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Supplemental Digital Content is available in the text., Background and Purpose: Evaluation of the lung apices using computed tomography angiography of the head and neck during acute ischemic stroke (AIS) can provide the first objective opportunity to screen for coronavirus disease 2019 (COVID-19). Methods: We performed an analysis assessing the utility of apical lung exam on computed tomography angiography for COVID-19–specific lung findings in 57 patients presenting with AIS. We measured the diagnostic accuracy of apical lung assessment alone and in combination with patient-reported symptoms and incorporate both to propose a COVID-19 era AIS algorithm. Results: Apical lung assessment when used in isolation, yielded a sensitivity of 0.67, specificity of 0.93, positive predictive value of 0.19, negative predictive value of 0.99, and accuracy of 0.92 for the diagnosis of COVID-19, in patients presenting to the hospital for AIS. When combined with self-reported clinical symptoms of cough or shortness of breath, sensitivity of apical lung assessment improved to 0.83. Conclusions: Apical lung assessment on computed tomography angiography is an accurate screening tool for COVID-19 and can serve as part of a combined screening approach in AIS.

Background This study evaluates the mortality risk of patients with emergent large vessel occlusion (ELVO) and COVID-19 during the pandemic. Methods We performed a retrospective cohort study of two cohorts of consecutive patients with ELVO admitted to a quaternary hospital from March 1 to April 17, 2020. We abstracted data from electronic health records on baseline, biomarker profiles, key time points, quality measures and radiographic data. Results Of 179 patients admitted with ischemic stroke, 36 had ELVO. Patients with COVID-19 and ELVO had a higher risk of mortality during the pandemic versus patients without COVID-19 (OR 16.63, p = 0.004). An age-based sub-analysis showed in-hospital mortality in 60% of COVID-19 positive patients between 61-70 years-old, 66.7% in between 51-60 years-old, 50% in between 41-50 years-old and 33.3% in between 31-40 years old. Patients that presented with pulmonary symptoms at time of stroke presentation had 71.4% mortality rate. 27.3% of COVID-19 patients presenting with ELVO had a good outcome at discharge (mRS 0-2). Patients with a history of cigarette smoking (p = 0.003), elevated d-dimer (p = 0.007), failure to recanalize (p = 0.007), and elevated ferritin levels (p = 0.006) had an increased risk of mortality. Conclusion Patients with COVID-19 and ELVO had a significantly higher risk for mortality compared to COVID-19 negative patients with ELVO. A small percentage of COVID-19 ELVO patients had good outcomes. Age greater than 60 and pulmonary symptoms at presentation have higher risk for mortality. Other risk factors for mortality were a history of cigarette smoking, elevated, failure to recanalize, elevated d-dimer and ferritin levels.

Background Acute stroke resolution via endovascular thrombectomy requires transcarotid access when transfemoral access is not possible. Although postoperative complications such as cervical hematoma and airway compression have been reported, an appropriate postprocedural management is largely unknown yet. We aim to provide new insights and learning points from our experience using the Jaw Elevation Device (JED) as a tool to facilitate recovery post surgery. Case Description A 79-year-old female underwent endovascular thrombectomy via transcervical, transcarotid access for a left internal carotid artery occlusion. No intraprocedural complications were reported. After successful thrombectomy, manual compression was applied in the carotid artery, and to achieve neck immobilization a JED was used for 4 hours after the procedure. No complications occurred. Conclusions JED appears to be a reasonable option to facilitate patient recovery due to its capacity to maintain the airway, provide mild compression for hemostasis, and prevent cervical hematoma through a comfortable neck immobilization.

BACKGROUND AND PURPOSE: Our hypothesis is that the COVID-19 pandemic led to delayed presentations for patients with acute ischemic stroke. This study evaluates the impact of the coronavirus disease 2019 pandemic on presentation, treatment, and outcomes of patients with emergent large-vessel occlusion using data from a large health system in the Bronx, New York. MATERIALS AND METHODS: We performed a retrospective cohort study of 2 cohorts of consecutive patients with emergent large-vessel occlusion admitted to 3 Montefiore Health System hospitals in the Bronx from January 1 to February 17, 2020, (prepandemic) and March 1 to April 17, 2020 (pandemic). We abstracted data from the electronic health records on presenting biomarker profiles, admission and postprocedural NIHSS scores, time of symptom onset, time of hospital presentation, time of start of the thrombectomy procedure, time of revascularization, presenting ASPECTS, TICI recanalization score, mRS, functional outcomes, and mortality. RESULTS: Of 179 patients admitted with ischemic stroke during the study periods, 80 had emergent large-vessel occlusion, of whom 36 were in the pandemic group. Patients in the pandemic group were younger (66 versus 72 years, P

We present a radiology-pathology case series of 3 patients with coronavirus disease 2019 (COVID-19) with acute ischemic stroke due to fulminant carotid thrombosis overlying mild atherosclerotic plaque and propose a novel stroke mechanism: COVID-associated carotid atherothrombosis.

Background and Purpose: Mycotic aneurysms (MA) are rare neurovascular complications of infective endocarditis (IE). The natural history and outcomes of MA under contemporary medical therapy have not been well characterized. The purpose of this study is to describe treatments and outcomes of patients with ruptured and unruptured MA in IE, specifically in relation to medical versus surgical/endovascular treatment. Methods: Retrospective chart review was performed at 3 US academic medical centers of adult patients with IE and MA. Information was collected regarding risk factors, imaging, treatments, and outcomes, including ischemic stroke, intracerebral hemorrhage, MA size changes, and inhospital mortality. Results: Thirty-five patients with IE had 63 MA. Nineteen patients had at least one ruptured MA; 13 patients underwent invasive treatment and 6 received antibiotics alone. Of 19 patients on antibiotics alone (6 with at least one ruptured MA and 13 with unruptured MA), 14 underwent repeat imaging and 5 had enlarging MA. Of 16 patients treated invasively, 2 had unruptured MA initially treated with antibiotics but ultimately underwent intervention. No MA ruptured after aneurysm discovery. Fifteen patients underwent cardiothoracic surgery (CTS), of which 11 had unsecured MA and 4 had secured MA. No patients suffered perioperiative neurological events attributable to their MA. Three patients treated with antibiotics alone and 3 patients treated invasively died from causes unrelated to their MAs. Conclusions: For patients with unruptured MA, treatment with antibiotics alone may have similar outcomes to invasive treatment. Further investigation is warranted to determine the risk of undergoing CTS with unsecured MA.

Background and purpose Carotid artery webs are shelf-like protrusions of intimal fibrous tissue arising from the posterior wall of the carotid bulb, found to have a 2.3% prevalence in the United States (Sajedi et al., 2019). Previous studies have demonstrated its association with ipsilateral anterior circulation stroke. (Labeyrie et al., 2020; Yu et al., 2020) The aim of this study is to assess the prevalence of carotid webs in the largest US epidemiologic study to date, and to further characterize the clinical features of carotid web patients. Materials and methods We assembled a cohort of 1467 adult patients with CTA neck from 1/1/2011 - 1/1/2017. CTAs were reviewed for diagnosis of carotid web. Demographic and clinical details of web patients were obtained. Differences in demographics and CTA indication between patients with and without carotid web were assessed using appropriate statistical tests. Results 24 (24/1467=1.6%) carotid web patients were identified (mean age: 63 years; 62.5% female; 50% African American). Twelve (12/24=50%) had ipsilateral anterior circulation stroke. Of them, 8 were deemed cryptogenic. Four (4/24=16.7%) web patients had at least one recurrent stroke in the ipsilateral anterior circulation. One case was reported on the radiology report at the time the study was initially performed. Conclusion This study confirms a prevalence of 1.6% in our urban, North American cohort. Among carotid web patients, there was a high incidence of ipsilateral anterior circulation stroke, the majority of which were classified as cryptogenic. This study affirms the importance of the diagnosis of carotid web, especially in cryptogenic stroke patients, as a potential unrecognized stroke risk factor.

Background: Obstructive hydrocephalus is a neurologic condition that has varied clinical and imaging presentations, as well as a multitude of congenital etiologies including aqueductal stenosis and less commonly arachnoid cysts. Aqueductal stenosis is a physical limitation to cerebrospinal fluid flow along the course of the aqueduct, which results in enlargement of the third and lateral ventricles. Arachnoid cysts are thin walled and fluid filled central nervous system lesions that can result in mass effect on adjacent structures. While arachnoid cysts are mostly asymptomatic, they may present with neurological symptoms that vary depending on the location of the lesion. Suprasellar cysts in particular may cause obstructive hydrocephalus as well as endocrine dysfunction. Reversible cerebral vasoconstriction syndrome (RCVS) is an unusual condition caused by cerebral arterial vasoconstriction that often presents initially with a thunderclap headache. Frequently, there is some environmental trigger associated with this condition. RCVS more commonly affects women and can induce stroke. Case Description: A 57-year-old female presented to the emergency department with progressive headache and visual changes. Initial workup suggested the patient’s symptoms where related to RCVS but subsequent surgical management of what was presumed to be long standing, compensated hydrocephalus resulted in resolution of the patient’s symptoms. Conclusion: We report, to the best of our knowledge, the first case of aquedutal stenosis and suprasellar arachnoid cyst with concomitant RCVS. The presence of multiple pathologies found on radiologic imaging illustrates the challenges presented by incidental findings and subsequent anchoring bias in medical diagnosis.

Objective We aim to characterize the incidence, risk for mortality, and identify risk factors for mortality in patients presenting with hemorrhage and COVID-19. Methods This retrospective cohort study included a cohort of patients admitted to one of three major hospitals of our healthcare network including, an academic medical center and comprehensive stroke center, which accepts transfers for complex cases from eight community hospitals, during March 1 to May 1, 2020. All patients that received imaging of the neuroaxis and had positive PCR testing for COVID-19 were identified and reviewed by an attending neuroradiologist. Demographics and comorbidities were recorded. Biomarkers were recorded from the day of the hemorrhagic event. Vital signs from the day of the hemorrhagic event mechanical ventilation orders at admission were recorded. Imaging findings were divided into 5 subtypes; acute subdural hematoma (SDH), subarachnoid hemorrhage (SAH), multi-compartmental hemorrhage (MCH), multi-focal intracerebral hemorrhage (MFH), and focal intracerebral hemorrhage (fICH). Outcomes were recorded as non-routine discharge and mortality. Results We found a total of 35 out of 5227 patients with COVID-19 that had hemorrhage of some kind. Mortality for the entire cohort was 45.7 % (n = 16). SDH patients had a mortality rate of 35.3 % (n = 6), SAH had a mortality of 50 % (n = 1), MCH patients had a mortality of 71.4 % (n = 5), MFH patients had a mortality of 50 % (n = 2), fICH patients had a mortality of 40 % (n = 2). Patients with severe pulmonary COVID requiring mechanical ventilation (OR 10.24 [.43−243.12] p = 0.015), with INR > 1.2 on the day of the hemorrhagic event (OR 14.36 [1.69−122.14] p = 0.015], and patients presenting with spontaneous vs. traumatic hemorrhage (OR 6.11 [.31−118.89] p = 0.023) had significantly higher risk for mortality. Conclusions Hemorrhagic presentations with COVID-19 are a rare but serious way in which the illness can manifest. It is important for neurosurgeons to realize that patients can present with these findings without primary pulmonary symptoms, and that severe pulmonary symptoms, elevated INR, and spontaneous hemorrhagic presentations is associated with increased risk for mortality.

ObjectiveSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is protean in its manifestations, affecting nearly every organ system. However, nervous system involvement and its effect on disease outcome are poorly characterized. The objective of this study was to determine whether neurologic syndromes are associated with increased risk of inpatient mortality.MethodsA total of 581 hospitalized patients with confirmed SARS-CoV-2 infection, neurologic involvement, and brain imaging were compared to hospitalized non-neurologic patients with coronavirus disease 2019 (COVID-19). Four patterns of neurologic manifestations were identified: acute stroke, new or recrudescent seizures, altered mentation with normal imaging, and neuro-COVID-19 complex. Factors present on admission were analyzed as potential predictors of in-hospital mortality, including sociodemographic variables, preexisting comorbidities, vital signs, laboratory values, and pattern of neurologic manifestations. Significant predictors were incorporated into a disease severity score. Patients with neurologic manifestations were matched with patients of the same age and disease severity to assess the risk of death.ResultsA total of 4,711 patients with confirmed SARS-CoV-2 infection were admitted to one medical system in New York City during a 6-week period. Of these, 581 (12%) had neurologic issues of sufficient concern to warrant neuroimaging. These patients were compared to 1,743 non-neurologic patients with COVID-19 matched for age and disease severity admitted during the same period. Patients with altered mentation (n = 258, p = 0.04, odds ratio [OR] 1.39, confidence interval [CI] 1.04–1.86) or radiologically confirmed stroke (n = 55, p = 0.001, OR 3.1, CI 1.65–5.92) had a higher risk of mortality than age- and severity-matched controls.ConclusionsThe incidence of altered mentation or stroke on admission predicts a modest but significantly higher risk of in-hospital mortality independent of disease severity. While other biomarker factors also predict mortality, measures to identify and treat such patients may be important in reducing overall mortality of COVID-19.

Background and Purpose Mechanical thrombectomy has significantly improved post-ischemic stroke clinical outcomes. However, the post-ischemic stroke mortality rate appears to be unchanged. We reviewed potential risk factors that can be related to mortality in patients who underwent mechanical thrombectomy. Materials and Methods A retrospective review was conducted in acute anterior circulation ischemic stroke patients who underwent mechanical thrombectomy but expired within 90 days in a high volume comprehensive stroke center between January 2017 and January 2020. Pre thrombectomy risk factors evaluated include age, NIHSS, ASPECT score, baseline mRS, occlusion site, and IV tPA administration. Post-thrombectomy risk factors include ASPECT score at 24 hours, TICI score, post-procedural subarachnoid hemorrhage (SAH), hemorrhagic transformation, and decompressive craniectomy. Procedural risk factors included the mode of anesthesia, intraprocedural systolic (SBP), diastolic (DBP), and mean arterial pressure (MAP) were reviewed as well as procedural blood pressure variability. The difference between the highest and lowest recorded blood pressure was defined as procedural variability. Results Mechanical thrombectomy was performed in 290 patients, and 54 patients (54/290, 18.6%) were expired at 90 days, which include 42 anterior (77.8%) and 22 posterior circulation patients (22.2%). In 42 anterior circulation acute ischemic stroke patients who expired (M:F=25:17), the mean age was 77.5 ± 13, and 42.86% was at or more than 80 years old. Baseline estimated mRS three or above were seen in 92.7%. The number of days from admission to decease was 7 (median). Pre-procedural ASPECT score >6 was noted in 32 patients (32/42, 76.19%) but in 11 patients (11/42, 26.19%) on post-procedure ASPECT at 24 hours. MCA, ICA and CCA occlusion was found in 69.05%, 19.5%, and 9.52%, respectively. Pre thrombectomy IV tPA was administered in 17 patients (17/42, 40.48%). TICI 2b or three were achieved in 54.7%, with the median number of passes were 2. Ten patients (23.81%) developed post thrombectomy symptomatic intracranial hemorrhages (sICH), and the hemorrhagic transformation was seen in 14.29% (n=6). Three patients (7.14%) received decompressive craniectomy. Mean ‘arrival to groin puncture time’ and ‘groin to reperfusion time’ were 1.13 ± 0.19 hours and 1 hour ± 0.042, respectively. Monitored Anesthesia Care (n=29, 69.04%) was used for most of the procedure. Mean procedural variability of MAP, DBP and SBP were 24.32 + 23.79 mmHg, 16.38 ± 24.83 mmHg, and 40.19 ± 26.83 mmHg, respectively. Conclusion Older age, low baseline estimated mRS, the relatively lower rate of successful reperfusion, the higher rate of sICH, delayed groin to reperfusion time, and higher intraprocedural variability in MAP and DBP were observed in patients with mortality in our study. Disclosures A. Toma: None. A. Vijayashankar: None. N. Haranhalli: None. R. Zampolin: None. D. Altschul: None. A. Brook: None. S. Lee: None.

Objective We aim to demonstrate the safety and effectiveness of extra-femoral endovascular access for mechanical thrombectomy for acute ischemic stroke patients whose vascular anatomy precludes safe or maneuverable trans-femoral access. Methods Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to conduct a systematic review and meta-analysis with articles published until March 2018. The search protocol, including research questions and inclusion and exclusion criteria, were developed a priori. Our own institutional retrospective data were included in the cohort of case series. Results Eleven studies including 51 patients were included. Age ranged from 4th to 10th decade of life (average: 9.3rd decade) and 40.1% received IV tissue plasminogen activator. Initial National Institutes of Health Stroke Scale (NIHSS) score ranged from 1 to 36, (average: 17.6). Of the 51 patients, 39 (76%) patients suffered from anterior circulation large vessel occlusions versus 12 (24%) from posterior circulation occlusions. Site of access included 26 (51%) radial artery punctures, 23 (45%) direct percutaneous cervical carotid punctures, 1 brachial artery puncture, and 1 direct extradural vertebral artery puncture. Technical success was achieved in 43/51 (84%) of patients. The average modified Rankin Scale at discharge was 2.93 (n=26). There were no complications in 25 patients who underwent radial arterial access. Two (7.4%) of 27 cervical access patients developed hematoma. Conclusions Trans-carotid and trans-radial access for intervention in acute ischemic stroke is safe and effective. There may be instances in which these approaches should be considered first line before standard femoral approaches.

This presentation describes the imaging scales and techniques used in the 2015 endovascular stroke trials and the revised 2015 American Heart Association/American Stroke Association guidelines for endovascular stroke treatment.

A 56-year-old woman on hemodialysis through left arm arteriovenous fistula presented with headache, aphasia, and gradually worsening left facial swelling (figure 1A). MRI showed left temporal intracerebral hemorrhage with arterialized veins (figure 2, A and B). Cerebral angiography revealed multiple areas of venous flow reversal suggesting venous hypertension (figure 2C). Fistulogram demonstrated chronic left cephalic vein occlusion with outflow retrograde through the left internal jugular, facial, intracranial, and then centrally through right internal jugular veins. Recanalization of the venous occlusion improved facial swelling (figure 1B). Early recognition of facial swelling may prevent intracerebral hemorrhage in patients with arteriovenous fistula.1,2

This article reviews the imaging of lumbar spinal fusion and its major indications. The most common procedures are described for the purpose of allowing understanding of postoperative imaging. Imaging options are reviewed for preoperative workup, intraoperative guidance, and postoperative purposes. Examples of hardware integrity, fusion, and loosening are provided.

Background: Realistic virtual reality (VR) simulators have greatly expanded the tools available for training surgeons and interventionalists. While this technology is effective in improving performance in many fields, it has never been evaluated for neuroendovascular procedures. This study aims to determine whether VR is an effective tool for improving neuroendovascular skill among trainees. Methods: Trainees performed two VR revascularizations of a right-sided middle cerebral artery (MCA) thrombosis and their times to procedural benchmarks (time to enter internal carotid artery [ICA], traverse clot, and complete procedure) were compared. To determine whether the improvement was case specific, trainees with less procedural exposure were timed during VR left-sided ICA (LICA) aneurysm coiling before or after performing MCA thrombectomy simulations. To determine the value of observing simulations, medical students were timed during the right MCA revascularization simulations after watching other VR procedures. Results: Trainees significantly improved their time to every procedural benchmark during their second MCA revascularization (mean decrease = 1.08, 1.57, and 2.24 min; P = 0.0072, 0.0466, and 0.0230). In addition, time required to access the LICA during aneurysm coiling was shortened by 0.77 min for each previous VR right MCA revascularization performed (P = 0.0176; r2 = 0.71). Finally, medical students’ MCA revascularization simulation times improved by 0.87 min for each prior simulation viewed (P < 0.0221; r2 = 0.96). Conclusion: Both performance and viewing of simulated procedures produced significant decreases in time to reach neuroendovascular procedural benchmarks. These data show that VR simulation is a valuable tool for improving trainee skill in neuroendovascular procedures.

In 2015, five trials demonstrated the efficacy of endovascular treatment for acute stroke, culminating in the revised American Heart Association/American Stroke Association (AHA/ASA) recommendations for stroke management. The different clinical scales used in these trials may be unfamiliar to emergency and on-call radiologists. The modified Rankin Scale was used to describe patient disability for prestroke assessment in three of the trials and for the 90-day follow up in all five trials. The Barthel index was used in one trial to score prestroke ability to perform activities of daily living. The NIH Stroke Scale was used as part of eligibility criteria in four of the stroke trials to assess pre-existing neurological deficits. Also, the modified Rankin Scale and the NIH Stroke Scale are used in the revised AHA/ASA recommendations. By understanding these scales, emergency and on-call radiologists will better appreciate the stroke patient’s condition and will be able to more actively collaborate in the care of acute stroke patients.

Head CT scans are considered the imaging modality of choice to screen patients with head trauma for neurocranial injuries; however, widespread CT imaging is not recommended and much research has been conducted to establish objective clinical predictors of intracranial injury (ICI) in order to optimize the use of neuroimaging in children with minor head trauma. To evaluate whether a strict application of the New Orleans Criteria (NOC), Canadian CT Head Rule (CCHR) and National Emergency X-Radiography Utilization Study II (NEXUS II) in pediatric patients with head trauma presenting to a non-trauma center (level II) could reduce the number of cranial CT scans performed without missing clinically significant ICI. We conducted an IRB-approved retrospective analysis of pediatric patients with head trauma who received a cranial CT scan between Jan. 1, 2001, and Sept. 1, 2008, and identified which patients would have required a scan based on the criteria of the above listed decision instruments. We then determined the sensitivities, specificities and negative predictive values of these aids. In our cohort of 2,101 patients, 92 (4.4%) had positive head CT findings. The sensitivities for the NOC, CCHR and NEXUS II were 96.7% (95%CI 93.1–100), 65.2% (95%CI 55.5–74.9) and 78.3% (95%CI 69.9–86.7), respectively, and their negative predictive values were 98.7%, 97.6% and 97.2%, respectively. In contrast, the specificities for these aids were 11.2% (95%CI 9.8–12.6), 64.2% (95%CI 62.1–66.3) and 34.2% (95%CI 32.1–36.3), respectively. Therefore, in our population it would have been possible to scan at least 10.9% fewer patients. The number of cranial CT scans conducted in our pediatric cohort with head trauma would have been reduced had any of the three clinical decision aids been applied. Therefore, we recommend that further validation and adoption of pediatric head CT decision aids in non-trauma centers be considered to ultimately increase patient safety while reducing medical expense.

Mesenchymal neoplasms of the female genital tract are a diverse group of tumors, of which the most common are smooth muscle tumors. There is a significant overlap in the imaging characteristics of benign and malignant tumors and final diagnosis often requires pathologic correlation. However, familiarity with typical radiologic features, common imaging pitfalls, and the utility of different imaging modalities can be valuable in the evaluation of mesenchymal tumors. This article highlights the imaging features of the most commonly encountered mesenchymal tumors in the female genital tract.

In the setting of acute central nervous system (CNS) emergencies, computed tomography (CT) and conventional magnetic resonance imaging (MRI) play an important role in the identification of life-threatening intracranial injury. However, the full extent or even presence of brain damage frequently escapes detection by conventional CT and MRI. Advanced MRI techniques such as diffusion tensor imaging (DTI) are emerging as important adjuncts in the diagnosis of microstructural white matter injury in the acute and postacute brain-injured patient. Although DTI aids in detection of brain injury pathology, which has been repeatedly associated with typical adverse clinical outcomes, the evolution of acute changes and their long-term prognostic implications are less clear and the subject of much active research. A major aim of current research is to identify imaging-based biomarkers that can identify the subset of TBI patients who are at risk for adverse outcome and can therefore most benefit from ongoing care and rehabilitation as well as future therapeutic interventions.The aim of this study is to introduce the current methods used to obtain DTI in the clinical setting, describe a set of common interpretation strategies with their associated advantages and pitfalls, as well as illustrate the clinical utility of DTI through a set of specific patient scenarios. We conclude with a discussion of future potential for the management of TBI.

We describe a 65-year-old, nonalcoholic, right-handed female with multiple vascular risk factors who developed transient visuospatial hemineglect and global aphasia after presenting with the classic triad of Wernicke’s encephalopathy (mental status changes, nystagmus/ophthalmoplegia, and ataxia). A brain MRI showed no evidence of acute infarction, but demonstrated signal change in the medial thalami and mammillary bodies. Intravenous thiamine therapy was given, and visuospatial hemineglect and ophthalmoplegia disappeared while the aphasia improved. The occurrence of these acute transient clinical features has not been previously reported in Wernicke’s encephalopathy.