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Owing to prolonged hospitalization and the complexity of care required for patients with aneurysmal subarachnoid hemorrhage (aSAH), these patients have a high risk of complications. The risk for wound infection after microsurgical treatment for aSAH was analyzed. All patients who underwent microsurgical treatment for aSAH between August 1, 2007, and July 31, 2019, and were recorded in the Post–Barrow Ruptured Aneurysm Trial database were retrospectively reviewed. The patients were analyzed for risk factors for wound infection after treatment. Of 594 patients who underwent microsurgical treatment for aSAH, 23 (3.9%) had wound infections. There was no significant difference in age between patients with wound infection and patients without infection (mean, 52.6 ± 12.2 years vs. 54.2 ± 4.0 years; P = 0.45). The presence of multiple comorbidities (including diabetes, tobacco use, and obesity), external ventricular drain, ventriculoperitoneal shunt, pneumonia, or urinary tract infection was not associated with an increased risk for wound infection. Furthermore, there was no significant difference in mean operative time between patients with wound infection and those without infection (280 ± 112 minutes vs. 260 ± 92 minutes; P = 0.38). Patients who required decompressive craniectomy (DC) were at increased risk of wound infection (odds ratio, 5.0; 95% confidence interval, 1.8–14.1; P = 0.002). Among the 23 total infections, 9 were diagnosed following cranioplasty after DC. Microsurgical treatment for aSAH is associated with a relatively low risk of wound infection. However, patients undergoing DC may be at an increased risk for infection. Additional attention and comprehensive wound care are warranted for these patients. [ABSTRACT FROM AUTHOR]

Background Transradial artery (TRA) access for neuroendovascular procedures is associated with fewer complications than transfemoral artery (TFA) access. This study compares hospital costs associated with TRA access to those associated with TFA access for neurointerventions. Methods Elective neuroendovascular procedures at a single center were retrospectively analyzed from October 1, 2018 to May 31, 2019. Hospital costs for each procedure were obtained from the hospital financial department. The primary outcome was the difference in the mean hospital costs after propensity adjustment between patients who underwent TRA compared with TFA access. Results Of the 338 elective procedures included, 63 (19%) were performed through TRA versus 275 (81%) through TFA access. Diagnostic procedures were more common in the TRA cohort (51 of 63, 81%) compared with the TFA cohort (197 of 275, 72%), but the difference was not significant (p=0.48). The TRA cohort had a shorter length of hospital stay (mean (SD) 0.3 (0.5) days) compared with the TFA cohort (mean 0.7 (1.3) days; p=0.02) and lower hospital costs (mean $12 968 ($6518) compared with the TFA cohort (mean $17 150 ($10 946); p=0.004). After propensity adjustment for age, sex, symptoms, angiographic findings, procedure type, sheath size, and catheter size, TRA access was associated with a mean hospital cost of $2514 less than that for TFA access (95% CI -$4931 to -$97; p=0.04). Conclusion Neuroendovascular procedures performed through TRA access are associated with lower hospital costs than TFA procedures. The lower cost is likely due to a decreased length of hospital stay for TRA. [ABSTRACT FROM AUTHOR]

Background Recently, middle meningeal artery (MMA) embolization has emerged as a potentially safe and effective method of treating chronic subdural hematoma (cSDH). Objective To report a single-center experience with MMA embolization and examines the type of embolic material used, the extent of penetration, and the number of MMA branches embolized. Methods A retrospective analysis of all patients with MMA embolization from 2018 through 2019 was performed. A failed outcome was defined as either surgical rescue and/or greater than 10 mm of hematoma residual or reaccumulation following embolization. Results Of 35 patients, surgery had failed for 9 (26%) and initial conservative treatment had failed for 6 (17%). Of 41 MMA embolizations, including those in six patients with bilateral cSDH who underwent bilateral MMA embolization, 29 (72%) were performed using ethylene vinyl alcohol copolymer (Onyx), 7 (17%) using particles, and 5 (12%) using n-butyl cyanoacrylate. Both the anterior and posterior MMA divisions were embolized in 29 cases (71%); distal penetration of these branches was achieved in 25 embolizations (61%). Twenty-six (63%) cSDHs completely resolved. Complete resolution was seen in 22 of 29 hematomas (76%) in which both anterior and posterior MMA branches were occluded versus 4 of 12 (33%) following single-branch embolization (p=0.014). Embolization of one cSDH (2%) failed. Conclusion MMA embolization of cSDHs appears to be both safe and efficacious. Furthermore, embolization of both the anterior and posterior MMA branches may be associated with increased odds of complete resolution. [ABSTRACT FROM AUTHOR]

Background Both stentriever and direct-aspiration thrombectomy effectively treat large-vessel occlusions. However, data are limited comparing clinical outcomes after aspiration-first versus stentriever-assisted aspiration for thrombectomy. Methods A retrospective cohort study compared procedure times and radiographic outcomes after two mechanical thrombectomy techniques (aspiration first or stentriever). To minimize bias and variability inherent to multi-operator series, we assessed consecutive patients with cerebrovascular occlusions treated by a single surgeon during a 1 year period at two stroke centers. Expanded Thrombolysis in Cerebral Infarction (eTICI) grades were assessed by an investigator blinded to treatment. Results Data from 93 patients (median age 70 years) were analyzed: 73 patients (78.5%) were treated with a strentriever-first strategy and 20 (21.5%) were treated with aspiration first, with stentriever rescue therapy required in only three of these cases following unsuccessful aspiration. There were no significant differences in patient demographics, sites of occlusion, or rates of tandem occlusions between aspiration-first and stentriever-assisted groups (p≥0.36). The rate of first-pass eTICI ≥2b was 75.0% (15/20) for aspiration-first and 52.1% (38/73) for strentriever-first groups (p=0.07), while the rate of final eTICI ≥2b was 100% (20/20) and 82.2% (60/72), respectively (p=0.04). The aspiration-first technique was associated with procedural times ≤25 min in a multivariable analysis (adjusted OR 4.77, 95% CI 1.15 to 18.39; p=0.03). Conclusions In this single-surgeon series, an aspiration-first technique was associated with a statistically significant improvement in eTICI outcomes and faster procedure times compared with stentriever-assisted aspiration. Further prospective studies are necessary to minimize selection bias inherent in this study design. [ABSTRACT FROM AUTHOR]

Background Middle meningeal artery (MMA) embolization results in fewer treatment failures than surgical evacuation for chronic subdural hematomas (cSDHs). We compared the total 1-year hospital cost for MMA embolization versus surgical evacuation for patients with cSDH. Methods Data for patients who presented with cSDHs from January 1, 2018, through May 31, 2020, were retrospectively reviewed. Patients were grouped by initial treatment (surgery vs MMA embolization), and total hospital cost was obtained. A propensity-adjusted analysis was performed. The primary outcome was difference in mean hospital cost between treatments. Results Of 170 patients, 48 (28%) underwent embolization and 122 (72%) underwent surgery. cSDHs were larger in the surgical (20.5 (6.7) mm) than in the embolization group (16.9 (4.6) mm; P<0.001); and index hospital length of stay was longer in the surgical group (9.8 (7.0) days) than in the embolization group (5.7 (2.4) days; P<0.001). More patients required additional hematoma treatment in the surgical cohort (16%) than in the embolization cohort (4%; P=0.03), and more required readmission in the surgical cohort (28%) than in the embolization cohort (13%; P=0.04). After propensity adjustment, MMA embolization was associated with a lower total hospital cost compared to surgery (mean difference -$32 776; 95% CI -$52 766 to -$12 787; P<0.001). A propensity-adjusted linear regression analysis found that unexpected additional treatment was the only significant contributor to total hospital cost (mean difference $96 357; 95% CI $73 886 to $118 827; P<0.001). Conclusions MMA embolization is associated with decreased total hospital cost compared with surgery for cSDHs. This lower cost is directly related to the decreased need for additional treatment interventions. [ABSTRACT FROM AUTHOR]

Purpose: Pediatric intracranial injuries due to penetrating gunshot wounds are a rare entity that is often fatal. A subset of patients may experience an intracerebral arterial injury; however, literature on the pediatric population is limited. This study analyzes a large institution's experience with pediatric head gunshot wounds and intracranial arterial injuries. Methods: All pediatric patients ≤ 18 years of age who presented to our institution with a penetrating gunshot wound from 2008 to 2018 were retrospectively analyzed. Results: Thirty-seven patients presented with an intracerebral penetrating gunshot injury. There were 18 deaths (49%) in the cohort. A total of 20 patients (54%) had vascular imaging. Of the remaining 17 patients with no vascular imaging, 13 (35%) died before any vascular studies were obtained. Four (20%) of the 20 patients with vascular imaging experienced an intracerebral arterial injury. Three of these 4 patients died before treatment could be administered. One patient with a firearm injury underwent embolization of a distal middle cerebral artery pseudoaneurysm and was discharged home with a Glasgow Outcome Scale score of 5 on follow-up. Conclusion: Pediatric patients with penetrating intracranial gunshot wounds often die before vascular imaging can be obtained. [ABSTRACT FROM AUTHOR]

Background: Treatment of small ruptured aneurysms (SRAs) remains controversial, with literature reporting difficulty with endovascular versus microsurgical approaches. This paper analyzes outcomes after endovascular coiling and microsurgical clipping among patients with SRAs prospectively enrolled in the Barrow Ruptured Aneurysm Trial (BRAT). Method: All BRAT patients were included in this study. Patient demographics, aneurysm size, aneurysm characteristics, procedure-related complications, and outcomes at discharge and at 1-year and 6-year follow-up were evaluated. A modified Rankin scale (mRS) score > 2 was considered a poor outcome. Results: Of 73 patients with SRAs, 40 were initially randomly assigned to endovascular coiling and 33 to microsurgical clipping. The rate of treatment crossover was significantly different between coiling and clipping; 25 patients who were assigned to coiling crossed over to clipping, and no clipping patients crossed over to coiling (P < 0.001). Among SRA patients, 15 underwent coiling and 58 underwent clipping; groups did not differ significantly in demographic characteristics or aneurysm type (P ≥ 0.11). Mean aneurysm diameter was significantly greater in the endovascular group (3.0 ± 0.3 vs 2.6 ± 0.6; P = 0.02). The incidence of procedure-related complications was similar for endovascular and microsurgical treatments (odds ratio [95% confidence interval], 1.0 [0.1–10.0], P = 0.98). Both groups had comparable overall outcome (mRS score > 2) at discharge and 1-year and 6-year follow-up (P = 0.48 and 0.73, respectively). Conclusions: Most SRA patients in the BRAT underwent surgical clipping, with a high rate of crossover from endovascular approaches. Endovascular treatment was equivalent to surgical clipping with regard to procedure-related complications and neurologic outcomes. [ABSTRACT FROM AUTHOR]

Background The transradial artery (TRA) approach for neuroendovascular procedures continues to gain popularity, but neurointerventionalists still lag behind interventional cardiologists in the adoption of a TRA-first approach. This study compares the complications and efficiency of the TRA approach to the standard transfemoral artery (TFA) approach at our institution during our initial phase of adopting a TRA-first approach. Methods A retrospective analysis was performed on all consecutive neuroangiographic procedures performed at a large cerebrovascular center from October 1, 2018 to June 30, 2019. The standard TFA approach was compared with TRA access, with the primary outcome of complications analyzed via a propensity-adjusted analysis. Results A total of 1050 consecutive procedures were performed on 877 patients during this 9-month period; 206 (20%) procedures were performed via TRA and 844 (80%) via TFA. The overall complication rate was significantly higher with the TFA procedures than with the TRA procedures (7% (60/844) vs 2% (4/206), respectively; p=0.003). A propensity-adjusted analysis showed that the TFA approach was a significant risk factor for a complication (OR 3.6, 95% CI 1.3 to 10.2, p=0.01). However, the propensity analysis showed that fluoroscopy times were on average 4 min less for TFA procedures than for TRA procedures (p=0.003). Conclusion The TRA approach for neuroendovascular procedures appears to be safer than the TFA approach. Although a steep learning curve is initially encountered when adopting the TRA approach, the transition to a TRA-first practice can be performed safely for neurointerventional procedures and may reduce complications. [ABSTRACT FROM AUTHOR]

Background CT angiography (CTA) is widely used for the detection of vascular lesions in patients with nontraumatic subarachnoid hemorrhage (NTSAH); However, digital subtraction angiography (DSA) remains the gold standard for diagnosis. Our aim was to analyze the diagnostic yield of Dsa after negative high-resolution CTA findings. Methods Records of patients with a CTA-negative NTSAH at a single institution from 2014 to 2018 were retrospectively analyzed. NTSAH patterns were categorized as cortical, perimesencephalic, or diffuse. subsequent DSA findings were compared across the three cohorts. Results A total of 186 patients had CTA-negative NTSAH. The NTSAH pattern was identified as cortical (n=77, 41.4%), diffuse (n=60, 32.3%), or perimesencephalic (n=49, 26.3%). In eight patients (4%), DSA revealed a vascular lesion (one cervical arteriovenous fistula and seven atypical aneurysms) after negative CTA findings. All eight patients with positive DSA findings had diffuse sah (13% of patients with a diffuse pattern). The seven aneurysms included four blister or dissecting (two basilar artery, one superior cerebellar artery, and one dorsal wall internal carotid artery), two fusiform (one posterior communicating artery and one anterior spinal artery), and one saccular aneurysm (middle cerebral artery). Conclusion DSA identified a causative lesion in 4% of patients with CTA-negative ntsah, but only in patients with diffuse NTSAH. Most of the lesions detected were atypical aneurysms and were found on delayed angiograms. These results suggest that Dsa can help to diagnose CTA-negative ntsah caused by unusual aneurysms, and repeat DSA may be needed only for patients with diffuse NTSAH. [ABSTRACT FROM AUTHOR]

Background The selective posterior cerebral artery (PCA) amobarbital test, or PCA Wada test, is used to predict memory impairment after epilepsy surgery in patients who have previously had a failed internal carotid artery (ICA) amobarbital test. Methods Medical records from 2012 to 2018 were retrospectively reviewed for all patients with seizures who underwent a selective PCA Wada test at our institution following a failed or inconclusive ICA Wada test. standardized neuropsychological testing was performed before and during the Wada procedure and postoperatively in patients who underwent resection. Results Thirty-three patients underwent a selective PCA Wada test, with no complications. Twenty-six patients with medically refractory epilepsy had a seizure focus amenable to selective amygdalohippocampectomy (AHE). six patients (23%, n=26) had a failed PCA Wada test and did not undergo selective AHE, seven (27%) declined surgical resection, leaving 13 patients who underwent subtemporal selective AHE. Hippocampal sclerosis was found in all 13 patients (100%). Twelve patients (92%) subsequently underwent formal neuropsychological testing and all were found to have stable memory. Ten patients (77%) were seizure-free (Engel class i), with average follow-up of 13 months. Conclusion The selective PCA Wada test is predictive of memory outcomes after subtemporal selective AHE in patients with a failed or inconclusive ICA Wada test. Furthermore, given the low risk of complications and potential benefit of seizure freedom, a selective PCA Wada test may be warranted in patients with medically intractable epilepsy who are candidates for a selective AHE and who have a prior failed or inconclusive ICA Wada test. [ABSTRACT FROM AUTHOR]

Disorders of consciousness impair early recovery after aneurysmal subarachnoid hemorrhage (aSAH). Modafinil, a wakefulness-promoting agent, is efficacious for treating fatigue in stroke survivors, but data pertaining to its use in the acute setting are scarce. This study sought to assess the effects of modafinil use on mental status after aSAH. Modafinil timing and dosage, neurological examination, intubation status, and physical and occupational therapy participation were documented. Repeated-measures paired tests were used for a before-after analysis of modafinil recipients. Propensity score matching (1:1 nearest neighbor) for modafinil and no-modafinil cohorts was used to compare outcomes. Modafinil (100–200 mg/day) was administered to 21% (88/422) of aSAH patients for a median (IQR) duration of 10.5 (4–16) days and initiated 14 (7–17) days after aSAH. Improvement in mentation (alertness, orientation, or Glasgow Coma Scale score) was documented in 87.5% (77/88) of modafinil recipients within 72 hours and 86.4% (76/88) at discharge. Of 37 intubated patients, 10 (27%) were extubated within 72 hours after modafinil initiation. Physical and occupational therapy teams noted increased alertness or participation in 47 of 56 modafinil patients (83.9%). After propensity score matching for baseline covariates, the modafinil cohort had a greater mean (SD) change in Glasgow Coma Scale score than the no-modafinil cohort at discharge (2.2 [4.0] vs. −0.2 [6.32], P = 0.003). A temporal relationship with improvement in mental status was noted for most patients administered modafinil after aSAH. These findings, a favorable adverse-effect profile, and implications for goals-of-care decisions favor a low threshold for modafinil initiation in aSAH patients in the acute-care setting. [ABSTRACT FROM AUTHOR]