Publications by authors named "Waleed Brinjikji"

430 Publications

Natural history, angiographic presentation and outcomes of anterior cranial fossa dural arteriovenous fistulas.

J Neurointerv Surg 2022 Aug 9. Epub 2022 Aug 9.

Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan.

Background: Anterior cranial fossa dural arteriovenous fistulas (ACF-dAVFs) are aggressive vascular lesions. The pattern of venous drainage is the most important determinant of symptoms. Due to the absence of a venous sinus in the anterior cranial fossa, most ACF-dAVFs have some degree of drainage through small cortical veins. We describe the natural history, angiographic presentation and outcomes of the largest cohort of ACF-dAVFs.

Methods: The CONDOR consortium includes data from 12 international centers. Patients included in the study were diagnosed with an arteriovenous fistula between 1990-2017. ACF-dAVFs were selected from a cohort of 1077 arteriovenous fistulas. The presentation, angioarchitecture and treatment outcomes of ACF-dAVF were extracted and analyzed.

Results: 60 ACF-dAVFs were included in the analysis. Most ACF-dAVFs were symptomatic (38/60, 63%). The most common symptomatic presentation was intracranial hemorrhage (22/38, 57%). Most ACF-dAVFs drained through cortical veins (85%, 51/60), which in most instances drained into the superior sagittal sinus (63%, 32/51). The presence of cortical venous drainage predicted symptomatic presentation (OR 9.4, CI 1.98 to 69.1, p=0.01). Microsurgery was the most effective modality of treatment. 56% (19/34) of symptomatic patients who were treated had complete resolution of symptoms. Improvement of symptoms was not observed in untreated symptomatic ACF-dAVFs.

Conclusion: Most ACF-dAVFs have a symptomatic presentation. Drainage through cortical veins is a key angiographic feature of ACF-dAVFs that accounts for their malignant course. Microsurgery is the most effective treatment. Due to the high risk of bleeding, closure of ACF-dAVFs is indicated regardless of presentation.
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http://dx.doi.org/10.1136/jnis-2022-019160DOI Listing
August 2022

Mechanical Thrombectomy via Transradial Approach for Posterior Circulation Stroke: A Systematic Review and Meta-Analysis.

Cureus 2022 Jul 5;14(7):e26589. Epub 2022 Jul 5.

Neuroradiology, Mayo Clinic, Rochester, USA.

Mechanical thrombectomy for acute ischemic stroke (AIS) is traditionally performed via transfemoral access. While the majority of AISs are due to anterior circulation large vessel occlusions (AC-LVO), we performed a systematic review and meta-analysis to examine the feasibility of and outcomes following a transradial artery access for posterior circulation large vessel occlusion (PC-LVO) strokes. A systematic literature review of the English language literature was conducted using PubMed, MEDLINE, and Embase as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcomes of interest included 90-day modified Rankin scale (mRS) 0-2, puncture to recanalization time, and thrombolysis in cerebral infarction (TICI) scores 2b/3 and 3. We calculated pooled event rates and their corresponding 95% confidence intervals (CI) for all outcomes. We included seven studies with 68 patients in our analysis. All patients underwent mechanical thrombectomy via transradial artery access for AIS due to PC-LVO. The pooled meantime of puncture to recanalization was 29.19 (95% CI=24.05 to 35.42) minutes. Successful recanalization (TICI2b/3) was achieved in 98.69% (95% CI=93.50 to 100) of patients and complete recanalization (TICI 3) in 52.16% (95% CI=34.18 to 79.60) of the patients. Overall, 56.84% (95% CI=41.26 to 78.30) of patients achieved mRS 0-2. Transradial artery access for mechanical thrombectomy for PC-LVO stroke displays early promise and feasibility, particularly regarding very high rates of successful recanalization and low puncture to recanalization time.
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http://dx.doi.org/10.7759/cureus.26589DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9351823PMC
July 2022

Intracranial Aneurysms in Loeys-Dietz Syndrome: A Multicenter Propensity-Matched Analysis.

Neurosurgery 2022 Jul 14. Epub 2022 Jul 14.

Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA.

Background: Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder characterized by a classic triad of hypertelorism, bifid uvula and/or cleft palate, and generalized arterial tortuosity. There are limited data on the prevalence and rupture risk of intracranial aneurysms (IAs) in the setting of LDS, with no established guidelines.

Objective: To analyze the prevalence and rupture risk of IA in LDS.

Methods: Electronic medical records of patients with a confirmed diagnosis of LDS and available cerebrovascular imaging were reviewed. Patients were divided into 2 groups based on the presence of IA. Unmatched and propensity-matched analyses were used to identify potential risk factors for aneurysm formation.

Results: Records of 1111 patients were screened yielding a total of 60 patients with a diagnosis of LDS. Eighteen (30%) patients had IA, 4 (22.2%) of whom had multiple aneurysms for a total of 24 IAs. Twenty-three (95.8%) aneurysms were located in the anterior circulation; none of them were ruptured. On unmatched analysis, age (P = .015), smoking history (P = .034), hypertension (P = .035), and number of extracranial aneurysms (P < .001) were significantly higher in patients with IA. After matching for age, sex, race, stroke history, family history, and extracranial aneurysms, smoking history (P = .009) remained significant.

Conclusion: Patients with LDS have an increased risk of IAs, especially with a history of smoking. The prevalence rate of IAs in our series was 30%. Screening imaging should be considered at diagnosis, and patients should be encouraged to abstain from smoking. Further studies are needed to elucidate the risk of IA rupture and treatment considerations in this unique population.
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http://dx.doi.org/10.1227/neu.0000000000002070DOI Listing
July 2022

Combined CSF-venous Fistula and middle meningeal artery embolization for treatment of spontaneous intracranial hypotension.

Interv Neuroradiol 2022 Jun 17:15910199221109044. Epub 2022 Jun 17.

Division of Neuroradiology, Department of Radiology, 6915Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.

Transvenous Onyx embolization was recently described as an effective treatment of spontaneous intracranial hypotension caused by CSF-venous fistulas. Patients with CSF-venous fistulas can present with a wide spectrum of clinical and imaging findings, sometimes including spontaneous subdural hematomas, subdural hygromas, or a combination of both. Here, we describe four patients with spontaneous intracranial hypotension complicated by subdural fluid collections caused by CSF-venous fistulas. The patients were treated with transvenous Onyx embolization of their CSF-venous fistulas and transarterial particle embolization of the bilateral middle meningeal arteries, with both procedures performed in a single treatment session. All four patients had clinical improvement and decreased size or resolution of their subdural fluid collections. Based on our findings, we believe that middle meningeal embolization could be a useful adjunct to CSF-venous fistula embolization. A case-control study comparing patients who did or did not undergo middle meningeal embolization will be necessary to validate this supposition.
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http://dx.doi.org/10.1177/15910199221109044DOI Listing
June 2022

Neuroprotection in Acute Ischemic Stroke: A Battle Against the Biology of Nature.

Front Neurol 2022 31;13:870141. Epub 2022 May 31.

Department of Neuroradiology, Mayo Clinic, Rochester, MN, United States.

Stroke is the second most common cause of global death following coronary artery disease. Time is crucial in managing stroke to reduce the rapidly progressing insult of the ischemic penumbra and the serious neurologic deficits that might follow it. Strokes are mainly either hemorrhagic or ischemic, with ischemic being the most common of all types of strokes. Thrombolytic therapy with recombinant tissue plasminogen activator and endovascular thrombectomy are the main types of management of acute ischemic stroke (AIS). In addition, there is a vital need for neuroprotection in the setting of AIS. Neuroprotective agents are important to investigate as they may reduce mortality, lessen disability, and improve quality of life after AIS. In our review, we will discuss the main types of management and the different modalities of neuroprotection, their mechanisms of action, and evidence of their effectiveness after ischemic stroke.
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http://dx.doi.org/10.3389/fneur.2022.870141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9195142PMC
May 2022

Efficacy and safety of SOFIA aspiration catheter for mechanical thrombectomy via ADAPT and Solumbra echniques in acute ischemic stroke: A systematic review and meta-analysis.

Interv Neuroradiol 2022 Jun 12:15910199221107438. Epub 2022 Jun 12.

Department of Neurosurgery, 6915Mayo Clinic, Rochester, MN, USA.

Introduction: SOFIA catheter is a relatively new and recently FDA-approved aspiration catheter. This systematic review aims to investigate the safety and efficacy of SOFIA catheter for treatment of acute ischemic stroke (AIS) via ADAPT and Solumbra techniques.

Methods: Search of all studies evaluating the SOFIA catheter for mechanical thrombectomy (MT) for treatment of AIS via ADAPT and Solumbra techniques from inception through 2020 on Pubmed, PMC, and Embase was performed. We analyzed the angiographic and clinical outcomes of both techniques with SOFIA catheter using the random-effects model.

Results: From 18 studies, 1836 patients were included with 1365 receiving MT using ADAPT and 471 with solumbra technique. The mean age was 69.8 years and 51.1% of the patients were women. The rate of rescue therapy was 30%. The outcomes rates of ADAPT group were as follows; mFPE (59.3%), FPE (34.4%) final TICI 2b/3 (89.3%), procedural complications (8%), embolization to new territory (ENT) (2.3%), symptomatic ICH (5.4%), mean NIHSS (8.97), 90-day-mRS 0-2 (48.8%), and mortality (15.3%). The outcomes rates of Solumbra group were as follows; mFPE (60.5%), FPE (46.7%), final TICI 2b/3 (93%), procedural complications (6.4%), ENT (2%), symptomatic ICH (6%), mean NIHSS (7.59), mRS 0-2 (53.8%), and mortality (10.8%). ICA and posterior circulation strokes, and tandem lesions had worse outcomes (P < .005). MCA strokes were associated with better outcomes (P = .005). ASPECT scores' association with the clinical outcomes was found statistically significant.

Conclusion: SOFIA catheter is effective and safe to treat acute ischemic stroke regardless of applied MT technique.
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http://dx.doi.org/10.1177/15910199221107438DOI Listing
June 2022

Interpretable Machine Learning Modeling for Ischemic Stroke Outcome Prediction.

Front Neurol 2022 19;13:884693. Epub 2022 May 19.

Department of Radiology, Mayo Clinic, Rochester, MN, United States.

Background And Purpose: Mechanical thrombectomy greatly improves stroke outcomes. Nonetheless, some patients fall short of full recovery despite good reperfusion. The purpose of this study was to develop machine learning (ML) models for the pre-interventional prediction of functional outcome at 3 months of thrombectomy in acute ischemic stroke (AIS), using clinical and auto-extractable radiological information consistently available upon first emergency evaluation.

Materials And Methods: A two-center retrospective cohort of 293 patients with AIS who underwent thrombectomy was analyzed. ML models were developed to predict dichotomized modified Rankin score at 90 days (mRS-90) using clinical and imaging features, both separately and combined. Conventional and experimental imaging biomarkers were quantified using automated image-processing software from non-contract computed tomography (CT) and computed tomography angiography (CTA). Shapley Additive Explanation (SHAP) was applied for model interpretability and predictor importance analysis of the optimal model.

Results: Merging clinical and imaging features returned the best results for mRS-90 prediction. The best performing classifier was Extreme Gradient Boosting (XGB) with an area under the receiver operating characteristic curve (AUC) = 84% using selected features. The most important classifying features were age, baseline National Institutes of Health Stroke Scale (NIHSS), occlusion side, degree of brain atrophy [primarily represented by cortical cerebrospinal fluid (CSF) volume and lateral ventricle volume], early ischemic core [primarily represented by e-Alberta Stroke Program Early CT Score (ASPECTS)], and collateral circulation deficit volume on CTA.

Conclusion: Machine learning that is applied to quantifiable image features from CT and CTA alongside basic clinical characteristics constitutes a promising automated method in the pre-interventional prediction of stroke prognosis. Interpretable models allow for exploring which initial features contribute the most to post-thrombectomy outcome prediction overall and for each individual patient outcome.
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http://dx.doi.org/10.3389/fneur.2022.884693DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9160988PMC
May 2022

Trends in Utilization of Temporary and Permanent Cerebrospinal Fluid Diversion and Catheter Cerebral Angiography for Patients with Aneurysmal Subarachnoid Hemorrhage in the United States.

World Neurosurg 2022 Aug 2;164:e1161-e1178. Epub 2022 Jun 2.

Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.

Introduction: We sought to analyze the rate of utilization of methods of cerebrospinal fluid diversion over time in a nationally representative cohort of patients admitted with aneurysmal subarachnoid hemorrhage (aSAH).

Methods: The Nationwide Inpatient Sample was queried for patients admitted with aSAH from 2006 to 2018. Patients who received external ventricular drainage (EVD), lumbar drainage, ventriculoperitoneal shunt (VPS), and cerebral angiography were then identified. A Cochrane-Armitage test was conducted to assess the linear trend of proportions of EVD, lumbar drains, VPS, and mean cerebral angiograms per admission. Four regression analyses were conducted to infer the association of baseline variables to EVD, lumbar drain, VPS, and mean number of cerebral angiographies.

Results: A total of 133,567 admissions were identified from 2006-2018 involving aSAH. Of these, 41.82% received EVD, 6.22% received lumbar drainage, 10.58% received VPS, and 75.03% had cerebral angiograms. There was an average upward trend of 1.57% in annual EVD utilization, downward trend of -0.28% in utilization of lumbar drainage, no changes in VPS utilization, and an upward trend of 0.04 angiograms per year (P < 0.001). There was a higher proportion of Black patients treated with EVD and VPS in both urban teaching hospitals and large hospitals.

Conclusions: Our results show the temporal trends in utilization of temporary and permanent methods of cerebrospinal fluid diversion and catheter cerebral angiography among patients with aSAH in the United States. The underutilization of VPS following EVD and the differences in EVD and VPS utilization depending on race and hospital size deserve further exploration.
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http://dx.doi.org/10.1016/j.wneu.2022.05.125DOI Listing
August 2022

Journal Selection Primer for Neuroradiology Researchers.

Acad Radiol 2022 Jun 2. Epub 2022 Jun 2.

Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota. Electronic address:

Junior Neuroradiology investigators face a rapidly expanding universe of potential journals for manuscript submission. Each journal possesses many unique features, including scope/breadth of research focus, willingness to accept specific types of articles (for example, Review Articles, or Case Reports), status of indexing on major academic indices, scholarly relevance (usually defined as Impact Factor) and access type (Open Access, subscription, or Hybrid Access). An uninformed choice of target journal can burden not only Editors and Reviewers but also increase the effort and frustration level of relatively inexperienced investigators and ultimately result in a worthy manuscript not getting published. In order to assist Junior Neuroradiology investigators in optimizing journal selection for manuscript submission, we provide a Primer that includes background information on all the journal features listed previously. We also provide detailed tabular data for all Radiology, Neuroradiology, and associated Neuroscience Clinical Journals that follow proper academic standards as a quick and useful reference guide for optimal journal selection.
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http://dx.doi.org/10.1016/j.acra.2022.05.004DOI Listing
June 2022

Unifying theory of carotid plaque disruption based on structural phenotypes and forces expressed at the lumen/wall interface.

Stroke Vasc Neurol 2022 Jun 1. Epub 2022 Jun 1.

Department of Neurology, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA.

Objectives: To integrate morphological, haemodynamic and mechanical analysis of carotid atheroma driving plaque disruption.

Materials And Methods: First, we analysed the phenotypes of carotid endarterectomy specimens in a photographic dataset A, and matched them with the likelihood of preoperative stroke. Second, laser angioscopy was used to further define the phenotypes in intact specimens (dataset B) and benchmark with histology. Third, representative vascular geometries for each structural phenotype were analysed with Computational Fluid Dynamics (CFD), and the mechanical strength of the complicated atheroma to resist penetrating forces was quantified (n=14).

Results: In dataset A (n=345), ulceration (fibrous cap disruption) was observed in 82% of all plaques, intraplaque haemorrhage in 68% (93% subjacent to an ulcer) and false luminal formation in 48%. At least one of these 'rupture' phenotypes was found in 97% of symptomatic patients (n=69) compared with 61% in asymptomatic patients. In dataset B (n=30), laser angioscopy redemonstrated the structural phenotypes with near-perfect agreement with histology. In CFD, haemodynamic stress showed a large pulse magnitude, highest upstream to the point of maximal stenosis and on ulceration the inflow stream excavates the necrotic core cranially and then recirculates into the true lumen. Based on mechanical testing (n=14), the necrotic core is mechanically weak and penetrated by the blood on fibrous cap disruption.

Conclusions: Fibrous cap ulceration, plaque haemorrhage and excavation are sequential phenotypes of plaque disruption resulting from the chiselling effect of haemodynamic forces over unmatched mechanical tissue strength. This chain of events may result in thromboembolic events independently of the degree of stenosis.
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http://dx.doi.org/10.1136/svn-2021-001451DOI Listing
June 2022

Dynamic Vertebral Artery Compression by Solitary Osteochondroma Presenting With Recurrent Posterior Circulation Strokes.

Stroke 2022 Aug 27;53(8):e379-e380. Epub 2022 May 27.

Department of Neurology (J.P.K.), Mayo Clinic, Rochester, MN.

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http://dx.doi.org/10.1161/STROKEAHA.122.039124DOI Listing
August 2022

Correlation of von Willebrand factor and platelets with acute ischemic stroke etiology and revascularization outcome: an immunohistochemical study.

J Neurointerv Surg 2022 May 20. Epub 2022 May 20.

Department of Neurology, Emory University, Atlanta, Georgia, USA.

Background: Platelets and von Willebrand factor (vWF) are key components of acute ischemic stroke (AIS) emboli. We aimed to investigate the CD42b (platelets)/vWF expression, its association with stroke etiology and the impact these components may have on the clinical/procedural parameters.

Methods: CD42b/vWF immunostaining was performed on 288 emboli collected as part of the multicenter STRIP Registry. CD42b/VWF expression and distribution were evaluated. Student's t-test and χ test were performed as appropriate.

Results: The mean CD42b and VWF content in clots was 44.3% and 21.9%, respectively. There was a positive correlation between platelets and vWF (r=0.64, p<0.001**). We found a significantly higher vWF level in the other determined etiology (p=0.016*) and cryptogenic (p=0.049*) groups compared with cardioembolic etiology. No significant difference in CD42b content was found across the etiology subtypes. CD42b/vWF patterns were significantly associated with stroke etiology (p=0.006*). The peripheral pattern was predominant in atherosclerotic clots (36.4%) while the clustering (patchy) pattern was significantly associated with cardioembolic and cryptogenic origin (66.7% and 49.8%, respectively). The clots corresponding to other determined etiology showed mainly a diffuse pattern (28.1%). Two types of platelets were distinguished within the CD42b-positive clusters in all emboli: vWF-positive platelets were observed at the center, surrounded by vWF-negative platelets. Thrombolysis correlated with a high platelet content (p=0.03*). vWF-poor and peripheral CD42b/vWF pattern correlated with first pass effect (p=0.03* and p=0.04*, respectively).

Conclusions: The vWF level and CD42b/vWF distribution pattern in emboli were correlated with AIS etiology and revascularization outcome. Platelet content was associated with response to thrombolysis.
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http://dx.doi.org/10.1136/neurintsurg-2022-018645DOI Listing
May 2022

Intra-procedural cerebral sinus thrombosis during endovascular treatment of idiopathic intracranial hypertension.

Neuroradiol J 2022 Apr 29:19714009221096837. Epub 2022 Apr 29.

Department of Radiology, Mayo Clinic, Rochester, MN, USA.

Stenting of the intracranial venous sinuses has shown promising results in patients who are refractory to medical treatment of idiopathic intracranial hypertension (IIH). Among the reported complications associated with this procedure, in-stent thrombosis is an unreported one. We present a case of cerebral sinus thrombosis during endovascular treatment of IIH. A 33-year-old man with multiple comorbidities was presented with non-specific vision changes and headaches. Initial workup revealed a diagnosis of idiopathic intracranial hypertension which was treated medically but with no improvement. Therefore, cerebral sinus stenting was pursued. During the procedure, an in-stent thrombus was identified which was retrieved mechanically and was sent for histological and immunohistochemical evaluation. The retrieved thrombus was predominantly composed of RBCs (57.8%) followed by fibrin (30.78%), platelet (6.4%), and WBCs (5.95%), with high expression of CitH3 (neutrophil extra cellular traps specific marker) (10.9%), and CD66 (11.35%).
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http://dx.doi.org/10.1177/19714009221096837DOI Listing
April 2022

An in vitro model for Extracellular DNA Traps (ETs)-rich Human Thrombus Analogs.

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

Radiology, Mayo Clinic, Rochester, Minnesota, USA.

Background: Extracellular DNA traps (ETs) have important implications in both thrombosis and thrombolysis. Thus, developing benchtop thrombus analogs that recapitulate clinical ETs is potentially of great value for preclinical development and testing of thrombolytic agents and thrombectomy devices. In this study, we aimed to develop ETs-rich thrombus analogs for preclinical testing.

Methods: Red blood cell (RBC)-rich, fibrin-rich, and platelet-rich thrombus analogs were created using human whole blood, platelet-poor plasma, and platelet-rich plasma obtained from the blood bank following institutional approval. Peripheral blood mononuclear cells (9.9×10 cells/mL) isolated from human whole blood and lipopolysaccharide (1 µg/mL) were added to induce ETs. Histochemical, immunohistochemistry and immunofluorescence were used to identify thrombus components and ETs. Scanning electronic microscopy was used to investigate the ultrastructure of the thrombus analogs. The thrombus compositions, morphologic features of ETs and citrullinated histone H3 (H3Cit) expression were compared with those of thrombi retrieved from patients by thrombectomy.

Results: ETs-rich thrombus analogs were more compacted th-an the ETs-poor thrombus analogs. ETs were identified in both ETs-rich thrombus analogs and patient thrombi showing morphologic features including nuclear lobulation, nuclear swelling, diffused chromatin within cytoplasm, DNA/chromatin extending intracellularly and extracellularly, and extracellular chromatin patches and bundles. In the ETs-poor thrombus analogs, ETs were not observed and H3Cit expression was absent to minimal. The compositions and H3Cit expression in the ETs-rich thrombus analogs fell in the range of patient thrombi.

Conclusions: ETs-rich thrombus analogs can be consistently created in vitro and may benefit the preclinical development and testing of new thrombolytic agents and thrombectomy devices.
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http://dx.doi.org/10.1136/neurintsurg-2022-018790DOI Listing
April 2022

Change of Heart: The Underexplored Role of Plaque Hemorrhage in the Evaluation of Stroke of Undetermined Etiology.

J Am Heart Assoc 2022 05 27;11(9):e025323. Epub 2022 Apr 27.

Department of Radiology Mayo Clinic Rochester MN.

In the evaluation of embolic strokes of undetermined source, great emphasis is often placed on cardiovascular disease, namely on atrial fibrillation. Other pathophysiologic mechanisms, however, may also be involved. Carotid artery intraplaque hemorrhage (IPH)-the presence of blood components within an atheromatous plaque-has become increasingly recognized as a possible etiologic mechanism in some cryptogenic strokes. IPH is a marker of plaque instability and is associated with ipsilateral neurologic ischemic events, even in nonstenotic carotid plaques. As recognition of carotid IPH as an etiology of embolic strokes has grown, so too has the complexity with which such patients are evaluated and treated, particularly because overlaps exist in the risk factors for atrial fibrillation and IPH. In this article, we review what is currently known about carotid IPH and how this clinical entity should be approached in the context of the evaluation of embolic strokes of undetermined source.
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http://dx.doi.org/10.1161/JAHA.122.025323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9238607PMC
May 2022

Mycotic aneurysm.

Pract Neurol 2022 Apr 25. Epub 2022 Apr 25.

Mayo Clinic Rochester, Rochester, Minnesota, USA

Angioinvasive fungal infections of the cerebral vasculature often lead to significant morbidity and mortality. High clinical suspicion and early antifungal therapy could improve outcomes. We describe the fatal case of a patient with a rapidly enlarging cavernous carotid aneurysm due to angioinvasive fungus. This case highlights the challenges in diagnosis and management of this condition.
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http://dx.doi.org/10.1136/practneurol-2021-003260DOI Listing
April 2022

A national survey of venous sinus stenting practices for idiopathic intracranial hypertension.

J Neurointerv Surg 2022 Apr 15. Epub 2022 Apr 15.

Neuroscience Institute, Queen's Medical Center, University of Hawaii, Honolulu, HI, USA.

Background: Little is currently known about physician opinions and preferences on venous sinus stenting (VSS) for idiopathic intracranial hypertension (IIH), practice patterns, or clinical volumes.

Methods: A 19 question online survey was designed and distributed to physician members of the Society of Neurointerventional Surgery (SNIS).

Results: A total of 107 individual survey responses were obtained (14% of SNIS members). The majority of respondents (85%) indicated that they had performed at least one VSS procedure independently during their careers. Mean (SD) and median (range) career case volumes were 20.9 (33.8) and 10.0 (0.0-200.0), respectively. On a 1-10 scale, most respondents reported a high level of interest in treating IIH patients with VSS (median 8), a high level of comfort/expertise in treating IIH patients with VSS (median 9), and that VSS was effective in the long term reduction of symptoms and papilledema in IIH patients (median 8). Fifty-nine per cent of respondents reported increasing VSS volumes compared with previous years. A major complication during a VSS procedure, including two deaths, was reported by 11% of respondents.

Conclusions: This is the first study designed to understand the opinions and practices of neurointerventionists regarding VSS for IIH. Overall physician opinion on VSS was quite positive, supported by increasing procedural volumes reported by most over the past few years. However, only a small percentage of respondents had substantial experience with VSS and major complications were not rare.
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http://dx.doi.org/10.1136/neurintsurg-2022-018832DOI Listing
April 2022

Risk of Early Versus Later Rebleeding From Dural Arteriovenous Fistulas With Cortical Venous Drainage.

Stroke 2022 07 14;53(7):2340-2345. Epub 2022 Apr 14.

Wessex Neurological Center (A.J.D., D.A., J.M.), University Hospital Southampton, United Kingdom.

Background: Cranial dural arteriovenous fistulas with cortical venous drainage are rare lesions that can present with hemorrhage. A high rate of rebleeding in the early period following hemorrhage has been reported, but published long-term rates are much lower. No study has examined how risk of rebleeding changes over time. Our objective was to quantify the relative incidence of rebleeding in the early and later periods following hemorrhage.

Methods: Patients with dural arteriovenous fistula and cortical venous drainage presenting with hemorrhage were identified from the multinational CONDOR (Consortium for Dural Fistula Outcomes Research) database. Natural history follow-up was defined as time from hemorrhage to first treatment, rebleed, or last follow-up. Rebleeding in the first 2 weeks and first year were compared using incidence rate ratio and difference.

Results: Of 1077 patients, 250 met the inclusion criteria and had 95 cumulative person-years natural history follow-up. The overall annualized rebleed rate was 7.3% (95% CI, 3.2-14.5). The incidence rate of rebleeding in the first 2 weeks was 0.0011 per person-day; an early rebleed risk of 1.6% in the first 14 days (95% CI, 0.3-5.1). For the remainder of the first year, the incidence rate was 0.00015 per person-day; a rebleed rate of 5.3% (CI, 1.7-12.4) over 1 year. The incidence rate ratio was 7.3 (95% CI, 1.4-37.7; , 0.026).

Conclusions: The risk of rebleeding of a dural arteriovenous fistula with cortical venous drainage presenting with hemorrhage is increased in the first 2 weeks justifying early treatment. However, the magnitude of this increase may be considerably lower than previously thought. Treatment within 5 days was associated with a low rate of rebleeding and appears an appropriate timeframe.
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http://dx.doi.org/10.1161/STROKEAHA.121.036450DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9232241PMC
July 2022

Human "live cadaver" neurovascular model for proximal and distal mechanical thrombectomy in stroke.

J Neurointerv Surg 2022 Apr 13. Epub 2022 Apr 13.

Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA

Background: Preclinical testing platforms that accurately replicate complex human cerebral vasculature are critical to advance neurointerventional knowledge, tools, and techniques. Here, we introduced and validated a human "live cadaveric" head-and-neck neurovascular model optimized for proximal and distal vascular occlusion and recanalization techniques.

Methods: Human cadaveric head-and-neck specimens were cannulated bilaterally in the jugular veins, carotid, and vertebral arteries. Specimens were then coupled with modular glass models of the aorta and extracranial carotid arteries, as well as radial and femoral access ports. Intracranial physiological flow was simulated using a flow-delivery system and blood-mimicking fluid. Baseline anatomy, histological, and mechanical properties of cerebral arteries were compared with those of fresh specimens. Radiopaque clot analogs were embolized to replicate proximal and distal arterial occlusions, followed by thrombectomy. Experienced interventionalists scored the model on different aspects.

Results: Compared with counterpart fresh human arteries, formalin-fixed arteries showed similar mechanical properties, including maximum stretch, increased tensile strength/stiffness, and friction coefficients were also not significantly different. On histology, minimal endothelial damage was noted in arteries after 3 months of light fixation, otherwise the arterial wall maintained the structural integrity. Contrast angiographies showed no micro- or macro-vasculature obstruction. Proximal and distal occlusions created within the middle cerebral arteries were consistently obtained and successfully recanalized. Additionally, interventionists scored the model highly realistic, indicating great similarity to patients' vasculature.

Conclusions: The human "live cadaveric" neurovascular model accurately replicates the anatomy, mechanics, and hemodynamics of cerebral vasculature and allows the performance of neurointerventional procedures equivalent to those done in patients.
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http://dx.doi.org/10.1136/neurintsurg-2022-018686DOI Listing
April 2022

Particle theory in middle meningeal artery embolization for chronic subdural hematoma.

Authors:
Waleed Brinjikji

Interv Neuroradiol 2022 04 7;28(2):131. Epub 2022 Apr 7.

Department of Neurosurgery and Radiology, Mayo Clinic, Rochester, USA.

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http://dx.doi.org/10.1177/15910199221091896DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9131501PMC
April 2022

Transarterial Embolization of Ethmoidal Dural Arteriovenous Fistula: 2-Dimensional Video.

Oper Neurosurg (Hagerstown) 2022 06 5;22(6):e275. Epub 2022 Apr 5.

Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA.

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http://dx.doi.org/10.1227/ons.0000000000000174DOI Listing
June 2022

Feasibility of telesurgery in the modern era.

Neuroradiol J 2022 Mar 27:19714009221083141. Epub 2022 Mar 27.

Department of Radiology, RinggoldID:6915Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.

Telesurgery is not a foreign concept and dates to as early as the 1920s. The use of robots in medicine has had a very positive effect and improved outcomes with little to no adverse effects. Having global access to telemedicine and telesurgery during the COVID-19 pandemic and being able to provide top medical care to gravely ill and contagious patients without compromising the safety of the medical team would be a very big achievement. We explore the hurdles needed to make it a realistic goal and give recommendations to achieve it utilizing the major advancements that have occurred over the past few years in the fields of engineering, communication etc. The biggest issues needed to be addressed are of financial investment, legal concerns, and availability of high-speed uninterrupted data connections.
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http://dx.doi.org/10.1177/19714009221083141DOI Listing
March 2022

Trends in Admissions and Outcomes for Treatment of Aneurysmal Subarachnoid Hemorrhage in the United States.

Neurocrit Care 2022 08 18;37(1):209-218. Epub 2022 Mar 18.

Department of Neurology, Mayo Clinic, Rochester, MN, USA.

Background: Lifestyle modifications and advances in surgical and endovascular techniques for treating unruptured intracranial aneurysm (UIA) have vastly evolved over the last few decades and may have reduced the incidence of aneurysmal subarachnoid hemorrhage (aSAH). However, the actual impact of these changes on the rates and outcomes of aSAH remain unexplored. Thus, we studied national aSAH admissions and outcome trends and changes of major risk factors over time.

Methods: We queried the National Inpatient Sample between 2006 and 2018 to identify adult patients admitted and treated for UIA or ruptured aneurysm with aSAH. The Cochran-Armitage test was conducted to assess the linear trend of proportion of prevalence, inpatient mortality, hypertension, and current smoking status among aSAH admissions. Multivariable logistic regression was conducted to assess the odds of presenting with aSAH versus UIA, in addition to the odds of inpatient mortality among patients with aSAH.

Results: A total of 159,913 patients presented with UIA and 133,567 presented with aSAH. Admissions for aSAH decreased by 0.97% (p < 0.001) per year. Current smoking and hypertension were associated with higher odds of being admitted for aSAH compared with the treatment for UIA (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.29-1.48; OR 1.15, 95% CI 1.08-1.22, respectively). Compared with White patients, Black patients (OR 1.32, 95% CI 1.21-1.43), Hispanic patients (OR 1.38, 95% CI 1.25-1.52), and patients of other races and/or ethnicities (OR 1.73, 95% CI 1.54-1.95) had a higher chance of presenting with aSAH. Rates of inpatient mortality among aSAH admissions showed no change over time (p = 0.21). Among patients admitted with aSAH, current smoking and hypertension showed an upward trend of 0.58% (p < 0.001) and 1.60% (p < 0.001) per year, respectively.

Conclusions: Despite a downward trend in the annual frequency of hospitalizations for aSAH, inpatient mortality rates for patients undergoing treatment of the ruptured aneurysm have remained unchanged in the United States. Smoking and hypertension are increasingly prevalent among patients with aSAH. Thus, efforts to control these modifiable risk factors must be further strengthened.
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http://dx.doi.org/10.1007/s12028-022-01476-5DOI Listing
August 2022

Imaging Findings of Pediatric Orbital Masses and Tumor Mimics.

Radiographics 2022 May-Jun;42(3):880-897. Epub 2022 Mar 4.

From the Departments of Radiology (A.K.J., J.B.G., L.J.E., G.B.L., J.C.B., W.B., V.M.S.), Ophthalmology (L.A.D.), Neurology (G.F.K.), Neurosurgery (W.B.), and Radiation Oncology (N.N.L.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905.

Pediatric orbital masses are not common but encompass a wide spectrum of benign and malignant entities that range from developmental anomalies to primary and secondary orbital malignancies and metastatic disease. Certain orbital tumors are unique to pediatric patients, such as retinoblastoma and neuroblastoma. Clinical symptoms and signs are often insufficient to differentiate between orbital lesions, and imaging is essential for narrowing the diagnostic considerations and determining the most appropriate management strategy. MRI is the primary imaging modality for evaluating orbital masses in children, with US and CT playing complementary roles. The authors review a spectrum of masses and tumor mimics that affect the pediatric globe and orbit. The shared and differentiating characteristics of pediatric orbital lesions are reviewed. Emphasis is placed on utilizing an orbital compartment-based approach to narrow the differential diagnosis. By using this organizational scheme, the authors describe intraocular processes (retinoblastoma, persistent fetal vasculature, and Coats disease), intraconal lesions (lymphatic malformation, schwannoma, optic nerve sheath meningioma, and optic pathway glioma), extraconal lesions (infantile hemangioma, rhabdomyosarcoma, idiopathic orbital inflammation, lymphoma, venous varix, plexiform neurofibroma, and pleomorphic adenoma of the lacrimal gland), and lesions involving the bony orbit (dermoid cyst, metastatic neuroblastoma, and Langerhans cell histiocytosis). The authors describe the basic management of each entity. Orbital infections and traumatic lesions are beyond the scope of this article. RSNA, 2022.
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http://dx.doi.org/10.1148/rg.210116DOI Listing
May 2022

Carotid artery endarterectomy in patients with symptomatic non-stenotic carotid artery disease.

Stroke Vasc Neurol 2022 06 3;7(3):251-257. Epub 2022 Mar 3.

Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA

Object: We sought to determine the safety and efficacy in secondary stroke prevention of carotid endarterectomy (CEA) in patients with symptomatic non-stenotic carotid artery disease (SyNC).

Methods: This was a single-centre retrospective case series. All patients who underwent CEA for unilateral anterior circulation cerebrovascular events with ipsilateral <50% carotid stenosis from 2002 to 2020 were included. Imaging hallmarks including the degree of luminal stenosis and the presence of various vulnerable plaque characteristics (eg, intraplaque haemorrhage (IPH) on MR angiography, ulceration or low-density plaque on CT angiography) were assessed. The presence of vulnerable plaque characteristics was compared between arteries ipsilateral to the ischaemic event and contralateral arteries. The prevalence of perioperative/intraoperative complications, as well as recurrent ischaemic events at follow-up was determined.

Results: Thirty-two patients were included in the analysis, of which 25.0% were female. Carotid arteries ipsilateral to an ischaemic event had a significantly higher prevalence of IPH when compared with contralateral arteries (80.0% vs 0.0%; p<0.001). There were no intraoperative complications. One patient (3.1%) developed symptoms of transient ipsilateral ischaemia 1 day following CEA which resolved without treatment. In a median follow-up of 18.0 months (IQR 5.0-36.0), only one patient (3.1%) experienced a transient neurologic deficit with complete resolution (annualised rate of recurrent stroke after CEA of 1.5% for a total follow-up of 788 patient-months following CEA). All other patients (31/32, 96.9%) were free of recurrent ischaemic events.

Conclusion: CEA appears to be safe and well-tolerated in patients with SyNC. Additional studies with larger cohorts and longer follow-up intervals are needed in order to determine the role of CEA in this patient population.
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http://dx.doi.org/10.1136/svn-2021-000939DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9240461PMC
June 2022

Spontaneous intracranial hypotension: searching for the CSF leak.

Lancet Neurol 2022 04 25;21(4):369-380. Epub 2022 Feb 25.

University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.

Spontaneous intracranial hypotension is caused by loss of CSF at the level of the spine. The most frequent symptom of this disorder is orthostatic headache, with the headache worsening in the upright position and subsiding after lying down. Neuroimaging has a crucial role in diagnosing and monitoring spontaneous intracranial hypotension, because it provides objective (albeit often subtle) data despite the variable clinical syndromes and often normal lumbar puncture opening pressure associated with this disorder. Spine imaging aims to classify and localise the site of CSF leakage as either (1) a ventral dural leak, (2) a leaking spinal nerve root diverticulum, or (3) a direct CSF-venous fistula. Searching for a CSF leak can be very difficult; the entire spine must be scrutinised for a dural breach often the size of a pin. Precisely locating the site of CSF leakage is fundamental to successful treatment, which includes a targeted epidural patch and surgical closure when conservative measures do not provide long-term relief. Increased awareness of spontaneous intracranial hypotension among clinicians highlights the need for dedicated diagnostic and therapeutic guidelines.
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http://dx.doi.org/10.1016/S1474-4422(21)00423-3DOI Listing
April 2022

Histological composition of retrieved emboli in acute ischemic stroke is independent of pre-thrombectomy alteplase use.

J Stroke Cerebrovasc Dis 2022 Apr 17;31(4):106376. Epub 2022 Feb 17.

Department of Neurosurgery, Baptist Medical Center, Jacksonville, Florida, USA.

Background And Purpose: Given recent evidence suggesting the clot composition may be associated with revascularization outcomes and stroke etiology, clot composition research has been a topic of growing interest. It is currently unclear what effect, if any, pre-thrombectomy thrombolysis has on clot composition. Understanding this association is important as it is a potential confounding variable in clot composition research. We retrospectively evaluated the composition of retrieved clots from ischemic stroke patients who did and did not receive pre-treatment tPA to study the effect of tPA on clot composition.

Materials And Methods: Consecutive patients enrolled in the Stroke Thromboembolism Registry of Imaging and Pathology (STRIP) were included in this study. All patients underwent mechanical thrombectomy and retrieved clots were sent to a central core lab for processing. Histological analysis was performed using Martius Scarlett Blue (MSB) staining and area of the clot was also measured on the gross photos. Student's t test was used for continuous variables and chi-squared test for categorical variables.

Results: A total of 1430 patients were included in this study. Mean age was 68.4±13.5 years. Overall rate of TICI 2c/3 was 67%. A total of 517 patients received tPA (36%) and 913 patients did not (64%). Mean RBC density for the tPA group was 42.97±22.62% compared to 42.80±23.18% for the non-tPA group (P=0.89). Mean WBC density for the tPA group was 3.74±2.60% compared to 3.42±2.21% for the non-tPA group (P=0.012). Mean fibrin density for the tPA group was 26.52±15.81% compared to 26.53±15.34% for the non-tPA group (P=0.98). Mean platelet density for the tPA group was 26.22±18.60% compared to 26.55±19.47% for the non-tPA group (P=0.75). tPA group also had significantly smaller clot area compared to non-tPA group.

Conclusions: Our study 1430 retrieved emboli and ischemic stroke patients shows no interaction between tPA administration and clot composition. These findings suggest that tPA does not result in any histological changes in clot composition.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2022.106376DOI Listing
April 2022

Corrigendum to "Comparison of Balloon Guide Catheters and Standard Guide Catheters for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis" [World Neurosurgery 154 (2021), 144-153].

World Neurosurg 2022 Apr 5;160:149. Epub 2022 Feb 5.

Nested Knowledge, Inc., St. Paul, Minnesota, USA; Superior Medical Experts, St. Paul, Minnesota, USA; Duke University Law School, Durham, North Carolina, USA. Electronic address:

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http://dx.doi.org/10.1016/j.wneu.2022.01.073DOI Listing
April 2022

Evidence-Based Disparities in Stroke Care Metrics and Outcomes in the United States: A Systematic Review.

Stroke 2022 03 2;53(3):670-679. Epub 2022 Feb 2.

Department of Radiology, Mayo Clinic, Rochester, MN (W.B.).

Stroke disproportionately affects racial minorities, and the level to which stroke treatment practices differ across races is understudied. Here, we performed a systematic review of disparities in stroke treatment between racial minorities and White patients. A systematic literature search was performed on PubMed to identify studies published from January 1, 2010, to April 5, 2021 that investigated disparities in access to stroke treatment between racial minorities and White patients. A total of 30 studies were included in the systematic review. White patients were estimated to use emergency medical services at a greater rate (59.8%) than African American (55.6%), Asian (54.7%), and Hispanic patients (53.2%). A greater proportion of White patients (37.4%) were estimated to arrive within 3 hours from onset of stroke symptoms than African American (26.0%) and Hispanic (28.9%) patients. A greater proportion of White patients (2.8%) were estimated to receive tPA (tissue-type plasminogen activator) as compared with African American (2.3%), Hispanic (2.6%), and Asian (2.3%) patients. Rates of utilization of mechanical thrombectomy were also lower in minorities than in the White population. As shown in this review, racial disparities exist at key points along the continuum of stroke care from onset of stroke symptoms to treatment. Beyond patient level factors, these disparities may be attributed to other provider and system level factors within the health care ecosystem.
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http://dx.doi.org/10.1161/STROKEAHA.121.036263DOI Listing
March 2022

The re-invention of the vascular neuroradiologist in the age of direct-to-consumer radiology applications.

Authors:
Waleed Brinjikji

Interv Neuroradiol 2022 02 31;28(1):7-8. Epub 2022 Jan 31.

Department of Neurosurgery and Neuroradiology, Mayo Clinic, Rochester, MN.

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http://dx.doi.org/10.1177/15910199221077754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8905074PMC
February 2022
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