Endovascular aspiration to treat acute ischemic stroke caused by embolic carcinoma

Although cardiac myxomas have been known to cause acute ischemic stroke and other cerebrovascular complications, intracranial embolization of metastatic tumor fragments is rare. This is likely because venous emboli generally cause pulmonary embolism. Pulmonary vein metastases and patent foramen ovales have previously shown to propagate intracranial embolic carcinomas, but these events are very uncommon, and are not well characterized. We report a rare case of large-cell, high-grade neuroendocrine lung cancer embolus occluding the basilar artery, which likely detached into the bloodstream from the lung after intruding into a pulmonary vein. The embolus was treated with endovascular aspiration, and achieved modified Thrombolysis In Cerebral Infarction 2c revascularization. After initial neurological recovery, the patient suffered respiratory arrest and support was withdrawn 48 h later. We discuss the tumor characteristics and implications for treatment of acute ischemic stroke in patients with cancer diagnoses.

Open and endovascular treatment of spinal dural arteriovenous fistulas: a 10-year experience

OBJECTIVE Vascular malformations of the spine represent rare clinical entities with profound neurological implications. Previously reported studies on management strategies for spinal dural arteriovenous fistulas (sDAVFs) appeared before the advent of modern liquid embolic agents. Authors of the present study review their institutional experience with endovascularly and surgically treated sDAVFs. METHODS The authors performed a retrospective, observational, single-center case series on sDAVFs treated with endovascular embolization, microsurgical occlusion, or both between 2004 and 2013. The mode, efficacy, and clinical effect of treatment were evaluated. RESULTS Forty-seven patients with spinal arteriovenous malformations were evaluated using spinal angiography, which demonstrated 34 Type I sDAVFs (thoracic 20, lumbar 12, and cervical 2). Twenty-nine of the patients (85%) were male, and the median patient age was 63.3 years. Twenty patients underwent primary endovascular embolization (16 Onyx, 4 N-butyl cyanoacrylate [NBCA]), and 14 underwent primary surgical clipping. At a mean follow-up of 36 weeks, according to angiography or MR angiography, 5 patients treated with endovascular embolization demonstrated persistent arteriovenous shunting, whereas none of the surgically treated patients showed lesion persistence (p = 0.0237). Thirty patients (88%) experienced some resolution of their presenting symptoms (embolization 17 [85%], surgery 13 [93%], p = 1.00). CONCLUSIONS Microsurgical occlusion remains the most definitive treatment modality for sDAVFs, though modern endovascular techniques remain a viable option for the initial treatment of anatomically amenable lesions. Treatment of these lesions usually results in some clinical improvement.

Diagnostic quality and accuracy of low dose 3D-DSA protocols in the evaluation of intracranial aneurysms

BACKGROUND

3D-DSA is the 'gold standard' imaging technique for the diagnosis and characterization of intracranial aneurysms.

OBJECTIVE

To compare the image quality and accuracy of low dose 3D-DSA protocols in patients with unruptured intracranial aneurysms.

MATERIALS AND METHODS

The standard manufacturer 5 s 0.36 μGy/f protocol and one of three low dose 3D-DSA protocols (5 s 0.10 μGy/f, 5 s 0.17 μGy/f, 5 s 0.24 μGy/f) were performed in 12 patients with unruptured intracranial aneurysms. Three interventional neuroradiologists, two neurosurgeons, and two neurologists rated the image quality of all 3D reconstructions as good, acceptable, or poor. Three interventional neuroradiologists measured two dimensions of each aneurysm for all protocols. The radiation dose metric Ka,r (reference point air kerma, in mGy) was recorded for each 3D-DSA protocol.

RESULTS

The standard 5 s 0.36 μGy/f protocol earned the highest average subjective rating of 2.76, followed by the 5 s 0.24 μGy/f (2.72), and 5 s 0.17 μGy/f (2.59) protocols. The ranges of differences in aneurysm measurements between the 5 s 0.24 μGy/f protocol and the standard were <0.5 mm. The median Ka,r metrics for each protocol were as follows: 5 s 0.36 μGy/f (89.0 mGy), 5 s 0.24 μGy/f (57.7 mGy), 5 s 0.17 μGy/f (45.9 mGy), and 5 s 0.10 μGy/f (27.6 mGy).

CONCLUSIONS

Low dose 3D-DSA protocols with preserved image quality are achievable, and can help reduce exposure of patients and operators to unnecessary radiation. The 5 s 0.24 μGy/f protocol generates one-third smaller radiation dose than the standard 5 s 0.36 μGy/f protocol without compromising diagnostic image quality or accuracy.