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Abstract Objectives DCI and hydrocephalus are the most common complications that predict poor outcomes after aSAH. The relationship between sex, DCI and hydrocephalus are not well established; thus, we aimed to examine sex differences in DCI and hydrocephalus following aSAH in a systematic review and meta-analysis. Methods A systematic search was conducted using the PubMed, Scopus and Medline databases from inception to August 2022 to identify cohort, case control, case series and clinical studies reporting sex and DCI, acute and chronic shunt-dependent hydrocephalus (SDHC). Random-effects meta-analysis was used to pool estimates for available studies. Results There were 56 studies with crude estimates for DCI and meta-analysis showed that women had a greater risk for DCI than men (OR 1.24, 95% CI 1.11–1.39). The meta-analysis for adjusted estimates for 9 studies also showed an association between sex and DCI (OR 1.61, 95% CI 1.27–2.05). For acute hydrocephalus, only 9 studies were included, and meta-analysis of unadjusted estimates showed no association with sex (OR 0.95, 95%CI 0.78–1.16). For SDHC, a meta-analysis of crude estimates from 53 studies showed that women had a somewhat greater risk of developing chronic hydrocephalus compared to men (OR 1.14, 95% CI 0.99–1.31). In meta-analysis for adjusted estimates from 5 studies, no association of sex with SDHC was observed (OR 0.87, 95% CI 0.57–1.33). Conclusions Female sex is associated with the development of DCI; however, an association between sex and hydrocephalus was not detected. Strategies to target females to reduce the development of DCI may decrease overall morbidity and mortality after aSAH.

Minimally invasive interspinous process devices (IPD), including interspinous distraction devices (IDD) and interspinous stabilizers (ISS), are increasingly utilized for treating symptomatic lumbar canal stenosis (LCS). There is ongoing debate around their efficacy and safety over traditional decompression techniques with and without interbody fusion (IF). This study presents a comprehensive review of IPD and investigates if: (I) minimally invasive IDD can effectively substitute direct neural decompression and (II) ISS are appropriate substitutes for fusion after decompression. Articles published up to 22(nd) January 2020 were obtained from PubMed search. Relevant articles published in the English language were selected and critically reviewed. Observational studies across different IPD brands consistently show significant improvements in clinical outcomes and patient satisfaction at short-term follow-up. Compared to non-operative treatment, mini-open IDD was had significantly greater quality of life and clinical outcome improvements at 2-year follow-up. Compared to open decompression, mini-open IDD had similar clinical outcomes, but associated with higher complications, reoperation risks and costs. Compared to open decompression with concurrent IF, ISS had comparable clinical outcomes with reduced operative time, blood loss, length of stay and adjacent segment mobility. Mini-open IDD had better outcomes over non-operative treatment in mild-moderate LCS at 2-year follow-up, but had similar outcomes with higher risk of re-operations than open decompression. ISS with open decompression may be a suitable alternative to decompression and IF for stable grade 1 spondylolisthesis and central stenosis. To further characterize this procedure, future studies should focus on examining enhanced new generation IPD devices, longer-term follow-up and careful patient selection.

Up to 70% of multiple myeloma (MM) patients develop vertebral metastasis and subsequent pathological vertebral fractures (PVF). With contemporary systemic therapies, life expectancy of MM patients has improved drastically, and the need to manage pain and associated disability from PVF is increasingly a high priority. The aim of this review is to provide an updated comprehensive synthesis of evidence in the use of vertebral augmentation, including percutaneous vertebroplasty (PV) and balloon kyphoplasty (BKP), to treat MM-related PVF. A comprehensive multi-database search in accordance with PRISMA guidelines was performed up to 10 February 2021. Relevant English language articles were selected and critically reviewed. A total of 23 clinical studies have been included in the review. PV and BKP showed significant pain and functional improvements in terms of analgesia requirements, Cervical Spine Function Score, Eastern Cooperative Oncology Group scale, EQ-5D score, Karnofsky score, Neck Pain Disability Index, Oswestry Disability Index, Short form-36 (SF-36) questionnaire and VAS pain scale. Both procedures also reported promising radiographic outcomes in terms of vertebral height improvement, maintenance and restoration, as well as kyphotic deformity correction. Asymptomatic cement leakage was commonly reported. There was no significant difference between the two procedures. PV and BKP are safe and effective procedure that offers pain relief, reduction in pain associated disability and reduction of fracture incidence. Its minimally invasive approach is associated with minimal morbidity risk, making it a viable option in frail patients. Narrative review.

Background Fever in aneurysmal subarachnoid hemorrhage (aSAH) has been associated with delayed cerebral ischemia (DCI), but its relevance in risk stratification has not been explored. This study investigated whether early temperature elevation following aSAH predicts impending clinical deterioration caused by DCI. Methods Relevant cases were identified from a prospectively maintained database for consecutive patients with aSAH treated at our center between July 2015 and January 2020. Temperature readings obtained every 2 hours for individual patients from admission through day 14 were recorded and analyzed. Demographic, clinical, treatment, and angiographic data were extracted from the electronic medical record. The primary end point was the occurrence of DCI (clinical and radiographic vasospasm). Multivariate logistic regression analyses were performed to account for patient age, smoking status, and VASOGRADE classification. Results The study included 175 patients (124 women) with aSAH. The median age at diagnosis was 55.4 years (range, 20.5–87.2 years). Clinical DCI occurred in 58 patients; 2 (1.1%) responded to hemodynamic augmentation, and 56 (32.0%) required intra-arterial therapy. Temperature graphs showed a marked divergence on day 4 between clinical DCI and non-DCI groups (1.12°C ± 0.15°C and 0.76°C ± 0.08°C, respectively, P = 0.007). Patients with temperature elevation ≥2.5°C on day 4 or 5 compared with their admission temperature were more likely to clinically deteriorate owing to DCI (odds ratio 4.55, 95% confidence interval 1.31–15.77, P = 0.017). Conclusions Temperature elevation of ≥2.5°C on day 4 or 5 compared with baseline suggests a greater risk of clinical deterioration owing to DCI.

Small trials have demonstrated promising results utilising intravenous milrinone for the treatment of delayed cerebral ischaemia (DCI) after subarachnoid haemorrhage (SAH). Here we summarise and contextualise the literature and discuss the future directions of intravenous milrinone for DCI. A systematic, pooled analysis of literature was performed in accordance with the PRISMA statement. Methodological rigour was analysed using the MINORS criteria. Extracted data included patient population; treatment protocol; and clinical, radiological, and functional outcome. The primary outcome was clinical resolution of DCI. Eight hundred eighteen patients from 10 single-centre, observational studies were identified. Half (n = 5) of the studies were prospective and all were at high risk of bias. Mean age was 52 years, and females (69%) outnumbered males. There was a similar proportion of low-grade (WFNS 1-2) (49.7%) and high-grade (WFNS 3-5) (50.3%) SAH. Intravenous milrinone was administered to 523/818 (63.9%) participants. Clinical resolution of DCI was achieved in 375/424 (88%), with similar rates demonstrated with intravenous (291/330, 88%) and combined intra-arterial-intravenous (84/94, 89%) therapy. Angiographic response was seen in 165/234 (71%) receiving intravenous milrinone. Hypotension (70/303, 23%) and hypokalaemia (31/287, 11%) were common drug effects. Four cases (0.5%) of drug intolerance occurred. Good functional outcome was achieved in 271/364 (74%) patients. Cerebral infarction attributable to DCI occurred in 47/250 (19%), with lower rates in asymptomatic spasm. Intravenous milrinone is a safe and feasible therapy for DCI. A signal for efficacy is demonstrated in small, low-quality trials. Future research should endeavour to establish the optimal protocol and dose, prior to a phase-3 study.

Tumour to tumour metastasis is a rare event, especially in the pituitary. Metastases to pituitary adenomas most commonly occurs in late stage disease, commonly presenting with visual field defects and adenohypophyseal dysfunction. The most frequent primary cancers are lung, breast and renal carcinoma which deposit most commonly in prolactinomas, somatotropinomas, gonadotropinomas. In nearly 40% of cases, sellar symptoms are the harbinger to the diagnosis of primary malignancy. The abnormal vascularity and growth promoting microenvironment of pituitary adenomas may encourage metastatic seeding and proliferation of these "collision tumours". Here, we present a case of a breast carcinoma metastasis to a pituitary null-cell adenoma in the setting of immunotherapy. Infundibular thickening in the setting of immunotherapy is often ascribed to hypophysitis, but our case highlights that metastatic spread should be part of the differential diagnosis.

Women are over-represented in aSAH cohorts, but whether their outcomes differ to men remains unclear. We examined if sex differences in neurological complications and aneurysm characteristics contributed to aSAH outcomes. In a retrospective cohort (2010–2016) of all aSAH cases across two hospital networks in Australia, information on severity, aneurysm characteristics and neurological complications (rebleed before/after treatment, postoperative stroke

Prospective experimental uncontrolled trial. Lumbar microinstability (MI) is a common cause of lower back pain (LBP) and is related to intervertebral disc degeneration that leads to inability to adequately absorb applied loads. The term “microinstability” has recently been introduced to denote a specific syndrome of biomechanical dysfunction with minimal anatomical change. Trans-facet fixation (TFF) is a minimally invasive technique that involves the placement of screws across the facet joint and into the pedicle, to attain improved stability in the spine. In this study, we aimed to evaluate the effectiveness, in terms of pain and disability reduction, of a stand-alone TFF in treatment of patients with chronic low back pain (LBP) due to MI. Moreover, as a secondary endpoint, the purpose was to assess the feasibility and safety of a novel percutaneous CT-guided technique. We performed percutaneous CT-guided TFF in 84 consecutive patients presenting with chronic LBP attributable to MI at a single lumbar level without spondylolysis. Pre- and post-procedure pain and disability levels were measured using the visual analogue scale (VAS) and Oswestry Disability Index (ODI). At 2 years, TFF resulted in significant reductions in both VAS and ODI scores. CT-guided procedures were tolerated well by all patients under light sedation with a mean procedural time of 45 min, and there were no reported immediate or delayed procedural complications. TFF seems to be a powerful technique for lumbar spine stabilization in patients with chronic mechanical LBP related to lumbar MI. CT-guided technique is fast, precise, and safe and can be performed in simple analgo-sedation.

INTRODUCTION: Endovascular clot retrieval (ECR) is the standard of care for acute ischaemic stroke (AIS) due to large vessel occlusion (LVO). However, isolated occlusion of the M2 segment of the Middle Cerebral Artery (MCA) was underrepresented in the landmark trials. Given the potential treatment benefit associated with M2 MCA occlusions, we aimed to evaluate the outcome of patients undergoing ECR for M2 occlusion. METHODS: We conducted a systematic review and meta-analysis of the available literature that included patients with M2 MCA occlusions who underwent ECR. Successful reperfusion was defined as a treatment in cerebral ischemia (TICI) score of 2b-3. Good outcome was defined as a modified Rankin Scale (mRS) score ≤ 2. We also analysed complications such as post-procedure symptomatic intracranial haemorrhage (sICH) and mortality at 3 months. RESULTS: 15 studies including 1105 patients with isolated M2 occlusions were analysed. Successful reperfusion occurred in in 75.4% (95% CI 67.7-84.1%) of patients; good outcome was observed in 58.3% (95% CI 51.7-63.8% of patients. The rate of sICH was 5.1% (95% CI 4.2-8.3%), and 3-month mortality rate was 12.2% (95% CI 10.4-16.3%). CONCLUSION: The outcomes of ECR treatment of M2 occlusions are favourable, with good safety profile. Comparison to medical management from large registries or randomized controlled trials is warranted. This article is protected by copyright. All rights reserved.

Strokes associated with cervical artery dissection have been managed primarily with antithrombotics with poor outcomes. The additive role of endovascular thrombectomy remains unclear. The objective was to perform systematic review and meta-analysis to compare endovascular thrombectomy and medical therapy for acute ischemic stroke associated with cervical artery dissection. Studies from six electronic databases included outcomes of patient cohorts with acute ischemic stroke secondary to cervical artery dissection who underwent treatment with endovascular thrombectomy. A meta-analysis of proportions was conducted with a random effects model. Modified Rankin score at 90 days (mRS 0–2) was the primary outcome. Other outcomes included proportion of patients with thrombolysis in cerebral infarction (TICI) 2b-3 flow, 90-day mortality rate, and 90-day symptomatic intracerebral hemorrhage (sICH) rate. Six studies were included, comprising 193 cases that underwent thrombectomy compared with 59 cases that were managed medically. Successful recanalization with a pooled proportion of thrombolysis in cerebral infarction (TICI) 2b-3 flow in the thrombectomy group was 74%. Favorable outcome (mRS 0–2) was superior in the pooled thrombectomy group (62.9%, 95% CI 55.8–69.5%) compared with medical management (41.5%, 95% CI 29.0–55.1%, P = 0.006). The pooled rate of 90-day mortality was similar for endovascular vs medical (8.6% vs 6.3%). The pooled rate of symptomatic intracranial haemorrhage (sICH) did not significantly differ (5.9% vs 4.2%, P = 0.60). Current data suggest that endovascular thrombectomy may be an option in patients with acute ischemic stroke due to cervical artery dissection. This requires further confirmation in higher quality prospective studies.

Background Evidence is lacking regarding the role of radiologic surveillance for asymptomatic intracranial aneurysms (AIAs) in the elderly (≥65 years). We sought to establish if long-term clinical and radiologic observation is warranted for older patients with AIAs. Methods A retrospective cohort of 193 consecutive patients with 255 AIAs were clinically and radiologically observed between January 2011 and January 2019. The primary end points were documented aneurysm growth, subarachnoid hemorrhage, or definitive treatment with microsurgical clipping or endovascular coiling. Baseline patient and aneurysm characteristics were obtained. Univariate and multivariate comparisons were performed. Results Aneurysm growth was observed in 8 patients (4.2%) at a median follow-up of 58.2 months (interquartile range, 38.4–78.5 months). The median aneurysm size at initial diagnosis was 3.5 mm (interquartile range, 2.2–5 mm). Aneurysms larger than 7 mm selected for surveillance were noted in 37 patients (19.2%). The growth rate was estimated at 0.2 mm per person-year. At the end of the study period, 175 patients (90.7%) were alive, 6 (3.1%) were lost to follow-up, and 12 (6.2%) died of unrelated causes. During the 1025.2 person-years follow-up, no patient had experienced subarachnoid hemorrhage, and none required definitive treatment. The presence of aneurysmal bleb (odds ratio, 6.02; 95% confidence interval, 1.15–31.43; P = 0.033) and multiple intracranial aneurysms (odds ratio, 10.98; 95% confidence interval, 1.27–94.91; P = 0.029) were associated with growth. Conclusions AIAs in older patients deemed suitable for conservative management do not require robust follow-up. The current study suggests a potential role for closer surveillance for patients with multiple intracranial aneurysms or aneurysms with bleb morphology.

BackgroundCoccydynia has many causes, including fracture, subluxation, and hypermobility of sacrococcygeal segments. Existing treatments are limited in their effectiveness. Coccygeoplasty (CP) is a relatively new, minimally invasive treatment that appears to address this difficult clinical challenge.ObjectiveTo describe clinical results at the time of the procedure and at 3- and 12-months' follow-up of patients with coccydynia related to subluxation and coccyx hypermobility treated with the CP technique. Additionally, to determine if there is any correlation between the final imaging and clinical results at 3- and 12-months' follow-up.MethodsA prospectively maintained database was used, and all patients who underwent CP for chronic coccydynia between January 2005 and October 2018 were retrospectively reviewed. All the patients had painful hypermobility (greater than 25°) with anterior flexion confirmed on radiological imaging. Alternative causes of coccydynia were excluded using CT and MRI. Procedures were performed under local anesthesia with combined fluoroscopic and CT guidance. Clinical follow-up was performed at two time points: 3 and 12 months after treatment using the Visual Analogue Scale (VAS).ResultsTwelve patients were treated in a single center. No procedural complications occurred. At 3- and 12-months' follow-up, the majority (75%) of patients had significantly lower VAS scores than at baseline, with mean changes of 3.5 and 4.9, respectively. There was no pain recurrence at 12 months and just one patient had no improvement of the pain. Follow-up CT images confirmed fixation of the sacrococcygeal bone segments in nine patients; however, no correlation was found between final imaging results and clinical outcome (p=0.1).ConclusionsPatients with refractory painful coccyx subluxation and hypermobility undergoing CP have a favorable clinical response at 3- and 12-months' follow-up. Further studies are required to validate this technique and to identify predictors of treatment response. Coccygeoplasty may be considered a reasonable alternative to coccygectomy.

BACKGROUND AND PURPOSE: Evidence from randomized controlled trials for the efficacy of vertebral augmentation in vertebral compression fractures has been mixed. However, claims-based analyses from national registries or insurance datasets have demonstrated a significant mortality benefit for patients with vertebral compression fractures who receive vertebral augmentation. The purpose of this study was to calculate the number needed to treat to save 1 life at 1 year and up to 5 years after vertebral augmentation. MATERIALS AND METHODS: A 10-year sample of the 100% US Medicare data base was used to identify patients with vertebral compression fractures treated with nonsurgical management, balloon kyphoplasty, and vertebroplasty. The number needed to treat was calculated between augmentation and nonsurgical management groups from years 1–5 following a vertebral compression fracture diagnosis, using survival probabilities for each management approach. RESULTS: The adjusted number needed to treat to save 1 life for nonsurgical management versus kyphoplasty ranged from 14.8 at year 1 to 11.9 at year 5. The adjusted number needed to treat for nonsurgical management versus vertebroplasty ranged from 22.8 at year 1 to 23.8 at year 5. CONCLUSIONS: Both augmentation modalities conferred a prominent mortality benefit over nonsurgical management in this analysis of the US Medicare registry, with a low number needed to treat. The calculations based on this data base resulted in a low number needed to treat to save 1 life at 1 year and at 5 years.

Up to 20% of patients fail to achieve reperfusion with modified Thrombolysis in Cerebral Infarction (mTICI) scores of 0-1 after mechanical thrombectomy (MT). Furthermore, underlying intracranial atherosclerotic disease, particularly when associated with70% residual or flow limiting stenosis, is associated with higher rates of failed MT and high failure risk MT. The aim of this study was to systematically review the procedural and clinical outcomes in patients with failed MT and high failure risk MT. We also explored differences between patients receiving acute rescue stenting compared with medical management alone.A systematic literature search was conducted in Ovid MEDLINE, PubMed, Embase, and Cochrane online scientific publication databases for English language publications from their date of inception until October 2018. Studies including adult patients with acute ischemic stroke because of emergent large vessel occlusion with failed (mTICI score 0-1) or high failure risk MT within the anterior circulation who underwent rescue stenting were included. A systematic review and meta-analysis of proportions was performed.Rescue intracranial stenting after failed MT or high failure risk MT results in improved clinical outcomes compared with patients without stenting (48.5% vs. 19.7%, respectively; P0.001), without an increase in the rate of symptomatic intracranial hemorrhage, despite additional use of antiplatelet agents (9.7% vs. 14.1%, respectively; P = 0.04).In patients who fail initial attempts at MT or are high risk for acute reocclusion, rescue intracranial stenting could be considered with the aim to improve functional outcomes. Antiplatelet agents do not increase the risk of hemorrhage in these patients.

Background Clinical utility of endovascular adjunct for tumor resection is well established, but its role in acute subarachnoid hemorrhage secondary to neoplastic pseudoaneurysm rupture has not been reported. Case Description We discuss a 46-year-old patient presenting with a World Federation of Neurological Surgeons grade 1 subarachnoid hemorrhage from a ruptured posterior cerebral artery pseudoaneurysm due to glioblastoma tumor invasion. Conclusions A combined targeted endovascular embolization with microsurgical resection to spare the calcarine artery was used to avoid disruption to the optic radiation fiber pathway.

Background Carotid artery stenting (CAS) is an established treatment for carotid artery stenosis, typically in a semielective or elective setting. The growth of mechanical thrombectomy for acute stroke has led to an increased use of emergent carotid artery stenting (eCAS). This single-center retrospective case series evaluates the safety and efficacy of eCAS using a dual-layer micromesh nitinol stent to treat carotid artery stenosis in the acute stroke setting. Methods Ethics approval was granted by the institutional review board. Clinical data of all patients who underwent CAS using the Casper dual-layer micromesh nitinol stent system (MicroVention, Terumo, Tustin, California, USA) at a tertiary level 24-hour endovascular thrombectomy service over a 2-year period (June 2016−June 2018) were retrospectively obtained and reviewed. Results Twenty eCAS procedures were performed in 19 patients over the study period. Most patients had tandem lesions (12/20; 60%). Median National Institute of Health Stroke Scale score on admission was 17 (interquartile range 9–22). Stent deployment was technically successful in all patients. Recanalization rate was 95%. Symptomatic intracranial hemorrhage occurred in 2 patients (10%), both resulting in death. No other procedure-related deaths occurred. Stent thrombosis occurred in 2 patients. One delayed embolic stroke occurred. No other stent-related complications occurred. Median National Institute of Health Stroke Scale score at 24 hours postprocedure was 3 (interquartile range 1–12). Six patients had a good clinical outcome (modified Rankin Scale score between 0 and 2) at 3- to 6-month follow-up (38%). Conclusions eCAS using the Casper stenting system is effective and technically feasible in the acute stroke setting, although the ideal antiplatelet and anticoagulation regime is not clearly established.

BackgroundWith the benefit of mechanical thrombectomy firmly established, the focus has shifted to improved delivery of care. Reducing time from symptom onset to reperfusion is a primary goal. Technology promises tremendous opportunities in the prehospital space to achieve this goal.MethodsThis review explores existing, fledgling, and potential future technologies for application in the prehospital space.ResultsThe opportunity for technology to improve stroke care resides in the detection, evaluation, triage, and transport of patients to an appropriate healthcare facility. Most prehospital technology remains in the early stages of design and implementation.ConclusionThe major challenges to tackle for future improvement in prehospital stroke care are that of public awareness, emergency medical service detection, and triage, and improved systems of stroke care. Thoughtfully applied technology will transform all these areas.

Background Despite decades of research, cerebral vasospasm (CV) continues to account for high morbidity and mortality in patients who survive their initial aneurysmal subarachnoid hemorrhage. Objective To define the scope of the problem and review key treatment strategies that have shaped the way CV is managed in the contemporary era. Methods A literature search was performed of CV management after aneurysmal subarachnoid hemorrhage. Results Recent advances in neuroimaging have led to improved detection of vasospasm, but established treatment guidelines including hemodynamic augmentation and interventional procedures remain highly variable among neurosurgical centers. Experimental research in subarachnoid hemorrhage continues to identify novel targets for therapy. Conclusions Proactive and preventive strategies such as oral nimodipine and endovascular rescue therapies can reduce the morbidity and mortality associated with CV.

Current evidence does not conclusively justify conservative management of unruptured intracranial aneurysms (UIA) in the elderly (age ≥ 65 years). To rationalise intervention, the authors investigated the role of age and comorbidity burden on treatment outcomes. A retrospective chart review for consecutive cases of UIAs treated in the elderly between 2007 and 2018 was performed. Preoperative Charlson Comorbidity Index (CCI) and Neurovascular Comorbidities Index (NCI) were calculated. Standard statistical methods with univariate and multiple logistic regression were used. A total of 123 patients (46 surgery, 77 endovascular) with 131 UIAs were treated. The mean age was 70.6 ± 4.1 years, and 90 patients were female (73.1%). The mean aneurysm size was 8.6 ± 5.0 mm, and the mean follow up period was 22.9 ± 21.3 months. The rates of poor outcome (mRS > 1) at discharge, 6 weeks and 6 months were 9.8%, 5.8% and 3.6%, respectively. There was no difference in outcomes between surgical and endovascular treatment. Correlation and regression analyses revealed that aneurysm size, higher preoperative comorbidity index (CCI > 4), and endovascular treatment with a stent or flow diverter (p = 0.009, 0.02, and 0.005, respectively) were associated with a poor outcome. When adjusted in a multivariate analysis, only high comorbidity burden (CCI > 4) predicted unfavourable outcome (p = 0.01). Elderly patients who undergo treatment for UIAs are at high risk of postoperative deterioration. Careful preoperative case selection based on comorbidity burden, rather than chronological age, would be useful for improved risk stratification.

BackgroundDelivery of acute stroke endovascular intervention can be challenging because it requires complex coordination of patient and staff across many different locations. In this proof-of-concept paper we (a) examine whether WiFi fingerprinting is a feasible machine learning (ML)-based real-time location system (RTLS) technology that can provide accurate real-time location information within a hospital setting, and (b) hypothesize its potential application in streamlining acute stroke endovascular intervention.MethodsWe conducted our study in a comprehensive stroke care unit in Melbourne, Australia that offers a 24-hour mechanical thrombectomy service. ML algorithms including K-nearest neighbors, decision tree, random forest, support vector machine and ensemble models were trained and tested on a public WiFi dataset and the study hospital WiFi dataset. The hospital dataset was collected using the WiFi explorer software (version 3.0.2) on a MacBook Pro (AirPort Extreme, Broadcom BCM43x×1.0). Data analysis was implemented in the Python programming environment using the scikit-learn package. The primary statistical measure for algorithm performance was the accuracy of location prediction.ResultsML-based WiFi fingerprinting can accurately predict the different hospital zones relevant in the acute endovascular intervention workflow such as emergency department, CT room and angiography suite. The most accurate algorithms were random forest and support vector machine, both of which were 98% accurate. The algorithms remain robust when new data points, which were distinct from the training dataset, were tested.ConclusionsML-based RTLS technology using WiFi fingerprinting has the potential to streamline delivery of acute stroke endovascular intervention by efficiently tracking patient and staff movement during stroke calls.

Artificial intelligence is a rapidly evolving field, with modern technological advances and the growth of electronic health data opening new possibilities in diagnostic radiology. In recent years, the performance of deep learning (DL) algorithms on various medical image tasks have continually improved. DL algorithms have been proposed as a tool to detect various forms of intracranial hemorrhage on non-contrast computed tomography (NCCT) of the head. In subtle, acute cases, the capacity for DL algorithm image interpretation support might improve the diagnostic yield of CT for detection of this time-critical condition, potentially expediting treatment where appropriate and improving patient outcomes. However, there are multiple challenges to DL algorithm implementation, such as the relative scarcity of labeled datasets, the difficulties in developing algorithms capable of volumetric medical image analysis, and the complex practicalities of deployment into clinical practice. This review examines the literature and the approaches taken in the development of DL algorithms for the detection of intracranial hemorrhage on NCCT head studies. Considerations in crafting such algorithms will be discussed, as well as challenges which must be overcome to ensure effective, dependable implementations as automated tools in a clinical setting.

The current COVID-19 global pandemic could potentially affect emergent large vessel occlusion (ELVO) ischemic stroke1 through at least two mechanisms. The first is possible increased stroke incidence due to procoagulant effects of the virus or the immune response to it.2–5 The second, more tangible, is the effect on ELVO triage and treatment times, a phenomenon already reported for emergent care of myocardial infarction6 and recently for acute stroke care during COVID-19 disruption in France.7 On the JNIS website currently is a paper from the Chinese epicenter, focused on the second of these. The authors present a single-center experience during the height of the pandemic (total lockdown in Wuhan until the end of newly diagnosed cases) and compare time intervals and procedural outcomes to pre-pandemic cases. Importantly, this is distinct from confirmed and suspected COVID-19 patients undergoing thrombectomy. Those patients were transferred from the community directly to a sequestered hospital environment; their treatment and outcomes after stroke remain unknown. Only limited case series have been published to date about treatment of known COVID-19-positive patients with stroke.8 9 The current paper is focused instead on the impact of the required modifications in the processes for patients with ELVO during the COVID-19 pandemic. Delays were expected because of expanded patient evaluation and staff protection …

Background Visceral and renal artery aneurysms (VRAAs) are uncommon but are associated with a high mortality rate in the event of rupture. Endovascular treatment is now first line in many centres, but preservation of arterial flow may be difficult in unfavourable anatomy including wide necked aneurysms, parent artery tortuosity and proximity to arterial bifurcations. Endovascular stenting, and in particular flow-diversion, is used in neurovascular intervention to treat intracranial aneurysms but is less often utilised in the treatment of VRAAs. The CASPER stent is a low profile dual-layer braided nitinol stent designed for carotid stenting with embolic protection and flow-diversion properties. We report the novel use of the CASPER stent for the treatment of VRAAs. We present a case series describing the treatment of six patients with VRAAs using the CASPER stent. Results Six patients with unruptured VRAAs were treated electively. There were three splenic artery aneurysms and three renalartery aneurysms. Aneurysms were treated with the CASPER stent, with or without loose aneurysm coil packing or liquid embolic depending on size and morphology. All stents were successfully deployed with no immediate or periprocedural complications. Four aneurysms completely occluded after serial imaging follow up with one case requiring repeat CASPER stenting for complete occlusion. In one patient a single aneurysm remained patent at last follow up, A single case was complicated by delated splenic infarction and surgical splenectomy. Conclusion Preliminary experience with the CASPER stent suggests it is technically feasible and effective for use in the treatment of VRAAs.

BackgroundOperating rooms contribute between 20% to 70% of hospital waste. This study aimed to evaluate the waste burden of neurointerventional procedures performed in a radiology department, identify areas for waste reduction, and motivate new greening initiatives.MethodsWe performed a waste audit of 17 neurointerventional procedures at a tertiary-referral center over a 3-month period. Waste was categorized into five streams: general waste, clinical waste, recyclable plastic, recyclable paper, and sharps. Our radiology department started recycling soft plastics from 13 December 2019. Hence, an additional recyclable soft plastic waste stream was added from this time point. The weight of each waste stream was measured using a digital weighing scale.ResultsWe measured the waste from seven cerebral digital subtraction angiograms (DSA), six mechanical thrombectomies (MT), two aneurysm-coiling procedures, one coiling with tumour embolization, and one dural arteriovenous fistula embolization procedure. In total, the 17 procedures generated 135.3 kg of waste: 85.5 kg (63.2%) clinical waste, 28.0 kg (20.7%) general waste, 14.7 kg (10.9%) recyclable paper, 3.5 kg (2.6%) recyclable plastic, 2.2 kg (1.6%) recyclable soft plastic, and 1.4 kg (1.0%) of sharps. An average of 8 kg of waste was generated per case. Coiling cases produced the greatest waste burden (13.1 kg), followed by embolization (10.3 kg), MT (8.8 kg), and DSA procedures (5.1 kg).ConclusionNeurointerventional procedures generate a substantial amount of waste, an average of 8 kg per case. Targeted initiatives such as engaging with suppliers to revise procedure packs and reduce packaging, digitizing paper instructions, opening devices only when necessary, implementing additional recycling programs, and appropriate waste segregation have the potential to reduce the environmental impact of our specialty.

The Heidenhain variant of Creutzfeld-Jakob disease (HvCJD) is a relentlessly progressive and fatal neurodegenerative disorder characterised by prominent visual features early in its clinical course. However, seizures are uncommonly reported in HvCJD. The case history of a patient admitted to our institution with HvCJD and seizures is described followed by a systematic review of the association between HvCJD and seizures. A systematic search of the databases Medline, PubMed, and PsycInfo was conducted, from inception to November 2019, using keywords relating to 'Creutzfeldt-Jakob disease' and 'Heidenhain variant', to ascertain the frequency of seizures in HvCJD, as well as, seizure semiology and electrographic features. The Preferred Items Reporting for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in the construction of this systematic review. All studies, including case reports of patients who met the diagnostic criteria for HvCJD where details pertaining to clinical presentation, imaging, biochemical and EEG findings were available were included. There were 46 articles reporting on a total of 73 patients. Seizures occurred in only four out of 73 cases (5.5%). The semiology of these seizures were focal motor seizures with or without secondary generalisation and occipital lobe seizures. Imaging and electrographic findings were most commonly abnormal in the posterior cerebral cortices (in particular the occipital and occipito-parietal regions). This systematic review suggests that seizures are uncommon in HvCJD despite the frequency of imaging and electrographic abnormalities in the posterior cerebral regions. A key limitation of this systematic review is the variability of publications in terms of incomplete reporting of clinical data, in particular potential under-reporting of seizures, as well as follow up, which may have contributed to the lower frequency of seizures reported in patients with HvCJD.

Background Osteoporotic vertebral compression fractures (OVCFs) are prevalent, with associated morbidity and mortality. Vertebral augmentation (VA), defined as either vertebroplasty and/or balloon kyphoplasty (BKP), is a minimally invasive surgical treatment to reduce pain and further collapse and/or renew vertebral body height by introducing bone cement into fractured vertebrae. Nonsurgical management (NSM) for OVCF carries inherent risks. Purpose To summarize the literature and perform a meta-analysis on the mortality outcomes of patients with OVCF treated with VA compared with those in patients treated with NSM. Materials and Methods A single researcher performed a systematic literature review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or PRISMA, guidelines. Online scientific databases were searched in April 2018 for English-language publications. Included studies investigated mortality in patients with OVCF with VA as the primary intervention and NSM as the comparator. A meta-analysis was performed for studies that reported hazard ratios (HRs) and 95% confidence intervals (CIs). HR was used as a summary statistic and was random-effect-models tested. The χ

Objective Since the introduction of endovascular technology to treat thoracic and abdominal aortic aneurysms, there has been a global research effort focused on assessing the effectiveness of treatment. A bibliometric analysis is used to identify the scientific impact of an article, impactful authors, institutions, and collaborative groups. Our objective was to identify and to analyze the 100 most cited articles in the field of endovascular treatment of thoracic and abdominal aortic aneurysms. Methods We performed a retrospective bibliometric analysis in April 2018. Articles were searched on the Science Citation Index Expanded database using Web of Science to identify the most cited articles in endovascular therapy for thoracic and aortic aneurysms since 1945. Use of selected key terms (“AAA,” “aortic aneurysm,” “thoracic aneurysm,” “abdominal aneurysm,” “endovascular,” “endoluminal,” “stent,” “graft,” “repair,” “EVAR,” and “TEVAR”) yielded a total of 23,354 articles. The top 100 articles were identified and analyzed to extract relevant information including year of publication, citation count, journal, authorship country of origin, and article type. Results The earliest articles were published in 1991, with the majority being published in the 2000s (n = 59). The number of citations for the top 100 articles ranged from 151 to 1142, with a median citation count of 212. All articles were cited an average of 22.4 times per year. Almost half (n = 46) of the top 100 articles were published in the Journal of Vascular Surgery. Thirty-nine authors contributed four or more articles, with two being credited on 10 papers to make the list. The majority (n = 62) of the articles arose from the United States, while the United Kingdom contributed 11 articles. There were 7 guidelines and 12 randomized controlled trials, and the majority constituted level III or level IV evidence. Conclusions This study provides a comprehensive and informative analysis of the most cited and impactful research undertaken in the field of endovascular treatment of abdominal and thoracic aortic aneurysms. By quantitatively assessing the 100 most cited articles in the field, we recognize the contributions of key authors, institutions, and collaborative groups and develop an understanding of the strengths of past research and the requirements for future global efforts.

BackgroundThe Journal of NeuroInterventional Surgery (JNIS) published its first volume in 2009. Over the ensuing years, JNIS flourished and has published a considerable number of high-profile articles. Citation analysis is a method of quantifying various metrics related to scholarly publications.ObjectiveTo apply citation analysis to the 100 most cited papers in the history of JNIS.MethodsThe most cited articles in JNIS were identified by using the Web of Science database. The top 100 articles were ranked according to their number of citations. Further information was obtained for each article, including citations per year, year of publication, authorship, article topics, and article type and level of evidence.ResultsThe total number of citations for the 100 most cited articles in JNIS ranged from 18 to 132 (median 26.0). Most articles (75%) were published between 2012 and 2015 and originated in the USA (79%). Eighteen authors have contributed five or more articles to the top 100 list. The most common topics are related to acute ischemic stroke and cerebral aneurysm.ConclusionsThis study highlights the influence of JNIS over its first decade by providing a comprehensive list of the 100 most cited articles and their authors as well as topics covered. This study also highlights the important factors driving the growth of JNIS.

Neural compression associated with lumbar disc herniation is usually managed surgically by microdiscectomy. However, 10%-20% of patients re-present with debilitating back pain, and approximately 15% require further surgery.Using an ovine model of microdiscectomy, the present study investigated the relative potential of pentosan polysulfate-primed mesenchymal progenitor cells (pMPCs) or MPC alone implanted into the lesion site to facilitate disc recovery.An ovine model of lumbar microdiscectomy was used to compare the relative outcomes of administering MPCs or pMPCs to the injury site postsurgery.At baseline 3T magnetic resonance imaging (MRI) of 18 adult ewes was undertaken followed by annular microdiscectomy at two lumbar disc levels. Sheep were randomized into three groups (n=6). The injured controls received no further treatment. Defects of the treated groups were implanted with a collagen sponge and MPC (5×10Both the MPC- and pMPC-injected groups exhibited less reduction in disc height (p.05) and lower Pfirrmann grades (p≤.001) compared with the untreated injury controls, but morphologic scores for the pMPC-injected discs were lower (p.05). The PG content of the AF injury site region (AF1) of pMPC discs was higher than MPC and injury control AF1 (p.05). At the AF1 and contralateral AF2 regions, the DNA content of pMPC discs was significantly lower than injured control discs and MPC-injected discs. Histologic and birefringent microscopy revealed increased structural organization and reduced degeneration in pMPC discs compared with MPC and the injured controls.In an ovine model 6 months after administration of pMPCs to the injury site disc PG content and matrix organization were improved relative to controls, suggesting pMPCs' potential as a postsurgical adjunct for limiting progression of disc degeneration after microdiscectomy.

Introduction Mechanical thrombectomy has become the standard of care for management of most large vessel occlusion (LVO) strokes. When patients with LVO present with minor stroke symptomatology, no consensus on the role of mechanical thrombectomy exists. Methods A systematic review and meta-analysis were performed to identify studies that focused on mechanical thrombectomy, either as a standalone treatment or with intravenous tissue plasminogen activator (IV tPA), in patients with mild strokes with LVO, defined as a baseline National Institutes of Health Stroke Scale score ≤5 at presentation. Data on methodology, quality criteria, and outcome measures were extracted, and outcomes were compared using odds ratio as a summary statistic. Results Five studies met the selection criteria and were included. When compared with medical therapy without IV tPA, mechanical thrombectomy and medical therapy with IV tPA were associated with improved 90-day modified Rankin Scale (mRS) score. Among medical patients who were not eligible for IV tPA, those who underwent mechanical thrombectomy were more likely to experience good 90-day mRS than those who were not. There was no significant difference in functional outcome between mechanical thrombectomy and medical therapy with IV tPA, and no treatment subgroup was associated with intracranial hemorrhage or death. Conclusions In patients with mild strokes due to LVO, mechanical thrombectomy and medical therapy with IV tPA led to better 90-day functional outcome. Mechanical thrombectomy plays an important role in the management of these patients, particularly in those not eligible for IV tPA.

Objective Selection of patients with acute ischemic stroke for endovascular thrombectomy (EVT) is complex and time-critical. Benefits of EVT are well established for patients with small core infarcts. The aim of this study was to compare clinical outcomes of EVT in patients with larger established infarcts (Alberta Stroke Programme Early CT Score [ASPECTS] ≤6) with patients with smaller infarcts (ASPECTS 7–10). Methods The study included 355 patients with acute ischemic stroke due to large vessel occlusion who underwent EVT. ASPECTS was assigned to baseline noncontrast computed tomography, and collateral perfusion scores were assigned to multiphase computed tomography angiography. Baseline stroke severity, collateral grading, and clinical outcome data (complication rate, symptomatic intracranial hemorrhage and 90-day modified Rankin Scale score) were compared between patients with borderline (≤6) and high (7–10) ASPECTS. Results There were 34 (10%) patients with borderline ASPECTS. There was no difference in rate of good clinical outcome (37% vs. 46%, P = 0.852), symptomatic intracerebral hemorrhage (9% vs. 9%, P = 0.984), or mortality (20% vs. 22%, P = 0.818) between patients with borderline ASPECTS and high ASPECTS at 90 days. Moreover, there was no significant difference in collateral perfusion grade. Conclusions This study identifies similar clinical benefit of EVT in patients with acute large vessel occlusion stroke with borderline ASPECTS and high ASPECTS.

IntroductionEndovascular interventions for intracranial aneurysms have evolved substantially over the past several decades. A citation rank list is used to measure the scientific and/or clinical impact of an article. Our objective was to identify and analyze the characteristics of the 100 most cited articles in the field of endovascular therapy for intracranial aneurysms.MethodsWe performed a retrospective bibliometric analysis between July and August 2017. Articles were searched on the Science Citation Index Expanded database using Web of Science in order to identify the most cited articles in the endovascular therapy of intracranial aneurysms since 1945. Using selected key terms (‘intracranial aneurysm’, ‘aneurysm’, ‘aneurysmal subarachnoid’, ‘endovascular’, ‘coiling’, ‘stent-assisted’, ‘balloon-assisted’, ‘flow-diversion’) yielded a total of 16 314 articles. The top 100 articles were identified and analyzed to extract relevant information, including citation count, authorship, article type, subject matter, institution, country of origin, and year of publication.ResultsCitations for the top 100 articles ranged from 133 to 1832. All articles were cited an average of 27 times per year. There were 45 prospective studies, including 7 level–II randomized controlled trials. Most articles were published in the 2000s (n=53), and the majority constituted level III or level IV evidence. Half of the top 100 articles arose from the USA.ConclusionThis study provides a comprehensive overview of the most cited articles in the endovascular management of intracranial aneurysms. It recognizes the contributions made by key authors and institutions, providing an important framework to an enhanced understanding of the evidence behind the endovascular treatment of aneurysms.

The AJNR published a game changing manuscript in 1997. A group composed mostly of neurointerventionalists described the use of polymethylmethacrylate in painful osteoporotic vertebral compression fractures.1 Soon thereafter, this then nascent technique began to flourish throughout many parts of the world. Since its inception, the JNIS has published content covering all aspects of neurointervention, including spine intervention; the first issue featured an article prospectively evaluating pain and functional outcomes after vertebroplasty.2 Over the years, JNIS has featured a variety of articles that advanced our knowledge and improved the capability of percutaneous approaches to treat spinal lesions, for example, in cancer patients.3 4 Moreover, the manuscripts have promoted understanding of the capabilities of percutaneous approaches to treating extra-spinal locations, for example, sacroplasty,5 6 acetabuloplasty,7 and even calcaneoplasty.8 JNIS has been receiving an ever-increasing number of high-quality manuscript submissions. This was very apparent during the most acute period of the COVID-19 pandemic.9 Topics related to mechanical spine have been a critical part of that growth. This commentary will highlight that subject matter—important spine articles from the last few years. Driven by clinical results, the number of patients treated with cement augmentation increased year over year from the time of the seminal Jensen AJNR paper. The simultaneous 2009 publication of two blinded studies in the NEJM raised some questions regarding the effectiveness of vertebroplasty over a sham procedure. Subsequent randomized control trials demonstrated vertebroplasty provided improved patient outcomes compared with sham procedures. These results have been extensively discussed in JNIS and other venues.10 The scientific discourse and conflicting results have impacted patient …

To meet the growing demand for interventional radiology (IR), more hospitals are investing in state-of-the-art angiography suites, but these are expensive investments. Both the initial construction cost and the ongoing operational costs are significant. For health services, it is important to commission an angiography suite that can satisfy both present and future healthcare demands to maximize the value of the initial expenditure and the opportunities provided by this ongoing investment. Smart angiography suites (SAS) could be the solution that future-proof angiography services. Similar to the smart operating theatre, SAS refers to the incorporation of audio-video technology and internet connectivity into the angiography suite.1 SAS has the ability to record high resolution audio-visual data from the angiography suite and stream it to a remote audience at low latency to enable bi-directional communication and collaboration. SAS, alongside other telemedicine concepts, have also gained new-found interest and relevance in light of the global coronavirus pandemic and the travel restrictions associated with this. We reviewed the current literature to provide an overview of the SAS, its potential, and associated legal and ethical considerations. For hospitals, SAS can be as rudimentary as a webcam or as advanced as a comprehensive commercial solution such as Olympus MedPrescence, Proximie, Tegus Medical, Sony Nucleus or InTouch Health VisitOR. In general, commercial solutions will include audio-video equipment setup, internet streaming and broadcasting setup, and an end-user viewing software. Most commercial solutions are compatible with pre-existing equipment (vendor neutral) (see figure 1 for an example solution). Different solutions also offer varying features of different video layouts, video freezing, telestration with or without augmented reality, integration with picture archiving and communication system, and security. The cost of a commercial SAS solution varies with each company offering a different type of license. Figure 1 An example of a smart angiography suite solution, from …

BACKGROUND Indications for treatment and outcomes after endovascular management of carotid blowout syndrome for patients with head and neck cancer are not well defined. We investigated the safety and effectiveness of endovascular embolization and stent-graft reconstruction. METHODS A literature review was performed for studies published between 2001 and 2015 with relevance to treatment outcomes. Our institutional database was examined to identify patients treated with endovascular techniques. RESULTS A total of 266 patients were included. Rates of procedural stroke were higher after embolization of internal carotid artery (ICA)/common carotid artery (CCA) compared to stent graft (embolization 10.3%; stent graft 2.5%; P

Glioblastoma (GB) classically presents with symptoms of raised intracranial pressure and gradual progressive neurological deficits. An acute presentation, with intracerebral haemorrhage (ICH) and rapid clinical deterioration, occurs infrequently. Contemporary imaging modalities do not reliably reflect underlying mass lesions in parenchymal brain haemorrhage at first presentation. We report a delayed diagnosis of GB in a 21-year-old patient presenting with spontaneous ICH and a negative initial neurovascular workup. A comprehensive literature review was performed to investigate the incidence of malignant aetiology for spontaneous ICH in young adults, and to underscore the importance of early utilisation of diagnostic magnetic resonance imaging (MRI) in such cases.

Objectives Conventional anatomical descriptions of the cervical internal carotid artery (ICA) report that no branches arise from this segment. However reports of ICA branches exist. The study aim was to determine the prevalence of anomalous branches of the ICA using colour duplex ultrasound (CDU). Methods Four hundred consecutive patients (800 carotid vessels) referred to a tertiary hospital vascular laboratory for investigation of carotid disease were included. A clear differentiation of a low resistive ICA and a high resistive external carotid artery (ECA) waveform was required. CDU was performed on a Philips IU22 ultrasound system with a 9–3 MHz linear array transducer employing a standard carotid imaging protocol. The origin of each ICA branch was identified using B-mode and CDU. Anatomical orientation of ICA branches and distance from bifurcation was recorded and spectral CDU analysis was performed. Results Twenty ICA branches, tracking cephaladly, were detected in 16 patients (4%), or 2.5% (20/800) vessels. The median age was 73 years; 50% were female and 50% male. All patients demonstrated a single branch [unilateral anomaly ( n = 12 patients), bilateral anomaly ( n = 4) patients]. Eighty-five percent arose from the posterior wall of the ICA. The median distance from ICA bifurcation was 4 mm (range 0–18 mm). ICA branch diameters ranged from 1.2 mm to 2.4 mm (median 1.4 mm, mean 1.6 mm). Eighty percent of ICA branches had less than 50% stenosis. Spectral analysis revealed high resistive waveforms in all branches. Conclusions Branches from the ICA exist and can be characterised with CDU. Prevalence in a tertiary hospital referral cohort is 4%. Given their potential clinical implications, standard carotid imaging protocols should consider routine assessment and reporting of ICA branches.

Background: Objective assessment and quantification of the severity of cerebral vasospasm following aneurysmal subarachnoid hemorrhage is not routinely utilized. We investigated the feasibility of angiographic perfusion imaging derived from digital subtraction angiography (DSA) following endovascular vasospasm treatment procedures. Methodology: Real-time blood flow analysis was performed using parametric color coding on pre- and postintervention DSA. Semiquantitative parenchymal perfusion parameters (arrival time [AT] of contrast, time to peak [TTP] opacification, and mean transit time [MTT] of contrast) were calculated across 3 vascular territories (anterior cerebral artery [ACA], middle cerebral artery [MCA], and lenticulostriate arteries) using standard 2-D angiographic perfusion software. The pre- and postintervention arterial vessel diameters were compared. Results: Twelve endovascular vasospasm treatments in 6 patients were performed. All patients received intra-arterial vasodilator therapy with either nimodipine, milrinone, or both. Following intra-arterial intervention, parenchymal flow analysis showed improvement in TTP and MTT across all vascular territories (p < 0.002) and improvement in AT in the ACA and MCA territories (p < 0.03). Improvement in parenchymal perfusion parameters was associated with improvement in vessel diameters in all territories following treatment (p < 0.05). Conclusion: Real-time parenchymal perfusion imaging during endovascular vasospasm treatment procedures is feasible and provides reliable semiquantitative measurement of angiographic treatment response.

Treatment of unruptured intracranial aneurysms can reduce the risk of subarachnoid hemorrhage and its associated morbidity and mortality. However, current methods to predict the risk of rupture and optimize treatment strategies for intracranial aneurysms are limited. Assessment of intra-aneurysmal flow using 4-dimensional magnetic resonance imaging (4D MRI) is a novel tool that could be used to guide therapy. A systematic search of the literature was performed to provide a state-of-the-art review on 4D MRI assessment of unruptured intracranial aneurysms. A total of 18 studies were available for review. Eccentric flow on 4D MRI is associated with a greater aspect ratio and peak wall shear stress (WSS). WSS, vorticity, and peak velocity are greater in saccular than fusiform aneurysms. Unstable aneurysms are associated with greater WSS, peak wall stress, and flow jet angle and may exhibit wall enhancement. In comparison to computational fluid dynamics (CFD), 4D MRI has a lower spatial resolution and reports lower WSS and velocity magnitudes, but these parameters equalize when spatial resolution is matched. 4D MRI demonstrates the intra-aneurysmal hemodynamic changes associated with flow diversion, including significantly decreased flow velocity. Thus, 4D MRI is a novel, noninvasive imaging tool used for the evaluation of hemodynamics within intracranial aneurysms. Hemodynamic indices derived from 4D MRI appear to correlate well with the simulated (CFD) values and may be used to measure the success of endovascular therapies and risk factors for aneurysm growth and rupture.

PurposeLumbar spinal canal stenosis and lumbar spinal foraminal stenosis are common, degenerative pathologies which can result in neurogenic claudication and have a negative impact on function and quality of life. Percutaneous interspinous devices (PIDs) are a recently-developed, minimally-invasive, alternative treatment option. This study details a 9 year single-centre experience with PIDs and examines the complementary use of spinous process augmentation (spinoplasty) to reduce failure rates.MethodsA retrospective cohort assessment of 800 consecutive patients who presented to a specialized spine hospital was performed with 688 receiving treatment. Inclusion was based on high-grade stenosis, failure of conservative management and electromyography. 256 had a PID alone while 432 had concurrent polymethyl methacrylate (PMMA) augmentation of the adjacent spinous processes. The patients were followed up at 3 and 12 months using the Zurich Claudication Questionnaire (ZCQ) and Oswestry Disability Index (ODI).ResultsBoth groups showed marked improvement in the patients’ ZCQ scores (3.2 to 1.3) and ODI scores (32 to 21), with strong satisfaction results (1.7). The symptom recurrence rate from complications for the group which received concurrent spinous process augmentation was reduced when compared with the PID alone cohort (ConclusionThis study demonstrates the efficacy of percutaneous interspinous devices in treating lumbar spinal stenosis. It also provides evidence that concurrent spinous process augmentation reduces the rate of symptom recurrence.

No aspect of neurointerventional practice has been associated with as longstanding contention and debate as to its effectiveness as has vertebroplasty (VP). Four blinded randomized controlled trials published since 2009 have demonstrated conflicting results regarding a conferred benefit in pain reduction and functional improvement for patients who undergo VP for osteoporotic vertebral compression fractures. Significant heterogeneity exists between each of these trials, which has resulted in difficulty for interventionalists and surgeons to translate the trial findings into routine clinical practice. In addition, patients and their families are ever more enlightened and enabled via the internet and social media to review both medical literature and websites. Without the proper background and context, their decisions may be lacking appropriate and necessary scientific discussion. This review article summarizes the randomized controlled trial data to date, with particular focus on the aforementioned four blinded studies. We will also evaluate the profound impact of the decrease in vertebral augmentation utilization on short- and long-term patient morbidity and mortality using available national and administrative datasets from both within the USA and internationally. We also consider future trial design to help evaluate this procedure and determine its role in modern neurointerventional practice.

Introduction Carotid artery stenting (CAS) is an effective treatment for clinically significant carotid artery stenosis in selected patients. The increasing utilisation of endovascular management for acute ischaemic stroke has led to the use of CAS in the emergent setting for patients presenting with acute stroke and concomitant carotid artery stenosis. A variety of carotid artery stents are available and differ in material, shape and cell geometry. Microporous stents represent a new type of stent with significantly reduced cell size. We present a single-centre retrospective case series of emergent CAS (eCAS) procedures using a dual-layer micromesh nitinol stent in the acute stroke setting. Materials and methods Ethics approval was granted by the institutional review board. Clinical data of all patients who underwent CAS using the Casper stent (Microvention, Terumo, Tustin, CA, USA) at a tertiary level 24-hour mechanical thrombectomy (MT) service over a two-year period (June 2016-June 2018) were retrospectively obtained and reviewed. Data collected included patient demographics, presenting symptoms, pre- and postprocedural National Institute of Health Stroke Scale (NIHSS) score, imaging findings including severity of stenosis or presence of tandem occlusion, use of intravenous thrombolysis (IV tPA) and/or antiplatelet agents, thrombectomy device and stents used, modified thrombolysis in cerebral infarction (mTICI) score and follow-up modified Rankin scale (mRS) data. Any complications were identified and categorised. All eCAS procedures were performed using the Casper dual-layer micromesh nitinol stent system. Results Twenty eCAS procedures were performed in nineteen patients during this period. Patients received between 1 and 2 Casper stents of varying sizes. The majority of patients had tandem lesions (12/20; 60%) and carotid lesions were most commonly located in the proximal ICA (n=15; 75%). Median NIHSS score on admission was 17 (IQR 9–22). IV tPA was administered prior to six eCAS procedures (30%). Stent deployment was technically successful in all patients and was performed concurrently with MT in fifteen cases (75%). Recanalization rate was 95%. No intraprocedural complications occurred. Symptomatic intracranial haemorrhage (sICH) occurred in two patients (10%) and both resulted in death. No other procedure-related deaths occurred. Stent thrombosis occurred in two patients. No other stent-related complications occurred. Non-neurological complications included coagulopathy (3/20; 15%), hypotension (2/20; 10%), acute kidney injury (1/20; 5%) and aspiration pneumonia (1/20; 5%). Median NIHSS score at 24 hours postprocedure was 3 (IQR 1–12). Thirty-eight percent of patients had a good clinical outcome (modified Rankin scale between 0–2) at 3–6 month follow up. Conclusion eCAS using the Casper stenting system is effective and technically feasible in patients presenting with acute stroke and concomitant carotid artery stenosis. Disclosures A. Lamanna: None. J. Maingard: None. H. Kok: None. C. Barras: None. A. Jhamb: None. V. Thijs: None. R. Chandra: None. D. Brooks: None. H. Asadi: None.

Vertebral compression fractures (VCFs) are a common cause of back pain and disability and are usually osteoporotic in nature. Therapy aims to adequately control pain and allow early mobilisation and return of function while preventing additional fractures. A proportion of patients do not achieve adequate pain relief using conservative measures alone. Unwanted adverse effects from medications may also ensue. Vertebroplasty represents an alternative treatment option for VCFs. Patients with acute VCFs (≤6 weeks old) may gain the most benefit from vertebroplasty as healed fractures are not as amenable to cement injection. High-quality studies have reported conflicting results regarding the use of vertebroplasty in the treatment of acute VCFs. Despite high-quality evidence, varying study designs and heterogenous patient cohorts make interpretation of this data difficult. Only one sham-controlled randomised controlled trial (RCT) has evaluated vertebroplasty exclusively in patients with acute VCFs, reporting favourable results. Pooled data from RCTs also suggest vertebroplasty to be safe. This article provides a concise and critical review of the current literature regarding vertebroplasty for the treatment of acute VCFs.

Microsurgical clipping and endovascular coiling are effective treatment modalities for the treatment of unruptured and ruptured intracranial aneurysms. Several randomized controlled trials and numerous observational studies have compared these two modalities in the ruptured and unruptured settings, suggesting improved initial outcomes with endovascular coiling yet greater durability with microsurgical clipping. Due to the introduction of a number of novel devices to the endovascular armamentarium, with flow diverters being the most mature, as well as minimally invasive microsurgical approaches, the microsurgical clipping versus endovascular coiling debate has expanded to include new endovascular devices, hybrid treatments, and minimally invasive microsurgical approaches.

Vertebral compression fractures are an important cause of back pain and disability in patients with osteoporosis and spinal neoplasms. Vertebroplasty is a minimally invasive procedure that involves the percutaneous injection of cement into the fractured vertebral body. This procedure is generally offered as a treatment option for a small subset of patients with symptomatic osteoporotic or neoplastic vertebral fractures that result in significant pain and disability.

Highlights • Spinal dural arteriovenous fistula is an uncommon cause of longitudinal transverse myelitis. • Spinal dural arteriovenous fistula can be easily misdiagnosed. • It usually presents with venous congestive myelopathy symptoms and misdiagnosis is common. • Prescence of flow voids on MRI should raise the suspicion of underlying fistula. • Intravenous steroid and lumbar puncture may be associated with acute neurological deterioration., Introduction and importance Spinal dural arteriovenous fistula (SDAVF) is an uncommon cause of longitudinal extensive transverse myelitis (LETM). It usually presents with vague congestive myelopathy symptoms and diagnosis is usually difficult on initial presentation. Common daily neurological interventions can aggravate the underlying pathophysiology leading to undesirable acute neurological deterioration. Intravenous steroids administration and lumbar (LP) puncture as a diagnostic tool are amongst the most commonly reported aggravating interventions. This rare case presentation highlights this association with its negative impact on the patient outcome in misdiagnosed cases. Case presentation The authors present a sixty-eight-year-old male with paraplegia following steroid administration and LP for presumed inflammatory/autoimmune LETM in the setting of misdiagnosed SDAVF. The absence of flow voids on the conventional T2-weighted magnetic resonance image (MRI) lead to misdiagnosis. He had satisfactory neurological recovery few hours after surgical disconnection. Clinical discussion SDAVF is known to cause congestive myelopathy symptoms. Spinal angiogram is the gold standard for diagnosis. Although the exact mechanism is not fully understood, misdiagnosed cases like our case can develop severe neurological deterioration with steroid administration and lumbar puncture. Conclusion Although SDAVF is an uncommon cause of LETM, Clinicians should carefully exclude it before proceeding to steroid administration or performing LP as they can lead to devastating neurological deterioration.

Background Endovascular thrombectomy improves functional outcome in large vessel occlusion ischemic stroke. We examined disability, quality of life, survival and acute care costs in the EXTEND-IA trial, which used CT-perfusion imaging selection. Methods Large vessel ischemic stroke patients with favorable CT-perfusion were randomized to endovascular thrombectomy after alteplase versus alteplase-only. Clinical outcome was prospectively measured using 90-day modified Rankin scale (mRS). Individual patient expected survival and net difference in Disability/Quality-adjusted life years (DALY/QALY) up to 15 years from stroke were modeled using age, sex, 90-day mRS, and utility scores. Level of care within the first 90 days was prospectively measured and used to estimate procedure and inpatient care costs (US$ reference year 2014). Results There were 70 patients, 35 in each arm, mean age 69, median NIHSS 15 (IQR 12–19). The median (IQR) disability-weighted utility score at 90 days was 0.65 (0.00–0.91) in the alteplase-only versus 0.91 (0.65–1.00) in the endovascular group (p = 0.005). Modeled life expectancy was greater in the endovascular versus alteplase-only group (median 15.6 versus 11.2 years, p = 0.02). The endovascular thrombectomy group had fewer simulated DALYs lost over 15 years [median (IQR) 5.5 (3.2–8.7) versus 8.9 (4.7–13.8), p = 0.02] and more QALY gained [median (IQR) 9.3 (4.2–13.1) versus 4.9 (0.3–8.5), p = 0.03]. Endovascular patients spent less time in hospital [median (IQR) 5 (3–11) days versus 8 (5–14) days, p = 0.04] and rehabilitation [median (IQR) 0 (0–28) versus 27 (0–65) days, p = 0.03]. The estimated inpatient costs in the first 90 days were less in the thrombectomy group (average US$15,689 versus US$30,569, p = 0.008) offsetting the costs of interhospital transport and the thrombectomy procedure (average US$10,515). The average saving per patient treated with thrombectomy was US$4,365. Conclusion Thrombectomy patients with large vessel occlusion and salvageable tissue on CT-perfusion had reduced length of stay and overall costs to 90 days. There was evidence of clinically relevant improvement in long-term survival and quality of life. Clinical Trial Registration http://www.ClinicalTrials.gov NCT01492725 (registered 20/11/2011).