Complications and outcomes of carotid artery stenting in high-risk cases

OBJECTIVES

Carotid artery stenting is sometimes adapted for some at-risk cases; however, appropriate treatment timing with stroke onset is controversial. This study aims to identify factors that have an impact on complications and outcomes, especially in patients at high risk.

MATERIALS AND METHODS

We examined the characteristics of 152 consecutive patients treated by carotid artery stenting between January 2018 and March 2022 and retrospectively analyzed the risk factors for complications and poor outcomes (modified-Rankin-Scale deterioration), such as patient background, carotid artery stenting risks (access route tortuosity, severe calcification, vulnerable plaque, estimated glomerular filtration rate <30 mL/min/1.73 m2, etc.), characteristics of the stenosis, details of treatment, and treatment timing.

RESULTS

The average North American Symptomatic Carotid Endarterectomy Trial criteria score was 68.3% and the lesion length was 20.5±9.7mm. Among patients, 107 (70.4%) had a carotid artery stenting risk. In high-risk carotid artery stenting cases, symptomatic complications occurred in 32 (30.0%), and the 90-day modified Rankin scale score deteriorated in 15 cases (14.0%). Multivariate analysis showed that cases with triple antithrombotic therapy (p=0.003), stenting within 7 days (p=0.0032), and after 28+ days (p=0.0035) of stroke onset were independently associated factors for complications.

CONCLUSIONS

This study showed that among risk factors, triple antithrombotic therapy in particular was a risk factor for perioperative complications. Carotid artery stenting for patients with stroke after 28 days of onset affects the prognosis. Therefore, although further study is warranted, waiting more than one month for treatment in patients requiring carotid artery stenting is a potential risk.

Renin-angiotensin-aldosterone system inhibitors as a risk factor for chronic subdural hematoma recurrence: A matter of debate

OBJECTIVES

Chronic subdural hematoma (cSDH) is a common central nervous system condition. Recent reports indicate that cSDH affects long-term prognosis; however, its definitive risk factors remain unknown. An antihypertensive drug, renin-angiotensin-aldosterone system inhibitors (RAASi), can affect vascular permeability and cell proliferation processes, which may suppress the recurrence of cSDH. However, several studies have reported negative results to this effect. Therefore, we aimed to evaluate antihypertensive drugs, including RAASi, as risk factors for recurrent cSDH.

MATERIALS AND METHODS

A total of 203 consecutive cases of surgically treated cSDH were retrospectively reviewed. Clinical and radiological parameters were compared between the groups with and without cSDH recurrence to identify risk factors.

RESULTS

Of the included cases, 68 (33.5%) used RAASi and 37 (18.2%) developed recurrence within 60 days of surgery. In the multiple logistic regression analysis adjusted by composite risk score, the odds ratios (95% confidence interval) of RAASi, calcium channel blockers, diuretics, β and α blockers, for the recurrent risk of cSDH after surgery were 2.49 (1.16, 5.42), 1.79 (0.84, 3.82), 1.83 (0.62, 4.87), 0.90 (0.28, 2.44), and 0.96 (0.21, 3.20), respectively. The Cox proportional hazard model also demonstrated that RAASi-use was an independent risk factor for cSDH recurrence.

CONCLUSIONS

Present series suggests RAASi-use as a risk factor for cSDH recurrence, although the role of RAASi-use in cSDH remains debatable. Further studies for deeper understanding of the microenvironment of hematoma and the surroundings are preferable. (235 words).

Preoperative tumor embolization prolongs time to recurrence of meningiomas: a retrospective propensity-matched analysis

BACKGROUND

Meningiomas are often embolized preoperatively to reduce intraoperative blood loss and facilitate tumor resection. However, the procedure is controversial and its effects have not yet been reported. We evaluated preoperative embolization for meningiomas and its effect on postoperative outcome and recurrence.

METHODS

We retrospectively reviewed the medical records of 186 patients with WHO grade I meningiomas who underwent surgical treatment at our hospital between January 2010 and December 2020. We used propensity score matching to generate embolization and no-embolization groups (42 patients each) to examine embolization effects.

RESULTS

Preoperative embolization was performed in 71 patients (38.2%). In the propensity-matched analysis, the embolization group showed favorable recurrence-free survival (RFS) (mean 49.4 vs 24.1 months; Wilcoxon p=0.049). The embolization group had significantly less intraoperative blood loss (178±203 mL vs 221±165 mL; p=0.009) and shorter operation time (5.6±2.0 hours vs 6.8±2.8 hours; p=0.036). There were no significant differences in Simpson grade IV resection (33.3% vs 28.6%; p=0.637) or overall perioperative complications (21.4% vs 11.9%; p=0.241). Tumor embolization prolonged RFS in a subanalysis of cases who experienced recurrence (n=39) among the overall cases before variable control (mean RFS 33.2 vs 16.0 months; log-rank p=0.003).

CONCLUSIONS

After controlling for variables, preoperative embolization for meningioma did not improve the Simpson grade or patient outcomes. However, it might have effects outside of surgical outcomes by prolonging RFS without increasing complications.

Predictors of Outcomes Six Months after Endovascular Coil Embolization of Poor-Grade Aneurysmal Subarachnoid Hemorrhage

Objective

To identify factors associated with the outcome and prognosis of coil embolization for poor-grade aneurysmal subarachnoid hemorrhage (aSAH).

Methods

We retrospectively reviewed 118 patients with World Federation of Neurosurgical Societies (WFNS) grade IV or V subarachnoid hemorrhage at our institute between January 2010 and December 2020. Outcomes were assessed using modified Rankin Scale (mRS) scores at discharge and at six months after aSAH onset. In addition, patient background, aneurysm characteristics, and treatment outcome were compared between patients showing favorable (mRS scores: 0-2) and unfavorable (mRS scores: 3-6) outcomes at six months. Factors for change of mRS during follow-up were explored, and cut off values were calculated for age using the receiver operating characteristic analysis.

Results

Endovascular treatment was performed in 51 of the 118 enrolled patients. Data were analyzed for 43 of these patients who underwent coil embolization of ruptured aneurysms and had complete datasets. The mean age was 61.7 years and 24 (55.8%) patients had WFNS grade V aSAH. Coil embolization-related complications were observed in three patients. There were no treatment-related deaths; however, eight patients (18.6%) died at three months. Multivariate analysis showed that the maximum diameter of the aneurysm (p=0.041) and the postoperative dual antiplatelet therapy (DAPT) (p=0.040) were associated with unfavorable and favorable outcomes, respectively. Older age (p=0.033) was independently associated with mRS score deterioration following discharge. Age 72 years and older was the cut off value for mRS deterioration.

Conclusion

Aneurysm size and postoperative DAPT might be associated with outcomes at 6 months. Moreover, we identified older age as an independent factor that influences mRS deterioration following discharge; thus, especially in cases of elderly patients over 72 years of age, it is highly likely that long-term care to prevent disuse and regular follow-up on imaging will be necessary.

Primary Meningeal Melanocytoma Located in the Craniovertebral Junction: A Case Report and Literature Review

Primary meningeal melanocytoma is a rare benign tumor in the central nervous system (CNS), comprising less than 0.1% of all intracranial tumors. A 44-year-old man presented with occipital headache, nausea, and vomiting. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a well-defined intradural extramedullary mass lesion at the craniovertebral junction (CVJ). Gross total removal was achieved, and the patient improved symptomatically. The pathologic findings were consistent with meningeal melanocytoma. No tumor recurrence was seen on follow-up MRI two years after surgery. Cases of primary meningeal melanocytoma located at the CVJ are rare. The preoperative differential diagnosis of meningeal melanocytoma from meningioma is sometimes difficult because of their similar appearance on CT and MRI. Complete surgical removal is curative for most cases. We present a case of gross total removal of a meningeal melanocytoma located in the CVJ with references to the literature.

Renal Dysfunction is the Strongest Prognostic Factor After Carotid Artery Stenting According to Real-World Data

PURPOSE

Through the progression of devices, the adaptation of carotid artery stenting (CAS) has been expanded according to the non-inferiority of CAS for carotid endarterectomy reported by several randomized control trials. To maintain favorable outcomes, identifying prognostic factors is essential for optimizing treatment indications and periprocedural management. This study focused on the prognostic factors of CAS using real-world data.

METHODS

This retrospective multicenter cohort study aimed to identify the prognostic factors after CAS using real-world data from the stroke registry of Yokohama (STrOke Registry of Yokohama; STORY) from January 1, 2018 to May 31, 2021. Patient characteristics, procedural factors, complications, and prognoses were collected using medical records.

RESULTS

Data from 107 patients were enrolled in this study after excluding those with insufficient data (2 cases). The mean participant age was 74.9±8.2 years, and 66 patients (61.7%) were symptomatic. Symptomatic lesions were a significant prognostic factor in the overall analysis (p=0.003). A multivariate analysis showed that the estimated glomerular filtration rate (eGFR) (odds ratio: 1.11, p=0.003) and staged CAS (odds ratio: 38.9, p=0.04) were independent prognostic factors. The odds ratio and relative risk of mRS deterioration when eGFR was under 49 mL/min/1.73 m² compared with when eGFR was above 49 mL/min/1.73 m² were 5.2 and 3.74, respectively.

CONCLUSIONS

In this real-world multicenter study, we established independent prognostic factors for CAS using high totality data. For patients with symptomatic lesions and low eGFR (≤49 mL/min/1.73 m²), indication for treatment should be considered strictly.

Safety and Efficacy of Preoperative Embolization in Patients with Meningioma

Preoperative embolization for intracranial meningioma has remained controversial for several decades. In this study, we retrospectively reviewed our experience of embolization using particulate embolic material and coil to clarify the therapeutic efficacy, safety, and risk of complication. Methods  We reviewed 69 patients who underwent embolization with particulate embolic material followed by surgical resection. An additional 6 procedures were included for patients in whom recurrence was treated, for a total of 75 procedures of preoperative embolization. We analyzed the following clinical data: age, sex, tumor size pathology, complications related to embolization, and surgeon's opinion on the intraoperative ease of debulking and blood transfusion. Embolization was performed mainly from the branches of the external carotid artery. Results  No allogenic blood transfusions were needed for any patients. The surgeon had the opinion that whitening and softening of the tumor allowed for easy debulking during decompression of the tumor in most of the patients. Hemorrhagic complications were seen in two patients after embolization. Emergency tumor removal was performed in both of those patients, and they were recovered well after surgery. Transient cranial nerve palsy was seen in one patient. One ischemic complication and one allergic complication occurred. Conclusion  Preoperative embolization could give us an advantage in surgery for meningioma. The procedure reduces intraoperative blood loss and operating time by softening the tumor consistency. However, we must pay attention to the possibility of embolic complications and keep the preparation of emergency craniotomy, particularly in patients with large meningiomas.