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BackgroundTransverse sinus stenosis (TSS) and sigmoid sinus wall anomalies (SSWAs) are the most common causes of pulsatile tinnitus (PT). While these conditions may co-occur, they usually require different management approaches. This study aims to evaluate whether TSS stenting alone, without targeted treatment of SSWAs, is sufficient to resolve PT in patients presenting with PT, TSS, and SSWAs.MethodsWe conducted a retrospective study of consecutive patients diagnosed with PT, TSS, and SSWAs who underwent transvenous endovascular treatment between September 2020 and January 2024. The primary outcome was treatment success at 3 months, defined as complete resolution of baseline PT. Secondary outcomes included treatment success at 24 hours and 1 year, PT recurrence within 1 year, and major complications.ResultsThirty-three patients with PT, TSS, and SSWAs underwent 38 procedures. Among these, 14 cases (36.8%) had dehiscence alone, 3 cases (7.9%) with diverticulum alone, and 20 cases (52.6%) involved both dehiscence and diverticulum. Stenting alone was performed in 25 cases (65.8%), stent-assisted coiling in 9 cases (23.7%), and coiling alone in 4 cases (10.5%). The primary outcome of complete resolution of PT at 3 months was achieved in 86.1% (31/36) of cases, with partial resolution in an additional 13.9% (5/36) of cases. There was no difference in outcomes between cases of isolated stenting and those involving coiling or stent-assisted coiling.ConclusionTransverse sinus stenting alone, without dedicated treatment of SSWAs, resolves PT in patients with TSS and SSWAs. These results support the growing evidence that SSWAs are secondary to TSS in patients with PT and/or idiopathic intracranial hypertension, suggesting that additional interventions like coiling or surgery of SSWAs may be unnecessary.

Endovascular thrombectomy (EVT) improves long-term outcomes and decreases mortality in ischemic stroke patients. However, a significant proportion of patients do not benefit from EVT recanalization, a phenomenon known as futile recanalization or reperfusion without functional independence (RFI). In this study, we aim to identify the major stroke risk factors and patient characteristics associated with RFI. This is a retrospective cohort study of 297 consecutive patients with ischemic stroke who received EVT at three academic stroke centers in China from March 2019 to March 2022. Patient age, sex, modified Rankin Scale (mRS), National Institute of Health Stroke Scale (NIHSS), Alberta stroke program early CT score (ASPECTS), time to treatment, risk factors and comorbidities associated with cerebrovascular diseases were collected, and potential associations with futile recanalization were assessed. RFI was successful reperfusion defined as modified thrombolysis in cerebral infarction (mTICI) ≥ 2b without functional independence at 90 days (mRS ≥ 3). Of the 297 initial patients assessed, 231 were included in the final analyses after the application of the inclusion and exclusion criteria. Patients were divided by those who had RFI (  = 124) versus no RFI (  = 107). Older age (OR 1.041, 95% CI 1.004 to 1.073;  = 0.010), chronic kidney disease (OR 4.399, 0.904-21.412;  = 0.067), and higher 24-h NIHSS (OR 1.284, 1.201-1.373;  < 0.001) were independent predictors of RFI. Conversely, an mTICI score of 3 was associated with a reduced likelihood of RFI (OR 0.402, 0.178-0.909;  = 0.029). In conclusion, increased age, higher 24-h NIHSS and lack of an mTICI score of 3 were independently associated with RFI and have potential prognostic values in predicting patients that are less likely to respond to EVT recanalization therapy.

Not in the history of transmissible illnesses has there been an infection as strongly associated with acute cerebrovascular disease as the novel human coronavirus SARS-CoV-2. While the risk of stroke has known associations with other viral infections, such as influenza and human immunodeficiency virus, the risk of ischemic and hemorrhagic stroke related to SARS-CoV-2 is unprecedented. Furthermore, the coronavirus disease 2019 (COVID-19) pandemic has so profoundly impacted psychosocial behaviors and modern medical care that we have witnessed shifts in epidemiology and have adapted our treatment practices to reduce transmission, address delayed diagnoses, and mitigate gaps in healthcare. In this narrative review, we summarize the history and impact of the COVID-19 pandemic on cerebrovascular disease, and lessons learned regarding the management of patients as we endure this period of human history.

Background: Inflammatory biomarkers, key predictors of ischemic stroke prognosis, may exhibit sex-specific predictive patterns. Objectives: This study investigates sex-based differences in inflammatory biomarkers as predictors of 90-day clinical outcomes in acute ischemic stroke patients undergoing mechanical thrombectomy (MT). Design: Multicenter retrospective study. Methods: This study included 970 patients consecutively treated with MT for anterior circulation large vessel occlusion between 2016 and 2023. Inflammatory indices, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio, monocyte-to-lymphocyte ratio (MLR), C-reactive protein (CRP), systemic inflammation response index, and systemic immune-inflammation index, were measured on admission and 24-h post-MT. Inverse probability weighting was used to balance baseline characteristics between male and female patients. Least absolute shrinkage and selection operator regression and logistic regression were used to identify independent predictors of 90-day good functional outcomes (modified Rankin scale (mRS) score 0–2) and death, stratified by sex and age groups (<55 and ⩾55 years). Results: In the male weighted population (516 patients), multivariable analysis showed that MLR (odds ratio (OR): 0.37, 95% confidence interval (CI): 0.13–0.95, p = 0.041), 24-h NLR (OR: 0.88, 95% CI: 0.83–0.94, p < 0.001), and 24-h MLR (OR: 0.33, 95% CI: 0.12–0.94, p < 0.001) were independent predictors of 90-day good functional outcome with age-specific differences noted. Twenty-four-hour MLR (OR: 5.05, 95% CI: 1.36–4.28, p = 0.047) and erythrocyte sedimentation rate (OR: 1.02, 95% CI: 1.01–1.04, p = 0.025) were independent predictors of death, respectively, for men <55 and men ⩾55 years. In the weighted female population (454 patients), 24-h NLR (OR: 0.89, 95% CI: 0.81–0.96, p = 0.007) and 24-h CRP (OR: 0.98, 95% CI: 0.97–0.99, p = 0.029) were independent predictors of good functional outcomes. Twenty-four-hour CRP was also an independent predictor of 90-day death (OR: 1.01, 95% CI: 1.00–1.02, p = 0.017) in women with no age-specific differences noted. Interaction analysis revealed significant sex-specific relationships for MLR and CRP but not for NLR. Conclusion: This study highlights sex-based differences in the predictive value of widely available inflammatory biomarkers for stroke outcomes. MLR was a distinct predictor in men, while CRP was uniquely associated with outcomes in women. These findings underscore the need for sex-stratified approaches in stroke management and research. Plain language summary Understanding how sex influences the inflammation response after large strokes, using a method called inverse probability weighting analysis Why was the study done? Inflammatory markers are important for predicting how well a person will recover from an ischemic stroke. These markers may affect men and women differently. This study looks at how these markers predict recovery in men and women after undergoing mechanical thrombectomy (MT) for an acute ischemic stroke. What did the researchers do? This study included 970 patients treated with MT for large vessel occlusion. Several inflammatory markers were measured when the patients arrived at the hospital and 24 hours after the thrombectomy. The study used a statistical method called inverse probability weighting to adjust for differences between male and female patients. Different statistical models were used to find predictors of good recovery and death, based on gender and age groups (<55 years and over 55 years). What did the researchers find? For men (516 patients), the analysis showed that higher admission MLR (an inflammatory marker based on blood cells) and NLR (another blood-cell-derived marker) 24 hours after the procedure were linked to better recovery. Additionally, higher MLR 24 hours after MT and ESR (a different marker) were linked to a higher risk of death in younger and older men, respectively. For women (454 patients), NLR and CRP (inflammation-related blood protein) 24 hours after MT were linked to better recovery. CRP was also associated with a higher risk of death, but there were no differences based on age in women. What do the findings mean? The study shows that men and women may have different inflammatory markers that can predict stroke recovery. For men, MLR was a key marker, while for women, CRP was more important. These findings suggest that stroke treatment and research should consider sex-based differences to improve patient outcomes.

Space occupying cerebral edema is a feared complication after large ischemic stroke, occurring in up to 30% of patients with middle cerebral artery (MCA) occlusion and peaking 2–4 days after injury. Little is known about the factors and outcomes associated with peak edema timing, especially after 96 h. We aimed to characterize differences and compare discharge status between patients who experienced maximum midline shift (MLS) or decompressive hemicraniectomy (DHC) in the acute (< 48 h), average (48–96 h), and subacute (> 96 h) groups. We performed a two-center, retrospective study of patients with ≥ 1/2 MCA territory infarct and MLS. We constructed a multivariable model to test the association of subacute peak edema and favorable discharge status, adjusting for various confounders. Of 321 eligible patients, 32%, 36%, and 32% experienced acute, average, and subacute peak edema. Subacute peak edema was significantly associated with higher odds of favorable discharge than acute peak edema (aOR, 2.05; 95% CI, 1.03–4.11). Subacute peak edema after large MCA stroke is associated with better discharge status compared to acute peak edema courses. Understanding how the timing of cerebral edema affects risk of unfavorable discharge has important implications for treatment decisions and prognostication.

Objective To describe the frequency and the distribution of degenerative disc disease (DDD) detected in athletes who underwent spine MRI in the 2016 Summer Olympic Games in Rio de Janeiro. Methods Data on spine MRI examinations from the 2016 Summer Olympics were retrospectively analyzed. We assessed the frequency of DDD of the cervical (Cs), thoracic (Ts), and lumbar (Ls) spine using Pfirrmann’s classification. Grade II and III were considered as mild, grade IV as moderate, and grade V as severe disc degeneration. Data were analyzed according to the location of the degenerative disc, type of sport, age-groups, and gender of the athletes. Results One hundred out of 11,274 athletes underwent 108 spine MRI’s (21 C, 6 T, and 81 L) (53% Females (F), 47% Males (M)). The frequency of DDD was 40% (42% F, 58% M) over the entire spine (28% mild, 9% moderate and 3% severe). There were 58% (12%F, 88%M) of the cervical spine discs that showed some degree of degeneration (44% mild, 13.5% moderate and 1% severe). Athletics, Boxing, and Swimming were the sports most affected by DDD in the Cs. There were 12.5% of the thoracic discs that showed some degree of degeneration, all were mild DDD and were exclusively seen in female athletes. There were 39% (53% F, 47% M) of the lumbar discs with DDD (26% mild, 9% moderate, and 4% severe). Conclusion Athletes who underwent spine MRI during the 2016 Summer Olympic Games show a high frequency of DDD of cervical and lumbar spines. Recognition of these conditions is important to develop training techniques that may minimize the development of degenerative pathology of the spine.

The role of intravenous thrombolysis (IVT) in combination with endovascular thrombectomy (EVT) for the treatment of large vessel occlusion acute ischemic stroke has been evaluated exclusively outside the US, in randomized clinical trials which failed to demonstrate non-inferiority of skipping IVT. Because practice patterns and IVT dosing differ within the US, and prior observational US-based cohorts suggested improved clinical outcomes in patients who received IVT before EVT, a US-based evaluation is needed. This is a quasi-experimental study of a large US cohort using a regression discontinuity design (RDD) that enables the estimation of causal effects when randomization is not feasible. In this multi-center prospective cohort of patients undergoing EVT, we observed a sharp drop (65%) in the probability of receiving IVT at the cutoff of IVT eligibility time window while there were no significant differences in potential confounders including age, NIHSS, and ASPECTS at the cutoff. We found no association between IVT treatment and functional independence (mRS 0–2) at 90-days in patients undergoing EVT, nor in the secondary outcomes of excellent outcomes (mRS 0–1) at 90 days, mortality, symptomatic intracranial hemorrhage, first pass reperfusion, or final reperfusion.

IntroductionWe have demonstrated in a multicenter cohort that the COVID-19 pandemic has led to a delay in intravenous thrombolysis (IVT) among stroke patients. Whether this delay contributes to meaningful short-term outcome differences in these patients warranted further exploration.MethodsWe conducted a nested observational cohort study of adult acute ischemic stroke patients receiving IVT from 9 comprehensive stroke centers across 7 U.S states. Patients admitted prior to the COVID-19 pandemic (1/1/2019–02/29/2020) were compared to patients admitted during the early pandemic (3/1/2020–7/31/2020). Multivariable logistic regression was used to estimate the effect of IVT delay on discharge to hospice or death, with treatment delay on admission during COVID-19 included as an interaction term.ResultsOf the 676 thrombolysed patients, the median age was 70 (IQR 58–81) years, 313 were female (46.3%), and the median NIHSS was 8 (IQR 4–16). Longer treatment delays were observed during COVID-19 (median 46 vs 38 min, p = 0.01) and were associated with higher in-hospital death/hospice discharge irrespective of admission period (OR per hour 1.08, 95% CI 1.01–1.17, p = 0.03). This effect was strengthened after multivariable adjustment (aOR 1.15, 95% CI 1.07–1.24, p < 0.001). There was no interaction of treatment delay on admission during COVID-19 (pinteraction = 0.65). Every one-hour delay in IVT was also associated with 7% lower odds of being discharged to home or acute inpatient rehabilitation facility (aOR 0.93, 95% CI 0.89–0.97, p < 0.001).ConclusionTreatment delays observed during the COVID-19 pandemic led to greater early mortality and hospice care, with a lower probability of discharge to home/rehabilitation facility. There was no effect modification of treatment delay on admission during the pandemic, indicating that treatment delay at any time contributes similarly to these short-term outcomes.

BackgroundDespite successful reperfusion after thrombectomy for large vessel occlusion (LVO) stroke, up to half of patients are dependent or dead at 3-month follow-up.The aim of the current study is to demonstrate safety and efficacy of administering adjunct intra-arterial (IA) tenecteplase in anterior circulation LVO patients who have achieved successful reperfusion defined as eTICI 2b50 to 3.MethodsANGEL-TNK is a multicentre, open-label, assessor-blinded endpoint, prospective randomised, controlled trial that will enrol up to 256 patients. Patients who meet inclusion criteria with anterior circulation LVO stroke and successful reperfusion will be randomised to receive IA tenecteplase or best medical management at 1:1 ratio.ResultsThe primary endpoint is a 90-day excellent outcome defined as modified Rankin Scale (mRS) 0–1. The primary safety endpoint is symptomatic intracranial haemorrhage within 48 hours from randomisation. Secondary endpoints include 90-day ordinal mRS, mRS 0–2, mRS 0–3, all-cause mortality and any intracranial haemorrhage.ConclusionIn patients with anterior circulation LVO stroke, the ANGEL-TNK trial will inform whether adjunct IA tenecteplase administered after successful thrombectomy reperfusion improves patient outcomes.Trial registration number NCT05624190.