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Background Prior studies have suggested an association between clot histological composition and cause of stroke. However, the results have been conflicting. Our objective is to provide an updated systematic review and meta‐analysis of the association between clot histological composition and cause of stroke for patients who underwent mechanical thrombectomy. Methods We searched Cochrane Library, Embase, and MEDLINE databases for English language articles reporting clot histology in adult patients who underwent mechanical thrombectomy for acute ischemic stroke between January 2000 and March 2024. Studies included reported on the association between causes of clots and the quantity of red blood cells and fibrin and/or platelets. Random effects meta‐analysis was used. Results A total of 448 records were identified. Of these, 25 studies were included in the qualitative synthesis, and 17 contained data in a format suitable for quantitative review. A total of 1656 patients had continuous data on clot composition and its association with cause of stroke. The pooled mean percentage difference between the cardioembolic group and the large artery atherosclerosis /noncardioembolic group was −10.3% (95% CI −16.3% to −4.4%) for red blood cells and +9.9% (95% CI +4.5% to +15.4%) for fibrin and/or platelets. Only 7 studies reported on overall white blood cells quantity. Of these, the pooled percentage difference of white blood cells between the cardioembolic group and the large artery atherosclerosis/non‐cardioembolic group was +1.1% (95% CI +0.3% to +1.9%). Conclusion Our results suggest that cardioembolic clots have higher fibrin and/or platelets and lower red blood cells compared with large artery atherosclerosis/noncardioembolic clots. However, these differences are unlikely to be of clinical utility in differentiating cause of stroke. Future studies would benefit from more rigorous analysis of clot constituents beyond cellular composition. more...

Background Timely imaging is essential for patients undergoing mechanical thrombectomy (MT). Our objective was to evaluate the safety and feasibility of low‐field portable magnetic resonance imaging (pMRI) for bedside evaluation following MT. Methods Patients with suspected large‐vessel occlusion undergoing MT were screened for eligibility. All pMRI examinations were conducted in the standard ferromagnetic environment of the interventional radiology suite. Clinical characteristics, procedural details, and pMRI features were collected. Subsequent high‐field conventional MRI within 72±12 hours was analyzed. If a conventional MRI was not available for comparison, computed tomography within the same time frame was used for validation. Results Twenty‐four patients were included (63% women; median age, 76 years [interquartile range, 69–84 years]). MT was performed with a median access to revascularization time of 15 minutes (interquartile range, 8–19 minutes), and with a successful outcome as defined by a thrombolysis in cerebral infarction score of ≥2B in 90% of patients. The median time from the end of the procedure to pMRI was 22 minutes (interquartile range, 16–32 minutes). The median pMRI examination time was 30 minutes (interquartile range, 17–33 minutes). Of 23 patients with available subsequent imaging, 9 had infarct progression compared with immediate post‐MT pMRI and 14 patients did not have progression of their infarct volume. There was no adverse event related to the examination. Conclusion Low‐field pMRI is safe and feasible in a post‐MT environment and enables timely identification of ischemic changes in the interventional radiology suite. This approach can facilitate the assessment of baseline infarct burden and may help guide physiological interventions following MT. more...

Background The purpose of this study is to evaluate the impact multiple overlapping flow‐diverting stents have on aneurysm occlusion rates and iatrogenic complications relative to single flow‐diverting stents. Methods A retrospective review of a multicenter aneurysm database from 2012 to 2020 was performed to identify saccular aneurysms treated initially with single and multiple flow‐diverting stents with ≥12‐month angiographic and clinical follow‐up. Aneurysm occlusion rates as a function of stent number served as a primary outcome measure with iatrogenic complications serving as a secondary outcome measure. Results A total of 250 patients were initially treated with a single Pipeline embolization device (PED), and 48 patients were initially treated with multiple PEDs. There was no significant difference in aneurysm size, morphology, or dual‐antiplatelet therapy regimen used between groups. There was no significant difference in the aneurysm occlusion (single, 83.6%, versus multiple, 83.4%; P=0.65) or retreatment rates (single, 8.0%, versus multiple, 10.4%; P=0.58) between groups. There was no significant difference in the number of procedure‐related complications between groups (single, 8.0%, versus multiple, 4.2%; P=0.42), with 0.8% of patients treated with a single PED and 2.1% of patients treated with multiple PEDs experiencing a procedure‐related ischemic stroke. Conclusions There is no significant difference in overall aneurysm occlusion rates between aneurysms treated initially with single versus multiple overlapping PEDs nor are there significant differences in procedure‐related complications. Single PED flow diversion may be preferred whenever possible, with multiple PED constructs reserved for extenuating clinical circumstances as may be encountered with giant aneurysms. more...

Background: The coronavirus (COVID-19) pandemic has caused unprecedented suspensions of neurosurgical elective surgeries, a large proportion of which involve spine procedures. The goal of this study is to report granular data on the impact of early COVID-19 pandemic operating room restrictions upon neurosurgical case volume in academic institutions, with attention to its secondary impact upon neurosurgery resident training. This is the first multicenter quantitative study examining these early effects upon neurosurgery residents caseloads. Methods: A retrospective review of neurosurgical caseloads among seven residency programs between March 2019 and April 2020 was conducted. Cases were grouped by ACGME Neurosurgery Case Categories, subspecialty, and urgency (elective vs. emergent). Residents caseloads were stratified into junior (PGY1-3) and senior (PGY4-7) levels. Descriptive statistics are reported for individual programs and pooled across institutions. Results: When pooling across programs, the 2019 monthly mean (SD) case volume was 214 (123) cases compared to 217 (129) in January 2020, 210 (115) in February 2020, 157 (81), in March 2020 and 82 (39) cases April 2020. There was a 60% reduction in caseload between April 2019 (207 [101]) and April 2020 (82 [39]). Adult spine cases were impacted the most in the pooled analysis, with a 66% decrease in the mean number of cases between March 2020 and April 2020. Both junior and senior residents experienced a similar steady decrease in caseloads, with the largest decreases occurring between March and April 2020 (48% downtrend). Conclusions: Results from our multicenter study reveal considerable decreases in caseloads in the neurosurgical specialty with elective adult spine cases experiencing the most severe decline. Both junior and senior neurosurgical residents experienced dramatic decreases in case volumes during this period. With the steep decline in elective spine cases, it is possible that fellowship directors may see a disproportionate increase in spine fellowships in the coming years. In the face of the emerging Delta and Omicron variants, programs should pay attention toward identifying institution-specific deficiencies and developing plans to mitigate the negative educational effects secondary to such caseloads reduction. more...

Introduction: Numerical classification systems for the internal carotid artery (ICA) are available, but modifications have added confusion to the numerical systems. Furthermore, previous classifications may not be applicable uniformly to microsurgical and endoscopic procedures. The purpose of this study was to develop a clinically useful classification system. Materials and Methods: We performed cadaver dissections of the ICA in 5 heads (10 sides) and evaluated 648 internal carotid arteries with computed tomography angiography. We identified specific anatomic landmarks to define the beginning and end of each ICA segment. Results: The ICA was classified into eight segments based on the cadaver and imaging findings: (1) Cervical segment; (2) cochlear segment (ascending segment of the ICA in the temporal bone) (relation of the start of this segment to the base of the styloid process: Above, 425 sides [80%]; below, 2 sides [0.4%]; at same level, 107 sides [20%];P< 0.0001) (relation of cochlea to ICA: Posterior, 501 sides [85%]; posteromedial, 84 sides [14%];P< 0.0001); (3) petrous segment (horizontal segment of ICA in the temporal bone) starting at the crossing of the eustachian tube superolateral to the ICA turn in all 10 samples; (4) Gasserian-Clival segment (ascending segment of ICA in the cavernous sinus) starting at the petrolingual ligament (PLL) (relation to vidian canal on imaging: At same level, 360 sides [63%]; below, 154 sides [27%]; above, 53 sides [9%];P< 0.0001); in this segment, the ICA projected medially toward the clivus in 275 sides (52%) or parallel to the clivus with no deviation in 256 sides (48%;P< 0.0001); (5) sellar segment (medial loop of ICA in the cavernous sinus) starting at the takeoff of the meningeal hypophyseal trunk (ICA was medial into the sella in 271 cases [46%], lateral without touching the sella in 127 cases [23%], and abutting the sella in 182 cases [31%];P< 0.0001); (6) sphenoid segment (lateral loop of ICA within the cavernous sinus) starting at the crossing of the fourth cranial nerve on the lateral aspect of the cavernous ICA and located directly lateral to the sphenoid sinus; (7) ring segment (ICA between the 2 dural rings) starting at the crossing of the third cranial nerve on the lateral aspect of the ICA; (8) cisternal segment starting at the distal dural ring. Conclusions: The classification may be applied uniformly to all skull base surgical approaches including lateral microsurgical and ventral endoscopic approaches, obviating the need for 2 separate classification systems. The classification allows extrapolation of relevant clinical information because each named segment may indicate potential surgical risk to specific structures. more...

To characterize smoking and alcohol use, and to describe predictors of oral cancer knowledge among a predominantly African-American population.A cross-sectional study was conducted between September, 2013 among drag racers and fans in East St. Louis. Oral cancer knowledge was derived from combining questionnaire items to form knowledge score. Covariates examined included age, sex, race, marital status, education status, income level, insurance status, tobacco and alcohol use. Adjusted linear regression analysis measured predictors of oral cancer knowledge.Three hundred and four participants completed questionnaire; 72.7% were African Americans. Smoking rate was 26.7%, alcohol use was 58.3%, and mean knowledge score was 4.60 ± 2.52 out of 17. In final adjusted regression model, oral cancer knowledge was associated with race and education status. Compared with Caucasians, African Americans were 29% less likely to have high oral cancer knowledge (β = -0.71; 95% CI: -1.35, -0.07); and participants with a high school diploma or less were 124% less likely to have high oral cancer knowledge compared with college graduates (β = -1.24; 95% CI: -2.44, -0.41).There was lower oral cancer knowledge among African Americans and those with low education. The prevalence of smoking was also very high. Understanding predictors of oral cancer knowledge is important in future design of educational interventions specifically targeted towards high-risk group for oral cancer. more...