Correlating Age and Hematoma Volume with Extent of Midline Shift in Acute Subdural Hematoma Patients: Validation of an Artificial Intelligence Tool for Volumetric Analysis

OBJECTIVE

Decision for intervention in acute subdural hematoma patients is based on a combination of clinical and radiographic factors. Age has been suggested as a factor to be strongly considered when interpreting midline shift (MLS) and hematoma volume data for assessing critical clinical severity during operative intervention decisions for acute subdural hematoma patients. The objective of this study was to demonstrate the use of an automated volumetric analysis tool to measure hematoma volume and MLS and quantify their relationship with age.

METHODS

A total of 1789 acute subdural hematoma patients were analyzed using qER-Quant software (Qure.ai, Mumbai, India) for MLS and hematoma volume measurements. Univariable and multivariable regressions analyzed association between MLS, hematoma volume, age, and MLS:hematoma volume ratio.

RESULTS

In comparison to young patients (≤ 70 years), old patients (>70 years) had significantly higher average hematoma volume (old: 62.2 mL vs. young 46.8 mL, P < 0.0001), lower average MLS (old: 6.6 mm vs. young: 7.4 mm, P = 0.025), and lower average MLS:hematoma volume ratio (old: 0.11 mm/mL vs. young 0.15 mm/mL, P < 0.0001). Young patients had an average of 1.5 mm greater MLS for a given hematoma volume in comparison to old patients. With increasing age, the ratio between MLS and hematoma volume significantly decreases (P = 0.0002).

CONCLUSIONS

Commercially available, automated, artificial intelligence (AI)-based tools may be used for obtaining quantitative radiographic measurement data in patients with acute subdural hematoma. Our quantitative results are consistent with the qualitative relationship previously established between age, hematoma volume, and MLS, which supports the validity of using AI-based tools for acute subdural hematoma volume estimation.

Early Experience With Artificial Intelligence Software to Detect Intracranial Occlusive Stroke in Trauma Patients

Objective Identifying ischemic stroke is a diagnostic challenge in the trauma subpopulation. We describe our early experience with artificial intelligence-assisted image analysis software for automatically identifying acute ischemic stroke in trauma patients.  Methods Patients were retrospectively screened for (i) admission to the trauma service at a level one trauma center between 2020 and 2022, (ii) radiologist-confirmed intracranial occlusion, (iii) occlusion identified on computed tomography angiography performed within 24 hours of admission, (iv) no intracranial hemorrhage, and (v) contemporaneous analysis with the large vessel occlusion (LVO) detection program. Baseline characteristics, stroke detection, response-activation, and outcome data were summarized.  Results Of 9893 trauma patients admitted, 88 (0.89%) patients had a cerebral stroke diagnosis, of which 10 patients (10/88; 11.4%) met inclusion criteria. Most patients were admitted following a fall (8/10; 80%). Six (6/10; 60.0%) patients had LVOs. The program correctly detected 83.3% (5/6) of patients, and these patients were triaged in less than one hour from arrival on average. The program did not falsely identify non-LVOs as LVOs for any patients. Conclusions Identifying adjunct tools to aid timely identification and treatment of ischemic stroke in trauma patients is necessary to increase the chances for meaningful neurological recovery. Our early experience exhibited potential for using automated software to aid occlusion identification and subsequent stroke team mobilization. Future studies in larger cohorts will expand upon these preliminary findings to establish the accuracy and clinical benefit of automated stroke detection tool integration for the trauma population.

Factors Affecting Selection of TraineE for Neurointervention (FASTEN)

BACKGROUND AND IMPORTANCE

Neurointervention is a very competitive specialty in the United States due to the limited number of training spots and the larger pool of applicants. The training standards are continuously updated to ensure solid training experiences. Factors affecting candidate(s) selection have not been fully established yet. Our study aims to investigate the factors influencing the selection process.

METHODS

A 52-question survey was distributed to 93 program directors (PDs). The survey consisted of six categories: (a) Program characteristics, (b) Candidate demographics, (c) Educational credentials, (d) Personal traits, (e) Research and extracurricular activities, and (f) Overall final set of characteristics. The response rate was 59.1%. As per the programs' characteristics, neurosurgery was the most involved specialty in running the training programs (69%). Regarding demographics, the need for visa sponsorship held the greatest prominence with a mean score of 5.9 [standard deviation (SD) 2.9]. For the educational credentials, being a graduate from a neurosurgical residency and the institution where the candidate's residency training is/was scored the highest [5.4 (SD = 2.9), 5.4 (SD = 2.5), respectively]. Regarding the personal traits, assessment by faculty members achieved the highest score [8.9 (SD = 1)]. In terms of research/extracurricular activities, fluency in English had the highest score [7.2 (SD = 1.9)] followed by peer-reviewed/PubMed-indexed publications [6.4 (SD = 2.2)].

CONCLUSION

Our survey investigated the factors influencing the final decision when choosing the future neurointerventional trainee, including demographic, educational, research, and extracurricular activities, which might serve as valuable guidance for both applicants and programs to refine the selection process.

COManeci MechANical Dilation for vasospasm (COMMAND): multicenter experience

BACKGROUND

We report the largest multicenter experience to date of utilizing the Comaneci device for endovascular treatment of refractory intracranial vasospasm.

METHODS

Consecutive patients undergoing Comaneci mechanical dilatation for vasospasm were extracted from prospectively maintained registries in 11 North American centers (2020-2022). Intra-arterial vasodilators (IAV) were allowed, with the Comaneci device utilized after absence of vessel dilation post-infusion. Pre- and post-vasospasm treatment scores were recorded for each segment, with primary radiological outcome of score improvement post-treatment. Primary clinical outcome was safety/device-related complications, with secondary endpoints of functional outcomes at last follow-up.

RESULTS

A total of 129 vessels in 40 patients (median age 52 years; 67.5% females) received mechanical dilation, 109 of which (84.5%) exhibited pre-treatment severe-to-critical vasospasm (ie, score 3/4). Aneurysmal subarachnoid hemorrhage was the most common etiology of vasospasm (85%), with 65% of procedures utilizing Comaneci-17 (92.5% of patients received IAV). The most treated segments were anterior cerebral artery (34.9%) and middle cerebral artery (31%). Significant vasospasm drop (pre-treatment score (3-4) to post-treatment (0-2)) was achieved in 89.9% of vessels (96.1% of vessels experienced ≥1-point drop in score post-treatment). There were no major procedural/post-procedural device-related complications. Primary failure (ie, vessel unresponsive) was encountered in one vessel (1 patient) (1/129; 0.8%) while secondary failure (ie, recurrence in previously treated segment requiring retreatment in another procedure) occurred in 16 vessels (7 patients) (16/129; 12.4%), with median time-to-retreatment of 2 days. Favorable clinical outcome (modified Rankin Scale 0-2) was noted in 51.5% of patients (median follow-up 6 months).

CONCLUSIONS

The Comaneci device provides a complementary strategy for treatment of refractory vasospasm with reasonable efficacy/favorable safety. Future prospective trials are warranted.

Case report: Utilization and efficacy of large-bore catheters in mechanical thrombectomies

Thrombotic strokes are caused by occlusion of flow in a blood vessel by a clot or thrombus, resulting in disruption of oxygen and nutrients to the brain that can result in neurological deficits. There are many devices now available for safe and effective removal of thrombi from large blood vessels. This report focuses on the Zoom 0.088" large-bore catheter, which has the potential to be navigated into a large vessel for thrombus removal via aspiration, and weigh the risks and benefits of its utilization in thrombectomy patients. In this case, we discuss the use of this device for thrombectomy of a left M1 middle cerebral artery occlusion that resulted in a distal left MCA dissection and eventual loss of access to the site of the thrombus. Ultimately, the patient died from a large stroke in the left MCA territory. In light of this occurrence, we seek to explore the utility and feasibility of large-bore catheters and their risks in thrombectomy candidates.

An Oropharyngeal Obstructive Lesion in a Neonate

Neonatal HNT in the pharynx is a rare cause of respiratory distress and poor feeding in the newborn, but must be differentiated from teratoma, encephalocele, and nasal glioma. While surgical resection is the preferred treatment modality, we posit there is a role for sclerosis of the glial heterotopic cyst if complete surgical excision is not possible or carries risk of high morbidity. Here, we present a case of a 7-day-old neonate presenting with acute respiratory distress found to have a nasopharyngeal/oropharyngeal mass ultimately treated with sclerotherapy at 9 months of age.

Treatment of cerebral vasospasm secondary to subarachnoid hemorrhage utilizing the Comaneci device

Delayed cerebral ischemia due to vasospasm following subarachnoid hemorrhage continues to have high morbidity and mortality despite current treatments. This report highlights the use of the Comaneci (Rapid Medical, Yokneam, Israel), a device FDA approved for temporary coil embolization assistance, for the treatment of symptomatic vasospasm. Ten days post subarachnoid hemorrhage, a patient developed acute left-sided hemiparesis with angiographic vasospasm. Through a Headway 17 microcatheter, a Comaneci 17 was deployed in the right ICA terminus, M1, M2, A1, and, A2 segments resulting in improvement of angiographic vasospasm and the patient's left-sided hemiparesis. On the following day, a repeat angiogram demonstrated no recurrence of vasospasm. The patient had complete return on neurologic function by post bleed day 18 continuing to her four-week follow-up appointment. This case demonstrates the feasibility of the Comaneci device as an effective tool in the treatment of vasospasm following subarachnoid hemorrhage.

Effect of short term immobilization on mechanical characteristics of skeletal muscle in uromastix

Gastrocnemius muscles of Uromastix were used to observe the effects of short term (7 days) immobilization in flexed position. Results demonstrated significantly (P < 0.01) lesser magnitude as well as rate of rise in isometric twitch and tetanic tensions with insignificantly different twitch/tetanus ratio in the immobilized muscles. Both the twitch and tetanus also demonstrated significantly (P<0.01) higher twitch half relaxation and twitch/tetanus half relaxation time ratio. While, immobilized muscles showed insignificantly higher twitch contraction, tetanus half relaxation and duration of active state as well as peak twitch duration, than control ones. These changes in the mechanical contraction parameters were not found to be associated with changes in weight, resting, stretched and shortened length of the immobilized muscles. A comparison of present results with previous work performed on skeletal muscles of Uromastix at longer period (20 days) of immobilization has suggested that Uromastix muscles are no prone to a significant immobilization atrophy. However, decreased mechanical response after immobilization irrespective of the period of immobilization in Uromastix muscles is probably due to a depletion in various substrates involved in muscle mechanics.

Effect of temperature on the maximum rate of rise of tension in denervated rat diaphragm muscle

Effects of chronic denervation and temperature were studied on the maximum rate of rise of tension in isometric twitch and tetanus of rat diaphragm muscles. The muscles were denervated for 15-20 days and the maximum rate of rise of tension was measured according to Hill (1951). The results showed that the maximum rate of rise of tension in twitch and tetanus was temperature dependent, exponentially increasing with increasing temperatures in both the normal and denervated muscles. A further observation was that the maximum rate of rise of tension in denervated muscle was always smaller than normal controls. It is suggested that probable changes in the series elasticity and duration of active state in the denervated muscle are responsible for the observed changes.

Effect of triturated dilutions of ethanol on the peristaltic contractions of isolated rabbit intestine

Effect of triturated dilutions of ethanol from to 10(-3) to 10(-24) were studied on the peristaltic contractions of isolated rabbit intestinal pieces. Triturated dilutions of ethanol were applied in two doses. It was generally observed that the addition of first dose was followed by a small increase of 1.1 gms. in the resting tension which occurred at a slower rate in about 36.5 sec. The second doses however, increased the resting tension by 24 gms, in about 21 sec. In addition, the active tensions showed large variations on the application of first doses of triturated ethanol, while the second doses always decreased this parameter below the first dose levels. The rate of contractions was however, unaltered by both the first and second doses of ethanol, although an increase in the contraction times was found to be balanced by a simultaneous decrease either in the peak duration or relaxation times. The results are discussed in terms of electrophysiological, active state and free ionic Ca++ release phenomena.

A comparative study of the effects of ethanol, acetylcholine and adrenaline on various parameters of intestinal contractions of rabbit

A comparative study was carried out to observe the effects of ethanol, acetylcholine and adrenaline on various parameters of the contraction cycle of rabbit intestine. Acetylcholine and adrenaline were used in concentrations of 10(-3), either alone or in combination with absolute ethanol. The results showed that ethanol and acetylcholine had no effect on the rate of intestinal contractions while adrenaline increased it significantly. However, all these drugs decreased the active tension of the contracting intestine, the decrease being minimum for ethanol, moderate for acetylcholine and maximum for adrenaline. On the contrary, a small transient decrease in resting tension was produced by ethanol and this occurred at a very fast rate while adrenaline produced a marked decrease in this parameter, its rate being 6-10 times slower. Ethanol and acetylcholine were also found to increase the resting tension, it being 2 times greater and occurring at a faster rate with acetylcholine. It is suggested that these drugs produce their effect by altering resting membrane potential, Ca++ and other ion fluxes.

Effect of Mukteswar and Komarov strains of newcastle disease vaccines on egg production

Effect of live mesogenic strains of Mukteswar and Komarov ND vaccines was studied on the egg production of laying birds. The results showed that pullets vaccinated with Mukteswar ND vaccine produced more eggs than the Komarov vaccinated or non vaccinated birds. The peak egg production was noted at the age of 29 weeks in these birds and this latter decreased. When birds were re-vaccinated with the same vaccine and route, at the age of 32 weeks, the egg production again increased to 81%. Intra muscular vaccination with Komarov ND vaccine demonstrated 11% less egg production than the birds vaccinated with Mukteswar ND vaccine. In all the experiments, birds were found to be severely affected by the hot weather resulting in a drop of egg production.

Effect of hypothermia on the twitch and tetanic contractions of denervated rat diaphragm muscle under isotonic conditions

Effect of hypothermia was studied on the twitch and tetanic contractions of the chronically denervated rat diaphragm muscles under isotonic conditions. The muscles were denervated for 15-20 days and the temperature was lowered from 35 degrees C to 15 degrees C. The results showed that hypothermia and chronic denervation had very little effect on the isotonic contraction parameters since these were found to be unaltered at all temperatures except at 15 degrees C. It is suggested that denervation has no significant effect on the contractile component of our experimental muscles.