BACKGROUND:The prevalence of medical complications in patients with acute ischemic stroke undergoing mechanical thrombectomy (MT) is sparse. This study aims to quantify and evaluate trends in common medical complications in acute ischemic stroke MT hospitalizations in the United States over the past decade. METHODS:We utilized the 2010 to 2022 Nationwide Inpatient Sample (NIS) to conduct a serial cross-sectional study. All adult acute ischemic stroke MT hospitalizations (aged ≥18 years) were identified using International Classification of Diseases codes. We computed the weighted prevalence of acute myocardial infarction, acute renal failure, deep venous thrombosis, gastrointestinal bleeding (GIB), pneumonia, pulmonary embolism, sepsis, and urinary tract infection (UTI) across age and sex strata. Poisson regression models were utilized to evaluate the association of each complication with hospital-level factors and to study trends over time. RESULTS:Among 233 812 weighted MT hospitalizations (50.3% women; mean age 68.9 years), 35.9% had at least 1 complication. The age and sex-standardized prevalence was highest for acute renal failure (15.6%), UTI (11.3%), and pneumonia (6.8%), whereas acute myocardial infarction (4.7%), GIB (2%), deep venous thrombosis (4.3%), and pulmonary embolism (1.9%) were less common. Disparities in complication burden were present by age/sex (GIB: women 18-39 years, 0.9%; men ≥80 years, 2.7%). Age/sex-standardized prevalence of acute renal failure increased ≈2-fold across the study period from 11.0% in 2010 to 18.5% in 2022, whereas prevalence of sepsis, pulmonary embolism, and acute myocardial infarction also increased marginally over time (all P-for-trend <0.05; deep venous thrombosis rose 5%/y in women; UTI declined in both sexes; pneumonia declined in men (all P-for-trend <0.05); GIB was stable. We report prevalence risk ratios (PRRs); for example, PRR 1.81 indicates an 81% higher prevalence. Each unit increase in National Institutes of Health Stroke Scale score (UTI PRR, 1.02 [95% CI, 1.01-1.02]) and early mechanical ventilation (pneumonia PRR, 3.41 [95% CI, 3.03-3.83]) were associated with increased prevalence of all complications, while intravenous thrombolysis was associated with lower risk for most events (UTI: PRR, 0.91 [95% CI, 0.86-0.96]; sepsis: PRR, 0.77 [95% CI, 0.70-0.84]; pneumonia: PRR, 0.81 [95% CI, 0.75-0.88]). Mortality fell from 23.7% (2010) to 11.8% (2022), whereas routine home discharge rose from 11.9% to 19.9%. All complications were associated with a lower likelihood of routine home discharge, and all except UTI were associated with an increase in in-hospital mortality (sepsis: PRR, 1.55 [95% CI, 1.42-1.67]). CONCLUSIONS:The prevalence of pneumonia and UTI declined, whereas acute renal failure prevalence more than doubled in acute ischemic stroke MT hospitalizations over the last decade. Complications were consistently linked to poorer discharge outcomes and higher in-hospital mortality, underscoring the need for targeted prevention strategies to optimize postthrombectomy care.

To analyze trends in the prevalence of medical complications in aneurysmal subarachnoid hemorrhage (aSAH) hospitalizations in the USA over the last decade. A serial cross-sectional study was performed using the 2006–2022 National Inpatient Sample. Adult (≥ 18 years) primary aSAH hospitalizations with and without complications were identified using International Classification of Diseases codes. Negative binomial regression models were used to evaluate the associations between complications, individualized hospitalization characteristics, and hospital outcomes. Of 163,349 aSAH hospitalizations over the study period, 68.2

Data on how percutaneous endoscopic gastrostomy (PEG) utilization has changed over time in patients with acute ischemic stroke (AIS) in the United States are sparse. This study evaluates 17-year trends in PEG utilization in AIS hospitalizations in the United States. The 2006-2022 National Inpatient Sample was used to conduct a serial cross-sectional study. International Classification of Diseases codes were used to identify primary AIS hospitalizations with and without PEG. We used joinpoint regression to compute the annualized percentage change (APC) in PEG usage over time and used multivariable regression to evaluate the association of IV thrombolysis (IV-tPA), mechanical thrombectomy (MT), and other hospitalization factors with odds of PEG use. Of 8,079,538 primary AIS admissions over the study period, the overall PEG prevalence was 3.9% but usage in the subset of AIS admissions undergoing MT was 11.0%. PEG utilization increased with age in both sexes (18-39-year-olds: men 2.7%; women 2.5%; 80 years or older: men 4.7% and women 4.6%). After multivariable adjustment, increasing Elixhauser comorbidity scores (OR 1.31, 95% CI 1.30-1.32) and MT utilization (OR 1.61, 95% CI 1.54-1.68) were associated with higher odds of PEG use while IV-tPA was associated with lower odds of utilization (OR 0.94, 95% CI 0.91-0.97) when compared with no treatment. PEG use declined by 2.9% annually across the study period (average APC 2.9%, 95% CI -3.2 to -2.5%), but the rate of decline was fastest in the period 2014-2018 (APC -7.4%, 95% CI -8.6 to -4.9), followed by 2006-2014 (APC -1.9%, 95% CI -2.5 to -0.9). Utilization did not change significantly in the period 2018-2022. The average time from admission to PEG placement was 9.3 days, and this increased progressively over time (p trend <0.001). PEG use in patients with AIS declined over the past decade. This decline is likely due to multifactorial reasons that warrant further studies, but changing clinical practice toward allowing for some more time for patients with AIS to recover from poststroke dysphagia may be one of the potential contributory factors.

BACKGROUND AND OBJECTIVES:There is paucity of data on the population-level incidence of moyamoya angiopathy (MMA) in the United States. The aim of this study was to estimate sex-specific, age-specific, and race-specific incidence of MMA in the United States over the period 2011-2020. METHODS:We used the State Ambulatory Surgery, Emergency, and Inpatient Databases of Florida (2005-2020), Georgia (2010-2020), Maryland (2012-2020), and New York (2005-2020) to conduct a retrospective study. We validated ICD-10 codes for MMA in a single academic center in the United States and used primary and secondary ICD-9/10 discharge codes to identify all new cases of MMA in these 4 states from 2011 to 2020. Incident MMA counts were combined with census data to compute incidence separately for moyamoya disease (MMD) and moyamoya syndrome (MMS). Multivariable-adjusted Poisson regression models were used to compare MMA incidence between demographic subgroups, and joinpoint regression was used to evaluate trends over time. RESULTS:Among 24,614 MMA hospitalizations over the study period, 4,192 incident cases were identified from 2011 to 2020. The median age at hospitalization was 41.0 years (interquartile range 24.0-54.0), and 67.9% of admissions were in women. The overall age-standardized and sex-standardized incidence of MMA was 0.75 (95% CI 0.73-0.77) cases/100,000/year. The incidence of isolated MMD was 0.57 (95% CI 0.54-0.59), whereas that of MMS was 0.18 (95% CI 0.16-0.20). MMD incidence increased with age, up to 45-64 years (trend p value = 0.041), whereas that of MMS declined with age (trend p value <0.001). Following multivariable Poisson regression, the overall MMA incidence in women was approximately 2 times that in men (adjusted incidence rate ratio [aIRR] 1.97, 95% CI 1.69-2.30). Incidence was higher in Asian (aIRR 2.46, 95% CI 1.88-3.23) and Black (aIRR 2.58, 95% CI 2.17-3.07) individuals compared with non-Hispanic White individuals. Incidence increased over time (annualized percentage change 7.7%, 95% CI 5.3%-10.5%), with most of this increase occurring in individuals aged 45-64 years and 65 years or older. DISCUSSION:The incidence of MMA in the United States is higher than previously believed. Overall incidence in Black individuals is just as high as that in Asian individuals, and both are higher than that of non-Hispanic White individuals. Further studies are needed to understand the genetic and environmental factors contributing to race/ethnic disparities in MMA incidence in the United States.

BACKGROUND:Neuroendovascular interventions, including pipeline embolization device (PED)/flow diverter placement and coil embolization, are increasingly used in the management of nontraumatic subarachnoid hemorrhages (SAH). However, literature on trends, predictors of patient selection, and complications remains limited. This study aims to identify factors influencing treatment selection and risks associated with PED versus coil embolization in SAH. METHODS:The 2016 to 2021 National Inpatient Sample was used to identify adult inpatients with a primary diagnosis of nontraumatic SAH. Univariate and multivariable analyses adjusting for demographics, comorbidity status, and hemorrhage etiology were used to characterize statistical associations. RESULTS:Of 62,567 patients identified as having an SAH from 2016 to 2021, 409 patients (0.65%) underwent PED, and 6834 patients (10.9%) underwent coil embolization. The remaining 88% underwent nonendovascular management. Complications associated with PED placement and not coil embolization included gastrointestinal (5.1% vs. 2.2%; P < 0.05) and respiratory tract bleeding (3.2% vs. 0.7%; P < 0.001). Those who underwent PED were less likely to have hydrocephalus (47.4% vs. 56.5%; P < 0.05) and receive external ventricular drain or ventriculoperitoneal shunt placement (38.9% vs. 48.4%; P < 0.01). After controlling for confounding factors, predictors for receiving coil embolization instead of PED placement included SAH originating from the anterior communicating artery (odds ratio [OR]: 4.0; 95% confidence interval [CI]: 2.87-5.90; P < 0.001), posterior communicating artery (OR: 2.0; CI: 1.90-3.63; P < 0.001), and middle cerebral artery (OR: 2.02; CI: 1.36-3.13; P < 0.05). CONCLUSIONS:PED is associated with a higher incidence of systemic hemorrhagic complications, particularly gastrointestinal and respiratory tract bleeding, compared to coil embolization. Patients undergoing PED require careful patient selection and postprocedural management.

Background and ObjectivesData on how percutaneous endoscopic gastrostomy (PEG) utilization has changed over time in patients with acute ischemic stroke (AIS) in the United States are sparse. This study evaluates 17-year trends in PEG utilization in AIS hospitalizations in the United States. MethodsThe 2006-2022 National Inpatient Sample was used to conduct a serial cross-sectional study. International Classification of Diseases codes were used to identify primary AIS hospitalizations with and without PEG. We used joinpoint regression to compute the annualized percentage change (APC) in PEG usage over time and used multivariable regression to evaluate the association of IV thrombolysis (IV-tPA), mechanical thrombectomy (MT), and other hospitalization factors with odds of PEG use. ResultsOf 8,079,538 primary AIS admissions over the study period, the overall PEG prevalence was 3.9% but usage in the subset of AIS admissions undergoing MT was 11.0%. PEG utilization increased with age in both sexes (18-39-year-olds: men 2.7%; women 2.5%; 80 years or older: men 4.7% and women 4.6%). After multivariable adjustment, increasing Elixhauser comorbidity scores (OR 1.31, 95% CI 1.30-1.32) and MT utilization (OR 1.61, 95% CI 1.54-1.68) were associated with higher odds of PEG use while IV-tPA was associated with lower odds of utilization (OR 0.94, 95% CI 0.91-0.97) when compared with no treatment. PEG use declined by 2.9% annually across the study period (average APC 2.9%, 95% CI -3.2 to -2.5%), but the rate of decline was fastest in the period 2014-2018 (APC -7.4%, 95% CI -8.6 to -4.9), followed by 2006-2014 (APC -1.9%, 95% CI -2.5 to -0.9). Utilization did not change significantly in the period 2018-2022. The average time from admission to PEG placement was 9.3 days, and this increased progressively over time (p trend <0.001). DiscussionPEG use in patients with AIS declined over the past decade. This decline is likely due to multifactorial reasons that warrant further studies, but changing clinical practice toward allowing for some more time for patients with AIS to recover from poststroke dysphagia may be one of the potential contributory factors.

BACKGROUND AND OBJECTIVES:In October 2023, the Centers for Medicare & Medicaid Services (CMS) in the United States expanded coverage for carotid artery stenting (CAS) to include non-high-risk patients with carotid disease. The aim of this study was to provide a 17-year snapshot of trends in carotid revascularization practices in the United States before this CMS policy change went into effect. METHODS:We conducted a serial cross-sectional study using the 2006-2022 National Inpatient Sample and a retrospective cohort study using the State Emergency and Inpatient Databases of Florida (2005-2021), Georgia (2010-2020), Maryland (2012-2021), and New York (2005-2020). Cases of carotid revascularizations in these databases were identified using International Classification of Diseases codes. We calculated age-specific and sex-specific proportions of revascularizations for CAS and combined annual CAS/carotid endarterectomy (CEA) counts with census data to determine utilization rates per 100,000 population. Joinpoint regression estimated annualized percentage change (APC) over time. Hospitalizations in the 6 months preceding revascularization defined symptomatic vs asymptomatic cases and characterized the subset with symptomatic stenosis. RESULTS:Of 1,779,948 weighted revascularizations, the mean patient age was 71.0 years and 40.9% were performed in women. 17.2% of procedures were CAS, and this proportion more than doubled from 14.3% to 29.0%. Transcarotid artery revascularization accounted for 9.1% in 2022. The CAS proportion increased across age groups, including in those aged older than 70 years and in women, even after excluding mechanical thrombectomy admission. Carotid revascularization usage per 100,000 population declined (APC -3.9%, 95% CI -4.1% to -3.3%) but plateaued after 2015. Although CEA utilization declined from 2006 to 2022 (APC -5.5%, 95% CI -5.9% to -5.1%), CAS use declined from 2006 to 2016 (APC -3.2%, 95% CI -4.6% to -2.1%) but increased from 2016 to 2022 (APC 12.0%, 95% CI 10.1%-14.1%). Only 25.7% of revascularizations in the 4 states were performed for symptomatic disease, with 75.3% of hospitalizations in women for asymptomatic disease. DISCUSSION:Despite uncertain benefit in selected age and sex groups, including those older than 70 years and with asymptomatic carotid disease, CAS use increased across groups over the past decade and now accounts for >25% of carotid revascularizations in the United States.

Background Rescue intracranial stenting (RICS) is increasingly recognized as a potentially effective rescue strategy following failed mechanical thrombectomy (MT) for large vessel occlusion due to intracranial atherosclerosis, but population‐level data on contemporary patterns of RICS utilization in MT are lacking. The aim of this study is to describe trends in the utilization of RICS in MT in the United States in the last decade. Methods We conducted a serial cross‐sectional study using all primary acute ischemic stroke (AIS) admissions with MT in the 2010–2020 National Inpatient Sample. RICS admissions were defined as those with procedural codes for “percutaneous insertion of intracranial vascular stent” on same day as MT. We used joinpoint regression to evaluate trends in RICS over time and utilized multivariable‐adjusted regression to compare odds of in‐hospital mortality and routine home discharge between RICS versus non‐RICS admissions over time. Results Of the 5 190 148 primary AIS admissions in the United States across the study period, 3.0% had codes for MT. The proportion of MT admissions increased by over 8‐fold from 0.8% in 2010 to 6.5% in 2020. RICS was utilized in 1.8% of MT admissions but this proportion declined by 5.4% annually (annualized percentage change [APC] −5.4% [95% CI, −7.7% to −3.1%]). However, as a proportion of all AIS admissions, RICS in all AIS increased by 20.5% annually (APC 20.5%, [95% CI, 16.0%–25.2%]). Odds of in‐hospital mortality did not differ between RICS compared to non‐RICS MT admissions (odds ratio 1.39 [95% CI, 0.83–2.32]) but RICS admissions had 50% lower odds of routine home discharge compared with non‐RICS admissions. Conclusion RICS is utilized in just under 2% of MT admissions in the United States. This proportion has declined over time but because of increased MT usage in AIS over time, overall utilization in AIS has increased exponentially over time.

INTRODUCTION: Decompressive craniectomy (DC) is a common neurosurgical procedure used to reduce elevated intracranial pressure. Many patients subsequently require cranioplasty (CP) and/or ventriculoperitoneal shunt (VPS) placement. METHODS: This multi-centered retrospective study included 237 adult patients who underwent DC between 2016-2022. Statistical analyses examined associations between procedure timing and outcomes, including shunt revision, readmission rate, LOS, and 6-month Glasgow Outcome Scale (GOS). RESULTS: A total of 237 patients that received DC (54% trauma, 31% stroke, 15% other / multiple indications) were included in our study. The median (IQR) age was 50 years (34-63) and 64% of patients were male. Multivariate regression analysis revealed significant associations between procedure timing and LOS. Patients receiving CP before VPS had the longest average LOS (p=0.008), followed by concurrent CP/VPS (p<0.001), and VPS before CP (p=0.003). However, timing did not impact 6-month GOS, hospital readmission, subdural hygroma, or shunt revision rates at 6 months. Patients receiving synthetic cranioplasty materials had significantly longer LOS compared to autologous bone flaps (p=0.04). Approximately 10% of patients experienced postoperative infection or ventriculitis, with no significant difference between timing groups. CONCLUSIONS: Data from this large multi-centered study revealed that the timing sequence between CP and VPS did not have a significant effect on functional outcomes at 6-months. Additionally, patients who underwent VPS before or concurrently with CP minimized hospital LOS compared to CP before VPS.

Background How the prevalence of atrial fibrillation (AF) has changed over time in various demographic subgroups of patients with acute ischemic stroke (AIS) undergoing mechanical thrombectomy (MT) in the United States is unknown. Whether in‐hospital outcomes differ between patients with AF versus patients without AF after MT remains uncertain. Methods We conducted a serial cross‐sectional study using all primary AIS discharges in the 2010 to 2020 National Inpatient Sample. Discharges with MT codes were identified (n = 155 277), and the proportion with AF in various age, sex, and racial subgroups were computed. We used multivariable‐adjusted negative binomial regression to compare AF prevalence between demographic subgroups and joinpoint regression to evaluate trends over time. Multivariable‐adjusted generalized linear models were used to evaluate the association of AF with in‐hospital outcomes. Results Across the study period, 45.0% of AIS discharges with MT had AF, but prevalence varied by age, sex, and race or ethnicity. After multivariable adjustment, AF prevalence was 4% higher in women versus men (prevalence rate ratio, 1.04 [95% CI, 1.01–1.07]) and was lower in Black versus White (prevalence rate ratio, 0.80 [95% CI, 0.77–0.84]) but higher in Asian compared with White discharges (prevalence rate ratio, 1.11 [95% CI, 1.05–1.18]). Prevalence increased with age (prevalence rate ratio for ≥80 years versus 18–39 years, 5.23 [95% CI, 4.28–6.39]). Following joinpoint regression, prevalence increased by 3.2% (95% CI, 1.3%–5.2%) annually across the period 2010 to 2015 but declined by −2.2% (95% CI −2.9% to −1.4%) from 2015 to 2020. AF was associated with 22% lower odds of in‐hospital death (odds ratio, 0.78 [95% CI, 0.71–0.85]) and 13% greater odds of routine home discharge (odds ratio, 1.13 95% CI, 1.04–1.22]) compared with no AF. Conclusion AF prevalence in patients undergoing MT in the United States is approximately twice that of the general AIS population. AF prevalence in MT increased from 2010 to 2015 but declined from 2015 to 2020. In the subset of patients with AIS undergoing MT, AF is associated with reduced in‐hospital death.

Background How the prevalence of atrial fibrillation (AF) differs between various demographic subgroups of acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy (MT) in the United States (US) is unknown. Data on whether AF prevalence in MT admissions changed over the last decade are sparse.Methods We conducted a serial cross-sectional study using all primary AIS discharges in the 2010-2020 National Inpatient Sample. Discharges with MT codes were identified (n=155,277) and the proportion with AF in various age, sex and racial subgroups were computed. We used multivariable-adjusted negative binomial regression to compare AF prevalence between demographic subgroups and Joinpoint regression to evaluate trends over time. Multivariable-adjusted generalized linear models were used to evaluate the association of AF with in-hospital outcomes.Results Across the study period, 45.0% of AIS discharges with MT had AF but marked disparity existed by age, sex and race. After multivariable adjustment, AF prevalence was 4% higher in women vs. men (prevalence rate ratio [PRR] 1.04, 95%CI 1.01-1.07), was lower in Black vs White (PRR 0.80, 95%CI 0.77-0.84) but higher in Asian compared to White discharges (PRR 1.11, 95%CI 1.05-1.18). Prevalence increased with age (PRR for ≥80 years vs 18-39 years: 5.23, 95%CI 4.28-6.39). Following joinpoint regression, prevalence increased by 3.2% (95%CI 1.3 to 5.2%) annually across the period 2010-2015 but declined by -2.2% (95%CI -2.9% to -1.4%) from 2015-2020. AF was associated with 27% lower odds of in-hospital mortality (Odds ratio 0.72, 95%CI 0.62-0.84) and 31% greater odds of routine home discharge (Odds ratio, 95%CI 1.17 to 1.47) compared to no AF.Conclusion AF prevalence in MT patients in the US is approximately twice that of the general AIS population but marked disparity exists by age, sex and race. AF Prevalence in MT increased from 2010-2015 but declined in the period 2015-2020.What is new? What are the clinical implications? ### Competing Interest StatementDr Chaturvedi is an associate editor for the Stroke journal and Dr Otite is on the Stroke journal editorial board. The other authors have no relevant disclosures### Funding StatementNone### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:IRB approval not needed according to the Healthcare Cost and Utilizations ProjectI confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.YesAll data used in this study can be purchased directly from the Healthcare Cost and Utilization Project. The authors are bound by data use agreeement not to share HCUP data

Arteriovenous fistulas of the filum terminale are rare vascular malformations that predominantly affect males and can present with various neurological symptoms. In this study, we indexed previously published cases of filum terminale arteriovenous fistulas demonstrating that endovascular and microsurgical management are both proven to be appropriate and successful treatment modalities with low complication rates. Endovascular treatment is far less invasive; however, it is associated with higher failure rates, which need to be managed surgically. In this case, we report a 64-year-old male patient who presented with lower back pain and bilateral lower extremity weakness. He was found to have a filum terminal arteriovenous fistula causing thoracolumbar spinal cord edema. Following a failed attempt of endovascular embolization complicated by declining neuromonitoring signals, open microsurgical obliteration of the lesion was successfully performed. While endovascular management of filum terminale arteriovenous fistulas is a viable and successful treatment modality in select cases, surgeons should be prepared to manage these cases with an open microsurgical approach should embolization fail or become unsafe. Proper radiologic characterization of the lesion and accurate localization of the location of the fistula are requisites to a safe and successful obliteration of these lesions.

Background: Utilization of oral anticoagulants for acute ischemic stroke (AIS) prevention in patients with atrial fibrillation (AF) increased in the United States over the last decade. Whether this increase has been accompanied by any change in AF prevalence in AIS at the population level remains unknown. The aim of this study is to evaluate trends in AF prevalence in AIS hospitalizations in various age, sex, and racial subgroups over the last decade. Methods: We used data contained in the 2010–2020 National Inpatient Sample to conduct a serial cross-sectional study. Primary AIS hospitalizations with and without comorbid AF were identified using International Classification of Diseases Codes. Joinpoint regression was used to compute annualized percentage change (APC) in prevalence and to identify points of change in prevalence over time. Results: Of 5,190,148 weighted primary AIS hospitalizations over the study period, 25.1% had comorbid AF. The age- and sex-standardized prevalence of AF in AIS hospitalizations increased across the entire study period 2010–2020 (average APC: 1.3%, 95% confidence interval (CI): 0.8–1.7%). Joinpoint regression showed that prevalence increased in the period 2010–2015 (APC: 2.8%, 95% CI: 1.9–3.9%) but remained stable in the period 2015–2020 (APC: –0.3%, 95% CI: –1.0 to 1.9%). Upon stratification by age and sex, prevalence increased in all age/sex groups from 2010 to 2015 and continued to increase throughout the entire study period in hospitalizations in men 18–39 years (APC: 4.0%, 95% CI: 0.2–7.9%), men 40–59 years (APC: 3.4%, 95% CI: 1.9–4.9%) and women 40–59 years (APC: 4.4%, 95% CI: 2.0–6.8%). In contrast, prevalence declined in hospitalizations in women 60–79 (APC: –1.0%, 95% CI: –0.5 to –1.5%) and women ⩾ 80 years over the period 2015–2020 but plateaued in hospitalizations in similar-aged men over the same period. Conclusion: AF prevalence in AIS hospitalizations in the United States increased over the period 2010–2015, then plateaued over the period 2015–2020 due to declining prevalence in hospitalizations in women ⩾ 60 years and plateauing prevalence in hospitalizations in men ⩾ 60 years.

Introduction: The American Heart Association recommends a Door-to-Recanalization/Reperfusion (DTRp) time of ≤120 minutes. We aim to identify aortic arch and carotid artery anatomy parameters associated with a delayed DTRp at a comprehensive stroke center (CSS). Methods: We performed a retrospective chart review of patients who underwent mechanical thrombectomy (MT) for an anterior circulation large vessel occlusion (LVO) at a CSS from 1/2015 to 12/2021. We compared various aortic arch and carotid artery anatomy parameters between patients who achieved DTRp in ≤120 minutes vs.>120 minutes. A blinded board-certified neuroradiologist used the pre-MT CT Angiogram to document different aortic arch and carotid artery anatomy variables. A binary logistic regression analysis was performed, controlling for age, gender, presenting mean arterial pressure (MAP), presenting serum glucose, Hb A1C, LDL, intravenous alteplase, left hemispheric location, location of occlusion [proximal (ICA or M1 segment of the middle cerebral artery) versus distal (M2 segment of the middle cerebral artery)], ASPECTS≥6, general anesthesia, transradial approach, number of passes. Results: 256 patients met our inclusion criteria. The mean age was 65.18±14.89 years. In our cohort, the presence of a bovine arch was significantly associated with a DTRp of >120 minutes (39.19% vs. 20.59%; OR, 0.37; 95 % CI, 0.15-0.94; P 0.035). Whereas, the other aortic arch and carotid artery anatomy parameters were not significantly associated with DTRp of >120 minutes, as shown in the Table. Conclusion: Among aortic arch and carotid artery anatomy parameters, the presence of a bovine arch was associated with significantly delayed DTRp of >120 minutes in our cohort.

Introduction Transradial access (TRA) for neuroendovascular interventions has been associated with multiple benefits, including decreased risk of complications, faster recovery times, and improved overall patient satisfaction in comparison to transfemoral access (TFA). We sought to assess the safety and suitability of an 088 catheter, in this case the Infinity guide catheter, to understand the optimal patient population for utilization in neurointerventions. To our knowledge, this is the first prospective study to investigate procedural characteristics and complications associated with the use of an 088 catheter. Methods After obtaining approval from our Institutional Review Board, prospective patients undergoing neurointerventional procedures at our institution, beginning from December 2020 to present, were serially enrolled after evaluation for suitability for TRA by ultrasound visualization and measurement of vessel diameter. A prospective Excel database was generated on an encrypted and password‐protected computer, with variables including patient demographics, co‐morbidities, procedure type, catheter specifics, vessel diameter, procedural characteristics, TRA to TFA conversion, and complications. Results 78 patients were enrolled over a 1.5 year study period (Table 1). The average patient age was 62.4 ± 16.1 years, with a moderate male predilection (46/78 (59%)). Procedure subtypes for enrolled patients included 36 (46.2%) patients who underwent stroke intervention, 6 (7.7%) aneurysm coil embolization, 9 (11.5%) aneurysm flow diversion, 5 (6.4%) carotid stenting, 5 (6.4%) AVM/AVF embolization, 4 (5.1%) tumor embolization, and 13 other procedures (9 (11.5%) MMA embolization, 3 (3.8%) vessel embolization, 1 (1.3%) aneurysm Onyx embolization). All procedures were performed via right radial access under direct ultrasound visualization. Average radial diameter was 2.97 ± 0.46mm and average fluoroscopy time was 48.99 ± 23.54 minutes. Parent vessel spasm was noted in 25/78 (32.1%) of cases and guide catheter kinking was noted in 4/78 (5.1%). TRA to TFA conversion was noted in 14/78 (17.9%) patients, primarily due to vessel tortuosity (57.1%; 8/14 cases). Minor complications included post‐procedural hand/wrist pain in 14/78 (17.9%) patients, and hand bruising in 6/78 (7.7%). Post‐operative vessel patency was noted in 71/78 (91%) of cases via ultrasound, with 57/78 (73.1%) having good pulsation noted on reverse Barbeau testing. No serious radial artery complications were noted. The overall rate of major complications was 7.7%, with two cases of ischemic stroke, contrast extravasation/intracerebral hemorrhage, and vessel rupture noted. Conclusions This prospective pilot study demonstrates the safety and suitability of the 088 Infinity guide catheter via TRA radial approach for neuroendovascular interventions. Further studies will be needed to assess the efficacy of the 088 Infinity in comparison to other 088 catheters, as well as the optimal settings by which we can minimize rates of TFA conversion and TRA‐related complications.

Introduction Management of acute large vessel occlusion due to intracranial stenosis remains challenging with high complication and poor recanalization rates. Morbidity is also related to the intracranial exchange that is required for stent placement after the rescue angioplasty. We aim to present our initial experience of deployment of Neuroform Atlas stent through the lumen of a Gateway angioplasty balloon to avoid microcatheter exchange. Methods Patients were identified from prospectively collected mechanical thrombectomy stroke database from Feb 2019 to July 2021. Demographic and clinical information was collected. Primary outcomes were favorable functional outcome at hospital discharge (modified Rankin Scale (mRS) score of 0–3), and the rate of intracranial hemorrhage (ICH). Good angiographic recanalization (TICI ≥ 2b), and mortality at 30 days were other outcomes. Results We identified 5 patients treated with this approach [mean age 54 ± 14 years, all were men] who presented with large vessel occlusion of middle cerebral artery. Initial median NIHSS was 8 (range 6–16) with one patient received IV t‐PA. Patient initially underwent mechanical thrombectomy using the Solumbra technique. Due to reocclusion or impending occlusion with evidence of atherosclerotic plaque, rescue angioplasty with stent placement was performed. Patients were loaded with 650 mg of aspirin and 180 mg of ticagrelor through nasogastric tube prior. Balloon angioplasty was performed using the gateway balloon size ranging from 1.5 to 3 mm which was inflated to subnominal pressures over 1 minutes. This was followed by placing Neuroform atlas stent through the gateway balloon with size ranging from 3 to 4 mm diameter and length ranges from 21–24 mm. TICI ≥ 2b was achieved in 4 patients. Mean time from symptoms onset to revascularization was (336 ± 90) minutes. One patient had asymptomatic ICH. 2 patients had mRs 0–3 at the time of discharge and one patient was dead at 1 month Conclusions Our preliminary experience showed lower risk of guidewire perforation as well as potentially decreased operative time and early reperfusion by deploying the Neuroform stent through a compatible gateway balloon microcatheter. This should be investigated further in a large multicenter study

Neuroform Atlas stent can be deployed directly via gateway balloon for angioplasty and stent placement without the need for exchange maneuver required for Wingspan stent use. We present our initial experience of this strategy in intracranial atherosclerosis‐associated large vessel occlusions.

BackgroundCoronavirus disease 2019 (COVID-19) is an immunoinflammatory and hypercoagulable state that contributes to respiratory distress, multi-organ dysfunction, and mortality. Dipyridamole, by increasing extracellular adenosine, has been postulated to be protective for COVID-19 patients through its immunosuppressive, anti-inflammatory, anti-coagulant, vasodilatory, and anti-viral actions. Likewise, low-dose aspirin has also demonstrated protective effects for COVID-19 patients. This study evaluated the effect of these two drugs formulated together as Aggrenox in hospitalized COVID-19 patients.MethodsIn an open-label, single site randomized controlled trial (RCT), hospitalized COVID-19 patients were assigned to adjunctive Aggrenox (Dipyridamole ER 200mg/ Aspirin 25mg orally/enterally) with standard of care treatment compared to standard of care treatment alone. Primary endpoint was illness severity according to changes on the eight-point COVID ordinal scale, with levels of 1 to 8 where higher scores represent worse illness. Secondary endpoints included all-cause mortality and respiratory failure. Outcomes were measured through days 14, 28, and/or hospital discharge.ResultsFrom October 1, 2020 to April 30, 2021, a total of 98 patients, who had a median [IQR] age of 57 [47, 62] years and were 53.1% (n = 52) female, were randomized equally between study groups (n = 49 Aggrenox plus standard of care versus n = 49 standard of care alone). No clinically significant differences were found between those who received adjunctive Aggrenox and the control group in terms of illness severity (COVID ordinal scale) at days 14 and 28. The overall mortality through day 28 was 6.1% (3 patients, n = 49) in the Aggrenox group and 10.2% (5 patients, n = 49) in the control group (OR [95% CI]: 0.40 [0.04, 4.01], p = 0.44). Respiratory failure through day 28 occurred in 4 (8.3%, n = 48) patients in the Aggrenox group and 7 (14.6%, n = 48) patients in the standard of care group (OR [95% CI]: 0.21 [0.02, 2.56], p = 0.22). A larger decrease in the platelet count and blood glucose levels, and larger increase in creatinine and sodium levels within the first 7 days of hospital admission were each independent predictors of 28-day mortality (p < 0.05).ConclusionIn this study of hospitalized patients with COVID-19, while the outcomes of COVID illness severity, odds of mortality, and chance of respiratory failure were better in the Aggrenox group compared to standard of care alone, the data did not reach statistical significance to support the standard use of adjuvant Aggrenox in such patients.

Introduction Continued advancements in the treatments for neurological disease have helped interventionalists to refine approaches that offer improved surgical efficacy and patient outcomes. Carotid‐artery stenting (CAS) is a safe and effective alternative to carotid endarterectomy (CEA), that allows for revascularization of the internal carotid artery (ICA) in a minimally‐invasive manner. Traditionally, the mainstay for CAS has been through the femoral artery; however, patients with carotid‐artery disease (CAD) often have concomitant peripheral artery disease which confer increased risk of significant life‐threatening access‐site complications, such as retroperitoneal hematoma and limb ischemia. Given this, CAS via the radial artery has become increasingly popular. This study seeks to investigate the safety and feasibility of the transradial approach (TRA), in comparison to the traditional transfemoral approach (TFA), for carotid‐artery stenting. Methods The authors conducted a retrospective analysis of all adult patients (age >18) who underwent carotid‐artery stenting via TRA or TFA over a 4‐year study period (2018‐2021) across 4 different international academic centers. Important variables, such as patient demographics, comorbidities, procedural details, results, and complications were collected. Statistical analysis was performed to assess the strength of association and correlation for these variables. Results A total of 313 patients were enrolled during the study period. CAS via TFA was attempted in 251 patients and via TRA in 62 patients, respectively. Overall, CAS via TRA was found to be successful in 48/62 (76%) patients, and via TFA in 246/251 (98%) patients. Baseline demographics were similar for the two groups, with a female gender predilection, median age of 69, and hypertension and hyperlipidemia serving as the most common medical comorbidities. 14/62 (22.6%) patients who underwent TRA were converted to TFA. Spasm of the radial artery, kinking of the catheter and severe tortuosity of the vessels were the primary reasons for access site conversion. A total of five major access site‐related complications, including two deaths, and seven minor complications were noted in the TFA cohort. No serious access related complications were noted in the TRA group. In the multivariate‐analysis, after adjusting for age, hyperlipidemia, chronic heart failure, combination of stent plus angioplasty and fluoroscopy times, there was no statistically significant difference observed among the 2 groups in terms of procedural (OR: 0.31; CI: 0.36‐2.69; P = 0.29) and overall access site complications (OR: 0.17, CI: 0.02‐1.98, P = 0.16). Conclusions TRA seems to be a safe alternative approach for carotid stenting. In our cohort, no serious access site‐related complications were noted with TRA in comparison to the TFA group. Continued improvements in terms of patient selection, sample size, as well as advances in technique and technology will help to further refine TRA for CAS. Further studies and analysis will need to be performed to delineate the crucial variables that contribute to improved functional outcomes for these patients.