A cortically-weighted versus total Alberta Stroke Program Early Computed Tomography Score in thrombectomy outcome models.

OBJECTIVES: Individual subcortical infarct scoring for the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) can be difficult and is subjected to higher inter-reader variability. This study compares performance of the 10-point ASPECTS with a new 7-point cortically-weighted score in predicting post-thrombectomy functional outcomes. MATERIALS AND METHODS: Prospective registry data from two comprehensive stroke centers (Site 1 2016-2021; Site 2: 2019-2021) included patients with either M1 segment of middle cerebral artery or internal carotid artery occlusions who underwent thrombectomy. Two multivariate proportional odds training models utilizing either 10-point or 7-point ASPECTS predicting 90-day shift in modified Rankin score were generated using Site 1 data and validated with Site 2 data. Models were compared using multiclass receiver operator characteristics, corrected Akaike's Information Criterion, and likelihood ratio test. RESULTS: Of 328 patients (Site 1 = 181, Site 2 = 147), median age was 71y (IQR 61-82), 119 (36%) had internal carotid artery occlusions, and median 10-point ASPECTS was 9 (IQR 8-10). There was no difference in performance between models using either total or cortically-weighted ASPECTS (p=0.14). Validation cohort data were correctly (i.e., predicting modified Rankin score within one point) classified 50% (cortically-weighted score model) and 56% (total score model) of the time. CONCLUSIONS: The 7-point cortically-weighted ASPECTS was similarly predictive of post-thrombectomy functional outcome as 10-point ASPECTS. Given noninferior performance, the cortically-weighted score is a potentially reliable, but simplified, alternative to the traditional scoring paradigm, with potential implications in automated image analysis tool development.

Tenzing 7 delivery catheter with or without a leading microwire for single pass aspiration thrombectomy: A multicenter experience.

INTRODUCTION: Aspiration mechanical thrombectomy traditionally includes use of an inner microcatheter and leading microwire to navigate an aspiration catheter (AC) to the site of occlusion. Early clinical experience suggests that a leading microwire is often not needed with the Tenzing 7 (T7, Route 92 Medical, San Mateo, CA), a soft tapered tip ledge-reducing delivery catheter. This multicenter experience aims to describe AC delivery success in single-pass thrombectomy using T7 with and without a leading microwire. METHODS: A retrospective review was conducted of consecutive patients who underwent single-pass thrombectomy with T7 at six institutions between 2020 and 2022. We examined the percentage of successful AC delivery, puncture-to-revascularization time, and procedural complication rate. RESULTS: A leading microwire with T7 was used in 19/89 (21%) of patients, and it was not used with T7 in 70/89 (79%) of patients. Successful AC delivery was similar with and without microwires (97% vs. 90%, p = 0.15). Median puncture-to-revascularization times were similar (17 min microwire vs. 16 min no-microwire, p = 0.12). No complications were associated with microwire use; one (1.4%) patient had a T7-related vasospasm resolved with verapamil during thrombectomy without a leading microwire. Differences in complication rates were not statistically significant (p = 0.46). CONCLUSION: In our real-world clinical experience, leading microwire use was infrequently necessary with the T7 delivery catheter. Successful AC delivery and complication rates were similar with and without microwire use in single-pass T7 thrombectomies. Initial pass with T7 may be performed without use of leading microwire, reserving microwire use for refractory cases or known difficult-to-navigate vasculature.

Differential thrombectomy utilization across hospital classifications in the United States.

OBJECTIVES: To determine hospital-level factors associated with thrombectomy uptake. MATERIALS AND METHODS: The Nationwide Emergency Department Sample was retrospectively queried to determine the total number of thrombectomies performed based on different hospital characteristics. Joint point analysis was used to determine which years were associated with significant increases in the number of high-volume thrombectomy centers (ostensibly defined as >50 thrombectomies/year), thrombectomy-capable centers (>15 thrombectomies/year), and total number of thrombectomies performed. Multivariable logistic regression was used to determine hospital factors associated with having an increased odds of performing thrombectomies, and of being classified as a high-volume thrombectomy or a thrombectomy-capable center. RESULTS: Between 2007-2020 there was a stepwise increase in the number of thrombectomy-capable and high-volume thrombectomy centers in the United States. In 2020, there were a total of 15,705 thrombectomies performed, with 89 high-volume thrombectomy centers, and 359 thrombectomy-capable centers. The number of thrombectomy-capable centers significantly increased after 2011. After 2013 and 2016 there was a significant change in the growth rate of high-volume thrombectomy centers. There was also a significant increase in the total number of thrombectomies performed after 2016. Hospital characteristics that were associated with an increased likelihood of being classified as thrombectomy-capable or high-volume included trauma level 1 and 2 hospitals. CONCLUSIONS: Between 2007 and 2020, there was a marked growth in thrombectomy utilization for acute ischemic stroke. This growth outpaced new diagnoses of ischemic stroke, and was driven largely by certain hospital types, with the greatest rises following seminal publications of positive randomized thrombectomy trials.

Tissue Clock Beyond Time Clock: Endovascular Thrombectomy for Patients With Large Vessel Occlusion Stroke Beyond 24 Hours.

BACKGROUND AND PURPOSE: Randomized trials proved the benefits of mechanical thrombectomy (MT) for select patients with large vessel occlusion (LVO) within 24 hours of last-known-well (LKW). Recent data suggest that LVO patients may benefit from MT beyond 24 hours. This study reports the safety and outcomes of MT beyond 24 hours of LKW compared to standard medical therapy (SMT). METHODS: This is a retrospective analysis of LVO patients presented to 11 comprehensive stroke centers in the United States beyond 24 hours from LKW between January 2015 and December 2021. We assessed 90-day outcomes using the modified Rankin Scale (mRS). RESULTS: Of 334 patients presented with LVO beyond 24 hours, 64% received MT and 36% received SMT only. Patients who received MT were older (67±15 vs. 64±15 years, P=0.047) and had a higher baseline National Institutes of Health Stroke Scale (NIHSS; 16±7 vs.10±9, P<0.001). Successful recanalization (modified thrombolysis in cerebral infarction score 2b-3) was achieved in 83%, and 5.6% had symptomatic intracranial hemorrhage compared to 2.5% in the SMT group (P=0.19). MT was associated with mRS 0-2 at 90 days (adjusted odds ratio [aOR] 5.73, P=0.026), less mortality (34% vs. 63%, P<0.001), and better discharge NIHSS (P<0.001) compared to SMT in patients with baseline NIHSS ≥6. This treatment benefit remained after matching both groups. Age (aOR 0.94, P<0.001), baseline NIHSS (aOR 0.91, P=0.017), Alberta Stroke Program Early Computed Tomography (ASPECTS) score ≥8 (aOR 3.06, P=0.041), and collaterals scores (aOR 1.41, P=0.027) were associated with 90-day functional independence. CONCLUSION: In patients with salvageable brain tissue, MT for LVO beyond 24 hours appears to improve outcomes compared to SMT, especially in patients with severe strokes. Patients' age, ASPECTS, collaterals, and baseline NIHSS score should be considered before discounting MT merely based on LKW.

Outcomes following thrombectomy for acute large vessel occlusion beyond 24 hours or with unknown time of onset.

BACKGROUND: Endovascular thrombectomy (EVT) is recommended in medically eligible patients with large vessel occlusions (LVO) within 24 hours of symptom onset. While there is evidence that EVT ≥24h after last known well (LKW) is associated with favorable outcomes in patients who meet DAWN/DEFUSE-3 criteria, it is unknown if more liberal criteria can be applied. METHODS: A single center, prospective observational cohort of consecutive adult stroke patients was queried for symptomatic occlusions of the internal carotid (ICA) or proximal middle cerebral (M1) arteries (October 2019-January 2022), with a National Institutes of Health Stroke Scale (NIHSS) ≥6, pre-stroke modified Rankin Scale (mRS) 0-2, and Alberta Stroke Program Early Computed Tomography Scale score 3-10. These inclusion criteria were extrapolated from recently published data indicating a benefit with EVT with more liberal patient selection. Patients who underwent EVT ≥24h after LKW were compared against those treated medically. The primary outcome was a good functional outcome (90-day mRS 0-2), which was evaluated using multivariable logistic regression. RESULTS: Of the 27 included patients, the median age was 65y (IQR 49-76) with a median NIHSS of 15 (IQR 8-26), and 17 (63.0%) underwent EVT (median LKW-to-puncture 35.5h (IQR 26.9-65.8h). The primary outcome was no different with EVT in unadjusted regression (OR 1.17, 95%CI 0.17-8.09), and there remained no association across all multivariable models tested. Age, pre-stroke disability, and M1 occlusions were non-significantly associated with the primary outcome (p>0.05). There was a non-significant trend indicating a favorable shift in 90-day mRS with EVT (proportional OR 2.04, 95%CI 0.44-9.48). CONCLUSIONS: Using more liberal inclusion criteria for EVT in the ultra-extended window, there was no statistically significant difference in the rate of good functional outcome with EVT. Larger studies are called upon to evaluate outcomes when more liberal criteria are used to assess thrombectomy eligibility.

Embolic infarct topology differs between atrial fibrillation subtypes and embolic stroke of undetermined source.

BACKGROUND: The lack of superiority of anticoagulation over antiplatelet therapy in embolic stroke of undetermined source (ESUS) may be in part due to the misclassification of radiographic ESUS patterns as cardioembolic. In this imaging analysis, we sought to differentiate clinical and radiographic patterns of ESUS patients from patterns in patients with a highly probable cardioembolic source. MATERIALS & METHODS: A prospective registry of consecutive adults with acute infarction on diffusion-weighted magnetic resonance imaging was queried. Patients with infarctions due to small vessel disease, large vessel disease, and other causes were excluded. Multivariable logistic regression was used to identify independent predictors of two potentially embolic patterns: (1) multifocal and (2) cortical lesions, comparing patients with ESUS against those with atrial fibrillation (AF). RESULTS: Among 1243 screened patients, 343 (27.6%) experienced strokes due to ESUS or AF. Prior to the index stroke, patients with AF as compared to ESUS were older (median 75 vs. 65, p<0.01) and had more heart failure (25.9% vs. 8.4%, p<0.01). The odds of multifocal infarction were the same between patients with ESUS and both AF subtypes (p>0.05), however, cortical involvement was more associated with both AF versus ESUS (77.7% vs. 65.7%, P=0.02). A higher Fazekas grade of white matter disease was inversely associated with cortical infarction among included patients (aOR 0.77, 95% CI 0.62-0.96). CONCLUSION: Cortical infarctions were twice as common among patients with AF versus ESUS. Subcortical infarct topography was strongly associated with chronic microvascular ischemic changes and therefore may not represent embolic phenomena. Larger-scale investigations are warranted to discern whether large or multifocal subcortical infarcts ought to be excluded from the ESUS designation.

Unique Clinicopathologic Subclassifiers of Cryptogenic Cerebral Emboli.

INTRODUCTION: Ipsilateral nonstenotic (<50%) internal carotid artery (ICA) plaque, cardiac atriopathy, and patent foramen ovale (PFO) may account for a substantial proportion of embolic stroke of undetermined source (ESUS). METHODS: Consecutive stroke patients at our center (2019-2021) with unilateral, anterior circulation ESUS were categorized into the following mutually exclusive etiologies: (1) nonstenotic ipsilateral ICA plaque (NSP, ≥3mm in maximal axial diameter), (2) sex-adjusted mod-to-severe left atrial enlargement (LAE), (3) PFO, and (4) "occult ESUS" (patients who failed to meet criteria for these 3 groups). Descriptive statistics and multivariable logistic regression were used to model group characteristics. RESULTS: Of 132 included patients, the median age was 65 (IQR 56-73), 74 (56%) of whom were White, and 54 (41%) were female. Twenty-one patients (16%) had NSP proximal to the infarct territory, 17 (13%) had LAE, 9 (7%) had a PFO, and 85 (64%) had no other mechanism. Patients with LAE were older (p=0.004), and had more frequent intracranial occlusions of the internal carotid and proximal middle cerebral artery (p=0.048), while tobacco use was most commonly found among patients with NSP (75%) when compared to other ESUS groups (p=0.02). Five of 9 patients with LAE who underwent outpatient telemetry had paroxysmal atrial fibrillation (56%), while zero patients with PFO or NSP had paroxysmal atrial fibrillation (p=0.005). Older age (adjusted OR [aOR] 1.05, 95%CI 1.03-1.07), coronary artery disease (aOR 3.22, 95%CI 1.61-6.44) and hypertension (aOR 2.16, 95%CI 1.14-4.06) were independently associated with LAE, while only tobacco use was associated with NSP when compared to other ESUS subclassifiers (OR 3.18, 95%CI 1.08-0.42). Age and tobacco use were both inversely associated with PFO (aOR 0.93, 95%CI 0.88-0.98, and aOR 0.10, 95%CI 0.02-0.90, respectively). CONCLUSIONS: Certain clinical and radiographic features may be useful in predicting the proximal source of occult cerebral emboli, and can be used for cost-effective outpatient diagnostic testing.

Delays in thrombolysis during COVID-19 are associated with worse neurological outcomes: the Society of Vascular and Interventional Neurology Multicenter Collaboration.

INTRODUCTION: We have demonstrated in a multicenter cohort that the COVID-19 pandemic has led to a delay in intravenous thrombolysis (IVT) among stroke patients. Whether this delay contributes to meaningful short-term outcome differences in these patients warranted further exploration. METHODS: We conducted a nested observational cohort study of adult acute ischemic stroke patients receiving IVT from 9 comprehensive stroke centers across 7 U.S states. Patients admitted prior to the COVID-19 pandemic (1/1/2019-02/29/2020) were compared to patients admitted during the early pandemic (3/1/2020-7/31/2020). Multivariable logistic regression was used to estimate the effect of IVT delay on discharge to hospice or death, with treatment delay on admission during COVID-19 included as an interaction term. RESULTS: Of the 676 thrombolysed patients, the median age was 70 (IQR 58-81) years, 313 were female (46.3%), and the median NIHSS was 8 (IQR 4-16). Longer treatment delays were observed during COVID-19 (median 46 vs 38 min, p = 0.01) and were associated with higher in-hospital death/hospice discharge irrespective of admission period (OR per hour 1.08, 95% CI 1.01-1.17, p = 0.03). This effect was strengthened after multivariable adjustment (aOR 1.15, 95% CI 1.07-1.24, p < 0.001). There was no interaction of treatment delay on admission during COVID-19 (pinteraction = 0.65). Every one-hour delay in IVT was also associated with 7% lower odds of being discharged to home or acute inpatient rehabilitation facility (aOR 0.93, 95% CI 0.89-0.97, p < 0.001). CONCLUSION: Treatment delays observed during the COVID-19 pandemic led to greater early mortality and hospice care, with a lower probability of discharge to home/rehabilitation facility. There was no effect modification of treatment delay on admission during the pandemic, indicating that treatment delay at any time contributes similarly to these short-term outcomes.

Dual-center study comparing transradial and transfemoral approaches for flow diversion treatment of intracranial aneurysms.

BACKGROUND: The transfemoral approach (TFA) has been the traditional approach for neurointerventional cases. While the TFA allows for triaxial support in flow diverting stent cases, it is associated with access site complications. Recently, the transradial approach (TRA) has emerged as a safer alternative to the TFA. To the best of our knowledge, there have only been single-center studies comparing outcomes in flow diverter cases for these approaches. We demonstrate the safety and feasibility of the TRA for placement of flow diverting stents in the treatment of unruptured intracranial aneurysms at two high-volume centers. MATERIALS AND METHODS: We performed a retrospective review of prospectively collected institutional databases at two high-volume neuroendovascular centers. Cases from 2016 to 2018 of unruptured intracranial aneurysms treated by flow diverting stenting accessed through either the TRA or the TFA were compared. Patient demographics, procedural and radiographic metrics including location and size of the aneurysm, size, and length of the flow diverter implant, and fluoroscopic time were recorded. Puncture site complications and length of hospital stay were also included in the data analysis. RESULTS: There were three out of 29 TRA cases which were converted to the TFA. None of the TRA patients experienced site complications, whereas three TFA patients experienced site complications. While TRA and TFA patients did not differ significantly in their exposure to radiation, TRA patients experienced shorter hospital stays. CONCLUSIONS: While long-term studies are still lacking regarding this approach, we demonstrate that the TRA is a safe and feasible approach for flow diverter stent placement.

Decline in Rehab Transfers Among Rehab-Eligible Stroke Patients During the COVID-19 Pandemic.

OBJECTIVE: To characterize differences in disposition arrangement among rehab-eligible stroke patients at a Comprehensive Stroke Center before and during the COVID-19 pandemic. MATERIALS AND METHODS: We retrospectively analyzed a prospective registry for demographics, hospital course, and discharge dispositions of rehab-eligible acute stroke survivors admitted 6 months prior to (10/2019-03/2020) and during (04/2020-09/2020) the COVID-19 pandemic. The primary outcome was discharge to an inpatient rehabilitation facility (IRF) as opposed to other facilities using descriptive statistics, and IRF versus home using unadjusted and adjusted backward stepwise logistic regression. RESULTS: Of the 507 rehab-eligible stroke survivors, there was no difference in age, premorbid disability, or stroke severity between study periods (p>0.05). There was a 9% absolute decrease in discharges to an IRF during the pandemic (32.1% vs. 41.1%, p=0.04), which translated to 38% lower odds of being discharged to IRF versus home in unadjusted regression (OR 0.62, 95%CI 0.42-0.92, p=0.016). The lower odds of discharge to IRF persisted in the multivariable model (aOR 0.16, 95%CI 0.09-0.31, p<0.001) despite a significant increase in discharge disability (median discharge mRS 4 [IQR 2-4] vs. 2 [IQR 1-3], p<0.001) during the pandemic. CONCLUSIONS: Admission for stroke during the COVID-19 pandemic was associated with a significantly lower probability of being discharged to an IRF. This effect persisted despite adjustment for predictors of IRF disposition, including functional disability at discharge. Potential reasons for this disparity are explored.

Cerebrovascular events and outcomes in hospitalized patients with COVID-19: The SVIN COVID-19 Multinational Registry.

BACKGROUND: Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients. AIM: To summarize the findings of a multinational observational cohort of patients with SARS-CoV-2 and cerebrovascular disease. METHODS: Retrospective observational cohort of consecutive adults evaluated in the emergency department and/or admitted with coronavirus disease 2019 (COVID-19) across 31 hospitals in four countries (1 February 2020-16 June 2020). The primary outcome was the incidence rate of cerebrovascular events, inclusive of acute ischemic stroke, intracranial hemorrhages (ICH), and cortical vein and/or sinus thrombosis (CVST). RESULTS: Of the 14,483 patients with laboratory-confirmed SARS-CoV-2, 172 were diagnosed with an acute cerebrovascular event (1.13% of cohort; 1130/100,000 patients, 95%CI 970-1320/100,000), 68/171 (40.5%) were female and 96/172 (55.8%) were between the ages 60 and 79 years. Of these, 156 had acute ischemic stroke (1.08%; 1080/100,000 95%CI 920-1260/100,000), 28 ICH (0.19%; 190/100,000 95%CI 130-280/100,000), and 3 with CVST (0.02%; 20/100,000, 95%CI 4-60/100,000). The in-hospital mortality rate for SARS-CoV-2-associated stroke was 38.1% and for ICH 58.3%. After adjusting for clustering by site and age, baseline stroke severity, and all predictors of in-hospital mortality found in univariate regression (p < 0.1: male sex, tobacco use, arrival by emergency medical services, lower platelet and lymphocyte counts, and intracranial occlusion), cryptogenic stroke mechanism (aOR 5.01, 95%CI 1.63-15.44, p < 0.01), older age (aOR 1.78, 95%CI 1.07-2.94, p = 0.03), and lower lymphocyte count on admission (aOR 0.58, 95%CI 0.34-0.98, p = 0.04) were the only independent predictors of mortality among patients with stroke and COVID-19. CONCLUSIONS: COVID-19 is associated with a small but significant risk of clinically relevant cerebrovascular events, particularly ischemic stroke. The mortality rate is high for COVID-19-associated cerebrovascular complications; therefore, aggressive monitoring and early intervention should be pursued to mitigate poor outcomes.

"COVID-19 and cervical artery dissection- A causative association?"

COVID-19 is a pandemic disease which predominantly affects the respiratory system, however it also causes multi-organ dysfunction in a subset of patients. There is a growing evidence that it increases the propensity of strokes in younger patients. Besides producing a prothrombotic state, arterial dissection could be one of its many manifestations, increasing the risks of stroke. Herein, we report the first case of spontaneous bilateral vertebral artery dissection in a patient with COVID-19. 39-year female presented with spontaneous bilateral vertebral artery dissections without any instigating traumatic events and no history of connective tissue disorders. Whether this patient's vertebral artery dissections were triggered by exaggerated inflammatory response or arteriopathy secondary to COVID-19 remains speculative. Nonetheless, arterial dissection could be one of it's complications. It is important for the physicians to be aware of different clinical manifestations of COVID-19 as we manage these patients with no historical experience, to provide adequate care.

Stroke in COVID-19: a single-centre initial experience in a hotspot of the pandemic.

BACKGROUND: COVID-19, caused by SARS-CoV-2, is a global pandemic that has been an immense burden on healthcare systems all over the world. These patients may be at higher risk for acute ischaemic stroke (AIS). We present our experience with AIS in patients with COVID-19. METHODS: We reviewed all patients admitted to our hospital during a 6-week period with a positive nasopharyngeal swab test for SARS-CoV-2. Among these patients, we identified AIS. We reviewed the demographics, clinical, laboratory, imaging characteristics, treatments received and outcomes of AIS in patients with COVID-19. RESULTS: We identified 683 patients admitted with COVID-19 during the study period, of which 20 patients had AIS. Large-vessel occlusion (LVO) was noted in 11 patients (55%). Intravenous alteplase was administered in four patients (20%) and mechanical thrombectomy was performed in five patients (25%). Respiratory symptoms preceded the onset of AIS in most of the patients (70%) by 1 to 21 days. Mortality in patients with AIS was 50% compared with 26% of all COVID-19 admissions. Most of these patients died due to non-neurological causes (70%). Three patients with AIS had clinical and imaging findings consistent with COVID-19, but were negative for multiple nasopharyngeal swab tests. INTERPRETATION: LVO was more common in patients with AIS and COVID-19. They had more severe disease and higher mortality rates. Most of the patients had respiratory symptoms preceding AIS by days to weeks. This could explain certain patients with clinical picture of COVID-19 but negative nasopharyngeal swab tests.

Left distal radial access in patients with arteria lusoria: insights for cerebral angiography and interventions.

BACKGROUND: The transradial approach (TRA) is frequently used for neurointerventional procedures as it is safer, improves patient comfort, and decreases costs and procedural time in comparison with the transfemoral approach (TFA). Patients with arteria lusoria, or an aberrant right subclavian artery (ARSA), provide a unique challenge for cerebral angiography and interventions when using the TRA. OBJECTIVE: To examine the hypothesis that the extreme angulation encountered while accessing the great vessels from the right TRA could be overcome by reversing the approach to the left distal TRA (dTRA). METHODS: A prospectively maintained database of transradial neurointerventional cases since 2018 was searched. Six cases from 850 were identified, in which the left dTRA was used. Three cases were for patients with an ARSA. For the three cases of interest, patient history, pathology, imaging, and access techniques were reviewed. RESULTS: Two diagnostic cerebral angiography cases and one intervention were successfully performed through a left dTRA. CONCLUSIONS: Proper positioning of the left wrist and familiarity with forming the Simmons catheter can overcome this anatomical challenge. This technique and results further demonstrate that the left distal radial artery is a feasible access site for catheterization of bilateral carotid, left vertebral, and right subclavian arteries for patients with an ARSA.

Hyperacute Management of Ischemic Strokes: JACC Focus Seminar.

Acute ischemic stroke is the leading cause of disability and among the leading causes of mortality worldwide. Intravenous tissue plasminogen activator has been a cornerstone for treatment of acute ischemic stroke for more than 20 years; however, its use is limited due to a narrow therapeutic window, several contraindications, and low efficacy to recanalize the artery in large vessel occlusion. Recently, the addition of endovascular mechanical thrombectomy of large artery occlusion has revolutionized the stroke treatment for most disabling strokes. The paper reviews updates to the thrombolytic treatment as well as catheter-based treatment, and results from recent trials in the selection of patients in an extended time window using perfusion imaging.

First case series of the transradial approach for neurointerventional procedures in pediatric patients.

OBJECTIVE: The transradial approach (TRA) has been widely adopted by interventional cardiologists but is only now being accepted by neurointerventionalists. The benefits of the TRA over the traditional transfemoral approach (TFA) include reduced risk of adverse clinical events and faster recovery. The authors assessed the safety and feasibility of the TRA for neurointerventional cases in the pediatric population. METHODS: Pediatric patients undergoing cerebrovascular interventions since implementation of the TRA at the authors' institution were retrospectively reviewed. Pertinent patient information, procedure indications, vessels catheterized, fluoroscopy time, and complications were reviewed. RESULTS: There were 4 patients in this case series, and their ages ranged from 13 to 15 years. Each patient tolerated the procedure performed using the TRA without any postprocedural issues, and only 1 patient experienced radial artery spasm, which resolved with the administration of intraarterial verapamil. None of the patients required conversion to the TFA. CONCLUSIONS: The TRA can be considered a safe alternative to the TFA for neurointerventional procedures in the pediatric population and provides potential advantages. However, as pediatric patients require special consideration due to their smaller-caliber arteries, routine use of ultrasound guidance is advised when attempting the TRA.

Microsurgical Clip Ligation of an Unruptured Azygos Bifurcation Aneurysm Indented by the Falx Cerebri: 3-Dimensional Operative Video.

Dissecting pericallosal aneurysms from the falx cerebri is technically challenging, as one must release the adherent dome but minimize shearing injury, which could result in intraoperative rupture. We discuss a 51-yr-old woman with a history of hypertension and smoking who presented with severe headaches and was found to have a 6-mm unruptured, multilobulated pericallosal aneurysm abutting the falx, with anterior and superior projecting domes on either side. She also had an azygos anterior cerebral artery (ACA), a rare anatomic variant associated with pericallosal aneurysms, where both A1 segments form a single A2. After considering endovascular and open surgical techniques, we proceeded with clip ligation given her younger age, smoking history, daughter aneurysms seen on angiography, and azygos ACA. We positioned her supine with her head turned lateral, left side down to maximize gravitational retraction, mapped a bicoronal incision, and performed a small craniotomy, followed by an interhemispheric approach. Rather than cutting the falx around the dome, a described technique that risks blind vessel injury, we temporarily clipped inflow vessels to reduce the dome's turgor and sharply and bluntly dissected apart its attachments, which freed the aneurysm from beneath the falx and allowed visualization of associated vessels. Using suction to manipulate the dome, we then placed stacked, angled clips, and used a micro-Doppler to confirm brisk inflow and outflow. Postoperatively, she was neurologically intact, and her angiogram showed no residual aneurysm. Our 3-dimensional video demonstrates a safer, alternative approach to treating this rare aneurysm with its associated anatomical variant. Patient consented to her clinical presentation and microscope media being used for academic purposes.

The Neuro Radialist.

Trans-radial approach (TRA) has been used in cardiac and peripheral interventional radiology practices for decades, because of safety and patient comfort. There is interest in TRA in the cerebrovascular field, with potential to replicate benefits over trans-femoral approach. TRA is technically more challenging and has a learning curve, which hinders its use as the first-line approach; however, as more neuro-interventionalists embrace TRA, techniques are being optimized simultaneously for supra-aortic vessel catheterization. This article describes advantages, patient selection, conventional and distal radial access, and detailed techniques of trans-radial catheterization for diagnostic angiography, as well as cerebrovascular interventions and its current limitations.