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We analyzed the effect of specific optimization steps to reduce treatment delays in a nonacademic stroke hospital setting. The data from patients with ischemic stroke who had been treated with intravenous tissue plasminogen activator or endovascular therapy, or both, were analyzed. The metrics were divided into 2 periods: preoptimization period (October 1, 2015 to September 30, 2016) and postoptimization period (October 1, 2016 to September 30, 2017). The key interventions were 1) notification by the emergency medical service to the emergency department and stroke team; 2) division of the stroke alert between level 1 (intravenous/intra-arterial candidate) and level 2; 3) direct transportation of level 1 patients to brain computed tomography; 4) limitation of nonessential interventions; 5) stroke orientation; 6) 24-hour, 7-day code stroke response by a vascular neurologist; 7) earlier notification of the interventional radiology team; 8) direct transportation from computed tomography to angiography suite for large vessel occlusion; and 9) multidisciplinary monthly meetings to discuss delayed cases. A total of 279 patients were identified. No significant differences in any of the baseline characteristics were documented. Almost all metrics favored the postoptimization period, with remarkable improvement in the door-to-puncture time (median, 64 minutes; interquartile range, 36–86; vs. 47 minutes; interquartile range, 20–62; P = 0.001). We observed an increased percentage of good clinical outcomes in the postoptimization group (60.1% vs. 54.8%; P = 0.500). We found an 8.4% increase in patients with good clinical outcomes in the postoptimization group compared with our previously reported work. For acute reperfusion therapies, significant reductions in workflow intervals can be achieved after simple optimization methods in a nonacademic community-based hospital. [ABSTRACT FROM AUTHOR]

To evaluate variability in aneurysm detection and the potential of artificial intelligence (AI) software as a screening tool by comparing conventional computed tomography angiography (CTA) images (standard care) with AI software. Neuroradiologists reviewed 770 CTA images and reported the presence or absence of saccular aneurysms. Subsequently, the images were analyzed by AI software. If the software suspected an aneurysm, it flagged the corresponding image. In cases where there was a mismatch between the radiologist's report and the AI findings, an expert neurosurgeon evaluated CTA images providing a definitive conclusion on the presence or absence of an aneurysm. AI software flagged 33 cases as potential aneurysms; 16 cases were positively identified as aneurysms by radiologists, and 17 were dismissed. A total of 737 cases were considered negative by AI software, while in the same group, radiologists identified aneurysms in 28 CTA images. Compared with the radiologist's report, AI performance had a sensitivity of 36%, specificity of 97.6%, and negative predictive value of 96.2%. There were 45 mismatch cases between AI and radiologists. AI flagged 17 images as showing an aneurysm that was unreported by radiologists; the expert neurosurgeon confirmed that 7 of the 17 images showed an aneurysm. In 28 images considered negative by AI, radiologists indicated aneurysms; 17 of those confirmed by the neurosurgeon. AI has the potential to increase the diagnosis of unruptured intracranial aneurysms. However, it must be used as an adjacent tool within the standard of care due to limited applicability in real-world settings. [ABSTRACT FROM AUTHOR]

Abstract: Cervical dissections are a rare but potentionally devastating complication of positioning in anesthetized patients. A 40-year-old woman was noted to have right arm weakness after a prolonged dental procedure. Imaging revealed bilateral carotid dissections with severe stenosis. The patient had further clinical deterioration despite therapeutic anticoagulation. Carotid stenting of the symptomatic left carotid artery led to improved flow and the patient had no further events. Caution should be exercised during prolonged neck hyperextension to avoid the potentially devastating complication of cervical dissection. Carotid stenting may be necessary to maintain adequate flow in patients with clinical instability despite medical therapy. [Copyright &y& Elsevier]

A cardiac myxoma (CM) is the most common primary tumor of the heart. This case report highlights that for metastatic CMs, even after a successful total resection, there is a small but real risk of recurrence that can manifest as late as 10 years after initial tumor resection. We present the case of a 53-year-old woman who visited the emergency room after a 4-day worsening right-sided weakness. The patient was diagnosed with a left CM 10 years previously, and a complete surgical resection was performed at that time. A noncontrast computed tomography of the head revealed a left parietal hematoma and a contrast computed tomography scan of the head revealed an enlarged left parieto-occipital vein that was subsequently shown to be part of an arteriovenous fistula. After embolization of the fistula was performed, postprocedure magnetic resonance imaging of the brain showed redemonstration of acute intraparenchymal hemorrhage with vasogenic edema. The history of a previously resected CM and the multifocal distribution of brain lesions opened the possibility of slow-growing metastasis from the previous myxoma. Our case report demonstrates the metastatic nature of CMs to the central nervous system, even after successful gross total resection and no local relapsing mass in subsequent ultrasonographic follow-ups. A comprehensive evaluation on clinical and imagological grounds is mandatory to rule out the presence of myxomatous metastatic disease. Awareness and recognition of the potential neurologic manifestations of a metastatic CM will prevent unnecessary diagnostic workup and treatments. [ABSTRACT FROM AUTHOR]

Objective Carotid artery stenosis is frequently diagnosed through screening tests with noninvasive imaging. Because of differences noted between the various modalities, we sought to investigate our experience comparing noninvasive imaging (ultrasound, computed tomography angiography, magnetic resonance angiography) with invasive imaging (digital subtraction angiography). Methods In a multicenter retrospective analysis, 249 carotid vessels were reviewed based on angiography with the associated noninvasive imaging. Results Overall, medical or surgical decision management was changed in 43% (107/243) of cases investigated with digital subtraction angiography owing to a discrepancy between the measured percentage stenosis. In patients with potentially treatable carotid stenosis, angiography revealed nonsignificant stenosis 25.7% of the time. Conclusions Angiography should be considered the confirmatory test for degree of stenosis in certain patients before definitive surgical treatment. [ABSTRACT FROM AUTHOR]

Background Tandem occlusion resulting in acute ischemic stroke is associated with high morbidity and mortality and a poor response to thrombolytic therapy. The use of endovascular strategies for tandem stroke cases results in an improved outcome for this subgroup of patients. We present 2 cases with a pattern of tandem occlusion consisting of proximal obstruction at the origin of the common carotid artery (CCA) with concomitant intracranial occlusion treated by endovascular techniques. Methods The 2 patients presented each with occlusion at the left CCA origin and ipsilateral intracranial vessel (left middle cerebral artery and carotid terminus, respectively). A transfemoral anterograde approach was used to deliver a balloon-mounted stent across the proximal CCA origin occlusion to gain access to the distal cerebral vasculature. Subsequently, a stent retriever assisted mechanical aspiration thrombectomy was used to revascularize the intracranial occlusion. Results Complete revascularization with Thrombolysis in Cerebral Infarction scores of 2b and improvement in neurologic deficits occurred in both cases. Good clinical outcome was achieved for both patients at 3-month follow-up. Conclusions An anterograde transfemoral approach should be considered in cases of tandem occlusion of the proximal CCA and middle cerebral artery. [ABSTRACT FROM AUTHOR]

Background: Timely recognition of stroke at major pediatric medical centers is improving, and although treatment guidelines for pediatric stroke exist, no extensive study establishing the efficacy of surgical or thrombolytic treatment has been completed. Extrapolation of adult guidelines to pediatric patients remains the mainstay of treatment in the absence of adequate information regarding safety and efficacy in children. Recent trials have demonstrated revascularization and clinical improvement after endovascular retrieval therapy in adults with acute large vessel occlusive stroke. Furthermore, successful mechanical thrombectomy using a variety of techniques has been documented in numerous children and adolescents.Patient Description: We present a 15-year-old boy with altered mental status and left hemiparesis due to acute ischemic stroke secondary to blockage of the right internal carotid artery terminus, most likely precipitated by end-stage heart failure and cardiac embolism. Mechanical aspiration thrombectomy using the Penumbra aspiration catheter without any adjunct surgical equipment or thrombolytic therapy was used to remove thrombus and treat the patient's acute ischemic stroke. He experienced complete artery recanalization with a Thrombolysis in Cerebral Infarction (TICI) score of 2C after the procedure. He also exhibited an 8 point improvement in his pediatric National Institutes of Health Stroke Scale score within 24 hours.Conclusions: Mechanical aspiration thrombectomy is commonly used in adult hospitals but infrequently employed in pediatric patients with arterial ischemic stroke. Given its efficacy in our patient, we encourage a larger systematic trial to evaluate the use of mechanical thrombectomy in pediatric patients with acute ischemic stroke. [ABSTRACT FROM AUTHOR]