Minimally Invasive Intracerebral Hemorrhage Evacuation Improves Pericavity Cerebral Blood Volume

Cerebral blood volume mapping can characterize hemodynamic changes within brain tissue, particularly after stroke. This study aims to quantify blood volume changes in the perihematomal parenchyma and pericavity parenchyma after minimally invasive intracerebral hemorrhage evacuation (MIS for ICH). Thirty-two patients underwent MIS for ICH with pre- and post-operative CT imaging and intraoperative perfusion imaging (DynaCT PBV Neuro, Artis Q, Siemens). The pre-operative and post-operative CT scans were segmented using ITK-SNAP software to calculate hematoma volumes and to delineate the pericavity tissue. Helical CT segmentations were registered to cone beam CT data using elastix software. Mean blood volumes were computed inside subvolumes by dilating the segmentations at increasing distances from the lesion. Pre-operative perihematomal blood volumes and post-operative pericavity blood volumes (PBV) were compared. In 27 patients with complete imaging, post-operative PBV significantly increased within the 6-mm pericavity region after MIS for ICH. The mean relative PBV increased by 21.6 and 9.1% at 3 mm and 6 mm, respectively (P = 0.001 and 0.016, respectively). At the 9-mm pericavity region, there was a 2.83% increase in mean relative PBV, though no longer statistically significant. PBV analysis demonstrated a significant increase in pericavity cerebral blood volume after minimally invasive ICH evacuation to a distance of 6 mm from the border of the lesion.

Characterization of length of stay after minimally invasive endoscopic intracerebral hemorrhage evacuation

BACKGROUND

Minimally invasive evacuation may help ameliorate outcomes after intracerebral hemorrhage (ICH). However, hospital length of stay (LOS) post-evacuation is often long and costly.

OBJECTIVE

To examine factors associated with LOS in a large cohort of patients who underwent minimally invasive endoscopic evacuation.

METHODS

Patients presenting to a large health system with spontaneous supratentorial ICH qualified for minimally invasive endoscopic evacuation if they met the following inclusion criteria: age ≥18, premorbid modified Rankin Scale (mRS) score ≤3, hematoma volume ≥15 mL, and presenting National Institutes of Health Stroke Scale (NIHSS) score ≥6. Demographic, clinical, radiographic, and operative characteristics were included in a multivariate logistic regression for hospital and ICU LOS dichotomized into short and prolonged stay at 14 and 7 days, respectively.

RESULTS

Among 226 patients who underwent minimally invasive endoscopic evacuation, the median intensive care unit and hospital LOS were 8 (4-15) days and 16 (9-27) days, respectively. A greater extent of functional impairment on presentation (OR per NIHSS point 1.10 (95% CI 1.04 to 1.17), P=0.007), concurrent intraventricular hemorrhage (OR=2.46 (1.25 to 4.86), P=0.02), and deep origin (OR=per point 2.42 (1.21 to 4.83), P=0.01) were associated with prolonged hospital LOS. A longer delay from ictus to evacuation (OR per hour 1.02 (1.01 to 1.04), P=0.007) and longer procedure time (OR per hour 1.91 (1.26 to 2.89), P=0.002) were associated with prolonged ICU LOS. Prolonged hospital and ICU LOS were in turn longitudinally associated with a lower rate of discharge to acute rehabilitation (40% vs 70%, P<0.0001) and worse 6-month mRS outcomes (5 (4-6) vs 3 (2-4), P<0.0001).

CONCLUSIONS

We present factors associated with prolonged LOS, which in turn was associated with poor long-term outcomes. Factors associated with LOS may help to inform patient and clinician expectations of recovery, guide protocols for clinical trials, and select suitable populations for minimally invasive endoscopic evacuation.

Transcranioplasty Ultrasonography Through a Sonolucent Prosthesis: A Review of Feasibility, Safety, and Benefits

Data on the effectiveness of transcranioplasty ultrasonography through sonolucent cranioplasty (SC) are new and heterogeneous. We performed the first systematic literature review on SC. Ovid Embase, Ovid Medline, and Web of Science Core Collection were systematically searched and published full text articles detailing new use of SC for the purpose of neuroimaging were critically appraised and extracted. Of 16 eligible studies, 6 reported preclinical research and 12 reported clinical experiences encompassing 189 total patients with SC. The cohort age ranged from teens to 80s and was 60% (113/189) female. Sonolucent materials in clinical use are clear PMMA (polymethylmethacrylate), opaque PMMA, polyetheretherketone, and polyolefin. Overall indications included hydrocephalus (20%, 37/189), tumor (15%, 29/189), posterior fossa decompression (14%, 26/189), traumatic brain injury (11%, 20/189), bypass (27%, 52/189), intracerebral hemorrhage (4%, 7/189), ischemic stroke (3%, 5/189), aneurysm and subarachnoid hemorrhage (3%, 5/189), subdural hematoma (2%, 4/189), and vasculitis and other bone revisions (2%, 4/189). Complications described in the entire cohort included revision or delayed scalp healing (3%, 6/189), wound infection (3%, 5/189), epidural hematoma (2%, 3/189), cerebrospinal fluid leaks (1%, 2/189), new seizure (1%, 2/189), and oncologic relapse with subsequent prosthesis removal (<1%, 1/189). Most studies utilized linear or phased array ultrasound transducers at 3-12 MHz. Sources of artifact on sonographic imaging included prosthesis curvature, pneumocephalus, plating system, and dural sealant. Reported findings were mainly qualitative. We, therefore, suggest that future studies should collect quantitative measurement data during transcranioplasty ultrasonography to validate imaging techniques.

Trends in Immunotherapy Clinical Trials to Treat Glioblastoma: A Look at Progress and Challenges

PURPOSE

We aimed to catalog past and present clinical trials on immunotherapy treatments for glioblastoma (GBM) and discover relevant trends in this field.

METHODS

Former and ongoing clinical trials involving the use of immunotherapy to treat GBM were queried in July 2022 within the clinicaltrials.gov registry (https://clinicaltrials.gov/). Pertinent trials were categorized by variables including immunotherapy classification, tumor type (newly diagnosed versus recurrent), country of origin, start date, clinical phase, study completion status, estimated subject enrollment, design, publication status, and funding source.

RESULTS

A list of 173 trials was identified in total. The number of immunotherapy clinical trials to treat GBM has increased over time. The largest proportion of trials were gene therapies (97 studies; 56.1%) and viral therapies (37 studies; 21.4%). Studies were designated as a biologic (45.1%), drug (43.9%), genetic (2.3%), or procedure (1.2%). Trials spanned 19 countries; China, the second largest contributor (5.8%) after the United States (70.0%), has increased clinical trial development in the past years. The average time to completion was 52.3 months. Trials were primarily funded by academic centers; however, one-fourth of the trials were funded by industry and 2 were funded by foundations. One-t of the trials were active and over one-third were linked to publications.

CONCLUSIONS

Our findings provide a comprehensive summary of the state of immunotherapy clinical trials for GBM, highlighting the evolving nature and growing scope of this field.

Preoperative cerebral angiography nearly doubles the rate of diffusion-weighted imaging lesion detection following minimally invasive surgery for intracerebral hemorrhage

BACKGROUND

Diffusion-weighted imaging (DWI) lesions have been linked to poor outcomes after intracerebral hemorrhage (ICH). We aimed to assess the impact of cerebral digital subtraction angiography (DSA) on the presence of DWI lesions in patients who underwent minimally invasive surgery (MIS) for ICH.

METHODS

Retrospective chart review was performed on ICH patients treated with MIS in a single health system from 2015 to 2021. One hundred and seventy consecutive patients who underwent postoperative MRIs were reviewed. Univariate analyses were conducted to determine associations. Variables with p<0.05 were included in multivariate analyses.

RESULTS

DWI lesions were present in 88 (52%) patients who underwent MIS for ICH. Of the 83 patients who underwent preoperative DSA, 56 (67%) patients demonstrated DWI lesions. In this DSA cohort, older age, severe leukoaraiosis, larger preoperative hematoma volume, and increased presenting National Institutes of Health Stroke Score (NIHSS) were independently associated with DWI lesion identification (p<0.05). In contrast, of 87 patients who did not undergo DSA, 32 (37%) patients demonstrated DWI lesions on MRI. In the non-DSA cohort, presenting systolic blood pressure, intraventricular hemorrhage, and NIHSS were independently associated with DWI lesions (p<0.05). Higher DWI lesion burden was independently associated with poor modified Rankin Scale (mRS) at 6 months on a univariate (p=0.02) and multivariate level (p=0.02).

CONCLUSIONS

In this cohort of ICH patients who underwent minimally invasive evacuation, preprocedural angiography was associated with the presence of DWI lesions on post-ICH evacuation MRI. Furthermore, the burden of DWI lesions portends a worse prognosis after ICH.

Dysphagia after ischemic and hemorrhagic stroke: A propensity-matched 20-year analysis of the national inpatient sample

OBJECTIVE

Dysphagia is a common symptom of acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH), but little is known surrounding national trends of this post-stroke condition. Hence, this study aimed to identify the risk factors for dysphagia following AIS and ICH and evaluate in-hospital outcomes in these patients.

METHODS

The 2000-2019 Nationwide Inpatient Sample was queried for patients admitted with AIS (ICD9 433, 43401, 43411, 43491, ICD-10 I63) and ICH (ICD9 431, 432.9, ICD-10 I61, I62.9). Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences >0.1 were used in multivariable regression to generate adjusted odds ratios (AOR)/β-coefficients for the presence of dysphagia on outcomes.

RESULTS

Of 10,415,286 patients with AIS, 956,662 (9.2%) had in-hospital dysphagia. Total of 2,000,868 patients with ICH were identified; 203,511 (10.2%) had in-hospital dysphagia. Patients with dysphagia after AIS were less likely to experience in-hospital mortality (OR 0.61;95%CI: 0.60-0.63) or be discharged home (AOR 0.51;95%CI: 0.51-0.52), had increased length of stay (Beta-coefficient = 0.43 days; 95%CI: 0.36-0.50), and had increased hospital charges ($14411.96;95%CI: 13565.68-15257.44) (all p < 0.001). Patients with dysphagia after ICH were less likely to experience in-hospital mortality (AOR 0.39;95%CI: 0.37-0.4), less likely to be discharged home (AOR 0.59,95%CI:0.57-0.61), have longer hospital stay (Beta-coefficient = 1.99 days;95%CI: 1.78-2.21), and increased hospital charges ($28251.93; 95%CI: $25594.57-30909.28)(all p < 0.001).

CONCLUSION

This is the first study to report on national trends in patients with dysphagia after AIS and ICH. These patients had longer hospital LOS, worse functional outcomes at discharge, and higher hospital costs.

Trends and In-Hospital Outcomes in Patients with Vocal Fold Paralysis after Ischemic and Intracerebral Hemorrhagic Stroke: A Propensity Matched 20-Year Analysis of the Nationwide Inpatient Sample

OBJECTIVE

Laryngeal manifestations of stroke have been sparsely described in the literature, specifically vocal fold paralysis (VFP). This study aimed to identify the prevalence, characteristics, and in-hospital outcomes of patients presenting with VFP after acute ischemic stroke (AIS) and intracranial hemorrhage (ICH).

METHODS

A query of the 2000-2019 Nationwide Inpatient Sample was performed for patients admitted with AIS (International Classification of Diseases, Ninth Revision 433, 43,401, 43,411, 43,491, International Classification of Diseases, Tenth Revision I63) and ICH (International Classification of Diseases, Ninth Revision 431, 432.9, International Classification of Diseases, Tenth Revision I61, I62.9). Demographics, comorbidities, and outcomes were identified. Univariate analysis with t-tests or χ2 performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences > 0.1 used in multivariable regression to generate adjusted odds ratios (AOR)/β-coefficients for VFP on outcomes. Significance was set at an alpha level of < 0.001. All analysis were performed in R version 4.1.3.

RESULTS

A total of 10,415,286 patients with AIS were included; 11,328 (0.1%) had VFP. Of 2,000,868 patients with ICH 2132 (0.1%) had in-hospital VFP. Multivariable analysis revealed that patients with VFP after AIS were less likely to be discharged home (AOR 0.32; 95% confidence interval {CI}: 0.18-0.57; P < 0.001) and elevated total hospital charges (β coefficient = 59,684.6; 95% CI = 18,365.12-101,004.07; P = 0.005). Patients with VFP after ICH were less likely to experience in-hospital mortality (AOR 0.53; 95% CI: 0.34-0.79; P = 0.002) with longer hospital stays (1.99 days; 95% CI: 1.78-2.21; P < 0.001) and elevated total hospital charges (β coefficient = 53,905.35; 95% CI = 16,352.84-91,457.85; P = 0.005)..

CONCLUSIONS

VFP in patients with ischemic stroke and ICH; although an infrequent complication is associated with functional impairment, longer hospital stay, and higher charges.

Cigarette Smoking as a Risk Factor for Hematoma Expansion in Primary Intracerebral Hemorrhage: Analysis From a Randomized Clinical Trial

Background Cigarette smoking is a well-known risk factor for ischemic and hemorrhagic stroke. We evaluated the impact of smoking status on hematoma expansion and clinical outcome in patients with primary intracerebral hemorrhage. Methods and Results This is a post hoc exploratory analysis of the ATACH (Antihypertensive Treatment at Acute Cerebral Hemorrhage)-2 trial. Patients with intracerebral hemorrhage were randomized into intensive blood pressure lowering (systolic blood pressure, <139 mm Hg) versus standard blood pressure lowering (systolic blood pressure, 140-179 mm Hg) in this study. We compared the demographic characteristics; hematoma size, location, and expansion rate; and clinical outcome based on subjects' smoking status. Of a total of 914 patients in the trial with known smoking status, 439 (48%) patients were ever smokers (264 current smokers and 175 former smokers). Current and former smokers were younger and more likely to be men. Baseline Glasgow Coma Scale score and initial hematoma size did not vary based on smoking status. Ever smokers had higher rates of thalamic hemorrhage (42% versus 34%) and intraventricular hemorrhage (29% versus 23%); this rate was highest among former smokers versus current smokers (49% versus 35%, respectively). Ever smokers had a higher rate of hematoma expansion in 24 hours (adjusted relative risk [RR] [95% CI], 1.46 [1.08-1.96]) compared with nonsmokers on multivariate analysis. There was no significant difference in the rate of death and disability at 90 days between the 2 groups (adjusted RR [95% CI], 1.18 [0.998-1.40]). Conclusions Our analysis demonstrates cigarette smoking as an independent predictor for hematoma expansion. There was no significant difference in death and disability based on smoking status.

Transvenous balloon-assisted approach to anterior fossa dural arteriovenous fistula using retrograde pressure cooker technique

Endovascular embolization is the first-line therapy for dural arteriovenous fistulas (dAVFs). Transarterial embolization (TAE) may be limited by poor anatomical access. Transvenous embolization avoids this, but carries a risk of hemorrhage, venous redirection, and neurologic deterioration. Dual-lumen balloon microcatheters like the Scepter Mini (Microvention, Aliso Viejo, CA, USA) provide flow arrest and prevent reflux during TAE with liquid embolic agents (LEAs), but use in the distensible veins may be challenging. In this video, we use a Scepter Mini in a transvenous approach to a Cognard type IV anterior ethmoidal dAVF as a safe alternative to surgery, transvenous pressure cooker, and trans-ophthalmic TAE (video 1). The Scepter Mini was navigated transvenously to the anterior superior sagittal sinus. LEA was injected with excellent penetration to the venous pouch and further penetration into the network of tortuous feeders. No neurologic complications were experienced, and follow-up angiogram 9 months later demonstrated cure of the dAVF. Video 2 describes procedural considerations in transvenous approaches, steps of the procedure, and includes references1-10 which are relevant to this topic.neurintsurg;jnis-2023-020530v1/V1F1V1Video 1 neurintsurg;jnis-2023-020530v1/V2F2V2Video 2 .

External ventricular drain training in medical students improves procedural accuracy and attitudes towards virtual reality

OBJECTIVE

Neurosurgery residents face a learning curve at the beginning of residency. Virtual reality (VR) training may alleviate challenges through an accessible, reusable, anatomical model.

METHODS

Medical students performed external ventricular drain (EVD) placements in VR to characterize the learning curve from novice to proficient. Distance from catheter to Foramen of Monro and location with respect to ventricle were recorded. Changes in attitudes towards VR were assessed. Neurosurgery residents performed EVD placements to validate proficiency benchmarks. Resident and student impressions of the VR model were compared.

RESULTS

Twenty-one students with no neurosurgical experience and 8 neurosurgery residents participated. Student performance improved significantly from trial 1 to 3 (15 mm [12.1-20.70] vs 9.7 [5.8-15.3], p=.02). Student attitudes regarding VR utility improved significantly post-trial. The distance to Foramen of Monro was significantly shorter for residents than for students in trial 1 (9.05 [8.25-10.73] vs 15 [12.1-20.70], p=.007) and trial 2 (7.45 [6.43-8.3] vs 19.5 [10.9-27.6], p=.002). By trial 3 there was no significant difference (10.1 [8.63-10.95 vs 9.7 [5.8-15.3], p=.62). Residents and students provided similarly positive feedback for VR in resident curricula, patient consent, preoperative practice and planning. Residents provided more neutral-to-negative feedback regarding skill development, model fidelity, instrument movement, and haptic feedback.

CONCLUSIONS

Students showed significant improvement in procedural efficacy which may simulate resident experiential learning. Improvements in fidelity are needed before VR can become a preferred training technique in neurosurgery.

Minimally invasive intracerebral hemorrhage evacuation: A bibliometric analysis of current research trends

OBJECTIVE

Intracerebral hemorrhage (ICH) is associated with significant morbidity and mortality. Randomized clinical trials focusing on minimally invasive surgery (MIS) for ICH evacuation have suggested a potential benefit regarding mortality but results remain unclear regarding impact on functional outcome. This study presents a bibliometric analysis investigating the current trends in the literature on MIS for ICH.

METHODS

Using the Scopus collection database, a search was performed to identify literature that discussed MIS for ICH from 2000 to 2021. Primary research articles were included in this study. Reviews and book chapters were excluded. Analysis and visualization of the included literature were completed with VOSviewer.

RESULTS

A total of 278 articles were identified. An upward trend in publications began in 2008, with the most publications in 2021 (36) followed by 2020 (25). The most citations occurred in 2013 (1192). The h-index, i-10 and i-100 were 37, 79 and 6 respectively. For the top 100 most cited studies, the mean citation count was 45.55 with a range of 6-760. The highest-producing institutions of MIS for ICH literature were Johns Hopkins University (31, 15 %), University of Chicago with (21, 10 %), Guiyang Medical College (17, 8 %), and Icahn School of Medicine at Mount Sinai (15, 7 %). Keyword analysis revealed four major avenues: 1) medication enhancement of clot removal, 2) minimally invasive devices such as endoscopes, 3) craniotomy approach, and 4) physiology of clot removal.

CONCLUSIONS

The literature on MIS for ICH has been expanding since 2008. Key topics include thrombolysis, device innovation, and surgical approach.

Abstract WP206: Acute Ischemic Stroke And Vocal Fold Paralysis: A Propensity Matched 20-year Analysis Of The National Inpatient Sample

Introduction: Lower cranial nerve motor dysfunction is a well-distinguished feature in acute ischemic stroke (AIS). As a result, patients can present with vocal dysfunction, including vocal fold paralysis (VFP). Few studies have examined VFP in AIS patients.

Objective: To identify the incidence and characteristics of patients presenting with VFP after AIS.

Methods: A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with AIS (ICD9 433, 43401, 43411, 43491, ICD-10 I63). Demographics, comorbidities, and outcomes were identified. Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences >0.1 used in multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for VFP on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3.

Results: 10,415,286 patients with AIS were included; 11,328 (0.1%) had VFP. At baseline, a higher percentage of patients with VFP were younger, male, insured by Medicaid, had a higher Elixhauser Comorbidity Score, and were more likely to have a tracheostomy and ventilator use (all p<0.001). Following propensity matching, multivariate analysis revealed that patients with VFP were less likely to be discharged home (AOR 0.32; 95%CI: 0.18-0.57; p<0.001) with no effect of VFP on in-hospital mortality, length of stay, or total hospital charges (p> 0.001)

Conclusion: This is the first study to report on national trends of patients with VFP after AIS, and we found that VFP patients were more male, younger, higher overall disease burden, and required more in-hospital procedures. Though rare, VFP causes significant morbidity for patients after AIS. Patients experience significant functional deficits at discharge, as represented by the low rate of home discharge.

Abstract TP87: Predictors Of Diffusion-weighted Imaging Lesion Burden In Patients After Minimally Invasive Surgery For Intracerebral Hemorrhage

Introduction: The etiology of diffusion-weighted imaging (DWI) lesions in patients after minimally invasive surgery (MIS) for acute intracerebral hemorrhage (ICH) remains unclear.

Methods: Postoperative brain MRIs of patients with spontaneous ICH from 2016-2021 who underwent imaging within one month of MIS were reviewed. DWI lesions were quantified. Lesions within 10 mm of the hematoma were excluded. Siderosis and microbleeds were identified. Leukoaraiosis was quantified using the Fazekas score. Univariate analyses were conducted to determine predictors of DWI lesion burden, and variables with P≤0.1 were included in multivariate analyses.

Results: DWI lesions were present in 84 (49%) postoperative MRIs. The average number of DWI lesions was 2.11 (range 0-74, SD 6.50). Factors associated with DWI burden in univariate analyses included increased presenting systolic blood pressure (SBP) (P=0.003), Fazekas score (P=0.004), delta SBP on day of admission (P=0.034), preoperative angiogram (P=0.062), microbleeds on MRI (P=0.065), increased presenting National Institutes of Health Stroke Score (P=0.066), presence of intraventricular hemorrhage (P=0.069), and decreased presenting Glasgow Coma Scale (P=0.076). Upon multivariate analysis, increased Fazekas score (OR 2.04, 95% CI 1.21-3.43, P=0.008), presenting SBP (OR 1.04, 95% CI 1.00-1.06, P=0.014), and preoperative angiogram (OR 10.35, 95% CI 1.44-74.36], P=0.020) were predictive of DWI burden.

Conclusions: In this unique postoperative ICH cohort, white matter changes, presenting SBP, and preoperative angiogram predicted DWI lesion burden. Larger studies are needed to understand the implications of DWI burden after MIS for ICH recovery.

Abstract TP139: Characterizing Patients With Dysphagia Following Acute Ischemic Stroke: A Propensity Matched Analysis Of The 2000-2019 National Inpatient Sample

Introduction: Dysphagia is a common complication among acute ischemic stroke (AIS) patients and is associated with increased mortality and morbidity. A complete understanding of the characteristics of patients who present with dysphagia after AIS is warranted.

Objective: To identify the risk factors and outcomes of patients presenting with dysphagia after AIS over twenty years.

Methods: A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with AIS (ICD9 433, 43401, 43411, 43491, ICD-10 I63). Demographics, comorbidities, and outcomes were identified. Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences >0.1 used in multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for dysphagia on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3.

Results: 10,415,286 patients with AIS were included; 956,662 (9.2%) had in-hospital dysphagia. A higher percentage of patients with dysphagia were older, had higher Elixhauser Comorbidity Score, higher NIH Stroke Scale (NIHSS) score and a were insured by Medicare (p<0.001). After propensity matching, patients with dysphagia after AIS were less likely to experience in-hospital mortality (OR 0.61; 95%CI: 0.60-0.63) or be discharged home (AOR 0.51; 95%CI: 0.51-0.52), had decreased length of stay (0.43 days; 95%CI: 0.36-0.50), and had increased hospital charges ($14411.96; 95%CI: 13565.68-15257.44) (all p<0.001).

Conclusion: This propensity matched 20-year national analysis confirmed that dysphagia is a significant issue following AIS. These patients were more frequently male with worse neurological presentations. Despite better odds for survival and shorter hospital stay, they experience significant functional deficits at discharge and have increased hospital costs.

Abstract TMP78: Using Interventional CT Perfusion Imaging To Evaluate Cerebral Blood Volume Surrounding Intracerebral Hemorrhage Site Following Minimally Invasive Evacuation

Introduction: Computed tomography perfusion (CTP) characterizes hemodynamic changes within brain tissue, particularly after stroke. This study aims to quantify cerebral blood volume (CBV) changes and identify predictors of CBV increase in the pericavity parenchyma after minimally invasive intracerebral hemorrhage evacuation (MIS for ICH).

Methods: Thirty-two patients underwent MIS for ICH with pre/postoperative native CT imaging and intraoperative perfusion imaging (DynaCT PBV Neuro, Artis Q, Siemens). Scans were segmented using ITK-SNAP software to calculate hematoma volumes pre/post-evacuation and to delineate the pericavity tissue. Helical CT segmentations were registered to cone beam CT data using elastix software. Mean CBVs were computed inside subvolumes by dilating the segmentations with spheres with varying diameters.

Results: In 27 patients with complete imaging, CTP analysis demonstrated significant increases in CBV from the 6 mm to 20 mm pericavity regions. CBV increased on average 32.7% from 2.27 mL/100mg (IQR 1.87-3.02) to 2.80 mL/100mg (2.41-3.61) in the 10 mm pericavity region (P=0.003). Factors associated with increased CBV in the univariate analysis (P≤0.10) included age (P=0.082) and percentage of hematoma evacuation (P=0.078). Upon multivariate linear regression, age (OR 4.49, [95% CI, 1.01-1.98], P=0.048) and percentage of hematoma evacuation (OR 4.09, [95% CI, 1.70-9.84], P=0.046) remained significantly predictive of increased CBV.

Conclusions: CTP analysis demonstrated a significant increase in pericavity cerebral blood volume after MIS for ICH. Patient age and hematoma evacuation percentage may be predictive of CBV increase after MIS for ICH. Figure 1: Topographic map showing blood flow improvement at different distances from the lesion.

Abstract TMP44: Artificial Intelligence-driven Automated Intracerebral Hemorrhage Volume Calculation Is More Accurate Than ABC/2

Introduction: Treatment of spontaneous intracerebral hemorrhage (ICH) requires rapid, accurate estimation of hemorrhage volume to determine appropriate patient care and guide prognosis. ICH volume estimation on Computed Tomography (CT) imaging using the ABC/2 formula is the clinical gold standard, however this method can be inaccurate, suffers from observer scoring variability, and takes time to make the measurement on a workstation. Semi-Autonomous Segmentation (SAS) is the gold standard for hemorrhage volume estimation, however it is not used clinically due to the increased time for analysis. Recently, artificial intelligence (AI) driven segmentation has been developed (Viz.ai, San Francisco, California) to automatically detect ICH and calculate hematoma volume.

Objective: Our goal is to validate the accuracy of the Viz.ai ICH segmentation algorithm as a tool for determining hemorrhage volume by comparing its performance to both ABC/2 and SAS.

Methods: Seventy head CTs positive for ICH were analyzed with SAS in 3D Slicer to determine ICH volume as the standard reference volume. The same CT scans were then analyzed using the ABC/2 method. Finally, scans were uploaded to Viz.ai for ICH volume analysis.

Results: Compared against standard SAS, Viz.ai ICH volumes were more accurate than ABC/2 in 77% of cases. Average difference between Viz.ai ICH volume and SAS ICH volume was 4.9±4.2 mL (R2=0.98). Average difference between ABC/2 ICH volume and SAS ICH volume was 10.6±11.4 mL (R2=0.77).

Conclusion: This study indicates that Viz.ai more accurately estimates ICH volume than ABC/2 over a broad range of hematoma volumes when compared to standard SAS, which when coupled with significantly faster analysis compared to SAS justifies the use of AI in ICH triage workflow.

Infantile dural sinus malformation: curative embolization in two stages with the Scepter mini balloon microcatheter

Endovascular embolization is the mainstay for treatment of infantile dural sinus malformations.1 2 Distal access and flow control are limiting factors in controlled embolization.3-6 The Scepter mini catheter (Microvention, Aliso Viejo, California, USA) is a low-profile, dual-lumen balloon microcatheter designed to provide navigability in small-caliber, tortuous intracranial vessels. In this technical video, we demonstrate the staged embolization of a dural sinus malformation with multiple arteriovenous fistulae using the Scepter mini catheter (video 1). In the newborn patient, embolizations were performed through the parietal branches of the left and right middle meningeal arteries. The catheter easily navigated into the small feeding arteries. No neurological complications occurred due to the procedures. Post-embolization injections demonstrated significant flow reduction into the malformation. Three-month follow-up angiography illustrated resolution of the previously dilated left transverse sinus. Complete obliteration of the dural sinus malformation was achieved in the newborn patient. neurintsurg;15/1/97/V1F1V1Video 1Curative embolization in two stages with the Scepter mini balloon microcatheter. ΑP, anteroposterior; CCA, common carotid artery.

Neuroimaging through Sonolucent Cranioplasty: A Systematic Scoping Review Protocol

Cranioplasty is a neurosurgical procedure in which the skull bone is repaired after craniectomy. Recently, studies have suggested that sonolucent synthetic materials are safe and useful for cranioplasty. Sonolucent cranioplasty (SC) implants provide unprecedented opportunity in adult neurosurgery to monitor neuroanatomy, assess hemodynamics, view devices located within the implant, and conduct focused ultrasound treatments. Current research on SC includes proof-of-concept cadaveric studies, patient-related safety and feasibility studies, and case series demonstrating transcranioplasty ultrasonography (TCUS). The purpose of this protocol is to investigate the current literature on SC use and outcomes in TCUS. We will perform a systematic literature search following PRISMA-ScR guidelines. The search will be conducted using Ovid Embase, Ovid Medline, and Web of Science Core Collection databases. Titles, abstracts, and full texts will be screened. Joanna Briggs Institute critical appraisal tools will be utilized. Data extraction points will include subject characteristics, SC implant characteristics, ultrasound characteristics, and sonographic findings. These findings will provide a comprehensive review of the literature on sonolucent cranioplasty and directions for future research.

Prognostic Utility of Serum Biomarkers in Intracerebral Hemorrhage: A Systematic Review

Background. Intracerebral hemorrhage (ICH) accounts for 10-20% of all strokes and is associated with high morbidity and mortality. Recent studies have identified serum biomarkers as a means to improve outcome prognostication in poor grade ICH patients. Poor prognosis of ICH patients and complex pathophysiology of the disease necessitate prognostic serum biomarkers to help guide treatment recommendations. Objective. The objective is to systematically review all biomarkers used to predict long-term functional outcome in patients with spontaneous intracerebral hemorrhage. Results. We identified 36 studies investigating the predictive utility of 50 discrete biomarkers. Data from 4865 ICH patients were reviewed. Inflammatory biomarkers (11/50) were most often studied, followed by oxidative (8/50), then neuron and astrocyte-specific (7/50). S100 calcium binding protein B, white blood cell count, and copeptin were the most often studied individual biomarkers. The prognostic utility of 23 biomarkers was analyzed using receiver operating characteristic curves. Area under the curve (AUC) values for all available biomarkers except neutrophil/lymphocyte ratio were acceptable. Twenty of the 23 biomarkers were characterized by at least one excellent AUC value. Vascular endothelial growth factor, glial fibrillary astrocyte protein, and S100 calcium binding protein B were characterized by outstanding AUC. Conclusions. We identified the inflammatory and neuron and astrocyte-specific biomarker categories as having the greatest number of significant individual biomarker predictors of long-term outcome. Further investigation utilizing cross-validation of prediction models in a second independent group and blinded assessment of outcomes for the predictive utility of biomarkers in patients with ICH is warranted.

Time from image acquisition to endovascular team notification: a new target for enhancing acute stroke workflow

OBJECTIVE

To quantify the time between initial image acquisition (CT angiography (CTA)) and notification of the neuroendovascular surgery (NES) team, a potentially high yield time window to target for optimization of endovascular thrombectomy (ET) treatment times.

METHODS

We reviewed our multihospital database for all patients with a stroke with emergent large vessel occlusion treated with ET between January 1, 2017 and August 5, 2020. We dichotomized patients into rapid (≤20 min) and delayed (>20 min) notification times and analyzed treatment characteristics and outcomes.

RESULTS

Of 367 patients with ELVO undergoing ET for whom notification data were available, the median time from CTA to NES team notification was 24 min (IQR 12-47). The median total treatment time was 180 min (IQR 129-252). The median times from CTA to NES team notification for rapid (n=163) and delayed (n=204) cohorts were 11 (IQR 6-15) and 43 (IQR 30-80) min, respectively (p<0.001). The median overall times to reperfusion were 134 min (IQR 103-179) and 213 min (IQR 172-291), respectively (p<0.001). The delayed patients had a significantly lower National Institutes of Health Stroke Scale (NIHSS) score on presentation (15 (IQR 9-20) vs 16 (IQR 11-22), p=0.03), were younger (70 (IQR 60-79) vs 77 (IQR 64-85), p<0.001), and more often presented with posterior circulation occlusion (16.7% vs 7.4%, p<0.01). The group with rapid notification time had a statistically larger median improvement in NIHSS score from admission to discharge (6 (IQR 0.5-14) vs 5 (IQR 0.5-10), p=0.04).

CONCLUSIONS

Time delays from initial CTA acquisition to NES team notification can prevent expedient treatment with ET. Process improvements and automated stroke detection on imaging with automated notification of the NES team may ultimately improve time to reperfusion.

"Staying Home"-Early Changes in Patterns of Neurotrauma in New York City During the COVID-19 Pandemic

OBJECTIVE

New York City is the epicenter of the novel coronavirus disease 2019 (COVID-19) pandemic in the United States. Traumatic brain injury accounts for a significant proportion of admissions to our trauma center. We sought to characterize the effect of the pandemic on neurotraumas, given the cancellation of nonessential activities during the crisis.

METHODS

Retrospective and prospective reviews were performed from November 2019 to April 2020. General demographics, clinical status, mechanism of trauma, diagnosis, and treatment instituted were recorded. We dichotomized the data between pre-COVID-19 (before 1 March) and COVID-19 periods and compared the differences between the 2 groups. We present the timeline of events since the beginning of the crisis in relation to the number of neurotraumas.

RESULTS

A total of 150 patients composed our cohort with a mean age of 66.2 years (standard deviation ±18.9), and 66% were male. More males sustained neurotrauma in the COVID-19 period compared with the pre-COVID-19 (60.4% vs. 77.6%, P = 0.03). The most common mechanism of trauma was mechanical fall, but it was observed less frequently compared with the pre-COVID-19 period (61.4% vs. 40.8; P = 0.03). Subdural hematoma, traumatic subarachnoid hemorrhage, and intracerebral contusion accounted for the most common pathologies in both periods. Nonoperative management was selected for most patients (79.2 vs. 87.8%, P = 0.201) in both periods.

CONCLUSIONS

A decrease in the frequency of neurotraumas was observed during the COVID-19 crisis concomitant with the increase in COVID-19 patients in the city. This trend began after the cancellation of nonessential activities and implementation of social distancing recommendations.