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Background: Despite the well-established potent benefit of mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke, access to MT has not been studied globally. We conducted a worldwide survey of countries on 6 continents to define MT access (MTA), the disparities in MTA, and its determinants on a global scale. Methods: Our survey was conducted in 75 countries through the Mission Thrombectomy 2020+ global network between November 22, 2020, and February 28, 2021. The primary end points were the current annual MTA, MT operator availability, and MT center availability. MTA was defined as the estimated proportion of patients with LVO receiving MT in a given region annually. The availability metrics were defined as ([current MT operators×50/current annual number of estimated thrombectomy-eligible LVOs]×100 = MT operator availability) and ([current MT centers×150/current annual number of estimated thrombectomy-eligible LVOs]×100= MT center availability). The metrics used optimal MT volume per operator as 50 and an optimal MT volume per center as 150. Multivariable-adjusted generalized linear models were used to evaluate factors associated with MTA. Results: We received 887 responses from 67 countries. The median global MTA was 2.79% (interquartile range, 0.70–11.74). MTA was Conclusions: Access to MT on a global level is extremely low, with enormous disparities between countries by income level. The significant determinants of MT access are the country’s per capita gross national income, prehospital LVO triage policy, and MT operator and center availability.

The Woven EndoBridge (WEB) device is becoming increasingly popular for treatment of wide-neck aneurysms. As experience with this device grows, it is important to identify factors associated with occlusion following WEB treatment to guide decision making and screen patients at high risk for recurrence. The aim of this study was to identify factors associated with adequate aneurysm occlusion following WEB device treatment in the neurosurgical literature and in our case series. A systematic review of the present literature was conducted to identify studies related to the prediction of WEB device occlusion. In addition, a retrospective review of our institutional data for patients treated with the WEB device was performed. Demographics, aneurysm characteristics, procedural variables, and 6-month follow-up angiographic outcomes were recorded. Seven articles totaling 450 patients with 456 aneurysms fit our criteria. Factors in the literature associated with inadequate occlusion included larger size, increased neck width, partial intrasaccular thrombosis, irregular shape, and tobacco use. Our retrospective review identified 43 patients with 45 aneurysms. A total of 91.1% of our patients achieved adequate occlusion at a mean follow-up time of 7.32 months. Increasing degree of contrast stasis after WEB placement on the post-deployment angiogram was significantly associated with adequate occlusion on follow-up angiogram (p = 0.005) and with Raymond-Roy classification (p = 0.048), but not with retreatment (p = 0.617). In our systematic review and case series totaling 450 patients with 456 aneurysms, contrast stasis on post-deployment angiogram was identified as a predictor of adequate aneurysm occlusion, while morphological characteristics such as larger size and wide neck negatively impact occlusion.

The rise in popularity of social media (SoMe) in medicine has created a powerful tool for the professional development and continued education of clinicians. Numerous benefits of social media exist; however, significant challenges concerning professionalism, confidentiality and spread of misinformation may limit its usefulness.To understand the ways the top 100 Twitter influencers interact with SoMe, their views on SoMe, and its future in the medical field.Literature was reviewed to obtain common concerns about social media in the medical field. A survey with 30 questions was sent to the top 100 Twitter influencers in the Neurosurgical field identified by Riccio et al. The survey assessed participant demographics, SoMe activity, stance towards SoMe, and views on the future of SoMe.Most participants were in the age group of 35-44 years (n=23, 44.2%), resided in the United States (n= 39, 73.6%), have been in practice for 6-10 years (n=14, 26.4%), and ranked Twitter as the mostly used platform (n=37,72.6%). Per participant Reponses, 35 (66%) participants have taken a political stance on SoMe, 0 (0%) have gotten into any legal issues regarding a post shared on social media, 45 (84.9%) agreed/strongly that SoMe is essential for networking and mentorship, and 49 (92.3%) agreed/strongly that that SoMe will continue to play a major role in the medical field.Although social media has its advantages, several disadvantages render it a double-edged sword. Maximizing SoMe's benefits and minimizing its misuse will further strengthen its role in the medical field.

Background The radial approach has been gaining more widespread use by neurointerventionalists fueled by data from the cardiology literature showing better safety and overall reduced morbidity. Objective To present our institution's experience with the radial approach for neuroendovascular interventions in 614 consecutive patients who underwent a cumulative of 760 procedures. Methods A retrospective analysis was performed and identified neuroendovascular procedures performed via the upper extremity vasculature access site. Results Amongst 760 procedures, 34.2% (260) were therapeutic, and 65.7% (500) were nontherapeutic angiograms. Access sites were 71.5% (544) via a conventional radial artery, 27.8% (211) via a distal radial artery, 0.5% (4) via an ulnar artery, and 0.1% (1) via the brachial artery. Most of the procedures (96.9%) were performed via the right-sided (737), 2.9% (22) via the left-sided, and 0.1% (1) via a bilateral approach. Major access site complications occurred at a rate of 0.9% (7). The rate of transfemoral conversion was 4.7% (36). There was a statistically higher incidence of transfemoral conversion when repeat procedures were performed using the same access site. Also, there was no significant difference between nontherapeutic procedures performed using the right and left radial access, and conventional versus distal radial access. Procedural metrics improved after completion of 14 procedures, indicating a learning curve that should be surpassed by operators to reach optimal outcomes. Conclusion Radial artery catheterization is a safe and effective means of carrying out a wide range of neuroendovascular procedures associated with excellent clinical outcomes and an overall low rate of periprocedural complications.

OBJECTIVE External ventricular drain (EVD) placement is a common neurosurgical procedure. While this procedure is simple and effective, infection is a major limiting factor. Factors predictive of infection reported in the literature are not conclusive. The aim of this retrospective, single-center large series was to assess the rate and independent predictors of ventriculostomy-associated infection (VAI). METHODS The authors performed a retrospective chart review of consecutive patients who underwent EVD placement between January 2012 and January 2018. RESULTS A total of 389 patients were included in the study. The infection rate was 3.1% (n = 12). Variables that were significantly associated with VAI were EVD replacement (OR 10, p = 0.001), bilateral EVDs (OR 9.2, p = 0.009), duration of EVD placement (OR 1.1, p = 0.011), increased CSF output/day (OR 1.0, p = 0.001), CSF leak (OR 12.9, p = 0.001), and increased length of hospital stay (OR 1.1, p = 0.002). Using multivariate logistic regression, independent predictors of VAI were female sex (OR 7.1, 95% CI 1.1–47.4; p = 0.043), EVD replacement (OR 8.5, 95% CI 1.44–50.72; p = 0.027), increased CSF output/day (OR 1.01, 95% CI 1.0–1.02; p = 0.023), and CSF leak (OR 15.1, 95% CI 2.6–87.1; p = 0.003). CONCLUSIONS The rate of VAI was 3.1%. Routine CSF collection (every other day or every 3 days) and CSF collection when needed were not associated with VAI. The authors recommend CSF collection when clinically needed rather than routinely.

Data in neurointerventional literature is extremely limited regarding the safety and efficacy of flow diversion using transradial access (TRA). We aim to demonstrate the safety and efficacy of intracranial aneurysm treatment with the Pipeline Embolization Device (PED) using TRA compared to transfemoral access (TFA). We conducted a retrospective analysis of a prospectively maintained database and identified 79 consecutive patients who underwent neuroendovascular embolization for cerebral aneurysms using the PED from April 2018 through October 2019. Patients were divided into 2 groups: TRA (32 patients) and TFA (47 patients). A comparative analysis was performed between the two groups. There was no significant difference in postoperative intracranial hemorrhage (p>.99), symptomatic ischemic stroke (p=.512), access site complications (p=.268), or other complications (p=.512). However, there was a significant increase in overall complications (14.9% vs. 0.0%, p=.038) and procedure duration (71.4 min ± 31.2 vs. 58.5 ± 20.3, p=.018) in the TFA group. There was no significant difference in complete occlusion at latest follow-up (19/25, 76.0% vs. 35/40, 87.5%; p=.311), 6-month follow-up (17/23, 73.9% vs. 33/38, 86.8%; p=.303), or 12-month follow-up (8/8, 100.0% vs. 5/6, 83.3%; p=.429). There was also no significant difference in rate of retreatment (p>.99), morbidity (p=.512), mortality (p>.99), latest follow-up (p=.985), or loss of follow-up (p=.298). The feasibility and efficacy of flow diversion with the PED via TRA for the treatment of intracranial aneurysms is comparable to TFA. Widespread adoption of this approach may be facilitated by improvements in device navigation and manipulation via radial-specific engineering.

OBJECTIVEThe advent of mechanical thrombectomy (MT) has become an effective option for the treatment of acute ischemic stroke in addition to tissue plasminogen activator (tPA). With recent advances in device technology, MT has significantly altered the hospital course and functional outcomes of stroke patients. The authors’ goal was to establish the most up-to-date reperfusion and functional outcomes with the evolution of MT technology.METHODSThe authors conducted a retrospective study of 403 patients who underwent MT for ischemic stroke at their institution from 2010 to 2017. They collected data on patient comorbidities, National Institutes of Health Stroke Scale (NIHSS) score on arrival, tPA administration, revascularization outcomes, and functional outcomes on discharge.RESULTSIn 403 patients, the mean NIHSS score on presentation was 15.8 ± 6.6, with 195 (48.0%) of patients receiving tPA prior to MT. Successful reperfusion (thrombolysis in cerebral infarction score 2B or 3) was achieved in 84.4%. Hemorrhagic conversion with significant mass effect was noted in 9.9% of patients. The median lengths of ICU and hospital stay were 3.0 and 7.0 days, respectively. Functional independence (modified Rankin Scale score 0–2) was noted in 125 (31.0%) patients, while inpatient mortality occurred in 43 (10.7%) patients.CONCLUSIONSAs MT has established acute ischemic stroke as a neurosurgical disease, there is a pressing need to understand the hospital course, hospital- and procedure-related complications, and outcomes for this new patient population. The authors provide a detailed account of key metrics for MT with the latest device technology and identify the predictors of unfavorable outcomes and inpatient mortality.

Mobile stroke units (MSUs) have been implemented worldwide for stroke care, but outcome data are lacking to show their efficacy specifically in patients undergoing mechanical thrombectomy (MT). Here, we include patients from our stroke network MSU and compare them to patients who arrived conventionally.A retrospective review of a stroke database was performed to identify patients who underwent MT after arrival via an MSU from August 2019 to December 2020. Demographic factors, past medical history, stroke characteristics, treatment variables, complications, and functional outcomes were recorded. These were compared to date-matched patients who underwent MT after arrival via conventional means.Seven patients were treated with MT after arriving by an MSU. These patients were compared to 50 date-matched patients who underwent thrombectomy after arrival through conventional means. No statistically significant difference between cohorts was observed in terms of demographic variables, comorbidities, stroke characteristics, or tissue plasminogen activator administration. Patients from the MSU cohort had significantly shorter time from symptom onset to groin puncture time (191.33 minutes ±77.53 vs. 483.51 minutes ±322.66, P = 0.034). Importantly, MSU-transferred patients had significantly better discharge functional status measured by using the modified Rankin Scale (1.86 ± 1.35 vs. 3.57 ± 1.88, P = 0.024). No significant difference in final thrombolysis in cerebral infarction score, complications, length of stay, or mortality was observed.Our pilot study demonstrates the efficacy of the MSU in decreasing door-to-puncture time and a concordant improvement in the discharge modified Rankin Scale score. Further prospective studies are needed to assess cost-efficacy and optimal protocol for MSUs in stroke care.

OBJECTIVE The objective of this study was to demonstrate the feasibility and safety of CorPath GRX robotic-assisted (RA) transradial (TR) carotid artery stenting (CAS) compared with manual TR CAS. METHODS The authors conducted a retrospective analysis of a prospectively maintained database and identified 13 consecutive patients who underwent TR CAS from June 2019 through February 2020. Patients were divided into 2 groups: RA (6 patients) and manual (7 patients). RESULTS Among 6 patients in the RA group with a mean age of 70.0 ± 7.2 years, technical success was achieved in all 6 (100%) procedures; there were no technical or access-site complications and no catheter exchanges. Transfemoral conversion was required in 1 (16.7%) case due to a tortuous aortic arch. There were no perioperative complications, including myocardial infarction, stroke, and mortality. The mean procedure duration was significantly longer in the RA group (85.0 ± 14.3 minutes [95% CI 69.9–100.0] vs 61.2 ± 17.5 minutes [95% CI 45.0–77.4], p = 0.0231). There was no significant difference in baseline characteristics, fluoroscopy time, contrast dose, radiation exposure, catheter exchanges, technical success, transfemoral conversion, technical or access-site complications, myocardial infarction, stroke, other complications, or mortality. CONCLUSIONS The authors’ results suggest that RA TR CAS is feasible, safe, and effective. Neurovascular-specific engineering and software modifications are needed prior to complete remote control. Remote control has important implications regarding patient access to lifesaving procedures for conditions such as stroke and aneurysm rupture as well as operative precision. Future clinical investigations among larger cohorts are needed to demonstrate reliable performance and patient benefit.

Objective Double stent-assisted coiling of wide-neck bifurcation aneurysms (WNBAs) can be technically challenging with high thromboembolic rates. Single stent-assisted coiling (SSAC) decreases procedural complexity and thromboembolic risk but increases risk of coil prolapse and recanalization. In this study, we present our institution's experience with SSAC of WNBA performed via a “shouldering” and “framing” with a single Atlas stent and a spherical 3-dimensional (3D) Stryker coil. Methods A retrospective review of 35 patients who underwent SSAC of WNBA performed via a shouldering and framing with a single Atlas stent and a spherical 3D Stryker coil from 2018 to 2019. Data collection were performed on baseline demographics, clinical presentation, aneurysm characteristics, angiographic and functional outcomes, and perioperative and postoperative complications. Results Of 35 patients, the mean age was 59.9 ± 11.6 years and 25/35 (71.4%) were women. The mean aneurysm diameter was 6.3 ± 3.4 mm, the mean neck size was 3.9 ± 1.3 mm, and the mean dome-to-neck ratio was 1.5 ± 0.6. Initial complete/near-complete occlusion was demonstrated in 30/35 (85.7%) patients. On angiographic follow-up at a mean of 6 months, 9/24 (37.5%) patients showed progressive thrombosis, 13/24 (54.2%) showed stable occlusion, and 2/24 (8.5) showed recanalization. Thromboembolic events occurred in 2/35 (5.7%) patients, intraoperative technical complications occurred in 2/35 (5.7%) patients, and access-site complications occurred in 2/35 (5.7%) patients. The were no cases of retreatment, rehemorrhage, or procedural-related permanent morbidity or mortality. Conclusions Coil embolization performed via shouldering with a single Atlas stent and framing with a spherical 3D Stryker coil is a feasible, safe, and effective neuroendovascular treatment for WNBAs.

BackgroundThe coronavirus disease 2019 is associated with neurological manifestations including stroke.ObjectivesWe present a case series of coronavirus disease 2019 patients from two institutions with acute cerebrovascular pathologies. In addition, we present a pooled analysis of published data on large vessel occlusion in the setting of coronavirus disease 2019 and a concise summary of the pathophysiology of acute cerebrovascular disease in the setting of coronavirus disease 2019.MethodsA retrospective study across two institutions was conducted between 20 March 2020 and 20 May 2020, for patients developing acute cerebrovascular disease and diagnosed with coronavirus disease 2019. We performed a literature review using the PubMed search engine.ResultsThe total sample size was 22 patients. The mean age was 59.5 years, and 12 patients were female. The cerebrovascular pathologies were 17 cases of acute ischemic stroke, 3 cases of aneurysm rupture, and 2 cases of sinus thrombosis. Of the stroke and sinus thrombosis patients, the mean National Institute of Health Stroke Scale was 13.8 ± 8.0, and 16 (84.2%) patients underwent a mechanical thrombectomy procedure. A favorable thrombolysis in cerebral infarction score was achieved in all patients. Of the 16 patients that underwent a mechanical thrombectomy, the mortality incidence was five (31.3%). Of all patients (22), three (13.6%) patients developed hemorrhagic conversion requiring decompressive surgery. Eleven (50%) patients had a poor functional status (modified Rankin Score 3–6) at discharge, and the total mortality incidence was eight (36.4%).ConclusionsDespite timely intervention and favorable reperfusion, the mortality rate in coronavirus disease 2019 patients with large vessel occlusion was high in our series and in the pooled analysis. Notable features were younger age group, involvement of both the arterial and venous vasculature, multivessel involvement, and complicated procedures due to the clot consistency and burden.

Background The Neuroform Atlas stent™ (by Stryker, Fremont, California) represents the most recent widely available upgrade to intracranial stenting, providing a laser cut open cell stent with a diameter of 3.0 to 4.5 mm that is delivered through an 0.017-inch microcatheter. Objective To report our initial multicenter experience of the safety, efficacy, and feasibility of the Atlas stent used for treating aneurysms, as well as one case of intracranial stenosis and one carotid artery dissection as well as other pathologies. Methods A retrospective multicenter study of subjects treated with Atlas stent during the period 2018 to 2019. Results The total number of patients included in our analysis was 71 patients. The stent was utilized to treat 69 aneurysm cases. Of the aneurysms, 36% presented with acute rupture and 56% of the ruptured aneurysms were high grade. Mean aneurysm dimension was 7 mm with an average neck width of 4.1 mm. Around 30% had received prior treatment. Telescoping or Y-stent was used in 16% of cases. We did not observe any symptomatic major complications in our series. Asymptomatic major complications were seen in 7 patients (10.1%); technical complications occurred in 4.3%. Immediate modified Raymond-Roy-occlusion-outcome class I/II was observed in 87%, and this increased to 97.7% at latest follow-up, which was at 4 mo; 91.8% of patients achieved favorable clinical outcome, and mortality rate was 1.4%. Conclusion Our series demonstrates the safety, feasibility, and efficacy of the Atlas stent. The low complication rate and the high obliteration rate managing complex aneurysms, even in an acute ruptured setting, are notable.

Background Distal transradial catheterization in the anatomic snuffbox is an alternate route of access that has started to gain consideration for neuroendovascular procedures. Objective To assess the feasibility and outcomes and present our institution's experience in performing neuroendovascular procedures via distal transradial access (dTRA). Methods We conducted a retrospective analysis and identified 120 patients who underwent consecutive neuroendovascular procedures via dTRA in the anatomic snuffbox. Data collection was performed on indication for procedure, sheath size, number of vessels selectively catheterized, fluoroscopy time, procedure duration, radiation exposure, conversion to femoral approach, access site complication, and procedure success. Results Of 120 patients with an average age of 54.7 yr ± 14.7, 73 (60.8%) underwent diagnostic angiograms, 38 (31.7%) underwent follow-up angiograms, and 9 (7.5%) underwent therapeutic procedures. The overall mean number of vessels catheterized was 2.5 ± 0.1 per procedure, the mean procedure time was 68.3 min ± 43.4, the mean fluoroscopy time was 10.8 min ± 7.6, the mean contrast dose was 70.6 mL ± 39.1, and the mean radiation exposure was 27 672.2 mGycm2 ± 42 728.4. Successfully completed therapeutic procedures included aneurysm 1 (0.8%), arteriovenous malformation (AVM)/arteriovenous fistula/carotid cavernous fistula 7 (5.8%), and 1 (0.8%) other treatment. Three patients (2.5%) required adjunct transfemoral endovenous access for AVM embolization. Two minor complications (1.67%) were a local wrist hematoma and a radial artery vasospasm without any sequelae. Conclusion Distal radial artery catheterization in the anatomic snuffbox is a safe and effective access site to perform neuroendovascular procedures. Complications and conversion rate are low making it a safe alternative.

OBJECTIVEMechanical thrombectomy (MT) is now the standard of care for acute ischemic stroke (AIS) secondary to large-vessel occlusion, but there remains a question of whether elderly patients benefit from this procedure to the same degree as the younger populations enrolled in the seminal trials on MT. The authors compared outcomes after MT of patients 80–89 and ≥ 90 years old with AIS to those of younger patients.METHODSThe authors retrospectively analyzed records of patients undergoing MT at their institution to examine stroke severity, comorbid conditions, medical management, recanalization results, and clinical outcomes. Univariate and multivariate logistic regression analysis were used to compare patients < 80 years, 80–89 years, and ≥ 90 years old.RESULTSAll groups had similar rates of comorbid disease and tissue plasminogen activator (tPA) administration, and stroke severity did not differ significantly between groups. Elderly patients had equivalent recanalization outcomes, with similar rates of readmission, 30-day mortality, and hospital-associated complications. These patients were more likely to have poor clinical outcome on discharge, as defined by a modified Rankin Scale (mRS) score of 3–6, but this difference was not significant when controlled for stroke severity, tPA administration, and recanalization results.CONCLUSIONSOctogenarians, nonagenarians, and centenarians with AIS have similar rates of mortality, hospital readmission, and hospital-associated complications as younger patients after MT. Elderly patients also have the capacity to achieve good functional outcome after MT, but this potential is moderated by stroke severity and success of treatment.

Background Several independent randomized controlled trials have shown superior efficacy of mechanical thrombectomy (MT) for management of acute ischemic stroke (AIS). However, elderly patients have been underrepresented or excluded in these trials. The aim of this study was to investigate the feasibility and safety of MT in patients with AIS ≥90 years old. Methods A retrospective review was performed of patients ≥90 years old presenting with AIS who underwent MT between 2010 and 2018. Results Of 453 patients with AIS, 5.74% (n = 26) were ≥90 years old, and 69.32% (n = 314) were 60–89 years old. Of baseline characteristics between both groups, there was a significant difference in age, sex, body mass index, smoking, hyperlipidemia, atrial fibrillation, and diabetes mellitus. Mean National Institutes of Health Stroke Scale score on admission was higher in the nonagenarians (17 vs. 15). Similar proportions of both groups received tissue plasminogen activator, 57.69% (n = 15) versus 42.68% (n = 134), P = 0.14). There was no difference in periprocedural and postprocedural complications, good Thrombolysis In Cerebral Infarction scores (88.46% [n = 23] vs. 87.58% [n = 275], P = 1.00), good modified Rankin Scale scores (34.62% [n = 4] vs. 49.36% [n = 155], P = 0.40), or mortality (11.54% [n = 3] vs. 13.06% [n = 41], P = 0.82). Conclusions Age is a factor that affects functional outcome following MT. Advancements in catheter techniques, technical experience, and great outcomes with MT allow for pushing the boundaries to consider age as one factor, rather than an exclusion criterion. Our results show that MT is safe and feasible in nonagenarians.

Machine learning algorithms have received increased attention in neurosurgical literature for improved accuracy over traditional predictive methods. In this review, the authors sought to assess current applications of machine learning for outcome prediction of neurosurgical treatment of intracranial aneurysms and identify areas for future research.A PRISMA-compliant systematic review of the PubMed, MEDLINE, and EMBASE databases was conducted for all studies utilizing machine learning for outcome prediction of intracranial aneurysm treatment. Patient characteristics, machine learning methods, outcomes of interest, and accuracy metrics were recorded from included studies.16 studies were ultimately included in qualitative synthesis. Studies primarily analyzed angiographic outcomes, functional outcomes, or complication prediction using clinical, radiological, or composite variables. The majority of included studies utilized supervised learning algorithms for analysis of dichotomized outcomes.Commonly included variables were demographics, presentation variables (including ruptured or unruptured status), and treatment used. Areas for future research include increased generalizability across institutions and for smaller datasets, as well as development of front-end tools for clinical applicability of published algorithms.

Care for acute ischaemic stroke is one of the most rapidly evolving fields due to the robust outcomes achieved by mechanical thrombectomy. Large vessel occlusion (LVO) accounts for up to 38% of acute ischaemic stroke and comes with devastating outcomes for patients, families and society in the pre-intervention era. A paradigm shift and a breakthrough brought mechanical thrombectomy back into the spotlight for acute ischaemic stroke; this was because five randomised controlled trials from several countries concluded that mechanical thrombectomy for acute stroke offered overwhelming benefits. This review article will present a comprehensive overview of LVO management, techniques and devices used, and the future of stroke therapy. In addition, we review our institution experience of mechanical thrombectomy for posterior and distal circulation occlusion.

Introduction : Stroke is a leading cause of morbidity, mortality and healthcare spending in the United States. Acute management of ischemic stroke is time‐dependent and evidence suggests improved clinical outcomes for patients treated at designated certified stroke centers. There is an increasing trend among hospitals to obtain certification as designated stroke centers. A common source or integrated tool providing both information and location of all available stroke centers in the US irrespective of the certifying organization is not readily available. The objective of our research is to generate a comprehensive and interactive electronic resource with combined data on all geographically‐coded certified stroke centers to assist in pre‐hospital triage and study healthcare disparities in stroke including availability and access to acute stroke care by location and population. Methods : Data on stroke center certification was primarily obtained from each of the three main certifying organizations: The Joint Commission (TJC), Det Norske Veritas (DNV) and Healthcare Facilities Accreditation Program (HFAP). Geographic mapping of all stroke center locations was performed using the ArcGIS Pro application. The most current data on stroke centers is presented in an interactive electronic format and the information is frequently updated to represent newly certified centers. Utility of the tool and its analytics are shown. Role of the tool in improving pre‐hospital triage in the stroke systems of care, studying healthcare disparities and implications for public health policy are discussed. Results : Aggregate data analysis at the time of submission revealed 1,806 total certified stroke centers. TJC‐certified stroke centers represent the majority with 106 Acute Stroke Ready (ASR), 1,040 Primary Stroke Centers (PSCs), 49 Thrombectomy Capable Centers (TSCs) and 197 Comprehensive Stroke Centers (CSCs). A total of 341 DNV‐certified programs including 36 ASRs, 162 PSCs, 16 PSC Plus (thrombectomy capable) and 127 CSCs were identified. HFAP‐certified centers (75) include 16 ASRs, 49 PSCs, 2 TSCs and 8 CSCs. A preliminary map of all TJC‐certified CSCs and TSCs is shown in the figure (1). Geospatial analysis reveals distinct areas with currently limited access to certified stroke centers and currently, access to certified stroke centers is extremely limited to non‐existent in fe States (for example: Idaho, Montana, Wyoming, New Mexico and South Dakota). Conclusions : Stroke treatment and clinical outcomes are time‐dependent and prompt assessment and triage by EMS directly to appropriate designated stroke centers is therefore critical. A readily available electronic platform providing location and treatment capability for all nearby certified centers will enhance regional stroke systems of care, including enabling more rapid inter‐hospital transfers for advanced intervention. Identifying geographic areas of limited access to treatment can also help improve policy and prioritize the creation of a more equitable and well‐distributed network of stroke care in the United States.

Introduction : Neuroendovascular procedures are becoming more routine in the treatment of intracranial conditions such as aneurysms, arterial stenosis, and ischemic stroke. These patients are frequently treated with antiplatelet agents prior to the procedure to prevent thrombotic complications. The combination of aspirin and a P2Y12 inhibitor such as clopidogrel is often initiated days before elective procedures or as loading doses for emergent procedures. However, some patients may still experience post procedural thrombotic or hemorrhagic complications which may be related to platelet inhibition. Methods : A retrospective review of patients who underwent a neuroendovascular procedure from 1/2017 to 12/2019 in a single tertiary care academic hospital. Procedures included flow‐diverting stent placement for aneurysms, intracranial, and cervical carotid artery stenting. Patients undergoing elective procedure were started on Aspirin and Clopidogrel 75 mg daily. Patients undergoing emergent procedures were given loading doses of Aspirin (650 mg) and Clopidogrel (600 mg). P2Y12 assay was checked prior to receiving Platelet inhibitor and from 3–6 hours after Clopidogrel loading dose. Optimal platelet inhibition was classified as reduction in P2Y12 assay by at least 60%. Patients with suboptimal platelet inhibition Results : Total neuroendovascular procedures requiring stents were 687 over the period of 3 years. mean age of patients was 61 years. This neuroendovascular procedure consisted of aneurysm stenting (239), aneurysm stent‐assisted coiling 112, intracranial stent for failed mechanical thrombectomy 62, carotid artery stent 108. Suboptimal platelet inhibition was noted in 54% (282) of 523 patients after receiving Clopidogrel. After receiving Ticagrelor, optimal inhibition was noted in 80% (226) of 282 patients with median increase of 26%. 62 patients with suboptimal response to Ticagrelor, 47 were started on Prasugrel. Thrombotic complications were noted in 7 patients, 6 of them were noted to have 70% platelet inhibition was noted in 14 patients with mean P2Y12 value of 59. Conclusions : Patients receiving P2Y12 ADP antiplatelet therapy may have suboptimal platelet inhibition which results in increased thrombotic risk. Patients who have significant platelet inhibition (>70%) after loading dose are at increased risk for hemorrhagic complications. Better platelet inhibition was achieved with Ticagrelor in Clopidogrel hypo‐response patients. In patients with Clopidogrel hyper‐response, dosing was changed to half the dose or alternate day to reduce hemorrhagic complications. As the use of endovascular therapies requiring dual anti‐platelet agents becomes more established, there is an increasing need to develop titration protocols that minimize the risk of thrombotic and hemorrhagic events based on platelet inhibition.

Introduction : Atrial fibrillation (AF) is a recognized risk factor of ischemic stroke and AF‐related stroke is twice more likely to prove fatal. Long‐term cardiac rhythm monitoring has greater diagnostic yield compared to conventional monitoring in detecting AF. Utility of implantable loop recorder (ILR) in detecting AF was established not only in patients with cryptogenic stroke but more recently in strokes due large artery atherosclerosis and small vessel disease Stroke AF trial. We present a collaborative care pathway and share multi‐year data on ILR implantation. Methods : A review of prospectively collected registry of ILR implantations performed at a Comprehensive stroke center was conducted. Data from 2017–2019 of in‐patient and out‐patient implantation was analyzed. Eligible patients identified by vascular neurology (VN) underwent in‐patient implantation primarily by interventional neurology (IN) and as out‐patient by electrophysiology Cardiology. In‐patient implant and programming were done on the day of discharge. Continuous monitoring was followed by EP Cardiology. AF detection was urgently communicated by EP Cardiology and anticoagulation initiated by VN. Patients lost to follow up or lacking information in medical records were excluded from analysis. Results : Total of 428 ILR implantations were performed over a period of 3 years (1/2017 ‐ 12/2019) with majority implants as in‐patient prior to discharge 290 (67.8%) and out‐patient 78 (32.2%). Inpatient ILR placement was noted to be 75% in 2017, 78% in 2018 and 80% in 2019. 57.2% of in‐patient ILRs were placed by IN and 42.8% by EP. Average time to in‐patient ILR was 4.1 days with 77% within 5, 18.5% within 10, and Conclusions : A multispecialty collaborative care pathway to increase implantation rate in eligible patients is recommended. In‐patient implantation allows establishing continuity of care, patient retention, prevents lost to follow‐up, avoids delay in monitoring, and importantly decreases the risk of stroke recurrence by early initiation of anticoagulation.

Purpose Spinal Vascular Malformations (SVM) are a heterogenous group of vascular abnormalities. The gold standard for diagnosis of SVMs is the spinal digital subtraction angiography (DSA) which can be challenging sometimes because of the large number of segmental arteries that need to be catheterized and the limitations in term of contrast volume used and fluoroscopy time. We will be describing and comparing the use of the time-resolved imaging of contrast kinetics (TRICKS) sequence and the DSA in the diagnosis of spinal dural arteriovenous fistulas (SDAVFs) in our institution. Methods It is a retrospective cohort study of 27 patients who had a TRICKS MRI followed by a DSA for the diagnosis of their SDAVFs between November 2003 and November 2021. Results 19 (70.4%) patients were positive for a SDAVF on both TRICKS MRI and DSA. Out of those 19, 9 (47.4%) were in the exact location on both TRICKS MRI and DSA while 10 (52.6%) were in different locations. With respect to the 10 patients who had discrepancies in their SDAVF localization between the two modalities, 9 (90%) patients had a 1-level difference and 1 (10%) had a 2- level difference. Conclusion TRICKS MRI represents an accurate screening tool to be performed before a spinal DSA in order to guide the interventionalist to focus on the correct level plus / minus 2 levels, this extra noninvasive screening tool will decrease the risk of a kidney injury from an overuse of contrast and minimize the fluoroscopy/radiation overexposure.

Background and Purpose: Epidemiological studies have shown racial and ethnic minorities to have higher stroke risk and worse outcomes than non-Hispanic Whites. In this cohort study, we analyzed the STAR (Stroke Thrombectomy and Aneurysm Registry) database, a multi-institutional database of patients who underwent mechanical thrombectomy for acute large vessel occlusion stroke to determine the relationship between mechanical thrombectomy outcomes and race. Methods: Patients who underwent mechanical thrombectomy between January 2017 and May 2020 were analyzed. Data included baseline characteristics, vascular risk factors, complications, and long-term outcomes. Functional outcomes were assessed with respect to Hispanic status delineated as non-Hispanic White (NHW), non-Hispanic Black (NHB), or Hispanic patients. Multivariate analysis was performed to identify variables associated with unfavorable outcome or modified Rankin Scale ≥3 at 90 days. Results: Records of 2115 patients from the registry were analyzed. Median age of Hispanic patients undergoing mechanical thrombectomy was 60 years (72–84), compared with 63 years (54–74) for NHB, and 71 years (60–80) for NHW patients ( P P P P Conclusions: Hispanic patients are less likely to have favorable outcome at 90 days following mechanical thrombectomy compared to NHW or NHB patients. Further prospective studies are required to validate our findings.

Background The coronavirus disease 2019 (COVID-19) pandemic is an ongoing public health emergency. While most cases end in asymptomatic or minor illness, there is growing evidence that some COVID-19 infections result in nonconventional dire consequences. We sought to describe the characteristics of patients with intracranial hemorrhage who were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Also, with the existing literature, we raise the idea of a possible association between SARS-CoV-2 infection and intracranial hemorrhage and propose possible pathophysiological mechanisms connecting the two. Methods We retrospectively collected and analyzed intracranial hemorrhage cases who were also positive for SARS-CoV-2 from 4 tertiary-care cerebrovascular centers. Results We identified a total of 19 patients consisting of 11 males (58%) and 8 females (42%). Mean age was 52.2, with 95% younger than 75 years of age. With respect to COVID-19 illness, 50% had mild-to-moderate disease, 21% had severe disease, and 20% had critical disease requiring intubation. Of the 19 cases, 12 patients had intraparenchymal hemorrhage (63%), 6 had subarachnoid hemorrhage (32%), and 1 patient had a subdural hematoma (5%). A total of 43% had an intracerebral hemorrhage score of 0–2 and 57% a score of 3–6. Modified Rankin Scale cores at discharge were 0–2 in 23% and 3–6 in 77%. The mortality rate was 59%. Conclusions Our series sheds light on a distinct pattern of intracerebral hemorrhage in COVID-19–positive cases compared with typical non–COVID-19 cases, namely the severity of hemorrhage, high mortality rate, and the young age of patients. Further research is warranted to delineate a potential association between SARS-CoV-2 infection and intracranial hemorrhage.

Background Arterial dissections are a common cause of stroke in second decade–fourth decade patients, but may occur at any age. There are no previous reports of an intracranial carotid artery dissection that evolved spontaneously into both complications (i.e., stroke, pseudoaneurysm). To our knowledge, this is the first case of arterial dissection complicated by an occlusion and a pseudoaneurysm occurring at the same site. Case Description The patient is a 57-year-old woman who was found by a family member with complete right-side weakness and without the ability to communicate. On admission, her National Institutes of Health Stroke Scale score was 18 and her cerebral angiogram showed a left cavernous carotid occlusion. Mechanical thrombectomy failed to open the occlusion; therefore, an enterprise stent was deployed. Four weeks after the left internal carotid artery (ICA) stent placement, the patient presented with a complete ptosis of the left eye with minimally reactive pupil and a third nerve palsy. Computed tomography angiogram showed an 8-mm aneurysm of the left cavernous ICA. A cerebral angiogram was performed and showed a 10- × 7-mm cavernous pseudoaneurysm. The decision was made to treat the aneurysm with Pipeline-assisted coiling. The procedure went well without any complications. Conclusions Intracranial dissection/occlusion is a frequent cause of brain infarction, especially in mid-adulthood. Clinical signs of subarachnoid hemorrhage, compressive nerve palsies, and epistaxis in a patient who had endovascular treatment for an intracranial arterial dissection occlusion should be considered as signs for pseudoaneurysm formation, and an angiography should be obtained as soon as possible.

Background and purpose Flow-diversion therapy (FDT) for large and complex intracranial aneurysms is effective and considered superior to primary coil embolization. Data evaluating common treatment with both FDT and coiling continues to emerge, but information on outcomes remains scarce. This study aims to examine further the efficiency and outcomes correlated with joint FDT using pipeline embolization device (PED) and coiling compared to PED-alone in treating intracranial aneurysms. Materials and methods Comparative review and analysis of aneurysm treatment with PED in 416 subjects were conducted. Joint modality, PED, and coiling were compared to PED-alone for aneurysm occlusion, recurrence, retreatment, thromboembolic or hemorrhagic events, and functional outcome using the modified Rankin Scale. Data on patient demographics, aneurysm characteristics, clinical and angiographic follow up, were also collected. Both univariate analysis and multivariate logistic regression modeling using mixed-effects were performed. Results Total of 437 aneurysms were treated using PED of which 74 were managed with both PED and coiling. Average patient-age was 56 years, the majority were men (85%), an average aneurysm size was 9 mm, and the majority were saccular aneurysms (84%). Larger aneurysm size was associated with a poor outcome in patients with unruptured aneurysms (OR = 1.06). Adjusted regression analyses revealed no differences between treatment groups in thromboembolic or hemorrhagic events, aneurysm occlusion rate, residual flow on follow up angiography, or functional outcome. Conclusions Treatment of intracranial aneurysms with joint PED and coiling was safe with no increase in complications when compared to PED alone. Aneurysm occlusion rates and functional outcome with PED and coiling stays comparable to treatment with PED-alone.

Background Machine learning algorithms depend on accurate and representative datasets for training in order to become valuable clinical tools that are widely generalizable to a varied population. We aim to conduct a review of machine learning uses in stroke literature to assess the geographic distribution of datasets and patient cohorts used to train these models and compare them to stroke distribution to evaluate for disparities. Aims 582 studies were identified on initial searching of the PubMed database. Of these studies, 106 full texts were assessed after title and abstract screening which resulted in 489 papers excluded. Of these 106 studies, 79 were excluded due to using cohorts from outside the United States or being review articles or editorials. 27 studies were thus included in this analysis. Summary of review Of the 27 studies included, 7 (25.9%) used patient data from California, 6 (22.2%) were multicenter, 3 (11.1%) were in Massachusetts, 2 (7.4%) each in Illinois, Missouri, and New York, and 1 (3.7%) each from South Carolina, Washington, West Virginia, and Wisconsin. 1 (3.7%) study used data from Utah and Texas. These were qualitatively compared to a CDC study showing the highest distribution of stroke in Mississippi (4.3%) followed by Oklahoma (3.4%), Washington D.C. (3.4%), Louisiana (3.3%), and Alabama (3.2%) while the prevalence in California was 2.6%. Conclusions It is clear that a strong disconnect exists between the datasets and patient cohorts used in training machine learning algorithms in clinical research and the stroke distribution in which clinical tools using these algorithms will be implemented. In order to ensure a lack of bias and increase generalizability and accuracy in future machine learning studies, datasets using a varied patient population that reflects the unequal distribution of stroke risk factors would greatly benefit the usability of these tools and ensure accuracy on a nationwide scale.

BackgroundDuring the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study’s objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines.MethodsWe conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March–31 May 2020. The prior 1-year control period (1 March–31 May 2019) was obtained to account for seasonal variation.FindingsThere was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI −24.3% to −20.7%, pInterpretationThere was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction.

Neuroangiography has seen a recent shift from transfemoral to transradial access. In transradial neuroangiography, the right dominant hand is the main access used. However, the left side may be used specifically for left posterior circulation pathologies and when right access cannot be used. This study describes our initial experience with left radial access for diagnostic neuroangiography and assesses the feasibility and safety of this technique. We performed a retrospective review of a prospective database of consecutive patients between April 2018 and January 2020, and identified 20 patients whom a left radial access was used for neurovascular procedures. Left transradial neuroangiography was successful in all 20 patients and provided the sought diagnostic information; no patient required conversion to right radial or femoral access. Pathology consisted of anterior circulation aneurysms in 17 patients (85%), brain tumor in 1 patient (5%), and intracranial atherosclerosis disease involving the middle cerebral artery in 2 patients (10%). The left radial artery was accessed at the anatomic snuffbox in 18 patients (90%) and the wrist in 2 patients (10%). A single vessel was accessed in 7 (35%), two vessels in 8 (40%), three vessels in 4 (20%), and four vessels in 1 (5%). Catheterization was successful in 71% of the cases for the right internal carotid artery and in only 7.7% for the left internal carotid artery. There were no instances of radial artery spasm, radial artery occlusion, or procedural complications. Our initial experience found the left transradial access to be a potentially feasible approach for diagnostic neuroangiography even beyond the left vertebral artery. The approach is strongly favored by patients but has significant limitations compared with the right-sided approach.

Objective The objective of this study was to demonstrate the feasibility and safety of CorPath GRX robotic-assisted (RA) transradial (TR) carotid artery stenting (CAS) compared with manual TR CAS. Methods The authors conducted a retrospective analysis of a prospectively maintained database and identified 13 consecutive patients who underwent TR CAS from June 2019 through February 2020. Patients were divided into 2 groups: RA (6 patients) and manual (7 patients). Results Among 6 patients in the RA group with a mean age of 70.0 ± 7.2 years, technical success was achieved in all 6 (100%) procedures; there were no technical or access-site complications and no catheter exchanges. Transfemoral conversion was required in 1 (16.7%) case due to a tortuous aortic arch. There were no perioperative complications, including myocardial infarction, stroke, and mortality. The mean procedure duration was significantly longer in the RA group (85.0 ± 14.3 minutes [95% CI 69.9-100.0] vs 61.2 ± 17.5 minutes [95% CI 45.0-77.4], p = 0.0231). There was no significant difference in baseline characteristics, fluoroscopy time, contrast dose, radiation exposure, catheter exchanges, technical success, transfemoral conversion, technical or access-site complications, myocardial infarction, stroke, other complications, or mortality. Conclusions The authors' results suggest that RA TR CAS is feasible, safe, and effective. Neurovascular-specific engineering and software modifications are needed prior to complete remote control. Remote control has important implications regarding patient access to lifesaving procedures for conditions such as stroke and aneurysm rupture as well as operative precision. Future clinical investigations among larger cohorts are needed to demonstrate reliable performance and patient benefit.

Endovascular embolization of arteriovenous malformations (AVMs) and dural arteriovenous fistulas (DAVFs) has become the mainstay in treatment for these pathologies. Traditional techniques required the formation of a proximal plug of Onyx around the microcatheter prior to embolization to avoid reflux. Recently, dual-lumen balloon catheters have been introduced as a potential solution to this issue. We sought to compare our institutional experience with dual-lumen balloons to traditional microcatheters in the endovascular embolization of AVMs and DAVFs. A retrospective analysis of consecutive patients treated with Scepter between 2016 and 2020 was obtained. A control cohort treated with Marathon between 2012 and 2020 was also obtained. Variables collected included patient demographics, procedure times, pedicles treated, operative complications, obliteration rate, and retreatment rate. A total of 44 trial (30 DAVFs and 14 AVMs) and 25 control (15 DAVFs and 10 AVMs) subjects were identified. Average Scepter procedure times were 66.0 and 68.0 min for DAVFs and AVMs, respectively. Average Scepter volume of Onyx injected was 2.2 and 1.4 mL for DAVFs and AVMs, respectively. Complete angiographic occlusion Scepter rate was 86.7% and 50.0% for DAVFs and AVMs, respectively. The Scepter retreatment rate was 13.3% and 50.0% for DAVFs and AVMs, respectively. Predictors of angiographic occlusion included the number of pedicles (OR 0.54, 95%CI 0.30–0.97, p = 0.04). Predictors of retreatment included DAVF (OR 0.16, 95%CI 0.04–0.66, p = 0.01) and Marathon (OR 3.34, 95%CI 1.00–11.56, p = 0.05). Our study shows that dual-lumen balloon catheters are a viable option in the embolization of DAVFs and AVMs.

Background Mobile stroke units (MSUs), specialized ambulances with a built-in computed tomography (CT) scanner and telemedicine connected stroke team, have been on the rise in recent years largely due to the ‘time is brain’ concept. We aim to report our initial experience since establishing our MSU, the first unit in the Tri-state area, and assess its impact on the stroke standards of care timeline. Methods We conducted a retrospective analysis of a prospectively maintained database of all MSU dispatched cases from August 2019 to March 2020. Results Of 195 MSU responses, 101 were treated and transported by the MSU. The mean time (hr:mm) of dispatch to scene arrival was 0:07 + 0:03, scene arrival to CT start was 0:10 + 0:03, CT start to teleneuro start was 0:05 + 0:03, teleneuro start to scene departure was 0:06 + 0:05, scene departure to hospital arrival was 0:12 + 0:06, and hospital arrival to arterial puncture was 2:59 + 1:01. The mean time of dispatch to arterial puncture was 3:34 + 1:02. The mean teleneuro consult duration was 0:04 + 0:02. The mean time of last know well (LKW) to tPA administration was 1:28 + 0:48 with 4 (57.1 %) patients receiving tPA within 60 min of LKW and 5 (71.4 %) patients receiving tPA within 90 min. The mean time of dispatch to tPA was 0:37 + 0:09 and scene arrival to tPA administration was 0:28 + 0:07. Conclusion MSUs may expedite each step along the stroke standards of care. In theory, this should drastically improve functional outcomes. However, the impact on functional outcomes or reductions in stroke-related morbidity is still unknown.

Background Visual dysfunction and headache are major symptoms in patients with idiopathic intracranial hypertension (IIH). We aimed to evaluate the improvement of these symptoms in patients who underwent ventriculoperitoneal (VPS) and lumboperitoneal (LPS) shunting. Methods Electronic medical records were reviewed to identify baseline and treatment characteristics for patients diagnosed with IIH over 10 years. Visual outcomes and headache were evaluated at the latest follow-up post shunting. Results We included 163 patients with a mean age of 32.6 years. Most patients (74.2%) underwent VPS versus 25.8% of patients who received LPS. After a mean follow-up duration of 35 months, there was a 58.3% decrease in patients reporting headache (P = 0.006), an 87.7% decrease in papilledema (P = 0.1), a 100% resolution of diplopia with VPS or LPS, and an 88.5% decrease in transient visual obscurations (P = 1). In the worse eye, improved visual acuity (VA) occurred in 53.7% of eyes (P = 1), was stable in 16.4%, and worsened in 29.8%. The mean LogMAR VA was improved by 0.06 LogMAR (20/68) in the worse eye (P = 0.97) and 0.08 LogMAR (20/31) in the better eye (P = 0.7). The visual function that impairs daily activity was decreased by 55.4% (P = 0.08). Patients shunted within 1 month of presentation had a significantly higher rate of headache (P = 0.04) and VA improvement (P Conclusions VPS and LPS are effective in improving visual symptoms and headache in patients with IIH.

Introduction: Flow diversion has introduced a paradigm shift in the endovascular field by providing a more physiological approach to treat aneurysms. We aim to assess the efficacy and safety of flow diversion in treating a diverse large cohort of aneurysms with up to 5 years follow up. Methods: This is an analysis of a prospectively maintained database at a single-institution. Patients included in the analysis were consecutively treated patients between 2010 and 2019. Results: A total of 598 aneurysms were treated during a period extending from 2010-2019 (84.28% females, mean age 55.5 years, av. size 8.49mm). Adequate aneurysm occlusion rates were 63%(376), 73%(436), and 79%(472) at 6 ,12 and 24-month follow-up, respectively. The complete occlusion rate was 75% at a mean duration of 9 months. Of all patients, 8%(48) required retreatment. On multivariate analysis decreasing PED length (0.35,p=0.01), decreasing PED width (0.63,p=0.01), decreasing dome size (0.46,p=0.01), decreased neck width (0.46,p=0.01), absence of wall irregularity (0.60,p=0.01), lack of branching vessel (0.57,p=0.01), and previous treatment (0.56,p=0.05) were independent predictors of aneurysm occlusion.Morbidity rate occurred at a rate of 5.8% and morality at a rate of 2.2%. Ischemic stroke occurred at a rate of 3%. Delayed aneurysmal rupture and distal intraparenchymal hemorrhage occurred at a rate of 3.7%. On multivariate analysis; predictors of stroke were aneurysm size > 15mm. Predictors of DAR/DIPH were increasing aneurysm size, an increasing number of PED used, subjects presenting with a symptomatic aneurysm. Predictors of in-stent stenosis was balloon angioplasty. While increasing age and previous treatment were negatively associated with in-stent stenosis. Predictors of Morbidity were posterior circulation aneurysms, symptomatic presentation, increasing aneurysm size, and hypertension. While, predictors of unfavorable outcome were age > 75, acute SAH, increasing aneurysm size, and posterior circulation aneurysms. Conclusion: At a high-volume center with experienced operators, treatment with PED was associated with durable aneurysm occlusion and low risk of complications. The results support the increasing use of flow diverters.

Background CSF shunting is among the most widely utilized interventions in patients with idiopathic intracranial hypertension (IIH). Ventriculoperitoneal shunting (VPS) and lumboperitoneal shunting (LPS) are 2 possible treatment modalities. Objective To evaluate and compare complications, malfunction, infection, and revision rates associated with VPS compared to LPS. Methods Electronic medical records were reviewed to identify baseline and treatment characteristics for patients diagnosed with IIH treated with VPS or LPS. Results A total of 163 patients treated with either VPS (74.2%) or LPS (25.8%) were identified. The mean follow-up was 35 mo. Shunt revision was required in 40.9% of patients. There was a nonsignificant higher rate of revision with LPS (52.4%) than VPS (36.4%, P = .07). In multivariate analysis, increasing patient age was associated with higher odds of shunt revision (P = .04). LPS had higher odds of shunt revision, yet this association was not significant (P = .06). Shunt malfunction was the main indication for revision occurring in 32.7%, with a significantly higher rate with LPS than VPS (P = .03). In total, 15 patients had shunt infection (9.4% VPS vs 12.2% LPS P = .50). The only significant predictor of procedural infection was the increasing number of revisions (P = .02). Conclusion The incidence of shunt revision was 40.9%, with increasing patient age as the sole predictor of shunt revision. The incidence of shunt malfunction was significantly higher in patients undergoing LPS, while there was no significant difference in the incidence of shunt infection between the 2 modalities.

Background and importance Pivotal trials have shown the tremendous efficacy of mechanical thrombectomy in proximal occlusions (PO). However distal occlusions (DO) involving M2 and beyond, distal ACA (A2) and posterior cerebral arteries were not represented. The thoughts are that distal vessels supply a smaller brain area, however, with significant symptoms paired with accessible occlusions, the concept may need to be revisited. In this study, we investigated the efficacy and safety of distal circulation mechanical thrombectomies compared to proximal circulation mechanical thrombectomies. Methods A retrospective review of patients presenting with distal circulation acute ischemic stroke (AIS) who underwent mechanical thrombectomy at a tertiary referral center between 2010 and 2018. Results Out of 453 patients who underwent mechanical thrombectomy for AIS, 73 patients had a DO (average age 72 years, 59% female). The mean NIHSS upon admission was 12 (95% CI: 11–14). The mean procedure time was 45 minutes (95% CI: 38–52) and mean time to revascularization, from symptom onset to finishing the thrombectomy procedure, was 522 minutes (95% CI: 438–5607). 45% (n=34) of subjects received tPA. Vessels involved included M2 (89%, n=68), A2 (3%, n=2), PCA (3%, n=2), and M3/4 (5%, n=4). A stentreiver alone was used in 11% of the cases (n=8), aspiration alone in 8% (n=6), and both stentreiver and aspiration in 72% (n=55), with failed attempts in 9% (n=7) of cases. Most procedures required one pass to recanalize the vessel (55%, n=42). TICI > 2b was achieved in 88% (n=67) of the subjects. Mean length of stay was eight days (95% CI: 6–10). Mortality was noted in 8% (n=6) of patients and independent functional outcome of mRS 2b) was not significantly different between DO and PO. However, procedure time was significantly shorter in the DO group (45 min vs. 52 min, p=0.05) and the mean number of passes were lower in the DO group (1.5 vs. 1.8, p=0.01). Mortality rate and good functional outcome was not significantly different between both groups. On multivariate analysis, DO group had a significantly shorter length of stay by about two days, compared to PO, when controlling for confounders (coef: -2 days, 95%CI: -4 to 0 days, p=0.05). Subjects with PO were over five times more likely to have a good TICI score compared to DO group (OR: 5.69, 95% CI: 1.22–26.5, p Conclusion Mechanical thrombectomy procedure for distal circulation strokes is as effective and safe as a proximal group. Though distal vessels supply smaller brain area, however when symptoms are pronounced the benefit of the procedure outweighs the risks. Disclosures A. Sweid: None. J. Head: None. S. Tjoumakaris: None. V. Xu: None. K. Shivashankar: None. T. Alexander: None. M. Gooch: None. N. Herial: None. R. Rosenwasser: None. P. Jabbour: None.

Background External ventricular drain (EVD) placement is a common neurosurgical procedure. While this procedure is simple and effective, infection is a major limiting factor. Factors predictive of infection reported in the literature are not conclusive. Objective The aim of this retrospective single-center large sample was to assess the rate and factors predictive of infection. Methods We performed a retrospective review of patients who underwent EVD placement between January 2012 and January 2018. Results A total of 714 patients were included in the study. The infection rate was 3.6% (26/714). In 45% of the cases, the indication for ventriculostomy placement was for acute subarachnoid hemorrhage (aSAH) or intracerebral hemorrhage (ICH). Of the factors that were an independently significant predictor of ventriculostomy-associated infection (VAI) was the placement of a second EVD; the likelihood was eight times higher than if only a single EVD was placed (OR: 7.95, 95% CI: 1.01–62.9, p 1060, p Conclusion Our study shows that the rate of VAI was 3.6%. Only three variables were significant independent predictors of VAI; these were the replacement of the EVD, routine CSF aspiration, and intrathecal drug delivery. Disclosures A. Sweid: None. S. Tjoumakaris: None. C. Wamsley: None. E. Mann: None. C. Neely: None. J. Head: None. M. Gooch: None. N. Herial: None. T. Alexander: None. S. Missios: None. N. Chalouhi: None. R. Rosenwasser: None. P. Jabbour: None.

Objective 20% of all acute ischemic strokes (AIS) occur in the posterior circulation (PC), which carry a high mortality rate close to 95%. Early recanalization improves outcomes as shown by several reports. Often trials excluded patients with posterior circulation strokes. We sought to investigate the prevalence, safety, and the clinical outcomes of PC-MT at our institution. Methods A retrospective review of patients presenting with PC AIS who underwent mechanical thrombectomy at a tertiary referral center between 2010 and 2018. Results Out of 453 patients who underwent mechanical thrombectomy for AIS, 45 patients had a PC stroke (av age 58 years, 56% male). The mean NIHSS upon admission was 17 (95%CI:14–20). The mean time from symptoms onset to groin puncture was 9 hours (95%CI:6–11), the mean procedure time was 53 minutes (95%CI:43–64) and mean time to revascularization, from symptoms onset was 866 minutes (95%CI:602–1129). Only 33% received tPA. Vessels involved included the basilar artery (87%, n=39), the posterior cerebral artery (4%, n=2), and the vertebral artery (9%, n=4). The procedures were divided into stentreiver alone (22%, n=10), aspiration alone (13%, n=6), and stentreiver with aspiration (51%, n=23), and failed procedure in 13% (n=6) of individuals. Most procedures required one pass to recanalize the vessel (44%, n=20). TICI > 2b was achieved in 69% of the subjects. Mean length of stay was 11 days (95%CI:8–14). Mortality rate was 38% and independent functional outcome of mRS 2b) was significantly lower in PC compared to AC (70% vs 90%,p Conclusions MT is a safe and efficacious first-line therapy for PC strokes. PC-MT provides a high rate of recanalization without procedural complications. Improvement in functional outcome remains low, and mortality remains high, but with a much better outcome than leaving the disease untreated. Disclosures A. Sweid: None. K. Hafazalla: None. S. Tjoumakaris: None. V. Xu: None. K. Shivashankar: None. T. Alexander: None. M. Gooch: None. N. Herial: None. N. Chalouhi: None. R. Rosenwasser: None. P. Jabbour: None.

Introduction Coiling has been the first line armamentarium for treating intracranial aneurysms, especially ruptured ones. Coiling has a relatively high recurrence rate as compared to clipping which leads to increased costs and procedural risks. Purpose We aimed to determine complication rates, occlusion outcomes, functional status, and mortality of Anterior communicating artery (ACOM) aneurysms following coiling. We also determined re-treatment rate and compared occlusion outcomes between recoiling and clipping of recurrences. We also assessed factors predictive of aneurysms recurrence. Materials and methods We performed a retrospective cohort study of consecutive patients with ACOM aneurysms. Results 516 ACOM aneurysms were included (Av age 55.5 years, 54.3% female). 78% (401) presented as ruptured aneurysms, 55.6% presented with a high-grade H&H. The average aneurysm size was 5.8 mm(SD=2.8). 93%(478) were treated with coiling as stand-alone divided into primary coiling 86%(412), balloon-assisted coiling 12%(57), and stent-assisted coiling 2%(9). While 7%(37) were treated with coiling in addition to clipping, coiling was placed to secure the dome, and then the aneurysm was clipped during the same hospital stay in acute settings. At the end of the procedure, >95% occlusion was achieved in 90.9% of the cases. The average length of hospital stay was 15.8days, and the mortality rate was 7.2%. There was a significant six folds higher aneurysm recurrence in the coiled group reaching 17.3%(78) while in the clipped/coiled group the recurrence rate was 2.9%(1) (p=0.026). Of all patients with recurrence (n=79), 28 were treated with clipping, 22 with coiling, 16 with coiling followed by clipping due to recurrence, and 13 patients were not re-treated. Out of the whole 38 patients who received coiling at least once, 34 needed recoiling once, 3 required recoiling twice, and 1 patient required recoiling four times. Approximately 76% of coiled patients(n=29) showed recurrence, while none of the clipped patients showed recurrence(p Conclusion The recurrence rate of coiled aneurysms compared to clipping was associated with 6 folds higher rate of recurrence. Clipping of a recurred ACOM aneurysms achieves higher occlusion outcomes, lower recurrence rate, and comparable risk of complication and functional outcome compared to coiling. Increasing aneurysm size and ruptured status was a significant predictor of aneurysm recurrence. Disclosures A. Sweid: None. N. Herial: None. S. Tjoumakaris: None. S. Rahm: None. C. Andrews: None. M. Gooch: None. R. Rosenwasser: None. P. Jabbour: None.

Background and importance Foot drop is defined as a weakness in the ankle and foot dorsiflexors. A disruption of the neural pathway starting from the mesial frontal cortex and ending in the peroneal nerve can lead to foot drop. Unilateral foot drop due to lower motor neuron injury is well documented. However, bilateral foot drop due to a central cause is very rare. Clinical presentation A 29-year-old male presenting with bilateral lower extremity weakness in addition to rigidity. The patient is known to have bipolar disorder and an Anterior communicating artery aneurysm (ACoA) for which he has not followed up. A CTA showed a partially thrombosed 5 mm × 6 mm ACoA aneurysm. The patient underwent placement of flow diverter PED. Conclusion Central causes of acute bilateral foot drop are rare but should be considered in the differential diagnosis. Thrombo-embolism due to a partially thrombosed aneurysm is a well known phenomenon, all treatment options should be considered keeping in mind the risks associated with the different techniques due to the intra saccular thrombus.

Background Flow-diverting stents had gained prominence among neurointerventionalists. Aneurysms originating from distal vessels, particularly dissecting or fusiform, pose more technical challenges. The aim of the following single center large series was to report the safety, efficacy, and functional outcome of flow diversion for aneurysms originating from small caliber vessel and compare to proximal vessels group. Methods A retrospective chart review of a prospectively maintained database for subjects treated with flow diversion from 2010-2019. Results A total of 598 aneurysms were treated during a period extending from 2010-2019 (87.8% large caliber group versus 12.20% small caliber group); 84.28% (N.=504) were females and the average age was 55.5 years. Ischemic stroke occurred at a rate of 2.99% with a non-significant difference between both groups. Delayed aneurysmal rupture and distal intraparenchymal bleed occurred at a rate of 3.70% with a non-significant difference between both groups. Complete aneurysms occlusion was seen at a rate of 75.3% with a non-significant difference between both groups. Morbidity rate occurred at a rate of 5.8% with non-significant difference between both groups. Multivariate logistic regression showed that small vessel was an independent predictor of aneurysm obliteration with a 2.6-fold-higher likelihood. Conclusions Flow-diverting stents are being used to treat diverse types of aneurysms and in various locations, in distal small caliber vessels where other treatment options pose a considerable risk. Small caliber group had similar complication and occlusion rates compared to proximal vessel group.

Background Nearly 20% of individuals with an aneurysm will harbor multiple aneurysms—these individuals are at increased risk of subarachnoid hemorrhage. Treatment of bilateral aneurysms with flow diverters (FD), Pipeline Embolization Device (PED) has not yet been established as an effective therapy. Our aim is to evaluate the safety and efficacy of a two-stage treatment of bilateral aneurysms with PEDs placed 6 months apart. Methods This study is a retrospective review analyzing the clinical and angiographic outcomes of 16 individuals with bilateral aneurysms who were treated with a two-stage flow diversion treatment at a tertiary referral center between January 2010 and July 2018. Results 16 individuals with 33 aneurysms who were treated with flow diversion bilaterally; one patient had two aneurysms treated with a single FD on the contralateral side. The aneurysms treated were either ophthalmic, superior hypophyseal, posterior communicating, or cavernous segment aneurysms with an average size of 6.5 mm. There were no major complications such as in-stent stenosis, thromboembolic events, distal intra-parenchymal hemorrhage, re-rupture, stent migration, or neurological death. All patients had good functional outcomes. At 24 months follow-up, 81% of aneurysms showed complete occlusion of all treated aneurysms. No aneurysm required re-treatment. Conclusions This study demonstrates that a two-stage flow diversion treatment of bilateral aneurysms is both safe and efficacious. Timing of the contralateral flow diverter stent is critical. We found that 6 months allows for adequate neurological recovery and stent endothelization.