BackgroundEndovascular thrombectomy (EVT) has become the mainstay treatment for large vessel occlusion, with favorable safety and efficacy profile. However, the safety and efficacy of EVT in concurrent multi-territory occlusions (MTVOs)... more
BackgroundEndovascular thrombectomy (EVT) has become the mainstay treatment for large vessel occlusion, with favorable safety and efficacy profile. However, the safety and efficacy of EVT in concurrent multi-territory occlusions (MTVOs) remains unclear.ObjectiveTo investigate the prevalence, clinical and technical outcomes of concurrent EVT for MTVOs.MethodsData were included from the Stroke Thrombectomy and Aneurysm Registry (STAR) with 32 stroke centers for EVT performed to treat bilateral anterior or concurrent anterior and posterior circulation occlusions between 2017 and 2021. Patients with MTVO were identified, and propensity score matching was used to compare this group with patients with occlusion in a single arterial territory.ResultsOf a total of 7723 patients who underwent EVT for acute ischemic stroke, 54 (0.7%) underwent EVT for MTVOs (mean age 69±12.5; female 50%). 28% had bilateral and 72% had anterior and posterior circulations occlusions. The rate of successful reca...
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In three recent cases of acute complete internal artery occlusions, we used stent retriever deployed through the mechanical aspiration/distal access catheters to achieve recanalization. In all cases the stent retriever was used as an... more
In three recent cases of acute complete internal artery occlusions, we used stent retriever deployed through the mechanical aspiration/distal access catheters to achieve recanalization. In all cases the stent retriever was used as an anchor and supplemented mechanical thrombectomy. This report describes the technical details of the procedure and presents an alternative plan of action in difficult cases when standard thrombectomy techniques do not work.
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Introduction: Non-traumatic Intracerebral Hemorrhage (ICH) accounts for 2 million strokes annually worldwide. This stroke burden disproportionately impacts minorities, and results in severe neurological deficits. Sex differences in brain... more
Introduction: Non-traumatic Intracerebral Hemorrhage (ICH) accounts for 2 million strokes annually worldwide. This stroke burden disproportionately impacts minorities, and results in severe neurological deficits. Sex differences in brain structure and function, such as a larger mean length of frontal horn in males and increased global cerebral blood flow in women, can contribute to hematoma volume and expansion of ICH into nearby structures. No studies have yet to investigate sex differences in the incidence of Intraventricular Hemorrhage (IVH) and hydrocephalus as sequelae of ICH, both or which correlate with poor long-term outcomes. Methods: A retrospective review of a comprehensive stroke center spontaneous ICH database from 2019-2022 was performed, including patient characteristics such as history of diabetes mellitus, hypertension, coronary artery disease, tobacco use, and anticoagulant use in addition to ICH characteristics such as hematoma location volume, expansion, incidenc...
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OBJECTIVE Although younger adults have been shown to have better functional outcomes after mechanical thrombectomy (MT) for acute ischemic stroke (AIS), the significance of this relationship in the adolescent and young adult (AYA)... more
OBJECTIVE Although younger adults have been shown to have better functional outcomes after mechanical thrombectomy (MT) for acute ischemic stroke (AIS), the significance of this relationship in the adolescent and young adult (AYA) population is not well defined given its undefined rarity. Correspondingly, the goal of this study was to determine the prognostic significance of age in this specific demographic following MT for large-vessel occlusions. METHODS A prospectively maintained international multi-institutional database, STAR (Stroke Thrombectomy and Aneurysm Registry), was reviewed for all patients aged 12–18 (adolescent) and 19–25 (young adult) years. Parameters were compared using chi-square and t-test analyses, and associations were interrogated using regression analyses. RESULTS Of 7192 patients in the registry, 41 (0.6%) satisfied all criteria, with a mean age of 19.7 ± 3.3 years. The majority were male (59%) and young adults (61%) versus adolescents (39%). The median pre...
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BackgroundEndovascular thrombectomy (EVT) is the standard-of-care for proximal large vessel occlusion (LVO) stroke. Data on technical and clinical outcomes in distal vessel occlusions (DVOs) remain limited.MethodsThis was a retrospective... more
BackgroundEndovascular thrombectomy (EVT) is the standard-of-care for proximal large vessel occlusion (LVO) stroke. Data on technical and clinical outcomes in distal vessel occlusions (DVOs) remain limited.MethodsThis was a retrospective study of patients undergoing EVT for stroke at 32 international centers. Patients were divided into LVOs (internal carotid artery/M1/vertebrobasilar), medium vessel occlusions (M2/A1/P1) and isolated DVOs (M3/M4/A2/A3/P2/P3) and categorized by thrombectomy technique. Primary outcome was a good functional outcome (modified Rankin Scale ≤2) at 90 days. Secondary outcomes included recanalization, procedure-time, thrombectomy attempts, hemorrhage, and mortality. Multivariate logistic regressions were used to evaluate the impact of technical variables. Propensity score matching was used to compare outcome in patients with DVO treated with aspiration versus stent retrieverResultsWe included 7477 patients including 213 DVOs. Distal location did not indepen...
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Recent randomized controlled trials of stroke thrombectomy have led the American Heart Association to provide recommendations that thrombectomy be pursued in patients with large vessel occlusions who meet certain criteria. Evolving... more
Recent randomized controlled trials of stroke thrombectomy have led the American Heart Association to provide recommendations that thrombectomy be pursued in patients with large vessel occlusions who meet certain criteria. Evolving recommendations allow the Brain Attack Coalition to establish, update, and maintain a hierarchal system of care involving the proper management of different types of acute stroke. This chapter will outline various stroke systems of care and assist emergency medicine providers in evaluating, managing, and triaging patients with different types of stroke. The history behind the development of stroke centers as well as the qualifications for each level of care are discussed here alongside example cases of patients best managed at the various hospital subtypes.
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BackgroundAtrial fibrillation (AF) associated ischemic stroke is associated with worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Conversely,... more
BackgroundAtrial fibrillation (AF) associated ischemic stroke is associated with worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Conversely, AF is not associated with hemorrhagic complications or functional outcomes in patients undergoing mechanical thrombectomy (MT). This differential effect of MT and IVT in AF associated stroke raises the question of whether bridging thrombolysis increases hemorrhagic complications in AF patients undergoing MT.MethodsThis international cohort study of 22 comprehensive stroke centers analyzed patients with large vessel occlusion (LVO) undergoing MT between June 1, 2015 and December 31, 2020. Patients were divided into four groups based on comorbid AF and IVT exposure. Baseline patient characteristics, complications, and outcomes were reported and compared.Results6461 patients underwent MT for LVO. 2311 (35.8%) patients had comorbid AF. In non-AF patient...
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BackgroundCurrently, there are no large-scale studies in the neurointerventional literature comparing safety between transradial (TRA) and transfemoral (TFA) approaches for flow diversion procedures. This study aims to assess complication... more
BackgroundCurrently, there are no large-scale studies in the neurointerventional literature comparing safety between transradial (TRA) and transfemoral (TFA) approaches for flow diversion procedures. This study aims to assess complication rates in a large multicenter registry for TRA versus TFA flow diversion.MethodsWe retrospectively analyzed flow diversion cases for cerebral aneurysms from 14 institutions from 2010 to 2019. Pooled analysis of proportions was calculated using weighted analysis with 95% CI to account for results from multiple centers. Access site complication rate and overall complication rate were compared between the two approaches.ResultsA total of 2,285 patients who underwent flow diversion were analyzed, with 134 (5.86%) treated with TRA and 2151 (94.14%) via TFA. The two groups shared similar patient and aneurysm characteristics. Crossover from TRA to TFA was documented in 12 (8.63%) patients. There were no access site complications in the TRA group. There was...
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Introduction/purpose Idiopathic intracranial hypertension (IIH), otherwise known as pseudotumor cerebri or benign intracranial hypertension, is a syndrome defined by a severe headache in the setting of increased intracranial pressure... more
Introduction/purpose Idiopathic intracranial hypertension (IIH), otherwise known as pseudotumor cerebri or benign intracranial hypertension, is a syndrome defined by a severe headache in the setting of increased intracranial pressure (ICP) in the absence of an intracranial mass. The pathophysiology of IIH remains poorly understood. However, venous outflow obstruction detected by cerebral venous manometry at the transverse sinus has been recognized as a contributing factor in a subset of patients with IIH, and stent placement in this subset of patients is associated with good clinical outcomes. Surgeons often determine candidacy for stent placement based on the magnitude of the venous pressure gradient across the site of stenosis. Furthermore, there is little known about venous sinus pressure waveform morphology in patients with this condition or how it changes after stenting. The purpose of this study was to prospectively analyze patients’ venous sinus waveforms, their component peaks, and the influence of stenosis or anesthesia on waveform morphology with a goal of ultimately providing insight into the waveform and pathological morphologic changes seen with venous sinus stenosis. Materials and methods Fifteen patients with IIH were enrolled prospectively and underwent waveform recording during catheter venography and manometry. Ten patients (Group A) with venous sinus stenosis and pressure gradient >8 mmHg underwent waveform recording during awake venography and then pre- and post-stent manometry while under general anesthesia. Five control IIH patients (Group B) without a trans-stenosis gradient underwent awake recording only. Results All Group A patients underwent successful stenting with reduction of their gradient from 15.1 (+6.19) mmHg to 1.2 (+0.60) mmHg. This resulted in statistically significant reduction of the transverse sinus amplitude from 8.3 mmHg to 2.8 mmHg (p<0.05). Qualitative evaluation of the venous sinus waveform morphology yielded a number of never before reported findings. In Group A patients before stenting, the observed venous waveform progressed from an ICP-dominated waveform to CVP-dominated waveform from the superior sagittal sinus to the internal jugular vein. Stenting abolished the pathologic high amplitude waveform and lowered the amplitude distal to the stenosis while smoothing the transition from the intracranial to central venous measurement points. Group B patients displayed respiratory variability of the waveform which was absent in 8/10 Group A patients. The use of general anesthesia appeared to blunt the waveform peaks in 5/10 Group A patients. Conclusion In conclusion, the cerebral venous waveform morphology appears to be influenced by both the intracranial pressure (ICP) waveform and the central venous pressure (CVP) waveform. Additionally, venous sinus stenosis with significant venous outflow obstruction results in morphologic changes to the waveforms. After performing stenting in patients with stenosis, waveforms return to match the control group. Future studies should expand on the qualitative patterns described in this study and place a significant amount of consideration in determining the clinical and hemodynamic ramifications of these findings. Disclosures J. West: None. R. Garner: None. G. Greeneway: None. J. Traunero: None. C. Aschenbrenner: None. J. Singh: None. S. Wolfe: None. K. Fargen: None.
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Introduction There is currently no published data evaluating the incidence of mechanical thrombectomy among stroke centers, the times at which they occur, or their burden on physicians that perform these procedures. Methods Ten... more
Introduction There is currently no published data evaluating the incidence of mechanical thrombectomy among stroke centers, the times at which they occur, or their burden on physicians that perform these procedures. Methods Ten institutions queried their stroke databases to identify all patients undergoing emergent angiography with intent to perform thrombectomy for ELVO during a three month time period (June 1st, 2016 to August 31st, 2016). Data collected included origin of patient, time of initial consultation or completion of angiographic imaging, time of groin puncture, time of groin closure, and day of the week. Results During the 92 day study period, a total of 189 patients underwent emergent angiography with intent to pursue mechanical thrombectomy for ELVO at the 10 centers. The average number of procedures per hospital over the study period was 18.9 (average of 0.2 cases per day per center). This ranged from 0.49 cases per day at the highest volume center to 0.09 cases per day at the lowest volume center. Most procedures (75%) started during daytime hours (6a-10p) with the majority of groin punctures occurring during non-work hours (59%; Figure). There was no differences in procedural frequency based on day of the week. The three-hour peak time period where most procedures were started was between 8pm and 11 pm (42 cases; 22.2% of the total). The median time from notification to groin puncture was 84 min (SEM 10.0, interquartile range 55.5–144.5) and median procedural time was 57 min (SEM 2.5, interquartile range 33–79.5 min). The average overall physician time required for each individual patient from time of notification until groin closure was just over 2.5 hours at 154 min (SEM 8.0, interquartile range 114–206.5). Time from imaging to puncture was longer during nighttime hours than during daytime (median 113 vs. 87 min; p=0.03) but procedural length did not differ based on time of day (p=0.21). Conclusion This is the first study to quantify the time requirement of mechanical thrombectomy and the call burden on neurointerventional physicians at stroke centers. Over a three month period at 10 stroke centers across the United States, mechanical thrombectomy procedures occurred once every 5 days on average, although nearly 60% occurred during non-work hours. As ELVO awareness increases, thrombectomy call has important operational implications for hospitals implementing stroke call coverage. Abstract O-004 Figure 1 Disclosures T. Wilson: None. T. Kim: None. C. Frey: None. A. Spiotta: None. R. de Leacy: None. J. Mocco: None. F. Albuquerque: None. A. Ducruet: None. A. Cheema: None. A. Arthur: None. V. Srinivasan: None. P. Kan: 2; C; Stryker; Medtronic. M. Mokin: None. T. Dumont: None. A. Rai: None. T. Leslie-Mazwi: None. J. Hirsch: None. J. Singh: None. J. Singh: None. S. Wolfe: None. K. Fargen: None.
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BACKGROUND Minimally invasive surgery procedures, including stereotactic catheter aspiration and clearance of intracerebral hemorrhage (ICH) with recombinant tissue plasminogen activator hold a promise to improve outcome of supratentorial... more
BACKGROUND Minimally invasive surgery procedures, including stereotactic catheter aspiration and clearance of intracerebral hemorrhage (ICH) with recombinant tissue plasminogen activator hold a promise to improve outcome of supratentorial brain hemorrhage, a morbid and disabling type of stroke. A recently completed Phase III randomized trial showed improved mortality but was neutral on the primary outcome (modified Rankin scale score 0 to 3 at 1 yr). OBJECTIVE To assess surgical performance and its impact on the extent of ICH evacuation and functional outcomes. METHODS Univariate and multivariate models were used to assess the extent of hematoma evacuation efficacy in relation to mRS 0 to 3 outcome and postulated factors related to patient, disease, and protocol adherence in the surgical arm (n = 242) of the MISTIE trial. RESULTS Greater ICH reduction has a higher likelihood of achieving mRS of 0 to 3 with a minimum evacuation threshold of ≤15 mL end of treatment ICH volume or ≥70% ...
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Introduction: Previous studies have reported that Hispanic stroke patients have limited access to mechanical thrombectomy (MT) compared to other ethnic groups. This has resulted in worse stroke outcomes in this group. However, limited... more
Introduction: Previous studies have reported that Hispanic stroke patients have limited access to mechanical thrombectomy (MT) compared to other ethnic groups. This has resulted in worse stroke outcomes in this group. However, limited data is available about the outcomes of MT in Hispanic patients. Methods: We used data from the Stroke Thrombectomy and Aneurysm Registry (STAR) that combined the prospectively maintained databases of 28 thrombectomy-capable stroke centers in the US, Europe, and Asia. Consecutive patients who underwent MT were included in these analyses and patients were divided into 2 groups (Hispanics vs. non-Hispanics). Baseline features, time from symptom onset, thrombolysis receipt, final thrombolysis in cerebral infarction (TICI) score, symptomatic hemorrhage, and 90-day functional outcomes (measured by modified Rankin scale-mRS) were compared between Hispanic and non-Hispanics patients. A generalized linear model with logit link was used to assess the relationsh...
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Aging worsens outcome in traumatic brain injury (TBI), but available studies may not provide accurate outcome predictions due to confounding associated injuries. Our goal was to develop a predictive tool using variables available at... more
Aging worsens outcome in traumatic brain injury (TBI), but available studies may not provide accurate outcome predictions due to confounding associated injuries. Our goal was to develop a predictive tool using variables available at admission to predict outcome related to severity of brain injury in aging patients. Characteristics and outcomes of blunt trauma patients with isolated TBI of ages ≥ 50 in National Trauma Data Bank (NTDB) were evaluated. Equations predicting survival and independence at DC (IDC) were developed and validated using patients from our trauma registry, comparing predicted to actual outcomes. Logistic regression for survival and IDC was performed in 57,588 patients using age, gender, Glasgow Coma Scale score (GCS), and revised trauma score (RTS). All variables were independent predictors of outcome. Two models were developed using these data. The first included age, gender, and GCS. The second substituted RTS for GCS. C statistics from the models for survival ...
Research Interests: Medicine, Logistic Regression, Independent Living, Population, Humans, and 15 moreFemale, Male, Glasgow Coma Scale, Patient Admission, Clinical Sciences, Aged, Middle Aged, Retrospective Studies, Prognosis, Age Factors, Logistic Models, confounding, Decision Support Techniques, glasgow outcome scale, and Patient discharge
BACKGROUND AND IMPORTANCE: Cavernous malformations of the cranial nerves are exceedingly rare. The classic radiographic appearance of cavernous malformations may not be obvious when located in a cranial nerve. CLINICAL PRESENTATION: We... more
BACKGROUND AND IMPORTANCE: Cavernous malformations of the cranial nerves are exceedingly rare. The classic radiographic appearance of cavernous malformations may not be obvious when located in a cranial nerve. CLINICAL PRESENTATION: We present 2 cases of acute oculomotor paresis caused by cavernous malformations of the oculomotor nerve that were mistaken for a thrombosed posterior communicating artery aneurysm on magnetic resonance imaging, magnetic resonance angiography, and digital subtraction angiography. Both patients underwent a craniotomy with exploration of the lesion. Both cavernous malformations were completely resected while the integrity of the third cranial nerve was maintained. One patient experienced complete resolution of the oculomotor palsy. CONCLUSION: Although rare, cavernous malformations should be included in the differential diagnosis of a partially thrombosed posterior communicating artery aneurysm. Exploration and complete lesional resection are possible with...
Research Interests: Radiology, Neurosurgery, Magnetic Resonance Imaging, Medicine, Humans, and 12 moreMale, Cavernous Malformations, Differential Diagnosis, Clinical Sciences, Aged, Adult, Aneurysm, Neurosciences, Oculomotor Nerve, Magnetic resonance angiography, Intracranial aneurysm, and Digital subtraction angiography
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The authors report the case of a 30-year-old female patient with suspected Cushing’s disease with an anatomical variation of hypoplastic inferior petrosal sinuses and nearly exclusive anterior drainage from the cavernous sinus, who... more
The authors report the case of a 30-year-old female patient with suspected Cushing’s disease with an anatomical variation of hypoplastic inferior petrosal sinuses and nearly exclusive anterior drainage from the cavernous sinus, who underwent external jugular venous blood sampling with successful disease confirmation and microadenoma localization. The patient presented with signs and symptoms consistent with Cushing’s syndrome, but with discordant preliminary diagnostic testing. She underwent attempted bilateral inferior petrosal sinus sampling; however, she had hypoplastic inferior petrosal sinuses bilaterally and predominantly anterior drainage from the cavernous sinus into the external jugular circulation. Given this finding, the decision was made to proceed with external jugular venous access and sampling in addition to internal jugular venous sampling. A positive adrenocorticotropic hormone (ACTH) response to corticotropin-releasing factor was obtained in the right external jugu...
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ImportanceThere is substantial controversy with regards to the adequacy and use of noncontrast head computed tomography (NCCT) for late-window acute ischemic stroke in selecting candidates for mechanical thrombectomy.ObjectiveTo assess... more
ImportanceThere is substantial controversy with regards to the adequacy and use of noncontrast head computed tomography (NCCT) for late-window acute ischemic stroke in selecting candidates for mechanical thrombectomy.ObjectiveTo assess clinical outcomes of patients with acute ischemic stroke presenting in the late window who underwent mechanical thrombectomy stratified by NCCT admission in comparison with selection by CT perfusion (CTP) and diffusion-weighted imaging (DWI).Design, Setting, and ParticipantsIn this multicenter retrospective cohort study, prospectively maintained Stroke Thrombectomy and Aneurysm (STAR) database was used by selecting patients within the late window of acute ischemic stroke and emergent large vessel occlusion from 2013 to 2021. Patients were selected by NCCT, CTP, and DWI. Admission Alberta Stroke Program Early CT Score (ASPECTS) as well as confounding variables were adjusted. Follow-up duration was 90 days. Data were analyzed from November 2021 to March...
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Background Limited studies have evaluated the use of ultrasound for detection of intracerebral hemorrhage (ICH) using diagnostic ultrasound Transcranial Doppler machines in adults. The feasibility of ICH detection using Point of care... more
Background Limited studies have evaluated the use of ultrasound for detection of intracerebral hemorrhage (ICH) using diagnostic ultrasound Transcranial Doppler machines in adults. The feasibility of ICH detection using Point of care Ultrasound (POCUS) machines has not been explored. We evaluated the feasibility of using cranial POCUS B mode imaging performed using intensive care unit (ICU) POCUS device for ICH detection with a secondary goal of mapping optimal imaging technique and brain topography likely to affect sensitivity and specificity of ICH detection with POCUS. Materials and methods After obtaining IRB approval, a blinded investigator performed cranial ultrasound (Fujifilm, Sonosite® Xporte, transcranial and abdominal presets) through temporal windows on 11 patients with intracerebral pathology within 72 h of last CT/MRI (computed tomography scan/magnetic resonance imaging) brain after being admitted to a neurocritical care unit in Aug 2020 and Nov 2020–Mar 2021. Images w...
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BackgroundThis study aims to explore factors that affect venous sinus pressures and associated gradients while awake and under general anesthesia (GA) both before and after venous sinus stenting (VSS) in patients with idiopathic... more
BackgroundThis study aims to explore factors that affect venous sinus pressures and associated gradients while awake and under general anesthesia (GA) both before and after venous sinus stenting (VSS) in patients with idiopathic intracranial hypertension (IIH).MethodsA retrospective analysis was performed examining pressures and gradients in patients with IIH having undergone awake venography followed by VSS under GA.Results174 patients were included. Compared with awake, GA superior sagittal sinus (SSS) pressures were 2.6 mmHg lower (p=0.01) resulting in a total cranial gradient reduction of 2.5 mmHg (p=0.002). The transverse-sigmoid gradient, the most commonly stented segment, did not differ under the two conditions (p=0.30). Regression analyses demonstrated that body mass index, gender, blood pressure, and end-tidal carbon dioxide content significantly affected venous pressures (all p<0.05). After stenting, mean total cranial gradients decreased by 13.2 mmHg while skull base g...
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In the past 20 years, no drug therapies have been successfully translated into human use for intracerebral hemorrhage (ICH), the most devastating stroke subset. One likely factor is lack of effective animal models of human disease... more
In the past 20 years, no drug therapies have been successfully translated into human use for intracerebral hemorrhage (ICH), the most devastating stroke subset. One likely factor is lack of effective animal models of human disease including common comorbidities, such as hypertension and diabetes. We evaluated the cardiometabolic rodent model, (mRen2)27, where overexpression of Ren2 results in extreme hypertension, glucose intolerance and obesity, as an appropriate ICH model. Methods: Sprague Dawley (SD) and (mRen2)27 rats were sacrificed at 14‐, 32‐, and 52‐weeks. Brains were sectioned sagittally at 5 μm. Whole‐brain sections were stained using Hematoxylin & Eosin (H&E) and Van Geison (VG) collagen staining to visualize the pial blood vessels. Wall‐to‐lumen ratios for vessels were calculated and compared using a student t‐test to determine significance. Results: There was no significant difference in arteriolar morphology at 14‐weeks between male SD and mRen animals (SD, n=16 and mR...
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Background and purpose Acute ischemic stroke has increasingly become a procedural disease following the demonstrated benefit of mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) on clinical outcomes and tissue... more
Background and purpose Acute ischemic stroke has increasingly become a procedural disease following the demonstrated benefit of mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) on clinical outcomes and tissue salvage in randomized trials. Given these data and anecdotal experience of decreased numbers of decompressive hemicraniectomies (DHCs) performed for malignant cerebral edema, we sought to correlate the numbers of strokes, thrombectomies, and DHCs performed over the timeline of the 2013 failed thrombolysis/thrombectomy trials, to the 2015 modern randomized MT trials, to post-DAWN and DEFUSE 3. Materials and methods This is a multicenter retrospective compilation of patients who presented with ELVO in 11 US high-volume comprehensive stroke centers. Rates of tissue plasminogen activator (tPA), thrombectomy, and DHC were determined by current procedural terminology code, and specificity to acute ischemic stroke confirmed by each institution. Endpoints include...
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OBJECTIVE In this article, the authors describe the impact of the COVID-19 virtual match cycle and discuss approaches to optimize future cycles through applicant and neurosurgical education leadership insights. METHODS Anonymous surveys... more
OBJECTIVE In this article, the authors describe the impact of the COVID-19 virtual match cycle and discuss approaches to optimize future cycles through applicant and neurosurgical education leadership insights. METHODS Anonymous surveys of neurosurgery program leaders (program directors and program chairs), program administrators (PAs), and 2020–2021 neurosurgery residency match applicants were distributed by the SNS, in conjunction with the Association of Resident Administrators in Neurological Surgery and AANS Young Neurosurgeons Committee. RESULTS Responses were received from 77 (67.0%) of 115 PAs, 119 (51.7%) of 230 program leaders, and 124 (44.3%) of 280 applicants representing geographically diverse regions. During the virtual application cycle relative to the previous year, programs received more Electronic Residency Application Service applications (mean 314.8 vs 285.3, p < 0.0001) and conducted more applicant interviews (mean 45.2 vs 39.9, p = 0.0003). More than 50% of a...
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Objective: To assess quality of communication in acute neurological emergencies and define domains for improvement Background: Communication is of central concern in healthcare. However, evidence shows it is often poorly addressed during... more
Objective: To assess quality of communication in acute neurological emergencies and define domains for improvement Background: Communication is of central concern in healthcare. However, evidence shows it is often poorly addressed during rapid health changes and clinical uncertainty. Acute neurological emergencies pose an inherently unique challenge as patients often cannot communicate, and families have no time to process the neurological debilitation or comfortably express patients’ wishes about quality of life. Also, multiple providers involved may convey different sentiments behind their assessment of neurological recovery, which may affect families’ medical decisions and lead to therapeutic nihilism. While emerging critical care studies have addressed communication gaps and strategies to improve them, no similar studies exist for acute neurological emergencies. Methods: ONGOING IRB-approved prospective observational study in a 22-bed Neuro ICU. All admitted patients and involve...
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Background: Elevated blood pressure after endovascular thrombectomy (EVT) has been associated with an increased risk of hemorrhagic transformation and poor functional outcomes. However, the optimal hemodynamic management after EVT remains... more
Background: Elevated blood pressure after endovascular thrombectomy (EVT) has been associated with an increased risk of hemorrhagic transformation and poor functional outcomes. However, the optimal hemodynamic management after EVT remains unknown, and the blood pressure course in the acute phase of ischemic stroke has not been well characterized. This study aimed to identify patient subgroups with distinct blood pressure trajectories after EVT and study their association with radiographic and functional outcomes. Methods: This multicenter retrospective cohort study included consecutive patients with anterior circulation large-vessel occlusion ischemic stroke who underwent EVT. Repeated time-stamped blood pressure data were recorded for the first 72 hours after thrombectomy. Latent variable mixture modeling was used to separate subjects into five groups with distinct postprocedural systolic blood pressure (SBP) trajectories. The primary outcome was functional status, measured on the ...
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Cerebral arteriovenous malformations (AVMs) are leading causes of lesional hemorrhagic stroke in both the pediatric and young adult population, with sporadic AVMs accounting for the majority of cases. Recent evidence has identified... more
Cerebral arteriovenous malformations (AVMs) are leading causes of lesional hemorrhagic stroke in both the pediatric and young adult population, with sporadic AVMs accounting for the majority of cases. Recent evidence has identified somatic mosaicism in key proximal components of the RAS-MAPK signaling cascade within endothelial cells collected from human sporadic cerebral AVMs, with early preclinical models supporting a potential causal role for these mutations in the pathogenesis of these malformations. Germline mutations that predispose to deregulation of the RAS-MAPK signaling axis have also been identified in hereditary vascular malformation syndromes, highlighting the key role of this signaling axis in global AVM development. Herein, we review the most recent genomic and preclinical evidence implicating somatic mosaicism in the RAS-MAPK signaling pathway in the pathogenesis of sporadic cerebral AVMs. Also, we review evidence for RAS-MAPK dysregulation in hereditary vascular mal...
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INTRODUCTION Latex perfusion is an effective tool to study cerebrovascular pathology in the animal brain. It provides, low-cost, high fidelity anatomical information on ex-vivo analysis, and can be utilized to study multiple, states.... more
INTRODUCTION Latex perfusion is an effective tool to study cerebrovascular pathology in the animal brain. It provides, low-cost, high fidelity anatomical information on ex-vivo analysis, and can be utilized to study multiple, states. However, current methods of latex casting and tissue-clearance do not allow for, immunohistochemical analysis following sample processing. This results in experiments that require, increased numbers of animals to attain adequate data. NEW METHOD In this paper, we present a modified latex perfusion and tissue processing protocol for ex-vivo analysis, of the cerebral vasculature. The method consists of injection of the arterial tree with liquid latex, followed by tissue clearance with a scale solution. RESULTS Our results demonstrate effective and reliable perfusion of the murine cerebrovascular tree, rendering, the arterial morphology of the brain in high detail, while allowing for post-perfusion, immunohistochemistry of the sample. COMPARISON WITH EXISTING METHOD Our technique bypasses the limitations of previous latex angiography protocols by allowing for postperfusion, pathologic analysis of casted cerebrovascular tissue. CONCLUSION This protocol provides a reliable, low-cost, method of cerebrovascular perfusion that reduces the number of animals required to generate robust data from latex-casted brain tissue.
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BackgroundThe off-hour effect has been observed in the medical care of acute ischemic stroke. However, it remains unclear if time of arrival affects revascularization rates and outcomes after endovascular therapy (EVT) for emergent large... more
BackgroundThe off-hour effect has been observed in the medical care of acute ischemic stroke. However, it remains unclear if time of arrival affects revascularization rates and outcomes after endovascular therapy (EVT) for emergent large vessel occlusion (ELVO). We aimed to investigate the clinical outcomes of EVT between on-hour and off-hour admissions.MethodsPatients who underwent EVT for ELVO from January 2013 to June 2019 from the STAR Registry were included. Patients were grouped based on time of groin puncture: on-hour period (Monday through Friday, 7:00 am–4:59 pm) and off-hour period (overnight 5:00pm–6:59am and the weekends). Primary outcome was final modified Rankin Scale (mRS) at 90 days on mRS-shift analysis.ResultsA total of 1919 patients were included in the study from six centers. The majority of patients (1169, 60.9%) of patients presented during the off-hour period. The mean age was 68.1 years and 50.5% were women. Successful reperfusion, as defined by a Thrombolysi...
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The relationship between degree of angiographic venous sinus stenosis and the trans-stenosis pressure gradient magnitude in idiopathic intracranial hypertension (IIH) is poorly understood. The present study aimed to assess the utility of... more
The relationship between degree of angiographic venous sinus stenosis and the trans-stenosis pressure gradient magnitude in idiopathic intracranial hypertension (IIH) is poorly understood. The present study aimed to assess the utility of angiography, venography, and non-invasive imaging (MRV or CTV) for the diagnosis and characterization of clinically significant VSS. Retrospective analysis of a prospectively collected database was performed to identify patients with medically refractory IIH who were evaluated by angiography and venous manometry for the presence of VSS with associated clinically significant pressure gradient. Angiographic stenosis was measured by two independent raters using novel methodology. Thirty-seven patients met inclusion criteria for the study. In total, 70% of patients had clinically significant pressure gradients and were selected for stenting. The optimal percentage stenosis for detection of a significant pressure gradient was 34% stenosis on venous phase...
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Occipital condyle fractures (OCFs) have traditionally been described based on anatomic characteristics; however, recent literature has proposed management based on biomechanical stability and neural element compression. The treatment of... more
Occipital condyle fractures (OCFs) have traditionally been described based on anatomic characteristics; however, recent literature has proposed management based on biomechanical stability and neural element compression. The treatment of biomechanically stable fractures varies between observation and cervical immobilization. Before determining the best management approach, an understanding of concomitant cervical spine fractures in the presence of OCFs is important. The primary aim of this pilot study was to determine the rate of occurrence of biomechanically significant cervical spine fractures with OCFs. A retrospective chart review was performed of 13,363 patients presenting to a level 1 trauma center between 2013 and 2017 with a diagnosis of OCF. Forty-six patients presented with OCFs, with an average Glasgow Coma Scale score of 12 on presentation and an average Injury Severity Score of 23. The average patient age was 42.1 years, and 4 patients had bilateral OCFs. Approximately 3...
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Background Some emergent large vessel occlusions (ELVOs) are refractory to reperfusion because of underlying intracranial atherosclerosis (ICAS), often requiring rescue therapy (RT) with balloon angioplasty, stenting, or both. In this... more
Background Some emergent large vessel occlusions (ELVOs) are refractory to reperfusion because of underlying intracranial atherosclerosis (ICAS), often requiring rescue therapy (RT) with balloon angioplasty, stenting, or both. In this study, we investigate the safety, efficacy, and long‐term outcomes of RT in the setting of mechanical thrombectomy for ICAS‐related ELVO. Methods and Results We queried the databases of 10 thrombectomy‐capable centers in North America and Europe included in STAR (Stroke Thrombectomy and Aneurysm Registry). Patients with ELVO who underwent ICAS‐related RT were included. A matched sample was produced for variables of age, admission National Institute of Health Stroke Scale, Alberta Stroke Program Early CT Score, onset to groin puncture time, occlusion site, and final recanalization. Out of 3025 patients with MT, 182 (6%) patients required RT because of underlying ICAS. Balloon angioplasty was performed on 122 patients, and 117 patients had intracranial s...
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Introduction: Recent trials have proven safety and efficacy of mechanical thrombectomy for patients presenting with emergent large vessel occlusion beyond 6 hours of symptom onset. While evidence supports using baseline CT scan to... more
Introduction: Recent trials have proven safety and efficacy of mechanical thrombectomy for patients presenting with emergent large vessel occlusion beyond 6 hours of symptom onset. While evidence supports using baseline CT scan to evaluate the candidacy for mechanical thrombectomy for patients presenting in the early window, late window trials have used advanced imaging such as CT and MR perfusion. We aim to assess outcomes of MT stratified by admission Alberta Stroke Program Early CT Score (ASPECTS). Methods: We used data from the prospectively maintained registries of 28 stroke centers in the Stroke Thrombectomy and Aneurysm (STAR) collaboration. Demographics, comorbidities, LVO site, ASPECTS, MT technique, radiographic and clinical outcome data were collected. Patients with M1 or ICA occlusion were included in these analyses. Multivariable analysis was performed using a generalized linear model with logit link to assess for variables associated with favorable outcomes. Results: 3...
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Research Interests: Neurosurgery and Medicine
Introduction: Blood pressure (BP) is an important modifiable parameter after endovascular thrombectomy (EVT). Observational studies have found associations between elevated BP after EVT with hemorrhagic transformation and poor functional... more
Introduction: Blood pressure (BP) is an important modifiable parameter after endovascular thrombectomy (EVT). Observational studies have found associations between elevated BP after EVT with hemorrhagic transformation and poor functional outcome. However, blood pressure course after EVT has not been well characterized and optimal hemodynamic management in the immediate post-stroke period remains unresolved. We utilized blood pressure data up to 72 hours after EVT to identify distinct systolic BP (SBP) trajectories and studied their associations with functional outcome. Methods: We retrospectively studied a multicenter cohort of 1060 patients with large-vessel occlusion stroke who underwent EVT. BP was recorded non-invasively recorded at least hourly for the first 72 hours. Functional outcome was assessed using the modified Rankin scale (mRS). Favorable functional outcome was defined as mRS <. Latent variable mixture modeling was applied to identify patient subgroups that have comp...
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Simulation is rapidly growing as a means of training a new generation of physicians in specific procedural skills. Endovascular surgical neuroradiology is one specialty within neurosurgery that is particularly well suited for... more
Simulation is rapidly growing as a means of training a new generation of physicians in specific procedural skills. Endovascular surgical neuroradiology is one specialty within neurosurgery that is particularly well suited for simulation-based training. As the procedures are performed with catheters, wire, and similar devices outside of the patient with a visual representation of what is occurring inside the patient on fluoroscopy, endovascular simulators are relatively simple to create. Several studies have shown that simulation courses with supervised practice is an effective platform for teaching cerebral angiography skills. Flow model simulation is a means of learning device techniques in a fluid-based medium. However the complex interactions between wire and catheter, skills dependent on the fluid medium such as contrast injection and embolism prevention, and capturing nuanced, subtle proceduralist hand movements have been extraordinarily difficult to replicate in simulation. In this chapter, we review endovascular simulation, the available literature on endovascular surgical neuroradiology simulation, currently available simulators, and the future role of neuroendovascular simulation in physician practice and training.
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Abstract Cerebral vasospasm is a focal or diffuse, temporary narrowing of cerebral arteries as evidenced by digital subtraction angiography, transcranial Doppler, magnetic resonance, or computed tomography angiography. Cerebral vasospasm... more
Abstract Cerebral vasospasm is a focal or diffuse, temporary narrowing of cerebral arteries as evidenced by digital subtraction angiography, transcranial Doppler, magnetic resonance, or computed tomography angiography. Cerebral vasospasm often results when cerebral vessels are exposed to blood in the subarachnoid space (subarachnoid hemorrhage), but may also occur after traumatic brain injury or secondary to inflammatory conditions such as meningitis and vasculitis. Radiographic spasm may progress to clinical (symptomatic) vasospasm as evidenced by neurologic deterioration and eventual permanent neurologic defect secondary to infarction. Autoregulatory dysfunction, inflammation, microcirculatory failure, and spreading cortical depolarization are multiple facets of the disease process that must be addressed with multimodal treatment to achieve improved neurologic outcomes. Rapid identification of symptomatic vasospasm with urgent treatment is essential to prevent permanent neurologic deficit. Ultimately, symptomatic vasospasm is best managed with hypertension followed by endovascular treatment with intra-arterial spasmolytics and/or balloon angioplasty.