Chirag D. Gandhi

The history of the Department of Neurosurgery at the New York Medical College (NYMC) began in New York City in the early 20th century. The purpose of this manuscript is to educate on the history of neurosurgery at NYMC and Westchester Medical Center (WMC) from its early beginnings to its current state as a leader of neurosurgery in the region. Led by notable neurosurgeons, such as Thomas Hoen and Isadore Tarlov, the department provided critical neurosurgical treatments to patients at the Flower-Fifth Avenue Hospital (now known as the Terence Cardinal Cooke Health Care Center) and Metropolitan Hospital and was home to research advancements in peripheral nerve repair and spinal cord pathology. The department made the transition to WMC in the 1970s under the direction of Alan Rothballer, and a residency program was instituted by Samuel Kasoff and Richard Rovit in 1991. In 2020, Chirag Gandhi became chair and established fellowships in endovascular neurosurgery and neurocritical care, expanding opportunities for education. Building on this rich tradition, the NYMC/WMC Department of Neurosurgery continues to provide high-quality neurosurgical care while emphasizing resident education and research.

BACKGROUND: Chronic subdural hematoma is a complex but commonly treated neurosurgical condition, particularly affecting the elderly. Traditional treatment involves open surgeries, but middle meningeal artery embolization (MMAE) has emerged as an effective, minimally invasive adjunctive. The objective of this study is to assess the safety and efficacy of MMAE in combination with surgery using real-world data. METHODS: This retrospective cohort study analyzed data from the TriNetX Research Network. Outcomes of mortality, reoperation, and hospital readmission were studied using Cox proportional hazard models controlling for age, sex, indications of severity, type of surgical intervention, antiplatelet/anticoagulant use, comorbidities, and hospitalization events. Patients were followed for up to 6 years. RESULTS: This study included 38 049 patients with chronic subdural hematoma, of which 486 received surgery with MMAE and 5362 received surgery monotherapy. At 90 days after surgery, mortality was 5.2% in the MMAE group and 7.7% in the surgery monotherapy group ( P =0.0467). After 6 years, mortality was 11.2% in the MMAE group and 19.0% in the surgery monotherapy group ( P P =0.173). Patients with MMAE had significantly lower rates of rehospitalization at 1 year (2.1% versus 4.4%; P =0.0195), even after adjustment (hazard ratio, 0.414 [95% CI, 0.203–0.845]; P =0.015). CONCLUSIONS: Among patients with chronic subdural hematoma who received surgery, patients receiving adjunctive MMAE experienced lower mortality rates out to 6 years of follow-up, but the difference was not significant after full adjustment. Beginning 1 year after surgery, patients receiving combination therapy had significantly lower long-term rehospitalization compared with patients receiving surgery monotherapy. Future prospective studies will help identify strengths and weaknesses of this highly promising treatment modality.

Introduction: This study conducts a comprehensive bibliometric analysis of global stroke mortality research, by assessing publication trends, top authors, institutions, countries, and thematic analysis of keywords. Methods: We performed a bibliometric analysis using Web of Science data retrieved on December 21, 2024, based on title searches for “Stroke mortality,” “CVA mortality,” “Cerebral infarction mortality,” and “Cerebrovascular accident mortality.” We generated descriptive statistics, investigated publication and citation trends, and performed advanced mappings for keyword frequency and thematic evolution. Results: Of 2,261 stroke mortality documents from 636 journals (1961–2024), the annual growth was 1.73%. Each document averaged 37.7 citations, with 46,494 total references. This study included 14,456 authors (48 single‐authored) and averaged 8.89 coauthors per document; 21.32% involved international collaboration. Publication output increased markedly post‐2000, peaking with 1,171 studies in 2017–2024. Stroke (246 articles) was the most productive journal followed by Journal of Stroke & Cerebrovascular Diseases (137); the USA (2,975 articles) and China (2,536) dominated global output. Wang Y led as the most prolific author (77 articles), and Capital Medical University in China produced the highest number of publications (143). Collaboration networks featured strong multinational clusters led by the USA, China, and key European nations. Conclusion: This bibliometric analysis showed a steady but modest research growth, with the USA and China leading in output and citation. Thematic shifts revealed movement from clinical risk factors to public health and biological predictors. While strong international collaborations exist, regional partnerships remain limited in areas like Africa and Latin America.

Super large-bore aspiration catheters have emerged as promising tools for endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). The Route 92 Reperfusion System utilizes super large-bore catheters with specialized delivery mechanisms to maximize first-pass effect (FPE) and reperfusion rates. To evaluate the efficacy and safety of the Route 92 super large bore reperfusion System in treating AIS-LVO. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched five databases from inception through December 2025. Studies evaluating Route 92 Reperfusion System outcomes in AIS-LVO patients were included. Primary outcomes were FPE and functional independence (modified Rankin Scale (mRS) 0–2). Secondary outcomes included successful reperfusion (modified thrombolysis in cerebral infarction (mTICI) scores), symptomatic intracranial hemorrhage (sICH), mortality, and adverse events. Random-effects models were used for all analyses. Seven studies comprising 490 patients were included. In comparative analyses, Route 92 (0.088”) demonstrated significantly higher FPE rates (risk difference (RD): 0.18, number needed to treat (NNT) = 6, p = 0.001) and near-complete reperfusion (RD: 0.23, NNT = 4, p = 0.0005) compared to other techniques. Single-arm analyses showed 56% achieved FPE, 94% achieved near-complete to complete reperfusion, and 43% achieved functional independence at follow-up. The system demonstrated favorable safety with 3% sICH rate and 20% mortality. National Institutes of Health Stroke Scale (NIHSS) scores improved significantly (mean difference (MD): -9.55, p < 0.00001). The Route 92 Reperfusion System achieves high rates of FPE and successful reperfusion with acceptable safety profiles. Future RCTs is warranted to support these findings.

BACKGROUND: Acute ischemic stroke affecting the middle cerebral artery (MCA) remains a major global cause of death and disability. However, it remains unclear whether the laterality of MCA strokes independently influences inpatient outcomes. Despite the fact that the National Institutes of Health Stroke Scale score is heavily weighted toward left-sided acute ischemic stroke, we hypothesize that right MCA strokes (R-MCASs) are associated with worse inpatient outcomes because they would require more severe deficits to amount to a comparable National Institutes of Health Stroke Scale score for a left MCA stroke. METHODS: A retrospective cross-sectional analysis was conducted using data from the National Inpatient Sample between 2015 and 2022. This nationally representative sample included adult patients (aged ≥18 years) in the United States hospitalized primarily for MCA strokes and with reported National Institutes of Health Stroke Scale scores. Patients were stratified into R-MCAS and left MCA stroke. Outcomes included odds of inpatient mortality, routine discharge, complications, and receipt of reperfusion therapy. Propensity score–based inverse probability of treatment weighting is adjusted for confounding factors. Multivariable logistic regression evaluated adjusted odds ratios (aORs) and 95% CIs for all outcomes. RESULTS: Among 489 360 acute ischemic stroke hospitalizations, 263 495 (53.8%) were left MCA stroke, and 225 865 (46.2%) were R-MCAS. Following inverse probability of treatment weighting, R-MCASs were significantly more likely to receive endovascular thrombectomy (aOR, 1.26 [95% CI, 1.22–1.30]; P P =0.018). R-MCAS was associated with significantly increased odds of cerebral edema/herniation (aOR, 1.53 [95% CI, 1.47–1.59]; P P P P P P <0.001). CONCLUSIONS: Patients with R-MCAS were more likely to receive endovascular thrombectomy and less likely to receive intravascular thrombolysis. R-MCASs were also associated with worse discharge disposition and increased likelihood of inpatient mortality. The National Institutes of Health Stroke Scale bias toward assessment and valuation of patients’ language abilities may place patients with R-MCAS at increased risk of adverse poststroke outcomes and complications. Recognition of the subtle signs of nondominant hemisphere strokes may lead to more rapid detection, effective treatment, and improved outcomes.

Background: The National Institutes of Health Stroke Scale (NIHSS) quantifies stroke severity, yet variability in its reporting may reflect healthcare disparities and affect outcomes. This study analyzes trends in NIHSS reporting in the National Inpatient Sample (NIS) database and its relationship with patient characteristics and outcomes. Methods: This retrospective cross-sectional study used data from the NIS between May 2016 and December 2022. This nationally representative sample included patients in the US hospitalized with acute ischemic stroke (AIS). Primary outcomes include NIHSS reporting rate over time, factors associated with reporting, and subsequent discharge disposition. Propensity score matching (PSM) accounted for patient demographics, hospital characteristics, severity of illness, and use of reperfusion therapy. Results: Among 4,558,909 AIS hospitalizations, NIHSS was reported in 1,930,880 (42.4%). The proportion of hospitalizations with reported NIHSS increased from 14.33% in December 2016 to 56.27% in December 2022. After PSM, reporting of NIHSS was associated with higher odds of routine discharge (Adjusted Odds Ratio = 1.03, 95% CI: [1.01–1.04]; p < 0.001) and lower odds of inpatient mortality (0.650 [0.632–0.668], p < 0.001). Scores were less likely to be reported in females (0.970 [0.961–0.979], p < 0.001) and Black (0.963 [0.939–0.988], p = 0.004) or Hispanic patients (0.960 [0.926–0.996], p = 0.030), as well as in smaller and less urban hospitals. Discussion: Since the implementation of NIHSS reporting, rates have increased to more than half of all AIS hospitalizations as of December 2022. NIHSS reporting was significantly associated with improved discharge disposition, and patient demographics impacted odds of having a reported NIHSS, highlighting persistent disparities in stroke care.

Background and Objectives: Hypothyroidism affects 4.6% of the US population, with incidence increasing in recent years. Systemic effects of hypothyroidism include increased serum cholesterol, endothelial dysfunction, and hypertension, which are widely recognized risk factors for stroke. To better understand the prognostic value of thyroid hormone levels in acute ischemic stroke (AIS), this population-based, cross-sectional study aims to examine the clinical outcomes of patients with AIS with hypothyroidism. Methods: The National (Nationwide) Inpatient Sample was queried from 2016 to 2020 for patients with AIS with a diagnosis of hypothyroidism using International Classification of Disease Ninth and Tenth Revision diagnostic codes. patients with AIS with and without hypothyroidism were assessed for baseline clinical characteristics, interventions, complications, and clinical outcomes. Propensity score matched analysis (1:1) was conducted to control for possible confounding variables. Results: Of 2,946,195 patients with AIS identified, 388,235 (13.2%) had a concurrent diagnosis of hypothyroidism. After propensity-score matching, hypothyroidism patients were more likely to experience discharge home (odds ratio (OR) = 0.70; p < 0.01), shorter length of stay (LOS) (4.93 vs. 5.19 days; p < 0.01), and lower rates of inpatient death (OR = 0.80; 95% CI: 0.76–0.84; p < 0.01), compared to patients without hypothyroidism. Conclusions: This retrospective analysis found that patients with hypothyroidism had shorter inpatient LOS, improved discharge disposition, and lower rates of mortality, suggesting that low thyroid hormone levels may be protective in outcomes of AIS. With the rising prevalence of hypothyroidism in the US population, it is increasingly important to investigate its potential effects on patients with cerebrovascular disease.

The association of anesthesia approach during endovascular thrombectomy (EVT) with clinical outcomes in large strokes is unexplored. We aimed to evaluate whether general anesthesia (GA), compared with non-GA, was associated with better functional outcomes in the SELECT2 trial. In a prespecified secondary analysis of the SELECT2 trial that enrolled patients with large strokes on noncontrast CT (Alberta Stroke Program Early CT Score [ASPECTS] 3-5), CT perfusion/MRI (core volume ≥50 mL), or both, functional outcomes were compared in EVT-treated patients who received GA or non-GA and whether this association was modified by stroke severity (NIH Stroke Scale score), ischemic injury estimates, and collateral status was evaluated. The primary outcome was 90-day functional status (ordinal modified Rankin Scale [mRS]). Secondary outcomes were functional independence (mRS scores 0-2), independent ambulation (mRS scores 0-3), complete dependence or death (mRS scores 5-6), and mortality. Of 178 EVT patients (median [interquartile range] age 66 [58-75] years, stroke severity 19 [15-23], CT-ASPECTS 4 [3-5], and core volume 101.5 [70-138] mL, 71 women [39.9%]), 104 (58%) received GA. Time from randomization to arterial puncture was longer with GA (40 [23-59] minutes) vs non-GA (27 [18-47] minutes), but procedural duration (GA: 57 [31.5-77] minutes vs non-GA: 49.5 [30-71] minutes) was similar. Successful reperfusion (modified treatment in cerebral infarction [mTICI] score 2b-3) rates were similar (GA 81 (78%) vs non-GA 62 (84%), adjusted relative risk [aRR] 0.91, 95% CI 0.79-1.06). In addition, mRS distribution did not differ between GA and non-GA groups (adjusted generalized odds ratio 1.21, 95% CI 0.86-1.70), as well as independent ambulation (GA: 41% vs non-GA: 34%, aRR 1.22, 95% CI 0.86-1.74) and functional independence (GA: 22% vs non-GA: 18%, aRR 1.32, 95% CI 0.75-2.35). Stroke severity, ASPECTS, ischemic core volume, or collaterals did not modify the association between anesthesia and functional outcome (all p-interaction >0.05). Patients experienced systolic blood pressure (SBP) variability ≥40 mm Hg and minimum intraprocedural SBP (p-interaction = 0.77 and 0.89, respectively). In patients with large core strokes randomized in SELECT2, EVT outcomes did not differ significantly based on anesthesia approach (GA or non-GA) without heterogeneity across stroke severity and size. While GA was associated with higher SBP variability and lower minimum SBP, this did not modify GA association with functional outcomes. While allocation to anesthesia approach was nonrandomized, our findings suggest that optimizing institutional protocols for preferred anesthesia technique, whether GA or non-GA, may enhance EVT procedural outcomes. ClinicalTrials.gov ID: NCT03876457. This study provides Class II evidence that in patients presenting within 24 hours with large vessel occlusion strokes undergoing EVT, the 90-day mRS score is comparable in those with or without GA.

Introduction: The emergence of connectomics in neurosurgery has allowed for construction of detailed maps of white matter connections, incorporating both structural and functional connectivity patterns. The advantage of mapping cerebral vascular lesions to guide surgical approach shows great potential. We aim to identify the clinical utility of connectomics for the surgical treatment of pediatric arteriovenous malformations (AVMs). Case Presentation: We present two illustrative cases of the application of connectomics to the management of cerebral AVM in a 9-year-old and 8-year-old female. Using magnetic resonance anatomic and diffusion tensor imaging, a machine learning algorithm generated patient-specific representations of the corticospinal tract for the first patient, and the optic radiations for the second patient. The default mode network and language network were also examined for each patient. The imaging output served as an adjunct to guide operative decision-making. It assisted with selection of the superior parietal lobule as the operative corridor for the first case. Furthermore, it alerted the surgeon to white matter tracts in close proximity to the AVM nidus during resection. Finally, it aided in risk versus benefit analysis regarding treatment approach, such as craniotomy for resection for the first patient versus radiosurgery for the second patient. Both patients had favorable neurologic outcomes at the available follow-up period. Conclusion: Use of the software integrated well with clinical workflow. The output was used for planning and overlaid on the intraoperative neuro-navigation system. It improved visualization of eloquent regions, especially those networks not visible on standard anatomic imaging. Future studies will focus on expanding the cohort, conducting in pre- and postoperative connectomic analysis with correlation to clinical outcome measures, and incorporating functional magnetic resonance imaging.