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Background/Objectives: MMAE (middle meningeal artery embolization) has emerged as a potential effective treatment for cSDH (chronic subdural hematoma). In this study, MMAE efficiency with regards to cSDH cause and architecture was explored. The comparability of cSDH thickness and volume as parameters for cSDH pre- and post-MMAE assessment was also analyzed. Methods: In this retrospective cohort study, 52 consecutive cSDH patients treated with MMAE in a single tertiary center were included. The cohort was divided into two group pairs pertaining to cSDH cause (spontaneous or traumatic) and cSDH architecture (non-mature or mature). The radiological outcome was compared in each group before and after MMAE and between each group pair using CT imaging. A correlation analysis between cSDH thickness and volume before and after MMAE was also performed. Results: A statistically significant positive linear association between cSDH thickness and volume at admission and at each follow-up interval (1–3, 3–6, 6–12 months) was noticed. cSDH thickness and volume reduction in each group was statistically significant, except for a traumatic cSDH volume reduction at 6–12 months. There was no statistically significant difference between each group pair in the cSDH thickness and volume reduction difference at all the follow-up intervals. Conclusions: A comparable efficiency of MMAE may be achieved in non-mature and mature as well as in spontaneous and traumatic cSDH, with an advantage for spontaneous cSDH at 6–12 months follow-up compared to traumatic cSDH. Traumatic cSDH may require a relatively long-term follow-up post-MMAE. cSDH thickness and volume, as parameters for pre- and post-MMAE cSDH evaluation, appear similar.

Background/Objectives: Cerebral white matter disease is a common finding in patients with sickle cell that has been linked to cognitive impairment. However, there is no standardized approach for quantification of the cerebral disease burden. The Fazekas score is widely used to quantify the burden of white matter disease in chronic small vessel disease. However, its utility in sickle cell disease, specifically the inter-rater variability, has not been established. Methods: A patient cohort was compiled for the purpose of a research ethics board (REB)-approved retrospective study of adult patients with sickle cell disease, each of whom underwent MRI/MRA between the years 2017 and 2019. A total of 90 such patients were captured. All MRI/MRA studies were performed on three Tesla MRIs. Two independent neuroradiologists assessed the axial FLAIR MRI brain sequence (see image 1) for each of the 90 patients, with the sole focus of assigning a Fazekas score (0–3) to each study as a means of quantifying the burden of ischemic white matter lesions. The neuroradiologists were blinded to the scoring assigned by their counterpart and to the clinical information. After the initial assessment was completed, studies with discrepant Fazekas scores were documented and discussed by both readers. A consensus Fazekas score was then assigned to each of these studies. Results: Cohen’s weighted kappa was used as a measure of agreement between readers. The expected agreement was 74.65%, with an observed agreement of 94.44% between readers, with a kappa of 0.7808. Conclusions: We conclude on the basis of our study that there is good inter-reader reliability of Fazekas scoring on axial FLAIR MRI brain sequence in patients with sickle cell disease. The Fazekas is a promising measure that could easily be integrated in systematic evaluation of cerebrovascular lesions of adults with sickle cell disease.

Trials of the efficacy and safety of endovascular thrombectomy in patients with large ischemic strokes have been carried out in limited populations. We performed a prospective, randomized, open-label, adaptive, international trial involving patients with stroke due to occlusion of the internal carotid artery or the first segment of the middle cerebral artery to assess endovascular thrombectomy within 24 hours after onset. Patients had a large ischemic-core volume, defined as an Alberta Stroke Program Early Computed Tomography Score of 3 to 5 (range, 0 to 10, with lower scores indicating larger infarction) or a core volume of at least 50 ml on computed tomography perfusion or diffusion-weighted magnetic resonance imaging. Patients were assigned in a 1:1 ratio to endovascular thrombectomy plus medical care or to medical care alone. The primary outcome was the modified Rankin scale score at 90 days (range, 0 to 6, with higher scores indicating greater disability). Functional independence was a secondary outcome. The trial was stopped early for efficacy; 178 patients had been assigned to the thrombectomy group and 174 to the medical-care group. The generalized odds ratio for a shift in the distribution of modified Rankin scale scores toward better outcomes in favor of thrombectomy was 1.51 (95% confidence interval [CI], 1.20 to 1.89; P<0.001). A total of 20% of the patients in the thrombectomy group and 7% in the medical-care group had functional independence (relative risk, 2.97; 95% CI, 1.60 to 5.51). Mortality was similar in the two groups. In the thrombectomy group, arterial access-site complications occurred in 5 patients, dissection in 10, cerebral-vessel perforation in 7, and transient vasospasm in 11. Symptomatic intracranial hemorrhage occurred in 1 patient in the thrombectomy group and in 2 in the medical-care group. Among patients with large ischemic strokes, endovascular thrombectomy resulted in better functional outcomes than medical care but was associated with vascular complications. Cerebral hemorrhages were infrequent in both groups. (Funded by Stryker Neurovascular; SELECT2 ClinicalTrials.gov number, NCT03876457.).

Background/Objectives: Headaches in Moyamoya angiopathy are common but poorly understood. We aimed to investigate if headaches in Moyamoya angiopathy improve after revascularization surgery and whether this is associated with improvement in cerebrovascular reactivity on MRI (CVR-MRI). Methods: We included consecutive adult patients with Moyamoya angiopathy who had chart data on headaches, CVR-MRI, and underwent extracranial–intracranial bypass surgery between January 2010 and September 2022 at a tertiary neurovascular referral center. Clinical and CVR-MR imaging data of all patients were collected through systematic chart review, complemented by standard-of-care headache questionnaires from patients who were operated between 2018 and 2022. We evaluated headache features and explored the association between headaches and CVR before and after revascularization surgery. Results: Fifty-nine patients were included (mean age 47 ± 14 years, 43 females (73%)); among them, 41/59 (69%) reported headaches pre-surgery. Headache improved in 28/41 (68%) patients after revascularization surgery with a reduction in pain severity (median VAS-score from 5/10 to 2.5/10; p = 0.002), analgesic use (from 84% to 40%; p = 0.007), and sick leave (from 60% to 16%; p < 0.001). Improvement in headaches was associated with improvement in CVR (OR 5.3; 95% CI: 1.2–23.5) and sick leave reduction (OR 1.4; 95% CI: 1.6–121.4). Conclusions: Headaches in Moyamoya angiopathy are common and disabling. They may improve in most patients after revascularization surgery and seem to be associated with improvement in CVR, supporting the hypothesis of a potential vascular origin of the headaches.

BackgroundSubarachnoid hyperdensity (SAH) after endovascular thrombectomy is a well-known phenomenon. Nevertheless, the clinical significance and natural history of this phenomenon is not well described. In addition, we test previously postulated hypotheses of distal occlusions sites and antithrombotic use to SAH prevalence and extent.MethodsWe performed a retrospective analysis of all patients presenting with acute stroke and treated by endovascular thrmbectomy in our tertiary center January 2016 and February 2021. Only patients who underwent CT scan of the brain within 24 h after procedure were included.Results394 patients were included in this study. SAH after EVT was evident on CT in18.3% of those. Most of these (10.7%), had non-resolving hyperdensity (persistent SAH) on follow up imaging. A minority (2.6%) had resolving hyperdensity (transient SAH). Only 2% had a combination of subarachnoid hyperdensity and intracerebral hemorrhage (SAH + ICH). Transient and persistent SAH were associated with good functional and imaging outcomes as compared to SAH + ICH patients. Older age, large infarct size, stentretriever use and partial recanalization were correlated with SAH + ICH. Distal occlusions and distal vessel angulations resulting in higher traction potential were more prevalent in persistent SAH group. Higher number of thrombectomy passes was correlated with the extent of persistent SAH. Transient SAH group did not show statistically significant demographic or procedural trends.DiscussionWe propose therefore a distinct classification of the post thrombectomy SAH subtypes and discuss the putative pathophysiological mechanisms of the three distinct phenomena and their predictive factors.

Haemorrhagic stroke is a severe condition with poor prognosis. Biological sex influences the risk factors, presentations, treatment, and patient outcomes of intracerebral haemorrhage, aneurysmal subarachnoid haemorrhage, and vascular malformations. Women are usually older at onset of intracerebral haemorrhage compared with men but have an increased risk of aneurysmal subarachnoid haemorrhage as they age. Female-specific factors such as pregnancy, eclampsia or pre-eclampsia, postmenopausal status, and hormone therapy influence a woman's long-term risk of haemorrhagic stroke. The presence of intracranial aneurysms, arteriovenous malformations, or cavernous malformations poses unique clinical dilemmas during pregnancy and delivery. In the absence of evidence-based guidelines for managing the low yet uncertain risk of haemorrhagic stroke during pregnancy and delivery in women with vascular malformations, multidisciplinary teams should carefully assess the risks and benefits of delivery methods for these patients. Health-care providers should recognise and address the challenges that women might have to confront when recovering from haemorrhagic stroke.

Introduction: Distal territory blood flow is independently associated with subsequent strokes in symptomatic vertebrobasilar atherosclerotic disease. We aimed to assess infarct patterns in relation to hemodynamic status in the prospective Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke (VERiTAS) study. Methods: Distal territory blood flow was measured using quantitative magnetic resonance angiography (MRA) in 72 patients with symptomatic atherosclerotic vertebrobasilar disease, and then dichotomized into normal (n = 54) and low (n = 18) flow. Patients were followed longitudinally on standard medical management. Two observers blinded to flow status independently reviewed the imaging performed at the time of subsequent strokes, in order to adjudicate the likely mechanism based on infarct patterns. The frequency of stroke mechanisms was qualitatively compared based on flow status. Results: During a median follow-up period of 23 months, 10/72 patients had a subsequent stroke; 5 of these had low distal flow. Infarct patterns were adjudicated to be consistent with hemodynamic (n = 2), embolic (n = 4), and junctional plaque/perforator (n = 4) infarcts. Hemodynamic infarcts were seen in 40% (2/5) low-flow patients, in comparison to 0% (0/5) normal-flow patients. Conclusion: In contrast to normal-flow patients, those with low distal flow seem to be uniquely susceptible to hemodynamic infarctions, although other patterns of infarction can also be seen in these hemodynamically impaired patients.

Sex disparities have been reported across many aspects of acute ischemic stroke (AIS) care; however, there is a relative paucity of research examining sex differences in outcomes following endovascular treatment (EVT). Some studies report worse functional independence for females following EVT. Few, if any of these studies account for differences in age, baseline function, and comorbidity burden. This retrospective cohort study aimed to assess for sex differences in functional outcomes following EVT by comparing 90-day modified Rankin Scale (mRS) of males and females while controlling for baseline function and comorbidity burden. Baseline demographic and clinical data, and stroke severity were compared for 230 consecutive patients undergoing EVT for AIS between October 2014 and July 2019 at a tertiary stroke centre in Toronto, Canada. Effect of sex on likelihood of functional independence post-EVT was assessed using regression analysis with and without correction for age, baseline mRS, and Charlson Comorbidity Index (CCI). Females undergoing EVT for AIS were older (75 ± 13 vs. 66 ± 15, < 0.0001), with worse clinical and functional baselines. Unadjusted, males were more functionally independent (90-day mRS < 3) [OR = 1.831, 95%CI 1.082-3.098]. After controlling for age, baseline mRS and CCI, there was no difference between groups [OR 1.21, 95%CI 0.61-2.37]. This study provides evidence that prior findings of sex disparities in function after EVT may be accounted for by differences in age, baseline clinical status and functional independence between males and females when a comprehensive measure of comorbidity burden is utilized.

Purpose Different CT-based protocols are being used in acute ischemic stroke. We aimed to assess the added value of delayed-phase CT angiography (CTA) and CT perfusion (CTP) to a basic protocol using non-contrast computerized tomography (NCCT) with arterial-phase CTA in patient selection for mechanical thrombectomy. Methods We retrospectively included consecutive acute ischemic stroke patients with a symptomatic intracranial arterial occlusion between January 2015 and November 2016 who underwent NCCT, arterial and delayed-phase CTA, and CTP. These imaging studies were grouped into five protocols: (1) NCCT and arterial-phase CTA; (2) NCCT, arterial-phase CTA, and CTP; (3) NCCT, arterial- and delayed-phase CTA; (4) NCCT, arterial- and delayed-phase CTA, and CTP; and (5) NCCT and delayed-phase CTA. Two interventional neuro-radiologists independently decided on mechanical thrombectomy for each patient based on the protocols. They reached consensus for discrepant decisions. We assessed the raters’ confidence level, inter-rater agreement, and compared treatment decisions for the different protocols. Results We included 73 patients (44% male, mean age 74). The inter-rater agreement was substantial for protocols with three or more modalities ( ҡ  = 0.613–0.704) and moderate for two-modality protocols ( ҡ  = 0.506–0.529). The highest agreement and confidence level was achieved for the combination of NCCT, arterial-phase CTA, and CTP. Adding CTP to NCCT and arterial-phase CTA resulted in a 10% increase of recommendations for mechanical thrombectomy and adding delayed-phase CTA resulted in a 4% increase. These management changes did not reach statistical significance ( p  = 0.07; p  = 0.25, respectively). Conclusion Adding CTP and/or a delayed-phase CTA to NCCT with arterial-phase CTA improves the decision-maker’s confidence level and creates a trend towards a lower threshold for mechanical thrombectomy.

It is unknown if the COVID-19 pandemic and public health measures had an immediate impact on stroke subtypes and etiologies in patients not infected with COVID-19. We aimed to evaluate if the proportion of non-COVID-19-related stroke subtypes (ischemic vs. hemorrhagic) and etiologies (cardioembolic, atherosclerosis, small vessel disease, and others) during the pandemic's first wave were different from prepandemic. For this retrospective cohort study, we included patients without COVID-19 with ischemic or hemorrhagic stroke at two large Canadian stroke centers between March-May 2019 (prepandemic cohort) and March-May 2020 (pandemic cohort). Proportions of stroke subtypes and etiologies were compared between cohorts using chi-square tests. The prepandemic cohort consisted of 234 stroke patients and the pandemic cohort of 207 stroke patients. There were no major differences in baseline characteristics. The proportions of ischemic versus hemorrhagic stroke were similar (ischemic stroke: 77% prepandemic vs. 75% pandemic; hemorrhagic stroke:12% prepandemic vs. 14% pandemic; > 0.05). There were no differences in etiologies, except for a decreased proportion of ischemic stroke due to atherosclerosis in the pandemic cohort (26% prepandemic vs. 15% pandemic; difference: 10.6%, 95%CI: 1.4-19.7; = 0.03). Notably, during the pandemic, the cause of ischemic stroke was more often unknown because of incomplete work-up (13.3% prepandemic vs. 28.2% pandemic, difference: 14.9%, 95%-CI: 5.7-24.2; = <0.01). In this study, the pandemic had no clear effect on stroke subtypes and etiologies suggesting a limited impact of the pandemic on stroke triggers. However, the shift from atherosclerosis toward other causes warrants further exploration.