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Background: Successful reperfusion is one of the strongest predictors of functional outcomes after mechanical thrombectomy (MT). Despite continuous advancements in MT technology and techniques, reperfusion failure still occurs in ≈15% to 30% of patients with large vessel occlusion strokes undergoing MT. We aim to evaluate the safety and efficacy of rescue intracranial stenting for large vessel occlusion stroke after failed MT. Methods: The SAINT (Stenting and Angioplasty in Neurothrombectomy) Study is a retrospective analysis of prospectively collected data from 14 comprehensive stroke centers through January 2015 to December 2020. Patients were included if they had anterior circulation large vessel occlusion stroke due to intracranial internal carotid artery and middle cerebral artery-M1/M2 segments and failed MT. The cohort was divided into 2 groups: rescue intracranial stenting and failed recanalization (modified Thrombolysis in Cerebral Ischemia score 0–1). Propensity score matching was used to balance the 2 groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale at 90 days. Secondary outcomes included functional independence (90-day modified Rankin Scale score 0–2). Safety measures included symptomatic intracranial hemorrhage and 90-day mortality. Results: A total of 499 patients were included in the analysis. Compared with the failed reperfusion group, rescue intracranial stenting had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 2.31 [95% CI, 1.61–3.32]; P P P =0.04) at 90 days. Rates of symptomatic intracerebral hemorrhage were comparable across both groups (7.1% versus 10.2%; aOR, 0.99 [95% CI, 0.42–2.34]; P =0.98). The matched cohort analysis demonstrated similar results. Specifically, rescue intracranial stenting (n=107) had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 3.74 [95% CI, 2.16–6.57]; P P P =0.03) at 90 days with similar rates of symptomatic intracerebral hemorrhage (7.5% versus 11.2%; aOR, 0.87 [95% CI, 0.31–2.42]; P =0.79) compared with patients who failed to reperfuse (n=107). There was no heterogeneity of treatment effect across the prespecified subgroups for improvement in functional outcomes. Conclusions: Acute intracranial stenting appears to be a safe and effective rescue strategy in patients with large vessel occlusion stroke who failed MT. Randomized multicenter trials are warranted.

BackgroundRandomized clinical trials have failed to prove that the safety and efficacy of endovascular treatment for symptomatic intracranial atherosclerotic disease (ICAD) is better than that of medical management. A recent study using a self-expandable stent showed acceptable lower rates of periprocedural complications.ObjectiveTo study the safety and efficacy of a balloon-mounted stent (BMS) in the treatment of symptomatic ICAD.MethodsProspectively maintained databases from 15 neuroendovascular centers between 2010 and 2020 were reviewed. Patients were included if they had severe symptomatic intracranial stenosis in the target artery, medical management had failed, and they underwent intracranial stenting with BMS after 24 hours of the qualifying event. The primary outcome was the occurrence of stroke and mortality within 72 hours after the procedure. Secondary outcomes were the occurrence of stroke, transient ischemic attacks (TIAs), and mortality on long-term follow-up.ResultsA total of 232 patients were eligible for the analysis (mean age 62.8 years, 34.1% female). The intracranial stenotic lesions were located in the anterior circulation in 135 (58.2%) cases. Recurrent stroke was the qualifying event in 165 (71.1%) while recurrent TIA was identified in 67 (28.9%) cases. The median (IQR) time from the qualifying event to stenting was 5 (2–20.75) days. Strokes were reported in 13 (5.6%) patients within 72 hours of the procedure; 9 (3.9%) ischemic and 4 (1.7%) hemorrhagic, and mortality in 2 (0.9%) cases. Among 189 patients with median follow-up time 6 (3–14.5) months, 12 (6.3%) had TIA and 7 (3.7%) had strokes. Three patients (1.6%) died from causes not related to stroke.ConclusionOur study has shown that BMS may be a safe and effective treatment for medically refractory symptomatic ICAD. Additional prospective randomized clinical trials are warranted.

BackgroundThere is little data available to guide optimal anesthesia management during rescue intracranial angioplasty and stenting (ICAS) for failed mechanical thrombectomy (MT). We sought to compare the procedural safety and functional outcomes of patients undergoing rescue ICAS for failed MT under general anesthesia (GA) vs non-general anesthesia (non-GA).MethodsWe searched the data from the Stenting and Angioplasty In Neuro Thrombectomy (SAINT) study. In our review we included patients if they had anterior circulation large vessel occlusion strokes due to intracranial internal carotid artery (ICA) or middle cerebral artery (MCA-M1/M2) segments, failed MT, and underwent rescue ICAS. The cohort was divided into two groups: GA and non-GA. We used propensity score matching to balance the two groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included functional independence (90-day mRS0-2) and successful reperfusion defined as mTICI2B-3. Safety measures included symptomatic intracranial hemorrhage (sICH) and 90-day mortality.ResultsAmong 253 patients who underwent rescue ICAS, 156 qualified for the matching analysis at a 1:1 ratio. Baseline demographic and clinical characteristics were balanced between both groups. Non-GA patients had comparable outcomes to GA patients both in terms of the overall degree of disability (mRS ordinal shift; adjusted common odds ratio 1.29, 95% CI [0.69 to 2.43], P=0.43) and rates of functional independence (33.3% vs 28.6%, adjusted odds ratio 1.32, 95% CI [0.51 to 3.41], P=0.56) at 90 days. Likewise, there were no significant differences in rates of successful reperfusion, sICH, procedural complications or 90-day mortality among both groups.ConclusionsNon-GA seems to be a safe and effective anesthesia strategy for patients undergoing rescue ICAS after failed MT. Larger prospective studies are warranted for more concrete evidence.

Background By 2030, nonacute subdural hematomas (NASHs) will likely be the most common cranial neurosurgery pathology. Treatment with surgical evacuation may be necessary, but the recurrence rate after surgery is as high as 30%. Minimally invasive middle meningeal artery embolization (MMAE) during the perioperative period has been posited as an adjunctive treatment to decrease the potential for recurrence after surgical evacuation. We evaluated the safety and efficacy of concurrent MMAE in a multi-institutional cohort. Methods Data from 145 patients (median age 73 years) with NASH who underwent surgical evacuation and MMAE in the perioperative period were retrospectively collected from 15 institutions. The primary outcome was the rate of recurrence requiring repeat surgical intervention. We collected clinical, treatment, and radiographic data at initial presentation, after evacuation, and at 90-day follow-up. Outcomes data were also collected. Results Preoperatively, the median hematoma width was 18 mm, and subdural membranes were present on imaging in 87.3% of patients. At 90-day follow-up, median NASH width was 6 mm, and 51.4% of patients had at least a 50% decrease of NASH size on imaging. Eight percent of treated NASHs had recurrence that required additional surgical intervention. Of patients with a modified Rankin Scale score at last follow-up, 87.2% had the same or improved mRS score. The total all-cause mortality was 6.0%. Conclusion This study provides evidence from a multi-institutional cohort that performing MMAE in the perioperative period as an adjunct to surgical evacuation is a safe and effective means to reduce recurrence in patients with NASHs.

The optimization of antithrombotic therapy for acute stroke treatment and secondary prevention is an evolving process based on an increasing array of studies that provide an evidence-based approach. Options have increased dramatically with the release of the non-vitamin K oral anticoagulants and with the results of recent randomized clinical trials designed to assess potential benefits versus risks for patients in an individualized fashion. Recent studies have provided important information to guide choice and dosing of antiplatelet agents as well as the length of treatment. Anticoagulant use is particularly pertinent for stroke prevention in patients at higher risk of atrial fibrillation and may have a place in certain other stroke mechanisms. One important focus of study is the potential benefit of combined antiplatelet and anticoagulant therapy. Options for our patients, when the initial choice of therapy does not demonstrate benefit or is not well tolerated, clearly, are valuable. For example, short-term dual antiplatelet therapy for minor stroke and transient ischemic attack is being adopted, but with the recognition that longer-term combined therapy is not worth the increased risk of bleeding. Alternative antiplatelet choices, such as cilostazol and possibly ticagrelor, may be of benefit for refractory patients and this could affect the decision-making process. This review represents an effort to incorporate the information from more recent stroke prevention and treatment studies with information gleaned from prior studies.

BackgroundThe effectiveness of mechanical thrombectomy (MT) was demonstrated in five landmark trials published in2015.Mechanical thrombectomy is now standard of care for acute ischemic stroke and has been growing in popularity after publication of landmark trials.ObjectiveTo analyze outcomes and trends of the use of MT and intravenous thrombolysis (IVT) in patients with acute ischemic stroke in US hospitals before and after publication of these trials.MethodsPatients discharged with a diagnosis of ischemic stroke between 2012 to 2017 were diagnosed using ICD codes from the National Inpatient Sample. Thereafter, patients given acute stroke treatment were identified using the corresponding procedure codes for IVT and MT. The primary clinical outcomes of in-hospital mortality and disability were then compared between two time periods: 2012–2014 (pre-landmark trials) and 2015–2017 (post-landmark trials). Binary logistic regression and Χ2tests were used for statistical analysis.ResultsA total of 57 675 patients (median age 68.9 years (range 18-90), 50.1% female) were identified with acute procedures. Of these patients, 57.6% were from the post-landmark trials time period. Despite an increased number of cases, the rate of IVT decreased from 84.3% to 75.9% and the rate of IVT+MT decreased from 7.1% to 6.3%. After publication of the pivotal trials in 2015, the rates of MT increased from 8.7% to 17.8%. Significant reductions of in-hospital mortality (7.1% vs 8.7%, pConclusionThe analysis showed a significant increase in the proportion of patients receiving MT after 2015. This has translated into reduction of in-hospital mortality and improvement in disability.

Background: Time to reperfusion remains one of the strongest predictors of outcome in large vessel occlusion strokes (LVOS). Herein, we aim to assess the impact of unfavorable vascular anatomy on mechanical thrombectomy (MT) number of passes and procedural times. Methods: Retrospectively review of a prospective MT database spanning January-July 2018 including acute LVOS involving the middle cerebral artery-M1 segment and available baseline CT angiography. The AIM2 score (Table 1) was applied with patients categorized as favorable (AIM2: 0-2) versus unfavorable (AIM2: >=3) anatomy. The primary outcome was the rate of Results: Patients with unfavorable anatomy (n=15) were significantly younger (52±19, p=0.02) and had lower rates of hypertension (46% vs 80%, p=0.01) and smoking (0% vs 39%, p Conclusions: The AIM2 score system represents a simple method for the systematically evaluation of vascular anatomy in MT and correlates significantly with increased number of MT passes.

Background and PurposeThe Penumbra JET 7 reperfusion catheter is used in the revascularization of large vessel occlusions in acute ischemic stroke. Description of its use in clinical practice remains limited. Our purpose is to describe our initial experience with the Penumbra JET 7 reperfusion catheter and to report on its safety and efficacy in different thrombectomy techniques.Materials and MethodsWe conducted a retrospective study of 50 patients treated with thrombectomy using the Penumbra JET 7 reperfusion catheter. Mean patient age and admission National Institutes of Health Stroke Scale were 70.6 and 17.76, respectively. The most common sites of vessel occlusion were the M1 segment (72%) followed by distal internal carotid artery (14%). Thrombectomy was performed using the direct aspiration first-pass technique and/or aspiration in conjunction with a stent retriever.ResultsRevascularization was achieved in a total of 44 cases (88%). Successful navigation of the Penumbra JET 7 reperfusion catheter to the occlusion site with clot engagement was achieved in 94% of cases. Mean time from vascular access to revascularization was 31.60 min. No catheter-related complications occurred. Clinical outcome data were collected from 43 patients (86%). Of those patients, 51% achieved good outcome (modified Rankin score of 0–2) at 60 or more days follow-up, 28% had poor outcome (modified Rankin score of 3–5), and 9 patients died (21%).ConclusionThe use of the Penumbra JET 7 reperfusion catheter for treatment of acute ischemic stroke was observed to be safe and effective with appropriate revascularization outcomes in different thrombectomy techniques.

Objective: To compare inpatient mortality rates in patients who underwent intracranial endovascular stenting and/or angioplasty of the vertebral artery or basilar artery by analyzing data from the National inpatient sample database (2012-2015). Methods: We extracted data utilizing ICD-9 diagnosis codes for occlusion and stenosis of vertebral artery with or without stroke (433.20, 433.21) and occlusion and stenosis of basilar artery with or without stroke (433.00, 433.01). The cohort included total of 201 patients. Binary logistic regression and Chi-square tests were utilized for data analysis. Results: A total number of 201 patients underwent either intracranial angioplasty alone or stenting with or without angioplasty for either vertebral or basilar artery stenosis. Male patients were predominant (74%). The majority were 51 to 75 years of age (76.1%). 55% of the patients had stenosis of the basilar artery, 45% had vertebral artery stenosis. The majority of patients underwent stenting with or without angioplasty (69%); 47% had basilar stenting and 53% had vertebral stenting. The common co-morbidities observed were hypertension (84%), diabetes mellitus (37%), peripheral vascular disease (20%) and obesity (14%). The overall mortality rate in this cohort was 17.4%. The mortality rate was significantly higher in patients with basilar artery stenosis when compared with vertebral artery stenosis regardless of type of procedure performed (24% vs 9%, P = 0.004). The mortality during hospitalization was not significantly affected by the type of procedure (angioplasty vs stenting with or without angioplasty), or by the aforementioned comorbidities. The significant predictor of mortality was basilar artery stenosis (OR 2.87, 95% CI 1.18-6.98, P =0.02). Conclusion: The overall mortality in this cohort of patients who underwent angioplasty vs stenting with or without angioplasty for basilar or vertebral intracranial artery stenosis was 17.4%. Mortality rate was significantly higher in patients with basilar artery stenosis (24%) compared to those with vertebral artery stenosis (9%). The type of procedure performed (angioplasty vs stenting with or without angioplasty) had no significant statistical impact.

To use a nationwide database of hospital admissions to assess for trends in inpatient mortality from acute spontaneous intracerebral hemorrhage as well as associated potentially contributing factors.Adults with intracerebral hemorrhage in the US National Inpatient Sample database from 2012 to 2015 were included in this study. We assessed for mortality rate as well as potential impact of various comorbidities and demographic factors such as ethnicity and median house hold income on inpatient mortality rate.A total of 47,700 patients were identified with a mean age of 68 years. The overall mortality rate was 24%. Hypertension was the commonest comorbidity (84%) followed by diabetes mellitus (28%). Positive associated factors for mortality rate were coagulopathy (OR 1.28, 95% CI 1.19-1.38, P.001), female gender (OR 1.12, 95% CI 1.08-1.17, P.001), and congestive heart failure (OR 1.16, 95% CI 1.08-1.24, P.001). Age greater than 75 was also associated with higher mortality (P.001). Factors associated with reduced mortality were hypertension (OR .76, 95% CI .72-0.81, P.001), hypothyroidism (OR .87, 95% CI .81-.93, P.001) and obesity (OR .64, 95% CI .59-.69, P.001).The inpatient mortality of 24% represents a decline when compared to previous years. Attention to the associated factors with mortality, that we report, could have some potential impact on management. Of interest, we found support for obesity paradox in which obesity may have an actual salutary effect on vascular disease outcome. Our observed paradoxical effects, not only for obesity, but also hypertension and hypothyroidism, warrant further study.

Objective: To observe for trends in the inpatient mortality rate following nontraumatic intracerebral hemorrhage (ICH) and to determine the effect of pertinent comorbidities on inpatient mortality using the US National Inpatient Sample (NIS) database. Method: Using the NIS (2012-first three quarter of 2015) database, patient records of adults with ICH were analyzed. We extracted data with a principal diagnosis of ICH using the diagnostic code 431 (ICD-9-CM) and clinical classifications software code 109 (acute cerebrovascular disease) so that traumatic ICH cases were eliminated. Results: A total number of 47,700 patients were included in this study. The mean age was 68 years. The majority of the patients ranged in age from 51 to 75 years (49%), were male (52%) and Caucasian (60%). Weekend admissions made up 27% of cases. Pertinent comorbidities noted in this cohort include coagulopathy (8%), diabetes (28%), hypertension (84%), liver disease (3%), renal failure (14%) and obesity (9%). The overall inpatient mortality rate was 24%. The mortality rate was high in females (25%) vs males (23%, p< 0.001); underlying coagulopathy (29% vs 24% without, p< 0.001) and liver disease (27% vs 24% without, p=0.019). Mortality rate was also elevated in patients >75 years old (28%, p< 0.001). There was no association between inpatient mortality rate and median household income, or the presence of diabetes or renal failure. It was significantly low with hypertension (23% vs 29%, p< 0.001) and obesity (17% vs 25%, p< 0.001). When the group of ICH patients without hypertension was compared with the hypertensive group we found a significantly higher proportion of patients with coagulopathy (11% vs 8%) and liver disease (5% vs 3%). However obesity did not confer a significant risk of comorbid coagulopathy (8% vs 8%) or liver disease (2.9% vs 3.1%). Conclusion: The overall observed inpatient mortality rate in this study of patients admitted for nontraumatic ICH was 24%. Comorbidities which increased the mortality rate significantly were female gender, age greater than 75 years, coagulopathy and liver disease. It was significantly low in hypertension and in obesity. The paradoxical effect of hypertension and obesity on inpatient mortality needs to be further assessed in prospective studies.

Objective The use and timing of flow diversion for aneurysmal subarachnoid hemorrhage is controversial. The objective of this study is to perform a meta-analysis and systematic review to compare overall complication rate between early versus delayed flow diversion for ruptured aneurysms. Methods A literature search for all eligible articles was performed using PubMed, Cochrane, and Web of Science databases. The primary outcome was the overall complication rate (any complication in the perioperative period), and secondary outcomes were 1) hemorrhage and 2) stroke/death (all hemorrhagic/ischemic strokes and/or death). Results Thirteen articles including 142 patients met inclusion criteria. Eighty-nine (62.7%) patients underwent early deployment of flow diverters (i.e., 2 days or less). The odds ratio for overall complication rate with early versus delayed flow diversion was 0.95 (95% confidence interval [CI] 0.36–2.49, P = 0.42). The odds ratio for the secondary outcome of hemorrhagic complication for early versus delayed flow diversion was 1.44 (95% CI 0.45–4.52, P = 0.87) and of stroke/death was 1.67 (95% CI 0.5–4.9, P = 0.69). The odds ratio of early versus delayed flow diversion for blister/dissecting/fusiform aneurysms was 0.82 (95% CI 0.29–2.30) and for saccular/giant aneurysms was 2.23 (95% CI 0.17–29.4). At last follow-up, 71.6% of patients had good performance status (modified Rankin Scale score 0–2), and the rate of angiographic aneurysm occlusion was 90.2%. Conclusions This meta-analysis did not show a difference in overall complication rate between early versus delayed flow diversion for ruptured aneurysms. Early flow diversion for ruptured blister/fusiform/dissecting aneurysms carries a lower risk of aneurysm rerupture and overall complications as compared with that for ruptured saccular/giant aneurysms.

To estimate the prevalence of ischemic stroke (IS) and atrial fibrillation (AF) in young patients with migraine and to identify the independent predictors of IS in a large cohort of hospitalized patients.A cohort of patients with migraine with aura (MA) and migraine without aura (MO) was identified from the National Inpatient Sample database for the years 2012 to 2015. Ischemic stroke was identified by the International Classification of Diseases-9-CM codes. Binary logistic regression and Chi-square tests were utilized.A total number of 834,875 young patients (18-44 years) were included in this study with a mean age of 33 years. The prevalence of IS was 1.3% and was significantly higher in patients with MA (3.7% versus 1.2%, P0.001). The prevalence of AF was 0.9% and it was significantly higher in patients with MA (1.2% versus 0.8%, P0.001). Migraine with aura was an independent predictor of IS (OR 3.23, 95% CI 3.05-3.42, P0.001) and AF (OR 1.63, 95% CI 1.42-1.88, P0.001). Other predictors of IS were hypertension (OR 2.2, 95% CI 2.12-2.3, P0.001), diabetes mellitus (DM) (OR 1.37, 95% CI 1.31-1.42, P0.001), peripheral vascular disease (PVD) (OR 12.08, 95% CI 11.23-12.98, P0.001) and smoking (OR 1.37, 95% CI 1.31-1.42, P0.001).In this relatively large study, the overall prevalence of IS in young migraine patients was low at 1.3%. The prevalence of IS and AF was significantly higher in patients with MA. Presence of PVD confers a high risk of IS in young patients with migraine. Migraine aura was observed to be an independent predictor of IS and AF in patients with history of migraine. Optimal control of vascular risk factors in migraine patients appears to be indicated despite the overall low risk.