A case of myxopapillary ependymoma with predominant giant cell morphology: A rare entity with comprehensive genomic profiling and review of literature

In the evolving landscape of ependymoma classification, which integrates histological, molecular, and anatomical context, we detail a rare case divergent from the usual histopathological spectrum. We present the case of a 37-year-old man with symptomatic spinal cord compression at the L3-L4 level. Neuroradiological evaluation revealed an intradural, encapsulated mass. Histologically, the tumor displayed atypical features: bizarre pleomorphic giant cells, intranuclear inclusions, mitotic activity, and a profusion of eosinophilic cytoplasm with hyalinized vessels, deviating from the characteristic perivascular pseudorosettes or myxopapillary patterns. Immunohistochemical staining bolstered this divergence, marking the tumor cells positive for glial fibrillary acidic protein and epithelial membrane antigen with a characteristic ring-like pattern, and CD99 but negative for Olig-2. These markers, alongside methylation profiling, facilitated its classification as a myxopapillary ependymoma (MPE), despite the atypical histologic features. This profile underscores the necessity of a multifaceted diagnostic process, especially when histological presentation is uncommon, confirming the critical role of immunohistochemistry and molecular diagnostics in classifying morphologically ambiguous ependymomas and exemplifying the histological diversity within MPEs.

Comparative outcomes of awake spine surgery under spinal versus general anesthesia: a comprehensive systematic review and meta-analysis

BACKGROUND

Awake surgery, under spinal anesthesia (SA), is an alternative to surgery under general anesthesia (GA), in neurological and spine surgery. In the literature, there seem to be some evidence supporting benefits associated with the use of this anesthetic modality, as compared to GA. Currently, there is a notable lack of updated and comprehensive review addressing the complications associated with both awake SA and GA in spine surgery. We hence aimed to perform a systematic review of the literature and meta-analysis on the topic.

METHODS

A systematic search was conducted to identify studies that assessed SA in spine surgery from database inception to April 14, 2023, in PubMed, Medline, Embase, and Cochrane databases. Outcomes of interest included estimated blood loss, length of hospital stay, operative time, and overall complications. Meta-analysis was conducted using random effects models.

RESULTS

In total, 38 studies that assessed 7820 patients were included. The majority of the operations that were treated with SA were single-level lumbar cases. Awake patients had significantly shorter lengths of hospital stay (Mean difference (MD): - 0.40 days; 95% CI - 0.64 to - 0.17) and operative time (MD: - 19.17 min; 95% CI - 29.68 to - 8.65) compared to patients under GA. The overall complication rate was significantly higher in patients under GA than SA (RR, 0.59 [95% CI 0.47-0.74]). Patients under GA had significantly higher rates of postoperative nausea/vomiting RR, 0.60 [95% CI 0.39-0.90]) and urinary retention (RR, 0.61 [95% CI 0.37-0.99]).

CONCLUSIONS

Patients undergoing awake spine surgery under SA had significantly shorter operations and hospital stays, and fewer rates of postoperative nausea and urinary retention as compared to GA. In summary, awake spine surgery offers a valid alternative to GA and added benefits in terms of postsurgical complications, while being associated with relatively low morbidity.

Direct Versus Indirect Revascularization for Moyamoya: a Large Multicenter Study

BACKGROUND

Moyamoya is a chronic occlusive cerebrovascular disease of unknown etiology causing neovascularization of the lenticulostriate collaterals at the base of the brain. Although revascularization surgery is the most effective treatment for moyamoya, there is still no consensus on the best surgical treatment modality as different studies provide different outcomes.

OBJECTIVE

In this large case series, we compare the outcomes of direct (DR) and indirect revascularisation (IR) and compare our results to the literature in order to reflect on the best revascularization modality for moyamoya.

METHODS

We conducted a multicenter retrospective study in accordance with the Strengthening the Reporting of Observational studies in Epidemiology guidelines of moyamoya affected hemispheres treated with DR and IR surgeries across 13 academic institutions predominantly in North America. All patients who underwent surgical revascularization of their moyamoya-affected hemispheres were included in the study. The primary outcome of the study was the rate of symptomatic strokes.

RESULTS

The rates of symptomatic strokes across 515 disease-affected hemispheres were comparable between the two cohorts (11.6% in the DR cohort vs 9.6% in the IR cohort, OR 1.238 (95% CI 0.651 to 2.354), p=0.514). The rate of total perioperative strokes was slightly higher in the DR cohort (6.1% for DR vs 2.0% for IR, OR 3.129 (95% CI 0.991 to 9.875), p=0.052). The rate of total follow-up strokes was slightly higher in the IR cohort (8.1% vs 6.6%, OR 0.799 (95% CI 0.374 to 1.709) p=0.563).

CONCLUSION

Since both modalities showed comparable rates of overall total strokes, both modalities of revascularization can be performed depending on the patient's risk assessment.

General Versus Nongeneral Anesthesia for Spinal Surgery: A Comparative National Analysis of Reimbursement Trends Over 10 Years

BACKGROUND AND OBJECTIVES

Nongeneral anesthesia (non-GA) spine surgery is growing in popularity and has facilitated earlier postoperative recovery, reduced cost, and fewer complications compared with spine surgery under general anesthesia (GA). Changes in reimbursement policies have been demonstrated to correlate with clinical practice; however, they have yet to be studied for GA vs non-GA spine procedures. We aimed to investigate trends in physician reimbursement for GA vs non-GA spine surgery in the United States.

METHODS

We queried the ACS-NSQIP for GA and non-GA (regional, epidural, spinal, and anesthesia care/intravenous sedation) spine surgeries during 2011-2020. Work relative value units per operative hour (wRVUs/h) were retrieved for decompression or stabilization of the cervical, thoracic, and lumbar spine. Propensity score matching (1:1) was performed using all baseline variables.

RESULTS

We included 474 706 patients who underwent spine decompression or stabilization procedures. GA was used in 472 248 operations, whereas 2458 operations were non-GA. The proportion of non-GA spine operations significantly increased during the study period. Operative times ( P < .001) and length of stays ( P < .001) were shorter in non-GA when compared with GA procedures. Non-GA lumbar procedures had significantly higher wRVUs/h when compared with the same procedures performed under GA (decompression; P < .001 and stabilization; P = .039). However, the same could not be said about cervicothoracic procedures. Lumbar decompression surgeries using non-GA witnessed significant yearly increase in wRVUs/h ( P < .01) contrary to GA ( P = .72). Physician reimbursement remained stable for procedures of the cervical or thoracic spine regardless of the anesthesia.

CONCLUSION

Non-GA lumbar decompressions and stabilizations are associated with higher and increasing reimbursement trends (wRVUs/h) compared with those under GA. Reimbursement for cervical and thoracic surgeries was equal regardless of the type of anesthesia and being relatively stable during the study period. The adoption of a non-GA technique relative to the GA increased significantly during the study period.

Technical and clinical outcomes in concurrent multivessel occlusions treated with mechanical thrombectomy: insights from the STAR collaboration

BACKGROUND

Endovascular 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.

OBJECTIVE

To investigate the prevalence, clinical and technical outcomes of concurrent EVT for MTVOs.

METHODS

Data 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.

RESULTS

Of 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 recanalization (Thrombolysis in Cerebral Infarction 2b/3), complications, modified Rankin score at 90 days, and mortality was not significantly different between the matched cohorts. Multivariate analysis confirmed that MTVOs were not associated with poor functional outcome, symptomatic intracranial hemorrhage, or longer procedure time.

CONCLUSION

Compared with EVT for single vessel occlusions, EVT in appropriately selected patients with MTVOs has a similar efficacy and safety profile.

Comprehensive analysis of the impact of procedure time and the 'golden hour' in subpopulations of stroke thrombectomy patients

OBJECTIVE

To evaluate the effect of procedure time on thrombectomy outcomes in different subpopulations of patients undergoing endovascular thrombectomy (EVT), given the recently expanded indications for EVT.

METHODS

This multicenter study included patients undergoing EVT for acute ischemic stroke at 35 centers globally. Procedure time was defined as time from groin puncture to successful recanalization (Thrombolysis in Cerebral Infarction score ≥2b) or abortion of procedure. Patients were stratified based on stroke location, use of IV tissue plasminogen activator (tPA), Alberta Stroke Program Early CT score, age group, and onset-to-groin time. Primary outcome was the 90-day modified Rankin Scale (mRS) score, with scores 0-2 designating good outcome. Secondary outcome was postprocedural symptomatic intracranial hemorrhage (sICH). Multivariate analyses were performed using generalized linear models to study the impact of procedure time on outcomes in each subpopulation.

RESULTS

Among 8961 patients included in the study, a longer procedure time was associated with higher odds of poor outcome (mRS score 3-6), with 10% increase in odds for each 10 min increment. When procedure time exceeded the 'golden hour', poor outcome was twice as likely. The golden hour effect was consistent in patients with anterior and posterior circulation strokes, proximal or distal occlusions, in patients with large core infarcts, with or without IV tPA treatment, and across age groups. Procedures exceeding 1 hour were associated with a 40% higher sICH rate. Posterior circulation strokes, delayed presentation, and old age were the variables most sensitive to procedure time.

CONCLUSIONS

In this work we demonstrate the universality of the golden hour effect, in which procedures lasting more than 1 hour are associated with worse clinical outcomes and higher rates of sICH across different subpopulations of patients undergoing EVT.

A THOROUGH STUDY AND META-ANALYSIS OF THE PROGNOSTIC RELEVANCE OF THE C-REACTIVE-ALBUMIN RATIO IN ACUTE PANCREATITIS

Although most cases of acute pancreatitis (AP) are minor, severe cases are associated with a substantial risk of death. Acute pancreatitis (AP) is a common illness. Therefore, it is critical to assess AP severity as soon as possible. This review aimed to ascertain the predictive significance of the CRP to albumin ratio in individuals with AP. We searched PubMed, Science Direct, and Cochrane Library electronic databases Until January 2023. Studies that reported the CRP/alb ratio at admission and its relationship to the severity or death of patients with AP were included. Using a random-effects model, we computed the pooled mean difference (MD) and 95% confidence interval (CI). The quality of the included studies was evaluated using the Newcastle-Ottawa scale. This meta-analysis combined data from six trials with a total of 2244 patients. Upon admission, the CRP/alb ratio was higher in patients with severe AP than in those with mild to moderate AP (pooled MD:3.59; 95% CI:2.51-4.68; p<0.00001). Additionally, non-survivor AP patients had a substantially higher CRP/alb ratio than survivor AP patients (pooled MD:2.12; 95% CI:0.43-3.8; p<0.01). Individuals with AP may benefit from a high CRP/ALB ratio as a preliminary indicator of poor prognosis.

Multicenter investigation of technical and clinical outcomes after thrombectomy for distal vessel occlusion by frontline technique

BACKGROUND

Endovascular 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.

METHODS

This 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 retriever RESULTS: We included 7477 patients including 213 DVOs. Distal location did not independently predict good functional outcome at 90 days compared with proximal (p=0.467). In distal occlusions, successful recanalization was an independent predictor of good outcome (adjusted odds ratio (aOR) 5.11, p<0.05) irrespective of technique. Younger age, bridging therapy, and lower admission National Institutes of Health Stroke Scale (NIHSS) were also predictors of good outcome. Procedure time ≤1 hour or ≤3 thrombectomy attempts were independent predictors of good outcomes in DVOs irrespective of technique (aOR 4.5 and 2.3, respectively, p<0.05). There were no differences in outcomes in a DVO matched cohort of aspiration versus stent retriever. Rates of hemorrhage and good outcome showed an exponential relationship to procedural metrics, and were more dependent on time in the aspiration group and attempts in the stent retriever group.

CONCLUSIONS

Outcomes following EVT for DVO are comparable to LVO with similar results between techniques. Techniques may exhibit different futility metrics; stent retriever thrombectomy was influenced by attempts whereas aspiration was more dependent on procedure time.

Myocardial injury in patients with acute ischemic stroke detected by cardiovascular magnetic resonance imaging

BACKGROUND

Patients with acute ischemic stroke (AIS) are at high risk of adverse cardiovascular events. Until now, the burden of myocardial injury derived from cardiovascular magnetic resonance imaging (CMR) has not been established in this population.

METHODS

Patients with AIS underwent CMR at 3 Tesla within 120 h after the index stroke as part of a prospective, single-center study. Patients with persistent atrial fibrillation were excluded. Morphology and function of both cardiac chambers and atria were assessed applying SSFP cine. Myocardial tissue differentiation was based on native and contrast-enhanced imaging including late gadolinium enhancement (LGE) after 0.15 mmol/kg gadobutrol for focal fibrosis and parametric T2- and T1-mapping for diffuse findings. To detect myocardial deformation global longitudinal (GLS), circumferential (GCS) and radial (GRS) strain was measured applying feature tracking. Cardiac troponin was measured using a high-sensitivity assay (99th percentile upper reference limit 14 ng/L). T2 mapping values were compared with 20 healthy volunteers.

RESULTS

CMR with contrast media was successfully performed in 92 of 115 patients (mean age 74 years, 40% female, known myocardial infarction 6%). Focal myocardial fibrosis (LGE) was detected in 31 of 92 patients (34%) of whom 23/31 (74%) showed an ischemic pattern. Patients with LGE were more likely to have diabetes, prior myocardial infarction, prior ischemic stroke, and to have elevated troponin levels compared to those without. Presence of LGE was accompanied by diffuse fibrosis (increased T1 native values) even in remote cardiac areas as well as reduced global radial, circumferential and longitudinal strain values. In 14/31 (45%) of all patients with LGE increased T2-mapping values were detectable.

CONCLUSIONS

More than one-third of patients with AIS have evidence of focal myocardial fibrosis on CMR. Nearly half of these changes may have acute or subacute onset. These findings are accompanied by diffuse myocardial changes and reduced myocardial deformation. Further studies, ideally with serial CMR measurements during follow-up, are required to establish the impact of these findings on long-term prognosis after AIS.

Comparison of Flow-Redirection Endoluminal Device and Pipeline Embolization Device in the Treatment of Intracerebral Aneurysms

BACKGROUND

The use of flow diverters for treating intracranial aneurysms has been widely used in the past decade; however, data comparing pipeline embolization device (PED; Medtronic Inc) and flow-redirection endoluminal device (FRED; MicroVention) in the treatment of intracranial aneurysms remain scarce.

OBJECTIVE

To compare the outcomes of PED and FRED in the treatment of intracranial aneurysms.

METHODS

This is a single-center retrospective review of aneurysms treated with PED and FRED devices. Patients treated with PED or FRED were included. Cases requiring multiple or adjunctive devices were excluded. Primary outcome was complete aneurysm occlusion at 6 months. Secondary outcomes included good functional outcome, need for retreatment, and any complication.

RESULTS

The study cohort comprised 150 patients, including 35 aneurysms treated with FRED and 115 treated with PED. Aneurysm characteristics including location and size were comparable between the 2 cohorts. 6-month complete occlusion rate was significantly higher in the PED cohort (74.7% vs 51.5%; P = .017) but lost significance after inverse probability weights. Patients in the PED cohort were associated with higher rates of periprocedural complications (3.5% vs 0%; P = .573), and the rate of in-stent stenosis was approximately double in the FRED cohort (15.2% vs 6.9%; P = .172).

CONCLUSION

Compared with PED, FRED offers modest 6-month occlusion rates, which may be due to aneurysmal and baseline patient characteristics differences between both cohorts. Although not significant, FRED was associated with a higher complication rate mostly because of in-stent stenosis. Additional studies with longer follow-up durations should be conducted to further evaluate FRED thrombogenicity.

Multicenter investigation of technical and clinical outcomes after thrombectomy for Proximal Medium Vessel Occlusion (pMeVO) by frontline technique

BACKGROUND

Endovascular thrombectomy(EVT) is the standard of care for large vessel occlusion(LVO) stroke. Data on technical and clinical outcome in proximal medium vessel occlusions(pMeVOs) comparing frontline techniques remain limited.

METHODS

We report an international multicenter retrospective study of patients undergoing EVT for stroke at 32 centers between 2015-2021. Patients were divided into LVOs(ICA/M1/Vertebrobasilar) or pMeVOs(M2/A1/P1) and categorized by thrombectomy technique. Primary outcome was 90-day good functional outcome(mRS ≤ 2). Multivariate logistic regressions were used to evaluate the impact of technical variables on clinical outcomes. Propensity score matching was used to compare outcome in patients with pMeVO treated with aspiration versus stent-retriever.

RESULTS

In the cohort of 5977 LVO and 1287 pMeVO patients, pMeVO did not independently predict good-outcome(p  =  0.55). In pMeVO patients, successful recanalization irrespective of frontline technique(aOR = 3.2,p < 0.05), procedure time ≤ 1-h(aOR = 2.2,p < 0.05), and thrombectomy attempts ≤ 4(aOR =  2.8,p < 0.05) were independent predictors of good-outcomes.In a propensity-matched cohort of aspiration versus stent-retriever pMeVO patients, there was no difference in good-outcomes. The rates of hemorrhage were higher(9%vs.4%,p < 0.01) and procedure time longer(51-min vs. 33-min,p < 0.01) with stent-retriever, while the number of attempts was higher with aspiration(2.5vs.2,p < 0.01). Rates of hemorrhage and good-outcome showed an exponential relationship to procedural metrics, and were more dependent on time in the aspiration group compared to attempts in the stent-retriever group.

CONCLUSIONS

Clinical outcomes following EVT for pMeVO are comparable to those in LVOs. The golden hour or 3-pass rules in LVO thrombectomy still apply to pMeVO thrombectomy. Different techniques may exhibit different futility metrics; SR thrombectomy was more influenced by attempts whereas aspiration was more dependent on procedure time.

Artificial neural networks predict the need for permanent cerebrospinal fluid diversion following posterior fossa tumor resection

Background

Resection of posterior fossa tumors (PFTs) can result in hydrocephalus that requires permanent cerebrospinal fluid (CSF) diversion. Our goal was to prospectively validate a machine-learning model to predict postoperative hydrocephalus after PFT surgery requiring permanent CSF diversion.

Methods

We collected preoperative and postoperative variables on 518 patients that underwent PFT surgery at our center in a retrospective fashion to train several statistical classifiers to predict the need for permanent CSF diversion as a binary class. A total of 62 classifiers relevant to our data structure were surveyed, including regression models, decision trees, Bayesian models, and multilayer perceptron artificial neural networks (ANN). Models were trained using the (N = 518) retrospective data using 10-fold cross-validation to obtain accuracy metrics. Given the low incidence of our positive outcome (12%), we used the positive predictive value along with the area under the receiver operating characteristic curve (AUC) to compare models. The best performing model was then prospectively validated on a set of 90 patients.

Results

Twelve percent of patients required permanent CSF diversion after PFT surgery. Of the trained models, 8 classifiers had an AUC greater than 0.5 on prospective testing. ANNs demonstrated the highest AUC of 0.902 with a positive predictive value of 83.3%. Despite comparable AUC, the remaining classifiers had a true positive rate below 35% (compared to ANN, P < .0001). The negative predictive value of the ANN model was 98.8%.

Conclusions

ANN-based models can reliably predict the need for ventriculoperitoneal shunt after PFT surgery.

International Controlled Study of Revascularization and Outcomes Following COVID-Positive Mechanical Thrombectomy

Background and purpose

Previous studies suggest that mechanisms and outcomes in patients with COVID‐19‐associated stroke differ from those in patients with non‐COVID‐19‐associated strokes, but there is limited comparative evidence focusing on these populations. The aim of this study, therefore, was to determine if a significant association exists between COVID‐19 status with revascularization and functional outcomes following thrombectomy for large vessel occlusion (LVO), after adjustment for potential confounding factors.

Methods

A cross‐sectional, international multicenter retrospective study was conducted in consecutively admitted COVID‐19 patients with concomitant acute LVO, compared to a control group without COVID‐19. Data collected included age, gender, comorbidities, clinical characteristics, details of the involved vessels, procedural technique, and various outcomes. A multivariable‐adjusted analysis was conducted.

Results

In this cohort of 697 patients with acute LVO, 302 had COVID‐19 while 395 patients did not. There was a significant difference (p < 0.001) in the mean age (in years) and gender of patients, with younger patients and more males in the COVID‐19 group. In terms of favorable revascularization (modified Thrombolysis in Cerebral Infarction [mTICI] grade 3), COVID‐19 was associated with lower odds of complete revascularization (odds ratio 0.33, 95% confidence interval [CI] 0.23–0.48; p < 0.001), which persisted on multivariable modeling with adjustment for other predictors (adjusted odds ratio 0.30, 95% CI 0.12–0.77; p = 0.012). Moreover, endovascular complications, in‐hospital mortality, and length of hospital stay were significantly higher among COVID‐19 patients (p < 0.001).

Conclusion

COVID‐19 was an independent predictor of incomplete revascularization and poor functional outcome in patients with stroke due to LVO. Furthermore, COVID‐19 patients with LVO were more often younger and had higher morbidity/mortality rates.

Characteristics of a COVID-19 Cohort With Large Vessel Occlusion: A Multicenter International Study

BACKGROUND

The mechanisms and outcomes in coronavirus disease (COVID-19)-associated stroke are unique from those of non-COVID-19 stroke.

OBJECTIVE

To describe the efficacy and outcomes of acute revascularization of large vessel occlusion (LVO) in the setting of COVID-19 in an international cohort.

METHODS

We conducted an international multicenter retrospective study of consecutively admitted patients with COVID-19 with concomitant acute LVO across 50 comprehensive stroke centers. Our control group constituted historical controls of patients presenting with LVO and receiving a mechanical thrombectomy between January 2018 and December 2020.

RESULTS

The total cohort was 575 patients with acute LVO; 194 patients had COVID-19 while 381 patients did not. Patients in the COVID-19 group were younger (62.5 vs 71.2; P < .001) and lacked vascular risk factors (49, 25.3% vs 54, 14.2%; P = .001). Modified thrombolysis in cerebral infarction 3 revascularization was less common in the COVID-19 group (74, 39.2% vs 252, 67.2%; P < .001). Poor functional outcome at discharge (defined as modified Ranklin Scale 3-6) was more common in the COVID-19 group (150, 79.8% vs 132, 66.7%; P = .004). COVID-19 was independently associated with a lower likelihood of achieving modified thrombolysis in cerebral infarction 3 (odds ratio [OR]: 0.4, 95% CI: 0.2-0.7; P < .001) and unfavorable outcomes (OR: 2.5, 95% CI: 1.4-4.5; P = .002).

CONCLUSION

COVID-19 was an independent predictor of incomplete revascularization and poor outcomes in patients with stroke due to LVO. Patients with COVID-19 with LVO were younger, had fewer cerebrovascular risk factors, and suffered from higher morbidity/mortality rates.

Aneurysmal recurrence after successful flow-diversion embolization

Aneurysmal recurrence after successful flow-diversion embolization is exceptionally rare. The rarity of recurrence has called into question the yield of interval surveillance imaging. Here we report the case of a recurrent intracranial aneurysm despite complete angiographic resolution after flow-diversion therapy with a Pipeline embolization device (PED). Given the absence of poor wall apposition, endoleak, and device migration, how this aneurysm recurred remains unclear, particularly given the recurrence was at a timepoint at which complete reendothelialization of the device would be expected. The patient ultimately underwent interval treatment with a second device placed across the neck of the aneurysm. Although rare, reports of aneurysmal recurrences support the use of interval non-invasive imaging surveillance to ensure successful embolization in this patient population.

Clipping Could Be the Best Treatment Modality for Recurring Anterior Communicating Artery Aneurysms Treated Endovascularly

BACKGROUND

The anterior communicating artery (AcoA) is the most common location for intracranial aneurysms.

OBJECTIVE

To present occlusion outcomes, complication rate, recurrence rate, and predictors of recurrence in a large cohort with AcoA aneurysms treated primarily with endosaccular embolization. We also attempt to present data on the most effective treatment modality for recurrent AcoA aneurysms.

METHODS

This is a retrospective, single-center study, reviewing the outcomes of 463 AcoA aneurysms treated endovascularly between 2003 and 2018.

RESULTS

The study cohort consisted of 463 patients. Adequate immediate occlusion was achieved in 418 (90.3%). Independent functional status at discharge was observed in 269 patients (58.0%), and the mortality rate was 6.8% (31). At 6 months, adequate occlusion was achieved in 418 (90.4%). Of all the patients, recurrence was observed in 101 cases (21.8%), and of those, 98 (22.4%) underwent retreatment. The combined frequency of retreatment for the coiling group was 42.4%, which was significantly higher than the 0 incident of retreatment in the clipping group (P < .0001). Among the retreatment cohort, there was a significantly higher subsequent retreatment rate in the endovascular group (0% in the clipping group vs 42.4% in the endovascular group, P < .0001).

CONCLUSION

Coiling with and without stent/balloon assistance is a relatively safe and effective modality for the treatment of AcoA aneurysms; however, in the setting of recurrence, microsurgical reconstruction leads to improved outcomes regarding durable occlusion, thus avoiding the potential for multiple interventions in the future.

Permanent Cerebrospinal Fluid Diversion in Adults With Posterior Fossa Tumors: Incidence and Predictors

BACKGROUND

Posterior fossa tumors (PFTs) can cause hydrocephalus. Hydrocephalus can persist despite resection of PFTs in a subset of patients requiring permanent cerebrospinal fluid (CSF) diversion. Characteristics of this patient subset are not well defined.

OBJECTIVE

To define preoperative and postoperative variables that predict the need for postoperative CSF diversion in adult patients with PFTs.

METHODS

We surveyed the CNS (Central Nervous System) Tumor Outcomes Registry at Emory (CTORE) for patients who underwent PFT resection at 3 tertiary-care centers between 2006 and 2019. Demographic, radiographic, perioperative, and dispositional data were analyzed using univariate and multivariate models.

RESULTS

We included 617 patients undergoing PFT resection for intra-axial (57%) or extra-axial (43%) lesions. Gross total resection was achieved in 62% of resections. Approximately 13% of patients required permanent CSF diversion/shunting. Only 31.5% of patients who required pre- or intraop external ventricular drain (EVD) placement needed permanent CSF diversion. On logistic regression, size, transependymal flow, use of perioperative EVD, postoperative intraventricular hemorrhage (IVH), and surgical complications were predictors of permanent CSF diversion. Preoperative tumor size was only independent predictor of postoperative shunting in patients with subtotal resection. In patients with intra-axial tumors, transependymal flow (P = .014), postoperative IVH (P = .001), surgical complications (P = .013), and extent of resection (P = .03) predicted need for shunting. In extra-axial tumors, surgical complications were the major predictor (P = .022).

CONCLUSION

Our study demonstrates that presence of preoperative hydrocephalus in patients with PFT does not necessarily entail the need for permanent CSF diversion. We report the major predictive factors for needing permanent CSF diversion.

POS1278 THE PREVALENCE AND CLINICAL SIGNIFICANCE OF ULTRASONOGRAPHIC FINDINGS OF DISTAL MEDIAL HAMSTRING TENDONS IN PATIENTS WITH POSTEROMEDIAL KNEE PAIN

Background:

Periarticular abnormalities are common ultrasonographic (U/S) findings in individuals with knee pain. Incidental U/S observations, including thickening of the distal hamstring tendons, require explanations for their clinical importance. Tendon thickness may be a good indicator of tendinopathy and tendon dysfunction. Also, it is uncertain whether these tendon changes are correlated with knee pain or not?

Objectives:

The aim of this study was to determine U/S findings of distal medial hamstring tendons in patients with posteromedial (PM) knee pain and assess the diagnostic values of tendon thickness in predicting tendinopathy.

Methods:

We studied distal medial hamstring tendons (semimembranosus [SM] and semitendinosus [ST]) of 104 patients (104 knees) with non-traumatic unilateral PM knee pain and 118 healthy controls (236 knees). U/S evaluations included tendon thickness, echogenicity, the presence of intrasubstance tears, calcification, and vascularity.

Results:

The mean age (standard deviation) of the patients and control groups were 51.7 (10.4) years and 49.8 (9.9) years, respectively. The mean visual analogue scale (VAS) for pain among patients was 5.1 and 58.6% of them located the pain at medial joint line. The studied patients had significantly higher mean SM thickness (7.17 mm vs. 5.46 mm, respectively) and ST thickness (3.93 mm vs. 3.45 mm, respectively) than the controls. U/S abnormalities among patients were hypoechogenicity (62.5%), intrasubstance tears (31.7%), loss of fibrillar pattern (23.1%), Baker cyst (20.2%), calcification (18.3%), Anserine bursitis (11.5%), and neovascularization (6.7%). We found significant correlations between tendon thickness and VAS (r=0.752, p=0.004), and pain location (r=0.680, p=0.008). SM thickness had higher accuracy to predict tendinopathy than ST thickness (80.6% vs. 68.9%, respectively).

Table 1.

Diagnostic values of tendon thickness in predicting tendinopathy.

TendonsCutoffSensitivitySpecificity+PV-PVAccuracyAUCSM>6.670.289.885.776.880.60.835ST>3.756.779.671.167.668.90.696

SM: semimembranosus, ST: semitendinosus, +PV: positive predictive value, -PV: negative predictive value, AUC: area under curve.

Conclusion:

U/S changes are frequently present in patients with PM knee pain. Tendon thickness is an accurate predictor of tendinopathy. These findings suggest that U/S screening of all individuals with PM knee pain is a useful tool for improving patients’ outcomes and decreasing tendon-related disability.

Disclosure of Interests:

None declared

Abstract P20: Bridging Therapy Increases Hemorrhagic Complications Without Improving Functional Outcomes in Atrial Fibrillation Associated Stroke

* on behalf of the Stroke Thrombectomy and Aneurysm Registry (STAR) Collaborators

Introduction: Intravenous thrombolysis complications are enriched in AF associated stroke, as these patients have worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications. These data suggest that AF patients may be at particularly high risk for complications of bridging therapy for large vessel occlusions treated with mechanical thrombectomy (MT). Here we determine whether clinical outcomes differ in AF associated stroke treated with MT and bridging therapy.

Methods: We performed a retrospective cohort study of the Stroke and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4,169 patients who underwent MT for an anterior circulation stroke, 1,517 (36.4 %) of which had comorbid AF. Prospectively defined baseline characteristics and clinical outcomes were compared.

Results: Hemorrhagic complications after MT were similar in patients with or without AF. In patients without AF, bridging therapy improved 90-day outcomes (aOR 1.32, 1.02-1.74, p<0.05) without increasing hemorrhagic complications. In patients with AF, bridging therapy independently predicted hemorrhagic complications in AF patients (aOR 2.08, 1.06-4.06, p<0.033) without improving functional outcomes.

Conclusions: Bridging therapy in AF patients undergoing thrombectomy independently increased the odds of intracranial hemorrhage and did not improve functional outcomes. AF patients may represent a high-risk subgroup for thrombolytic complications. Randomized trials are warranted to determine whether patients with AF associated stroke may benefit by deferring bridging therapy at thrombectomy-capable centers.

Anterior perforated substance region aneurysms: review of a series treated with microsurgical technique

Aneurysms arising from the distal carotid, proximal A1, and proximal M1 that project posteriorly and superiorly toward the anterior perforated substance (APS) are rare. Their open surgical treatment is particularly difficult due to poorly visualized origin of the aneurysm and the abundance of surrounding perforators. We sought to analyze the anatomical and clinical characteristics of APS aneurysms and discuss surgical nuances that can optimize visualization, complete neck clip obliteration, and preservation of adjacent perforators. Thirty-two patients with 36 APS aneurysms were surgically treated between November 2000 and September 2017. Patients were prospectively enrolled in a cerebral aneurysm database and their clinical, imaging, and surgical records were retrospectively reviewed. Twenty-seven aneurysms originated from the distal ICA, 7 from the proximal A1, and 2 from the proximal M1; 15 patients presented with subarachnoid hemorrhage. Careful intraoperative dissection revealed 4 aneurysms originating at the takeoff of a perforator; another 25 had at least 1 adherent perforator. All aneurysms were clipped except for one that was trapped. Postoperatively, 3 patients had radiographic infarctions in perforator territory with only 1 developing delayed clinical hemiparesis. Good outcome (modified Rankin Scale, 0-2) was achieved in 28 patients (88%). APS aneurysms present a challenging subset of aneurysms due to their complex anatomical relationship with surrounding perforators. These should be identified on preoperative imaging based on location and projection. Successful microsurgical clipping relies on optimization of the surgical view, meticulous clip reconstruction, preservation of all perforators, and electrophysiological monitoring to minimize ischemic complication.

Myocardial Fibrosis Among Antiretroviral Therapy-Treated Persons With Human Immunodeficiency Virus in South Africa

BACKGROUND

Heart failure is a prominent cardiovascular disease (CVD) manifestation in sub-Sarahan Africa. Myocardial fibrosis is a central feature of heart failure that we aimed to characterize among persons with human immunodeficiency virus (PWH) in South Africa.

METHODS

Cardiovascular magnetic resonance (CMR) imaging was performed among PWH with viral suppression and uninfected controls, both free of known CVD. Plasma levels of N-terminal pro B-type natriuretic peptide (NT-proBNP) were measured. Comparisons by human immunodeficiency virus (HIV) status were made using linear and logistic regression, adjusted for age, sex, and hypertension.

RESULTS

One hundred thirty-four PWH and 95 uninfected persons completed CMR imaging; age was 50 and 49 years, with 63% and 67% female, respectively. Compared with controls, PWH had greater myocardial fibrosis by extracellular volume fraction ([ECV] absolute difference, 1.2%; 95% confidence interval [CI], 0.1-2.3). In subgroup analyses, the effect of HIV status on ECV was more prominent among women. Women (vs controls) were also more likely to have elevated NT-proBNP levels (>125 pg/mL; odds ratio, 2.4; 95% CI, 1.0-6.0). Among all PWH, an elevated NT-proBNP level was associated with higher ECV (3.4% higher; 95% CI, 1.3-5.5).

CONCLUSIONS

Human immunodeficiency virus disease may contribute to myocardial fibrosis, with an effect more prominent among women. Research is needed to understand heart failure risk among PWH within sub-Saharan Africa.

Differential effect of mechanical thrombectomy and intravenous thrombolysis in atrial fibrillation associated stroke

BACKGROUND

Atrial fibrillation (AF) associated ischemic stroke has worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Limited data exist about the effect of AF on procedural and clinical outcomes after mechanical thrombectomy (MT).

OBJECTIVE

To determine whether recanalization efficacy, procedural speed, and clinical outcomes differ in AF associated stroke treated with MT.

METHODS

We performed a retrospective cohort study of the Stroke Thrombectomy and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4169 patients who underwent MT for an anterior circulation stroke, 1517 (36.4 %) of whom had comorbid AF. Prospectively defined baseline characteristics, procedural outcomes, and clinical outcomes were reported and compared.

RESULTS

AF predicted faster procedural times, fewer passes, and higher rates of first pass success on multivariate analysis (p<0.01). AF had no effect on intracranial hemorrhage (aOR 0.69, 95% CI 0.43 to 1.12) or 90-day functional outcomes (aOR 1.17, 95% CI 0.91 to 1.50) after MT, although patients with AF were less likely to receive IVT (46% vs 54%, p<0.0001).

CONCLUSIONS

In patients treated with MT, comorbid AF is associated with faster procedural time, fewer passes, and increased rates of first pass success without increased risk of intracranial hemorrhage or worse functional outcomes. These results are in contrast to the increased hemorrhage rates and worse functional outcomes observed in AF associated stroke treated with supportive care and or IVT. These data suggest that MT negates the AF penalty in ischemic stroke.

Dissecting the Financial Relationship Between Industry and Academic Neurosurgery

BACKGROUND

Established by the Centers for Medicare and Medicaid Services (CMS), the Open Payments Database (OPD) has reported industry payments to physicians since August 2013.

OBJECTIVE

To evaluate the frequency, type, and value of payments received by academic neurosurgeons in the United States over a 5-yr period (2014-2018).

METHODS

The OPD was queried for attending neurosurgeons from all neurosurgical training programs in the United States (n = 116). Information from the OPD was analyzed for the entire cohort as well as for comparative subgroup analyses, such as career stage, subspecialty, and geographic location.

RESULTS

Of all identified neurosurgeons, 1509 (95.0%) received some payment from industry between 2014 and 2018 for a total of 106 171 payments totaling $266 407 458.33. A bimodal distribution was observed for payment number and total value: 0 to 9 (n = 438) vs > 50 (n = 563) and 0-$1000 (n = 418) vs >$10 000 (n = 653), respectively. Royalty/License was the most common type of payment overall (59.6%; $158 723 550.57). The median number (40) and value ($8958.95) of payments were highest for mid-career surgeons. The South-Central region received the most money ($117 970 036.39) while New England received the greatest number of payments (29 423). Spine surgeons had the greatest median number (60) and dollar value ($20 551.27) of payments, while pediatric neurosurgeons received the least (8; $1108.29). Male neurosurgeons received a greater number (31) and value ($6395.80) of payments than their female counterparts (11, $1643.72).

CONCLUSION

From 2014 to 2018, payments to academic neurosurgeons have increased in number and value. Dollars received were dependent on geography, career stage, subspecialty and gender.

Sheltered Neurosurgery During COVID-19: The Emory Experience

Background

The 2019 novel coronavirus disease (COVID-19) pandemic has directly and indirectly impacted health care systems, including residency programs. Social distancing, cancellation of elective cases, and staff re-deployment have compromised clinical and academic teaching. We describe the neurosurgical experience at Emory University during the COVID-19 pandemic and the impact of COVID-19-related policies on resident experience.

Methods

We retrospectively reviewed all neurosurgical cases performed at Emory University Hospital between March 16, the day cancellation of elective cases was effective, and April 15, 2020, and the same period in the preceding 3 years. For the study period, we collected the number of cases and their distribution by subspecialty along with total hospital charges.

Results

Compared with an average of 606 cases performed during the study period over the past 3 years, only 145 neurosurgical cases were performed between March 16 and April 15, 2020, which corresponds to an 80% reduction in case volume and 66% decrease in hospital revenue in 2020. When divided by subspecialty, the most significant reduction was observed in functional (84%; P < 0.01) followed by spine (78%; P < 0.01) surgery, although all subspecialties were significantly impacted. Assessing junior resident experience, we observed a significant reduction in number of neurosurgical admissions (47%; P < 0.01) and bedside procedures (59%; P < 0.01) in the study period in 2020 compared with the past 3 years, with no significant reduction in number of consultations (17%; P > 0.1).

Conclusions

Even at academic centers that were not hugely impacted by the COVID-19 pandemic, prophylactic and preparedness measures still exhibited an unprecedented toll on neurosurgical resident and fellow experience.

An Analysis of Publication Productivity During Residency for 1506 Neurosurgical Residents and 117 Residency Departments in North America

BACKGROUND

Bibliometrics is defined as the study of statistical and mathematical methods used to quantitatively analyze scientific literature. The application of bibliometrics in neurosurgery continues to evolve.

OBJECTIVE

To calculate a number of publication productivity measures for almost all neurosurgical residents and departments within North America. These measures were correlated with survey results on the educational environment within residency programs.

METHODS

During May to June 2017, data were collected from departmental websites and Scopus to compose a bibliometric database of neurosurgical residents and residency programs. Data related to authorship value and study content were collected on all articles published by residents. A survey of residency program research and educational environment was administered to program directors and coordinators; results were compared with resident academic productivity.

RESULTS

The median number of publications in residency was 3; median h-index and Resident index were 1 and 0.17 during residency, respectively. There was a statistically significant difference in academic productivity among male neurosurgical residents compared with females. The majority of articles published were tier 1 clinical articles. Residency program research support was significantly associated with increased resident productivity (P < .001). Scholarly activity requirements were not associated with increased resident academic productivity.

CONCLUSION

This study represents the most comprehensive bibliometric assessment of neurosurgical resident academic productivity during training to date. New benchmarks for individual and department academic productivity are provided. A supportive research environment for neurosurgical residents is associated with increased academic productivity, but a scholarly activity requirement was, surprisingly, not shown to have a positive effect.

The use of alternatives to clopidogrel in flow-diversion treatment with the Pipeline embolization device

OBJECTIVEThromboembolic complications continue to be encountered with Pipeline embolization devices (PEDs) despite routine clopidogrel/aspirin antiplatelet therapy. This study examined the safety and efficacy of prasugrel in the management of clopidogrel-resistant patients treated for cerebral aneurysms.METHODSFour hundred thirty-seven consecutive patients were identified between January 2011 and May 2016. Patients allergic, or having less than 30% platelet inhibition, to a daily 75-mg dose of clopidogrel received 10 mg of prasugrel daily (n = 20) or 90 mg of ticagrelor twice daily (n = 2). The mean (± SD) follow-up duration was 15.8 ± 12.4 months. The primary outcome was the modified Rankin Scale (mRS) score registered before discharge and at each follow-up visit. To control confounding, multivariable mixed-effects logistic regression and propensity score conditioning were used.RESULTSTwenty-six (5.9%) of 437 patients presented with a subarachnoid hemorrhage (SAH). The mean patient age was 56.3 years, and 62 were women (14.2%). One of the 7 patients lost to follow-up received prasugrel. One patient was allergic to clopidogrel and prasugrel simultaneously. All patients receiving prasugrel or ticagrelor (n = 22) had an mRS score ≤ 2 on their latest follow-up visit (mean score 0.67 ± 1.15). In a multivariate analysis, clopidogrel did not affect the mRS score on last follow-up (p = 0.14). Multivariable logistic regression showed that clopidogrel was not associated with an increased long-term recurrence rate (OR 0.17, 95% CI 0.01-2.70, p = 0.21), an increased thromboembolic complication rate (OR 0.46, 95% CI 0.12-1.67, p = 0.24), or an increased hemorrhagic event rate (OR 0.39, 95% CI 0.91-1.64, p = 0.20). None of the patients receiving prasugrel or ticagrelor died or suffered a long-term recurrence or a hemorrhagic event; only 1 patient suffered from mild aphasia subsequent to a thromboembolic event. Three patients taking clopidogrel died during the study: 2 from acute SAH and 1 from intraparenchymal hemorrhage. Clopidogrel was not associated with an increased mortality rate (OR 2.18, 95% CI 0.11-43.27, p = 0.61). The same associations were present in propensity score-adjusted models.CONCLUSIONSIn a cohort of patients treated with PEDs, prasugrel (10 mg/day) was a safe alternative to clopidogrel-resistant or clopidogrel-allergic patients, or nonresponders.

Postgraduate publishing output in pediatric neurosurgery: correlation with fellowship site and individual scholars

OBJECTIVE

The objective of this study was to analyze the publication output of postgraduate pediatric neurosurgery fellows for a 10-year period as well as identify 25 individual highly productive pediatric neurosurgeons. The correlation between academic productivity and the site of fellowship training was studied.

METHODS

Programs certified by the Accreditation Council for Pediatric Neurosurgery Fellowships that had 5 or more graduating fellows from 2006 to 2015 were included for analysis. Fellows were queried using Scopus for publications during those 10 years with citation data through 2017. Pearson correlation coefficients were calculated, comparing program rankings of faculty against fellows using the revised Hirsch index (r-index; primary) and Hirsch index (h-index; secondary). A list of 25 highly accomplished individual academicians and their fellowship training locations was compiled.

RESULTS

Sixteen programs qualified with 152 fellows from 2006 to 2015; 136 of these surgeons published a total of 2009 articles with 23,735 citations. Most publications were pediatric-specific (66.7%) clinical articles (93.1%), with middle authorship (55%). Co-investigators were more likely from residency than fellowship. There was a clustering of the top 7 programs each having total publications of around 120 or greater, publications per fellow greater than 12, more than 1200 citations, and adjusted ir10 (revised 10-year institutional h-index) and ih10 (10-year institutional h-index) values of approximately 2 or higher. Correlating faculty and fellowship program rankings yielded correlation coefficients ranging from 0.53 to 0.80. Fifteen individuals (60%) in the top 25 (by r5 index) list completed their fellowship at 1 of these 7 institutions.

CONCLUSIONS

Approximately 90% of fellowship-trained pediatric neurosurgeons have 1 or more publications, but the spectrum of output is broad. There is a strong correlation between where surgeons complete their fellowships and postgraduate publications.

How Does the Media Portray Neurosurgeons?

BACKGROUND

It is not unusual to find neurosurgeons in the news and entertainment. The present study examined the portrayal of neurosurgeons by major print and online media sources.

METHODS

Two search strategies identified articles from October 1, 2012 to October 1, 2017 containing the keyword "neurosurgeon." The top 25 newspapers in the United States, determined by their circulation, were searched using the LexisNexis Academic or NewsBank databases; a layman's Google News search was used to collect online stories. Each identified article was evaluated to confirm the relevance and then examined for content. Relevant characteristics for each article and neurosurgeon were determined and analyzed.

RESULTS

Our searches returned 1005 articles comprising 561 unique stories about 203 different neurosurgeons. One particular neurosurgeon had 459 reports (45.7%). More articles were reported in 2015 (405; 40.3%) than any other single year. Most articles featured male neurosurgeons (879; 87.1%) and neurosurgeons who had been practicing for >20 years (636; 63.0%), with just 10 institutions accounting for the training of most of them (733; 72.6%). The articles were classified as positive (270; 26.9%), negative (356; 35.4%), or neutral (379; 37.7%) in terms of their reflection on the field of neurosurgery. The odds of a negative story were greater for male neurosurgeons, within 10 years of residency completion, and in a nonacademic position.

CONCLUSIONS

Neurosurgeons are naturally subject to media coverage, and we must be cognizant that this predilection can serve as both an occupational advantage and an occupational hazard.

Pipeline for Distal Cerebral Circulation Aneurysms

BACKGROUND

Pipeline embolization device (PED; Medtronic, Dublin, Ireland) utilization is not limited to the treatment of giant wide-necked aneurysms. It has been expanded to handle small blisters, fusiforms, and dissecting intracranial aneurysms.

OBJECTIVE

To report the use of the PED in various off-label distal cerebral circulation (DCC) arteries with a follow-up to assess clinical outcomes.

METHODS

Between 2011 and 2016, of 437 consecutive patients, 23 patients with aneurysms located in DCCs were treated with PED. Data on patient presentation, aneurysm characteristics, procedural outcomes, postoperative course, and aneurysm occlusion were gathered. To control confounding, we used multivariable logistic regression and propensity score conditioning.

RESULTS

A total of 437 patients (mean age 52.12 years; 62 women [14.2%]) underwent treatment with PED in our institution. Twenty-three of 437 (5.2%) received a pipeline in a distal artery: 11/23 middle cerebral artery, 6/23 posterior cerebral artery, 3/23 anterior cerebral artery (A1/A2, pericallosal artery), and 3/23 posterior inferior cerebellar artery. Twenty percent of the aneurysms were treated in the past, 10% had previously ruptured, and 5.9% ruptured at presentation to our hospital. The mean aneurysm size was 9.0 ± 6 mm. The mean follow-up was 12 mo (SD = 12.5). In multivariable logistic regression, no associations were found between PED deployment in DCCs and aneurysm occlusion or thromboembolic complications. PED use in DCC was associated with a good clinical outcome. Twenty-two people of 23 (95%) had a good clinical outcome in the latest follow-up.

CONCLUSION

Treatment of DCC aneurysms with PED is technically challenging mainly because of the small caliber and tortuosity of the parent arteries. The results of this study further support the safety of flow diverters in the treatment of various distal aneurysms.

Correlation between pre-admission blood pressure and outcome in a large telestroke cohort

BACKGROUND

Telemedicine rapidly connects patients, with acute ischemic stroke symptoms, with neurovascular specialists for assessment to reduce chemical thrombolysis delivery times. Management of AIS includes maintaining target systolic blood pressures (SBP). In this retrospective study, we assess the efficacy of the telestroke (TS) system at a primary stroke center and the prognostic value of SBP throughout the transportation process.

METHODS

Patients presenting with acute-onset neurological symptoms to the TS hospitals network, over a 5-year period, were assessed. Those with a confirmed diagnosis of AIS were included. We examined demographics, presenting-NIHSS, last SBP before transfer from the network hospital and continuous BP during transport, stroke risk factors, hospital-course, door-to-needle (DTN) time, treatments, and modified Rankin Scale(mRS). Multivariate analysis was conducted to evaluate the prognostic value of SBP on stroke outcome.

RESULTS

Of 2,928 patients identified, 1,353 were diagnosed with AIS. Mean age was 66.6 years (SD = 15.4), 47.6% female. Most cases affected the MCA(44.5%). Mean presenting-NIHSS was 8.67(SD = 8.38) and mean SBP was 148 mmHg(SD = 25.39). 73.2% treated using a standard protocol, 23.7% given IVrt-PA, and 6.8% received mechanical thrombectomy(MT). Mean DTN was 96 min(SD = 46; 27.3% <60 min). Age, presenting-NIHSS and pre-existing hypertension were associated with higher mortality and/or higher mRS. SBP was not associated with higher mortality and morbidity.

CONCLUSIONS

This study displays better clinical outcomes at latest follow-up when compared to current international TS studies. SBP during transportation to the hub hospital did not prove to be a useful prognostic metric. However, future studies should address the limitations of this study to confirm these findings.

Rapid M1 Hemoclips Arteriotomy Repair After Emergency Coil Embolectomy

BACKGROUND

The vascular closure staple clips have been studied in animal models and shown to have comparable results with sutured repair when it comes to the healing process, degree of vessel narrowing, and risk of thrombosis. However, they are clearly superior when the speed of application is taken into account, and they were clinically used in many vascular repair processes. Nevertheless, their usefulness in intracranial vascular surgery has not been described.

OBJECTIVE

To describe the usefulness of hemoclips in fast and efficient repair of medium-sized and large intracranial vessels.

METHODS

Two female patients diagnosed with giant symptomatic cavernous sinus aneurysms were undergoing elective endovascular procedures that were complicated by the dislodgement of coils into the M1 segment of the middle cerebral artery. Both patients were treated performing M1 arteriotomies and coil embolectomy. To avoid prolonged temporary occlusion in the M1 perforator's territory, the arteriotomies were repaired using microhemoclips in less than 10 min with re-establishment of flow.

RESULTS

In both patients, flow was re-established in the M1 segments. In 1 patient, the coils extended to the temporal M2 causing intimal injury and leading to diminished flow. M1 segments in both patients were patent on later angiographic studies.

CONCLUSION

We describe the advantage of emergent cerebrovascular arteriotomy and embolectomy in a rapid repair process that helped avoid massive ischemic injury. We believe this technique should be added to the armamentarium of neurosurgical cerebrovascular options.

A comparison of two stroke cohorts cared for by two different specialties in a practice-based tele-stroke population

OBJECTIVES

Neurologists have continually led the assessment and management of Acute Ischemic Stroke(AIS) by use of IV-rtPA, anti-platelet therapy, antihypertensives, and other pharmacologic agents. Since the advent of mechanical thrombectomy(MT) and its proven efficacy, neurovascular surgeons(NS) are playing an increasingly important role in the management and overall care of AIS. We assessed outcomes of AIS patients managed by NS, who have been traditionally managed by neurologists.

PATIENTS AND METHODS

Outcomes of AIS patients who presented to the telestroke system, over a 5-year period, were assessed. NIHSS and mRS stroke scales were used as outcome metrics. Multivariate analysis was conducted to compare outcomes of patients treated by neurovascular surgeons and those treated by neurologists.

RESULTS

1353 AIS patients were identified. 21.6% received care from neurosurgeons and 78.4% received care from neurologists. Of the neurologist-managed group: 7.8% received MT and were followed by NS, 34% received IVrt-PA, average discharge NIHSS = 9.0 (SD = 8.42), latest follow-up mRS < 2 = 57.5% and mortality rate = 9.4%. Of the neurovascular surgeon-managed group: 7.4% patients received MT, 20% received IVrt-PA, average discharge NIHSS = 0.14(SD = 0.72), latest follow-up mRS ≤2 = 98.6% and mortality rate = 8.3%. There were no significant differences between groups in MT use (OR 1.22; CI95%, 0.971-2.09; p = 0.464), IVrt-PA administration (OR 0.98; CI95%, 0.70-1.38; p = 0.924), mortality rate (OR 1.21; 0.71-2.03; p = 0.483) and patients' latest mRS, p = 0.873.

CONCLUSIONS

AIS requires multidisciplinary management. Care provided by neurosurgeons has similar efficacy and patient outcomes as the care provided by neurologists. These findings support the role and ability of neurosurgeons to manage and care for these patients.