Delayed presentation of acute ischemic strokes during the COVID-19 crisis

This article is made available for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.Background: The COVID-19 pandemic has disrupted established care paths worldwide. Patient awareness of the pandemic and executive limitations imposed on public life have changed the perception of when to seek care for acute conditions in some cases. We sought to study whether there is a delay in presentation for acute ischemic stroke patients in the first month of the pandemic in the US. Methods: The interval between last-known-well (LKW) time and presentation of 710 consecutive patients presenting with acute ischemic strokes to 12 stroke centers across the US were extracted from a prospectively maintained quality database. We analyzed the timing and severity of the presentation in the baseline period from February to March 2019 and compared results with the timeframe of February and March 2020. Results: There were 320 patients in the 2-month baseline period in 2019, there was a marked decrease in patients from February to March of 2020 (227 patients in February, and 163 patients in March). There was no difference in the severity of the presentation between groups and no difference in age between the baseline and the COVID period. The mean interval from LKW to the presentation was significantly longer in the COVID period (603±1035 min) compared with the baseline period (442±435 min, P<0.02). Conclusion: We present data supporting an association between public awareness and limitations imposed on public life during the COVID-19 pandemic in the US and a delay in presentation for acute ischemic stroke patients to a stroke center

The contralateral transcingulate approach: operative technique and results with vascular lesions

BACKGROUND: The contralateral transcingulate approach is a variation of the contralateral transcallosal approach for lesions located in the cingulate gyrus and deep white matter of the medial frontal lobe. OBJECTIVE: To more thoroughly describe the contralateral transcingulate approach by reporting our operative technique and results. METHODS: This approach positions the head with the midline horizontally, lesion on the upside, allowing gravity retraction of the dependent frontal lobe. Bifrontal craniotomy and splitting of the interhemispheric fissure create a crossing trajectory from the contralateral fissure to the ipsilateral cingulate gyrus that maximizes lateral exposure. RESULTS: Eleven patients with vascular lesions were treated with the contralateral transcingulate approach (9 patients with cavernous malformations and 2 patients with arteriovenous malformations). Eight lesions were located on the left side, 5 in the cingulate gyrus, and 6 in the deep frontal lobe. The falx was cut in 5 patients to extend the crossing trajectory. All lesions were removed completely, with neurological morbidity in 1 patient caused by venous infarction. CONCLUSION: Although similar to the contralateral transcallosal approach, the contralateral transcingulate approach accesses lesions outside the ventricle and has a steeper crossing trajectory. This approach requires no disruption of brain tissue with lesions on the cingulate surface and only a small incision in cingulate gyrus with lesions in the deep frontal lobe. The ipsilateral pericallosal and callosomarginal arteries provide dependable landmarks for transcingulate dissection. The contralateral transcingulate approach offers an alternative medial approach to lesions near language and motor areas and avoids lateral transcortical approaches, awake speech mapping, and risk to eloquent cortex in the dominant hemisphere

Abstract 175: Impact of COVID‐19 on Intracranial Aneurysm Treatment and Outcomes: A Nationwide Propensity Score Matched Study.

Introduction The coronavirus disease 2019 (COVID‐19) pandemic has had a global impact on healthcare systems. There is limited data on the influence of COVID‐19 on treatment and outcomes in patients with intracranial aneurysms. We aimed to investigate the impact of COVID‐19 on the overall complications, including ischemic stroke and subarachnoid hemorrhage (SAH) rates in patients treated for intracranial aneurysms (IAs). Methods This national, multicenter, retrospective cohort study included patients diagnosed and treated for IAs from January 2016 to December 2020 in the National Inpatient Sample (NIS). A total of 57,715 admissions were identified. Of these, 45,979 occurred pre‐COVID and 11,736 during the COVID pandemic period. The outcome data points included the occurrence of postprocedural ischemic strokes or SAHs, death, non‐routine discharge, total charges (US dollars), and length of stay (days). A 1:1 propensity score matching protocol was applied using a K‐nearest neighbor approach to evaluate differences in the outcome data points between the pre‐COVID and during COVID periods. The trends during the study period were assessed using piecewise joinpoint regression with the Mann‐Kendall test. Results Overall, the mean age was 65 years, with most of the patients (69.9%) being females. Endovascular interventions were performed in 82.9% of pre‐COVID IAs admissions compared to 82.4% during the COVID period, while open surgical treatment was performed in 17.1% of pre‐COVID and 17.6% of the patients during COVID (p=0.625). After matching, there were no differences in length of stay (p=0.266), non‐home discharge (p=0.475), and in‐hospital mortality rates (p=0.305) between the two periods; however, the overall complication rate was significantly higher during the pandemic (31.1% vs. 28.3%; p<0.001). From 2016 to 2020, an upward trend in hospitalizations for ischemic stroke was seen among patients treated for IAs (6.1% to 7.9%; p=0.04). No trends were observed with respect to the occurrence of SAH or death (p=0.31). Patients hospitalized after treatment of IAs during the COVID pandemic had significantly higher odds of ischemic strokes (OR 1.13; 95% CI 1.05 to 1.22; p=0.03) but not SAH (OR 0.97; 95% CI 0.88 to 1.06; p=0.89). Conclusion The COVID‐19 pandemic has significantly impacted the healthcare system. In patients receiving treatment for IAs, this analysis noted a correlation between the COVID‐19 pandemic and postoperative complications, notably ischemic strokes. Unraveling the pandemic’s “black box” leads to awareness of plausible breaches within the system, which acts as a crucial component in improving situational readiness and preparedness in the event of similar large‐scale crises

Endoscopic Transforaminal Transchoroidal Approach to the Third Ventricle for Cystic and Solid Tumors

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Abstract 174: Treatment of Unruptured Saccular Aneurysms with PED: A Systematic Review and Meta‐Analysis of Long‐Term Outcomes

Introduction The Pipeline Embolization Device (PED) is commonly used for intracranial aneurysm treatment. While its effectiveness for certain types of aneurysms is well‐established, its efficacy for saccular aneurysms remains debatable. This review and meta‐analysis aimed to assess the long‐term outcomes of PED treatment for unruptured intracranial aneurysms (UIA). Methods A systematic review and meta‐analysis were conducted following PRISMA guidelines. Studies with at least one year of follow‐up after PED treatment for saccular aneurysms were included. The primary endpoint was angiographic complete aneurysm occlusion at long‐term (≥ 12 mo.) follow‐up. Secondary outcomes included long‐term complications. We conducted a meta‐regression analysis to explore the potential sources of heterogeneity across studies. Results Eleven studies on 594 patients with 726 aneurysms were included, of which 5% were previously treated. The mean age was 55.7 years, and 78.3% were women. The mean aneurysm size was 7.72 mm, 8.95% were treated with more than one device, and 2.9% had adjunct coiling. The long‐term complete occlusion rate was 81% (CI 95%: 72% to 88%, p<0.01). Regarding long‐term complications, the rate of symptomatic ischemic stroke was 1% (CI 95%: 0% to 4%, p=0.07), the rate of delayed rupture was 1% (95%, CI 0% to 3%, p=0.02), and the rate of intracranial hemorrhage was 3% (CI 95%: 1% to 6%, p=0.81). The meta‐regression analysis revealed a decreasing trend per year for aneurysmal occlusion, ischemic stroke rate, and aneurysmal rupture rate over time and an increasing trend for ICH over time. Conclusion PED demonstrates high long‐term occlusion and low complication rates, suggesting it is a safe and effective treatment option for unruptured intracranial saccular aneurysms. However, studies with greater than 5‐10 years of follow‐up are needed to evaluate the clinical and radiographical outcomes of incompletely occluded aneurysms Additionally, as newer devices exhibit reduced thrombogenic profiles and ICH rates increase over time, reevaluation of antiplatelet therapy's role, including dosage and DAPT, is warranted

Percutaneous Closure Device for the Carotid artery: An integrated review and design analysis

Endovascular thrombectomies (EVTs) are the current standard of care therapy for treating acute ischemic strokes. While access through the femoral or radial arteries is routine, up to 20% of EVTs through these sites are unable to access the cerebral vasculature on the first pass. These shortcomings are commonly due to tortuous vasculature, atherosclerotic arteries, and type III aortic arch, seen especially in the elderly population. Recent studies have shown the benefits of accessing the cerebral vasculature through a percutaneous direct carotid puncture (DCP), which can reduce the time of the procedure by half. However, current vascular closure devices (VCDs) designed for the femoral artery are not suited to close the carotid artery due to the anatomical differences. This unmet clinical need further limits a DCP approach. Thus, to foster safe adoption of this potential approach, a VCD designed specifically for the carotid artery is needed. In this review, we outline the major biomechanical properties and shortcomings of current VCDs and propose the requirements necessary to effectively design and develop a carotid closure device

Aneurysms with persistent patency after treatment with the Pipeline Embolization Device

The Pipeline Embolization Device (PED) was approved for the treatment of intracranial aneurysms from the petrous to the superior hypophyseal segment of the internal carotid artery. However, since its approval, its use for treatment of intracranial aneurysms in other locations and non-sidewall aneurysms has grown tremendously. The authors report on a cohort of 15 patients with 16 cerebral aneurysms that incorporated an end vessel with no significant distal collaterals, which were treated with the PED. The cohort includes 7 posterior communicating artery aneurysms, 5 ophthalmic artery aneurysms, 1 superior cerebellar artery aneurysm, 1 anterior inferior cerebellar artery aneurysm, and 2 middle cerebral artery aneurysms. None of the aneurysms achieved significant occlusion at the last follow-up evaluation (mean 24 months). Based on these observations, the authors do not recommend the use of flow diverters for the treatment of this subset of cerebral aneurysms

Safety and efficacy of ticagrelor for neuroendovascular procedures. A single center initial experience

ABSTRACT Introduction Although platelet response testing is controversial, up to one-third of neuroendovascular patients are &apos;resistant&apos; to clopidogrel and are at risk for in stent thrombotic complications and may require alternative antiplatelet therapy. Ticagrelor is a new reversible ADP P2Y12 platelet receptor inhibitor with no known resistance. We describe the clinical experience with ticagrelor for neuroendovascular procedures as an alternative in clopidogrel P2Y12 platelet resistant patients. Methods We reviewed our cerebrovascular database for all patients who were non-responders to clopidogrel, defined as P2Y12% inhibition &lt;30%, despite repeat clopidogrel loading dose of at least 600 mg, and who were then administered ticagrelor. Results 18 patients were non-responders to clopidogrel; 10 (56%) were men, eight (44%) were women, with a median age of 61 years (range 38-84). All patients received loading doses of at least 600 mg of clopidogrel and showed P2Y12 levels below 20% prior to ticagrelor administration. Patients were loaded with 180 mg of ticagrelor, and all but one patient showed an initial P2Y12 response above 60%. 11 patients underwent stenting, two underwent coiling, and five underwent treatment by pipeline embolization device. No patient experienced any adverse effects in the postoperative period related to the use of ticagrelor. Conclusions Ticagrelor offers an effective alternative to clopidogrel non-responders. All of our patients showed immediate platelet inhibition after a loading dose of 180 mg of ticagrelor, with no adverse effects. The cost of medication, patient compliance (twice a day doses), and reversible inhibition should be taken into consideration when using ticagrelor