Middle Cerebral Artery Stenosis Associated with Moyamoya Pattern Collateralization

Background and Purpose: Moyamoya disease is a well described phenomenon. This pattern of collateralization associated with isolated middle cerebral artery stenosis and the natural history of this entity have not been well described. Methods: Cerebral angiograms and CT angiograms performed between August 2004 and August of 2006 demonstrating moyamoya collateralization were retrospectively reviewed. All cases of middle cerebral artery stenosis associated with a rete pattern of collateralization were included in this series. Demographic, clinical, and angiographic data were obtained. Results: There were three cases of middle cerebral artery stenosis associated with a moyamoya pattern of collateralization. The average age of the patients was 36-years old, 2 were male, and all were Caucasian. All patients presented with ischemic symptoms. The average degree of stenosis was 91%. No stenosis was seen in the supraclinoid internal carotid arteries or elsewhere in the intracranial vasculature. Conclusion: We describe an unusual pattern of anastomosis associated with isolated severe middle cerebral artery stenosis or occlusion in Caucasians

Decline in subarachnoid haemorrhage volumes associated with the first wave of the COVID-19 pandemic

BACKGROUND: During the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study\u27s objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines. METHODS: We conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March-31 May 2020. The prior 1-year control period (1 March-31 May 2019) was obtained to account for seasonal variation. FINDINGS: There was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI -24.3% to -20.7%, p\u3c0.0001). Embolisation of ruptured aneurysms declined with 1170-1035 procedures, respectively, representing an 11.5% (95%CI -13.5% to -9.8%, p=0.002) relative drop. Subgroup analysis was noted for aneurysmal SAH hospitalisation decline from 834 to 626 hospitalisations, a 24.9% relative decline (95% CI -28.0% to -22.1%, p\u3c0.0001). A relative increase in ruptured aneurysm coiling was noted in low coiling volume hospitals of 41.1% (95% CI 32.3% to 50.6%, p=0.008) despite a decrease in SAH admissions in this tertile. INTERPRETATION: There was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction

Abstract 1122‐000163: Stroke Center Accessibility Study in the U.S. Using Geospatial Analysis and Machine Learning

Introduction: Background: Several accrediting bodies certify the level of stroke care hospitals provide. The Joint Commission on Hospital Accreditation (JC) is the largest accrediting body in the United States. There is no open source Geographic Information Systems (GIS) dataset showing the distribution of JC accredited centers by ZIP code. Objective: to create a stroke center accessibility and stroke center desert system using geospatial analysis and machine learning which provides real‐time assessment of stroke center availability, distribution and access to care. Methods: Geospatial data layers of JC accredited stroke centers were compiled using data sources including U.S. Census Bureau and CDC. Map layers corresponding to the levels of JC accredited stroke hospitals geolocated using ZIP code were created as follows: 1) Acute Stroke Ready 2) Primary 3) Thrombectomy Capable 4) Comprehensive Stroke Center. A GIS dataset displaying stroke mortality by region was obtained from the ArcGIS Living Atlas. Stroke center deserts are analyzed using a 4.5 hour drive map along with population and diversity. Machine learning models were implemented to estimate stroke mortality as a function of distance to care centers and capability levels of the stroke centers. Results: Stroke centers are highly concentrated within large urban centers. There are geographic regions that have poor access to stroke centers. Such regions include the Gulf Coast States of Louisiana, Mississippi, and Alabama that have large areas with poor stroke center access while having some of the highest stroke mortality in the country. (Figure 1 ‐ Stroke Center Distribution in the United States) Dot Symbols: Blue = Acute Stroke Ready; Green = Primary; Yellow = Thrombectomy Capable; Red = Comprehensive Raster Data: Stroke Mortality by ZIP Code; White to Purple Scale with Purple = Highest Mortality Conclusions: There are regional variations in stroke center availability. There are certain regions with high stroke mortality with very little stroke center access. Geospatial AI tools can be utilized to improve stroke systems of care

Abstract Number ‐ 214: Woven EndoBridge in Conjunction with Coiling: Novel Technique for Treatment of a Large Basilar‐tip Aneurysm

Introduction Basilar tip aneurysmscan bechallenging to treatgiven their location andoftencomplex geometryand size.Endovascular coilinghas historically been the standardoftreatmentfor less complex aneurysms, proving to bebothsuccessfulandsafe.However, recanalization ratesfor large and giant aneurysmshave beenunacceptably high.More recently, devicessuch asthe Woven EndoBridge (WEB) have been developed toreduce the rate of recanalization.Here we describea uniquecase of alarge basilar tip aneurysm that was treated withcombination oftheWEBdeviceandcoilembolizationsimultaneously. Methods Case report. Results A woman in her fifties presented with several days of headache, nausea and vomiting, vision changes, and unsteady gait. MRA of the brain visualized a large unruptured basilar tip saccular aneurysm which was confirmed via a diagnostic cerebral angiogram (size: 12.9×11.2×14.0 mm, neck: 4.5 mm) [Figure 2A]. Given the sizeand locationof the aneurysm,we attempted embolization with the largest available WEBSLdevice. This device was undersized for the aneurysm.We therefore utilized a novel combinationcoiling,to partially fill the dome and posterior aneurysm sac,and the largest WEB SL available (11×9 mm). Using a radial system, the WEB device was partly unsheathed at the base of the aneurysm. Then, using a femoral system three coils (18 Hydroframe 28cm 7mm, 18 Hydroframe 15cm 7mm 10, 10 Hydroframe 23cm 7mm) were introduced into the remaining space of the aneurysm, filling the void between the aneurysm dome and the partly deployed WEB SL device. Once all coils were appropriately placed and stable, the WEB device was fully deployed, which lead to successful embolization and occlusion of the aneurysm [Figure 2B]. Conclusions The challenge of treatinglargebasilar tip aneurysmshasencouragedthedevelopment of innovative devices and novel interventional techniques.Here we demonstratethepossibility ofcombiningaWEBdevicewith standard coilingto treatlarge, wide‐necked basilar tip saccularaneurysms that are not ideal candidates for standard therapy

Treatment of vertebral artery origin stenosis with anti-proliferative drug-eluting stents

Vertebral artery origin stenosis is a known cause of stroke that is treatable with angioplasty and stenting. Previous studies have demonstrated that this technique is safe but is limited by high rates of in-stent stenosis. Anti-proliferative drug-eluting stents are an alternative for reducing in-stent stenosis at the vertebral artery origin. This retrospective study included five consecutive patients treated with anti-proliferative drug-eluting stents. The patients' demographics, indications for treatment, procedural technique, and clinical and radiographic follow-up are presented along with a review of the literature. No peri-procedural complications occurred. One patient had a transient ischemic attack (TIA) during the follow-up period. No patients had hemodynamically significant (>50%) in-stent stenosis at follow-up. Among the 287 cases reported in the literature, there were two strokes (.7%), four TIAs (1.4%), and no procedurally related deaths. Among patients undergoing angiographic follow-up, 26% were found to have >50% in-stent stenosis. Anti-proliferative drug-eluting stents hold promise for reducing in-stent stenosis at the vertebral artery origin

Ipsilateral Infarct in Newly Diagnosed Cervical Internal Carotid Artery Atherosclerotic Occlusion

OBJECTIVE: We aimed to determine factors associated with recent infarct (RI) in patients with newly identified atherosclerotic cervical internal carotid artery occlusion (CICAO). METHODS: This was a retrospective review of consecutive patients who underwent cervical CT angiography from 2002 to 2006 at a single tertiary center. RI was defined by positive diffusion-weighted imaging/apparent diffusion coefficient magnetic resonance imaging (MRI) in the correspondent CICAO territory. Subjects were dichotomized into those with a RI versus patients with no RI (No-RI). RESULTS: Of 2,459 patients with cervical CT angiograms in the study period, 108 (4.4%) had complete medical records and brain MRI and were included. The mean age was 64 ± 13 years, 58% were men, and 62 (57%) had a RI. The demographics of the RI and No-RI patients were comparable, with the exception that those with RI had a lower frequency of coronary artery disease (CAD, 13 vs. 54%; p < 0.01) and dyslipidemia (38 vs. 69%; p < 0.01). The use of antiplatelets was not statistically different between the groups (56 vs. 71%; p = 0.1). Subjects with RI were less likely on statins (21 vs. 56%; p < 0.01) and antihypertensives (9 vs. 71%; p < 0.01). Multivariate regression revealed that CAD, the use of statins, and the use of antihypertensives were associated with No-RI CICAO presentation. CONCLUSION: The use of statins and antihypertensives is associated with a decreased risk of RI atherosclerotic CICAO