Farhan Siddiq

Objectives: Acute ischemic stroke patients with severe acute respiratory syndrome coronavirus maybe candidates for acute revascularization treatments (intravenous thrombolysis and/or mechanical thrombectomy). Materials and Methods: We analyzed the data from 62 healthcare facilities to determine the odds of receiving acute revascularization treatments in severe acute respiratory syndrome coronavirus infected patients and odds of composite of death and non-routine discharge with severe acute respiratory syndrome coronavirus infected and non-infected patients undergoing acute revascularization treatments after adjusting for potential confounders. Results: Acute ischemic stroke patients with severe acute respiratory syndrome coronavirus infection were significantly less likely to receive acute revascularization treatments (odds ratio 0.6, 95% confidence interval 0.5-0.8, p=0.0001). Among ischemic stroke patients who received acute revascularization treatments, severe acute respiratory s...

Introduction: The Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) was prematurely terminated due to excessively high rate of stroke and death in patients randomized to intracranial stent placement. Equivalent results with primary angioplasty in several uncontrolled studies will continue to raise the question that a policy of mandatory stent placement may have led to a higher peri-procedural stroke and death without a clear evidence of incremental benefit. Methods: The primary aim of the study is to compare the clinical and angiographic efficacy of primary angioplasty and angioplasty followed by stent placement in preventing restenosis, stroke, requirement for second treatment, and death in patients with symptomatic intracranial stenosis. The study prospectively evaluated acute,1-month, 6 month, and 1-year efficacy and safety of the two existing neurointerventional techniques for treatment of moderate intracranial stenosi...

Context: Transradial access has been increasingly utilized for neurointerventional procedures including carotid angioplasty and stent placement (CAS) over the past decade. At our center, we adopted transradial approach as the preferred approach in 2020. Objective: To compare the results of transradial approach with transfemoral approach for CAS as part of a quality assurance initiative. Methods: We analyzed data collected for all non-urgent CAS procedures performed at our institute in the last 24 months by same interventionalists to minimize inter-operator variability. We looked at the rates of technical failure; hemorrhagic complications classified as major (hemoglobin decrease >5 g/dL or intracranial hemorrhage with deficits), minor (hemoglobin decreases 3-5 g/dL or intracranial hemorrhage without residual deficits), or insignificant; and any stroke and/or death within 1-month post procedure. Results: A total of 182 non-urgent CAS procedures were performed at our institution; 1...

Object: To study the 30 day stroke and death rate in intracranial angioplasty and stent treated patients meeting Stenting versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial eligibility criteria. Background: SAMMPRIS trial, comparing aggressive medical versus stent treatment in patients with symptomatic intracranial stenosis, was halted after a 14% stroke and death rate observed in the stent treated group. Material and Methods: A retrospective analysis of 96 patients treated with intracranial angioplasty and stent placement at two University affiliated institutions was performed. Patients were divided into SAMMPRIS eligible and ineligible groups based on inclusion and exclusion criteria for SAMMPRIS trial. Results: Sixty-nine patients were determined to be SAMMPRIS eligible and 27 patients were ineligible. SAMMPRIS eligible group was divided into angioplasty and stent treated subgroups (30 and 39 patients, respectively). The...

Background: Histamine (H) 2 blockers led to a significant increase of the relative bioavailability of nimodipine and therefore may change tolerability of nimodipine in patients with aneurysmal subarachnoid hemorrhage (SAH). Objective: To determine the effect of H2 blockers on outcome of SAH patients being treated with nimodipine on outcomes. Methods: We analyzed data from Cerner Health Facts® which collected data from participating facilities from January 1st, 2000 to July 1st, 2018. We identified SAH patients who underwent endovascular or surgical treatment for intracranial aneurysm and received nimodipine with or without H2 blockers. Outcome was defined by discharge destination and classified into none to minimal disability, moderate to severe disability, or death. Results: A total of 815 (54.8%) of 1488 SAH patients received H2 blockers in addition to nimodipine. There were no differences in rates of cerebral ischemia (8.8% versus 9.8%) or performance of angioplasty (3.8% versus ...

Background: Carotid revascularization procedure, carotid endarterectomy (CEA) and carotid stent placement (CAS), are some of the most common procedures performed in United States and expected to change due to wider adoption of CAS. We performed this study to determine the changes in utilization of CEA and CAS in United States using nationally representative data. Methods: We used the National Inpatient Sample (NIS) from 2005 to 2014 to assess the changes in utilization of CEA and CAS over last 10 years in patients with symptomatic and asymptomatic carotid artery stenosis. NIS is the largest all payer dataset that includes diagnoses, admissions and discharge, demographics, and outcomes data of patients admitted to short stay non-Federal hospitals in the United States. We analyzed patterns of changes in utilization in various subsets of patients with carotid artery stenosis. Results: A total of 1,186,182 patients underwent carotid revascularization procedures during study period; 1,03...

Objective: To identify factors and outcomes associated with timing of ruptured cerebral aneurysm obliteration treatment in patients with subarachnoid hemorrhage (SAH) after hospitalization in United States. Background: Recent studies have shown that early surgical treatment of aneurysm in SAH patients can improve outcomes. These results have not been validated in actual clinical practice to date. Material and Methods: We analyzed the data from Nationwide Inpatient Sample (NIS 2005-2009) for all patients presenting with primary diagnosis of SAH, receiving aneurysm treatment (endovascular coil embolization or surgical clip placement). Early treatment was defined as aneurysm treatment performed within 48 hours of the hemorrhage and delayed treatment was performed after 48 hours. Clinical outcome was defined as minimal or no disability (self-care), moderate to severe disability (extended care facility) based on discharge disposition; and in-hospital death. Multivariate logistic regressi...

Background and Purpose: Acute ischemic stroke may occur in patients with Coronavirus disease 2019 but risk factors, in hospital events, and outcomes are not well studied in large cohorts. We identified risk factors, co-morbidities, and outcomes in patients with Coronavirus disease 2019 with or without acute ischemic stroke and compared with patients without Coronavirus disease 2019 and acute ischemic stroke. Methods: We analyzed the data from 54 healthcare facilities using the Cerner de-identified Coronavirus disease 2019 dataset. The dataset included patients with an emergency department or inpatient encounter with a discharge diagnoses codes that could be associated to suspicion of or exposure to Coronavirus disease 2019, or confirmed Coronavirus disease 2019. Results: A total of 103 (1.3%) patients developed acute ischemic stroke among 8,163 patients with Coronavirus disease 2019. Among all Coronavirus disease 2019 patients, the proportion of patients with hypertension, diabetes ...

Background and Purpose: Intracerebral hemorrhage can occur in acute ischemic stroke patients receiving alteplase (recombinant tissue plasminogen activator). Antifibrinolytic medications such as the synthetic lysine analogs tranexamic acid and ε;-aminocaproic acid that inhibit fibrinolysis by attaching to the lysine-binding site of the plasminogen molecule have been utilized. However, the efficacy of antifibrinolytic medication in prevention of hematoma expansion is not known. Methods: We analyzed the effect of antifibrinolytic medication in acute ischemic stroke patients with intracerebral hemorrhage associated with Alteplase from 2012 to 2017. The Region-of-Interest method on a Horos Open Source Medical Image Viewer (Version 3.3.6) was utilized for volume measurement. We compared the change in hemorrhage volume in patients who did and did not receive antifibrinolytic medication. Results: A total of 36 patients (mean age 72.7±11.5, 56% were men) who received intravenous alteplase wi...

Background: Intravascular ultrasonography (IVUS) has been previously used for guiding intravascular stent placement in interventional cardiology. Objective: To evaluate the feasibility of aneurysm embolization using detachable coils under IVUS guidance. Method: Two different experimental models of aneurysm were used. IVUS guided embolization in conjunction with flouroscopic imaging and subsequently alone were performed in a silicone model with a side wall aneurysm. IVUS guided embolization in conjunction with flouroscopic imaging was also used in in-vitro model of side wall aneurysm created using sheep vessels. The visibility of aneurysm, microcatheter, and coils ascertained by the IVUS was graded as excellent, good, or poor based on visualization of these items as distinct structures. The agreement between simultaneously acquired angiographic and IVUS images for detecting increasing intra-aneurysmal coil mass and coil prolapse was assessed in 10 and 6 simultaneously acquired angiog...

Introduction: Cilostazol, a selective inhibitor of phosphodiesterase 3, may reduce symptomatic vasospasm and associated cerebral ischemia and improve outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH) due to its anti-platelet, anti-proliferative, and vasodilatory effects. Due to recent publication of randomized controlled clinical trials, a meta-analysis was performed to identify the common treatment effect. Methods: We performed a meta-analysis of four randomized controlled clinical trials. The primary endpoint of interest was cerebral ischemia related to vasospasm. Secondary endpoints were angiographic vasospasm, new cerebral infarct, mortality, and death or disability at the 90 days following randomization. Using random-effects models with study as a random effect, relative risks (RR) and 95% confidence intervals (CI) were generated Results: A total of 405 subjects (200 randomized to oral cilostazol 100 mg twice per day) were included in the meta-analysis. The pr...

Background: To determine the exposure risk for coronavirus 2019 (COVID-19) during neurology practice. Neurological manifestations of COVID-19 are increasingly being recognized mandating high level of participation by neurologists. Methods: An American Academy of Neurology survey inquiring about various aspects of COVID-19 exposure was sent to a random sample of 800 active American Academy of Neurology members who work in the United States. Use of second tier protection (1 or more including sterile gloves, surgical gown, protective goggles/face shield but not N95 mask) or maximum protection (N95 mask in addition to second tier protection) during clinical encounter with suspected/confirmed COVID-19 patients was inquired. Results: Of the 81 respondents, 38% indicated exposure to COVID-19 at work, 1% at home, and none outside of work/home. Of the 28 respondents who did experience at least 1 symptom of COVID-19, tiredness (32%) or diarrhea (8%) were reported. One respondent tested positi...

Background and PurposeWe report the results of intra‐arterial injection of lidocaine in the middle meningeal artery in patients with intractable headache or status migrainosus.MethodsWe treated four patients with intra‐arterial lidocaine (2 mg/ml) in doses up to 50 mg in each middle meningeal artery via a microcatheter bilaterally (except in one patient). In two patients with intractable headache, the daily maximum intensity of headache (graded by 11‐point numeric rating scale) was recorded for 7 days postprocedure. In two patients with status migrainosus, migraine‐related disability 3 months prior and after treatment using MIDAS (Migraine Disability Assessment) questionnaire was recorded.ResultsIntra‐arterial lidocaine reduced the headache intensity from 8/10 and 10/10 to 0/10 in the two patients with intractable headaches for 2 days (day 0 and day 1) postprocedure. Despite recurrence of headache on day 2, the intensity was less than preprocedure intensity up to the last day record...

OBJECTIVE To identify the rates of and factors associated with repeat revascularization in large cohort of patients prospectively followed over 10 years in Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). METHODS We compared the effect of CAS versus CEA on risk of repeat revascularization after adjusting for age, gender, symptomatic status and initial severity of stenosis (≥70% versus <70%) using Cox Proportional Hazards analysis. We used Kaplan-Meir analysis to assess repeat revascularization free survival for overall cohort. RESULTS Repeat revascularization was performed in 90 (3.9%, 95% confidence interval (CI) 3.1%-4.8%) of 2318 patients; 6 (6.7%, 95% CI 2.5%-14.0%) patients experienced the composite endpoint of any stroke, myocardial infarction, or death within 30 days post repeat revascularization. There was no difference in risk of repeat revascularization in patients who underwent CAS (compared with CEA) as index procedure (hazards ratio 0.92, 95% CI 0.69-1.23, p=0.5765). Patient's age (hazards ratio 1.01, 95% CI 1.01-1.02, p<.0001) was associated with performance of repeat revascularization. The mean (± standard deviation [SD]) repeat revascularization free survival was 8.2±0.1 years and 8.0±0.1 years for CAS and CEA, respectively (log-rank test P=0.0823). CONCLUSIONS A low rate of repeat revascularization was seen without any significant difference among patients who underwent CEA or CAS over 10 years. The 6.7% rate of composite endpoint within 30 days post procedure highlights the need for standardizing the indications for repeat revascularization.

Acute stroke from intracranial internal carotid artery (ICA) occlusion can occasionally resemble angiographic cervical ICA dissection which may cause delays in endovascular acute ischemic stroke treatment. To determine the angiographic characteristics of the phenomenon of "pseudodissection" and its clinical implications in acute ischemic stroke endovascular treatment. Retrospective analysis of angiographic and clinical data from 31 patients with ischemic acute stroke secondary to intracranial ICA occlusion, treated with endovascular therapy at two University-affiliated institutions, was performed. Pseudodissection was defined as angiographic appearance of typical cervical ICA dissection with evidence of normal inner vascular wall upon further catheter exploration. Angiographic appearance pseudodissection was identified in 7 out of 31 patients (22.6%). Six patients had guide catheters placed proximal to pseudodissection in anticipation of stent placement for treatment of ICA dissection. All 7 patients had further exploration of the presumed dissected segment (6 microcatheter, 1 diagnostic catheter) which demonstrated normal vascular inner wall. The clot was located more commonly in the petro-cavernous segment in the pseudodissection patients (5/7, 71%). Carotid terminus clot was more common in ICA occlusion patients than pseudodissection patients (18/24, 75% vs. 2/7, 29% respectively, P < .0001). Recanalization was less common in pseudodissection patients compared to ICA occlusion patients (3/7 and 21/24 respectively, P = .029). Early recognition of pseudodissection in the ICA is important in the setting of acute ischemic stroke to avoid delay in treatment of intracranial ICA occlusion.

BackgroundRandomized clinical trials have failed to prove that the safety and efficacy of endovascular treatment for symptomatic intracranial atherosclerotic disease (ICAD) is better than that of medical management. A recent study using a self-expandable stent showed acceptable lower rates of periprocedural complications.ObjectiveTo study the safety and efficacy of a balloon-mounted stent (BMS) in the treatment of symptomatic ICAD.MethodsProspectively maintained databases from 15 neuroendovascular centers between 2010 and 2020 were reviewed. Patients were included if they had severe symptomatic intracranial stenosis in the target artery, medical management had failed, and they underwent intracranial stenting with BMS after 24 hours of the qualifying event. The primary outcome was the occurrence of stroke and mortality within 72 hours after the procedure. Secondary outcomes were the occurrence of stroke, transient ischemic attacks (TIAs), and mortality on long-term follow-up.ResultsA...

Objective: To investigate the effect of early hyperchloremia on 90-day outcomes in acute ischemic stroke Methods: We analyzed data from Albumin in Acute Ischemic Stroke (ALIAS) Part 1 and 2 trials which recruited patients with acute ischemic stroke within 5 hours of onset. Patients with hyperchloremia (defined as 110 mmol/L or greater) at baseline, 24, or 48 hours after randomization were identified. We trichotomized patients into 3 groups; no instances, one instance, and two or more instances of measured hyperchloremia within the first 48 hours. Serum creatinine levels at baseline, 24, and 48 hours were used to identify acute kidney injury (AKI) via the Acute Kidney Injury Network (AKIN) classification. Logistic regressions were performed to determine the effects of hyperchloremia on outcomes defined by modified Rankin scales or National Institutes of Health Stroke Scale scores at 90 days and mortality at 90 days. Results: Among the total of 1275 patients analyzed, zero, one and tw...

Introduction: Several studies have shown improved outcomes in ischemic stroke patients treated with mechanical thrombectomy in clinical trials after introduction of stent retrievers. The outcomes of patients undergoing endovascular treatment in general practice are expected to improve. We performed this analysis to evaluate trends in utilization of endovascular treatment in acute ischemic stroke and associated rates of death and disability in real world practice. Methods: We obtained data for patients admitted with primary diagnosis of ischemic stroke in United States from 2009-2016 using Nationwide Inpatient Sample. We determined the rate and pattern of utilization, and associated in-hospital outcomes of endovascular treatment among them. Outcomes were classified as minimal disability, moderate to severe disability, and death based on discharge disposition and compared between two time periods: 2009-2011 and 2013-2016 to represent pre and post stent retriever approvals in United St...

Background: Relatively limited information is available about trends over time in the use of endovascular treatment in patients of different ages hospitalized with acute ischemic stroke and the association between use of thrombectomy treatment and hospital outcomes in age strata. We performed this analysis to evaluate trends in the utilization of endovascular treatment in acute ischemic stroke by age strata in real-world practice. Methods: We conducted this study by identifying patients admitted with a primary diagnosis of ischemic stroke in the United States from 2007 to 2016 using the Nationwide Inpatient Sample. International Classification of Diseases, ninth revision, and tenth, Clinical Modification (ICD-9-CM, ICD-10-CM) codes were used to identify patients admitted for ischemic stroke and undergoing endovascular treatment. Results: Of the 4,590,533 patients admitted with ischemic stroke, 269,922 (5.88%) received intravenous thrombolytic treatment, and 51,375 (1.12%) underwent ...

Introduction: Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) results, published in 2010, showed no difference in composite outcome (stroke, myocardial infarction, or death) between carotid artery stent placement (CAS) and carotid endarterectomy (CEA). The impact of these results on the pre-existing practices has not been studied. The aim of our study is to determine whether any change in utilization and outcomes of CAS and CEA subsequent to the CREST results. Methods: We estimated the frequency of CAS and CEA procedures in the years 2009 (pre-CREST period) and 2011 (post-CREST period), using data from the National In-patient Sample (NIS). Pre- and post-CREST CAS and post-CREST CEA rates and outcomes were compared with pre-CREST CEA (reference). Results: A total of 225,191 patients underwent CEA or CAS in pre- and post-CREST period. The frequency of CAS did not change after CREST publication. In the pre-CREST period, CAS group (compared with CEA) were younger ...

Background: One month dual antiplatelet therapy, with Aspirin and Clopidogrel, following intra- and/or extra-cranial stent placement is the standard of care to prevent in- stent thrombosis. Cilostazol, a novel antiplatelet drug, with vasodilatory effects and smooth muscle cell proliferation inhibition, has recently been demonstrated to be safe and efficacious in secondary stroke prevention and has a safety profile comparable to both Aspirin and Clopidogrel. Objective: To evaluate the safety and clinical efficacy of Cilostazol and Aspirin therapy following internal carotid angioplasty and stent placement prior to and one month post-procedure. Methods: We conducted a Phase I open label, non-randomized single center prospective study. All patients received Aspirin (325 mg/day) and Cilostazol (200 mg/day) for at least 3 days before internal carotid stenting. The two anti-platelet agents were continued for one month after the procedure and then patients were continued on aspirin daily. T...

Background: Thrombolytic related intracerebral hemorrhage (ICH) is an infrequent occurrence in patients with acute ischemic stroke. There is controversy surrounding the value of neurosurgical evacuation of hematomas and decompression in these patients and whether such availability is a necessary pre-requisite for administration of thrombolytics. Objective: To report the frequency and outcomes of patients who suffer from thrombolytic related ICH and undergo a craniotomy. Materials/Methods: Using the Nationwide Inpatient Sample (NIS) from 2002 to 2010, acute ischemic stroke patients who suffered from thrombolytic related ICH were identified using ICD-9 codes. Patients were divided into those who received craniotomy and those who received medical management alone. Discharge destination and mortality were primary endpoints. Results: A total of 7359 patients suffered thrombolytic related ICH, 125 (1.7%) of those patients underwent craniotomy and 7234 patients (98.3%) received medical tre...

Context: Long-term anticoagulation has been consistently shown to reduce the rate of ischemic stroke among selected patients with atrial fibrillation (AFib). There is paucity of data regarding number of eligible patients with AFib in United States who could benefit from long-term anticoagulation. Objective: To provide national estimate of eligible hospitalized patients with AFib who could benefit from long-term anticoagulation. Methods: We analyzed data from Nationwide Inpatient Sample (NIS) for the year 2016. NIS represents the largest all payer nationally representative dataset of hospitalizations in United States. We identified patients with primary or secondary diagnosis of AFib who were aged 75 years or greater, women aged 65-74 years, men aged 65-74 years with history of ischemic stroke/transient cerebral ischemia( TIAs), and patients aged 18-64 years with AF and ischemic stroke/TIAs (CHA2DS2-VASc score of 2 or greater) who were hospitalized and discharged alive to provide nat...

Background and Purpose: Acute ischemic stroke may occur in patients with coronavirus disease 2019 (COVID-19), but risk factors, in-hospital events, and outcomes are not well studied in large cohorts. We identified risk factors, comorbidities, and outcomes in patients with COVID-19 with or without acute ischemic stroke and compared with patients without COVID-19 and acute ischemic stroke. Methods: We analyzed the data from 54 health care facilities using the Cerner deidentified COVID-19 dataset. The dataset included patients with an emergency department or inpatient encounter with discharge diagnoses codes that could be associated to suspicion of or exposure to COVID-19 or confirmed COVID-19. Results: A total of 103 (1.3%) patients developed acute ischemic stroke among 8163 patients with COVID-19. Among all patients with COVID-19, the proportion of patients with hypertension, diabetes, hyperlipidemia, atrial fibrillation, and congestive heart failure was significantly higher among th...

The present review aims to discuss the recent advances in surgical management of spontaneous intracerebral hemorrhage (ICH), safety and efficacy of minimally invasive surgical techniques, and the existing evidence supporting their use. Newer surgical techniques, collectively referred to as minimally invasive surgery (MIS), have been evaluated and studied in management of ICH. Stereotactic evacuation of intracerebral hemorrhage using aspiration-irrigation technique has showed significant reductions in the hematoma volume with minimal intra-operative bleeding. Catheter-based evacuation in combination with use of recombinant tissue plasminogen activator (rt-PA) produces lysis and drainage of spontaneous ICH and intraventricular hemorrhage (IVH) rapidly with minimal major adverse events. Recent advances in the management of spontaneous ICH highlights potential advantages including safety and efficacy in clot lysis and reduction in hematoma volume especially with image-guided catheter-ba...

Objective: To test whether the frequency of intracranial stent placement has decreased in most endovascular neurosurgical centers after the publication of SAMMPRIS. Background: Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) trial was published in 2011 which reported high rates of post-operative stroke and death in intracranial stent treated group and off setting the pre assumed benefit of the procedure for prevention of recurrent ischemic stroke in this patient population Methods: We used Minnesota Hospital Association (MHA) data from 2008-2012 to identify patient who were treated with intracranial stent placement using ICD-9 codes. 2011 year was excluded from the analysis to account for transitions period during the year of SAMMPRIS publication. Prior to 2011 years were included in “pre SAMMPRIS group” and 2012 was included in “post SAMMPRIS group”. Patients demographic, in-hospital complications and discharge destinations were compared between the two groups. We also assessed the frequency of procedures per year. Results: The frequency of intracranial stent placement decreased by approximately half in the post SAMMPRIS period. Three years prior to 2011, approximately 30 procedures were documented each year whereas in 2012 only 17 procedures were reported in the state (p < 0.0001). Age, gender, medical comorbidity, in-hospital complications, in-hospital mortality and discharge destination did not differ between the pre and post SAMMPRIS patient population (see Table). Conclusion: After the publication of SAMMPRIS results in 2011, the frequency of intracranial stent placement has decreased significantly. The patients who are currently offered this treatment do not appear to be different from population prior to SAMMPRIS publication. Disclosure: Dr. Siddiq has nothing to disclose. Dr. Malik has nothing to disclose. Dr. Nickles has nothing to disclose. Dr. Qureshi has nothing to disclose.

Introduction Successful endovascular embolisation of intracranial arteriovenous malformations (AVMs) or arteriovenous fistulae (AVFs) requires distal navigation of very small microcatheters to the nidus or fistulous point of the malformation. Such small microcatheters can only be navigated by flow direction or over 0.008 or 0.010 microwires, and the lack of support from these microwires often makes distal navigation challenging. Further, these small microcatheters are sometimes prone to rupture from the high injection pressures used during embolisation or retention within the feeding artery after embolisation. Additionally, not all of them are compatible with Ethylene Vinyl Alcohol Co-polymer (Onyx), which is currently the most widely used liquid embolic agent. Herein we report our initial experience with successful distal navigation of a small but robust microcatheter over a 0.014 wire system and subsequent successful embolisation using either Onyx or n-Butyl Cyano-acrylate (n-BCA). Materials and Methods A series of 6 patients (4 men, age 38–80 years) presented to our hospital with intracranial AVMs and dural AVFs. Of these 3 were ruptured Borden Type III dural AVFs and 3 were pial AVMs (2 ruptured, 1 with hemiplegia, proptosis). In each of these malformations, we navigated a “Headway Duo” microcatheter [156 cm long, 0.34 ml dead space, 2.6 French (proximally) and 1.6 French (distally), Microvention, Tustin, Ca, USA], which is Onyx and n-BCA compatible, in combination with a Synchro 2 microwire (Stryker, Fremont, Ca, USA) to the nidus/fistulous point of these malformations. We performed embolisation using a mixture of Onyx 18 and Onyx 34 with or without coils or using nBCA in each instance. Results We achieved successful navigation of the headway DUO microcatheter over a 0.014 microwire system and accessed the nidus/fistulous point in each of these malformations. Subsequently, we were able to successfully embolise the malformation using Onyx in 10 vessels, n-BCA in 2 vessels, in a total of 6 malformations in 6 patients. In one patient, we were also able to place coils in 3 feeder branches by using this microcatheter system in order to reduce the flow rate as a prelude to liquid embolisation. There was no instance of vascular injury, catheter rupture, or catheter retention. No patient had clinical deficits related to embolisations. Two of the three AVMs underwent surgery after pre-surgical embolisations, one is awaiting surgery. Angiographic cure was achieved with endovascular embolisation in 2 out of the 3 AVFs, and by surgical disconnection of the fistula in one. Conclusion We were able to safely and successfully perform endovascular embolisation of a series of intra-cranial arterial malformations using a new robust but small diameter microcatheter in combination with Onyx or n-BCA after successful navigation of this microcatheter to the nidal or fistulous point over a 0.014 wire system. Disclosures W. Tekle: None. B. Jagadeesan: None. F. Siddiq: None. A. Khan: None. A. Grande: None. R. Tummala: None.

Postthrombolytic intracerebral hemorrhage (ICH) is an infrequent occurrence in patients with acute ischemic stroke. There is controversy surrounding the value of neurosurgical treatment of symptomatic hematomas in these patients and whether availability of neurosurgical treatment is a necessary prerequisite for administration of thrombolytic agents. We report the frequency and outcomes of patients who undergo craniotomy for postthrombolytic ICH. Patients with acute ischemic stroke who experienced postthrombolytic ICH were identified using the Nationwide Inpatient Sample from 2002-2010 and International Classification of Diseases, 9th Revision, Clinical Modification codes. Patients were divided into patients who received craniotomy and patients who received medical management alone. Discharge destination and mortality were primary endpoints. An estimated 7607 patients experienced postthrombolytic ICH; 125 (1.6%) patients underwent craniotomy, and 7482 patients (98.4%) received medical treatment alone. Patients in the craniotomy group were younger (53.7 years old ± 36 vs. 72.4 years old ± 29, P = 0.09) and were frequently in the extreme severity All Patient Refined Diagnosis Related Group category compared with patients in the medical management group (92.2% vs. 55.5%, P = 0.001). The mean length of stay was also longer in the craniotomy group (21.5 days vs. 10 days, P < 0.0001). In-hospital mortality was greater in the medical management group (30.5% vs. 24.2%, P = 0.5). After adjusting for age, gender, and All Patient Refined Diagnosis Related Group severity index, the odds ratios of in-hospital mortality, discharge to extended care facility, and discharge to home or self-care were 0.8 (95% confidence interval [CI] 0.3-2.0, P = 0.5), 5.4 (95% CI 0.6-52.0, P = 0.1), and 0.2 (95% CI 0.02-1.8, P = 0.1) for the craniotomy group compared with the medical management group. Emergent craniotomy for postthrombolytic ICH in patients with acute stroke is a salvage treatment offered to a small proportion of patients. Although biases introduced by patient selection cannot be excluded in our analysis, the excessively high rates of death or disability associated with surgical evacuation limit the value of such a procedure in current practice.

Population-based autopsy series have shown an average rate of atherosclerosis in the circle of Willis of 36%–47% among subjects in the fourth decade of life which increases to 75%–97% in the sixth decade. 1–4 Thirty percent of patients may have atherosclerotic ...

We compared the clinical features and outcomes of patients with spinal epidural abscess treated with prolonged parenteral antibiotics alone or combined with computed tomography-guided percutaneous needle aspiration drainage with those of patients undergoing surgical decompression. A retrospective analysis of 57 cases of spinal epidural abscess treated at an academic teaching hospital during a 14-year period. The lumbar region was most frequently involved, and 46% of patients were immunocompromised. Staphylococcus aureus was the most frequently encountered pathogen. For 60 treatment courses, management included medical only (25 patients), medical plus computed tomography-guided percutaneous needle aspiration (7 patients), or surgical drainage approaches (28 patients). Prolonged use of parenteral antibiotics alone or combined with percutaneous needle drainage yielded clinical outcomes at least comparable with antibiotics plus surgical intervention, irrespective of patient age, presence of comorbid illness, disease onset, neurologic abnormality at time of presentation, or abscess size. Patients with spinal epidural abscess can be safely and effectively treated with conservative medical treatment without the need for surgery.

The objective of this study is to show the effectiveness of Factor IX complex concentrate (FIXCC) for rapid reversal of an elevated International Normalized Ratio (INR) in patients with anticoagulation-associated intracerebral hemorrhage (AAICH). We, retrospectively, analyzed the clinical data of 19 patients with the diagnosis of AAICH from January 2005 to May 2006. A comparison was made among patients treated with FFP and Vit.K [FFP-group (n = 9)] and patients treated with FIXCC in addition to FFP and Vit.K [FIXCC-group (n = 10)]. INR of 1.4 or less was taken as target. Mean INR on admission for FFP and FIXCC group was 1.84 +/- 0.31 and 2.44 +/- 1.48, respectively (P = 0.315). After administration of therapy, the INR was reduced from 1.84 +/- 0.31 to 1.34 +/- 0.08 (P < 0.05) in FFP group and 2.44 +/- 1.48 to 1.34 +/- 0.07 (P < 0.005) in FIXCC group. Three patients in FFP group (33%) and 8 patients in FIXCC group (80%) reached their target INR in 3-4 h after initiation of therapy (P = 0.012). Mean time taken by both FFP and FIXCC groups to reach the target INR was 8.52 +/- 5.60 h and 4.25 +/- 2.12 h, respectively (P < 0.05). The mean rate of INR correction was 0.06 +/- 0.03 and 0.27 +/- 0.25 per hour for the FFP and FIXCC group, respectively (P < 0.005). There was one death in FIX group and two in FFP group and no thrombotic complications. Our data suggests that FIXCC in combination with FFP and Vit.K may result in decreased time required when compared to FFP and Vit.K alone for correction of warfarin associated coagulopathy in neurosurgical emergencies.

Background: In the Interventional Management of Stroke III trial, there was a 35% incidence of improvement or resolution of occlusion in IV alteplase treated patients selected by computed tomographic (CT) angiogram for endovascular treatment. Objective: To determine the frequency of resolution or change in occlusion site in patients with CT angiogram demonstrated occlusion in IV alteplase treated or untreated patients. Methods: All acute ischemic stroke patients who underwent a computed tomographic (CT) angiogram and subsequently underwent endovascular treatment were included. The CT angiogram images were reviewed by an independent reviewer to determine presence and location of arterial occlusion and severity of occlusion was classified by a previously described grading scheme. The cerebral angiographic images were reviewed for similar endpoints. Clinical outcome at discharge was determined using modified Rankin scale (mRS). Results: CT angiogram was performed in 151 patients (mean ...