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Introduction: Diabetic gastroparesis (DGp) is a component of autonomic neuropathy resulting from long-standing poorly controlled type 1 and type 2 diabetes. There are currently no approved vitamin D supplementation recommendations for people with DGp. Objectives: To investigate the relationship between vitamin D insufficiency and DGp, as well as the efficacy of intramuscular vitamin D therapy. Methodology: 71 patients (18 DM Gp & 53 Non-DM Gp) seeking treatment for gastroparesis symptoms were studied. The blood levels of vitamin D, homocysteine, gastric emptying test (GET) at 1, 2, and 4 h were recorded. 25-OH vitamin D levels were detected by kit. Potential clinical and statistical correlations between all results, symptoms, and GET data were explored. Descriptive statistics were used to investigate etiologic differences at baseline while multiple linear regression models were employed to explore relationships of vitamin D deficiency with diabetic gastroparesis and its intramuscular vitamin D treatment. Results: Majority of DGp patients were older than 18 years (88%) and were non-smokers (83%). The majority of those with and without diabetes were married (11; 71% vs. 34; 64%). The majority of participants in the DM group had only completed elementary school (n=7/18; 38.8%).

Some data suggest a vasodilatory effect of sympathetic blockade in patients with aneurysmal subarachnoid hemorrhage, but the effect on medium-sized intracranial arteries remains unclear. We report the results of serial cerebral angiography to study the cerebral vasodilatory effects of percutaneous inferior sympathetic ganglion block in 2 patients.Serial ipsilateral intracranial angiograms were obtained before and after percutaneous inferior sympathetic ganglion block and were imported to a DICOM reader, Horos Open-Source Medical Image Viewer (version 3.3.6). The percent change of arterial diameter was calculated in the intracranial internal carotid artery (ICA), middle carotid artery (MCA), and anterior cerebral artery (ACA). We assessed the interobserver reliability using the Bland-Altman method.In Patient 1, there was an average increase in diameter of intracranial ICA and MCA at 1 minute, 5 minutes, and 10 minutes, with a relative decrease in the diameter of the ACA. In Patient 2, there was an average relative increase in diameter of intracranial ICA and MCA at 1 minute, 5 minutes, 10 minutes, 20 minutes, and 30 minutes, with a relative increase in diameter at 5 minutes, 10 minutes, and 30 minutes in the ACA. The Bland-Altman coefficient of variation was -5.35 (range -0.44 to 0.28) with all the data points within the 98% upper and lower limits of acceptance.We observed vasodilation in medium-sized intracranial arteries ipsilateral to the percutaneous inferior sympathetic ganglion block as early as 1 minute post treatment and persisting for at least until 30 minutes post blockade.

Background: Patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may have an increased risk of acute cardiovascular events in the convalescent period. Aims: To determine whether patients with SARS-CoV-2 infection have an increased risk of cardiovascular events during the convalescent period. Methods: We analyzed 10,691 hospitalized adult pneumonia patients with SARS-CoV-2 infection and contemporary matched controls of pneumonia patients without SARS-CoV-2 infection. The risk of new cardiovascular events following >30 days pneumonia admission (convalescent period) was ascertained using Cox proportional hazards regression analysis to adjust for potential confounders. Results: Among 10,691 pneumonia patients with SARS-CoV-2 infection, 697 patients (5.8%; 95% CI, 5.4–6.2%) developed new cardiovascular events (median time interval of 218 days post pneumonia admission; interquartile range Q1 = 117 days, Q3 = 313 days). The risk of new cardiovascular events was not significantly higher among pneumonia patients with SARS-CoV-2 infection compared with those with pneumonia without SARS-CoV-2 infection (hazard ratio (HR), 0.90, 95% CI, 0.80–1.02) after adjustment for potential confounders. In addition, no significant difference in the rate of a new ischemic stroke (HR, 0.84; 95% CI, 0.70–1.02) or ischemic heart disease (HR, 1.00; 95% CI, 0.87–1.15) was observed between the pneumonia patients with and without SARS-CoV-2 infection. Conclusion: Our study suggests that new cardiovascular events rate in the convalescent period among pneumonia patients with SARS-CoV-2 infection was not significantly higher than the rate seen with other pneumonias.

Middle meningeal artery embolization (MMAE) is an effective minimally invasive treatment for chronic subdural hematomas (cSDHs). The authors investigated outcomes of primary, adjunct, and rescue MMAE and primary surgery for the treatment of cSDH using a large-scale national database.A retrospective study of all patients who underwent MMAE and/or surgery to treat cSDH was performed using the TriNetX Analytics Network. Primary MMAE was compared with adjunct and rescue MMAE and primary surgery. Primary outcomes included headache, facial weakness, mortality, and treatment failure, within 6 months.A total of 4274 patients with cSDH met the inclusion criteria. Of these, 209 (4.9%) were treated with primary MMAE, 4050 (94.8%) were treated with primary surgery, 15 (0.35%) were treated using MMAE as an adjunct therapy, and 18 (0.42%) were treated using MMAE as a rescue following a failed surgical intervention. There were no significant differences in headache, facial weakness, and mortality between the groups. Patients who underwent primary MMAE had a significantly higher Charlson comorbidity index (P 0.0001) than those who underwent primary surgery. The need for surgical rescue was not significantly different between primary MMAE, adjunct MMAE, and rescue MMAE (P 0.05). Additionally, patients with primary surgery had significantly higher treatment failure than those with primary MMAE (odds ratio = 2.11, 95% confidence interval = 1.11-4.01, P = 0.020).This analysis suggests no significant difference in the need for surgical rescue, complication, or mortality between primary MMAE, adjunct MMAE, and rescue MMAE. Additionally, primary MMAE is associated with a significantly lower need for surgical rescue than primary surgery.

Introduction: The diagnosis of pregnancy from forensic bloodstains can be useful in cases of infanticide, criminal abortions and missing person identification. Objective: This research illustrated the use of a rapid, precise, and tremendously responsive enzyme immunoassay kit designed for medical usage, which is put to good use in our lab for qualitative HCG detection in blood stains and has proven to be a useful tool in forensic pregnancy identification. Methods: HCG concentrations had previously been generally known, and total eighty whole blood samples were taken: forty expectant females (every single one between months one to six of pregnancy), twenty healthy young males, and twenty postmenopausal females with good health ration has been cleared in all data. Results: Enzyme immunoassay is a useful forensic technique for detecting human chorionic gonadotropin hormone in pregnant women. In the forty sample batch that was dated for six months, 37 samples (92.5%) yielded positive results, 38 of which (95%) yielded good outcomes in the qualitative analysis, most of them within the sensitivities boundary. The samples that were diluted to 1/100 and 1/200 and kept at room temperature for one week and six months period, respectively, produced just two (5.0%) and five (12.5%) successful results and the samples showed negative results when diluted to 1/200 and stored for six months. Practical implication This paper reports on human chorionic gonadotropin (HCG) detection in bloodstains based on enzyme immunoassay. Conclusion: Enzyme immunoassay has proven to be a suitable method intended for detecting an hCG hormone in blood stains, allowing for the qualitative assessment of hCG, and making it particularly interesting for use in forensic science applications. Keywords: Enzyme immunoassay, human chorionic gonadotropin (hCG), pregnancy, bloodstain

Cerebral vasospasm remains a significant source of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage. Dantrolene has shown promise in several animal studies in the treatment of cerebral vasospasm. The present study seeks to critically review the evidence of its use in human subjects, aiming to 1) describe the forms and dosages used, 2) describe its safety profile, and 3) describe its effectiveness in treating cerebral vasospasm.A systematic review of intra-arterial dantrolene use in cerebral vasospasm was performed. A total of 86 articles were identified across all databases, 6 of which were ultimately included in the present study. Primary outcomes included a description of the form and dosage of dantrolene prescribed, the incidence of adverse effects after dantrolene use, and its efficacy for the treatment of cerebral vasospasm.Study designs included 2 randomized controlled trials (33.3%), 2 case series (33.3%), and 2 case reports (33.3%). Both the intra-arterial and intravenous administration of dantrolene has been performed with varying dose regimens. Although there exists limited clinical information regarding side effects, a case of liver toxicity was reported. All existing studies reported benefit in vasospasm measured either by transcranial Doppler or digital subtraction angiography. The level of evidence was low, consisting largely of retrospective studies that had a high likelihood of bias.Dantrolene is a promising new therapeutic agent in the treatment of cerebral vasospasm. Although existing reports of its use are encouraging, high-quality prospective randomized trials are necessary for recommendations pertaining to dose, route, indications, and efficacy.

BackgroundHyperglycemia has been associated with poor outcomes in acute ischemic stroke patients undergoing endovascular treatment. We analyzed the effect of intensive glucose control on death and disability rates in patients with acute ischemic stroke undergoing endovascular treatment.MethodsWe analyzed the effect of intensive (serum glucose ResultsA total of 146 patients (mean age 68.1±13.9 years, 50.7% men) underwent endovascular treatment for acute ischemic stroke; 72 and 74 patients were randomized to intensive and standard treatments, respectively. The rates of death (20.3% and 22.2%), favorable 90-day primary outcome (17.6% and 19.4%), and serious adverse events (41.9% and 56.98%) were similar between the two groups. The AUC of serum glucose was not associated with death within 90 days (OR 1, 95% CI 1 to 1) or favorable outcome at 90 days (OR 1, 95% CI 1 to 1). Glucose variability was not associated with death or favorable outcome at 90 days.ConclusionWe did not identify any beneficial effect of intensive glucose reduction on rates of death or favorable outcomes at 90 days among acute ischemic stroke patients undergoing endovascular treatment.

Background and Purpose: Although many stroke centers in United States are using intravenous (IV) tenecteplase (TNK) for acute ischemic stroke patients, there is paucity of comparative data between IV TNK and IV alteplase from real-world settings. Materials and Methods: We analyzed the data from 122 healthcare facilities to determine the effect of IV TNK (compared with IV alteplase) on occurrence of two outcomes in acute ischemic stroke patients stratified by use of thrombectomy: non-routine discharge or death, and intracranial hemorrhage after adjusting for potential confounders. Results: Among 30,643 acute ischemic stroke patients analyzed, 29,480 (96.2%) and 1,163 (3.8%) patients received IV alteplase and IV TNK, respectively. The proportion of patients who received thrombectomy was significantly higher among patients who received IV TNK compared with those who received IV alteplase (16.7% versus 11.0%, p Conclusions: In an analysis of real-world data, IV TNK was associated with higher rates of intracranial hemorrhage compared with IV alteplase in patients with acute ischemic stroke.

Introduction: Although there is emphasis on performing carotid artery stent placement (CAS) within two weeks after index event of transient ischemic attack (TIA) or minor stroke in patients with cervical internal carotid artery (ICA) stenosis, the risk and characteristics of recurrent cerebral ischemic events while waiting for CAS are not well defined. Method: We analyzed patients admitted to our institution over a 45-month period with symptomatic cervical ICA stenosis. All patients were initiated on daily aspirin and clopidogrel 75mg on the day of admission. We identified any new cerebral ischemic events that occurred between index event and CAS and categorized them as TIA, and minor or major ischemic strokes. We calculated the risk of new ipsilateral cerebral ischemic events between index ischemic event and CAS. Results: The mean age of 150 patients analyzed was 67 years (range: 46-94 years; 106 were men); and 94 and 56 patients had ≥ 70% and 50-69% stenosis, respectively. The mean and median time intervals between index event and CAS performance were 25 and 6 days, respectively. A total of 6 new cerebral ischemic events (5 TIAs and 1 major stroke) were observed over 3,776 patient days of observation. The risk of new ipsilateral cerebral ischemic events between index ischemic event and CAS performance was 1.6 per 1000 patient days of observation. Conclucion: We identified a low risk of new ipsilateral cerebral ischemic events in patients with ≥ 50% ICA stenosis while waiting for CAS presumably due to early initiation of dual antiplatelets.

Clopidogrel bolus is an option used before carotid artery stent (CAS) placement when sustained clopidogrel pretreatment is not used.To compare the effect of clopidogrel bolus (450 mg administered ≥4 hours) with sustained clopidogrel pretreatment (48 hours or greater) before CAS among patients recruited in the Carotid Revascularization Endarterectomy versus Stenting Trial.We compared the rates of primary end point (either any stroke, myocardial infarction, or death during the periprocedural period or any ipsilateral stroke within 4 years) between patients who received clopidogrel bolus and those who received sustained clopidogrel pretreatment using Cox proportional hazards analysis after adjusting for age, sex, symptomatic status, and initial severity of stenosis (≥70% vs70%) over 4 years.The rate of periprocedural stroke (7.3% vs 3.4%, P = .03) and primary end point (11.3% vs 5.9%, P = .02) was significantly higher among patients who received clopidogrel bolus. The risk of primary end point was significantly higher in patients who received clopidogrel bolus (hazards ratio 1.9, 95% CI 1.1-3.4, P = .02) after adjusting for potential confounders. The overall mean (±standard deviation) primary end point-free survival based on Kaplan-Meier analysis was 7.0 ± 0.2 years for patients who received clopidogrel bolus and 8.9 ± 0.1 years for those who received sustained clopidogrel pretreatment (log-rank test P = .011).Clopidogrel bolus was associated with higher rates of adverse outcomes compared with sustained clopidogrel pretreatment in patients who underwent CAS. Therefore, clopidogrel bolus may not be equivalent to sustained clopidogrel pretreatment.

Background and purpose We report the results of intra-arterial injection of lidocaine in the middle meningeal artery in patients with intractable headache or status migrainosus. Methods We treated four patients with intra-arterial lidocaine (2 mg/ml) in doses up to 50 mg in each middle meningeal artery via a microcatheter bilaterally (except in one patient). In two patients with intractable headache, the daily maximum intensity of headache (graded by 11-point numeric rating scale) was recorded for 7 days postprocedure. In two patients with status migrainosus, migraine-related disability 3 months prior and after treatment using MIDAS (Migraine Disability Assessment) questionnaire was recorded. Results Intra-arterial lidocaine reduced the headache intensity from 8/10 and 10/10 to 0/10 in the two patients with intractable headaches for 2 days (day 0 and day 1) postprocedure. Despite recurrence of headache on day 2, the intensity was less than preprocedure intensity up to the last day recorded (by 3 and 2 points on day 7). In the two patients with status migrainosus, there was immediate reduction in headache intensity following intra-arterial lidocaine. The post treatment 3-month MIDAS score was lower in both patients compared with pretreatment 3-month score; 3 versus 30 and 55 versus 90. Severe disability preprocedure by MIDAS was reduced to little or no disability postprocedure in one patient. Conclusions Intra-arterial lidocaine resulted in amelioration of headache in patients with intractable headache and those with status migrainosus with improvement lasting longer than the short half-life of lidocaine possibly related to central desensitization.

BackgroundRandomized clinical trials have failed to prove that the safety and efficacy of endovascular treatment for symptomatic intracranial atherosclerotic disease (ICAD) is better than that of medical management. A recent study using a self-expandable stent showed acceptable lower rates of periprocedural complications.ObjectiveTo study the safety and efficacy of a balloon-mounted stent (BMS) in the treatment of symptomatic ICAD.MethodsProspectively maintained databases from 15 neuroendovascular centers between 2010 and 2020 were reviewed. Patients were included if they had severe symptomatic intracranial stenosis in the target artery, medical management had failed, and they underwent intracranial stenting with BMS after 24 hours of the qualifying event. The primary outcome was the occurrence of stroke and mortality within 72 hours after the procedure. Secondary outcomes were the occurrence of stroke, transient ischemic attacks (TIAs), and mortality on long-term follow-up.ResultsA total of 232 patients were eligible for the analysis (mean age 62.8 years, 34.1% female). The intracranial stenotic lesions were located in the anterior circulation in 135 (58.2%) cases. Recurrent stroke was the qualifying event in 165 (71.1%) while recurrent TIA was identified in 67 (28.9%) cases. The median (IQR) time from the qualifying event to stenting was 5 (2–20.75) days. Strokes were reported in 13 (5.6%) patients within 72 hours of the procedure; 9 (3.9%) ischemic and 4 (1.7%) hemorrhagic, and mortality in 2 (0.9%) cases. Among 189 patients with median follow-up time 6 (3–14.5) months, 12 (6.3%) had TIA and 7 (3.7%) had strokes. Three patients (1.6%) died from causes not related to stroke.ConclusionOur study has shown that BMS may be a safe and effective treatment for medically refractory symptomatic ICAD. Additional prospective randomized clinical trials are warranted.

Pulsatile tinnitus occurs due to turbulent blood flow through a stenotic vessel including the internal carotid artery. The presence of sensorineural hearing loss suggests involvement of the posterior circulation vasculature.A 58-year-old woman presented to the ear, nose and throat clinic with acute onset of right ear pulsations and high-pitched tinnitus. An audiogram demonstrated mild sensorineural hearing loss in the right ear. Her computed tomography angiogram revealed moderate stenosis of the right internal carotid artery and she underwent revascularization with angioplasty and stent placement. A repeat audiogram demonstrated improvement in sensorineural hearing loss in the right.Pulsatile tinnitus and unilateral sensorineural hearing loss maybe a reversible manifestation of a stenotic internal carotid artery.

Background We performed this meta-analysis of randomized clinical trials to compare the outcomes in patients treated with endovascular thrombectomy who receive prior intravenous thrombolysis with those who do not receive such treatment. Recently, one randomized trial reported outcomes to address this issue, so timely update of meta-analysis is needed to determine the value of administering intravenous thrombolysis before endovascular thrombectomy. Materials and methods Four randomized clinical trials are included in our meta-analysis. We calculated pooled odds ratios and 95% CIs using random-effects models. The primary efficacy endpoint was a favorable outcome defined by a modified Rankin Scale score of 0 (no symptoms), 1 (no significant disability), or 2 (slight disability) at 90 days post-randomization. Secondary endpoints analyzed were any intracerebral hemorrhage, symptomatic intracerebral hemorrhage, and mortality. Results Of the 1633 patients randomized, the proportion of patients who achieved a favorable outcome was similar between endovascular thrombectomy alone and combined approach with intravenous thrombolysis and endovascular thrombectomy (1631 patients analyzed; odds ratio 1.02; CI 0.84–1.25; p = 0.83). Risk of any intracerebral hemorrhage was significantly lower among those randomized to endovascular thrombectomy alone (1633 patients analyzed; odds ratio 0.75; CI 0.57–0.99; p = 0.04). Rates of symptomatic intracerebral hemorrhage (p = 0.36) and mortality (p = 0.62) were not significantly different between the two groups. Conclusions Compared with endovascular thrombectomy preceded by intravenous thrombolysis, endovascular thrombectomy resulted in similar rates of favorable outcome with a lower rate of intracerebral hemorrhage. A large phase 3 trial is required to conclusively demonstrate equivalency of both approaches to guide future practice.

Background and Purpose: Acute ischemic stroke may occur in patients with coronavirus disease 2019 (COVID-19), but risk factors, in-hospital events, and outcomes are not well studied in large cohorts. We identified risk factors, comorbidities, and outcomes in patients with COVID-19 with or without acute ischemic stroke and compared with patients without COVID-19 and acute ischemic stroke. Methods: We analyzed the data from 54 health care facilities using the Cerner deidentified COVID-19 dataset. The dataset included patients with an emergency department or inpatient encounter with discharge diagnoses codes that could be associated to suspicion of or exposure to COVID-19 or confirmed COVID-19. Results: A total of 103 (1.3%) patients developed acute ischemic stroke among 8163 patients with COVID-19. Among all patients with COVID-19, the proportion of patients with hypertension, diabetes, hyperlipidemia, atrial fibrillation, and congestive heart failure was significantly higher among those with acute ischemic stroke. Acute ischemic stroke was associated with discharge to destination other than home or death (relative risk, 2.1 [95% CI, 1.6–2.4]; P P =0.03) after adjusting for potential confounders. Conclusions: Acute ischemic stroke was infrequent in patients with COVID-19 and usually occurs in the presence of other cardiovascular risk factors. The risk of discharge to destination other than home or death increased 2-fold with occurrence of acute ischemic stroke in patients with COVID-19.

Although many stroke centers in United States are using intravenous (IV) tenecteplase (TNK) for acute ischemic stroke patients, there is paucity of comparative data between IV TNK and IV alteplase from real-world settings.We analyzed the data from 122 healthcare facilities in Cerner Real World Data and included patients admitted between February 2016 to April 2022 to determine the effect of IV TNK (compared with IV alteplase) on occurrence of two outcomes in acute ischemic stroke patients stratified by use of thrombectomy: non-routine discharge or death, and intracranial hemorrhage after adjusting for potential confounders.Among 30,643 acute ischemic stroke patients analyzed, 29,480 (96.2%) and 1,163 (3.8%) patients received IV alteplase and IV TNK, respectively. The proportion of patients who received thrombectomy was significantly higher among patients who received IV TNK compared with those who received IV alteplase (16.7% versus 11.0%, p0.001). Occurrence of intracranial hemorrhage was more common among patients treated with IV TNK in acute ischemic stroke patients who did not receive thrombectomy (7.9% versus 5.1%, p0.001) but not in those who received thrombectomy (20.1% versus 16.8%, p = 0.234). In the logistic regression analysis, patients treated with IV TNK who did not receive thrombectomy were at higher risk of intracranial hemorrhage (OR, 1.34, 95% CI 1.05-1.72, p = 0.02) after adjusting for age (age strata), gender, race/ethnicity, hypertension, diabetes mellitus, atrial fibrillation, hyperlipidemia, malignancy, nicotine dependence, previous ischemic stroke, previous transient ischemic attack, previous intracerebral hemorrhage, previous subarachnoid hemorrhage, previous acute myocardial infarction, atherosclerosis of aorta, previous AKI, congestive heart failure, peripheral vascular disease, and hospital type, aphasia, hemiplegia, neglect, somnolence, stupor and coma, dysphagia, and homonymous hemianopsia. There was no difference in the rate of non-routine discharge or death between patients treated with IV TNK and those treated with IV alteplase in the multivariate analyses.In an analysis of real-world data, IV TNK was associated with higher rates of intracranial hemorrhage compared with IV alteplase in patients with acute ischemic stroke who did not undergo thrombectomy.

Background Spinal arachnoid webs are a rare anatomic entity manifesting as neuropathic back pain, compressive myelopathy, radiculopathy and hydrocephalus. Typical treatments include hemi or full laminectomy with durotomy and microsurgical resection which can result in secondary scarring, and recurrent blockage of cerebrospinal fluid flow perpetuating the cycle. Case Description A 66-year-old woman presented with progressively worsening gait and memory. Magnetic resonance imaging (MRI) demonstrated an arachnoid web in the high thoracic region, causing cerebrospinal fluid flow obstruction and hydrocephalus. A standard lumbar drainage catheter was introduced percutaneously into the lumbar thecal sac, and advanced in a cephalad direction, across the arachnoid web, to the high thoracic region. The patient underwent continuous cerebrospinal fluid drainage through this catheter for a total of three days, displaying measurable clinical improvement that persisted at the three months follow up visit. Phase-contrast MRI demonstrated interval reconstitution of dorsal synchronous cerebrospinal fluid flow at the 2nd thoracic vertebral level, both on day three, as well as at the three months control imaging study. Conclusion This minimally invasive approach seems useful in achieving restoration of spinal fluid flow at the thoracic region when the underlying blockage results from an arachnoid web and leads to quantifiable clinical improvement.

Objectives: Acute ischemic stroke patients with severe acute respiratory syndrome coronavirus maybe candidates for acute revascularization treatments (intravenous thrombolysis and/or mechanical thrombectomy). Materials and Methods: We analyzed the data from 62 healthcare facilities to determine the odds of receiving acute revascularization treatments in severe acute respiratory syndrome coronavirus infected patients and odds of composite of death and non-routine discharge with severe acute respiratory syndrome coronavirus infected and non-infected patients undergoing acute revascularization treatments after adjusting for potential confounders. Results: Acute ischemic stroke patients with severe acute respiratory syndrome coronavirus infection were significantly less likely to receive acute revascularization treatments (odds ratio 0.6, 95% confidence interval 0.5-0.8, p=0.0001). Among ischemic stroke patients who received acute revascularization treatments, severe acute respiratory syndrome coronavirus infection was associated with increased odds of death or non-routine discharge (odds ratio 3.0, 95% confidence interval 1.8-5.1). The higher odds death or non-routine discharge (odds ratio 2.1, 95% confidence interval 1.9-2.3) with severe acute respiratory syndrome coronavirus infection were observed in all ischemic stroke patients without any modifying effect of acute revascularization treatments (interaction term for death (p=0.9) or death or non-routine discharge (p=0.2). Conclusions: Patients with acute ischemic stroke patients with severe acute respiratory syndrome coronavirus infection were significantly less likely to receive acute revascularization treatments. Severe acute respiratory syndrome coronavirus infection was associated with a significantly higher rate of death or non-routine discharge among acute ischemic stroke patients receiving revascularization treatments.

Objective: To investigate the effect of early hyperchloremia on 90-day outcomes in acute ischemic stroke Methods: We analyzed data from Albumin in Acute Ischemic Stroke (ALIAS) Part 1 and 2 trials which recruited patients with acute ischemic stroke within 5 hours of onset. Patients with hyperchloremia (defined as 110 mmol/L or greater) at baseline, 24, or 48 hours after randomization were identified. We trichotomized patients into 3 groups; no instances, one instance, and two or more instances of measured hyperchloremia within the first 48 hours. Serum creatinine levels at baseline, 24, and 48 hours were used to identify acute kidney injury (AKI) via the Acute Kidney Injury Network (AKIN) classification. Logistic regressions were performed to determine the effects of hyperchloremia on outcomes defined by modified Rankin scales or National Institutes of Health Stroke Scale scores at 90 days and mortality at 90 days. Results: Among the total of 1275 patients analyzed, zero, one and two or more occurrence of hyperchloremia within 48 hours were observed in 976, 191 and 108 patients respectively. Compared with patients without hyperchloremia, patients with two or more occurrences of hyperchloremia at significantly higher odds of non-favorable outcomes within 90 days after adjustment for age, NIHSS score, initial systolic blood pressure, and ALIAS treatment group (albumin or placebo) (OR 3.0, 95%, CI 1.8-5.0). Patients with two or more occurrences of hyperchloremia also presented higher odds of death within 90 days vs the non-hyperchloremia group. Patients with one occurrence of hyperchloremia were not at higher odds for non-favorable outcomes at 90 days. There was no association between occurrence of two or more occurrence of hyperchloremia and AKI (OR 0.8, 95% CI 0.3-1.9). Conclusions: The independent association between sustained hyperchloremia and non-favorable outcomes at 90 days suggest that avoidance of hyperchloremia may increase the rate of favorable outcomes in patients with acute ischemic stroke.

Background and Purpose: Intracerebral hemorrhage can occur in acute ischemic stroke patients receiving alteplase (recombinant tissue plasminogen activator). Antifibrinolytic medications such as the synthetic lysine analogs tranexamic acid and ε;-aminocaproic acid that inhibit fibrinolysis by attaching to the lysine-binding site of the plasminogen molecule have been utilized. However, the efficacy of antifibrinolytic medication in prevention of hematoma expansion is not known. Methods: We analyzed the effect of antifibrinolytic medication in acute ischemic stroke patients with intracerebral hemorrhage associated with Alteplase from 2012 to 2017. The Region-of-Interest method on a Horos Open Source Medical Image Viewer (Version 3.3.6) was utilized for volume measurement. We compared the change in hemorrhage volume in patients who did and did not receive antifibrinolytic medication. Results: A total of 36 patients (mean age 72.7±11.5, 56% were men) who received intravenous alteplase with subsequent intracerebral hemorrhage were identified. Fourteen patients received antifibrinolytic treatment; five patients had reduction or stabilization in hematoma volume (overall pre-treatment volume 13.87±15.74 cm 3 and post-treatment volume 16.74±29.67 cm 3 ). Mean fibrinogen level in the antifibrinolytic medication group was 297 mg/dL; two patients had levels < 200 mg/dL. In the cohort of patients did not receive antifibrinolytics, 15 out of 22 patients had reduction or stabilization in hematoma volume (overall pre-treatment volume 19.25±33.33 cm 3 and post-treatment volume 17.41±26.56 cm 3 ). Mean volume difference in the group that received antifibrinolytic medication was 36% and 9% in the group that did not receive antifibrinolytic medication. [Figure 1] Conclusion: We did not identify any advantage of antifibrinolytic treatment in reduction or stabilization in hematoma volume in patients with Alteplase-associated intracerebral hemorrhages.

Background: Clopidogrel bolus is an option used prior to carotid artery stent placement (CAS) when sustained clopidogrel pre-treatment is not used. Objective: To compare the effect of clopidogrel bolus (450 mg administered ≥4 hours) with sustained clopidogrel pre-treatment (48 hours or greater) prior to CAS in patients prospectively followed over 10 years in Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Methods: The rates of primary endpoint (composite of any stroke, myocardial infarction (MI), or death during the periprocedural period or ipsilateral stroke within 4 years after randomization) were compared between patients who received clopidogrel bolus with those who received sustained clopidogrel pre-treatment after adjusting for age, gender, symptomatic status and initial severity of stenosis (≥70% versus Results: The rate of periprocedural stroke (7.3% versus 3.4%, p=0.03) and primary end point (11.3% versus 5.9%, p=0.02) was significantly higher among patients who received clopidogrel bolus. The risk of primary end point was significantly higher in patients who received clopidogrel bolus (hazards ratio [HR] 1.9, 95% confidence interval [CI] 1.1-3.4, p=0.02) after adjusting for potential confounders. The overall mean (± SD) primary end point free survival based on Kaplan-Meier analysis was 7.0±0.2 years for patients who received clopidogrel bolus and 8.9±0.1 years for those who received sustained clopidogrel pre-treatment (log-rank test P=0.011). Conclusion: Clopidogrel bolus was associated with higher rates of adverse outcomes compared with sustained clopidogrel pre-treatment in patients who underwent CAS. Therefore, clopidogrel bolus may not be equivalent to sustained clopidogrel pre-treatment.

Context: Transradial access has been increasingly utilized for neurointerventional procedures including carotid angioplasty and stent placement (CAS) over the past decade. At our center, we adopted transradial approach as the preferred approach in 2020. Objective: To compare the results of transradial approach with transfemoral approach for CAS as part of a quality assurance initiative. Methods: We analyzed data collected for all non-urgent CAS procedures performed at our institute in the last 24 months by same interventionalists to minimize inter-operator variability. We looked at the rates of technical failure; hemorrhagic complications classified as major (hemoglobin decrease >5 g/dL or intracranial hemorrhage with deficits), minor (hemoglobin decreases 3-5 g/dL or intracranial hemorrhage without residual deficits), or insignificant; and any stroke and/or death within 1-month post procedure. Results: A total of 182 non-urgent CAS procedures were performed at our institution; 116 (64%) were initiated using transfemoral approach and 66 (36%) were initiated using transradial approach. The median age was similar between the two group (66.5 years versus 66.7 years). There were 6 (3%) CAS procedures initiated using transradial approach but later converted to transfemoral due to anatomical and/or technical difficulties. One (0.6%) CAS procedure initiated using transfemoral approach was converted to transradial approach due to severe iliofemoral atherosclerosis. The rates of any stroke and/or death were 1.6% (n=1) and 3.3%% (n-=4) in patients undergoing CAS using transradial and transfemoral approaches, respectively. The rate of major hemorrhagic complications were 1.6% (n=1) and 5.7% (n-=7) in patients undergoing CAS using transradial and transfemoral approaches, respectively. Conclusions: The rates of major hemorrhagic complications were lower among patients who underwent CAS via transradial approach compared with CAS using transfemoral approach although the rates of technical failure remain relatively high with transradial approach.

Background: Undiagnosed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may be seen in acute stroke patients. Rapid screening is important to reduce exposure to medical professionals and other patients during acute assessment and treatment. Chest computed tomographic (CT) scan may be another time-sensitive option for identification of SARS-CoV-2 infection in acute stroke patients. Objective: We report our experience of incorporating chest CT scan in the initial neuroimaging protocol for evaluation of acute stroke patients. Methods: All acute stroke patients underwent chest CT scan concurrent to CT head, CT angiogram of head and neck and CT perfusion for 10 months. We identified patients who had chest CT scan findings that were suggestive of SARS-CoV-2 infection including bilateral, multilobar ground glass opacification with a peripheral or posterior distribution, and/or consolidation. All patients subsequently underwent polymerase chain reaction (PCR) testing using nasopharyngeal specimen for identification of SARS-CoV-2 with contact isolation. Sensitivity, specificity, and likelihood ratios were calculated. Results: A total of 530 consecutive acute stroke patients (mean age in years 65.6± SD; 15.4; 280 were men) underwent neuroimaging with concurrent chest CT scan. The chest CT scan identified findings suggestive of SARS-CoV-2 infection in 34 (6.4%) patients. Subsequent PCR testing confirmed the diagnosis of SARS-CoV-2 infection in 21 of 34 patients. Among 491 patients in whom chest CT scan did not identify any findings suggestive of SARS-CoV-2 infection, 387 underwent PCR tests; PCR testing confirmed the diagnosis of SARS-CoV-2 infection in 13 of 34 patients. Sensitivity and specificity of chest CT scan for detecting SARS-CoV-2 infection was 61.9% and 96.2%, respectively. Positive and negative likelihood ratio of chest CT scan for detecting SARS-CoV-2 infection is 16.26 and 0.39, respectively. Conclusions: Although specificity was high, the relatively low sensitivity of chest CT scan in identifying SARS-CoV-2 infection limits the value of adding this imaging to standard neuroimaging in acute stroke patients. At our institution, we have subsequently discontinued the protocol.

Context: Current guidelines recommend bed rest for 24 hours after receiving intravenous alteplase which may not be necessary and delay rehabilitation in a large proportion of acute ischemic stroke patients. Objective: To determine the feasibility of “early mobilization protocol” within the intensive care unit (ICU) in patients with acute ischemic stroke who received intravenous alteplase. Methods: All consecutive patients were admitted to the ICU with an acute ischemic stroke who received intravenous alteplase from October 2019-June 2021 were considered for “early mobilization protocol”. Patients≥18 years of age with minor, moderate or severe ischemic stroke (NIHSS score ≤22) were eligible and mobilization was initiated within 13-24 hours after intravenous alteplase administration. Exclusion criteria included hemodynamic instability, on mechanical ventilation, unstable neurological examination or progressive symptoms, or presence of external ventricular drain for hemorrhagic transformation within 24 hours of intravenous alteplase. Results: A total of 137 patients (56.8%) patients were eligible among 241 patients who were admitted to our institution with acute ischemic stroke after receiving intravenous alteplase. Mean age (±SD) was 63.4±16.6 and 66.2±17.0 years for the patients included and excluded in the early mobilization protocol, respectively. The mean NIHSS score (±SD) at baseline was 5.3±4.4 and 9.9±7.3 for the patients included and excluded in the early mobilization protocol, respectively. Early mobilization protocol was initiated at 18.3±3.6 hours in eligible patients compared with routine mobilization initiated at 41.6±19.8 hours in excluded patients (p Conclusion: Early mobilization protocol in patients post intravenous alteplase treatment can be initiated in the ICU in appropriately selected patients without any adverse effects on neurological and functional outcomes.

Background and Purpose: Hyperglycemia has been associated with higher rates of death or disability in acute ischemic stroke patients undergoing endovascular treatment. However, it remains unclear whether intensive serum glucose reduction can reduce the rates of death or disability in patients undergoing endovascular treatment. Methods: We analyzed the effect of intensive (serum glucose Results: A total of 146 patients (mean age 68.1±13.9, 50.7% were men) underwent endovascular treatment for acute ischemic stroke; 72 and 74 patients were randomized to intensive and standard treatments, respectively. The rates of death (20.3%, and 22.2%), favorable 90-day primary outcome (17.6% and 19.4%), and serious adverse events (41.9% and 56.98%) were similar between the two groups. The area under the curve of serum glucose was not associated with death within 90 days (OR 1, 95% CI 1-1) or favorable outcome at 90 days (OR 1, 95% CI 1-1). Glucose variability was not associated with death or favorable outcome at 90 days. Intensive treatment was not associated with cerebral hemorrhagic events. Conclusion: We did not identify any beneficial effect of intensive glucose reduction on rates of death or favorable outcomes at 90 days among acute ischemic stroke patients undergoing endovascular treatment. We also did not observe any relationship between various glycemic parameters and death or favorable outcomes at 90 days.

Based on the relationship between hyperchloremia and mortality in critically ill patients, we investigated the effect of early hyperchloremia on 90-day outcomes in acute ischemic stroke patients.Acute ischemic stroke patients recruited within 5 h of symptom onset were analyzed. Hyperchloremia (defined as 110 mmol/L or greater) at either baseline, or 24, or 48 h after randomization was identified and classified as one occurrence or two or more occurrences. Logistic regression analyses were performed to determine the effects of hyperchloremia on: favorable outcomes (defined by a National Institutes of Health Stroke Scale and/or modified Rankin scale scores of 0-1) at 90-day, death or disability at 90-day, and death within 90-day after accounting for potential confounders.Among the total of 1275 patients, one and two or more occurrence of hyperchloremia within 48 h were seen in 191 patients and 108 patients, respectively. Compared with patients without hyperchloremia, patients with two or more occurrences of hyperchloremia at significantly higher odds of lack of favorable outcomes (odds ratio 3.0, 95% confidence interval 1.8-5.1) and death or disability (odds ratio 2.6, 95% confidence interval 1.6-4.1) at 90-day after adjustment for age, National Institutes of Health Stroke Scale score strata (6-9, 10-19, ≥ 20), study intervention, initial SBP, and intra-arterial treatment.The independent association between sustained hyperchloremia and lack of favorable outcomes at 90-day suggest that avoidance of hyperchloremia may reduce the rate of lack of favorable outcomes and death or disability in patients with acute ischemic stroke.

Background and purpose Due to higher rates of 1-month stroke and death with Wingspan intracranial stent placement observed in SAMMPRIS, the Food and Drug Administration (FDA) announced a more limited indication for Wingspan stent. Methods We compared the results of intracranial stent placement with best medical treatment in patients recruited in SAMMPRIS who met the new "on label" criteria with those who were categorized as "off label." The primary endpoint was any stroke or death occurring within 30 days of enrollment, or an ischemic stroke in the territory of the symptomatic intracranial artery from day 31 after study entry to completion of follow-up. Results A total of 31 (7%) among 451 recruited patients met the "on label" criteria. The relative risk of primary endpoint was lower in "on label" patients treated with stent placement compared with best medical treatment (relative risk .61, 95% confidence interval .2-1.7) but higher in "off label" patients (relative risk 1.81, 95% confidence interval 1.2-2.6). Primary endpoint was seen in 20% and 23.4% of patients treated with stent placement in "on label" and "off label" patients, respectively. Primary endpoint was seen in 25% and 14.2% of patients treated with best medical treatment in "on label" and "off label" patients, respectively. Conclusion The new FDA "on label" criteria may identify a small group of people, who may benefit from intracranial stent placement due to higher risk of primary endpoint in those treated with best medical treatment.

Background and purpose Drug-eluting balloons (DEBs) have been proposed as an option for the treatment of in-stent restenosis (ISR) following carotid artery stent placement. We report our experience and review of literature to provide additional data. Methods For literature review, PubMed search was conducted to identify studies published between 2005 and 2019, reporting data on management of carotid ISR with DEBs. Two cases with carotid ISR, which were successfully treated with DEB at our facility, were also included in the final compilation of results RESULTS: A total of seven studies demonstrating the use of the DEBs for treatment of carotid ISR were identified. They encompassed 31 patients, 11 (35.5%) of whom presented with symptomatic ISR, with the remaining 20 patients (64.5%) asymptomatic. DEB angioplasty followed by stent placement was performed in 3 patients, whereas DEB alone was utilized in 28 patients. Periprocedural complications included asymptomatic dissection from DEB inflation in 1 patient and transient neurological deficits in another patient. Follow-up period was variable and ranged from 1 month to 5 years. Three patients were noted to develop recurrent asymptomatic stenosis, whereas 1 patient developed an episode of symptomatic restenosis post procedural on follow-up. In our two cases, both patients were noted to have protracted period of hypotension postprocedure without any new or recurrent neurological symptoms. Conclusion The use of DEBs is a promising development and a viable alternative for management of severe and recurrent carotid ISR.

Dysphagia after acute ischemic stroke is frequent and increases the risk of pneumonia, insertion of feeding tube, hospital length-of-stay and rates of discharge to institutional care. However, the financial impact of dysphagia after acute ischemic stroke is not well understood.Estimates were derived from published medical and economic literature to provide a range of estimates for the annual direct hospital cost of dysphagia associated with acute ischemic stroke in the United States. We also estimated the cost savings associated with a hypothetical new therapeutic intervention under a variety of assumptions.The 1-year costs per patient of acute hospital and post hospitalization care were $67,100 to $112,400 in acute ischemic stroke patient with dysphagia and $54,0310 to $51,979.8 in acute ischemic stroke patient without dysphagia in the two models. The estimated incremental cost in United States for ischemic stroke patients with dysphagia was $ 4,610,038,961.13 (95% confidence interval [CI] $3,796,502,674-$5,423,575,248) according to assumptions of Model 1. The estimated incremental cost in United States for ischemic stroke patients with dysphagia was $ 20,114,218,586.23 (95% CI $16564650600.42-$23663786572.04) according to assumptions of Model 2. The cost savings per year with a new therapeutic intervention ranged from $509,444,886.6 to $3,601,651,036 depending upon the magnitude of benefit.Our analysis provides additional justification using financial basis for a much larger investment in research and development for treatment of dysphagia associated with ischemic stroke.

Supplemental Digital Content is available in the text., Background: To determine the exposure risk for coronavirus 2019 (COVID-19) during neurology practice. Neurological manifestations of COVID-19 are increasingly being recognized mandating high level of participation by neurologists. Methods: An American Academy of Neurology survey inquiring about various aspects of COVID-19 exposure was sent to a random sample of 800 active American Academy of Neurology members who work in the United States. Use of second tier protection (1 or more including sterile gloves, surgical gown, protective goggles/face shield but not N95 mask) or maximum protection (N95 mask in addition to second tier protection) during clinical encounter with suspected/confirmed COVID-19 patients was inquired. Results: Of the 81 respondents, 38% indicated exposure to COVID-19 at work, 1% at home, and none outside of work/home. Of the 28 respondents who did experience at least 1 symptom of COVID-19, tiredness (32%) or diarrhea (8%) were reported. One respondent tested positive out of 12 (17%) of respondents who were tested for COVID-19 within the last 2 weeks. One respondent received health care at an emergency department/urgent care or was hospitalized related to COVID-19. When seeing patients, maximum protection personal protective equipment was used either always or most of the times by 16% of respondents in outpatient setting and 56% of respondents in inpatient settings, respectively. Conclusions: The data could enhance our knowledge of the factors that contribute to COVID-19 exposure during neurology practice in United States, and inform education and advocacy efforts to neurology providers, trainees, and patients in this unprecedented pandemic.

Objectives Acute ischemic stroke patients with severe acute respiratory syndrome coronavirus maybe candidates for acute revascularization treatments (intravenous thrombolysis and/or mechanical thrombectomy). Materials and Methods We analyzed the data from 62 healthcare facilities to determine the odds of receiving acute revascularization treatments in severe acute respiratory syndrome coronavirus infected patients and determined the odds of composite of death and non-routine discharge with severe acute respiratory syndrome coronavirus infected and non-infected patients undergoing acute revascularization treatments after adjusting for potential confounders. Results Acute ischemic stroke patients with severe acute respiratory syndrome coronavirus infection were significantly less likely to receive acute revascularization treatments (odds ratio 0.6, 95% confidence interval 0.5–0.8, p = 0.0001). Among ischemic stroke patients who received acute revascularization treatments, severe acute respiratory syndrome coronavirus infection was associated with increased odds of death or non-routine discharge (odds ratio 3.0, 95% confidence interval 1.8–5.1). The higher odds death or non-routine discharge (odds ratio 2.1, 95% confidence interval 1.9–2.3) with severe acute respiratory syndrome coronavirus infection were observed in all ischemic stroke patients without any modifying effect of acute revascularization treatments (interaction term for death (p = 0.9) or death or non-routine discharge (p = 0.2). Conclusions Patients with acute ischemic stroke with severe acute respiratory syndrome coronavirus infection were significantly less likely to receive acute revascularization treatments. Severe acute respiratory syndrome coronavirus infection was associated with a significantly higher rate of death or non-routine discharge among acute ischemic stroke patients receiving revascularization treatments.

OBJECTIVE Middle meningeal artery embolization (MMAE) is an increasingly utilized approach for the treatment of chronic subdural hematomas (CSDHs). The course of morphological progression of CSDHs following MMAE is poorly understood. Herein, the authors aimed to describe these morphological changes and assess their prognostic significance for the outcomes on follow-up. METHODS A single-institution retrospective cohort study of CSDH cases treated by upfront MMAE, without prior or adjunctive surgical evacuation, was performed. Clinical outcomes, complications, and the need for rescue surgery on follow-up were recorded. Hematomas were categorized into 6 morphological subtypes. All baseline and follow-up head CT scans were assessed for CSDH structural appearance, density, and loculation. Changes in CSDH size were quantified via 3D reconstruction for volumetric measurement. RESULTS Overall, 52 CSDHs in 45 patients treated with upfront MMAE were identified. Hematomas were followed for a mean of 92.9 days. Volume decreased by ≥ 50% in 79.6% of the CSDHs. The overall rescue surgery rate was 9.6%. A sequence of morphological changes after MMAE was identified. Hematomas that diverged from this sequence (5.4%) all progressed toward treatment failure and required rescue surgery. The CSDHs were categorized into early, intermediate, and late stages based on the baseline morphological appearance. Progression from early to intermediate and then to late stage took 12.7 and 30.0 days, respectively, on average. The volume of early/intermediate- and late-stage hematomas decreased by ≥ 50%, a mean of 78.2 and 47.6 days after MMAE, respectively. Early- and intermediate-stage hematomas showed a trend toward more favorable outcomes compared with late-stage hematomas. The density of homogeneous hypodense hematomas (HSDHs) transiently increased immediately after MMAE (p < 0.001). A marked decrease in density and volume 1 to 3 weeks after MMAE in HSDHs was detected, the lack of which indicated an eventual need for rescue surgery. In HSDHs, a baseline mean density of < 20 HU, and a lower density than baseline by 1 month post-MMAE were predictors of favorable outcomes. The baseline hematoma volume, axial thickness, midline shift, and loculation were not correlated with MMAE outcomes. Loculated, trabecular, and laminar hematomas, which are known to have unfavorable surgical outcomes, had MMAE outcomes similar to those of other "surgical" hematomas. CONCLUSIONS The current study was the first to describe the nature, sequence, and timing of morphological changes of CSDHs after MMAE treatment and has identified structural features that can predict treatment outcomes.

To identify rates of and factors associated with repeat revascularization in a large cohort of patients prospectively followed over 10 years in Carotid Revascularization Endarterectomy versus Stenting Trial.We compared the effect of carotid angioplasty and stenting (CAS) versus carotid endarterectomy (CEA) on risk of repeat revascularization after adjusting for age, sex, symptomatic status, and initial severity of stenosis (≥70% vs.70%) using Cox proportional hazards analysis. We used Kaplan-Meier analysis to assess repeat revascularization-free survival for the overall cohort.Repeat revascularization was performed in 90 (3.9%, 95% confidence interval [CI] 3.1%-4.8%) of 2318 patients; 6 (6.7%, 95% CI 2.5%-14.0%) patients experienced the composite end point of any stroke, myocardial infarction, or death within 30 days after repeat revascularization. There was no difference in risk of repeat revascularization in patients who underwent CAS (compared with CEA) as the index procedure (hazard ratio 0.92, 95% CI 0.69-1.23, P = 0.5765). Patient's age (hazard ratio 1.01, 95% CI 1.01-1.02, P0.0001) was associated with performance of repeat revascularization. Mean ± SD repeat revascularization-free survival was 8.2 ± 0.1 years and 8.0 ± 0.1 years for CAS and CEA, respectively (log-rank test P = 0.0823).A low rate of repeat revascularization was seen without any significant difference among patients who underwent CEA or CAS over 10 years. The 6.7% rate of composite end point within 30 days after procedure highlights the need for standardizing the indications for repeat revascularization.