Two patients diagnosed with arteriovenous malformation (AVM) in close association with a developmental venous anomaly (DVA) are reported. The first patient presented with episodes of left extremity weakness and numbness as well as chronic headaches. The second patient presented with spontaneous intracerebral hemorrhage. Cerebral angiography showed that both the AVM and the transmedullary veins of the DVA drained through the transcortical vein. The AVMs were treated by highly selective transarterial embolization with Onyx embolic agent while preserving the DVAs. It is suggested that the cause of the presentation in both patients was secondary to the association of the AVM with the delicate hemodynamic balance and less robust angioarchitecture of the DVA.

A woman in her early 60s with hypertension and hyperlipidemia was undergoing investigations for anemia of unknown etiology. She developed a sudden reduction in visual acuity and bilateral visual field impairment. MRI and angiography revealed acute infarcts in the posterior circulation and severe narrowing of the left vertebral artery origin. Digital subtraction angiography demonstrated a high-grade stenosis of the left vertebral artery origin with a thrombus just distal to the stenosis. The patient developed recurrent infarcts while on antithrombotic therapy. The lesion was successfully treated by vertebral artery origin angioplasty and stenting (VOAS) using a flow reversal technique and distal embolic protection. She was discharged to a rehabilitation facility 4 days later without worsening or new neurological deficits. A search of the literature yielded a similar report managed with anticoagulation and subsequent VOAS after complete lysis of the thrombus. Our report highlights the technique, safety and feasibility of VOAS in the presence of a thrombus using a flow reversal technique and distal protection.

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Introduction: An overwhelming benefit from endovascular treatment (EVT) of acute ischemic stroke (AIS) has been shown in recent trials, making it the new evidence-based standard of care for ischemic stroke due to anterior circulation large vessel occlusion. We sought to determine usage, safety and efficacy of EVT in patients ≥80 years of age. Methods: Using GWTG stroke registry data from MGH and UAMS, we analyzed 7,505 consecutive stroke admissions from 01/2009 - 06/2016. Univariate analysis was carried out to compare AIS patients < 80 vs. those ≥ 80yr. Results: Of the total 7,505 AIS patients, 3,722 presented within 12 hr of last known well and of these 334 (334/3722, 9%) underwent EVT. The majority of AIS patients undergoing EVT were younger than 80yr of age (264/334, 79%). Of the patients who underwent EVT, younger patients were more often male, Caucasian, and had stroke risk factors of atrial fibrillation, CAD, hypertension and smokers. The two groups were similar in NIHSS, initial clinical presentation, modified pre-stroke Rankin scale of ≤ 3, and initiation of tPA as a drip and ship or stroke center front-door administration. Higher rates of pneumonia were observed in younger patients while rates of sICH were similar. Younger patients were more often discharged to home/inpatient rehabilitation facility. On univariate analysis, in-hospital mortality was significantly higher in patients ≥ 80yr [Unadj. OR 2.50 (1.24, 5.03), p=0.01], however the strength of the association attenuated substantially after adjusting for significant covariates [Adj. OR 2.34 (0.99, 5.47), p=0.05] (Table). Conclusion: Elderly stroke patients are largely excluded from clinical trials and data are limited on the effectiveness of EVT in this cohort. Our results showed that rate of sICH and adjusted in-hospital mortality was not statistically different between those < 80yr vs. ≥ 80yr. Further studies are needed to explore the functional outcome of the elderly stroke patients undergoing EVT.

Introduction: Endovascular therapy is the current standard of care for eligible patients with acute ischemic stroke (AIS) due to large artery anterior circulation occlusion. All patients with moderate to severe symptoms and a treatable occlusion should be considered for EVT. We sought to evaluate temporal trends in the rates of EVT use at the two large academic stroke centers in the US. Methods: Using GWTG stroke registry data from MGH and UAMS, we analyzed 7,505 consecutive stroke admissions from 01/09 - 06/16. We evaluated the temporal trends in patient characteristics, clinical care and timeliness of care among the population of all patients and those treated within 6 or 12 hr from last known well (LKW). Results: Of the total 7,505 AIS patients, 3,722 (49%) presented within 12 hr of LKW and 2,716 (36%) within 6 hr. There were a total of 404 EVT performed at the two centers (334 ≤ 12 hr and 304 ≤ 6 hr). We observed a significant increase in the rates of EVTs performed over the past eight years with a near doubling of EVT and the sharpest rise in 2013-14 after the MR CLEAN results were presented (Figure 1). While patient characteristics remained largely unchanged, care got faster with significant decreases in time from door to CT, to tPA and to EVT. In addition, rates of drip and ship tPA cases increased from 26% to 39%. Conclusion: At two major academic stroke centers, rates of EVT increased sharply after high quality evidence supporting its use were presented. An ongoing national emphasis on improving door to tPA times appears to be working, and to be associated with improvements in EVT delivery as well. Further work is needed to improve prehospital triage and inhospital delays to increase access to rapid EVT.