Artificial intelligence improves transfer times and ischemic stroke workflow metrics.

INTRODUCTION: Rapid initiation of mechanical thrombectomy (MT) for the treatment of large-vessel occlusion (LVO) critically improves patient outcomes. Artificial intelligence algorithms aid in the identification of LVOs and improve door to puncture times as well as patient transfer times. OBJECTIVES: We aimed to determine whether the implementation of an LVO detection algorithm that provides immediate active notification to the thrombectomy team provider's cell phone would improve ischemic stroke workflow at our institution and aid in patient transfer from outlying hospitals when compared to our prior system of passive computed tomography perfusion software analysis and radiologist interpretation and notification. METHODS: A retrospective review of our institutional thrombectomy registry was performed for all patients who underwent MT between January 2020 and March 2022. Demographic, radiographic, and stroke workflow metrics and notification times were collected. Transfer times and stroke metrics were compared pre- and post-implementation of the Viz.ai (Viz.ai, San Francisco, California, USA) smartphone application. RESULTS: Two hundred sixty-two patients underwent MT during the study period. Door-to-puncture time decreased 15 min (p = 0.009) after the implementation of Viz.ai at our Comprehensive Stroke Center. Transfer time from outside hospitals that implemented Viz.ai was reduced by 37 min (p = 0.04). There was no significant change in transfer time over the same time period in outlying hospitals that did not implement the Viz.ai software. CONCLUSION: Active notification of the neurosurgical team significantly reduces patient transfer time and initiation of MT.

Cerebrospinal Fluid Leakage from Scrotum Secondary to Ventriculoperitoneal Shunt Migration.

Ventriculoperitoneal (VP) shunts are a common neurosurgical procedure used to treat hydrocephalus. Despite their efficacy, many shunts fail and require revisions. The most common causes of shunt failure include obstruction, infection, migration, and perforation. Extraperitoneal migrations require urgent attention. We present a case of migration to the scrotum, a unique complication that may be present in young patients due to the presence of a patent processus vaginalis. Here, we discuss a case of a 16-month-old male patient with a VP shunt presenting with cerebrospinal fluid (CSF) drainage from his scrotum after an indirect hernia repair. This case represents an important reminder for physicians about the sequelae associated with VP shunt complications, particularly extraperitoneal migration, and brings awareness to the underlying factors that may increase this risk.

Incidence of mechanical thrombectomy among stroke patients brought directly to a comprehensive stroke center versus transfer from a primary stroke center in upstate New York.

BACKGROUND: Faster time to treatment for stroke is associated with improved outcomes. In cases of large vessel occlusion (LVO), standard of care treatment with thrombectomy can only be provided at a comprehensive stroke center (CSC). We examine the outcomes of patients who are directly brought to our center, a CSC, compared to those seen at a primary stroke center (PSC) and then transferred. METHODS: Patients with LVO presenting to our center from 1/1/2019 to 12/31/2019 were included. Cohorts of patients presenting first to a PSC and presenting first to a CSC were compared. Demographics and outcome metrics (Discharge Modified Rankin Scale (mRS) and National Institute of Health Stroke Severity Scale (NIHSS) scores) were obtained for all LVO patients. Imaging was also assessed. RESULTS: Of 864 stroke admissions, 346 had LVO (40%) with 183 (53%) transferring from a PSC and 163 (47%) presenting directly. Similar percentages of each cohort were taken for thrombectomy (25.1% transfer and 31.3% direct). However, as distance between PSC and CSC increased, likelihood of thrombectomy decreased. Transfer patients were more likely to be excluded from thrombectomy secondary to a large volume of complete stroke (p = 0.0001). Direct presenters had lower discharge mRS scores than transfer patients (p < 0.01), however, severity of stroke upon admission was similar in the two groups. CONCLUSION: Patients transferred from a PSC were more likely to have a worse outcome at time of discharge than those presenting directly to our center. Large volume of completed stroke was a frequent reason for exclusion from thrombectomy. Optimizing stroke protocols to CSC in cases of LVOs may result in better outcomes.

Risk of Neurological Decline in Patients With Temporal Lobe Brain Masses.

AIM: The objective of this study was to assess which clinical and radiographic findings may be associated with neurological decline in patients with temporal lobe mass lesions. PATIENTS AND METHODS: This represents a retrospective cohort study. Neurological decline was defined as a decline in Glasgow Coma Scale of 2 or more or new anisocoria. Adult patients aged 18 to 89 years with isolated temporal lobe, intra-axial, contrast-enhancing masses diagnosed between 1/1/2010 and 12/31/2020 were included. Clinical and radiographic findings were collected for each patient. Linear regression analysis was used to identify findings predictive of neurological decline. Patients with neurological decline were compared to stable patients to identify factors that may increase risk for neurological decline. RESULTS: A total of 71 patients met the inclusion criteria. Four out of the 71 patients experienced neurological decline, representing an incidence of 6%. Linear regression analysis identified only radiographic transtentorial herniation as a predictor of neurological decline (ß=0.26, p=0.03). A midline shift greater than 5 mm (100% vs. 40%; odds ratio=1.12, 95% confidence interval=1.00-1.32; p=0.05) and radiographic transtentorial herniation (75% vs. 18%; odds ratio=32.12, 95% confidence interval=3.91-264.18; p=0.03) were significantly more prevalent in patients with neurological decline and were associated with an increased risk of neurological decline. CONCLUSION: Radiographic transtentorial herniation and a midline shift greater than 5 mm may be useful findings to suggest an increased risk of neurological decline in patients with masses of the temporal lobe. This knowledge may be useful to neurosurgeons and physicians in other specialties to best care for this patient population.

Use of intravenous cangrelor in the treatment of ruptured and unruptured cerebral aneurysms: an updated single-center analysis and pooled analysis of current studies.

BACKGROUND: Intracranial stent placement for the treatment of cerebral aneurysms is increasingly utilized in both ruptured and unruptured scenarios. Intravenous (IV) cangrelor is a relatively new antiplatelet agent that was initially approved for coronary interventions. In addition to our institution, five other centers have published their results using IV cangrelor in neurointerventional procedures. This article combines the aneurysm treatment data from all prior studies to provide insight into the safety and efficacy of cangrelor for intracranial aneurysm treatment. METHODS: A prospectively maintained database was reviewed to identify all cases of IV cangrelor administration during aneurysm embolization. 20 additional patients were identified who had not been previously published. In addition, a literature search was performed to identify prior publications regarding cangrelor in neurointervention. The data from these were combined with our institutional results in a pooled-analysis. RESULTS: Overall, 85 patients who received IV cangrelor during aneurysm embolization were identified, including 46 ruptured and 39 unruptured cases. The asymptomatic and symptomatic intracranial hemorrhage rates were 4% (2/46) for ruptured cases and 2.6% (1/39) for unruptured cases. The rate of retroperitoneal hematoma and gastrointestinal bleeding was 0%. There were no incidents of intraprocedural thromboembolic complication or intraprocedural in-stent thrombosis in either cohort. One subject suffered an ischemic stroke at 24 hours secondary to in-stent thrombosis in a ruptured case. CONCLUSIONS: IV cangrelor during aneurysm embolization appears to be safe, with a symptomatic intracranial hemorrhage rate of 4% in ruptured cases and 2.6% in unruptured cases. More research is needed to determine the ideal dosing regimen.

Developing a fast-track discharge protocol for patients with cerebral aneurysms treated via neuroendovascular techniques.

INTRODUCTION: As we emerge from the current pandemic, hospitals, staff, and resources will need to continue to adjust to meet ongoing healthcare demands. Lessons learned during past shortages can be used to optimize peri-procedural protocols to safely improve the utilization of hospital resources. METHODS: Retrospective review of patients who underwent elective endovascular intracranial aneurysm treatment was performed. Multivariable logistic regression was used to identify factors associated with patients who were able to be discharged within 24 h of elective procedures. Rates of complications (particularly readmission) were determined. RESULTS: 330 patients underwent elective endovascular aneurysm treatment with 86 (26.1%) discharged within 24 h. Factors associated with earlier discharge included procedure years (2019-2021) and male sex. Patients were more likely to be discharged later (after 24 h) if they underwent stent-coil embolization or flow-diversion. There was no association between discharge timing and likelihood of readmission. DISCUSSION: Our review highlights the safety of earlier discharge and allowed us to prepare a fast-track protocol for same-day discharge in these patients. This protocol will be studied prospectively in the next phase of this study. As we gain more comfort with emerging, minimally invasive endovascular therapies, we hope to safely achieve same-day discharge on a protocolized and routine basis, reducing the demand of elective aneurysm treatments on our healthcare system. CONCLUSION: We retrospectively demonstrate that early discharge following elective aneurysm treatment is safe in our cohort and provide a fast-track pathway based on these findings for other centers developing similar protocols.

Comparison of hydrogel coils versus bare platinum coils for the treatment of anterior communicating artery aneurysms.

INTRODUCTION: While endovascular coiling has been shown to be a safe treatment option for intracranial aneurysms, there remains concern regarding increased recurrence and retreatment rates. Preliminary studies evaluating hydrogel coated coils have demonstrated decreased recurrence rates compared to bare metal coils. METHODS: A retrospective chart review was done on all patients with anterior communicating artery aneurysms (ACoAAs) treated with endovascular coiling between 2014 and 2018. Treatment groups were divided into hydrogel coated coils or bare metal coils. Patients were categorized into the hydrogel group when ≥ 70% of the coil length was hydrogel coated. RESULTS: Eighty-four ACoAAs were treated with coil embolization between 2014 and 2018. Postoperative imaging was available for 68 patients. Twenty-six patients were categorized into the hydrogel treatment group. Aneurysm recurrence was seen in 7.7% (2/26) of patients treated with hydrogel coated coils compared to 33.3% (14/42) of those treated with bare metal coils (P = 0.03). Subanalysis of patients with ruptured aneurysms revealed decreased recurrence rates in patients treated with hydrogel coated coils at 5.9% (1/17) compared to patients treated with bare metal coils at 39.4% (13/33) (P = 0.01). CONCLUSIONS: Hydrogel-coated coils may reduce recurrence rates in the treatment of both ruptured and unruptured ACoAAs.

Does Pre-existing Anticoagulation or Antiplatelet Therapy Increase the Risk of Traumatic Subarachnoid Hemorrhage Progression?

BACKGROUND: Isolated traumatic subarachnoid hemorrhage (tSAH) is a common finding in mild traumatic brain injury that often results in transfer to a tertiary center. Patients prescribed blood-thinning medications (BTs) are believed to be at higher risk of clinical or radiographic worsening. OBJECTIVE: To compare the rates of radiographic progression and need for neurosurgical intervention in patients with tSAH who are on anticoagulation (AC) and antiplatelet (AP) therapies with those who are not. METHODS: Analysis using a retrospective cohort design identified patients older than 18 years with isolated tSAH and a Glasgow Coma Scale of 15 on admission. Clinical information including use of BTs, administration of reversal agents, radiographic progression, and need for neurosurgical intervention was collected. Patients on BTs were divided into AP, AC, and AP/AC groups based on drug type. RESULTS: Three hundred eighty-four patients were included with 203 in the non-BT group and 181 in the BT group. Overall, 2.1% had worsening scans, and none required operative intervention. There was no difference in radiographic worsening between the non-BT and BT groups (2.4% vs 1.6%; P = 1.00). Crosswise comparison revealed no difference between the non-BT group and each BT subtype (AP, AP/AC, or AC). The non-BT group was more likely to have radiographic improvement than the BT group (45.8% vs 30.9%; P = .002). CONCLUSION: Neurologically intact patients on BTs with isolated tSAH are not at increased risk of radiographic progression or neurosurgical intervention. The presence of BTs should not influence management decisions for increased surveillance.

Utility of 3-dimensionally printed models for parent education in pediatric plagiocephaly.

Objectives: Demonstrate the benefits of using 3D printed skull models when counseling families regarding disorders of the cranial vault (namely plagiocephaly and craniosynostosis), as traditional imaging review and discussion is often insufficient. Methods: 3D printed skull models of a patient with plagiocephaly were used during clinic appointments to aid in the counseling of parents. Surveys were distributed following the appointment to evaluate the utility of these models during the discussion. Results: Fifty surveys were distributed (with a 98% response rate). 3D models were both empirically and anecdotally helpful for parents in understanding their child's diagnosis. Conclusion: Advances in 3D printing technology and software have made producing models more accessible. Incorporating physical, disorder-specific models into our discussions has led to improvements in our ability to communicate with our patients and their families. Innovation: Disorders of the cranial can be challenging to describe to the parents and guardians of affected children; using 3D printed models is a useful adjunct in patient-centered discussions. The subject response to the use of these emerging technologies in this setting suggests a major role for 3D models in patient education and counseling for cranial vault disorders.

Long Segment Anterior Cervical Discectomy and Fusion, Including C2: Surgical Pearls and Review of Our Experience.

STUDY DESIGN: A retrospective study of thirteen patients undergoing 5-level anterior spinal surgery for cervical myelopathy. OBJECTIVE: While limited literature exists in reviewing the treatment of high cervical pathology extending caudally, we believe long segment surgery beginning at C2-3 can be accomplished with good success and is an option more patients may benefit from. We aim to describe the technique in accessing the C2-C3 disk space and efficacy of treating multilevel disease beginning at the C2 vertebral body. This includes an extensive technical report and surgical pearls. SUMMARY OF BACKGROUND DATA: Compression at the level of C2 can be daunting to access because of steep approach required. Few studies have described the technique in reaching the C2 level, with less information describing the efficacy of a 5-level anterior fusion starting at C2. METHODS: Patients who underwent surgery between 2000 and 2016 were identified utilizing the department billing database and ICD codes. Patients age, operative indications, levels treated, length of hospital stay, fusion outcome, and operative complications were explored. Independent analysis of fusion was performed. RESULTS: The average length of hospital stay was 3.9 days. Eight patients reported significant improvement of hand weakness, numbness, and/or gait at 6 months follow-up. The most frequent complication was dysphagia (23%). One patient experienced recurrent symptoms secondary to nonunion, and another patient suffered a postoperative neurological worsening because of anterior spinal artery syndrome. CONCLUSION: This retrospective review discusses the technique to visualize and fully decompress C2-C3 spinal segments. In addition, we explored the efficacy and perioperative risk in long segment anterior cervical discectomy and fusion.

Epidural hematoma from impact while zorbing.

Injuries suffered while participating in extreme sports account for numerous emergency department visits. Isolated head injuries are a common presentation. Zorbing is an activity native to New Zealand. Like many emerging extreme sports there is little information regarding its safety. We conservatively managed a patient who suffered a skull fracture and epidural hematoma while zorbing. Publications (especially in the medical literature) are lacking regarding zorbing-related injuries. We hope that presenting this case will help elucidate the possibility of severe head injury despite the protective bubble offered by the sport.

Characterization of antiplatelet response to low-dose cangrelor utilizing platelet function testing in neuroendovascular patients.

STUDY OBJECTIVES: The optimal antiplatelet therapy for emergent neuroendovascular stenting is uncertain. Cangrelor is an intravenous P2Y12 inhibitor that is an attractive option due its favorable pharmacokinetic profile and ease of measurability but optimal dosing remains unclear. The primary objective of this study is to characterize the dose response of low dose cangrelor (<2 mcg/kg/min) with the utilization of platelet function testing (PFT). DESIGN: A retrospective review of all patients treated with cangrelor for either procedural stenting or bridging was conducted between January 1st, 2019 and October 31st, 2020. Seventy-two patients met inclusion criteria. An in-depth analysis of dose response to low dose cangrelor based on PFT was performed. PATIENTS: Neuroendovascular patients treated with cangrelor. SETTING: Albany Medical Center Hospital. INTERVENTION AND MAIN RESULTS: Patients who underwent procedural stenting were given a bolus of 5 mcg/kg and an initial infusion rate of either 0.75 mcg/kg/min or 1 mcg/kg/min. Patients who were bridged with cangrelor were administered an initial infusion rate of 0.75 mcg/kg/min or 1 mcg/kg/min. Twelve patient's doses were titrated to achieve a platelet reactivity unit (PRU) between 50-150; three patient's doses were titrated multiple times. Based on initial PFT results, utilizing the 1 mcg/kg/min maintenance dose resulted in more patients being in the acceptable (10-180) and desired (50-150) PRU range than the 0.75 mcg/kg/min dose (47% vs 56% and 70% vs 80%, respectively). Final recorded PRU results showed that 64% of patients had PRUs in the optimal range (50-150) and 88% of patients had PRUs in the desire range (10-180). CONCLUSIONS: Utilizing low doses of cangrelor with platelet function testing is an option during emergent neuroendovascular stenting and bridging. Cangrelor demonstrates significant variability in response at low doses and exhibits a dose response relationship when PFT is utilized.

Delayed hypersensitivity reaction to a dural repair substitute.

BACKGROUND: Modern neurosurgeons commonly rely on dural grafts to aid in obtaining watertight closures when the native dura itself cannot be approximated. CASE PRESENTATION: We present a patient who developed a symptomatic, delayed hypersensitivity reaction to a cellulose-based synthetic dural graft, which resolved after reoperation and removal of the graft. DISCUSSION: Dural grafts are a safe and common implant utilized in neurosurgery. Nevertheless, as with all implanted material, there is a chance for symptomatic immune reactions to occur. CONCLUSION: This type of response is exceedingly uncommon, but recognition of this rare presentation may help other providers recognize it in the future.

Stent-in-stent technique for the management of blood blister-like basilar apex aneurysms.

Blood blister-like basilar apex aneurysms are rare thin-walled vascular lesions with a poorly defined aneurysmal neck. We present two patients with ruptured blister aneurysms of the basilar apex who were treated using the stent-in-stent technique. Long-term follow-up showed persistent and complete occlusion of the aneurysms without radiographically or neurological complications. There is no optimal treatment of choice for the basilar apex blood blister-like aneurysms. Double- or triple-stent placement using the stent-in-stent technique can be a safe and feasible option for these uncommon and challenging intracranial aneurysms.

Rare presentation of intradural calcium pyrophosphate dihydrate crystal deposition.

Calcium pyrophosphate dihydrate crystal deposition (CPPD), also known as pseudogout, can have spinal manifestations in roughly one quarter of patients. We present a rare, intradural manifestation of CPPD requiring surgical intervention, with a review of pertinent differential diagnoses on imaging. A 48-year-old male presented with urinary retention, and was found to have an intradural lesion with peripheral enhancement on gadolinium T1-weighted magnetic resonance imaging. Due to the patient's progressive neurological deterioration, he was taken for a minimally invasive approach for resection of the lesion. Histopathological analysis revealed crystal deposits with rhomboidal birefringence consistent with CPPD. The imaging features of this lesion were atypical for any of the traditional intradural extramedullary lesions. Typically seen extradurally, recognizing CPPD as a potential culprit for intradural compression is helpful to recognize for providers.

Use of intravenous cangrelor and stenting in acute ischemic stroke interventions: a new single center analysis and pooled-analysis of current studies.

INTRODUCTION: Emergent stenting of both extra- and intracranial occlusions during acute ischemic stroke procedures is complicated by the need for immediate platelet inhibition to prevent thromboembolic complications. IV cangrelor is a relatively new antiplatelet that was initially approved for coronary interventions. Five prior case series have been published evaluating the results of IV cangrelor in neurointerventional procedures. We sought to combine the data from all prior studies and analyze only ischemic stroke interventions. METHODS: A prospectively maintained database was reviewed to identify all cases of IV cangrelor administration during acute ischemic stroke intervention. Nine additional patients were identified who have not been previously published. In addition, a literature search was performed to identify five prior publications of cangrelor in neurointervention. The data from these was combined with our institution in a pooled-analysis. RESULTS: Overall, 129 patients who received IV cangrelor during an acute ischemic stroke intervention were identified. The asymptomatic intracranial hemorrhage rate was 12.6%(11/87). The symptomatic intracranial hemorrhage rate was 6.2% (8/129). The rate of retroperitoneal hematoma and gastrointestinal bleeding were also low (1.5% and 0.8%, 2/129 and 1/129). There was one case of intraprocedural thromboembolic complication (0.8%) and no cases of intraprocedural in-stent thrombosis(0%). CONCLUSIONS: IV cangrelor during acute ischemic stroke intervention appears to be safe, with a symptomatic intracranial hemorrhage rate of 6.2%. More research is needed to determine the ideal dosing regimen.

Outpatient management of chronic expanding subdural hematomas with endovascular embolization to minimize inpatient admissions during the COVID-19 viral pandemic.

Chronic subdural hematomas are complex collections that usually form after a trauma, particularly in elderly patients. This vulnerable population is at increased risk given the current viral pandemic. We share our experience in managing minimally symptomatic, enlarging subdural collections via middle meningeal embolization through the outpatient setting. This approach minimizes inpatient hospitalizations in hopes or reducing nosocomial spread (e.g., of COVID-19).