BackgroundAtrial fibrillation (AF) associated ischemic stroke has worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Limited data exist about the effect of AF on procedural and clinical outcomes after mechanical thrombectomy (MT).ObjectiveTo determine whether recanalization efficacy, procedural speed, and clinical outcomes differ in AF associated stroke treated with MT.MethodsWe performed a retrospective cohort study of the Stroke Thrombectomy and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4169 patients who underwent MT for an anterior circulation stroke, 1517 (36.4 %) of whom had comorbid AF. Prospectively defined baseline characteristics, procedural outcomes, and clinical outcomes were reported and compared.ResultsAF predicted faster procedural times, fewer passes, and higher rates of first pass success on multivariate analysis (p<0.01). AF had no effect on intracranial hemorrhage (aOR 0.69, 95% CI 0.43 to 1.12) or 90-day functional outcomes (aOR 1.17, 95% CI 0.91 to 1.50) after MT, although patients with AF were less likely to receive IVT (46% vs 54%, p<0.0001).ConclusionsIn patients treated with MT, comorbid AF is associated with faster procedural time, fewer passes, and increased rates of first pass success without increased risk of intracranial hemorrhage or worse functional outcomes. These results are in contrast to the increased hemorrhage rates and worse functional outcomes observed in AF associated stroke treated with supportive care and or IVT. These data suggest that MT negates the AF penalty in ischemic stroke.

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Syndrome of the trephined (SoT) is a severe complication following decompressive craniectomy resulting in neurological decline which can progress to aphasia, catatonia, and even death. While cranioplasty can reverse neurological symptoms of SoT, awareness of SoT is poor outside of the neurosurgery community. The authors performed a systematic review of the literature on SoT with a focus on reconstructive implications. Search terms “syndrome of the trephined” and “sunken flap syndrome” were applied to PubMed to identify primary studies through October 2021. Full-text review yielded 11 articles discussing SoT and reconstructive techniques or implications with 56 patients undergoing cranial reconstruction. Average age of the patients was 41.8±9.5 years. Sixty-three percent of the patients were male. The most common indication for craniectomy was traumatic brain injury (43%), followed by tumor resection (23%), intracerebral hemorrhage (11%), and aneurysmal subarachnoid hemorrhage (2%). Patients most commonly suffered from motor deficits (52%), decreased wakefulness (30%), depression or anxiety (21%), speech deficits (16%), headache (16%), and cognitive difficulties (2%). Time until presentation of symptoms following decompression was 4.4±8.9 months. Patients typically underwent cranioplasty with polyetheretherketone (48%), titanium mesh (21%), split thickness calvarial bone (16%), full thickness calvarial bone (14%), or split thickness rib graft (4%). Eight percent of patients required free tissue transfer for soft tissue coverage. Traumatic Brain Injury (TBI) was a risk factor for development of SoT when adjusting for age and sex (odds ratio: 8.2, 95% confidence interval: 1.2–8.9). No difference significant difference was observed between length until initial improvement of neurological symptoms following autologous versus allograft reconstruction (P=0.47). SoT can be a neurologically devastating complication of decompressive craniectomy which can resolve following urgent cranioplasty. Familiarity with this syndrome and its reconstructive implications is critical for the plastic surgery provider, who may be called upon to assist with these urgent cases.

BACKGROUND Spinal arachnoid webs are rarely described bands of thickened arachnoid tissue in the dorsal thoracic spine. Much is unknown regarding their origins, risk factors, natural history, and outcomes. OBJECTIVE To present the single largest case series, detailing presenting symptoms and outcomes amongst operative and nonoperative patients, to better understand the role of intervention. METHODS This retrospective chart review identified 38 patients with arachnoid webs. Patient demographics, radiologic signs, symptoms, and surgical history data were extracted from the electronic medical record. Symptoms were divided by location and character. 28 patients were successfully contacted for follow up outcome surveys. RESULTS 26 patients (68%) underwent surgical intervention, 12 (32%) were managed non-operatively. 15 (39%) patients had undergone a previous unsuccessful surgery at a different site for their symptoms prior to arachnoid web diagnosis. Commonly presenting symptoms included myelopathy (68%), focal thoracic back pain (68%), lower extremity weakness (45%), numbness and sensory changes (58%), and lower extremity radicular pain (42%), upper extremity weakness (24%), and radicular pain (37%). Focal thoracic pain was associated with thoracic level (P &lt; .02). Myelopathic symptoms were less common in postoperative patients. Postoperative patients described significantly more upper extremity (P &lt; .01) and thoracic (P &lt; .01) numbness and paresthesias. Surveyed nonoperative patients universally described their symptoms as either stable or worsening. CONCLUSION Spinal arachnoid webs present with thoracic myelopathy and back pain but can also present with upper extremity symptoms. Surgical intervention stabilizes or improves symptoms and is well received. Nonoperative patients do not spontaneously improve.

* on behalf of the Stroke Thrombectomy and Aneurysm Registry (STAR) Collaborators Introduction: Intravenous thrombolysis complications are enriched in AF associated stroke, as these patients have worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications. These data suggest that AF patients may be at particularly high risk for complications of bridging therapy for large vessel occlusions treated with mechanical thrombectomy (MT). Here we determine whether clinical outcomes differ in AF associated stroke treated with MT and bridging therapy. Methods: We performed a retrospective cohort study of the Stroke and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4,169 patients who underwent MT for an anterior circulation stroke, 1,517 (36.4 %) of which had comorbid AF. Prospectively defined baseline characteristics and clinical outcomes were compared. Results: Hemorrhagic complications after MT were similar in patients with or without AF. In patients without AF, bridging therapy improved 90-day outcomes (aOR 1.32, 1.02-1.74, p<0.05) without increasing hemorrhagic complications. In patients with AF, bridging therapy independently predicted hemorrhagic complications in AF patients (aOR 2.08, 1.06-4.06, p<0.033) without improving functional outcomes. Conclusions: Bridging therapy in AF patients undergoing thrombectomy independently increased the odds of intracranial hemorrhage and did not improve functional outcomes. AF patients may represent a high-risk subgroup for thrombolytic complications. Randomized trials are warranted to determine whether patients with AF associated stroke may benefit by deferring bridging therapy at thrombectomy-capable centers.

INTRODUCTION:It is not well understood why repetitive head injury causes the behavioral and pathologic sequelae associated with Chronic Traumatic Encephalopathy. Cellular prion protein (PrPC) is associated with several neurodegenerative diseases including Alzheimer’s disease and Creutzfeldt-Jakob disease and we have previously demonstrated that PrPC is required for the pathology and behavior associated with CTE after TBI. We show that Prpc knockout leads to differential mice cortex gene expression in a murine repetitive head injury model.METHODS:Experimental groups consisted of PrPC-knockout (Prnp-/-) and PrPC wild type (WT) mice. Bilateral close head injury consisted of daily impactions over 10 days with appropriate unimpacted control. All animals were allowed to recover for 6 weeks. Mice were sacrificed and brain cortexes rapidly dissected and flash frozen for RNA extraction, sequencing, and quantification.RESULTS:We identified 52 upregulated and 134 downregulated genes in WT impacted compared to unimpacted WT mice. 301 genes were upregulated and 85 downregulated in Prnp-/- impacted mice compared to Prnp-/- mice without impactions. We identified 85 upregulated and 86 downregulated genes in Prnp-/- impacted mice compared to WT impacted mice. RNA expression of KLK6 is upregulated by a factor of 2.3 and KChip3 is downregulated by a factor of 1.3 in Prnp-/- impacted mice compared to WT impacted mice.CONCLUSIONS:Deletion of PrPc in a murine model of CTE leads to differential expression of multiple gene clusters. Deletion of Prpc in impacted mice upregulates KLK6 and downregulates KCHip3 which have been implicated in neurodegenerative processes and neuroinflammation including Alzheimer’s disease. We have previously demonstrated that Prpc is required for cognitive deficits and standard histologic pathology following head injury who's biochemical mechanism may implicate KLK6 and KCHip3.

This review examines various aspects of traumatic brain injury (TBI) and its potential role as a causative agent for type 2 diabetes mellitus (T2DM) in the veteran population. The pituitary glands and the hypothalamus, both housed in the intracranial space, are the most important structures for the homeostatic regulation of almost every hormone in the human body. As such, TBI not only causes psychological and cognitive impairments but can also disrupt the endocrine system. It is well established that in addition to having a high prevalence of chronic traumatic encephalopathy (CTE), veterans have a very high risk of developing various chronic medical conditions. Unfortunately, there are no measures or prophylactic agents that can have a meaningful impact on this medically complex patient population. In this review, we explore several important factors pertaining to both acute and chronic TBI that can provide additional insight into why veterans tend to develop T2DM later in life. We focus on the unique combination of risk factors in this population not typically found in civilians or other individuals with a non-military background. These include post-traumatic stress disorder, CTE, and environmental factors relating to occupation and lifestyle.

To the Editor:We would like to thank Harel et al 1 for their interest in our work 2 detailing the natural and operative course of the treatment of spinal arachnoid webs (SAWs). We appreciate their highlights, including the important presenting symptom of myelopathy, and the lack of spontaneous resolution with conservative management.We agree with the authors that the preoperative history is important in correctly diagnosing these patients. We did not find a significant association with previous surgery (39%); central nervous system hemorrhage, infections, or trauma (8%); or general trauma (13%) in our population; 2 however, given the rarity of description of these entities, it is possible that this is due to a sampling error. As described in our work, a significant proportion of the previous surgeries seem to have been attempts at treating the preoperative symptoms before recognition/diagnosis of the arachnoid web, eg, lumbar laminectomies attempting to address lower extremity weakness. We further agree with distinguishing between a SAW and thoracic intradural spinal cord herniation (ISCH). The authors provide some excellent radiographic and intraoperative imaging to aid in distinguishing these two. 1 As the authors describe, the operative approach to these 2 lesions is very different, and thus, care must be taken to distinguish the "scalpel sign" of the SAW from the "C-shaped dorsal indentation" of the ISCH. Intraoperative ultrasound, as the authors attest, is a very useful adjunct for both surgeries and can help distinguish SAW from ISCH before durotomy, as well as confirming normal flow of cerebrospinal fluid after lesionectomy. The authors note that an intraoperative ultrasound can also be useful for performing midline myelotomies for syrinxes. Although we agree with the technique, it should be noted that only 1 patient in our study required the use of a myelotomy for shunting of a thoracic syrinx. Of the 12 patients who presented with a syrinx, the majority had spontaneous resolution of their syrinx after lysis of the web (Laxpati et al, 2 Figure 1). Long-term outcomes regarding symptoms and imaging findings, as well as recurrence, remain to be established for this population.Regarding conservative management, we agree with the authors that symptomatic patients should be offered operative intervention. We did not identify any patients with spontaneous resolution of their symptoms or their SAW, and there was a trend toward worsening of symptoms in many (Laxpati et al 2 ). It remains to be seen whether asymptomatic and incidentally identified patients should be offered surgical intervention, and we suspect more data are needed to determine whether future myelopathy is inevitable or progresses only in certain patients.We thank the authors for their important insights and contributions to this field. It will take concerted multi-institutional effort with attention to long-term outcomes to best understand this pathology and better guide the care of our patients.