Objective To measure the global impact of COVID-19 pandemic on volumes of IV thrombolysis (IVT), IVT transfers, and stroke hospitalizations over 4 months at the height of the pandemic (March 1 to June 30, 2020) compared with 2 control 4-month periods. Methods We conducted a cross-sectional, observational, retrospective study across 6 continents, 70 countries, and 457 stroke centers. Diagnoses were identified by their ICD-10 codes or classifications in stroke databases. Results There were 91,373 stroke admissions in the 4 months immediately before compared to 80,894 admissions during the pandemic months, representing an 11.5% (95% confidence interval [CI] −11.7 to −11.3, p < 0.0001) decline. There were 13,334 IVT therapies in the 4 months preceding compared to 11,570 procedures during the pandemic, representing a 13.2% (95% CI −13.8 to −12.7, p < 0.0001) drop. Interfacility IVT transfers decreased from 1,337 to 1,178, or an 11.9% decrease (95% CI −13.7 to −10.3, p = 0.001). Recovery of stroke hospitalization volume (9.5%, 95% CI 9.2–9.8, p < 0.0001) was noted over the 2 later (May, June) vs the 2 earlier (March, April) pandemic months. There was a 1.48% stroke rate across 119,967 COVID-19 hospitalizations. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was noted in 3.3% (1,722/52,026) of all stroke admissions. Conclusions The COVID-19 pandemic was associated with a global decline in the volume of stroke hospitalizations, IVT, and interfacility IVT transfers. Primary stroke centers and centers with higher COVID-19 inpatient volumes experienced steeper declines. Recovery of stroke hospitalization was noted in the later pandemic months.

Myasthenic crisis (MC) represents the most severe and life-threatening complication of myasthenia gravis (MG). Some patients exhibit refractory responses to conventional immunotherapies, including intravenous immunoglobulin and plasma exchange. This report describes a patient with MC refractory to repetitive high-dose steroids and intravenous immunoglobulin, requiring ventilator support. Within 2 days of eculizumab administration, significant improvement enabled ventilator discontinuation. Subsequent doses further ameliorated limb and pharyngeal weakness, leading to independence. A literature review that identified ten cases reported across five publications highlighted the favorable outcomes achieved with eculizumab in refractory MC, while concomitant respiratory infection was shown to complicate the recovery from MG-related respiratory failure. Although the randomized controlled trials have excluded MC cases, eculizumab has emerged as a promising option for rescue therapy in refractory MC. Larger studies that specifically include MC cases are warranted.

Introduction: During carotid artery stenting (CAS), safe navigation of the guiding catheter (GC) is essential for the success of procedures. However, in cases where stenosis or floating thrombi are located in the common carotid artery (CCA), especially for proximal lesions, advancing the GC without touching the lesions is often difficult. We describe a preliminary experience of the “no-touch” technique for navigating the GC to the CCA using an inner catheter with a specifically designed shape and stiffness optimized to overcome tortuous anatomy. Methods: We retrospectively reviewed CAS procedures involving the “no-touch” technique for treating stenotic lesions in the CCA. A 4-Fr Newton-shaped stiff catheter was positioned in the CCA. Given its high stiffness and dedicated shape, contact with the lesser curvature of the aortic arch absorbed kickback force. Then, a 6-Fr intermediate catheter and an 8- or 9-Fr balloon GC were coaxially advanced in sequence to the target position without guidewire support, ensuring “no-touch” with the plaques. Patient characteristics, aortic arch type, lesion location, and periprocedural complications were recorded. Results: The technique was applied to eight procedures (six left-sided lesions) in 7 patients (median age, 76 years; six men) among 53 CAS procedures performed on 49 patients. Lesions were located at the proximal CCA (four procedures) or the carotid bifurcation (four procedures). Three patients had floating thrombi, and four had type III aortic arches. GCs were successfully navigated without touching the lesions in all cases, with no periprocedural complications. Conclusion: The “no-touch” technique with a Newton-shaped stiff catheter is useful and feasible for navigating the GC in treating stenotic lesions in the CCA, particularly with tortuous anatomy, proximal lesions, and vulnerable plaques.

Background: When inserting central venous catheters, inadvertent injury of major vessels is a rare yet critical complication. Direct surgery is sometimes overly invasive. This report describes a subclavian artery injury caused by inadvertent cannulation of a dialysis catheter, successfully treated with a covered stent. Case Presentation: An 82‐year‐old woman with acute renal failure due to sepsis required emergency dialysis. During the insertion of a 12‐Fr dialysis catheter into the right jugular vein, pulsatile reflux was noted. Computed tomography revealed catheter misplacement in the subclavian artery. Considering the patient's fragility, endovascular repair was performed. After embolization of side branches, a GORE VIABAHN stentgraft was delivered using a pull‐through technique and deployed to seal the injury site. The patient was discharged without neurological or vascular complications. Conclusion: Covered stents offer an effective solution for major vessel injuries requiring immediate hemostasis, particularly when direct surgery is complicated by underlying medical or anatomical conditions.

Myasthenia gravis (MG) is an autoimmune disease affecting the neuromuscular junction, most commonly associated with anti-acetylcholine receptor antibodies, less frequently with muscle-specific kinase antibodies, and occasionally with low-density lipoprotein receptor-related protein 4 antibodies. However, a subset of patients with MG tests negative for all of these three antibodies - termed triple-seronegative MG - posing significant diagnostic and therapeutic challenges. Fast-acting therapies, such as intravenous methylprednisolone (IVMP), intravenous immunoglobulin (IVIG) and plasma exchange (PLEX), are typically recommended during disease exacerbation. However, some patients are refractory to these interventions. For refractory patients with triple-seronegative MG, the efficacy of a recent monoclonal antibody therapy as rescue therapy remains uncertain. We report a case of triple-seronegative MG refractory to repeated IVIG, IVMP and PLEX, in which clinical improvement was achieved following treatment with rozanolixizumab. This case, with long-term follow-up, suggests the potential utility of rozanolixizumab as rescue therapy in a patient subgroup which is typically excluded from randomized controlled trials. Larger studies specifically including patients with triple-seronegative MG are warranted.

BACKGROUND: Intracranial atherosclerotic disease–related large-vessel occlusion (ICAD-LVO) is associated with residual stenosis and early reocclusion following mechanical thrombectomy (MT), particularly in Asian populations. Conventional stent retrievers (SRs) are optimized for embolus removal and may not provide sufficient mechanical dilation. The Tigertriever is a radially adjustable SR with operator-controlled expansion and manual constriction, enabling stentoplasty and safe retrieval. OBSERVATIONS: This study retrospectively analyzed the data of 3 consecutive patients with ICAD-LVO who were treated using a sequential algorithm that included initial conventional MT, followed by Tigertriever-assisted stentoplasty and loading doses of DAPT. Durable recanalization was performed in 2 cases involving the middle cerebral artery and internal carotid artery, respectively, with 1 patient showing significant functional improvement, from a modified Rankin Scale score of 5 to 1 on day 7. The third case involved the vertebral artery and showed temporary recanalization despite eventual recurrent occlusion, with neurological preservation reflecting collateral adaptation. LESSONS: Tigertriever-assisted stentoplasty combined with DAPT is a promising sequential bridge strategy for refractory ICAD-LVO identified during thrombectomy. By achieving direct mechanical vessel dilation similar to balloon angioplasty while simultaneously maintaining antegrade flow, the Tigertriever provides a physiological bridge during which loading doses of DAPT can reach effective platelet inhibition. https://thejns.org/doi/10.3171/CASE26605