BACKGROUND AND OBJECTIVES:Pediatric intracranial aneurysms are rare and often exhibit complex morphologies not amenable to conventional microsurgical reconstruction or endovascular embolization. The Pipeline Embolization Device (PED) is an alternative endovascular treatment of these lesions; however, this device is not approved by the US Food and Drug Administration for use in children due to limited data. Here, we investigated the safety and efficacy of the PED in the pediatric population and compared these outcomes with those in adult populations to expand the current literature in using this device in children. METHODS:A systematic literature review of the PubMed database was performed to identify studies describing the PED in children (18 years or younger). The authors' institutional experience with the device in children was included. Basic analyses of the pediatric cohort were performed. Comparative analyses of safety and efficacy outcomes were conducted between the pediatric cohort and previous adult studies. RESULTS:A total of 114 pediatric patients with 120 intracranial aneurysms were included. Six previous adult studies provided 2098 patients with 2393 aneurysms. There were no significant differences in major complications or neurologic mortality between populations. Pediatric patients were more likely to develop asymptomatic in-stent stenosis (4.2% vs 1.1%, P = .005) and asymptomatic in-stent thrombosis (3.4% vs 0.2%, P < .001). Complete aneurysm occlusion was higher in children on follow-up angiography (92.0% vs 76.7%, P < .001). The incidence rates of major complications and neurologic mortality per patient-month at risk were similar between populations. CONCLUSION:In this study, we found that off-label use of the PED for pediatric intracranial aneurysms has an overall similar safety profile, yet improved efficacy outcome compared with on-label use in adults. These data may help lay the foundation for approval of the PED in treating pediatric intracranial aneurysms.

BACKGROUND AND OBJECTIVES:Dual antiplatelet therapy (DAPT) is considered the standard medication regimen after Pipeline Embolization Device (PED) treatment of intracranial aneurysms. However, the optimal duration of DAPT after PED remains uncertain. We compared the safety and efficacy of 3 months vs 6 months or more of DAPT in the PED treatment of intracranial aneurysms. METHODS:We performed a retrospective cohort comparison study of 257 consecutive patients with intracranial aneurysms treated with PED who were either prescribed a 3-month (early termination) or ≥6-month course (standard duration) of DAPT. All patients had clinical follow-up of at least 3 months after discontinuation of DAPT. Baseline demographics, aneurysm characteristics, periprocedural data, complications before and after discontinuation of DAPT, and aneurysm occlusion rates on follow-up angiography were compared between cohorts. RESULTS:The study cohort consisted of 257 patients, including 155 patients in the early termination group and 102 patients in the standard duration group. Total complications after DAPT discontinuation were significantly lower in the early termination cohort (1.3% vs 9.8%, P = .002). There were no significant differences in total major complications between groups after DAPT cessation, nor were there differences in any specific major complication. Minor thromboembolic complications were significantly lower in the early termination cohort (1.3% vs 8.8%, P = .008) after DAPT discontinuation without a significant difference in any specific event. The rate of complete aneurysm occlusion on 6-month follow-up angiography was significantly higher in the early termination cohort (82.6% vs 70.6%, P = .024). CONCLUSION:In this study, we found that early termination of DAPT at 3 months after PED treatment has overall similar safety and efficacy outcomes as compared with the current standard 6-month regimen. These preliminary data encourage prospective studies to determine optimal DAPT durations in the PED treatment of intracranial aneurysms.

Introduction: Mechanical thrombectomy (MT) is the standard treatment for Acute ischemic stroke (AIS) patients with large intracranial vessel occlusion (LVO). The TRACE III trial demonstrated that treatment with tenecteplase (TNK) administered within 24 hours after stroke onset improves functional outcome in AIS patients with LVOs who do not undergo MT. TRACE III results are felt to have less impact in the U.S as the majority of AIS with LVO in this country are offered MT. However, the TRACE III results would be relevant to the cohort of LVO patients who do not go to thrombectomy, and therefore we sought to review the reasons AIS patients with LVO are excluded from MT. Methods: During a 2 year period at out academic comprehensive stroke center (CSC) from July 2022 to June 2024, we identified 58 patients with AIS and LVO who did not undergo MT. We excluded AIS who presented > 24 hours from last know normal (LKN), patients with chronic occlusions, and patients who did not have an LVO. LVO was defined as anterior circulation occlusion of the internal carotid artery terminus (ICAT) or the middle cerebral artery (M1 and M2 segments). We performed a retrospective chart review collecting data on demographics, National Institutes of Health Stroke Scale (NIHSS), CT head and neck angiogram findings, thrombolysis administration, and reviewed the reasons documented for not pursuing MT. Results: Among the 58 AIS patients who did not undergo MT, the mean age was 70.8 years (range, 30.8 to 95.0) and 31 (53.4%) were female. The mean NIHSS was 14.1 (range, 0 to 31). The LVO locations included 24 (41.4%) M2, 23 (39.7%) M1, and 11(19.0%) ICAT. Twenty-three patients (39.7%) had a concomitant tandem lesion with cervical carotid occlusion, and 17 (29.3%) of patients received thrombolysis with TNK. The reason for not pursuing thrombectomy were as follows: proximal carotid occlusion in 16 (27.6%), low NIHSS in 13 (22.4%), large core infarct in 9 (15.5%), distal occlusion (M2s) in 8 (13.8%), hemorrhage in 4 (6.9%), poor baseline in 3 (5.2%), and Other in 5 (8.6%). Conclusions: At our academic CSC, the most common reason for excluding LVO stroke patients from thrombectomy include tandem lesions with cervical carotid occlusion, low NIHSS, large core infarcts, and distal occlusion. Understanding the reasons AIS patients with LVOs are excluded from thrombectomy will allow clinicians to identify populations for further clinical study.

INTRODUCTION: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke for select patients with large vessel occlusion (LVO). Although racial disparities in the utilization of thrombectomy have been previously identified, disparities in the utilization of thrombectomy in a single center with a standardized patient selection protocol have not been described in the literature. METHODS: Using the American Heart Association Quality Improvement Programs Registry, we retrospectively reviewed the records of 1,143 patients with LVO between December 1, 2014, and May 31, 2021. Patient records were assessed for demographic data, stroke risk factors, process metrics, and success of thrombectomy. A Pearson’s Chi-Squared and an independent two-sample t-test were used to determine the significance. Following this, a multivariate logistic regression was run to determine predictably of thrombectomy outcomes. RESULTS: Of the 1,143 LVO patients, 567 were male (49.6%), 576 were female, (50.4%), 963 were white (84.3%), and 180 were nonwhite (15.7%). Based on our Pearson’s Chi-squared analysis, female patients were more like to undergo thrombectomy compared to male patients (62.4% vs. 48.9%; P < 0.001). White patients were also more likely to undergo thrombectomy compared to nonwhite patients (58.7% vs. 39.7%; P < 0.001). After the multivariate logistic regression analysis and after controlling for comorbidities, insurance status, age, time to presentation (last known well to arrival), transfer from outside hospital, and zip codes, white patients were 2.29 times more likely to receive a thrombectomy compared to nonwhite patients (odds ratio [OR], 2.29, 95% confidence interval [CI], 1.33, 3.944). Patients with Medicare insurance were 33.57 times more likely to receive a thrombectomy compared to those without medicare (OR, 33.57, 95% CI, 20.37, 55.327). In the regression model, sex did not contribute significantly to the likelihood of receiving a thrombectomy. CONCLUSIONS: White patients were more likely to undergo MT. Female patients tended to have higher rates of MT, accounting for the fact that other variables could have influenced this. These disparities may result from a multitude of other factors such as eligibility for MT, delayed presentation, and adequate diagnosis of LVO in the emergency department. This study highlights the importance of and potential causes of these disparities. Further investigation with data from multiple centers is necessary to validate these findings and identify strategies for improving utilization of thrombectomy.

INTRODUCTION:Flow diversion is an effective first-line treatment for intracranial aneurysms; however, the rate of incomplete occlusion is not insignificant. Data in neuroendovascular literature is limited regarding the implications of persistent incomplete occlusion despite flow diversion. METHODS:We conducted a retrospective analysis of a prospectively maintained database and identified 125 consecutive patients with treatment naïve intracranial aneurysms who underwent flow diversion with the PED from April 2014 - November 2022. Patients were divided into 3 groups based on the duration of stasis: venous, capillary, and no stasis. Comparative and multivariate analyses were performed between the three groups. RESULTS:At latest follow-up, complete occlusion occurred in 69.6 % and 82.4 % showed progression of occlusion. Retreatment was required in 2.4 %. There was no significant difference in retreatment (p = 0.667), complete occlusion (p = 0.774) or progression of occlusion (p = 0.848) at latest follow up. No patients experienced subarachnoid hemorrhage post-treatment. On multivariate analysis, hypertension was a negative predictor for complete occlusion (p = 0.006) and progression of occlusion (p = 0.017), while duration of stasis was noncontributory. The mean latest follow up was 12.55 months. CONCLUSION:Flow diversion is a safe and effective first line treatment for intracranial aneurysms with a relatively low complication rate. Hypertension was a negative predictor of complete occlusion and progression of occlusion, while the degree of occlusion post-flow diversion may not be predictive of future rupture risk and the Raymond Roy Occlusion classification may not apply. The degree of stasis after initial treatment was not predictive of future occlusion, retreatment, nor aneurysm rupture risk. However, stasis degree may be worth additional analysis given this studies sample size, lack of long-term follow-up, and the lack of predictive factors in current literature to guide post-flow diversion management.

BACKGROUND:A number of large bore guide catheters are currently available for use in neuroendovascular surgery. This study represents a multi-institutional retrospective series of patients undergoing mechanical thrombectomy with the use of a TracStar Large Distal Platform (LDP) guide catheter and assessed its performance in vivo in 107 patients. OBJECTIVE:To review a multi-institutional initial experience with the TracStar LDP guide catheter during mechanical thrombectomy for emergent large vessel occlusion (ELVO). METHODS:A retrospective review was performed at two level one stroke centres to include all patients who underwent mechanical thrombectomy and had the TracStar LDP guide catheter used during the intervention. RESULTS:The TracStar LDP guide catheter was successfully used in 107 mechanical thrombectomies. In anterior circulation ELVO, the guide catheter advanced into the cavernous segment of the internal carotid artery in 62.6% (62/99) of cases. In posterior circulation cases, the guide catheter advanced to the basilar artery in 87.5% (7/8) of cases. A thrombolysis in cerebral infarction 2b or greater reperfusion was obtained in 90.7% (97/107). No complications occurred related to the TracStar LDP guide catheter. Three complications occurred with aspiration catheters including a small dissection that did not require further intervention and fracturing of the AXS Catalyst 6 catheter tip in two cases. No thromboembolic events occurred. CONCLUSIONS:The TracStar LDP large bore guide catheter is safe and effective at navigating the tortuous vascular anatomy often encountered during mechanical thrombectomy for stroke. The flexible distal and stiffer proximal components provide a good combination of navigability and support for use in neuroendovascular interventions.

Introduction: Carotid blowout syndrome (CBS) is a potentially life-threatening complication of head and neck cancer and associated treatment. In this study, we assess the safety and efficacy of deconstructive and reconstructive procedures with a focus on CBS recurrence. Methods: We conducted a multicenter retrospective analysis of a prospectively maintained database and identified 80 consecutive neurointerventions for CBS from 2016 to 2020. Patients were divided into 2 groups: deconstructive embolization (68 patients) and reconstructive stenting (12 patients). A comparative analysis was performed between the two groups. Results: The CBS recurrence rate was 23.8 % with 84.2 % of recurrences occurring within 90 days of the primary event. The median time to rebleeding was 8.0 days (IQR: 2.0 - 28.5) with a mortality rate of 26.3 %. There was no significant difference in rates of peri-operative ischemic stroke (1.5 % vs. 0 %, p=0.672) or peri-operative mortality (1.5 % vs. 0 %, p=0.670). CBS recurrence was significantly higher in the reconstructive group (58.3 % vs. 17.6 %, p=0.002). On multivariate analysis, reconstructive stenting independently predicted rebleeding (adjusted hazard ratio 8.31, 95 % CI: 2.34-29.59, p=0.001). There was no significant association between CBS recurrence and pre-operative (p=0.600) or post-operative (p=0.275) anticoagulant/antiplatelet use. Conclusion: CBS remains a challenging and potentially catastrophic complication of head and neck cancers. Reconstructive procedures, including stenting, predicted CBS recurrence independent of bleeding site or tumor invasion. Postoperative surveillance based on time intervals to CBS recurrence and engineering advancements including improved vessel reconstruction devices have the potential to reduce rehemorrhage rates and improve patient outcomes. Further clinical investigations amongst larger cohorts are needed.

ImportanceRecent large infarct thrombectomy trials used heterogeneous imaging modalities and time windows for patient selection. Noncontrast computed tomographic (CT) scan is the most common stroke imaging approach. It remains uncertain whether thrombectomy is effective for patients with large infarcts identified using noncontrast CT alone within 24 hours of stroke onset.ObjectiveTo evaluate the effect of thrombectomy in patients with a large infarct on a noncontrast CT scan within 24 hours of onset.Design, Setting, and ParticipantsOpen-label, blinded–end point, bayesian-adaptive randomized trial with interim analyses for early stopping (futility or success) or population enrichment, which was conducted at 47 US academic and community-based stroke thrombectomy centers. Three hundred patients presenting within 24 hours with anterior-circulation, large-vessel occlusion and large infarct on noncontrast CT scan, with Alberta Stroke Program Early CT Scores of 2 to 5, were randomized to undergo thrombectomy or usual care. Enrollment occurred July 16, 2019 to October 17, 2022; final follow-up, January 25, 2023.InterventionThe intervention patients (n = 152) underwent endovascular treatment using standard thrombectomy devices and usual medical care. Control patients (n = 148) underwent usual medical care alone.Main Outcomes and MeasuresThe primary efficacy end point was improvement in 90-day functional outcome measured using mean utility-weighted modified Rankin Scale (UW-mRS) scores (range, 0 [death or severe disability] to 10 [no symptoms]; minimum clinically important difference, 0.3). A bayesian model determined the posterior probability that the intervention would be superior to usual care; statistical significance was a 1-sided posterior probability of .975 or more. The primary adverse event end point was 90-day mortality; secondary adverse event end points included symptomatic intracranial hemorrhage and radiographic intracranial hemorrhage.ResultsThe trial enrolled 300 patients (152 intervention, 148 control; 138 females [46%]; median age, 67 years), without early stopping or enrichment; 297 patients completed the 90-day follow-up. The mean (SD) 90-day UW-mRS score was 2.93 (3.39) for the intervention group vs 2.27 (2.98) for the control group with an adjusted difference of 0.63 (95% credible interval [CrI], −0.09 to 1.34; posterior probability for superiority of thrombectomy, .96). The 90-day mortality was similar between groups: 35.3% (53 of 150) for the intervention group vs 33.3% (49 of 147) for the control group. Six of 151 patients (4.0%) in the intervention group and 2 of 149 (1.3%) in the control group experienced 24-hour symptomatic intracranial hemorrhage. Fourteen patients of 148 (9.5%) in the intervention group vs 4 of 146 (2.7%) in the control group experienced parenchymal hematoma type 1 hemorrhages; 14 (9.5%) in the intervention group vs 5 (3.4%) in the control group experienced parenchymal hematoma type 2 hemorrhages; and 24 (16.2%) in the intervention group vs 9 (6.2%) in the control group experienced subarachnoid hemorrhages.Conclusions and RelevanceAmong patients with a large infarct on noncontrast CT within 24 hours, thrombectomy did not demonstrate improvement in functional outcomes. But the width of the credible interval around the effect estimate includes the possibility of both no important effect and a clinically relevant benefit, so the potential role of thrombectomy with this imaging approach and time window will likely require additional study.Trial RegistrationClinicalTrials.gov Identifier: NCT03805308

INTRODUCTION:Venous sinus stenting is a well established alternative to cerebrospinal fluid diversion for the treatment of idiopathic intracranial hypertension (IIH) with associated venous sinus stenosis. During this procedure, distal guide catheter placement within the venous sinuses may be desirable to facilitate stent delivery. We report our initial experience using the TracStar LDP™ (Imperative Care, Campbell, USA, 0.088-inch inner diameter) as the guide catheter for intracranial access during venous sinus stenting. METHODS:A multi-institutional retrospective chart review of a prospectively maintained IRB-approved database was performed. Consecutive patients who underwent venous sinus stenting from 1/1/2020-9/6/2021 for IIH were included. Patient characteristics, procedural details, TracStar distal reach, outcomes, and complications were collected and analyzed. RESULTS:Fifty-eight patients were included. The mean age was 33.8 years and 93.1% of patients were female. Visual changes prompted evaluation in 86.2% of patients. Stent placement was successful in all patients. The TracStar LDP catheter was advanced to the location of stent placement in 97.9% of cases in which it was attempted. The large 0.088-inch inner diameter lumen enabled compatibility with all desired stent sizes ranging from six to 10 millimeters. Gradient pressure across transverse sinus stenosis dropped from an average of 19.5 mmHg pre-procedure to 1.7 mmHg post-stent placement (p < 0.001). Clinical improvement was achieved in 87.9% (51/58) of patients. There were no catheter-related complications. CONCLUSION:The TracStar LDP is a safe and effective access platform for reaching treatment locations in patients who present with idiopathic intracranial hypertension and who are candidates for venous sinus stent placement.

INTRODUCTION: Endovascular mechanical thrombectomy (EVT) has become the standard of care treatment for both intravenous tissue plasminogen activator eligible and ineligible patients presenting with an acute ischemic stroke due to a large vessel occlusion (LVO) within 24 h. Due to limited access to EVT, patients typically present to a non-EVT-capable center and are transferred to a larger, EVT-capable center. Quality improvement work has focused on improving this process to shorten the time to definitive recanalization of the affected vessel. MATERIALS AND METHODS: We retrospectively reviewed 98 consecutive patients who were transferred from an outside institution to our Comprehensive Stroke Center from July 2019 to September 2021. Thirty-nine of these patients had a diagnosed LVO at the transferring center on computed tomography angiography and were transferred directly to the angiography suite (DAT) whereas 59 patients were transferred to our Emergency Department for further imaging (EDT). Three of the patients in the DAT group did not undergo thrombectomy as there was no LVO identified on catheter angiography and were excluded from the study. RESULTS: Demographic and medical comorbidities were similar between the two groups. The DAT group had more severe strokes on presentation compared to the EDT group as measured by the National Institute of Health Stroke Severity (17.5 vs. 15, P = 0.048). Last known well (LKW) to arrival time in the angiography suite was significantly shorter in the DAT group (280 min vs. 474 min, P = 0.002). Patients in the DAT group were revascularized faster than the EDT group relative to LKW (320 min vs. 534 min, P < 0.001) while door-to-groin puncture and door-to-revascularization rates were similar. Modified Rankin score, incidence of symptomatic intracranial hemorrhage, and need for decompressive hemicraniectomy were similar between the two groups. Successful revascularization as measured by thrombolysis in cerebral infarction score occurred at a higher rate in the DAT group but was not statistical significance (97% vs. 85%, P = 0.055). DISCUSSION/CONCLUSION: DAT resulted in safe EVT compared to EDT with significant improvement in LKW to angiography suite presentation and subsequent vessel recanalization. Patients who underwent DAT experienced similar functional outcomes compared to EDT despite experiencing more severe strokes.

Background:The United States is experiencing a rapidly increasing rate of opioid drug abuse. Intravenous drug use (IVDU)-related endocarditis can lead to significant neurological complications with high morbidity and mortality. When patient care necessitates anticoagulation, the standards for radiographic screening and the risk for intracranial hemorrhage are not clearly elucidated. Methods:We conducted a retrospective cohort study involving patients treated for infective endocarditis at a single institution from 2014 to 2018. Patients were grouped based in history of IVDU and their demographics and clinical predictors for intracranial hemorrhage were analyzed. Results:A total of 351 patients met inclusion criteria for this study, of whom 170 patients (48%) had a history of IVDU-associated endocarditis. IVDU was associated with an increased prevalence of intracranial hemorrhage (25.9% versus 13.9%; P=0.005), including intraparenchymal hemorrhage (12.4% versus 5.1%; P=0.012), subarachnoid hemorrhage (17.6 versus 4.4%; P=0.001), and cerebral microbleeds (14.1% versus 7.2%; P=0.022). IVDU was also associated with an increased incidence of infectious intracranial aneurysm (10.6% versus 1.8%; P=0.001) and brain abscesses (4.7% versus 1.1%; P=0.025). Multivariate analysis showed that the presence of intracranial septic emboli (odds ratio [OR], 18.47 [8.4-40.250]; P=0.001) and infectious intracranial aneurysm (OR, 12.38 [3.24-47.28]; P=0.001) as significant predictive factors for intracranial hemorrhage after presenting with endocarditis. Conclusion:The opioid epidemic has increased the incidence of infective endocarditis and resultant neurovascular complications. IVDU-associated endocarditis is associated with increased hemorrhagic stroke and more frequent neurodiagnostic imaging.

Introduction: Mechanical thrombectomy is the standard of care for acute ischemic stroke for select patients with large vessel occlusion (LVO). Racial and gender disparities exist in the incidence, morbidity, and mortality related to stroke. Furthermore, racial disparities in the utilization of thrombectomy have been previously identified. However, disparities in the utilization of thrombectomy in a single center with a standardized patient selection protocol have not been described. Methods: Using the American Heart Association Quality Improvement Programs Registry, we retrospectively reviewed the records of 1,143 patients with LVO between December 1, 2014, and May 31, 2021. Patient records were assessed for demographic data, stroke risk factors, process metrics, and success of thrombectomy. A Pearson’s Chi-Squared and an Independent two-sample T-test were used to determine significance. Results: Of the 1,143 LVO patients, 50.4% were female, 49.6% were male, 84.3% were white, 15.7% were nonwhite. Males were more likely to have diabetes compared to females (22.8% versus 17.9%; p=0.044). There were no significant differences based on race for stroke risk factors including diabetes and atrial fibrillation. Patient selection for thrombectomy was determined by a protocol agnostic to gender and race. Female patients were more likely to undergo thrombectomy compared to males (62.4% versus 48.9%; p<0.001). White patients were more likely to undergo thrombectomy compared to nonwhites (58.7% versus 39.7%; p<0.001). White patients were more likely to have a shorter interval between their last known well (LKW) to arrival (454 minutes versus 533 minutes; p=0.008) despite the fact our nonwhite patients were more likely to originate from our local county (58.1% versus 8.3%; p<0.001). Conclusions: In our analysis of LVO patients, female patients and white patients were more likely to undergo mechanical thrombectomy. The higher incidence of diabetes in males may have resulted in the patients presenting with a larger core infarct, making them ineligible for thrombectomy. Further investigation with data from multiple centers will be necessary to validate these findings and identify strategies for improving utilization of thrombectomy.

Introduction: Mobile Stroke Treatment Units (MSTU) can reduce time to pre-arrival intravenous thrombolysis (IVtPA) and reversal for intracerebral hemorrhage (ICH). We are reporting our experience as a comprehensive stroke center (CSC) receiving MSTU patients. Methods: We retrospectively reviewed consecutive patients transported by MSTU to our academic CSC from May 2019-May 2021 for suspected stroke. The Columbus MSTU is owned by a separate health system, but is a collaborative venture with 3 CSCs and Columbus Division of Fire, operating daily from 7am-7pm. Data was abstracted on demographics, clinical presentation, last known normal (LKN) time, initial National Institutes of Health Stroke Scale (NIHSS), neuroimaging, and IVtPA administration. Results: Among 144 patients transported to our CSC by MSTU, mean age was 66 years (range, 21-99) and 84 (88%) were female. Mean initial NIHSS was 8.6 (range, 0 to 32) and 84 (58.2%) had a final diagnosis of stroke. IVtPA was administered in 26 (18.1%) with a mean LKN to IVtPA time of 109 minutes (range, 41 to 243). Among 26 patients treated with IVtPA, 18 (69.2%) received IVtPA in MSTU and 8 (30.8%) received rescue IVtPA in CSC Emergency Room (ER). 14 patients underwent thrombectomy with median door-to-groin time of 63.5 minutes (range, 28 to 129). We identified 10 (6.9%) cases that received rescue thrombolysis or reversal for ICH after arrival to the CSC ER. Dispatch data was available in 7 of these patients. The median dispatch to on-scene time was 7 minutes (range, 5 to 17). Median dispatch to CSC ER arrival was 53 minutes (range, 40 to 88). Among patients who received rescue therapy in CSC ER, 8 received IVtPA and 2 received reversal for ICH (prothrombin complex concentrate for warfarin and cryoprecipitate/transhexamic acid for IVtPA). Among the 8 MSTU patients who received IVtPA in the CSC ER, reasons included clinical worsening en route (1), new collateral information obtained at the CSC ER (4), and other (3). Conclusion: In our series of suspected stroke patients evaluated by MSTU, 6.9% of the overall cases received rescue stroke treatment after arrival to the CSC ER. Among MSTU patients who received IVtPA, 30% had thrombolytic treatment after arrival to the CSC ER. Further studies are warranted to assess limitations of MSTU care.

Carole A. Miller, M.D., was born (May 7, 1939) and raised in Kalamazoo, Michigan. She obtained her undergraduate and medical degrees at the Ohio State University. She went on to complete her neurosurgical training at the Ohio State University Medical Center. After her first faculty role at the University of Michigan (1971), she returned to the Ohio State University Medical Center (1975) where she spent nearly 4 decades. She thrived in the specialty, achieving in every facet of academic practice including scientific contributions, graduate medical education, clinical care, and leadership roles within her academic department, locally, and at the national level of organized neurosurgery. Dr. Miller passed away peacefully, on October 28, 2015, after a courageous battle with cancer. Based on her essential programmatic and specialty-related contributions, she is remembered as the 'founding mother' of neurosurgery at the Ohio State University.

Objectives: Carotid blowout syndrome (CBS) is a rare, life-threatening complication for patients with head and neck cancer (HNC). The primary objective was to identify factors associated with survival following CBS. Materials and Methods: A retrospective analysis of HNC patients treated at a single tertiary care hospital with CBS between 2016 and 2020 was performed. A multivariate Cox proportional-hazards model identified independent predictors of survival. A p value of < 0.05 was considered significant. Kaplan-Meier survival analysis was performed. Results: 45 patients were identified. The majority were male (80.0%) with a mean age of 64 years at time of blowout. Oropharynx was the most common primary site (48.9%) and 73.3% of patients had stage IV disease. 35 (77.7%) patients had active tumor at time of CBS. 93.3% of patients previously received RT with a mean total dose of 62.5 +/- 14.8 Gy. Threatened/type I, impending/type II, and acute/type III CBS occurred in 6.7%, 62.2%, and 31.1% of cases, respectively. Patients underwent either embolization (80.0%) or endovascular stent placement (20.0%). The 30-day and 1-year OS rates were 70.1% and 32.0%, respectively. Primary oropharyngeal tumors (adjusted hazard ratio [aHR], 4.31 [1.30-15.15 95% confidence interval]), active tumor at time of CBS (aHR 8.21 [2.10-54.95]), ICA or CCA rupture (aHR 5.81 [1.63-21.50]), and acute/type III CBS (aHR 2.98 [1.08-7.98]) were independent predictors of survival. Conclusion: Primary oropharyngeal tumors, active tumor at time of CBS, ICA or CCA rupture, and acute/type III hemorrhage were independent predictors of survival. Multidisciplinary management and prompt, protocol-directed intervention may improve outcomes following CBS.

OBJECTIVE: The impact of neurosurgical resident hospital coverage system, performed via a night float (12-hour shifts overnight) or a 24-hour call, on neurological surgery resident training and patient care is unknown. DESIGN: Retrospective review comparing night float and 24-hour call coverage on trainee surgical experience, elective time, annual program surveys, patient outcomes, and length of stay. SETTING: The Ohio State Wexner Medical Center Neurosurgery residency program, Columbus, Ohio. PARTICIPANTS: The neurosurgical residents from 2016 to 2019. RESULTS: Monthly cases performed by junior residents significantly increased after transitioning to a 24-hour call schedule (18 versus 30, p < 0.001). There were no differences for total cases among program graduates during this time (p = 0.7). Trainee elective time significantly increased after switching to 24-hour call coverage (18 versus 24 months after the transition; p = 0.004). Riskadjusted mortality and length of stay indices were not different (0.5 versus 0.3, p = 0.1; 0.9 versus 0.9; p = 0.3). Program surveys had minimal change after the transition to 24-hour call. CONCLUSIONS: Transitioning from a night float to a 24hour call coverage system led to improved junior resident case volume and elective time without detrimental effect on patient-related outcomes. (C) 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

BACKGROUND: Prior studies demonstrated reduced risk for venous thromboembolism (VTE) in neurosurgical patients secondary to prophylaxis with both heparin and low-molecular-weight heparin. The ability to monitor low molecular-weight heparin by obtaining anti -factor Xa (anti-Xa) serum levels provides an opportunity to evaluate safety and efficacy. The aim of this study was to describe characteristics of patients who have anti-Xa levels outside of the goal range (0.2-0.4/0.5 IU/mL) and investigate incidence of major bleeding and VTE. METHODS: A single-center, retrospective, observational study was conducted on neurosurgical patients receiving enoxaparin for VTE prophylaxis between August 2019 and December 2020. Significance testing was conducted via Fisher exact test and independent samples t test. RESULTS: The study included 85 patients. Patients were less likely to have an anti-Xa level in the goal range if they were male, had a higher weight, or were morbidly obese. Three neuroendovascular patients (3.5%) experienced a major bleed. Serum anti-Xa levels were significantly higher in patients who experienced major bleeds compared with patients who did not (0.45 +/- 0.16 IU/mL vs. 0.28 +/- 0.09 IU/mL, P = 0.003). Patients with a supra prophylactic anti-Xa level (>0.5 IU/mL) were more likely to experience a major bleed (P = 0.005). One VTE event occurred: the patient experienced a pulmonary embolism with anti-Xa level at goal. CONCLUSIONS: Anti-Xa-guided enoxaparin dosing for VTE prophylaxis in neurosurgical patients may help prevent major bleeding. These data suggest that a higher anti-Xa level may predispose patients to major bleeding. Further evaluation is needed to identify the goal anti-Xa level for VTE prophylaxis in this population.

AORTIC ARCH pathology, as a part of acute aortic syndrome, is a difficult clinical problem to address. Whether it presents as an intramural hematoma with impending rupture, isolated aneurysmal disease, or acute localized dissection, it creates a clinical challenge to the perioperative team. Some of the difficulty stems from determining the best operative strategy, either an open approach, total endovascular repair, or a hybrid of the two. Hybrid aortic arch repair involves 2 steps—open aortic branch revascularization and endovascular aortic repair. 1 Gregory AJ Prusinkiewicz CA Herget E et al. Subclavian graft thrombosis as an alternative cause for delayed spinal cord ischemia following hybrid aortic arch repair. J Cardiothorac Vasc Anesth. 2014; 28: 718-722 Google Scholar Variations of these 2 steps may be used. Each involves its own set of risks.

Introduction: Acute ischemic stroke (AIS) patients who present to a spoke Emergency Room (ER) and require transfer to a comprehensive stroke center (CSC) hub face potential delays Methods: We performed a retrospective review of 269 suspected AIS patients who received intravenous tissue plasminogen activator (tPA) from July 2016 to October 2017 in our academic telestroke network. During this period, nearly all tPA patients were transferred to the CSC hub. Data was collected on patient demographics, National Institutes of Health Stroke Scale (NIHSS), door to needle time (DTN), and distance to CSC. ER-to-CSC was defined as the time from patient arrival at Spoke ER to arrival at CSC. Top volume ER status was assigned to the 4 Spoke ERs with the highest volume of tPA. Results: Among 269 AIS patients who received tPA at spoke ERs, the mean age was 65.4 years (range, 21 to 95), 49% were female, and 91.8% were white. The initial median NIHSS was 6 (range, 0 to 30) and the mean DTN was 73.1 minutes (range, 14 to 234). The mean distance from Spoke ER to CSC was 55.2 miles (range 5.8 to 125) and the mean ER-to-CSC was 2.6 hours (range 0.62 to 6.3) (Figure 1). In univariate analysis, the following factors were significantly associated with ER-to-CSC: distance (p < 0.0001), DTN (p < 0.0001), NIHSS (p 0.0007), and top volume ER status (p 0.0034). Patient sex, age, race, SBP, weight, initial NIHSS, daytime shift, and weekend status were not significantly associated with ER-to-CSC. Significant variables from the univariate analysis were included in multivariate linear regression model in which DTN (P < 0.0001), distance (P < 0.0001), and NIHSS (P 0.024) association with ER-to-CSC remained significant. Conclusions: In our series of AIS tPA patients transferred to CSC, the mean time from spoke ER arrival to CSC arrival was 2.6 hours. Factors associated with CSC arrival time include markers of ER performance (DTN), severity (NIHSS), and distance. Further study is warranted to improve transfer time in AIS.