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Competing Interests: Competing interests: None declared.

Background: First-pass efficacy (FPE) is an established marker of technical and clinical efficacy among mechanical thrombectomy (MT) techniques. It is unclear what the optimal approach is in achieving FPE. We present a single-center experience comparing rates of FPE among 2 MT techniques and evaluate the potential predictors of FPE among other outcomes., Methods: A single-center retrospective analysis was carried out of patients with consecutive large-vessel occlusion strokes (LVOS) of anterior circulation from September 2015 to April 2019 who underwent MT and for whom data were available on the status of FPE. Four MT techniques were identified: ADAPT (a direct first-pass aspiration), SrADAPT (stent retriever with aspiration), SRBG (stent retriever with balloon guide catheter), and STRAP (stent retriever-aspiration and proximal flow arrest). The primary outcome was FPE and secondary outcomes included the rate of successful reperfusion., Results: Among 226 patients with LVOS of the anterior circulation who underwent MT, data were available for 164 on FPE for the 4 MT techniques. SRBG was the most prevalent technique. No significant difference was found in rates of FPE among the 4 MT techniques (P = 0.332). No independent predictors of FPE were identified on multivariable analysis. STRAP had the highest rate of successful reperfusion compared with the other techniques (P = 0.049) and was the only independent predictor of that outcome (P = 0.027)., Conclusions: Among patients with LVOS of the anterior circulation, the rate of FPE did not differ among the 4 MT techniques. There were no predictors of FPE among the studied variables. STRAP was the only predictor of successful reperfusion., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Academic physicians aim to provide clinical and surgical care to their patients while actively contributing to a growing body of scientific literature. The coronavirus disease 2019 (COVID-19) pandemic has resulted in procedural-based specialties across the United States witnessing a sharp decline in their clinical volume and surgical cases., Objective: To assess the impact of COVID-19 on neurosurgical, stroke neurology, and neurointerventional academic productivity., Methods: The study compared the neurosurgical, stroke neurology, and neurointerventional academic output during the pandemic lockdown with the same time period in previous years. Editors from a sample of neurosurgical, stroke neurology, and neurointerventional journals provided the total number of original manuscript submissions, broken down by months, from the year 2016 to 2020. Manuscript submission was used as a surrogate metric for academic productivity., Results: 8 journals were represented. The aggregated data from all eight journals as a whole showed that a combined average increase of 42.3% was observed on original submissions for 2020. As the average yearly percent increase using the 2016-2019 data for each journal exhibited a combined average increase of 11.2%, the rise in the yearly increase for 2020 in comparison was nearly fourfold. For the same journals in the same time period, the average percent of COVID-19 related publications from January to June of 2020 was 6.87%., Conclusion: There was a momentous increase in the number of original submissions for the year 2020, and its effects were uniformly experienced across all of our represented journals., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

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., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The Pipeline Embolization Device™ (PED; Covidien Neurovascular Inc, Irvine, CA, USA) is a flow-diverting stent often used for the endovascular treatment of large or giant, wide-necked intracranial aneurysms of the internal carotid artery. Because of the inherent thrombogenicity of intracranial stents, dual-antiplatelet therapy is initiated after placement, which has been shown to decrease morbidity and mortality related to perioperative ischemic events in neurointerventional procedures. However, in some series, as much as 50% of patients demonstrate clopidogrel non-responsiveness. In these non-responders, alternate agents such as ticagrelor can be used to achieve adequate anticoagulation. Compared with clopidogrel, a prodrug requiring Cytochrome P450 enzymolysis for activation, ticagrelor directly and reversibly inhibits the P2Y12 ADP receptor. The absorption of the prodrug and the formation of its active metabolite is comparatively quicker ( t max 1.3-2 hours; 1.5-3 hours, respectively). To date, there have been no documented cases of ticagrelor non-responsiveness involving patients undergoing placement of flow-diverting stents or other endovascular neuro-interventional procedures.

Background and Purpose: Preclinical data suggest that cell-based therapies have the potential to improve stroke outcomes., Methods: Eighteen patients with stable, chronic stroke were enrolled in a 2-year, open-label, single-arm study to evaluate the safety and clinical outcomes of surgical transplantation of modified bone marrow-derived mesenchymal stem cells (SB623)., Results: All patients in the safety population (N=18) experienced at least 1 treatment-emergent adverse event. Six patients experienced 6 serious treatment-emergent adverse events; 2 were probably or definitely related to surgical procedure; none were related to cell treatment. All serious treatment-emergent adverse events resolved without sequelae. There were no dose-limiting toxicities or deaths. Sixteen patients completed 12 months of follow-up at the time of this analysis. Significant improvement from baseline (mean) was reported for: (1) European Stroke Scale: mean increase 6.88 (95% confidence interval, 3.5-10.3; P<0.001), (2) National Institutes of Health Stroke Scale: mean decrease 2.00 (95% confidence interval, -2.7 to -1.3; P<0.001), (3) Fugl-Meyer total score: mean increase 19.20 (95% confidence interval, 11.4-27.0; P<0.001), and (4) Fugl-Meyer motor function total score: mean increase 11.40 (95% confidence interval, 4.6-18.2; P<0.001). No changes were observed in modified Rankin Scale. The area of magnetic resonance T2 fluid-attenuated inversion recovery signal change in the ipsilateral cortex 1 week after implantation significantly correlated with clinical improvement at 12 months (P<0.001 for European Stroke Scale)., Conclusions: In this interim report, SB623 cells were safe and associated with improvement in clinical outcome end points at 12 months., Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01287936., (© 2016 American Heart Association, Inc.)

Aim: To explore the predictors of infarct core expansion despite full reperfusion after intra-arterial therapy (IAT)., Methods: We retrospectively reviewed 604 consecutive patients who underwent IAT for anterior circulation large vessel occlusion acute ischemic stroke in two tertiary centers (2008-2013/2010-2013). Sixty patients selected by MRI or CT perfusion presenting within <24 h of onset with modified Thrombolysis In Cerebral Infarction (mTICI) grade 3 or 2c reperfusion were included. Significant infarct growth (SIG) was defined as infarct expansion >11.6 mL., Results: Mean age was 67.0±13.7 years, 56% were men. Mean National Institute of Health Stroke Scale (NIHSS) score was 16.2±6.1, time from onset to puncture was 6.8±3.1 h, and procedure length was 1.3±0.6 h. MRI was used for baseline core analysis in 43% of patients. Mean baseline infarct volume was 17.1±19.1 mL, absolute infarct growth was 30.6±74.5 mL, and final infarct volume was 47.7±77.7 mL. Overall, 35% of patients had SIG. Three of 21 patients (14%) treated with stent-retrievers had SIG compared with 14 of 39 (36%) with first-generation devices. Eight of 21 patients (38%) with intravenous tissue plasminogen activator (IV t-PA) had infarct growth compared with 25/39 (64%) without. 23% of patients with SIG had a modified Rankin Scale score ≤2 at 3 months compared with 48% of those without SIG. Multivariate logistic regression indicated that race affected infarct growth. Use of IV t-PA (p=0.03) and stent-retrievers (p=0.03) were independently and inversely correlated with SIG., Conclusions: Despite full reperfusion, infarct growth is relatively frequent and may explain poor clinical outcomes in this setting. Ethnicity was found to influence SIG. Use of IV t-PA and stent-retrievers were associated with less infarct core expansion., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objective: The incidence of acute ischemic stroke is highest in the elderly. Information regarding outcomes of elderly patients undergoing different modalities of intra-arterial therapy (IAT) for acute ischemic stroke (AIS) is scarce and conflicting. This study compares the safety, technical efficacy and outcomes of elderly patients (≥80 years) to non-elderly patients (<80 years) who underwent multimodality IAT., Methods: From a registry of consecutive patients treated with IAT for AIS at our institution over a 3.5-year period, patients with anterior circulation occlusions aged ≥80 years were compared to the patients <80 years., Results: Between 2008 and 2012, 24 patients ≥80 years (elderly) and 95 patients <80 years (non-elderly) received IAT for anterior circulation occlusions. In the elderly, there were more females (66.7% vs. 28.4%, p=<0.001) and atrial fibrillation (58.3% vs. 25.2%, p=0.003). Between the 2 groups, there was no difference in NIHSS score (17.2 vs. 16.3, p=0.17), THRIVE score (4.21 vs. 4.39, p=0.633), recanalization rate (70.1% vs. 85.3%, p=0.13), or severe reperfusion hemorrhages (8.3% vs. 4.2%, p=0.425). There was no significant difference in 3-month mortality (33.3% vs. 16.8%, p=0.28); however, fewer elderly patients reached good 3-month outcome (0% vs. 40.0%, p=<0.001). After controlling for baseline factors, only female gender (OR 5.3, 95% CI 1.7-16.7; p=0.04) and higher 3-month mRS (OR 1.6; 95% CI 1.1-2.40; p=0.008) were independently associated with elderly age., Conclusion: Despite similar safety profiles and recanalization rates, elderly patients had poor functional outcomes after IAT. Intra-arterial therapy in the elderly should be pursued very cautiously only after careful analysis of the risks and benefits for each patient., (Copyright © 2014. Published by Elsevier B.V.)

Objective: The degree of coronary artery calcification has been shown to predict outcomes in coronary artery disease. The impact of intracranial carotid artery calcification on the prognosis of acute ischemic stroke (AIS) is unknown. The authors sought to examine if the degree of intracranial carotid artery calcification influences reperfusion or outcomes in AIS intervention., Methods: All anterior circulation large vessel occlusion AIS cases that underwent intra-arterial therapy from January 2009 to July 2012 were reviewed. Clinical and radiographic data were collected. Non-contrast brain CT scans were assigned a Calcium Extent Score (degree of calcification of the carotid wall circumference), Calcium Thickness Score (thickness of the calcified plaque), and total Carotid Siphon Calcium (CSC) Score (8-point scale)., Results: One-hundred seventeen patients met inclusion criteria. The mean age was 65.4±15.6 years and 36% were male. Calcification was present in the intracranial carotid artery of 84 patients (71%). Inter-rater agreement for total CSC score was strong (Spearman's rho=0.883, p<0.001). The mean Calcium Extent Score was 1.5±1.3, Calcium Thickness Score 1.3±1.0 and total CSC Score 2.8±2.2. Reperfusion and mRS were not associated with CSC. Multivariate linear regression analysis revealed that older age, history of coronary disease and cervical internal carotid occlusion/near-occlusion were independently associated with higher total CSC scores., Conclusion: Extensive calcification on the intracranial carotid artery does not have impact on reperfusion or clinical outcomes in AIS patients undergoing endovascular therapy. Higher CSC scores are associated with coronary artery disease, increasing age and cervical internal carotid artery occlusion/near-occlusion., (Copyright © 2014 Elsevier B.V. All rights reserved.)

INTRODUCTION: Acute ischemic stroke (AIS) complicating cardiac interventions (CI) is well described. The use of mechanical thrombectomy (MT) for treatment of emergent large vessel occlusion (ELVO) in this setting, however, is not widely reported. METHODS: Cases of patients undergoing MT for AIS with ELVO at a single institution were reviewed. Cases preceded by recent CI were investigated retrospectively. Data was collected for patient demographics, type of cardiac intervention, stroke characteristics, neurovascular intervention, and patient outcomes. RESULTS: Between 2008 and 2017, registry analysis identified nine patients treated with MT for AIS complicating recent CI. Patients were more commonly male with a mean age of 67 years. A large majority had a known cardiac arrhythmia. Coronary artery bypass graft surgery (CABG) was the most identified CI, followed by valve repair, and cardiac ablations. Mean presenting NIHSS was 18. Most presented with hemiplegia. Seven cases were found to have MCA occlusions. Stentretrievers were used in 6 cases with excellent recanalization in five MCA cases (TICI 2c or 3) and in two basilar cases. Despite immediate improvements in NIHSS scores in most cases, functional outcomes were poor in 7 cases (mRS of 4-6). Three cases were complicated by hemorrhage and three cases ended in mortality. CONCLUSION: AIS with ELVO following recent CI is associated with high rates of mortality and poor functional outcomes despite MT. Further work is needed to understand the key drivers to poor outcomes in this ELVO subgroup. [ABSTRACT FROM AUTHOR]

Cone beam computed tomography (CBCT) imaging is used commonly in neurointerventional surgery for rapid intraprocedural assessment and planning of intracranial interventions. Our goal was to evaluate the ability of immediate postprocedural CBCT scan in assessing potential complications in pediatric patients. A retrospective review was completed to include all pediatric patients at our hospital with an immediate postprocedural CBCT scan with the Artis Q system. Demographic, clinical, and imaging data were examined. CBCT images were reviewed by 3 independent neurointerventionalists to assess ventricular system/subarachnoid spaces, gray-white differentiation, and ischemia or hemorrhage if present. Each assessment was rated qualitatively on a 4-point scale and was compared with conventional computed tomography (cCT) scan when available. Interrater reliability was assessed and radiation dose data were reviewed. Thirty-five patients were included with an average age of 11.0 ± 5.1 years (median, 10.9; range, 1.1–18 years). Of the patients, 54.3% were boys; 34.3% were Hispanic and 34.3% were non-Hispanic white. Diagnoses included a variety of vascular pathologies. CBCT scan had a mean score of 2.69 ± 0.54 out of 3 for ventricular and subarachnoid space assessment with a combined interrater reliability of 0.82, 1.71 ± 1.38 for hemorrhage with a combined interrater reliability of 1.00, and 0.52 ± 0.60 for gray-white differentiation with a combined interrater reliability of 0.79. Immediate postprocedural CBCT images were adequate to detect ventricular size/subarachnoid spaces changes and large volume hemorrhage compared with cCT scan in pediatric patients. However, there are limitations using immediate CBCT images to detect small volume hemorrhage and ischemic changes. [ABSTRACT FROM AUTHOR]