were described using the 90-day modified Rankin score (mRS) as “good” 0-2 or “poor” 3-6. Multivariable logistic regression model was used to identify predictors of rHT and sICH. Results: 600 (24%) had rHT and 145 (5.8%) had sICH. On multivariable regression model, independent predictors for both rHT and sICH were higher admission NIHSS (OR 1.03, p Conclusion: Compared to posterior circulation, anterior circulation strokes have higher rates of rHT and sICH. Baseline hyperlipidemia is protective for rHT or sICH post MT and this association needs further study. Clinical severity of stroke, poor ASPECTS on admission and higher thrombectomy attempts are associated with higher rates of rHT or sICH. Both rHT and sICH are independently associated with poor functional outcomes.

BackgroundThe efficacy of endovascular thrombectomy (ET) for acute ischemic stroke (AIS) in octogenarians is still controversial.ObjectiveTo evaluate, using a large multicenter cohort of patients, outcomes after ET in octogenarians compared with younger patients.MethodsData from prospectively maintained databases of patients undergoing ET for AIS at seven US-based comprehensive stroke centers between January 2013 and January 2018 were reviewed. Demographic, procedural, and outcome variables were collected. Outcomes included 90-day modified Rankin Scale (mRS) score, postprocedural National Institutes of Health Stroke Scale score, postprocedural hemorrhage, and mortality. Univariate and multivariate analyses were performed to assess the independent effect of age ≥80 on outcome measures. Subgroup analyses were also performed based on location of stroke, success of recanalization, or ET technique used.ResultsRates of functional independence (mRS score 0–2) after ET in elderly patients were significantly lower than for younger counterparts. Age ≥80 was independently associated with increased mortality and poor outcome. Age ≥80 showed an independent negative prognostic effect on outcome even when patients were divided according to thrombectomy technique, location of stroke, or success of recanalization. Age ≥80 independently predicted higher rate of postprocedural hemorrhage, but not success of recanalization. Baseline deficit and number of reperfusion attempts, but not Thrombolysis in Cerebral Infarction score were associated with lower odds of good outcome.ConclusionThe large effect size of ET on AIS outcomes is significantly diminished in the elderly population when using comparable selection criteria to those used in younger counterparts. This raises concerns about the risk–benefit ratio and the cost-effectiveness of performing this procedure in the elderly before optimizing patient selection.

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

Endoscopic third ventriculostomy (ETV) has gained traction as a method for treating post-hemorrhagic hydrocephalus of prematurity (PHHP) in an effort to obviate lifelong shunt dependence in neonates. However, data remains limited regarding inpatient failures. A retrospective analysis of the NIS between 1998 and 2014 was performed. Discharges with age

Spinal vascular malformations are difficult to diagnose lesions that can be associated with significant permanent morbidity. The angioarchitecture of spinal vascular anatomy and the associated pathologies have only recently been illuminated by the advent of spinal angiography. However, conventional spinal digital subtraction angiography is often limited by significant variability, overlapping vessels, as well as an inability to understand the precise location of the nidus or fistula in relation to the spinal cord and spine. In this study, we present 4 unique cases wherein 3-dimensional rotational angiography (3DRA) with dual volume acquisition was useful in defining the anatomy of spinal fistulas as well as planning treatment.

Introduction Mechanical thrombectomy has become the standard treatment for large vessel occlusion (LVO) in acute ischemic stroke (AIS) in well-selected patients. Although many devices and strategies exist, the use of a balloon-tip guide catheter (BGC) with stent-retriever (SR) may hold several advantages. We aim to assess the efficacy and identify predictors of technical success of this unique approach. Methods From our prospectively maintained database, we identified consecutive cases in which a BGC was used for stent-retriever thrombectomy in anterior circulation LVO between 2015 and 2016. Baseline and procedural characteristics were captured and analyzed. Predictors of technical and clinical outcomes were identified by multivariable logistic regression analysis. Results Ninety-three patients with AIS-LVO were treated with BGC-assisted mechanical thrombectomy. The mean age was 71 years old (SD 14), with 49.5% male (n=46). Pre-operative IV-tPA was administered in 55.9% (n=52) of cases. The most common location of occlusive thrombus was M1 (64.5%, n=60). Successful recanalization (mTICI=2b-3) was achieved in 86.0% (n=80) of cases while complete revascularization (mTICI-3) was achieved in 56.5% (n=52). There was a first-pass success rate of 52.7% (n=49). At discharge, 38.7% of the patients were functionally independent (mRS≤2). Multivariate analysis revealed that the middle cerebral artery location was strongly predictive of first-pass success, resulting in mTICI =2b revascularization (OR 7.10, p=0.018). Additionally, female gender (OR 2.85, p=0.042) and decreasing mTICI were associated with a poor clinical outcome (mRS≥4; OR 1.76, p=0.008). Conclusions BGC assistance in stent retrieval thrombectomy is safe and effective for AIS due to anterior circulation LVO. Further investigation is required to elucidate the optimal treatment strategy based on patient and disease characteristics.

Introduction Acute ischemic stroke (AIS) still remains one of the top leading causes of morbidity and mortality in the United States. In 2007, the DESTINY trial demonstrated lower mortality rates in patients with large hemispheric strokes following hemicraniectomy. 7 years later, the MR CLEAN trial showed improved outcomes in AIS following endovascular mechanical thrombectomy (MT) when compared to intravenous tPA alone. However, during the enrollment period for this trial there remains limited data regarding the effects of MT on the need for hemicraniectomy. Methods A retrospective analysis of the Nationwide Inpatient Sample (NIS) between 1998–2015 was performed. Patients with an ICD-9-CM diagnosis code indicating an anterior circulation ischemic stroke (433.11, 434.01, 434.11, and 434.91) were included. Patients with an ICD-9-CM diagnosis code indicating trauma, neoplasm, SAH/aneurysm, posterior circulation ischemic stroke, or abscess (191.x, 198.3, 324.0, 430, 433.01, 433.21, 437.3, 437.5, 437.6, 443.24, 747.81, 800.xx, 801.xx, 851.xx, 852.xx, 853.xx, and 854.xx) were excluded. In order to limit the analysis to AIS, patients who did not have the ICD-9-CM procedure code of tPA (99.10) were excluded. Those patients who underwent thrombectomy (39.74) and hemicraniectomy (01.24, 01.25, 01.39, 01.53, and 01.59) were also indentified. Logistic regression model was used to analyze the effect of thrombectomy on rates of hemicraniectomy in patients with AIS who received tPA. Results A total of 59,703 patients in the NIS were identified as having an acute anterior circulation ischemic stroke that subsequently received tPA. 3597 patients were also identified as having undergone MT and 606 patients were found to have undergone hemicraniectomy as well. Logistic regression model demonstrated that patients who underwent MT were significantly more likely to undergo hemicraniectomy (OR 4.52, 95% CI 3.72–5.49, p Conclusions Although MT has proven to be an effective treatment for AIS, it appears that prior to MR CLEAN, patients who underwent MT had a higher likelihood of requiring a hemicraniectomy during the same hospital admission. Since MTs were not standardized prior to 2014, the variability in procedural technique could ultimately cause unreliable degrees of recanalization and thus lead to varied outcomes. Therefore, the effect of MT on hemicraniectomy rates in patients with AIS warrants further investigation following the advent of standardized thrombectomy techniques. Disclosures E. Luther: None. D. McCarthy: None. R. Starke: None.

Introduction Following publication of the ISUIA and ISAT studies, the paradigm for treatment of cerebral aneurysms shifted from open surgical clipping to endovascular embolization as primary therapy in a majority of cases. While this trend has been widely acknowledged, patient population, outcome data and large-scale treatment patterns have not been reported in recent years. Methods The National Inpatient Sample from 2004–2014 was reviewed. Subarachnoid hemorrhage (SAH) and unruptured aneurysm (UA) discharges were identified along with treatment given, surgical clipping or endovascular repair. UA that were not primary diagnoses were labeled as incidental. The Elixhauser comorbidity readmission index (ELIX) was used to estimate patient baseline health status. SAH severity and outcomes were analyzed with the NIS-SAH severity score (NIS-SSS) and NIS-severity outcome measure (NIS-SOM), which correlate directly with Hunt-Hess score and mRS outcome, respectively. Time trend series plots were created. Following Shapiro-Wilks normality confirmation, linear and logistic regression were utilized to estimate significant changes in the yearly mean or median of treatments. Per capita values were analyzed to control for population growth. Comparisons of means/distributions of normally continuous variables was carried out using least squared means analysis; while, nonparametric distributions were compared with the Wilcoxon rank sum test. P-values of ≤0.05 were considered statistically significant. Statistical analysis performed with SAS 9.4 (Cary, NC). Results A total of 379,437 SAH and 378,242 UA discharges were reviewed. For UA and SAH, endovascularly treated patients were significantly older (p 7, correlating with Hunt-Hess ≥ 4, were more likely to be managed endovascularly (p For SAH treatment, yearly discharges for clipping decreased (-264.1, p=0.0002) and increased for endovascular (+366, p=0.0003) treatment (2004 vs. 2014; SAH-clipping 6579 vs 3400; SAH-endovascular 3878 vs 7535). For treated UA, yearly discharges for clipping remained stable and increased for endovascular therapy (+630, p Conclusion Patients with ruptured and unruptured aneurysms are increasingly treated with endovascular therapy over clipping. Mortality rates of ruptured aneurysms is improving regardless of treatment; whereas, mortality in unruptured aneurysms is only improving for surgical clipping. Disclosures D. McCarthy: None. E. Luther: None. S. Chen: None. S. Sur: None. M. Brunet: None. D. Sheinberg: None. E. Peterson: None. R. Starke: None.

Introduction Carotid blowout syndrome (CBS) refers to the acute rupture of any segment of the common carotid artery, including both the external and extracranial internal carotid arteries (ICA). CBS often results in life threatening hemorrhage and acute upper airway obstruction. CBS is a well-known phenomenon in patients with head and neck cancer and typically occurs via direct extension of tumor into the arterial wall or iatrogenically during surgical manipulation. With a reported incidence of 4.3% following radical neck dissection and mortality rates as high as 60%, CBS must always be considered in any patient with head or neck cancer and acute hemorrhage in the oro- or nasopharynx of unknown origin. Accepted management strategies for CBS include open surgical ligation or endovascular treatment via parent vessel sacrifice or intraluminal stent placement. One of the more feared complications associated with endovascular parent vessel sacrifice is distal migration of embolic material, which can lead to ischemic stroke. Delayed migration of embolic material into the oro- or nasopharynx is extremely uncommon. We present a case of a coil migration into the nasopharynx one year following endovascular treatment of CBS that occurred during nasopharyngeal carcinoma resection. Methods A 41-year-old female presented with brisk oral cavity hemorrhage after undergoing surgical resection of nasopharyngeal carcinoma seven weeks prior. Results Computed tomography angiography (CTA) revealed a small 0.2×0.2×0.3 cm pseudoaneurysm arising from the medial aspect of the right ICA at the level of C1-C2 vertebrae that abutted the nasopharynx. After radiographically passing a balloon test occlusion (BTO), the decision was made to endovascularly sacrifice the right ICA. With the balloon inflated, embolization with coils and onyx was performed in the petrous segment of the ICA. Angiography and CTA confirmed pseudoaneurysm obliteration and complete vessel occlusion. Three-month follow-up CTA demonstrated stable vessel occlusion. Eleven months following ICA sacrifice, she started to complain of throat irritation and difficulty swallowing. During a scheduled sinus debridement, exposed coils were visualized in the right nasopharynx. CTA revealed vessel wall dehiscence with extrusion of coils into the nasopharynx but continued occlusion of the vessel. The exposed coils were clipped and extracted endoscopically for symptomatic relief. Three-month follow-up angiogram confirmed stable vessel occlusion and patient has remained asymptomatic. Conclusion CBS can be a rare and devastating complication of head and neck surgery, often requiring immediate endovascular treatment. Coil migration is a rare complication following cerebral pseudoaneurysm obliteration via endovascular vessel sacrifice. When a patient has a partially extruding coil, it is imperative to obtain imaging and treat as soon as possible to avoid further coil migration and possible airway compromise. Disclosures D. Sheinberg: None. D. McCarthy: None. E. Luther: None. S. Chen: None. R. Starke: None.

Cerebral aneurysm rupture is a devastating event resulting in subarachnoid hemorrhage and is associated with significant morbidity and death. Up to 50% of individuals do not survive aneurysm rupture, with the majority of survivors suffering some degree of neurological deficit. Therefore, prior to aneurysm rupture, a large number of diagnosed patients are treated either microsurgically via clipping or endovascularly to prevent aneurysm filling. With the advancement of endovascular surgical techniques and devices, endovascular treatment of cerebral aneurysms is becoming the first-line therapy at many hospitals. Despite this fact, a large number of endovascularly treated patients will have aneurysm recanalization and progression and will require retreatment. The lack of approved pharmacological interventions for cerebral aneurysms and the need for retreatment have led to a growing interest in understanding the molecular, cellular, and physiological determinants of cerebral aneurysm pathogenesis, maturation, and rupture. To this end, the use of animal cerebral aneurysm models has contributed significantly to our current understanding of cerebral aneurysm biology and to the development of and training in endovascular devices. This review summarizes the small and large animal models of cerebral aneurysm that are being used to explore the pathophysiology of cerebral aneurysms, as well as the development of novel endovascular devices for aneurysm treatment.

Background: The transradial approach (TRA) to endovascular procedures decreases access site morbidity and mortality when compared to the traditional transfemoral technique (TFA). Despite its improved safety profile, there remains concerns that performing mechanical thrombectomy (MT) via TRA may lead to longer revascularization times and thus worse outcomes. However, TRA may confer an added benefit in mechanical thrombectomy (MT) where navigation of challenging aortic arch and carotid anatomy is often facilitated by a right radial artery trajectory. In this study, we compare technical and clinical outcomes in patients who underwent MT via TRA versus TFA. Methods: We performed a retrospective review of our institutional database to identify 51 patients with challenging vascular anatomy who underwent MT for anterior circulation large vessel occlusion between February 2015 and February 2017. Patient characteristics, procedural techniques, and outcomes were recorded and TFA and TRA cohorts were compared. Results: Of the 51 patients, 35% of patients (n=18) underwent MT via TRA. There were no significant differences between the cohorts in patient characteristics, clot location, or aortic arch type and presence of ICA tortuosity. There were no significant differences in technical or clinical outcomes between the 2 cohorts, including rates of single-pass recanalization (54.6% vs. 55.6%, p=0.949) and average number of passes (1.9 vs. 1.7, p=0.453). Mean time from vascular access to reperfusion (61.9 vs. 61.1 mins, p=0.920), rates of successful revascularization (>= TICI2b; 87.9% vs. 88.9%, p=1.0) and functional outcomes (mRS >=2, 39.4% vs. 33.3%, p=0.669) were also similar between the TFA and TRA cohorts, respectively. Conclusions: Our results demonstrate equivalence in efficacy and efficiency between transradial and transfemoral access for MT in acute large vessel occlusion in the anterior circulation in patients with challenging vascular anatomy. Given the established advantage in access-site morbidity, our data suggests that the transradial approach may be superior to the transfemoral approach in well-selected patients undergoing MT.

BackgroundThe transradial approach for endovascular angiography and interventional procedures is superior to the traditional transfemoral approach in several metrics, including lower access-site complication rates, higher patient satisfaction, and lower hospital costs. Interventional cardiologists have begun to adopt the distal transradial approach (dTRA) for coronary interventions as it has an improved safety profile and improved procedural ergonomics. Adaptation of dTRA for neuroendovascular procedures promises similar benefit, but requires a learning curve.ObjectiveTo report the first use of dTRA for diagnostic cerebral angiography and demonstrate the feasibility and safety of a dTRA.MethodsA retrospective review of our prospective institutional database of consecutive cases of cerebral DSA performed via dTRA between August 2018 and December 2018 was performed. Patient demographics, procedural and radiographic metrics, and clinical data were recorded.Results85 patients were identified with an average age of 53.8 years (range 18–82); 67 (78.8%) patients were female. 78 patients underwent successful dTRA diagnostic cerebral angiography, with a mean of five vessels catheterized and average fluoroscopy time of 12.0 min, or 2.6 min for each vessel. Seven patients required conversion to transfemoral access, with the most common reason being inability to advance the wire and radial artery spasm. There were no complications.ConclusiondTRA is associated with decreased rates of radial artery occlusion, ischemic hand events, as well as improved patient comfort, faster periprocedural management, and cost benefits. Our preliminary experience with dTRA for diagnostic cerebral angiography demonstrates excellent feasibility and safety in combination with relative efficiency.

The posterior approach is commonly performed in the treatment of multilevel degenerative cervical myelopathy (DCM) with spinal cord compression. Both posterior laminoplasty and laminectomy with fusion can achieve adequate decompression of the spinal cord and obtain satisfactory neurologic outcomes. Lateral mass screw (LMS) fixation is the prevalent fixation technique for the posterior cervical approach. LMS fixation achieves a high fusion rate and is associated with a low complication profile. Neurologic injury, vascular injury, and hardware failure rarely occur in LMS cases. LMS has become the standard technique for posterior fixation in the subaxial cervical spine for various pathologies. Nevertheless, LMS fixation has its own limitations and isn’t indicated under certain circumstances. In such circumstances, alternative techniques including cervical pedicle screw, translaminar screw, and transfacet screw can be very useful for posterior cervical fixation instead of LMS. In this chapter, we will give a comprehensive explanation of these common alternatives for posterior cervical fixation.

BackgroundA transradial approach (TRA) is associated with fewer access site complications than a transfemoral technique (TFA).However, there is concern that performing mechanical thrombectomy (MT) via TRA may lead to longer revascularization times and thus worse outcomes. Nonetheless, TRA may confer added benefits in MT since navigation of challenging aortic arch and carotid anatomy is often facilitated by a right radial artery trajectory.ObjectiveTo compare outcomes in patients who underwent MT via TRA versus TFA.MethodsWe performed a retrospective review of our institutional database to identify 51 patients with challenging vascular anatomy who underwent MT for anterior circulation large vessel occlusion between February 2015 and February 2018. Patient characteristics, procedural techniques, and outcomes were recorded. TFA and TRA cohorts were compared.ResultsOf the 51 patients, 18 (35%) underwent MT via TRA. There were no significant cohort differences in patient characteristics, clot location, or aortic arch type and presence of carotid tortuosity. There were no significant differences in outcomes between the two cohorts, including single-pass recanalization rate (54.5% vs 55.6%, p=0.949) and average number of passes (1.9 vs 1.7, p=0.453). Mean access-to-reperfusion time (61.9 vs 61.1 min, p=0.920), successful revascularization rates (Thrombolysis in Cerebral Infarction score ≥2b 87.9% vs 88.9%, p=1.0) and functional outcomes (modified Rankin Scale score≤2, 39.4% vs 33.3%, p=0.669) were similar between TFA and TRA cohorts, respectively.ConclusionsOur results demonstrate equivalence in efficacy and efficiency between TRA and TFA for MT of anterior circulation large vessel occlusion in patients with challenging vascular anatomy. TRA may be better than TFA in well-selected patients undergoing MT.

Normal vascular development includes the formation and specification of arteries, veins, and intervening capillaries. Vein of Galen malformations (VOGM) are among the most common and severe neonatal brain arterio-venous malformations, shunting arterial blood into the brain’s deep venous system through aberrant direct connections. Exome sequencing of 55 VOGM probands, including 52 parent-offspring trios, revealed enrichment of rare, damaging de novo mutations in chromatin modifier genes that play essential roles in brain and vascular development. Other VOGM probands harbored rare, inherited damaging mutations in Ephrin signaling genes, including a genome-wide significant mutation burden in EPHB4. Inherited mutations showed incomplete penetrance and variable expressivity, with mutation carriers often exhibiting cutaneous vascular abnormalities, suggesting a two-hit mechanism. Identified mutations collectively account for ~30% of studied VOGM cases. These findings provide insight into disease biology and may have clinical implications for risk assessment.