Racial and Ethnic Disparities in the Medical Management of Poststroke Complications Among Patients With Acute Stroke

BACKGROUND

To inform clinical practice, we sought to identify racial and ethnic differences in the medical management of common poststroke complications.

METHODS AND RESULTS

A cohort of acutely hospitalized, first-time non-Hispanic White (NHW), non-Hispanic Black, and Hispanic patients with stroke was identified from electronic medical records of 51 large health care organizations (January 1, 2003 to December 5, 2022). Matched propensity scores were used to account for baseline differences. Primary outcomes included receipt of medication(s) associated with the management of the following poststroke complications: arousal/fatigue, spasticity, mood, sleep, neurogenic bladder, neurogenic bowel, and seizure. Differences were measured at 14, 90, and 365 days. Subgroup analyses included differences restricted to patients with ischemic stroke, younger age (<65 years), and stratified by decade (2003-2012 and 2013-2022). Before matching, the final cohort consisted of 348 286 patients with first-time stroke. Matching resulted in 63 722 non-Hispanic Black-NHW pairs and 24 009 Hispanic-NHW pairs. Non-Hispanic Black (versus NHW) patients were significantly less likely to be treated for all poststroke complications, with differences largest for arousal/fatigue (relative risk (RR), 0.58 [95% CI, 0.54-0.62]), spasticity (RR, 0.64 [95% CI, 0.0.62-0.67]), and mood disorders (RR, 0.72 [95% CI, 0.70-0.74]) at 14 days. Hispanic-NHW differences were similar, albeit with smaller magnitudes, with the largest differences present for spasticity (RR, 0.67 [95% CI, 0.63-0.72]), arousal/fatigue (RR, 0.77 [95% CI, 0.70-0.85]), and mood disorders (RR, 0.79 [95% CI, 0.77-0.82]). Subgroup analyses revealed similar patterns for ischemic stroke and patients aged <65 years. Disparities for the current decade remained significant but with smaller magnitudes compared with the prior decade.

CONCLUSIONS

There are significant racial and ethnic disparities in the treatment of poststroke complications. The differences were greatest at 14 days, outlining the importance of early identification and management.

Polyetheretherketone Implant Cranioplasty for Large Cranial Defects: A Seven-Year Follow-Up

BACKGROUND

Goals of a cranioplasty include protection of the brain, restoration of normal appearance, and neurological function improvement. Although choice of materials for cranial remodeling has changed through the years, computer-designed polyetheretherketone (PEEK) implant has gained traction as a preferred material used for cranioplasty. However, long-term outcomes and complications of PEEK implants remain limited. The goal of this study was to report long-term clinical outcomes after PEEK implant cranioplasty.

METHODS

A retrospective chart review was performed on patients undergoing PEEK cranioplasty between January 2007 and February 2023. Preoperative, intraoperative, and postoperative data were collected and analyzed.

RESULTS

Twenty-two patients were included in this study. Mean postoperative follow-up time was 83.45 months (range: 35.47-173.87). Before PEEK implant cranioplasty, patients with multiple cranial procedures had undergone a mean of 2.95 procedures. PEEK implant cranioplasty indications were prior implant infection (14) and secondary reconstruction of cranial defect (8). The mean implant size was 180.43 cm2 (range: 68.00-333.06). Four patients received a 2-piece implant. Postoperative complications included: perioperative subgaleal self-resolving fluid collection in 1 patient, hematoma in another, and 3 infections resulting in explantations with successful reinsertion in 2 patients. Four of 5 patients with preoperative history of seizures reported improved seizures and all 4 patients with preoperative syndrome of the trephined reported improved symptoms and neurological function.

CONCLUSION

At a mean follow-up of 7 years, most PEEK implants continued to provide protection to the brain and consistent symptom relief in patients suffering from prior postcraniectomy/craniotomy sequelae of seizures and syndrome of the trephined.

Variability in the Transition of Care to Poststroke Rehabilitation During the First Wave of COVID-19

OBJECTIVE

The aim of the study is to evaluate transitions of acute stroke and inpatient rehabilitation facility care during the first wave of COVID-19.

DESIGN

This is a retrospective observational study (3 comprehensive stroke centers with hospital-based inpatient rehabilitation facilities) between January 1, 2019, and May 31, 2019 (acute stroke = 584, inpatient rehabilitation facility = 210) and January 1, 2020, and May 31, 2020 (acute stroke = 534, inpatient rehabilitation facility = 186). Acute stroke characteristics included stroke type, demographics, and medical comorbidities. The proportion of patients admitted for acute stroke and inpatient rehabilitation facility care was analyzed graphically and using t test assuming unequal variances.

RESULTS

The proportion of intracerebral hemorrhage patients (28.5% vs. 20.5%, P = 0.035) and those with history of transient ischemic attack (29% vs. 23.9%; P = 0.049) increased during the COVID-19 first wave in 2020. Uninsured acute stroke admissions decreased (7.3% vs. 16.6%) while commercially insured increased (42.7% vs. 33.4%, P < 0.001).Acute stroke admissions decreased from 116.5 per month in 2019 to 98.8 per month in 2020 ( P = 0.008) with no significant difference in inpatient rehabilitation facility admissions (39 per month in 2019, 34.5 per month in 2020; P = 0.66).In 2019, monthly changes in acute stroke admissions coincided with inpatient rehabilitation facility admissions.In 2020, acute stroke admissions decreased 80.6% from January to February, while inpatient rehabilitation facility admissions remained stable. Acute stroke admissions increased 12.8% in March 2020 and remained stable in April, while inpatient rehabilitation facility admissions decreased by 92%.

CONCLUSIONS

Acute stroke hospitalizations significantly decreased per month during the first wave of COVID-19, with a delayed effect on the transition from acute stroke to inpatient rehabilitation facility care.

Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide-Neck Aneurysms - SCENT: 3-year outcomes

BACKGROUND

To report the 3-year safety and effectiveness of the Surpass Streamline flow diverter in the SCENT trial (Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide-Neck Aneurysms).

METHODS

The Surpass Streamline flow diverter device was evaluated in a multicenter, prospective, single-arm, non-randomized interventional trial including patients with uncoilable or previously treated but failed aneurysms of the intracranial internal carotid artery. 3-year outcomes were tabulated with descriptive statistics and compared with 1-year outcomes.

RESULTS

Of 180 patients in the modified intent-to-treat (mITT) cohort, 36-month clinical and angiographic follow-up was available in 134 and 117 cases, respectively. Effectiveness endpoint of complete aneurysm occlusion without clinically significant stenosis or retreatment was met in 71.8% (79/110, 95% CI 62.4% to 80.0%) of cases. Safety composite endpoint was 12.2% (22/180) over the 3-year period, with two major safety events (ipsilateral ischemic strokes) occurring between 12-36 months. Complete aneurysm occlusion was noted in 77.8% (91/117), and 99.1% (116/117) of the patients demonstrated adequate aneurysm occlusion (complete occlusion or neck residual). There were four cases (2.2%) of aneurysm rupture, all occurring within the first month of the index procedure. Target aneurysm retreatment rate was 2.8% (5/180).

CONCLUSION

The present findings support the long-term safety and effectiveness of the Surpass Streamline flow diverter device.

TRIAL REGISTRATION

NCT01716117.

A Transcriptomic Comparative Study of Cranial Vasculature

In genetic studies of cerebrovascular diseases, the optimal vessels to use as controls remain unclear. Our goal is to compare the transcriptomic profiles among 3 different types of control vessels: superficial temporal artery (STA), middle cerebral arteries (MCA), and arteries from the circle of Willis obtained from autopsies (AU). We examined the transcriptomic profiles of STA, MCA, and AU using RNAseq. We also investigated the effects of using these control groups on the results of the comparisons between aneurysms and the control arteries. Our study showed that when comparing pathological cerebral arteries to control groups, all control groups presented similar responses in the activation of immunological processes, the regulation of intracellular signaling pathways, and extracellular matrix productions, despite their intrinsic biological differences. When compared to STA, AU exhibited upregulation of stress and apoptosis genes, whereas MCA showed upregulation of genes associated with tRNA/rRNA processing. Moreover, our results suggest that the matched case-control study design, which involves control STA samples collected from the same subjects of matched aneurysm samples in our study, can improve the identification of non-inherited disease-associated genes. Given the challenges associated with obtaining fresh intracranial arteries from healthy individuals, our study suggests that using MCA, AU, or paired STA samples as controls are feasible strategies for future large-scale studies investigating cerebral vasculopathies. However, the intrinsic differences of each type of control should be taken into consideration when interpreting the results. With the limitations of each control type, it may be most optimal to use multiple tissues as controls.

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage.

METHODS

A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Deep-learning-enabled brain hemodynamic mapping using resting-state fMRI

Cerebrovascular disease is a leading cause of death globally. Prevention and early intervention are known to be the most effective forms of its management. Non-invasive imaging methods hold great promises for early stratification, but at present lack the sensitivity for personalized prognosis. Resting-state functional magnetic resonance imaging (rs-fMRI), a powerful tool previously used for mapping neural activity, is available in most hospitals. Here we show that rs-fMRI can be used to map cerebral hemodynamic function and delineate impairment. By exploiting time variations in breathing pattern during rs-fMRI, deep learning enables reproducible mapping of cerebrovascular reactivity (CVR) and bolus arrival time (BAT) of the human brain using resting-state CO2 fluctuations as a natural "contrast media". The deep-learning network is trained with CVR and BAT maps obtained with a reference method of CO2-inhalation MRI, which includes data from young and older healthy subjects and patients with Moyamoya disease and brain tumors. We demonstrate the performance of deep-learning cerebrovascular mapping in the detection of vascular abnormalities, evaluation of revascularization effects, and vascular alterations in normal aging. In addition, cerebrovascular maps obtained with the proposed method exhibit excellent reproducibility in both healthy volunteers and stroke patients. Deep-learning resting-state vascular imaging has the potential to become a useful tool in clinical cerebrovascular imaging.

Effect of inpatient rehabilitation facility care on ninety day modified Rankin score in ischemic stroke patients

OBJECTIVE

To determine Inpatient Rehabilitation Facility (IRF) treatment effect on modified Rankin Scale (mRS) scores at 90 days in acute ischemic stroke (AIS) patients.

MATERIALS AND METHODS

This prospective cross-sectional study included 738 AIS patients admitted 1/1/2018-12/31/2020 to a Comprehensive Stroke Center with a Stroke Rehabilitation program. We compared outcomes for patients who went directly home versus went to IRF at hospital discharge: (1) acute care length of stay (LOS), (2) National Institutes of Health Stroke Scale (NIHSS) score, (3) mRS score at hospital discharge and 90 days, (4) the proportion of mRS scores ≤ 2 from hospital discharge to 90 days.

RESULTS

Among 738 patients, 499 went home, and 239 went to IRF. IRF patients were more likely to have increased acute LOS (10.7 vs 3.9 days; t-test, P<0.0001), increased mean NIHSS score (7.8 vs 4.8; t-test, P<0.0001) and higher median mRS score (3 vs 1, t-test, P<0.0001) compared to patients who went home. At 90 days, ischemic stroke patients who received IRF care were more likely to progress to a mRS ≤ 2 (18.7% increase) compared to patients discharged home from acute care (16.3% decrease). Home patients experienced a one-point decrease in mRS at 90 days compared to those who received IRF treatment (median mRS of 3 vs. 2, t-test, P<0.05).

CONCLUSIONS

In ischemic stroke patients, IRF treatment increased the likelihood of achieving mRS ≤ 2 at 90 days indicating the ability to live independently, and decreased the likelihood of mRS decrease, compared with patients discharged directly home after acute stroke care.

Technical Nuances and Outcomes of Telescoping Pipeline Flow Diverters: A Multicenter Study

BACKGROUND

"Telescoping" multiple overlapping Pipeline Embolization Devices (PEDs; Medtronic) has increased their utility by allowing for more impermeable coverage and providing the ability to off-set landing zone sites and extend treatment constructs.

OBJECTIVE

To consider the technical nuances and challenges of telescoping PEDs for the treatment of intracranial aneurysms.

METHODS

Databases from 3 U.S. academic neurovascular centers were retrospectively queried to identify patients with intracranial aneurysms treated with multiple PED constructs. Data on patient and aneurysm characteristics, as well as outcomes including Raymond-Roy occlusion classification, modified Rankin Scale score, and complications, were gathered.

RESULTS

Forty-six patients had 48 intracranial aneurysms treated, including 16 (33%) in whom placement of telescoping PEDs was planned. Fourteen (30%) patients presented with a ruptured aneurysm. Twenty-one aneurysms (44%) were treated with proximal extension, 13 (27%) with distal extension, and 14 (29%) with PED placement inside one another. Thirty (70%) patients had complete aneurysm occlusion at follow-up. Two (4%) patients had to be retreated. Three patients with unruptured and 1 with ruptured aneurysm had a permanent intraprocedural complication. We present descriptive cases illustrating PEDs that were placed inside one another, proximally, distally, and to improve wall apposition because of vessel tortuosity.

CONCLUSION

Our data indicate a higher than expected complication rate that is likely because of the technical complexity of these cases. The case illustrations presented demonstrate the indications and challenging aspects of telescoping PEDs.

The effects of aneurysmal subarachnoid hemorrhage on cerebral vessel diameter and flow velocity

BACKGROUND

Transcranial Doppler flow velocity is used to monitor for cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Generally, blood flow velocities appear inversely related to the square of vessel diameter representing local fluid dynamics. However, studies of flow velocity-diameter relationships are few, and may identify vessels for which diameter changes are better correlated with Doppler velocity. We therefore studied a large retrospective cohort with concurrent transcranial Doppler velocities and angiographic vessel diameters.

METHODS

This is a single-site, retrospective, cohort study of adult patients with aneurysmal subarachnoid hemorrhage, approved by the UT Southwestern Medical Center Institutional Review Board. Study inclusion required transcranial Doppler measurements within </= 24 hours of vessel imaging. Vessels assessed were: bilateral anterior, middle, posterior cerebral arteries; internal carotid siphons; vertebral arteries; and basilar artery. Flow velocity-diameter relationships were constructed and fitted with a simple inverse power function. A greater influence of local fluid dynamics is suggested as power factors approach two.

RESULTS

98 patients were included. Velocity-diameter relationships are curvilinear, and well fit by a simple inverse power function. Middle cerebral arteries showed the highest power factors (>1.1, R²>0.9). Furthermore, velocity and diameter changed (P<0.033) consistent with the signature time course of cerebral vasospasm.

CONCLUSIONS

These results suggest that middle cerebral artery velocity-diameter relationships are most influenced by local fluid dynamics, which supports these vessels as preferred endpoints in Doppler detection of cerebral vasospasm. Other vessels showed less influence of local fluid dynamics, pointing to greater role of factors outside the local vessel segment in determining flow velocity.

Abstract 146: Racial Disparities In The Treatment Of Post-stroke Complications Among Acute Stroke Patients

Introduction: Racial differences in the treatment of post-stroke sequelae may contribute to known disparities in post-stroke function. Our objective was to quantify the magnitude and timing of racial differences in the treatment of common stroke post-complications to better inform and modify clinical practice.

Methods: Electronic medical record data from 65 large health care organizations (August 2002-July 2022) were used to identify a cohort of non-Hispanic White (NHW), Black and Hispanic hospitalized acute stroke patients. Baseline differences between populations were adjusted for using a matched propensity score which accounted for 41 demographic and clinical factors. Outcomes included the use of medication(s) for treatment of arousal, spasticity, mood, sleep, bladder incontinence and seizure. Differences were measured at 14-, 90-, and 365-days.

Results: Prior to matching, the final cohort consisted of 428,155 patients of which n= 309,029 were NHW, n= 82,564 were black, and 28,375 were Hispanic. For the NHW-Black comparison 80,564 pairs were matched, whereas 28,375 pairs were matched for the NHW-Hispanic comparison. All baseline covariates were balanced after matching. Compared to NHW, black patients were significantly less likely to receive treatment for every condition at nearly every timepoint. The largest differences were present for the treatment of arousal (RR: 0.70, 95% CI: 0.66- 0.74), spasticity (RR: 0.73, 95% CI: 0.71-0.76), and mood (RR: 0.83 (0.82, 0.85) at 14-days. Differences for the NHW-Hispanic comparison were similar but with slightly smaller magnitudes.

Conclusions: There are significant racial disparities in the treatment of common post-stroke sequelae. Differences were greatest at 14-days indicating the acute hospitalization and rehabilitation are crucial to identify and treat complications to reduce disparities in post-stroke function.

Abstract WMP64: Increased Risk Of Adverse Outcomes With Methocarbamol Versus Cyclobenzaprine Use In Medication Naïve Acute Stroke Patients

Introduction: Methocarbamol and Cyclobenzaprine are often used interchangeably as muscle relaxants for acute stroke patients. There is limited data comparing medication side effect profiles within this hemodynamically vulnerable population.

Methods: Electronic medical records from 65 health care organizations (Aug 2002-Jul 2022) were used to identify a cohort of medication naïve acute stroke patients (ICD-10 codes I61-I63) who received Methocarbamol or Cyclobenzaprine. A 1:1 matched propensity score was used to adjust for baseline demographic and comorbidity differences. Outcomes included the 30-day relative risk (RR) and risk difference (RD) for: falls, sedation/fatigue, bradycardia, hypotension, seizure, urinary retention, and death. Sensitivity analysis focused on 30-day risk among patients aged > 65 years.

Results: Prior to matching, the final cohort consisted of 34,865 stroke patients who received Methocarbamol (n=20,150) or Cyclobenzaprine (n=14,715). A total of 13,667 pairs were matched, all baseline covariates were well balanced. In the adjusted analyses, Methocarbamol (vs. Cyclobenzaprine) use during the acute stroke period was associated with a 44% increased risk of fall (RR: 1.44; 95% CI: 1.31-1.50) sedation/fatigue (RR: 1.54 95% CI: 1.44-1.65), bradycardia (RR: 1.32; 95% CI: 1.19-1.44), hypotension (RR: 1.29 95% CI: 1.20-1.38), and seizure (RR: 1.32 95%CI: 1.24-1.40). Results were not affected by age as adverse event risks were similar among patients aged >65.

Conclusions: Compared to Cyclobenzaprine, Methocarbamol use was associated with increased 30-day risk of a range of adverse outcomes across the age spectrum for acute stroke patients.

Abstract TP148: Anesthesia Protocol For Acute Ischemic Stroke Facilitates General Anesthesia In EVT And Optimizes Key Performance Measures

Background: Currently, there is no consensus on the ideal anesthetic strategy for patients undergoing EVT for an LVO. Recently published clinical trials show no difference in mortality, recanalization, and functional outcome related to anesthetic technique, while ongoing trials look at treatment benefits in patients randomized to general anesthesia (GA) compared to conscious sedation during EVT. Utilizing a well-outlined standardized anesthesia protocol for GA in patients undergoing EVT can optimize key performance measures for EVT without adding unnecessary delays.

Methods: This is a retrospective review of a prospectively collected database of patients who underwent EVT for LVO at a single academic CSC between January 2021 and August 2022. A multispecialty work group convened to outline best practices in the angio suite. All procedures were performed under GA while adhering to the “EVT Anesthesia Workflow.” The endorsed workflow outlined the protocol for notification of anesthesia and the angio team; the responsibility for order placements, request for bed, and procedural consent; and the expectations for all teams members to have lead on prior to patient arrival to the angio suite with biplane placement so that groin access could be obtained concurrently with intubation, to perform all cases under GA if deemed appropriate by anesthesia (unless requested otherwise), and that arterial line monitoring should not delay the procedure start time. Furthermore, pre and intraprocedural blood pressure parameters and post-EVT blood pressure goals were outlined.

Results: A total of 102 patients were reviewed, all underwent general anesthesia (5% were intubated before angio suite arrival; n=5). Mode of arrival included 47 interfacility transfers, 35 primary facility ED, and 20 inpatients. The overall median angio door-to-intubation time was 6 minutes, and angio door-to-puncture was 10 minutes. The median puncture-to-device time was 24 minutes.

Conclusion: A multispecialty collaboration to define agreed-upon workflows that outline responsibilities, expectations and goals can facilitate rapid treatments in an emergent setting. An EVT Anesthesia Workflow facilitated the use of GA in EVT without adding delays to key EVT performance measures.

Somatic Variants in SVIL in Cerebral Aneurysms

Background and Objectives

While somatic mutations have been well-studied in cancer, their roles in other complex traits are much less understood. Our goal is to identify somatic variants that may contribute to the formation of saccular cerebral aneurysms.

Methods

We performed whole-exome sequencing on aneurysm tissues and paired peripheral blood. RNA sequencing and the CRISPR/Cas9 system were then used to perform functional validation of our results.

Results

Somatic variants involved in supervillin (SVIL) or its regulation were found in 17% of aneurysm tissues. In the presence of a mutation in theSVILgene, the expression level of SVIL was downregulated in the aneurysm tissue compared with normal control vessels. Downstream signaling pathways that were induced by knockdown ofSVILvia the CRISPR/Cas9 system in vascular smooth muscle cells (vSMCs) were determined by evaluating changes in gene expression and protein kinase phosphorylation. We found thatSVILregulated the phenotypic modulation of vSMCs to the synthetic phenotype via Krüppel-like factor 4 and platelet-derived growth factor and affected cell migration of vSMCs via the RhoA/ROCK pathway.

Discussion

We propose that somatic variants form a novel mechanism for the development of cerebral aneurysms. Specifically, somatic variants inSVILresult in the phenotypic modulation of vSMCs, which increases the susceptibility to aneurysm formation. This finding suggests a new avenue for the therapeutic intervention and prevention of cerebral aneurysms.

CVR-MRICloud: An online processing tool for CO2-inhalation and resting-state cerebrovascular reactivity (CVR) MRI data

Cerebrovascular Reactivity (CVR) provides an assessment of the brain’s vascular reserve and has been postulated to be a sensitive marker in cerebrovascular diseases. MRI-based CVR measurement typically employs alterations in arterial carbon dioxide (CO2) level while continuously acquiring Blood-Oxygenation-Level-Dependent (BOLD) images. CO2-inhalation and resting-state methods are two commonly used approaches for CVR MRI. However, processing of CVR MRI data often requires special expertise and may become an obstacle in broad utilization of this promising technique. The aim of this work was to develop CVR-MRICloud, a cloud-based CVR processing pipeline, to enable automated processing of CVR MRI data. The CVR-MRICloud consists of several major steps including extraction of end-tidal CO2 (EtCO2) curve from raw CO2 recording, alignment of EtCO2 curve with BOLD time course, computation of CVR value on a whole-brain, regional, and voxel-wise basis. The pipeline also includes standard BOLD image processing steps such as motion correction, registration between functional and anatomic images, and transformation of the CVR images to canonical space. This paper describes these algorithms and demonstrates the performance of the CVR-MRICloud in lifespan healthy subjects and patients with clinical conditions such as stroke, brain tumor, and Moyamoya disease. CVR-MRICloud has potential to be used as a data processing tool for a variety of basic science and clinical applications.

Surgical Management of a Massive Frontal Bone Hemangioma: Case Report

Intraosseous hemangiomas are rare, benign tumors that can arise from the calvarium. These lesions often invade the outer table of the skull, but typically spare the inner table and intracranial structures. En bloc surgical resection is the standard treatment for intraosseous hemangiomas. However, a piecemeal resection may be required to safely remove the tumor in cases involving the inner table to protect the underlying brain parenchyma and vascular structures. Proper reconstruction is critical to optimize the cosmetic outcome, and a staged procedure allowing implantation of a custom-made implant can be considered for large lesions involving the forehead. We present a case of a patient with a large frontal intraosseous hemangioma with intradural involvement to highlight the surgical nuances of resection and review the existing literature regarding optimal management of these patients.

Time trends in the risk of delayed cerebral ischemia after subarachnoid hemorrhage: a meta-analysis of randomized controlled trials

OBJECTIVE

Delayed cerebral ischemia (DCI) contributes to morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Continuous improvement in the management of these patients, such as neurocritical care and aneurysm repair, may decrease the prevalence of DCI. In this study, the authors aimed to investigate potential time trends in the prevalence of DCI in clinical studies of DCI within the last 20 years.

METHODS

PubMed, Embase, and the Cochrane library were searched from 2000 to 2020. Randomized controlled trials that reported clinical (and radiological) DCI in patients with aSAH who were randomized to a control group receiving standard care were included. DCI prevalence was estimated by means of random-effects meta-analysis, and subgroup analyses were performed for the DCI sum score, Fisher grade, clinical grade on admission, and aneurysm treatment method. Time trends were evaluated by meta-regression.

RESULTS

The search strategy yielded 5931 records, of which 58 randomized controlled trials were included. A total of 4424 patients in the control arm were included. The overall prevalence of DCI was 0.29 (95% CI 0.26–0.32). The event rate for prevalence of DCI among the high-quality studies was 0.30 (95% CI 0.25–0.34) and did not decrease over time (0.25% decline per year; 95% CI −2.49% to 1.99%, p = 0.819). DCI prevalence was higher in studies that included only higher clinical or Fisher grades, and in studies that included only clipping as the treatment modality.

CONCLUSIONS

Overall DCI prevalence in patients with aSAH was 0.29 (95% CI 0.26–0.32) and did not decrease over time in the control groups of the included randomized controlled trials.

Abstract WP63: The Effect Of Inpatient Rehabilitation Facility Treatment On 90 Day Outcomes: A Shift Analysis Of Modified Rankin Scale Score In Ischemic Stroke Patients

Introduction: Several AHA Guidelines recommend inpatient rehabilitation facility (IRF) care to enhance post-stroke recovery. We evaluated the IRF treatment effect on modified Rankin scale (mRS) score change at 90 days in ischemic stroke (IS) patients.

Methods: Using prospectively collected data from Get With the Guidelines-Stroke, the Uniformed Data System for Medical Rehabilitation registry and the electronic medical record, we identified IS patients with discharge disposition of home or IRF between 1/1/2018-12/31/2020. Sociodemographics, clinical variables and IS treatment rates were summarized. IRF outcomes, including length of stay (LOS), improvement in mobility and self-care scores and discharge disposition were compared in thrombectomy vs no thrombectomy groups. mRS at IRF discharge was calculated with a Cronbach interrater score of 0.88; shift analyses of mRS at hospital discharge and 90 days were completed for IS patients in the Home and IRF care groups.

Results: Among 738 patients, 499 went home, 239 went to IRF. IRF patients were more likely to have Medicare insurance (49.2 vs 28.9%), undergo thrombectomy (16.3 vs 4.6%) have increased LOS (12.7 vs 4.8 days) and stroke severity (mean NIHSS 7.8 vs 4.8; mean mRS 3.1 vs 1.7) compared to Home (Table 1). At IRF, 39 patients previously underwent thrombectomy, 200 did not. Both groups had a IRF LOS >14 days and considerable recovery in the self-care and mobility domains (Table 2). Shift analysis of mRS at hospital discharge compared to 90 days yielded significant improvements in mRS of 0-2 and lower mortality in the IRF group compared to home group (Figure).

Conclusion: In ischemic stroke patients with higher disease severity, IRF treatment is a catalyst for improved functional recovery.

Non-contrast hemodynamic imaging of Moyamoya disease with MR fingerprinting ASL: A feasibility study

PURPOSE

MR Fingerprinting (MRF) Arterial Spin Labeling (ASL) is a non-contrast technique to estimate multiple brain hemodynamic and structural parameters in a single scan. The purpose of this study is to examine the feasibility and initial utility of MRF-ASL in Moyamoya disease.

METHODS

MRF-ASL, conventional single-delay ASL, Time-of-flight (TOF) MR angiography, and contrast-based dynamic-susceptibility-contrast (DSC) MRI were prospectively collected from a group of Moyamoya patients in North America (N = 21, 4 men and 17 women). Sixteen healthy subjects (7 men and 9 women) also underwent an MRF-ASL scan. Cerebral blood flow (CBF), bolus arrival time (BAT), and tissue T1 were compared between Moyamoya patients and healthy controls. Perfusion parameters from MRF-ASL were compared to those from other MRI sequences. Multi-linear regression was used for comparisons of parameter values between Moyamoya and control groups. Linear mixed-effects models was used when comparing MRF-ASL to PCASL and DSC parameters. Spearman's Rank Correlation Coefficient was calculated when comparing MRF-ASL to and MRA grades. A P value of 0.05 or less was considered significant.

RESULTS

BAT in stenotic internal carotid artery (ICA) territories was prolonged (P < 0.001) in Moyamoya patients, when compared with healthy controls. CBF in stenotic ICA territories of Moyamoya patients was not different from CBF in healthy controls; but in the PCA territories, CBF in Moyamoya patients was higher (P < 0.01) than controls. Quantitative T1 values in the stenotic ICA territories was longer (P < 0.05) than that in controls. Hemodynamic parameters estimated from MRF-ASL were significantly correlated with single-delay ASL and DSC. Longer BAT was associated with more severe intracranial artery stenosis in ICA.

CONCLUSIONS

MRF-ASL is a promising technique to assess perfusion and structural abnormalities in Moyamoya patients.

Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association

Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke. The first section focuses on preoperative optimization, including the role of preoperative carotid revascularization in patients with high-grade carotid stenosis and delaying surgery in patients with recent strokes. The second section reviews intraoperative strategies to reduce the risk of stroke, focusing on blood pressure control, perioperative goal-directed therapy, blood transfusion, and anesthetic technique. Finally, this statement presents strategies for the evaluation and treatment of patients with suspected postoperative strokes and, in particular, highlights the value of rapid recognition of strokes and the early use of intravenous thrombolysis and mechanical embolectomy in appropriate patients.

Cerebrovascular Reactivity Mapping Using Resting-State BOLD Functional MRI in Healthy Adults and Patients with Moyamoya Disease

Background Cerebrovascular reserve, the potential capacity of brain tissue to receive more blood flow when needed, is a desirable marker in evaluating ischemic risk. However, current measurement methods require acetazolamide injection or hypercapnia challenge, prompting a clinical need for resting-state (RS) blood oxygen level-dependent (BOLD) functional MRI data to measure cerebrovascular reactivity (CVR). Purpose To optimize and evaluate an RS CVR MRI technique and demonstrate its relationship to neurosurgical treatment. Materials and Methods In this HIPAA-compliant study, RS BOLD functional MRI data collected in 170 healthy controls between December 2008 and September 2010 were retrospectively evaluated to identify the optimal frequency range of temporal filtering on the basis of spatial correlation with the reference standard CVR map obtained with CO₂ inhalation. Next, the optimized RS method was applied in a new, prospective cohort of 50 participants with Moyamoya disease who underwent imaging between June 2014 and August 2019. Finally, CVR values were compared between brain hemispheres with and brain hemispheres without revascularization surgery by using Mann-Whitney U test. Results A total of 170 healthy controls (mean age ± standard deviation, 51 years ± 20; 105 women) and 100 brain hemispheres of 50 participants with Moyamoya disease (mean age, 41 years ± 12; 43 women) were evaluated. RS CVR maps based on a temporal filtering frequency of [0, 0.1164 Hz] yielded the highest spatial correlation (r = 0.74) with the CO₂ inhalation CVR results. In patients with Moyamoya disease, 77 middle cerebral arteries (MCAs) had stenosis. RS CVR in the MCA territory was lower in the group that did not undergo surgery (n = 30) than in the group that underwent surgery (n = 47) (mean, 0.407 relative units [ru] ± 0.208 vs 0.532 ru ± 0.182, respectively; P = .006), which is corroborated with the CO₂ inhalation CVR data (mean, 0.242 ru ± 0.273 vs 0.437 ru ± 0.200; P = .003). Conclusion Cerebrovascular reactivity mapping performed by using resting-state blood oxygen level-dependent functional MRI provided a task-free method to measure cerebrovascular reserve and depicted treatment effect of revascularization surgery in patients with Moyamoya disease comparable to that with the reference standard of CO₂ inhalation MRI. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Wolf and Ware in this issue.

The professional and personal impact of the coronavirus pandemic on US neurointerventional practices: a nationwide survey

BACKGROUND

Little is currently known about the effects of the coronavirus (COVID-19) pandemic on neurointerventional (NI) procedural volumes or its toll on physician wellness.

METHODS

A 37-question online survey was designed and distributed to physician members of three NI physician organizations.

RESULTS

A total of 151 individual survey responses were obtained. Reduced mechanical thrombectomy procedures compared with pre-pandemic were observed with 32% reporting a greater than 50% reduction in thrombectomy volumes. In concert with most (76%) reporting at least a 25% reduction in non-mechanical thrombectomy urgent NI procedures and a nearly unanimous (96%) cessation of non-urgent elective cases, 68% of physicians reported dramatic reductions (>50%) in overall NI procedural volume compared with pre-pandemic. Increased door-to-puncture times were reported by 79%. COVID-19-positive infections occurred in 1% of physician respondents: an additional 8% quarantined for suspected infection. Sixty-six percent of respondents reported increased career stress, 56% increased personal life/family stress, and 35% increased career burnout. Stress was significantly increased in physicians with COVID-positive family members (P<0.05).

CONCLUSIONS

This is the first study designed to understand the effects of the COVID-19 pandemic on NI physician practices, case volumes, compensation, personal/family stresses, and work-related burnout. Future studies examining these factors following the resumption of elective cases and relaxing of social distancing measures will be necessary to better understand these phenomena.

Combined Microsurgical, Endovascular, and Endoscopic Approach to the Treatment of a Giant Vertebrobasilar Aneurysm

BACKGROUND

Dolichoectasia is defined as elongation and dilatation of a blood vessel. In the intracranial circulation, the basilar artery is affected in 80% of cases. These are challenging lesions with an aggressive natural history, and treatment carries a relatively high rate of morbidity and mortality. We describe a case of multimodal treatment including endovascular, open microsurgical, and endoscopic endonasal approach (EEA) for management.

OBJECTIVE

To describe the technical nuance of the addition of the EEA for management of posterior circulation dolichoectasia.

METHODS

A 44-yr-old Hispanic woman with a 2-mo history of progressive headaches, gait disturbance, and lower cranial nerve dysfunction presented with acute neurologic decline. MRI demonstrated a dolichoectatic vertebrobasilar system with a giant 4.5-cm fusiform basilar aneurysm.

RESULTS

She underwent concomitant endovascular bilateral vertebral artery sacrifice with suction decompression and trapping by clip ligation distal to the lesion. Postoperatively, she developed symptomatic pontine compression. She was then taken for a transclival EEA for intra-aneurysmal thrombectomy. Thereafter, she made a significant functional recovery.

CONCLUSION

The addition of endoscopic reconstruction to the treatment of a dolichoectatic basilar aneurysm is an operative nuance that can be employed in treating these highly morbid lesions. This case describing a multimodal treatment paradigm including EEA reconstruction can serve as an example for the future of treatment select cases of dolichoectasia of the vertebrobasilar complex.

Lumbar drain trial outcomes of normal pressure hydrocephalus: a single-center experience of 254 patients

OBJECTIVE

A short-term lumbar drain (LD) trial is commonly used to assess the response of normal pressure hydrocephalus (NPH) patients to CSF diversion. However, it remains unknown whether the predictors of passing an LD trial match the predictors of improvement after ventriculoperitoneal shunting. The aim of this study was to examine outcomes, complication rates, and associations between predictors and outcomes after an LD trial in patients with NPH.

METHODS

The authors retrospectively reviewed the records of 254 patients with probable NPH who underwent an LD trial between March 2008 and September 2017. Multivariate regression models were constructed to examine predictors of passing the LD trial. Complications associated with the LD trial procedure were recorded.

RESULTS

The mean patient age was 77 years and 56.7% were male. The mean durations of gait disturbance, cognitive decline, and urinary incontinence were 29 months, 32 months, and 28 months, respectively. Of the 254 patients, 30% and 16% reported objective and subjective improvement after the LD trial, respectively. Complications included a sheared LD catheter, meningitis, lumbar epidural abscess, CSF leak at insertion site, transient lower extremity numbness, slurred speech, refractory headaches, and hyponatremia. Multivariate analyses using MAX-R revealed that a prior history of stroke predicted worse outcomes, while disproportionate subarachnoid spaces (uneven enlargement of supratentorial spaces) predicted better outcomes after the LD trial (r2 = 0.12, p < 0.05).

CONCLUSIONS

The LD trial is generally safe and well tolerated. The best predictors of passing the LD trial include a negative history of stroke and having disproportionate subarachnoid spaces.

Embolization of brain arteriovenous malformations with intent to cure: a systematic review

OBJECTIVE

Endovascular embolization has been established as an adjuvant treatment strategy for brain arteriovenous malformations (AVMs). A growing body of literature has discussed curative embolization for select lesions. The transition of endovascular embolization from an adjunctive to a definitive treatment modality remains controversial. Here, the authors reviewed the literature to assess the lesional characteristics, technical factors, and angiographic and clinical outcomes of endovascular embolization of AVMs with intent to cure.

METHODS

Electronic databases—Ovid MEDLINE, Ovid Embase, and PubMed—were searched for studies in which there was evidence of AVMs treated using endovascular embolization with intent to cure. The primary outcomes of interest were angiographic obliteration immediately postembolization and at follow-up. The secondary outcomes of interest were complication rates. Descriptive statistics were used to calculate rates and means.

RESULTS

Fifteen studies with 597 patients and 598 AVMs treated with intent-to-cure embolization were included in this analysis. Thirty-four percent of AVMs were Spetzler-Martin grade III. Complete obliteration immediately postembolization was reported in 58.3% of AVMs that had complete treatment and in 45.8% of AVMs in the entire patient cohort. The overall clinical complication rate was 24.1%. The most common complication was hemorrhage, occurring in 9.7% of patients. Procedure-related mortality was 1.5%.

CONCLUSIONS

While endovascular embolization with intent to cure can be an option for select AVMs, the reported complication rates appear to be increased compared with those in studies in which adjunctive embolization was the goal. Given the high complication rate related to a primary embolization approach, the risks and benefits of such a treatment strategy should be discussed among a multidisciplinary team. Curative embolization of AVMs should be considered an unanticipated benefit of such therapy rather than a goal.

Detection of delayed cerebral ischemia using objective pupillometry in patients with aneurysmal subarachnoid hemorrhage

OBJECTIVE

Cerebral vasospasm causing delayed cerebral ischemia (DCI) is a source of significant morbidity after subarachnoid hemorrhage (SAH). Transcranial Doppler is used at most institutions to detect sonographic vasospasm but has poor positive predictive value for DCI. Automated assessment of the pupillary light reflex has been increasingly used as a reliable way of assessing pupillary reactivity, and the Neurological Pupil Index (NPi) has been shown to decrease hours prior to the clinical manifestation of ischemic injury or herniation syndromes. The aim of this study was to investigate the role of automated pupillometry in the setting of SAH, as a potential adjunct to TCD.

METHODS

Our analysis included patients that had been diagnosed with aneurysmal SAH and admitted to the neuro–intensive care unit of the University of Texas Southwestern Medical Center between November 2015 and June 2017. A dynamic infrared pupillometer was used for all pupillary measurements. An NPi value ranging from 3 to 5 was considered normal, and from 0 to 2.9 abnormal. Sonographic vasospasm was defined as middle cerebral artery velocities greater than 100 cm/sec with a Lindegaard ratio greater than 3 on either side on transcranial Doppler. Most patients had multiple NPi readings daily and we retained the lowest value for our analysis. We aimed to study the association between DCI and sonographic vasospasm, and DCI and NPi readings.

RESULTS

A total of 56 patients were included in the final analysis with 635 paired observations of daily TCD and NPi data. There was no statistically significant association between the NPi value and the presence of sonographic vasospasm. There was a significant association between DCI and sonographic vasospasm, χ2(1) = 6.4112, p = 0.0113, OR 1.6419 (95% CI 1.1163–2.4150), and between DCI and an abnormal decrease in NPi, χ2(1) = 38.4456, p < 0.001, OR 3.3930 (95% CI 2.2789–5.0517). Twelve patients experienced DCI, with 7 showing a decrease of their NPi to an abnormal range. This change occurred > 8 hours prior to the clinical decline 71.4% of the time. The NPi normalized in all patients after treatment of their vasospasm.

CONCLUSIONS

Isolated sonographic vasospasm does not seem to correlate with NPi changes, as the latter likely reflects an ischemic neurological injury. NPi changes are strongly associated with the advent of DCI and could be an early herald of clinical deterioration.

Prevalence of and Risk Factors for Cerebral Microbleeds in Moyamoya Disease and Syndrome in the American Population

BACKGROUND AND PURPOSE

Cerebral microbleeds (CMB) are reported to be frequent in moyamoya disease (MMD) and moyamoya syndrome (MMS) in the Asian population. It is associated with an increased risk of intracerebral hemorrhage. The significance of CMB in MMD/MMS in non-Asian populations has not been well established. Our study aimed to investigate the prevalence of CMB in MMD/MMS in a moymoya cohort with a majority of non-Asians and to identify risk factors for developing a CMB and its predictive value for subsequent vascular events.

METHODS

The moyamoya database was compiled by screening for MMD/MMS among patients admitted to the Zale-Lipshy University Hospital at the University of Texas Southwestern Medical Center. We identified and analyzed data of 67 patients with MMD or MMS. Patients were characterized as CMB+ or CMB- based on MRI findings. In CMB+ patients, the total number and location of CMB were identified. Univariate and multivariate logistic regression were used to identify risk factors for developing CMB and whether CMB are associated with the development of subsequent vascular events.

RESULTS

Out of a total of 67 patients, 11 (16%) had CMB. Males had significantly higher odds of having CMB as compared to females (OR 1.76; 95% CI 1.40-24.3, p = 0.021). The incidence of CMB was also associated with age at diagnosis (mean age of CMB+ patients vs. CMB- patients: 44 vs. 34 years, respectively, p = 0.024), smoking (p = 0.006), and hemorrhagic stroke at presentation (p = 0.034). Logistic regression with multivariate analysis found that gender and age at diagnosis remained statistically significant. New ischemic events occurred in 2 (20%) out of 10 CMB+ patients and 13 (23%) out of 55 CMB- patients, respectively (p = 0.79). While 2 (3%) CMB- patients had a new cerebral hemorrhage during follow-up, none of the CMB+ patients did.

CONCLUSIONS

CMB are less prevalent in MMD/MMS in the USA than in Asia. An older age at diagnosis and male gender were associated with CMB. The presence of CMB was not associated with an increased risk of a subsequent ischemic or hemorrhagic stroke.

Clinical outcomes of normal pressure hydrocephalus in 116 patients: objective versus subjective assessment

OBJECTIVE

Objective assessment tests are commonly used to predict the response to ventriculoperitoneal (VP) shunting in patients with normal pressure hydrocephalus (NPH). Whether subjective reports of improvement after a lumbar drain (LD) trial can predict response to VP shunting remains controversial. The goal in this study was to compare clinical characteristics, complication rates, and shunt outcomes of objective and subjective LD responders who underwent VP shunt placement.

METHODS

This was a retrospective review of patients with NPH who underwent VP shunt placement after clinical improvement with the LD trial. Patients who responded after the LD trial were subclassified into objective LD responders and subjective LD responders. Clinical characteristics, complication rates, and shunt outcomes between the 2 groups were compared with chi-square test of independence and t-test.

RESULTS

A total of 116 patients received a VP shunt; 75 were objective LD responders and 41 were subjective LD responders. There was no statistically significant difference in patient characteristics between the 2 groups, except for a shorter length of stay after LD trial seen with subjective responders. The complication rates after LD trial and VP shunting were not significantly different between the 2 groups. Similarly, there was no significant difference in shunt response between objective and subjective LD responders. The mean duration of follow-up was 1.73 years.

CONCLUSIONS

Reports of subjective improvement after LD trial in patients with NPH can be a reliable predictor of shunt response. The currently used objective assessment scales may not be sensitive enough to detect subtle changes in symptomatology after LD trial.

Fifty shades of gradients: does the pressure gradient in venous sinus stenting for idiopathic intracranial hypertension matter? A systematic review

OBJECTIVE

The role of venous sinus stenting (VSS) for idiopathic intracranial hypertension (IIH) is not well understood. The aim of this systematic review is to attempt to identify subsets of patients with IIH who will benefit from VSS based on the pressure gradients of their venous sinus stenosis.

METHODS

MEDLINE/PubMed was searched for studies reporting venous pressure gradients across the stenotic segment of the venous sinus, pre- and post-stent pressure gradients, and clinical outcomes after VSS. Findings are reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

From 32 eligible studies, a total of 186 patients were included in the analysis. Patients who had favorable outcomes had higher mean pressure gradients (22.8 ± 11.5 mm Hg vs 17.4 ± 8.0 mm Hg, p = 0.033) and higher changes in pressure gradients after stent placement (19.4 ± 10.0 mm Hg vs 12.0 ± 6.0 mm Hg, p = 0.006) compared with those with unfavorable outcomes. The post-stent pressure gradients between the 2 groups were not significantly different (2.8 ± 4.0 mm Hg vs 2.7 ± 2.0 mm Hg, p = 0.934). In a multivariate stepwise logistic regression controlling for age, sex, body mass index, CSF opening pressure, pre-stent pressure gradient, and post-stent pressure gradient, the change in pressure gradient with stent placement was found to be an independent predictor of favorable outcome (p = 0.028). Using a pressure gradient of 21 as a cutoff, 81/86 (94.2%) of patients with a gradient > 21 achieved favorable outcomes, compared with 82/100 (82.0%) of patients with a gradient ≤ 21 (p = 0.022).

CONCLUSIONS

There appears to be a relationship between the pressure gradient of venous sinus stenosis and the success of VSS in IIH. A randomized controlled trial would help elucidate this relationship and potentially guide patient selection.

Matricidal cavernous aneurysms: a multicenter case series

Background

Cavernous carotid artery aneurysms (CCAs) represent a unique subset of intracranial aneurysms due to their distinct natural history and the anatomy of the cavernous sinus. Enlarging CCAs can cause elastic compression of the parent internal carotid artery (ICA). We suggest defining aneurysms that cause luminal stenosis of their parent vessels as ‘matricidal aneurysms.’

Though many patients are asymptomatic, presenting symptoms of CCAs include ophthalmoplegia with resulting diplopia, vision changes, pain, ptosis, facial numbness, and cavernous-carotid fistula. Less commonly, patients with CCAs can present with epistaxis, subarachnoid hemorrhage, and—in cases of matricidal aneurysms—ischemia due to stenosis. The proper management of stenosis caused by a matricidal CCA is not well established and may not be intuitive.

Methods

We present a multicenter retrospective case series of patients with matricidal CCAs.

Results

Forty patients with matricidal aneurysms presented with both asymptomatic and symptomatic stenosis. These patients were either treated with conservative medical management, coiling, flow diversion, or endovascular sacrifice of the parent artery. Planned treatment modalities were not executed in 11 cases (28% treatment failure rate). Presenting symptoms, patient outcomes, and follow-up data are presented for all cases.

Conclusion

Matricidal aneurysms require careful consideration and planning. The restricted anatomy of the cavernous sinus can make successful execution of endovascular interventions more difficult. Direct elastic compression of the parent artery does not respond to angioplasty and stenting in the same way atherosclerotic stenosis does. Because of this, planning for the possibility of parent vessel sacrifice is important.

Abstract WP168: Cerebrovascular Reactivity Predicts Surgical Decisions in Moyamoya Patients

Introduction: Moyamoya disease (MMD) is characterized by chronic occlusion of the distal intracranial internal carotid arteries and can be treated by revascularization surgery. At present, surgical decisions are primarily based on symptomatology and imaging studies using DSA and SPECT, which are are costly, invasive, time consuming and qualitative. Here we applied a novel iVas-MRI technique that provides quantitative assessment of multiple hemodynamic parameters in a 9-minute scan in MMD patients, and evaluated the ability of iVas parametric maps to predict surgical decisions in such patients.

Methods: Sixteen MMD patients were scanned on 3T MRI. Each patient had at least one hemisphere pending decision regarding surgery at the time of MRI. During iVas-MRI, a concomitant CO2/O2 breathing challenge was performed while BOLD images were continuously collected. BOLD images and end-tidal (Et) CO2 and O2 traces were used to calculate maps of cerebrovascular reactivity (CVR, based on BOLD signal change to EtCO2 change), cerebral blood volume (CBV, based on BOLD signal change to EtO2 change), and bolus arrival time (BAT, based on the time lag between EtCO2/O2 and BOLD signal). Parametric values from the ICA perfusion territory were compared between two groups, surgical and medical, with decision made by the treating neurosurgeons blinded to research data. The area-under-the-ROC-curve (AUC) was calculated to evaluate the performance of the MRI indices in predicting surgical decisions.

Results: Out of the 23 hemispheres under consideration, 9 were diagnosed as surgical and 14 considered medical. CVR, CO2-BAT and O2-BAT values showed significant differences between the two groups (p=0.0002, 0.005 and 0.001, respectively), while CBV values showed no difference (p=0.45). Brain hemispheres that required revascularization surgeries had lower CVR and longer BAT, compared to medically-managed hemispheres. ROC analyses revealed an AUC of 0.89, 0.84 and 0.95 for CVR, O2-BAT, and CO2-BAT respectively.

Conclusion: Our results showed that CVR and BAT had a great accuracy in predicting surgical decisions. Therefore, iVas-MRI may be a cost-effective and reliable method to select between medical and surgical treatments for MMD patients.

Objective Pupillometry as an Adjunct to Prediction and Assessment for Oculomotor Nerve Injury and Recovery: Potential for Practical Applications

BACKGROUND

Pupillary light reflex examinations are intrinsic to any good neurological examination. Consistent evidence has shown that automated pupillometry assessments provide superior accuracy and interrater correlation compared with bedside eye examinations. Pupillary indexes such as the neurological pupil index (NPI) can also provide several hours of warning before the advent of herniation syndromes or third nerve palsy.

METHODS

We determined the unique temporal relationship between NPI changes and third nerve palsy occurrence and recovery in an initially neurologically intact hospitalized patient. A 53-year-old woman presented with aneurysmal subarachnoid hemorrhage and headaches. Her aneurysm was treated surgically without complications. After lumbar drainage for hydrocephalus, she developed isolated left third nerve palsy that slowly recovered over the following weeks. Pupilometer data were obtained throughout her hospital stay.

RESULTS

A total of 121 pupillary measurement sets were obtained. The NPI had decreased to an abnormal level (<3) 12 hours before she became symptomatic. The NPI also started improving 24 hours before improvement in her clinical examination. The patient did not display signs of neurological dysfunction related to vasospasm during her stay.

CONCLUSION

The NPI seems to reliably correlate with third nerve function and appears to possess predictive temporal properties that could allow practitioners to anticipate neurological injury and recovery. These findings could affect the fields of neurosciences, trauma, military medicine, critical care, and ophthalmology.

Wide-neck bifurcation aneurysms of the middle cerebral artery and basilar apex treated by endovascular techniques: a multicentre, core lab adjudicated study evaluating safety and durability of occlusion (BRANCH)

Background and purpose

BRANCH (wide-neck bifurcation aneurysms of the middle cerebral artery and basilar apex treated by endovascular techniques) is a multicentre, retrospective study comparing core lab evaluation of angiographic outcomes with self-reported outcomes.

Materials and methods

Consecutive patients were enrolled from 10 US centres, aged between 18 and 85 with unruptured wide-neck middle cerebral artery (MCA) or basilar apex aneurysms treated endovascularly. Patient demographics, aneurysm morphology, procedural information, mortality and morbidity data and core lab and self-reported modified Raymond Roy (RR) outcomes were obtained.

Results

115 patients met inclusion criteria. Intervention-related mortality and significant morbidity rates were 1.7% (2/115) and 5.8% (6/103) respectively. Core lab adjudicated RR1 and 2 occlusion rates at follow-up were 30.6% and 32.4% respectively. The retreatment rate within the follow-up window was 10/115 (8.7%) and in stent stenosis at follow-up was 5/63 (7.9%). Self-reporting shows a statistically significant direction to angiographic RR one outcomes at follow-up compared with core lab evaluation, with OR 1.75 (95% CI 1.08 to 2.83).

Conclusion

Endovascular treatment of wide-neck MCA and basilar apex aneurysms resulted in a core lab adjudicated RR1 occlusion rate of 30.6%. Self-reported results at follow-up favour better angiographic outcomes, with OR 1.75 (95% CI 1.08 to 2.83). These data demonstrate the need for novel endovascular devices specifically designed to treat complex intracranial aneurysms, as well as the importance of core lab adjudication in assessing outcomes in such a trial.

Treatment of blood blister aneurysms of the internal carotid artery with flow diversion

Background

Blood blister aneurysms (BBA) are a rare subset of intracranial aneurysms that represent a therapeutic challenge from both a surgical and endovascular perspective.

Objective

To report multicenter experience with flow diversion exclusively for BBA, located at non-branching segments along the anteromedial wall of the supraclinoidal internal carotid artery (ICA).

Methods

Consecutive cases of BBA located at non-branching segments along the anteromedial wall of the supraclinoidal ICA treated with flow diversion were included in the final analysis.

Results

49 patients with 51 BBA of the ICA treated with devices to achieve the flow diversion effect were identified. 43 patients with 45 BBA of the ICA were treated with the pipeline embolization device and were included in the final analysis. Angiographic follow-up data were available for 30 patients (32 aneurysms in total); 87.5% of aneurysms (28/32) showed complete obliteration, 9.4% (3/32) showed reduced filling, and 3.1% (1/32) persistent filling. There was no difference between the size of aneurysm (≤2 mm vs >2 mm) or the use of adjunct coiling and complete occlusion of the aneurysm on follow-up (P=0.354 and P=0.865, respectively). Clinical follow-up data were available for 38 of 43 patients. 68% of patients (26/38) had a good clinical outcome (modified Rankin scale score of 0–2) at 3 months. There were 7 (16%) immediate procedural and 2 (5%) delayed complications, with 1 case of fatal delayed re-rupture after the initial treatment.

Conclusions

Our data support the use of a flow diversion technique as a safe and effective therapeutic modality for BBA of the supraclinoid ICA.

Evaluation of previously embolized intracranial aneurysms: inter-and intra-rater reliability among neurosurgeons and interventional neuroradiologists

BACKGROUND

The angiographic evaluation of previously coiled aneurysms can be difficult yet remains critical for determining re-treatment.

OBJECTIVE

The main objective of this study was to determine the inter-rater reliability for both the Raymond Scale and per cent embolization among a group of neurointerventionalists evaluating previously embolized aneurysms.

METHODS

A panel of 15 neurointerventionalists examined 92 distinct cases of immediate post-coil embolization and 1 year post-embolization angiographs. Each case was presented four times throughout the study, along with alterations in demographics in order to evaluate intra-rater reliability. All respondents were asked to provide the per cent embolization (0-100%) and Raymond Scale grade (1-3) for each aneurysm. Inter-rater reliability was evaluated by computing weighted kappa values (for the Raymond Scale) and intraclass correlation coefficients (ICC) for per cent embolization.

RESULTS

10 neurosurgeons and 5 interventional neuroradiologists evaluated 368 simulated cases. The agreement among all readers employing the Raymond Scale was fair (κ=0.35) while concordance in per cent embolization was good (ICC=0.64). Clinicians with fewer than 10 years of experience demonstrated a significantly greater level of agreement than the group with greater than 10 years (κ=0.39 and ICC=0.70 vs κ=0.28 and ICC=0.58). When the same aneurysm was presented multiple times, clinicians demonstrated excellent consistency when assessing per cent embolization (ICC=0.82), but moderate agreement when employing the Raymond classification (κ=0.58).

CONCLUSIONS

Identifying the per cent embolization in previously coiled aneurysms resulted in good inter- and intra-rater agreement, regardless of years of experience. The strong agreement among providers employing per cent embolization may make it a valuable tool for embolization assessment in this patient population.

Delayed treatment of ruptured brain AVMs: is it ok to wait?

OBJECTIVE Despite a hemorrhagic presentation, many patients with arteriovenous malformations (AVMs) do not require emergency resection. The timing of definitive management is not standardized in the cerebrovascular community. This study was designed to evaluate the safety of delaying AVM treatment in clinically stable patients with a new hemorrhagic presentation. The authors examined the rate of rehemorrhage or neurological decline in a cohort of patients with ruptured brain AVMs during a period of time posthemorrhage. METHODS Patients presenting to the authors' institution from January 2000 to December 2015 with ruptured brain AVMs treated at least 4 weeks posthemorrhage were included in this analysis. Exclusion criteria were ruptured AVMs that required emergency surgery involving resection of the AVM, prior treatment of AVM at another institution, or treatment of lesions within 4 weeks for other reasons (subacute surgery). The primary outcome measure was time from initial hemorrhage to treatment failure (defined as rehemorrhage or neurological decline as a direct result of the AVM). Patient-days were calculated from the day of initial rupture until the day AVM treatment was initiated or treatment failed. RESULTS Of 102 ruptured AVMs in 102 patients meeting inclusion criteria, 7 (6.9%) failed the treatment paradigm. Six patients (5.8%) had a new hemorrhage within a median of 248 days (interquartile range 33-1364 days). The total "at risk" period was 18,740 patient-days, yielding a rehemorrhage rate of 11.5% per patient-year, or 0.96% per patient-month. Twelve (11.8%) of 102 patients were found to have an associated aneurysm. In this group there was a single (8.3%) new hemorrhage during a total at-risk period of 263 patient-days until the aneurysm was secured, yielding a rehemorrhage risk of 11.4% per patient-month. CONCLUSIONS It is the authors' practice to rehabilitate patients after brain AVM rupture with a plan for elective treatment of the AVM. The present data are useful in that the findings quantify the risk of the authors' treatment strategy. These findings indicate that delaying intervention for at least 4 weeks after the initial hemorrhage subjects the patient to a low (< 1%) risk of rehemorrhage. The authors modified the treatment paradigm when a high-risk feature, such as an associated intracranial aneurysm, was identified.

Management of Patients on Non-Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association

Non-vitamin K oral anticoagulants (NOACs) are now widely used as alternatives to warfarin for stroke prevention in atrial fibrillation and management of venous thromboembolism. In clinical practice, there is still widespread uncertainty on how to manage patients on NOACs who bleed or who are at risk for bleeding. Clinical trial data related to NOAC reversal for bleeding and perioperative management are sparse, and recommendations are largely derived from expert opinion. Knowledge of time of last ingestion of the NOAC and renal function is critical to managing these patients given that laboratory measurement is challenging because of the lack of commercially available assays in the United States. Idarucizumab is available as an antidote to rapidly reverse the effects of dabigatran. At present, there is no specific antidote available in the United States for the oral factor Xa inhibitors. Prothrombin concentrate may be considered in life-threatening bleeding. Healthcare institutions should adopt a NOAC reversal and perioperative management protocol developed with multidisciplinary input.

Multiparametric estimation of brain hemodynamics with MR fingerprinting ASL

PURPOSE

Assessment of brain hemodynamics without exogenous contrast agents is of increasing importance in clinical applications. This study aims to develop an MR perfusion technique that can provide noncontrast and multiparametric estimation of hemodynamic markers.

METHODS

We devised an arterial spin labeling (ASL) method based on the principle of MR fingerprinting (MRF), referred to as MRF-ASL. By taking advantage of the rich information contained in MRF sequence, up to seven hemodynamic parameters can be estimated concomitantly. Feasibility demonstration, flip angle optimization, comparison with Look-Locker ASL, reproducibility test, sensitivity to hypercapnia challenge, and initial clinical application in an intracranial steno-occlusive process, Moyamoya disease, were performed to evaluate this technique.

RESULTS

Magnetic resonance fingerprinting ASL provided estimation of up to seven parameters, including B1+, tissue T₁ , cerebral blood flow (CBF), tissue bolus arrival time (BAT), pass-through arterial BAT, pass-through blood volume, and pass-through blood travel time. Coefficients of variation of the estimated parameters ranged from 0.2 to 9.6%. Hypercapnia resulted in an increase in CBF by 57.7%, and a decrease in BAT by 13.7 and 24.8% in tissue and vessels, respectively. Patients with Moyamoya disease showed diminished CBF and lengthened BAT that could not be detected with regular ASL.

CONCLUSION

Magnetic resonance fingerprinting ASL is a promising technique for noncontrast, multiparametric perfusion assessment. Magn Reson Med 78:1812-1823, 2017. © 2016 International Society for Magnetic Resonance in Medicine.

Risk of Shunting After Aneurysmal Subarachnoid Hemorrhage

Background and Purpose—

Shunt dependent hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH) is a common sequela that may lead to poor neurological outcome and predisposes to various interventions, admissions, and complications. We reviewed post-aSAH shunt dependency in a population-based sample and tested the feasibility of a clinical risk score to identify subgroups of aSAH patients with increasing risk of shunting for hydrocephalus.

Methods—

A total of 1533 aSAH patients from the population-based Eastern Finland Saccular Intracranial Aneurysm Database (Kuopio, Finland) were used in a recursive partitioning analysis to identify risk factors for shunting after aSAH. The risk model was built and internally validated in random split cohorts. External validation was conducted on 946 aSAH patients from the Southwestern Tertiary Aneurysm Registry (Dallas, TX) and tested using receiver-operating characteristic curves.

Results—

Of all patients alive ≥14 days, 17.7% required permanent cerebrospinal fluid diversion. The recursive partitioning analysis defined 6 groups with successively increased risk for shunting. These groups also successively risk stratified functional outcome at 12 months, shunt complications, and time-to-shunt rates. The area under the curve–receiver-operating characteristic curve for the exploratory sample and internal validation sample was 0.82 and 0.78, respectively, with an external validation of 0.68.

Conclusions—

Shunt dependency after aSAH is associated with higher morbidity and mortality, and prediction modeling of shunt dependency is feasible with clinically useful yields. It is important to identify and understand the factors that increase risk for shunting and to eliminate or mitigate the reversible factors. The aSAH-PARAS Consortium (Aneurysmal Subarachnoid Hemorrhage Patients’ Risk Assessment for Shunting) has been initiated to pool the collective insights and resources to address key questions in post-aSAH shunt dependency to inform future aSAH treatment guidelines.

Multiparametric imaging of brain hemodynamics and function using gas-inhalation MRI

Diagnosis and treatment monitoring of cerebrovascular diseases routinely require hemodynamic imaging of the brain. Current methods either only provide part of the desired information or require the injection of multiple exogenous agents. In this study, we developed a multiparametric imaging scheme for the imaging of brain hemodynamics and function using gas-inhalation MRI. The proposed technique uses a single MRI scan to provide simultaneous measurements of baseline venous cerebral blood volume (vCBV), cerebrovascular reactivity (CVR), bolus arrival time (BAT), and resting-state functional connectivity (fcMRI). This was achieved with a novel, concomitant O₂ and CO₂ gas inhalation paradigm, rapid MRI image acquisition with a 9.3min BOLD sequence, and an advanced algorithm to extract multiple hemodynamic information from the same dataset. In healthy subjects, CVR and vCBV values were 0.23±0.03%/mmHg and 0.0056±0.0006%/mmHg, respectively, with a strong correlation (r=0.96 for CVR and r=0.91 for vCBV) with more conventional, separate acquisitions that take twice the scan time. In patients with Moyamoya syndrome, CVR in the stenosis-affected flow territories (typically anterior-cerebral-artery, ACA, and middle-cerebral-artery, MCA, territories) was significantly lower than that in posterior-cerebral-artery (PCA), which typically has minimal stenosis, flow territories (0.12±0.06%/mmHg vs. 0.21±0.05%/mmHg, p<0.001). BAT of the gas bolus was significantly longer (p=0.008) in ACA/MCA territories, compared to PCA, and the maps were consistent with the conventional contrast-enhanced CT perfusion method. FcMRI networks were robustly identified from the gas-inhalation MRI data after factoring out the influence of CO₂ and O₂ on the signal time course. The spatial correspondence between the gas-data-derived fcMRI maps and those using a separate, conventional fcMRI scan was excellent, showing a spatial correlation of 0.58±0.17 and 0.64±0.20 for default mode network and primary visual network, respectively. These findings suggest that advanced gas-inhalation MRI provides reliable measurements of multiple hemodynamic parameters within a clinically acceptable imaging time and is suitable for patient examinations.