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Objective: Pre-existing brain atrophy may affect the outcomes of patients treated with mechanical thrombectomy (MT) for large-vessel-occlusion because it is an indicator of low brain reserve. We performed a systematic literature review to assess the impact of brain atrophy on MT-related clinical outcomes. Methods: We conducted a systematic search of PubMed, MEDLINE, EMBASE, and Cochrane Library databases from inception to March 2021 using keywords with Boolean operators(“brain atrophy”; “atrophy”; “white matter”; and “thrombectomy”). Articles published in English that evaluated the impact of pre-existing brain atrophy on outcomes of MT-treated acute ischemic stroke were eligible for inclusion. Results: Four articles were included. Brain atrophy index was a predictor of mortality (odds ratio [OR]:1.81–1.87, 95% confidence interval [CI]:1.16–2.93) after adjustments for age and white matter lesions. Global cortical atrophy scale was an independent predictor of futile recanalization (OR 1.15, 95% CI 1.08–1.22) in multivariate-adjusted logistic regression. Automated measurement of CSF identified increasing volumes associated with reduced 3-month functional independence and higher modified Rankin scale scores. STandards for ReportIng Vascular changes on Neuroimaging criteria for brain atrophy were associated with unfavorable outcome in ordinal-shift analysis (OR 2.72, 95% CI 1.25–5.91). Conclusions: The few studies available highlight heterogeneity of neuroimaging methodologies for assessing brain atrophy and difficulty addressing the multiple confounders involved in clinical outcomes. More consistent, accurate investigation is needed before proposing brain atrophy as a possible parameter to improve patient selection for MT. Advances in knowledge: Brain atrophy is associated with many of the clinical confounders frequently present in patients with acute ischemic stroke. Heterogeneity in classification methodologies for brain atrophy and complexity analyzing multiple clinical confounders make it difficult to assess the true impact of this radiological finding on MT-related outcomes.

Background The use of balloon guide catheters (BGCs) for proximal flow arrest during neurointerventional procedures has been limited owing to the incompatibility of BGCs with large-bore aspiration catheters and difficulty in device navigation. The objective of our study was to describe the use of the Walrus catheter (Q'Apel Medical, Fremont, California, USA), a new 8F BGC, with a variety of aspiration catheters and procedures requiring flow arrest. Methods Consecutive cases using Walrus BGCs for proximal flow arrest during mechanical thrombectomy for acute stroke cases were recorded. The procedure indication, vessel occlusion site, technique, first-pass effect (modified thrombolysis in cerebral infarction score of 2C or 3 after the first recanalization attempt), and complications were recorded and evaluated statistically. Results Our study included 57 patients who had undergone mechanical thrombectomy. In addition to mechanical thrombectomy, the Walrus BGC was used in conjunction with the following techniques: stent retrieval in 2 patients (3.5%), stent retrieval followed by aspiration (Solumbra technique) in 41 (71.9%), and aspiration followed by stent retrieval in 14 patients (24.6%). Eight different aspiration catheters were used in 56 of these 57 procedures. The first-pass effect (modified thrombolysis in cerebral infarction score of 2C and 3) was achieved in 36 (63.2%) of 57 procedures. Two patients (3.5%) had experienced intraoperative complications (symptomatic intracerebral hemorrhage) and one patient (1.8%) had died in-hospital. Conclusions Our results have demonstrated that the Walrus BGC is a highly navigable 8F guide catheter compatible with most available aspiration catheters. Owing to its compatibility with most available aspiration catheters and ease of use, the Walrus BGC is a valuable addition to the tools available for mechanical thrombectomy.

BackgroundThere are no reports that describe complete flow control using concurrent transient rapid ventricular pacing or intravenous (IV) adenosine and afferent arterial balloon flow arrest to aid transvenous embolization of cerebral arteriovenous malformations (AVM). We describe our experience with the use of this technique in patients undergoing transvenous AVM embolization.MethodsConsecutive patients in whom transvenous embolization was attempted at our institute between January 2017 and July 2019 were included. Anatomical AVM features, number of embolization stages, technique of concurrent transient rapid ventricular pacing and afferent arterial balloon flow arrest, complications, and clinical and radiological outcomes were recorded and tabulated.ResultsTransvenous AVM embolization was attempted in 12 patients but abandoned in two patients for technical reasons. Complete embolization was achieved in 10 patients, five of whom had infratentorial AVMs. All 10 had a single primary draining vein. Rapid ventricular pacing was used in nine cases; IV adenosine injection was used in one case to achieve cardiac standstill. Complete AVM nidus obliteration was achieved with excellent neurologic outcome in nine cases, with transvenous embolization alone in two cases, and with staged transarterial followed by transvenous embolization in the others. Two patients developed hemorrhagic complications intraprocedurally. One patient was managed conservatively and the other operatively with AVM excision and hematoma evacuation; both made an excellent recovery without any neurologic deficits at 3 months.ConclusionComplete flow control using concurrent transient rapid ventricular pacing with afferent arterial balloon flow arrest technique is safe and feasible for transvenous embolization of select AVMs.

Objectives To assess the immediate impact of prayer on physiological state by systematically reviewing objective, controlled experimental studies in the literature. Content Experimental studies measuring objective physiological changes induced by prayer. Studies containing the keyword, “Prayer” anywhere in the title or abstract were curated from the following databases: Public/Publisher Medline (PubMed), Excerpta Medica Database (EMBASE) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) in May 2019. Titles and abstracts were screened with the remaining 30 articles analyzed for inclusion. Only experimental studies were included. Summary Eight experimental studies were identified of which five investigated neurocognitive changes and three investigated systemic physiological changes during prayer. The five studies focusing on neuroactivity used functional MRI (fMRI), electroencephalography or SPECT imaging to obtain measurements. The remaining three studies analyzed an array of systemic physiological metrics, including blood pressure, heart rate, respiratory rate, peripheral resistance, baroreceptor sensitivity and/or cardiovascular rhythm variability during prayer. All studies aside from one saw objective changes during prayer. Neurocognitive changes were mainly associated with improved mental functioning, control and pain tolerance. Prayer was found to slow down physiological functions in two of the three vital-based studies, with the third reporting no change in physiological status. None of the studies measured blood marker changes. Outlook Experimental studies show prayer to induce healthy neurocognitive and physiological changes. Additional studies exploring objective measures from prayer are encouraged to provide practitioners with a more nuanced, scientific perspective when it comes to prescribing prayer as a complementary and alternative medicine (CAM) therapy.

BackgroundRadial access has become popular among neurointerventionalists because it has favorable risk profiles compared with femoral access. Difficulties in accessing or navigating the radial artery have been viewed as a reason to convert to femoral access, but ulnar artery access may prevent complications associated with transfemoral procedures.ObjectiveTo evaluate the safety and feasibility of ulnar access for neurointerventions and diagnostic neuroangiographic procedures.MethodsConsecutive patients who underwent diagnostic angiography or neurointerventional procedures via ulnar access between July 1, 2019 and April 15, 2020 were included. Data recorded were demographics, procedure indication, devices, technique, and complications. Descriptive analysis was performed.ResultsUlnar artery access was obtained for 21 procedures in 18 patients (mean age 70.3±7.8 years; nine men). Procedures included 13 diagnostic angiograms and eight neurointerventions (3 left middle meningeal artery embolization, 1 of which was aborted; 2 carotid artery stenting; 2 angioplasty; 1 mechanical thrombectomy for in-stent thrombosis). A right-sided approach with ultrasound guidance was used for all cases except one. Indications included small caliber radial artery (n=9), radial artery occlusion (n=10), and radial artery preservation for potential bypass (n=2). A 5-French slender sheath was used for diagnostic angiography; a 6-French slender sheath was used for neurointerventions. No case required conversion to femoral access. Two patients had minor hematomas after the procedure; one other had ulnar artery occlusion on 30-day ultrasonography.ConclusionUlnar access is safe and feasible for diagnostic and interventional neuroangiographic procedures. It provides a useful alternative to radial access, potentially avoiding complications associated with femoral access.

There is wide variation in the reported size of ruptured intracranial aneurysms and methods of size estimation. There is widespread belief that small aneurysms

Introduction: Genome-wide association studies (GWAS) have identified numerous stroke-associated SNPs. To understand how SNPs affect gene expression related to increased stroke risk, we studied epigenetic landscapes surrounding 26 common, validated stroke-associated loci. Methods: We mapped the SNPs to linkage disequilibrium (LD) blocks and examined H3K27ac, H3K4me1, H3K9ac, and H3K4me3 histone marks and transcription-factor binding-sites in pathologically relevant cell types (hematopoietic and vascular cells). Hi-C data were used to identify topologically associated domains (TADs) encompassing the LD blocks and overlapping genes. Results: Fibroblasts, smooth muscle, and endothelial cells showed significant enrichment for enhancer-associated marks within stroke-associated LD blocks. Genes within encompassing TADs reflected vessel homeostasis, cellular turnover, and enzymatic activity. Conclusions: Stroke-associated genetic variants confer risk predominantly through vascular cells rather than hematopoietic cell types.

This meeting abstract was removed due to the OA licensing requirements of this journal. The full abstract is listed here : https://www.svin.org/files/SVIN_2021_Abstracts_for_Web.pdf

This meeting abstract was removed due to the OA licensing requirements of this journal. The full abstract is listed here : https://www.svin.org/files/SVIN_2021_Abstracts_for_Web.pdf

Mechanical thrombectomy (MT) for large vessel acute ischemic stroke (AIS) has enabled biologic analyses of resected clots. While clot histology has been well-studied, little is known about gene expression within the tissue, which could shed light on stroke pathophysiology. In this methodological study, we develop a pipeline for obtaining useful RNA from AIS clots. A total of 73 clot samples retrieved by MT were collected and stored in RNALater and in 10% phosphate-buffered formalin. RNA was extracted from all samples using a modified Chemagen magnetic bead extraction protocol on the PerkinElmer Chemagic 360. RNA was interrogated by UV–Vis absorption and electrophoretic quality control analysis. All samples with sufficient volume underwent traditional qPCR analysis and samples with sufficient RNA quality were subjected to next-generation RNA sequencing on the Illumina NovaSeq platform. Whole blood RNA samples from three patients were used as controls, and H&amp, E-stained histological sections of the clots were used to assess clot cellular makeup. Isolated mRNA was eluted into a volume of 140 µL and had a concentration ranging from 0.01 ng/µL to 46 ng/µL. Most mRNA samples were partially degraded, with RNA integrity numbers ranging from 0 to 9.5. The majority of samples (71/73) underwent qPCR analysis, which showed linear relationships between the expression of three housekeeping genes (GAPDH, GPI, and HPRT1) across all samples. Of these, 48 samples were used for RNA sequencing, which had moderate quality based on MultiQC evaluation (on average, ~35 M reads were sequenced). Analysis of clot histology showed that more acellular samples yielded RNA of lower quantity and quality. We obtained useful mRNA from AIS clot samples stored in RNALater. qPCR analysis could be performed in almost all cases, while sequencing data could only be performed in approximately two-thirds of the samples. Acellular clots tended to have lower RNA quantity and quality.

Background Controversy exists regarding the optimum number of flow diverters for the treatment of intracranial aneurysms. We explored the effect of the number of Pipeline embolization devices (PEDs; Medtronic, Dublin, Ireland) deployed on rates of aneurysm occlusion and complications. Methods Consecutive patients who underwent saccular intracranial aneurysm treatment solely with the PED were included in this retrospective study. Computed tomographic, magnetic resonance, or digital subtraction angiographic images at 6 and 12 months and last follow-up (>12 months) were reviewed for aneurysm occlusion. Complication and retreatment rates were recorded and analyzed statistically. Results The study included 141 aneurysm treatments in 119 patients. A single PED was deployed in 105 cases, two PEDs in 31 cases, and three PEDs in 5 cases (total = 182 devices). Six-month angiographic data were available for 103 patients. Occlusion rates were 67.1% for single-PED cases and 90.0% for cases with > 1 PED (p = 0.028). The 12-month occlusion rate (follow-up available for 132) for single-PED cases was 74.7% compared to 91.7% for multiple-PED cases (p = 0.04). On multivariate analysis, number of PEDs was an independent predictor of aneurysm occlusion at 12 months (odds ratio 6.3, 95% confidence interval 1.8–22.8, p = 0.005). Thromboembolic complication rates were the same in the single- and multiple-PED treatment groups (2.8%). The retreatment rate was higher in patients treated with a single PED (16.2% vs. 0%, p = 0.01). Conclusions Deployment of > 1 Pipeline embolization device was associated with higher intracranial aneurysm occlusion and lower retreatment rates. No significant difference was found in complication rates.

Introduction The Woven Endobridge (WEB) device is a barrel-shaped nitinol mesh deployed within the aneurysmal sac. The absence of metallic mesh in the vessel lumen obviates the need for potent antiplatelet therapy, which makes this devices interesting for acutely ruptured aneurysms not amenable to clipping or coiling. Methods We performed a comprehensive systematic search of Pubmed, MEDLINE and EMBASE databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Keywords combined with Boolean operators to increase search sensitivity and specificity (‘woven endobridge device’ AND ‘ruptured’) were used. Results Five studies were included, totalizing 276 ruptured aneurysms. Overall, 222 (80.4%) were wide-neck and 236 (85.5%) were located in the anterior circulation. Grade of SAH based on Hunt and Hess scale was reported in four studies with 64 (25.7%) of patients presenting with a poor grade (Hunt and Hess 4-5). Intraoperative and post-operative complications occurred in 7.2% (95% CI, 3.8-13.4) and 4.3% (95% CI, 1.9-9.2) respectively. The rate of rebleeding after treatment was 0%. The rates of adequate occlusion and retreatment at last follow-up were 86.5% (95% CI, 75.6-93) and 5.9% (95% CI, 3.2-10.6), respectively. The rate of favorable outcome was 71% (95% CI, 64-77) and mortality was 19.4% (95% CI, 14.3-25.7). The United-States multicenter study reported use of intraoperative single-antiplatelet therapy (SAPT) in 13.1% and dual-antiplatelet therapy (DAPT) in 2.2%, while 18.7% were discharged under DAPT. The remaining 4 European studies reported no use of antiplatelets during the procedure unless stenting was needed. Two studies reported no use of antiplatelet regimen during follow-up, while 2 studies reported use of SAPT for 4-6 weeks. Conclusions Treatment of acutely ruptured aneurysms with WEB device results in high rates of adequate occlusion, with low perioperative complications, no rebleeding and low recurrence. This device is promising for wide-necked ruptured aneurysms that are not amenable to clipping or coiling, considering its lower need for antiplatelet regimen either during procedure or follow-up. Disclosures A. Monteiro: None. A. Lazar: None. M. Waqas: None. H. Rai: None. A. Baig: None. R. Dossani: None. F. Almayman: None. J. Cappuzzo: None. J. Davies: 1; C; National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR001413 to the University at Buffalo. K. Snyder: 2; C; Canon Medical Systems Corporation, Penumbra Inc., Medtronic, and Jacobs Institute. E. Levy: 2; C; Claret Medical, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, Rebound, StimMed;. 4; C; NeXtGen Biologics, RAPID Medical, Claret Medical, Cognition Medical, Imperative Care (formerly the Stroke Project), Rebound Therapeutics, StimMed, Three Rivers Medical;. A. Siddiqui: 2; C; Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA Inc., Cerebrotech Medical Systems Inc., Cerenovus, Corindus Inc., Endostream Medical Ltd., Imperative Care, Inc. Integra LifeSciences C. 4; C; Adona Medical, Inc, Amnis Therapeutics, (Purchased by Boston Scientific October 2017), Blink TBI Inc., Buffalo Technology Partners Inc., Cerebrotech Medical Systems, Inc., Cognition Medical, Endostrea.

Introduction Ischemic stroke secondary to acute extracranial internal carotid artery (EC-ICA) occlusion accounts for approximately 20% of all stroke cases. Pure EC-ICA lesions account for only a minority of cases as a larger subgroup of people who experience these occlusions, concomitantly develop an intracranial anterior circulation large vessel occlusion (ACLVO), i.e. a tandem lesions. Endovascular management includes acute carotid artery stenting (CAS) with or without balloon angioplasty for pure EC-ICA occlusions and concurrent mechanical thrombectomy (MT) for tandem lesions. In lieu of the scarcity of randomized data and abundance of observational studies, we intend to perform a systematic review and pooled analysis of the data over the past decade to evaluate clinical outcomes, safety and feasibility of endovascular management of acute EC-ICA strokes. Methods Systematic search of the Pubmed, MEDLINE, and EMBASE databases was conducted based on Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. We performed a systematic review of all acute EC-ICA stroke papers (including tandem lesions) published between January 2010 and December 2020. A pooled analysis of the extracted data was performed. Results Data from 1153 patients from 22 studies were pooled and analyzed. Mean age after pooling was 66.9 years, mean NIHSS at admission was 15.9,% IV tPA use before endovascular intervention was seen 56.1% of studies. 82.8% of subjects had a tandem lesion involving both Extracranial and intracranial part of ICA and only 17.2% had a pure and isolated EC-ICA lesion. Angioplasty + stenting (both) was done in 77.6% of cases. Pooling was also done for any and all approaches taken in case of a tandem lesion i.e. anterograde or retrograde. Anterograde approach was taken in 61.7% of cases whereby CAS was performed first followed by MT. Outcome measures were reported as successful recanalization (TICI ≥ 2B) in 80.0% of cases, with good outcome (90-day mRS Conclusion Our systematic review for endovascular treatment of EC-ICA strokes found a high rate of good outcomes and an impressive rate for recanalization, with low mortality rates. Since these results are from observational, retrospective studies, more rigorous randomized trials are required to establish the best approach. Disclosures A. Baig: None. M. Waqas: None. S. Khan: None. A. Monteiro: None. H. Rai: None. R. Dossani: None. J. Cappuzzo: None. F. Almayman: None. J. Davies: 1; C; National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR001413 to the University at Buffalo. K. Snyder: 2; C; Canon Medical Systems Corporation, Penumbra Inc., Medtronic, and Jacobs Institute. E. Levy: 2; C; Claret Medical, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, Rebound, StimMed;. 4; C; NeXtGen Biologics, RAPID Medical, Claret Medical, Cognition Medical, Imperative Care (formerly the Stroke Project), Rebound Therapeutics, StimMed, Three Rivers Medical;. A. Siddiqui: 2; C; Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA Inc., Cerebrotech Medical Systems Inc., Cerenovus, Corindus Inc., Endostream Medical Ltd., Imperative Care, Inc. Integra LifeSciences C. 4; C; Adona Medical, Inc, Amnis Therapeutics, (Purchased by Boston Scientific October 2017), Blink TBI Inc., Buffalo Technology Partners Inc., Cerebrotech Medical Systems, Inc., Cognition Medical, Endostrea.

Background: 30% of minor stroke symptom (MSS) patients (NIHSS= Methods: Retrospective review of MSS-LVO patients across two multi-hospital centers from June 2015 thru June 2018 was conducted. Patients who underwent immediate EVT without signs of deterioration were excluded. Baseline characteristics, management, and outcomes were compared with t-tests, Mann-Whitney U, Chi-square, Fisher’s exact test, and Fisher-Freeman-Halton test for continuous and categorical variables, as appropriate using SPSS Software. Results: Of the 45 MSS-LVO patients who were included, 12 suffered END. Demographics and baseline characteristics were not significantly different across groups. Weakness was more often a presenting symptom in the No-END cohort (84.8% vs 41.7% in END group, p=0.01). The END group showed a lower diastolic BP at the time of the highest NIHSS (86mmHg vs 72mmHg in END group, p= 0.03). The highest BP was comparable across groups (180/84 in the No END group vs 182/91 in END group, p>0.05); although in the END group, the high BP correlated with a higher NIHSS (3 vs 0 in No END group, p=0.01). Patients in the END group were more likely to receive tpA (58.3% vs 15.2% in No END group, p=0.01). The 24-hour NIHSS was greater in the END group (2.5 vs. 0, p=0.02). 84.4% of patients in the No END group had good functional outcome at 3-5 days (mRS 0-2), compared to 45.5% of the END patients (p=0.02). 25% of the END group had in-hospital mortality, while there were no deaths in the No END group. Fewer patients were discharged home (72.7% in No END vs 58.3% in END group, p=0.04). Conclusion: END in MSS patients is associated with worse outcomes at 3-5 days and higher in-hospital mortality. Presenting symptoms and BP fluctuations may be factors in predicting END. Further studies are needed to elucidate the risk factors associated with END in MSS-LVO patients.

BackgroundDetermining stroke etiology is crucial for secondary prevention, but intensive workups fail to classify ~30% of strokes that are cryptogenic.ObjectiveTo examine the hypothesis that the transcriptomic profiles of clots retrieved during mechanical thrombectomy are unique to strokes of different subtypes.MethodsWe isolated RNA from the clots of 73 patients undergoing mechanical thrombectomy. Samples of sufficient quality were subjected to 100-cycle, paired-end RNAseq, and transcriptomes with less than 10 million unique reads were excluded from analysis. Significant differentially expressed genes (DEGs) between subtypes (defined by the Trial of Org 10 172 in Acute Stroke Treatment) were identified by expression analysis in edgeR. Gene ontology enrichment analysis was used to study the biologic differences between stroke etiologies.ResultsIn all, 38 clot transcriptomes were analyzed; 6 from large artery atherosclerosis (LAA), 21 from cardioembolism (CE), 5 from strokes of other determined origin, and 6 from cryptogenic strokes. Among all comparisons, there were 816 unique DEGs, 174 of which were shared by at least two comparisons, and 20 of which were shared by all three. Gene ontology analysis showed that CE clots reflected high levels of inflammation, LAA clots had greater oxidoreduction and T-cell processes, and clots of other determined origin were enriched for aberrant platelet and hemoglobin-related processes. Principal component analysis indicated separation between these subtypes and showed cryptogenic samples clustered among several different groups.ConclusionsExpression profiles of stroke clots were identified between stroke etiologies and reflected different biologic responses. Cryptogenic thrombi may be related to multiple etiologies.

BackgroundFew studies have compared technical success and effectiveness of transradial access (TRA) versus transfemoral access (TFA) for mechanical thrombectomy (MT) for acute ischemic stroke (AIS). We compared the two approaches for technical success, effectiveness, and outcomes.MethodsWe retrospectively compared TRA with TFA for AIS MT at our institute. We additionally performed a systematic review and meta-analysis of studies describing the use of TRA alone or in comparison with TFA for MT. Primary outcomes included rate of successful reperfusion (thrombolysis in cerebral infarction (TICI)>2b), number of passes, access-site complications, and 3- month mortality and favorable functional outcomes (modified Rankin Scale (mRS) score 0–2).ResultsA total of 222 consecutive patients (TRA=93, TFA=129) were included in our case series. The rate of successful reperfusion was significantly higher for the TFA cohort (91.4% vs 79.6%, P=0.01) with lower mean number of passes (1.8±1.2 vs 2.4±1.6, P=0.014). Three-month mortality in the TFA group was lower (22.1% vs 40.9% for the TRA cohort (P=0.004), with a higher rate of favorable functional outcomes (51.3% vs 34.1%, P=0.015). A meta-analysis of 10 studies showed significant heterogeneity in rates of successful reperfusion (57.1% to 95.6%, heterogeneity=67.55%, P=0.001). None of the previous comparative studies reported 3-month mortality and functional outcomes.ConclusionsThis case series demonstrate a higher successful reperfusion rate, fewer passes, lower 3-month mortality, and improved 3-month functional outcomes with TFA. The systematic review highlights the inadequacy of existing evidence. Prospective comparative studies are needed before a ‘radial-first’ approach can be adopted for stroke intervention.

Background: Decompressive craniectomy (DC) is the preferred surgical management option for lowering refractory intracranial pressure in cases of traumatic brain injury (TBI). A number of randomized controlled trials have demonstrated decreased mortality but increased morbidity following DC for TBI patients. Here, we reviewed the frequency of postoperative hemorrhagic complications following DC correlating with poor outcomes. Methods: We retrospectively reviewed the medical records of patients who presented with TBI and underwent DC during the years 2015–2017. The frequency and characteristics of hemorrhagic complications were correlated with the patients’ outcomes. Results: There were 74 patients with TBI included in the study who underwent DC. Of these, 31 patients developed expansion of existing hemorrhagic lesions, 13 had new contusions, three developed new extradural hemorrhages, two developed new subdural hematomas, and one patient developed an intraventricular hemorrhage. Those who developed expansion of existing hemorrhagic lesions following DC had longer ICU stays and poorer outcomes (Glasgow outcome scale). Conclusion: After 74 DC performed in TBI patients, 67% developed new hemorrhagic lesions or expansion of previously existing hemorrhages. This finding negatively impacted clinical outcomes, including mortality.

Introduction Middle meningeal artery (MMA) embolization for the treatment of subacute/chronic subdural hematoma (cSDH) is an emerging therapy for minimally invasive treatment of subdural blood products. Trans radial access (TRA) may offer certain benefits to this patient population who are often on blood thinners with multiple comorbid medical issues. Methods 46 consecutive patients between 2018 and January of 2020 undergoing trans radial access for MMA embolization with Onyx were analyzed from a single center prospectively maintained database. Patient demographics, comorbidities, ambulatory times, subdural resorption status, and guide catheter type were recorded. We specifically looked at conversion to femoral access and complication rates from access for this series. Multivariate analysis with SPSS version 25 was utilized. Results 46 patients were included in this study. The average age was 71.7± 14 years. TRA was successful for MMA embolization in 44 patients (95%). There were no access site complications. The mean cSDH size was 14 ±5 mm. 5 patients had recurrent cSDH prior to undergoing MMA embolization (10.8%). 4 patients (8.7%) had adjuvant MMA embolization performed within 24 hrs of burr hole evacuation. Symptomatic improvement was seen in 88.6% of patients (39/44). Mean length of stay was 4 ±3 days, all patients previously ambulatory were ambulated immediately post procedure. 3 patients were appropriate for same day discharge. Mean followup was 8 weeks ± 4. 86.4% of patients had either resolution or partial resolution of the cSDH at mean follow-up. Univariate analysis revealed use of antiplatelet agents was associated with failed resorption of cSDH (83.3% vs 23%, P=0.009). Charlson comorbidity index, gender, age, and treatment approach (adjuvant vs primary) were not associated with failed resorption status. 48% of patients had a Charlson Comorbidity index >5. 91% of TRA embolizations were performed with a 6F 071 guide catheter. Conclusion MMA embolization with Onyx for cSDH appears to result in symptomatic and radiographic relief in the majority of patients. Trans radial access via 6F 071 guide catheter in this population with numerous comorbidities offers a safe and effective strategy for early ambulation and procedural success. Disclosures G. Rajah: None. M. Waqas: None. R. Dossani: None. A. Gong: None. K. Rho: None. S. Housley: None. H. Rai: None. F. Chin: None. M. Tso: None. E. Levy: None. A. Siddiqui: None. K. Snyder: None. J. Davies: None.

Background The advantages of transradial neuroangiography over a transfemoral access with respect to fewer access site complications, shorter procedure duration and better patient comfort are well described. Radial arterial lines are routinely placed in the ICU in critically ill neurosurgical patients and in the OR on patients undergoing complex neurovascular procedures. We describe the utility of rewiring a radial arterial line in exchange for an arterial sheath for the purpose of diagnostic cerebral arteriography or neurointervention. Rewiring a radial arterial line has the practical benefit of avoiding repeat needle puncture in the setting of an existing catheter that can be ready exchanged for an arterial sheath using a wire exchange technique. Methods Consecutive patients who had transradial neuro-angiography through arterial line access over the 12 months were included in the study. The technique for transradial access was modified in the presence of arterial line. The Arterial line catheter was re-wired and exchanged with 5Fr or 6 Fr sheath as necessary. Data on demographics, indication, devices, and complications was recorded and analyzed. Results Twelve procedures were performed on 11 patients. Mean age was 58.6 +12.9 years; 7 were female. Seven procedures were performed using left-sided arterial line access while 5 procedures were performed using the right side. The most common indication was post-operative angiogram after clipping of aneurysms (n=8), coiling of anterior communicating artery aneurysm (n=1), arteriovenous fistula surgery (n=1). Two cases were performed to evaluate intraventricular hemorrhage (n=1), and arteriovenous malformation resection (n=1). No access site complication was observed. The radial artery sheath was either removed or sutured in place to be used as an arterial line if the patient needed to return to the operating room or the ICU. Conclusion Arterial line rewiring allows rapid transradial access with an arterial sheath and avoids repeat needle puncture. This improvised approach to transradial interventions is especially useful for immediate post-operative evaluation of vascular disorders. Disclosures R. Dossani: None. M. Waqas: None. M. Tso: None. G. Rajah: None. H. Rai: None. A. Levy: None. A. Siddiqui: None. J. Davies: None.

Background Transradial access for neurointerventions offers advantages of fewer access-site complications, reduced procedure time, and greater patient comfort over transfemoral access. Data about transradial access for flow diversion are limited. We share our early experience with transradial access for flow diversion in a relatively large case series. Methods Consecutive patients who underwent Pipeline embolization device (Medtronic) deployment via transradial access were included in the study, irrespective of location and laterality of the intracranial aneurysm. The cases were performed between July 2016 and October 2019. Demographics, aneurysm characteristics, and procedure-related details (including catheter systems used) were recorded and statistically evaluated. Results Thirty-five transradial flow diversion procedures were attempted in 32 patients, of which 33 procedures were successful. In two cases involving left common carotid artery and internal carotid artery access, guide catheter herniation into the aortic arch led to abandonment of transradial access in favor of transfemoral access. The most common aneurysm locations in the transradial access procedures were the posterior communicating artery ( n = 7), ophthalmic artery ( n = 7), and superior hypophyseal artery ( n = 7). Most transradial access procedures (66.7%) were performed using a biaxial catheter system. 6-French Benchmark (Penumbra) and Phenom 27 (Medtronic) were the most commonly utilized guide- and microcatheters, respectively. One patient had intraprocedural subarachnoid hemorrhage. No access-site complications occurred. Conclusion This study demonstrates safety and feasibility of transradial access for Pipeline embolization device deployment and shows the versatility of this approach for different catheter systems. Tortuosity and acute angulation of the left common carotid artery and internal carotid artery were associated with approach failure.

Background and purposeWe previously reported a single-centre study demonstrating that smoking confers a six-fold increased risk for having an unruptured intracranial aneurysm (UIA) in women aged between 30 and 60 years and this risk was higher if the patient had chronic hypertension. There are no data with greater generalisability evaluating this association. We aimed to validate our previous findings in women from a multicentre study.MethodsA multicentre case-control study on women aged between 30 and 60 years, that had magnetic resonance angiography (MRA) during the period 2016–2018. Cases were those with an incidental UIA, and these were matched to controls based on age and ethnicity. A multivariable conditional logistic regression was conducted to evaluate smoking status and hypertension differences between cases and controls.ResultsFrom 545 eligible patients, 113 aneurysm patients were matched to 113 controls. The most common reason for imaging was due to chronic headaches in 62.5% of cases and 44.3% of controls. A positive smoking history was encountered in 57.5% of cases and in 37.2% of controls. A multivariable analysis demonstrated a significant association between positive smoking history (OR 3.7, 95%CI 1.61 to 8.50), hypertension (OR 3.16, 95% CI 1.17 to 8.52) and both factors combined with a diagnosis of an incidental UIA (OR 6.9, 95% CI 2.49 to 19.24).ConclusionsWomen aged between 30 and 60 years with a positive smoking history have a four-fold increased risk for having an UIA, and a seven-fold increased risk if they have underlying chronic hypertension. These findings indicate that women aged between 30 and 60 years with a positive smoking history might benefit from a screening recommendation.

PURPOSE: Few studies have examined the geometry of endovascular mechanical thrombectomy pathways. Here we examine the tortuosity and angulations of catheter pathways from the aortic arch to the termination of the internal carotid artery (ICA) and its association with thrombectomy performance. METHODS: We included 100 consecutive anterior circulation large vessel occlusion thrombectomy patients over 12 months. Computed Tomography angiograms (CTA) were used for 3D segmentation of catheter pathway from the aortic arch to ICA termination. Tortuosity index (TI) and angulations of the catheter pathway were measured in a semiautomated fashion. TI and angulation degree were compared between sides and correlated with age and procedural measures. RESULTS: We analyzed 188 catheter pathways in 100 patients. Severe angulation (≤30°) was present in 5.8% and 39.4% of common carotid artery (CCA) and extracranial ICA segments, respectively. Five pathways (2.6%) had 360° loop. CCA and extracranial ICA tortuosity had a weak but significant correlation with age (r=0.17, 0.21, p-value= 0.05, 0.02 respectively), time from groin puncture to the site of occlusion (r=0.29, 0.25, p-values= 0.008, 0.026 respectively) and fluoroscopy time (r= 0.022, 0.31, p-values= 0.016, 0.001 respectively). There was a significant difference in the pattern of angulation (p-value=0.04) and tortuosity between right and left side in CCA segment (TI= 0.20 ± 0.086 vs. 0.15 ± 0.82, p-value

Background Intravenous (IV) alteplase with mechanical thrombectomy has been found to be superior to alteplase alone in select patients with intracranial large vessel occlusion. Current guidelines discourage the use of antiplatelet agents or heparin for 24 h following alteplase. However, their use is often necessary in certain circumstances during thrombectomy procedures. Objective To study the safety and outcomes in patients who received blood thinning medications for thrombectomy after IV Tissue-Type plasminogen activator (tPA). Methods This is a multicenter retrospective review of the use of antiplatelet agents and/or heparin in patients within 24 h following tPA administration. Patient demographics, comorbidities, bleeding complications, and discharge outcomes were collected. Results A series of 88 patients at 9 centers received antiplatelet medications and/or heparin anticoagulation following IV alteplase for revascularization procedures requiring stenting. The mean National Institutes of Health Stroke Scale (NIHSS) on admission was 14.6. Reasons for use of a stent included internal carotid artery occlusion in 74% of patients. Thrombolysis in cerebral infarction (TICI) 2b-3 revascularization was accomplished in 90% of patients. The rate of symptomatic intracranial hemorrhage (sICH) was 8%; this was not significantly different than the sICH rate for a matched group of patients not receiving antiplatelets or heparin during the same time frame. Functional independence at 90 d (modified Rankin Scale 0-2) was seen in 57.8% of patients. All-cause mortality was 12%. Conclusion The use of antiplatelet agents and heparin for stroke interventions following IV alteplase appears to be safe without significant increased risk of hemorrhagic complications in this group of patients when compared to control data and randomized controlled trials.

BackgroundAcute isolated posterior cerebral artery occlusions (aPCAOs) were excluded or under-represented in major randomized trials of mechanical thrombectomy (MT). The benefit of MT in comparison to intravenous tissue plasminogen activator (alteplase; IV-tPA) alone in these patients remains controversial and uncertain.MethodsWe performed a systematic search of PubMed, MEDLINE, and EMBASE databases for articles comparing MT with or without bridging IV-tPA and IV-tPA alone for aPCAO using keywords (‘posterior cerebral artery’, ‘thrombolysis’ and ‘thrombectomy’) with Boolean operators. Extracted data from patients reported in the studies were pooled into groups (MT vs IV-tPA alone) for comparison. Estimated rates for favorable outcome (modified Rankin scale score 0–2), symptomatic intracranial hemorrhage (sICH), and mortality were extracted.ResultsSeven articles (201 MT patients, 64 IV-tPA) were included, all retrospective. There was no statistically significant difference between pooled groups in median age, median presentation National Institutes of Health Stroke Scale (NIHSS) score, PCAO segment, and median time from symptom onset to puncture or needle. The recanalization rate was significantly higher in the MT group than the IV-tPA group (85.6% vs 53.1%, pConclusionsWe found no significant differences in odds of favorable outcome, sICH, and mortality in MT and IV-tPA in comparable aPCAO patients, despite superior MT recanalization rates. Equipoise remains regarding the optimal treatment modality for these patients.

Introduction The effectiveness of mechanical thrombectomy in patients presenting with a low NIHSS and large vessel occlusion is uncertain. The objective of this study was to compare clinical outcomes of patients with successful (TICI 2b/3) and failed (TICI 0/2a) reperfusions during endovascular mechanical thrombectomy for low NIHSS large vessel occlusion stroke. Materials and methods We conducted a retrospective analysis on all patients who underwent stent retriever and/or aspiration thrombectomy between January 2012 to May 2017 at the Gates Vascular Institute in Buffalo, NY. Thirty-one patients with a large vessel occlusion and NIHSS ≤ 6 were identified. These patients were divided into two groups, those who received TICI 2b/3 recanalization and those who received TICI 0/2a. Demographic, procedural and outcome data was collected. Occurrence of vasospasm, thromboembolic complications, symptomatic hemorrhage, discharge NIHSS, hospital stay and outcome at 90 days were compared between the two groups. Results Of the 31 thrombectomies, 26 were TICI 2b/3 while 5 were TICI 0/2a. The mean age of patients who attained successful reperfusion was 68.35 ± 11.88 years with 11 males (42%) whereas that of failed patients was 65 ± 15.20 years with 3 males (60%). Of the TICI 2b/3 patients, there were 7 incidences of vasospasm (27%), 3 symptomatic intracranial hemorrhages (12%), 4 hospital deaths (15%) and 20 favorable outcomes (mRS 0–2 at 90 days) (77%). In contrast, there were 0 vasospasms, 2 symptomatic intracranial hemorrhages (40%), 2 hospital deaths (40%) and only 2 favorable outcomes in the TICI 0/2a group (40%). Neither group had any thromboembolic complications. Median (IQR) discharge NIHSS was 2 (1–4.75) in the TICI 2b/3 group compared to 3 (3–40) in the TICI 0/2a group. Both groups shared a median decrease in NIHSS score of 2 post-thrombectomy. Differences between the two groups were not statistically significant. Conclusion While mild stroke patients with TICI 2b/3 reperfusion had better outcomes across the board, the differences were not statistically significant. Mechanical thrombectomy may confer benefits upon mild stroke patients with large vessel occlusion; however, additional research is needed to validate these benefits. Disclosures F. Chin: None. M. Waqas: None. H. Shallwani: None. H. Rai: None. E. Levy: 1; C; Medtronic US SWIFT PRIME Trials. 2; C; Pulsar Vascular. Advisory Board- Stryker, NeXtGen Biologics, MEDX, Cognition Medical.. 4; C; Intratech Medical Ltd., NeXtGen Biologics.. 6; C; Abbott Vascular for carotid training sessions. A. Siddiqui: 1; C; Cerenovus LARGE Trial, ARISE II Trial, Medtronic SWIFT PRIME and SWIFT DIRECT Trials, MicroVention FRED Trial & CONFIDENCE Study, MUSC POSITIVE Trial, Penumbra 3D Separator Trial, COMPASS Trial etc.. 2; C; Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA Inc., Cerebrotech Medical. Systems Inc., Cerenovus, Claret Medical, Corindus Inc., Endostream Medical Ltd etc.. 4; C; Amnis Therapeutics, Apama Medical, BlinkTBI Inc., Buffalo Technology Partners Inc, Cardinal Health, Cerebrotech Medical Systems Inc, Claret Medical, Coggnition Medical, Endostream Medical Ltd etc.

Introduction By 2050, the number of octogenarians will triple that in 2015. Currently over a third of stroke cases occur in patients aged 80 years or older. A better understanding of stroke intervention in octogenarians is warranted considering a rapidly aging population. Here we aimed to identify risk factors predictive of favorable outcomes in octogenarian stroke patients who received mechanical thrombectomy intervention. Materials and methods A retrospective analysis was conducted on all consecutive patients who underwent mechanical thrombectomy between January 2012 to May 2017 at the Gates Vascular Institute in Buffalo, NY. Eighty-eight octogenarian patients with large vessel occlusion were identified. These patients were divided into two groups, those with favorable outcome (mRS 0–2 at 90 days) and those with unfavorable outcome (mRS 3–6 at 90 days). Demographic, procedural, radiographic and outcome data was collected. Variables including but not limited to comorbidities, smoking status, time between symptom onset to hospital arrival, infarct core, initial NIHSS score, admission glucose, creatinine, albumin, IV tPA administration, general anesthesia, procedure type, clot location and etc. were compared between the two groups. Results Of the 88 octogenarian thrombectomies, 29 had favorable 90-day outcome (33%) whereas 59 had unfavorable outcome (67%). Factors that were significantly different between those with favorable and unfavorable outcome include: presence of infarct core before intervention, NIHSS score upon admission and procedure time. Of the 29 favorable outcomes, 5 presented with infarct cores (17%) whereas 30 of the 59 unfavorable outcome patients presented with infarct cores (51%). The median (IQR) NIHSS upon admission for the favorable outcome interventions was 12 (9–15) in contrast to 18 (14–21.5) for unfavorable outcome cases. Mean procedure time for favorable outcomes was 54.02 ± 31.41 minutes compared to 68.04 ±. 30.97 minutes for unfavorable outcomes. Conclusion Our study suggests infarct core, initial NIHSS score and procedure time to be potential predictors of outcome in octogenarian stroke patients receiving mechanical thrombectomy. Additional research is warranted to further evaluate the significance of these predictors. Disclosures F. Chin: None. M. Waqas: None. H. Shallwani: None. H. Rai: None. E. Levy: 1; C; Medtronic US SWIFT PRIME Trials. 2; C; Pulsar Vascular. Advisory Board- Stryker, NeXtGen Biologics, MEDX, Cognition Medical. 4; C; Intratech Medical Ltd., NeXtGen Biologics. 6; C; Abbott Vascular for carotid training sessions. A. Siddiqui: 1; C; Cerenovus LARGE Trial, ARISE II Trial, Medtronic SWIFT PRIME and SWIFT DIRECT Trials, MicroVention FRED Trial & CONFIDENCE Study, MUSC POSITIVE Trial, Penumbra 3D Separator Trial, COMPASS Trial etc. 2; C; Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA Inc., Cerebrotech Medical. Systems Inc., Cerenovus, Claret Medical, Corindus Inc., Endostream Medical Ltd etc. 4; C; Amnis Therapeutics, Apama Medical, BlinkTBI Inc., Buffalo Technology Partners Inc, Cardinal Health, Cerebrotech Medical Systems Inc, Claret Medical, Coggnition Medical, Endostream Medical Ltd etc.

With an increasing use of intraoperative fluoroscopy in operating rooms worldwide, the topic of radiation exposure has become a major concern among hospital staff, doctors and patients alike. Since fluoroscopy has become an integral part in orthopedic intraoperative management, we sought to identify whether surgeon grade or experience plays a role in the amount of radiation used and consequently exposed. We performed a systematic review examining the association between surgeon experience and radiation exposure using primary outcome measures (radiation dose and total screening time/fluoroscopy time). To be included in the review, the study population had to compare varying surgeon experience levels and their effect on the primary outcomes. A total of eighteen studies were included in the review. The studies were a mix of prospective and retrospective studies with low to moderate quality as evaluated by the MINORs criteria. Studies were variable in defining surgeon experience levels and in the type of operations being performed. Majority of the studies showed that inexperienced surgeons/trainees had a higher total fluoroscopy time and a higher mean radiation exposure as compared to experienced surgeons. We conclude that higher surgeon experience significantly reduces usage of fluoroscopy and the consequent radiation exposure in orthopedic procedures. Introduction of strict radiation guidelines involving limited usage of fluoroscopy and supervision of trainees may be beneficial in controlling radiation exposure in the future.

The literature demonstrates a favorable first pass effect with balloon-guide catheter (BGC) for mechanical thrombectomy. An 8F BGC is routinely used with femoral access. We present the first video report of 8F BGC advanced through the radial artery using a sheathless technique (video 1). An approximately 70-year-old patient presented with left-sided hemiplegia, neglect, and dysarthria. A CT angiogram demonstrated right M1 occlusion, and the patient underwent urgent mechanical thrombectomy. Radial approach was preferred owing to patient history of anticoagulation. A 6F Sim Select intermediate catheter was used to minimize the step off as the 8F BGC was advanced into the radial artery over an 035 exchange-length Advantage Glidewire. A skin nick over the Glidewire Advantage facilitated the introduction of the 8F BGC into the radial artery. Standard mechanical thrombectomy using a combination of stent retriever and aspiration catheter (Solumbra technique) was performed, and thrombolysis in cerebral infarction 3 recanalization was achieved after a single pass. The National Institutes of Health Scale score improved from 12 to 4, with mild left facial droop, dysarthria, and decreased speech fluency. The patient was discharged from the hospital on postoperative day 2. Ultrasound should be used for immediate assessment of radial artery size and conversion to femoral access without delay if the radial artery is less than 2.5 mm.Video 1

Introduction Although mechanical thrombectomy (MT) is a proven therapy for acute large vessel occlusion strokes, futile recanalization in the elderly is common and costly. Strategies to minimize futile recanalization may reduce unnecessary thrombectomy transfers and procedures. We evaluated whether a simple and rapid visual assessment of brain atrophy and leukoaraiosis on a plain head CT correlates with futile stroke recanalization in the elderly. Methods Consecutive stroke patients admitted for thrombectomy, older than 65 years of age, all with TICI 2b/3 recanalization rates were retrospectively studied from multiple comprehensive stroke centers. Brain atrophy and leukoaraiosis were visually analyzed from pre-intervention plain head CTs using a simplified scheme based on validated scales. Baseline demographics were collected and the primary outcome measure was 90-day modified Rankin score (mRS). Cochran-Armitage trend test was applied in analyzing the association of the severity of brain atrophy and leukoaraiosis with 90-day mRS. Results Between 2017 and 2019, 175 patients > 65 years who underwent thrombectomy with TICI 2b/3 recanalization from two comprehensive stroke centers were evaluated. The median age was 77 years. IV-tPA was given in 59% of patients, average initial NIHSS was 19, average baseline mRS was 0.77 and median time to recanalization was 300 minutes. Age and severity of atrophy/leukoaraiosis was categorized into three groups of increasing severity and associated with 90 day mRS 0-3 rates of 62%, 49% and 41% (p=0.037) respectively. Conclusions A simplified, visual assessment of the degree of brain atrophy and leukoaraiosis measured on plain head CT correlates with futile recanalization in patients age >65 years. Although additional validation is needed, these findings suggest that brain atrophy and leukoaraiosis may have value as a surrogate marker of prestroke functional status. In doing so, simplified visual plain head CT grading scales may minimize elderly futile recanalization.

OBJECTIVE Acute basilar artery occlusion (BAO) is a rare large-vessel occlusion associated with high morbidity and mortality. Modern thrombectomy with stent retrievers and large-bore aspiration catheters is highly effective in achieving recanalization, but a direct comparison of different techniques for acute BAO has not been performed. Therefore, the authors sought to compare the technical effectiveness and clinical outcomes of stent retriever–assisted aspiration (SRA), aspiration alone (AA), and a stent retriever with or without manual aspiration (SR) for treatment of patients presenting with acute BAO and to evaluate predictors of clinical outcome in their cohort. METHODS A retrospective analysis of databases of large-vessel occlusion treated with endovascular intervention at two US endovascular neurosurgery centers was conducted. Patients ≥ 18 years of age with acute BAO treated between January 2013 and December 2020 with stent retrievers or large-bore aspiration catheters were included in the study. Demographic information, procedural details, angiographic results, and clinical outcomes were extracted for analysis. RESULTS Eighty-three patients (median age 67 years [IQR 58–76 years]) were included in the study; 33 patients (39.8%) were female. The median admission National Institutes of Health Stroke Scale (NIHSS) score was 16 (IQR 10–21). Intravenous alteplase was administered to 26 patients (31.3%). The median time from symptom onset to groin or wrist puncture was 256 minutes (IQR 157.5–363.0 minutes). Overall, successful recanalization was achieved in 74 patients (89.2%). The SRA technique had a significantly higher rate of modified first-pass effect (mFPE; 55% vs 31.8%, p = 0.032) but not true first-pass effect (FPE; 45% vs 34.9%, p = 0.346) than non-SRA techniques. Good outcome (modified Rankin Scale [mRS] score 0–2) was not significantly different among the three techniques. Poor outcome (mRS score 3–6) was associated with a higher median admission NIHSS score (12.5 vs 19, p = 0.007), a higher rate of adjunctive therapy usage (9% vs 0%, p < 0.001), and a higher rate of intraprocedural complications (10.7% vs 14.5%, p = 0.006). The admission NIHSS score significantly predicted good outcome (OR 0.98, 95% CI 0.97–0.099; p = 0.032). Incomplete recanalization after thrombectomy significantly predicted mortality (OR 1.68, 95% CI 1.18–2.39; p = 0.005). CONCLUSIONS The evaluated techniques resulted in high recanalization rates. The SRA technique was associated with a higher rate of mFPE than AA and SR, but the clinical outcomes were similar. A lower admission NIHSS score predicted a better prognosis for patients, whereas incomplete recanalization after thrombectomy predicted mortality.

N-butyl 2-cyanoacrylate (nBCA) is a fast-acting liquid adhesive that polymerizes when it comes in contact with blood anions. We present the principles of nBCA preparation and delivery for tumor embolization of a right convexity meningioma in a patient who presented with a 6-month history of word-finding difficulty and memory loss video 1. Angiography of the middle meningeal artery showed a hairpin turn that was not negotiable with a number of different microwires, including the Synchro-2, Chikai 014 and Balt hybrid 008 wire. Due to the tortuous hairpin turn, the microcatheter position was distal to the tumor blush for the convexity meningioma. Given the distal microcatheter position, we opted for nBCA as the liquid embolic of choice for tumor embolization. The time of polymerization for nBCA may be delayed using glacial acetic acid, which makes nBCA ideal when the microcatheter is in a distal position relative to the target location for embolization. The patient underwent successful embolization using nBCA and was taken for a right frontal craniotomy for resection of the meningioma the next day. The intraoperative blood loss was 100 mL and the postoperative MRI showed gross total resection. The patient had an uncomplicated hospital course and was discharged home on post-procedure day 3.Video 1

BackgroundThe purpose of this cross-sectional study was to determine the percentage of the US population with 60 min ground or air access to accredited or state-designated endovascular-capable stroke centers (ECCs) and non-endovascular capable stroke centers (NECCs) and the percentage of NECCs with an ECC within a 30 min drive.MethodsStroke centers were identified and classified broadly as ECCs or NECCs. Geographic mapping of stroke centers was performed. The population was divided into census blocks, and their centroids were calculated. Fastest air and ground travel times from centroid to nearest ECC and NECC were estimated.ResultsOverall, 49.6% of US residents had 60 min ground access to ECCs. Approximately 37.7% (113 million) lack 60 min ground or air access to ECCs. Approximately 84.4% have 60 min access to NECCs. Ground-only access was available to 77.9%. Approximately 738 NECCs (45.4%) had an ECC within a 30 min drive.ConclusionNearly one-third of the US population lacks 60 min access to endovascular stroke care, but this is highly variable. Transport models and planning of additional centers should be tailored to each state depending on location and proximity of existing facilities.

Background: Tigertriever (Rapid Medical, Sunrise, FL) is an adjustable-diameter stent retriever that is being tested in an investigational device exemption clinical trial, Treatment with Intent to Generate Reperfusion (TIGER). The retriever is available in three lengths with corresponding adjustable diameters; however, a single device cannot be used for multiple thrombectomy attempts. A clicker-based expansion mechanism allows incremental expansion of the retriever and step-wise increase in radial force to the parent vessel diameter. The clicker mechanism is used to expand the stent retriever until it is apposed with the vessel walls. Rest of the procedure is similar to a mechanical thrombectomy performed with a conventional stent retriever and is demonstrated in the video. Case Description: We present a case of a 59-year-old woman who presented with left-upper extremity weakness, facial droop, and hemineglect. Perfusion imaging demonstrated increased time-to-peak. Angiography showed right internal carotid artery terminus occlusion. The patient underwent successful mechanical thrombectomy (Thrombolysis in Cerebral Infarction 2b reperfusion) using the Tigertriever and was discharged home without any perioperative complications. Conclusion: An adjustable, expandable stent retriever allows operator to size the stent retriever to match the target artery diameter. The expandable design of stent retriever has potential implications for distal vessel occlusion mechanical thrombectomy.

Angiographic stenosis may not be an accurate reflection of physiological flow limitation. Measurement of instant flow reserve (IFR) to quantify functional flow limitation across stenosis may be valuable in identifying lesions causing significant flow limitation. A case of left middle cerebral artery atherosclerotic disease is presented. Because medical therapy had failed, endovascular revascularization was chosen. In this video 1, IFR measurement to guide submaximal balloon angioplasty with a 1.5×9 mm non-compliant Mini-Trek balloon (Abbott) is demonstrated. Pressure gradient across the middle cerebral artery-M1 stenosis was measured with a Volcano pressure wire (Philips) before and after submaximal balloon angioplasty. An excellent radiographic result and flow improvement into the severely stenosed segment were achieved, with an IFR increase from 0.23 to 0.89. The degree of corresponding stenosis changed from 85% to 30%. No periprocedural complication was observed. IFR can help to identify lesions requiring treatment in select patients and prevent the tendency to overtreat a lesion that is not physiologically significant.Video 1

Effectiveness of mechanical thrombectomy for mild-deficit stroke due to large-vessel occlusion is controversial. We present a single-center consecutive case series on thrombectomy for large-vessel occlusion mild stroke. We evaluated various thrombectomy parameters to better understand disagreement in the literature.Data from a retrospective cohort of large-vessel occlusion mild stroke patients (National Institutes of Health Stroke Scale6) treated with mechanical thrombectomy over 6 years and 2 months were analyzed. Patients were divided into 2 groups: successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b or 3) and failed reperfusion (modified Thrombolysis in Cerebral Infarction 0,1, or 2a). Ninety-day modified Rankin Scale in-hospital mortality, and symptomatic hemorrhage rates were compared between groups. Multivariate logistic regression was performed to evaluate reperfusion status as a predictor of 90-day favorable (modified Rankin Scale 0-2) and excellent (modified Rankin Scale 0-1) outcomes.We identified 61 patients with large-vessel occlusion mild stroke who underwent thrombectomy. Reperfusion was successful in 49 patients and a failure in 12. The successful group exhibited significantly higher rates of favorable outcome (83.7% vs. 25.0%; p 0.001) and excellent outcome (69.4% vs.16.7%; p = 0.002) at 90 days. In-hospital mortality was significantly higher in the failure group (41.7% vs.10.2%; p = 0.019). Multivariate logistic regression identified successful reperfusion as a significant predictor (p = 0.001) of 90-day favorable outcome.Reperfusion success was significantly associated with improved functional outcomes in large-vessel occlusion mild stroke mechanical thrombectomy. Future studies should consider reperfusion rates when evaluating the effectiveness of thrombectomy against that of medical management in these patients.

BackgroundMiddle meningeal artery (MMA) embolization is an emerging therapy for the resolution of subacute or chronic subdural hematoma (CSDH). CSDH patients are often elderly and have several comorbidities. We evaluated our experience with transradial access (TRA) for MMA embolization using predominantly Onyx under conscious sedation.MethodsData for consecutive patients who underwent transradial MMA embolization for CSDH during a 2-year period (2018–2019) were analyzed from a single-center, prospectively-maintained database. Patient demographics, comorbidities, ambulatory times, subdural hematoma resorption status, and guide catheter type were recorded. Conversion to femoral access and complication rates were also recorded. Univariate and multivariate analyses were performed.ResultsForty-six patients (mean age, 71.7±14.4 years) were included in this study. Mean CSDH size was 14±5.5 mm. Most (91.3%) TRA embolizations were performed with 6-French 0.071-inch Benchmark guide catheters (Penumbra). MMA embolization was successful in 44 patients (95.7%) (including two cases of TRA conversion). Twenty-one (48%) patients had a severe Charlson Comorbidity Index (>5). Symptomatic improvement was noted in 39 of 44 patients (88.6%). Mean length of stay was 4±3 days. Patients were ambulated immediately postprocedure. At mean follow-up (8±4 weeks), 86.4% of patients had complete or partial CSDH resolution. Persistent use of antiplatelet agents after the procedure was associated with failed or minimal CSDH resorption (5 of 6, 83.3% vs 9 of 38 23.7% with complete or near-complete resolution; P=0.009).ConclusionTransradial Onyx MMA embolization under conscious sedation is safe and effective for CSDH treatment. TRA may be especially useful in elderly patients with numerous comorbidities.

The impact of ADAPT—“a direct aspiration first pass technique”—on intracranial vasculature is not well understood, since the change of arterial diameter is often not visible during aspiration. We present a unique case in which the impact of aspiration on the parent vessel was visualized due to a previously deployed Neuroform Atlas stent and a Pipeline embolization device. The patient presented with right internal carotid artery occlusion. An aspiration catheter was advanced over the microcatheter system and corked into the clot, located within the stents in proximal M1. The stents were seen to collapse both during electronic pump and hand aspiration with no evidence of stent migration. This demonstrates that it is crucial to engage the clot interface with the tip of the aspiration catheter while performing ADAPT. Placing the aspiration catheter remote from the clot may result in collapse of the artery proximal to the clot with subsequent ADAPT failure.(video 1)video 1.

Background: Accurate assessment of the frequency of large vessel occlusion (LVO) is important to determine needs for neurointerventionists and thrombectomy-capable stroke facilities. Current estimates vary from 13% to 52%, depending on acute ischemic stroke (AIS) definition and methods for AIS and LVO determination. We sought to estimate LVO prevalence among confirmed and suspected AIS patients at 2 comprehensive US stroke centers using a broad occlusion site definition: internal carotid artery (ICA), first and second segments of the middle cerebral artery (MCA M1,M2), the anterior cerebral artery, vertebral artery, basilar artery, or the proximal posterior cerebral artery. Methods: We analyzed prospectively maintained stroke databases of patients presenting to the centers between January and December 2017. ICD-10 coding was used to determine the number of patients discharged with an AIS diagnosis. Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) was reviewed to determine LVO presence and site. Percentages of patients with LVO among the confirmed AIS population were reported. Results: Among 2245 patients with an AIS discharge diagnosis, 418 (18.6%:95% confidence interval [CI] 17.3%-20.0%) had LVO documented on CTA or MRA. Most common occlusion site was M1 (n=139 [33.3%]), followed by M2 (n=114 [27.3%]), ICA (n=69[16.5%]), and tandem ICA-MCA lesions (n=44 [10.5%]). Presentation National Institutes of Health Stroke Scale scores were significantly different for different occlusion sites (P=.02). Conclusions: The LVO prevalence in our large series of consecutive AIS patients was 18.6% (95% CI 17.3%-20.0%). Despite the use of a broad definition, this estimate is less than that reported in most previous studies.