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

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

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

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

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

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

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

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

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

A 60-year-old caucasian woman was transferred from an outside hospital with one week history of severe headache, intermittent nausea, vomiting, and a one day history of episodes of dizziness, ataxia, and falls. An initial non-contrast computed tomographic of head demonstrated diffuse cerebral edema prompting transfer to our institution for further evaluation and management.

Background Hematoma volume in chronic subdural hematoma (CSDH) may predict neurologic deterioration and need for surgical evacuation. Several computer software–assisted methods exist for accurate volume measurements of intracerebral hemorrhage, but no reliable method has been identified for measurement of CSDH volume. Methods A total of 30 consecutive patients with CSDH from 2018–2019 admitted to our institution were selected. The noncontrast computed tomography head studies were reviewed by 2 residents. The region of interest method on a Horos Open Source Medical Image Viewer (version 3.3.6) was utilized for volume measurement by each resident (resident-1 and resident-2) independently. Resident-1 repeated the protocol on the same studies 1 month later. We calculated the intra- and interobserver reliability of hematoma volume measurements using the Bland–Altman method. Results Mean age of the patients was 79 years (range, 50–92 years). For interobserver analysis, resident-1 mean hematoma volume was 85.46 cm3 (range, 6.40–178.63 cm3) and was 87.15 cm3 (range, 8.79–165.97 cm3) for resident-2. The Bland–Altman coefficient of variation was 13.15% (range, 0.07%–46.29%, 97% within the limits of acceptance). For intraobserver analysis, the initial average volume measured by resident-1 was 85.46 cm3 (range, 6.40–178.63 cm3) and subsequent was 95.26 cm3 (range, 10.48–182.99 cm3). The Bland–Altman coefficient of variation was 13.76% (range, 0.81%–48.34%, 97% within the limits of acceptance). Conclusions We are reporting inter- and intraobserver reliability for a novel volumetric analysis of CSDH volume using Horos Medical Image Viewer region of interest generated volume calculation. This method is accurate and efficient and could have important clinical and research implications for risk stratification.