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Objective: The aim of this study is to explain the technique used for removing and replacing a novel percutaneous interspinous device (PID). Procedure: Three male patients, with a mean age of 66 years (range 62-72), were included in the study due to displacement ( N = 2) or misplacement ( N = 1) of the novel PID. This occurred after a mean of 23.3 ± 10.5 days from the initial placement (range 13-34) at the L4-L5 level ( N = 1) and L3-L4 level ( N = 2). Following the removal of the PID, four new devices were implanted. Conclusion: The novel PID can be safely removed either immediately after its placement during the procedure or after a certain period of days or months from its implantation. The removal procedure can be performed percutaneously under imaging guidance, by closing the four retractable wings, using the same instrumentation as utilized during the initial implantation., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Percutaneous cement discoplasty (PCD) is a minimally invasive procedure. We aim to explore the efficacy and indication(s) of PCD in patients with degenerative disc disease (DDD)., Methods: The search was conducted across Ovid MEDLINE, Ovid Embase, and PubMed. Data on study design, patient demographics, pre- and post-procedure Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores, and complications were extracted. Inclusion criteria focused on adult patients with degenerative spinal diseases treated with cement discoplasty. The overall effect size was evaluated using a forest plot, and heterogeneity was assessed using the I 2 statistic and chi-squared test., Results: The search strategy yielded six studies, which included 336 patients (73.8% female, 26.2% male) with a mean average age of 74.6 years. VAS scores were reported in all studies, showing a significant difference between pre- and post-PCD pain scores (Weighted Mean Difference [WMD]: -3.45; 95% CI: -3.83, -3.08; I 2 = 15%; P < .001). ODI scores were reported in 83% of studies, with a significant difference between pre- and post-PCD scores (WMD: -22.22; 95% CI: -25.54, -18.89; I 2 = 61%; p < .001). Complications reported included infections, thrombophlebitis, vertebral fractures, disc extrusion, and the need for further operations., Conclusions: The analysis showed clinically significant improvements in pain and functional disability based on VAS and ODI scores. However, due to methodological limitations and a high risk of bias, the validity and generalizability of the findings are uncertain. Despite these issues, the results provide preliminary insights into PCD's potential efficacy and can guide future research to address current limitations., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: The mantra "time is brain" cannot be overstated for patients suffering from acute ischemic stroke. This is especially true for those with large vessel occlusions (LVOs) requiring transfer to an endovascular thrombectomy (EVT) capable center. We sought to evaluate the spoke hospital door in-door out (DIDO) times for patients transferred to our hub center for EVT., Methods: Individuals who first presented with LVO to a spoke hospital and were then transferred to the hub for EVT were retrospectively identified from a prospectively maintained database from January 2019 to November 2022. DIDO was defined as the time between spoke hospital door in arrival and door out exit. Baseline characteristics, treatments, and outcomes were compared, dichotomizing DIDO at 90 minutes based in the American Heart Association goal for DIDO ≤90 minutes for 50% of transfers. Multivariable regression analyses were performed for determinants of the 90-day ordinal modified Rankin Scale (mRS) and DIDO., Results: We identified 194 patients transferred for EVT with available DIDO. The median age was 67 years (IQR 57-80), and 46% were female. The median National Institutes of Health Stroke Scale (NIHSS) was 16 (10-20), 50% were treated with intravenous thrombolysis at a spoke, and TICI 2B-3 reperfusion was achieved in 87% at the hub. The median DIDO was 120 minutes (97-149), with DIDO ≤90 minutes achieved in 18%. DIDO was a significant determinant of 90-day ordinal mRS ( B  = 0.007, 95% CI = 0.001-0.012, p  = 0.013), even when accounting for the last known well-to-spoke door in, spoke door out-to-hub arrival, hub arrival-to-puncture, puncture-to-first pass, age, NIHSS, intravenous thrombolysis, TICI 2B-3, and symptomatic intracranial hemorrhage. Importantly, determinants of DIDO included Black race or Hispanic ethnicity ( B  = 0.918, 95% CI = 0.010-1.826, p  = 0.048), atrial fibrillation or heart failure ( B  = 0.793, 95% CI = 0.257-1.329, p  = 0.004), and basilar LVO location ( B  = 2.528, 95% CI = 1.154-3.901, p  < 0.001)., Conclusion: Spoke DIDO was the most important period of time for long-term outcomes of LVO stroke patients treated with EVT. Targets were identified to reduce DIDO and improve patient outcomes., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Basilar artery occlusion (BAO) is an infrequent but often fatal subtype of stroke. Predicting outcomes and selecting patients for endovascular therapy (EVT) remains challenging. Advances in neuroimaging and the development of prognostic scoring systems have augmented clinical decision-making over time. Recent randomized trials, BEST (Basilar Artery Occlusion Endovascular Intervention vs. Standard Medical Treatment), BASICS (Basilar Artery International Cooperation Study), BAOCHE (Basilar Artery Occlusion CHinese Endovascular Trial) and ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion), compared EVT and medical management for patients with BAO. These trials yielded mixed results. The former two suggested unclear benefit while the latter two supported a benefit of EVT. While all had limitations, most providers agree caution should be exercised when excluding patients from EVT who may stand to benefit. Further studies are therefore needed to determine the effectiveness, safety, selection criteria, and optimal technical approach for EVT among patients with BAO. Hyperacute-phase advanced imaging can offer several benefits to aid decision making. It is reasonable to exclude patients with low National Institutes of Health Stroke Scale (NIHSS), large imaging-proven cores, and evidence of perforator occlusion by branch atheromatous disease. Herein, we review the clinical presentation, imaging work-up, treatments, and clinical outcomes for BAO, while highlighting knowledge gaps in treatment selection and technique., Competing Interests: Declaration of conflicting interestsJAH is a consultant for Medtronic. ABP is a consultant for Medtronic, Microvention, and Penumbra.

Background: The utility of intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MT) in large vessel occlusion stroke (LVO) is controversial. Some data suggest IVT increases MT technical difficulty. Within our hub-and-spoke telestroke network, we examined how spoke-administered IVT affected hub MT procedure time and pass number., Methods: Patients presenting to 25 spoke hospitals who were transferred to the hub and underwent MT from 2018 to 2020 were identified from a prospectively maintained database. MT procedure time, fluoroscopy time, and pass number were obtained from operative reports., Results: Of 107 patients, 48 received IVT at spokes. Baseline characteristics and NIHSS were similar. The last known well (LKW)-to-puncture time was shorter among IVT patients (4.3 ± 1.9 h vs. 10.5 ± 6.5 h, p < 0.0001). In patients that received IVT, mean MT procedure time was decreased by 18.8 min (50.5 ± 29.4 vs. 69.3 ± 46.7 min, p = 0.02) and mean fluoroscopy time was decreased by 11.3 min (21.7 ± 15.8 vs. 33.0 ± 30.9 min, p = 0.03). Furthermore, IVT-treated patients required fewer MT passes (median 1 pass [IQR 1.0, 1.80] vs. 2 passes [1.0, 2.3], p = 0.0002) and were more likely to achieve reperfusion in ≤2 passes (81.3% vs. 59.3%, p = 0.01). An increased proportion of IVT-treated patients achieved TICI 2b-3 reperfusion after MT (93.9% vs. 83.8%, p = 0.045). There were no associations between MT procedural characteristics and LKW-to-puncture time., Conclusion: Within our network, hub MT following spoke-administered IVT was faster, required fewer passes, and achieved improved reperfusion. This suggests spoke-administered IVT does not impair MT, but instead may enhance it.

Objectives: Aging in place (residential stability) is a desirable means of aging where adults remain in their homes, even when facing challenges that impair their capacity for self-care. Residential stability, especially following acute health challenges, depends on individual and community factors, possibly including proximity to medical facilities. Methods: We explored the association between the density of medical facilities around homes with risk of incident myocardial infarction (MI) and with aging in place following incident MI. Results: Densities of neighborhood pharmacies were not associated with aging in place or time to MI. High densities of neighborhood clinical care facilities were significantly associated with decreased residential stability. Discussion: The lack of significant associations between medical facility exposures and MI-related outcomes, coupled with prior findings, casts doubt on their salience and may indicate that other neighborhood features are more strongly associated with these outcomes.

Background: The number needed to treat is a commonly used statistical term in modern neurointerventional practice. It represents the number of patients that need to be treated for one patient to benefit from an intervention. Given its growing popularity in reflecting study results, understanding the basics behind this statistic is of practical value to the neurointerventionalist., Methods: Here, we review the basic theory and calculation of the number needed to treat, its application to stroke interventions, and its limitations. In addition, we demonstrate several simple methods of calculating the number needed to treat utilizing recent thrombectomy trial results. By presenting the number needed to treat as a universal metric, we provide a comprehensive comparative of the number needed to treat for key stroke therapies, including mechanical thrombectomy, tissue plasminogen activator, carotid endarterectomy, and prevention with antiplatelet and statin drugs., Conclusions: In comparison with available stroke therapies, mechanical thrombectomy stands out as the most effective acute intervention in patients with emergent large-vessel occlusions. Understanding how the number needed to treat is derived and its implications helps provide perspective to clinical trial data, identify health-care resource priorities, and improve communication with patients, health-care providers, and additional key stakeholders.

This article was first published in JNIS. Cite this article as: Pierot L, Jayaraman MV, Szikora I, et al. Standards of practice in acute ischemic stroke intervention: international recommendations. Journal of NeuroInterventional Surgery. Published Online First: 28 August 2018. doi: 10.1136/neurintsurg-2018-014287.

Triage of posterior circulation stroke from emergent large-vessel occlusion (pc-ELVO) is challenging owing to the stuttering clinical course and potential for rapid decline. Growing clinical data support the use of mechanical thrombectomy in pc-ELVO, but there are limited data addressing the clinical and imaging criteria for patient selection. We present our triage algorithm used to select patients for endovascular therapy (EVT) in the setting of pc-ELVOS. We use a consecutive retrospective database from 2004 to 2016 to describe the practice patterns and prognostic factors for pc-ELVO patients treated using both medical and EVT. Patients with moderate to severe deficits (NIHSS > 10) did better when they received EVT ( p < 0.03), whereas patients with stable, mild deficits (NIHSS ≤ 10) did well (90% favorable outcome) regardless of treatment type. Roughly one-third of patients presenting with mild deficits deteriorated to moderate to severe deficits (NIHSS > 10), most of whom subsequently received EVT (9 of 12), with 56% favorable outcomes. Cerebellar and brainstem infarct volumes were independent imaging predictors of outcome. These results can be used to define triage criteria for use of EVT in pc-ELVO in future practice and clinical trials.

Purpose: The purpose of this article is to present a case series of transarterial venous sinus occlusion for dural arteriovenous fistulas (DAVFs) of the transverse and sigmoid sinuses., Materials and Methods: From 2006 to 2012, 11 patients with DAVF of the transverse and sigmoid sinuses were treated with transarterial closure of the affected venous sinus using ethylene vinyl alcohol copolymer (ONYX). The consecutive retrospective cohort included six female and five male patients with an age range of 30-79. Patients presented with stroke, intracranial hemorrhage, seizure, headache, focal neurologic deficit or cognitive change. Lesions were categorized as Cognard II a + b (n = 5) or Cognard II b (n = 6). Four of this latter group consisted of isolated sinus segments. Selection criteria for dural sinus occlusion included direct multi-hole fistulas involving a broad surface in length or circumference of the sinus wall. External carotid artery (ECA) branches were directly embolized when considered safe. High-risk arterial supply from ICA, PICA, AICA or ECA cranial nerve branches were closed via retrograde approach during sinus occlusion., Results: DAVF closure was accomplished in all 11 patients with a total of 17 embolization procedures using ONYX. High-risk arterial collaterals were closed via artery-artery or artery-sinus-artery embolization. The vein of Labbe was spared in the four cases with initial antegrade flow. No neurologic complications occurred, and DAVF closures were durable on three-month angiography., Conclusion: Transarterial closure of the transverse and sigmoid sinuses., (© The Author(s) 2016.)

This study was undertaken to determine the impact of shared decision-making when selecting a sedation option, from no sedation (local anesthetic), minimal sedation (anxiolysis with a benzodiazepine) or moderate sedation (benzodiazepine and opiate), for venous access device placement (port-a-cath and tunneled catheters) on patient choice, satisfaction and recovery time. This is an IRB-approved, HIPPA-compliant, retrospective study of 198 patients (18-85 years old, 60% female) presenting to an ambulatory vascular interventional radiology department for venous access device placement between 22 October 2014 and 7 October 2015. Patients were educated about sedation options and given the choice of undergoing the procedure with no sedation (local anesthetic only), or minimal or moderate sedation. Satisfaction was assessed through three survey questions. No sedation was selected by 53/198 (27%), minimal sedation by 71/198 (36%) and moderate sedation by 74/198 (37%). All subjects would recommend the option to another patient and valued the opportunity to select a sedation option. Post-procedure recovery time differences were statistically significant (p<0.0001) with median recovery times of 0 minutes for no sedation, 38 minutes for minimal sedation and 64 minutes for moderate sedation. In conclusion, patient sedation preference for venous access device placement is variable, signifying there is a role for shared decision-making as it empowers the patient to select the option most aligned with his or her goals. The procedure is well-tolerated, associated with high satisfaction, and the impact on departmental flow is notable because patients choosing no or minimal sedation results in a decreased post-procedure recovery time burden., (© The Author(s) 2016.)

Identifying the relevant geography is an ongoing obstacle to effectively evaluate the influence of neighborhood built environment on physical activity. We characterized density and diversity of destinations that 77 older adults experienced within individually representative GPS activity spaces and traditional residential buffers and assessed their associations with accelerometry-measured physical activity. Traditional residential buffers had lower destination density and diversity than activity spaces. Activity spaces based only on pedestrian and bicycling trips had higher destination densities than all-mode activity spaces. Regardless of neighborhood definition, adjusted associations between destinations and physical activity generally failed to reach statistical significance. However, within pedestrian and bicycling-based activity spaces each additional destination type was associated with 243.3 more steps/day (95% confidence interval (CI) 36.0, 450.7). Traditional buffers may not accurately portray the geographic space or neighborhood resources experienced by older adults. Pedestrian and bicycling activity spaces elucidate the importance of destinations for facilitating active transportation.

We report an unusual case of asymptomatic accelerated right carotid artery in-stent restenosis in a patient referred for revascularization of a de novo stenosis of her left internal carotid artery.

The authors present an unusual case of small-cell carcinoma of the esophagus, which manifested on double-contrast esophagography as an ulcerated submucosal mass. The lesion underwent dramatic regression after combination chemotherapy and radiation therapy, which has occasionally been used as an alternative to surgery in patients with this rare but aggressive esophageal neoplasm.