The nature of the CSF leak is a circumscribed longitudinal slit at the ventral, lateral, or dorsal dura mater. An extradural pathology, diskogenic microspurs, was the single cause for all ventral CSF leaks. These findings challenge the notion that CSF leaks in SIH are idiopathic or due to a weak dura. Microsurgery is the treatment of choice in cases with intractable SIH.

Background and Purpose-Sustained successful reperfusion is an important prognostic factor for good clinical outcome in acute ischemic stroke. We aimed to identify the prevalence, clinical impact, and predictors of early reocclusion after initially successful thrombectomies within a prospective cohort. Methods-A total of 711 stroke patients with successful reperfusion (modified Thrombolysis in Cerebral Infarction, 2b/3) followed with magnetic resonance or computed tomographic angiography at 24 to 48 hours were included. Multivariable logistic regression analysis was used to evaluate associated factors and clinical impact. Results are displayed as adjusted odds ratio (aOR) and 95% CI. Improvement in accuracy of additional imaging findings on angiography control runs after the intervention was evaluated by area under the curve. Results-Early reocclusion was observed in 16 of 711 successfully reperfused patients (2.3%; 95% CI: 1.1-3.3; median delay: 20 hours). Suggestive predictors were higher platelets on admission (aOR, 1.01; 95% CI: 1.01-1.02), prestroke functional dependence (aOR, 7.12; 95% CI: 1.49-34.03), and stroke of undetermined or other specified pathogenesis in the TOAST classification (aOR, 7.19; 95% CI: 1.10-47.05 and aOR, 36.50; 95% CI: 4.47-298.11, respectively). When implementing residual embolic fragments or stenosis at the thrombectomy site into the logistic regression model, discrimination between patients with and without reocclusion improved significantly (area under the curve, 0.955 versus 0.854; P=0.023). Early reocclusion was an independent predictor of unfavorable outcome at 90 days (aOR for modified Rankin Scale ≤2, 0.13; 95% CI: 0.03-0.57). Conclusions-Early reocclusion within 48 hours after successful mechanical thrombectomy is rare but associated with poor outcome. Patients with high platelets on admission and residual embolic fragments or stenosis at the thrombectomy site are at high risk for reocclusion, which may be prevented or corrected after carefully re-evaluating the past angiographic run. (Stroke. 2018;49:00-00.

Background The supplementary grading system for brain arteriovenous malformations (AVM) was introduced in 2010 as a tool for improving preoperative risk prediction and selecting surgical patients. Objective To demonstrate, in this multicenter validation study, that supplemented Spetzler-Martin grades have greater predictive accuracy than Spetzler-Martin grades alone. Methods Data collected from 1009 AVM patients who underwent AVM resection were used to compare predictive powers of Spetzler-Martin grades (SM) and supplemented Spetzler-Martin grades (SM-Supp). Patients included the original 300 UCSF patients plus those treated thereafter (N=117), and an additional 592 patients from three other centers. Results In the combined cohort, the SM-Supp system performed better than SM system alone: AUROC=0.75 (95% CI: 0.71 - 0.78) for SM-Supp and AUROC=0.69 (95% CI: 0.65 - 0.73) for SM (p < 0.001). Stratified analysis fitting models within three different follow-up groupings (< 6 months, 6 months – 2 years, and > 2 years) demonstrated that the SM-Supp system performed better than SM system for both medium (AUROC=0.71 vs. 0.62, p=0.003) and long follow-up (AUROC=0.69 vs. 0.58, p=0.001). Patients with SM-Supp grades ≤ 6 had acceptably low surgical risks (0 – 24%), with a significant increase in risk for grades above 6 (39% – 63%). Conclusion This study validates the predictive accuracy of the supplementary grading system in a multicenter cohort. SM-Supp grade of 6 is a cut-off or boundary for AVM operability. Supplemented grading is currently the best method of estimating neurological outcomes after AVM surgery, and we recommend it as a starting point in the evaluation of AVM operability.

Object The aim of this study was to identify patients who are likely to benefit from surgery for unruptured brain arteriovenous malformations (ubAVMs). Methods The authors' database was interrogated for the risk and outcome of hemorrhage after referral and the outcome from surgery. Furthermore, the outcome from surgery incorporated those cases excluded from surgery because of perceived greater risk (sensitivity analysis). Finally, a comparison was made for the authors' patients between the natural history and surgery. Data were collected for 427 consecutively enrolled patients with ubAVMs in a database that included patients who were conservatively managed. Kaplan-Meier analysis was performed on patients observed for more than 1 day to determine the risk of hemorrhage. Variables that may influence the risk of first hemorrhage were assessed using Cox proportional hazard regression models and Kaplan-Meier life table analyses from referral until the first occurrence of the following: hemorrhage, treatment, or last review. The outcome from surgery (leading to a new permanent neurological deficit with last review modified Rankin Scale [mRS] score > 1) was determined. Further sensitivity analysis was made to predict risk from surgery for the total ubAVM cohort by incorporating outcomes of surgical cases as well as cases excluded from surgery because of perceived risk, and assuming an adverse outcome for these excluded cases. Results A total of 377 patients with a ubAVM were included in the analysis of the risk of hemorrhage. The 5-year risk of hemorrhage for ubAVM was 11.5%. Hemorrhage resulted in an mRS score > 1 in 14 cases (88% [95% CI 63%–98%]). Patients with Spetzler-Ponce Class A ubAVMs treated by surgery (n = 190) had a risk from surgery of 1.6% (95% CI 0.3%–4.8%) for a permanent neurological deficit leading to an mRS score > 1 and 0.5% (95% CI < 0.1%–3.2%) for a permanent neurological deficit leading to an mRS score > 2. Patients with Spetzler-Ponce Class B ubAVMs treated by surgery (n = 107) had a risk from surgery of 14.0% (95% CI 8.6%–22.0%) for a permanent neurological deficit leading to an mRS score > 1. Sensitivity analysis of Spetzler-Ponce Class B ubAVMs, including those in patients excluded from surgery, showed that the true risk for surgically eligible patients may have been as high as 15.6% (95% CI 9.9%–23.7%) for mRS score > 1, had all patients who were perceived to have a greater risk experienced an adverse outcome. Patients with Spetzler-Ponce Class C ubAVMs treated by surgery (n = 44) had a risk from surgery of 38.6% (95% CI 25.7%–53.4%) for a permanent neurological deficit leading to an mRS score > 1. Sensitivity analysis of Class C ubAVMs, including those harbored by patients excluded from surgery, showed that the true risk for surgically eligible patients may have been as high as 60.9% (95% CI 49.2%–71.5%) for mRS score > 1, had all patients who were perceived to have a greater risk experienced an adverse outcome. Conclusions Surgical outcomes for Spetzler-Ponce Class A ubAVMs are better than those for conservative management.