Faculty Bibliography

Introduction: Most stroke/neuro-interventional centers require advanced biplane imaging for evaluation of complex cerebrovascular lesions. Purchasing such equipment is cost-prohibitive for many hospital systems. Additionally, operator-preference often prevents the use of other imaging platforms as a back up for acute neuro-interventional cases. However, most hospitals are often equipped with multiple single plane imaging platforms for IR & Cardiac purposes. Advanced single plane imaging in most catheterization labs provide reasonable penetration and field of view (FOV) for doing acute cases like mechanical thrombectomy. Methods: A retrospective review of our multi-center database of acute stroke patients treated with endovascular therapy was performed. 207 patients were categorized by type of imaging platform on which thrombectomy was performed and relevant angiographic and clinical data was gathered. Primary outcome was measured using angiographic outcome. This included comparisons between two groups of TICI scores: TICI 0-2A vs. TICI 2B-3 and TICI 2B vs. TICI 2C/3. Secondary outcome was safety which was reported as incidence of intracranial hemorrhage between the two groups Results: 146 biplane patients achieved scores of 2B or higher, meanwhile 12 biplane patients received scores of 2A or lower. 44 of 49 single plane patients achieved TICI scores of 2B-3 while 5 had scores of 0-2A, showing no significant difference (p > 0.05). In a second comparison, 97 biplane patients that had outcomes of 2C or 3, and 49 patients with outcomes of 2B; while 29 monoplane patients achieved a score of 2c or 3 and 15 with 2B (p > 0.05). For our secondary measure, ICH in the biplane group was 38/146 and in monoplane group was 9/49, the difference not being statistically significant (p > 0.05) Conclusions: There was no significant difference in safety or efficacy outcomes when comparing thrombectomies performed using biplane vs. monoplane imaging. Thrombectomies performed with either imaging system is equally safe and effective

Introduction: Chronic subdural hematoma (cSDH) can be associated with slow cognitive decline, co-ordination symptoms and rarely motor-sensory deficits. Open surgical treatment may or may not be always effective or indicated. Some far east operators have studied hypertrophy of Middle Meningeal Artery (MMA) and its embolization for treatment of such recalcitrant lesions. We present our experience of MMA embolization as an earlyadoptive technique for treatment for poor or failed surgical candidates. Methods: 10 patients diagnosed with unilateral or bilateral cSDH underwent MMA embolization. Size of SDH volume and densities were measured from time of initial discovery on imaging to pre-operative, immediate postoperative, and long-term follow-up. Time between procedure to obliteration was also measured based on follow-up imaging. Results: Out of 10 patients, 5 patients were diagnosed with recurrent cSDH, and 5 with primary cSDH. 7 patients had bilateral cSDH, and 3 unilateral cSDH. Average volume on admission and pre-operatively were 20.7 and 20.6 cc, respectively. MMA embolization was on average performed of 26 days post symptoms onset. Immediate post-op CT was performed an average of 46 hours and showed enhancement of the subdural in 40% cases. This was associated with greater visualization of their extent with average increase in SDH volume to 21.2 cc. Follow-up CT imaging for these patients was done at an average of 128 days post-procedure. Average volume was down to 13.13 cc with mean reduction of 45% from presentation. 3 patients were determined to have complete obliteration after 1 year. Conclusions: MMA Embolization has been shown to have a marked reduction in SDH volume post-operatively and can be used as a curative measure for patients who fail conservative medical management and neurosurgical intervention

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

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