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Catapano JS, Koester SW, Hanalioglu S, Farhadi DS, Naik A, Hartke JN, Tunc O, Winkler EA, Chang SW, Lawton MT, Jadhav AP, Ducruet AF, Albuquerque FC. Middle meningeal artery embolization associated with reduced chronic subdural hematoma volume and midline shift in the acute postoperative period. J Neurointerv Surg 2024; 16:478-481. [PMID: 37321836 DOI: 10.1136/jnis-2022-020054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/21/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization for endovascular treatment of chronic subdural hematoma (cSDH) is growing in popularity. cSDH volume and midline shift were analyzed in the immediate postoperative window after MMA embolization. METHODS A retrospective analysis of cSDHs managed via MMA embolization from January 1, 2018 to March 30, 2021 was performed at a large quaternary center. Pre- and postoperative cSDH volume and midline shift were quantified with CT. Postoperative CT was obtained 12 to 36 hours after embolization. Paired t-tests were used to determine significant reduction. Multivariate analysis was performed using logistic and linear regression for percent improvement from baseline volume. RESULTS In total, 80 patients underwent MMA embolization for 98 cSDHs during the study period. The mean (SD) initial cSDH volume was 66.54 (34.67) mL, and the mean midline shift was 3.79 (2.85) mm. There were significant reductions in mean cSDH volume (12.1 mL, 95% CI 9.32 to 14.27 mL, P<0.001) and midline shift (0.80 mm, 95% CI 0.24 to 1.36 mm, P<0.001). In the immediate postoperative period, 22% (14/65) of patients had a>30% reduction in cSDH volume. A multivariate analysis of 36 patients found that preoperative antiplatelet and anticoagulation use was significantly associated with an expansion in volume (OR 0.028, 95% CI 0.000 to 0.405, P=0.03). CONCLUSION MMA embolization is safe and effective for the management of cSDH and is associated with significant reductions in hematoma volume and midline shift in the immediate postoperative period.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Sahin Hanalioglu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Dara S Farhadi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Anant Naik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joelle N Hartke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Osman Tunc
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Steven W Chang
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Rai AT, Halak AA, Lakhani DA, Tarabishy AR, Siddiqui AH. Population-based estimates suggest middle meningeal artery embolization for subdural hematomas could significantly expand the scope of neurovascular therapies. J Neurointerv Surg 2024:jnis-2024-021686. [PMID: 38604765 DOI: 10.1136/jnis-2024-021686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/25/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND This study quantifies the impact of middle meningeal artery embolization (MMAE) for subdural hematomas (SDHs) by estimating a target population. METHODS A population-based study at a tertiary hospital, the main SDH facility for a four-county population, used primary ICD-10 codes over 3 years to collate SDH hospitalizations. Clinical and imaging data confirmed traumatic versus non-traumatic and acute versus non-acute (mixed or chronic) SDH. The MMAE-eligible population included patients with non-traumatic, non-acute SDH aged ≥18 years plus patients with 'traumatic' but non-acute SDH aged ≥60 years presenting with a fall. This was contrasted with the rate of large vessel strokes in the same population. RESULTS 1279 hospitalizations with a primary ICD-10 SDH diagnosis were identified, with 389 from the study population. Excluding repeat admissions, 350 patients were analyzed, 233 (67%) traumatic, and 117 (33%) non-traumatic SDH. Regarding etiology, 'fall ≥60 years' was the most common category in the entire cohort (n=156; 45% (95% CI 39% to 50%)). The SDH rate was 52/100 000 persons/year (95% CI 47 to 57). The rate of all non-traumatic, non-acute SDH in patients aged ≥18 years was 17/100 000 persons/year (95% CI 15 to 20), combining with 'traumatic' but non-acute fall-related SDH in patients aged ≥60 years yielded 41/100 000 persons/year (95% CI 36 to 47). This demographic may represent an MMAE-eligible population, exceeding large vessel stroke rates (31/100 000 persons/year) in the same population, estimating 139 387 potential MMAE cases/year (95% CI 121 517 to 158 168) in the USA. CONCLUSION MMAE could transform non-acute SDH management, especially in the elderly, potentially surpassing the impact of large vessel stroke. Clinical trials are essential for validation of its efficacy and safety compared with standard management.
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Affiliation(s)
- Ansaar T Rai
- Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - Abdulrahman A Halak
- Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - Dhairya A Lakhani
- Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - Abdul R Tarabishy
- Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
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Weiss D, Lang H, Rubbert C, Jannusch K, Kaschner M, Ivan VL, Caspers J, Turowski B, Jansen R, Lee JI, Ruck T, Meuth SG, Gliem M. Diagnostic Value of Perfusion Parameters for Differentiation of Underlying Etiology in Internal Carotid Artery Occlusions. Clin Neuroradiol 2024; 34:219-227. [PMID: 37884790 PMCID: PMC10881783 DOI: 10.1007/s00062-023-01349-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 09/08/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE Occlusions of the internal carotid artery (ICA) may be caused by dissection, embolic or macroangiopathic pathogenesis, which partially influences the treatment; however, inferring the underlying etiology in computed tomography angiography can be challenging. In this study, we investigated whether computed tomography perfusion (CT-P) parameters could be used to distinguish between etiologies. METHODS Patients who received CT‑P in acute ischemic stroke due to ICA occlusion between 2012 and 2019 were retrospectively analyzed. Group comparisons between etiologies regarding the ratios of CT‑P parameters between both hemispheres for relative cerebral blood volume (rCBV), relative cerebral blood flow (rCBF), time to maximum (Tmax), and mean transit time (MTT) were calculated by one-factorial analysis of variance (ANOVA) and compared by pairwise Bonferroni post hoc tests. An receiver operating characteristics (ROC) analysis was performed if differences in group comparisons were found. Multinomial logistic regression (MLR) including pretherapeutic parameters was calculated for etiologies. RESULTS In this study 69 patients (age = 70 ± 14 years, dissection = 10, 14.5%, embolic = 19, 27.5% and macroangiopathic = 40, 58.0%) were included. Group differences in ANOVA were only found for MTT ratio (p = 0.003, η2 = 0.164). In the post hoc test, MTT ratio showed a differentiability between embolic and macroangiopathic occlusions (p = 0.002). ROC analysis for differentiating embolic and macroangiopathic ICA occlusions based on MTT ratio showed an AUC of 0.77 (p < 0.001, CI = 0.65-0.89) and a cut-off was yielded at a value of 1.15 for the MTT ratio (sensitivity 73%, specificity 68%). The MLR showed an overall good model performance. CONCLUSION It was possible to differentiate between patients with embolic and macroangiopathic ICA occlusions based on MTT ratios and to define a corresponding cut-off. Differentiation from patients with dissection versus the other etiologies was not possible by CT‑P parameters in our sample.
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Affiliation(s)
- Daniel Weiss
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Henrik Lang
- Department of Neurology, Medical Faculty, University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Christian Rubbert
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Kai Jannusch
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Marius Kaschner
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Vivien Lorena Ivan
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Julian Caspers
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Bernd Turowski
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Robin Jansen
- Department of Neurology, Medical Faculty, University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - John-Ih Lee
- Department of Neurology, Medical Faculty, University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Tobias Ruck
- Department of Neurology, Medical Faculty, University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Sven Günther Meuth
- Department of Neurology, Medical Faculty, University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Michael Gliem
- Department of Neurology, Medical Faculty, University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
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Moughal S, Booth TC. Correspondence on 'Non-ischemic cerebral enhancing (NICE) lesions after flow diversion for intracranial aneurysms: a multicenter study' by Richter et al. J Neurointerv Surg 2024:jnis-2024-021548. [PMID: 38388481 DOI: 10.1136/jnis-2024-021548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/24/2024]
Affiliation(s)
- Saad Moughal
- Department of Radiology, Manchester Royal Infirmary, Manchester, UK
| | - Thomas C Booth
- Department of Neuroradiology, King's College Hospital NHS Foundation Trust, London, UK
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
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Li Y, Cao W, Xu X, Li T, Chen Y, Wang Y, Chen J, Gao P, Yang B, Dmytriw AA, Regenhardt RW, Chen F, Ma Q, Lu J, Liu Y, Wang C, Bai X, Jiao L. Early venous filling after mechanical thrombectomy in acute ischemic stroke due to large vessel occlusion in anterior circulation. J Neurointerv Surg 2024; 16:248-252. [PMID: 37197935 DOI: 10.1136/jnis-2023-020336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/28/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND The significance of early venous filling (EVF) after mechanical thrombectomy (MT) in acute ischemic stroke (AIS) is not fully understood. In this study, we aimed to investigate the impact of EVF after MT. METHODS From January 2019 to May 2022, AIS patients with successful recanalization (modified Thrombolysis in Cerebral Infarction score (mTICI) ≥2b) after MT were retrospectively reviewed. EVF was evaluated on final digital subtraction angiography runs after successful recanalization and was categorized into phase subgroups (arterial phase and capillary phase) and pathway subgroups (cortical veins subgroup and thalamostriate veins subgroup), respectively. The impact of EVF subgroups on functional outcomes after successful recanalization were both investigated. RESULTS A total of 349 patients achieving successful recanalization after MT were included, including 45 patients in the EVF group and 304 patients in the non-EVF group. Multivariable logistic regression analysis showed the EVF group had a higher rate of intracranial hemorrhage (ICH; 66.7% vs 22%, adjusted odds ratio (aOR) 6.805, 95% CI 3.389 to 13.662, P<0.001), symptomatic ICH (sICH; 28.9% vs 4.9%, aOR 6.011, 95% CI 2.493 to 14.494, P<0.001) and malignant cerebral edema (MCE; 20% vs 6.9%, aOR 2.682, 95% CI 1.086 to 6.624, P=0.032) than the non-EVF group. Furthermore, the cortical veins subgroup of EVF had a higher rate of mortality than the thalamostriate veins subgroup (37.5% vs 10.3%, P=0.029). CONCLUSIONS EVF is independently associated with ICH, sICH and MCE after successful recanalization of MT, but not with favorable outcome and mortality.
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Affiliation(s)
- Yi Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurology, Guangzhou Red Cross Hospital, Guangzhou, China
| | - Wenbo Cao
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Xin Xu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Tianhua Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Yanfei Chen
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Yabing Wang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Jian Chen
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Peng Gao
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Bin Yang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Adam A Dmytriw
- Neurointerventional Program, Departments of Medical Imaging & Clinical Neurological Sciences, London Health Sciences Centre, London, Ontario, Canada
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fei Chen
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Qingfeng Ma
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jie Lu
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Radiology and Nuclear Medicine, Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Yuqi Liu
- Department of Neurological Sciences, Escope Innovation Academy, Beijing, China
| | - Chunliang Wang
- Department of Neurological Sciences, Escope Innovation Academy, Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
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Shotar E, Mathon B, Rouchaud A, Mounayer C, Salle H, Bricout N, Lejeune JP, Janot K, Zemmoura I, Naggara O, Roux A, Goutagny S, Guedon A, Brunel H, Troude L, Dufour H, Bernat AL, Tuilier T, Bresson D, Apra C, Fouet M, Escalard S, Chauvet D, Baptiste A, Lebbah S, Dechartres A, Clarençon F. Embolization of the middle meningeal artery for the prevention of chronic subdural hematoma recurrence in high-risk patients: a randomized controlled trial-the EMPROTECT study protocol. J Neurointerv Surg 2024:jnis-2023-021249. [PMID: 38307722 DOI: 10.1136/jnis-2023-021249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/10/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization has been proposed as a treatment of chronic subdural hematoma (CSDH). The benefit of the procedure has yet to be demonstrated in a randomized controlled trial. We aim to assess the efficacy of MMA embolization in reducing the risk of CSDH recurrence 6 months after burr-hole surgery compared with standard medical treatment in patients at high risk of postoperative recurrence. METHODS The EMPROTECT trial is a multicenter open label randomized controlled trial (RCT) involving 12 French centers. Adult patients (≥18 years) operated for CSDH recurrence or for a first episode with a predefined recurrence risk factor are randomized 1:1 to receive either MMA embolization within 7 days of the burr-hole surgery (experimental group) or standard medical care (control group). The number of patients to be included is 342. RESULTS The primary outcome is the rate of CSDH recurrence at 6 months. Secondary outcomes include the rate of repeated surgery for a homolateral CSDH recurrence during the 6-month follow-up period, the rate of disability and dependency at 1 and 6 months, defined by a modified Rankin Scale (mRS) score ≥4, mortality at 1 and 6 months, total cumulative duration of hospital stay during the 6-month follow-up period, directly or indirectly related to the CSDH and embolization procedure-related complication rates. CONCLUSIONS The EMPROTECT trial is the first RCT evaluating the benefit of MMA embolization as a surgical adjunct for the prevention of CSDH recurrence. If positive, this trial will have a significant impact on patient care. TRIAL REGISTRATION NUMBER NCT04372147.
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Affiliation(s)
- Eimad Shotar
- Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne Université, INSERM, Institut de la Vision, Paris, France
| | - Bertrand Mathon
- Neurosurgery, Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne Université, Paris, France
| | - Aymeric Rouchaud
- Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, France
- University of Limoges, CNRS, XLIM, UMR 7252, Limoges, France
| | - Charbel Mounayer
- Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, France
- University of Limoges, CNRS, XLIM, UMR 7252, Limoges, France
| | | | - Nicolas Bricout
- Interventional Neuroradiology, Centre Hospitalier Regional Universitaire de Lille, Lille, Hauts-de-France, France
| | | | - Kevin Janot
- Neuroradiology, University Hospital of Tours, Tours, France
| | - Ilyess Zemmoura
- Department of Neursurgery, Tours University Hospital, Tours, France
| | - Olivier Naggara
- Department of Neuroradiology, Hospital Saint Anne, Paris, France
| | - Alexandre Roux
- Department of Neursurgery, Sainte Anne Hospital, Paris, France
| | | | - Alexis Guedon
- Neuroradiology, Lariboisière Hospital, Paris, France
| | - Herve Brunel
- Neuroradiology, La Timone Hospital, Paris, France
| | - Lucas Troude
- Department of Neursurgery, Hopital Nord, Marseille, France
| | - Henry Dufour
- Department of Neursurgery, La Timone Hospital, Marseille, France
| | - Anne-Laure Bernat
- Neurosurgery, Groupe hospitalier Lariboisiere Fernand-Widal, Paris, Île-de-France, France
| | - Titien Tuilier
- Neuroradiology, Henri Mondor University Hospital, Creteil, France
| | | | - Caroline Apra
- Department of Neursurgery, Henri-Mondor Hospital, Créteil, France
| | - Mathilde Fouet
- Department of Neursurgery, Percy Military Teaching Hospital, Clamart, France
| | - Simon Escalard
- Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - Dorian Chauvet
- Neurosurgery, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Amandine Baptiste
- Unité de Recherche Clinique, Pitié-Salpêtrière Hospital, Paris, France
| | - Said Lebbah
- Unité de Recherche Clinique, Pitié-Salpêtrière Hospital, Paris, France
| | - Agnès Dechartres
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, AP-HP, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Paris, France
| | - Frédéric Clarençon
- Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne Université, Paris, France
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7
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Marei O, Podlasek A, Soo E, Butt W, Gory B, Nguyen TN, Appleton JP, Richard S, Rice H, de Villiers L, Carraro do Nascimento V, Domitrovic L, McConachie N, Lenthall R, Nair S, Malik L, Panesar J, Krishnan K, Bhogal P, Dineen RA, England TJ, Campbell BCV, Dhillon PS. Safety and efficacy of adjunctive intra-arterial antithrombotic therapy during endovascular thrombectomy for acute ischemic stroke: a systematic review and meta-analysis. J Neurointerv Surg 2024:jnis-2023-021244. [PMID: 38253378 DOI: 10.1136/jnis-2023-021244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/06/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Half of patients who achieve successful recanalization following endovascular thrombectomy (EVT) for acute ischemic stroke experience poor functional outcome. We aim to investigate whether the use of adjunctive intra-arterial antithrombotic therapy (AAT) during EVT is safe and efficacious compared with standard therapy (ST) of EVT with or without prior intravenous thrombolysis. METHODS Electronic databases were searched (PubMed/MEDLINE, Embase, Cochrane Library) from 2010 until October 2023. Data were pooled using a random-effects model and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk of bias was assessed using ROBINS-I and ROB-2. The primary outcome was functional independence (modified Rankin Scale (mRS) 0-2) at 3 months. Secondary outcomes were successful recanalization (modified Thrombolysis In Cerebral Infarction (TICI) 2b-3), symptomatic intracranial hemorrhage (sICH), and 90-day mortality. RESULTS 41 randomized and non-randomized studies met the eligibility criteria. Overall, 15 316 patients were included; 3296 patients were treated with AAT during EVT and 12 020 were treated with ST alone. Compared with ST, patients treated with AAT demonstrated higher odds of functional independence (46.5% AAT vs 42.6% ST; OR 1.22, 95% CI 1.07 to 1.40, P=0.004, I2=48%) and a lower likelihood of 90-day mortality (OR 0.71, 95% CI 0.61 to 0.83, P<0.0001, I2=20%). The rates of sICH (OR 1.00, 95% CI 0.82 to 1.22,P=0.97, I2=13%) and successful recanalization (OR 1.09, 95% CI 0.84 to 1.42, P=0.52, I2=76%) were not significantly different. CONCLUSION The use of AAT during EVT may improve functional outcomes and reduce mortality rates compared with ST alone, without an increased risk of sICH. These findings should be interpreted with caution pending the results from ongoing phase III trials to establish the efficacy and safety of AAT during EVT.
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Affiliation(s)
- Omar Marei
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Anna Podlasek
- Tayside Innovation Medtech Ecosystem (TIME), University of Dundee, Dundee, UK
| | - Emma Soo
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Waleed Butt
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU de Nancy, Nancy, Lorraine, France
| | - Thanh N Nguyen
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
- Radiology, Boston Medical Center Department of Radiology, Boston, Massachusetts, USA
| | - Jason P Appleton
- Stroke Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | | | - Hal Rice
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Laetitia de Villiers
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
| | | | - Luis Domitrovic
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Norman McConachie
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Robert Lenthall
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sujit Nair
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Luqman Malik
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jasmin Panesar
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kailash Krishnan
- Stroke Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Pervinder Bhogal
- Interventional Neuroradiology, Royal London Hospital, London, UK
| | - Robert A Dineen
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Bruce C V Campbell
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Permesh Singh Dhillon
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Department of Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
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8
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Pearl MS, Tsuchida TN, Oluigbo C, Kratimenos P, Anwar T, Kousa Y, Gaillard WD, Chang T. Definitive treatment of seizures due to hemimegalencephaly in neonates and young infants by transarterial embolization: technical considerations for 'endovascular embolic hemispherectomy'. J Neurointerv Surg 2023; 16:81-87. [PMID: 36302639 DOI: 10.1136/jnis-2022-019049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 10/11/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND This case series describes the technical considerations and effectiveness of 'endovascular embolic hemispherectomy' for the treatment of medically intractable seizures in neonates and young infants with hemimegalencephaly (HME) and in whom surgical hemispherectomy is not a viable option. METHODS This is a descriptive review of the endovascular technique used to treat consecutive pediatric patients with serial transarterial embolization for intractable seizures due to HME between 2018 and 2022. Clinical presentation, endovascular procedural details and complications, and efficacy were examined. RESULTS Three infants (13-day-old, 13-week-old and 15-day-old) with HME and intractable seizures underwent a total of 10 transarterial embolizations. Anticipated intraprocedural events included vasospasm and focal subarachnoid hemorrhage in all three infants, effectively controlled endovascularly, and non-target embolization in one infant. No infants had symptomatic intracranial hemorrhage or femoral artery occlusion. EEG background quiescence and seizure cessation was achieved after the final stage of embolization in all patients. All infants were discharged home from the neonatal ICU (median length of stay 36 days, range 27-74 days) and remain seizure-free to date (4 years, 9 months, and 8 months). None have developed hydrocephalus, required surgical hemispherectomy or other neurosurgical interventions. CONCLUSION Endovascular hemispherectomy can be safely used to provide definitive treatment of HME-related epilepsy in neonates and young infants when intraprocedural events are managed effectively. This less invasive novel approach should be considered a feasible early alternative to surgical hemispherectomy. Further studies are needed to enhance the safety profile and to assess long-term neurodevelopmental outcome and durability of freedom from seizures.
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Affiliation(s)
- Monica S Pearl
- Radiology, Children's National Hospital, Washington, District of Columbia, USA
- Radiology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Tammy N Tsuchida
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Chima Oluigbo
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
- Department of Neurosurgery, Children's National Health System, Washington, District of Columbia, USA
| | - Panagiotis Kratimenos
- Neonatology, Children's National Hospital, Washington, District of Columbia, USA
- Neonatology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Tayyba Anwar
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Youssef Kousa
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - William D Gaillard
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Taeun Chang
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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9
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Ruan J, Shi Y, Luo P, Li L, Huang J, Chen J, Yang H. Safety and feasibility of intra-arterial delivery of teniposide to high grade gliomas after blood-brain barrier disruption: a case series. J Neurointerv Surg 2023:jnis-2023-021055. [PMID: 38071559 DOI: 10.1136/jnis-2023-021055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 11/11/2023] [Indexed: 12/22/2023]
Abstract
BACKGROUND This case series describes the safety and efficacy of superselective intra-arterial (IA) cerebral infusion of teniposide for the treatment of patients with glioma, to provide new ideas and methods for the treatment of high grade gliomas. METHODS 12 patients with glioma who were previously treated with standard therapy were treated with superselective IA cerebral infusion of teniposide. Patients received at least two cycles of treatment (one cycle: 150 mg/time, used for 1 day, repeated at 28 day intervals) after blood-brain barrier disruption. Patients received individualized treatment on the tumor location. The ophthalmic artery was bypassed during the super-selective arterial infusion. RESULTS No significant differences in biochemical indexes and Karnofsky performance status (KPS) score were observed before and after treatment, and no evident adverse events occurred (P>0.05). In a recent response evaluation (August 2023), two (8%) patients presented with a complete response (16.7%), four had a partial response (33.3%), four had stable disease (33.3%), and two showed progressive disease (16.7%). The overall response rate and disease control rate were 50.0% and 83.3%, respectively. In addition, we described the detailed course of treatment in two patients. Case No 1 (recurrent tumor) and case No 2 (primary tumor) received six and three cycles of teniposide infusion, respectively. After treatment, the tumors of the patients were significantly reduced without evident adverse effects. CONCLUSION This small series suggests that superselective IA cerebral infusion of teniposide may be a safe and effective therapy in the multimodal treatment of malignant glioma and warrants further study in larger prospective investigations.
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Affiliation(s)
- Jian Ruan
- Department of Neuro-Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - You Shi
- Department of Neuro-Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - Pengren Luo
- Department of Neuro-Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - Lin Li
- Department of Neuro-Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - Jiashang Huang
- Department of Neuro-Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - Jie Chen
- Department of Neuro-Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - Haifeng Yang
- Department of Neuro-Oncology, Chongqing University Cancer Hospital, Chongqing, China
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10
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Abdelnaby R, Charalambous D, Mohamed KA, Ebrahim MA, El-Din El-Agawy MS, Wiesmann M, Schulz JB, Nikoubashman O, Reich A, Pinho J. Factors associated with the laterality of Cardio- Embolic stroke. J Stroke Cerebrovasc Dis 2023; 32:107460. [PMID: 37924780 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 10/20/2023] [Accepted: 10/30/2023] [Indexed: 11/06/2023] Open
Abstract
OBJECTIVE Understanding the lateralization factors, including the anatomic and hemodynamic mechanisms, is essential for diagnosing cardio-embolic stroke. This study aims to investigate the elements, for the first time together, that could affect the laterality of stroke. METHODS We performed a monocentric retrospective case-control study based on prospective registries of acute ischemic stroke patients in the comprehensive stroke center of the RWTH University hospital of Aachen for three years (June 2018-June 2021). We enrolled 222 patients with cardioembolic stroke (136 left stroke and 86 right stroke) admitted for first-ever acute ischemic stroke with unilateral large vessel occlusion of the anterior circulation. The peak systolic velocity (PSV) asymmetry of middle cerebral artery (MCA) was assessed by doppler as well as internal carotid artery (ICA) angle, aortic arch (AA) branching pattern and anatomy were assessed by CT-Angiography. RESULTS We found that the increasing left ICA angle (p = 0.047), presence of bovine type AA anatomy (p = 0.041) as well as slow PSV of the right MCA with a value of >15% than left (p = 0.005) were the predictors for left stroke lateralization, while the latter was an independent predictor for the left stroke (OR=3.341 [1.415-7.887]). Inter-Rater Reliability ranged from moderate to perfect agreement. CONCLUSION The predictors for left stroke lateralization include the higher values of left ICA angle, presence of the bovine type AA and the slow right MCA PSV.
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Affiliation(s)
- Ramy Abdelnaby
- Department of Neurology, University Hospital, RWTH Aachen University, Aachen, Germany.
| | - Demetris Charalambous
- Department of Neurology, University Hospital, RWTH Aachen University, Aachen, Germany
| | | | | | - Mosaab Salah El-Din El-Agawy
- Department of Anatomy & Embryology, Faculty of Medicine, Mansoura University, Mansoura, Egypt; Department of Anatomy & Embryology, Faculty of Medicine, New Mansoura University, New Mansoura, Egypt
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, RWTH Aachen University, Germany
| | - Jörg B Schulz
- Department of Neurology, University Hospital, RWTH Aachen University, Aachen, Germany; JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, RWTH Aachen University, Germany
| | - Arno Reich
- Department of Neurology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - João Pinho
- Department of Neurology, University Hospital, RWTH Aachen University, Aachen, Germany
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11
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Chen H, Salem MM, Colasurdo M, Sioutas GS, Khalife J, Kuybu O, Carroll KT, Hoang AN, Baig AA, Salih M, Khorasanizadeh M, Baker C, Mendez Ruiz A, Cortez GM, Abecassis Z, Ruiz Rodríguez JF, Davies JM, Narayanan S, Cawley CM, Riina H, Moore J, Spiotta AM, Khalessi A, Howard BM, Hanel RA, Tanweer O, Tonetti D, Siddiqui AH, Lang M, Levy EI, Jovin TG, Grandhi R, Srinivasan VM, Levitt MR, Ogilvy CS, Jankowitz B, Thomas AJ, Gross BA, Burkhardt JK, Kan P. Standalone middle meningeal artery embolization versus middle meningeal artery embolization with concurrent surgical evacuation for chronic subdural hematomas: a multicenter propensity score matched analysis of clinical and radiographic outcomes. J Neurointerv Surg 2023:jnis-2023-020907. [PMID: 37932033 DOI: 10.1136/jnis-2023-020907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 10/19/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Middle meningeal artery embolization (MMAE) has emerged as a promising therapy for chronic subdural hematomas (cSDHs). The efficacy of standalone MMAE compared with MMAE with concurrent surgery is largely unknown. METHODS cSDH patients who underwent successful MMAE from 14 high volume centers with at least 30 days of follow-up were included. Clinical and radiographic variables were recorded and used to perform propensity score matching (PSM) of patients treated with standalone MMAE or MMAE with concurrent surgery. Multivariable logistic regression models were used for additional covariate adjustments. The primary outcome was recurrence requiring surgical rescue, and the secondary outcome was radiographic failure defined as <50% reduction of cSDH thickness. RESULTS 722 MMAE procedures in 588 cSDH patients were identified. After PSM, 230 MMAE procedures remained (115 in each group). Median age was 73 years, 22.6% of patients were receiving anticoagulation medication, and 47.9% had no preoperative functional disability. Median midline shift was 4 mm and cSDH thickness was 16 mm, representing modestly sized cSDHs. Standalone MMAE and MMAE with surgery resulted in similar rates of surgical rescue (7.8% vs 13.0%, respectively, P=0.28; adjusted OR (aOR 0.73 (95% CI 0.20 to 2.40), P=0.60) and radiographic failure (15.5% vs 13.7%, respectively, P=0.84; aOR 1.08 (95% CI 0.37 to 2.19), P=0.88) with a median follow-up duration of 105 days. These results were similar across subgroup analyses and follow-up durations. CONCLUSIONS Standalone MMAE led to similar and durable clinical and radiographic outcomes as MMAE combined with surgery in select patients with moderately sized cSDHs and mild clinical disease.
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Affiliation(s)
- Huanwen Chen
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
- Neurology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marco Colasurdo
- Interventional Radiology, Oregon Health and Science University, Portland, Oregon, USA
| | - Georgios S Sioutas
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jane Khalife
- Department of Neurosurgery, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Okkes Kuybu
- Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Kansas, USA
| | - Kate T Carroll
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Alex Nguyen Hoang
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Ammad A Baig
- Neurosurgery, Buffalo State, The State University of New York, Buffalo, New York, USA
| | - Mira Salih
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Cordell Baker
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Aldo Mendez Ruiz
- Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Kansas, USA
| | | | - Zack Abecassis
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | | | - Jason M Davies
- Neurosurgery and Biomedical Engineering, Toshiba Stroke and Vascular Research Institute, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Sandra Narayanan
- Department of Neurology, Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | | | | | - Justin Moore
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alexander Khalessi
- Department of Neurological Surgery, University of California San Diego, La Jolla, California, USA
| | - Brian M Howard
- Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Omar Tanweer
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Daniel Tonetti
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Michael Lang
- Department of Neurosurgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Elad I Levy
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Tudor G Jovin
- Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | | | - Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | | | - Brian Jankowitz
- Neurosurgery, University of Pennsylvania, Camden, Pennsylvania, USA
| | - Ajith J Thomas
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Bradley A Gross
- Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jan Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter Kan
- Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
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12
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Cummins DD, Caton MT, Hemphill K, Lamboy A, Tu-Chan A, Meisel K, Narsinh KH, Amans MR. Cerebrovascular pulsatile tinnitus: causes, treatments, and outcomes in 164 patients with neuroangiographic correlation. J Neurointerv Surg 2023; 15:1014-1020. [PMID: 36190940 DOI: 10.1136/jnis-2022-019259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/29/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pulsatile tinnitus (PT) can cause significant detriment to quality of life and may herald a life-threatening condition. Endovascular evaluation is the gold standard for the definitive diagnosis of PT and facilitates treatment. However, no large study has determined the distribution of causes and treatment outcomes of PT evaluated endovascularly. METHODS Consecutive patients evaluated at a multidisciplinary PT clinic from a single academic center were retrospectively reviewed. Patients with a suspected cerebrovascular etiology of PT based on clinical and/or non-invasive imaging, who were evaluated by endovascular techniques (arteriography, venography, manometry, and/or balloon test occlusion), were included in analysis. Baseline clinical features and treatment results by final etiology of PT were compared. RESULTS Of 552 patients referred for PT evaluation, 164 patients (29.7%) who underwent endovascular evaluation of PT were included. Mean (±SD) age at first clinical evaluation was 54.3±14.1 years (range 25-89 years); 111 patients (67.7%) were female. PT causes were 75.6% vascular and 24.4% non-vascular. Arteriovenous shunting lesions caused 20.7% of cases, venous etiologies 48.2%, and arterial etiologies 6.7%. Of patients with a shunting lesion treated with endovascular embolization, 96.9% had lasting significant improvement or resolution in PT. Endovascular stenting for venous sinus stenosis gave 84.6% of patients lasting improvement or resolution in PT. Arterial and non-vascular PT had fewer patients treated endovascularly and less improvement in PT symptoms. CONCLUSION PT with a suspected vascular cause is most often attributable to venous etiologies. PT caused by arteriovenous shunting or venous sinus stenosis may be effectively treated endovascularly.
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Affiliation(s)
- Daniel D Cummins
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - M Travis Caton
- Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Kafi Hemphill
- Neurology, University of California San Francisco, San Francisco, California, USA
| | - Allison Lamboy
- Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Adelyn Tu-Chan
- Neurology, University of California San Francisco, San Francisco, California, USA
| | - Karl Meisel
- Neurology, University of California San Francisco, San Francisco, California, USA
| | - Kazim H Narsinh
- Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Matthew R Amans
- Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
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13
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Baek JH, Kim BM, Kim DJ, Heo JH, Nam HS, Kim YD, Rho MH, Chung PW, Won YS, Chung Y. Preprocedural determination of an occlusion pathomechanism in endovascular treatment of acute stroke: a machine learning-based decision. J Neurointerv Surg 2023; 15:e2-e8. [PMID: 35710314 DOI: 10.1136/neurintsurg-2022-018946] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/17/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate whether an occlusion pathomechanism can be accurately determined by common preprocedural findings through a machine learning-based prediction model (ML-PM). METHODS A total of 476 patients with acute stroke who underwent endovascular treatment were retrospectively included to derive an ML-PM. For external validation, 152 patients from another tertiary stroke center were additionally included. An ML algorithm was trained to classify an occlusion pathomechanism into embolic or intracranial atherosclerosis. Various common preprocedural findings were entered into the model. Model performance was evaluated based on accuracy and area under the receiver operating characteristic curve (AUC). For practical utility, a decision flowchart was devised from an ML-PM with a few key preprocedural findings. Accuracy of the decision flowchart was validated internally and externally. RESULTS An ML-PM could determine an occlusion pathomechanism with an accuracy of 96.9% (AUC=0.95). In the model, CT angiography-determined occlusion type, atrial fibrillation, hyperdense artery sign, and occlusion location were top-ranked contributors. With these four findings only, an ML-PM had an accuracy of 93.8% (AUC=0.92). With a decision flowchart, an occlusion pathomechanism could be determined with an accuracy of 91.2% for the study cohort and 94.7% for the external validation cohort. The decision flowchart was more accurate than single preprocedural findings for determining an occlusion pathomechanism. CONCLUSIONS An ML-PM could accurately determine an occlusion pathomechanism with common preprocedural findings. A decision flowchart consisting of the four most influential findings was clinically applicable and superior to single common preprocedural findings for determining an occlusion pathomechanism.
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Affiliation(s)
- Jang-Hyun Baek
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung Moon Kim
- Interventional Neuroradiology, Department of Radiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Joon Kim
- Interventional Neuroradiology, Department of Radiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Hoe Heo
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyo Suk Nam
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Dae Kim
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myung Ho Rho
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Pil-Wook Chung
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yu Sam Won
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yeongu Chung
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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14
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Kim C, Sohn JH, Lee M, Kim Y, Mo HJ, Oh MS, Yu KH, Lee SH. Impact of prior use of antiplatelet agents and non-vitamin K antagonist oral anticoagulants on stroke outcomes among endovascular-treated patients with high pre-stroke CHA2DS2-VASc score. J Neurointerv Surg 2023:jnis-2023-020698. [PMID: 37620129 DOI: 10.1136/jnis-2023-020698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/12/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND We assessed the influence of prior non-vitamin K antagonist (NOAC) use on stroke outcomes after endovascular treatment (EVT) in patients at a high risk of stroke based on their pre-stroke CHA2DS2-VASc score, and compared them with those who did not use any antithrombotic (NAU) or antiplatelet (APT) agents. METHODS Data were collected from a multicenter database comprising consecutive acute ischemic stroke patients who underwent EVT during a span of 103 months. We evaluated pre-stroke CHA2DS2-VASc scores in enrolled patients and measured instances of successful reperfusion and symptomatic hemorrhagic transformation (SHT) following EVT as the main outcome measures. RESULTS Among 12 807 patients with acute ischemic stroke, 3765 (29.4%) had a history of atrial fibrillation. Of these, 418 patients with CHA2DS2-VASc scores ≥2 received EVT alone. The prior NOAC group showed higher successful reperfusion rates compared with the prior NAU and APT groups (p=0.04). Multivariate analysis revealed that prior NOAC use increased the likelihood of successful reperfusion after EVT (OR [95% CI] 2.54 [1.34 to 4.83], p=0.004) and improved stroke outcomes, while the prior APT group did not. Furthermore, the prior NOAC use group was not associated with SHT after EVT. Propensity score matching confirmed these findings. CONCLUSION Prior use of NOAC is associated with improved outcomes in high-risk stroke patients (pre-stroke CHA2DS2-VASc score ≥2) undergoing EVT.
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Affiliation(s)
- Chulho Kim
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea (the Republic of)
- Institute of New Frontier Research Team, Hallym University, Chuncheon, Korea (the Republic of)
| | - Jong-Hee Sohn
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea (the Republic of)
- Institute of New Frontier Research Team, Hallym University, Chuncheon, Korea (the Republic of)
| | - Minwoo Lee
- Department of Neurology, Hallym Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea (the Republic of)
| | - Yerim Kim
- Department of Neurology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea (the Republic of)
| | - Hee Jung Mo
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea (the Republic of)
| | - Mi Sun Oh
- Department of Neurology, Hallym Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea (the Republic of)
| | - Kyung-Ho Yu
- Department of Neurology, Hallym Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea (the Republic of)
| | - Sang-Hwa Lee
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea (the Republic of)
- Institute of New Frontier Research Team, Hallym University, Chuncheon, Korea (the Republic of)
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15
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Akimoto T, Ohtake M, Miyake S, Suzuki R, Iida Y, Shimohigoshi W, Higashijima T, Nakamura T, Shimizu N, Kawasaki T, Sakata K, Yamamoto T. Preoperative tumor embolization prolongs time to recurrence of meningiomas: a retrospective propensity-matched analysis. J Neurointerv Surg 2023; 15:814-820. [PMID: 35803729 PMCID: PMC10359541 DOI: 10.1136/neurintsurg-2022-019080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/12/2022] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Taisuke Akimoto
- Neurosurgery, Yokohama City University School of Medicine Graduate School of Medicine, Yokohama, Kanagawa, Japan
- Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Makoto Ohtake
- Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Shigeta Miyake
- Neurosurgery, Yokohama City University School of Medicine Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Ryosuke Suzuki
- Neurosurgery, Yokohama City University School of Medicine Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Yu Iida
- Neurosurgery, Yokohama City University School of Medicine Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Wataru Shimohigoshi
- Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Takefumi Higashijima
- Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Taishi Nakamura
- Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Nobuyuki Shimizu
- Neurosurgery, Yokohama City University School of Medicine Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Takashi Kawasaki
- Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Katumi Sakata
- Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Tetsuya Yamamoto
- Neurosurgery, Yokohama City University School of Medicine Graduate School of Medicine, Yokohama, Kanagawa, Japan
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16
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Akkari FG, Stathopoulos C, Puccinelli F, Hajdu SD, Beck-Popovic M, Munier FL, Saliou G, Bartolini B. Absorbable gelatin compressed sponge (Gelfoam) embolization of distal external carotid artery branches in intra-arterial chemotherapy for retinoblastoma. J Neurointerv Surg 2023:jnis-2023-020206. [PMID: 37142396 DOI: 10.1136/jnis-2023-020206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/26/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND In intra-arterial chemotherapy for retinoblastoma, a backflow from unreachable external carotid artery branches in the ophthalmic artery can be challenging. OBJECTIVE To describe a new endovascular technique using Gelfoam pledgets to temporarily occlude distal branches of the external carotid artery to reverse the competitive backflow into the ophthalmic artery in order to perform intra-arterial chemotherapy via the ostium of the ophthalmic artery in selected cases. METHODS We queried our prospectively collected database of 327 consecutive patients treated for retinoblastoma by intra-arterial chemotherapy and identified those employing Gelfoam pledgets. We describe this new technique with emphasis on feasibility and safety. RESULTS We treated 11 eyes with 14 infusions of intra-arterial chemotherapy using Gelfoam pledgets to occlude the distal branches of the external carotid artery. We report no perioperative complications due to this occlusion technique. At the ophthalmologic follow-up 1 month after the injection of Gelfoam pledgets, all cases showed tumor regression or stable disease. Two injections into the same eye as the rescue intra-arterial chemotherapy infusion resulted in a transient exudative retinal detachment, and one injection in a heavily pretreated case was followed by iris neovascularization and retinal ischemia. None of the pledget injections led to irreversible vision-threatening intraocular complications. CONCLUSIONS Intra-arterial chemotherapy in retinoblastoma using Gelfoam to transiently occlude the distal branches of the external carotid artery and reverse the backflow into the ophthalmic artery seems feasible and safe. Larges series will help to confirm the effectiveness of this new technique.
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Affiliation(s)
- Fouad Georges Akkari
- Interventional Neuroradiological Unit, Service of Diagnostic and Interventional Radiology, Department of Medical Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Christina Stathopoulos
- Jules-Gonin Eye Hospital, Fondation Asile des Aveugles, University of Lausanne, Lausanne, Switzerland
| | - Francesco Puccinelli
- Interventional Neuroradiological Unit, Service of Diagnostic and Interventional Radiology, Department of Medical Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Steven D Hajdu
- Interventional Neuroradiological Unit, Service of Diagnostic and Interventional Radiology, Department of Medical Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Maja Beck-Popovic
- Unit of Pediatric Hematology-Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Francis L Munier
- Jules-Gonin Eye Hospital, Fondation Asile des Aveugles, University of Lausanne, Lausanne, Switzerland
| | - Guillaume Saliou
- Interventional Neuroradiological Unit, Service of Diagnostic and Interventional Radiology, Department of Medical Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Bruno Bartolini
- Interventional Neuroradiological Unit, Service of Diagnostic and Interventional Radiology, Department of Medical Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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17
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Griswold E, Cappello J, Ghandehari H. Silk-elastinlike protein-based hydrogels for drug delivery and embolization. Adv Drug Deliv Rev 2022; 191:114579. [PMID: 36306893 DOI: 10.1016/j.addr.2022.114579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 01/24/2023]
Abstract
Silk-Elastinlike Protein-Based Polymers (SELPs) can form thermoresponsive hydrogels that allow for the generation of in-situ drug delivery matrices. They are produced by recombinant techniques, enabling exact control of monomer sequence and polymer length. In aqueous solutions SELP strands form physical crosslinks as a function of temperature increase without the addition of crosslinking agents. Gelation kinetics, modulus of elasticity, pore size, drug release, biorecognition, and biodegradation of SELP hydrogels can be controlled by placement of amino acid residues at strategic locations in the polymer backbone. SELP hydrogels have been investigated for delivery of a variety of bioactive agents including small molecular weight drugs and fluorescent probes, oligomers of glycosaminoglycans, polymeric macromolecules, proteins, plasmid DNA, and viral gene delivery systems. In this review we provide a background for use of SELPs in matrix-mediated delivery and summarize recent investigations of SELP hydrogels for controlled delivery of bioactive agents as well as their use as liquid embolics.
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Affiliation(s)
- Ethan Griswold
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA; Utah Center of Nanomedicine, University of Utah, Salt Lake City, UT 84112, USA
| | - Joseph Cappello
- Department of Molecular Pharmaceutics, University of Utah, Salt Lake City, UT 84112, USA
| | - Hamidreza Ghandehari
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA; Utah Center of Nanomedicine, University of Utah, Salt Lake City, UT 84112, USA; Department of Molecular Pharmaceutics, University of Utah, Salt Lake City, UT 84112, USA.
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18
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Parizadeh D, Vasconcelos AHC, Miller DA, Fermo OP, Huynh TJ. Dual microcatheter and coil/balloon pressure cooker technique for transvenous embolization of cerebrospinal fluid-venous fistulas. J Neurointerv Surg 2022; 15:614. [PMID: 35705358 DOI: 10.1136/neurintsurg-2022-019005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/01/2022] [Indexed: 11/03/2022]
Abstract
Cerebrospinal fluid-venous fistula is increasingly recognized as a cause of spontaneous intracranial hypotension.1 Transvenous embolization is emerging as an efficacious minimally invasive treatment.2-4 The procedure aims to embolize paraspinal and foraminal veins draining the fistula; however, complete embolization may be challenging as numerous small venous tributaries at the foraminal venous plexus, including dorsal muscular branches, may serve as additional routes of cerebrospinal fluid egress.5 To ensure curative embolization, we adopted a dual microcatheter pressure cooker technique, previously used for treatment of brain arteriovenous malformations.6 This allows improved control of embolic material reflux and greater chance of complete embolization of the site of the fistula and all potential venous tributaries. Video 1 demonstrates this technique employed in a typical case using Onyx (Medtronic, Minnesota, USA) to embolize a cerebrospinal fluid-venous fistula at the left L1 neural foramen.neurintsurg;neurintsurg-2022-019005v1/V1F1V1Video 1Disclaimer: this video summarises a scientific article published by BMJ Publishing Group Limited (BMJ). The content of this video has not been peer-reviewed and does not constitute medical advice. Any opinions expressed are solely those of the contributors. Viewers should be aware that professionals in the field may have different opinions. BMJ does not endorse any opinions expressed or recommendations discussed. Viewers should not use the content of the video as the basis for any medical treatment. BMJ disclaims all liability and responsibility arising from any reliance placed on the content.
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Affiliation(s)
- Donna Parizadeh
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - David A Miller
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Olga P Fermo
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | - Thien J Huynh
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
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19
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Li W, Bai X, Hao J, Xu X, Lin F, Jiang Q, Ding C, Dai G, Peng F, Zhang M, Feng Y, Wang J, Chen X, Xue T, Guo X, Fu Z, Chen WH, Zhang L, Wang C, Jiao L. Thrombosis origin identification of cardioembolism and large artery atherosclerosis by distinct metabolites. J Neurointerv Surg 2022:neurintsurg-2022-019047. [PMID: 35654581 DOI: 10.1136/neurintsurg-2022-019047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/13/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND The diagnosis of cerebral thrombosis origin is challenging and remains unclear. This study aims to identify thrombosis due to cardioembolism (CE) and large artery atherosclerosis (LAA) from a new perspective of distinct metabolites. METHODS Distinct metabolites between 26 CE and 22 LAA origin thrombi, which were extracted after successful mechanical thrombectomy in patients with acute ischemic stroke in the anterior circulation, were analyzed with a ultra performance liquid chromatography coupled with quadrupole time-of-flight mass spectrometry (UPLC-QTOF-MS) system. Enriched metabolic pathways related to the metabolites were identified. Least absolute shrinkage selection operator regression analyses and a filtering method were used to select potential predictors. Furthermore, four machine learning classifiers, including decision tree, logistic regression, random forest (RF), and k means unsupervised classification model, were used to evaluate the predictive ability of the selected metabolites. RESULTS UPLC-QTOF-MS analysis revealed that levels of 88 and 55 metabolites were elevated in LAA and CE thrombi, respectively. Kyoto Encyclopedia of Genes and Genomes analysis revealed a significant difference between the pathways enriched in the two types of thrombi. Six metabolites (diglyceride (DG, 18:3/24:0), DG (22:0/24:0), phytosphingosine, galabiosylceramide (18:1/24:1), triglyceride (15:0/16:1/o-18:0), and glucosylceramide (18:1/24:0)) were finally selected to build a predictive model. The predictive RF model was confirmed to be the best, with a satisfactory stability and prediction capacity (area under the curve=0.889). CONCLUSIONS Six metabolites as potential predictors for distinguishing between cerebral thrombi of CE and LAA origin were identified. The results are useful for understanding the pathogenesis and for secondary stroke prevention.
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Affiliation(s)
- Wei Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng City, Shandong Province, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Jiheng Hao
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng City, Shandong Province, China
| | - Xin Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Feng Lin
- Department of Neurology, Sanming First Hospital and First Hospital of Sanming Affiliated to Fujian Medical University, Sanming City, Fujian Province, China
| | - Qunlong Jiang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng City, Shandong Province, China
| | - Chunguang Ding
- National Center for Occupational Safety and Health, NHC, Beijing, China
| | - Gaolei Dai
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng City, Shandong Province, China
| | - Fangda Peng
- National Center for Occupational Safety and Health, NHC, Beijing, China
| | - Meng Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng City, Shandong Province, China
| | - Yao Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jiyue Wang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng City, Shandong Province, China
| | - Xianyang Chen
- Zhongguancun Biological and Medical Big Data Center, Beijing, China.,Bao Feng Key Laboratory of Genetics and Metabolism, Beijing, China
| | - Teng Xue
- Bao Feng Key Laboratory of Genetics and Metabolism, Beijing, China.,Zhongyuanborui Key Laborotory of Genetics and Metabolism, Guangdong-Macao In-depth Cooperation Zone in Hengqin, Zhuhai City, Guangdong Province, China
| | - Xiaofan Guo
- Department of Neurology, Loma Linda University Health, Loma Linda, California, USA
| | - Zhaolin Fu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Wen-Huo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital, Fujian Medical University, Zhangzhou City, Fujian Province, China
| | - Liyong Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng City, Shandong Province, China
| | - Chaodong Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China .,China International Neuroscience Institute (China-INI), Beijing, China.,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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20
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Mereuta OM, Abbasi M, Arturo Larco JL, Dai D, Liu Y, Arul S, Kadirvel R, Hanel RA, Yoo AJ, Almekhlafi MA, Layton KF, Delgado Almandoz JE, Kvamme P, Mendes Pereira V, Jahromi BS, Nogueira RG, Gounis MJ, Patel B, Aghaebrahim A, Sauvageau E, Bhuva P, Soomro J, Demchuk AM, Thacker IC, Kayan Y, Copelan A, Nazari P, Cantrell DR, Haussen DC, Al-Bayati AR, Mohammaden M, Pisani L, Rodrigues GM, Puri AS, Entwistle J, Meves A, Savastano L, Cloft HJ, Nimjee SM, McBane Ii RD, Kallmes DF, Brinjikji W. Correlation of von Willebrand factor and platelets with acute ischemic stroke etiology and revascularization outcome: an immunohistochemical study. J Neurointerv Surg 2022; 15:488-494. [PMID: 35595407 DOI: 10.1136/neurintsurg-2022-018645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/01/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Platelets and von Willebrand factor (vWF) are key components of acute ischemic stroke (AIS) emboli. We aimed to investigate the CD42b (platelets)/vWF expression, its association with stroke etiology and the impact these components may have on the clinical/procedural parameters. METHODS CD42b/vWF immunostaining was performed on 288 emboli collected as part of the multicenter STRIP Registry. CD42b/VWF expression and distribution were evaluated. Student's t-test and χ2 test were performed as appropriate. RESULTS The mean CD42b and VWF content in clots was 44.3% and 21.9%, respectively. There was a positive correlation between platelets and vWF (r=0.64, p<0.001**). We found a significantly higher vWF level in the other determined etiology (p=0.016*) and cryptogenic (p=0.049*) groups compared with cardioembolic etiology. No significant difference in CD42b content was found across the etiology subtypes. CD42b/vWF patterns were significantly associated with stroke etiology (p=0.006*). The peripheral pattern was predominant in atherosclerotic clots (36.4%) while the clustering (patchy) pattern was significantly associated with cardioembolic and cryptogenic origin (66.7% and 49.8%, respectively). The clots corresponding to other determined etiology showed mainly a diffuse pattern (28.1%). Two types of platelets were distinguished within the CD42b-positive clusters in all emboli: vWF-positive platelets were observed at the center, surrounded by vWF-negative platelets. Thrombolysis correlated with a high platelet content (p=0.03*). vWF-poor and peripheral CD42b/vWF pattern correlated with first pass effect (p=0.03* and p=0.04*, respectively). CONCLUSIONS The vWF level and CD42b/vWF distribution pattern in emboli were correlated with AIS etiology and revascularization outcome. Platelet content was associated with response to thrombolysis.
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Affiliation(s)
| | - Mehdi Abbasi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jorge L Arturo Larco
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Daying Dai
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yang Liu
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Santhosh Arul
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ricardo A Hanel
- Department of Neurosurgery, Baptist Medical Center, Jacksonville, Florida, USA
| | - Albert J Yoo
- Department of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth, Texas, USA
| | - Mohammed A Almekhlafi
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kennith F Layton
- Department of Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | - Josser E Delgado Almandoz
- Department of NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Peter Kvamme
- Department of Radiology, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Vitor Mendes Pereira
- Departments of Medical Imaging and Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Babak S Jahromi
- Departments of Radiology and Neurosurgery, Northwestern University, Chicago, Illinois, USA
| | - Raul G Nogueira
- Department of Neurology, Emory University, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Matthew J Gounis
- Department of Radiology, University of Massachusetts Medical School, New England Center for Stroke Research, Worcester, Massachusetts, USA
| | - Biraj Patel
- Departments of Radiology and Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA
| | - Amin Aghaebrahim
- Department of Neurosurgery, Baptist Medical Center, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Department of Neurosurgery, Baptist Medical Center, Jacksonville, Florida, USA
| | - Parita Bhuva
- Department of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth, Texas, USA
| | - Jazba Soomro
- Department of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth, Texas, USA
| | - Andrew M Demchuk
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ike C Thacker
- Department of Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | - Yasha Kayan
- Department of NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Alexander Copelan
- Department of NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Pouya Nazari
- Departments of Radiology and Neurosurgery, Northwestern University, Chicago, Illinois, USA
| | - Donald Robert Cantrell
- Departments of Radiology and Neurosurgery, Northwestern University, Chicago, Illinois, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, Emory University, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Mahmoud Mohammaden
- Department of Neurology, Emory University, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Leonardo Pisani
- Department of Neurology, Emory University, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Gabriel Martins Rodrigues
- Department of Neurology, Emory University, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts Medical School, New England Center for Stroke Research, Worcester, Massachusetts, USA
| | - John Entwistle
- Departments of Radiology and Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA
| | - Alexander Meves
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Luis Savastano
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Harry J Cloft
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shahid M Nimjee
- Department of Neurological Surgery, Ohio State University, Columbus, Ohio, USA
| | - Robert D McBane Ii
- Gonda Vascular Center, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
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21
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Bosch J, Pearce LA, Sharma M, Canavan M, Whiteley WN, Mikulík R, Mundl H, Yusuf S, Hart RG, O'Donnell MJ. Rivaroxaban versus aspirin on functional and cognitive outcomes after embolic stroke of undetermined source: NAVIGATE ESUS trial. J Stroke Cerebrovasc Dis 2022; 31:106404. [PMID: 35292423 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/30/2022] [Accepted: 02/08/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The effect of interventions on functional impairment is an important outcome in stroke prevention trials and should be considered as an adjunct to counting discrete events. In the NAVIGATE-ESUS trial, 7213 patients with recent embolic strokes of undetermined source were randomized to rivaroxaban (15 mg once daily) or aspirin (100 mg daily). After 11 months there was no effect on the prevention of recurrent stroke. AIMS To determine the effect of rivaroxaban compared to aspirin on functional and cognitive outcomes. METHODS Function and cognition were measured at baseline, 1 year, and study end using the Standard Assessment of Global Everyday Activities (SAGEA), a 15-item scale assessing cognitive, instrumental, and basic activities of daily living as well as mobility, and the Montreal Cognitive Assessment (MoCA). Changes in scores were calculated by subtracting either study end or 1-year scores from baseline, and differences in distributions were compared using the Mann-Whitney U test. SAGEA and MoCA scores were also correlated with recurrent stroke. RESULTS Follow-up SAGEA scores were available in 6378 (88%) participants. There was no difference in change in function for those allocated to rivaroxaban compared to aspirin (Mann-Whitney U test, p = 0.8), with both distributions having a median (25p,75p) change of 0 (-2,1). Overall, more of those who experienced a recurrent stroke (n=247; mostly minor ischemic), reported functional difficulty at study end versus entry, compared with those who did not (51% versus 30%, chi-square test, p< 0.001), and this was consistent across global regions. There was no difference in the change in cognition by treatment group, nor were recurrent strokes associated with a change in cognition. CONCLUSIONS Rivaroxaban, compared to aspirin, was not associated with changes in functional or cognitive status in patients with recent ESUS. The SAGEA scale detected changes in functional status associated with recurrent strokes in an international stroke population.
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Affiliation(s)
- Jackie Bosch
- School of Rehabilitation Sciences, Population Health Research Institute (PHRI), McMaster University, Hamilton, Canada.
| | | | - Mukul Sharma
- Department of Medicine (Neurology), PHRI/ McMaster University / Hamilton Health Sciences (HHS), Hamilton, Canada
| | | | - William N Whiteley
- Center for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Robert Mikulík
- International Clinical Research Centre and Department of Neurology, St. Anne's University Hospital and Medical Facility of Masaryk University, Brno, Czech Republic
| | | | - Salim Yusuf
- PHRI/McMaster University/ HHS, Hamilton, Canada
| | | | - Martin J O'Donnell
- HRB-Clinical Research Facility, National University Ireland - Galway, Galway, Ireland
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22
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Kompella D, Saleem M, Suter B, Harris DM. Multimodal Imaging Characterization of a Congenital Multilobular Interventricular Membranous Septal Aneurysm in a Patient Presenting with Embolic Stroke. CASE (Phila) 2022; 6:103-106. [PMID: 35602987 PMCID: PMC9120856 DOI: 10.1016/j.case.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
• TTE is often performed to search for cardiac sources of emboli. • TTE must be comprehensive and assess the atria, valves, and ventricles. • TTE can be utilized to identify IVMSA as a rare cause of recurrent strokes. • Comprehensive imaging studies should be utilized to confirm the diagnosis of IVMSA. • Multidisciplinary care is necessary in the management of these patients.
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Affiliation(s)
- Divya Kompella
- Correspondence: Divya Kompella, MD, 231 Albert Sabin Way, Cincinnati, Ohio 45267-0557
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23
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Ahmed SU, Kelly ME, Peeling L. Endovascular retrieval of bullet fragment from the basilar artery terminus. J Neurointerv Surg 2022; 14:1042-1044. [PMID: 35459712 DOI: 10.1136/neurintsurg-2022-018751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/03/2022] [Indexed: 11/04/2022]
Abstract
A pediatric patient presented after a gunshot injury to the right shoulder and thorax region, with injuries requiring a thoracotomy, tracheal repair, axillary artery repair, and external fixation of the humerus. A CT scan of the brain showed a metal fragment in the interpeduncular cistern. CT angiography confirmed a pellet occluding the basilar apex. Successful endovascular retrieval resulted in mobilizing the pellet from the basilar apex to the left vertebral artery proximal to the posterior inferior cerebellar artery. This vertebral artery was then sacrificed proximally to prevent re-embolization. We present our technique and discuss endovascular options for management of intracranial arterial embolization of bullet fragments.
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Affiliation(s)
- Syed Uzair Ahmed
- Division of Neurosurgery, Department of Surgery, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Michael E Kelly
- Division of Neurosurgery, Department of Surgery, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Lissa Peeling
- Division of Neurosurgery, Department of Surgery, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
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24
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De Leacy R, Ansari SA, Schirmer CM, Cooke DL, Prestigiacomo CJ, Bulsara KR, Hetts SW. Endovascular treatment in the multimodality management of brain arteriovenous malformations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee. J Neurointerv Surg 2022; 14:1118-1124. [PMID: 35414599 DOI: 10.1136/neurintsurg-2021-018632] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/07/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The purpose of this review is to summarize the data available for the role of angiography and embolization in the comprehensive multidisciplinary management of brain arteriovenous malformations (AVMs METHODS: We performed a structured literature review for studies examining the indications, efficacy, and outcomes for patients undergoing endovascular therapy in the context of brain AVM management. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS The multidisciplinary evaluation and treatment of brain AVMs continues to evolve. Recommendations include: (1) Digital subtraction catheter cerebral angiography (DSA)-including 2D, 3D, and reformatted cross-sectional views when appropriate-is recommended in the pre-treatment assessment of cerebral AVMs. (I, B-NR) . (2) It is recommended that endovascular embolization of cerebral arteriovenous malformations be performed in the context of a complete multidisciplinary treatment plan aiming for obliteration of the AVM and cure. (I, B-NR) . (3) Embolization of brain AVMs before surgical resection can be useful to reduce intraoperative blood loss, morbidity, and surgical complexity. (IIa, B-NR) . (4) The role of primary curative embolization of cerebral arteriovenous malformations is uncertain, particularly as compared with microsurgery and radiosurgery with or without adjunctive embolization. Further research is needed, particularly with regard to risk for AVM recurrence. (III equivocal, C-LD) . (5) Targeted embolization of high-risk features of ruptured brain AVMs may be considered to reduce the risk for recurrent hemorrhage. (IIb, C-LD) . (6) Palliative embolization may be useful to treat symptomatic AVMs in which curative therapy is otherwise not possible. (IIb, B-NR) . (7) The role of AVM embolization as an adjunct to radiosurgery is not well-established. Further research is needed. (III equivocal, C-LD) . (8) Imaging follow-up after apparent cure of brain AVMs is recommended to assess for recurrence. Although non-invasive imaging may be used for longitudinal follow-up, DSA remains the gold standard for residual or recurrent AVM detection in patients with concerning imaging and/or clinical findings. (I, C-LD) . (9) Improved national and international reporting of patients of all ages with brain AVMs, their treatments, side effects from treatment, and their long-term outcomes would enhance the ability to perform clinical trials and improve the rigor of research into this rare condition. (I, C-EO) . CONCLUSIONS Although the quality of evidence is lower than for more common conditions subjected to multiple randomized controlled trials, endovascular therapy has an important role in the management of brain AVMs. Prospective studies are needed to strengthen the data supporting these recommendations.
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Affiliation(s)
- Reade De Leacy
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sameer A Ansari
- Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Daniel L Cooke
- Radiology and Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | | | - Ketan R Bulsara
- Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
| | - Steven W Hetts
- Radiology and Biomedical Imaging, University California San Francisco, San Francisco, California, USA
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25
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Ker PJ. Cryptogenic, Embolic Stroke-Looking Backstage. J Stroke Cerebrovasc Dis 2022; 31:106353. [PMID: 35247732 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 12/22/2021] [Accepted: 01/23/2022] [Indexed: 11/30/2022] Open
Abstract
Stroke is a common and devastating event and the majority of cases are caused by thromboembolism from the left atrium, left ventricle or left sided valves. This case report describes a case of embolic stroke with the origin of the thrombus from the left inferior pulmonary vein. The importance of this case is twofold. Firstly, it is the fourth case report of pulmonary venous thrombosis, a very rare condition, due to COVID-19 infection and secondly, it focuses attention on the fact that the left atrium is not the most proximal address of arterial thromboembolism-the pulmonary veins are. Thus, it is proposed that a thorough assessment of the pulmonary veins should be done in all cases of arterial thromboembolism.
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Affiliation(s)
- Prof James Ker
- Department of Internal Medicine, University of Pretoria, Pretoria, South Africa.
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26
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Das R, Wale A, Renani SA, Ratnam L, Mailli L, Chun JY, Das S, Duggal B, Manyonda I, Belli AM. Randomised Controlled Trial of Particles Used in Uterine fibRoid Embolisation (PURE): Non-Spherical Polyvinyl Alcohol Versus Calibrated Microspheres. Cardiovasc Intervent Radiol 2022; 45:207-215. [PMID: 34984488 PMCID: PMC8807446 DOI: 10.1007/s00270-021-02977-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 08/18/2021] [Indexed: 11/30/2022]
Abstract
Purpose The PURE study is a randomised controlled trial (RCT) comparing the clinical and MRI outcomes of patients treated with non-spherical polyvinyl alcohol, ns-PVA (Contour PVA–Boston Scientific–355–500 & 500–700 microns) versus calibrated hydrogel microspheres (Embozene–Varian Inc–700 & 900 microns) for symptomatic uterine fibroids. Materials and Methods Prospective, ethically approved non-sponsored RCT in 84 patients in a single UK tertiary IR unit, ISRCTN registry trial number ISRCTN18191539 in 2013 and 2014. All patients with symptomatic fibroid disease were eligible. UAE followed a standardised protocol with UFS-QOL and contrast-enhanced MRI before and 6 months post UAE. Outcome measures included: (1) Uterine Fibroid Symptom and Quality of Life questionnaire (UFS-QOL). (2) Percentage total and dominant fibroid infarction. (3) Uterine and dominant fibroid volume reduction. (4) Volume of embolics. Results Sixty-three patients completed the QOL follow-up (33 ns-PVA vs 30 Embozenes), the groups were equivalent at baseline. Patients were followed up for 6 months following UAE. There was no significant difference in symptom scores or HR-QOL between ns-PVA and Embozenes, p = 0.67 and 0.21, respectively. 92.7% of patients treated with ns-PVA achieved > 90% dominant fibroid infarction versus 61.8% treated with Embozenes (p = 0.0016). 66% of patients treated with ns = PVA achieved > 90% total fibroid percentage infarction compared with 35% in the Embozene group (p = 0.011). The mean vials/syringes used were 5.2 with Embozenes versus 4.1 using PVA (p = 0.08). Conclusion The PURE study informs IRs regarding the efficacy of embolic agents in UAE, with superior fibroid infarction on MRI using ns-PVA versus Embozenes however no significant difference in clinical outcomes at 6 months after UAE. Supplementary Information The online version contains supplementary material available at 10.1007/s00270-021-02977-0.
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Affiliation(s)
- Raj Das
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK.
| | - Anita Wale
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Seyed Ameli Renani
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Lakshmi Ratnam
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Leto Mailli
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Joo-Young Chun
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Sourav Das
- Department of Gynaecology, St. George's Hospital, London, UK
| | - Balpreet Duggal
- Department of Gynaecology, St. George's Hospital, London, UK
| | - Isaac Manyonda
- Department of Gynaecology, St. George's Hospital, London, UK
| | - Anna-Maria Belli
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
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27
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Kim JM, Byun JS, Kim J, Park MS, Hong SA, Nam TK, Choi HH, Hong S, Han SH, Jeong HB, Park KY, Kim HR. Analysis of microRNA signatures in ischemic stroke thrombus. J Neurointerv Surg 2021; 14:neurintsurg-2021-017597. [PMID: 34244338 DOI: 10.1136/neurintsurg-2021-017597] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/28/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND We investigated the microRNA expression pattern from thrombus retrieved by mechanical thrombectomy in acute stroke patients to understand the stroke mechanism. METHODS This study included acute ischemic stroke patients who had undergone intra-arterial thrombectomy at Chung-Ang University Hospital in Seoul, Korea between February 2016 and March 2019. The thrombus was retrieved and stored at -70℃ after obtaining informed consent. MicroRNA microarray analysis was performed for the patients with identified stroke mechanisms including (1) large artery atherosclerosis, (2) cardioembolism with atrial fibrillation, and (3) cardioembolism with valvular heart disease. The microRNAs derived from microarray analysis were validated by quantitative real-time polymerase chain reaction (qRT-PCR) from different patient populations. The correlation analysis was performed between microRNA levels and laboratory data to understand the functional relevance of the altered microRNA. RESULTS In total, 55 thrombi were obtained from 74 patients, and the microRNAs were analyzed in 45 samples. Microarray analysis of 2578 microRNAs revealed that 50 microRNAs were significantly altered among the three groups. Validation using qRT-PCR showed that miR-378f and miR-450b-5p were significantly elevated among the cardioembolic thrombi; both microRNAs were inversely correlated with the ejection fraction from echocardiography. Thrombi from patients with early neurological deterioration exhibited higher levels of miR-93-5p and lower levels of miR-629-5p than those from neurologically stable patients. CONCLUSIONS The microRNA expression pattern can provide information regarding the mechanism of stroke by reflecting the underlying pathological status of the organ from which the thrombus was derived.
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Affiliation(s)
- Jeong-Min Kim
- Department of Neurology, Seoul National University Hospital, Jongno-gu, Seoul, Korea
| | - Jun-Soo Byun
- Department of Neurology, Chung-Ang University, Seoul, Seoul, Korea (the Republic of)
| | - Jiah Kim
- Department of Neurology, Samsung Medical Center, Gangnam-gu, Seoul, Korea (the Republic of)
| | - Moo-Seok Park
- Department of Neuroradiology, Ewha Women's University Hospital, Seoul, Korea (the Republic of)
| | - Soon Auck Hong
- Department of Pathology, Chung-Ang University, Seoul, Korea (the Republic of)
| | - Taek-Kyun Nam
- Department of Neurosurgery, Chung-Ang University, Seoul, Korea (the Republic of)
| | - Hyun Ho Choi
- Department of Neurosurgery, Chung-Ang University, Seoul, Korea (the Republic of)
| | - Sungguan Hong
- Department of Chemistry, Chung-Ang University, Seoul, Korea (the Republic of)
| | - Su-Hyun Han
- Department of Laboratory Medicine, Chung-Ang University, Seoul, Korea (the Republic of)
| | - Hae-Bong Jeong
- Department of Neurology, Chung-Ang University, Seoul, Seoul, Korea (the Republic of)
| | - Kwang-Yeol Park
- Department of Neurology, Chung-Ang University, Seoul, Seoul, Korea (the Republic of)
| | - Hye Ryoun Kim
- Department of Laboratory Medicine, Chung-Ang University, Seoul, Korea (the Republic of)
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Fontana L, Cirio JJ, Lylyk P, Rodriguez-Granillo GA. Emerging role of spectral computed tomography in neurocardiology. Rev Cardiovasc Med 2021; 22:51-65. [PMID: 33792248 DOI: 10.31083/j.rcm.2021.01.215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/12/2021] [Accepted: 03/19/2021] [Indexed: 11/06/2022] Open
Abstract
The complex and reciprocal relationship between the brain and the heart has gained increasing attention under the concept of neurocardiology. Myocardial injury is common in cerebrovascular disease, and cardiovascular complications are the second leading cause of death after stroke. Cardiac computed tomography (CT) is a fast and reliable non-invasive tool for the assessment of cardioembolic sources. Compared to single energy CT, spectral/dual energy cardiac CT improves tissue characterization and also leads to significant reductions in contrast volume. In this review article, we portray the potential clinical applications of spectral CT in neurocardiology, focusing in the enhanced diagnosis of cardioembolic sources and cardiovascular risk assessment of patients with stroke, including improved detection of thrombus, identification of subtle myocardial disease, and pulmonary complications within the same session.
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Affiliation(s)
- Lucia Fontana
- Department of Cardiovascular Imaging, Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina
| | - Juan J Cirio
- Stroke Unit, Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina
| | - Pedro Lylyk
- Department of Interventional Neuroradiology, Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina
| | - Gaston A Rodriguez-Granillo
- Department of Cardiovascular Imaging, Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina
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29
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Ferracci FX, Courthéoux P, Borha A, Blond S, Emery E. Multimodal management of ruptured cerebral micro-arteriovenous malformations: A retrospective series of 19 cases and a review of the literature. Neurochirurgie 2020; 67:132-139. [PMID: 33189739 DOI: 10.1016/j.neuchi.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 09/27/2020] [Accepted: 11/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Micro-arteriovenous malformations (micro-AVMs) are defined as AVMs just visible on angiography with a nidus size between 0.5 and 1cm. Their principal manifestation is intracranial hemorrhage and their diagnosis and therapeutic management are still unclear. METHODS The aim of our work was to show the clinical presentation, treatment and outcome of ruptured cerebral micro-AVMs in a retrospective cohort study of 19 patients and a systematic review of the literature. RESULTS We obtained a total of 20 micro-AVMs in 19 patients. The mean age was 47.3 years. Clinical presentation was acute bleeding. The mean volume of hematoma was 12.9 mm3 (0 - 60.4), with topographic distribution as follows: 64% cortical with supratentorial bleeding, 26% deep, and 10% in the posterior fossa. Among the 20 micro-AVMs of the series, 11 (55%) had endovascular management, 6 (30%) had surgical treatment and 3 (15%) had GK radiosurgery alone. All of our patients have been cured at the end of the follow up without re-permeabilization. In our series, clinical outcome showed good recovery with a mean score of 4.6 on Glasgow Outcome Scale (GOS). In the literature, 88% of patients had a GOS of 4 or 5. DISCUSSION Intracerebral hematoma (ICH) was the main clinical manifestation. In the case of negative initial angiographic assessment, patients must have supraselective angiographic exploration. In the case of conservative treatment of hematoma, endovascular obliteration and microsurgical exclusion seems to be reasonable therapeutic options, according to our observations.
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Affiliation(s)
- F-X Ferracci
- Department of Neurosurgery, CHU de Rouen, 76000 Rouen, France.
| | - P Courthéoux
- Department of Neuroradiology, CHU de Caen, 14000 Caen, France
| | - A Borha
- Department of Neurosurgery, CHU de Caen, 14000 Caen, France
| | - S Blond
- Department of Neurosurgery, CHRU de Lille, 59000 Lille, France
| | - E Emery
- Department of Neurosurgery, CHU de Caen, 14000 Caen, France; Université Caen Normandie, Medical school, 14000 Caen, France
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Mordhorst A, Baxter K. Acute mesenteric ischemia leading to diagnosis of advanced spindle cell carcinoma of the lung. J Vasc Surg Cases Innov Tech 2020; 6:557-561. [PMID: 33134642 PMCID: PMC7588807 DOI: 10.1016/j.jvscit.2020.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 08/27/2020] [Indexed: 11/30/2022]
Abstract
Acute ischemic events secondary to pulmonary malignancy are rare. Those who present with acute peripheral arterial occlusions from malignant sources will typically have advanced pulmonary malignancy or myxomatous tumors. A 79-year-old woman had presented to Vancouver General Hospital with acute mesenteric ischemia. The pathology reports after embolectomy indicated cell morphology consistent with spindle cell carcinoma of the lung. Imaging investigations revealed a right upper lobe mass not present on chest imaging studies performed 14 months previously. The findings from the present report serves to remind us that acute ischemic events in the setting of no known history of malignancy or cardiac disease should prompt investigations into possible malignant sources.
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Affiliation(s)
- Alexa Mordhorst
- Division of Vascular Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Keith Baxter
- Division of Vascular Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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31
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White AC, Folzenlogen ZA, Harland TA, Case DE, Roark CD, Kumpe DA, Seinfeld J. Intraosseous Cannulation of a Calvarial Diploic Vein for Embolization of a Symptomatic Dural Arteriovenous Fistula: A Technical Case Report. Oper Neurosurg (Hagerstown) 2020; 18:E132-E137. [PMID: 31245820 DOI: 10.1093/ons/opz179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 04/06/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Dural arteriovenous fistulas (DAVFs) may present unique challenges for treatment depending on the anatomy and pattern of venous drainage. If endovascular techniques are to be employed, the DAVF must be amenable to transvenous or transarterial therapy. When access of peripheral vasculature does not provide a straightforward path, less conventional options may be available. This case highlights a novel, technically simple, and effective approach for the treatment of a subset of DAVFs, with venous drainage through calvarial diploic veins, that would make endovascular treatment otherwise challenging or impossible. CLINICAL PRESENTATION We present a case of a 66-yr-old female patient who was diagnosed with a symptomatic DAVF located along the sphenoid ridge with a large intraosseous channel containing the draining vein of the fistula. This lesion was successfully treated with transcranial endovascular embolization via direct intraosseous cannulation of the calvarial diploic vein. This novel approach obviated the need for a full-thickness craniotomy, afforded only minimal bone loss, and preserved the integrity of the dura. A 3-mo follow-up angiogram confirmed complete cure of the DAVF with no residual arteriovenous shunt. At 20 mo postembolization, the patient was symptom free, with no reported neurologic deficits. Complete diagnostic work-up, treatment planning in a multidisciplinary environment, and a novel approach for endovascular embolization utilizing a hybrid operating suite played key roles in the successful implementation of this technique. CONCLUSION This is the first report of direct intraosseous cannulation of a calvarial diploic vein for successful transcranial endovascular embolization of a symptomatic DAVF.
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Affiliation(s)
- Andrew C White
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado.,Department of Radiology, University of Louisville, Louisville, Kentucky
| | - Zach A Folzenlogen
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado
| | - Tessa A Harland
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado
| | - David E Case
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado
| | - Christopher D Roark
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado
| | - David A Kumpe
- Departments of Neurosurgery and Radiology, University of Colorado Hospital, Aurora, Colorado
| | - Joshua Seinfeld
- Department of Neurosurgery, University of Colorado Hospital, Aurora, Colorado
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32
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Jensen MM, Barber ZB, Khurana N, Isaacson KJ, Steinhauff D, Green B, Cappello J, Pulsipher A, Ghandehari H, Alt JA. A dual-functional Embolization-Visualization System for Fluorescence image-guided Tumor Resection. Theranostics 2020; 10:4530-4543. [PMID: 32292513 PMCID: PMC7150499 DOI: 10.7150/thno.39700] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 01/08/2020] [Indexed: 02/06/2023] Open
Abstract
Rationale: Intraoperative bleeding impairs physicians' ability to visualize the surgical field, leading to increased risk of surgical complications and reduced outcomes. Bleeding is particularly challenging during endoscopic-assisted surgical resection of hypervascular tumors in the head and neck. A tool that controls bleeding while marking tumor margins has the potential to improve gross tumor resection, reduce surgical morbidity, decrease blood loss, shorten procedure time, prevent damage to surrounding tissues, and limit postoperative pain. Herein, we develop and characterize a new system that combines pre-surgical embolization with improved visualization for endoscopic fluorescence image-guided tumor resection. Methods: Silk-elastinlike protein (SELP) polymers were employed as liquid embolic vehicles for delivery of a clinically used near-infrared dye, indocyanine green (ICG). The biophysical properties of SELP, including gelation kinetics, modulus of elasticity, and viscosity, in response to ICG incorporation using rheology, were characterized. ICG release from embolic SELP was modeled in tissue phantoms and via fluorescence imaging. The embolic capability of the SELP-ICG system was then tested in a microfluidic model of tumor vasculature. Lastly, the cytotoxicity of the SELP-ICG system in L-929 fibroblasts and human umbilical vein endothelial cells (HUVEC) was assessed. Results: ICG incorporation into SELP accelerated gelation and increased its modulus of elasticity. The SELP embolic system released 83 ± 8% of the total ICG within 24 hours, matching clinical practice for pre-surgical embolization procedures. Adding ICG to SELP did not reduce injectability, but did improve the gelation kinetics. After simulated embolization, ICG released from SELP in tissue phantoms diffused a sufficient distance to deliver dye throughout a tumor. ICG-loaded SELP was injectable through a clinical 2.3 Fr microcatheter and demonstrated deep penetration into 50-µm microfluidic-simulated blood vessels with durable occlusion. Incorporation of ICG into SELP improved biocompatibility with HUVECs, but had no effect on L-929 cell viability. Principle Conclusions: We report the development and characterization of a new, dual-functional embolization-visualization system for improving fluorescence-imaged endoscopic surgical resection of hypervascular tumors.
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Affiliation(s)
- M. Martin Jensen
- Department of Bioengineering, University of Utah, Salt Lake City, UT, 84112 USA
- Utah Center for Nanomedicine, Nano Institute of Utah, University of Utah, Salt Lake City, UT, 84112 USA
| | - Zachary B. Barber
- Department of Bioengineering, University of Utah, Salt Lake City, UT, 84112 USA
- Utah Center for Nanomedicine, Nano Institute of Utah, University of Utah, Salt Lake City, UT, 84112 USA
| | - Nitish Khurana
- Utah Center for Nanomedicine, Nano Institute of Utah, University of Utah, Salt Lake City, UT, 84112 USA
- Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT, 84112 USA
| | - Kyle J. Isaacson
- Department of Bioengineering, University of Utah, Salt Lake City, UT, 84112 USA
- Utah Center for Nanomedicine, Nano Institute of Utah, University of Utah, Salt Lake City, UT, 84112 USA
| | - Douglas Steinhauff
- Department of Bioengineering, University of Utah, Salt Lake City, UT, 84112 USA
- Utah Center for Nanomedicine, Nano Institute of Utah, University of Utah, Salt Lake City, UT, 84112 USA
| | - Bryant Green
- Department of Bioengineering, University of Utah, Salt Lake City, UT, 84112 USA
- Utah Center for Nanomedicine, Nano Institute of Utah, University of Utah, Salt Lake City, UT, 84112 USA
| | - Joseph Cappello
- Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT, 84112 USA
| | - Abigail Pulsipher
- Utah Center for Nanomedicine, Nano Institute of Utah, University of Utah, Salt Lake City, UT, 84112 USA
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT 84113
| | - Hamidreza Ghandehari
- Department of Bioengineering, University of Utah, Salt Lake City, UT, 84112 USA
- Utah Center for Nanomedicine, Nano Institute of Utah, University of Utah, Salt Lake City, UT, 84112 USA
- Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT, 84112 USA
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT 84113
| | - Jeremiah A. Alt
- Department of Bioengineering, University of Utah, Salt Lake City, UT, 84112 USA
- Utah Center for Nanomedicine, Nano Institute of Utah, University of Utah, Salt Lake City, UT, 84112 USA
- Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah, Salt Lake City, UT, 84112 USA
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT 84113
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Goddard JK, Nussbaum ES, Madison M, Lassig J, Torok C, Giannakidis D, Hanson S, McDonald W, Kallmes KM, Nussbaum LA. Endovascular aspiration to treat acute ischemic stroke caused by embolic carcinoma. Interv Neuroradiol 2019; 25:403-406. [PMID: 30786802 DOI: 10.1177/1591019918817224] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
| | - Eric S Nussbaum
- 2 Department of Neurosurgery, National Brain Aneurysm and Tumor Center, Twin Cities, USA
| | | | | | | | | | | | | | | | - Leslie A Nussbaum
- 2 Department of Neurosurgery, National Brain Aneurysm and Tumor Center, Twin Cities, USA
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Jahan R, Villablanca JP, Harris RJ, Duarte-Vogel S, Williams CK, Vinters HV, Rao N, Enzmann DR, Ellingson BM. Selective middle cerebral artery occlusion in the rabbit: Technique and characterization with pathologic findings and multimodal MRI. J Neurosci Methods 2018; 313:6-12. [PMID: 30529458 DOI: 10.1016/j.jneumeth.2018.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 11/29/2018] [Accepted: 12/04/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND A reliable animal model of ischemic stroke is vital for pre-clinical evaluation of stroke therapies. We describe a reproducible middle cerebral artery (MCA) embolic occlusion in the French Lop rabbit characterized with multimodal MRI and histopathologic tissue analysis. NEW METHOD Fluoroscopic-guided microcatheter placement was performed in five consecutive subjects with angiographic confirmation of MCA occlusion with autologous clot. Multimodal MRI was obtained prior to occlusion and up to six hours post after which repeat angiography confirmed sustained occlusion. The brain was harvested for histopathologic examination. RESULTS Angiography confirmed successful MCA catheterization and durable (>6 h) MCA occlusion in all animals. There was increase of ADC volume over time and variable final core volume presumably related to individual variation in collateral flow. FLAIR hyperintensity indicative of cytotoxic edema and parenchymal contrast enhancement reflective of blood brain barrier disruption was observed over time. Tissue staining of the ischemic brain showed edema and structural alterations consistent with infarction. COMPARISON WITH EXISTING METHODS This study describes a technique of selective catheterization and embolic occlusion of the MCA in the rabbit with MRI characterization of evolution of ischemia in the model. CONCLUSIONS We demonstrate the feasibility of a rabbit model of embolic MCA occlusion with angiographic documentation. Serial MR imaging demonstrated changes comparable to those observed in human ischemic stroke, confirmed histopathologically.
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Affiliation(s)
- Reza Jahan
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.
| | - J Pablo Villablanca
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Robert J Harris
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Sandra Duarte-Vogel
- Division of Laboratory Animal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Christopher K Williams
- Department of Pathology & Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Harry V Vinters
- Department of Pathology & Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Neal Rao
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Dieter R Enzmann
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Benjamin M Ellingson
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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Sheen JJ, Suh DC. Low-angled microcatheter approach for coil embolization of the anterior choroidal artery aneurysm. Neuroradiology 2017; 59:1053-6. [PMID: 28744729 DOI: 10.1007/s00234-017-1879-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 07/03/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Thromboembolic complication is a serious concern following coil embolization for aneurysms involving the anterior choroidal artery (AChA). To minimize this complication and to improve packing density, we present a technical concept of coil embolization. METHODS We attempted packing of the aneurysmal sac by lowering the microcatheter approach angle into an aneurysm to secure AChA origin as well as to improve coil packing density of the aneurysm. This technical concept involves approaching the aneurysm sac with an adjusted shaping of the microcatheter tip to achieve the effect which was not obtained when the microcatheter approach angle into the aneurysm sac was high (≥90°). We evaluated immediate angiographic outcome by the Raymond classification, coil packing density, and follow-up results (modified Rankin Scale (mRS) and recurrence) in seven aneurysms involving AChA in six patients. RESULTS We achieved immediate angiographic outcome of the Raymond classes I or II with 31% mean packing density. The AChA origin was preserved without any procedure-related complication. There was neither clinical event (mRS = 0) nor aneurysm recurrence confirmed on the source image of magnetic resonance angiography during 6-9 months follow-up. CONCLUSIONS The technical concept of low-angled microcatheter approach can be useful to improve coil packing density and to secure AChA origin when AChA arises near the aneurysm.
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Lapchak PA, Zhang JH. Data Standardization and Quality Management. Transl Stroke Res 2018; 9:4-8. [PMID: 28283966 DOI: 10.1007/s12975-017-0531-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 02/26/2017] [Accepted: 03/01/2017] [Indexed: 10/20/2022]
Abstract
Important questions regarding the conduct of scientific research and data transparency have been raised in various scientific forums over the last 10 years. It is becoming clear, that in spite of published RIGOR guidelines, that improvement in the transparency of scientific research is required to focus on the discovery and drug development process so that a treatment can be provided to stroke patients. We have the unique privilege of conducting research using animal models of a disease so that we can address the development of a new therapy, and we should do this with great care and vigilance. This document identifies valuable resources for researchers to become Good Laboratory Practices compliant and increase and improve data transparency and provides guidelines for accurate data management to continue to propel the translational stroke research field forward while recognizing that there is a shortage of research funds worldwide. While data audits are being considered worldwide by funding agencies and they are used extensively by industry, they are still quite controversial for basic researchers. Due to the special exploratory nature of basic and translational science research, the current challenging funding environment, and independent and individualized laboratory activities, it is debatable if current individualized non-standardized data management and monitoring represents the best approach. Thus, herein, we propose steps to prepare research study data in an acceptable form for archival purposes so that standards for translational research data can be comparable to those that are accepted and adhered to by the clinical community. If all translational research laboratories follow and institute the guidelines while conducting translational research, data from all sources may be more comparable and reliable.
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Abstract
Occlusion of the basilar artery can be treated with endovascular thrombectomy, although the results have not been well studied. Persistent fetal cerebrovascular anatomy can lead to unusual presentation of carotid atherosclerotic disease and can be a barrier to successful mechanical thrombectomy if not recognized. This case presents a rare persistent carotico-basilar anastomosis which resulted in basilar occlusion via the persistent hypoglossal artery and coincident absence of contralateral vertebral arterial access due to a left vertebral artery terminating in the left posterior inferior cerebellar artery. Preoperative recognition of this anatomy afforded by review of cross-sectional imaging was critical to success during this emergent procedure.
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Affiliation(s)
- Alfred P See
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Bruno C Flores
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Andrew Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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See AP, Baranoski JF, Flores BC, Ducruet A, Albuquerque FC. Basilar stroke from a persistent hypoglossal artery. BMJ Case Rep 2017; 2017:bcr-2016-012859. [PMID: 28130280 DOI: 10.1136/bcr-2016-012859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Occlusion of the basilar artery can be treated with endovascular thrombectomy, although the results have not been well studied. Persistent fetal cerebrovascular anatomy can lead to unusual presentation of carotid atherosclerotic disease and can be a barrier to successful mechanical thrombectomy if not recognized. This case presents a rare persistent carotico-basilar anastomosis which resulted in basilar occlusion via the persistent hypoglossal artery and coincident absence of contralateral vertebral arterial access due to a left vertebral artery terminating in the left posterior inferior cerebellar artery. Preoperative recognition of this anatomy afforded by review of cross-sectional imaging was critical to success during this emergent procedure.
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Affiliation(s)
- Alfred P See
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Bruno C Flores
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Andrew Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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Neki H, Kohyama S, Otsuka T, Yonezawa A, Ishihara S, Yamane F. Optimal first coil selection to avoid aneurysmal recanalization in endovascular intracranial aneurysmal coiling. J Neurointerv Surg 2017; 10:50-54. [PMID: 28130502 DOI: 10.1136/neurintsurg-2016-012877] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 01/11/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Aneurysmal recanalization is a problem with endovascular coiling and one of its risk factors is the low volume embolization ratio (VER). The first coil VER (1st VER) is believed to be critical for obtaining a high VER. The main objective of this study was to evaluate factors potentially useful for selecting the optimal 1st VER for endovascular coiling. METHODS 609 initial saccular aneurysmal treatments performed between January 2010 and December 2014 at our institution were included in this retrospective study. Attempted procedures, retreatment cases, intraoperative rupture cases, and stent-assisted coiling cases were excluded. Age, sex, aneurysm location, ruptured aneurysm, aneurysm shape, neck size, maximum aneurysm size, dome-to-neck ratio, aneurysm volume, procedure, immediate Raymond scale score, 1st VER, and VER between the recanalization groups and non-recanalization groups were compared. RESULTS The factors related to recanalization were ruptured aneurysms, neck width, maximum aneurysm size, aneurysm volume, procedure, 1st VER, and VER. The cut-off values for aneurysm recanalization were a 1st VER of 10.0% and a VER of 33.0%. The maximum average VER of normal size aneurysms was found in the groups with a 1st VER of 17.5-20.0%. CONCLUSIONS 1st VER was found to be a helpful index for estimating aneurysmal recanalization after coil embolization. The target 1st VER was 17.5-20.0% for obtaining a higher VER and avoiding recanalization.
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Affiliation(s)
- Hiroaki Neki
- Division of Endovascular Neurosurgery, Stroke Center, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Shinya Kohyama
- Division of Endovascular Neurosurgery, Stroke Center, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Toshihiro Otsuka
- Division of Endovascular Neurosurgery, Stroke Center, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Azusa Yonezawa
- Division of Endovascular Neurosurgery, Stroke Center, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Shoichiro Ishihara
- Division Neurosurgery, Saitama Sekishinkai Hospital, Sayama, Saitama, Japan
| | - Fumitaka Yamane
- Division of Endovascular Neurosurgery, Stroke Center, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
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Yeo LLL, Wu YM, Chen YL, Yeh CH, Lee TH, Wong HF. MRI audit of complications in intracranial stenosis treated with Wingspan device. J Neurointerv Surg 2016; 9:466-470. [PMID: 27986847 DOI: 10.1136/neurintsurg-2016-012799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 11/15/2016] [Accepted: 11/21/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To evaluate the safety and efficacy of the Wingspan device for the treatment of symptomatic intracranial atherosclerotic stenosis (ICAS). METHODS We audited a prospective ongoing database of consecutive patients who received Wingspan stenting between January 2013 and December 2015. All patients underwent MRI to audit any complications during the early follow-up period. We focused on the clinical demographics, lesion characteristics, treatment results, and periprocedural complications. Functional outcomes were measured with the modified Rankin Scale (mRS) at discharge and after 3 months. RESULTS Intracranial stenting was performed in 50 patients (100%). Mean stenosis pre-stenting was 76.5±13.1% and post-stenting residual stenosis was 19.8±13.8%. The overall 30-day rate of procedure-related complications was 6.0% (3/50). Two patients (4%) developed in-stent restenosis, one of whom had a dissection at the middle cerebral artery. Interestingly, on the follow-up MRI scan there was a high incidence of asymptomatic diffusion-weighted imaging (DWI) hyperintensities, 46% (23/50) presumed to be due to microembolic causes. At the 90-day, 180-day, and 1-year follow-up, three patients had further strokes resulting in a total complication rate of 12%. 92% had excellent outcomes (mRS 0-1) and only one patient had deterioration of his mRS score. CONCLUSIONS ICAS treated by Wingspan stenting using pre-placement balloon angioplasty appears safe and effective with a high technical success rate and favorable outcomes. There is a high incidence of asymptomatic DWI hyperintensites post-procedure, but these do not appear to result in long-term sequelae.
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Affiliation(s)
- Leonard L L Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Y M Wu
- Division of Neuroradiology, Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine and School of Medical Technology, Chang Gung University; Taoyuan, Taiwan
| | - Y L Chen
- College of Medicine and School of Medical Technology, Chang Gung University; Taoyuan, Taiwan.,Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - C H Yeh
- Division of Neuroradiology, Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine and School of Medical Technology, Chang Gung University; Taoyuan, Taiwan
| | - T H Lee
- College of Medicine and School of Medical Technology, Chang Gung University; Taoyuan, Taiwan.,Department of Neurology, Stroke Center, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - H F Wong
- Division of Neuroradiology, Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine and School of Medical Technology, Chang Gung University; Taoyuan, Taiwan
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Scharf EL, Chakraborty T, Rabinstein A, Miranpuri AS. Endovascular management of cerebral septic embolism: three recent cases and review of the literature. J Neurointerv Surg 2016; 9:463-465. [PMID: 27899517 DOI: 10.1136/neurintsurg-2016-012792] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 11/11/2016] [Accepted: 11/14/2016] [Indexed: 11/03/2022]
Abstract
Endovascular management of acute ischemic stroke secondary to septic emboli from bacterial endocarditis is case-specific and outside established guidelines. We report three new cases of an acute ischemic stroke secondary to septic embolus from two different centers. All cases reported here were large vessel occlusions of the middle cerebral artery in anticoagulated patients. In one case the embolus was noted to be firm and aspiration thrombectomy was attempted in lieu of stent retrieval. Thrombolysis in Cerebral Ischemia (TICI) 3 recanalization was achieved and the patient experienced a good outcome with resolution of deficits. In this case, pathologic analysis of the embolus was available. These additional three cases from two centers add to the small but growing literature for interventional management of acute ischemic stroke in bacterial endocarditis.
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Affiliation(s)
- Eugene L Scharf
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Tia Chakraborty
- Department of Neurology, The Mayo Clinic, Rochester, Minnesota, USA
| | | | - Amrendra S Miranpuri
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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Wen LL, Zhang X, Zhang QR, Wu Q, Chen SJ, Deng JL, Huang K, Wang HD. Flat-detector computed tomography PBV map in the evaluation of presurgical embolization for hypervascular brain tumors. J Neurointerv Surg 2016; 9:1139-1144. [PMID: 27856651 DOI: 10.1136/neurintsurg-2016-012658] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 10/22/2016] [Accepted: 10/27/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Preoperative embolization of hypervascular brain tumors is frequently used to minimize intraoperative bleeding. OBJECTIVE To explore the efficacy of embolization using flat-detector CT (FDCT) parenchymal blood volume (PBV) maps before and after the intervention. MATERIALS AND METHODS Twenty-five patients with hypervascular brain tumors prospectively received pre- and postprocedural FDCT PBV scans using a biplane system under a protocol approved by the institutional research ethics committee. Semiquantitative analysis, based on region of interest measurements of the pre- and post-embolization PBV maps, operating time, and blood loss, was performed to assess the feasibility of PBV maps in detecting the perfusion deficit and to evaluate the efficacy of embolization. RESULTS Preoperative embolization was successful in 18 patients. The relative PBV decreased significantly from 3.98±1.41 before embolization to 2.10±2.00 after embolization. Seventeen patients underwent surgical removal of tumors 24 hours after embolization. The post-embolic tumor perfusion index correlated significantly with blood loss (ρ=0.55) and operating time (ρ=0.60). CONCLUSIONS FDCT PBV mapping is a useful method for evaluating the perfusion of hypervascular brain tumors and the efficacy of embolization. It can be used as a supplement to CT perfusion, MRI, and DSA in the evaluation of tumor embolization.
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Affiliation(s)
- Li-Li Wen
- Department of Neurosurgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, PR China
| | - Xin Zhang
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, PR China
| | - Qing-Rong Zhang
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, PR China
| | - Qi Wu
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, PR China
| | - Shu-Juan Chen
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, PR China
| | - Jin-Long Deng
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, PR China
| | | | - Han-Dong Wang
- Department of Neurosurgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, PR China
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Randhawa N, Squires JP, Heran MKS, Mann SK. Where did the clot go? An unusual complication of mechanical thrombectomy caused by malignancy related subclavian steal phenomenon in a patient with acute basilar artery occlusion. J Neurointerv Surg 2016; 9:e22. [PMID: 27799374 DOI: 10.1136/neurintsurg-2016-012665.rep] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2016] [Indexed: 11/04/2022]
Abstract
Subclavian steal is a relatively common vascular phenomenon usually caused by atherosclerotic disease. While symptoms are rare, arm claudication of the ipsilateral limb is most common, with paroxysmal symptoms of vertebrobasilar insufficiency (often exercise induced) being relatively uncommon. Here we present a case of brachial artery embolism during mechanical thrombectomy for basilar artery thrombosis, secondary to subclavian steal phenomenon. This atypical and potentially irreversible complication should be considered in patients with acute ischemic stroke undergoing neurointerventional management when subclavian steal is discovered angiographically.
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Affiliation(s)
- Nikkie Randhawa
- Department of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathan P Squires
- Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Sharanpal K Mann
- Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
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Randhawa N, Squires JP, Heran MKS, Mann SK. Where did the clot go? An unusual complication of mechanical thrombectomy caused by malignancy related subclavian steal phenomenon in a patient with acute basilar artery occlusion. BMJ Case Rep 2016; 2016:bcr-2016-012665. [PMID: 27797875 DOI: 10.1136/bcr-2016-012665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Subclavian steal is a relatively common vascular phenomenon usually caused by atherosclerotic disease. While symptoms are rare, arm claudication of the ipsilateral limb is most common, with paroxysmal symptoms of vertebrobasilar insufficiency (often exercise induced) being relatively uncommon. Here we present a case of brachial artery embolism during mechanical thrombectomy for basilar artery thrombosis, secondary to subclavian steal phenomenon. This atypical and potentially irreversible complication should be considered in patients with acute ischemic stroke undergoing neurointerventional management when subclavian steal is discovered angiographically.
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Affiliation(s)
- Nikkie Randhawa
- Department of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathan P Squires
- Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Sharanpal K Mann
- Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
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Dabus G, Hacein-Bey L, Varjavand B, Tomalty RD, Han PP, Yerokhin V, Linfante I, Mocco J, Oxley T, Spiotta A, Chaudry MI, Turner RD, Turk AS. Safety, immediate and mid-term results of the newer generation of hydrogel coils in the treatment of ruptured aneurysms: a multicenter study. J Neurointerv Surg 2016; 9:419-424. [PMID: 27798856 DOI: 10.1136/neurintsurg-2016-012780] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 09/29/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the 'real-world' performance of the newer generation of hydrogel coils in ruptured aneurysms. METHODS A multicenter retrospective study was carried out of angiographic and clinical outcome data on consecutive patients with ruptured aneurysms treated with at least 70% of the newer generation of hydrogel coils. Demographics and data on clinical grade, smoking, use of statins, aneurysm size, location, technique used, packing density, immediate angiographic result, angiographic follow-up, rebleeding and clinical outcome were obtained and analyzed. RESULTS Eighty patients (54F; 26M) with an average age of 55.1 years were entered in the study. Forty-four presented good clinical grade (Hunt and Hess 1 or 2). Forty-two (52.5%) aneurysms were ≤5 mm. 56.7% of the aneurysms were treated with simple coil embolization and 39.6% with balloon-assisted coil. The packing density ranged from 9.3% to 92.6% (mean 48.5%). Immediate occlusion rates (Raymond-Roy Scale) were: complete occlusion (class I) in 57.5%, residual neck (class II) in 32.5% and residual aneurysm (class III) in 10%. Intraoperative rupture occurred in 3 cases (3.75%). Clinical follow-up, available in 73 patients, showed a good outcome (modified Rankin Scale 0-2) in 76.3%. Preliminary data on imaging follow-up were available in 54 patients (average 6.8 months) with complete occlusion in 77.8%, residual neck in 20.3% and residual aneurysm in 1.9%. There was no re-hemorrhage. CONCLUSIONS Our data show that the use of the newer-generation hydrogel coils in the treatment of ruptured aneurysms is feasible, safe and effective with high immediate and mid-term occlusion rates and low morbidity.
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Affiliation(s)
- Guilherme Dabus
- Miami Cardiac & Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
| | | | | | | | - Patrick P Han
- St John Neuroscience Institute, Tulsa, Oklahoma, USA
| | | | - Italo Linfante
- Miami Cardiac & Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
| | - J Mocco
- Mount Sinai Hospital, New York, New York, USA
| | | | - Alejandro Spiotta
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - M Imran Chaudry
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Raymond D Turner
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Aquilla S Turk
- Medical University of South Carolina, Charleston, South Carolina, USA
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46
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Seker F, Pfaff J, Wolf M, Schönenberger S, Nagel S, Herweh C, Pham M, Bendszus M, Möhlenbruch MA. Impact of thrombus length on recanalization and clinical outcome following mechanical thrombectomy in acute ischemic stroke. J Neurointerv Surg 2016; 9:937-939. [PMID: 27634955 DOI: 10.1136/neurintsurg-2016-012591] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/21/2016] [Accepted: 08/29/2016] [Indexed: 01/29/2023]
Abstract
PURPOSE The impact of thrombus length on recanalization in IV thrombolysis for acute intracranial artery occlusion has been well studied. Here we analyzed the influence of thrombus length on the number of thrombectomy maneuvers needed for recanalization, intraprocedural complications, recanalization success, and clinical outcome after mechanical thrombectomy. METHODS We retrospectively analyzed angiographic and clinical data from 72 consecutive patients with acute occlusion of the M1 segment of the middle cerebral artery who were treated with mechanical thrombectomy using stent retrievers. Successful recanalization was defined as a Thrombolysis in Cerebral Infarction score of 2b or 3. Good neurological outcome was defined as a modified Rankin Scale score of ≤2 at 90 days after stroke onset. RESULTS Mean thrombus length was 13.4±5.2 mm. Univariate binary logistic regression did not show an association of thrombus length with the probability of a good clinical outcome (OR 0.95, 95% CI 0.84 to 1.03, p=0.176) or successful recanalization (OR 0.92, 95% CI 0.81 to 1.05, p=0.225). There was no significant correlation between thrombus length and the number of thrombectomy maneuvers needed for recanalization (p=0.112). Furthermore, thrombus length was not correlated with the probability of intraprocedural complications (p=0.813), including embolization in a new territory (n=3). CONCLUSIONS In this study, thrombus length had no relevant impact on recanalization, neurological outcome, or intraprocedural complications following mechanical thrombectomy of middle cerebral artery occlusions. Therefore, mechanical thrombectomy with stent retrievers can be attempted with large clots.
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Affiliation(s)
- Fatih Seker
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johannes Pfaff
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Marcel Wolf
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Herweh
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Mirko Pham
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
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Kansagra AP, McEachern JD, Madaelil TP, Wallace AN, Cross DT, Moran CJ, Derdeyn CP. Intra-arterial versus intravenous abciximab therapy for thrombo embolic complications of neuroendovascular procedures: case review and meta-analysis. J Neurointerv Surg 2016; 9:131-136. [PMID: 27540089 DOI: 10.1136/neurintsurg-2016-012587] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 07/20/2016] [Accepted: 07/29/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Abciximab is used to treat thromboembolic complications of neuroendovascular procedures, but outcomes of treatment are not well defined. OBJECTIVE To examine the angiographic and clinical outcomes based on route of abciximab administration and degree of vessel recanalization. MATERIALS AND METHODS A prospectively maintained database of neuroendovascular procedures performed between January 2004 and May 2015 was retrospectively reviewed to identify cases with thromboembolic complications treated with abciximab. In these cases, route of administration, degree of vessel recanalization, and presence or absence of infarction were determined. A meta-analysis of similar cases in the literature was also performed. RESULTS Abciximab was administered in 0.24% (47 of 19 566) of procedures to treat thromboemboli in 59 vessels. Angiographic improvement was seen in 94% after IA therapy and 79% after IV therapy (p=0.133). In our meta-analysis of 391 treated patients, angiographic improvement was greater after IA (91.7%) than IV (77.4%) treatment (p<0.001). Postprocedural infarction occurred more frequently with distal lesions (42%) than local lesions (12%) (p=0.014), and occlusive lesions (36%) than non-occlusive lesions (4.8%) (p=0.010). Infarction was significantly less common with complete angiographic resolution (0%) than with partial or no improvement (54%) (p<0.001). Symptomatic intracranial hemorrhage occurred in 2.1%. CONCLUSIONS Abciximab produces a high rate of angiographic improvement and a low incidence of postprocedural infarct in neuroendovascular procedures complicated by thromboemboli. IA abciximab produces greater angiographic improvement than IV treatment. Postprocedural infarction is less common in patients with complete angiographic response than in those with partial or no response.
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Affiliation(s)
- Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - James D McEachern
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Thomas P Madaelil
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Adam N Wallace
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - DeWitte T Cross
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, USA.,Department of Neurosurgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, USA.,Department of Neurosurgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Colin P Derdeyn
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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48
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Meimoun P, Mesnildray P, Clerc J, Luycx-Bore A, Boulanger J. [Voluminous thrombus straddling the patent foramen oval in the setting of massive pulmonary embolism, treated successfully by surgery]. Ann Cardiol Angeiol (Paris) 2016; 65:363-365. [PMID: 27427466 DOI: 10.1016/j.ancard.2016.04.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 04/29/2016] [Indexed: 10/21/2022]
Abstract
Paradoxical embolism is rarely demonstrated, often suggested, and the diagnosis has been largely presumptive in most cases. The patent foramen ovale (PFO) is an important predisposing anatomic factor for such a complication. We describe a case where a voluminous thrombus straddling the PFO was diagnosed by echocardiography including the 3D modality, in the setting of acute massive pulmonary embolism. The treatment is not codified in this setting, and the thrombus was successfully removed by surgery, associated with PFO closure, and anticoagulation.
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Affiliation(s)
- P Meimoun
- Service de cardiologie-USIC, centre hospitalier de Compiègne, 8, rue Henri-Adnot, 60200 Compiègne, France.
| | - P Mesnildray
- Département de chirurgie cardiaque, centre cardiologique du Nord, 32-36, rue des Moulins-Gémeaux, 93207 Saint-Denis, France
| | - J Clerc
- Service de cardiologie-USIC, centre hospitalier de Compiègne, 8, rue Henri-Adnot, 60200 Compiègne, France
| | - A Luycx-Bore
- Service de cardiologie-USIC, centre hospitalier de Compiègne, 8, rue Henri-Adnot, 60200 Compiègne, France
| | - J Boulanger
- Service de cardiologie-USIC, centre hospitalier de Compiègne, 8, rue Henri-Adnot, 60200 Compiègne, France
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Belton PJ, Nanda A, Alqadri SL, Khakh GS, Chandrasekaran PN, Newey C, Humphries WE. Paradoxical cerebral air embolism causing large vessel occlusion treated with endovascular aspiration. BMJ Case Rep 2016; 2016:bcr-2016-012535. [PMID: 27435840 DOI: 10.1136/bcr-2016-012535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Cerebral air embolism is a dreaded complication of invasive medical procedures. The mainstay of therapy for patients with cerebral air embolism has been hyperbaric oxygen therapy, high flow oxygen therapy, and anticonvulsants. We present a novel therapeutic approach for treatment of cerebral air embolism causing large vessel occlusion, using endovascular aspiration. Our patient developed a cerebral air embolism following sclerotherapy for varicose veins. This caused near total occlusion of the superior division of the M2 segment of the right middle cerebral artery. Symptoms included unilateral paralysis, unintelligible speech, and hemianopia; National Institutes of Health Stroke Scale (NIHSS) on presentation was 16. The air embolism was treated using a distal aspiration technique. Angiography following aspiration showed Thrombolysis in Cerebral Infarction 2B reperfusion. Following aspiration, the patient was re-examined; NIHSS at that time was 4. At 1 month follow-up, the modified Rankin Scale score was 1 and NIHSS was 1. Treatment of cerebral air embolism is discussed.
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Affiliation(s)
- Patrick J Belton
- Division of Neurosurgery, University of Missouri Columbia School of Medicine, Columbia, Missouri, USA
| | | | - Syeda L Alqadri
- Department of Neurology, University of Missouri Columbia School of Medicine, Columbia, Missouri, USA
| | - Gurpreet S Khakh
- Department of Neurology, University of Missouri Columbia School of Medicine, Columbia, Missouri, USA
| | | | - Christopher Newey
- Department of Neurology, University of Missouri Columbia School of Medicine, Columbia, Missouri, USA
| | - William E Humphries
- Division of Neurosurgery, University of Missouri Columbia School of Medicine, Columbia, Missouri, USA
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Chen T, Kalani MYS, Ducruet AF, Albuquerque FC, McDougall CG. Development of syndrome of inappropriate antidiuretic hormone secretion (SIADH) after Onyx embolisation of a cavernous carotid fistula. J Neurointerv Surg 2016; 9:e3. [PMID: 27013230 DOI: 10.1136/neurintsurg-2015-012104.rep] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2016] [Indexed: 11/03/2022]
Abstract
Patients with cavernous carotid fistulas (CCFs) can present with pituitary hypoperfusion and hypopituitarism; however, there are no previous reports of pituitary or hormonal abnormalities developing after CCF embolisation in an asymptomatic patient. We describe a patient with no hormonal abnormalities who developed syndrome of inappropriate antidiuretic hormone (SIADH) secretion after CCF embolisation. The patient had bilateral indirect CCFs, which were completely embolised via a transvenous approach, and was neurologically stable postoperatively and discharged. In the subsequent 2 weeks the patient was readmitted twice for acute hyponatraemia and a tonic-clonic seizure. Laboratory studies revealed severe SIADH. Clinical status and sodium levels improved after treatment. One year later the patient was weaned off all medications and remained neurologically stable. SIADH may be a delayed phenomenon after CCF embolisation. Given the proximity of embolised vessels to the pituitary's vascular supply, CCF treatment may result in flow disturbance, ischaemia and hormonal abnormalities.
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Affiliation(s)
- Tsinsue Chen
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - M Yashar S Kalani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Cameron G McDougall
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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