Faculty Bibliography

Introduction: The efficacy of MDCT-based-angiography in management of acute stroke and/or emergent-large-vessel-occlusion is well established. However, concern for contrast-induced nephropathy(CIN) especially in patients with major risk factors like Diabetes & Chronic kidney disease often delays rapid evaluation of ELVO patients. Many published studies report the overall incidence of CIN after administration of IV or IA iodinated contrast and highlight the direct correlation of dose on higher incidence of CIN. None, however, have examined impact of sequential IV-IA bolus for neuroangiographic evaluation on renal function in patients with DM and/or CKD. Methods: A retrospective study of our 2015-2017 stroke database of 168 patients was conducted to identify all patients with preexisting DM and/or CKD who developed CIN during their hospital course. We also reviewed the prevalence of dehydration (BUN/Cr <20), CHF and anemia (Hb <8 g/dL) for these patients on admission. Results: For all 168 patients; average IA, IV and cumulative IV-IA contrast (Omnipaque 350) doses within 24 hours were 89.9, 91.7 and 181.6 cc respectively. 68 patients had DM and/or CKD of which 3 developed CIN. Under the definition of >=25% increase in baseline Cr within 72-120 hours of receiving contrast, all 3 had CIN. However, under the definition of >=0.5 mg/dL increase in Cr within 72 hours, none had CIN. All 3 only had preexisting DM as risk factor and had age appropriate baseline Cr on admission. The baseline Cr for each of the 3 patients were 0.82, 1.17 & 0.47 mg/dL respectively while the elevated Cr were 1.03, 1.17 & 0.76 mg/dL respectively. All 3 returned to within baseline by discharge with no mortality or need for hemodialysis. Conclusions: There is low risk of developing CIN in high risk patients like CKD or DM following rapid sequential dual IV/IA contrast bolus in acute stroke patients and therefore should not delay rapid neuro-angiographic evaluation

Introduction: Subclavian steal syndrome (SSS) is usually due to stenosis of the Subclavian Artery (SA) proximal to the origin of the vertebral artery (VA). SSS with intact SA in patients with dialysis arterio-venous fistulas (AVF) has been occasionally reported[1-4]. We present a unique case of the same successfully treated with a covered stent. Methods: A 65-year-old male with DM, HTN, ESRD and left brachial artery- basilic vein fistula (2.27 L/min flow) had multiple admissions with vertebrobasilar symptoms in the setting of elevated BP. Repeated evaluations with CT/CTA/MRI were negative for steno-occlusive disease or infarction. Therefore, symptoms were attributed to hypertensive urgency. On his third presentation in 4 months, he had additional symptoms of left arm pain, weakness and numbness. Signs included left arm hyperemia, warmth and mild motor-sensory deficits. Results: MRA demonstrated reverse flow of blood in left VA with focal stenosis of proximal left SA. Angiogram showed a kinked LSA and rapid/ early shunting to the subcalvian vein. There was no ante-grade visualization of the LVA with reverse flow from the RVA via VB junction. However on compression of the shunt with a BP cuff, antegrade flow in LVA reappeared with disappearance of RVA-LVA steal. BP transduction revealed a 50-mmHg point difference across the kinked segment. Subsequently, proximal left SA was stented with a covered biliary stent resulting in disappearance in RVALVA & LSA-LSV shunts, reappearance of antegrade LVA flow and resolution of symptoms. Conclusions: High-flow AVF is an underdiagnosed cause of symptomatic SSS. We suggest determining AVF flow speeds in any hemodialysis patient who presents with symptoms of posterior circulation insufficiency and obtaining noninvasive vascular studies if flow exceeds 2 L/min or if there has been a recent increase in measured flow during hemodialysis. Obtaining vascular studies with and without fistula compression could be of additional diagnostic utility

Introduction: Eptifibatide (Integrilin) has been demonstrated to improve clinical outcomes in both intracoronary and carotid artery stenting, when administered perioperatively. This evidence promotes the investigation of eptifibatide's role in neuroendovascular stenting. Methods: 38 patients between 2013-2017 underwent intracranial stenting with eptifibatide administration within 24 hours of procedure. Cumulative and average eptifibatide dosages were determined for all patients. Peri and post-procedural bleeding complications were defined as intercranial hemorrhage (ICH), symptomatic intercranial hemorrhage (sICH), and peripheral bleeding (retroperitoneal, access site bleeding, GI bleeding). Final Thrombolysis in Cerebral Infarction (TICI) scores as well as modified Rankin Scales (mRS) at discharge were also collected. Comparisons of these outcomes were made between patients with high-dose Integrilin and low-dose Integrilin, which we defined as above or equal to and below 0.75 mcg/kg/ min, respectively. A similar comparison was performed for patients who received above and below calculated dosage of median cumulative dose (0.71 mg/kg) Results: Of all 38 patients, 7 (21.8%) patients were found to have intracerebral hemorrhage, with 3 of these patients showing symptoms. Additionally, 6 patients (18.7%) experienced peripheral bleeding complications. Mean eptifibatide dosage was determined to be 0.77 mcg/kg/min. Analysis of the primary endpoint of all-cause bleeding complications yielded no significance between high-dose and low-dose Integrilin (p > 0.05). However, the incidence of sICH was significantly greater in patients receiving an average dosage at 0.75 mcg/kg/min or higher (p < 0.05). Furthermore, angiographic assessment revealed that more patients who receive a cumulative dosage of 0.71 mg/kg or greater achieved a TICI score of 2c-3 in comparison to those who achieved TICI 2b (p < 0.05). Conclusions: Usage of eptifibatide for patients undergoing neurovascular stenting at higher average dosages may result in a higher incidence of symptomatic ICH, however higher cumulative dosages may improve angiographic outcomes

Introduction: Adult onset focal dystonia often affects the upper extremities and cervical region but less often the lower extremities. Dystonia is the second most reported movement disorder post-stroke and often has a delayed presentation ranging from weeks to months. Most reports are in cases where there is permanent and substantial tissue injury. The clinical significance of Basal ganglia infarction or petechial hemorrhage following endovascular therapy for MCA occlusion is not well understood. The development of dystonia in the setting of a recanalized LMCA has never been reported before. Methods: A 39-year-old female presented with Left MCA occlusion. She had no other medical history except for an idiopathic left basal ganglia hemorrhagic stroke 6 months ago with residual mild forearm weakness. She underwent urgent mechanical thrombectomy with successful sequential recanalization of her inferior followed by superior division. The latter was complicated by a mild self-limiting subarachnoid hemorrhage in the left sylvian fissure. She had small petechial hemorrhages in the left basal ganglia on MRI. However, she recovered completely in 5 days and was discharged with a NIHSS of 1 (similar to baseline) as well as mRS of 2. Ten months later, she developed a painful, fixed right lower extremity dystonia where her ankle was inverted and plantarflexed with her toes curled. This was treated with multiple anticholinergic & GABAergic medications as well as Botox to only achieve partial success. Currently

Introduction: Eptifibitide is a commonly used antithrombotic shown to reduce ischemic complications related to percutaneous coronary intervention. Recent findings suggest that eptifibatide administration has the potential to improve post-procedural outcomes in the context of neuroendovascular therapy for acute ischemic stroke. Methods: 49 patients between 2014 and 2017 underwent thrombectomy for acute stroke and received eptifibitide. Cumulative and average eptifibatide dosages were determined for all patients. Peri- and and post-procedural bleeding complications were categorized into: intercranial hemorrhage (ICH), symptomatic intercranial hemorrhage (sICH), and peripheral bleeding (retroperitoneal, access site bleeding, and GI bleeding). Additionally, reperfusion Thrombolysis in Cerebral Infarction (TICI) scores as well as discharge modified Rankin Scales (mRS) were also collected. Patients were divided into those who received an average infusion rate of 0.75 mcg/kg/min or higher and those who received lower, with rates of functional and clinical outcomes analyzed. An identical analysis was done for patients above and below median cumulative dosage (0.32 mg/kg). Results: Of 49 total patients, 16 (32.7%) patients were found to have intracranial hemorrhage, with 5 showing resulting clinical symptoms. 14 patients (28.6%) experienced peripheral bleeding complications. The mean eptifibatide infusion for the selected patients was 0.75 mcg/kg/min with a median cumulative dosage of 0.32 mg/kg. On analysis, patients who received a higher average infusion of eptifibitide had higher incidence of all-cause bleeding complications (p < 0.05), however individual analysis of each bleeding complication showed no significant relationship (p > 0.05). Additionally, patients who received higher infusions of eptifibitide or higher cumulative doses of eptifibitide increased rate of achieving TICI scores of 2c-3 in comparison to patients who achieved a TICI score of 2b (p < 0.05). Conclusions: Usage of eptifibatide for patients undergoing neuroendovascular therapy for acute stroke at increased dosages may increase risk of overall bleeding complications. Higher dosage or infusion rate of eptifibatide may contribute to better post-procedural cerebral reperfusion