Publications by authors named "Aman B Patel"

125 Publications

Intrasaccular flow disruption for ruptured aneurysms: an international multicenter study.

J Neurointerv Surg 2022 Jul 22. Epub 2022 Jul 22.

Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA.

Background: The Woven EndoBridge (WEB) device is a novel intrasaccular flow disruptor tailored for bifurcation aneurysms. We aim to describe the degree of aneurysm occlusion at the latest follow-up, and the rate of complications of aneurysms treated with the WEB device stratified according to rupture status.

Methods: Our data were taken from the WorldWideWeb Consortium, an international multicenter cohort including patients treated with the WEB device. Aneurysms were classified into two groups: ruptured and unruptured. We compared clinical and radiologic outcomes of both groups. Propensity score matching (PSM) was done to match according to age, gender, bifurcation, location, prior treatment, neck, height, dome width, daughter sac, incorporated branch, pretreatment antiplatelets, and last imaging follow-up.

Results: The study included 676 patients with 691 intracranial aneurysms (529 unruptured and 162 ruptured) treated with the WEB device. The PSM analysis had 55 pairs. In both the unmatched (85.8% vs 84.3%, p=0.692) and matched (94.4% vs 83.3%, p=0.066) cohorts there was no significant difference in the adequate occlusion rate at the last follow-up. Likewise, there were no significant differences in both ischemic and hemorrhagic complications between the two groups. There was no documented aneurysm rebleeding after WEB device implantation.

Conclusion: There was no significant difference in both the radiologic outcomes and complications between unruptured and ruptured aneurysms. Our findings support the feasibility of treatment of ruptured aneurysms with the WEB device.
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http://dx.doi.org/10.1136/jnis-2022-019153DOI Listing
July 2022

International controlled study of revascularization and outcomes following COVID-positive mechanical thrombectomy.

Eur J Neurol 2022 Jul 12. Epub 2022 Jul 12.

Department of Neurology, Alexandria University Hospital, Alexandria, Egypt.

Background And Purpose: Previous studies suggest that mechanisms and outcomes in patients with COVID-19-associated stroke differ from those in patients with non-COVID-19-associated strokes, but there is limited comparative evidence focusing on these populations. The aim of this study, therefore, was to determine if a significant association exists between COVID-19 status with revascularization and functional outcomes following thrombectomy for large vessel occlusion (LVO), after adjustment for potential confounding factors.

Methods: A cross-sectional, international multicenter retrospective study was conducted in consecutively admitted COVID-19 patients with concomitant acute LVO, compared to a control group without COVID-19. Data collected included age, gender, comorbidities, clinical characteristics, details of the involved vessels, procedural technique, and various outcomes. A multivariable-adjusted analysis was conducted.

Results: In this cohort of 697 patients with acute LVO, 302 had COVID-19 while 395 patients did not. There was a significant difference (p < 0.001) in the mean age (in years) and gender of patients, with younger patients and more males in the COVID-19 group. In terms of favorable revascularization (modified Thrombolysis in Cerebral Infarction [mTICI] grade 3), COVID-19 was associated with lower odds of complete revascularization (odds ratio 0.33, 95% confidence interval [CI] 0.23-0.48; p < 0.001), which persisted on multivariable modeling with adjustment for other predictors (adjusted odds ratio 0.30, 95% CI 0.12-0.77; p = 0.012). Moreover, endovascular complications, in-hospital mortality, and length of hospital stay were significantly higher among COVID-19 patients (p < 0.001).

Conclusion: COVID-19 was an independent predictor of incomplete revascularization and poor functional outcome in patients with stroke due to LVO. Furthermore, COVID-19 patients with LVO were more often younger and had higher morbidity/mortality rates.
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http://dx.doi.org/10.1111/ene.15493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9349405PMC
July 2022

A Prospective, Multicenter, Single-Group Target-Value Clinical Trial to Evaluate the Safety and Efficacy of a Large Bore Aspiration Catheter System for the Endovascular Treatment of Acute Ischemic Stroke.

Front Neurol 2022 9;13:864563. Epub 2022 Jun 9.

Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.

Objective: This study was conducted to determine the safety and efficacy of the Esperance Distal Access Catheter (0.071"), a novel large bore aspiration catheter in treating acute ischemic stroke (AIS) with large vessel occlusion (LVO).

Methods: A prospective multicenter clinical trial involving 15 stroke centers was performed. Baseline characteristics, procedural data, and angiographic and clinical outcomes of all acute stroke procedures (from May 2020 to March 2021) using the novel large bore aspiration catheter were analyzed.

Results: During the study period, 160 consecutive patients were recruited. The mean age and median baseline NIHSS were 65.4 years and 16, respectively. Successful reperfusion was achieved in 147 (91.9%) cases [at least modified Thrombolysis in Cerebral Infarction (mTICI) 2b] with aspiration alone, with complete reperfusion (mTICI 3) in 94 (58.8%) cases. Successful/complete first pass reperfusion was achieved in 104 (64.60%) cases, including mTICI 2b in 34 (21.1%) cases and mTICI 3 in 70 (43.5%) cases. The time from groin puncture to successful reperfusion was 44 (33, 62) min. There were 16 (9.9%) cases requiring rescue therapy using stent-retriever. Procedure-related complications included 2 (1.3%) cases of arterial perforation, 2 (1.3%) cases of arterial dissection, 12 (7.5%) cases of distal embolization, and 1(0.6%) case of puncture site infection. The rate of symptomatic intracranial hemorrhage (sICH) was 3.8% and mortality rate was 13.8%. A total of 99 (62.3%) cases had a favorable outcome (mRS 0-2) at 90 days.

Conclusions: In current practice, the first-line aspiration approach with the Esperance Distal Access Catheter is safe and efficacious. This device may achieve high reperfusion rates with lower instances of rescue stent retriever therapy.
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http://dx.doi.org/10.3389/fneur.2022.864563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9218266PMC
June 2022

Racial and Social Determinants of Civilian Gunshot Wounds to the Head.

Neurohospitalist 2022 Jul 28;12(3):444-452. Epub 2022 Mar 28.

Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.

Objective: To assess the clinical, racial, and social characteristics of victims of Gunshot wounds (GSWs) to the head and assess for associations between these factors and outcomes.

Summary Background Data: Previous literature has not focused on the association of race and socioeconomic factors with these specific injuries.

Methods: We identified patients with GSWs to the head who presented to 2 urban academic medical centers between 1998 and 2020, and extracted patient-level demographic data, information about the clinical and surgical course, and outcomes at discharge and follow-up.

Results: The cohort included 250 patients, 90% (n = 226) of whom were male, with a mean age of 28 years. Forty-five percent were white (n = 112), 19% Black (n = 48), 18% Latinx (n = 45), with 6% "other" (n = 16), and 12% "unknown" (n = 29). The majority of patients presented with assault-related trauma (n = 153, 61%) as compared to self-inflicted injuries (n = 97, 39%). Across the entire cohort, sex, age, race, and median income by ZIP code were not significant predictors of outcome. Victims of assault by GSW to the head were more likely to be age 18 or younger (OR 5.26, P = 0.01), between the ages of 19 and 33 years (OR 4.7, P = 0.001), Black (OR 6.66, P < .001), and Latinx (OR 2.65, P = 0.03). Most patients (n = 155, 63%) had a poor functional outcome (modified Rankin Score 3-6) at discharge.

Conclusion: Age, race, and income status were not independent predictors of mortality or functional outcome at discharge in our population. Assault-related GSWs to the head mostly involved young Black or Latinx men of lower socioeconomic status, while self-inflicted injuries were largely seen in older white men.
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http://dx.doi.org/10.1177/19418744221077552DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9214932PMC
July 2022

Carotid Stenting Versus Endarterectomy for Asymptomatic Carotid Artery Stenosis: A Systematic Review and Meta-Analysis.

Stroke 2022 Jun 22:101161STROKEAHA122038994. Epub 2022 Jun 22.

China International Neuroscience Institute (China-INI), Peoples Republic of China (J.W., X.B., T.W., L.J.).

Background: To compare safety and efficacy between carotid artery stenting (CAS) and carotid endarterectomy (CEA) in treating asymptomatic carotid artery stenosis based on results from randomized controlled trials.

Methods: Randomized controlled trials comparing CAS and CEA in treating asymptomatic carotid artery stenosis were searched from databases of the EMBASE, PubMed, MEDLINE, and Cochrane libraries. Two independent reviewers identified eligible studies, extracted relevant data, and used the Cochrane risk of bias tool to assess quality. Mantel-Haenszel method random-effects models were used to estimate odds ratio (OR) regarding perioperative risks between CAS and CEA. Kaplan-Meier curve data were extracted and analyzed through Exp[(O-E)/Var] fixed-effect models to calculate the Peto odds ratio (OR) regarding long-term outcomes.

Results: Sixteen articles from 7 randomized controlled trials were included, reporting relevant outcomes for 7230 asymptomatic carotid artery stenosis patients (CAS: n=3920; CEA: n=3198). Compared with the CEA group, CAS group had no difference in perioperative composite end point events including stroke, death, and myocardial infarction (MI; OR, 1.13 [95% CI, 0.87-1.47]; =0.37, I=0%). Compared with CEA, CAS had a higher risk of any stroke during the perioperative period (OR, 1.62 [95% CI, 1.16-2.24]; =0.004, I=0%) and an increased risk of nondisabling stroke (OR, 1.81 [95% CI, 1.23-2.65]; =0.003, I=0%), but there was no significant difference in disabling stroke and death between groups (OR, 0.91 [95% CI, 0.50-1.65]; =0.76, I=0%). For long-term outcomes, no difference regarding the composite outcome of any stroke, death, and myocardial infarction existed between CEA and CAS (Peto OR, 1.18 [95% CI, 0.94-1.48]; =0.14, I=0%). Individual-level patient data would be important to verify the long-term outcome results.

Conclusions: When treating asymptomatic carotid artery stenosis, CAS has comparable perioperative and long-term composite outcomes compared with CEA. However, CAS may have a higher risk of any stroke and nondisabling stroke in the perioperative period.
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http://dx.doi.org/10.1161/STROKEAHA.122.038994DOI Listing
June 2022

Iatrogenic traumatic superficial temporal arteriovenous fistula development post-craniectomy: A case report.

Neuroradiol J 2022 Jun 14:19714009221108670. Epub 2022 Jun 14.

Department of Neurosurgery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

We report a case of superficial temporal arteriovenous fistula development following frontotemporoparietal hemicraniectomy. This patient presented with intracerebral hemorrhage (ICH) secondary to underlying arteriovenous malformation (AVM) rupture. Following decompressive hemicraniectomy and follow-up successful resection of the underlying AVM, the patient returned to the hospital with a seizure. Repeat angiography was performed, demonstrating no intracranial vascular lesion recurrence. However, an incidental superficial temporal arteriovenous fistula was identified, which was not visualized on initial angiography assessing the prior AVM. These lesions have been treated successfully in the past with surgical, endovascular, or combined approaches. As this patient was scheduled to undergo cranioplasty following AVM resection, the decision to occlude the fistula surgically was made. During cranioplasty, the fistula was identified as an engorged venous complex contiguous with the superficial temporal artery (STA) and was occluded. Follow-up angiography confirmed successful fistula occlusion and the patient has remained asymptomatic.
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http://dx.doi.org/10.1177/19714009221108670DOI Listing
June 2022

Basilar artery occlusion: A review of clinicoradiologic features, treatment selection, and endovascular techniques.

Interv Neuroradiol 2022 Jun 12:15910199221106049. Epub 2022 Jun 12.

Department of Neurology, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Basilar artery occlusion (BAO) is an infrequent but often fatal subtype of stroke. Predicting outcomes and selecting patients for endovascular therapy (EVT) remains challenging. Advances in neuroimaging and the development of prognostic scoring systems have augmented clinical decision-making over time. Recent randomized trials, BEST (Basilar Artery Occlusion Endovascular Intervention vs. Standard Medical Treatment), BASICS (Basilar Artery International Cooperation Study), BAOCHE (Basilar Artery Occlusion CHinese Endovascular Trial) and ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion), compared EVT and medical management for patients with BAO. These trials yielded mixed results. The former two suggested unclear benefit while the latter two supported a benefit of EVT. While all had limitations, most providers agree caution should be exercised when excluding patients from EVT who may stand to benefit. Further studies are therefore needed to determine the effectiveness, safety, selection criteria, and optimal technical approach for EVT among patients with BAO. Hyperacute-phase advanced imaging can offer several benefits to aid decision making. It is reasonable to exclude patients with low National Institutes of Health Stroke Scale (NIHSS), large imaging-proven cores, and evidence of perforator occlusion by branch atheromatous disease. Herein, we review the clinical presentation, imaging work-up, treatments, and clinical outcomes for BAO, while highlighting knowledge gaps in treatment selection and technique.
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http://dx.doi.org/10.1177/15910199221106049DOI Listing
June 2022

Angiographic Pulse Wave Coherence in the Human Brain.

Front Bioeng Biotechnol 2022 3;10:873530. Epub 2022 May 3.

Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, United States.

A stroke volume of arterial blood that arrives to the brain housed in the rigid cranium must be matched over the cardiac cycle by an equivalent volume of ejected venous blood. We hypothesize that the brain maintains this equilibrium by organizing coherent arterial and venous pulse waves. To test this hypothesis, we applied wavelet computational methods to diagnostic cerebral angiograms in four human patients, permitting the capture and analysis of cardiac frequency phenomena from fluoroscopic images acquired at faster than cardiac rate. We found that the cardiac frequency reciprocal phase of a small region of interest (ROI) in a named artery predicts venous anatomy pixel-wise and that the predicted pixels reconstitute venous bolus passage timing. Likewise, a small ROI in a named vein predicts arterial anatomy and arterial bolus passage timing. The predicted arterial and venous pixel groups maintain phase complementarity across the bolus travel. We thus establish a novel computational method to analyze vascular pulse waves from minimally invasive cerebral angiograms and provide the first direct evidence of arteriovenous coupling in the intact human brain. This phenomenon of arteriovenous coupling may be a physiologic mechanism for how the brain precisely maintains mechanical equilibrium against volume displacement and kinetic energy transfer resulting from cyclical deformations with each heartbeat. The study also paves the way to study deranged arteriovenous coupling as an underappreciated pathophysiologic disturbance in a myriad of neurological pathologies linked by mechanical disequilibrium.
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http://dx.doi.org/10.3389/fbioe.2022.873530DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9110661PMC
May 2022

A trans-orbital pencil in the left carotid artery of a 40-year-old man: clinical and radiographic images.

Orbit 2022 May 17. Epub 2022 May 17.

Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1080/01676830.2022.2068153DOI Listing
May 2022

Deconstructive repair of a traumatic vertebrovertebral arteriovenous fistula via a contralateral endovascular approach.

J Cerebrovasc Endovasc Neurosurg 2022 May 16. Epub 2022 May 16.

Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Vertebrovertebral arteriovenous fistulas (VVAVFs) are rare entities that lack consensus guidelines for their management. Our case describes the successful treatment of a traumatic VVAVF via a contralateral deconstructive endovascular approach. A 64-year-old female presented following a traumatic fall. Computed tomography angiogram highlighted a 2 cm pseudoaneurysm of the right vertebral artery (VA) with epidural contrast enhancement and a hematoma with flow voids within the epidural space. Digital subtraction angiography showed a VVAVF at C2-3 with retrograde filling of the distal right VA. Having undergone several unsuccessful passes of the proximal dissection flap in the right VA, the patient underwent a contralateral deconstructive approach with correction of the VVAVF without complication. The remaining feeding branches had occluded after 1 week. The patient made a complete recovery without neurological sequelae at 3-month follow-up.
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http://dx.doi.org/10.7461/jcen.2022.E2021.10.002DOI Listing
May 2022

Understanding Delays in MRI-based Selection of Large Vessel Occlusion Stroke Patients for Endovascular Thrombectomy.

Clin Neuroradiol 2022 Apr 29. Epub 2022 Apr 29.

Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA, 02114.

Purpose: Given the efficacy of endovascular thrombectomy (EVT), optimizing systems of delivery is crucial. Magnetic resonance imaging (MRI) is the gold standard for evaluating tissue viability but may require more time to obtain and interpret. We sought to identify determinants of arrival-to-puncture time for patients who underwent MRI-based EVT selection in a real-world setting.

Methods: Patients were identified from a prospectively maintained database from 2011-2019 that included demographics, presentations, treatments, and outcomes. Process times were obtained from the medical charts. MRI times were obtained from time stamps on the first sequence. Linear and logistic regressions were used to infer explanatory variables of arrival-to-puncture times and effects of arrival-to-puncture time on functional outcomes.

Results: In this study 192 patients (median age 70 years, 57% women, 12% non-white) underwent MRI-based EVT selection. 66% also underwent computed tomography (CT) at the hub before EVT. General anesthesia was used for 33%. Among the entire cohort, the median arrival-to-puncture was 102 min; however, among those without CT it was 77 min. Longer arrival-to-puncture times independently reduced the odds of 90-day good outcome (∆mRS ≤ 2 from pre-stroke, aOR = 0.990, 95%CI = 0.981-0.999, p = 0.040) when controlling for age, NIHSS, and good reperfusion (TICI 2b-3). Independent determinants of longer arrival-to-puncture were CT plus MRI (β = 0.205, p = 0.003), non-white race/ethnicity (β = 0.162, p = 0.012), coronary disease (β = 0.205, p = 0.001), and general anesthesia (β = 0.364, p < 0.0001).

Conclusion: Minimizing arrival-to-puncture time is important for outcomes. Real-world challenges exist in an MRI-based EVT selection protocol; avoiding double imaging is key to saving time. Racial/ethnic disparities require further study. Understanding variables associated with delay will inform protocol changes.
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http://dx.doi.org/10.1007/s00062-022-01165-yDOI Listing
April 2022

Comparing treatment outcomes of various intracranial bifurcation aneurysms locations using the Woven EndoBridge (WEB) device.

J Neurointerv Surg 2022 Apr 28. Epub 2022 Apr 28.

Department of Interventional Neuroradiology, Erasmus Hospital, Bruxelles, Bruxelles, Belgium.

Background: The Woven EndoBridge (WEB) device has Food and Drug Administration approval for treatment of wide-necked intracranial bifurcation aneurysms. The WEB device has been shown to result in adequate occlusion in bifurcation aneurysms overall, but its usefulness in the individual bifurcation locations has been evaluated separately only in few case series, which were limited by small sample sizes.

Objective: To compare angiographic and clinical outcomes after treatment of bifurcation aneurysms at various locations, including anterior communicating artery (AComA), anterior cerebral artery (ACA) bifurcation distal to AComA, basilar tip, internal carotid artery (ICA) bifurcation, and middle cerebral artery (MCA) bifurcation aneurysms using the WEB device.

Methods: A retrospective cohort analysis was conducted at 22 academic institutions worldwide to compare treatment outcomes of patients with intracranial bifurcation aneurysms using the WEB device. Data include patient and aneurysm characteristics, procedural details, angiographic and functional outcomes, and complications.

Results: A total of 572 aneurysms were included. MCA (36%), AComA (35.7%), and basilar tip (18.9%) aneurysms were most common. The rate of adequate aneurysm occlusion was significantly higher for basilar tip (91.6%) and ICA bifurcation (96.7%) aneurysms and lower for ACA bifurcation (71.4%) and AComA (80.6%) aneurysms (p=0.04).

Conclusion: To our knowledge, this is the most extensive study to date that compares the treatment of different intracranial bifurcation aneurysms using the WEB device. Basilar tip and ICA bifurcation aneurysms showed significantly higher rates of aneurysm occlusion than other locations.
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http://dx.doi.org/10.1136/neurintsurg-2022-018694DOI Listing
April 2022

Visceral Adiposity and Risk of Stroke: A Mendelian Randomization Study.

Front Neurol 2022 11;13:804851. Epub 2022 Apr 11.

Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.

Purpose: In recent years, metabolic syndrome has risen in prevalence and brought a heavy disease burden to modern society. As the representative aspect of metabolic syndrome, obesity has been shown to be related to an increased risk of stroke. Given that visceral adipose tissue (VAT) forms the fundamental basis of central obesity, we sought to explore a causal relationship between VAT and stroke by using mendelian randomization (MR) methods.

Methods: Based on two large genome-wide association studies (GWAS) including 325,153 and 35,762 cases of VAT and stroke, respectively, we conducted a MR study which has the inherent advantage of reducing the noise of confounding and reverse causation.

Results: VAT had a significant causal association with ischemic stroke (OR, per 1kg increase in VAT mass, 1.30; 95% CI, 1.18 ~ 1.45; = 5.87E-07) as opposed to intracranial hemorrhage (ICH) (OR, 1.15; 95% CI, 0.70 ~ 1.88, = 5.81E-01) as evaluated with inverse-variance weighting (IVW). Regarding subtypes of ischemic stroke, there was a significant causal effect for cardioembolic stroke (OR, 1.34; 95% CI, 1.13 ~ 1.58, = 8.07E-04), and potential causal effect for small-vessel stroke (OR, 1.32; 95% CI, 1.06 ~ 1.65, = 1.39E-02) and large-artery atherosclerotic stroke (OR, 1.33; 95% CI, 1.03 ~ 1.70, = 2.59E-02).

Conclusions: This study provides potential evidence for a causal role of VAT in ischemic stroke and could suggest novel genetical therapeutic strategies for distinct subtypes of ischemic stroke.
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http://dx.doi.org/10.3389/fneur.2022.804851DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9035635PMC
April 2022

Multicenter Study for the Treatment of Sidewall versus Bifurcation Intracranial Aneurysms with Use of Woven EndoBridge (WEB).

Radiology 2022 Aug 19;304(2):372-382. Epub 2022 Apr 19.

From the Department of Neurosurgery and Neurointerventional Surgery, Louisiana State University, 1501 Kings Hwy, Shreveport, LA 71104 (N.A., H.H.C.S., S.K., A.A., A. Savardekar, A.M.); Neuroradiology & Neurointervention Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (M.D., M.A.A.S., A.A.D.); Department of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St Michael's Hospital, University of Toronto, Toronto, Canada (J.D.B.D., C.P.F., Y.I., S.M., J.S.); Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier de Toulouse, Hôpital Purpan, Toulouse, France (A. Sweid, A.G., P.J.); Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pa (S.V.L., C.C.); Department of Neurovascular Intervention, Ospedale Careggi di Firenze, Florence, Italy (L.R., N.L.); Department of Neurosurgery & Interventional Neuroradiology, New York Presbyterian Hospital, Weill Cornell School of Medicine, New York, NY (S.H.S., S.B., J.K.); Department of Radiodiagnosis and Interventional Radiology, Centre Hospitalier Vaudois de Lausanne, Lausanne, Switzerland (G.S.); Vascular and Interventional Neuroradiology Section, Universitätsklinikum Heidelberg, Heidelberg, Germany (M.M.); Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (J.E.V., R.W.R., J.D.R., C.J.S., A.B.P.); Endovascular Neurosurgery and Interventional Radiology Team, Clínica La Sagrada Familia, Buenos Aires, Argentina (I.L., P.L.); Department of Neurosurgery, Orlando Health Neuroscience and Rehabilitation Institute, Orlando, Fla (P.M.F., J.A.V.); Subdivision of Interventional Neuroradiology, Department of Radiology, Clinical Hospital Center Sisters of Mercy, Zagreb, Croatia (V.Ž., V.K.); Department of Neurosurgery, UTMB and Baylor School of Medicine, Houston, Tex (M.U.H., P.K.); Department of Neurosurgery, Barrow Neurologic Institute, Phoenix, Ariz (C.R., A.F.D., F.C.A.); Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY (M.W., V.M.T., A. Siddiqui); Interventional Radiology and Neurointerventional Services, Department of Radiology, Austin Health, Melbourne, Victoria, Australia (Y.R., H.A.); Department of Neurosurgery and Radiology, Geisinger Hospital, Danville, Pa (C.M.S., C.J.G.); Department of Neurovascular Intervention, Ospedale Niguarda Cà Granda, Milan, Italy (M. Piano, G.P.); Department of Neurointerventional Radiology, UMass Memorial Hospital, Worcester, Mass (A.L.K., A.S.P.); Department of Neurovascular Intervention, Ospedale San Raffaele Milano, Milan, Italy (C.M., P.P.); Department of Interventional Neuroradiology, Hôpital Universitaire Erasme, Brussels, Belgium (S.E., B.L.); Department of Neurosurgery, University of Miami, Miami, Fla (R.M.S.); Department of Neuroscience, Valley Baptist Neuroscience Institute, Harlingen, Tex (A.H.); Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Ala (A. Salehani, J.J.); Department of Neuroradiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland (P.S., A.B., M. Psychogios); and Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (P.S.).

Background The Woven EndoBridge (WEB) device was explicitly designed for wide-neck intracranial bifurcation aneurysms. Small-scale reports have evaluated the off-label use of WEB devices for the treatment of sidewall aneurysms, with promising outcomes. Purpose To compare the angiographic and clinical outcomes of the WEB device for the treatment of sidewall aneurysms compared with the treatment of bifurcation aneurysms. Materials and Methods A retrospective review of the WorldWideWEB Consortium, a synthesis of retrospective databases spanning from January 2011 to June 2021 at 22 academic institutions in North America, South America, and Europe, was performed to identify patients with intracranial aneurysms treated with the WEB device. Characteristics and outcomes were compared between bifurcation and sidewall aneurysms. Propensity score matching (PSM) was used to match by age, pretreatment ordinal modified Rankin Scale score, ruptured aneurysms, location of aneurysm, multiple aneurysms, prior treatment, neck, height, dome width, daughter sac, and incorporated branch. Results A total of 683 intracranial aneurysms were treated using the WEB device in 671 patients (median age, 61 years [IQR, 53-68 years]; male-to-female ratio, 1:2.5). Of those, 572 were bifurcation aneurysms and 111 were sidewall aneurysms. PSM was performed, resulting in 91 bifurcation and sidewall aneurysms pairs. No significant difference was observed in occlusion status at last follow-up, deployment success, or complication rates between the two groups. Conclusion No significantly different outcomes were observed following the off-label use of the Woven EndoBridge, or WEB, device for treatment of sidewall aneurysms compared with bifurcation aneurysms. The correct characterization of the sidewall aneurysm location, neck angle, and size is crucial for successful treatment and lower retreatment rate. © RSNA, 2022 See also the editorial by Hetts in this issue.
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http://dx.doi.org/10.1148/radiol.212006DOI Listing
August 2022

Extensive Cerebral Arteriovenous Malformation-Associated Intraventricular Hemorrhage.

Neurohospitalist 2022 Apr 27;12(2):418-419. Epub 2021 Sep 27.

Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1177/19418744211049047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8995612PMC
April 2022

Telerobotic neurovascular interventions with magnetic manipulation.

Sci Robot 2022 04 13;7(65):eabg9907. Epub 2022 Apr 13.

Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA.

Advances in robotic technology have been adopted in various subspecialties of both open and minimally invasive surgery, offering benefits such as enhanced surgical precision and accuracy with reduced fatigue of the surgeon. Despite the advantages, robotic applications to endovascular neurosurgery have remained largely unexplored because of technical challenges such as the miniaturization of robotic devices that can reach the complex and tortuous vasculature of the brain. Although some commercial systems enable robotic manipulation of conventional guidewires for coronary and peripheral vascular interventions, they remain unsuited for neurovascular applications because of the considerably smaller and more tortuous anatomy of cerebral arteries. Here, we present a teleoperated robotic neurointerventional platform based on magnetic manipulation. Our system consists of a magnetically controlled guidewire, a robot arm with an actuating magnet to steer the guidewire, a set of motorized linear drives to advance or retract the guidewire and a microcatheter, and a remote-control console to operate the system under real-time fluoroscopy. We demonstrate our system's capability to navigate narrow and winding pathways both in vitro with realistic neurovascular phantoms representing the human anatomy and in vivo in the porcine brachial artery with accentuated tortuosity for preclinical evaluation. We further demonstrate telerobotically assisted therapeutic procedures including coil embolization and clot retrieval thrombectomy for treating cerebral aneurysms and ischemic stroke, respectively. Our system could enable safer and quicker access to hard-to-reach lesions while minimizing the radiation exposure to physicians and open the possibility of remote procedural services to address challenges in current stroke systems of care.
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http://dx.doi.org/10.1126/scirobotics.abg9907DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9254892PMC
April 2022

In Reply: Flow Diversion for Middle Cerebral Artery Aneurysms: An International Cohort Study.

Neurosurgery 2022 06 29;90(6):e178. Epub 2022 Mar 29.

Département de Radiologie, Radio-oncologie et Médecine Nucléaire, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada.

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http://dx.doi.org/10.1227/neu.0000000000001934DOI Listing
June 2022

In a hub-and-spoke network, spoke-administered thrombolysis reduces mechanical thrombectomy procedure time and number of passes.

Interv Neuroradiol 2022 Mar 23:15910199221087498. Epub 2022 Mar 23.

Neurology, 2348Massachusetts General Hospital, Harvard Medical School, Boston, USA.

Background: The utility of intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MT) in large vessel occlusion stroke (LVO) is controversial. Some data suggest IVT increases MT technical difficulty. Within our hub-and-spoke telestroke network, we examined how spoke-administered IVT affected hub MT procedure time and pass number.

Methods: Patients presenting to 25 spoke hospitals who were transferred to the hub and underwent MT from 2018 to 2020 were identified from a prospectively maintained database. MT procedure time, fluoroscopy time, and pass number were obtained from operative reports.

Results: Of 107 patients, 48 received IVT at spokes. Baseline characteristics and NIHSS were similar. The last known well (LKW)-to-puncture time was shorter among IVT patients (4.3 ± 1.9 h vs. 10.5 ± 6.5 h, p < 0.0001). In patients that received IVT, mean MT procedure time was decreased by 18.8 min (50.5 ± 29.4 vs. 69.3 ± 46.7 min, p = 0.02) and mean fluoroscopy time was decreased by 11.3 min (21.7 ± 15.8 vs. 33.0 ± 30.9 min, p = 0.03). Furthermore, IVT-treated patients required fewer MT passes (median 1 pass [IQR 1.0, 1.80] vs. 2 passes [1.0, 2.3], p = 0.0002) and were more likely to achieve reperfusion in ≤2 passes (81.3% vs. 59.3%, p = 0.01). An increased proportion of IVT-treated patients achieved TICI 2b-3 reperfusion after MT (93.9% vs. 83.8%, p = 0.045). There were no associations between MT procedural characteristics and LKW-to-puncture time.

Conclusion: Within our network, hub MT following spoke-administered IVT was faster, required fewer passes, and achieved improved reperfusion. This suggests spoke-administered IVT does not impair MT, but instead may enhance it.
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http://dx.doi.org/10.1177/15910199221087498DOI Listing
March 2022

Retreatment of Residual and Recurrent Aneurysms After Embolization With the Woven EndoBridge Device: Multicenter Case Series.

Neurosurgery 2022 05;90(5):569-580

Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA.

Background: The Woven EndoBridge (WEB) device (Terumno Corp. [parent company of Microvention]) was approved by the U.S. Food and Drug Administration as the first intrasaccular device for intracranial aneurysm treatment in December 2018. Its use has become more common since then, but both trial results and postmarket experiences have raised questions about the efficacy in achieving complete aneurysm obliteration. Retreatment after WEB embolization has not been extensively discussed.

Objective: To discuss the incidence and retreatment of aneurysms after initial WEB embolization.

Methods: Retrospective review across 13 institutions identified all occurrences of WEB retreatment within neurovascular databases. Details regarding demographics, aneurysm characteristics, treatment considerations, clinical outcomes, and aneurysm occlusion were obtained and analyzed.

Results: Thirty aneurysms were retreated in 30 patients in a cohort of 342 WEB-treated aneurysms. The retreatment rate was 8.8%. Endovascular methods were used for 23 cases, and 7 were treated surgically. Two aneurysms presented with rehemorrhage after initial WEB embolization. Endovascular treatments included stent-assisted coiling (12), flow diversion (7), coiling (2), PulseRider (Johnson & Johnson)-assisted coiling (1), and additional WEB placement (1). Surgical treatments included primary clipping (6) and Hunterian ligation (1). There were no major complications within the study group.

Conclusion: WEB retreatments were successfully performed by a variety of techniques, including stent-assisted coiling, clipping, and flow diversion as the most common. These procedures were performed safely with subsequent obliteration of most aneurysms. The potential need for retreatment of aneurysms should be considered during primary WEB treatments.
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http://dx.doi.org/10.1227/neu.0000000000001883DOI Listing
May 2022

Characteristics of a COVID-19 Cohort With Large Vessel Occlusion: A Multicenter International Study.

Neurosurgery 2022 06 7;90(6):725-733. Epub 2022 Mar 7.

Department of Biomedical Engineering, American University of Beirut, Beirut, Lebanon.

Background: The mechanisms and outcomes in coronavirus disease (COVID-19)-associated stroke are unique from those of non-COVID-19 stroke.

Objective: To describe the efficacy and outcomes of acute revascularization of large vessel occlusion (LVO) in the setting of COVID-19 in an international cohort.

Methods: We conducted an international multicenter retrospective study of consecutively admitted patients with COVID-19 with concomitant acute LVO across 50 comprehensive stroke centers. Our control group constituted historical controls of patients presenting with LVO and receiving a mechanical thrombectomy between January 2018 and December 2020.

Results: The total cohort was 575 patients with acute LVO; 194 patients had COVID-19 while 381 patients did not. Patients in the COVID-19 group were younger (62.5 vs 71.2; P < .001) and lacked vascular risk factors (49, 25.3% vs 54, 14.2%; P = .001). Modified thrombolysis in cerebral infarction 3 revascularization was less common in the COVID-19 group (74, 39.2% vs 252, 67.2%; P < .001). Poor functional outcome at discharge (defined as modified Ranklin Scale 3-6) was more common in the COVID-19 group (150, 79.8% vs 132, 66.7%; P = .004). COVID-19 was independently associated with a lower likelihood of achieving modified thrombolysis in cerebral infarction 3 (odds ratio [OR]: 0.4, 95% CI: 0.2-0.7; P < .001) and unfavorable outcomes (OR: 2.5, 95% CI: 1.4-4.5; P = .002).

Conclusion: COVID-19 was an independent predictor of incomplete revascularization and poor outcomes in patients with stroke due to LVO. Patients with COVID-19 with LVO were younger, had fewer cerebrovascular risk factors, and suffered from higher morbidity/mortality rates.
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http://dx.doi.org/10.1227/neu.0000000000001902DOI Listing
June 2022

Transradial versus transfemoral access for embolization of intracranial aneurysms with the Woven EndoBridge device: a propensity score-matched study.

J Neurosurg 2022 Feb 4:1-8. Epub 2022 Feb 4.

23Department of Neurosurgery, University of Miami, Miami, FL.

Objective: Transradial access (TRA) is commonly utilized in neurointerventional procedures. This study compared the technical and clinical outcomes of the use of TRA versus those of transfemoral access (TFA) for intracranial aneurysm embolization with the Woven EndoBridge (WEB) device.

Methods: This is a secondary analysis of the Worldwide WEB Consortium, which comprises multicenter data related to adult patients with intracranial aneurysms who were managed with the WEB device. These aneurysms were categorized into two groups: those who were treated with TRA or TFA. Patient and aneurysm characteristics and technical and clinical outcomes were compared between groups. Propensity score matching (PSM) was used to match groups according to the following baseline characteristics: age, sex, subarachnoid hemorrhage, aneurysm location, bifurcation aneurysm, aneurysm with incorporated branch, neck width, aspect ratio, dome width, and elapsed time since the last follow-up imaging evaluation.

Results: This study included 682 intracranial aneurysms (median [interquartile range] age 61.3 [53.0-68.0] years), of which 561 were treated with TFA and 121 with TRA. PSM resulted in 65 matched pairs. After PSM, both groups had similar characteristics, angiographic and functional outcomes, and rates of retreatment, thromboembolic and hemorrhagic complications, and death. TFA was associated with longer procedure length (median 96.5 minutes vs 72.0 minutes, p = 0.006) and fluoroscopy time (28.2 minutes vs 24.8 minutes, p = 0.037) as compared with TRA. On the other hand, deployment issues were more common in those treated with TRA, but none resulted in permanent complications.

Conclusions: TRA has comparable outcomes, with shorter procedure and fluoroscopy time, to TFA for aneurysm embolization with the WEB device.
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http://dx.doi.org/10.3171/2021.12.JNS212293DOI Listing
February 2022

Association of Infarct Topography and Outcome After Endovascular Thrombectomy in Patients With Acute Ischemic Stroke.

Neurology 2022 03 31;98(11):e1094-e1103. Epub 2022 Jan 31.

From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston.

Background And Objectives: The care of patients with large vessel occlusion (LVO) stroke has been revolutionized by endovascular thrombectomy (EVT). While EVT has a large effect size, most patients treated with EVT remain disabled or die within 90 days. A better understanding of outcomes may influence EVT selection criteria, novel therapies, and prognostication. We sought to identify associations between outcomes and brain regions involved in ischemic lesions.

Methods: For this cohort study, consecutive patients with LVO who were treated with EVT and underwent post-EVT MRI were identified from a tertiary referral center (2011-2019). Acute ischemic lesions were manually segmented from diffusion-weighted imaging and spatially normalized. Individual lesions were parcellated (atlas-defined 94 cortical regions, 14 subcortical nuclei, 20 white matter tracts) and reduced to 10 essential lesion patterns with the use of unsupervised dimensionality reduction techniques. Ninety-day modified Rankin Scale (mRS) score (>2) was modeled via bayesian regression, taking the 10 lesion patterns as inputs and controlling for lesion size, age, sex, acute NIH Stroke Scale (NIHSS) score, alteplase, prior stroke, intracerebral hemorrhage, and good reperfusion (Thrombolysis in Cerebral Infarction 2b-3). In comparative analyses, 90-day mRS score was modeled considering covariates only, and compartment-wise relevances for acute stroke severity and 90-day mRS score were evaluated.

Results: There were 151 patients with LVO identified (age 68 ± 15 years, 52% female). The median NIHSS score was 16 (interquartile range 13-20); 56% had mRS score >2. Lesion locations predictive of 90-day mRS score involved bilateral but left hemispherically more pronounced precentral and postcentral gyri, insular and opercular cortex, and left putamen and caudate (area under the curve 0.91, highest probability density interval [HPDI] covering 90% certainty 0.90-0.92). The lesion location model outperformed the simpler model relying on covariates only (bayesian model comparison of 97% weight to the model with vs 3% weight to the model without lesion location). While lesions affecting subcortical nuclei had the highest relevance for stroke severity (posterior distribution mean 0.75, 90% HPDI 0.256-1.31), lesions affecting white matter tracts had the highest relevance for 90-day mRS score (0.656, 90% HPDI 0.0864-1.12).

Discussion: These data describe the significance for outcomes of specific brain regions involved in ischemic lesions on MRI after EVT. Future work in additional datasets is needed to confirm these granular findings.
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http://dx.doi.org/10.1212/WNL.0000000000200034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8935439PMC
March 2022

Hemodynamic Differences Between Basilar Artery Fenestration and Normal Vertebrobasilar Artery: A Pilot Study.

Front Neurol 2021 13;12:766174. Epub 2022 Jan 13.

Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.

Basilar artery fenestration has been proposed as a contributor to ischemic stroke, as unique flow patterns induced by fenestration may be related to thrombus formation or insufficiency. This study aimed to evaluate the hemodynamics of basilar artery fenestration (BAF) using computational fluid dynamics (CFD). Patients with BAF and normal vertebrobasilar system were recruited and separately evaluated using CFD. Specific geometric vascular models were reconstructed based on 3D-rotational angiography (3D-RA). Patients were divided into the BAF group and control group (i.e., patients with the normal vertebrobasilar system). Hemodynamic and geometric variables were calculated and compared between groups using Student's -test or Wilcoxon rank-sum test. Overall, 24 patients were included, with 12 patients each in the BAF group and the control group. The BAF group had a significantly smaller basilar artery diameter than the control group (3.1 ± 0.51 vs. 3.76 ± 0.4, = 0.002). Compared to the control group, the BAF group had higher values of maxOSI (median, 0.3 vs. 0.09, = 0.028), TAWSSG (median, 983.42 vs. 565.39, = 0.038) in the flow confluence, higher SAR-TAWSSG in bifurcation (median, 70.22 vs. 27.65, = 0.002) and higher SAR-TAWSSG in basilar artery (median, 48.75 vs. 16.17, < 0.001) of the vertebrobasilar artery. This pilot study suggested that hemodynamic differences between BAF and normal vertebrobasilar artery across multiple shear flow parameters. The disturbed flow in the BAF may increase the risk of thrombus formation, plaque instability, and subsequent ischemic cerebrovascular events. These should be confirmed by future studies.
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http://dx.doi.org/10.3389/fneur.2021.766174DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8792536PMC
January 2022

Antegrade or Retrograde Approach for the Management of Tandem Occlusions in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

Front Neurol 2021 12;12:757665. Epub 2022 Jan 12.

Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.

Acute ischemic stroke (AIS) caused by tandem intracranial and extracranial occlusions is not rare. However, optimal strategy between antegrade (extracranial first) or retrograde (intracranial first) approaches still remains elusive. This systematic review and meta-analysis aim to compare the two approaches to provide updated clinical evidence of strategy selection. PubMed, Ovid, Web of Science, and the Cochrane Library were searched for literature comparing antegrade and retrograde approaches for patients with AIS with concomitant tandem occlusions. Outcomes including successful reperfusion [Throbolysis in Cerebral Infarction (TICI) 2b-3] and 90-day favorable outcome [modified Rankin Scale (mRS) 0-2], any intracerebral hemorrhage, symptomatic intracerebral hemorrhage, procedural complications, and mortality were evaluated. The risk of bias was assessed using the Newcastle-Ottawa Scale and illustrated in the Funnel plot. Heterogeneity was assessed by statistic. Subgroup and sensitivity analyses were also performed. A total of 11 studies accounting 1,517 patients were included. 831 (55%) patients were treated with an antegrade approach and 686 (45%) patients were treated with the retrograde approach. A higher successful reperfusion rate was achieved in retrograde group than that of antegrade group [83.8 vs. 78.0%; odds ratio (OR): 0.63, 95% CI: 0.40-0.99, = 0.04]. 90-day favorable outcome (mRS 0-2 at 90 days) also showed significantly higher in retrograde group compared with antegrade group (47.3 vs. 40.2%; OR: 0.72, 95% CI: 0.58-0.89, = 0.002). The incidence of any intracranial hemorrhage (ICH), symptomatic intracranial hemorrhage, 90-day mortality, and other complications did not differ between two groups. In AIS with tandem occlusions, the retrograde approach might achieve a higher successful reperfusion rate and better functional outcome with a comparable safety profile when compared with an antegrade approach. Further prospective controlled studies with more meticulous design and a higher level of evidence are needed to confirm these results. "PROSPERO" database (CRD 42020199093), https://www.crd.york.ac.uk/PROSPERO/.
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http://dx.doi.org/10.3389/fneur.2021.757665DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8790816PMC
January 2022

Asymptomatic Moyamoya Disease in a North American Adult Cohort.

World Neurosurg 2022 May 29;161:e146-e153. Epub 2022 Jan 29.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Objective: The natural history of asymptomatic adult moyamoya disease (MMD) is unclear, and the benefit of treatment remains controversial. This study aimed to investigate the natural history of asymptomatic MMD in a North American cohort and to evaluate risk factors associated with and the effects of treatment on disease progression.

Methods: Medical records from 3 institutions of consecutive adult patients with MMD diagnosed between 1984 and 2018 were retrospectively reviewed. Patients with unilateral or bilateral asymptomatic MMD were evaluated for subsequent development of infarction or hemorrhage. Multivariate Cox proportional hazards regression assessed risk factors associated with infarction or hemorrhage, adjusting for age, sex, race, initial Suzuki grade, hypertension, hyperlipidemia, diabetes, obesity, presence of aneurysms, smoking status, aspirin, and statin use at diagnosis.

Results: We identified 106 hemispheres with asymptomatic MMD in 97 patients with mean 5.1 years (interquartile range, 1.0-7.9 years) of follow-up. Of 106 hemispheres, 59 were treated medically, and 47 were treated with revascularization with direct or indirect bypasses. The medical and surgical cohorts had a 1.9% and 1.3% annual rate of radiographic infarction or hemorrhage per hemisphere, respectively. Cox regression for radiographic events, including early postoperative events, showed no significant difference between the treatment groups (adjusted hazard ratio 0.34 [95% confidence interval 0.05-2.5]).

Conclusions: We found an overall 1.7% annual rate of radiographic infarction or hemorrhage in asymptomatic MMD hemispheres. Although we did not find a benefit to surgical treatment within the study period, asymptomatic patients with expected long-term survival may benefit from surgery given the sustained long-term benefits after surgery despite an initial postoperative risk.
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http://dx.doi.org/10.1016/j.wneu.2022.01.076DOI Listing
May 2022

Acute ischaemic stroke associated with SARS-CoV-2 infection in North America.

J Neurol Neurosurg Psychiatry 2022 04 25;93(4):360-368. Epub 2022 Jan 25.

Calgary Stroke Program, Cumming School of Medicine, Calgary, AB, Canada.

Background: To analyse the clinical characteristics of COVID-19 with acute ischaemic stroke (AIS) and identify factors predicting functional outcome.

Methods: Multicentre retrospective cohort study of COVID-19 patients with AIS who presented to 30 stroke centres in the USA and Canada between 14 March and 30 August 2020. The primary endpoint was poor functional outcome, defined as a modified Rankin Scale (mRS) of 5 or 6 at discharge. Secondary endpoints include favourable outcome (mRS ≤2) and mortality at discharge, ordinal mRS (shift analysis), symptomatic intracranial haemorrhage (sICH) and occurrence of in-hospital complications.

Results: A total of 216 COVID-19 patients with AIS were included. 68.1% (147/216) were older than 60 years, while 31.9% (69/216) were younger. Median [IQR] National Institutes of Health Stroke Scale (NIHSS) at presentation was 12.5 (15.8), and 44.2% (87/197) presented with large vessel occlusion (LVO). Approximately 51.3% (98/191) of the patients had poor outcomes with an observed mortality rate of 39.1% (81/207). Age >60 years (aOR: 5.11, 95% CI 2.08 to 12.56, p<0.001), diabetes mellitus (aOR: 2.66, 95% CI 1.16 to 6.09, p=0.021), higher NIHSS at admission (aOR: 1.08, 95% CI 1.02 to 1.14, p=0.006), LVO (aOR: 2.45, 95% CI 1.04 to 5.78, p=0.042), and higher NLR level (aOR: 1.06, 95% CI 1.01 to 1.11, p=0.028) were significantly associated with poor functional outcome.

Conclusion: There is relationship between COVID-19-associated AIS and severe disability or death. We identified several factors which predict worse outcomes, and these outcomes were more frequent compared to global averages. We found that elevated neutrophil-to-lymphocyte ratio, rather than D-Dimer, predicted both morbidity and mortality.
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http://dx.doi.org/10.1136/jnnp-2021-328354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8804309PMC
April 2022

Parkinson's Disease and Ischemic Stroke: a Bidirectional Mendelian Randomization Study.

Transl Stroke Res 2022 08 11;13(4):528-532. Epub 2022 Jan 11.

Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.

We aimed to assess the potential causal association between Parkinson's disease (PD) and ischemic stroke (IS) with Mendelian randomization methods. Summary statistics data from two large-scale genome-wide association studies (GWAS) for 33,674 PD cases and 40,585 IS cases were used in this study. We used inverse variance-weighted method for primary analysis, and four other Mendelian randomization methods (weighted median, MR-Egger regression methods, robust adjusted profile score, radial regression) to test whether PD was causal for IS and its subtypes. Analyses were bidirectional to assess reverse causality. Primary analysis showed PD had a significantly causal association with IS (OR 1.04; 95% CI, 1.02-1.07; p = 0.0019), and two subtypes of IS, cardioembolic stroke (OR 1.11; 95% CI, 1.06-1.18; p = 0.0001) and large artery stroke (OR 1.08; 95% CI, 1.01-1.15; p = 0.034), but not with small-vessel stroke (p = 0.180). The point estimates from sensitivity analyses were in the same direction. There was no strong evidence for a reverse causal association between PD and IS. Using multiple Mendelian randomization methods based on large-scale GWAS, PD is a potential cause of cardioembolic stroke and large artery stroke, but not small-vessel stroke. Ischemic stroke does not cause PD.
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http://dx.doi.org/10.1007/s12975-021-00974-6DOI Listing
August 2022

Cortical Spreading Depolarizations and Clinically Measured Scalp EEG Activity After Aneurysmal Subarachnoid Hemorrhage and Traumatic Brain Injury.

Neurocrit Care 2022 06 7;37(Suppl 1):49-59. Epub 2022 Jan 7.

Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.

Background: Spreading depolarizations (SDs) are associated with worse outcome following subarachnoid hemorrhage (SAH) and traumatic brain injury (TBI), but gold standard detection requires electrocorticography with a subdural strip electrode. Electroencephalography (EEG) ictal-interictal continuum abnormalities are associated with poor outcomes after TBI and with both delayed cerebral ischemia (DCI) and poor outcomes after SAH. We examined rates of SD detection in patients with SAH and TBI with intraparenchymal and subdural strip electrodes and assessed which continuous EEG (cEEG) measures were associated with intracranially quantified SDs.

Methods: In this single-center cohort, we included patients with SAH and TBI undergoing ≥ 24 h of interpretable intracranial monitoring via eight-contact intraparenchymal or six-contact subdural strip platinum electrodes or both. SDs were rated according to established consensus criteria and compared with cEEG findings rated according to the American Clinical Neurophysiology Society critical care EEG monitoring consensus criteria: lateralized rhythmic delta activity, generalized rhythmic delta activity, lateralized periodic discharges, generalized periodic discharges, any ictal-interictal continuum, or a composite scalp EEG tool for seizure risk estimation: the 2HELPS2B score. Among patients with SAH, cEEG was assessed for validated DCI biomarkers: new or worsening epileptiform abnormalities and new background deterioration.

Results: Over 6 years, SDs were recorded in 5 (18%) of 28 patients recorded with intraparenchymal electrodes and 4 (40%) of 10 patients recorded with subdural strip electrodes. There was no significant association between occurrence of SDs and day 1 cEEG findings (American Clinical Neurophysiology Society main terms lateralized periodic discharges, generalized periodic discharges, lateralized rhythmic delta activity, or seizures, individually or in combination). After SAH, established cEEG DCI predictors were not associated with SDs.

Conclusions: Intraparenchymal recordings yielded low rates of SD, and documented SDs were not associated with ictal-interictal continuum abnormalities or other cEEG DCI predictors. Identifying scalp EEG correlates of SD may require training computational EEG analytics and use of gold standard subdural strip electrocorticography recordings.
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http://dx.doi.org/10.1007/s12028-021-01418-7DOI Listing
June 2022

Middle meningeal artery embolization: preventing subdural hematoma recurrence and saving money?

J Neurointerv Surg 2022 08 5;14(8):745-746. Epub 2022 Jan 5.

Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA

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http://dx.doi.org/10.1136/neurintsurg-2021-018441DOI Listing
August 2022
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