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Moyamoya disease (MMD) is characterized by stenosis, occlusion, and formation of aberrant collaterals of brain vessels. This derangement in the brain vessels in conditions associated with changes in intracranial pressure can lead to arterial ischemic stroke (AIS). A major challenge for stroke physicians is to recommend the safest method of delivery for pregnant patients with MMD. Using a large national database, our objective in this study was to analyze the risk of AIS in patients with MMD who underwent vaginal delivery (VD) and cesarean section (C-section).We used the National Inpatient Sample database for the years 2013-2018 to identify patients with a diagnosis of MMD who underwent VD or C-section. Multiple logistic regression was performed to assess the risk of AIS in VD versus C-section.Of 2166 female patients with MMD, 97 underwent VD or C-section: 49 (50.51%) underwent VD, and 48 (49.48%) underwent C-section. The analysis of outcomes between VD and C-section showed a higher prevalence of AIS after VD compared with C-section (8.2% vs 6.3%, P = 0.716). The multivariate analysis for AIS showed that VD is not an independent risk factor compared with C-section (odds ratio = 2.1, 95% CI = 0.3-13.3, P = 0.417).Our data did not find evidence that VD and C-section are risk factors for AIS in pregnant patients with MMD.

To compare safety and efficacy profiles in aneurysms treated with Pipeline Embolization Device or Pipeline Flex versus Surpass Streamline flow diverters (FDs).Patients who underwent flow diversion for aneurysm treatment at 2 centers were included. Covariates comprised patient demographics, comorbidities, and aneurysm characteristics. Metrics included number of devices, adjuvant device use, case duration, and radiation exposure. Outcomes included periprocedural complications and radiographic results at follow-up. Propensity score-matched pairs were generated using demographic and aneurysm characteristics to verify the outcomes in equally sized groups.The majority of 141 flow diversion procedures performed on 126 patients were in the anterior circulation (96%) and unruptured (93%). Operators experienced more complications placing Surpass FDs compared with Pipelines (18.2% vs. 3.1%, P = 0.005) but used fewer Surpass devices per case (1 device in all Surpass cases and range for Pipeline cases 1-7; P0.001). Ballooning was more frequent for Surpass (29.5% vs. 2.1%, P0.001). There were no differences in mortality (2.1% vs. 0, P = 1.00), intracranial hemorrhage (3.1% vs. 0, P = 0.551), or stroke (4.2% vs. 6.8%, P = 0.680). Rates of aneurysm obliteration at follow-up were similar. Propensity-matched pairs had no differences in FD deployment complications or perioperative events, yet the significant differences remained for adjuvant balloon use and number of FDs deployed.While the devices demonstrated similar safety and efficacy profiles, deployment of the Surpass Streamline was more technically challenging than Pipeline Embolization Device or Pipeline Flex. Prospective cohort studies are needed to corroborate these findings.

Mechanical thrombectomy (MT) has been established as a standard of care for patients with acute ischemic stroke for the past five years. However, the direct benefits of this treatment in patients with baseline disability remains unclear. This study aims to elucidate the cost impact of performing MT on patients with moderate-to-severe baseline disability to work towards an optimized system of care for acute ischemic stroke. We developed a Markov economic model with a life-time horizon analysis of costs associated with mechanical thrombectomy in patients grouped on baseline disability as defined by modified Rankin Score. Our clinical and economic data is based on an American payer perspective. Our results identified a marginal cost-effective ratio (mCER) of $18,835.00 per quality-adjusted life year (QALY) when mechanical thrombectomy is reserved as a treatment only for patients with no-to-minimal baseline disability as compared to those with any level of baseline disability. Our results provide a framework for these future studies and highlight key sectors that drive cost in the surgical treatment and life-long care of patients with acute ischemic stroke.

Association between opioid abuse and intracranial aneurysms rupture has been suggested in recent studies. However, these observations are limited to single center studies and could be benefited from validation in larger cohorts. Hence, we aimed to study the association between age at aneurysmal subarachnoid hemorrhage (aSAH) and opioid use disorders (OUD) using a large, national database.This study was conducted using the 2016 and 2017 National Inpatient Sample (NIS) with ICD-10 codes. Cohorts were categorized as "Non-users", "OUD", and "Multi-drug users". Linear regression models were used to examine the association between OUD and multi-drug users with age at aneurysm rupture, and multiple logistic regression models were used for the association between in-hospital mortality and drug abuse.A total of 17,391 patients with aSAH were captured in the 2016 and 2017 NIS database. Out of these patients, 235 (1.4%) were included in the OUD group and 59 (0.3%) in the multi-drug users' group. Adjusted linear regression showed an unstandardized coefficient (UC) = -12.3 [95%CI = -14.4/-10.1, p 0.001] for OUD patients and an UC = -16.8 [95%CI = -21.1/-12.5, p 0.001] for multi-drug users, compared to non-users. The risk of in-hospital mortality was significantly increased in drug user, OR = 1.47 [95%CI: 1.1-2.01, p = 0.017] for OUD patients, and OR = 2.35 [95%CI: 1.35-4.11, p = 0.003] for multi-drug users.This is the first national study to examine the association between age at intracranial aneurysms rupture and opioid abuse. aSAH patients with history of OUD were 12 years younger compared to non-users, when OUD was combined with other drugs, the age at aneurysms rupture was 17 years younger. Further elucidation regarding the mechanisms by which opioids triggers aneurysms rupture and predispose to worsen outcomes following aSAH is required, as well as appropriate prevention, and management strategies for aSAH patients with OUD.

BackgroundThe aim of this article is to outline a position statement on pregnancy and parental leave for physicians practicing neurointerventional surgery.MethodsWe performed a structured literature review regarding parental leave policies in neurointerventional surgery and related fields. The recommendations resulted from discussion among the authors, and additional input from the Women in NeuroIntervention Committee, the full Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee, and the SNIS Board of Directors.ResultsSome aspects of workplace safety during pregnancy are regulated by the US Nuclear Regulatory Commission. Other aspects of the workplace and reasonable job accommodations are legally governed by the Family and Medical Leave Act of 1993, the Affordable Care Act of 2010 and the Fair Labor Standards Act of 1938, Americans with Disabilities Act of 1990, Title IX of the Education Amendments of 1972, Title VII of the Civil Rights Act of 1964 as well as rights and protections put forth by the Occupational Safety and Health Administration as part of the United States Department of Labor. Family friendly policies have been associated not only with improved job satisfaction but also with improved parental and infant outcomes. Secondary effects of such accommodations are to increase the number of women within the specialty.ConclusionsSNIS supports a physician’s ambition to have a family as well as start, develop, and maintain a career in neurointerventional surgery. Legal and regulatory mandates and family friendly workplace policies should be considered when institutions and individual practitioners approach the issue of childbearing in the context of a career in neurointerventional surgery.

BackgroundThe purpose of this guideline is to summarize the data available for performing mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) stroke in special populations not typically included in large randomized controlled clinical trials, including children, the elderly, pregnant women, patients who have recently undergone surgery, and patients with thrombocytopenia, collagen vascular disorders, and endocarditis.MethodsWe performed a literature review for studies examining the indications, efficacy, and outcomes for patients undergoing MT for ischemic stroke aged 80 years, pregnant patients, patients who have recently undergone surgery, and those with thrombocytopenia, collagen vascular diseases, or endocarditis. We graded the quality of the evidence.ResultsMT can be effective for the treatment of ELVO in ischemic stroke for patients over age 80 years and under age 18 years, thrombocytopenic patients, pregnant patients, and patients with endocarditis. While outcomes are worse compared to younger patients and those with normal platelet counts (respectively), there is still a benefit in the elderly (in both mRS and mortality). Data are very limited for patients with collagen vascular diseases; although diagnostic cerebral angiography carries increased risks, MT may be appropriate in carefully selected patients in whom untreated ELVO would likely result in disabling or fatal outcome.

Introduction: Moyamoya has been extensively described in East Asian populations, and despite its accepted clinical presentation and course, it is fundamental to describe major cerebrovascular complications in other ethnically diverse samples. Hence, we sought to determine if distinct ethnic groups are at higher risk of developing stroke using the National Inpatient Sample (NIS) database. Methods: We included all moyamoya patients admitted from January 2013 until December 2018 in the NIS database. Multivariate regression analysis was used to determine the risk of developing stroke and poor outcomes in different races compared to white patients. Results: Out of the 6093 admissions with diagnosis of moyamoya disease that were captured, 2,520 were white (41.6%), 2,078 were African American (AA) (34.1%), 721 were Hispanic (11.8%), and 496 were Asian (8.14%). For arterial ischemic stroke (AIS), we found that AA race had a significantly reduced risk of AIS compared to white patients (odds ratio = 0.8, 95% confidence interval: 0.7–0.9, p = 0.031). While being Hispanic or Asian significantly increased 1.5 and 2-fold the risk of hemorrhagic stroke. Conclusion: This study highlights the unique features and phenotypes of moyamoya cases among different ethnicities. While possibly AA are protected from developing AIS due to underlying causes of moyamoya such as sickle cell disease, Asians seems to be more susceptible to hemorrhagic stroke.

Introduction Woven EndoBridge (WEB) is a new endovascular treatment option for wide necked bifurcation aneurysms. Results from the WEB-IT trial showed a 0% risk of thromboembolic complications within 30 days post-op but the rate reported in the literature is as high as 10%. We are exploring potential risk factors associated with immediate thromboembolic complications in patients treated with the WEB device. Methods Retrospective study of forty-two patients with intracranial aneurysms who were treated with WEB at a single center from 2019–2021. Data was collected on patient demographics, comorbidities, aneurysm characteristics, procedural details, and hospital course. Bivariate analyses were performed to compare patients who experienced a periprocedural ischemic stroke to those who did not. Multiple logistic regression modeling was performed to identify independent risk factors for thromboembolic complications. Results Of the 42 patients that were treated with WEB, 6 suffered an ischemic stroke (AIS). These patients were more likely to have an underlying diagnosis of arrythmias (p value = 0.007). Furthermore, they had a median angle of 32.0° in the true neck view on diagnostic angiogram compared to 19.5° (p value = 0.046). Lastly, they had a longer procedure length of 228 min compared to 178 min (p value = 0.002). Patients with thromboembolic complications had a longer length of stay in the hospital and worse outcomes at three months follow up. On logistic regression modeling, these risk factors did not reach statistical significance. Conclusion Risk factors of thromboembolic complications after WEB placement include cardiac arrythmias, acute aneurysmal angle in the true neck view and a longer procedure length.

Background This study evaluates the mortality risk of patients with emergent large vessel occlusion (ELVO) and COVID-19 during the pandemic. Methods We performed a retrospective cohort study of two cohorts of consecutive patients with ELVO admitted to a quaternary hospital from March 1 to April 17, 2020. We abstracted data from electronic health records on baseline, biomarker profiles, key time points, quality measures and radiographic data. Results Of 179 patients admitted with ischemic stroke, 36 had ELVO. Patients with COVID-19 and ELVO had a higher risk of mortality during the pandemic versus patients without COVID-19 (OR 16.63, p = 0.004). An age-based sub-analysis showed in-hospital mortality in 60% of COVID-19 positive patients between 61-70 years-old, 66.7% in between 51-60 years-old, 50% in between 41-50 years-old and 33.3% in between 31-40 years old. Patients that presented with pulmonary symptoms at time of stroke presentation had 71.4% mortality rate. 27.3% of COVID-19 patients presenting with ELVO had a good outcome at discharge (mRS 0-2). Patients with a history of cigarette smoking (p = 0.003), elevated d-dimer (p = 0.007), failure to recanalize (p = 0.007), and elevated ferritin levels (p = 0.006) had an increased risk of mortality. Conclusion Patients with COVID-19 and ELVO had a significantly higher risk for mortality compared to COVID-19 negative patients with ELVO. A small percentage of COVID-19 ELVO patients had good outcomes. Age greater than 60 and pulmonary symptoms at presentation have higher risk for mortality. Other risk factors for mortality were a history of cigarette smoking, elevated, failure to recanalize, elevated d-dimer and ferritin levels.

Background Endovascular therapy is known to achieve a high rate of recanalization in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) and is currently the standard of care. Hemorrhagic conversion is a severe complication that may occur following AIS in patients undergoing endovascular thrombectomy (EVT). There is a scarcity of data on the risk factors related to HV in post-EVT patients, especially those who develop symptomatic hemorrhagic conversion. The main objective of our study is to identify independent predictors of radiographic and symptomatic hemorrhagic conversion in our diverse patient population with multiple baseline comorbidities that presented with AIS and were treated with EVT as per the most updated guidelines and practices. Methodology This is a retrospective chart review in which we enrolled adult patients treated with EVT for AIS at a comprehensive stroke center in the Bronx, NY, over a four-year period. Bivariate analyses followed by multiple logistic regression modeling were performed to determine the independent predictors of all and symptomatic hemorrhagic conversion. Results A total of 326 patients who underwent EVT for AIS were enrolled. Of these, 74 (22.7%) had an HC, while 252 (77.3%) did not. In total, 25 out of the 74 (33.7%) patients were symptomatic. In the logistic regression model, a history of prior ischemic stroke (odds ratio (OR) = 2.197; 95% confidence interval (CI) = 1.062-4.545; p-value = 0.034), Alberta Stroke Program Early CT Score (ASPECTS) of6 (OR = 2.207; 95% CI = 1.477-7.194; p-value = 0.019), and Thrombolysis in Cerebral Infarction (TICI) 2B-3 recanalization (OR = 2.551; 95% CI = 1.998-6.520; p-value=0.045) were found to be independent predictors of all types of hemorrhagic conversion. The only independent predictor of symptomatic hemorrhagic conversion on multiple logistic regression modeling was an elevated international normalized ratio (INR) (OR = 11.051; 95% CI = 1.866-65.440; p-value = 0.008). Conclusions History of prior ischemic stroke, low ASPECTS score, and TICI 2B-3 recanalization are independent predictors of hemorrhagic conversion while an elevated INR is the only independent predictor of symptomatic hemorrhagic conversion in post-thrombectomy patients.

BackgroundAntiplatelet and antithrombotic medication management before, during, and after neurointerventional procedures has significant practice variation. This document updates and builds upon the 2014 Society of NeuroInterventional Surgery (SNIS) Guideline ‘Platelet function inhibitor and platelet function testing in neurointerventional procedures’, providing updates based on the treatment of specific pathologies and for patients with specific comorbidities.MethodsWe performed a structured literature review of studies that have become available since the 2014 SNIS Guideline. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors.ResultsThe management of antiplatelet and antithrombotic agents before, during, and after endovascular neurointerventional procedures continues to evolve. The following recommendations were agreed on. (1) It is reasonable to resume anticoagulation after a neurointerventional procedure or major bleeding episode as soon as the thrombotic risk exceeds the bleeding risk in an individual patient (Class I, Level C-EO). (2) Platelet testing can be useful to guide local practice, and specific approaches to using the numbers demonstrate marked local variability (Class IIa, Level B-NR). (3) For patients without comorbidities undergoing brain aneurysm treatment, there are no additional considerations for medication choice beyond the thrombotic risks of the catheterization procedure and aneurysm treatment devices (Class IIa, Level B-NR). (4) For patients undergoing neurointerventional brain aneurysm treatment who have had cardiac stents placed within the last 6–12 months, dual antiplatelet therapy (DAPT) is recommended (Class I, Level B-NR). (5) For patients being evaluated for neurointeventional brain aneurysm treatment who had venous thrombosis more than 3 months prior, discontinuation of oral anticoagulation (OAC) or vitamin K antagonists should be considered as weighed against the risk of delaying aneurysm treatment. For venous thrombosis less than 3 months in the past, delay of the neurointerventional procedure should be considered. If this is not possible, see atrial fibrillation recommendations (Class IIb, Level C-LD). (6) For patients with atrial fibrillation receiving OAC and in need of a neurointerventional procedure, the duration of TAT (triple antiplatelet/anticoagulation therapy=OAC plus DAPT) should be kept as short as possible or avoided in favor of OAC plus single antiplatelet therapy (SAPT) based on the individual’s ischemic and bleeding risk profile (Class IIa, Level B-NR). (7) For patients with unruptured brain arteriovenous malformations there is no indication to change antiplatelet or anticoagulant management instituted for management of another disease (Class IIb, Level C-LD). (8) Patients with symptomatic intracranial atherosclerotic disease (ICAD) should continue DAPT following neurointerventional treatment for secondary stroke prevention (Class IIa, Level B-NR). (9) Following neurointerventional treatment for ICAD, DAPT should be continued for at least 3 months. In the absence of new stroke or transient ischemic attack symptoms, reversion to SAPT can be considered based on an individual patient’s risk of hemorrhage versus ischemia (Class IIb, Level C-LD). (10) Patients undergoing carotid artery stenting (CAS) should receive DAPT before and for at least 3 months following their procedure (Class IIa, Level B-R). (11) In patients undergoing CAS during emergent large vessel occlusion ischemic stroke treatment, it may be reasonable to administer a loading dose of intravenous or oral glycoprotein IIb/IIIa or P2Y12 inhibitor followed by maintenance intravenous infusion or oral dosing to prevent stent thrombosis whether or not the patient has received thrombolytic therapy (Class IIb, C-LD). (12) For patients with cerebral venous sinus thrombosis, anticoagulation with heparin is front-line therapy; endovascular therapy may be considered particularly in cases of clinical deterioration despite medical therapy (Class IIa, Level B-R).ConclusionsAlthough the quality of evidence is lower than for coronary interventions due to a lower number of patients and procedures, neurointerventional antiplatelet and antithrombotic management shares several themes. Prospective and randomized studies are needed to strengthen the data supporting these recommendations.

BACKGROUND AND PURPOSE: Our hypothesis is that the COVID-19 pandemic led to delayed presentations for patients with acute ischemic stroke. This study evaluates the impact of the coronavirus disease 2019 pandemic on presentation, treatment, and outcomes of patients with emergent large-vessel occlusion using data from a large health system in the Bronx, New York. MATERIALS AND METHODS: We performed a retrospective cohort study of 2 cohorts of consecutive patients with emergent large-vessel occlusion admitted to 3 Montefiore Health System hospitals in the Bronx from January 1 to February 17, 2020, (prepandemic) and March 1 to April 17, 2020 (pandemic). We abstracted data from the electronic health records on presenting biomarker profiles, admission and postprocedural NIHSS scores, time of symptom onset, time of hospital presentation, time of start of the thrombectomy procedure, time of revascularization, presenting ASPECTS, TICI recanalization score, mRS, functional outcomes, and mortality. RESULTS: Of 179 patients admitted with ischemic stroke during the study periods, 80 had emergent large-vessel occlusion, of whom 36 were in the pandemic group. Patients in the pandemic group were younger (66 versus 72 years, P

We present a radiology-pathology case series of 3 patients with coronavirus disease 2019 (COVID-19) with acute ischemic stroke due to fulminant carotid thrombosis overlying mild atherosclerotic plaque and propose a novel stroke mechanism: COVID-associated carotid atherothrombosis.

Aneurysmal subarachnoid hemorrhage (aSAH) is commonly associated with hydrocephalus due to subarachnoid hemorrhage blood products obstructing cerebrospinal fluid outflow. Hydrocephalus after aSAH is routinely managed with temporary external ventricular drainage (EVD) followed by standard EVD weaning protocols, which determine the need for ventriculoperitoneal shunting (VPS). We sought to investigate aSAH patients who initially passed EVD weaning trials and had EVD removal, but later presented with recurrent, delayed, symptomatic hydrocephalus requiring a VPS. We conducted a retrospective review of all patients at our tertiary care medical center who presented with aSAH, requiring an EVD. We analyzed variables associated with ultimate VPS dependency during hospitalization. We reviewed 489 patients with aSAH over a 6-year period (2008–2014). One hundred and thirty-eight (28.2%) developed hydrocephalus requiring a temporary EVD. Forty-four (31.9%) of these patients died or had withdrawal of care during admission, and were excluded from final analysis. Of the remaining 94 patients, 29 (30.9%) failed their clamp trial and required VPS. Sixty-five (69.1%) patients passed their clamp trial and were discharged without a VPS. However, 10 (15.4%) of these patients developed delayed hydrocephalus after discharge and ultimately required VPS [mean (range) days after discharge, 97.2 (35–188)]. Compared to early VPS, the delayed VPS group had a higher incidence of symptomatic vasospasm (90.0% vs 51.7%; P = 0.03). When comparing patients discharged from the hospital without VPS, delayed VPS patients also had higher 6- and 12-month mortality (P = 0.02) and longer EVD clamp trials (P

The Woven Endobridge (WEB) device is an FDA-approved intrasaccular flow disruptor to treat most intracranial wide-necked bifurcation aneurysms. 1 Based on the rising experience with safe and effective results, it has been increasingly utilized for the treatment of residual and recurrent aneurysms. 2 , 3 Additionally, the device has been reported as an off-label treatment option for Posterior communicating (Pcom) artery aneurysms with optimal morphology. 4 A transfemoral or transradial artery access is conventionally utilized for WEB embolization. 1 – 3 In this technical video, we share our experience with the use of direct carotid puncture to perform WEB embolization for a large recurrent Pcom aneurysm in an elderly female with a history of subarachnoid hemorrhage that was initially treated with surgical clipping. A direct puncture of the left common carotid artery (CCA) under ultrasound guidance was performed after failed attempts to select the left ICA via both transfemoral and transradial access due to type 3 aortic arch and extreme tortuosity of the proximal left CCA. The aneurysm was successfully treated with a 5 mm × 2 mm WEB SL device. There are limited studies of transcarotid access for neurointerventional procedures including mechanical thrombectomy, intracranial stent placement etc. 5 , 6 To the best of our knowledge, this technical video represents the first documented report of WEB embolization via transcarotid access. We aim to highlight the feasibility of transcarotid arterial access for WEB embolization as an effective bailout strategy. In addition, the nuances of direct carotid puncture along with possible complications, and potential management strategies have been discussed.

Introduction Given the efficacy of mechanical thrombectomies (MT) for large vessel occlusions (LVO), there is concern that the Hub and Spoke model of stroke care, which prioritizes initial assessment of the acute ischemic stroke (AIS) patient at a primary stroke center, would cause a delay in arterial reperfusion, thus leading to worse outcomes. In this study that occurred at our comprehensive stroke center in New York, we compared the clinical outcomes of patients that were either directly admitted for thrombectomy versus those who were transferred from another institution. Methods Retrospective review of the electronic medical record (EMR) was performed on all adult patients treated with endovascular therapy for ischemic stroke between January 2016 and February 2020. A bivariate analysis was performed to compare patients in the direct admit versus transfer group. A multivariable logistic regression model was developed to determine which factors affect 90-day modified Rankin score (mRS) and to evaluate if transfer status was an independent predictor in this model. Results Three hundred and twenty-five patients were included in this study; 127 patients belonged to the direct admit group while 198 were in the transfer group. Thirteen patients (20%) in the direct admit group had a 90-day mRS score of 0-2 and so did 29 patients (25.2%) in the transfer group; thus, no statistically significant difference found in clinical outcomes between both groups (p-value = 0.427). In a multivariable logistic regression model that accounts for age, gender, smoking status, baseline mRS, presenting National Institute of Health Stroke Scale (NIHSS), procedure duration, thrombolysis in cerebral infarction (TICI) score, post-NIHSS and decompressive hemicraniectomy, transfer status was not found to be predictive of clinical outcomes (OR 0.727 95% CI 0.349-1.516; p-value = 0.396). Conclusion Transfer status is not significantly associated with 90-day outcome. Since Hub and Spoke is not associated with worse outcomes compared to direct admit, it remains a viable model for providing effective care to stroke patients in an urban setting.

BrainPath (NICO, Indianapolis, Indiana) is a tool that can be used to evacuate supratentorial hematomas due to spontaneous intracerebral hemorrhage (ICH). However, when ICH occurs in the posterior fossa, an open approach is often undertaken to evacuate the hematoma. The application of minimally invasive technology, while available, has not been well established. Our objective was to describe the use of the image-guided, minimally invasive BrainPath system to evacuate a spontaneous cerebellar hemorrhage. We present the case of a sixty-four-year-old male patient with a cerebellar hematoma due to hypertensive hemorrhage. The patient's medical record, including the history and physical, progress notes, operative notes, discharge summary, and imaging studies were reviewed to document the clinical presentation as well as the details of the operative technique and postoperative outcomes in this paper. We discuss the technical nuances of the operative points in detail. In our example case, the BrainPath system was successfully used to evacuate the cerebellar hematoma and no procedural-related complications occurred. The patient's recovery remained uncomplicated at three months of follow-up. In summary, the BrainPath system offers a less invasive alternative to open evacuation for cerebellar bleeds.

Background Accurate diagnosis of patients with transient or minor neurological events can be challenging. Recent studies suggest that advanced neuroimaging can improve diagnostic accuracy in low‐risk patients with transient or minor neurological symptoms, but a cost‐effective emergency department diagnostic evaluation strategy remains uncertain. Methods and Results We constructed a decision‐analytic model to evaluate 2 diagnostic evaluation strategies for patients with low‐risk transient or minor neurological symptoms: (1) obtain advanced neuroimaging (magnetic resonance imaging brain and magnetic resonance angiography head and neck) on every patient or (2) current emergency department standard‐of‐care clinical evaluation with basic neuroimaging. Main probability variables were: proportion of patients with true ischemic events, strategy specificity and sensitivity, and recurrent stroke rate. Direct healthcare costs were included. We calculated incremental cost‐effectiveness ratios, conducted sensitivity analyses, and evaluated various diagnostic test parameters primarily using a 1‐year time horizon. Cost‐effectiveness standards would be met if the incremental cost‐effectiveness ratio was less than willingness to pay. We defined willingness to pay as $100 000 US dollars per quality‐adjusted life year. Our primary and sensitivity analyses found that the advanced neuroimaging strategy was more cost‐effective than emergency department standard of care. The incremental effectiveness of the advanced neuroimaging strategy was slightly less than the standard‐of‐care strategy, but the standard‐of‐care strategy was more costly. Potentially superior diagnostic approaches to the modeled advanced neuroimaging strategy would have to be >92% specific, >70% sensitive, and cost less than or equal to standard‐of‐care strategy’s cost. Conclusions Obtaining advanced neuroimaging on emergency department patient with low‐risk transient or minor neurological symptoms was the more cost‐effective strategy in our model.

Ischemic stroke and hemorrhagic stroke are the most common sequelae of the Moyamoya variants [Moyamoya disease (MMD) and syndrome (MMS)]. We sought to determine the rates of stroke subtypes and the predictive factors of arterial ischemic stroke (AIS) utilizing a large data sample of MMD and MMS patients in the US.We queried the 2016 and 2017 National Inpatient Sample database for Moyamoya diagnosis plus any of the following associated conditions; sickle cell disease, neurofibromatosis type 1, cranial radiation therapy or Down Syndrome. Multivariate regression determined the risk factors for AIS onset in MMD and MMS.2323 patients with a diagnosis of Moyamoya were included; 668 (28.8%) patients were classified as MMS and 1655 (71.2%) as MMD. AIS was the most common presentation in both cohorts; however, MMD patients had higher rates of AIS (20.4 vs 6%, p 0.001), hemorrhagic stroke (7.4vs 2.5%, p 0.001), and TIA (3.3vs 0.9%, p = 0.001) compared to MMS patients. Multivariate analysis showed that increasing age [OR = 1.017 95%CI: 1.008-1.03, p 0.001], lipidemia [OR = 1.32 95%CI: 1.02-1.74, p = 0.049], and current smoking status [OR = 1.43 95%CI: 1.04-1.97, p = 0.026] were independent risk factors for AIS in MMD patients, whereas hypertension [OR = 2.61 95%CI: 1.29-5.25, p = 0.007] and African-American race [OR = 0.274, 95%CI: .117-.64, p = 0.003] were independent predictors in the MMS cohort.AIS is the most common presentation in both, MMD and MMS. However, MMD patients had higher rates of stroke events compared to MMS. Risk factors for AIS in MMD included increasing age, lipidemia and smoking status, whereas in MMS hypertension was the only independent risk factor.

Background: Accurate diagnosis of patients with transient or minor neurological events is challenging with non-trivial rates of Emergency Department (ED) misdiagnosis reported. Recent studies suggest that advanced neuroimaging can improve diagnostic accuracy in presumed low-risk patients, but a cost-effective ED diagnostic evaluation strategy remains uncertain. We therefore evaluate two strategies designed to determine which patients with low-risk transient and minor neurological symptoms can be directly discharged from the ED. Methods: We constructed a decision-analytic model to evaluate two ED-based diagnostic evaluation strategies for patients with presumed low-risk transient or minor neurological symptoms: (1) obtain advanced neuroimaging (MRI brain and MRA head and neck) in the ED on every patient or (2) current ED standard of care of clinical evaluation and basic neuroimaging. The main probability variables were: proportion of patients with true ischemic events, specificity and sensitivity of each evaluation strategy, recurrent stroke rate, and direct healthcare costs. We calculated incremental cost-effectiveness ratios (ICER) and performed threshold analyses to evaluate diagnostic test parameters. Cost-effectiveness was defined as willingness to pay (WTP) Results: Our primary and sensitivity analyses found that the advanced neuroimaging strategy more cost-effective than ED standard of care, the latter of which has an ICER exceeding the WTP threshold. The total cost of the advanced neuroimaging strategy was $3,210 with an effectiveness of 0.9397 whereas the total cost of the standard ED strategy was $4,338 with an effectiveness of 0.9399 in the primary model. Using threshold analyses, we found that potential superior diagnostic approaches to the advanced neuroimaging strategy would have to be >92% specific, >70% sensitive, and cost less than or equal to the standard of care strategy. Conclusion: In our decision-analytic model, obtaining advanced neuroimaging on all patients presenting with low-risk transient and minor neurological symptoms was the more cost-effective strategy as compared to current practice.

The purpose of this publication is to provide a review of social media usage by neurointerventionalists. Using published literature and available local, regional, and national guidelines or laws, we reviewed data on social media usage as it pertains to neurointerventional surgery. Recommendations are provided based on the quality of information and conformity of medico-legal precedent and law. Social media is a growing entity as it is used both promotionally and educationally. Neurointerventionalists may post de-identified radiographic images with discussions, but should be conscientious and adhere to applicable laws and regulations, strict ethical codes, and institutional policies.

Objective We aim to characterize the incidence, risk for mortality, and identify risk factors for mortality in patients presenting with hemorrhage and COVID-19. Methods This retrospective cohort study included a cohort of patients admitted to one of three major hospitals of our healthcare network including, an academic medical center and comprehensive stroke center, which accepts transfers for complex cases from eight community hospitals, during March 1 to May 1, 2020. All patients that received imaging of the neuroaxis and had positive PCR testing for COVID-19 were identified and reviewed by an attending neuroradiologist. Demographics and comorbidities were recorded. Biomarkers were recorded from the day of the hemorrhagic event. Vital signs from the day of the hemorrhagic event mechanical ventilation orders at admission were recorded. Imaging findings were divided into 5 subtypes; acute subdural hematoma (SDH), subarachnoid hemorrhage (SAH), multi-compartmental hemorrhage (MCH), multi-focal intracerebral hemorrhage (MFH), and focal intracerebral hemorrhage (fICH). Outcomes were recorded as non-routine discharge and mortality. Results We found a total of 35 out of 5227 patients with COVID-19 that had hemorrhage of some kind. Mortality for the entire cohort was 45.7 % (n = 16). SDH patients had a mortality rate of 35.3 % (n = 6), SAH had a mortality of 50 % (n = 1), MCH patients had a mortality of 71.4 % (n = 5), MFH patients had a mortality of 50 % (n = 2), fICH patients had a mortality of 40 % (n = 2). Patients with severe pulmonary COVID requiring mechanical ventilation (OR 10.24 [.43−243.12] p = 0.015), with INR > 1.2 on the day of the hemorrhagic event (OR 14.36 [1.69−122.14] p = 0.015], and patients presenting with spontaneous vs. traumatic hemorrhage (OR 6.11 [.31−118.89] p = 0.023) had significantly higher risk for mortality. Conclusions Hemorrhagic presentations with COVID-19 are a rare but serious way in which the illness can manifest. It is important for neurosurgeons to realize that patients can present with these findings without primary pulmonary symptoms, and that severe pulmonary symptoms, elevated INR, and spontaneous hemorrhagic presentations is associated with increased risk for mortality.

Introduction The purpose of this study is to compare peri-procedural complication rates in patients at a single academic medical center treated with Surpass or Pipeline/Pipeline Flex flow diverter stents. Methods We performed a retrospective chart review of patients who underwent placement of a flow diverter stent from the last 3 years. We evaluated major complications including mortality, stroke, intracranial hemorrhage (ICH) or failure of device deployment, and minor complications including radial and groin access site hematoma, retroperitoneal hematoma (RPH), arterial dissection. We also recorded hospital course complications including urinary tract infection (UTI), pneumonia (PNA) and deep vein thrombosis (DVT). We examined the length of hospital stay (LOS), and disposition at discharge. We adjusted for the following variables: Patient age, gender, pre-existing medical comorbidities, laterality, anatomic location of treated aneurysm, device utilized, number of devices deployed per case, longest length and diameter of all devices deployed per case. Results We identified 23 Surpass cases and 99 pipeline cases performed on a total of 106 patients. The median number of devices used for Surpass was 1 (IQR 1,1) compared to Pipeline/Pipeline Flex 1 (IQR 1,3) which was statistically significantly different (p=0.0003)We found no significant difference in mortality(p=0.4949), stroke(p=0.3565), intracerebral hemorrhage(p=0.3310), or aborted procedures(p=0.4021). There was no significant difference in minor complications or hospital complications. The median length of stay was 1 day for both devices. Interquartile length for Surpass 1–3(75th%); and Pipeline 1–26(75th%), mann-whitney p=0.238 between the medians. Conclusions These results suggest that Surpass is non-inferior to Pipeline in regards to major and minor peri-procedural complications. Pipeline on average required a statistically significant more number of devices per procedure. There was no difference in the length of stay between Surpass and Pipeline. Further prospective data is needed to further confirm this hypothesis. Disclosures C. Feigen: None. N. Haranhalli: None. R. Holland: None. A. Brook: None. D. Altschul: 2; C; Microvention, Stryker.

Background and Purpose Mechanical thrombectomy has significantly improved post-ischemic stroke clinical outcomes. However, the post-ischemic stroke mortality rate appears to be unchanged. We reviewed potential risk factors that can be related to mortality in patients who underwent mechanical thrombectomy. Materials and Methods A retrospective review was conducted in acute anterior circulation ischemic stroke patients who underwent mechanical thrombectomy but expired within 90 days in a high volume comprehensive stroke center between January 2017 and January 2020. Pre thrombectomy risk factors evaluated include age, NIHSS, ASPECT score, baseline mRS, occlusion site, and IV tPA administration. Post-thrombectomy risk factors include ASPECT score at 24 hours, TICI score, post-procedural subarachnoid hemorrhage (SAH), hemorrhagic transformation, and decompressive craniectomy. Procedural risk factors included the mode of anesthesia, intraprocedural systolic (SBP), diastolic (DBP), and mean arterial pressure (MAP) were reviewed as well as procedural blood pressure variability. The difference between the highest and lowest recorded blood pressure was defined as procedural variability. Results Mechanical thrombectomy was performed in 290 patients, and 54 patients (54/290, 18.6%) were expired at 90 days, which include 42 anterior (77.8%) and 22 posterior circulation patients (22.2%). In 42 anterior circulation acute ischemic stroke patients who expired (M:F=25:17), the mean age was 77.5 ± 13, and 42.86% was at or more than 80 years old. Baseline estimated mRS three or above were seen in 92.7%. The number of days from admission to decease was 7 (median). Pre-procedural ASPECT score >6 was noted in 32 patients (32/42, 76.19%) but in 11 patients (11/42, 26.19%) on post-procedure ASPECT at 24 hours. MCA, ICA and CCA occlusion was found in 69.05%, 19.5%, and 9.52%, respectively. Pre thrombectomy IV tPA was administered in 17 patients (17/42, 40.48%). TICI 2b or three were achieved in 54.7%, with the median number of passes were 2. Ten patients (23.81%) developed post thrombectomy symptomatic intracranial hemorrhages (sICH), and the hemorrhagic transformation was seen in 14.29% (n=6). Three patients (7.14%) received decompressive craniectomy. Mean ‘arrival to groin puncture time’ and ‘groin to reperfusion time’ were 1.13 ± 0.19 hours and 1 hour ± 0.042, respectively. Monitored Anesthesia Care (n=29, 69.04%) was used for most of the procedure. Mean procedural variability of MAP, DBP and SBP were 24.32 + 23.79 mmHg, 16.38 ± 24.83 mmHg, and 40.19 ± 26.83 mmHg, respectively. Conclusion Older age, low baseline estimated mRS, the relatively lower rate of successful reperfusion, the higher rate of sICH, delayed groin to reperfusion time, and higher intraprocedural variability in MAP and DBP were observed in patients with mortality in our study. Disclosures A. Toma: None. A. Vijayashankar: None. N. Haranhalli: None. R. Zampolin: None. D. Altschul: None. A. Brook: None. S. Lee: None.

BACKGROUND Several predictors have been studied for shunt dependency after stroke and other brain injuries. However, little is known about the association between ventriculostomy-associated infections (VAIs) and impaired cerebrospinal fluid (CSF) outflow. Moreover, gram-negative (GN) VAIs induce a potent neuroinflammatory process and are clinically challenging to treat. OBJECTIVE To assess if GN-VAIs predict ventriculoperitoneal shunt (VPS) dependency. METHODS Retrospective analysis of postprocedure infection rates was performed in 586 patients with external ventricle drainage (EVD) placed on site between 2012 and 2018. We collected sex, age, stroke and nonstroke related, location of EVD placement, type of hospital, EVD duration, and EVD exchange. RESULTS Among 586 patients requiring an EVD, 55 developed a VAI. Most were caused by gram-positive (GP) pathogens (61.8%). A total of 120 patients required a conversion from EVD to VPS. Patients with VAIs had higher rates of VPS placement (49.09% vs 17.65%, P

Objective We aim to demonstrate the safety and effectiveness of extra-femoral endovascular access for mechanical thrombectomy for acute ischemic stroke patients whose vascular anatomy precludes safe or maneuverable trans-femoral access. Methods Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to conduct a systematic review and meta-analysis with articles published until March 2018. The search protocol, including research questions and inclusion and exclusion criteria, were developed a priori. Our own institutional retrospective data were included in the cohort of case series. Results Eleven studies including 51 patients were included. Age ranged from 4th to 10th decade of life (average: 9.3rd decade) and 40.1% received IV tissue plasminogen activator. Initial National Institutes of Health Stroke Scale (NIHSS) score ranged from 1 to 36, (average: 17.6). Of the 51 patients, 39 (76%) patients suffered from anterior circulation large vessel occlusions versus 12 (24%) from posterior circulation occlusions. Site of access included 26 (51%) radial artery punctures, 23 (45%) direct percutaneous cervical carotid punctures, 1 brachial artery puncture, and 1 direct extradural vertebral artery puncture. Technical success was achieved in 43/51 (84%) of patients. The average modified Rankin Scale at discharge was 2.93 (n=26). There were no complications in 25 patients who underwent radial arterial access. Two (7.4%) of 27 cervical access patients developed hematoma. Conclusions Trans-carotid and trans-radial access for intervention in acute ischemic stroke is safe and effective. There may be instances in which these approaches should be considered first line before standard femoral approaches.

Objectives Patients with aneurysmal subarachnoid hemorrhage (aSAH) often sustain substantial cognitive and functional impairment. Traditional outcome measures have emphasized radiographic and gross clinical outcomes, but cognitive and functional outcomes are less frequently documented. This pilot study assessed the feasibility of administering longitudinal cognitive and neuropsychological testing and tracked patterns of functional improvement in aSAH patients. Patients and methods Standardized cognitive and neuropsychological testing were administered to a prospective cohort of aSAH patients admitted for treatment to our tertiary care center. Thirty consecutive aSAH patients (Hunt and Hess score 1-3) were enrolled over 23-months and baseline evaluations were completed within 24-h after admission. Patients were followed prospectively after treatment (coiling or clipping) at 1-, 3-, 6-, and 12-months. Functional outcome measures included the Montreal Cognitive Assessment, the Neuropsychiatric Inventory–Questionnaire, and the Functional Activities Questionnaire. Results Of the 30 patients, 23 (77%) followed-up at 3-months, 21 (70%) at 6-months, and 19 (63%) at 12-months. Improvement from baseline to follow-up at 12-months was noted for general cognitive function (p = .004), memory (p = .025), and executive function (p = .039), with the greatest improvement occurring within 6-months. Daily function also improved mostly within 6-months (p = .022) while changes in neuropsychological disturbances were insignificant from baseline to follow-up at 12-months (p = .216). Conclusion Standardized cognitive and neuropsychological testing provides metrics for evaluating functional outcomes following treatment of aSAH. The addition of a brief battery of tests to routine clinical and radiographic evaluations is feasible. The main limitations are related to practice and referral patterns, and future studies are needed to evaluate the impact of treatment modalities on functional outcomes.

Patients with subarachnoid hemorrhage (SAH) usually have prolonged hospitalizations due to the need to closely monitor their neurological status. Therefore, these patients have higher risk of experiencing hospital-acquired complications (HACs), which can complicate their clinical course and recovery. However, there is no evidence on the impact of HACs of long-term clinical outcomes. We aimed to identify if HACs are independent risk factors for poor clinical outcomes at 12-18 months of follow-up.Retrospective analysis of 323 patients with SAH diagnosis from 2013 until June 2018. We collected patient-related factors (age, sex, body mass index (BMI), ethnicity), comorbidities (hypertension, smoke status, diabetes, coronary heart diseases, prothrombotic diseases and hypercholesterolemia), clinical variables (Hunt-Hess grade, modified Fisher grade, treatment, delayed cerebral ischemia), aneurysm characteristics (location, size) and HACs (pneumonia, deep vein thrombosis (DVT), urinary tract infection (UTI), external ventricular drainage (EVD) infections, sepsis, hyponatremia and acute respiratory distress syndrome). Poor outcomes were defined as mRS ≥ 3.204 patients were included in the primary analysis. 82 (40.2%) experienced one or more HACs during their hospital course. Patients that developed HACs have significantly increased ICU (12.1 ± 6.6 vs 24.3 ± 23.6, p .001) and hospital (18.7 ± 14.2 vs 35.3 ± 26.3, p .001) length of stays. Moreover, patients with HACs had significant higher rates of delayed cerebral ischemia, non-routine discharge and poor outcomes at 90 days. 177 patients had complete follow-ups at 12-18 months, HACs were independent risk factors for poor functional outcomes at 12-18 months after adjusting for demographic, comorbidities and clinical variables [OR = 3.205, 95% CI 1.231-8.347, p 0.001].HACs are an independent risk factor of sustaining poor clinical outcomes 12-18 months after a SAH. Furthermore, HACs are significantly related with the occurrence of DCI, with non-routine discharge and 90-day poor functional outcomes.

Despite being the current standard of care, outcomes after endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) remain highly variable. Though several scoring systems exist to predict outcomes in AIS, they were mainly developed to direct patient selection for treatment. Recognizing the integral role peri-procedural metrics play on outcome, our study aimed to develop a post-EVT prognostic score to predict 90-day functional dependency and death.We included all eligible adult AIS patients treated with EVT at our institution from June 2016 to January 2020. Data was systematically collected via chart review including pre-, intra- and post-procedural variables. The outcome was modified Rankin score (mRS) at 90 days post-EVT where a poor outcome was defined as mRS 3-6: 3-5 for functional dependency and 6 for death. Model selection methods including stepwise and Lasso were evaluated via cross-validation where the final multivariable logistic regression model was chosen by optimizing the Area Under the Receiver Operating Characteristic Curve (ROC AUC).We included 224 patients (mean age: 65 years old, male: 55%, 90-day poor outcome: 60%). The final model achieved a median AUC of 0.84, IQR: (0.80, 0.87). A 7-point score, called Bronx Endovascular Thrombectomy (BET) score, was developed with more points indicating higher likelihood of 90-day poor outcome (0 point: ≤21% risk; 1-2: 24%; 3: 61%; 4: 86%; 5: 96%; 6-7: ≥99%). One point was awarded for the following variables: current smoker, diabetic, general anesthesia received, puncture to perfusion time ≥45 minutes, and Thrombolysis in Cerebral Infarction (TICI) score3. Two points were awarded for a post-EVT National Institute of Health Stroke scale (NIHSS) of ≥10.Incorporating peri-procedural data we developed the competitive BET score predicting 90-day functional dependency and death, which may help providers, patients and caregivers manage expectations and organize early rehabilitative services.

Background The Woven EndoBridge device is a novel treatment option for wide-necked bifurcation intracranial aneurysms (WNBA). While this device has had good results, there remains a subset of WNBA that fail this treatment. The main objective of this study is to identify risk factors that are associated with incomplete occlusion of WEB treated aneurysms at short-term follow up. Methods This was a retrospective study of 31 patients with intracranial aneurysms who were treated with WEB at a single institution in the USA in 2019–2021. Data was collected via chart review on patient demographics, aneurysm characteristics, procedural details, and occlusion status at six months follow up. Bivariate analyses were performed comparing completely occluded aneurysms with neck remnants and residual aneurysms. Results 16 (52%) had completely occluded aneurysms while 11 (35%) patients had a neck remnant, and 4 (13%) patients had a residual aneurysm at follow up. Patients with neck remnants and residual aneurysms had aneurysms with a larger diameter. A large aneurysm diameter is an independent risk factor for incomplete occlusion (OR 4.23 95% CI 1.08–16.53 P value = 0.038). Patients with residual aneurysms had an average difference between the aneurysm width and WEB diameter of −0.08mm compared to 1.2 mm in patients with occluded aneurysms. 75% of patients with a residual aneurysm presented with a ruptured aneurysm. Lastly, more patients with a residual aneurysm had an immediate angiographic outcome of incomplete occlusion. Conclusion Larger aneurysms are at risk for incomplete occlusion status post WEB treatment. Larger, ruptured aneurysms with minimal difference in aneurysm and WEB diameter that fail to occlude immediately post-treatment are more likely to present as residual aneurysms at short-term follow up.

Background Acute aneurysmal subarachnoid hemorrhage (SAH) is a medical and neurosurgical emergency from ruptured brain aneurysm. Aneurysmal SAH is identified on brain computed tomography (CT) as increased density of basal cisterns and subarachnoid spaces from acute blood products. Aneurysmal SAH-like pattern on CT appears as an optical illusion effect of hypodense brain parenchyma and/or hyperdense surrounding cerebral cisterns and blood vessels termed as “pseudo-subarachnoid hemorrhage” (pseudo-SAH). Methods We reviewed clinical, laboratory, and radiographic data of all SAH diagnoses between January 2013 and January 2018, and found subsets of nonaneurysmal SAH, originally suspected to be aneurysmal in origin. We performed a National Library of Medicine search methodology using terms “subarachnoid hemorrhage,” “pseudo,” and “non-aneurysmal subarachnoid hemorrhage” singly and in combination to understand the sensitivity, specificity, and precision of pseudo-SAH. Results Over 5 years, 230 SAH cases were referred to our tertiary academic center and only 7 (3%) met the definition of pseudo-SAH. Searching the National Library of Medicine using subarachnoid hemorrhage yielded 27,402 results. When subarachnoid hemorrhage and pseudo were combined, this yielded 70 results and sensitivity was 50% (n = 35). Similarly, search precision was relatively low (26%) as only 18 results fit the clinical description similar to the 7 cases discussed in our series. Conclusions Aneurysmal SAH pattern on CT is distinct from nonaneurysmal and pseudo-SAH patterns. The origin of pseudo-SAH terminology appears mostly tied to comatose cardiac arrest patients with diffuse dark brain Hounsfield units and cerebral edema, and is a potential imaging pitfall in acute medical decision-making.

Objective To investigate effect of July admission on short-term outcome after endovascular coiling of patients with subarachnoid hemorrhage (SAH) owing to ruptured aneurysms. Methods Data from the National Inpatient Sample (2012–2014) were gathered. Adult patients with SAH who underwent endovascular therapy at a teaching hospital were identified. Admissions during July were compared with other months as well as based on admission quarter (AQ): AQ1 (July to September), AQ2 (October to December), AQ3 (January to March), and AQ4 (April to June). Outcome measures included inpatient morbidity (death, iatrogenic stroke, or myocardial infarction), inpatient mortality, and nonroutine discharges. Results The National Inpatient Sample database yielded 8515 patients with a diagnosis of SAH who underwent endovascular coiling between 2012 and 2014. Among these, 665 (7.8%) were admitted in July, and 7850 (92.2%) were admitted in other months. Overall, there were no differences in any of the examined outcomes, including morbidity (15.0% vs. 17.3%, P = 0.513), mortality (10.5% vs. 11.8%, P = 0.665), or nonroutine discharge (57.1% vs. 59.7%, P = 0.567), for patients admitted in July versus other months. Based on AQ, 24.5% of patients were admitted in AQ1, 26.0% in AQ2, 23.8% in AQ3, and 25.7% in AQ4. Similar to July versus other month admissions, there were no significant differences in outcomes based on AQ. Conclusions Based on findings of this national investigation, patients with SAH owing to ruptured aneurysms who undergo endovascular therapy during the beginning of the academic year in July may not have worse short-term outcome compared with patients with admissions during other months.

Background The relatively decreased time spent in the operating room and overall reduction in cases performed by neurosurgical trainees as a result of duty-hour restrictions demands that the pedagogical content within each surgical encounter be maximized and crafted toward the specific talents and shortcomings of the individual. It is imperative to future generations that the quality of training adapts to the changing administrative infrastructures and compensates for anything that may compromise the technical abilities of trainees. Neurosurgeons in teaching hospitals continue to experiment with various emerging technologies—such as simulators and virtual presence—to supplement and improve surgical training. Methods The authors participated in the Google Glass Explorer Program in order to assess the applicability of Google Glass as a tool to enhance the operative education of neurosurgical residents. Google Glass is a type of wearable technology in the form of eyeglasses that employs a high-definition camera and allows the user to interact using voice commands. Results Google Glass was able to effectively capture video segments of various lengths for residents to review in a variety of clinical settings within a large, tertiary care university hospital, as well as during a surgical mission to a developing country. The resolution and quality of the video were adequate to review and use as a teaching tool. Conclusion While Google Glass harbors the potential to dramatically improve both neurosurgical education and practice in a variety of ways, certain technical drawbacks of the current model limit its effectiveness as a teaching tool.

The neurovascular anatomy is highly complex, and knowledge of the neurovasculature is essential to improve neurosurgical outcome. The diagnosis and management of intracranial neoplasms and other neurological disorders depends on an extensive awareness of the general neuroanatomy and its close relation to the neurovasculature. Recognition of anatomical variations, anomalies, and malformations within the neurovascular tree is crucial to improving surgical outcomes and preventing neurosurgical complications. In this chapter, the neurovascular anatomy and its relation to common intracranial neoplasms is discussed, with illustrative case representations.

OBJECTIVEThe role of CT perfusion (CTP) in the management of patients with acute ischemic stroke (AIS) remains a matter of debate. The primary aim of this study was to evaluate the correlation between the areas of infarction and penumbra on CTP scans and functional outcome in patients with AIS.METHODSThis was a retrospective review of 100 consecutively treated patients with acute anterior circulation ischemic stroke who underwent CT angiography (CTA) and CTP at admission between February 2011 and October 2014. On CTP, the volume of ischemic core and penumbra was measured using the Alberta Stroke Program Early CT Score (ASPECTS). CTA findings were also noted, including the site of occlusion and regional leptomeningeal collateral (rLMC) score. Functional outcome was defined by modified Rankin Scale (mRS) score obtained at discharge. Associations of CTP and CTA parameters with mRS scores at discharge were assessed using multivariable proportional odds logistic regression models.RESULTSThe median age was 67 years (range 19–95 years), and the median NIH Stroke Scale score was 16 (range 2–35). In a multivariable analysis adjusting for potential confounding variables, having an infarct on CTP scans in the following regions was associated with a worse mRS score at discharge: insula ribbon (p = 0.043), perisylvian fissure (p < 0.001), motor strip (p = 0.007), M2 (p < 0.001), and M5 (p = 0.023). A worse mRS score at discharge was more common in patients with a greater volume of infarct core (p = 0.024) and less common in patients with a greater rLMC score (p = 0.004).CONCLUSIONSThe results of this study provide evidence that several CTP parameters are independent predictors of functional outcome in patients with AIS and have potential to identify those patients most likely to benefit from reperfusion therapy in the treatment of AIS.

BACKGROUND Poor cosmetic results following cervical laminectomy and fusion (CLF) are rarely considered in assessing surgical complications. Atrophy from muscle denervation and posterior bone loss may result in a sunken appearance; relative tension may lead to wide, unsightly scars. Paraspinal muscle flaps are routinely employed by plastic surgeons for closure of wound infection and dehiscence. OBJECTIVE To assess clinical and cosmetic results of CLF with/without a paraspinal muscle flap closure technique. METHODS A retrospectively collected cohort analysis was undertaken for a 12-yr period in CLF patients. During the study period, a paraspinal muscle flap closure technique was adopted. Wounds were inspected for scar width and depth using a scale devised to categorize the posterior neck contour. Minimum follow-up was 12 mo. RESULTS Of 159 patients, 94 wounds were evaluated of which 34 had muscle flap closure. There were no differences in age, sex, body mass index, mJOA scores, diabetes status, or number of spinal levels treated. Mean follow-up was 18.6 (12-48) and 49.8 (12-130) mo in the muscle flap and conventional closure groups respectively; contour scores were 1.20 vs 2.65 (P

Introduction: The “July effect” refers to the perceived notion that new hospital staff (students, residents, fellows, etc.) first starting training in July may contribute to an increased rate of adverse events during patient care. The purpose of this study is to investigate the effect of July admission on short-term outcome after endovascular coiling of patients with subarachnoid hemorrhage (SAH) due to ruptured aneurysms. Methods: Data from the National Inpatient Sample (2012 - 2014) was gathered. Adult patients with primary discharge diagnosis of SAH who underwent endovascular therapy at a teaching hospital were identified. Patients with intracranial injury, arteriovenous malformation, and associated craniotomy were excluded. Admissions during July were compared to other months, as well as based on admission quarter: AQ1 (Jul - Sep), AQ2 (Oct - Dec), AQ3, (Jan - Mar), and AQ4 (Apr - Jun). Outcome measures included inpatient morbidity (death, iatrogenic stroke, or myocardial infarction), inpatient mortality, and non-routine discharges. Results: There were 8,515 patients with diagnosis of SAH who underwent endovascular coiling between 2012 and 2014 from the NIS database. Among these, 665 (7.8%) were admitted in July and 7,850 (92.2%) in other months. Overall, there were no differences in any of the examined outcomes, including morbidity (15.0% vs. 17.3%, p=0.513), mortality (10.5% vs. 11.8%, p=0.665), or non-routine discharge (57.1% vs. 59.7%, p=0.567) for patients admitted in July versus other months, respectively. Based on AQ, 24.5% of patients were admitted in AQ1, 26.0% in AQ2, 23.8% in AQ3, and 25.7% in AQ4. Similar to July vs. other month admissions, there were no significant differences in outcomes based on AQ. Conclusion: Based on the findings of this national investigation, patients with SAH due to ruptured aneurysms who undergo endovascular therapy during the beginning of the academic year in July may not have worse short-term outcome compared to admissions during other months.

Acute ischemic stroke (AIS) is among the leading causes of death and long-term disability. Intravenous tissue plasminogen activator has been the mainstay of acute therapy. Recently, several prospective randomized trials documented the value of endovascular revascularization in selected patients with large-vessel occlusion within the anterior circulation. This finding has led to a paradigm shift in the management of AIS, including wide adoption of noninvasive neuroimaging to assess vessel patency and tissue viability, with the supplemental and independent use of intravenous tissue plasminogen activator to improve clinical outcomes. In this article, we review the landmark studies on management of AIS and the current position on the diagnosis and management of AIS. The review also highlights the importance of early stabilization and prompt initiation of therapeutic interventions before, during, and after the diagnosis of AIS within and outside of the hospital.