Faculty Bibliography

BACKGROUND:Flow-diverter stents (FDS) have become the standard of care for a wide range of intracranial aneurysms, but their efficacy/safety in the context of recurrent/recanalized aneurysms following stent-assisted coiling (SAC) is not well established. We evaluate the outcomes of FDS retreatment in a large multicenter cohort. METHODS:We retrospectively analyzed data from 118 patients across 22 institutions who underwent FDS retreatment for recurrent/persistent aneurysms after SAC (2008-22). The primary outcome was angiographic occlusion status at last follow-up, categorized as complete (100%), near-complete (90-99%), or incomplete (<90%) occlusion. Secondary outcomes included procedural complications and clinical outcomes measured by the modified Rankin Scale (mRS). RESULTS:A total of 118 patients (median age 57, 74.6% female) with median follow-up of 15.3 months were identified. Complete occlusion was achieved in 62.5% and near-complete occlusion in 25%. FDS deployment within the pre-existing stent was successful in 98.3% of cases. Major complications occurred in 3.4% of cases, including postoperative aneurysmal rupture with resultant mortality (1.6%) and thromboembolic events with long-term disability (1.6%). Favorable clinical outcomes (mRS 0-2) were observed in 95.1% of patients. Wider aneurysm neck diameter was a significant predictor of incomplete occlusion (adjusted OR (aOR) 1.23 per mm, P=0.044), with male sex trending towards association with non-occlusion (aOR 3.2, P=0.07), while baseline hypertension was associated with complete occlusion (aOR 0.32, P=0.048). CONCLUSIONS:FDS treatment for recurrent/residual aneurysms after SAC represents a viable treatment option for these challenging cases with acceptable safety and reasonable occlusion rates, although lower than de novo FDS occlusion rates.

PURPOSE/OBJECTIVE:We describe a case of bilateral, multiple, branch retinal artery occlusions (BRAO) associated with carotid webs. METHODS:A thorough chart review was conducted for the patient. Relevant literature was systematically reviewed. RESULTS:Eight cases of fibromuscular dysplasia (FMD) associated with retinal artery occlusions have been reported. Two additional cases of FMD with other ocular involvement have been described. No cases of carotid webs associated with retinal artery occlusions were found. CONCLUSION/CONCLUSIONS:Carotid webs, an uncommon variant of FMD, are a recognized causative etiology of arterial, ischemic stroke. The case described here of bilateral, multifocal BRAOs represents a unique manifestation of this variant of FMD. This diagnosis should be considered in the setting of an otherwise unrevealing BRAO workup, as recognition of this association may be sight and life-saving.

BACKGROUND/UNASSIGNED:Patient-reported outcome measures (PROMs) are increasingly utilized in observational and regulated studies of people with multiple sclerosis (MS). However, the impact of aging on PROMs for people with MS remains largely unknown. This study explores the cross-sectional characteristics and longitudinal trajectories of PROMs to determine their ability to predict clinical progression in a large group of people with MS 55 years and older. METHODS/UNASSIGNED:Included in the analysis were people with MS enrolled in the New York State Multiple Sclerosis Consortium (NYSMSC), 55 years or older, with at least 3 clinical visits recorded in the consortium database. All people in the NYSMSC complete PROMs through the LIFEware questionnaire. Additional clinical measures were also collected. The percentage of people with MS who reported severe limitations within each of the LIFEware domains was compared at their baseline visit (≥ 55 years) and at the most recent follow-up visit (average follow-up of 8.3 years). Comparisons between people with MS with stable or increasing disability were also performed. RESULTS/UNASSIGNED: = .018). People with increasing disability had significantly worse baseline physical PROMs when compared with people with stable MS. CONCLUSIONS/UNASSIGNED:An increase in physical limitations does not necessarily contribute to a rise in psychosocial limitations. Instead, as people with MS age, they tend to report improvements in their mental health over time. PROMs can be a complementary predictive indicator of future disease progression as individuals with MS age.

BACKGROUND:Supportive care is the primary focus of ICU management for unconscious patients early after severe acute brain injury. While benefits of early physical and occupational therapy are generally recognized, it remains uncertain how early therapy can begin and what patients most benefit form intensive, early therapy. Brain activation to motor commands detected by EEG also known as cognitive motor dissociation (CMD) is a predictor of recovery seen in up to 25% of patients. The purpose of this study was to determine if CMD patients that undergo early, intense physical and occupational therapy are particularly responsive to the treatment. METHODS:In this retrospective analysis of prospectively collected data from 119 ICU patients with acute, severe brain injury who were assessed using the Coma Recovery Scale-Revised (CRS-R). CMD was detected applying machine learning to EEG recorded during verbal command presentation. Time from admission, type, and frequency of physical/occupational therapy, and pre-defined adverse events were recorded. Glasgow Outcome Scale-Extended (GOS-E) at discharge, 3, 6, and 12 months were the primary outcome. Investigators were blinded to CMD status. Outcomes were compared in relation to CMD status and therapy characteristics applying Wilcoxon signed-rank tests and ordinal regression. RESULTS:CMD was detected in 16 (13%) patients and not associated with demographics or clinical factors. No therapy-related complications were observed. Between admission and discharge, GCS improved for all patients. Median delta GCS was the highest for CMD patients who received high-frequency therapy (OR 4.1 [1.1-16.3], p = 0.03). GOS-E was 4 or above in 26 (26%) by 12 months after the injury. CMD patients who received high-frequency therapy had larger increases in GOS-E at 6 and 12 months after discharge compared to those without CMD and those who did not receive frequency therapy (OR 10.7 [2.5,48.8] p = 0.001). CONCLUSIONS:Physical and occupational therapy can be applied in the ICU using a safety protocol and CMD patients may be particularly responsive to early, intense therapy. Multicenter trials integrating CMD status should determine optimal timing and dosage of rehabilitation to support the allocation of this limited resource.

PURPOSE OF REVIEW/OBJECTIVE:This review provides evidence for the mechanism of action (MOA) of Remote Electrical Neuromodulation (REN), a non-pharmacological therapeutic technology for treating migraine and other symptoms manifested by certain idiopathic pain diseases. It discusses the main physiological and anatomical aspects associated with conditioned pain modulation (CPM), and how REN is applied for the treatment of migraine pain and other symptoms. RECENT FINDINGS/RESULTS:) is FDA cleared for acute and preventive treatment of migraine in patients aged 8 years and above, and CE marked in patients aged 12 and above. In brief, the REN MOA is formulated on the observed concept that one of the descending pain inhibition mechanisms in the brain, known as CPM, is deficient among people diagnosed with certain idiopathic pain disorders, such as migraine. Hence, these people are more vulnerable to otherwise innocent external stimuli, which are misinterpreted in the brain as painful and can thus trigger a migraine attack, often presenting with increased pain sensitivity (hyperalgesia) and headache. Research has revealed that descending inhibitory mechanisms can be externally activated under certain conditions. REN operates through applying electrical stimulation with parameters designed to activate A-delta and C nociceptive nerve fibers in the skin to optimize this response, thereby enhancing CPM and increasing pain inhibition by releasing norepinephrine and serotonin. Based on current evidence, the review presents medical practitioners and researchers with a detailed explanation of the REN MOA in treating and preventing migraine, and potentially other idiopathic pain disorders.

BACKGROUND/UNASSIGNED:Left ventricular assist device (LVAD) recipients are at risk of developing early right ventricular failure (RVF), at times necessitating temporary mechanical support with right ventricular assist device (RVAD). The optimal timing of RVAD implantation in these patients is unclear. The aim of this study is to compare clinical outcomes between upfront RVAD (U-RVAD) and rescue RVAD (R-RVAD) in LVAD recipients with early RVF. METHODS/UNASSIGNED:In this single-center retrospective cohort study, we included all patients who underwent HeartMate 3 (HM3) LVAD implant and required temporary RVAD for severe early RVF (30 days of LVAD implantation), from January 2019 to September 2024. U-RVAD was defined as RVAD use during the index LVAD operation. Baseline characteristics, perioperative outcomes, and mortality were compared between patients with U-RVAD and those with R-RVAD. RESULTS/UNASSIGNED:= 0.041 and 0.008, respectively). In-hospital and 90-day all-cause mortality occurred in 11 (31%) and 12 (33%) patients receiving U-RVAD and 16 (57%) and 19 (68%) patients receiving R-RVAD, respectively. On binary logistic regression, U-RVAD was associated with lower 90-day mortality (adjusted odds ratio 0.23, 95% confidence interval 0.06-0.80). CONCLUSIONS/UNASSIGNED:In HM3 LVAD recipients with severe early RVF requiring RVAD, U-RVAD was associated with improved clinical outcomes.

OBJECTIVE:We examined the EMU referral patterns based on indications for video-EEG (vEEG) tests. The yield of vEEG studies and predictors of study outcomes were investigated. We also evaluated the clinical impact of vEEG. METHODS:We identified vEEG tests which primary aimed at capturing events for diagnostic purposes. Study outcomes were dichotomized into those that captured habitual events (positive) and those that did not (negative). The clinical impact of vEEG was assessed based on changes in diagnosis and antiseizure medications (ASM) after the test. RESULTS:Based on the purpose of EMU referral, a total of 153 patients were divided into 4 groups in this study: (I) Spells clarification in people with spells; (II) Event differentiation in people with epilepsy; (III): Reassessment of the prior diagnosis of epilepsy; (IV): Classification of seizure or epilepsy types. Delayed referrals were observed in patient groups III and IV. Habitual events were recorded in 89 patients, with 90 % occurring within 72 h. Baseline event frequency, prior EEG or image findings, and age were predictors of the study outcome. The admission diagnosis was changed after a positive or negative test in 11 and 9 patients, respectively. VEEG findings led to ASM escalation or de-escalation in 69 patients. SIGNIFICANCE/CONCLUSIONS:The referral patterns differ among studies based on study indications, and certain patient groups experienced delayed referrals. Predictive factors for the outcome include patient characteristics and medical history. Both positive and negative vEEG tests are valuable in correcting the misdiagnosis of epilepsy and guiding ASM treatments.

BACKGROUND/UNASSIGNED:Transient ischemic attack (TIA) carries a high risk of stroke, necessitating immediate evaluation and risk modification. Patients in high-social determinants of health-burden communities often face barriers to rapid outpatient care, while inpatient admission can be resource-intensive and burdensome. We describe outcomes from a rapid TIA inpatient workflow (Rapid TIA) implemented at an urban academic medical center. METHODS/UNASSIGNED:A retrospective single institution observational study of 411 consecutive patients admitted for TIA over 4 years in the Bronx, NY. Rapid TIA had 3 phases: (1) initial neurologic evaluation, (2) hospital admission and expedited implementation of care, and (3) transition to outpatient specialty care. We compared 6 variables related to care delivery, as well as long-term outcomes, in the pre-implementation vs post-implementation groups. RESULTS/UNASSIGNED:= 0.004). CONCLUSIONS/UNASSIGNED:Our study demonstrates that a rapid-inpatient TIA management pathway can significantly improve quality care and reduce readmissions. Rapid TIA may serve as a model for TIA care delivery in other underserved communities.

The choroid plexus (ChP), a highly vascularized brain structure responsible for cerebrospinal fluid (CSF) production, undergoes significant age-related changes that may contribute to neurodegenerative diseases involving disrupted immune regulation, fluid homeostasis and waste clearance. Compared to other brain regions, vascular research on the ChP remains limited despite its critical role as a central interface between the blood and CSF. This review focuses on age-related vascular and structural alterations in the ChP from both histopathological and neuroimaging perspectives, and explores their impact on CSF dynamics, immune regulation, and the integrity of the blood-CSF barrier (BCSFB). Rather than shrinking, the aging ChP often enlarges due to dystrophic changes, as shown in volumetric MRI studies. Histological studies reveal epithelial degeneration, basement membrane thickening, and stromal fibrosis in the normal aging process. In dementia such as Alzheimer's disease (AD), proteomic studies have identified upregulation of AD- and immune-related proteins, along with downregulation of proteins linked to CSF clearance and metabolic support. Emerging high-resolution contrast-enhanced MRI techniques now allow in vivo visualization of microvascular changes within the ChP, shedding light on its normal and abnormal aging processes. Understanding these alterations is critical, as they may influence the onset and progression of various neurological diseases such as AD, Parkinson's disease (PD), normal pressure hydrocephalus, and amyotrophic lateral sclerosis (ALS). The recent advancements and challenges described in this study underscore the need for deeper investigation into ChP aging to inform future diagnostic and therapeutic strategies of neurodegenerative diseases.