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Background Prior reports demonstrate the expression of estrogen and progesterone receptors in high-grade gliomas (HGGs), but the relationship between hormone receptor-positive disease and risk of HHGs in patients with breast cancer (BC) remains uncharacterized. Methods Using the SEER 18 registries (2000–2017), we examined the temporal trend of the incidence of HGGs and BC. The standardized incidence ratio was calculated to assess the risk of subsequent HGG in BC patients. Results During the study period, the incidence of BC and HGGs remained comparable for men and women. Among 976,134 patients with BC, we found a decreased incidence of HGGs in females, but not in males. Female BC patients with hormone receptor-positive disease were at a lower risk of developing glioblastoma and anaplastic astrocytoma. Conclusion Our study findings allude to the protective role of hormone exposure in the development of HGGs, which may lead to the development of therapies targeting hormonal pathways.

Purpose of the ReviewIn a short period of time, the field of interventional neurology has been transformed. Supported by strong Class IA evidence, the vascular and interventional neurology community has been empowered to realign systems of care to address the new challenges that have been introduced. Given the recent developments and accelerating pace of the field, the Society of Vascular and Interventional Neurology has collaborated with the American Academy of Neurology to provide an updated supplemental edition ofNeurology®focused on endovascular therapy for acute ischemic stroke.Recent FindingsIn this supplemental edition, the authors discuss the unmet need for endovascular therapy, emerging trends in stroke systems of care, the role of imaging in patient selection, prognostication and treatment-related factors, procedural considerations, current top tier guidelines, recent advances in neuroprotection, and future directions of the field.SummaryThe field of interventional neurology continues to grow and advance, particularly since the seminal stroke trials published between 2015 and 2018. Whereas this progress has significantly improved the ability to alter outcomes after acute ischemic stroke due to large vessel occlusion, important new hurdles present themselves to the neurology community.

Purpose of the ReviewThis article reviews common imaging modalities used in diagnosis and management of acute stroke. Each modality is discussed individually and clinical scenarios are presented to demonstrate how to apply these modalities in decision-making.Recent FindingsAdvances in neuroimaging provide unprecedented accuracy in determining tissue viability as well as tissue fate in acute stroke. In addition, advances in machine learning have led to the creation of decision support tools to improve the interpretability of these studies.SummaryNoncontrast head computed tomography (CT) remains the most commonly used initial imaging tool to evaluate stroke. Its exquisite sensitivity for hemorrhage, rapid acquisition, and widespread availability make it the ideal first study. CT angiography (CTA), the most common follow-up study after noncontrast head CT, is used primarily to identify intracranial large vessel occlusions and cervical carotid or vertebral artery disease. CTA is highly sensitive and can improve accuracy of patient selection for endovascular therapy through delineations of ischemic core. CT perfusion is widely used in endovascular therapy trials and benefits from multiple commercially available machine-learning packages that perform automated postprocessing and interpretation. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) can provide valuable insights for outcomes prognostication as well as stroke etiology. Optical coherence tomography (OCT), positron emission tomography (PET), single-photon emission computerized tomography (SPECT) offer similar insights. In the clinical scenarios presented, we demonstrate how multimodal imaging approaches can be tailored to gain mechanistic insights for a range of cerebrovascular pathologies.

BackgroundRandomized clinical trials have failed to prove that the safety and efficacy of endovascular treatment for symptomatic intracranial atherosclerotic disease (ICAD) is better than that of medical management. A recent study using a self-expandable stent showed acceptable lower rates of periprocedural complications.ObjectiveTo study the safety and efficacy of a balloon-mounted stent (BMS) in the treatment of symptomatic ICAD.MethodsProspectively maintained databases from 15 neuroendovascular centers between 2010 and 2020 were reviewed. Patients were included if they had severe symptomatic intracranial stenosis in the target artery, medical management had failed, and they underwent intracranial stenting with BMS after 24 hours of the qualifying event. The primary outcome was the occurrence of stroke and mortality within 72 hours after the procedure. Secondary outcomes were the occurrence of stroke, transient ischemic attacks (TIAs), and mortality on long-term follow-up.ResultsA total of 232 patients were eligible for the analysis (mean age 62.8 years, 34.1% female). The intracranial stenotic lesions were located in the anterior circulation in 135 (58.2%) cases. Recurrent stroke was the qualifying event in 165 (71.1%) while recurrent TIA was identified in 67 (28.9%) cases. The median (IQR) time from the qualifying event to stenting was 5 (2–20.75) days. Strokes were reported in 13 (5.6%) patients within 72 hours of the procedure; 9 (3.9%) ischemic and 4 (1.7%) hemorrhagic, and mortality in 2 (0.9%) cases. Among 189 patients with median follow-up time 6 (3–14.5) months, 12 (6.3%) had TIA and 7 (3.7%) had strokes. Three patients (1.6%) died from causes not related to stroke.ConclusionOur study has shown that BMS may be a safe and effective treatment for medically refractory symptomatic ICAD. Additional prospective randomized clinical trials are warranted.

Patients with chronic pancreatitis often experience severe, unrelenting abdominal pain, which can significantly impact their quality of life. Pain control, therefore, remains central to the overall management of chronic pancreatitis. Most of the strategies aimed at treating the pain of chronic pancreatitis are based on expert opinion and vary from one institution to another, as there are no uniform guidelines to direct a stepwise approach towards achieving this goal. In this editorial, we comment on best practice strategies targeted towards pain control in chronic pancreatitis, specifically highlighting the use of opioid medications in this patient population. We discuss various safe and efficacious prescription monitoring practices in this article.

Objective A high rate of cerebral aneurysm recurrence following endovascular coiling has prompted the use of digital subtraction angiography (DSA) for interval follow-up. However, the utility of skull x-rays as an alternative screening method for aneurysm recurrence is unproperly characterized. Methods Retrospective review of a prospective registry of ruptured and unruptured cerebral aneurysms. Anteroposterior and lateral skull x-rays were obtained immediately at the end of the procedure and at 6-month follow-up. Aneurysm recurrence was defined by comparing post-procedure and 6-month DSA imaging. A true positive was defined as a change in coil mass morphology on at least one projection with aneurysm recurrence on DSA, and a true negative defined as a stable coil mass on both projections and no recurrence on DSA. Receiver operating characteristic area under the curve (AUC) statistics was used to assess the performance of skull x-rays in identifying aneurysm recurrence. Results A total of 118 cerebral aneurysms were evaluated with DSA imaging and skull x-rays. A change in coil mass morphology on one projection of skull x-rays correctly detected all true recurrences with a sensitivity of 100% (95% confidence interval [CI], 91-100%). Skull x-rays failed to identify a stable aneurysm coil mass in 15 cases, with a specificity of 79% (68-88%). Skull x-rays performed with AUC 0.8958 (95% CI, 0.8490-0.9431) in identifying aneurysm recurrence. Conclusions The findings of our study suggest that skull x-rays may represent a low-cost, non-invasive screening tool to rule out aneurysm recurrence, which can potentially aid in decreasing the utilization of DSA in the follow-up of patients with coiled cerebral aneurysms.

Background and Purpose: The optimal endovascular stroke therapy (EVT) care delivery structure is unknown. Here, we present our experience in creating an integrated stroke system (ISS) to expand EVT availability throughout our region while maintaining hospital and physician quality standards. Methods: We identified all consecutive patients with large vessel occlusion acute ischemic stroke treated with EVT from January 2014 to February 2019 in our health care system. In October 2017, we implemented the ISS, in which 3 additional hospitals (4 total) became EVT-performing hospitals (EPHs) and physicians were rotated between all centers. The cohort was divided by time into pre-ISS and post-ISS, and the primary outcome was time from stroke onset to EPH arrival. Secondary outcomes included hospital and procedural quality metrics. We performed an external validation using data from the Southeast Texas Regional Advisory Council. Results: Among 513 patients with large vessel occlusion acute ischemic stroke treated with EVT, 58% were treated pre-ISS and 43% post-ISS. Over the study period, EVT procedural volume increased overall but remained relatively low at the 3 new EPHs (P P P Conclusions: In our system, increasing EVT availability decreased time from stroke onset to EPH arrival. The ISS provides a framework to maintain quality in lower volume hospitals.

Chronic pancreatitis (CP) is a risk factor for pancreatic ductal adenocarcinoma (PDAC); nevertheless, the true incidence of PDAC in CP patients in the United States remains unclear. We evaluated the risk of developing PDAC two or more years after a new diagnosis of CP. Retrospective study of veterans from September 1999 to October 2015. A three-year washout period was applied to exclude patients with preexisting CP and PDAC. PDAC risk was evaluated in patients with new-diagnosis CP and compared with controls without CP using Cox-proportional hazards model. CP, PDAC, and other covariates were extracted using ICD-9 codes. After exclusions, we identified 7,883,893 patients [new-diagnosis CP − 21,765 (0.28%)]. PDAC was diagnosed in 226 (1.04%) patients in the CP group and 15,858 (0.20%) patients in the control group (p 2 years [adjusted hazard ratio (HR) 4.28, 95% confidence interval (CI) 3.74–4.89, p

Background Pleomorphic xanthoastrocytomas (PXA) are circumscribed gliomas that typically have a favorable prognosis. Limited studies have revealed factors affecting survival outcomes in PXA. Here, we analyzed the largest PXA dataset in the literature and identify factors associated with outcomes. Methods Using the Surveillance, Epidemiology, and End Results (SEER) 18 Registries database, we identified histologically confirmed PXA patients between 1994 and 2016. Overall survival (OS) was analyzed using Kaplan-Meier survival and multivariable Cox proportional hazard models. Results In total, 470 patients were diagnosed with PXA (males = 53%; median age = 23 years [14-39 years]), the majority were Caucasian (n = 367; 78%). The estimated mean OS was 193 months [95% CI: 179-206]. Multivariate analysis revealed that greater age at diagnosis (≥39 years) (3.78 [2.16-6.59], P < .0001), larger tumor size (≥30 mm) (1.97 [1.05-3.71], P = .034), and postoperative radiotherapy (RT) (2.20 [1.31-3.69], P = .003) were independent predictors of poor OS. Pediatric PXA patients had improved survival outcomes compared to their adult counterparts, in which chemotherapy (CT) was associated with worse OS. Meanwhile, in adults, females and patients with temporal lobe tumors had an improved survival; conversely, tumor size ≥30 mm and postoperative RT were associated with poor OS. Conclusions In PXA, older age and larger tumor size at diagnosis are risk factors for poor OS, while pediatric patients have remarkably improved survival. Postoperative RT and CT appear to be ineffective treatment strategies while achieving GTR confer an improved survival in male patients and remains the cornerstone of treatment. These findings can help optimize PXA treatment while minimizing side effects. However, further studies of PXAs with molecular characterization are needed.

Background Chronic opioid use and dependence is common in patients with chronic pancreatitis. Patients with acute pancreatitis are frequently treated with opioids, but their risk for ongoing use is not well known. The aim of our study is to characterize opioid use in patients after an episode of acute pancreatitis and to assess persistent, chronic, and daily opioid use in such patients in the absence of chronic pancreatitis. Methods This is a single-center review of prospectively enrolled patients with acute pancreatitis. Using the Massachusetts Prescription Awareness Tool, we recorded all opioid prescriptions (ie, frequency, duration, and amount) for patients from December 2016 to September 2019, after index hospitalization for acute pancreatitis. Patients with chronic pancreatitis were excluded. We used univariate and multivariate analysis to determine predictors of opioid use at discharge and subsequent follow-up over 18 months. Results Of 235 enrolled patients who were opioid-naive, 123 patients (52.3%) received opioids at discharge after index hospitalization. In follow-up over 18 months, 40 patients (17.0%) received additional opioid prescriptions. These patients had more severe disease, longer length of stay, and higher pain score at discharge. Patients with prior history of acute pancreatitis, local complications, and higher pain scores were twice as likely to subsequently be prescribed opioids. Persistent opioid use was seen only in recurrent acute pancreatitis. There was no daily or chronic opioid use. Conclusions In the absence of chronic pancreatitis, there was no daily or chronic use of opioids in patients with acute pancreatitis. Persistent use was only seen in patients with recurrent acute pancreatitis. These patients are at increased risk of chronic opioid use and dependence.

Despite the increasing evidence of the association between breast cancer and meningioma in women, the relationship between these tumors remains improperly examined. In this study, we aim to identify the sociodemographic and clinicopathologic features of women with breast cancer associated with a higher risk of developing a meningioma.The SEER (Surveillance Epidemiology and End Results) database (18 registries) was used to identify women with breast cancer as their first neoplasm. The risk of subsequent meningioma was reported as the standardized incidence ratio (SIR) and was analyzed by sociodemographic and clinicopathologic subgroups. Results are given as SIR (95% confidence interval [CI]).A total of 564,516 women diagnosed with breast cancer between 2004 and 2016 were included for analysis. A 26% increased risk of meningioma development (SIR, 1.26; 95% CI, 1.19-1.33; P0.05) was found in the cohort compared with the general population. Patients aged between 18 and 49 years (SIR, 2.16; 95% CI, 1.78-2.61; P0.05) and those with a more advanced tumor stage (stage IV; SIR, 2.39; 95% CI, 1.71-3.25; P0.05) were at a higher risk. Hormone receptor expression and treatment modality subgroups were at a similar risk compared with the general population.Our study corroborated the known association between these tumors and found a 26% risk of meningioma development in women with breast cancer, with younger patients and those with a more aggressive disease having a higher than expected risk.

Patients with cerebral vasospasm caused by aneurysmal subarachnoid hemorrhage (aSAH) are often treated with intra-arterial (IA) vasodilator infusion. However, the optimal drug regimen is yet to be elucidated. A retrospective review of patients with aSAH and cerebral vasospasm treated with IA vasodilator infusion was performed. Patients in group 1 (2008–2011) were treated with a single agent, either nicardipine or verapamil, and patients in group 2 (2010–2016) were treated with a regimen of nitroglycerin, verapamil, and nicardipine. The post-infusion improvement ratio (PIIR) was compared between groups. Adjusted multivariate logistic regression models were utilized to determine whether patients treated with multiple vasodilators had an improved functional outcome, defined by the modified Rankin Scale, at discharge and 90-day follow-up. Among 116 patients from group 1 (N = 47) and group 2 (N = 69), the median age was 54.5 years [IQR, 46–53 years] and 78% were female. Use of multiple-agent therapy resulted in a 24.36% improvement in vessel diameter over single-agent therapy (median PIIR: group 1, 10.5% [IQR, 5.3–21.1%] vs group 2, 34.9% [IQR, 21.4–66.0%]; p < 0.0001). In the adjusted multivariate logistic regression, the use of multiple-agent therapy was associated with a better functional outcome at discharge (OR 0.15, 95% CI [0.04–0.55]; p < 0.01) and at 90-day follow-up (OR 0.20, 95% CI [0.05–0.77]; p < 0.05) when compared to single-agent therapy. In this study, we found that patients treated for cerebral vasospasm with IA infusion of multiple vasodilators had an increased vessel response and better functional outcomes compared to those treated with a single agent.

Bone disease (osteopenia or osteoporosis) is a highly prevalent condition in society and presents a tremendous, preventable public health burden. Screening procedures, such as, dual-energy X-ray absorptiometry scans, have allowed early identification and intervention to improve bone health, and reduce the risk of osteoporotic fractures, which carry significant morbidity and mortality. The association of bone disease has been recognized in several diseases of the gastrointestinal tract, resulting in established guidelines for screening in patients with malabsorptive disorders such as inflammatory bowel disease and celiac disease. Increasingly, the risk of bone disease has been recognized in patients with chronic pancreatitis (CP), who share similar risk factors as patients with other high gastrointestinal disorders. As a result, there have been a number of studies examining the prevalence and risks of bone disease and fractures in patients with CP. This review aims to summarize the recent literature and current recommendations related to bone disease in CP.

Growth differentiation factor (GDF) 11 levels decline with aging. The age-related loss of GDF 11 has been implicated in the pathogenesis of a variety of age-related diseases. GDF11 supplementation reversed cardiac hypertrophy, bone loss, and pulmonary dysfunction in old mice, suggesting that GDF11 has a rejuvenating effect. Less is known about the potential of GDF11 to improve recovery after an acute injury, such as stroke, in aged mice. GDF11/8 levels were assessed in young and aged male mice and in postmortem human brain samples. Aged mice were subjected to a transient middle cerebral artery occlusion (MCAo). Five days after MCAo, mice received and bromodeoxyuridine / 5-Bromo-2'-deoxyuridine (BrdU) and either recombinant GDF11 or vehicle for five days and were assessed for recovery for one month following stroke. MRI was used to determine cerebrospinal fluid (CSF) volume, corpus callosum (CC) area, and brain atrophy at 30 days post-stroke. Immunohistochemistry was used to assess gliosis, neurogenesis, angiogenesis and synaptic density. Lower GDF11/8 levels were found with age in both mice and humans (p

GOALS AND BACKGROUND Acute pancreatitis (AP) is a common emergency department (ED) diagnosis, amounting to enormous costs. Our previous pilot study demonstrated the feasibility of reducing hospitalization using an ED-based observation pathway. In this follow-up study, we hypothesize that the pathway is durable in clinical practice, outside of research supervision, and patients can safely be managed without hospitalization. STUDY We reviewed patients prospectively enrolled in the observation pathway after the end of the pilot study. We compared outcomes to patients enrolled in our pilot study and with a historic cohort of patients admitted with mild AP. Our primary outcome was hospitalization rate during the enrollment period and secondary outcomes included length of stay, 30-day readmissions, mortality, and health care utilization. RESULTS Over a 2-year period 165 patients met criteria for AP with 118 (71.5%) having mild AP. Fifty-four of 118 patients (45.8%) were enrolled in the observation pathway and of these, 45 patients were discharged from the ED, reducing hospitalization by 31.2%, compared with pilot study (22.2%) and historic cohort (0%) (P

Inferior vena cava (IVC) filters are placed to reduce venous thromboembolism (VTE)-related morbidity and mortality, though the evidence supporting this practice is limited. In 2010, the Food and Drug Administration (FDA) released a device safety advisory due to the risk of filter migration, fracture, and thrombosis with long-term use. The purpose of this study was to evaluate trends and predictors for IVCF placement and retrieval over a 10-year time period from a population health perspective. De-identified patient information from the State Inpatient Databases (SID) and the States Ambulatory Surgery and Services Databases (SASD) for Florida and California were used to identify all patients who underwent IVC filter placement from 2005 to 2014 and 2005 to 2011, respectively. Hospital practice patterns were assessed as a function of time as well as IVC filter placement and retrieval volume. Temporal trends were evaluated for statistical significance using the Cochran–Armitage test. A total of 181,260 IVC filters were placed in 178,327 patients over the study period. IVC filter placements peaked in 2010; following the FDA advisory in 2010, however, IVC filter placements monotonically decreased each subsequent year. The proportion of IVCF placement patients with both acute DVT and PE (17.6% vs 11.8%, P < 0.001) at the time of hospitalization increased; likewise, the proportion of IVCF patients with acute DVT or PE with a concomitant acute contraindication to anticoagulation at the time of hospitalization increased as well following 2010 (17.0% vs 11.9%, P < 0.001). From 2005 to 2014, there was a continual increase in both filter retrieval procedures as well overall percentage of filters retrieved. However, estimated retrieval rates remained low, with a retrieval rate of less than 6% in 2014. Following the FDA warning in 2010, there was a significant decrease in IVC filter placements, with filter placements more frequently performed in patients with poorer health. While retrieval rates increased over time, they remained low.

Key Points Question In patients with proximal anterior circulation occlusion stroke presenting in the extended window, are rates of favorable outcomes at 90 days comparable in the patients selected for thrombectomy with noncontrast computed tomography vs patients selected with computed tomography perfusion or magnetic resonance imaging? Findings In a multicenter cohort of 1604 patients in the extended window with large-vessel occlusion, patients selected by noncontrast computed tomography had comparable clinical and safety outcomes with patients selected by computed tomography perfusion or magnetic resonance imaging. Meaning These findings suggest noncontrast computed tomography alone may be used as an alternative to advanced imaging in selecting patients with late-presenting large-vessel occlusion for mechanical thrombectomy., This cohort study compares the clinical outcomes of patients with stroke who presented 6 to 24 hours after symptom onset and were selected for mechanical thrombectomy by noncontrast computed tomography vs those selected by computed tomography perfusion or magnetic resonance imaging., Importance Advanced imaging for patient selection in mechanical thrombectomy is not widely available. Objective To compare the clinical outcomes of patients selected for mechanical thrombectomy by noncontrast computed tomography (CT) vs those selected by computed tomography perfusion (CTP) or magnetic resonance imaging (MRI) in the extended time window. Design, Setting, and Participants This multinational cohort study included consecutive patients with proximal anterior circulation occlusion stroke presenting within 6 to 24 hours of time last seen well from January 2014 to December 2020. This study was conducted at 15 sites across 5 countries in Europe and North America. The duration of follow-up was 90 days from stroke onset. Exposures Computed tomography with Alberta Stroke Program Early CT Score, CTP, or MRI. Main Outcomes and Measures The primary end point was the distribution of modified Rankin Scale (mRS) scores at 90 days (ordinal shift). Secondary outcomes included the rates of 90-day functional independence (mRS scores of 0-2), symptomatic intracranial hemorrhage, and 90-day mortality. Results Of 2304 patients screened for eligibility, 1604 patients were included, with a median (IQR) age of 70 (59-80) years; 848 (52.9%) were women. A total of 534 patients were selected to undergo mechanical thrombectomy by CT, 752 by CTP, and 318 by MRI. After adjustment of confounders, there was no difference in 90-day ordinal mRS shift between patients selected by CT vs CTP (adjusted odds ratio [aOR], 0.95 [95% CI, 0.77-1.17]; P = .64) or CT vs MRI (aOR, 0.95 [95% CI, 0.8-1.13]; P = .55). The rates of 90-day functional independence (mRS scores 0-2 vs 3-6) were similar between patients selected by CT vs CTP (aOR, 0.90 [95% CI, 0.7-1.16]; P = .42) but lower in patients selected by MRI than CT (aOR, 0.79 [95% CI, 0.64-0.98]; P = .03). Successful reperfusion was more common in the CT and CTP groups compared with the MRI group (474 [88.9%] and 670 [89.5%] vs 250 [78.9%]; P

Background Several studies have reported changes in the volume and type of acute ischemic stroke (AIS) hospitalizations during the early stage of the COVID‐19 pandemic. However, population‐based assessments, which include lower volume centers and more comprehensive geographic areas, are limited. Here, we evaluate an entire state‐level experience during the first peak COVID pandemic and compare against a 1‐year prior historical period. Methods We conducted a retrospective population‐based study using the Texas Inpatient Public Use Data File, capturing all discharges from hospitals in the State of Texas, except federal hospitals. AIS admission volumes, patient characteristics, proportions of large vessel occlusion (LVO), admission rates to comprehensive stroke centers, use of intravenous tissue plasminogen activator and endovascular treatment, and patient outcomes were compared between April 1, 2019 and June 30, 2019 (historical control period) and April 1, 2020 and June 30, 2020 (pandemic period). Results A total of 9277 hospitalized AIS cases were identified during the pandemic period, a decrease of 12% (10 524) compared with the control period. Cases without LVO dropped by 15%, whereas LVO cases dropped by only 5%. There were no significant differences in age or race and ethnicity of patients. While admission rates to comprehensive stroke centers (39.6% versus 39.4%, P =0.81) and endovascular treatment use in LVO (17.0% versus 16.3%, P =0.45) were not different between the 2 periods, the use of intravenous tissue plasminogen activator (15.0% versus 13.6%, relative risk [RR], 0.90; 95% CI, 0.84–0.97; P =0.004) decreased. The percentage of patients who died or were discharged to hospice increased from 7.2% to 8.25% (RR, 1.17; 95% CI. 1.06–1.29; P =0.001). Conclusions This study from a statewide population‐level analysis confirms smaller hospital‐based cohorts observing decreasing numbers of milder AIS admissions, and lower use of thrombolysis. Although LVO admissions and endovascular treatment use were largely unchanged, these findings suggest missed treatment opportunities for patients with AIS in the pandemic.

Background As much of the scope of neurointerventional practice falls outside data covered by existing randomized clinical trials, and, as a result, may have failed to enter into existing guidelines, an evidence‐based framework for guideline and standards development is needed. We establish an evidence‐based framework to guide all subsequent guidelines and brief practice updates produced by the Society of Vascular and Interventional Neurology (SVIN). Methods The SVIN formed the Guidelines and Practice Parameters committee to develop the structure and procedures for guidelines and brief practice updates. Results In this article, the Guidelines and Practice Parameters committee has outlined the process by which the guidelines will be created and approved by the SVIN. Additionally, the Guidelines and Practice Parameters committee has adopted the American College of Cardiology/American Heart Association framework of Class of Recommendation and Level of Evidence. A unique, additional separation of the Expert Opinion endorsement category has been developed when high‐quality evidence does not exist at the time of the publication. Conclusions The SVIN has developed an evidence‐based framework for all guideline statements and brief practice updates. The SVIN guidelines and brief practice updates will guide clinicians in the field of interventional neurology to improve and standardize patient care.

Brain arteriovenous malformations (bAVMs) have long been considered to be congenital, developing between the third and eighth weeks of embryogenesis. However, cases reporting their de novo formation suggest that these lesions can develop after birth and have challenged this concept. We present a case of a 6-year-old boy with a history of a brainstem cavernous malformation diagnosed after birth who later developed a de novo bAVM. The de novo occurrence of this bAVM distant to the site of the cavernous malformation and a prior negative catheter angiography contributes to the uncertainty of the dynamics and pathophysiology of bAVMs.

BackgroundClinicalTrials.gov is one of the largest trials’ registries in the world.ObjectiveTo leverage the ClinicalTrials.gov database to define the portfolio of clinical trials of neurointervention.MethodsWe restricted our extraction to interventional clinical trials submitted between 2007 and 2018, and included MeSH terms that are part of the nervous system (n=19 344) or cardiovascular disease (n=19 234) categories and included a list of neurointerventional terms. The characteristics of trials, geographic distribution, dissemination, and funding sources were explored using descriptive and regression models.ResultsA total of 206 neurointerventional clinical trials across 1691 medical centers were identified. Acute stroke was the most studied conditions (68, 33%), followed by aneurysms (63, 31%), carotid stenosis (48, 24%), intracranial atherosclerotic disease (7, 3.5%), cerebral venous thrombosis (6, 3%), arteriovenous malformation (4, 2%), idiopathic intracranial hypertension (3, 1.5%), and others (6, 3%). Overall, 59 (29%) trials were completed, 79 (37%) were active trials (28% recruiting), and 22 (11%) were terminated or suspended. Academic centers and industry were the most common primary funding source (63% and 29%, respectively), with no funding source reported in 16 (7.7%) trials. Among 77 completed or terminated trials, only 9 (11.7%) trials reported findings within 12 months. Median time to publication for trials funded by academia was 1.66 years (interquartile range (IQR) 0.7–2.1) versus 2.1 years (IQR 1.2–3.25) for industry-funded studies.ConclusionsA low dissemination rate for results and a high rate of study non-completion, as well as lack of geographic dispersion of trials appear to be major challenges in the field.

Background Advances in acute and long-term poststroke care have resulted in improved survival and functional outcomes for patients who have suffered large vessel ischemic strokes. For years, tissue plasminogen activator was the mainstay of treatment for acute stroke. Its use was previously limited to patients without known comorbid intracranial vascular pathology because of concern for bleeding risk. More recently, however, the use of tissue plasminogen activator in select patients with vascular anomalies has increased and is now largely thought to be safe. With the safety and efficacy of mechanical thrombectomy now proven for large vessel occlusions (LVOs), similar investigation is needed to assess procedural safety in patients with concomitant arteriovenous (AV) malformations or fistulae. Methods We reviewed patients treated for LVOs at our institution and those of our collaborators and identified 6 patients who were treated for LVO with either known or incidentally identified concomitant AV malformations or dural AV fistulae. Results We present a case series of 6 patients with nonaneurysmal intracranial vascular lesions who underwent mechanical thrombectomy for LVO without complications related to these lesions. Conclusions Although limited by small size, our series adds to the literature evidence that mechanical thrombectomy for LVO can safely be performed with concomitant dural AV fistulae and AV malformations.

BACKGROUND AND PURPOSE: The validity of CT perfusion (CTP) predictions of expected infarction volume (“at risk” tissue) without rapid recanalization remains poorly characterized. METHODS: From the MR CLEAN trial, we included patients who underwent CTP without successful recanalization. “At risk” volume was defined as T max > 6 seconds and ischemic core as relative CBF < 30 (Olea Sphere). Coprimary outcomes were follow-up infarct volume (FIV) on CT at 1-5 days and 90-day mRS. Data are presented as median [IQR] or OR [95% CI] unless otherwise specified. RESULTS: Among 37 patients who met criteria, 14 (38%) were women, median age was 61 years [52-69], NIHSS was 19 [15-21], ASPECTS was 8 [7-9], and onset to imaging was 160 minutes [39-200]. Occlusion location was M1 for 22 (59%), ICA-T in 10 (27%), and M2 in 4 (11%). In univariable analysis, “at risk” volume correlated poorly with FIV (r =.06, P =.77). Among patients with predicted “at risk” volume < 100 mL, 36% had FIV > 200 mL. In adjusted linear regression, NIHSS but not “at risk” volume was associated with FIV (Coef 12, P =.045; Coef –.15, P =.8). In adjusted logistic regression, NIHSS but not “at risk” volume was associated with mRS 0-2 at 90 days (OR.7 [.5-.99]; OR 1.0 [.99-1.04]). CONCLUSION: Predictions of “at-risk” tissue using CTP may underestimate the natural history of infarction from acute large vessel occlusions. NIHSS may perform better as a predictor of clinical outcomes in patients without rapid recanalization.

IntroductionSeveral studies report substantial decreases in the volume of acute ischemic stroke (AIS) during the early stage of coronavirus disease 2019 (COVID-19) pandemic. Differences in characteristics of strokes such as increasing rates of large vessel occlusion (LVO) stroke were also observed comparing between pre-COVID and COVID eras. However, these findings were often based on data from selected hospitals or networks and estimates may be biased by level of stroke care and baseline case mix. A population-based study including rural hospitals and non-stroke centers covering a longer observation period beyond the early-pandemic epoch may lead to more accurate insights.MethodsWe conducted a retrospective population-based study using the Texas Inpatient Public Use Data File, capturing all discharges from hospitals in the State of Texas excluding federal hospitals. We assessed quarterly changes in volume, characteristics, care of AIS, and patient outcomes from April 1, 2019-June 30, 2020 and compared two time periods. 2020Q2 was defined as the pandemic period and the previous one year as the pre-pandemic period. Cases were defined as inpatient hospitalizations to acute care hospitals with a primary diagnosis of AIS. ICD-10 diagnosis and procedure codes were used to identify AIS, LVO, use of intravenous tissue plasminogen activator (IV-tPA) and endovascular treatment (EVT). Hospitals were determined as CSC (Comprehensive Stroke Center) and non-CSC based on designation by the Texas Department of State Health Services.ResultsThe number of AIS cases dropped substantially from 10,745 per quarter in the pre-pandemic period to 9,277 in the pandemic period (-14%) in Texas. The percentage of patients aged younger than 65 (39.0% vs 40.4%, p=0.014) and LVO stroke (30.0% vs 32.7%, p

Introduction Coronavirus disease (COVID-19) has been associated with coagulopathy, and D-dimer levels have been implicated as predictors of disease severity. In this study, we examined whether D-dimer remains useful to predict mortality in COVID-19 patients presenting with acute ischemic stroke (AIS). Methods We conducted a retrospective cohort study using the Optum® de-identified COVID-19 Electronic Health Record (EHR) dataset. Patients were included if they were 18 and older, were hospitalized within 7 days of confirmed COVID-19 from March 1, 2020 - November 30, 2020, and were tested for D-dimer during their hospitalization. ICD-9 and 10 diagnostic codes were used to identify AIS and comorbidities. D-dimer level was evaluated using receiver-operator curve analysis for the optimal threshold to predict in-hospital mortality and Kaplan-Meier survival curves were constructed. Risks of in-hospital mortality were compared between patients with D-dimer levels below and above the cutoff and risk ratios (RRs) were estimated adjusting for baseline characteristics and clinical variables. Results Among 15,250 patients hospitalized with COVID-19 positivity, 285 presented with AIS at admission (2%). Patients with AIS were older (median age 70 [60-79] vs 64 [52-75]) and had higher prevalence of congestive heart failure, hypertension, diabetes, vascular disease and atrial fibrillation. D-dimer levels at admission were greater for patients presenting with AIS (median [IQR], 1.42 [0.76-3.96] µg/ml feu) compared to those without AIS (0.94 [0.55-1.81] µg/ml feu) and peak levels were also greater for patients with AIS (3.86 [1.23-15.58] vs 1.42 [0.76-3.96] µg/ml feu). Peak D-dimer level was a good predictor of in-hospital mortality among all patients (c-statistic 0.774 [95% CI 0.764-0.784]) and among patients with AIS (c-statistic 0.751 [95% CI 0.691-0.810]). The optimum cutoff threshold was identified as 2.07 µg/ml feu with 72% sensitivity and 70% specificity, and elevated peak D-dimer level above this threshold was associated with increased mortality (adjusted RR 3.00 [95% CI 2.75-3.28]) among all patients. Among AIS patients, the optimum cutoff threshold was identified at 5.15 µg/ml feu with 73% sensitivity and 69% specificity. Elevated peak D-dimer level above this cut-off was associated with almost 3 times increased mortality (adjusted RR 2.89 [95% CI 1.87-4.47]). Conclusions Peak D-dimer levels above 5.15 µg/ml feu are associated with increased mortality in COVID-19 patients with AIS. Disclosures Y. Kim: None. S. Khose: None. R. Abdelkhaleq: None. S. Salazar-Marioni: None. S. Sheth: None.

BACKGROUND We introduced an inpatient pancreatitis consultative service aimed to 1) provide guideline-based recommendations to acute pancreatitis inpatients and 2) educate inpatient teams on best practices for acute pancreatitis management. We assessed the impact of pancreatitis service on acute pancreatitis outcomes. METHODS Inpatients with acute pancreatitis (2008-2018) were included in this cohort study. Primary outcomes included length of stay and refeeding time. The educational intervention was a guideline-based decision support tool, reinforced at hospital-wide educational forums. In Part A (n = 965), we compared outcomes pre-service (2008-2010) to post-service (2012-2018), excluding 2011, when the pancreatitis service was introduced. In Part B (n = 720, 2012-2018), we divided patients into 2 groups based on if co-managed with the pancreatitis service, and compared outcomes, including subgroup analysis based on severity, focusing on mild acute pancreatitis. RESULTS In Part A, for mild acute pancreatitis, length of stay (111 vs 88.4 h, P = .001), refeeding time (61.8 vs 47.4 h, P = .002), and infections (10.0% vs 1.87%, P < .001) were significantly improved after the pancreatitis service was introduced, with multivariable analysis showing reduced length of stay (odds ratio 0.83; 95% confidence interval, 0.82-0.84; P < .001) and refeeding time (odds ratio 0.75; 95% confidence interval, 0.74-0.77; P < .001). In Part B, for mild acute pancreatitis, refeeding time (44.2 vs 50.3 h, P = .123) and infections (5.58% vs 4.70%, P = .80) were similar in patients cared for without and with the service. Length of stay was higher in the pancreatitis service group (93.3 vs 81.2 h, P = .05), as they saw more gallstone acute pancreatitis patients who had greater length of stay and magnetic resonance cholangiopancreatography. In the post-service period, a majority of patients with moderate/severe acute pancreatitis and nearly all intensive care unit admits received care from the pancreatitis service. CONCLUSIONS Implementation of an inpatient pancreatitis service was associated with improved outcomes in mild acute pancreatitis. Guideline-based educational interventions have a beneficial impact on management of mild acute pancreatitis by admitting teams even without pancreatitis consultation.

Background Acute ischemic stroke (AIS) in the context of COVID‐19 has received considerable attention for its propensity to affect patients of all ages. We aimed to evaluate the effect of age on functional outcome and mortality following an acute ischemic event. Methods and Results A prospectively maintained database from comprehensive stroke centers in Canada and the United States was analyzed for patients with AIS from March 14 to September 30, 2020 who tested positive for SARS‐CoV‐2. The primary outcome was Modified Rankin Scale score at discharge, and the secondary outcome was mortality. Baseline characteristics, laboratory values, imaging, and thrombectomy workflow process times were assessed. Among all 126 patients with COVID‐19 who were diagnosed with AIS, the median age was 63 years (range, 27–94). There were 35 (27.8%) patients with AIS in the aged ≤55 years group, 47 (37.3%) in the aged 56 to 70 group, and 44 (34.9%) in the aged >70 group. Intravenous tissue plasminogen activator and thrombectomy rates were comparable across these groups, ( P =0.331 and 0.212, respectively). There was a significantly lower rate of mortality between each group favoring younger age (21.9% versus 45.0% versus 48.8%, P =0.047). After multivariable adjustment for possible confounders, a 1‐year increase in age was significantly associated with fewer instances of a favorable outcome of Modified Rankin Scale 0 to 2 (odds ratio [OR], 0.95; 95 CI%, 0.90–0.99; P =0.048) and higher mortality (OR, 1.06; 95 CI%, 1.02–1.10; P =0.007). Conclusions AIS in the context of COVID‐19 affects young patients at much greater rates than pre‐pandemic controls. Nevertheless, instances of poor functional outcome and mortality are closely tied to increasing age.

Background: Patients' perception regarding the risks of COVID-19 infection with gastrointestinal (GI) and the preventive measures taken in GI endoscopy units to mitigate infection risk remains unclear. We aimed to assess patients' perception regarding risks of COVID-19 with GI endoscopy and the changes in the endoscopy unit as a result of the ongoing pandemic. Methods: Outpatients undergoing GI endoscopy at our institution were categorized into those scheduled to undergo GI endoscopy (pre-procedure) and those who had recently undergone GI endoscopy during the pandemic (post-procedure). Two separate but similar survey instruments were designed. Patients were asked to respond on a 5-point Likert scale. Responses were stratified as 'low', 'neutral' and 'high' for analysis. Results: A total of 150 and 355 respondents completed the pre-procedure and post-procedure surveys, with a combined response rate of 82.5%. Non-white ethnicity was associated with reporting a 'high' level of concern for endoscopy related COVID-19 exposure in both the pre-procedure (OR 4.09, 95% CI 1.54-10.82) and post-procedure cohorts (OR 2.11, 95% CI 1.04-4.29). 42% of patients in the pre-procedure cohort and 11.8% in the post-procedure cohort reported their level of concern for COVID exposure as 'high'. Among the post-procedure cohort, 88% of the patients were likely to undergo repeat endoscopy during the pandemic if recommended. Conclusion: Patients are willing to undergo GI endoscopy during the COVID-19 pandemic. Non-white and older patients, and those undergoing screening examinations were more concerned with the GI endoscopy related COVID-19 transmission risk.

Background and Purpose: Patient selection for thrombectomy of acute ischemic stroke caused by large vessel occlusion in the delayed time window (>6 hours) is dependent on delineation of clinical-core mismatch or radiological target mismatch using perfusion imaging. Selection paradigms not involving advanced imaging and software processing may reduce time to treatment and broaden eligibility. We aim to develop a conversion factor to approximately determine the volume of hypoperfused tissue using the National Institutes of Health Stroke Scale (NIHSS) score (clinically approximated hypoperfused tissue [CAT] volume) and explore its ability to identify patients eligible for thrombectomy in the late-time window. Methods: We performed a retrospective analysis of anterior circulation large vessel occlusion strokes at 3 comprehensive stroke centers. Demographic, clinical, and imaging (computed tomography perfusion processed using RAPID, IschemaView) information was analyzed. A conversion factor, which is a multiple of the NIHSS score (for NIHSS score 6 seconds volume) was tested using DEFUSE-3 criteria (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3) eligibility as a gold standard in an independent cohort. Results: Of the 309 large vessel occlusion strokes (age, 70±14, 46% male, median NIHSS 16 [12–20]) included in this study, 38% of patients arrived beyond 6 hours of time from last known well. Conversion factors derived (derivation cohort-center A: 187) based on median values of Tmax>6 second volume for NIHSS score Conclusions: Clinical severity of stroke (NIHSS score) may be used to calculate the volume of hypoperfused tissue during large vessel occlusion stroke. CAT volumes for NIHSS score

Background: Coronavirus disease 2019 (COVID-19) has been associated with coagulopathy, and D-dimer levels have been used to predict disease severity. However, the role of D-dimer in predicting mortality in COVID-19 patients with acute ischemic stroke (AIS) remains incompletely characterized.Methods: We conducted a retrospective cohort study using the Optum® de-identified COVID-19 Electronic Health Record dataset. Patients were included if they were 18 or older, had been hospitalized within 7 days of confirmed COVID-19 positivity from March 1, 2020 to November 30, 2020. We determined the optimal threshold of D-dimer to predict in-hospital mortality and compared risks of in-hospital mortality between patients with D-dimer levels below and above the cutoff. Risk ratios (RRs) were estimated adjusting for baseline characteristics and clinical variables.Results: Among 15,250 patients hospitalized with COVID-19 positivity, 285 presented with AIS at admission (2%). Patients with AIS were older [70 (60–79) vs. 64 (52–75), p < 0.001] and had greater D-dimer levels at admission [1.42 (0.76–3.96) vs. 0.94 (0.55–1.81) μg/ml FEU, p < 0.001]. Peak D-dimer level was a good predictor of in-hospital mortality among all patients [c-statistic 0.774 (95% CI 0.764–0.784)] and among patients with AIS [c-statistic 0.751 (95% CI 0.691–0.810)]. Among AIS patients, the optimum cutoff was identified at 5.15 μg/ml FEU with 73% sensitivity and 69% specificity. Elevated peak D-dimer level above this cut-off was associated with almost 3 times increased mortality [adjusted RR 2.89 (95% CI 1.87–4.47), p < 0.001].Conclusions: COVID-19 patients with AIS present with greater D-dimer levels. Thresholds for outcomes prognostication should be higher in this population.

Background: Recent clinical trials have established the efficacy of endovascular stroke therapy and intravenous thrombolysis using advanced imaging, particularly computed tomography perfusion (CTP). The availability and utilization of CTP for patients and hospitals that treat acute ischemic stroke (AIS), however, is uncertain. Methods: We performed a retrospective cross-sectional analysis using 2 complementary Medicare datasets, full sample Texas and 5% national fee-for-service data from 2014 to 2017. AIS cases were identified using International Classification of Diseases , Ninth Revision and International Classification of Diseases , Tenth Revision coding criteria. Imaging utilization performed in the initial evaluation of patients with AIS was derived using Current Procedural Terminology codes from professional claims. Primary outcomes were utilization of imaging in AIS cases and the change in utilization over time. Hospitals were defined as imaging modality–performing if they submitted at least 1 claim for that modality per calendar year. The National Medicare dataset was used to validate state-level findings, and a local hospital-level cohort was used to validate the claims-based approach. Results: Among 50 797 AIS cases in the Texas Medicare fee-for-service cohort, 64% were evaluated with noncontrast head CT, 17% with CT angiography, 3% with CTP, and 33% with magnetic resonance imaging. CTP utilization was greater in patients treated with endovascular stroke therapy (17%) and intravenous thrombolysis (9%). CT angiography (4%/y) and CTP (1%/y) utilization increased over the study period. These findings were validated in the National dataset. Among hospitals in the Texas cohort, 100% were noncontrast head CT–performing, 77% CT angiography–performing, and 14% CTP-performing in 2017. Most AIS cases (69%) were evaluated at non-CTP–performing hospitals. CTP-performing hospitals were clustered in urban areas, whereas large regions of the state lacked immediate access. Conclusions: In state-wide and national Medicare fee-for-service cohorts, CTP utilization in patients with AIS was low, and most patients were evaluated at non-CTP–performing hospitals. These findings support the need for alternative means of screening for AIS recanalization therapies.

BACKGROUND AND PURPOSE: Previous studies have shown racial disparities in access to treatment and outcomes in ischemic stroke patients. We sought to define racial disparities in functional outcomes among ischemic stroke patients receiving endovascular thrombectomy (EVT). METHODS: We performed a retrospective review of patients in our institution’s prospectively collected stroke patient registry from 08/2015 to 06/2019 at 1 comprehensive and 2 thrombectomy-ready stroke centers. We reviewed patients aged ≥ 18 who received mechanical thrombectomy including only patients with race/ethnicity data belonging to the 3 largest race/ethnic groups: Non-Hispanic White (NHW), Non-Hispanic Black (NHB), and Hispanic (HIS). We compared baseline characteristics and performed multivariable logistic regression to evaluate differences in good functional outcome defined as 90-day modified Rankin score (90 day mRS 0–2) as the primary outcome. Secondary outcomes were discharge disposition, length of stay, and excellent functional outcome (90 day mRS 0–1). Results are given as OR [95% CI]. RESULTS: Among 666 patients that met inclusion criteria, 45% were NHW, 30% were NHB, and 19% were HIS. NHB and HIS patients were younger than NHW (average age NHB 62; HIS 64; and NHW 70; p