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Medical education faces a difficult challenge today; an exponential increase in knowledge and the rise and rise of disruptive technologies are making traditional education obsolete. As the world nears the era of Industry and Healthcare 4.0, the medical community needs to keep up and prepare physicians for a hyper-connected digital world. Virtual neurological care is poised to be at the forefront of care delivery claims, yet the virtual communication of neurological knowledge is still in its infancy. This increasing digitalization of care and education is both an opportunity and a challenge. With this paper, the authors aim to bridge the gap between technology and neurological education. After a thorough review of recent literature and assessing current trends, the authors propose that contemporary medical education must adhere to the following tenets: Hybrid, Mobile, Mixed-reality, Open Access, Collaborative, Peer-reviewed, Intelligent, Game-based, and Global. We identify and align education objectives with the needs of future digital neurologists. The authors also discuss real-world advances that are aligned to serve the next generation of patients and providers.

The correlation between noninvasive (oscillometric) blood pressure (NBP) and intra-arterial blood pressure (IAP) in critically ill patients receiving vasoactive medications in a Neurocritical Care Unit has not been systematically studied. The purpose of this study is to examine the relationship between simultaneously measured NBP and IAP recordings in these patients.Prospective observational study of patients (N = 70) admitted to a neurocritical care unit receiving continuous vasopressor or antihypertensive infusions. Paired NBP/IAP observations along with covariate and demographic data were abstracted via chart audit. Analysis was performed using SAS v9.4.A total of 2177 paired NBP/IAP observations from 70 subjects (49% male, 63% white, mean age 59 years) receiving vasopressors (n = 21) or antihypertensive agents (n = 49) were collected. Paired t test analysis showed significant differences between NBP versus IAP readings: ([systolic blood pressure (SBP): mean = 136 vs. 140 mmHg; p 0.0001], [diastolic blood pressure (DBP): mean = 70 vs. 68 mmHg, p 0.0001], [mean arterial blood pressure (MAP): mean = 86 vs. 90 mmHg, p 0.0001]). Bland-Altman plots for MAP, SBP, and DBP demonstrate good inter-method agreement between paired measures (excluding outliers) and demonstrate NBP-IAP SBP differences at extremes of blood pressures. Pearson correlation coefficients show strong positive correlations for paired MAP (r = 0.82), SBP (r = 0.84), and DBP (r = 0.73) recordings. An absolute NBP-IAP SBP difference of 20 mmHg was seen in ~ 20% of observations of nicardipine, ~ 25% of observations of norepinephrine, and ~ 35% of observations of phenylephrine. For MAP, the corresponding numbers were ~ 10, 15, and 25% for nicardipine, norepinephrine, and phenylephrine, respectively.Despite overall strong positive correlations between paired NBP and IAP readings of MAP and SBP, clinically relevant differences in blood pressure are frequent. When treating with vasoactive infusions targeted to a specific BP goal, it is important to keep in mind that NBP and IAP values are not interchangeable.

Background and purposeEndovascular techniques are frequently employed to treat large artery occlusion in acute ischemic stroke (AIS). We sought to determine the predictors and clinical impact of intracranial hemorrhage (ICH) after endovascular therapy.MethodsRetrospective analysis of consecutive patients presenting to 13 high volume stroke centers with AIS due to proximal occlusion in the anterior circulation who underwent endovascular treatment within 8 h from symptom onset. Logistic regression was performed to determine the variables associated with ICH, hemorrhagic infarction (HI), and parenchymal hematomas (PHs), as well as 90 day poor outcome (modified Rankin Scale score ≥3) and mortality.ResultsThere were a total of 363 ICHs (overall rate 32.3%; HI=267, 24%; PH=96, 8.5%) among the 1122 study patients (mean age 67±15 years; median National Institutes of Health Stroke Scale score 17 (IQR 13-20)). Independent predictors for HI included diabetes mellitus (OR 2.27, 95% CI (1.58 to 3.26), p

Background: Intracranial atherosclerotic disease (ICAD) is a common cause of stroke with a poor natural history despite medical therapy. Few studies have investigated endovascular therapies for the treatment of symptomatic ICAD in distal intracranial arteries. Here, we present the feasibility and safety of balloon angioplasty with and without stenting in patients with medically refractory small-artery symptomatic ICAD. Methods: Personal logs were reviewed to identify patients who were treated for small-artery ICAD (stenosis >50%) using angioplasty and/or stenting. Small cerebral arteries were defined by a diameter of ≤2 mm or any branch distal to a large intracranial vessel (i.e. distal to the internal carotid artery, M1, A1, or vertebrobasilar trunk). Patient characteristics, clinical manifestations, treatment, hospital course, and follow-up data were collected and analyzed. Results: Ten patients (12 arteries) were treated with either primary balloon angioplasty (58.3%) or angioplasty with stenting (41.6%) with a 100% technical success rate. Mean pretreatment stenosis was 79.9%, while mean posttreatment stenosis was 19.0%. There were no major periprocedural complications, including symptomatic intracranial hemorrhage or mortality; 3 cases were complicated by groin hematoma. Patients were followed for a mean total of 18.6 months with only 1 symptomatic restenosis which was retreated successfully. All patients had good functional outcome with a modified Rankin Scale of either 0 (80%) or 1 (20%) on follow-up. Conclusion: In our case series, treatment of symptomatic small-artery ICAD with angioplasty and/or stenting was safe and effective. These interventions should be considered as an alternative treatment for ICAD patients refractory to medical therapy.

BackgroundSimultaneous vasospasm and endovascular aneurysm treatment (SVAT) has been shown to be effective with good clinical outcomes in small series, but these studies have not examined predictive factors for clinical outcome after treatment.ObjectiveTo identify the safety and efficacy of SVAT in a large multicenter patient cohort and evaluate prognostic markers of clinical outcome following SVAT.MethodsThis study retrospectively enrolled 50 consecutive patients undergoing SVAT at 11 different centers. We analyzed Hunt and Hess and Fisher grades, aneurysm location, angiographic vasospasm grade, Glasgow Outcome Scale (GOS) at discharge, and 90-day modified Rankin Scale (mRS) scores.ResultsA total of 50 patients undergoing SVAT between the years 2003 and 2009 were identified. Patients presented, on average, 6.48±4.45 days after subarachnoid hemorrhage. Hunt and Hess and Fisher grades were 1 (n=7), 2 (n=12), 3 (n=14), 4 (n=15), 5 (n=2), and 3 and 4 (n=33), respectively. Aneurysm location was distributed as follows: anterior (n=32), posterior (n=16), anterior and posterior (n=2). Patients with good clinical condition (Hunt and Hess score 1–3) had significantly higher odds of surviving (OR=17.5, 95% CI 1.9 to 161.5), favorable GOS (OR=4.2, 95% CI 1.2 to 14.8), and favorable 90-day mRS (OR=4.2, 95% CI 1.2 to 14.8).ConclusionsSVAT is safe, with the majority of patients achieving good clinical outcome. Patients with lower Hunt and Hess grades have higher odds of surviving and favorable clinical prognosis.

Idiopathic inflammatory myopathies (IIM) are a group of chronic, autoimmune conditions affecting primarily the proximal muscles. The most common types are dermatomyositis (DM), polymyositis (PM), necrotizing autoimmune myopathy (NAM), and sporadic inclusion body myositis (sIBM). Patients typically present with sub-acute to chronic onset of proximal weakness manifested by difficulty with rising from a chair, climbing stairs, lifting objects, and combing hair. They are uniquely identified by their clinical presentation consisting of muscular and extramuscular manifestations. Laboratory investigations, including increased serum creatine kinase (CK) and myositis specific antibodies (MSA) may help in differentiating clinical phenotype and to confirm the diagnosis. However, muscle biopsy remains the gold standard for diagnosis. These disorders are potentially treatable with proper diagnosis and initiation of therapy. Goals of treatment are to eliminate inflammation, restore muscle performance, reduce morbidity, and improve quality of life. This review aims to provide a basic diagnostic approach to patients with suspected IIM, summarize current therapeutic strategies, and provide an insight into future prospective therapies.

Background: Recanalization and angiographic reperfusion are key elements to successful endovascular and interventional acute ischemic stroke (AIS) therapy. Intravenous recombinant tissue plasminogen activator (rt-PA), the only established revascularization therapy approved by the US Food & Drug Administration for AIS, may be less effective for large artery occlusion. Thus, there is enthusiasm for endovascular revascularization therapies, which likely provide higher recanalization rates, and trials are ongoing to determine clinical efficacy and compare various methods. It is anticipated that clinical efficacy will be well correlated with revascularization of viable tissue in a timely manner. Method: Reporting, interpretation, and comparison of the various revascularization grading methods require agreement on measurement criteria, reproducibility, ease of use, and correlation with clinical outcome. These parameters were reviewed by performing a Medline literature search from 1965 to 2011. This review critically evaluates current revascularization grading systems. Results and Conclusion: The most commonly used revascularization grading methods in AIS interventional therapy trials are the thrombolysis in cerebral ischemia (TICI, pronounced “tissy”) and thrombolysis in myocardial ischemia (TIMI) scores. Until further technical and imaging advances can incorporate real-time reliable perfusion studies in the angio-suite to delineate regional perfusion more accurately, the TICI grading system is the best defined and most widely used scheme. Other grading systems may be used for research and correlation purposes. A new scale that combines primary site occlusion, lesion location, and perfusion should be explored in the future.

BACKGROUND Stenting for symptomatic intracranial atherosclerotic disease is a therapeutic option in patients in whom medical therapy fails. OBJECTIVE To determine the periprocedural complication rates and mid-term restenosis rates in patients treated with balloon-expandable stents (BESs) compared with self-expanding stents (SESs). METHODS A retrospective review of consecutive patients treated with intracranial stents at 5 institutions was performed. Predictors of 30-day stroke and death as well as mid-term restenosis rates were analyzed. RESULTS A total of 670 lesions were treated in 637 patients with a mean age of 57 ± 13 years. A total of 454 lesions (68%) were treated with BESs and 216 lesions (32%) with SESs. The overall 30-day periprocedural complication rate was 6.1%, without any difference noted between the 2 groups. Patients treated within 24 hours of the index event were significantly more likely to have experienced a periprocedural complication (odds ratio [OR], 4.0; 95% confidence interval [CI]: 1.7-6.7; P < .007), whereas focal lesions were less likely to have a complication (OR, 0.31; 95% CI: 0.13-0.72; P < .001). Midterm restenosis was less likely in patients with a lower percentage of posttreatment stenosis (OR, 0.97; 95% CI: 0.95-0.99; P < .006), which was more common in BES-treated patients and focal concentric lesions (OR, 0.33; 95% CI: 0.23-0.55; P < .0001). CONCLUSION BESs have periprocedural complication rates similar to those of SESs. Less posttreatment stenosis was associated with lower rates of mid-term restenosis. Future randomized trials comparing BESs and SESs may help to identify the stent type that is safest and most durable.

BACKGROUND: Reperfusion therapy for acute ischemic stroke (AIS) is rapidly evolving, with the development of multiple endovascular modalities that can be used alone or in combination. OBJECTIVE: To determine which pharmacologic or mechanical modality may be associated with increased rates of recanalization. METHODS: A cohort of 1122 patients with AIS involving the anterior circulation treated at 13 stroke centers underwent intra-arterial (IA) therapy within 8 hours of symptom onset. Demographic information, admission National Institutes of Health Stroke Scale (NIHSS), mechanical and pharmacologic treatments used, recanalization grade, and hemorrhagic complications were recorded. RESULTS: The mean age was 6 7 ± 16 years and the median NIHSS was 1 7. The sites of arterial occlusion before treatment were M1 middle cerebral artery (MCA) in 561 (50%) patients, carotid terminus in 214 (19%) patients, M2 MCA in 171 (15%) patients, tandem occlusions in 141 (13%) patients, and isolated extracranial internal carotid artery occlusion in 35 (3%) patients. Therapeutic interventions included multimodal therapy in 584 (52%) patients, pharmacologic therapy only in 264 (24%) patients, and mechanical therapy only in 274 (24%) patients. Patients treated with multimodal therapy had a significantly higher Thrombolysis in Myocardial Infarction 2 or 3 recanalization rate (435 patients [74%]) compared with pharmacologic therapy only (160 patients, [61%]) or mechanical only therapy (173 patients [63%]), P < .001. In binary logistic regression modeling, independent predictors of Thrombolysis in Myocardial Infarction 2 or 3 recanalization were use of IA thrombolytic OR 1.58 (1.21-2.08), P < .001 and stent deployment 1.91 (1.23-2.96), P < .001. CONCLUSION: Multimodal therapy has significantly higher recanalization rates compared with pharmacologic or mechanical therapy. Among the individual treatment modalities, stent deployment or IA thrombolytics increase the chance of recanalization.

Object The authors evaluated the prognostic significance of blood glucose level at admission (BGA) and change in blood glucose at 48 hours from the baseline value (CG48) in nondiabetic and diabetic patients before and after endovascular therapy for acute ischemic stroke (AIS). Methods The BGA and CG48 data were analyzed in 614 patients with AIS who received endovascular therapy at 7 US centers between 2006 and 2009. Data reviewed included demographics, stroke risk factors, diabetic status, National Institutes of Health Stroke Scale (NIHSS) score at presentation, recanalization grade, intracranial hemorrhage (ICH) rate, and 90-day outcomes (mortality rate and modified Rankin Scale score of 3–6 [defined as poor outcome]). Variables with p values < 0.2 in univariate analysis were included in a binary logistic regression model for independent predictors of 90-day outcomes. Results The mean patient age was 67.3 years, the median NIHSS score was 16, and 27% of patients had diabetes. In nondiabetic patients, BGA ≥ 116 mg/dl (≥ 6.4 mmol/L) and failure of glucose level to drop > 30 mg/dl (> 1.7 mmol/L) from the admission value were both significant predictors of 90-day poor outcome and death (p < 0.001). In patients with diabetes, BGA ≥ 116 mg/dl (≥ 6.4 mmol/L) was an independent predictor of poor outcome (p = 0.001). The CG48 was not a predictor of outcome in diabetic patients. A simplified 6-point scale including BGA, Thrombolysis in Myocardial Infarction (TIMI) Grade 2–3 Reperfusion, Age, presentation NIHSS score, CG48, and symptomatic ICH (BRANCH) corresponded with poor outcomes at 90 days; the area under the curve value was > 0.79. Conclusions Failure of blood glucose values to decrease in the first 48 hours after AIS intervention correlated with poor 90-day outcomes in nondiabetic patients. The BRANCH scale shows promise as a simple prognostication tool after endovascular therapy for AIS, and it merits prospective validation.

Background and Purpose— Patients undergoing intra-arterial therapy (IAT) for acute ischemic stroke receive either general anesthesia (GA) or conscious sedation. GA may delay time to treatment, whereas conscious sedation may result in patient movement and compromise the safety of the procedure. We sought to determine whether there were differences in safety and outcomes in GA patients before initiation of IAT. Methods— A cohort of 980 patients at 12 stroke centers underwent IAT for acute stroke between 2005 and 2009. Only patients with anterior circulation strokes due to large-vessel occlusion were included in the study. A binary logistic-regression model was used to determine independent predictors of good outcome and death. Results— The mean age was 66±15 years and median National Institutes of Health Stroke Scale score was 17 (interquartile range, 13–20). The overall recanalization rate was 68% and the symptomatic hemorrhage rate was 9.2%. GA was used in 44% of patients with no differences in intracranial hemorrhage rates when compared with the conscious sedation group. The use of GA was associated with poorer neurologic outcome at 90 days (odds ratio=2.33; 95% CI, 1.63–3.44; P P Conclusions— Patients placed under GA during IAT for anterior circulation stroke appear to have a higher chance of poor neurologic outcome and mortality. There do not appear to be differences in hemorrhagic complications between the 2 groups. Future clinical trials with IAT can help elucidate the etiology of the differences in outcomes.

The practice of neurology presents a series of ethical challenges for the clinician. These rarely have simple or straightforward solutions, but require careful consideration by the neurologist. This section of , written by colleagues with particular interest in the area of bioethics, provides a case vignette that raises one or more ethical questions related to the subject area of this issue. The discussion that follows should help the reader understand and resolve the ethical dilemma.

The post-procedure intensive care of neuroinventional patients is integral to patient good outcomes. Neurointerventional patients may present either electively or emergently. In situations, the neurointensivist should be prepared and anticipate patient needs. The “time is brain” principle is highly relevant in the neurointensive care unit, with perioperative complications requiring rapid diagnosis and quick intervention. Communication between physicians taking care of the patient is also key. This chapter summarizes the neurocritical care needs after neurointerventional procedures. These procedures include aneurysm coiling, carotid stenting, intracranial embolization procedures, and acute stroke interventions, among others.

Background and Purpose: Endovascular techniques are frequently employed to treat large artery occlusion in acute ischemic stroke (AIS). We sought to determine the predictors and clinical impact of intracranial hemorrhage (ICH) after endovascular therapy. Methods: Retrospective analysis of consecutive patients presenting to 13 high-volume stroke centers with AIS due to proximal occlusion in the anterior circulation who underwent endovascular treatment within 8 hours from symptom onset. Logistic regression was performed to determine the variables associated with ICH, hemorrhagic infarction (HI), and parenchymal hematomas (PH) as well as 90-day poor outcome (mRS≥3), and mortality. Results: A total of 1122 patients (mean age, 67±15 years; median NIHSS, 17 [IQR13-20]) were studied. Independent predictors for HI included diabetes mellitus (OR 2.27, 95%CI [1.58-3.26], p Conclusions: In AIS patients undergoing endovascular therapy, diabetes mellitus, longer time to treatment, and Merci thrombectomy appear to be associated with a higher risk for HI while atrial fibrillation appears to result in a higher risk for PH. While both HI and PH are associated with poor outcomes only PH is associated with higher mortality.

Background: Randomized, double-blinded, placebo-controlled trials have significant impact on clinical practice. The ultimate goal of a clinical trial of therapy for acute ischemic stroke (AIS) is to compare 2 interventions. Challenges may include interventional therapy standardization, enrollment rate, patient selection, biases, data and safety monitoring, reporting, and financial and logistical support. Method: Selected randomized and single-arm prospective AIS trial designs. Clinical trial elements and their challenges are reviewed. Innovative designs and proposed recommendations to overcome some of the specific challenges and limitations are discussed. Results: AIS therapy trials have specific challenges related to ethical issues, enrollment rate, outcome measures, limited time to treatment, efficacy, safety, and limited or variable operator experience with complex technology in a delicate end organ. Proposed suggestions for improving trial design include the following: incorporation of a lead-in phase; careful patient and outcome measure selection; historical, concurrent, or hybrid controls; open data access; and a Bayesian approach. An open data paradigm may facilitate creation of computerized prediction models for future trials (minimizing cost by decreasing sample size or providing futility analyses and directing resources to other trials). Collaborative, consortium, and network infrastructures may allow more effective and efficient study completion. Self-learning, self-correcting trials with intrinsic flexibility to adapt may help future clinical trial design in AIS. Conclusion: The randomized clinical trial design in AIS endovascular therapy is challenging. Lead-in phases, careful patient selection, use of innovative outcome measures, control groups, and newer clinical trial design may enhance conduct of future trials, their validity, and their results.

Background We present a rare complication of trans-sphenoidal adenectomy (TSA) for pituitary macroadenoma: carotid cavernous fistula (CCF) that was treated with endovascular therapy. The incidence of internal carotid artery (ICA) injury following TSA is 1% and may spontaneously heal by packing and rarely manifest as symptomatic CCF/aneurysm. Treatment of post-TSA CCF may be challenging due to the breach of nasal floor and may be prone to recurrence. Presentation/intervention Uncontrolled intra-operative bleeding during a TSA led to an emergent angiogram to show slow-flow left CCF. Due to clinical deterioration with nasal bleeding, angiography was repeated after 4 h; the fistula had transformed into high flow with significant increase in size, and was therefore embolized using stent-assisted coiling. The fistula recanalized in a month with massive epistaxis and was re-treated using a covered stent graft. Conclusion This case represents several unique learning points: (1) CCF as a complication of TSA due to close anatomical proximity; (2) the role of endovascular management post-TSA complication; (3) stent-assisted coil embolization of high-flow fistula with moderate ICA laceration; (4) recanalization of CCF causing massive epistaxis; (5) rare use of covered stent graft stent in distal intracranial circulation maintaining integrity and patency of ICA; (6) long-term results after covered stent graft with no in-stent restenosis.

Trigeminal neuralgia is commonly treated with percutaneous balloon compression due to the high success rate, technical simplicity and cost efficiency.1-3 The procedure carries certain risks, most notably dysesthesias and masseter muscle weakness.4 5 However, more severe complications are rare. In this report, the case of a rare complication of percutaneous balloon compression for trigeminal neuralgia is presented, resulting in a carotid cavernous fistula treated via an endovascular approach.

The authors evaluated the prognostic significance of blood glucose level at admission (BGA) and change in blood glucose at 48 hours from the baseline value (CG48) in nondiabetic and diabetic patients before and after endovascular therapy for acute ischemic stroke (AIS).The BGA and CG48 data were analyzed in 614 patients with AIS who received endovascular therapy at 7 US centers between 2006 and 2009. Data reviewed included demographics, stroke risk factors, diabetic status, National Institutes of Health Stroke Scale (NIHSS) score at presentation, recanalization grade, intracranial hemorrhage (ICH) rate, and 90-day outcomes (mortality rate and modified Rankin Scale score of 3-6 [defined as poor outcome]). Variables with p values0.2 in univariate analysis were included in a binary logistic regression model for independent predictors of 90-day outcomes.The mean patient age was 67.3 years, the median NIHSS score was 16, and 27% of patients had diabetes. In nondiabetic patients, BGA ≥ 116 mg/dl (≥ 6.4 mmol/L) and failure of glucose level to drop30 mg/dl (1.7 mmol/L) from the admission value were both significant predictors of 90-day poor outcome and death (p0.001). In patients with diabetes, BGA ≥ 116 mg/dl (≥ 6.4 mmol/L) was an independent predictor of poor outcome (p = 0.001). The CG48 was not a predictor of outcome in diabetic patients. A simplified 6-point scale including BGA, Thrombolysis in Myocardial Infarction (TIMI) Grade 2-3 Reperfusion, Age, presentation NIHSS score, CG48, and symptomatic ICH (BRANCH) corresponded with poor outcomes at 90 days; the area under the curve value was0.79.Failure of blood glucose values to decrease in the first 48 hours after AIS intervention correlated with poor 90-day outcomes in nondiabetic patients. The BRANCH scale shows promise as a simple prognostication tool after endovascular therapy for AIS, and it merits prospective validation.

Background and Purpose— Whether stenting is superior to angioplasty in the treatment of intracranial atherosclerotic disease is unknown. Dissections, vessel rupture, and lesion recoil observed with primary angioplasty using balloon catheters designed for coronary arteries have undermined the role of primary angioplasty as a preferred treatment for intracranial atherosclerotic disease. The goal of this study is to report the immediate and 3-month outcomes of treating patients with intracranial atherosclerotic disease with angioplasty balloon catheters in a multicenter study. Methods— This is a retrospective review of 74 patients from 4 institutions treated with primary angioplasty for intracranial atherosclerotic disease over a 6-year time period. Technical success (residual stenosis ≤50%), periprocedural success (no vascular complication within 72 hours), and 3-month outcomes are reported. Results— The mean degree of stenosis pretreatment was 79%±14% and reduced to 34%±18% after angioplasty. Technical success was achieved in 68 (92%; 95% CI, 83% to 97%) of the 74 patients. Periprocedural success was achieved in 65 (88%; 95% CI, 78% to 94%) of the 74 patients. There were 4 (5%; 95% CI, 1.5% to 13%) major procedure-related strokes, 2 of which resulted in death within 6 hours of the procedure. The 30-day stroke/death rate was 5% (4 of 74; CI, 1.5% to 13%). Three-month follow-up was available in 71 patients. In this interval, 2 patients had new stroke, 1 in the ipsilateral territory and the other in the contralateral territory. The 3-month stroke or death rate was 8.5% (6 of 71; CI, 3.1% to 17.5%); the retreatment rate was 2.8% (2 of 71; CI, 0.3% to 10%). Conclusion— Balloon angioplasty is a relatively safe alternative treatment for intracranial atherosclerotic disease. Its role in the long-term secondary prevention of recurrent stroke as compared with intracranial stenting and medical therapy remains to be determined, preferably in a randomized study.

Background and Purpose: Intra-arterial reperfusion therapies are expanding frontiers in acute ischemic stroke (AIS) management but there is considerable variability in clinical practice. The use of general anesthesia (GA) is one example. We aimed to better understand sedation practices in AIS. Methods: An online survey was distributed to the 68 active members of the Society of Vascular and Interventional Neurology (SVIN). Survey development was based on discussions at the SVIN Endovascular Stroke Round Table Meeting (Chicago, IL, 2008). The final survey contained 12 questions. Questions were developed as single and multiple-item responses; with an option for a free-text response. Results: There was a 72% survey response rate (N=49/68). Respondents were interventional neurologists in practice 1-5 years (71.4%, N=35). The mean (± SD) AIS interventions performed per year at the respondents' institutions was 42.5 ± 25, median 35.0 (IQR 20, 60). The most frequent anesthesia type used was GA (anesthesia team), then conscious sedation (nurse administered), monitored anesthesia care (anesthesia team), and finally local analgesia alone. There was a preference for GA because of eliminating movement (65.3% of respondents; N=32/49), perceived procedural safety (59.2%, N=29/49), and improved procedural efficacy (42.9%, N=21/49). However, cited limitations to GA included risk of time delay (69.4%, N=34), of propagating cerebral ischemia due to hypoperfusion or other complications (28.6%, N=14), and lack of adequate anesthesia workforce (20.4%, N=7). Conclusions: The most frequent type of anesthesia used by Neurointerventionalists for AIS interventions is GA. Prior to making GA standard of care during AIS intervention, more data are needed about effects on clinical outcomes.

This technical report describes the successful use of the newly introduced Distal Access Catheter, initially designed to work with the Merci Retrieval System with the Penumbra aspiration system as the main aspiration catheter. Both devices, one a clot retriever and the other a thrombo-aspiration device, can be used and deployed via the same catheter saving time during acute stoke intervention. Moreover, the larger inner diameter of the distal access catheter may allow more effective clot aspiration.

The pericallosal artery is rarely associated with intracranial atherosclerotic disease and, until recently, was usually not amenable to endovascular therapy with balloon angioplasty and stenting. We present an elderly patient with postural left leg-shaking episodes secondary to pericallosal artery stenosis, which was treated initially with primary intracranial balloon angioplasty, and subsequently, angioplasty and stenting as a result of recurrent stenosis. Both procedures were preformed without complications, and the patient remained free of symptoms on 6-month follow-up. This case demonstrates unique clinical and neuroendovascular aspects; the isolated postural leg-shaking transient ischemic attacks, initially mistaken for radiculopathy and local joint etiology, were found later to be cerebrovascular ischemic in origin. Moreover, the correlation between the findings of computed tomography perfusion and angiography localized the lesion into the medial frontal lobe and pericallosal artery territory. In addition, the technical aspect provides insight into the current state of neuroendovascular techniques, addressing the difficulty of access into very small and distal intracranial arteries affected by stenosis.

Background and purpose Intracranial stenting and angioplasty has been increasingly utilized for the treatment of symptomatic intracranial atherosclerotic disease (ICAD). The use of self-expanding stents (SES) has been reported to have a high technical success rate but there are concerns with restenosis. We sought to determine if the use of balloon mounted stents (BMS) was associated with higher technical complication rates compared with self-expanding stents. Methods Three academic institutions contributed data on patients treated for symptomatic ICAD over a 3 year period (2006–2009). 259 consecutive patients were identified. Demographics, type of stent placed, periprocedural complications, per cent stenosis prior to treatment and after treatment, if the treatment was within 2 weeks of clinical symptomatology, lesion classification with the Mori scale and follow-up imaging for restenosis were collected retrospectively. A univariate analysis was performed to determine predictors of periprocedural stroke and also for restenosis at follow-up. Variables with a p value Results 259 patients with a mean age of 61±13 years with 168 (65%) patients presenting with strokes and the rest with transient ischemic attacks. The distribution of the lesions were as follows: vertebrobasilar 109 (42%), middle cerebral artery 85 (33%) and intracranial internal carotid artery 65 (25%). 79 (31%) BMS were implanted and 180 (69%) SES. A total of 17 (6.5%) patients developed a periprocedural stroke with no difference noted between use of type of stent. Patients in whom a BMS was implanted had a significant reduction in stenosis compared with SES (81±10% to 7±11% vs 80±12% to 24±9%; p Conclusions The use of BMS was not associated with higher complication rates but was associated with lower restenosis rates. Placement of stents in patients with more complex lesions is associated with higher periprocedural stroke rates and restenosis. Further prospective studies comparing BMS with SES are warranted.

Background and purpose The use of endovascular techniques to treat large artery occlusion in acute ischemic stroke has become more frequently employed as a treatment option. We sought to determine the predictors of intracranial hemorrhage after these procedures were performed. Methods This is a retrospective review of data from 13 high volume stroke centers that perform endovascular treatments for acute ischemic stroke. Patients with anterior circulation strokes treated under 8 h from symptom onset with endovascular therapy were included. Hemorrhages were classified as parenchymal hematoma (PH) types 1 and 2 and hemorrhagic infarction (HI) types 1 and 2. Patients with PH bleeds were considered symptomatic and HI bleeds were asymptomatic. Binary logistic regression modeling was performed to determine the variables associated with symptomatic and asymptomatic hemorrhages after correcting for multiple comparisons. Results A total of 1122 patients met the inclusion criterion for this study. Mean age for the cohort was 67±15 years with a median National Institutes of Health Stroke Scale (NIHSS) of 17 (IQR 13–20). The distribution for thrombus location at the initiation of endovascular therapy was as follows: M1 segment of the middle cerebral artery (MCA) 561 (50%), carotid terminus 214 (19%), M2 MCA 171 (15%), tandem occlusions 141 (13%) and isolated extracranial internal carotid artery occlusion 35 (3%). Parenchymal hematomas occurred in 96 (8.5%) patients and HI in 265 (24%) patients. There were no variables associated with symptomatic hemorrhages while the following variables were predictors of asymptomatic hemorrhage: diabetes mellitus (OR 2.02; 95% CI 1.46 to 2.79; p Conclusions Diabetic patients and those who have been treated with intravenous tPA prior to the procedure or intraprocedural use of thrombolytics or the Merci device appear to be at a higher risk for asymptomatic hemorrhage. Moreover, patients with asymptomatic hemorrhage appear to be at a higher risk for a worse clinical outcome at the 90 day follow-up.

Objective: CT angiography (CTA) has recently gained popularity for detection of stenotic and occlusive diseases in intracranial and neck vessels. With 3D reconstruction, CT angiogram can provide reasonably reliable estimates of vascular pathology. We wanted to look at the sensitivity and specificity of CTA in evaluating atherosclerotic diseases of the head and neck …

Objective: Dominance of arteries has been studied in different tissues/organs of body. Diagnostic, therapeutic and prognostic implications are hypothesized to be related to symmetry or asymmetry of circulation. One major implication in the case of the brain is the hypotheses that asymmetry exists …

Objective: Dominance of arteries has been studied in different tissues/organs of body. Diagnostic, therapeutic and prognostic implications are hypothesized to be related to symmetry or asymmetry of circulation. One major implication in the case of the brain is the hypotheses that asymmetry exists due to differences in vascular requirements of the brain tissue. Vertebral artery origin and …