What's the Future of Vascular Neurology?

The field of vascular neurology has made tremendous advances over the last several decades, with major shifts in diagnosis, treatment, prevention, and rehabilitation of patients with stroke. Furthermore, the individuals who are providing the care represent a different cohort than those who were caring for stroke patients 30 years ago, with the increasing need for rapid decision-making for acute interventions and a larger workforce being needed to provide the many complicated aspects of care of stroke patients. Understanding the history of the field is critical before one can speculate about its future directions. In summarizing some of the past massive shifts in the past few decades, this review will discuss future opportunities and future challenges and will introduce the rest of this special issue focusing on vascular neurology in a post-thrombectomy era. Although thrombolysis and thrombectomy remain a major part of ischemic stroke management and care, in the coming years, there will likely be further modifications in how we provide the care, who provides it, how we train those individuals who provide it, where it is provided, and what data inform early management decisions.

Clinical Utility of Routine Postprocedural Computed Tomography of the Head Following Elective Neuroendovascular Interventions

BACKGROUND

Little evidence supports acquisition of routine head imaging after uncomplicated elective neurosurgical procedures for patients with unchanged neurological examinations; however, imaging is still performed by some neurointerventionalists. We assessed the clinical utility of routine computed tomography of the head (CTH) following elective neuroendovascular interventions, including aneurysm coiling, aneurysm stent-assisted coiling, aneurysm flow diversion, arteriovenous malformation/fistula embolization, middle meningeal artery embolization for subdural hematoma, extracranial carotid artery stenting, and venous sinus stenting.

METHODS

Retrospective chart review identified patients undergoing neuroendovascular intervention from 2011 to 2021 at our institution. Demographic, clinical, and radiographic variables, including presenting signs and symptoms, antiplatelets and/or anticoagulant medications, intraprocedural complications, postprocedural CTH findings, and postprocedural neurological examinations, were recorded. Association of clinical variables with an abnormal postprocedural CTH was assessed with univariate analysis. Patients with ruptured vascular pathology, preoperative embolizations, and missing postprocedural CTH images and/or reports were excluded.

RESULTS

Of 509 procedures identified, 354 were eligible for analysis; 4.8% of patients (17/354) had abnormal findings on postprocedural CTH. Nine patients had intraprocedural complications or new postprocedural neurological deficits that would have prompted imaging regardless of institutional practice. None of the remaining 8 (2.3%) patients required additional procedures. New postprocedural neurological deficit was the only significant predictor of abnormal postprocedural CTH (odds ratio = 6.79; 95% confidence interval, 2.01-20.32; P = 0.0009).

CONCLUSIONS

In a large cohort of patients undergoing elective neuroendovascular intervention, no patients were identified for whom routine postprocedural CTH alone meaningfully altered their clinical care. Routine CTH is not necessary after uncomplicated elective neuroendovascular interventions performed with careful postprocedural neurological assessment.

Basilar Artery Bands: Anatomic and Histologic Study with Application to Coiling and Stenting Procedures

BACKGROUND

Internal bands of the basilar artery (BA) have been rarely studied. Because bands could have obvious consequences in patient diagnosis and care, the present multiinstitutional cadaveric study was performed.

METHODS

The intraluminal bands of BAs were studied in 80 cadaveric specimens derived from India (Group 1) and the United States (Group 2). Their orientation within the vessel was recorded. Measurements included the length of the BA, diameter of the BA, intraluminal band length and thickness, and distance of the band to the vertebrobasilar junction. Selected bands were submitted for histologic analysis.

RESULTS

In Group 1, an intraluminal band (all vertically oriented) was identified in 16.6%. The mean length and thickness of the bands were 2.04 mm and 1.33 mm, respectively. These bands were located at a mean distance of 1.74 mm superior to the vertebrobasilar junction. In Group 2, an intraluminal band was identified in 6%. One band was vertically positioned, and 2 were horizontally positioned. The mean length and thickness of the bands were 2.5 mm and 0.9 mm, respectively. These latter bands were located at a mean distance of 2.23 mm superior to the vertebrobasilar junction. Histologically, the bands were essentially extensions of the tunica media and interna of the artery.

CONCLUSIONS

To our knowledge, this study is the first multiethnic study of the prevalence and morphometry of the BA bands. A better understanding of these bands may help reveal their relationship to thrombus and aneurysmal formation and their impact on endovascular procedures.

Perioperative Coronavirus Disease 2019 (COVID-19) Incidence and Outcomes in Neurosurgical Patients at Two Tertiary Care Centers in Washington, DC, During a Pandemic: A 6-Month Follow-up

OBJECTIVE

Coronavirus disease 2019 (COVID-19) continues to affect all aspects of health care delivery, and neurosurgical practices are not immune to its impact. We aimed to evaluate neurosurgical practice patterns as well as the perioperative incidence of COVID-19 in neurosurgical patients and their outcomes.

METHODS

A retrospective review of neurosurgical and neurointerventional cases at 2 tertiary centers during the first 3 months of the first peak of COVID-19 pandemic (March 8 to June 8) as well as following 3 months (post-peak pandemic; June 9 to September 9) was performed. Baseline characteristics, perioperative COVID-19 test results, modified Medically Necessary, Time-Sensitive (mMeNTS) score, and outcome measures were compared between COVID-19-positive and-negative patients through bivariate and multivariate analysis.

RESULTS

In total, 652 neurosurgical and 217 neurointerventional cases were performed during post-peak pandemic period. Cervical spine, lumbar spine, functional/pain, cranioplasty, and cerebral angiogram cases were significantly increased in the postpandemic period. There was a 2.9% (35/1197) positivity rate for COVID-19 testing overall and 3.6% (13/363) positivity rate postoperatively. Age, mMeNTS score, complications, length of stay, case acuity, American Society of Anesthesiologists status, and disposition were significantly different between COVID-19-positive and-negative patients.

CONCLUSIONS

A significant increase in elective case volume during the post-peak pandemic period is feasible with low and acceptable incidence of COVID-19 in neurosurgical patients. COVID-19-positive patients were younger, less likely to undergo elective procedures, had increased length of stay, had more complications, and were discharged to a location other than home. The mMeNTS score plays a role in decision-making for scheduling elective cases.

Case Volumes and Perioperative Coronavirus Disease 2019 Incidence in Neurosurgical Patients During a Pandemic: Experiences at Two Tertiary Care Centers in Washington, DC

OBJECTIVE

The true incidence of perioperative coronavirus disease 2019 (COVID-19) has not been well elucidated in neurosurgical studies. We reviewed the effects of the pandemic on the neurosurgical case volume to study the incidence of COVID-19 in patients undergoing these procedures during the perioperative period and compared the characteristics and outcomes of this group to those of patients without COVID-19.

METHODS

The neurosurgical and neurointerventional procedures at 2 tertiary care centers during the pandemic were reviewed. The case volume, type, and acuity were compared to those during the same period in 2019. The perioperative COVID-19 tests and results were evaluated to obtain the incidence. The baseline characteristics, including a modified Medically Necessary Time Sensitive (mMeNTS) score, and outcome measures were compared between those with and without COVID-19.

RESULTS

A total of 405 cases were reviewed, and a significant decrease was found in total spine, cervical spine, lumbar spine, and functional/pain cases. No significant differences were found in the number of cranial or neurointerventional cases. Of the 334 patients tested, 18 (5.4%) had tested positive for COVID-19. Five of these patients were diagnosed postoperatively. The mMeNTS score, complications, and case acuity were significantly different between the patients with and without COVID-19.

CONCLUSION

A small, but real, risk exists of perioperative COVID-19 in neurosurgical patients, and those patients have tended to have a greater complication rate. Use of the mMeNTS score might play a role in decision making for scheduling elective cases. Further studies are warranted to develop risk stratification and validate the incidence.

Endovascular optical coherence tomography imaging in cerebrovascular disease

Endovascular optical coherence tomography (OCT) is the highest resolution imaging modality currently available with spatial resolution of 10 µm. Although originally developed for interventional cardiology, the ability to visualize the luminal environment and anatomy, along with the stent-vessel interaction could be of great utility for various cerebrovascular diseases, and the adoption of endovascular OCT imaging in the evolving field of interventional neuroradiology seems instinctive. The purpose of this study is to conduct a systematic review of the literature regarding applications of endovascular OCT in the diagnosis and treatment of cerebrovascular diseases. In addition, the authors report their institutional experience with the use of OCT in carotid atherosclerotic disease, cerebral aneurysms, and acute ischemic stroke. A systematic review of the literature was undertaken. Peer-reviewed articles were collected through MEDLINE, Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) searches through March 2020. A total of 34 studies with 598 patients were included in the qualitative synthesis. These include 23 studies of carotid atherosclerotic disease, 7 studies of cerebral aneurysms, and 4 studies of non-aneurysmal posterior circulation pathology. OCT imaging was feasible in 94% of patients with 0.6% complication rate. Endovascular OCT appears to be safe and feasible, allowing clinicians to visualize stent-vessel interactions, aneurysmal healing, and vulnerable atherosclerotic plaque features. OCT carries great promise, however additional investigations are needed before any imposing statement can be made about the role of OCT in cerebrovascular imaging.

Anxiety and depression in patients who undergo a cerebrovascular procedure

Background

Observe the relationship of anxiety and depression on quality of life outcomes after open and endovascular cerebrovascular procedures.

Methods

We retrospectively analyzed 349 patients who underwent a procedure for aneurysm, arteriovenous malformation, intraparenchymal hemorrhage, carotid stenosis, acute stroke, and conventional catheter angiogram over three years at a community hospital. We correlated pre-procedural anxiety and depression with Global Physical Health, Global Mental Health, and Modified Rankin Scale scores. We performed univariate and multivariate linear and logistic regression analyses adjusting for past medical history and sociodemographic factors.

Results

Anxiety or depression occurred in 18 % of patients. Patients with anxiety or depression were more likely to be female (81% vs 60.8%; p = 0.002) and younger (54 vs. 59 years old; p = 0.025). The groups did not differ in type or urgency of procedure, smoking or history of diabetes. Patients with anxiety or depression reported lower mental health scores at 30 days (45.1 vs 48.2; p = 0.002) post-procedure. In multivariate analyses, anxious or depressed patients had worse mental health scores at 30 days (t = − 2.893; p = 0.008) than those who did not have a history of anxiety or depression. There was no difference between groups in length of stay, mortality, physical health t-scores, functionality scores, or six month quality of life outcomes.

Conclusions

Patients undergoing cerebrovascular procedures who self-reported anxiety or depression showed a significant difference in mental health outcomes at 30 days, but six month mental health and other medical and functional outcomes measures were similar to patients without these diagnoses.

Distal radial approach for neurointerventional diagnosis and therapy

Background:

The transradial approach results in fewer complications at the puncture site, lower hospital costs, and greater comfort for patients. The distal transradial approach (dTRA) adds some benefits over the conventional radial approach. The objective is to describe initial experience with distal radial approach technique and the results obtained for neuroendovascular diagnostic and therapeutic procedures.

Methods:

Description of distal radial approach technique and obtained data from the first 3 months experience using this approach as the first choice for neuroendovascular procedures in two neuroendovascular centers.

Results:

Of the total of 94 procedures performed during 3 months, 67 were diagnostic and 27 were therapeutic. Eleven (16%) of the diagnostic procedures were performed through the dTRA. Of the 27 embolizations, eight (30%) were done using this approach. Every distal radial approach that was performed for diagnosis and therapeutics was successful.

Conclusion:

Puncture of the radial artery within the anatomical snuffbox is a radial approach variation option for diagnostic and therapeutic neuroendovascular procedures.

Neurointerventional Procedural Complications in a Growing Canadian Regional Stroke Center: Single Hospital Experience Analysis in the Context of Recommended Case Volumes

BACKGROUND

Evidence continues to emerge regarding the inverse relationship between high neurointerventional case volume and complication rates, leading several medical/surgical societies to recommend minimum volumes for specific procedures. Recent data suggest few centers are meeting these requirements. We report a single center's neurointerventional complication rates with associated case volumes, along with a review of the literature.

METHODS

A retrospective cohort review of all consecutive patients undergoing diagnostic catheter cerebral angiography and/or neurointerventional procedures between January 1, 2013, and March 1, 2018, was undertaken. No diagnostic or interventional procedures were excluded. All major and minor complications were recorded.

RESULTS

A total of 1000 procedures (463 diagnostic cerebral angiograms and 537 neurointerventional procedures) were completed. Of the neurointerventional procedures, 216 (40%) were endovascular thrombectomy, 170 (32%) were aneurysmal embolization, and 48 (9%) were carotid stenting. The mean and median age was 60 years. There were 460 women and 540 men. The total number of major complications for diagnostic angiography, endovascular thrombectomy, ruptured aneurysm embolization, unruptured aneurysm embolization, and carotid artery stenting were 4 (0.9%), 4 (1.9%), 10 (11%), 4 (5.4%), and 3 (6.3%), respectively.

CONCLUSIONS

We provided a single-center experience of the relationship between neurointerventional procedural case volume and complication rates in the growth phase of our center's establishment. We demonstrated that as our center was being developed, specific procedural staffing measures allowed proficiency maintenance, acquisition of new techniques, and complication avoidance, whereas specific case volumes crossed the suggested thresholds as defined in the literature.

Distal Radial Artery Access in the Anatomical Snuffbox for Neurointerventions: Case Report

BACKGROUND

The distal transradial approach (dTRA) is being widely adopted by interventional cardiologists, primarily owing to reduced morbidity and mortality from access site complications. The distal radial artery has advantages over standard radial access in relation to procedural positioning and radial artery preservation, particularly in patients who may require multiple angiograms. One disadvantage is the smaller diameter of the artery with more challenging puncture of a smaller, weaker artery. We demonstrate the feasibility of dTRA in 2 patients who underwent successful diagnostic angiography and mechanical thrombectomy.

CASE DESCRIPTION

Two patients underwent dTRA for neurointerventions. In patient 1, a 5-F Glidesheath Slender and a Sim2 catheter were used for a 6-vessel cerebral angiogram. In patient 2, an 0.88-inch sheathless guide catheter was used to perform a mechanical thrombectomy. Successful hemostasis in both cases was achieved with a Safeguard Radial Compression Device; no complications were observed.

CONCLUSIONS

Neurovascular access via dTRA is feasible, and further exploration is warranted.

GoPro Hero Cameras for Creation of a Three-Dimensional, Educational, Neurointerventional Video

Neurointerventional education relies on an apprenticeship model, with the trainee observing and participating in procedures with the guidance of a mentor. While educational videos are becoming prevalent in surgical cases, there is a dearth of comparable educational material for trainees in neurointerventional programs. We sought to create a high-quality, three-dimensional video of a routine diagnostic cerebral angiogram for use as an educational tool. A diagnostic cerebral angiogram was recorded using two GoPro HERO 3+ cameras with the Dual HERO System to capture the proceduralist's hands during the case. This video was edited with recordings from the video monitors to create a real-time three-dimensional video of both the actions of the neurointerventionalist and the resulting wire/catheter movements. The final edited video, in either two or three dimensions, can serve as another instructional tool for the training of residents and/or fellows. Additional videos can be created in a similar fashion of more complicated neurointerventional cases. The GoPro HERO 3+ camera and Dual HERO System can be used to create educational videos of neurointerventional procedures.

Mechanical thrombectomy for cerebral venous sinus thrombosis employing a novel combination of Angiojet and Penumbra ACE aspiration catheters: the Triaxial Angiojet technique

Cerebral venous sinus thrombosis (CVST) can be life threatening. A previously healthy woman in her early forties on oral contraceptives presented with global CVST and rapid clinical deterioration. A novel 'Triaxial Angiojet technique' (KSAW Shuttle [Cook Inc., Bloomington, IN, USA], 5 MAX ACE [Penumbra Inc., Alameda, CA, USA], and Angiojet [Boston Scientific, Marlborough, MA, USA]) was employed to gain access into the superior sagittal sinus. The 5 MAX ACE reperfusion catheter was shortened prior to placing a 4 Fr Angiojet catheter through it. This resulted in markedly improved recanalization with good anterograde flow. The patient was extubated on postoperative day 2 and discharged neurologically intact on postoperative day 10. We report the first case of placing an Angiojet catheter through a larger Penumbra reperfusion catheter when access through a tortuous sigmoid and transverse sinus could not be obtained with a 6 Fr support catheter.

Challenges in pediatric neuroanesthesia: awake craniotomy, intraoperative magnetic resonance imaging, and interventional neuroradiology

This article gives a review of 3 challenges in caring for children undergoing neurosurgical and neurointerventional procedures. Anesthesiologists may have experience with certain aspects of these situations but may not have extensive experience with each clinical setting. This review addresses issues with awake craniotomy, intraoperative magnetic resonance imaging, and neurointerventional procedures in children with neurologic disease. Familiarization with these complex clinical scenarios and their unique considerations allows the anesthesiologist to deliver optimal care and helps facilitate the best possible outcome for these patients.