Postoperative Management of Anterior Visual Pathway Cavernoma, a Unique Perspective: Case Report.

Cavernous malformations (CMs) are low-flow vascular lesions with an incidence of 0.1% to 0.7% in the general population. Less than 1% are found in the anterior visual pathway. The most common presenting symptoms are visual disturbances due to hemorrhage and the current standard of treatment is gross total resection. The authors report a case of a 42-year-old male with visual disturbance and findings on T1-weighted magnetic resonance imaging (MRI) suggesting CM of the right optic nerve and right optic chiasm. The patient underwent right pterional craniotomy for gross total resection of the lesion. One year postoperatively, the patient demonstrated improvement in visual deficits with no signs of recurrence on MRI. Thirty-two months postresection, MRI showed a small slightly lobulated area of T1 hyperintense material within the postoperative cavity along the right aspect of the optic chiasm. MRI at 39 months postresection showed previously seen small amounts of T1 hyperintensity in the central and right aspect of the optic chiasm, with significantly decreased conspicuity. These findings suggest a trace amount of recurrence in the 32-month postoperative imaging despite overall stable visual field testing. There is a paucity of literature concerning the retreatment of resected CM in the anterior visual pathway. The authors suggest serial imaging as an integral component of CM management. Although repeated visual field testing and clinical follow-up are important aspects of CM management, they are no substitute for the gold standard of MRI.

Clinical and Economic Impact of Time From Admission for CSF Rhinorrhea to Surgical Repair.

BACKGROUND: If conservative management of CSF leak is unsuccessful, surgical repair is indicated for the prevention of severe complications such as meningitis. This study investigated the influence of surgical timing on clinical and economic outcomes. METHODS: Retrospective review of the National Inpatient Sample (2012) and the Nationwide Inpatient Sample (2002-2011) for nonelective admissions with a principal diagnosis of CSF rhinorrhea treated with surgical repair of the meninges. Demographics and outcomes of patients undergoing meningeal repair for CSF rhinorrhea were analyzed. Cases were classified into four groups based on timing of surgical intervention: 1) performed on the day of admission (day 0), 2) performed between days 1 and 3, 3) performed between days 4 and 7, and 4) performed between days 8 and 14. RESULTS: A total of 1,088 emergent admissions were analyzed. On average, patients underwent surgical repair between the second and fourth day of admission. Lowest rates of meningitis were in patients treated on the day of admission (6.1%); those treated at 2 weeks had a 34.7% incidence. Multivariate analysis controlling for comorbidity burden, gender, and surgical timing found the highest odds of meningitis in patients treated with surgical repair during the second week of admission compared to repair on the day of admission (OR 8.2, P < .001). Length of stay (LOS) and hospital costs increased as time to repair increased. CONCLUSION: Multiple factors influence outcomes in patients with CSF rhinorrhea. Early surgical repair was significantly associated with decreased rates of meningitis, LOS, and hospital costs. Expedient treatment of patients admitted for CSF rhinorrhea may prove to be both a cost- and morbidity-saving measure. LEVEL OF EVIDENCE: 2C Laryngoscope, 129:539-543, 2019.

Replacement of primary monkey kidney cells by L20B cell line in the test for effective inactivation of inactivated poliovirus vaccine.

Absence of 'live' residual poliovirus in Inactivated Poliovirus Vaccine (IPV) is routinely checked using Primary Monkey Kidney Cells (PMKC). However, the increasing demand for IPV and the ethical, technical and safety issues associated with the use of non-human primates in research and quality control, has made the replacement of primary cells with an established cell line a priority, in line with the principles of the 3Rs (Replacement, Reduction and Refinement in animal testing). As an alternative to PMKC, we evaluated the L20B cell line; a mouse cell-line genetically engineered to express human poliovirus receptor, CD155. L20B is already used for the detection and diagnosis of poliovirus in clinical samples. We demonstrate the stability of L20B cells in terms of CD155 gene and receptor expression, and permissivity to polioviruses for at least 16 sequential passages. In addition, the L20B cell line was found to be at least as sensitive as PMKC in detecting the presence of 'live' poliovirus in IPV samples. Equivalence or superiority of L20B cells versus PMKCs was demonstrated for assessing the presence of residual 'live' poliovirus in formaldehyde-inactivated preparations for the three poliovirus serotypes. These results demonstrate that the L20B cell line is a suitable alternative to PMKC in IPV inactivation testing.

Intradural Carcinoid Tumor Found in a Patient with No History of Cancer.

BACKGROUND: Carcinoid tumors are rare neoplasms that often arise from the gastrointestinal or respiratory tracts. They often metastasize to bone tissue and pancreatic and hepatic sites. The central nervous system and most specifically the spinal cord are rarely involved. Primary carcinoid tumors of the central nervous system are even rarer. CASE DESCRIPTION: A 58-year-old man presented with progressive bilateral lower extremity weakness and a negative history of cancer. Imaging revealed an intradural mass at the L1 and L2 spinal levels. Surgical resection of the tumor via laminectomy was performed. The tumor was observed to have eroded through the dura and was compressing the spinal nerves. Histopathologically, the mass was observed to be of carcinoid origin. A subsequent octreoscan revealed no primary sites of carcinoid tumor. Postoperatively, the patient was followed for 1.5 years. The patient reported improvement in sensation to his lower extremities with no change in motor findings. CONCLUSIONS: Carcinoid tumors of the central nervous system are extremely rare, but they should remain in the differential diagnosis for patients experiencing extremity weakness and back or neck pain with an intradural mass and no primary source of the tumor identified or other manifestations of a primary tumor.

Primary Angioplasty Versus Stenting for Endovascular Management of Intracranial Atherosclerotic Disease Following Acute Ischemic Stroke.

BACKGROUND: The future of neuroendovascular treatment for intracranial atherosclerotic disease (ICAD) has been debated since the results of SAMMPRIS reflected poor outcomes following endovascular therapy. There is currently a large spectrum of current management strategies. We compared historical outcomes of patients with ICAD and stroke that were treated with angioplasty-alone versus stent placement. METHODS: We extracted a population from the Nationwide Inpatient Sample (NIS) (2005-2011) and the National Inpatient Sample (NIS) (2012) composed of patients with ICAD and infarction that were admitted nonelectively and received endovascular revascularization. Patients treated with thrombectomy or thrombolysis were excluded. Categorical variables were compared with Chi-squared tests. Binary logistic regression was performed to evaluate mortality while controlling for age, sex, severity, and comorbidities. RESULTS: About 2059 admissions met our criteria. A majority were treated via stent placement (71%). Angioplasty-alone had significantly higher mortality (17.6% vs. 8.4%, P<0.001), but no difference in iatrogenic stroke rate (3.4% vs. 3.6%, P=0.826), compared to stent placement. The adjusted odds ratio of mortality for stented patients was 0.536 (95% CI: 0.381-0.753, P<0.001) in comparison to patients treated with angioplasty alone. CONCLUSIONS: This study found the risk of mortality to be elevated following angioplasty alone in comparison to revascularization with stent placement, without a corresponding significant difference in iatrogenic stroke rate. This may represent selection bias due to patient characteristics not defined in the database, but it also may indicate that patients with ICAD and acute stroke have increased odds of stenosis that is refractory to angioplasty alone and have a high risk of mortality without revascularization.

Refractory Thoracolumbar Cerebrospinal Fluid Leak after Multiple Spinal Ependymoma Resections Treated with External Ventricular Drainage.

Study Design Case report. Objective Temporary external ventricular drainage for refractory thoracolumbar cerebrospinal fluid (CSF) leak is not reported in the literature. We describe a recent case that utilized this technique. Methods Retrospective review of the patient's case notes was performed and the literature on this subject reviewed. Results The patient underwent multiple complex spinal surgeries for resection of innumerable metastatic ependymoma lesions. A case of significant refractory CSF leak developed and as a last resort a right frontal external ventricular drain was placed. The CSF leak ceased, and the patient was eventually discharged home without further complication. Conclusion External ventricular drainage can be a viable option for temporary proximal CSF diversion to treat refractory thoracolumbar CSF leaks.

Trends in mortality following mechanical thrombectomy for the treatment of acute ischemic stroke in the USA.

BACKGROUND AND PURPOSE: Mechanical thrombectomy (MT) for the treatment of acute ischemic stroke has been growing in popularity while the therapeutic benefit of MT has been increasingly debated. Our objective was to examine national trends in mortality following MT. METHODS: We analyzed the National Inpatient Sample (2012) and the Nationwide Inpatient Sample (2008-2011) for patients with a primary diagnosis of acute ischemic stroke that received MT. Temporal trends in mortality were examined using Spearman's rank correlation. To account for confounding factors, mortality was further analyzed in binary logistic regression. RESULTS: Hospitals performing MT comprised 8% of all hospitals treating ischemic stroke. The percentage of stroke cases treated with MT increased from 0.6% of cases in 2008 to 1.1% in 2012, totaling 16 307 MT cases in a 5 year period. Inhospital mortality decreased over the study period from 25.4% in 2008 to 16.1% in 2012 (r=-0.081, p<0.001). This finding was supported by regression analysis as each incremental year reduced the odds of mortality by 20% (OR=0.832, p<0.001). Administration of recombinant tissue plasminogen activator was associated with a decrease in the odds of mortality (OR=0.805, p<0.001). CONCLUSIONS: Utilization of MT represents a small percentage of stroke cases, although the trend is increasing. Mortality following MT has been showing a steady decline over the past 5 years. This may be a result of a learning curve, improved patient selection, and/or device improvements. Randomized trials remain essential to evaluate the potential benefit of endovascular devices and identify the most appropriate patients.

Carotid Artery Stenosis with Acute Ischemic Stroke: Stenting versus Angioplasty.

BACKGROUND: When a patient with carotid artery stenosis presents emergently with acute ischemic stroke, the optimum treatment plan is not clearly defined. If intervention is warranted, and open surgery is prohibitive, endovascular revascularization may be performed. The use of stents places the patient at additional risk due to their thrombogenic potential. The intent of this study was to compare outcomes following endovascular approaches (angioplasty alone vs. stent) in the setting of acute stroke. METHODS: We extracted a population from the National Inpatient Sample (2012) and the Nationwide Inpatient Sample (2003-2011) composed of patients with carotid artery stenosis with infarction that were admitted nonelectively and received endovascular revascularization. Patients treated with mechanical thrombectomy or thrombolysis were excluded. Categorical variables were compared between treatment groups with Chi-squared tests. Binary logistic regression was performed to evaluate mortality and iatrogenic stroke while controlling for age, case severity, and comorbidity burden. RESULTS: About 6,333 admissions met our criteria. A majority were treated via stenting (89%, n = 5,608). The angioplasty-alone group had significantly higher mortality (9.0% vs. 3.8%, p < 0.001) and iatrogenic stroke rate (3.9% vs. 1.9%, p < 0.001) than the stent group. The adjusted odds ratios of mortality and iatrogenic stroke for patients treated with angioplasty alone were 1.953 (p < 0.001) and 1.451 (p = 0.105), respectively, in comparison to patients treated with carotid stenting. CONCLUSION: Multivariate analysis found the risk of mortality to be elevated following angioplasty alone. This may represent selection bias, but it also may indicate that symptomatic patients with stroke suffer from severe stenosis and unstable plaques that would benefit from stent placement. These results would caution angioplasty alone as an arm of a future randomized trial involving this severely burdened patient population requiring urgent intervention.

Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms.

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve patient outcomes. We present our experience with a minimally invasive pterional approach for anterior circulation aneurysms performed in a major tertiary cerebrovascular center and compare the results with an aged matched dataset from the Nationwide Inpatient Sample (NIS). From August 2008 to December 2012, 22 elective aneurysm clippings on patients ≤55 years of age were performed by the same dual fellowship-trained cerebrovascular/endovascular neurosurgeon. One patient (4.5%) experienced transient post-operative complications. 18 of 22 patients returned for follow-up imaging and there were no recurrences through an average duration of 22 months. A search in the NIS database from 2008 to 2010, also for patients aged ≤55 years of age, yielded 1,341 hospitalizations for surgical clip ligation of unruptured cerebral aneurysms. Inpatient length of stay and hospital charges at our institution using the minimally invasive thumb-sized pterional technique were nearly half that of NIS (length of stay: 3.2 vs 5.7 days; hospital charges: $52,779 vs. $101,882). The minimally invasive thumb-sized pterional craniotomy allows good exposure of unruptured small and medium-sized supraclinoid anterior circulation aneurysms. Cerebrospinal fluid drainage from key subarachnoid cisterns and constant bimanual microsurgical techniques avoid the need for retractors which can cause contusions, localized venous infarctions, and post-operative cerebral edema at the retractor sites. Utilizing this set of techniques has afforded our patients with a shorter hospital stay at a lower cost compared to the national average.

Multimodality intraoperative neurophysiological monitoring during Onyx embolization of cerebrovascular malformations.

General anesthesia prohibits neurological examination during embolization of cerebrovascular malformations when provocative testing prior to pedicle occlusion is needed. Intraoperative neurophysiological monitoring (IONM) has the potential to fill this gap but remains relatively unexplored. We conduct a retrospective review of consecutive patients with cerebrovascular malformations treated with Onyx (ethylene vinyl alcohol copolymer, dissolved in dimethyl sulfoxide) embolization under general anesthesia with IONM from 2009 to 2012. Somatosensory evoked potentials (SSEPs), transcranial motor evoked potentials (TcMEPs), visual evoked potential (VEPs), auditory brainstem response (ABR), and electroencephalography (EEG) were used selectively in all patients depending on the location of the malformation. Provocative testing combined with IONM was performed in 28 patients over 75 sessions. Three patients demonstrated changes in TcMEPs or ABR during provocative testing, which halted the planned embolization. Two patients demonstrated changes in baseline SSEPs after embolization, despite normal IONM during provocative testing, correlating with postprocedural contralateral weakness. Six patients developed visual deficits after arterial occlusion despite unchanged VEPs and occipital EEG during provocative testing and embolization. We therefore conclude that the sensitivity of TcMEPs and SSEPs is preferable to EEG, and we strongly caution against relying on occipital recorded VEPs to predict visual deficits.

Open direct carotid artery access for coiling of an intracranial aneurysm under conscious sedation.

We describe the case of a 61-year-old patient with significant medical co-morbidities and tortuous vascular anatomy presenting with a large middle cerebral artery aneurysm. To avoid the risks of general anesthesia and circumvent a majority of the tortuous vessels, the aneurysm was accessed by direct open exposure of the common carotid artery under conscious sedation and local anesthesia. We were able to achieve complete endovascular occlusion of the aneurysm and the patient tolerated the procedure well with no intra- or post-operative complications. Use of conscious sedation is possible and safe for direct open common carotid artery access in patients with significant vascular tortuosity that makes the standard trans-femoral approach difficult or impossible.

Beware of the aneurysm in stealth mode!

Endovascular treatment is one of the treatment options considered for acute stroke in many primary stroke centers. Outcome from such treatment can be very successful and gratifying if the intervention is timely and patient selection is appropriate. There are however certain pitfalls that need to be kept in mind which, if the interventionalist is not careful, can adversely affect the outcome. We describe such a case where the patient presented with acute stroke due to basilar artery thrombosis but also had an aneurysm in the affected vessel. We also make certain recommendations to reduce the chances of complications arising during treatment of patients with such a condition.

Current trends in surgical approach and outcomes following pituitary tumor resection.

OBJECTIVES/HYPOTHESIS: The goals of pituitary tumor resection include normalizing endocrine function, relieving mass effect, and minimizing risk of recurrence. This study investigated current trends in costs and complications for transfrontal and transsphenoidal pituitary surgery. STUDY DESIGN: Retrospective review of the 2008-2011 Nationwide Inpatient Sample for patients undergoing pituitary lesion resection. METHODS: Demographics and outcomes were compared between transfrontal and transsphenoidal surgical approaches using χ(2) tests. Multivariate analysis was performed to investigate outcomes while controlling for confounders. RESULTS: There were 8,543 admissions for resection of pituitary lesions that met our inclusion criteria. Most (>90%) were treated transsphenoidally. The transfrontal approach was most frequent in the young (<35 years) and in the South. Rates of mortality and complications were higher in patients undergoing transfrontal surgery. Multivariate analysis found transsphenoidal resection was associated with a reduction in hospital costs and length of stay by over 50%; low-volume hospitals had increased cost and length of stay. There was an increased rate of transfrontal approaches at low-volume centers. CONCLUSIONS: Multiple factors influence outcomes of pituitary tumor resection. Transsphenoidal pituitary surgery is associated with a shorter length of stay, lower cost, and lower complication rates when compared to transfrontal surgery. Case specifics, including tumor location and size, influence approach and lead to a selection bias that cannot be controlled for in the present study. The prevalence of transfrontal resections at low-volume centers may indicate an area of further investigation. Additionally, when controlling for surgical approach, low-volume centers were found to adversely affect economic outcomes and also warrants investigation. LEVEL OF EVIDENCE: 2c.

Mild exercise reduces cerebral vasospasm after aneurysm subarachnoid hemorrhage: a retrospective clinical study and correlation with laboratory investigation.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (SAH) is a leading cause of death and disability and is often complicated by cerebral vasospasm (CV). Conventional management to prevent CV includes bedrest; however, inactivity places the patient at risk for nonneurological complications. We investigated the effect of mild exercise after SAH in clinical and laboratory settings. METHODS: Clinical: Data from 80 patients with SAH were analyzed retrospectively. After aneurysms were secured, physical therapy was initiated as tolerated. CV and complications were compared by the timing of active physical therapy. Laboratory: 18 Rodents were divided into three groups: (1) control, (2) SAH without exercise, and (3) SAH plus mild exercise. On day 5, brainstems were removed and analyzed for the injury marker inducible nitric oxide synthase (iNOS). RESULTS: Clinical: Mild exercise before day 4 significantly lowered the incidence of symptomatic CV compared with the nonexercised group. There was no difference in the incidence of additional complications based upon exercise. Laboratory: Staining for iNOS was significantly higher in the SAH group than the control group, but there was no difference between exercised and nonexercised SAH groups, confirming that exercise did not promote neuronal injury. CONCLUSION: Early mobilization significantly reduced clinical CV. The relationship should be studied further in a prospective trial with defined exercise regimens.

Time-dependent changes in cerebrospinal fluid metal ions following aneurysm subarachnoid hemorrhage and their association with cerebral vasospasm.

Aneurysm subarachnoid hemorrhage affects 10 in 100,000 people annually, 40 % of whom will develop neurological deficits from ischemic stroke caused by cerebral vasospasm. Currently, the underlying mechanisms are uncertain. Metal ions are important modulators of neuronal electrophysiological conduction and smooth muscle cell activity, thereby potentially contributing to vasospasm. We hypothesized that metal ion concentrations in the cerebrospinal fluid (CSF) after aneurysm rupture would change over time and be associated with vasospasm. To test this hypothesis, for 21 days, we collected CSF from patients with aneurysmal rupture and subjected it to spectrometry to detect metals. A repeated measures analysis was performed to analyze concentration changes over time. Six of the seven patients with aneurysmal rupture experienced vasospasm, all resolving by day 14. Changes in Fe²âº and Zn²âº concentrations in the CSF paralleled the incidence of vasospasm in this study population. Na²âº, Ca²âº, Mg²âº, and Cu²âº concentrations exhibited no statistically significant changes over time. In conclusion, Fe²âº concentration in the CSF was significantly elevated during days 7-10, whereas Zn²âº concentrations spiked shortly thereafter, during days 11-14. This suggests that Fe²âº may be related to the induction of vasospasm and Zn²âº may be a marker of early brain injury secondary to ischemic injury and inflammation.

The penumbra coil 400 system for treatment of wide-necked intracranial aneurysms: initial single-center experience.

Endovascular treatment of wide-necked intracranial aneurysms frequently requires stent- or balloon-assisted coiling to prevent coil herniation into the parent artery. Provided that coils can be securely deployed within the aneurysm sac, these adjunctive devices and their associated risk can be avoided. The Penumbra 400 Coil (PC-400) has a larger diameter than conventional coils and is constructed completely of metal, a feature that increases the coil stability and may improve its ability to respect the aneurysm neck. The purpose of this study was to examine the frequency of adjunctive stent usage when coiling wide-necked intracranial aneurysms with the PC-400 in comparison with conventional coils. We examined consecutive patients with unruptured wide-necked aneurysms treated at our institution with endovascular coils. Aneurysm characteristics and procedural outcomes were compared between patients treated with PC-400 compared with a control group treated with conventional coils. Thirty-eight patients met criteria for this study. Stent-assisted coiling was required in 34 % fewer cases using PC-400 compared with conventional coils (P = .049). Fewer coils and less length were required with the PC-400 to obtain the same packing densities, occlusion types, and short-term stability. This may reduce treatment cost and prove to be valuable in patients with contraindications to dual antiplatelet therapy.

Final results of the multicenter, prospective Axium MicroFX for Endovascular Repair of IntraCranial Aneurysm Study (AMERICA).

BACKGROUND: We previously performed a multicenter prospective single-arm trial of 100 patients treated with Axium MicroFX Coils (ev3; Plymouth, Minnesota, USA), AMERICA: Axium MicroFX for Endovascular Repair of IntraCranial Aneurysm study. Initial angiographic and clinical outcomes were excellent. The final results are presented herein. METHODS: AMERICA is a multicenter, prospective single-arm trial evaluating the safety and efficacy of the ev3 Axium MicroFX coil system in 100 separate aneurysms between April 2010 and October 2012. Trial endpoints were 3-6 month angiographic occlusion and clinical status, as reported by treatment center. RESULTS: Mean follow-up was 157.9 days (median 153.5, range 1-445, SEM 9.3 days). At last follow-up imaging, 90.6% of all aneurysms, 90% of unruptured aneurysms, and 93.3% of ruptured aneurysms had Raymond grade I or II occlusion. Progression to further occlusion (lower Raymond occlusion grade) occurred in 29/85 aneurysms (34.1%). Aneurysm recurrence occurred in 11/85 aneurysms (12.9%). Ninety-nine per cent of patients treated electively and 68.7% of ruptured patients had a modified Rankin score of 0-2. Delayed adverse events (AEs), occurring after discharge and during the follow-up period, occurred in 10% of patients. In total, two AEs (one severe and one moderate) were potentially related to the device, thereby providing a 2% device-related AE rate. CONCLUSIONS: In this prospective, multicenter series of 100 aneurysms treated with Axium MicroFX PGLA (polyglycolic/polylactic acid) coils, 3-6 month angiographic occlusion and clinical outcomes were excellent. This study suggests that Axium MicroFX PGLA coils are safe and effective in the treatment of intracranial aneurysms.

Bilateral migration of open-cell design carotid stents in the early post-procedure period: a rare complication.

We describe migration of bilateral carotid stents in a 63-year-old man shortly after stenting. Carotid stent migration was found four days post-procedure on the right side and one day post-procedure on the left side on angiography and duplex ultrasound, respectively. This is the first reported case of bilateral carotid artery stenting complicated by bilateral proximal migration of open-cell design stents in the early post-procedure period.

Optimum timing of revascularization for emergent admissions of carotid artery stenosis with infarction.

OBJECTIVE: There is debate concerning the optimum timing of revascularization for emergent admissions of carotid artery stenosis with infarction. Our intent was to stratify clinical and economic outcomes based on the timing of revascularization. METHODS: We performed a retrospective cohort study using the Nationwide Inpatient Sample from 2002 to 2011. Patients were included if they were admitted non-electively with a primary diagnosis of carotid artery stenosis with infarction and subsequently treated with revascularization. Cases were stratified into four groups based upon the timing of revascularization: (1) within 48-h of admission, (2) between 48-h and day four of hospitalization, (3) between days five and seven, and (4) during the second week of admission. RESULTS: 27,839 cases met our inclusion criteria. The lowest odds of iatrogenic complications (OR=0.643, P<.001) and mortality (OR=0.631, P<.001) coincided with revascularization between days five and seven of hospitalization. Treatment with carotid artery stenting (CAS) and administration of recombinant tissue plasminogen activator (rtPA) increased the odds of complications and death. With regards to economic measures, administration of rtPA and utilization of CAS drove cost and length-of-stay up, while lower co-morbidity burden and earlier time to revascularization drove both measures down. CONCLUSIONS: The present study suggests that the optimum timing of revascularization may be near the end of the first week of hospitalization following acute stroke. However, this study must be cautioned with limitations including its inability to control for critical disease specific variables including symptom severity and degree of stenosis. Prospective examination seems warranted.

Stenting versus endarterectomy and the impact of ultra-early revascularization for emergent admissions of carotid artery stenosis.

BACKGROUND: The factors influencing outcomes after emergent admission for symptomatic carotid artery stenosis treated with revascularization by endarterectomy or stenting are yet to be fully elucidated. METHODS: We analyzed revascularization of carotid artery stenosis for patients admitted emergently using the Nationwide Inpatient Sample (2008-2011). Admission characteristics, economic measures, in-hospital mortality, and iatrogenic stroke were compared between (1) endarterectomy and stenting, (2) patients with and without cerebral infarction, and (3) ultra-early (within 48 hours of admission) and deferred (up to 2 weeks) intervention. RESULTS: 72,797 admissions meeting our inclusion criteria were identified. Factors associated with ultra-early revascularization were male patients, low comorbidity burden, stenosis without infarction, and stenting. Ultra-early intervention significantly decreased cost and length of stay, and stenting for patients without infarction decreased length of stay but increased cost. Patients without infarction treated within 48 hours had significantly lower mortality and iatrogenic stroke rate. Patients with infarction receiving ultra-early revascularization had increased odds of mortality and iatrogenic stroke in comparison with the deferred group. Patients with infarction receiving stenting experienced increased odds of mortality in comparison with those receiving endarterectomy, but there was no significant difference in iatrogenic stroke rate. Recombinant tissue plasminogen activator (rtPA) administration on the day of revascularization greatly increased the odds of iatrogenic stroke and mortality. CONCLUSIONS: Larger prospectively randomized trials evaluating the optimum timing of revascularization after emergent admission of carotid artery stenosis seem warranted.