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Background and purpose Previous studies suggest that mechanisms and outcomes in patients with COVID-19-associated stroke differ from those in patients with non-COVID-19-associated strokes, but there is limited comparative evidence focusing on these populations. The aim of this study, therefore, was to determine if a significant association exists between COVID-19 status with revascularization and functional outcomes following thrombectomy for large vessel occlusion (LVO), after adjustment for potential confounding factors. Methods A cross-sectional, international multicenter retrospective study was conducted in consecutively admitted COVID-19 patients with concomitant acute LVO, compared to a control group without COVID-19. Data collected included age, gender, comorbidities, clinical characteristics, details of the involved vessels, procedural technique, and various outcomes. A multivariable-adjusted analysis was conducted. Results In this cohort of 697 patients with acute LVO, 302 had COVID-19 while 395 patients did not. There was a significant difference (p < 0.001) in the mean age (in years) and gender of patients, with younger patients and more males in the COVID-19 group. In terms of favorable revascularization (modified Thrombolysis in Cerebral Infarction [mTICI] grade 3), COVID-19 was associated with lower odds of complete revascularization (odds ratio 0.33, 95% confidence interval [CI] 0.23-0.48; p < 0.001), which persisted on multivariable modeling with adjustment for other predictors (adjusted odds ratio 0.30, 95% CI 0.12-0.77; p = 0.012). Moreover, endovascular complications, in-hospital mortality, and length of hospital stay were significantly higher among COVID-19 patients (p < 0.001). Conclusion COVID-19 was an independent predictor of incomplete revascularization and poor functional outcome in patients with stroke due to LVO. Furthermore, COVID-19 patients with LVO were more often younger and had higher morbidity/mortality rates.

Background: Cerebrovascular reserve (CVR) assessment is valuable in predicting stroke risk in patients with cranio-cervical stenoses and occlusions. CTP with Acetazolamide challenge (AC) allows a qualitative and quantitative assessment of CVR but is limited by ROI positioning, motion and software. Artificial intelligence (AI) automated software with delay in arrival correction has been validated for the processing of CTP data for acute stroke and may more easily detect abnormal CVR. We sought to compare the results of image-processing with a standard platform (Vitrea™) and AI platform (RAPID™). Methods: Retrospective analysis of an IRB approved prospective database of patients who had CTP with acetazolamide (1g IV) who also had a stenosis/occlusion of the internal carotid or middle cerebral arteries was performed. Symptomatic status was defined as recurrent symptoms related to the vessel of interest within 6 months of scan. Two readers, blinded to the clinical scenario, independently reviewed the CTP datasets and identified CBF regional abnormalities and changes post AC using the 2 different platforms. Abnormal CVR was defined as an increase of CBF post AC of Results: Thirty patients fulfilling criteria received CTP before and after AC. 24 patients (80%) were symptomatic. Vitrea™ detected decrease in CBF pre-AC in 27 patients and worsening CBF value post-AC in 19 patients. 10 Patients had an increase >25% in CBF post AC. Rapid™ detected 5 patients with CBF lesion Conclusion: Automated post processing software with delay in arrival correction algorithm is less sensitive to abnormal CVR and has lower correlation with clinical presentation in this small cohort. Further study is warranted to identify thresholds that may better correlate.

Background: Cerebral endothelial cells (CECs) play a key role in mediating cerebral vascular hemostasis. The biological function of CECs in stroke patients remains unknown due to technical challenges to acquire patient CECs. We isolated and analyzed the function of CECs from living stroke patients. Methods: Cells were isolated from stent retrievers used for mechanical thrombectomy (MT) for patients with large vessel occlusion (LVO) after completion of the intervention as part of an IRB approved protocol. Patient endothelial cells (pCECs) were analyzed. Results: We isolated 300-400 primary brain endothelial cells per retriever from 5 patients with LVO with ages ranging from 69 to 86 years. The pCECs exhibited a typical monolayer cobblestone appearance and expressed VE-cadherin, but not α-smooth muscle actin, indicating that these cells are CECs. Western blot analysis showed that compared to human primary brain microvascular endothelial cells (hBMECs, Cell System), pCECs expressed significantly increased iNOS, VEGF, and VEGFR2, but reduced eNOS and Ang1. In vitro endothelial permeability and angiogenesis assays showed that pCECs robustly increased cell leakage and angiogenesis, respectively. Moreover, treatment of healthy hBMECs with exosomes derived from patient CECs (pCEC-Exos) significantly increased cell leakage and reduced cell integrity, which were associated with the reduction of tight junction proteins ZO1 and Occludin. Blockage of the caveolin endocytotic pathway by nystatin abolished the effect of pCEC-Exos on hBMEC function. Conclusions: Our data demonstrate that: 1) pCECs from stroke patients can be harvested; 2) pCECs are dysfunctional, and 3) pCEC-Exos induce dysfunction of healthy CECs. These data provide novel insights into the mediation of stroke-induced neurovascular dysfunction by pCECs.

Intro: Space weather induced geomagnetic storms have been associated with an increased risk of stroke occurrence. Data on image-proven, temporally related large vessel occlusion stroke (LVO) and geomagnetic storms are lacking. We sought to investigate this potential association to determine whether space weather forecasts can be used to predict incoming cluster events. Methods: Data from a Comprehensive Stroke Center were collected from January 1, 2017, to April 15, 2022. Space weather data were downloaded from the World Data Centre for Geomagnetism, Kyoto homepage (http://wdc.kugi.kyoto-u.ac.jp/kp/index.html#LIST) The indications for mechanical endovascular reperfusion (MER) were in accordance with the Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Univariate binary logistic regression was performed to assess the potential associations between space weather data and LVO MER cases with 48 hour lag effect. Geomagnetic activity was defined by the National Oceanic and Atmospheric Administration’s (NOAA) Space Weather Prediction Centre (SWPC) space weather scales. Results: Of the 1931 days included in this study, there were 538 (27.86%) days with at least one LVO MER (450 (23.3%) with 1, 81 (4.19%) with 2, and 7 (0.36%) with 3. There were 1784 days without geomagnetic storm activity and 147 days with minor to severe storms. 290 MER cases occurred out 1014 days of minimal activity (28.6%) 133 MER cases out 497 days of unsettled activity (26.76%) 0.91(0.72-116), 78 MER cases out of 273 days of active activity (28.57%) 1.00(0.74-1.34), 25 MER cases out 109 days of minor storm (22.94%) 0.74(0.47-1.19) and 12 MER cases out of the 38 days of moderate to extreme storms (31.58%) 1.15(0.57-2.31) p-value 0.697. Conclusion: There was no statistically significant association with geomagnetic storms and the occurrence of large vessel stroke interventions taking into consideration a 48 hour lag effect. Comprehensive stroke center readiness is of utmost importance, but space weather forecasts are unlikely to be helpful in predicting LVO stroke cluster events.

BackgroundThe mechanisms and outcomes in coronavirus disease (COVID-19)-associated stroke are unique from those of non-COVID-19 stroke.ObjectiveTo describe the efficacy and outcomes of acute revascularization of large vessel occlusion (LVO) in the setting of COVID-19 in an international cohort.MethodsWe conducted an international multicenter retrospective study of consecutively admitted patients with COVID-19 with concomitant acute LVO across 50 comprehensive stroke centers. Our control group constituted historical controls of patients presenting with LVO and receiving a mechanical thrombectomy between January 2018 and December 2020.ResultsThe total cohort was 575 patients with acute LVO; 194 patients had COVID-19 while 381 patients did not. Patients in the COVID-19 group were younger (62.5 vs 71.2; P < .001) and lacked vascular risk factors (49, 25.3% vs 54, 14.2%; P = .001). Modified thrombolysis in cerebral infarction 3 revascularization was less common in the COVID-19 group (74, 39.2% vs 252, 67.2%; P < .001). Poor functional outcome at discharge (defined as modified Ranklin Scale 3-6) was more common in the COVID-19 group (150, 79.8% vs 132, 66.7%; P = .004). COVID-19 was independently associated with a lower likelihood of achieving modified thrombolysis in cerebral infarction 3 (odds ratio [OR]: 0.4, 95% CI: 0.2-0.7; P < .001) and unfavorable outcomes (OR: 2.5, 95% CI: 1.4-4.5; P = .002).ConclusionCOVID-19 was an independent predictor of incomplete revascularization and poor outcomes in patients with stroke due to LVO. Patients with COVID-19 with LVO were younger, had fewer cerebrovascular risk factors, and suffered from higher morbidity/mortality rates.

Introduction: Most patients undergoing thrombectomy fail for full reperfusion. The present study tested whether small extracellular vesicles (sEVs) from stroke patient clots impair cerebral endothelial cell (CEC) function, which may contribute to dysfunction of downstream CECs, leading to reduction of cerebral tissue perfusion. Methods: Per IRB-approved protocol, clots were collected from 60 patients (30 males) with acute ischemic stroke subjected to thrombectomy. Red and white clots were determined by immunochemistry. Clot-sEVs were isolated and characterized using ultracentrifugation, size distribution, and Western blot. The effects of clot-sEVs on human CEC (hCEC) permeability and proteins were measured using trans-endothelial assay and trans-endothelial electrical resistance (TEER) and Western blot, respectively. Nystatin, an inhibitor of caveolin-dependent endocytosis, was employed to study hCEC uptake of clot-sEVs. Results: Clot-sEVs had a mean size of 73±2nm. Cellular source analysis of clot-sEVs revealed that 22%, 30%, and 44% of sEVs from red clots and 28%, 28%, and 52% of sEVs from white clots were from neutrophils, endothelial cells, and platelets, respectively. Compared to sEVs derived from donor plasma (plasma-sEVs), treatment of hCECs with clot-sEVs significantly increased cell permeability (227% vs 100% of plasma-sEVs) and reduced TEER (66.6ω.cm 2 vs 87.3ω.cm 2 ). Clot-sEVs significantly increased pro-inflammatory and pro-coagulation proteins in the hCECs including ICAM1, VCAM1, TNF-a, HMBG1, tissue factor, and significantly reduced tight junction proteins ZO-1 and Claudin-5. The effects of white clot-sEVs on hCEC dysfunction were greater than red clot-sEVs. Nystatin significantly reduced hCEC uptake of clot-sEV from 232% to 142% and the clot-sEV-increased permeability. Moreover, Pearson correlation showed that the severity of clot-sEV impaired hCEC function was significantly correlated with final TICI scores of the individual patients (permeability vs TICI, r=-0.3348, p=0.02; TEER vs TICI, r=0,3666, p=0.01). Conclusion: Clot-sEVs contribute to hCEC dysfunction by augmenting pro-inflammatory and pro-coagulation proteins. Blocking uptake of clot-sEVs by recipient cells may improve patient outcomes.

Introduction: Exosomes (~30-150nm microvessicles [MVs]), are important mediators of cell-cell communication and have been associated with injurious and neuroprotective processes in experimental stroke models. Since many patients treated with mechanical thrombectomy (MT) do not improve despite successful recanalization we hypothesized that these exosomes may mediate injurious processes leading to worse outcomes. Methods: As part of an IRB approved protocol we analyzed arterial blood and retrieved clots aspirated during MT from patients with anterior circulation LVO. MVs were isolated and their effects on BBB permeability and endothelial monolayer integrity measured by transepithelial/endothelial electrical resistance (TEER) in cultured human endothelial cells were measured. Following adjustment for age, DM, NIHSS this effect was also correlated (Pearson R) with NIHSS, RAPID™ CTP parameters, TICI score, BP post MT, 24hr ASPECTS, ICH incidence and mRS. Results: Forty-eight patients were enrolled; mean age was 71±14yrs, 56% were female and 20% were African-American. Mean NIHSS was 16±6.6 with a median baseline ASPECTS score of 9 (range 3-10). Baseline CTP parameters (N=21) were: infarct core 25.8±38.5cc, mismatch volume 103±72.2cc and hypoperfusion index (Tmax>10s/Tmax>6s) 0.34±0.25. Recanalization (TICI 2b/c/3) was achieved in 93.8%. The median 24hr ASPECTS was 7 (range 0-10). At last follow-up 43.5% of patients achieved a good outcome (mRS Conclusions: Arterial aspirate derived MVs can be isolated from LVO stroke patients. Their effects on BBB permeability and endothelial integrity significantly correlated with clinical and radiographical markers of poor outcomes. It is therefore plausible that clot derived exosomes may impact neurological outcomes following MT through endothelial and BBB injury. In addition, these in vitro BBB measures may serve as biomarkers for post-stroke outcomes.

Background: We propose that social distancing policies during COVID-19 may have negatively impacted the timely administration of intravenous tPA and mechanical thrombectomy (MT) in acute ischemic strokes (AIS). Methods: In this retrospective study conducted at 2 large stroke centers serving Southeast Michigan, we included consecutive patients admitted to our stroke unit from 3/20/20 to 5/20/20 (COVID) and a similar epoch in 2019 (pre-COVID). We compared demographics and time metrics. Results: 247 patients with AIS were included in the tPA analysis, 167 (68%) in 2019 vs 80 (32%) in 2020. Overall mean age was 67.2, 60% male and 49% African Americans (AA). tPA was given in 13/80 in 2019 vs 17/167 patients in 2019 (16% vs 10%, p=0.143). There was no difference in tPA rates between AA and non-AA in 2020. There was a trend toward faster tPA administration in 2020 vs 2019 (median: 37.8 vs 51 min, p=0.051), significant among AA (37.8 vs 58.8 min, p=0.029). Mild/rapidly improving strokes was less frequently a tPA exclusion in 2020 vs 2019 (0% vs 10%). Delayed presentation was significantly less frequent among non-AA in 2020 vs 2019 (54% vs 66%, p=0.045) but there was a trend toward more frequent delayed presentations in AA vs non-AA in 2020 (76 vs 54%, P=0.073). 69 patients were eligible to receive MT, 42 (61%) in 2019 and 27 (39%) in 2020. Mean age was 67.9 and 36% were AA. No differences were detected between 2019 and 2020 in MT rates or time metrics. In 2020, there was a slight trend toward lower MT rates for AA vs non-AA patients (69% vs 30%, p=0.10). Conclusion: During the COVID-19 pandemic in Detroit there was a trend toward faster tPA administration compared to the same period pre-COVID, especially among AA. There was no significant difference in MT rates or time metrics. In our AA-majority city, there was a trend towards more delayed presentations and lower MT rates among AA during COVID. The reasons for these differences are yet to be determined and warrant further research.

Background: Treatment of patients with cerebral large vessel occlusion with thrombectomy and tissue plasminogen activator (tPA) often leads to incomplete reperfusion. There is a compelling need to develop therapies to enhance the perfusion and to improve neurological outcomes. Methods: Using rat models of embolic middle cerebral artery occlusion (eMCAO) and transient MCAO (tMCAO), we investigated the effect of small extracellular vesicles (sEVs) derived from healthy rat cerebral endothelial cells (CECs) administered intravenously in combination with tPA (CECs/tPA) and as an acute intraarterial adjunct therapy with mechanical reperfusion on stroke outcomes. Recanalization, cerebral blood flow (CBF), and blood-brain barrier (BBB) permeability were analyzed. MicroRNAs (miRs) and proteins were analyzed in CECs harvested from ischemic rats by RT-PCR and Western blots. Transmission electron microscopy was employed to analyze the brain distribution of CEC-sEVs. The effect of sEVs derived from clots acquired from patients undergone thrombectomy was tested on human CEC permeability. Results: CEC-sEVs/tPA given 4h after eMCAO or CEC-sEVs given upon reperfusion after 2h tMCAO significantly reduced infarct volume by ~36% and ~43%, respectively, and robustly improved neurological outcomes compared with tPA or ischemia/reperfusion alone (n=10 rats/group). CEC-sEVs/tPA and upon reperfusion after eMCAO or tMCAO, resepectively, significantly increased recanalization of the occluded MCA, enhanced CBF and reduced BBB leakage. CEC-sEVs/tPA substantially reduced a network of microRNAs and proteins that mediate thrombosis, coagulation and inflammation in CECs. Moreover, CEC-sEVs intravenously administered crossed the BBB and were internalized by CECs cells, astrocytes, and neurons. Stroke patient-clot derived exosomes impaired human CEC permeability and upregulated pro-inflammatory and -coagulatant proteins, which were blocked by CEC-sEVs. Conclusion: CEC-sEVs have a therapeutic effect on acute ischemic stroke in rats by reducing neurovascular damage. Suppressing the network of pro-thrombotic, -coagulant and -inflammatory microRNAs and proteins in CECs by CEC-sEVs likely contributes to the therapeutic effect of CEC-sEVs.

Treatment of patients with cerebral large vessel occlusion with thrombectomy and tissue plasminogen activator (tPA) leads to incomplete reperfusion. Using rat models of embolic and transient middle cerebral artery occlusion (eMCAO and tMCAO), we investigated the effect on stroke outcomes of small extracellular vesicles (sEVs) derived from rat cerebral endothelial cells (CEC-sEVs) in combination with tPA (CEC-sEVs/tPA) as a treatment of eMCAO and tMCAO in rat. The effect of sEVs derived from clots acquired from patients who had undergone mechanical thrombectomy on healthy human CEC permeability was also evaluated. CEC-sEVs/tPA administered 4 h after eMCAO reduced infarct volume by ∼36%, increased recanalization of the occluded MCA, enhanced cerebral blood flow (CBF), and reduced blood-brain barrier (BBB) leakage. Treatment with CEC-sEVs given upon reperfusion after 2 h tMCAO significantly reduced infarct volume by ∼43%, and neurological outcomes were improved in both CEC-sEVs treated models. CEC-sEVs/tPA reduced a network of microRNAs (miRs) and proteins that mediate thrombosis, coagulation, and inflammation. Patient-clot derived sEVs increased CEC permeability, which was reduced by CEC-sEVs. CEC-sEV mediated suppression of a network of pro-thrombotic, -coagulant, and -inflammatory miRs and proteins likely contribute to therapeutic effects. Thus, CEC-sEVs have a therapeutic effect on acute ischemic stroke by reducing neurovascular damage.

Pial collateral perfusion to the ischemic penumbra plays a critical role in determining patient outcomes in acute stroke. We aimed to assess the validity and reliability of an intra-procedural technique for measuring and quantifying the pial collateral pressure (QPCP) to ischemic brain tissue during acute stroke secondary to LVO. QPCP measurements were correlated with standard computed tomography angiography (CTA) and digital subtraction angiography imaging assessments of pial collateral perfusion and outcomes after mechanical endovascular revascularization (MER). This prospective cohort study included 60 consecutive patients with middle cerebral artery (MCA)–M1 and proximal M2 occlusions. QPCP measurements were obtained during MER. The validity of QPCP measurements was evaluated using four widely accepted collateral grading scales. QPCP measurements were also analyzed as a predictor of patient outcomes utilizing National Institute of Health Stroke Scale reduction at 24 h and modified Rankin Scale (mRS) scores at 30 days. QPCP measurements and QPCP ratio (QPCP/systemic mean arterial blood pressure) showed a statistically significant association with single-phase pretreatment CTA Maas and American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology binary grading scales. Patient outcomes demonstrated for every 10-unit increase in QPCP, the odds of mRS 0-2 at 30 days increased by 76% (p = 0.019). QPCP measurements related best with the pretreatment CTA Maas collateral grading scale but were more strongly associated with patient outcomes than any of the four widely accepted collateral grading scales. Greater QPCP was significantly associated with better overall patient outcomes as defined by mRS at 30 days.

Coronavirus disease 2019 (COVID-19) is associated with a severe inflammatory response. Inflammation affects atherosclerotic plaque vulnerability and promotes a thrombogenic environment. We report a series of 6 patients with COVID-19 with acute ischemic stroke due to intraluminal carotid artery thrombus presenting during an 8-day period. Six patients were included (5 men) with a mean age of 65.8 years (range, 55–78 years). COVID-19 was diagnosed by detection of Severe Acute Respiratory Syndrome coronavirus 2 in 5 patients and was presumed due to typical clinical and imaging findings in 1 patient. All patients had vascular risk factors including diabetes (83%), hyperlipidemia (100%), and smoking (17%). Four patients presented with large infarcts with initial NIHSS scores of 24–30. During their hospitalization, all patients had elevated D-dimer and C-reactive protein levels, 5 patients had elevated lactate dehydrogenase and ferritin levels, 3 had elevated interleukin-6 levels, and 2 had elevated troponin levels. Inflammation related to COVID-19 may result in rupture of vulnerable atherosclerotic plaques, resulting in thrombosis and acute ischemic stroke.

Introduction: Patient outcomes after Mechanical Endovascular Revascularization (MER) are dependent on both patient-specific and procedure-specific factors. The pial collateral perfusion to the ischemic penumbra during a cerebral large vessel occlusion (LVO) is one of the most important factors in overall patient outcome. Using our technique of Quantifying of Pial Collateral Perfusion (QPCP) previously described, patient outcomes after MER for cerebral LVO were assessed. Methods: Fifty consecutive patients with proximal middle cerebral artery M1 occlusions for whom QPCP were recorded were included in the study. In addition to patient demographics, the primary outcomes investigated were National Institutes of Health Stroke Scale (NIHSS) scores post-procedure reduction compared to pre-procedure score, and modified Rankin Scale (mRS) score at 30-day and 3-month follow-up. In addition, overall stroke volume, time spent in hospital, and the incidence of hemorrhagic conversion were also assessed. Regression models were used to estimate the association between pial collateral perfusion pressure and the above outcomes. Results: Patients demonstrated for every 5-unit increase in pial collateral perfusion pressure (measured in mmHg) an association with a 0.54-unit decrease in the post-procedure NIHSS score with a P-value of 0.07 (β= -0.54; 95% CI -1.12,0.03). A 5-unit increase in pial collateral perfusion pressure was also associated with 11% lower odds of having a 30-day mRS of 4-5 vs. 0-1 or 2-3 with a P-value of 0.18 (OR=0.89; 95% CI 0.75,1.06). A higher pial collateral perfusion pressure was also associated with a 0.07-unit decrease in the log of the stroke volume (P-value - 0.32). There was no association with higher pial collateral perfusion pressure and incidence of hemorrhagic conversion on post-procedure imaging. Conclusions: The QPCP is an objective measure for predicting patient outcomes after MER for cerebral LVO. Higher pial collateral perfusion pressures are associated with greater improvements in post-reperfusion NIHSS scores and 30-day mRS scores.

Background: Mechanical thrombectomy (MT) for acute ischemic stroke (AIS) in the elderly presents a unique set of challenges and opportunities. Most existing studies include patients up to the age of 90 with stricter criteria of inclusion for patients ≥ 80 years of age. The following study compares the outcomes in octogenarians compared to younger patients in a single center. Methods: We conducted a retrospective chart review of patients who were ≥ 80yo who underwent MT from March 2016 to July 2019. Data on age, recanalization score measured by Thrombolysis in Cerebral Infarction (TICI) score and clinical outcomes were compared to 126 patients < 80 years of age treated during the same time period. Clinical outcomes were classified based on modified Rankin score (mRS) at discharge. Poor outcomes were defined as mRS 4-6. Good recanalization was defined as TICI score 2b or 3. Results: Eighty-three patients with a median age of 86±4.34yo were compared to 126 patients with median age of 63±12.48yo (p Conclusion: In our cohort, the clinical outcomes among octogenarians receiving MT were worse than in younger patients despite no difference in recanalization. Various factors may be responsible including overall health status, comorbid conditions and neuroplasticity. Further prospective multicentral studies are needed to better understand the benefit of MT in octogenarians.

Background: Mechanical endovascular reperfusion therapy (MER) has become standard of care for treatment of large vessel occlusion (LVO) acute ischemic strokes (AIS) within 24 hrs of last known well. Nearly 25% of all stroke patients have a recurrent event in 5 years. Intravenous alteplase use in AIS patients with recent ischemic stroke history is avoided due to the risk of intracranial hemorrhage, but this may not be the case for MER. Bouslama et al found no statistically significant differences in reperfusion rates, hemorrhagic complications, clinical outcomes, and mortality between patients who had repeated thrombectomy (RT) and those who had a single thrombectomy. Methods: This is a retrospective case series study of endovascular database for patients who underwent RT in our institution from March 2016 till March 2018. Demographic, clinical, procedural date, imaging and clinical outcomes were evaluated. Results: Total 145 patients with AIS received MER, 8 (5.5%) RT occurred in 5 patients. Mean age was 67 ± 21 years. Four of the five patients were females. All patients achieved successful reperfusion (TICI 2b-3). Three patients underwent one RT, one had two RT, and one had three RT. The average time between consecutive MER (8 total periods) was 106 days. The time between the first to last MER for each patient ranged from 3 days to 2 years. All patients were optimized on their medical therapy after the first stroke. Four of the five patients (80%) had RT in the same vascular territory. One patient had post procedure focal high grade stenosis after the 3 rd intervention in the same artery that was treated with elective angioplasty. One RT was complicated with fatal intracranial hemorrhage due to late presentation despite presence of large area of penumbra. Average MRS was 2.4. Conclusion: In patients presented with recurrent LVO, RT appears to be effective and relatively safe. Based on the available literature, prior MER should not discourage aggressive treatment that might lead to a good clinical outcome. It is unclear if prior MER therapy causes endothelial injury with risk for in situ de-novo stenosis or thrombus formation. Reperfusion injury risk in a recently infarcted territory should be weighted carefully when considering as hemorrhagic complications remain possible.

Distal fusiform aneurysms of the superior cerebellar artery (SCA) are rare and present several challenges to clinicians, especially when ruptured. While several treatment options are available, including surgical clipping and endovascular coiling, numerous challenges still remain due to the presence of vital neighboring neurovascular structures. In addition, the complications that arise due to the compromise of brainstem perforators make these aneurysms difficult to treat. This case report demonstrates the successful treatment of a ruptured fusiform aneurysm of the SCA with a flow-diverting device. We also conducted a literature review of the use of flow-diverting devices for treating such aneurysms. When choosing a treatment modality for a ruptured aneurysm, clinicians must consider both the patient-specific variables as well as aneurysm morphology. Treatment options including microsurgical clipping, endovascular coiling, and flow diversion carry risks. Therefore, the clinician must decide which option best fits each situation.

Study Objective Uterine arteriovenous malformations (AVMs) are rare occurrences, diagnosed radiologically, and often associated with bleeding and a history of uterine instrumentation. The objective of our study was to assess our health system's rate of overdiagnosis of uterine AVM on pelvic ultrasound. Design A retrospective chart review was performed from 2008 to present including patients who had the word “AVM” mentioned in their pelvic ultrasound reports. These reports were reviewed, and patients were included in the study if the ultrasound report had language that either stated that uterine AVM could not be excluded from the differential diagnosis for bleeding or that AVM was likely. Patients were excluded if the report stated that based on the US findings AVM was unlikely or virtually ruled out. Patients were deemed to have a true AVM if confirmed by subsequent MRI or angiography. Setting Data was extracted from Henry Ford Health System's electronic medical record extending from 2008 to present. The patient population sampled was from Southeast Michigan. Patients or Participants Women who presented with vaginal bleeding and underwent pelvic ultrasound. Interventions None. Measurements and Main Results 120 charts were reviewed that met our inclusion criteria. Of these, 19 (16%) were confirmed uterine AVM by either angiogram or MRI. An additional 21 (17%) had suspected AVMs but did not undergo confirmatory diagnosis. 80 (66%) had uterine AVM suggested as a diagnosis on their ultrasound report but were ultimately diagnosed with an alternative pathology, either clinically or with imaging. Our data show that 60% of AVM diagnoses on ultrasound reports were likely an overdiagnosis. 43 (35%) of these patients were treated for retained products of conception either surgically or medically. Conclusion Overdiagnosis is clinically important not only due to cost implications, but because in the setting of true uterine AVM, surgical treatment for retained products via D&C is contraindicated.

Background: Man-in-the-barrel syndrome (MBS) is an uncommon clinical condition for which patients present with bilateral brachial diplegia but intact lower extremity strength. This syndrome is typically attributed to a cranial/cortical injury rather than a spinal pathology. Case Description: A 62-year-old diabetic male presented with bilateral upper extremity paresis attributed to a ventral cervical epidural abscess diagnosed on magnetic resonance imaging. Emergent cervical decompression resulted in slight improvement of upper extremity strength. However, he later expired due to sepsis and respiratory compromise. Conclusion: Establishing the correct diagnosis via clinical examination and proceeding with appropriate management of MBS attributed to a cervical epidural abscess is critical to achieve a good outcome.

To evaluate the effects of preoperative embolization on overall surgical outcomes after meningioma resection and determine whether pre- and postembolization tumor enhancement patterns on magnetic resonance imaging (MRI) scans can be used to assess the efficacy of embolization.We developed a prospective database of all patients who underwent surgical resection with or without preoperative embolization for extra-axial intracranial meningiomas from 2004 to 2010. Using specialized computer software, the total volume of enhancement was calculated in pre- and postembolization MRI scans to quantify the percentage of embolization, which was described as the embolization fraction (EF).A total of 89 patients underwent surgical resection. Fifty two patients underwent embolization prior to surgery. Tumor location significantly correlated with the decision to embolize preoperatively. Adequate embolization was achieved in 58% of patients. Forty four patients (84.6%) had a postsurgical Karnofsky performance score (KPS) of 80 or above, while 46 patients (88.4%) had a postsurgical Glascow Outcome Score (GOS) of 4 or 5. The mean EF was 25.03% with a median of 18.72%. A greater extent of embolization as quantified by EF led to decreased intraoperative blood loss (r = -.319, P = .022) and better postsurgical outcomes as defined by KPS (r = .279, P = .044).Pre- and postembolization tumor enhancement patterns on magnetic resonance imaging defined as EF correlate with improved surgical facilitation and postoperative functional outcomes in the management of intracranial meningioma.

The Henry Ford Hospital (HFH) was founded in 1915 as a philanthropic gift from Henry Ford, the automobile magnate and inventor of the Model T. The hospital and its organizational structure represented a nonsectarian facility that would provide care for all members of society. The system was patterned after the newest and most modern medical centers at the time in Europe, Canada, and the United States, including the German Krankenhauser, the Johns Hopkins Hospital, the Mayo Clinic, and the Peter Bent Brigham Hospital in Boston. The HFH grew into the Henry Ford Health System in the 1970s to 1990s, with the acquisition of other hospitals, the development of a multiple-region-based clinic system through southeastern Michigan, and the development of comprehensive, vertically integrated health care systems. The Division of Neurosurgery at HFH was established by Albert Crawford in 1926. The tradition of training residents in neurosurgery began in 1946, and the residency training program was accredited by the American Board of Neurosurgery in 1954. In 1970, the Division of Neurosurgery of the Department of Surgery was combined with the Division of Neurology to create the joint Department of Neurology and Neurosurgery. A separate Department of Neurosurgery was established in 1981. Four individuals have served as chairmen of the Department of Neurosurgery at HFH, i.e., Albert Crawford (1926-1952), Robert Knighton (1952-1978), James Ausman (1978-1991), and Mark Rosenblum (1992 to the present). During the 1980s and 1990s, HFH evolved into the vertically integrated, regionally distributed Henry Ford Health System. Under the current direction of Dr. Rosenblum, the Department of Neurosurgery at HFH has grown to include 11 full-time neurosurgeons, 2 neuro-oncologists, and 3 investigators with Ph.D. degrees and has recently expanded into three additional hospitals in southeastern Michigan, paralleling the growth of the system. The faculty annually treats more than 2,000 cases in all neurosurgical subspecialties, ranging from neuro-oncological surgery, cranial base surgery, radiosurgery, cerebrovascular surgery, epilepsy surgery, treatment of movement disorders, pain and spasticity surgery, pediatric neurosurgery, and neurotrauma treatment to complex instrumentation of the spine. This article chronicles the history of the Henry Ford Health System and the Department of Neurosurgery, its research endeavors, and its residency training program.

The neurosurgical literature contains little information about the current management of patients with thyroid-stimulating hormone (TSH)-secreting pituitary adenomas or about the usefulness of the somatostatin analogue octreotide in such cases. While TSH-secreting pituitary adenomas are rare, our review and illustrative case demonstrate the effectiveness of pretreating patients with octreotide therapy not only to reduce tumor size prior to surgical resection but also to increase the possibility of clinical remission. A 52-year-old male presented with signs and symptoms of hyperthyroidism and elevated TSH, thyroxine, and triiodothyronine. Magnetic resonance imaging revealed a pituitary macroadenoma with extension into the suprasellar cistern. The patient was treated with octreotide for 6 months prior to surgery. Approximately 3 months after initiation of octreotide therapy, the patient exhibited excellent biochemical and clinical response. Tumor shrinkage of nearly 50% was associated with resolution of suprasellar extension and optic nerve compression. Subsequent transsphenoidal surgery for resection of residual adenoma was followed by symptomatic and hormonal remission without the need for reinstitution of octreotide therapy. Pretreatment with octreotide for TSH-secreting pituitary adenomas has a beneficial effect on disease symptoms and reduces tumor mass. We suggest that patients with these rare tumors can be managed with a combination of octreotide therapy and subsequent surgical removal of residual tumor. Although this combination treatment helps to facilitate clinical remission, only short-term follow-up has been reported and thus the optimal management of these patients remains to be determined.

ObjectThe authors report their results in a series of large or giant carotid ophthalmic segment aneurysms clipped using retrograde suction decompression.MethodsA retrospective review of clinical data and treatment summaries was performed for 18 patients with large or giant carotid artery ophthalmic segment aneurysms managed operatively via retrograde suction decompression. Visual outcomes, Glasgow Outcome Scale (GOS) scores, and operative complications were determined. Postoperative angiography was assessed.ResultsDuring a 17-year period, 18 patients underwent surgery performed using retrograde suction decompression. The mean aneurysm size was 26 mm. Three patients presented with subarachnoid hemorrhage. Fourteen of 18 patients presented with visual symptoms. Eleven (79%) of these 14 patients experienced visual improvement and the remaining 3 (21%) experienced worsened vision after surgery. Of 3 patients without visual symptoms and a complete visual examination before and after surgery, 1 had visual worsening postoperatively. One aneurysm required trapping and bypass, and all others could be clipped. Postoperative angiography demonstrated complete occlusion in 9 of 17 clipped aneurysms and neck remnants in the other 8 clipped aneurysms. One (5.5%) of 18 patients experienced a stroke. Eighteen patients had a GOS score of 5 (good outcome), and 1 patient had a GOS score of 4 (moderately disabled). There were no deaths. There was no morbidity related to the second incision or decompression procedure. Prolonged improvement did occur, and even in some cases of visual worsening in 1 eye, the overall vision did improve enough to allow driving.ConclusionsRetrograde suction decompression greatly facilitates surgical clipping for large and giant aneurysms of the ophthalmic segment. Visual preservation and improvement occur in the majority of these cases and is an important outcome measure. Developing endovascular technology must show equivalence or superiority to surgery for this specific outcome.

The authors reviewed their experience in 7 cases of nonacute intracranial occlusions and near occlusions in which the patients underwent intracranial angioplasty and stent implantation for direct cerebral revascularization.Between 2005 and 2008, 4 men and 3 women underwent direct cerebral revascularization of nonacute intracerebral occlusions or near occlusions. Five patients had chronic angiographically documented occlusion and 2 patients had chronic angiographically documented near occlusions. The locations of the treated vessels included 2 supraclinoid internal carotid arteries, 4 middle cerebral arteries, and 1 vertebral artery. Prior to intervention, all patients were symptomatic and experienced strokes ipsilateral to their occlusions. In addition, all patients had clinical or radiographic evidence of ongoing hemodynamic compromise. Five patients underwent successful intracranial angioplasty and stent placement and 2 patients underwent successful intracranial balloon angioplasty alone. The mean time from documented vessel occlusion to treatment was 35 days. All patients had successful revascularization determined using the Thrombolysis in Cerebral Infarction (TICI) scale: TICI Score 3, 2b, and 2a in 4, 2, and 1 patient, respectively, and the mean residual stenosis was 38%.After uneventful technical procedures, 1 patient suffered a perforator vessel stroke and 1 patient suffered a fatal hemorrhage. Mean modified Rankin Scale score of 2 (range 1-5) and mean Glasgow Outcome Scale score of 4 (range 1-6) were achieved during a mean clinical follow-up period of 399 days (range 1-840 days). Asymptomatic restenosis was documented in 4 patients, 1 underwent bypass retreatment, and 1 patient received repeated balloon angioplasty.Combined intracranial angioplasty and stent placement is a potential treatment option in selected patients for the direct revascularization of nonacute intracranial occlusions and near occlusions. Whether this represents a substantial risk reduction compared with the best medical therapy or a long-lasting treatment option is unknown.

WEB This is a Web exclusive article. ntercostal arteriovenous malformations (AVMs) and fistulas (AVFs) are rare lesions, and few case reports have been published [1–7]. Most have been secondary to trauma or iatrogenic therapeutic procedures [1–6], and one case was presumably congenital in origin. All have had single arterial feeders and draining veins. We present a case of congenital intercostal AVM in a young patient initially diagnosed on the basis of MRI findings and treated by a combination of transarterial and transvenous endovascular therapy and direct surgery.

Study design Case report. Objectives The objective of this study was to document the long-term follow-up of a single case. Summary of background data Radiosurgery is potentially a useful therapeutic option for spinal tumors. The authors present the unusual case of a patient with recurrent extraosseous Ewing's sarcoma of the lumbar spine, who experienced excellent clinical, radiographic, and oncologic response without complications after treatment with dedicated Novalis Shaped Beam Radiosurgery (Brain Lab, Inc.). Methods Observational. Results We observed excellent clinical and oncologic control at 1-year posttreatment. Conclusion Radiosurgery may be a valuable treatment option for recurrent spinal tumors.

Dural arteriovenous fistula (DAVF) is a rare type of cerebral arteriovenous malformation. Common presenting symptoms are related to hemorrhage. However, rarely these patients may present with myelopathy. We present two cases of DAVF presenting as rapidly progressive myelopathy. Two treatment options are available: microsurgical interruption of the fistula and endovascular embolization. These treatment options of DAVFs have improved significantly in the last decade. The optimal treatment of DAVFs remains controversial, and there is an ongoing debate as to whether primary endovascular or primary microsurgical treatment is the optimal management for these lesions. However, despite treatment a high percentage of patients are still left with severe disability. The potential for functional ambulation in patients with DAVF is related to the time of intervention. This emphasizes the important of early diagnosis and early intervention in DAVF. The eventual outcome may depend on several factors, such as the duration of symptoms, the degree of disability before treatment, and the success of the initial procedure to close the fistula. The usage of magnetic resonance imaging and selective angiography has significantly improved the ability to characterize DAVFs, however, these lesions remain inefficiently diagnosed. If intervention is delayed even prolonged time in rehabilitation does not change the grave prognosis. This review outlines the presentation, classication and management of DAVF as well as discussing patient outcomes.

Object. The goal of this study was to compare the freehand technique of catheter placement using external landmarks with the technique of using the Ghajar Guide for this procedure. The placement of a ventricular catheter can be a lifesaving procedure, and it is commonly performed by all neurosurgeons. Various methods have been described to cannulate the ventricular system, including the modified Friedman tunnel technique in which a soft polymeric tube is inserted through a burr hole. Paramore, et al., have noted that two thirds of noninfectious complications have been related to incorrect positioning of the catheter.Methods. Forty-nine consecutive patients were randomized between either freehand or Ghajar Guide—assisted catheter placement. The target was the foramen of Monro, and the course was through the anterior horn of the lateral ventricle approximately 10 cm above the nasion, 3 cm from the midline, to a depth of 5.5 cm from the inner table of the skull. In all cases, the number of passes was recorded for successful cannulation, and pre- and postplacement computerized tomography scans were obtained. Calculations were performed to determine the bicaudate index and the distance from the catheter tip to the target point.Conclusions. Successful cannulation was achieved using either technique; however, the catheters placed using the Ghajar Guide were closer to the target.