Pankajavalli Ramakrishnan

Background/Objectives: Pulsatile tinnitus (PT), headache, dizziness, and venous or pressure-associated imaging findings often coexist, but their relationships are incompletely defined, and otolaryngologists lack a practical evaluation pathway. We aimed to (1) characterize the clinical, imaging, and hemodynamic phenotype of adults evaluated for PT; (2) describe vestibular findings in a nested subgroup; and (3) propose an otology-led diagnostic pathway. Methods: Retrospective cohort of 29 adults with physician-documented PT (June 2024–May 2026), reported according to STROBE. A nested subgroup of five patients with interpretable video-oculography (VOG) underwent detailed vestibular review. Results: Migraine was documented in 20/29 (69.0%) and motion sensitivity in 9/29 (31.0%). Of 16 patients with magnetic resonance imaging/venography, 8 had an empty or partially empty sella and 6 had transverse-sinus narrowing, hypoplasia, or occlusion. Papilledema was absent in all 6 patients with documented ophthalmologic evaluation. Seven underwent catheter-based venous evaluation; one with transverse–sigmoid gradients of approximately 23 and 24 mmHg had PT resolution after stenting. In the nested subgroup, two patients had caloric abnormalities and three had position-sensitive mixed-vector ocular drift. Conclusions: Sound, vestibular symptoms, visual risk, and venous hemodynamics overlapped without a single causal pathway. We propose a stepwise, imaging-first pathway that evaluates these domains separately and a testable hypothesis for the vestibular findings.

Background/Objectives: To critically evaluate the evidence on sigmoid sinus wall reconstruction (SSWR) for venous pulsatile tinnitus (PT), with emphasis on outcome durability, objective hemodynamic assessment, pressure-associated findings, and safety. Methods: A critical review with a structured literature search and reporting informed by PRISMA 2020 was performed using PubMed/MEDLINE and backward citation searching. Embase, Scopus, and the Cochrane Library were used to identify contextual secondary reviews and to cross-check the primary-study set. A descriptive study-level appraisal addressed design, cohort size, follow-up, outcome objectivity, hemodynamic measurements, and complication reporting. The manuscript is presented as a critical review because no prospective registration or formal risk-of-bias assessment was undertaken. Results: Thirty-four records were identified, two duplicates were removed, and 32 records were screened; 10 studies were included in the qualitative synthesis. These comprised dedicated SSWR/resurfacing outcome cohorts and clinical, imaging, or pressure/hemodynamic studies, with some studies contributing to more than one domain. The cohorts were small, heterogeneous, and predominantly retrospective, and only one cohort had mean follow-up exceeding 5 years. In that cohort, complete PT elimination was reported in 24/37 ears (64.9%), with significant partial improvement in 10 additional ears, yielding an initial satisfactory response in 34/37 ears (91.9%); after recurrence was considered, the source authors reported long-term success in 31/37 ears (83.8%). IIH (3/35), papilledema (5/35), and venous sinus stenting (2/35) were reported separately during follow-up and were not combined into a composite prevalence. Objective pre- and postoperative intracranial pressure or venous hemodynamic measurements were sparse, and complication reporting was inconsistent. Conclusions: This critical review suggests symptomatic benefit from SSWR in selected patients but finds insufficient evidence to determine whether the procedure normalizes intracranial pressure, corrects upstream venous hemodynamics, prevents recurrence, or modifies long-term disease. Comparative treatment recommendations cannot be supported. Prospective multicenter studies with standardized objective, patient-reported, and safety outcomes are required.

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.

Stroke has become the single leading neurological illness that results in neurological disability and is the second most common cause of death worldwide. Approximately 85% of strokes are ischemic, whereas the remaining 15% are hemorrhagic. With the advent of increasingly effective treatment modalities, such as intravenous thrombolytics and endovascular mechanical thrombectomy, there has been a growing disparity in the ability to provide standard of care, despite substantial efforts made in lower- and middle-income countries. substantial effort in high-income countries to provide the current standard of care to patients with stroke, with the hope of improving outcomes. Extensive research has shown that the disparities in treatment among various countries stem from multiple sociocultural barriers and the lack of robust healthcare infrastructure. The societal influences in play include the lack of knowledge of stroke symptoms, cultural beliefs, health, and spiritual fatalism, which are then associated with delayed healthcare-seeking behaviors. As a result, it is imperative to increase access to treatment for patients with stroke to address inequities in stroke care and diminish the global burden of stroke. This narrative review highlights causes of major gaps in stroke treatment infrastructure in several global communities and examines the pertinent sociocultural factors that impede progress in stroke treatment.

Stroke is a leading cause of neurological disability and mortality worldwide, with acute ischemic strokes caused by large-vessel occlusions presenting significant health care challenges. While endovascular thrombectomy has emerged as a gold standard treatment, access to timely stroke care remains severely limited, especially in low- and middle-income countries. This review examines the multifaceted social, cultural, and systemic barriers that impede effective stroke care globally. We performed a comprehensive search of PubMed from 2004 to 2024, using keywords of acute stroke care, low-middle-income countries, social barriers, cultural barriers, and access. There are several recognized obstacles to stroke treatment, especially in the acute settings, including health fatalism, spiritual and religious beliefs that discourage medical intervention, and widespread lack of public awareness about stroke symptoms and urgency. Cultural misconceptions often lead individuals to delay or avoid seeking medical care, with some communities attributing stroke to supernatural forces or divine punishment. Language barriers, insufficient health care infrastructure, and socioeconomic challenges further compound these issues, particularly in regions such as sub-Saharan Africa and parts of Asia. Furthermore, there are critical infrastructural barriers to delivering acute stroke in a timely manner, including limited transportation to health care facilities and inadequate stroke centers in rural areas. A comprehensive strategy to address these challenges should focus on culturally sensitive education, community engagement, and infrastructure development. Recommendations include cooperating with religious and community leaders, developing targeted awareness campaigns, and creating inclusive health care approaches that respect local cultural contexts. Overall, addressing the global stroke burden not only requires technological interventions but also demands a holistic approach that bridges cultural understanding, challenges misconceptions, and empowers communities to recognize and respond to stroke as a critical medical emergency.

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.

Aneurysmal subarachnoid hemorrhage is one of the feared stroke subtypes with a high degree of morbidity and mortality. Even after the initial treatment of the ruptured aneurysm, patients remain critically ill due to numerous neurologic and systemic sequalae. Among them is cerebral vasospasm, which is a key contributor in the development of delayed cerebral ischemia (DCI). Whereas prevention of DCI with oral nimodipine is standard of care, neurointerventional strategies in the management of DCI are varied. Chemical angioplasty with intra-arterial vasodilators has been a conventional approach when noninvasive medical management fails but is associated with the need for retreatment and therefore felt to be least durable. Balloon angioplasty is also another classically employed, but less frequent intervention, and is limited by utility in the proximal arterial segment, a narrower safety profile, and challenging navigability. More recently, the use of retrievable stents is emerging as a novel strategy with the advantages of improved safety profile, and navigability to treat more distal segments. Here, a selective overview of some of these classic and innovative neurointerventional strategies is presented in the treatment of symptomatic vasospasm/DCI.

BACKGROUND: The availability of mechanical thrombectomy (MT) for acute ischemic stroke is limited, and vast disparities exist between countries. We aim to create a MT access score to measure the drivers of access to help quantify and accelerate treatment worldwide. METHODS: We used a systematic review complemented by a modified Delphi method. In the first of 3 rounds, 4 independent investigators performed a systematic literature review using key search terms that drive MT access, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In the second round, a panel of 6 anonymous international experts selected key attributes needed for scoring. In the final round, a total of 12 attributes were selected on consensus, each given a score on a 0 to 3 scale. An ultimate MT access score (range, 0–36) was proposed as a new tool to use in identifying barriers to MT access and assist in providing an initial framework for public health interventions. RESULTS: Of 2864 abstracts screened, 121 studies were included in the final systematic review. A total of 34 attributes that potentially drive MT access were initially identified. In the final round, 12 attributes were selected by the expert panel: public awareness, emergency medical services transportation, prehospital large vessel occlusion screening, interhospital transfer policy, emergency department protocols, stroke imaging protocols, emergency department stroke expertise or telestroke availability, interventionalists, MT-capable centers, device availability, and insurance coverage. These attributes were weighted as part of the final score of 0 to 36. CONCLUSIONS: The MT access score represents the first tool to quantify barriers to global MT access. Its implementation stands not just as an academic achievement but as a beacon of hope for improving stroke care and outcomes worldwide, bringing us a step closer to bridging the gap in stroke treatment disparities.