Faculty Bibliography
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210
Cone-beam CT angiography to assess the microvascular anatomy of intracranial arterial dissections
BACKGROUND:Intracranial artery dissection is a rare and generally under-recognized cause of ischaemic stroke or subarachnoid haemorrhage. OBJECTIVES/OBJECTIVE:The aim of this study was to analyse the efficacy of cone-beam computed tomography angiography (CBCT-A) to detect arterial ultrastructural alterations in intracranial artery dissection. METHOD/METHODS:This is an observational and retrospective case series. RESULTS:Between January 2018 and November 2020, four patients were admitted with an acute ischaemic stroke due to intracranial dissection studied with CBCT-A. In all cases, the CBCT-A documented vascular ultrastructural alterations related with the intracranial dissection. CONCLUSIONS:CBCT-A is an intraprocedural diagnostic technique that is useful for the diagnosis of intracranial dissections.
PMID: 34590889
ISSN: 2385-1996
CID: 5067542
Angio-anatomical study of the pterygovaginal artery based on cone-beam computed tomography
PURPOSE/OBJECTIVE:To investigate the anatomical characteristics and clinical implications of the pterygovaginal artery (PtVA), a recurrent branch from the distal internal maxillary artery (IMA), which courses through the pterygovaginal canal that connects the pterygopalatine fossa and nasopharynx. METHODS:Eighty-two patients with 90 sides of cone-beam computed tomography (CBCT) reconstructed from rotational angiography of the external or common carotid artery with a field of view covering the pterygopalatine fossa were retrospectively reviewed. The origin from the IMA, branching type, distribution, and anastomoses was evaluated. The underlying lesions were 36 hypervascular lesions with possible supply from PtVA (17 cavernous sinus arteriovenous fistulas (AVFs), 6 anterior condylar AVFs, and 13 nasopharyngeal, parasellar, or paraclival tumors) and 46 other diseases. RESULTS:PtVA was identified in 75 sides (83%). It originated from the pterygopalatine segment of the IMA in 45 sides (60%) and from the pterygoid segment in 30 sides (40%). It arose independently (77%), sharing the common trunk with the Vidian artery (15%) or with other branches. It ran posteromedially through the pterygovaginal canal to supply the mucosa over the nasopharyngeal roof, the choanae, and the pharyngeal ostium of the eustachian tube. It anastomosed with the ascending pharyngeal artery (n=37), the accessory meningeal artery (n=7), and the mandibular artery from the petrous internal carotid artery (n=2). It served as a feeder of osseous AVFs and skull base tumors. CONCLUSION/CONCLUSIONS:PtVA was often identified by CBCT even in normal anatomy. Its detailed angio-anatomy could be evaluated in the presence of parasellar or paraclival hypervascular lesions.
PMID: 33555352
ISSN: 1432-1920
CID: 4779352
Arterial and Venous 3D Fusion AV-3D-DSA: A Novel Approach to Cerebrovascular Neuroimaging
DSA is the standard imaging technique for evaluation of cerebrovascular conditions. However, One drawback is its limitation in depicting a single angiographic phase at a time. We describe a new 3D-DSA algorithm, which we call arterial and venous-3D-DSA, which allows the concurrent yet distinct display of the arterial and venous structures, which may be useful for different clinical and educational purposes.
PMID: 33832953
ISSN: 1936-959x
CID: 4840952
Penumbra Consumption Rates Based on Time-to-Maximum Delay and Reperfusion Status: A Post Hoc Analysis of the DEFUSE 3 Trial
BACKGROUND AND PURPOSE/OBJECTIVE:delays in patients with large vessel occlusion evaluated between 6 and 16 hours from last known normal. METHODS:6 or 10 s volume-baseline core volume). We stratified the cohort into 4 categories based on treatment modality and Thrombolysis in Cerebral Infarction (TICI score; untreated, TICI 0-2a, TICI 2b, and TICI3) and calculated penumbral consumption rates in each category. RESULTS:=0.92). CONCLUSIONS:>6-s mismatch volume may remain viable in untreated patients at 24 hours.
PMID: 34157865
ISSN: 1524-4628
CID: 4918372
Global Impact of COVID-19 on Stroke Care and Intravenous Thrombolysis
OBJECTIVE:The objectives of this study were to measure the global impact of the pandemic on the volumes for intravenous thrombolysis (IVT), IVT transfers, and stroke hospitalizations over 4 months at the height of the pandemic (March 1 to June 30, 2020) compared with two control 4-month periods. METHODS:We conducted a cross-sectional, observational, retrospective study across 6 continents, 70 countries, and 457 stroke centers. Diagnoses were identified by their ICD-10 codes and/or classifications in stroke databases. RESULTS:There were 91,373 stroke admissions in the 4 months immediately before compared to 80,894 admissions during the pandemic months, representing an 11.5% (95%CI, -11.7 to - 11.3, p<0.0001) decline. There were 13,334 IVT therapies in the 4 months preceding compared to 11,570 procedures during the pandemic, representing a 13.2% (95%CI, -13.8 to -12.7, p<0.0001) drop. Interfacility IVT transfers decreased from 1,337 to 1,178, or an 11.9% decrease (95%CI, -13.7 to -10.3, p=0.001). Recovery of stroke hospitalization volume (9.5%, 95%CI 9.2-9.8, p<0.0001) was noted over the two later (May, June) versus the two earlier (March, April) pandemic months. There was a 1.48% stroke rate across 119,967 COVID-19 hospitalizations. SARS-CoV-2 infection was noted in 3.3% (1,722/52,026) of all stroke admissions. CONCLUSIONS:The COVID-19 pandemic was associated with a global decline in the volume of stroke hospitalizations, IVT, and interfacility IVT transfers. Primary stroke centers and centers with higher COVID19 inpatient volumes experienced steeper declines. Recovery of stroke hospitalization was noted in the later pandemic months.
PMID: 33766997
ISSN: 1526-632x
CID: 4822932
New Focus on Endovascular Therapy for Ischemic Stroke
BACKGROUND:Over the past 2 decades, a growing number of large-scale clinical trials have helped expand the toolkit for emergency management of acute ischemic stroke. This article is intended to be an up-to-date resource to aid nonstroke specialist neurology providers and ophthalmologists in identifying situations and patient populations in which urgent stroke evaluation should be completed with options for emergent reperfusion therapy considered. EVIDENCE ACQUISITION/METHODS:The literature forming the foundation of the guidelines for early management of patients with acute ischemic stroke was reviewed, annotated, and summarized. RESULTS:Data from both initial and follow-up trials investigating the benefits and indications for use of intravenous thrombolysis and endovascular intervention for stroke are reviewed systematically, with an emphasis on new updates to qualifying patient populations and time periods for treatment. CONCLUSIONS:Recent studies underscore the conclusion that timely reperfusion in acute ischemic stroke is the most effective available treatment and that there are a growing number of new scenarios and patients for which interventions maybe applied.
PMID: 33999888
ISSN: 1536-5166
CID: 4876682
Anticoagulation use and Hemorrhagic Stroke in SARS-CoV-2 Patients Treated at a New York Healthcare System
BACKGROUND AND PURPOSE/OBJECTIVE:While the thrombotic complications of COVID-19 have been well described, there are limited data on clinically significant bleeding complications including hemorrhagic stroke. The clinical characteristics, underlying stroke mechanism, and outcomes in this particular subset of patients are especially salient as therapeutic anticoagulation becomes increasingly common in the treatment and prevention of thrombotic complications of COVID-19. METHODS:We conducted a retrospective cohort study of patients with hemorrhagic stroke (both non-traumatic intracerebral hemorrhage and spontaneous non-aneurysmal subarachnoid hemorrhage) who were hospitalized between March 1, 2020, and May 15, 2020, within a major healthcare system in New York, during the coronavirus pandemic. Patients with hemorrhagic stroke on admission and who developed hemorrhage during hospitalization were both included. We compared the clinical characteristics of patients with hemorrhagic stroke and COVID-19 to those without COVID-19 admitted to our hospital system between March 1, 2020, and May 15, 2020 (contemporary controls), and March 1, 2019, and May 15, 2019 (historical controls). Demographic variables and clinical characteristics between the individual groups were compared using Fischer's exact test for categorical variables and nonparametric test for continuous variables. We adjusted for multiple comparisons using the Bonferroni method. RESULTS:During the study period in 2020, out of 4071 patients who were hospitalized with COVID-19, we identified 19 (0.5%) with hemorrhagic stroke. Of all COVID-19 with hemorrhagic stroke, only three had isolated non-aneurysmal SAH with no associated intraparenchymal hemorrhage. Among hemorrhagic stroke in patients with COVID-19, coagulopathy was the most common etiology (73.7%); empiric anticoagulation was started in 89.5% of these patients versus 4.2% in contemporary controls (p ≤ .001) and 10.0% in historical controls (p ≤ .001). Compared to contemporary and historical controls, patients with COVID-19 had higher initial NIHSS scores, INR, PTT, and fibrinogen levels. Patients with COVID-19 also had higher rates of in-hospital mortality (84.6% vs. 4.6%, p ≤ 0.001). Sensitivity analyses excluding patients with strictly subarachnoid hemorrhage yielded similar results. CONCLUSION/CONCLUSIONS:We observed an overall low rate of imaging-confirmed hemorrhagic stroke among patients hospitalized with COVID-19. Most hemorrhages in patients with COVID-19 infection occurred in the setting of therapeutic anticoagulation and were associated with increased mortality. Further studies are needed to evaluate the safety and efficacy of therapeutic anticoagulation in patients with COVID-19.
PMCID:7444897
PMID: 32839867
ISSN: 1556-0961
CID: 4574182
Lacunar stroke: mechanisms and therapeutic implications
Lacunar stroke is a marker of cerebral small vessel disease and accounts for up to 25% of ischaemic stroke. In this narrative review, we provide an overview of potential lacunar stroke mechanisms and discuss therapeutic implications based on the underlying mechanism. For this paper, we reviewed the literature from important studies (randomised trials, exploratory comparative studies and case series) on lacunar stroke patients with a focus on more recent studies highlighting mechanisms and stroke prevention strategies in patients with lacunar stroke. These studies suggest that lacunar stroke is a heterogeneous disease with various mechanisms, including most commonly lipohyalinosis and less commonly atheromatous disease and cardioembolism, highlighting the importance of a careful review of brain and neurovascular imaging, a cardiac and systemic evaluation. A better understanding of pathomechanisms of neurological deterioration may lead to investigating the utility of novel treatment strategies and optimisation of short-term antithrombotic treatment strategies to reduce the risk of neurological deterioration and prevent long-term disability in patients with lacunar stroke.
PMID: 34039632
ISSN: 1468-330x
CID: 4888032
State of the Art: Venous Causes of Pulsatile Tinnitus and Diagnostic Considerations Guiding Endovascular Therapy
Venous variants and pathologic abnormalities are the most common causes of pulsatile tinnitus. These conditions include causes of turbulence within normally located veins and sinuses, and abnormally enlarged or abnormally located veins in close transmissive proximity to the conductive auditory pathway. Such disorders include pathologic abnormalities of the lateral sinus (transverse sinus stenosis and sigmoid sinus wall anomalies), abnormalities and variants of the emissary veins, and anomalies of the jugular bulb and jugular vein. Despite being the most common causes for pulsatile tinnitus, venous variants and pathologic abnormalities are often overlooked in the workup of pulsatile tinnitus. Such oversights can result in delayed patient care and prolonged patient discomfort. Advances in both cerebrovascular imaging and endovascular techniques allow for improved diagnostic accuracy and an increasing range of endovascular therapeutic options to address pulsatile tinnitus. This review illustrates the venous causes of pulsatile tinnitus and demonstrates the associated endovascular treatment. © RSNA, 2021.
PMID: 34032509
ISSN: 1527-1315
CID: 4887732
Journal of stroke & cerebrovascular diseases. 2021:30(7).DOI: 10.1016/j.jstrokecerebrovasdis.2021.105828
Structural and Functional Imaging of the Retina in Central Retinal Artery Occlusion - Current Approaches and Future Directions
Central retinal artery occlusion (CRAO) is a form of acute ischemic stroke which affects the retina. Intravenous thrombolysis is emerging as a compelling therapeutic approach. However, it is not known which patients may benefit from this therapy because there are no imaging modalities that adequately distinguish viable retina from irreversibly infarcted retina. The inner retina receives arterial supply from the central retinal artery and there is robust collateralization between this circulation and the outer retinal circulation, provided by the posterior ciliary circulation. Fundus photography can show canonical changes associated with CRAO including a cherry-red spot, arteriolar boxcarring and retinal pallor. Fluorescein angiography provides 2-dimensional imaging of the retinal circulation and can distinguish a complete from a partial CRAO as well as central versus peripheral retinal non-perfusion. Transorbital ultrasonography may assay flow through the central retinal artery and is useful in the exclusion of other orbital pathology that can mimic CRAO. Optical coherence tomography provides structural information on the different layers of the retina and exploratory work has described its utility in determining the time since onset of ischemia. Two experimental techniques are discussed. 1) Retinal functional imaging permits generation of capillary perfusion maps and can assay retinal oxygenation and blood flow velocity. 2) Photoacoustic imaging combines the principles of optical excitation and ultrasonic detection and - in animal studies - has been used to determine the retinal oxygen metabolic rate. Future techniques to determine retinal viability in clinical practice will require rapid, easily used, and reproducible methods that can be deployed in the emergency setting.
PMID: 34010777
ISSN: 1532-8511
CID: 4877322
