The curious case of the Zzz's

Excessive daytime sleepiness is a common presenting symptom that may present a diagnostic challenge for the sleep medicine clinician. We present a case of an adolescent female with excessive daytime sleepiness and "sleep attacks" who was evaluated using a 2-week sleep log, wrist actigraphy, baseline polysomnogram, and Multiple Sleep Latency Test. Multiple Sleep Latency Test results noted a short mean sleep latency without sleep onset rapid eye movement periods, concerning for possible central disorders of hypersomnolence. However, actigraphy data noted a habitual bedtime of midnight or later, resulting in less than recommended total sleep time for her age on weekdays with extended sleep periods on the weekends. The most unique actigraphy finding was exposure to ambient light throughout most overnight sleep periods. When actigraphy results were discussed with the patient, she revealed recent onset of severe anxiety with fear of sleeping in the dark. This case highlights the importance of thorough clinical evaluation, and careful interpretation of objective tests, when evaluating for causes of excessive daytime sleepiness.

CITATION

Dang L, Kanney ML, Hsu DP. The curious case of the Zzz's. J Clin Sleep Med. 2023;19(5):1009-1012.

Social impairment and snoring: a unique presentation of pediatric Chiari I malformation

Symptomatic progression of Chiari malformation type 1 (CM-1) can be difficult to recognize in children because of the slow progressive nature of the disorder and highly varied neurological symptoms. We present a case of an obese 11-year-old girl seeking an evaluation of snoring. Progressive social impairment and academic difficulties were also endorsed. The past medical history was remarkable for absence seizures at an earlier age with an incidental finding of CM-1 on brain imaging. No headaches, vision changes, or swallowing dysfunction were endorsed in the acute presentation. The patient underwent a polysomnogram, which revealed the unexpected finding of severe central sleep apnea. Magnetic resonance imaging of the brain revealed further herniation of the cerebellar tonsils and a cervical syrinx, which was not present on initial imaging. Posterior fossa decompression resulted in the successful resolution of symptoms. It was postulated that the social impairment and academic problems were manifestations of CM-1. There are no current standard protocols for disease surveillance of pediatric CM-1. Annual polysomnograms may serve as a useful tool.

CITATION

Kanney ML, Spear J, Hsu DP. Social impairment and snoring: a unique presentation of pediatric Chiari I malformation. J Clin Sleep Med. 2022;18(12):2867-2870.

Prevalence of Pulmonary Hypertension in Pediatric Patients With Obstructive Sleep Apnea and a Cardiology Evaluation: A Retrospective Analysis

STUDY OBJECTIVES

Pulmonary hypertension (PH) has been reported as a serious complication of obstructive sleep apnea (OSA) in children; however, estimated prevalence rates vary widely (zero to 85%). The purpose of this study is to determine the prevalence of PH in children with OSA and identify factors that may predict an increased PH risk in children with OSA.

METHODS

A retrospective review of all pediatric beneficiaries (88,058) in the San Antonio Military Health System with a diagnosis of OSA and a clinical evaluation by a pediatric cardiologist. OSA severity and nadir oxygen saturation were recorded from overnight polysomnography. Reason for referral, comorbid disorders, echocardiogram results, and cardiac diagnoses were obtained from cardiology records.

RESULTS

OSA was identified in 2,020 pediatric patients (2.3%). A pediatric cardiology consultation was reported for 296 patients with OSA. After excluding 95 patients for incorrect OSA diagnoses, incomplete data, or OSA treatment before cardiology evaluation, 163 patients were included in the final analysis. A diagnosis of PH was found in 3 patients with OSA (1.8%). Two of these patients had obesity, and all three had comorbid cardiac disorders.

CONCLUSIONS

Prevalence of PH in pediatric patients with OSA is low and none of the patients with PH had severe OSA. Current guidelines recommend PH screening in patients with severe OSA, yet OSA severity may not accurately predict risk. Factors evaluated in this study did not demonstrate an increased PH risk; additional research is necessary to improve screening in pediatric patients with OSA.

CITATION

Burns AT, Hansen SL, Turner ZS, Aden JK, Black AB, Hsu DP. Prevalence of pulmonary hypertension in pediatric patients with obstructive sleep apnea and a cardiology evaluation: a retrospective analysis. J Clin Sleep Med. 2019;15(8):1081-1087.

Risk of Distal Embolization From tPA (Tissue-Type Plasminogen Activator) Administration Prior to Endovascular Stroke Treatment

BACKGROUND AND PURPOSE

In large artery occlusion stroke, both intravenous (IV) tPA (tissue-type plasminogen activator) and endovascular stroke treatment (EST) are standard-of-care. It is unknown how often tPA causes distal embolization, in which a procedurally accessible large artery occlusion is converted to a more distal and potentially inaccessible occlusion.

METHODS

We analyzed data from a decentralized stroke telemedicine program in an integrated healthcare delivery system covering 21 hospitals, with 2 high-volume EST centers. We captured all cases sent for EST and examined the relationship between IV tPA administration and the rate of distal embolization, the rate of target recanalization (modified Treatment in Cerebral Infarction scale 2b/3), clinical improvement before EST, and short-term and long-term clinical outcomes.

RESULTS

Distal embolization before EST was quite common (63/314 [20.1%]) and occurred more often after IV tPA before EST (57/229 [24.9%]) than among those not receiving IV tPA (6/85 [7.1%]; P<0.001). Distal embolization was associated with an inability to attempt EST: after distal embolization, 26/63 (41.3%) could not have attempted EST because of the new clot location, while in cases without distal embolization, only 8/249 (3.2%) were unable to have attempted EST (P<0.001). Among patients who received IV tPA, 13/242 (5.4%) had sufficient symptom improvement that a catheter angiogram was not performed; 6/342 (2.5%) had improvement to within 2 points of their baseline NIHSS. At catheter angiogram, 2/229 (0.9%) of patients who had received tPA had complete recanalization without distal embolization. Both IV tPA and EST recanalization were associated with improved long-term outcome.

CONCLUSIONS

IV tPA administration before EST for large artery occlusion is associated with distal embolization, which in turn may reduce the chance that EST can be attempted and recanalization achieved. At the same time, some IV tPA-treated patients show symptomatic improvement and complete recanalization. Because IV tPA is associated with both distal embolization and improved long-term clinical outcome, there is a need for prospective clinical trials testing the net benefit or harm of IV tPA before EST.

Detection of Anterior Circulation Large Artery Occlusion in Ischemic Stroke Using Noninvasive Cerebral Oximetry

BACKGROUND AND PURPOSE

Large artery occlusion (LAO) in ischemic stroke requires recognition and triage to an endovascular stroke treatment center. Noninvasive LAO detection is needed to improve triage.

METHODS

Prospective study to test whether noninvasive cerebral oximetry can detect anterior circulation LAO in acute stroke. Interhemispheric ΔBrSO₂ in LAO was compared with controls.

RESULTS

In LAO stroke, mean interhemispheric ΔBrSO₂ was -8.3±5.8% (n=19), compared with 0.4±5.8% in small artery stroke (n=17), 0.4±6.0% in hemorrhagic stroke (n=14), and 0.2±7.5% in subjects without stroke (n=19) (P<0.001). Endovascular stroke treatment reduced the ΔBrSO₂ in most LAO subjects (16/19). Discrimination of LAO at a -3% ΔBrSO₂ cut had 84% sensitivity and 70% specificity. Addition of the G-FAST clinical score (gaze-face-arm-speech- time) to the BrSO₂ measure had 84% sensitivity and 90% specificity.

CONCLUSIONS

Noninvasive cerebral oximetry may help detect LAO in ischemic stroke, particularly when combined with a simple clinical scoring system.

Endovascular plug for internal carotid artery occlusion in the management of a cavernous pseudoaneurysm with bifrontal subdural empyema: technical note

The authors demonstrate the use of an endovascular plug in securing a carotid artery pseudoaneurysm in an emergent setting requiring craniotomy for a concurrent subdural empyema. They describe the case of a 14-year-old boy with sinusitis and bifrontal subdural empyema who underwent transsphenoidal exploration at an outside hospital. An injury to the right cavernous segment of the ICA caused torrential epistaxis. Bleeding was successfully controlled by inflating a Foley balloon catheter within the sphenoid sinus, and the patient was transferred to the authors' institution. Emergent angiography showed a dissection of the right cavernous carotid artery, with a large pseudoaneurysm projecting into the sphenoid sinus at the site of arterial injury. The right internal carotid artery was obliterated using pushable coils distally and an endovascular plug proximally. The endovascular plug enabled the authors to successfully exclude the pseudoaneurysm from the circulation. The patient subsequently underwent an emergent bifrontal craniotomy for evacuation of a left frontotemporal subdural empyema and exenteration of both frontal sinuses. He made a complete neurological recovery. Endovascular large-vessel sacrifice, obviating the need for numerous coils and antiplatelet therapy, has a role in the setting of selected acute neurosurgical emergencies necessitating craniotomy. The endovascular plug is a useful adjunct in such circumstances as the device can be deployed rapidly, safely, and effectively.

Inhaled corticosteroid related adrenal suppression detected by poor growth and reversed with ciclesonide

INTRODUCTION

This case series intends to highlight the association between decreased linear growth velocity and adrenal suppression in patients receiving inhaled corticosteroids for asthma. A potential treatment option is also discussed. Adrenal suppression secondary to inhaled corticosteroids has previously been reported and is often underrecognized. A decrease in linear height velocity has also been associated with inhaled corticosteroids. However, a decrease in height velocity has not been shown to predict adrenal suppression.

CASE STUDY

This case series of 15 patients receiving inhaled corticosteroids for control of asthma were noted to have a decrease in linear growth velocity ultimately associated with adrenal suppression. A change in inhaled corticosteroid to ciclesonide led to recovery of adrenal function without impacting asthma control.

RESULTS

Chart review from a pediatric pulmonology clinic was performed. Growth parameters and laboratory studies were recorded and analyzed. A mean decrease in height standard deviation score in the year prior to diagnosis of adrenal suppression was -0.59, -0.11, and -0.18, in pre-puberty, peri-puberty, and post-puberty patients, respectively. After ciclesonide therapy was initiated, a mean change in height standard deviation score of +0.40, +0.13, and -0.13, was noted for pre-puberty, peri-puberty, and post-puberty patients, respectively. A change in growth velocity of +5.3 cm/yr, +2.1 cm/yr, and -1.9 cm/yr, was noted for pre-puberty, peri-puberty, and post-puberty patients, respectively, after starting ciclesonide.

CONCLUSIONS

Height velocity should be monitored closely during routine asthma visits to identify potential adrenal suppression associated with inhaled corticosteroids use. Ciclesonide is a good option for asthma treatment that allows for adrenal recovery.

Evaluation of interpretation strategies and substantial bronchodilator response in pediatric patients with normal baseline spirometry

BACKGROUND

Controversy exists regarding the best method to interpret pediatric spirometry. There is also controversy regarding the benefit of performing post-bronchodilator spirometry after normal baseline spirometry. This study compares the use of lower limit of normal (LLN) against percent of predicted (PP) in the interpretation of spirometry. We also investigate the occurrence of a substantial bronchodilator response for patients who received post-bronchodilator spirometry.

METHODS

Spirometric tests performed in the pediatric clinic at San Antonio Military Medical Center were retrospectively reviewed. Results of spirometry were compared using LLN and PP for interpretation. Abnormal spirometry was defined as a low FEV1 or low FEV1/FVC, indicating evidence of airway obstruction. The presence of a substantial bronchodilator response was recorded and the results were analyzed.

RESULTS

Of 242 tests, 212 normal and 30 abnormal tests were reported using the LLN interpretation strategy. Using the PP interpretation strategy, there was a significant difference in the number of normal (183) and abnormal (59) tests, when compared to the LLN (P < .001). No significant difference between LLN versus PP interpretation strategies was noted in the number of baseline tests, normal or abnormal, that demonstrated a substantial response to bronchodilator. Of the subjects with normal baseline spirometry, 10% (PP) and 12% (LLN) had a substantial bronchodilator response. An abnormal baseline spirometry was more likely to have a substantial response to bronchodilator, compared to normal baseline spirometry (P < .001).

CONCLUSIONS

The use of LLN for interpretation is more likely to report a test as normal, when compared to the PP interpretation strategy. Although a substantial bronchodilator response is more likely to occur following abnormal baseline spirometry, 10-12% of subjects with normal baseline spirometry showed a substantial bronchodilator response. This suggests that normal baseline spirometry may miss reversible airway obstruction, which is a hallmark of asthma.

Outcome of pediatric inpatient asthma clinical pathway implementation in a military medical center

A performance improvement project was instituted at our facility to standardize pediatric inpatient asthma care by instituting an asthma clinical pathway (ACP). Formal asthma education and standardized postdischarge follow-up plans for all asthma inpatients were initiated. Patients treated by following the ACP were compared against historically similar patients from the previous 4 years. Differences in hospital length-of-stay (LOS) for patients treated on the ACP were compared to historical LOS. Adherence to The Joint Commission's home management plan of care metric, CAC-3, was also compared. There was a 25% lower hospital LOS in the ACP group compared to historical control group, 45.8 hours versus 60.9 hours (p < 0.002). CAC-3 adherence significantly increased from 48% to 89% (p < 0.001) after initiating formal asthma education. The implementation of a pediatric asthma inpatient performance improvement project was associated with a significant decrease in hospital LOS, when compared to historic controls. It also led to a significant improvement in adherence with The Joint Commission's CAC-3 measures.

Predictors and clinical relevance of hemorrhagic transformation after endovascular therapy for anterior circulation large vessel occlusion strokes: a multicenter retrospective analysis of 1122 patients

BACKGROUND AND PURPOSE

Endovascular techniques are frequently employed to treat large artery occlusion in acute ischemic stroke (AIS). We sought to determine the predictors and clinical impact of intracranial hemorrhage (ICH) after endovascular therapy.

METHODS

Retrospective analysis of consecutive patients presenting to 13 high volume stroke centers with AIS due to proximal occlusion in the anterior circulation who underwent endovascular treatment within 8 h from symptom onset. Logistic regression was performed to determine the variables associated with ICH, hemorrhagic infarction (HI), and parenchymal hematomas (PHs), as well as 90 day poor outcome (modified Rankin Scale score ≥3) and mortality.

RESULTS

There were a total of 363 ICHs (overall rate 32.3%; HI=267, 24%; PH=96, 8.5%) among the 1122 study patients (mean age 67±15 years; median National Institutes of Health Stroke Scale score 17 (IQR 13-20)). Independent predictors for HI included diabetes mellitus (OR 2.27, 95% CI (1.58 to 3.26), p<0.0001), preprocedure IV tissue plasminogen activator (tPA) (1.43 (1.03 to 2.08), p<0.037), Merci thrombectomy (1.47 (1.02 to 2.12), p<0.032), and longer time to puncture (1.001 (1.00 to 1.002), p<0.026). Patients with atrial fibrillation (1.61 (1.01 to 2.55), p<0.045) had a higher risk of PH while the use of IA tPA (0.57 (0.35 to 0.90), p<0.008) was associated with lower chances of PH. Both the presence of HI (2.23 (1.53 to 3.25), p<0.0001) and PH (6.24 (3.06 to 12.75), p<0.0001) were associated with poor functional outcomes; however, only PH was associated with higher mortality (3.53 (2.19 to 5.68), p<0.0001).

CONCLUSIONS

Greater understanding about the predictors and consequences of ICH post endovascular stroke therapy is essential to improve risk assessment, patient selection/clinical outcomes, and early prognostication. Our data suggest that patients with atrial fibrillation are particularly prone to severe ICH and question the 'benign' nature of HI suggested by earlier studies.

Successful treatment of persistent hypoxemia by nasal suctioning in a neonate with primary ciliary dyskinesia

Primary ciliary dyskinesia (PCD) is a genetic disorder that manifests clinically with chronic sinopulmonary and otologic disease. Despite the majority of patients presenting with respiratory symptoms in the neonatal period, the diagnosis is often delayed until several years of age. We report the case of a 5-day-old male who was diagnosed with PCD by electron microscopic evaluation of cilia obtained from nasal brush biopsy. This case also demonstrated the successful treatment of persistent hypoxemia with frequent nasal suctioning.

Device localization and dynamic scan plane selection using a wireless magnetic resonance imaging detector array

PURPOSE

A prototype wireless guidance device using single sideband amplitude modulation (SSB) is presented for a 1.5T magnetic resonance imaging system.

METHODS

The device contained three fiducial markers each mounted to an independent receiver coil equipped with wireless SSB technology. Acquiring orthogonal projections of these markers determined the position and orientation of the device, which was used to define the scan plane for a subsequent image acquisition. Device localization and scan plane update required approximately 30 ms, so it could be interleaved with high temporal resolution imaging. Since the wireless device is used for localization and does not require full imaging capability, the design of the SSB wireless system was simplified by allowing an asynchronous clock between the transmitter and receiver.

RESULTS

When coupled to a high readout bandwidth, the error caused by the lack of a shared frequency reference was quantified to be less than one pixel (0.78 mm) in the projection acquisitions. Image guidance with the prototype was demonstrated with a phantom where a needle was successfully guided to a target and contrast was delivered.

CONCLUSION

The feasibility of active tracking with a wireless detector array is demonstrated. Wireless arrays could be incorporated into devices to assist in image-guided procedures.

Abstract WP145: Medtronic Driver® Balloon-mounted Coronary Stent System In Endovascular Neurointervention: Off-label Clinical Experience At A Tertiary Referral Medical Center

Background: Balloon-mounted coronary stents have been employed in the endovascular management of ischemic cerebrovascular disease, where rapid and precise stenting with angioplasty may be performed in a patient with minimal or no sedation. The Medtronic Driver® balloon-mounted stent is known to have excellent trackability and deliverability, making it a viable tool in the armamentarium of the neurointerventional surgeon.

Methods: Retrospective review of 46 patients who underwent endovascular revascularization utilizing Medtronic Driver® stent from 2003-2011. Characteristics analyzed were patient demographics, lesion location, etiology of vascular lesion, degree of stenosis, extent of revascularization, short-term complications, and clinical outcome.

Results: Out of 46 patients with 51 Driver® stents studied, 21 were female and age of patients ranged from 37 to 91 years. The treatment data comprised of 22 internal carotid artery stents (19 patients) 1 common carotid artery stent, 25 vertebal artery stents (20 patients), and 3 basilar artery stents. 18 out of 51 stents were intracranial, including 7 ICA, 3 basilar and 8 vertebral artery. Extracranial stents comprised of 1 CCA, 15 ICA and 17 vertebral artery stents. Etiology of lesion included 41 stroke or TIA with symptomatic stenosis, 1 instent restenosis, and 4 dissections. Angiographically 5 patients had occluded vessels, 5 had <70% stenosis and 36 patients had 70-99% stenosis. The Driver® stent dimensions ranged from 3 mm x 9 mm to 4mm x 24 mm. Driver® stent placement failed in 2 cases and 4 patients developed instent-restenosis; two were stent occlusions in the same patient. Multiple Driver stents were used in 5 patients. 3 patients had symptomatic post-stenting hemorrhagic conversion and

4 deaths from non-procedure medical complications.

Conclusion: This study presents the largest single institution review of the Medtronic Driver® balloon- mounted coronary stent for use in neurointervention. The authors have demonstrated technical feasibility of the stent system and satisfactory revascularization in a variety of clinical indications.This device allows quick revascularization by performing stent-angioplasty together, and providing access for distal clot removal.

Cochlear implantation outcomes in patients with far advanced otosclerosis

OBJECTIVES

To compare hearing outcomes in patients with far advanced otosclerosis (FAO) undergoing cochlear implantation to an age-matched group of controls, to describe the effects of cochlear ossification on hearing, and to review the adverse effects of implantation in patients with FAO.

HYPOTHESIS

Hearing performance in patients with FAO after cochlear implantation is comparable to similarly treated postlingually deafened adults without FAO. Ossification or retrofenestral otosclerosis does not predict poor hearing outcomes. Modiolar-hugging technology reduces postoperative facial nerve stimulation.

STUDY DESIGN

Retrospective chart review.

SETTING

Academic neurotologic tertiary referral center.

PATIENTS

Thirty patients with FAO, who metaudiological criteria for cochlear implantation, were compared to 30 age-matched controls, postlingually deafened by non-otosclerotic causes.

MAIN OUTCOME MEASURES

Audiometric pre- and postoperative speech reception threshold, word, and sentence scores were analyzed. The presence of retrofenestral findings on computed tomography or intraoperative cochlear ossification were noted.

RESULTS

In the FAO group, radiographic abnormalities were noted in 26.4% of patients. Intraoperative ossification requiring drillout was seen in 29.4% of patients. None developed postoperative facial nerve stimulation. There was no difference between the FAO and control groups in the mean short-term and long-term postoperative speech reception threshold, word, and sentence scores (P = .77). The presence of radiographic abnormalities did not predict hearing outcome. Intraoperative cochlear ossification was not associated with worse short-term word and sentence scores (P = .58 and 0.79, respectively), and for the long-term hearing outcome (P = .24).

CONCLUSIONS

In patients with FAO, effective and safe hearing rehabilitation can be accomplished with cochlear implantation.

Standard of practice: endovascular treatment of intracranial atherosclerosis

BACKGROUND

Symptomatic intracranial atherosclerotic disease (ICAD) worldwide represents one of the most prevalent causes of stroke. When severe, studies show that it has a very high risk for recurrent stroke, highlighting the need for effective preventative strategies. The mainstay of treatment has been medical therapy and is of critical importance in all patients with this disease. Endovascular therapy is also a possible therapeutic option but much remains to be defined in terms of best techniques and patient selection. This guideline will serve as recommendations for diagnosis and endovascular treatment of patients with ICAD.

METHODS

A literature review was performed to extract published literature regarding ICAD, published from 2000 to 2011. Evidence was evaluated and classified according to American Heart Association (AHA)/American Stroke Association standard. Recommendations are made based on available evidence assessed by the Standards Committee of the Society of NeuroInterventional Surgery. The assessment was based on guidelines for evidence based medicine proposed by the American Academy of Neurology (AAN), the Stroke Council of the AHA and the University of Oxford, Centre for Evidence Based Medicine (CEBM).

RESULTS

59 publications were identified. The SAMMPRIS study is the only prospective, randomized, controlled trial available and is given an AHA level B designation, AAN class II and CEBM level 1b. The Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial arteries (SSYLVIA) trial was a prospective, non-randomized study with the outcome assessment made by a non-operator study neurologist, allowing an AHA level B, AAN class III and CEBM level 2. The remaining studies were uncontrolled or did not have objective outcome measurement, and are thus classified as AHA level C, AAN class IV and CEBM level 4.

CONCLUSION

Medical management with combination aspirin and clopidogrel for 3 months and aggressive risk factor modification is the firstline therapy for patients with symptomatic ICAD. Endovascular angioplasty with or without stenting is a possible therapeutic option for selected patients with symptomatic ICAD. Further studies are necessary to define appropriate patient selection and the best therapeutic approach for various subsets of patients.

Endovascular therapy of acute ischemic stroke: report of the Standards of Practice Committee of the Society of NeuroInterventional Surgery

OBJECTIVE

To summarize and classify the evidence for the use of endovascular techniques in the treatment of patients with acute ischemic stroke.

METHODS

Recommendations previously published by the American Heart Association (AHA) (Guidelines for the early management of adults with ischemic stroke (Circulation 2007) and Scientific statement indications for the performance of intracranial endovascular neurointerventional procedures (Circulation 2009)) were vetted and used as a foundation for the current process. Building on this foundation, a critical review of the literature was performed to evaluate evidence supporting the endovascular treatment of acute ischemic stroke. The assessment was based on guidelines for evidence based medicine proposed by the Stroke Council of the AHA and the University of Oxford, Centre for Evidence Based Medicine (CEBM). Procedural safety, technical efficacy and impact on patient outcomes were specifically examined.

Comparison of brain MR images at 1.5T using BLADE and rectilinear techniques for patients who move during data acquisition

BACKGROUND AND PURPOSE

MR imaging of moving patients can be challenging and motion correction techniques have been proposed though some have associated new artifacts. The objective of this study was to semiquantitatively compare brain MR images of moving patients obtained at 1.5T by using partially radial and rectilinear acquisition techniques.

MATERIALS AND METHODS

FLAIR, T2-, T1-, and contrast-enhanced T1-weighted image sets of 25 patients (14-94 years) obtained by using BLADE (like PROPELLER, a partially radial acquisition) and rectilinear techniques in the same imaging session were compared by 2 neuroradiologists in terms of extent of the motion artifact, image quality, and lesion visibility. ICC between opinions of the evaluators was calculated.

RESULTS

Of the total of 70 image sets, the motion artifact was small in the partially radial images in 43 and in the rectilinear images in 13, and the opinions of the evaluators were discordant in the remaining 14 sets (ICC = 0.63, P < .05). The quality of partially radial images was higher for 36 sets versus 9 rectilinear sets, with disagreement between the 2 evaluators in the remaining 25 (ICC = 0.15, P < .05). Pathologic lesions were better characterized on 37 sets of partially radial images versus 13 sets of rectilinear images, and opinions of the evaluators differed in 20 sets (ICC = 0.90, P < .05). The neuroradiologists deemed 4 sets of rectilinear images nondiagnostic compared with only 1 set of radial images.

CONCLUSIONS

The data demonstrate that our application of BLADE sequences reduces the extent of motion artifacts in brain images of moving patients, improving image quality and lesion characterization.

Patent foramen ovale associated with the unusual presentation of unilateral paramedian thalamic perforating artery infarction after embolic occlusion of 'artery of Percheron': case report and review of the literature

'Artery of Percheron' is a rare variation in blood supply in which a solitary arterial trunk arises from one of the proximal segments of the posterior cerebral arteries and supplies the paramedian thalami bilaterally. A young patient (in their early 30s) who presented with sudden onset of visual disturbance and speech difficulties is reported. A review of literature from 1981 to 2009 and review of the most widely reported clinical signs and symptoms are provided.

Intra-arterial stroke therapy: recanalization strategies, patient selection and imaging

With more than 700,000 strokes per year resulting in greater than 160,000 deaths per year, stroke remains the leading cause of disability and third leading cause of death in the United States. Despite an overall decline in stroke mortality over the past 40 years, the total number of stroke deaths continues to increase, suggesting an increase in stroke incidence. The last 20 years of neuroscience advances have moved stroke from a condition that is monitored clinically and imaged serially as it evolves to an entity that can be treated acutely, with remarkable alterations in its natural history.

Intra-arterial Thrombolysis or Stent Placement During Endovascular Treatment for Acute Ischemic Stroke Leads to the Highest Recanalization Rate: Results of a Multicenter Retrospective Study

BACKGROUND:

Reperfusion therapy for acute ischemic stroke (AIS) is rapidly evolving, with the development of multiple endovascular modalities that can be used alone or in combination.

OBJECTIVE:

To determine which pharmacologic or mechanical modality may be associated with increased rates of recanalization.

METHODS:

A cohort of 1122 patients with AIS involving the anterior circulation treated at 13 stroke centers underwent intra-arterial (IA) therapy within 8 hours of symptom onset. Demographic information, admission National Institutes of Health Stroke Scale (NIHSS), mechanical and pharmacologic treatments used, recanalization grade, and hemorrhagic complications were recorded.

RESULTS:

The mean age was 67 ± 16 years and the median NIHSS was 17. The sites of arterial occlusion before treatment were M1 middle cerebral artery (MCA) in 561 (50%) patients, carotid terminus in 214 (19%) patients, M2 MCA in 171 (15%) patients, tandem occlusions in 141 (13%) patients, and isolated extracranial internal carotid artery occlusion in 35 (3%) patients. Therapeutic interventions included multimodal therapy in 584 (52%) patients, pharmacologic therapy only in 264 (24%) patients, and mechanical therapy only in 274 (24%) patients. Patients treated with multimodal therapy had a significantly higher Thrombolysis in Myocardial Infarction 2 or 3 recanalization rate (435 patients [74%]) compared with pharmacologic therapy only (160 patients, [61%]) or mechanical only therapy (173 patients [63%]), P &lt; .001. In binary logistic regression modeling, independent predictors of Thrombolysis in Myocardial Infarction 2 or 3 recanalization were use of IA thrombolytic OR 1.58 (1.21-2.08), P &lt; .001 and stent deployment 1.91 (1.23-2.96), P &lt; .001.

CONCLUSION:

Multimodal therapy has significantly higher recanalization rates compared with pharmacologic or mechanical therapy. Among the individual treatment modalities, stent deployment or IA thrombolytics increase the chance of recanalization.

Outcomes of intra-arterial thrombolytic treatment in acute ischemic stroke patients with a matched defect on diffusion and perfusion MR images

BACKGROUND

For acute ischemic stroke patients with matched defects on diffusion-perfusion imaging, the effects of reperfusion therapy remain poorly documented. The outcomes in a rare series of patients who had a matched defect and then underwent intra-arterial thrombolytic treatment (IAT) are reported.

METHODS

Medical record and MR image review between 1 January 1998 and 15 October 2008 revealed only eight acute ischemic stroke patients satisfying the atypical combination of both matched defect and IAT. Successful recanalization (SR), favorable clinical response (FCR) and symptomatic intracranial hemorrhage (SICH) were defined respectively as thrombolysis in cerebral infarction score ≥2 after IAT, discharge National Institutes of Health Stroke Scale (NIHSS) 0-1/≥8 point decrease from baseline and intracranial hemorrhage in infarct zone with ≥4 point increase in NIHSS Score within 24 h of IAT.

RESULTS

Median (range) baseline NIHSS score was 16.5 (6-22). Median (range) time delays from symptom onset to MRI and to IAT initiation were 200 (83-240) and 267.5 (160-360) min, respectively. Median (range) values of diffusion and perfusion lesion volumes were 119.5 (24-205) and 118 (18-207) ml. Out of eight patients, one (12.5%) achieved FCR, four (50%) had SICH and five (62.5%) died. Out of six patients with SR, one achieved FCR and four had SICH and died, and of two patients without SR, none had FCR or SICH and one died.

CONCLUSION

Our data on rare patients with matched defects who nevertheless had attempted rescue with IAT confirm a poor risk-benefit ratio generated by low favorable responses and high mortality rates, especially in large ischemic lesions.

N-butyl 2-cyanoacrylate (n-BCA) embolization of a cerebellar hemangioblastoma

Hemangioblastomas (HBs) are highly vascular tumors whose resection can be associated with significant bleeding. Angioembolization has been used as an adjunct to surgical therapy, but particle embolization of cerebellar HBs has been associated with hemorrhage and resultant morbidity and mortality. We present a case of successful n-BCA embolization of an HB of the cerebellum.

Prediction of adverse outcomes by blood glucose level after endovascular therapy for acute ischemic stroke

OBJECT

The authors evaluated the prognostic significance of blood glucose level at admission (BGA) and change in blood glucose at 48 hours from the baseline value (CG48) in nondiabetic and diabetic patients before and after endovascular therapy for acute ischemic stroke (AIS).

METHODS

The BGA and CG48 data were analyzed in 614 patients with AIS who received endovascular therapy at 7 US centers between 2006 and 2009. Data reviewed included demographics, stroke risk factors, diabetic status, National Institutes of Health Stroke Scale (NIHSS) score at presentation, recanalization grade, intracranial hemorrhage (ICH) rate, and 90-day outcomes (mortality rate and modified Rankin Scale score of 3-6 [defined as poor outcome]). Variables with p values < 0.2 in univariate analysis were included in a binary logistic regression model for independent predictors of 90-day outcomes.

RESULTS

The mean patient age was 67.3 years, the median NIHSS score was 16, and 27% of patients had diabetes. In nondiabetic patients, BGA ≥ 116 mg/dl (≥ 6.4 mmol/L) and failure of glucose level to drop > 30 mg/dl (> 1.7 mmol/L) from the admission value were both significant predictors of 90-day poor outcome and death (p < 0.001). In patients with diabetes, BGA ≥ 116 mg/dl (≥ 6.4 mmol/L) was an independent predictor of poor outcome (p = 0.001). The CG48 was not a predictor of outcome in diabetic patients. A simplified 6-point scale including BGA, Thrombolysis in Myocardial Infarction (TIMI) Grade 2-3 Reperfusion, Age, presentation NIHSS score, CG48, and symptomatic ICH (BRANCH) corresponded with poor outcomes at 90 days; the area under the curve value was > 0.79.

CONCLUSIONS

Failure of blood glucose values to decrease in the first 48 hours after AIS intervention correlated with poor 90-day outcomes in nondiabetic patients. The BRANCH scale shows promise as a simple prognostication tool after endovascular therapy for AIS, and it merits prospective validation.

Conscious Sedation Versus General Anesthesia During Endovascular Therapy for Acute Anterior Circulation Stroke

Background and Purpose— Patients undergoing intra-arterial therapy (IAT) for acute ischemic stroke receive either general anesthesia (GA) or conscious sedation. GA may delay time to treatment, whereas conscious sedation may result in patient movement and compromise the safety of the procedure. We sought to determine whether there were differences in safety and outcomes in GA patients before initiation of IAT.

Methods— A cohort of 980 patients at 12 stroke centers underwent IAT for acute stroke between 2005 and 2009. Only patients with anterior circulation strokes due to large-vessel occlusion were included in the study. A binary logistic-regression model was used to determine independent predictors of good outcome and death.

Results— The mean age was 66±15 years and median National Institutes of Health Stroke Scale score was 17 (interquartile range, 13–20). The overall recanalization rate was 68% and the symptomatic hemorrhage rate was 9.2%. GA was used in 44% of patients with no differences in intracranial hemorrhage rates when compared with the conscious sedation group. The use of GA was associated with poorer neurologic outcome at 90 days (odds ratio=2.33; 95% CI, 1.63–3.44; P <0.0001) and higher mortality (odds ratio=1.68; 95% CI, 1.23–2.30; P <0.0001) compared with conscious sedation.

Conclusions— Patients placed under GA during IAT for anterior circulation stroke appear to have a higher chance of poor neurologic outcome and mortality. There do not appear to be differences in hemorrhagic complications between the 2 groups. Future clinical trials with IAT can help elucidate the etiology of the differences in outcomes.

Delayed progressive restenosis of the supraclinoid internal carotid artery treated with percutaneous transluminal angioplasty in a patient with aneurysmal subarachnoid hemorrhage

Typically occurring between 3 days and 3 weeks post-hemorrhage, cerebral vasospasm in the acute stage after aneurysmal subarachnoid hemorrhage is a major contributor to the morbidity and mortality associated with patient outcomes, despite advances in aneurysm treatment and vasospasm management. Though incompletely understood, cerebral vasospasm is well described in the immediate post-hemorrhage patient. Less detailed descriptions exist of delayed or progressive restenosis after aneurysmal subarachnoid hemorrhage and resultant vasospasm. We report a case of delayed progressive supraclinoid internal carotid artery restenosis treated with angioplasty 10 weeks after initial hemorrhage.

Endolymphatic Duct Status During Middle Fossa Dissection of the Internal Auditory Canal: A Human Temporal Bone Radiographic Study

OBJECTIVE

Successful hearing preservation after acoustic neuroma resection is sometimes complicated by delayed hearing deterioration. The middle fossa approach appears to offer superior long-term hearing results when compared to the retrosigmoid surgical approach. The goal of this study is to investigate the hypothesis that internal auditory canal (IAC) drilling during middle fossa acoustic neuroma removal is associated with a lower incidence of endolymphatic duct (ELD) injury, a potential cause of delayed hearing loss (HL) known to accompany retrosigmoid hearing preservation dissection techniques.

STUDY DESIGN

A human temporal bone anatomic and radiographic study complemented with a literature review.

METHODS

Twenty human temporal bones were analyzed with high-resolution multislice computed tomography (HRMCT) and subjected to standard extended middle fossa IAC dissection with labyrinthine preservation and follow-up HRMCT for analyses of the ELD.

RESULTS

Zero of 20 (0%) temporal bones were found to have violation of the ELD with preservation of the labyrinthine structures and the endolymphatic sac. Reviews of human and animal studies indicate that injury to the ELD may create endolymphatic hydrops, a known cause of hearing deterioration.

CONCLUSION

The ELD is not vulnerable to injury during IAC dissection using the middle fossa approach. A previous radiographic study has shown that the ELD is violated in 24% of temporal bones during retrosigmoid dissection of the IAC. These findings support and may help explain other outcome studies that show that long-term hearing results are superior with the use of the middle fossa approach when compared to results following retrosigmoid dissection.