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Background: Successful reperfusion is one of the strongest predictors of functional outcomes after mechanical thrombectomy (MT). Despite continuous advancements in MT technology and techniques, reperfusion failure still occurs in ≈15% to 30% of patients with large vessel occlusion strokes undergoing MT. We aim to evaluate the safety and efficacy of rescue intracranial stenting for large vessel occlusion stroke after failed MT. Methods: The SAINT (Stenting and Angioplasty in Neurothrombectomy) Study is a retrospective analysis of prospectively collected data from 14 comprehensive stroke centers through January 2015 to December 2020. Patients were included if they had anterior circulation large vessel occlusion stroke due to intracranial internal carotid artery and middle cerebral artery-M1/M2 segments and failed MT. The cohort was divided into 2 groups: rescue intracranial stenting and failed recanalization (modified Thrombolysis in Cerebral Ischemia score 0–1). Propensity score matching was used to balance the 2 groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale at 90 days. Secondary outcomes included functional independence (90-day modified Rankin Scale score 0–2). Safety measures included symptomatic intracranial hemorrhage and 90-day mortality. Results: A total of 499 patients were included in the analysis. Compared with the failed reperfusion group, rescue intracranial stenting had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 2.31 [95% CI, 1.61–3.32]; P P P =0.04) at 90 days. Rates of symptomatic intracerebral hemorrhage were comparable across both groups (7.1% versus 10.2%; aOR, 0.99 [95% CI, 0.42–2.34]; P =0.98). The matched cohort analysis demonstrated similar results. Specifically, rescue intracranial stenting (n=107) had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 3.74 [95% CI, 2.16–6.57]; P P P =0.03) at 90 days with similar rates of symptomatic intracerebral hemorrhage (7.5% versus 11.2%; aOR, 0.87 [95% CI, 0.31–2.42]; P =0.79) compared with patients who failed to reperfuse (n=107). There was no heterogeneity of treatment effect across the prespecified subgroups for improvement in functional outcomes. Conclusions: Acute intracranial stenting appears to be a safe and effective rescue strategy in patients with large vessel occlusion stroke who failed MT. Randomized multicenter trials are warranted.

BackgroundThere is little data available to guide optimal anesthesia management during rescue intracranial angioplasty and stenting (ICAS) for failed mechanical thrombectomy (MT). We sought to compare the procedural safety and functional outcomes of patients undergoing rescue ICAS for failed MT under general anesthesia (GA) vs non-general anesthesia (non-GA).MethodsWe searched the data from the Stenting and Angioplasty In Neuro Thrombectomy (SAINT) study. In our review we included patients if they had anterior circulation large vessel occlusion strokes due to intracranial internal carotid artery (ICA) or middle cerebral artery (MCA-M1/M2) segments, failed MT, and underwent rescue ICAS. The cohort was divided into two groups: GA and non-GA. We used propensity score matching to balance the two groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included functional independence (90-day mRS0-2) and successful reperfusion defined as mTICI2B-3. Safety measures included symptomatic intracranial hemorrhage (sICH) and 90-day mortality.ResultsAmong 253 patients who underwent rescue ICAS, 156 qualified for the matching analysis at a 1:1 ratio. Baseline demographic and clinical characteristics were balanced between both groups. Non-GA patients had comparable outcomes to GA patients both in terms of the overall degree of disability (mRS ordinal shift; adjusted common odds ratio 1.29, 95% CI [0.69 to 2.43], P=0.43) and rates of functional independence (33.3% vs 28.6%, adjusted odds ratio 1.32, 95% CI [0.51 to 3.41], P=0.56) at 90 days. Likewise, there were no significant differences in rates of successful reperfusion, sICH, procedural complications or 90-day mortality among both groups.ConclusionsNon-GA seems to be a safe and effective anesthesia strategy for patients undergoing rescue ICAS after failed MT. Larger prospective studies are warranted for more concrete evidence.

Background and Purpose: The Tigertriever is a novel, radially adjustable, fully visible, stentriever that permits the operator to align radial expansion with target vessel diameters. This multicenter trial compared the Tigertriever’s effectiveness and safety compared with established stent retrievers. Methods: Single arm, prospective, multicenter trial comparing the Tigertriever to efficacy and safety performance goals derived from outcomes in 6 recent pivotal studies evaluating the Solitaire and Trevo stent-retriever devices with a lead-in and a main-study phase. Patients were enrolled if they had acute ischemic stroke with National Institutes of Health Stroke Scale score ≥8 due to large vessel occlusion within 8 hours of onset. The primary efficacy end point was successful reperfusion, defined as core laboratory-adjudicated modified Thrombolysis in Cerebral Ischemia score 2b-3 within 3 passes of the Tigertriever. The primary safety end point was a composite of 90-day all-cause mortality and symptomatic intracranial hemorrhage. Secondary efficacy end points included 3-month good clinical outcome (modified Rankin Scale score 0–2) and first-pass successful reperfusion. Results: Between May 2018 and March 2020, 160 patients (43 lead-in, 117 main phase) at 17 centers were enrolled and treated with the Tigertriever. The primary efficacy end point was achieved in 84.6% in the main-study phase group compared with the 63.4% performance goal and the 73.4% historical rate (noninferiority P P P =0.004; superiority P =0.57). Good clinical outcome was achieved in 58% at 90 days. Conclusions: The Tigertriever device was shown to be highly effective and safe compared with Trevo and Solitaire devices to remove thrombus in patients with large-vessel occlusive stroke eligible for mechanical thrombectomy. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03474549.

BackgroundStent-assisted coiling of wide-necked intracranial aneurysms (IAs) using the Neuroform Atlas Stent System (Atlas) has shown promising results.ObjectiveTo present the primary efficacy and safety results of the ATLAS Investigational Device Exemption (IDE) trial in a cohort of patients with posterior circulation IAs.MethodsThe ATLAS trial is a prospective, multicenter, single-arm, open-label study of unruptured, wide-necked, IAs treated with the Atlas stent and adjunctive coiling. This study reports the results of patients with posterior circulation IAs. The primary efficacy endpoint was complete aneurysm occlusion (Raymond-Roy (RR) class I) on 12-month angiography, in the absence of re-treatment or parent artery stenosis >50%. The primary safety endpoint was any major ipsilateral stroke or neurological death within 12 months. Adjudication of the primary endpoints was performed by an imaging core laboratory and a Clinical Events Committee.ResultsThe ATLAS trial enrolled and treated 116 patients at 25 medical centers with unruptured, wide-necked, posterior circulation IAs (mean age 60.2±10.5 years, 81.0% (94/116) female). Stents were placed in all patients with 100% technical success rate. A total of 95/116 (81.9%) patients had complete angiographic follow-up at 12 months, of whom 81 (85.3%) had complete aneurysm occlusion (RR class I). The primary effectiveness outcome was achieved in 76.7% (95% CI 67.0% to 86.5%) of patients. Overall, major ipsilateral stroke and secondary persistent neurological deficit occurred in 4.3% (5/116) and 1.7% (2/116) of patients, respectively.ConclusionsIn the ATLAS IDE posterior circulation cohort, the Neuroform Atlas Stent System with adjunctive coiling demonstrated high rates of technical and safety performance.Trial registration numberhttps://clinicaltrials.gov/ct2/show/NCT02340585.

Introduction Endovascular management of wide-necked bifurcation aneurysms poses a therapeutic challenge as coiling often requires the use of multiple adjunctive stent constructs to achieve successful embolization without compromising parent vessel integrity. The Neuroform Atlas Stent System is a novel low-profile, intraluminal remodeling device. The study aims to investigate the safety and efficacy of the Y-configuration constructs with the ATLAS stent for aneurysm coil embolization. Methods Patients undergoing Y-stent assisted coil embolization in the ATLAS IDE trial (Investigational Device Exemption) were identified. The primary efficacy end point was complete aneurysm occlusion (Raymond-Roy class 1) on 12-month angiography, in the absence of retreatment or parent artery stenosis (>50%) at the target location. The primary safety end point was any major stroke or ipsilateral stroke or neurological death within 12 months. Adjudication of the primary end points was performed by an independent Imaging Core Laboratory and the Clinical Events Committee. Result A total of 60 patients of were identified. The mean age was 59 and 28.3% were men. The median aneurysm size was 6.7mm with a median neck size of 4.3 mm. Aneurysm locations were as follows: basilar apex (56.7%), basilar trunk (3.3%), anterior communicating artery (20%), anterior cerebral artery (3.3%), internal cerebral artery (3.3%) and middle cerebral artery (13.3%). The composite primary efficacy end point of complete aneurysm occlusion (Raymond-Roy 1) without parent artery stenosis or aneurysm retreatment was achieved in 81.1% of patients. Overall, 1.7% (1/60) of patients experienced a primary safety end point of major ipsilateral stroke or neurological death. Conclusions In the ATLAS IDE aneurysm cohort premarket approval study, the Neuroform Atlas stent with adjunctive Y-stent coiling met the primary end points and demonstrated high rates of long-term complete aneurysm occlusion at 12 months, with low rates of morbidity. Disclosures A. Jadhav: None. S. Desai: None. R. Hanel: None. D. Frei: None. A. Khaldi: None. S. Hetts: None. O. Zaidat: None. B. Jankowitz: None.

Background and objectiveStent-assisted coil embolization is a well-established treatment of intracranial wide-necked aneurysms. The Neuroform Atlas Stent System is a new generation microstent designed to enhance coil support, conformability, deliverability, and improve deployment accuracy. We present the 1-year efficacy and angiographic results of the Humanitarian Device Exemption (HDE) cohort from the Atlas Investigational Device Exemption (IDE) clinical trial.MethodThe Atlas IDE trial is a prospective, multicenter, single-arm, open-label study of unruptured wide-necked intracranial aneurysms treated with the Neuroform Atlas stent and approved coils. The primary efficacy endpoint was the rate of 12-month complete aneurysm angiographic occlusion (Raymond class I) without target aneurysm retreatment or significant parent artery stenosis (>50%) at the target location. The primary safety endpoint was the rate of major ipsilateral stroke or neurological death within 12 months. Imaging core laboratory and Clinical EventsCommittee adjudicated the primary endpoints.Results30 patients were enrolled at eight US centers, with 27 patients completing the 12-month angiographic follow-up. The mean age was 59.4±11.8 years and 24/30 patients (80%) were women. The mean aneurysm size was 5.3±1.7 mm and the dome:neck ratio was 1.1±0.2. Procedural technical success of Neuroform Atlas Stent deployment was 100%. 27 patients completed 12-month angiographic follow-up and 30 patients completed their 6-month follow-up. When applying the last observation carried forward method, the primary efficacy endpoint was observed in 26/30 patients (86.7%, 95% CI 69.3% to 96.2%) compared with 25/27 patients (92.6%, 95% CI 75.7% to 99.1%) who completed the 12-month angiographic follow-up. The primary safety endpoint of stroke occurred in one patient (3.3%), who made a complete clinical recovery at discharge. There were no neurological deaths.ConclusionThe Neuroform Atlas stent in conjunction with coils demonstrated a high rate of complete aneurysm occlusion at 12-month angiographic follow-up, with an improved safety profile in the HDE cohort.Clinical trial.gov registration numberNCT0234058;Results

BACKGROUND Heterogeneous effect of endovascular aneurysm therapy has been observed across different anatomic locations. There is a paucity of data for stent-assisted coiling of middle cerebral artery (MCA) aneurysms. OBJECTIVE To present the results of the MCA aneurysm group from the Neuroform Atlas (Stryker Neurovascular) investigational device exemption (IDE) trial. METHODS The Atlas IDE trial is a prospective, multicenter, single-arm, open-label study of wide-neck aneurysms (neck ≥ 4 mm or dome-to-neck ratio

Supplemental Digital Content is available in the text., Background and Purpose: Stent-assisted coil embolization using the new generation Neuroform Atlas Stent System has shown promising safety and efficacy. The primary study results of the anterior circulation aneurysm cohort of the treatment of wide-neck, saccular, intracranial, aneurysms with the Neuroform Atlas Stent System (ATLAS trial [Safety and Effectiveness of the Treatment of Wide Neck, Saccular Intracranial Aneurysms With the Neuroform Atlas Stent System]) are presented. Methods: ATLAS IDE trial (Investigational Device Exemption) is a prospective, multicenter, single-arm, open-label study of wide-neck (neck ≥4 mm or dome-to-neck ratio 50%) at the target location. The primary safety end point was any major stroke or ipsilateral stroke or neurological death within 12 months. Adjudication of the primary end points was performed by an independent Imaging Core Laboratory and the Clinical Events Committee. Results: A total of 182 patients with wide-neck anterior circulation aneurysms at 25 US centers were enrolled. The mean age was 60.3±11.4 years, 73.1% (133/182) women, and 80.8% (147/182) white. Mean aneurysm size was 6.1±2.2 mm, mean neck width was 4.1±1.2 mm, and mean dome-to-neck ratio was 1.2±0.3. The most frequent aneurysm locations were the anterior communicating artery (64/182, 35.2%), internal carotid artery ophthalmic artery segment (29/182, 15.9%), and middle cerebral artery bifurcation (27/182, 14.8%). Stents were placed in the anticipated anatomic location in all patients. The study met both primary safety and efficacy end points. The composite primary efficacy end point of complete aneurysm occlusion (Raymond-Roy 1) without parent artery stenosis or aneurysm retreatment was achieved in 84.7% (95% CI, 78.6%–90.9%) of patients. Overall, 4.4% (8/182, 95% CI, 1.9%–8.5%) of patients experienced a primary safety end point of major ipsilateral stroke or neurological death. Conclusions: In the ATLAS IDE anterior circulation aneurysm cohort premarket approval study, the Neuroform Atlas stent with adjunctive coiling met the primary end points and demonstrated high rates of long-term complete aneurysm occlusion at 12 months, with 100% technical success and

IntroductionWith the publication of the recent trials showing the tremendous benefits of mechanical thrombectomy, opportunities exist to refine prehospital processes to identify patients with larger stroke syndromes.Materials and methodsWe retrospectively reviewed consecutive patients who were brought via scene flight from rural parts of the region to our institution, from December 1, 2014 to June 5, 2015, with severe hemiparesis or hemiplegia. We assessed the accuracy of the diagnosis of stroke and the number of patients requiring endovascular therapy. Moreover, we reviewed the times along the pathway of patients who were treated with endovascular therapy.Results45 patients were brought via helicopter from the field to our institution. 27 (60%) patients were diagnosed with an ischemic stroke. Of these, 12 (26.7%) were treated with mechanical thrombectomy and 6 (13.3%) with intravenous tissue plasminogen activator alone. An additional three patients required embolization procedures for either a dural arteriovenous fistula or cerebral aneurysm. Thus a total of 15 (33%) patients received an endovascular procedure and 21/45 (46.7%) received an acute treatment. For patients treated with thrombectomy, the median time from first medical contact to groin puncture was 101 min, with 8 of the 12 patients (66.7%) being discharged to home.ConclusionsWe have presented a pilot study showing that severe hemiparesis or hemiplegia may be a reasonable prehospital tool in recognizing patients requiring endovascular treatment. Patients being identified earlier may be treated faster and potentially improve outcomes. Further prospective controlled studies are required to assess the impact on outcomes and cost effectiveness using this methodology.

BackgroundMechanical thrombectomy has become the accepted treatment for large vessel occlusion in acute ischemic stroke. Unfortunately, a large cohort of patients do not achieve functional independence with treatment, even though the results are more robust than with medical management. The hyperintense acute reperfusion marker (HARM) on MRI is an indication of the breakdown of the blood–brain barrier and reperfusion injury.ObjectiveTo examine the hypothesis that the presence of HARM on MRI correlates with worse neurological recovery after reperfusion therapy.MethodsWe retrospectively reviewed 35 consecutive patients who between February 24, 2016 and April 23, 2016 underwent MRI to determine the presence of HARM after thrombectomy for anterior circulation large vessel occlusion. Demographic, radiographic imaging, and outcome data were collected. Univariate and binary logistic regression models were performed to assess predictors for improvement of the National Institutes of Health Stroke Scale (NIHSS) score by ≥8 points at 24 hours.ResultsThe 35 patients studied had an average age of 64±14 years of age with a median NIHSS score of 15 (IQR 9–20). Eighteen patients (51%) were found to have a HARM-positive MRI. In univariate analysis, patients with HARM were older, had lower reperfusion rates and more postprocedural hemorrhages. In binary logistic regression modeling, the absence of HARM was independently associated with a ≥8-point NIHSS score improvement at 24 hours (OR=7.14, 95% CI 1.22 to 41.67).ConclusionsThis preliminary analysis shows that the presence of HARM may be linked to worse neurological recovery 24 hours after thrombectomy. Reperfusion injury may affect the number of patients achieving functional independence after treatment.

Introduction: Rapid delivery of intravenous t-PA in qualifying patients leads to better clinical outcomes. The American Heart Association has reduced target door to needle (DTN) times from 60 to 45 minutes in the hopes of continued process improvements across institutions. We thus started a quality improvement project called CODE FAST in order to reduce DTN times at our institution. These results were recently reported and published. Materials and Methods: We retrospectively reviewed data from our internally maintained database of patients treated with intravenous t-PA prior to and after implementation of the CODE FAST protocol. We assessed demographic information, time of day and times of arrival to first image and delivery of t-PA in patients from February 2014- February 2015. Outcomes were assessed based on discharge to home. Univariate analysis was performed to assess for improvement in DTN times prior to and after implementation of the protocol. We will present the latest data from February 2014- January 2016. Results: We previously reported 93 patients (41 pre-CODE FAST and 52 post-CODE FAST) received IV t-PA during the study period. We showed a substantial reduction in door to imaging time from a median of 16 to 8 minutes (p Conclusions: We present a quality improvement project that continues to be an overwhelmingly success in reducing DTN to less than 30 minutes. Further opportunies exist to reduce time further and improve discharge outcomes.

Recanalization of previously coiled aneurysms remains a major drawback of endovascular aneurysm therapy. We performed a prospective single arm trial to provide early initial data regarding the safety and angiographic durability of a new coil technology, the Axium MicroFX Polyglycolic/polylactic acid (PGLA) coil, which was designed to lower recanalization rates. Fifteen patients (16 aneurysms) were prospectively enrolled. Demographic and peri-procedural data were collected. Angiographic images of the initial coil embolization and three to six month follow-up angiographic images underwent blinded evaluation. Seven (47%) SAH and eight (53%) elective patients were enrolled. Blinded evaluation of the initial embolization demonstrated that 5/16 (31%) aneurysms achieved Raymond grade 1, 5/16 (31%) grade 2 and 6/16 (38%) grade 3. Three to six month angiography was obtained in 12/15 patients (80%); two patients expired (1 SAH, 1 elective) and one was lost to follow-up (SAH). All patients who underwent follow-up angiography had a mRS ≤1. Blinded evaluation of embolization demonstrated 7/13 aneurysms (54%) improved in Raymond grading, five (38%) were stable and one aneurysm (8%) worsened. One patient developed an asymptomatic peri-aneurysmal parent vessel stenosis. Axium MicroFX coils appear to be safe, though the small number of patients in this series obviates comparative analysis with other series. Further studies are needed with more patients to compare the angiographic durability of Axium MicroFX coils to other coils.

Percutaneous vascular closure devices are being increasingly used as alternatives to manual compression for the closure of femoral arteriotomy after endovascular procedures as they appear to reduce time to ambulate, improve patient's comfort, and are implicated with cost saving. However, vascular closure devices have been associated with an increased risk of complications including hematoma formation, local bleeding, arteriovenous fistula formation, pseudoaneurysm and arterial leg ischemia. To our knowledge, if the above complications occur it is usually within the first 30 days after the procedure. None have been reported in a delayed fashion ten months or longer after closure. We describe a 30-year-old man with a history of a giant basilar trunk aneurysm. He was placed on aspirin and clopidogrel prior to the procedure. He had bilateral femoral access with 6 French sheaths. Following the procedure, 6 French Angio-Seals (St. Jude Medical, St. Paul, MN, USA) were used for closure of bilateral femoral arteriotomies. Ten months after the procedure, the patient kicked a metal cart and developed a large right retroperitoneal iliopsoas hematoma. There was no evidence of pseudoaneurysm. The patient was managed conservatively and his serial hematocrit stayed stable. He did not require surgical intervention. Use of percutaneous vascular closure devices is associated with complications including risk of hematoma, pseudoaneurysm, intravenous fistula, rectal peritoneal hemorrhage, limb ischemia and possible surgical repair. Most complications occur peri-procedure or within 30 days postprocedure. This is the first reported case of a delayed complication at ten months after the initial procedure. Site-related complications associated with percutaneous vascular closure devices may occur in a delayed fashion, even ten months postprocedure, so should be considered in the management of patients.

Objective Hydrosoft coils were developed to serve as finishing coils to prevent aneurysmal recurrence at the neck. Initial animal studies were encouraging since some studies showed endothelial healing across the neck without recurrence over time. However, theoretical concerns exist regarding the potential threat to parent vessels as the Hydrosoft coils at the neck expand, as well as whether such coils can be adequately supple to safely serve as a true finishing coil. A retrospective review of the initial clinical experience utilizing Hydrosoft coils from three high-volume centers was performed. Methods Each center was asked to report angiographic (aneurysmal location, aneurysmal maximal size, neck size, incidence of intraprocedural parent vessel thrombosis, coil herniation, aneurysmal rupture as well as Raymond scale and percent occlusion after coiling) and clinical (rupture status, Hunt and Hess grade, incidence of stroke, hemorrhage, vasospasm and hydrocephalus) data on consecutive patients who underwent placement of Hydrosoft coils. Results A total of 141 patients were enrolled. Embolization achieved a Raymond Scale score of I (complete obliteration) in 79 aneurysms (56%), II (residual neck) in 40 aneurysms (28%) and III (residual dome) in 21 aneurysms (15%); in one case the Hydrosoft coil could not be placed. Procedural morbidity and mortality were 2.1% and 1.4%, respectively. No complications were definitively attributed to the use of Hydrosoft coils. There were three cases (2.1%) of parent vessel thrombosis, two of which resolved after intraprocedural administration of thrombolytic agents and did not lead to neurological sequelae. The incidences of intraprocedural or periprocedural aneurysmal rupture (2.1%), cerebral hemorrhage (3.5%), stroke (4.9%), vasospasm (26.2%) or hydrocephalus (31.1%) were comparable to contemporary literature. Conclusion The use of Hydrosoft coils appears to be safe and does not lead to higher complication rates than are currently accepted in the literature. Further prospective studies are required to determine whether the use of Hydrosoft coils results in a lower incidence of aneurysmal recurrence.

Background context Hemangiopericytoma (HPC) occurs infrequently in the central nervous system. Spinal involvement is particularly uncommon; and intradural localization is rare. Here, we describe an intradural extramedullary thoracic HPC that went undiagnosed initially on computed tomography scan of the abdomen. Purpose To describe the clinical presentation and operative management of a patient diagnosed with an intradural extramedullary thoracic HPC that was missed on initial workup. We also describe the pathologic features of HPC. Study design Case report. Methods Chart review and literature search. Case A 58-year-old man presented with acute weakness of the lower extremities and bladder and bowel incontinence. Magnetic resonance imaging of his spine revealed a T10 intradural extramedullary lesion that displaced the cord to the right. Results The patient was taken emergently to surgery for T9–T11 laminectomy and en bloc resection of the tumor. The lesion was identified and resected. Histology revealed randomly oriented tumor cells with irregular capillaries consistent with HPC. Postoperatively, the patient had an improved neurological examination, and he continued to do so with intense physical therapy. Conclusion The standard treatment for HPC is surgery when the lesion is resectable. Despite gross total resection, there is still a high risk of recurrence and metastasis; therefore, patients should be followed up closely by their physicians with serial postoperative clinical examinations and radiographic imaging.

Object Venous thromboembolism (VTE), a combination of deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major cause of morbidity and death in neurosurgical patients. This study evaluates 1) the risk of developing lower-extremity DVT following a neurosurgical procedure; 2) the timing of initiation of pharmacological DVT prophylaxis upon the occurrence of VTE; and 3) the relationship between DVT and PE as related to VTE prophylaxis in neurosurgical patients. Methods The records of all neurosurgical patients between January 2006 and December 2008 (2638 total) were reviewed for clinical documentation of VTE. As part of a quality improvement initiative, a subgroup of 1638 patients was studied during the implementation of pharmacological prophylaxis. A high-risk group of 555 neurosurgical patients in the intensive care unit underwent surveillance venous lower-extremity duplex ultrasonography studies twice weekly. All patients throughout the review received mechanical DVT prophylaxis. Pharmacological DVT prophylaxis, consisting of 5000 U of subcutaneous heparin twice daily (initially started within 48 hours of a neurosurgical procedure and subsequently within 24 hours of a procedure) was implemented in combination with mechanical prophylaxis. The DVT and PE rates were calculated for each group. Results In the surveillance group (555 patients), 84% of the DVTs occurred within 1 week and 92% within 2 weeks of a neurosurgical procedure. There was a linear correlation between the duration of surgery and DVT development. The use of subcutaneous heparin reduced the rate of DVT from 16% to 9% when medication was given at either 24 or 48 hours postoperatively, without any increase in hemorrhagic complications. In the overall group (2638 patients), there were 94 patients who exhibited clinical signs of a possible PE and therefore underwent spiral CT; 22 of these patients (0.8%) had radiological confirmation of PE. There was no correlation between the use of pharmacological prophylaxis at either time point and the occurrence of PE, despite a 43% reduction in the lower-extremity DVT rate with pharmacological intervention. Conclusions The majority of DVTs occurred within the first week after a neurosurgical procedure. There was a linear correlation between the duration of surgery and DVT occurrence. Use of early subcutaneous heparin (at either 24 or 48 hours) was associated with a 43% reduction of developing a lower-extremity DVT, without an increase in surgical site hemorrhage. There was no association of pharmacological prophylaxis with overall PE occurrence.

Object This study was conducted to evaluate the value of postoperative CT scans in determining the probability of return to the operating room (OR) and the optimal time to obtain such scans to determine the effects of surgery. Methods Between January and December 2006 (12 months), all postoperative head CT scans obtained for 3 individual surgeons were reviewed. Scans were divided into 3 groups, which were determined by the preference of each surgeon: Group A (early scans—scheduled between 0 and 7 hours); Group B (delayed scans—scheduled between 8 and 24 hours); and Group C (urgent scans—ordered because of a new neurological deficit). The initial scans were reviewed and analyzed in 2 different fashions. The first was to analyze the efficacy of the scans in predicting return to the OR. The second was to determine the optimal time for obtaining a scan. The second analysis was a review of serial postoperative scans for expected versus unexpected findings and changes in the acuity of these findings over time. Results In 251 (74%) of 338 cases, the patients had postoperative head CT scans within 24 hours of surgery. Analysis 1 determined the percent of patients returning to the OR for emergency treatment based on postoperative scans: Group A (early)—133 patients, with 0% returning to the OR; Group B (delayed)—108 patients, with 0% returning to the OR; and Group C (urgent)—10 patients, with 30% returning to the OR (p < 0.05). Analysis 2 determined the optimal timing of postoperative scans and changes in scan acuity: Group A (early scan) had an 11% incidence of change in acuity on subsequent scans. Group B (delayed scan) had a 3% incidence of change in acuity on follow-up scans (p < 0.05). Conclusions Routine postoperative scans at 0–7 hours or at 8–24 hours are not predictive of return to the OR, whereas patients with a new neurological deficit in the postoperative period have a 30% chance of emergency reoperation based on CT scans. In addition, early postoperative scans (0–7 hours) fail to predict CT changes, which might evolve over time and may influence postoperative medical management.

Study design Case report and literature review. Objective Spinal epidural arteriovenous fistulas with secondary reflux into the perimedullary veins are rare. We report a patient who presented with delayed progressive congestive myelopathy after lumbar surgery. The pathophysiology and the anatomic basis for the responsible arteriovenous fistula are discussed. Summary of background data Delayed neurological deterioration after spinal surgery is uncommon. Epidural fistulae uncommonly may become symptomatic from an epidural hematoma, mass effect from distended veins, and rarely from a spinal dural arteriovenous fistula. We report on a patient with delayed progressive congestive myelopathy after lumbar surgery, and discuss the pathophysiology and the anatomical basis for the causative fistula. Methods A 68-year-old man presented with progressive lower extremity weakness and sensory decrease, and loss of sphincter control 2 years after unilateral lumbar laminectomy and fusion for a disc herniation. MRI showed diffuse new cord edema and intradural perimedullary dilated vessels. Spinal angiography revealed an epidural arteriovenous fistula at the site of the previous laminectomy, with intradural perimedullary venous drainage. The fistula was successfully treated surgically and the patient experienced rapid and gradual neurologic improvement, being able to walk without a cane within 6 weeks of repair. Results There are few causes of delayed neurologic deterioration after lumbar spinal surgery. Epidural fistulas are uncommon and rarely symptomatic, and when they are, it is usually from an epidural hematoma or mass effect from distended epidural veins. Epidural may rarely result in spinal dural arteriovenous fistulas, the most common spontaneous spinal arteriovenous condition, causing a congestive myelopathy characterized by lower extremity spasticity, sensory changes, and loss of sphincter control. Conclusion Delayed neurologic deterioration after spinal surgery is uncommon. Epidural arteriovenous fistulas with secondary intradural drainage, which are rare, should be considered.

BackgroundRapid delivery of IV tissue plasminogen activator (tPA) in qualifying patients leads to better clinical outcomes. The American Heart Association has reduced target door-to-needle (DTN) times from 60 to 45 min in the hopes of continued process improvements across institutions.ObjectiveTo start a quality improvement project called CODE FAST in order to reduce DTN times at our institution.Materials and methodsWe retrospectively reviewed data from our internally maintained database of patients treated with intravenous tPA before and after implementation of the CODE FAST protocol. We assessed demographic information, time of day and times of arrival to first image and delivery of tPA in patients from February 2014 to February 2015. Outcomes were assessed based on discharge to home. Univariate analysis was performed to assess for improvement in DTN times before and after implementation of the protocol.ResultsA total of 93 patients (41 pre-CODE FAST and 52 post-CODE FAST) received IV tPA during the study period. Patients were equally matched between the two groups except that in the pre-CODE FAST era patients receiving tPA were younger and more likely to be men. There was a substantial reduction in door-to-imaging time from a median of 16 to 8 min (pConclusionsWe present a quality improvement project that has been overwhelmingly successful in reducing DTN time to

Purpose: We report clinical experience and long-term results in treating 39 AcomA aneurysms in 39 patients using the Penumbra PC400 large volume coil at 13 high volume centers. With its .020” coil size and use of 025” ID microcatheter, the safety and efficacy of the Penumbra Coil 400 (PC400) System in embolization of AcomA aneurysms has not yet been characterized. Methods: Our treatment cohort consisted of 39 aneurysms ranging between 3.5mm and 17mm, treated between March 2012 and May 2014. Six-month follow up were assessed. Data on angiographic results and procedural complications were collected prospectively and analyzed. Results: The mean aneurysm size was 6.2 mm, with 40.8% mean packing density. All aneurysms were treated entirely with PC400 coils, with mean of 5.1 coils placed. Twenty were ruptured and 19 unruptured. Sixty-six percent of the cases achieved an initial Raymond Scale of 1, and 23.7% achieved a Raymond scale of 2. The overall rate of retreatment was 0%, while the rate of morbidity and mortality caused by stroke Conclusion: ACE study data demonstrate that embolization using the PC400 System and 025” ID microcatheter in AcomA aneurysms leads to safe and effective short- and long-term outcomes.

OBJECTIVE Nitric oxide (NO), one of the most powerful endogenous vasodilators, is thought to play a major role in the development of delayed vasospasm in patients with subarachnoid hemorrhage (SAH). However, the role of the production of cerebral NO in patients with SAH is not known. In other SAH studies, NO metabolites such as nitrite and nitrate have been demonstrated to be decreased in cerebrospinal fluid and in plasma. METHODS In this study, a microdialysis probe was used, along with a multiparameter sensor, to measure NO metabolites, brain tissue oxygen tension, brain tissue carbon dioxide tension, and pH in the cortex of patients with severe SAH who were at risk for developing secondary brain damage and vasospasm. NO metabolites, glucose, and lactate were analyzed in the dialysates to determine the time course of NO metabolite changes and to test the interrelationship between the analytes and clinical variables. RESULTS Brain tissue oxygen tension was strongly correlated to dialysate nitrate and nitrite (r2 = 0.326;P < 0.001); however, no correlation was noted between brain tissue oxygen tension and NO metabolites in cerebrospinal fluid (r2 = 0.018;P = 0.734). No significant correlation between NO production, brain tissue carbon dioxide tension, and dialysate glucose and lactate was observed. CONCLUSION Cerebral ischemia and compromised substrate delivery are often responsible for high morbidity rates and poor outcomes after SAH. The relationship between brain tissue oxygen and cerebral NO metabolites that we demonstrate suggests that substrate delivery and NO are linked in the pathophysiology of vasospasm after SAH.

Object. Disturbed ionic and neurotransmitter homeostasis are now recognized as probably the most important mechanisms contributing to the development of secondary brain swelling after traumatic brain injury (TBI). Evidence obtained in animal models indicates that posttraumatic neuronal excitation by excitatory amino acids leads to an increase in extracellular potassium, probably due to ion channel activation. The purpose of this study was therefore to measure dialysate potassium in severely head injured patients and to correlate these results with measurements of intracranial pressure (ICP), patient outcome, and levels of dialysate glutamate and lactate, and cerebral blood flow (CBF) to determine the role of ischemia in this posttraumatic ion dysfunction.Methods. Eighty-five patients with severe TBI (Glasgow Coma Scale Score < 8) were treated according to an intensive ICP management-focused protocol. All patients underwent intracerebral microdialyis. Dialysate potassium levels were analyzed using flame photometry, and dialysate glutamate and dialysate lactate levels were measured using high-performance liquid chromatography and an enzyme-linked amperometric method in 72 and 84 patients, respectively. Cerebral blood flow studies (stable xenon computerized tomography scanning) were performed in 59 patients.In approximately 20% of the patients, dialysate potassium values were increased (dialysate potassium > 1.8 mM) for 3 hours or more. A mean amount of dialysate potassium greater than 2 mM throughout the entire monitoring period was associated with ICP above 30 mm Hg and fatal outcome, as were progressively rising levels of dialysate potassium. The presence of dialysate potassium correlated positively with dialysate glutamate (p < 0.0001) and lactate (p < 0.0001) levels. Dialysate potassium was significantly inversely correlated with reduced CBF (p = 0.019).Conclusions. Dialysate potassium was increased after TBI in 20% of measurements. High levels of dialysate potassium were associated with increased ICP and poor outcome. The simultaneous increase in dialysate potassium, together with dialysate glutamate and lactate, supports the concept that glutamate induces ionic flux and consequently increases ICP, which the authors speculate may be due to astrocytic swelling. Reduced CBF was also significantly correlated with increased levels of dialysate potassium. This may be due to either cell swelling or altered vasoreactivity in cerebral blood vessels caused by higher levels of potassium after trauma. Additional studies in which potassium-sensitive microelectrodes are used are needed to validate these ionic events more clearly.

Disturbed ionic and neurotransmitter homeostasis are now recognized to be probably the most important mechanisms contributing to the development of secondary brain swelling after traumatic brian injury (TBI). Evidence obtained from animal models indicates that posttraumatic neuronal excitation via excitatory amino acids leads to an increase in extracellular potassium, probably due to ion channel activation. The purpose of this study was therefore to measure dialysate potassium in severely head injured patients and to correlate these results with intracranial pressure (ICP), outcome, and also with the levels of dialysate glutamate, lactate, and cerebral blood flow (CBF) so as to determine the role of ischemia in this posttraumatic ionic dysfunction. Eighty-five patients with severe TBI (Glasgow Coma Scale score < 8) were treated according to an intensive ICP management-focused protocol. All patients underwent intracerebral microdialyis. Dialysate potassium levels were analyzed by flame photometry, as were dialysate glutamate and dialysate lactate levels, which were measured using high-performance liquid chromatography and an enzyme-linked amperometric method in 72 and 84 patients respectively. Cerebral blood flow studies (stable Xenon–computerized tomography scanning) were performed in 59 patients. In approximately 20% of the patients, potassium values were increased (dialysate potassium > 1.8 mmol). Mean dialysate potassium (> 2 mmol) was associated with ICP above 30 mm Hg and fatal outcome. Dialysate potassium correlated positively with dialysate glutamate (p < 0.0001) and lactate levels (p < 0.0001). Dialysate potassium was significantly inversely correlated with reduced CBF (p = 0.019). Dialysate potassium was increased after TBI in 20% of measurements. High levels of dialysate potassium were associated with increased ICP and poor outcome. The simultaneous increase of potassium, together with dialysate glutamate and lactate, supports the hypothesis that glutamate induces ionic flux and consequently increases ICP due to astrocytic swelling. Reduced CBF was also significantly correlated with increased levels of dialysate potassium. This may be due to either cell swelling or altered potassium reactivity in cerebral blood vessels after trauma.

Sodium nitroprusside (disodium nitroferricyanide) has been suggested to cause cytotoxicity through either the release of cyanide and/or nitric oxide. The present study investigated a possible mechanism that after a brief release of nitric oxide, iron moiety of breakdown products of sodium nitroprusside could cause a long lasting oxidative stress, such as hydroxyl radical generation, lipid peroxidation and cytotoxicity. Intranigral administration of sodium nitroprusside (0–16.8 nmol) to rats induced an acute increase in lipid peroxidation in the substantia nigra and a chronic dopamine depletion in the caudate nucleus. Photodegraded (nitric oxide-exhausted) sodium nitroprusside, however, still produced lipid peroxidation and neurotoxicity in the midbrain. Moreover, non-iron containing nitric oxide-donor compounds, such as S-nitroso-N-acetylpenicillamine, did not cause oxidative brain injury in vivo suggesting that nitric oxide may not mediate neurotoxicity induced by sodium nitroprusside. Additional in vitro studies demonstrated that both freshly prepared (nitric oxide donor) and photodegraded (nitric oxide-exhausted) sodium nitroprusside generated hydroxyl radicals in the presence of ascorbate and also increased lipid peroxidation in brain homogenates. These pro-oxidative effects of sodium nitroprusside were blocked by nitric oxide, S-nitroso-N-acetylpenicillamine, oxyhemoglobin, and deferoxamine (iron chelator). The present results suggest that iron moiety, rather than nitric oxide, may mediate the pro-oxidative properties of sodium nitroprusside. With this new information in mind, the misuse of sodium nitroprusside as a selective nitric oxide donor in both basic and clinical uses should be urgently addressed.

Increase packing density with the use of softer three-dimensional (3D) coils has been indicated in reducing aneurysm recurrence. We are reporting a multicenter initial experience of using the Orbit Galaxy XTRASOFT which is a stretch-resistant, softer 3D coil in both ruptured and unruptured aneurysms. A total of 57 consecutive patients from five high-volume neurointerventional centers were reported where at least one Galaxy XTRASOFT coil was used during a procedure. There were 25 patients with ruptured aneurysm and 32 with elective coiling. The overall complication rate was 3.5%, one patient with nonoperative retroperitoneal hematoma and one patient with intraoperative rupture but with no neurological deficit. The occlusion rate of 90% or greater was achieved in 86% of the cases. The discharge modified Rankin score of 0 or 1 was achieved in 100% of the elective coiling and 65% in the ruptured cases. Early experience with Galaxy XTRASOFT coils for both ruptured and unruptured aneurysms appears to be safe with good aneurysm obliteration and low complication rate.

Stroke is the third major cause of death in the US. In the past decade there has been an exponential growth in modalities to treat acute stroke with acute recanalization therapies, including intravenous thrombolysis, intra-arterial chemical thrombolysis and mechanical thrombectomy, thromboaspiration, or angioplasty. While these new modalities of therapy have been promising, there remains a very real limitation to the overall rate of successful recanalization for current standard interventions. As a result, extrapolation from the cardiac literature has lead to early efforts using primary intracranial stenting to achieve safe recanalization. A major advantage of intracranial stenting is immediate flow restoration, as time to recanalization has repeatedly been shown to be a strong predictor of outcome in stroke. We will provide a cursory review each of the major established methods of acute stroke recanalization therapy, followed by a detailed review of intracranial stenting for acute stroke recanalization.

World Health Organization grade II gliomas (GIIG) are diffuse, slow-growing, primary neuroectodermal tumors that occur in the central nervous system. They are generally seen in young individuals and are slightly more common in Whites and males. Most patients present with seizures but neurologic deficits are rare. Magnetic resonance imaging best detects GIIG and they are most frequently located in the frontal and temporal lobes. An accurate pathologic diagnosis is essential because the natural history of a GIIG may be unpredictable. In recent years, the emphasis has been on surgically removing as much tumor as safely possible to obtain an accurate diagnosis, improve symptoms, reduce tumor burden, and determine the need for adjuvant therapies. Radiation and chemotherapy are integral to the management of GIIG but their efficacy varies by tumor histology and is balanced against complications associated with them. Genetic, histopathologic, clinical, and radiographic changes are noted as GIIG progress to malignant gliomas. The risk of malignant transformation and subsequent survival may be predicted by pretreatment and treatment-related factors.

Venous thromboembolism (VTE), a combination of deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major cause of morbidity and death in neurosurgical patients. This study evaluates 1) the risk of developing lower-extremity DVT following a neurosurgical procedure; 2) the timing of initiation of pharmacological DVT prophylaxis upon the occurrence of VTE; and 3) the relationship between DVT and PE as related to VTE prophylaxis in neurosurgical patients.The records of all neurosurgical patients between January 2006 and December 2008 (2638 total) were reviewed for clinical documentation of VTE. As part of a quality improvement initiative, a subgroup of 1638 patients was studied during the implementation of pharmacological prophylaxis. A high-risk group of 555 neurosurgical patients in the intensive care unit underwent surveillance venous lower-extremity duplex ultrasonography studies twice weekly. All patients throughout the review received mechanical DVT prophylaxis. Pharmacological DVT prophylaxis, consisting of 5000 U of subcutaneous heparin twice daily (initially started within 48 hours of a neurosurgical procedure and subsequently within 24 hours of a procedure) was implemented in combination with mechanical prophylaxis. The DVT and PE rates were calculated for each group.In the surveillance group (555 patients), 84% of the DVTs occurred within 1 week and 92% within 2 weeks of a neurosurgical procedure. There was a linear correlation between the duration of surgery and DVT development. The use of subcutaneous heparin reduced the rate of DVT from 16% to 9% when medication was given at either 24 or 48 hours postoperatively, without any increase in hemorrhagic complications. In the overall group (2638 patients), there were 94 patients who exhibited clinical signs of a possible PE and therefore underwent spiral CT; 22 of these patients (0.8%) had radiological confirmation of PE. There was no correlation between the use of pharmacological prophylaxis at either time point and the occurrence of PE, despite a 43% reduction in the lower-extremity DVT rate with pharmacological intervention.The majority of DVTs occurred within the first week after a neurosurgical procedure. There was a linear correlation between the duration of surgery and DVT occurrence. Use of early subcutaneous heparin (at either 24 or 48 hours) was associated with a 43% reduction of developing a lower-extremity DVT, without an increase in surgical site hemorrhage. There was no association of pharmacological prophylaxis with overall PE occurrence.

Lesions of the lower clivus represent a technically challenging subset of skull base disease that requires careful treatment. A 75-year-old woman with tongue atrophy was referred for resection of a presumed clival chordoma. The lesion was resected via an endoscopic transnasal transclival approach with no complications. Pathology revealed only chronic inflammatory tissue consistent with a degenerative pannus. Degenerative pannus should be included in the differential diagnosis of lower clival extradural lesions. The endoscopic transnasal transclival corridor should be considered for resection of such lesions as an alternative to larger, more morbid, traditional skull base approaches.

This study was conducted to evaluate the value of postoperative CT scans in determining the probability of return to the operating room (OR) and the optimal time to obtain such scans to determine the effects of surgery.Between January and December 2006 (12 months), all postoperative head CT scans obtained for 3 individual surgeons were reviewed. Scans were divided into 3 groups, which were determined by the preference of each surgeon: Group A (early scans-scheduled between 0 and 7 hours); Group B (delayed scans-scheduled between 8 and 24 hours); and Group C (urgent scans-ordered because of a new neurological deficit). The initial scans were reviewed and analyzed in 2 different fashions. The first was to analyze the efficacy of the scans in predicting return to the OR. The second was to determine the optimal time for obtaining a scan. The second analysis was a review of serial postoperative scans for expected versus unexpected findings and changes in the acuity of these findings over time.In 251 (74%) of 338 cases, the patients had postoperative head CT scans within 24 hours of surgery. Analysis 1 determined the percent of patients returning to the OR for emergency treatment based on postoperative scans: Group A (early)-133 patients, with 0% returning to the OR; Group B (delayed)-108 patients, with 0% returning to the OR; and Group C (urgent)-10 patients, with 30% returning to the OR (p0.05). Analysis 2 determined the optimal timing of postoperative scans and changes in scan acuity: Group A (early scan) had an 11% incidence of change in acuity on subsequent scans. Group B (delayed scan) had a 3% incidence of change in acuity on follow-up scans (p0.05).Routine postoperative scans at 0-7 hours or at 8-24 hours are not predictive of return to the OR, whereas patients with a new neurological deficit in the postoperative period have a 30% chance of emergency reoperation based on CT scans. In addition, early postoperative scans (0-7 hours) fail to predict CT changes, which might evolve over time and may influence postoperative medical management.

Object. Brain tissue acidosis is known to mediate neuronal death. Therefore the authors measured the main parameters of cerebral acid—base homeostasis, as well as their interrelations, shortly after severe traumatic brain injury (TBI) in humans. Methods. Brain tissue pH, PCO2, PO2, and/or lactate were measured in 151 patients with severe head injuries, by using a Neurotrend sensor and/or a microdialysis probe. Monitoring was started as soon as possible after the injury and continued for up to 4 days. During the 1st day following the trauma, the brain tissue pH was significantly lower, compared with later time points, in patients who died or remained in a persistent vegetative state. Six hours after the injury, brain tissue PCO2 was significantly higher in patients with a poor outcome compared with patients with a good outcome. Furthermore, significant elevations in cerebral concentrations of lactate were found during the 1st day after the injury, compared with later time points. These increases in lactate were typically more pronounced in patients with a poor outcome. Similar biochemical changes were observed during later hypoxic events. Conclusions. Severe human TBI profoundly disturbs cerebral acid—base homeostasis. The observed pH changes persist for the first 24 hours after the trauma. Brain tissue acidosis is associated with increased tissue PCO2 and lactate concentration; these pathobiochemical changes are more severe in patients who remain in a persistent vegetative state or die. Furthermore, increased brain tissue PCO2 (> 60 mm Hg) appears to be a useful clinical indicator of critical cerebral ischemia, especially when accompanied by increased lactate concentrations.

Nitric oxide (NO) is a highly reactive molecule that is believed to be involved in many physiological events. In the brain, nitric oxide has been implicated in a number of biological responses such as neurotransmitter modulation, retrograde neurotransmitter and synaptic plasticity. Nitric oxide diffuses across membranes and has guanylate cyclase in the smooth muscle as its primary target, by which nitric oxide leads to vasodilation thus regulating cerebral blood flow [3].

Objective: To report a case of a recurrent stroke as a presenting symptom of a newly diagnosed HIV-associated MMS. Background There is increasing evidence that HIV infection is a risk factor of stroke. Moyamoya syndrome (MMS) is a progressive vasculopathy affecting the circle of Willis with collateral development. There are only four case reports of HIV associated MMS stroke. However, no recurrent strokes caused by newly diagnosed HIV associated MMS has been previously reported. Design/Methods: Case report. Results: A 35 year old African American male with past medical history of stroke and vertebral artery occlusion presented with acute onset of left facial droop, left hemiparesis and hemisensory loss, left sided neglect and right gaze preference. MRI showed a large right MCA territory infarct and MRA showed age indeterminant right vertebral artery occlusion at the origin, and right MCA occlusion. Subsequent cerebral angiogram revealed right MCA long segment stenosis with increased lenticulostriate proliferation consistent with early stages of MMS. On admission, his platelets count was 45, and thrombocytopenia evaluation revealed HIV (ELISA and WB positive,CD4+ count-137 and viral load -161,674). Further studies including CSF, echocardiogram, lipid panel, HgA1c, hypercoagulable and vasculitis workup were unremarkable. It is most likely that his previous stroke and vertebral artery stump occlusion was due to HIV vasculopathy. Conclusions: Recurrent stroke due to MMS could be the first presenting symptom of HIV. This case report underlines importance of Brain Attack Coalition recent revision recommending HIV testing for all stroke patients admitted to the Primary Stroke Centers. Disclosure: Dr. Alqadi has nothing to disclose. Dr. Nadareishvili has nothing to disclose. Dr. Jadhav has nothing to disclose. Dr. Burger has nothing to disclose. Dr. Khaldi has nothing to disclose. Dr. Feinberg has nothing to disclose.