Clinical relevance of intracranial hemorrhage after thrombectomy versus medical management for large core infarct: a secondary analysis of the SELECT2 randomized trial.

BACKGROUND: The incidence of intracerebral hemorrhage (ICH) and its effect on the outcomes after endovascular thrombectomy (EVT) for patients with large core infarcts have not been well-characterized. METHODS: SELECT2 trial follow-up imaging was evaluated using the Heidelberg Bleeding Classification (HBC) to define hemorrhage grade. The association of ICH with clinical outcomes and treatment effect was examined. RESULTS: Of 351 included patients, 194 (55%) and 189 (54%) demonstrated intracranial and intracerebral hemorrhage, respectively, with a higher incidence in EVT (134 (75%) and 130 (73%)) versus medical management (MM) (60 (35%) and 59 (34%), both P<0.001). Hemorrhagic infarction type 1 (HBC=1a) and type 2 (HBC=1b) accounted for 93% of all hemorrhages. Parenchymal hematoma (PH) type 1 (HBC=1c) and type 2 (HBC=2) were observed in 1 (0.6%) EVT-treated and 4 (2.2%) MM patients. Symptomatic ICH (sICH) (SITS-MOST definition) was seen in 0.6% EVT patients and 1.2% MM patients. No trend for ICH with core volumes (P=0.10) or Alberta Stroke Program Early CT Score (ASPECTS) (P=0.74) was observed. Among EVT patients, the presence of any ICH did not worsen clinical outcome (modified Rankin Scale (mRS) at 90 days: 4 (3-6) vs 4 (3-6); adjusted generalized OR 1.00, 95% CI 0.68 to 1.47, P>0.99) or modify EVT treatment effect (Pinteraction=0.77). CONCLUSIONS: ICH was present in 75% of the EVT population, but PH or sICH were infrequent. The presence of any ICH did not worsen functional outcomes or modify EVT treatment effect at 90-day follow-up. The high rate of hemorrhages overall still represents an opportunity for adjunctive therapies in EVT patients with a large ischemic core.

Endovascular Thrombectomy for Large Ischemic Stroke Across Ischemic Injury and Penumbra Profiles.

Importance: Whether endovascular thrombectomy (EVT) efficacy for patients with acute ischemic stroke and large cores varies depending on the extent of ischemic injury is uncertain. Objective: To describe the relationship between imaging estimates of irreversibly injured brain (core) and at-risk regions (mismatch) and clinical outcomes and EVT treatment effect. Design, Setting, and Participants: An exploratory analysis of the SELECT2 trial, which randomized 352 adults (18-85 years) with acute ischemic stroke due to occlusion of the internal carotid or middle cerebral artery (M1 segment) and large ischemic core to EVT vs medical management (MM), across 31 global centers between October 2019 and September 2022. Intervention: EVT vs MM. Main Outcomes and Measures: Primary outcome was functional outcome-90-day mRS score (0, no symptoms, to 6, death) assessed by adjusted generalized OR (aGenOR; values >1 represent more favorable outcomes). Benefit of EVT vs MM was assessed across levels of ischemic injury defined by noncontrast CT using ASPECTS score and by the volume of brain with severely reduced blood flow on CT perfusion or restricted diffusion on MRI. Results: Among 352 patients randomized, 336 were analyzed (median age, 67 years; 139 [41.4%] female); of these, 168 (50%) were randomized to EVT, and 2 additional crossover MM patients received EVT. In an ordinal analysis of mRS at 90 days, EVT improved functional outcomes compared with MM within ASPECTS categories of 3 (aGenOR, 1.71 [95% CI, 1.04-2.81]), 4 (aGenOR, 2.01 [95% CI, 1.19-3.40]), and 5 (aGenOR, 1.85 [95% CI, 1.22-2.79]). Across strata for CT perfusion/MRI ischemic core volumes, aGenOR for EVT vs MM was 1.63 (95% CI, 1.23-2.16) for volumes ≥70 mL, 1.41 (95% CI, 0.99-2.02) for ≥100 mL, and 1.47 (95% CI, 0.84-2.56) for ≥150 mL. In the EVT group, outcomes worsened as ASPECTS decreased (aGenOR, 0.91 [95% CI, 0.82-1.00] per 1-point decrease) and as CT perfusion/MRI ischemic core volume increased (aGenOR, 0.92 [95% CI, 0.89-0.95] per 10-mL increase). No heterogeneity of EVT treatment effect was observed with or without mismatch, although few patients without mismatch were enrolled. Conclusion and Relevance: In this exploratory analysis of a randomized clinical trial of patients with extensive ischemic stroke, EVT improved clinical outcomes across a wide spectrum of infarct volumes, although enrollment of patients with minimal penumbra volume was low. In EVT-treated patients, clinical outcomes worsened as presenting ischemic injury estimates increased. Trial Registration: ClinicalTrials.gov Identifier: NCT03876457.

Microplastics contamination in two species of gobies and their estuarine habitat of Indian Sundarbans.

Sundarbans, a Ramsar site of India is contaminated with heterogeneous microplastic wastes. Boddart's goggle eye mudskipper and Rubicundus eelgoby, were common gobies of Sundarbans estuary which accumulated microplastics during their normal biological activities. We estimated the abundance of microplastics in water, sediment; skin, gills, bucco-opercular cavity and gastrointestinal tract of these two goby fishes. Microplastic load estimated in gobies were 0.84 and 2.62 particles per fish species with a dominance of transparent, fibrous microplastics with 100-300 µm in length. ATR-FTIR and Raman spectroscopy revealed polyethylene as prevalent polymer. Surface degradations and adsorption of contaminants on microplastic surface were investigated by SEM-EDX analysis. Presence of hazardous polymers influenced high polymer hazard index and potential ecological risk index which indicated acute environmental threat to Sundarbans estuary and its resident organisms. Current study will provide a new information base on the abundance of microplastics and its ecological hazard in this biosphere reserve.

Mediation of Successful Reperfusion Effect through Infarct Growth and Cerebral Edema: A Pooled, Patient-Level Analysis of EXTEND-IA Trials and SELECT Prospective Cohort.

OBJECTIVE: Reperfusion therapy is highly beneficial for ischemic stroke. Reduction in both infarct growth and edema are plausible mediators of clinical benefit with reperfusion. We aimed to quantify these mediators and their interrelationship. METHODS: In a pooled, patient-level analysis of the EXTEND-IA trials and SELECT study, we used a mediation analysis framework to quantify infarct growth and cerebral edema (midline shift) mediation effect on successful reperfusion (modified Treatment in Cerebral Ischemia ≥ 2b) association with functional outcome (modified Rankin Scale distribution). Furthermore, we evaluated an additional pathway to the original hypothesis, where infarct growth mediated successful reperfusion effect on midline shift. RESULTS: A total 542 of 665 (81.5%) eligible patients achieved successful reperfusion. Baseline clinical and imaging characteristics were largely similar between those achieving successful versus unsuccessful reperfusion. Median infarct growth was 12.3ml (interquartile range [IQR] = 1.8-48.4), and median midline shift was 0mm (IQR = 0-2.2). Of 249 (37%) demonstrating a midline shift of ≥1mm, median shift was 2.75mm (IQR = 1.89-4.21). Successful reperfusion was associated with reductions in both predefined mediators, infarct growth (ß = -1.19, 95% confidence interval [CI] = -1.51 to -0.88, p < 0.001) and midline shift (adjusted odds ratio = 0.36, 95% CI = 0.23-0.57, p < 0.001). Successful reperfusion association with improved functional outcome (adjusted common odds ratio [acOR] = 2.68, 95% CI = 1.86-3.88, p < 0.001) became insignificant (acOR = 1.39, 95% CI = 0.95-2.04, p = 0.094) when infarct growth and midline shift were added to the regression model. Infarct growth and midline shift explained 45% and 34% of successful reperfusion effect, respectively. Analysis considering an alternative hypothesis demonstrated consistent results. INTERPRETATION: In this mediation analysis from a pooled, patient-level cohort, a significant proportion (~80%) of successful reperfusion effect on functional outcome was mediated through reduction in infarct growth and cerebral edema. Further studies are required to confirm our findings, detect additional mediators to explain successful reperfusion residual effect, and identify novel therapeutic targets to further enhance reperfusion benefits. ANN NEUROL 2023;93:793-804.

A comparative account of coelomocyte of earthworm ecotypes with reference to its morphology, morphometry, density, phagocytosis, autofluorescence, and oxidative status.

Earthworms inhabit different strata of moist soil. Epigeic and endogeic earthworms prefer superficial and inner stratum of soil respectively, whereas, semiaquatic species are distributed around hydrated soil near ponds and lakes. Coelomocytes, the chief immunoeffector cells of coelomic origin, perform diverse physiological functions like phagocytosis, maintenance of cellular homeostasis, and acid-base balance of coelomic fluid, graft rejection, elicitation of cytotoxic, and oxidative responses under the challenges of pathogens and toxins. The present study aims to analyze selected morphological and functional parameters in three differentially adapted Indian earthworms of nonsimilar habitats. Coelomocytes of Glyphidrilus tuberosus (Stephenson, 1916) (semiaquatic), Perionyx excavatus (Perrier, 1872) (epigeic), and Eutyphoeus orientalis (Beddard, 1883) (endogeic) were isolated for morphological and morphometric analyses and subjected to determination of phagocytic, oxidative, and cytotoxic responses. Activities of phenoloxidase, pro, and antioxidant enzymes, and autofluorescence were determined in the extruded coelomocytes of earthworms of three contrasting habitats. The differential result may be correlated with species-specific responses and variation in habitat preference and related adaptation.

En Plaque Meningiomas: A Narrative Review.

Background En plaque meningiomas are a rare subtype of meningiomas that are frequently encountered in the spheno-orbital region. Characterized by a hyperostotic and dural invasive architecture, these tumors present unique diagnostic and treatment considerations. Objective The authors conduct a narrative literature review of clinical reports of en plaque meningiomas to summarize the epidemiology, clinical presentation, diagnostic criteria, and treatment considerations in treating en plaque meningiomas. Additionally, the authors present a case from their own experience to illustrate its complexity and unique features. Methods A literature search was conducted using the MEDLINE database using the following terminology in various combinations: meningioma , meningeal neoplasms, en plaque , skull base , spheno-orbital, and sphenoid wing . Only literature published in English between 1938 and 2018 was reviewed. All case series were specifically reviewed for sufficient data on treatment outcomes, and all literature was analyzed for reports of misdiagnosed cases. Conclusion En plaque meningiomas may present with a variety of symptoms according to their location and degree of bone invasion, requiring a careful diagnostic and treatment approach. While early and aggressive surgical resection is generally accepted as the optimal goal of treatment, these lesions require an individualized approach, with further investigation needed regarding the role of new therapies.

Management of giant prolactinoma causing craniocervical instability: illustrative case.

BACKGROUND: Giant prolactinomas (>4 cm) are a rare entity, constituting less than 1% of all pituitary tumors. Diagnosis can usually be achieved through endocrinological analysis, but biopsy may be considered when trying to differentiate between invasive nonfunctioning pituitary adenomas and primary clival tumors such as chordomas. OBSERVATIONS: The authors presented a rare case of a giant prolactinoma causing significant clival and occipital condyle erosion, which led to craniocervical instability. They provided a review of the multimodal management. Management involved medical therapy with dopamine agonists, and surgery was reserved for acute neural compression or dopamine agonist resistance, with the caveat that surgery was extremely unlikely to lead to normalization of serum prolactin in dopamine agonist-resistant tumors. LESSONS: Adjunctive surgical therapy may be necessary in cases of skull base erosion, particularly when erosion or pathological fractures involve the occipital condyles. Modern posterior occipital-cervical fusion techniques have high rates of arthrodesis and can lead to symptomatic improvement. This procedure should be considered early in the multimodal approach to giant prolactinomas because of the often dramatic response to medical therapy and potential for further craniocervical instability.

A Comprehensive Multicomponent Neurosurgical Course with use of Virtual Reality: Modernizing the Medical Classroom.

OBJECTIVE: Surgical education has constantly evolved and has been recently severely impacted by the COVID-19 pandemic. While virtual reality (VR) has been utilized for resident training and neuroanatomy education, application of VR has been limited for neurosurgical education in medical school. This is the first report of a comprehensive, multicomponent teaching model with VR as a primary component to neurosurgical and neuroanatomy education for pre-clerkship medical students. DESIGN: Twelve second-year medical students were included in this prospective survey study that was conducted to evaluate a year-long neurosurgery elective course with an interactive VR platform as a primary teaching tool for neuroanatomy and neurosurgical procedures. The course had 4 components: (1) didactic/lecture-based learning, (2) problem-based learning, (3) hands-on skills lab, and (4) VR-based learning through Surgical Theater's Precision VR visualization platform. Outcome measures were based on confidence levels measured on pre- and post-course competency confidence surveys in students' ability to identify neuroanatomical structures, interpret neuroradiological imaging, and analyze neurosurgical cases, and student feedback on their experience with VR on a postcourse survey. SETTING: The survey study was conducted in the neurosurgery library and conference room at University Hospitals Cleveland Medical Center in Cleveland, Ohio, USA. PARTICIPANTS: All 12 second-year medical students who enrolled in the neurosurgery zero-credit hour course completed the course. RESULTS: At course conclusion, 100% of students reported significantly higher competency confidence levels on all topics, and 100% agreed utilizing VR helped them gain a deeper understanding of neuroanatomy/neurosurgery. 92% agreed that using VR helped them better retain the anatomical/functional details of the brain/spine, and 69% better understand neurosurgical skills taught, respectively. 100% of students found the course to be a valuable learning experience and VR a useful learning tool. CONCLUSION: A comprehensive multi-component neurosurgery elective course using VR as a primary teaching tool may improve neurosurgical education in medical school.

A case for palliative dermatology: COVID-19-related dermatoses.

The unprecedented coronavirus disease 2019 (COVID-19) pandemic has challenged health care systems in different ways. In the United Kingdom, various subspecialties are deployed to the wards to help medical workforce in the frontlines, with dermatologists helping with general medical wards and on-calls. We present a case of COVID-19-related urticaria manifesting in a palliative setting and responding well to systemic antihistamine. This pandemic has highlighted a new subspecialty that should be explored and researched-palliative dermatology-bridging elements of dermatology with the concepts of palliative medicine. As dermatologists, we should be in the position to help with the last stages of a patient's journey.

Effects of copper oxide nanoparticle on gill filtration rate, respiration rate, hemocyte associated immune parameters and oxidative status of an Indian freshwater mussel.

Waterbodies of India support a wide range of molluscs including Lamellidens marginalis, a pearl forming edible mussel of ecological significance. Report of copper oxide nanoparticle toxicity in Indian molluscs is limited in scientific literature. L. marginalis is a gill respiring filter feeder, which is toxicologically vulnerable to exposure of copper oxide nanoparticles liberated from electrical, textile and polymer industries. Experimental exposure of copper oxide nanoparticles for 7 days yielded a decrease in gill filtration rate, respiration rate, total count and phagocytic response of hemocytes, the chief immunoeffector cells of L. marginalis. Nanoparticle exposure resulted in decrease of phagocytic response of mussel hemocytes. Decrease in nitric oxide generation and phenoloxidase activity were recorded in L. marginalis exposed to 0.5, 1 and 5 mg copper oxide nanoparticles per litre of water for 7 and 14 days. Superoxide anion generation in hemocytes was increased under the exposure of copper oxide nanoparticles. Increase in superoxide anion and decrease in the activities of superoxide dismutase and catalase were indicative to oxidative stress in mussels. Copper oxide nanoparticle induced shift in filtration and respiration rate along with the hemocyte associated immune parameters were suggestive to an acute immunophysiological stress in L. marginalis. We estimated the functional performance of gill and physiological status of aquatic respiration in L. marginalis exposed to copper oxide nanoparticles. A parallel set of estimation of each parameter was carried out in L. marginalis exposed to identical copper sulphate concentrations to record and compare the ionic toxicity of copper in the same specimen.

Shift in phagocytosis, lysosomal stability, lysozyme activity, apoptosis and cell cycle profile in the coelomocytes of earthworm of polluted soil near a tannery field of India.

Calcutta Leather Complex of the state of West Bengal, India has been designated as an industrially active zone with around 400 active tannery units. This area spanning 4.5 km2 is surrounded by human habitation. The soil of this region is contaminated with metal pollutants and exhibited an alteration in selected physicochemical parameters, namely cation exchange capacity, moisture content, pH, total nitrogen, total organic carbon and water holding capacity. Metaphire posthuma, a common variety of endogeic earthworm inhabiting this region is thus continuously exposed to these toxic metals. Coelomocytes, the chief immune effector cells of earthworm presented a shift in phagocytosis, lysosomal membrane stability, lysozyme and phosphatase activity, physiological apoptosis and cell cycle profile of M. posthuma sampled from the soil of tannery industry. Presence of high concentration of toxic metals and change in the physicochemical characteristics of soil led to a state of cellular stress and immunocompromisation in M. posthuma, a common inhabitant of soil of this region. Experimental endpoints bear ecotoxicological significance as biomarkers of physiological stress in earthworm for monitoring the health of soil around this tannery industrial zone.

Analysis of oxidative stress and cellular aggregation in the coelomocytes of earthworms collected from metal contaminated sites of industrial and agricultural soils of West Bengal, India.

Endogeic earthworm Metaphire posthuma (Valliant, 1868) is a common biological component of the tropical soil of India and other countries. The species is reported to influence fertility and porosity of soil and bear a high composting potential. Intensive agricultural, industrial, and mining activities increase the amount of toxic metals in soil causing physiological adversity in earthworm and other biotic components in soil. Coelomocytes, the chief immunoeffector cells of earthworm, perform diverse physiological functions under the challenge of toxins and pathogens. The experimental earthworms collected separately from soils with agricultural and tannery activities were subjected to quantitation of prooxidation and antioxidation parameters for estimation of oxidative stress. Total count, cellular aggregation, generation of reactive oxygen species (ROS), superoxide anion, nitric oxide, activities of phenoloxidase, superoxide dismutase, catalase and glutathione-s-transferase, and amount of total protein were estimated in the coelomocytes of M. posthuma as experimental end points of toxicity screening. Concentrations of cadmium, chromium, lead, and mercury were determined in the soil samples to assess the degree of toxic contamination. The increase in the amount of prooxidants and decrease in the activities of antioxidant enzymes indicated the signs of oxidative stress in the coelomocytes of the organism. Aggregation of circulating coelomocytes is considered as an immune response involved in pathogen encapsulation response as reported in many invertebrates. Decrease in coelomocyte aggregation in earthworm collected from contaminated sites suggested a state of inappropriate shift of the innate immune status. Toxin-induced oxidative stress and reductions in cell aggregation response are the signs of immunocompromisation of M. posthuma. Present findings bear a prospect of this experimental species as an indicator of soil pollution.

Resection of 2 Intradural Extramedullary Cervical Spine Tumors in a Patient With Neurofibromatosis Type 2: 3-Dimensional Operative Video.

This 3-dimensional operative video illustrates resection of 2 cervical spine schwannomas in a 19-yr-old female with neurofibromatosis type 2. The patient presented with lower extremity hyperreflexity and hypertonicity. Magnetic resonance imaging (MRI) demonstrated 2 contrast-enhancing intradural extramedullary cervical spine lesions causing spinal cord compression at C4 and C5. The patient underwent a posterior cervical laminoplasty with a midline dural opening for tumor resection. Curvilinear spine cord compression is demonstrated in the operative video. After meticulous dissection, the tumors were resected without complication. The dural closure was performed in watertight fashion followed by laminoplasty using osteoplastic titanium miniplates and screws. Postoperative MRI demonstrated gross total resection with excellent decompression of the spinal cord. The postoperative course was uneventful. The natural history of this disease, treatment options, and potential complications are discussed.

Resection of a Lumbar Intradural Extramedullary Schwannoma: 3-Dimensional Operative Video.

This 3-dimensional operative video illustrates resection of a lumbar schwannoma in a 57-yr-old female who presented with right lower extremity numbness, paresthesias, as well as a long history of lower back pain with rest. On magnetic resonance imaging (MRI), there was evidence of an intradural extramedullary enhancing lesion at L5, nearly completely encompassing the spinal canal. This video demonstrates the natural history, treatment options, surgical procedure, risks, and complications of treatment of these types of tumors. The patient underwent a posterior lumbar laminectomy with a midline dural opening for tumor resection. The tumor was encountered intradurally and electromyography recording confirmed that the tumor arose from a lumbar sensory nerve root. The sensory root was then divided and the tumor was then removed. The mass was removed en bloc and histopathologic analysis was consistent with a schwannoma. Postoperative MRI demonstrated gross total resection of the patient's neoplasm with excellent decompression of the spinal cord. The patient had an uneventful postoperative course with full recovery and complete resolution of her back pain and leg paresthesias.

Immunotoxicity of copper nanoparticle and copper sulfate in a common Indian earthworm.

Copper oxide nanoparticles and copper sulfate are established contaminants of water and soil. Metaphire posthuma is a common variety of earthworm distributed in moist soil of Indian subcontinent. Comparative toxicity of copper nanoparticles and copper sulfate were investigated with reference to selected immune associated parameters of earthworm. Total count, phagocytic response, generation of cytotoxic molecules (superoxide anion, nitric oxide), activities of enzymes like phenoloxidase, superoxide dismutase, catalase, acid phosphatase, alkaline phosphatase and total protein of coelomocytes were estimated under the exposures of 100, 500, 1000mg of copper oxide nanoparticles and copper sulfate per kg of soil for 7 and 14 d. A significant decrease in the total coelomocyte count were recorded with maximum depletion as 15.45 ± 2.2 and 12.5 ± 2 × 104 cells/ml under the treatment of 1000mg/kg of copper nanoparticles and copper sulfate for 14 d respectively. A significant decrease in generation of nitric oxide and activity of phenoloxidase were recorded upon exposure of both toxins for 7 and 14 d indicating possible decline in cytotoxic status of the organism. A maximum inhibition of superoxide dismutase activity was recorded as 0.083 ± 0.0039 and 0.055 ± 0.0057 unit/mg protein/minute against 1000mg/kg of copper nanoparticles and copper sulfate treatment for 14 d respectively. Activities of catalase and alkaline phosphatase were inhibited by all experimental concentrations of both toxins in the coelomocytes of earthworm. These toxins were recorded to be modifiers of the major immune associated parameters of M. posthuma. Unrestricted contamination of soil by sulfate and oxide nanoparticles of copper may lead to an undesirable shift in the innate immunological status of earthworm leading to a condition of immune compromisation and shrinkage in population density of this species in its natural habitat. This article is the first time report of immunological toxicity of nanoparticles and sulfate salt of copper in M.posthuma inhabiting the soil of India, an agriculture based country.

Verapamil-induced breakdown of the blood-brain barrier presenting as a transient right middle cerebral artery syndrome.

A middle-aged patient presented for elective embolization of an incidentally found right internal carotid aneurysm. An angiogram was performed, during which the left internal carotid artery was visualized to evaluate a second, small aneurysm. During the embolization of the right internal carotid artery aneurysm, a catheter-induced vasospasm was identified that prompted treatment with intra-arterial verapamil. The procedure was uncomplicated; a postoperative rotational flat-panel computed tomography scan was performed on the angiography table that demonstrated right hemisphere contrast staining. The patient developed a right middle cerebral artery (MCA) syndrome after extubation with repeat cerebral angiography negative for occlusion and magnetic resonance imaging negative for stroke. The patient was observed for 48 hours, during which time the patient had slowly improved. At a six-week follow up visit, the patient had fully recovered. We present an interesting case of a verapamil-induced breakdown of the blood-brain barrier and self-limited right MCA syndrome.

Utilization of sinus stents as a novel approach for benign cystic lesions of the sella.

Steroid-releasing sinus stents have emerged as a safe and effective tool in endoscopic sinus surgery. In this case report, we present two patients with recurrent cystic sellar masses. Transsphenoidal approach was used to access the sella. Following resection and drainage of the cystic pathology, a Propel (Menlo Park, CA) stent was placed through the corridor of the resection site to stent the cavity open. This is the first report where a steroid-releasing sinus stent was used in the treatment of a sellar lesion. It supports that this technology is safe and effective for use in skull base surgery.

Contemporary management of carotid blowout syndrome utilizing endovascular techniques.

OBJECTIVES/HYPOTHESIS: To illustrate complex interdisciplinary decision making and the utility of modern endovascular techniques in the management of patients with carotid blowout syndrome (CBS). STUDY DESIGNS: Retrospective chart review. METHODS: Patients treated with endovascular strategies and/or surgical modalities were included. Control of hemorrhage, neurological, and survival outcomes were studied. RESULTS: Between 2004 and 2014, 33 patients had 38 hemorrhagic events related to head and neck cancer that were managed with endovascular means. Of these, 23 were localized to the external carotid artery (ECA) branches and five localized to the ECA main trunk; nine were related to the common carotid artery (CCA) or internal carotid artery (ICA), and one event was related to the innominate artery. Seven events related to the CCA/ICA or innominate artery were managed with endovascular sacrifice, whereas three cases were managed with a flow-preserving approach (covered stent). Only one patient developed permanent hemiparesis. In two of the three cases where the flow-preserving approach was used, the covered stent eventually became exposed via the overlying soft tissue defect, and definitive management using carotid revascularization or resection was employed to prevent further hemorrhage. In cases of soft tissue necrosis, vascularized tissues were used to cover the great vessels as applicable. CONCLUSIONS: The use of modern endovascular approaches for management of acute CBS yields optimal results and should be employed in a coordinated manner by the head and neck surgeon and the neurointerventionalist. LEVEL OF EVIDENCE: 4. Laryngoscope, 2016 127:383-390, 2017.

Intraventricular thrombolysis after endovascular treatment of a ruptured arteriovenous malformation.

Intraventricular haemorrhage (IVH) secondary to arteriovenous malformation (AVM) rupture carries significant morbidity and mortality. External ventricular drainage of IVH is frequently complicated by thrombus formation within the ventricular catheter and therefore often unsuccessful at treating hydrocephalus in this setting. Intraventricular administration of recombinant tissue-type plasminogen activator (rtPA) has proved successful in the treatment of spontaneous panventricular haemorrhage. However, usage of rtPA is contraindicated in the setting of a ruptured AVM or aneurysm in which the bleeding source has not been secured. There are only a few reports of intraventricular thrombolysis in the treatment of IVH from AVM rupture. We present the case of successful application of rtPA to treat IVH after endovascularly securing the haemorrhage site of the AVM. Intraventricular thrombolysis remains an option for the treatment of IVH in the setting of AVM rupture and should be considered on a case-by-case basis.

Intraventricular thrombolysis after endovascular treatment of a ruptured arteriovenous malformation.

Intraventricular haemorrhage (IVH) secondary to arteriovenous malformation (AVM) rupture carries significant morbidity and mortality. External ventricular drainage of IVH is frequently complicated by thrombus formation within the ventricular catheter and therefore often unsuccessful at treating hydrocephalus in this setting. Intraventricular administration of recombinant tissue-type plasminogen activator (rtPA) has proved successful in the treatment of spontaneous panventricular haemorrhage. However, usage of rtPA is contraindicated in the setting of a ruptured AVM or aneurysm in which the bleeding source has not been secured. There are only a few reports of intraventricular thrombolysis in the treatment of IVH from AVM rupture. We present the case of successful application of rtPA to treat IVH after endovascularly securing the haemorrhage site of the AVM. Intraventricular thrombolysis remains an option for the treatment of IVH in the setting of AVM rupture and should be considered on a case-by-case basis.