Aim is to assess the temporal changes and prognostic value of chest radiograph (CXR) in COVID-19 patients. Material and methods: We performed a retrospective study of confirmed COVID-19 patients presented to the emergency between March 07-17, 2020. Clinical & radiological findings were reviewed. Clinical outcomes were classified into critical & non-critical based on severity. Two independent radiologists graded frontal view CXRs into COVID-19 pneumonia category 1 (CoV-P1) with <4 zones and CoV-P2 with ≥4 zones involvement. Interobserver agreement of CoV-P category for the CXR preceding the clinical outcome was assessed using Kendall's τ coefficient. Association between CXR findings and clinical deterioration was calculated along with temporal changes of CXR findings with disease progression. Results: Sixty-two patients were evaluated for clinical features. 56 of these (total: 325 CXRs) were evaluated for radiological findings. Common patterns were progression from lower to upper zones, peripheral to diffuse involvement, & from ground glass opacities to consolidation. Consolidations starting peripherally were noted in 76%, 93% and 48% with critical outcomes, respectively. The interobserver agreement of the CoV-P category of CXRs in the critical and non-critical outcome groups were good and excellent, respectively (τ coefficient = 0.6 & 1.0). Significant association was observed between CoV-P2 and clinical deterioration into a critical status (χ2 = 27.7, p = 0.0001) with high sensitivity (95%) and specificity (71%) within a median interval time of 2 days (range: 0-4 days). Conclusion: Involvement of predominantly 4 or more zones on frontal chest radiograph can be used as predictive prognostic indicator of poorer outcome in COVID-19 patients.

Background and Purpose 3D high resolution BBMRI or MR VWI allows evaluation of the intracranial arterial wall and extraluminal pathology. We investigated the diagnostic accuracy and reliability of BBMRI for the intraluminal detection of large vessel arterial occlusions. Materials and Methods We retrospectively identified patients with intracranial arterial occlusions, confirmed by CTA or DSA who also underwent 3D BBMRI with non-enhanced and contrast enhanced T1 SPACE sequences. BBMRI findings were evaluated by two independent and blinded neuroradiologists. Large vessel intracranial arterial segments were graded on a three-point scale (grade 0-2) for intraluminal baseline T1 hyperintensity and contrast enhancement. Vessel segments were considered positive for arterial occlusion if focal weak (grade 1) or strong (grade 2) T1 hyperintense signal and/or enhancement replaced the normal intraluminal black blood signal. Results Thirty-one patients with 38 intracranial arterial occlusions were studied. Median interval time between BBMRI scanning and CTA/DSA reference standard studies was 2 days (0-20). Interobserver agreement was good for T1 hyperintensity (κ=0.63) and excellent for contrast enhancement (κ= 0.89). High sensitivity (100%) and specificity (99.8%) for intracranial arterial occlusion diagnosis was observed with either intraluminal T1 hyperintensity or contrast enhancement imaging criteria on BBMRI. Strong grade 2 intraluminal enhancement was maintained in > 80% of occlusions irrespective of location or chronicity. Relatively increased strong grade 2 intraluminal T1 hyperintensity was noted in chronic/incidental versus acute/subacute occlusions (45.5% vs 12.5%, p=0.04). Conclusion BBMRI with or without contrast has high diagnostic accuracy and reliability in evaluating intracranial large vessel arterial occlusions with near equivalency to DSA and CTA.

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Purpose Despite an overall reduction in the number of stroke cases presenting to hospitals during the COVID-19 pandemic, a remarkably high incidence of acute cerebrovascular disease associated with the infection has been reported. In this systematic review, we assess the neurological outcomes and complications of endovascular thrombectomy (EVT) for large vessel occlusions (LVO) in COVID-19 patients. Methods A literature search was performed in PubMed from December 1, 2019 through September 1st, 2020 using different combinations of suitable keywords. Ten studies reporting EVT outcomes and complications were identified. Two studies that included non-LVO pathologies and COVID-19 negative patients with the outcomes analysis were excluded. Patient demographics, comorbidities, anatomic thrombus location, neurological and angiographic outcomes were assessed. Results A total of 8 studies, in addition to our institutional case series, were ultimately included in this review. The mean age was 62.2 years, of which 67.6% were males. M1 segment involvement was the most commonly reported (53.8%) thrombus location. The mean NIHSS at presentation was 20.4 with no significant change at 24 h. Successful revascularization (TICI ≥ 2b) was achieved in 89%. Early proximal cerebral re-occlusion was reported in 6 patients (11%) and cerebral hemorrhage in 3 patients (4%). In hospital mortality was reported in 15 patients (28.8%). Conclusion Despite angiographically successful EVT of LVOs in the majority of patients, this literature analysis demonstrates overall poor outcomes and high mortality in COVID-19 patients post EVT. An unusual incidence of early intracerebral proximal arterial re-occlusion was notable.

Adjunctive intra-arterial conebeam CTA techniques are more effective in the diagnostic identification and anatomic delineation of micro-AVMs, relative to DSA alone, with the potential to improve microsurgical or radiosurgery treatment planning.

Intraosseous cranial arteriovenous malformations (AVMs) are very rare, challenging entities. The authors report the case of an extracranial parietooccipital vascular lesion. A 12-year-old boy presented with accelerated growth of a right scalp lesion over a few months. Digital subtraction angiography showed a large, right parietooccipital intraosseous AVM with multiple complex arterial feeders. Treatment of these lesions is difficult and can necessitate a multidisciplinary approach. In the featured case, 6 embolization procedures were performed over 1 year, including both transarterial and transvenous approaches, followed by total resection. The authors describe what is thought to be the second case of an AVM originating in the cranial bones and the first case with successful multidisciplinary management.

OBJECTIVEThe aim of this paper was assess the efficacy and safety of using the MynxGrip arterial closure device in pediatric neuroendovascular procedures where the use of closure devices remains off-label despite their validation and widespread use in adults.METHODSA retrospective review of all pediatric patients who underwent diagnostic or interventional neuroendovascular procedures at the authors’ institution was performed. MynxGrip use was predicated by an adequate depth of subcutaneous tissue and common femoral artery (CFA) diameter. Patients remained on supine bedrest for 2 hours after diagnostic procedures and for 3 hours after therapeutic procedures. Patient demographics, procedural details, hemostasis status, and complications were recorded.RESULTSOver 36 months, 83 MynxGrip devices were deployed in 53 patients (23 male and 30 female patients; mean age 14 years) who underwent neuroendovascular procedures. The right-side CFA was the main point of access for most procedures. The mean CFA diameter was 6.24 mm and ranged from 4 mm to 8.5 mm. Diagnostic angiography comprised 46% of the procedures. A single device failure occurred without any sequelae; the device was extracted, and hemostasis was achieved by manual compression with the placement of a Safeguard compression device. No other immediate or delayed major complications were recorded.CONCLUSIONSMynxGrip can be used safely in the pediatric population for effective hemostasis and has the advantage of earlier mobilization.

Background and PurposeStroke is a drastic complication and a poor prognostic marker of COVID-19 disease which emphasizes the importance of early identification and management of this complication. In this case series, we describe our experience of mechanical thrombectomy of large vessel occlusions (LVO) in patients with COVID-19.MethodsWe performed a retrospective study of a series of confirmed COVID-19 patients who underwent endovascular thrombectomy for acute cerebrovascular ischemic disease with large vessel occlusion. Patient demographics, presentations, lab values, angiographic and clinical outcomes were also reviewed.ResultsThree COVID-19 patients with large vessel occlusion who underwent endovascular thrombectomy were identified in our multi-center institution. Two patients had respiratory symptoms prior presentation and one patient presented initially with clinical deficits. Two patients had anterior circulation occlusion in the middle cerebral artery territory vs one had posterior circulation occlusion in the basilar artery. There was good angiographic outcome post thrombectomy in all patients, however poor clinical outcomes noted with no significant improvement in neurological manifestations in comparison with baseline at presentation. All patients developed critically severe symptoms during hospitalization requiring intubation and one patient died of COVID-19 related respiratory failure.ConclusionIn this small case series, we noted worse clinical outcomes in COVID-19 related LVO stroke despite effective thrombectomy, which may be related to the underlying COVID-19 disease and/or the nature of clot in these patients.