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Chronic subdural hematoma (CSDH) is an increasingly prevalent disease in the aging population. Patients with CSDH frequently suffer from concurrent vascular disease or develop secondary thrombotic complications requiring antithrombotic treatment.To determine the safety and impact of early reinitiation of antithrombotics after middle meningeal artery embolization for chronic subdural hematoma.This is a single-institution, retrospective study of patients who underwent middle meningeal artery (MMA) embolizations for CSDH. Patient with or without antithrombotic initiation within 5 days postembolization were compared. Primary outcome was the rate of recurrence within 60 days. Secondary outcomes included rate of reoperation, reduction in CSDH thickness, and midline shift.Fifty-seven patients met inclusion criteria. The median age was 66 years (IQR 58-76) with 21.1% females. Sixty-six embolizations were performed. The median length to follow-up was 20 days (IQR 14-44). Nineteen patients (33.3%) had rapid reinitiation of antithrombotics (5 antiplatelet, 11 anticoagulation, and 3 both). Baseline characteristics between the no antithrombotic (no-AT) and the AT groups were similar. The recurrence rate was higher in the AT group (no-AT vs AT, 9.3 vs 30.4%, P = .03). Mean absolute reduction in CSDH thickness and midline shift was similar between groups. Rate of reoperation did not differ (4.7 vs 8.7%, P = .61).Rapid reinitiation of AT after MMA embolization for CSDH leads to higher rates of recurrence with similar rates of reoperation. Care must be taken when initiating antithrombotics after treatment of CSDH with MMA embolization.

Background: First pass complete or near complete reperfusion defined as a modified Thrombolysis in Cerebral Infarction (mTICI) 2c/3 is the target for endovascular thrombectomy (EVT). Here, we examine whether additional passes in patients who achieve a first pass mTICI 2b, in order to attain mTICI 2c/3, improve clinical outcomes. Methods: From our prospectively maintained institutional registry at 4 comprehensive stroke centers, we identified patients treated with EVT (11/2017-12/2021). Per-pass mTICI grades were recorded at the time of the procedure. The primary outcome was functional independence rates at 90 days (mRS 0-2) in first pass mTICI 2b patients compared with multiple passes mTICI 2c/3 patients. Results: A total of 857 EVT patients were identified in the study period. The median age was 68 [58-79], 49.7% were female, median NIHSS was 16 [11-21], median ASPECTS was 9 [7-10], and 64% had MCA occlusions. First pass mTICI 2c/3 (FP-mTICI 2c/3) was achieved in 342 (39.9%) cases and first pass mTICI 2b (FP-mTICI 2b) was achieved in 123 (14.4%) patients. Of the FP-mTICI 2b group, 27 (21.9%) patients received additional passes to reach complete reperfusion. Good functional outcome was observed in 159 patients (46.5%) of the FP-mTICI 2c/3 reperfusion group as compared to 27 patients (28.1%) in the FP-mTICI 2b group (p=0.002). The rate of good functional outcome was not significantly different for patients who achieved mTICI 2c/3 following additional passes after a first pass mTICI 2b (28.1 vs. 29.6%, first pass mTICI 2b vs. first pass mTICI 2b with final mTICI 2c/3, p=0.954). Adjusted for age, sex and NIHSS at presentation, patients with FP-mTICI 2c/3 had a better chance of good outcomes than patients with FP-mTICI 2b (OR 2.23, 95% CI [1.38-3.62]). In multivariable analysis adjusting for age, sex, and NIHSS at presentation, patients with FP-mTICI 2b reperfusion followed by improved reperfusion to mTICI 2c/3 did not have better outcomes than patients with FP-mTICI 2b reperfusion (OR 1.14, 95% CI [0.41-3.12]). Conclusions: Additional EVT passes to achieve mTICI 2c/3 following a first pass mTICI 2b does not lead to significant improvement in functional outcomes. This study suggests that EVT can be terminated if FP-mTICI 2b-3 is achieved.

Carotid artery stenosis is a leading cause of ischemic stroke. While management of symptomatic carotid stenosis is well established, the optimal approach in asymptomatic carotid artery stenosis (aCAS) remains controversial. The rapid evolution of medical therapies within the time frame of existing landmark aCAS surgical revascularization trials has rendered their findings outdated. In this review, we sought to summarize the controversies in the management of aCAS by providing the most up-to-date medical and surgical evidence. Subsequently, we compile the evidence surrounding high-risk clinical and imaging features that might identify higher-risk lesions. With this, we aim to provide a practical framework for a precision medicine approach to the management of aCAS.

Background and Purpose: In spite of the increase of thrombolysis treatment rates at remote hospitals (spoke) due to implementation of telestroke systems, only 25% of telestroke patients who received tissue plasminogen activator (tPA) are transferred to a Comprehensive Stroke Center (CSC) in the United States. This leaves 3 out of 4 treated patients to receive their post-stroke care at telestroke spoke sites. As post-stroke rehabilitation is a pivotal component of recovery, we aimed to report outcomes of acute ischemic stroke (AIS) patients who received thrombolytic therapy, yet remained at a spoke hospital with a rehabilitation unit (RU). Methods: This was a retrospective review of the telestroke registry at our institution from January 2016 through July 2019. We included patients who received intravenous tPA at spoke sites and were not candidates to be transported to a CSC for mechanical thrombectomy (Drip-and-Stay paradigm). We compared baseline characteristics, discharge disposition, and excellent outcome [defined as a 90-day Modified Rankin Scale (mRS) of 0-1] of patients who remained at spoke sites with a RU to patients at spoke sites without a RU. A logistic regression model was used to assess the effect of RU on the possibility of having excellent outcomes controlling for confounding factors. Results: Of the 740 eligible AIS patients during the study period, 40% (n=294) received post-stroke care at a spoke with a RU. There were no significant differences in patient age, sex, admission NIHSS, door to needle times, or length of stay between patients in both groups. More patients in the spoke with rehabilitation units were discharged home (62% vs. 52%, P=0.001). Excellent long-term functional outcome was reported in 66% (n=193) of patients remaining at spoke sites with RU versus 58% (n=285) at those without RU (P=0.033). On multivariate analysis, RU was an independent predictor of having excellent outcomes (OR 2.02, 95% CI 1.42-2.87, P Conclusions: Our study indicates a higher likelihood of both favorable discharge outcome and excellent long-term functional outcome in drip-and-stay patients who receive their post-stroke care at spoke sites with RU.

Introduction: Recently, two randomized controlled trials proved the safety and efficacy of mechanical thrombectomy in patients presenting up to 24 hours from symptom onset. While the number of patients receiving mechanical thrombectomy has increased following the publication of the extended time window trials, the literature on acute stroke calls over telestroke is relatively scant. In this study we evaluate the volume of telestroke calls, rate of transfers to the thrombectomy center and MT receipt before and after the extended window MT trials publication. Methods: We interrogated the prospectively collected data from a major telestroke network in Southeast the United States to include patients who received a telestroke consult between January 2015 and July 2019. We compared the demographical and clinical characteristics and the outcomes between patients who presented before and after the publication of the extended window mechanical thrombectomy trials. Results: Total of 7,438 patients were evaluated during the study period. Of those, 3392 were after February 2018. There was no difference in age, race, or sex between the two groups (table 1). Patients in the post extended window group had lower National Institute of Health stroke scale (NIHSS) on presentation (3 vs. 4, P Conclusion: The number of telestroke consults almost doubled since the publication of the extended thrombectomy trials without increase in the rate of MT receipt. These findings have important operational implications for hospitals implementing telestroke call coverage.