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Patients with pre-stroke disability, defined as a modified Rankin Scale (mRS) ≥3, were excluded from most trials of endovascular thrombectomy (EVT) for acute stroke. We sought to evaluate the prognostic factors associated with favorable outcome in stroke patients with known disability undergoing EVT, and the impact of successful reperfusion.Consecutive acute stroke patients with pre-stroke disability, undergoing EVT, were retrospectively collected between 2016 to 2019 from a Canadian cohort and a multicenter French cohort (Endovascular Treatment in Ischemic Stroke registry-ETIS). Favorable outcome was defined as an mRS equal to pre-stroke mRS. Patients achieving successful reperfusion (defined as a modified Thrombolysis in Cerebral Infarction score of 2b/3) were compared with patients without successful reperfusion to determine if successful EVT was associated with better functional outcomes.Among 6220 patients treated with EVT, 280 (4.5%) patients with a pre-stroke mRS ≥3 were included. Sixty-one patients (21.8%) had a favorable outcome and 146 (52.1%) died at 3 months. Patients with successful reperfusion had a higher proportion of favorable 90-day mRS (27.6% versus 19.6%, p = 0.025) and a lower mortality (48.3% versus 69.6%, p = 0.008) than patients without successful reperfusion. After adjusting for baseline prognostic factors, successful reperfusion defined by TICI ≥2b was associated with favorable functional outcome (OR 3.16 CI95% [1.11-11.5]; p 0.048).In patients with pre-stroke disability, successful reperfusion is associated with a greater proportion of favorable outcome and lower mortality.

Purpose There is an an increasing awareness of the importance of health and lifestyle for stroke diseases like spontaneous subarachnoid hemorrhage (SAH). However, the importance of pre-existing medical conditions for clinical course and mortality after SAH has not been studied. The aim of the present study was to identify pre-existing conditions contributing to mortality after SAH. Methods Data were extracted from a Swedish national prospective study on patients with SAH. Variables were defined for age, sex, body mass index (BMI), clinical condition at admission, and for 10 pre-existing medical conditions. Models predicting mortality in three time intervals with all possible subsets of these variables were generated, compared and selected using Akaike’s information criterion. Results 1155 patients with ruptured aneurysms were included. The mortality within 1 week was 7.6%, 1 month 14.3%, and 1 year 18.7%. The most common pre-existing medical conditions were smoking (57.6%) and hypertension (38.7%). The model’s best predicting mortality within 1 week and from 1 week to 1 month included only the level of consciousness at admission and age, and these two variables were present in all the models among the top 200 in Akaike score for each time period. The most predictive model for mortality between 1 month and 1 year added previous stroke, diabetes, psychiatric disease, and BMI as predictors. Conclusion Mortality within the first month was best predicted simply by initial level of consciousness and age, while mortality within from 1 month to 1 year was significantly influenced by pre-existing medical conditions.

The Comprehensive Aneurysm Management (CAM) study is a pragmatic trial designed to manage unruptured intracranial aneurysm (UIA) patients within a care research framework.CAM is an all-inclusive study. Management options are allocated according to an algorithm combining pre-randomization and clinical judgment. Eligible patients are offered 1:1 randomized allocation of intervention versus conservative management and 1:1 randomization allocation of surgical versus endovascular treatment. Ineligible patients are registered. The primary outcome is survival without dependency (modified Rankin Scale score3) at 10 years. All UIA patients at 1 center are reported.Between February 2020 and July 2021, 403 UIA patients were recruited: 179 (44%) in one of the randomized controlled trials (RCTs) and 224 (56%) in one of the registries. Conservative management was recommended for 205 of 403 patients (51%); of 198 (49%) patients considered for curative treatment, 159 (80%) were randomly allocated conservative (n = 81) or curative treatment (n = 78). These patients were younger and had larger aneurysms than those in the observation registry (P = 0.004). In 39 of 198 patients (20%), conservative management was not considered reasonable (17 patients were recommended endovascular, 2 surgery, and 20 the RCT comparing endovascular with surgical treatment). In total, 70 patients were recruited in the RCT comparing surgery and endovascular treatment. After informed discussion at time of consent, 141 of 159 patients (89%) agreed with the randomly allocated management plan, while 11% crossed over to the alternative management option.CAM was successfully integrated into routine practice. Meaningful conclusions can be obtained if multiple centers actively participate in the trial.

This is an observational cohort study comparing 156 patients evaluated for acute stroke between March 30 and May 31, 2020 at a comprehensive stroke center with 138 patients evaluated during the corresponding time period in 2019. During the pandemic, the proportion of COVID-19 positive patients was low (3%), the time from symptom onset to hospital presentation was significantly longer, and a smaller proportion of patients underwent reperfusion therapy. Among patients directly evaluated at our institution, door-to-needle and door-to-recanalization metrics were significantly longer. Our findings support concerns that the current pandemic may have a negative impact on the management of acute stroke.

BackgroundAdverse events (AEs) or complications may arise secondary to the treatment of aneurysmal subarachnoid haemorrhage (SAH). The aim of this study was to identify AEs associated with microsurgical occlusion of ruptured aneurysms, as well as to analyse their risk factors and impact on functional outcome.MethodsPatients with aneurysmal SAH admitted to the neurosurgical centres in Sweden were prospectively registered during a 3.5-year period (2014–2018). AEs were categorised as intraoperative or postoperative. A range of variables from patient history and SAH characteristics were explored as potential risk factors for an AE. Functional outcome was assessed approximately 1 year after the bleeding using the extended Glasgow Outcome Scale.ResultsIn total, 1037 patients were treated for ruptured aneurysms, of which, 322 patients were treated with microsurgery. There were 105 surgical AEs in 97 patients (30%); 94 were intraoperative AEs in 79 patients (25%). Aneurysm rerupture occurred in 43 patients (13%), temporary occlusion of the parent artery >5 min in 26 patients (8%) and adjacent vessel injury in 25 patients (8%). High Fisher grade and brain oedema on CT were related to increased risk of AEs. At follow-up, 38% of patients had unfavourable outcome. Patients suffering AEs were more likely to have unfavourable outcome (OR 2.3, 95% CI 1.10 to 4.69).ConclusionIntraoperative AEs occurred in 25% of patients treated with microsurgery for ruptured intracerebral aneurysm in this nationwide survey. Although most operated patients had favourable outcome, AEs were associated with increased risk of unfavourable outcome.

BackgroundThe COVID-19 pandemic has disrupted acute stroke care logistics, including delays in hyperacute management and decreased monitoring following endovascular therapy (EVT). We aimed to assess the impact of the pandemic on 90-day functional outcome among patients treated with EVT.MethodsThis is an observational cohort study including all patients evaluated for an acute stroke between March 30, 2020 and September 30, 2020 (pandemic cohort) and 2019 (reference cohort) in a high-volume Canadian academic stroke center. We collected baseline characteristics, acute reperfusion treatment and management metrics. For EVT-treated patients, we assessed the modified Rankin score (mRS) at 90 days. We evaluated the impact of the pandemic on a 90-day favourable functional status (defined as mRS 0–2) and death using multivariable logistic regressions.ResultsAmong 383 and 339 patients included in the pandemic and reference cohorts, baseline characteristics were similar. Delays from symptom onset to evaluation and in-house treatment were longer during the early first wave, but returned to reference values in the subsequent months. Among the 127 and 136 EVT-treated patients in each respective cohort, favourable 90-day outcome occurred in 53/99 (53%) vs 52/109 (48%, p=0.40), whereas 22/99 (22%) and 28/109 (26%, p=0.56) patients died. In multivariable regressions, the pandemic period was not associated with 90-day favourable functional status (aOR 1.27, 95% CI 0.60 to 2.56) or death (aOR 0.74, 95% CI 0.33 to 1.63).ConclusionIn this single-center cohort study conducted in a Canadian pandemic epicenter, the first 6 months of the COVID-19 pandemic did not impact 90-day functional outcomes or death among EVT-treated patients.

Introduction: Several comprehensive stroke centers (CSC) have reported increased delays to reperfusion in acute stroke during the COVID-19 pandemic, but it is unknown whether the pandemic is associated with worse functional outcomes in EVT-treated patients. Methods: We performed an observational cohort study of consecutive adult patients evaluated for suspected stroke at our CSC (located in Montreal, a Canadian pandemic epicenter) between March 30 and May 15 2020 (prospective pandemic cohort) and 2019 (retrospective non-pandemic cohort). We excluded in-hospital strokes. We compared short-term (in-house door-to-puncture and door-to-recanalization delays, TICI 2b/3, complications during EVT) and long-term (90-day mRS ≤2 and death) outcomes with univariate analyses. We assessed the effect of the pandemic on 90-day mRS while controlling for clinical confounders. Results: Overall, 111 and 106 patients were included in the pandemic and non-pandemic cohorts, respectively. The prevalence of COVID-19 in the pandemic cohort was 3% (3/104). Among ischemic stroke patients, 31/77 (40%) and 41/71 (58%) underwent EVT in each respective cohort (p=0.03). Among EVT-treated patients, baseline characteristics and NIHSS scores were similar (median [interquartile range]: 20 [12-25] vs 18 [14-20], p=0.18), but pre-stroke mRS was lower in the exposed cohort (0 [0-1] vs 1 [0-2], p=0.04). Door-to-puncture (87 [65-102] vs 56 [47-74] min, p=0.07) metrics were similar, but door-to-recanalization (122 [99-126] vs 89 [67-97] min, p Conclusion: The COVID-19 pandemic does not appear to have a negative impact on 90-day functional status among EVT-treated patients despite increased delays to recanalization. However, patient selection may have been stricter during the pandemic, as a smaller proportion of evaluated patients underwent EVT and those treated had lower pre-stroke mRS.

Background Vascular injuries in transsphenoidal surgery for pituitary adenomas are uncommon but can result in serious disability or death. Case description A 46-year-old man, who underwent resection of a pituitary adenoma with suprasellar extension via a transsphenoidal approach, presented with massive epistaxis five days postoperatively. Angiography revealed an arteriovenous fistula (AVF) between the right sphenopalatine artery and a deep vein draining to the right internal jugular vein, as well as contrast agent extravasation at the fistula point. The AVF was catheterized and successfully occluded with N-butyl-2-cyanoacrylate. Conclusions Transsphenoidal pituitary surgery can be complicated by massive epistaxis from a lesion of a small branch of the external carotid artery. Airway protection through intubation and investigation with conventional digital subtraction angiography is recommended. The treatment of choice is endovascular embolization because it can be done immediately at the angiography suite.

Background: Effective management of a spinal dural arteriovenous fistula (SDAVF) can be accomplished with either microsurgery or endovascular embolization, but there is a consensus that in patients in whom a radiculomedullary artery supplying the anterior spinal artery (ASA) originates from the same feeding artery as the SDAVF, the endovascular approach is to be avoided. Case Description: The patient was a 46-year-old woman with progressive lower limb paraparesis, sensory deficit, and sphincter dysfunction. Magnetic resonance imaging (MRI) and spinal angiography showed an SDAVF fed by a branch from the left second lumbar segmental artery, and the artery of Adamkiewicz (AA), a major ASA supplier, originating from the same segmental artery just proximal to the SDAVF. Microsurgical disconnection of the SDAVF was attempted, but failed. Embolization with cyanoacrylates was done in two occasions, the first time through a microcatheter placed just distal to the origin of the AA and the second time through another feeder coming from the same segmental artery that could not be visualized in the previous angiographies. All procedures were neurologically uncomplicated. Magnetic resonance imaging (MRI) 1 month after the last embolization showed resolution of the spinal cord edema. MRI scan taken 68 months after embolization revealed a slightly atrophic spinal cord with visible central canal and no recurrence of medullary edema. The patient presented good, but incomplete neurological improvement. Conclusion: Microsurgery is the first choice for an SDAVF branching off the same radiculomedullary artery supplying the ASA, but uncomplicated embolization can be feasible after failed surgery.