1
|
Reynolds CD, Caton MT, Baker A, Smith ER, Amans MR, Cooke DL, Dowd CF, Higashida RT, Gupta N, Abla AA, Auguste K, Fox CH, Fullerton H, Hetts SW. Clarifying the clinical landscape of pediatric spinal arteriovenous shunts: an institutional experience and individual patient-data meta-analysis. J Neurointerv Surg 2023; 16:94-100. [PMID: 36922033 DOI: 10.1136/jnis-2022-019797] [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: 11/16/2022] [Accepted: 03/07/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Pediatric spinal arteriovenous shunts (SAVS) are rare lesions with heterogeneous pathogenesis and clinical manifestations. OBJECTIVE To evaluate the clinical characteristics, angioarchitecture, and technical/clinical outcomes in SAVS through a large single-center cohort analysis and meta-analysis of individual patient data. METHODS A retrospective institutional database identified children (aged 0-21 years) who underwent digital subtraction spinal angiography (DSA) for SAVS between January 1996 and July 2021. Clinical data were recorded to evaluate angioarchitecture, generate modified Aminoff-Logue gait disturbance scores (AL) and McCormick grades (MC), and assess outcomes. We then performed a systematic literature review following PRISMA-IPD (Preferred Reporting Items for Systematic Reviews and Meta-Analyses for individual patient data) guidelines, extracting similar data on individual patients for meta-analysis. RESULTS The cohort consisted of 28 children (M:F=11:17) with 32 SAVS lesions, with a mean age of 12.8±1.1 years at diagnosis. At presentation, SAVS were most highly concentrated in the cervical region (40.6%). Children had a median AL=2 and MC=2, with thoracolumbar AVS carrying the greatest disability. Among treated cases, complete obliteration was achieved in 48% of cases and median AL scores and MC grades both improved by one point. Systematic literature review identified 161 children (M:F=96:65) with 166 SAVS lesions with a mean age of 8.7±0.4 years. Among studies describing symptom chronicity, 37/51 (72.5%) of children presented acutely. At presentation, children had a median AL=4 and MC=3, with thoracolumbar AVS carrying the highest MC grades. After intervention, median AL and MC both improved by one point. CONCLUSIONS This study provides epidemiologic information on the location, onset, and presentation of the full spectrum of pediatric SAVS, highlighting the role of targeted treatment of high-risk features.
Collapse
Affiliation(s)
- Conner D Reynolds
- Department of Medical Imaging, The University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
| | - M Travis Caton
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Amanda Baker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Eric R Smith
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Matthew R Amans
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Christopher F Dowd
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Randall T Higashida
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Nalin Gupta
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Kurtis Auguste
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Christine H Fox
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Heather Fullerton
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
2
|
Caton MT, Duvvuri M, Baker A, Smith ER, Narsinh KH, Amans MR, Hetts SW, Higashida RT, Cooke DL, Dowd CF. Percutaneous sclerotherapy for head and neck lymphatic malformations in neonates and infants ≤12 months of age. J Neurointerv Surg 2023; 15:1242-1246. [PMID: 36414388 DOI: 10.1136/jnis-2022-019516] [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: 08/10/2022] [Accepted: 11/07/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Percutaneous sclerotherapy is an effective treatment for lymphatic malformations (LM) of the head and neck in adults. The purpose of this study was to examine the indications and efficacy of sclerotherapy for head/neck LM in the neonate and infant population. METHODS We retrospectively reviewed patients treated with percutaneous sclerotherapy for LM of the head/neck at age ≤12 months at a single vascular anomalies clinic. The clinical, anatomic, and technical aspects of each treatment, complications, and post-treatment clinical and imaging outcomes were analyzed. RESULTS 22 patients underwent 36 treatments during the first year of life. Median age at first treatment was 6.2 months (range 2-320 days). Severe airway compromise was the most frequent indication for treatment (31.8%). Sclerosants included doxycycline (80.5%), sodium tetradecyl sulfate (55.5%), bleomycin (11.1%) and ethanol (2.8%). There were no immediate procedure-related complications; sclerosant-related laboratory complications included transient metabolic acidosis (8.3%) and hemolytic anemia (5.5%). Median follow-up was 3.7 years (IQR 0.6-4.8). 47.6% of patients showed >75% lesion size reduction and 19.0% showed minimal response (<25% improvement). At last follow-up, 71.4% of children were developmentally normal and asymptomatic, 23.8% had recurring symptoms, and 4.8% required permanent tracheostomy. Patients with ongoing symptoms or limited response to percutaneous sclerotherapy (33.3%) were treated with long-term sirolimus. CONCLUSIONS Percutaneous sclerotherapy is a safe and effective treatment for symptomatic LM of the head and neck in neonates and infants. Treatment strategy and management of recurrent symptoms requires consensus from an experienced, multidisciplinary team.
Collapse
Affiliation(s)
- M Travis Caton
- Neurosurgery, Mount Sinai Health System, New York, New York, USA
- Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Madhavi Duvvuri
- Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Amanda Baker
- Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Eric R Smith
- Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Kazim H Narsinh
- Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Matthew R Amans
- Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Randall T Higashida
- Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Christopher F Dowd
- Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
3
|
Baker A, Hemphill K, Smith ER, Cooke DL, Hetts SW, Amans MR, Higashida RT, Narsinh KH. Transvenous coil embolization of a Cognard V transverse-sigmoid sinus dural arteriovenous fistula. Interv Neuroradiol 2023:15910199231188257. [PMID: 37552935 DOI: 10.1177/15910199231188257] [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: 08/10/2023] Open
Abstract
Dural arteriovenous fistulas with drainage into the spinal veins, classified as Cognard type 5, can be challenging to diagnose and treat. Brainstem and cervical spinal cord signal abnormalities on magnetic resonance imaging result from venous congestion, and can mimic tumor, infection, or inflammation.1-3 Transarterial and transvenous embolization techniques can be used to treat dural arteriovenous fistulas endovascularly. Efficacious transvenous treatment relies on the ability to safely catheterize the draining vein at the dural arteriovenous fistula site. Transvenous access options may seem limited in the setting of occluded venous sinuses. This case highlights the technical aspects of the transvenous approach to embolization of a transverse-sigmoid sinus dural arteriovenous fistula within an isolated sinus,4,5 demonstrating traversal of the occluded venous sinus from a contralateral approach.6,7[Media: see text].
Collapse
Affiliation(s)
- Amanda Baker
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Kafi Hemphill
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Eric R Smith
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Matthew R Amans
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Randall T Higashida
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Kazim H Narsinh
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| |
Collapse
|
4
|
Baker A, Caton MT, Smith ER, Narsinh KH, Amans MR, Higashida RT, Cooke DL, Dowd CF, Hetts SW. Evolving indications for pediatric neurointerventional radiology: A single institutional 25-year experience in infants less than one year of age and a brief historical review. Interv Neuroradiol 2023:15910199231154689. [PMID: 36760130 DOI: 10.1177/15910199231154689] [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: 02/11/2023] Open
Abstract
BACKGROUND AND PURPOSE Pediatric neurointerventional radiology is an evolving subspecialty with growing indications and technological advancement such as miniaturization of devices and decreased radiation dose. The ability to perform these procedures is continuously balanced with necessity given the inherently higher risks of radiation and cerebrovascular injury in infants. The purpose of this study is to review our institution's neurointerventional experience in infants less than one year of age to elucidate trends in this patient population. METHODS We retrospectively identified 132 patients from a neurointerventional database spanning 25 years (1997-2022) who underwent 226 procedures. Treatment type, indication, and location as well as patient demographics were extracted from the medical record. RESULTS Neurointerventional procedures were performed as early as day of life 0 in a patient with an arteriovenous shunting malformation. Average age of intervention in the first year of life is 5.9 months. Thirty-eight of 226 procedures were completed in neonates. Intra-arterial chemotherapy (IAC) for the treatment of retinoblastoma comprised 36% of neurointerventional procedures completed in infants less than one year of age followed by low flow vascular malformations (21.2%), vein of Galen malformations (11.5%), and dural arteriovenous fistulas (AVF) (9.3%). Less frequent indications include non-Galenic pial AVF (4.4%) and tumor embolization (3.0%). The total number of interventions has increased secondary to the onset of retinoblastoma treatment in 2010 at our institution. CONCLUSION The introduction of IAC for the treatment of retinoblastoma in the last decade is the primary driver for the increased trend in neurointerventional procedures completed in infants from 1997 to 2022.
Collapse
Affiliation(s)
- Amanda Baker
- Department of Radiology and Biomedical Imaging, 8785University of California, San Francisco, CA, USA
| | - Michael Travis Caton
- Department of Radiology and Biomedical Imaging, 8785University of California, San Francisco, CA, USA
| | - Eric R Smith
- Department of Radiology and Biomedical Imaging, 8785University of California, San Francisco, CA, USA
| | - Kazim H Narsinh
- Department of Radiology and Biomedical Imaging, 8785University of California, San Francisco, CA, USA
| | - Matthew R Amans
- Department of Radiology and Biomedical Imaging, 8785University of California, San Francisco, CA, USA
| | - Randall T Higashida
- Department of Radiology and Biomedical Imaging, 8785University of California, San Francisco, CA, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, 8785University of California, San Francisco, CA, USA
| | - Christopher F Dowd
- Department of Radiology and Biomedical Imaging, 8785University of California, San Francisco, CA, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, 8785University of California, San Francisco, CA, USA
| |
Collapse
|
5
|
Baker A, Raygor K, Caton MT, Narsinh KH, Smith E, Dowd CF, Cooke DL, Higashida RT, Amans MR, Abla AA, Hetts SW. Pharyngo-tympano-stapedial middle meningeal artery variant supply to a falcotentorial dural arteriovenous fistula. J Neurointerv Surg 2022; 14:neurintsurg-2022-018817. [PMID: 35545428 DOI: 10.1136/neurintsurg-2022-018817] [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: 02/22/2022] [Accepted: 04/29/2022] [Indexed: 11/03/2022]
Abstract
The pharyngo-tympano-stapedial middle meningeal artery (PTS-MMA) variant has been described in one case report and never in the setting of arterial supply to a dural arteriovenous fistula, to our knowledge. We report the case of a middle-aged patient with severe, daily headache who presented to our institution for angiography and treatment. CT angiography and MRI demonstrated an enlarged left middle meningeal artery coursing to a large venous varix in the falcotentorial region. Dural arteriovenous fistula was confirmed by subsequent cerebral angiography. Endovascular treatment was performed but without complete obliteration of the fistula. Follow-up angiography demonstrated parasitized arterial supply from a right middle meningeal artery arising from the proximal cervical internal carotid artery coursing through the middle ear consistent with a PTS-MMA variant. The fistula was then treated surgically without recurrence at the 6-month follow-up.
Collapse
Affiliation(s)
- Amanda Baker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Kunal Raygor
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - M Travis Caton
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Kazim H Narsinh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Eric Smith
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Christopher F Dowd
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Randall T Higashida
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Matthew R Amans
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
6
|
Caton MT, Smith ER, Baker A, Dowd CF, Higashida RT. Transradial Approach for Thoracolumbar Spinal Angiography and Tumor Embolization: Feasibility and Technical Considerations. Neurointervention 2022; 17:100-105. [PMID: 35340197 PMCID: PMC9256468 DOI: 10.5469/neuroint.2022.00010] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/10/2022] [Indexed: 11/24/2022] Open
Abstract
The transradial approach (TRA) is an effective and safe alternative to transfemoral access for diagnostic neuroangiography and craniocervical interventions. While the technical aspects of supraclavicular intervention are well-described, there are little data on the TRA for thoracolumbar angiography and intervention. The authors describe the feasibility of the TRA for preoperative thoracic tumor embolization, emphasizing technique, device selection, navigation, and catheterization of thoracolumbar segmental arteries. This approach extends the benefits of TRA to spinal interventional neuroradiology.
Collapse
Affiliation(s)
- Michael Travis Caton
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Eric Robert Smith
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Amanda Baker
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Christopher Foley Dowd
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, CA, USA.,Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Randall T Higashida
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, CA, USA.,Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
7
|
Narsinh KH, Paez R, Mueller K, Caton MT, Baker A, Higashida RT, Halbach VV, Dowd CF, Amans MR, Hetts SW, Norbash AM, Cooke DL. Robotics for neuroendovascular intervention: Background and primer. Neuroradiol J 2022; 35:25-35. [PMID: 34398721 PMCID: PMC8826289 DOI: 10.1177/19714009211034829] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The simultaneous growth of robotic-assisted surgery and telemedicine in recent years has only been accelerated by the recent coronavirus disease 2019 pandemic. Robotic assistance for neurovascular intervention has garnered significant interest due to opportunities for tele-stroke models of care for remote underserved areas. Lessons learned from medical robots in interventional cardiology and neurosurgery have contributed to incremental but vital advances in medical robotics despite important limitations. In this article, we discuss robot types and their clinical justification and ethics, as well as a general overview on available robots in thoracic/abdominal surgery, neurosurgery, and cardiac electrophysiology. We conclude with current clinical research in neuroendovascular intervention and a perspective on future directions.
Collapse
Affiliation(s)
- Kazim H Narsinh
- Department of Radiology and
Biomedical Imaging, University of California San Francisco, USA,Kazim H Narsinh and Daniel L Cooke, UCSF
Department of Radiology and Biomedical Imaging, 505 Parnassus Avenue, L-309, San
Francisco, CA 94117, USA. ;
| | - Ricardo Paez
- Department of Radiology and
Biomedical Imaging, University of California San Francisco, USA
| | | | - M Travis Caton
- Department of Radiology and
Biomedical Imaging, University of California San Francisco, USA
| | - Amanda Baker
- Department of Radiology and
Biomedical Imaging, University of California San Francisco, USA
| | - Randall T Higashida
- Department of Radiology and
Biomedical Imaging, University of California San Francisco, USA
| | - Van V Halbach
- Department of Radiology and
Biomedical Imaging, University of California San Francisco, USA
| | - Christopher F Dowd
- Department of Radiology and
Biomedical Imaging, University of California San Francisco, USA
| | - Matthew R Amans
- Department of Radiology and
Biomedical Imaging, University of California San Francisco, USA
| | - Steven W Hetts
- Department of Radiology and
Biomedical Imaging, University of California San Francisco, USA
| | | | - Daniel L Cooke
- Department of Radiology and
Biomedical Imaging, University of California San Francisco, USA,Kazim H Narsinh and Daniel L Cooke, UCSF
Department of Radiology and Biomedical Imaging, 505 Parnassus Avenue, L-309, San
Francisco, CA 94117, USA. ;
| |
Collapse
|
8
|
Caton MT, Mark IT, Narsinh KH, Baker A, Cooke DL, Hetts SW, Dowd CF, Halbach VV, Higashida RT, Ko NU, Chung SA, Amans MR. Endovascular Therapy for Intracranial Giant Cell Arteritis : Systematic Review, Technical Considerations and the Effect of Intra-arterial Calcium Channel Blockers. Clin Neuroradiol 2022; 32:1045-1056. [PMID: 35503467 PMCID: PMC9744710 DOI: 10.1007/s00062-022-01171-0] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/06/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Giant cell arteritis (GCA) is a systemic vasculitis that may cause ischemic stroke. Rarely, GCA can present with aggressive intracranial stenoses, which are refractory to medical therapy. Endovascular treatment (EVT) is a possible rescue strategy to prevent ischemic complications in intracranial GCA but the safety and efficacy of EVT in this setting are not well-described. METHODS A systematic literature review was performed to identify case reports and series with individual patient-level data describing EVT for intracranial GCA. The clinical course, therapeutic considerations, and technique of seven endovascular treatments in a single patient from the authors' experience are presented. RESULTS The literature review identified 9 reports of 19 treatments, including percutaneous transluminal angioplasty (PTA) with or without stenting, in 14 patients (mean age 69.6 ± 6.3 years). Out of 12 patients 8 (66.7%) with sufficient data had > 1 pre-existing cardiovascular risk factor. All patients had infarction on MRI while on glucocorticoids and 7/14 (50%) progressed despite adjuvant immunosuppressive agents. Treatment was PTA alone in 15/19 (78.9%) cases and PTA + stent in 4/19 (21.1%). Repeat treatments were performed in 4/14 (28.6%) of patients (PTA-only). Non-flow limiting dissection was reported in 2/19 (10.5%) of treatments. The indications, technical details, and results of PTA are discussed in a single illustrative case. We report the novel use of intra-arterial calcium channel blocker infusion (verapamil) as adjuvant to PTA and as monotherapy, resulting in immediate improvement in cerebral blood flow. CONCLUSION Endovascular treatment, including PTA with or without stenting or calcium channel blocker infusion, may be effective therapies in medically refractory GCA with intracranial stenosis.
Collapse
Affiliation(s)
- M. Travis Caton
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Ian T. Mark
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Kazim H. Narsinh
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Amanda Baker
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Daniel L. Cooke
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Steven W. Hetts
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Christopher F. Dowd
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Van V. Halbach
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Randall T. Higashida
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Nerissa U. Ko
- Department of Neurology, University of California, San Francisco, USA
| | - Sharon A. Chung
- Department of Medicine, Division of Rheumatology, University of California, San Francisco, USA
| | - Matthew R. Amans
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| |
Collapse
|
9
|
Narsinh KH, Narsinh K, McCoy DB, Sun Z, Halabi C, Meisel K, Tihan T, Chaganti K, Amans MR, Halbach VV, Higashida RT, Hetts SW, Dowd CF, Winkler EA, Abla AA, Nowakowski TJ, Cooke DL. Endovascular Biopsy of Vertebrobasilar Aneurysm in Patient With Polyarteritis Nodosa. Front Neurol 2021; 12:697105. [PMID: 34887823 PMCID: PMC8650719 DOI: 10.3389/fneur.2021.697105] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 10/08/2021] [Indexed: 12/15/2022] Open
Abstract
Background and Purpose: The management of unruptured intracranial aneurysms remains controversial. The decisions to treat are heavily informed by estimated risk of bleeding. However, these estimates are imprecise, and better methods for stratifying the risk or tailoring treatment strategy are badly needed. Here, we demonstrate an initial proof-of-principle concept for endovascular biopsy to identify the key molecular pathways and gene expression changes associated with aneurysm formation. We couple this technique with single cell RNA sequencing (scRNAseq) to develop a roadmap of the pathogenic changes of a dolichoectatic vertebrobasilar aneurysm in a patient with polyarteritis nodosa. Methods: Endovascular biopsy and fluorescence activated cell sorting was used to isolate the viable endothelial cells (ECs) using the established techniques. A single cell RNA sequencing (scRNAseq) was then performed on 24 aneurysmal ECs and 23 patient-matched non-aneurysmal ECs. An integrated panel of bioinformatic tools was applied to determine the differential gene expression, enriched signaling pathways, and cell subpopulations hypothesized to drive disease pathogenesis. Results: We identify a subset of 7 (29%) aneurysm-specific ECs with a distinct gene expression signature not found in the patient-matched control ECs. A gene set enrichment analysis identified these ECs to have increased the expression of genes regulating the leukocyte-endothelial cell adhesion, major histocompatibility complex (MHC) class I, T cell receptor recycling, tumor necrosis factor alpha (TNFα) response, and interferon gamma signaling. A histopathologic analysis of a different intracranial aneurysm that was later resected yielded a diagnosis of polyarteritis nodosa and positive staining for TNFα. Conclusions: We demonstrate feasibility of applying scRNAseq to the endovascular biopsy samples and identify a subpopulation of ECs associated with cerebral aneurysm in polyarteritis nodosa. Endovascular biopsy may be a safe method for deriving insight into the disease pathogenesis and tailoring the personalized treatment approaches to intracranial aneurysms.
Collapse
Affiliation(s)
- Kazim H Narsinh
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Kamileh Narsinh
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - David B McCoy
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Zhengda Sun
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Cathra Halabi
- Division of Neurovascular Neurology, Department of Neurology, University of California, San Francisco, San Francisco, CA, United States.,Weill Institute for Neuroscience, University of California, San Francisco, San Francisco, CA, United States
| | - Karl Meisel
- Division of Neurovascular Neurology, Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Tarik Tihan
- Division of Neuropathology, Department of Pathology, University of California, San Francisco, San Francisco, CA, United States
| | - Krishna Chaganti
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Matthew R Amans
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Van V Halbach
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Randall T Higashida
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Steven W Hetts
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Christopher F Dowd
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Ethan A Winkler
- Cerebrovascular Disorders Program, Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Adib A Abla
- Cerebrovascular Disorders Program, Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Tomasz J Nowakowski
- Department of Anatomy, Chan Zuckerberg Biohub, University of California, San Francisco, San Francisco, CA, United States
| | - Daniel L Cooke
- Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| |
Collapse
|
10
|
Narsinh KH, Mirza MH, Duvvuri M, Caton MT, Baker A, Winkler EA, Higashida RT, Halbach VV, Amans MR, Cooke DL, Hetts SW, Abla AA, Dowd CF. Radial artery access anatomy: considerations for neuroendovascular procedures. J Neurointerv Surg 2021; 13:1139-1144. [PMID: 34551992 DOI: 10.1136/neurintsurg-2021-017871] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 06/05/2021] [Accepted: 09/06/2021] [Indexed: 02/06/2023]
Abstract
Although enthusiasm for transradial access for neurointerventional procedures has grown, a unique set of considerations bear emphasis to preserve safety and minimize complications. In the first part of this review series, we will review important anatomical considerations for safe and easy neuroendovascular procedures from a transradial approach. These include normal and variant radial artery anatomy, the anatomic snuffbox, as well as axillary, brachial, and great vessel arterial anatomy that is imperative for the neuroendovascular surgeon to be intimately familiar prior to pursuing transradial access procedures. In the next part of the review series, we will focus on safety and complications specific to a transradial approach.
Collapse
Affiliation(s)
- Kazim H Narsinh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Mohammed H Mirza
- Department of Radiology, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - Madhavi Duvvuri
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - M Travis Caton
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Amanda Baker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Randall T Higashida
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Van V Halbach
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Matthew R Amans
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Christopher F Dowd
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
11
|
Narsinh KH, Mirza MH, Caton MT, Baker A, Winkler E, Higashida RT, Halbach VV, Amans MR, Cooke DL, Hetts SW, Abla AA, Dowd CF. Radial artery access for neuroendovascular procedures: safety review and complications. J Neurointerv Surg 2021; 13:1132-1138. [PMID: 34551991 DOI: 10.1136/neurintsurg-2021-017325] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 02/04/2021] [Accepted: 06/16/2021] [Indexed: 01/01/2023]
Abstract
Although enthusiasm for transradial access for neurointerventional procedures has grown, a unique set of considerations bear emphasis to preserve safety and minimize complications. In the first part of this review series, we reviewed anatomical considerations for safe and easy neuroendovascular procedures from a transradial approach. In this second part of the review series, we aim to (1) summarize evidence for safety of the transradial approach, and (2) explain complications and their management.
Collapse
Affiliation(s)
- Kazim H Narsinh
- Radiology & Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | - Mohammed H Mirza
- Radiology, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - M Travis Caton
- Radiology & Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | - Amanda Baker
- Radiology & Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | - Ethan Winkler
- Neurological Surgery, University California San Francisco, San Francisco, California, USA
| | - Randall T Higashida
- Radiology & Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | - Van V Halbach
- Radiology & Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | - Matthew R Amans
- Radiology & Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Radiology & Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Radiology & Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Neurological Surgery, University California San Francisco, San Francisco, California, USA
| | - Christopher F Dowd
- Radiology & Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| |
Collapse
|
12
|
Caton MT, Narsinh KH, Baker A, Hetts SW, Cooke DL, Higashida RT, Dowd CF, Halbach VV, Amans MR. Endovascular treatment strategy, technique, and outcomes for dural arteriovenous fistulas of the marginal sinus region. J Neurointerv Surg 2021; 14:155-159. [PMID: 34039683 DOI: 10.1136/neurintsurg-2021-017476] [Citation(s) in RCA: 2] [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: 02/28/2021] [Accepted: 05/11/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Dural arteriovenous fistulas (AVF) of the foramen magnum region (FMR) are technically challenging lesions to treat. Transvenous (TV), transarterial (TA), and surgical approaches have been described, but the optimum treatment strategy is not defined. OBJECTIVE To report treatment strategies and outcomes for FMR-AVF at a single, high-volume referral center. METHODS A retrospective review from January 2010 to August 2020 identified patients with FMR-AVF at a single referral center. Angiographic features, treatment (observation, endovascular, surgical), and follow-up of angiographic and clinical results were recorded. The technical aspects of TV embolization are then presented in detail. RESULTS 29 FMR-AVF were identified in 28 patients. Of these, 24/29 (82.8%) were treated and 5/29 (17.2%) were observed. Treatment was endovascular in 21/24 (87.5%), combined (endovascular+surgical) in 2/24 (8.3%), and surgical in 1/24 (4.2%). Endovascular treatments were 76.2% TV, 14.3% TA, and 9.5% combined TV/TA. Sufficient follow-up data were available for 20/28 (71.4%) with mean follow-up of 16.8 months. No AVF recurrence was seen for TA/TV, combined endovascular/surgical, or surgical groups, and there was one recurrence (7.1%) in the TV group. Symptomatic improvement was seen in all groups: TV (71.4% complete, 28.6% partial), TA (66.7% complete, 33.3% no follow-up), TV+TA (100% partial), endovascular/surgical (100% complete), and surgical (100% partial). Minor non-neurologic complications included 1/14 (7.1%) in the TV group and 1/3 (33.3%) in the TA/TV group. CONCLUSION Endovascular treatment is safe and effective for most FMR-AVF. TV embolization has a high cure rate with few complications.
Collapse
Affiliation(s)
- Michael Travis Caton
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Kazim H Narsinh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Amanda Baker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Randall T Higashida
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA.,Departments of Neurological Surgery, Neurology, and Anesthesiology, University of California San Francisco, San Francisco, CA, USA
| | - Christopher F Dowd
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA.,Departments of Neurological Surgery, Neurology, and Anesthesiology, University of California San Francisco, San Francisco, CA, USA
| | - Van V Halbach
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA.,Departments of Neurological Surgery, Neurology, and Anesthesiology, University of California San Francisco, San Francisco, CA, USA
| | - Matthew R Amans
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
13
|
Amans MR, Smith E, Narsinh KH, Dowd CF, Higashida RT, Halbach VV, Hetts SW, Cooke DL, Nelson J, Mccoy D, Ciano M, Dillon WP, Copelan AZ, Drocton GT, Khangura RS, Murph D, Hartley ZJ, Abla AA. Reply. AJNR Am J Neuroradiol 2021; 42:E58-E59. [PMID: 33985958 DOI: 10.3174/ajnr.a7160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- M R Amans
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - E Smith
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - K H Narsinh
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - C F Dowd
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - R T Higashida
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - V V Halbach
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - S W Hetts
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - D L Cooke
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - J Nelson
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - D Mccoy
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - M Ciano
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - W P Dillon
- Diagnostic and Interventional NeuroradiologyUniversity of California, San FranciscoSan Francisco, California
| | - A Z Copelan
- Neurointerventional RadiologyConsulting Radiologists, LtdMinneapolis, Minnesota
| | - G T Drocton
- Neurointerventional RadiologySutter HealthSacramento, California
| | - R S Khangura
- Neurointerventional RadiologySutter HealthSacramento, California
| | - D Murph
- Interventional NeuroradiologyAsheville Radiology AssociatesAsheville, North Carolina
| | - Z J Hartley
- Diagnostic RadiologyBrown UniversityProvidence, Rhode Island
| | - A A Abla
- NeurosurgeryUniversity of California, San FranciscoSan Francisco, California
| |
Collapse
|
14
|
Caton MT, Narsinh KH, Baker A, Dowd CF, Higashida RT, Cooke DL, Hetts SW, Halbach VV, Amans MR. Dural Arteriovenous Fistulas of the Foramen Magnum Region: Clinical Features and Angioarchitectural Phenotypes. AJNR Am J Neuroradiol 2021; 42:1486-1491. [PMID: 33958333 DOI: 10.3174/ajnr.a7152] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 02/26/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE AVFs of the foramen magnum region, including fistulas of the marginal sinus and condylar veins, have complex arterial supply, venous drainage, symptoms, and risk features that are not well-defined. The purpose of this study was to present the angioarchitectural and clinical phenotypes of a foramen magnum region AVF from a large, single-center experience. MATERIALS AND METHODS We retrospectively reviewed cases from a 10-year neurointerventional data base. Arterial and venous angioarchitectural features and clinical presentation were extracted from the medical record. Venous drainage patterns were stratified into 4 groups as follows: type 1 = unrestricted sinus drainage, type 2 = sinus reflux (including the inferior petrosal sinus), type 3 = reflux involving sinuses and cortical veins, and type 4 = restricted cortical vein outflow or perimedullary congestion. RESULTS Twenty-eight patients (mean age, 57.9 years; 57.1% men) had 29 foramen magnum region AVFs. There were 11 (37.9%) type 1, nine (31.0%) type 2, six (20.7%) type 3, and 3 (10.3%) type 4 fistulas. Pulsatile tinnitus was the most frequent symptom (82.1%), followed by orbital symptoms (31.0%), subarachnoid hemorrhage (13.8%), cranial nerve XII palsy (10.3%), and other cranial nerve palsy (6.9%). The most frequent arterial supply was the ipsilateral ascending pharyngeal artery (93.1% ipsilateral, 55.5% contralateral), vertebral artery (89.7%), occipital artery (65.5%), and internal carotid artery branches (48.3%). CONCLUSIONS We present the largest case series of foramen magnum region AVFs to date and show that clinical features relate to angioarchitecture. Orbital symptoms are frequent when sinus reflux is present. Hemorrhage was only observed in type 3 and 4 fistulas.
Collapse
Affiliation(s)
- M T Caton
- From the Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California, San Francisco, San Francisco, California
| | - K H Narsinh
- From the Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California, San Francisco, San Francisco, California
| | - A Baker
- From the Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California, San Francisco, San Francisco, California
| | - C F Dowd
- From the Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California, San Francisco, San Francisco, California
| | - R T Higashida
- From the Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California, San Francisco, San Francisco, California
| | - D L Cooke
- From the Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California, San Francisco, San Francisco, California
| | - S W Hetts
- From the Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California, San Francisco, San Francisco, California
| | - V V Halbach
- From the Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California, San Francisco, San Francisco, California
| | - M R Amans
- From the Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California, San Francisco, San Francisco, California
| |
Collapse
|
15
|
Narsinh KH, Kilbride BF, Mueller K, Murph D, Copelan A, Massachi J, Vitt J, Sun CH, Bhat H, Amans MR, Dowd CF, Halbach VV, Higashida RT, Moore T, Wilson MW, Cooke DL, Hetts SW. Combined Use of X-ray Angiography and Intraprocedural MRI Enables Tissue-based Decision Making Regarding Revascularization during Acute Ischemic Stroke Intervention. Radiology 2021; 299:167-176. [PMID: 33560189 DOI: 10.1148/radiol.2021202750] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background For patients with acute ischemic stroke undergoing endovascular mechanical thrombectomy with x-ray angiography, the use of adjuncts to maintain vessel patency, such as stents or antiplatelet medications, can increase risk of periprocedural complications. Criteria for using these adjuncts are not well defined. Purpose To evaluate use of MRI to guide critical decision making by using a combined biplane x-ray neuroangiography 3.0-T MRI suite during acute ischemic stroke intervention. Materials and Methods This retrospective observational study evaluated consecutive patients undergoing endovascular intervention for acute ischemic stroke between July 2019 and May 2020 who underwent either angiography with MRI or angiography alone. Cerebral tissue viability was assessed by using MRI as the reference standard. For statistical analysis, Fisher exact test and Student t test were used to compare groups. Results Of 47 patients undergoing acute stroke intervention, 12 patients (median age, 69 years; interquartile range, 60-77 years; nine men) underwent x-ray angiography with MRI whereas the remaining 35 patients (median age, 80 years; interquartile range, 68-86 years; 22 men) underwent angiography alone. MRI results influenced clinical decision making in one of three ways: whether or not to perform initial or additional mechanical thrombectomy, whether or not to place an intracranial stent, and administration of antithrombotic or blood pressure medications. In this initial experience, decision making during endovascular acute stroke intervention in the combined angiography-MRI suite was better informed at MRI, such that therapy was guided in real time by the viability of the at-risk cerebral tissue. Conclusion Integrating intraprocedural 3.0-T MRI into acute ischemic stroke treatment was feasible and guided decisions of whether or not to continue thrombectomy, to place stents, or to administer antithrombotic medication or provide blood pressure medications. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Lev and Leslie-Mazwi in this issue.
Collapse
Affiliation(s)
- Kazim H Narsinh
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Bridget F Kilbride
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Kerstin Mueller
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Daniel Murph
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Alexander Copelan
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Jonathan Massachi
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Jeffrey Vitt
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Chung-Huan Sun
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Himanshu Bhat
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Matthew R Amans
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Christopher F Dowd
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Van V Halbach
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Randall T Higashida
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Terilyn Moore
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Mark W Wilson
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Daniel L Cooke
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Steven W Hetts
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| |
Collapse
|
16
|
Narsinh KH, Caton MT, Mahmood NF, Higashida RT, Halbach VV, Hetts SW, Amans MR, Dowd CF, Cooke DL. Intrasaccular flow disruption (WEB) of a large wide-necked basilar apex aneurysm using PulseRider-assistance. Interdiscip Neurosurg 2020; 24. [PMID: 33816125 PMCID: PMC8018600 DOI: 10.1016/j.inat.2020.101072] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Large, wide-necked basilar apex aneurysms are difficult to treat. Microsurgical clipping can result in neurologic morbidity and mortality. Endovascular treatment often leaves remnants that need retreatment and/or stent placement with dual antiplatelet therapy. The Woven EndoBridge (WEB) is an intrasaccular flow disruption device that can be used without dual antiplatelet therapy. However, the WEB cannot typically be used in large or giant aneurysms > 10 mm because the largest diameter device is the 11 × 9.6 mm single layer sphere (SLS). We present a case in which we use a PulseRider aneurysm neck reconstruction device in the basilar artery to assist in WEB deployment within a 22 mm basilar apex aneurysm with 14 mm neck, thereby permitting aspirin monotherapy postoperatively.
Collapse
Affiliation(s)
- Kazim H Narsinh
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA 94143, USA
| | - M Travis Caton
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA 94143, USA
| | - Nausheen F Mahmood
- Department of Neurology, University of California San Francisco, San Francisco, CA 94143, USA
| | - Randall T Higashida
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA 94143, USA
| | - Van V Halbach
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA 94143, USA
| | - Steven W Hetts
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA 94143, USA
| | - Matthew R Amans
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA 94143, USA
| | - Christopher F Dowd
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA 94143, USA
| | - Daniel L Cooke
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA 94143, USA
| |
Collapse
|
17
|
Copelan AZ, Smith ER, Drocton GT, Narsinh KH, Murph D, Khangura RS, Hartley ZJ, Abla AA, Dillon WP, Dowd CF, Higashida RT, Halbach VV, Hetts SW, Cooke DL, Keenan K, Nelson J, Mccoy D, Ciano M, Amans MR. Recent Administration of Iodinated Contrast Renders Core Infarct Estimation Inaccurate Using RAPID Software. AJNR Am J Neuroradiol 2020; 41:2235-2242. [PMID: 33214184 DOI: 10.3174/ajnr.a6908] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 08/01/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Automated CTP software is increasingly used for extended window emergent large-vessel occlusion to quantify core infarct. We aimed to assess whether RAPID software underestimates core infarct in patients with an extended window recently receiving IV iodinated contrast. MATERIALS AND METHODS We reviewed a prospective, single-center data base of 271 consecutive patients who underwent CTA ± CTP for acute ischemic stroke from May 2018 through January 2019. Patients with emergent large-vessel occlusion confirmed by CTA in the extended window (>6 hours since last known well) and CTP with RAPID postprocessing were included. Two blinded raters independently assessed CT ASPECTS on NCCT performed at the time of CTP. RAPID software used relative cerebral blood flow of <30% as a surrogate for irreversible core infarct. Patients were dichotomized on the basis of receiving recent IV iodinated contrast (<8 hours before CTP) for a separate imaging study. RESULTS The recent IV contrast and contrast-naïve cohorts comprised 23 and 15 patients, respectively. Multivariate linear regression analysis demonstrated that recent IV contrast administration was independently associated with a decrease in the RAPID core infarct estimate (proportional increase = 0.34; 95% CI, 0.12-0.96; P = .04). CONCLUSIONS Patients who received IV iodinated contrast in proximity (<8 hours) to CTA/CTP as part of a separate imaging study had a much higher likelihood of core infarct underestimation with RAPID compared with contrast-naïve patients. Over-reliance on RAPID postprocessing for treatment disposition of patients with extended window emergent large-vessel occlusion should be avoided, particularly with recent IV contrast administration.
Collapse
Affiliation(s)
- A Z Copelan
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - E R Smith
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.).,Department of Radiology (E.R.S.), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - G T Drocton
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - K H Narsinh
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - D Murph
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - R S Khangura
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - Z J Hartley
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - A A Abla
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.).,Neurosurgery (A.A.A.), University of California, San Francisco, San Francisco, California
| | - W P Dillon
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - C F Dowd
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - R T Higashida
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - V V Halbach
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - S W Hetts
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - D L Cooke
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - K Keenan
- Department of Neurology (K.K.), University of California Davis, Sacramento, California
| | - J Nelson
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - D Mccoy
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - M Ciano
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - M R Amans
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| |
Collapse
|
18
|
Narsinh KH, Mueller K, Nelson J, Massachi J, Murph DC, Copelan AZ, Hetts SW, Halbach VV, Higashida RT, Abla AA, Amans MR, Dowd CF, Kim H, Cooke DL. Interrater Reliability in the Measurement of Flow Characteristics on Color-Coded Quantitative DSA of Brain AVMs. AJNR Am J Neuroradiol 2020; 41:2303-2310. [PMID: 33122213 DOI: 10.3174/ajnr.a6846] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 08/05/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND PURPOSE Hemodynamic features of brain AVMs may portend increased hemorrhage risk. Previous studies have suggested that MTT is shorter in ruptured AVMs as assessed on quantitative color-coded parametric DSA. This study assesses the interrater reliability of MTT measurements obtained using quantitative color-coded DSA. MATERIALS AND METHODS Thirty-five color-coded parametric DSA images of 34 brain AVMs were analyzed by 4 neuroradiologists with experience in interventional neuroradiology. Hemodynamic features assessed included MTT of the AVM and TTP of the dominant feeding artery and draining vein. Agreement among the 4 raters was assessed using the intraclass correlation coefficient. RESULTS The interrater reliability among the 4 raters was poor (intraclass correlation coefficient = 0.218; 95% CI, 0.062-0.414; P value = .002) as it related to MTT assessment. When the analysis was limited to cases in which the raters selected the same image to analyze and selected the same primary feeding artery and the same primary draining vein, interrater reliability improved to fair (intraclass correlation coefficient = 0.564; 95% CI, 0.367-0.717; P < .001). CONCLUSIONS Interrater reliability in deriving color-coded parametric DSA measurements such as MTT is poor so minor differences among raters may result in a large variance in MTT and TTP results, partly due to the sensitivity and 2D nature of the technique. Reliability can be improved by defining a standard projection, feeding artery, and draining vein for analysis.
Collapse
Affiliation(s)
- K H Narsinh
- From the Department of Radiology and Biomedical Imaging (K.H.N., J.M., D.C.M., A.Z.C., S.W.H., V.V.H., R.T.H., M.R.A., C.F.D., D.L.C.)
| | - K Mueller
- Siemens Medical Solutions (K.M.), Malvern, Pennsylvania
| | - J Nelson
- Center for Cerebrovascular Research (J.N., H.K.), Department of Anesthesiology
| | - J Massachi
- From the Department of Radiology and Biomedical Imaging (K.H.N., J.M., D.C.M., A.Z.C., S.W.H., V.V.H., R.T.H., M.R.A., C.F.D., D.L.C.)
| | - D C Murph
- From the Department of Radiology and Biomedical Imaging (K.H.N., J.M., D.C.M., A.Z.C., S.W.H., V.V.H., R.T.H., M.R.A., C.F.D., D.L.C.)
| | - A Z Copelan
- From the Department of Radiology and Biomedical Imaging (K.H.N., J.M., D.C.M., A.Z.C., S.W.H., V.V.H., R.T.H., M.R.A., C.F.D., D.L.C.)
| | - S W Hetts
- From the Department of Radiology and Biomedical Imaging (K.H.N., J.M., D.C.M., A.Z.C., S.W.H., V.V.H., R.T.H., M.R.A., C.F.D., D.L.C.)
| | - V V Halbach
- From the Department of Radiology and Biomedical Imaging (K.H.N., J.M., D.C.M., A.Z.C., S.W.H., V.V.H., R.T.H., M.R.A., C.F.D., D.L.C.)
| | - R T Higashida
- From the Department of Radiology and Biomedical Imaging (K.H.N., J.M., D.C.M., A.Z.C., S.W.H., V.V.H., R.T.H., M.R.A., C.F.D., D.L.C.)
| | - A A Abla
- Department of Neurological Surgery (A.A.A.), University of California San Francisco, San Francisco, California
| | - M R Amans
- From the Department of Radiology and Biomedical Imaging (K.H.N., J.M., D.C.M., A.Z.C., S.W.H., V.V.H., R.T.H., M.R.A., C.F.D., D.L.C.)
| | - C F Dowd
- From the Department of Radiology and Biomedical Imaging (K.H.N., J.M., D.C.M., A.Z.C., S.W.H., V.V.H., R.T.H., M.R.A., C.F.D., D.L.C.)
| | - H Kim
- Center for Cerebrovascular Research (J.N., H.K.), Department of Anesthesiology
| | - D L Cooke
- From the Department of Radiology and Biomedical Imaging (K.H.N., J.M., D.C.M., A.Z.C., S.W.H., V.V.H., R.T.H., M.R.A., C.F.D., D.L.C.)
| |
Collapse
|
19
|
Copelan A, Drocton G, Caton MT, Smith ER, Cooke DL, Nelson J, Abla AA, Fox C, Amans MR, Dowd CF, Halbach VV, Higashida RT, Lawton MT, Kim H, Fullerton HJ, Gupta N, Hetts SW. Brain Arteriovenous Malformation Recurrence After Apparent Microsurgical Cure: Increased Risk in Children Who Present With Arteriovenous Malformation Rupture. Stroke 2020; 51:2990-2996. [PMID: 32912090 DOI: 10.1161/strokeaha.120.030135] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Do children have an increased risk for brain arteriovenous malformation (AVM) recurrence compared with adults and does this risk vary depending on initial presentation with AVM rupture? METHODS We retrospectively studied 115 patients initially presenting with brain AVM under age 25 years who underwent complete surgical resection of the AVM as documented by digital subtraction angiography (DSA) and had delayed follow-up DSA to evaluate for AVM recurrence after apparent initial cure. RESULTS The mean time from baseline DSA to follow-up DSA was 2.3 years, ranging from 0 to 15 years. Twelve patients (10.4% of the 115 patient cohort and 16.7% of 72 patients with hemorrhage at initial presentation) demonstrated AVM recurrence on follow-up DSA. All patients with recurrence initially presented with intracranial hemorrhage, and intracranial hemorrhage was a significant predictor of recurrence (log rank P=0.037). Among patients with initial hemorrhage, the 5-year recurrence rate was 17.8% (95% CI, 8.3%-35.7%). All recurrences occurred in patients who were children at the time of their initial presentation; the oldest was 15 years of age at the time of initial AVM surgery. The 5-year recurrence rate for children (0-18 years of age) with an initial presentation of hemorrhage was 21.4% (95% CI, 10.1%-41.9%). Using Cox regression, we found the risk of AVM recurrence decreased by 14% per each year increase in age at the time of initial surgical resection (hazard ratio=0.86 [95% CI, 0.75-0.99]; P=0.031). CONCLUSIONS There is a high rate of recurrence of apparently cured brain AVMs in children who initially present with AVM rupture. Imaging follow-up is warranted to prevent re-rupture.
Collapse
Affiliation(s)
- Alexander Copelan
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging (A.C., G.D., M.T.C., E.R.S., D.L.C., M.R.A., C.F.D., V.V.H., R.T.H., S.W.H.), University of California, San Francisco
| | - Gerald Drocton
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging (A.C., G.D., M.T.C., E.R.S., D.L.C., M.R.A., C.F.D., V.V.H., R.T.H., S.W.H.), University of California, San Francisco
| | - M Travis Caton
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging (A.C., G.D., M.T.C., E.R.S., D.L.C., M.R.A., C.F.D., V.V.H., R.T.H., S.W.H.), University of California, San Francisco
| | - Eric R Smith
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging (A.C., G.D., M.T.C., E.R.S., D.L.C., M.R.A., C.F.D., V.V.H., R.T.H., S.W.H.), University of California, San Francisco
| | - Daniel L Cooke
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging (A.C., G.D., M.T.C., E.R.S., D.L.C., M.R.A., C.F.D., V.V.H., R.T.H., S.W.H.), University of California, San Francisco.,Center for Cerebrovascular Research (D.L.C., J.N., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.K., H.J.F., N.G., S.W.H.), University of California, San Francisco.,Pediatric Brain Center (D.L.C., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.J.F., S.W.H.), University of California, San Francisco
| | - Jeffrey Nelson
- Center for Cerebrovascular Research (D.L.C., J.N., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.K., H.J.F., N.G., S.W.H.), University of California, San Francisco
| | - Adib A Abla
- Center for Cerebrovascular Research (D.L.C., J.N., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.K., H.J.F., N.G., S.W.H.), University of California, San Francisco.,Pediatric Brain Center (D.L.C., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.J.F., S.W.H.), University of California, San Francisco.,Division of Cerebrovascular Neurosurgery, Department of Neurological Surgery (A.A.A., C.F.D., V.V.H., R.T.H.), University of California, San Francisco
| | - Christine Fox
- Center for Cerebrovascular Research (D.L.C., J.N., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.K., H.J.F., N.G., S.W.H.), University of California, San Francisco.,Pediatric Brain Center (D.L.C., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.J.F., S.W.H.), University of California, San Francisco.,Departments of Neurology and Pediatrics (C.F., H.J.F.), University of California, San Francisco
| | - Matthew R Amans
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging (A.C., G.D., M.T.C., E.R.S., D.L.C., M.R.A., C.F.D., V.V.H., R.T.H., S.W.H.), University of California, San Francisco.,Center for Cerebrovascular Research (D.L.C., J.N., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.K., H.J.F., N.G., S.W.H.), University of California, San Francisco.,Pediatric Brain Center (D.L.C., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.J.F., S.W.H.), University of California, San Francisco
| | - Christopher F Dowd
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging (A.C., G.D., M.T.C., E.R.S., D.L.C., M.R.A., C.F.D., V.V.H., R.T.H., S.W.H.), University of California, San Francisco.,Center for Cerebrovascular Research (D.L.C., J.N., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.K., H.J.F., N.G., S.W.H.), University of California, San Francisco.,Pediatric Brain Center (D.L.C., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.J.F., S.W.H.), University of California, San Francisco.,Division of Cerebrovascular Neurosurgery, Department of Neurological Surgery (A.A.A., C.F.D., V.V.H., R.T.H.), University of California, San Francisco.,Department of Anesthesia and Perioperative Care (C.F.D., V.V.H., R.T.H., H.K.), University of California, San Francisco
| | - Van V Halbach
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging (A.C., G.D., M.T.C., E.R.S., D.L.C., M.R.A., C.F.D., V.V.H., R.T.H., S.W.H.), University of California, San Francisco.,Center for Cerebrovascular Research (D.L.C., J.N., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.K., H.J.F., N.G., S.W.H.), University of California, San Francisco.,Pediatric Brain Center (D.L.C., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.J.F., S.W.H.), University of California, San Francisco.,Division of Cerebrovascular Neurosurgery, Department of Neurological Surgery (A.A.A., C.F.D., V.V.H., R.T.H.), University of California, San Francisco.,Department of Anesthesia and Perioperative Care (C.F.D., V.V.H., R.T.H., H.K.), University of California, San Francisco
| | - Randall T Higashida
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging (A.C., G.D., M.T.C., E.R.S., D.L.C., M.R.A., C.F.D., V.V.H., R.T.H., S.W.H.), University of California, San Francisco.,Center for Cerebrovascular Research (D.L.C., J.N., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.K., H.J.F., N.G., S.W.H.), University of California, San Francisco.,Pediatric Brain Center (D.L.C., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.J.F., S.W.H.), University of California, San Francisco.,Division of Cerebrovascular Neurosurgery, Department of Neurological Surgery (A.A.A., C.F.D., V.V.H., R.T.H.), University of California, San Francisco.,Department of Anesthesia and Perioperative Care (C.F.D., V.V.H., R.T.H., H.K.), University of California, San Francisco
| | - Michael T Lawton
- Division of Pediatric Neurosurgery, Department of Neurological Surgery (N.G.), University of California, San Francisco.,Division of Neurovascular Surgery, Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (M.T.L.)
| | - Helen Kim
- Center for Cerebrovascular Research (D.L.C., J.N., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.K., H.J.F., N.G., S.W.H.), University of California, San Francisco.,Department of Anesthesia and Perioperative Care (C.F.D., V.V.H., R.T.H., H.K.), University of California, San Francisco
| | - Heather J Fullerton
- Center for Cerebrovascular Research (D.L.C., J.N., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.K., H.J.F., N.G., S.W.H.), University of California, San Francisco.,Pediatric Brain Center (D.L.C., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.J.F., S.W.H.), University of California, San Francisco.,Departments of Neurology and Pediatrics (C.F., H.J.F.), University of California, San Francisco
| | - Nalin Gupta
- Center for Cerebrovascular Research (D.L.C., J.N., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.K., H.J.F., N.G., S.W.H.), University of California, San Francisco
| | - Steven W Hetts
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging (A.C., G.D., M.T.C., E.R.S., D.L.C., M.R.A., C.F.D., V.V.H., R.T.H., S.W.H.), University of California, San Francisco.,Center for Cerebrovascular Research (D.L.C., J.N., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.K., H.J.F., N.G., S.W.H.), University of California, San Francisco.,Pediatric Brain Center (D.L.C., A.A.A., C.F., M.R.A., C.F.D., V.V.H., R.T.H., H.J.F., S.W.H.), University of California, San Francisco
| | | |
Collapse
|
20
|
Meyers PM, Higashida RT. Commentary: Access Through the Anatomical Snuffbox for Neuroendovascular Procedures: A Single Institution Series. Oper Neurosurg (Hagerstown) 2020; 19:E471-E472. [DOI: 10.1093/ons/opaa172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/10/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Philip M Meyers
- Department of Radiology and Neurological Surgery, NeuroEndovascular Services, New York-Presbyterian Hospitals – Columbia, Columbia University, Vagelos College of Physicians and Surgeons, New York, New York
| | - Randall T Higashida
- Department of Radiology & Biomedical Imaging, Neurosurgery, Neurology, & Anesthesiology, Neuro Interventional Radiology, University of California San Francisco, San Francisco, California
| |
Collapse
|
21
|
Knox JA, Alexander MD, McCoy DB, Murph DC, Hinckley PJ, Ch'ang JC, Dowd CF, Halbach VV, Higashida RT, Amans MR, Hetts SW, Cooke DL. Impact of Aortic Arch Anatomy on Technical Performance and Clinical Outcomes in Patients with Acute Ischemic Stroke. AJNR Am J Neuroradiol 2020; 41:268-273. [PMID: 32001445 DOI: 10.3174/ajnr.a6422] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 12/11/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Arterial access is a technical consideration of mechanical thrombectomy that may affect procedural time, but few studies exist detailing the relationship of anatomy to procedural times and patient outcomes. We sought to investigate the respective impact of aortic arch and carotid artery anatomy on endovascular procedural times in patients with large-vessel occlusion. MATERIALS AND METHODS We retrospectively reviewed imaging and medical records of 207 patients from 2 academic institutions who underwent mechanical thrombectomy for anterior circulation large-vessel occlusion from January 2015 to July 2018. Preintervention CTAs were assessed to measure features of the aortic arch and ipsilateral great vessel anatomy. These included the cranial-to-caudal distance from the origin of the innominate artery to the top of the aortic arch and the takeoff angle of the respective great vessel from the arch. mRS scores were calculated from rehabilitation and other outpatient documentation. We performed bootstrap, stepwise regressions to model groin puncture to reperfusion time and binary mRS outcomes (good outcome, mRS ≤ 2). RESULTS From our linear regression for groin puncture to reperfusion time, we found a significant association of the great vessel takeoff angle (P = .002) and caudal distance from the origin of the innominate artery to the top of the aortic arch (P = .05). Regression analysis for the binary mRS revealed a significant association with groin puncture to reperfusion time (P < .001). CONCLUSIONS These results demonstrate that patients with larger takeoff angles and extreme aortic arches have an association with longer procedural times as approached from transfemoral access routes.
Collapse
Affiliation(s)
- J A Knox
- From the Departments of Radiology (J.A.K., D.B.M., D.C.M., P.J.H., C.F.D., V.V.H., R.T.H., M.R.A., S.W.H., D.L.C.) and
| | - M D Alexander
- Neurology (J.C.C.), University of California, San Francisco, San Francisco, California
| | - D B McCoy
- From the Departments of Radiology (J.A.K., D.B.M., D.C.M., P.J.H., C.F.D., V.V.H., R.T.H., M.R.A., S.W.H., D.L.C.) and
| | - D C Murph
- From the Departments of Radiology (J.A.K., D.B.M., D.C.M., P.J.H., C.F.D., V.V.H., R.T.H., M.R.A., S.W.H., D.L.C.) and
| | - P J Hinckley
- From the Departments of Radiology (J.A.K., D.B.M., D.C.M., P.J.H., C.F.D., V.V.H., R.T.H., M.R.A., S.W.H., D.L.C.) and
| | - J C Ch'ang
- Department of Radiology (M.D.A.), University of Utah, Salt Lake City, Utah
| | - C F Dowd
- From the Departments of Radiology (J.A.K., D.B.M., D.C.M., P.J.H., C.F.D., V.V.H., R.T.H., M.R.A., S.W.H., D.L.C.) and
| | - V V Halbach
- From the Departments of Radiology (J.A.K., D.B.M., D.C.M., P.J.H., C.F.D., V.V.H., R.T.H., M.R.A., S.W.H., D.L.C.) and
| | - R T Higashida
- From the Departments of Radiology (J.A.K., D.B.M., D.C.M., P.J.H., C.F.D., V.V.H., R.T.H., M.R.A., S.W.H., D.L.C.) and
| | - M R Amans
- From the Departments of Radiology (J.A.K., D.B.M., D.C.M., P.J.H., C.F.D., V.V.H., R.T.H., M.R.A., S.W.H., D.L.C.) and
| | - S W Hetts
- From the Departments of Radiology (J.A.K., D.B.M., D.C.M., P.J.H., C.F.D., V.V.H., R.T.H., M.R.A., S.W.H., D.L.C.) and
| | - D L Cooke
- From the Departments of Radiology (J.A.K., D.B.M., D.C.M., P.J.H., C.F.D., V.V.H., R.T.H., M.R.A., S.W.H., D.L.C.) and
| |
Collapse
|
22
|
Higashida RT. In Memoriam Grant Hieshima, MD: 1942–2019: Pioneer, Mentor, Visionary, Friend. J Neurointerv Surg 2019. [DOI: 10.1136/neurintsurg-2019-015390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
23
|
Mayer SA, Aldrich EF, Bruder N, Hmissi A, Macdonald RL, Viarasilpa T, Marr A, Roux S, Higashida RT. Thick and Diffuse Subarachnoid Blood as a Treatment Effect Modifier of Clazosentan After Subarachnoid Hemorrhage. Stroke 2019; 50:2738-2744. [PMID: 31394993 DOI: 10.1161/strokeaha.119.025682] [Citation(s) in RCA: 10] [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] [Indexed: 01/01/2023]
Abstract
Background and Purpose- Clazosentan, an endothelin receptor antagonist, has been shown to reduce angiographic vasospasm and vasospasm-related morbidity after aneurysmal subarachnoid hemorrhage (SAH), although no effect on long-term functional outcome has been demonstrated. Thick clot on initial computed tomography is associated with an increased risk of vasospasm and delayed cerebral ischemia. In this post hoc analysis, we hypothesized that use of clazosentan in this subpopulation would provide stronger benefit. Methods- We analyzed SAH patients enrolled in the CONSCIOUS-2 and CONSCIOUS-3 studies (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage) and compared the effects of clazosentan 5 mg/h, 15 mg/h, and placebo starting the day after aneurysm repair. The analysis was performed separately based on the presence or absence of thick (≥4 mm) and diffuse (≥3 cisterns) SAH on admission computed tomography. The primary composite end point was all-cause mortality and vasospasm-related morbidity at 6 weeks, and the main secondary end point was the extended Glasgow Outcome Scale at 3 months, adjusted for admission clinical grade. Results- Of 1718 randomized patients, 919 (53%) had thick and diffuse SAH. The primary composite end point in this group occurred in 36% of placebo-treated patients (n=294), 30% patients treated with clazosentan 5 mg/h (n=514; relative risk, 0.82; 95% CI, 0.67-0.99), and 19% patients treated with clazosentan 15 mg/h (n=111; relative risk, 0.54; 95% CI, 0.36-0.80). Despite this, death or poor functional outcome (Glasgow Outcome Scale ≤4) occurred in 33% of placebo-treated patients, 34% of patients treated with clazosentan 5 mg/h (relative risk 1.02; 95% CI, 0.84-1.23), and 35% of patients treated with clazosentan 15 mg/h (relative risk 1.14; 95% CI, 0.88-1.48). Conclusions- In an enriched population with thick and diffuse SAH, clazosentan at a dose of 5 and 15 mg/h was able to significantly reduce vasospasm-related morbidity in a dose-dependent manner. The absence of an effect on long-term functional status likely reflects the complexity and multiplicity of factors that contribute to poor outcome after SAH. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00558311; NCT00940095.
Collapse
Affiliation(s)
- Stephan A Mayer
- From the Department of Neurology, Henry Ford Hospital, Detroit, MI (S.A.M., T.V.)
| | | | - Nicolas Bruder
- Hopital de la Timone-Aix-Marseille Université, France (N.B.)
| | - Abdel Hmissi
- Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland (A.H., A.M., S.R.)
| | - R Loch Macdonald
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, ON, Canada (R.L.M.)
| | - Tanuwong Viarasilpa
- From the Department of Neurology, Henry Ford Hospital, Detroit, MI (S.A.M., T.V.).,Division of Critical Care, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand (T.V.)
| | - Angelina Marr
- Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland (A.H., A.M., S.R.)
| | - Sebastien Roux
- Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland (A.H., A.M., S.R.)
| | | |
Collapse
|
24
|
Donzelli GF, Nelson J, McCoy D, McCulloch CE, Hetts SW, Amans MR, Dowd CF, Halbach VV, Higashida RT, Lawton MT, Kim H, Cooke DL. The effect of preoperative embolization and flow dynamics on resection of brain arteriovenous malformations. J Neurosurg 2019; 132:1836-1844. [PMID: 31100732 DOI: 10.3171/2019.2.jns182743] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 09/26/2018] [Accepted: 02/25/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Preoperative embolization of brain arteriovenous malformations (AVMs) is performed to facilitate resection, although its impact on surgical performance has not been clearly defined. The authors tested for associations between embolization and surgical performance metrics. METHODS The authors analyzed AVM cases resected by one neurosurgeon from 2006 to 2017. They tested whether cases with and without embolization differed from one another with respect to patient and AVM characteristics using t-tests for continuous variables and Fisher's exact tests for categorical variables. They used simple and multivariable regression models to test whether surgical outcomes (blood loss, resection time, surgical clip usage, and modified Rankin Scale [mRS] score) were associated with embolization. Additional regression analyses integrated the peak arterial afferent contrast normalized for the size of the region of interest (Cmax/ROI) into models as an additional predictor. RESULTS The authors included 319 patients, of whom 151 (47%) had preoperative embolization. Embolized AVMs tended to be larger (38% with diameter > 3 cm vs 19%, p = 0.001), less likely to have hemorrhaged (48% vs 63%, p = 0.013), or be diffuse (19% vs 29%, p = 0.045). Embolized AVMs were more likely to have both superficial and deep venous drainage and less likely to have exclusively deep drainage (32% vs 17% and 12% vs 23%, respectively; p = 0.002). In multivariable analysis, embolization was not a significant predictor of blood loss or mRS score changes, but did predict longer operating times (+29 minutes, 95% CI 2-56 minutes; p = 0.034) and increased clip usage (OR 2.61, 95% CI 1.45-4.71; p = 0.001). Cmax/ROI was not a significant predictor, although cases with large Cmax/ROI tended to have longer procedure times (+25 minutes per doubling of Cmax/ROI, 95% CI 0-50 minutes; p = 0.051). CONCLUSIONS In this series, preoperative embolization was associated with longer median resection times and had no association with intraoperative blood loss or mRS score changes.
Collapse
Affiliation(s)
| | | | | | - Charles E McCulloch
- 4Biostatistics and Epidemiology, UCSF Medical Center, San Francisco, California; and
| | | | | | | | | | | | - Michael T Lawton
- 5Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | | |
Collapse
|
25
|
Higashida RT, Bruder N, Gupta R, Guzman R, Hmissi A, Marr A, Mayer SA, Roux S, Weidauer S, Aldrich EF. Reversal of Vasospasm with Clazosentan After Aneurysmal Subarachnoid Hemorrhage: A Pilot Study. World Neurosurg 2019; 128:e639-e648. [PMID: 31054336 DOI: 10.1016/j.wneu.2019.04.222] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 03/13/2019] [Revised: 04/24/2019] [Accepted: 04/25/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Clazosentan, an endothelin-1 receptor antagonist, has been shown to prevent the development of large vessel angiographic vasospasm after aneurysmal subarachnoid hemorrhage (aSAH). It has been hypothesized that clazosentan can also reverse established angiographic vasospasm. METHODS The REVERSE (resynchronization reverses remodeling in systolic left ventricular dysfunction) study was a prospective, multicenter, open-label, 2-stage pilot study of adult patients with aSAH who had received intravenous clazosentan (15 mg/hour) after developing moderate-to-severe angiographic vasospasm. The primary efficacy endpoint was the reversal of global cerebral vasospasm in large cerebral artery segments 3 hours after clazosentan initiation. The secondary endpoints included large artery vasospasm reversal at 24 hours and the maximum change in the angiographic cerebral circulation time. The change in vasospasm severity in the proximal and distal segments was investigated in an exploratory analysis. RESULTS The primary efficacy endpoint was met in 3 of 11 evaluable patients (27.3%; 95% confidence interval, 6.0-61.0). However, recruitment was stopped after stage 1 in accordance with the predefined interim analysis criteria. In the exploratory analysis, 50.0% and 77.8% of the patients showed a significant reversal of vasospasm or improvement to the admission state in ≥2 distal segments at 3 and 24 hours and 28.6% and 77.8% in ≥2 proximal segments, respectively. CONCLUSIONS Although the main analysis showed a reversal of large vessel vasospasm 3 hours after clazosentan initiation in a few patients, the exploratory analysis indicated a clear pharmacodynamic dilating effect on vasospastic cerebral vessels at 24 hours in most patients, in particular, in the distal arterial beds. This observation supported the inclusion of patients with established vasospasm in the ongoing REACT (prevention and treatment of vasospasm with clazosentan) trial.
Collapse
Affiliation(s)
- Randall T Higashida
- Department of Neuro Interventional Radiology, University of California, San Francisco, Medical Center, San Francisco, California, USA.
| | - Nicolas Bruder
- Department of Anesthesia and Critical Care, CHU Timone, Assistance Publique Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Rajiv Gupta
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital, Basel, Switzerland
| | - Abdel Hmissi
- Global Clinical Development, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Angelina Marr
- Global Clinical Development, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Stephan A Mayer
- Department of Neurology, Henry Ford Neuroscience Institute, Detroit, Michigan, USA
| | - Sébastien Roux
- Global Clinical Development, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Stefan Weidauer
- Department of Neurology, Sankt Katharinen Hospital, Frankfurt, Germany
| | - E François Aldrich
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| |
Collapse
|
26
|
Alexander MD, Halbach VV, Hallam DK, Cooke DL, Ghodke B, Dowd CF, Amans MR, Hetts SW, Higashida RT, Meyers PM. Relationship of clinical presentation and angiographic findings in patients with indirect cavernous carotid fistulae. J Neurointerv Surg 2019; 11:937-939. [DOI: 10.1136/neurintsurg-2018-014421] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/28/2019] [Accepted: 01/29/2019] [Indexed: 11/03/2022]
Abstract
IntroductionIndirect cavernous carotid fistulae (ICCFs) can present with insidious, non-specific symptoms and prove difficult to diagnose. This study evaluates associations among ICCF symptoms and angiographic findings.MethodsA retrospective analysis was performed of prospectively maintained records at four medical centers to identify patients with ICCFs evaluated with angiography. Patient demographics, symptoms, and angiographic findings were tabulated. Univariate and multivariate analyses were conducted to identify associations among these variables.ResultsRecords sufficient for review existed for 267 patients evaluated with angiography. Patients were most commonly women, in the sixth or seventh decade of life, and had symptoms for months before a definitive diagnosis. The most common symptoms included proptosis, diplopia, cranial nerve palsy, and chemosis. Cortical venous reflux was most common in patients with chemosis, orbital pain, or bruit. Intracranial hemorrhage was associated with cortical reflux and bilateral inferior petrosal sinus occlusion. Patients with loss of symptoms demonstrated higher rates of inferior petrosal sinus occlusion and a trend towards rupture.ConclusionA high index of suspicion is needed to promptly diagnose patients with ICCFs. High risk features are more common in the setting of chemosis, orbital pain, bruit, or spontaneous loss of symptoms. Patients with such symptoms warrant expedited angiographic evaluation.
Collapse
|
27
|
Alexander MD, Halbach VV, Hallam DK, Cooke DL, Ghodke BV, Dowd CF, Amans MR, Hetts SW, Higashida RT, Meyers PM. Long-Term Outcomes of Endovascular Treatment of Indirect Carotid Cavernous Fistulae: Superior Efficacy, Safety, and Durability of Transvenous Coiling Over Other Techniques. Neurosurgery 2018; 85:E94-E100. [DOI: 10.1093/neuros/nyy486] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 09/13/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Matthew D Alexander
- Departments of Radiology & Imaging Sciences and Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Van V Halbach
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Danial K Hallam
- Department of Radiology, University of Washington, Seattle, Washington
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | | | - Christopher F Dowd
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Matthew R Amans
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Randall T Higashida
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Philip M Meyers
- Departments of Radiology and Neurosurgery, Columbia University College of Physicians & Surgeons, New York, New York
| |
Collapse
|
28
|
Meyers PM, Higashida RT. Commentary on Optimal Treatment Strategy for Tandem Stroke. JACC Cardiovasc Interv 2018; 11:1300-1301. [PMID: 29976366 DOI: 10.1016/j.jcin.2018.05.024] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 05/15/2018] [Indexed: 10/28/2022]
|
29
|
Eskey CJ, Meyers PM, Nguyen TN, Ansari SA, Jayaraman M, McDougall CG, DeMarco JK, Gray WA, Hess DC, Higashida RT, Pandey DK, Peña C, Schumacher HC. Indications for the Performance of Intracranial Endovascular Neurointerventional Procedures: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e661-e689. [PMID: 29674324 DOI: 10.1161/cir.0000000000000567] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intracranial endovascular interventions provide effective and minimally invasive treatment of a broad spectrum of diseases. This area of expertise has continued to gain both wider application and greater depth as new and better techniques are developed and as landmark clinical studies are performed to guide their use. Some of the greatest advances since the last American Heart Association scientific statement on this topic have been made in the treatment of ischemic stroke from large intracranial vessel occlusion, with more effective devices and large randomized clinical trials showing striking therapeutic benefit. The treatment of cerebral aneurysms has also seen substantial evolution, increasing the number of aneurysms that can be treated successfully with minimally invasive therapy. Endovascular therapies for such other diseases as arteriovenous malformations, dural arteriovenous fistulas, idiopathic intracranial hypertension, venous thrombosis, and neoplasms continue to improve. The purpose of the present document is to review current information on the efficacy and safety of procedures used for intracranial endovascular interventional treatment of cerebrovascular diseases and to summarize key aspects of best practice.
Collapse
|
30
|
Cooke DL, Bauer D, Sun Z, Stillson C, Nelson J, Barry D, Hetts SW, Higashida RT, Dowd CF, Halbach VV, Su H, Saeed MM. Endovascular biopsy: Technical feasibility of novel endothelial cell harvesting devices assessed in a rabbit aneurysm model. Interv Neuroradiol 2018; 21:120-8. [PMID: 25934786 DOI: 10.15274/inr-2014-10103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The lack of safe and reliable methods to sample vascular tissue in situ limits discovery of the underlying genetic and pathophysiological mechanisms of many vascular disorders, including aneurysms. We investigated the feasibility and comparable efficacy of in vivo vascular endothelial cell sampling using a spectrum of endovascular devices. Using the rabbit elastase carotid aneurysm model we evaluated the performance of existing aneurysmal coils, intracranial stents, and stent-like devices to collect vascular endothelial cells. Additionally, we modified a subset of devices to assess the effects of alterations to coil pitch, coil wire contour, and stent surface finishing. Device performance was evaluated by (1) the number of viable endothelial cells harvested, (2) the degree of vascular wall damage analyzed using digital subtraction angiography and histopathological analysis, and (3) the ease of device navigability and retrieval. Isolated cells underwent immunohistochemical analysis to confirm cell type and viability. Coil and stent specifications, technique, and endothelial cell counts were tabulated and statistical analysis performed. Using conventional detachable-type and modified aneurysm coils 11 of 14 (78.6%) harvested endothelial cells with a mean of 7.93 (±8.33) cells/coil, while 15 of 15 (100%) conventional stents, stent-like devices and modified stents harvested endothelial cells with a mean of 831.33 (±887.73) cells/device. Coil stiffness was significantly associated with endothelial cell count in univariate analysis (p = 0.044). For stents and stent-like devices univariate analysis demonstrated stent-to-aorta diameter ratios (p = 0.001), stent length (p = 0.049), and the use of a pulling retrieval technique (p = 0.019) significantly predictive of endothelial cell counts, though a multivariate model using these variables demonstrated only the stent-to-aorta diameter ratio (p = 0.029) predictive of endothelial cell counts. Modified devices did not significantly impact harvesting. The efficacy and safety of existing aneurysm coils, intracranial stents and stent-like devices in collecting viable endothelial cells was confirmed. The technique is reproducible and the quantity and quality of collected endothelial cells is adequate for targeted genetic analysis.
Collapse
Affiliation(s)
- Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Diana Bauer
- Laboratory Animal Resource Center, University of California, San Francisco, CA, USA
| | - Zhengda Sun
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Carol Stillson
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Jeffrey Nelson
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | | | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Randall T Higashida
- Department of Radiology, Neurology, and Neurological Surgery, University of California, San Francisco, CA, USA
| | - Christopher F Dowd
- Department of Radiology, Neurology, and Neurological Surgery, University of California, San Francisco, CA, USA
| | - Van V Halbach
- Department of Radiology, Neurology, and Neurological Surgery, University of California, San Francisco, CA, USA
| | - Hua Su
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, CA, USA
| | - Maythem M Saeed
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| |
Collapse
|
31
|
Ammanuel S, Alexander MD, Damato B, Cooke DL, Halbach VV, Amans MR, Dowd CF, Higashida RT, Hetts SW. Improved procedural safety following protocol changes for selective ophthalmic arterial infusion of chemotherapy for treatment of ocular retinoblastoma. Interv Neuroradiol 2018; 24:345-350. [PMID: 29436917 DOI: 10.1177/1591019918755088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 11/16/2022] Open
Abstract
Purpose The aim was to evaluate the impact of protocol changes in selective ophthalmic arterial infusion (SOAI) for treatment of retinoblastoma (Rb). Methods A retrospective review was completed of 35 patients with Rb who were treated with SOAI between March 2010 and January 2017. Treatment details were tabulated for each SOAI session. SOAI protocol was changed in June 2015, and differences before and after this change were evaluated using two-tail chi-square tests and independent sample t-tests to note any differences in technical complications, need for enucleation, and other outcome variables Results 125 SOAI sessions occurred. No technical complications occurred during the study. Two complications (1.6%) occurred in the postoperative setting. Both complications occurred prior to the change in protocol. Comparing the complication rates between the two protocols showed no significant difference (2.2% versus 0.0%; p = 0.505); 29 of 43 (67.4%) eyes had their vision preserved overall. Conclusions SOAI is an effective treatment for Rb. The refined protocol described herein was associated with fewer complications.
Collapse
Affiliation(s)
- Simon Ammanuel
- 1 Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Matthew D Alexander
- 2 Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Bertil Damato
- 3 Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - Daniel L Cooke
- 1 Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Van V Halbach
- 1 Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Matthew R Amans
- 1 Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Christopher F Dowd
- 1 Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Randall T Higashida
- 1 Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Steven W Hetts
- 1 Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
32
|
Kondapavulur S, Cooke DL, Kao A, Amans MR, Alexander M, Darflinger R, Dowd CF, Higashida RT, Damato B, Halbach VV, Matthay KK, Hetts SW. Estimation of intra-arterial chemotherapy distribution to the retina in pediatric retinoblastoma patients using quantitative digital subtraction angiography. Interv Neuroradiol 2018; 24:214-219. [PMID: 29343147 DOI: 10.1177/1591019917749825] [Citation(s) in RCA: 6] [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: 11/16/2022] Open
Abstract
Background and purpose The purpose of this article is to estimate the distribution of superselective intra-arterial chemotherapy (IAC) delivery to ocular target tissue using quantitative digital subtraction angiography (qDSA). Materials and methods From March 2010 to January 2016, 50 ophthalmic artery contrast DSAs obtained immediately prior to IAC infusions in 22 patients were analyzed. This study was conducted under a retrospective review IRB (no. 10-01862). Parametric color-coded DSAs (iFlow, Siemens Medical) were post-processed (MATLAB, The Mathworks Inc.) using two methods: two box regions of interest (pre-retina and globe) and four custom regions of interest (ROIs-ophthalmic artery, choroid, supraclinoid internal carotid artery (ICA), cavernous ICA). Mean interobserver reliability of custom ROI selection is presented as a 95% confidence interval of interclass correlation, and fractional chemotherapy delivery to selected ROIs as means ± standard deviation in this study. Results The estimated fraction of chemotherapy delivered to the globe with the first method was 79.5%. Percentage regional delivery using the second method was as follows: ophthalmic artery, 85.8%; choroid, 60.5%; supraclinoid ICA, 14.2%. The cavernous ICA ROI (encompassing distal catheter and potential reflux) gave a signal equivalent to 9.3% of total delivery. Conclusion Parametric color-coded qDSA can estimate the fraction of IAC delivered to the retina and other orbital structures in ocular retinoblastoma patients. This information can inform delivery location and dosing strategies on a patient-specific basis.
Collapse
Affiliation(s)
- Sravani Kondapavulur
- 1 Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Daniel L Cooke
- 1 Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Andrew Kao
- 2 Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA
| | - Matthew R Amans
- 1 Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Matthew Alexander
- 1 Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Robert Darflinger
- 1 Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Christopher F Dowd
- 1 Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Randall T Higashida
- 1 Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Bertil Damato
- 2 Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA
| | - Van V Halbach
- 1 Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Katherine K Matthay
- 3 Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Steven W Hetts
- 1 Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| |
Collapse
|
33
|
Alexander MD, Rebhun JM, Hetts SW, Amans MR, Settecase F, Darflinger RJ, Dowd CF, Halbach VV, Higashida RT, Cooke DL. Technical factors affecting outcomes following endovascular treatment of posterior circulation atherosclerotic lesions. Surg Neurol Int 2017; 8:284. [PMID: 29279801 PMCID: PMC5705933 DOI: 10.4103/sni.sni_255_17] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 09/22/2017] [Indexed: 11/04/2022] Open
Abstract
Background Atherosclerotic disease of the vertebrobasilar system causes significant morbidity and mortality. All lesions require aggressive medical management, but the role of endovascular interventions remains unsettled. This study examines such endovascular interventions for vertebrobasilar atherosclerosis. Methods Retrospective review was performed of prospectively maintained procedure logs at three hospitals with comprehensive neurointerventional services. Patients with angiographically-proven stenosis undergoing elective stent placement were selected for analysis of demographic factors, lesion characteristics, and treatment details. Multivariate analysis was performed to evaluate for associations with ischemic stroke, death, and functional status as measured by modified Rankin scale at multiple intervals. Results One hundred and twenty-three lesions were treated in 110 patients. A total of 43 (58.1%) lesions caused stroke, while 66 (89.2%) caused transient ischemic attacks (TIAs). Forty lesions (32.5%) were at the vertebral origin; 97 (60.2%) were intracranial. A total of 112 (91.1%) were treated successfully. 4 (3.3%) of 10 (8.1%) procedural complications were symptomatic. Intracranial lesions were associated with death at 1 and 2 years (OR 24.91, P < 0.001) and mRS >2 at last contact (OR 12.83, P < 0.001). Stenting treatment with conjunctive angioplasty had lower rates of death (OR 0.303, P = 0.046) and mRS >2 at last contact (OR 0.234, P = 0.018) when angioplasty was performed with a device other than that packaged with the stent. Conclusion Endovascular treatment of vertebrobasilar atherosclerosis can be performed safely, particularly for vertebral origin lesions. Higher rates of technical failure and complication may be acceptable for certain intracranial lesions due to their refractory nature and the morbidity caused by such lesions. Treatment should be tailored to features of each individual lesion.
Collapse
Affiliation(s)
- Matthew D Alexander
- Department of Radiology and Imaging Sciences, Division of Neurointerventional Radiology, Salt Lake City, Utah, USA
| | - Jeffrey M Rebhun
- Ochsner Clinical School, University of Queensland, Brisbane, Australia
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Matthew R Amans
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Fabio Settecase
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Robert J Darflinger
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Christopher F Dowd
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Van V Halbach
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Randall T Higashida
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
34
|
Settecase F, McCoy DB, Darflinger R, Alexander MD, Cooke DL, Dowd CF, Hetts SW, Higashida RT, Halbach VV, Amans MR. Improving mechanical thrombectomy time metrics in the angiography suite: Stroke cart, parallel workflows, and conscious sedation. Interv Neuroradiol 2017; 24:168-177. [PMID: 29145742 DOI: 10.1177/1591019917742326] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Purpose Earlier reperfusion of large-vessel occlusion (LVO) stroke improves functional outcomes. We hypothesize that use of a stroke cart in the angiography suite, containing all commonly used procedural equipment in a mechanical thrombectomy, combined with parallel staff workflows, and use of conscious sedation when possible, improve mechanical thrombectomy time metrics. Methods We identified 47 consecutive LVO patients who underwent mechanical thrombectomy at our center, retrospectively and prospectively from implementation of these three workflow changes (19 pre- and 28 post-). For each patient, last known normal, NIHSS, angiography suite in-room time, type of anesthesia, groin puncture time, on-clot time, recanalization time, LVO location, number of passes, device(s) used, mTICI score, and outcome (mRS) were recorded. Between-group comparisons of time metrics and multivariate regression were performed. Results Stroke cart, parallel workflows, and primary use of conscious sedation decreased in-room time to groin puncture (-21.3 min, p < 0.0001), in-room to on-clot time (-24.1 min, p = 0.001), and in-room to reperfusion time (-29.5 min, p = 0.01). In a multivariate analysis, endotracheal intubation and general anesthesia were found to significantly increase in-room to on-clot time ( p = 0.01), in-room to reperfusion time ( p = 0.01), and groin puncture to on-clot time ( p = 0.05). The number of patients achieving a good outcome (mRS 0-2), however, did not significantly differ between the two groups (9/18 (47%) vs 14/28 (50%), p = 0.60). Conclusions Use of a stroke cart, parallel workflows by neurointerventionalists, technologists, and nursing staff, and use of conscious sedation may be useful to other institutions in efforts to improve procedural times.
Collapse
Affiliation(s)
- Fabio Settecase
- 1 Newport Harbor Radiology Associates Medical Group Inc, Newport Beach, USA.,2 Interventional Neuroradiology, Hoag Neurosciences Institute, Hoag Memorial Hospital Presbyterian, Newport Beach, USA.,3 Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, USA
| | - David B McCoy
- 4 Zuckerberg San Francisco General Hospital and Trauma Center, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, USA
| | - Robert Darflinger
- 3 Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, USA
| | - Matthew D Alexander
- 3 Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, USA
| | - Daniel L Cooke
- 3 Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, USA
| | - Christopher F Dowd
- 3 Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, USA
| | - Steven W Hetts
- 3 Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, USA
| | - Randall T Higashida
- 3 Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, USA
| | - Van V Halbach
- 3 Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, USA
| | - Matthew R Amans
- 3 Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, USA
| |
Collapse
|
35
|
Hetts SW, Yen A, Cooke DL, Nelson J, Jolivalt P, Banaga J, Amans MR, Dowd CF, Higashida RT, Lawton MT, Kim H, Halbach VV. Pial Artery Supply as an Anatomic Risk Factor for Ischemic Stroke in the Treatment of Intracranial Dural Arteriovenous Fistulas. AJNR Am J Neuroradiol 2017; 38:2315-2320. [PMID: 28970244 DOI: 10.3174/ajnr.a5396] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 08/03/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Although intracranial dural arteriovenous fistulas are principally supplied by dural branches of the external carotid, internal carotid, and vertebral arteries, they can also be fed by pial arteries that supply the brain. We sought to determine the frequency of neurologic deficits following treatment of intracranial dural arteriovenous fistulas with and without pial artery supply. MATERIALS AND METHODS One hundred twenty-two consecutive patients who underwent treatment for intracranial dural arteriovenous fistulas at our hospital from 2008 to 2015 were retrospectively reviewed. Patient data were examined for posttreatment neurologic deficits; patients with such deficits were evaluated for imaging evidence of cerebral infarction. Data were analyzed with multivariable logistic regression. RESULTS Of 122 treated patients, 29 (23.8%) had dural arteriovenous fistulas with pial artery supply and 93 (76.2%) had dural arteriovenous fistulas without pial arterial supply. Of patients with pial artery supply, 4 (13.8%) had posttreatment neurologic deficits, compared with 2 patients (2.2%) without pial artery supply (P = .04). Imaging confirmed that 3 patients with pial artery supply (10.3%) had cerebral infarcts, compared with only 1 patient without pial artery supply (1.1%, P = .03). Increasing patient age was also positively associated with pial supply and treatment-related complications. CONCLUSIONS Patients with dural arteriovenous fistulas supplied by the pial arteries were more likely to experience posttreatment complications, including ischemic strokes, than patients with no pial artery supply. The approach to dural arteriovenous fistula treatment should be made on a case-by-case basis so that the risk of complications can be minimized.
Collapse
Affiliation(s)
- S W Hetts
- From the Department of Radiology and Biomedical Imaging (S.W.H., D.L.C., P.J., M.R.A., C.F.D., R.T.H., V.V.H.)
| | - A Yen
- School of Medicine (A.Y., J.B.)
| | - D L Cooke
- From the Department of Radiology and Biomedical Imaging (S.W.H., D.L.C., P.J., M.R.A., C.F.D., R.T.H., V.V.H.)
| | - J Nelson
- Departments of Anesthesia and Perioperative Care (J.N., P.J., C.F.D., R.T.H., H.K., V.V.H.)
| | - P Jolivalt
- From the Department of Radiology and Biomedical Imaging (S.W.H., D.L.C., P.J., M.R.A., C.F.D., R.T.H., V.V.H.).,Departments of Anesthesia and Perioperative Care (J.N., P.J., C.F.D., R.T.H., H.K., V.V.H.)
| | | | - M R Amans
- From the Department of Radiology and Biomedical Imaging (S.W.H., D.L.C., P.J., M.R.A., C.F.D., R.T.H., V.V.H.)
| | - C F Dowd
- From the Department of Radiology and Biomedical Imaging (S.W.H., D.L.C., P.J., M.R.A., C.F.D., R.T.H., V.V.H.).,Departments of Anesthesia and Perioperative Care (J.N., P.J., C.F.D., R.T.H., H.K., V.V.H.).,Neurological Surgery (C.F.D., R.T.H., M.T.L., V.V.H.).,Neurology (C.F.D., R.T.H., V.V.H.), University of California, San Francisco, San Francisco, California
| | - R T Higashida
- From the Department of Radiology and Biomedical Imaging (S.W.H., D.L.C., P.J., M.R.A., C.F.D., R.T.H., V.V.H.).,Departments of Anesthesia and Perioperative Care (J.N., P.J., C.F.D., R.T.H., H.K., V.V.H.).,Neurological Surgery (C.F.D., R.T.H., M.T.L., V.V.H.).,Neurology (C.F.D., R.T.H., V.V.H.), University of California, San Francisco, San Francisco, California
| | - M T Lawton
- Neurological Surgery (C.F.D., R.T.H., M.T.L., V.V.H.)
| | - H Kim
- Departments of Anesthesia and Perioperative Care (J.N., P.J., C.F.D., R.T.H., H.K., V.V.H.)
| | - V V Halbach
- From the Department of Radiology and Biomedical Imaging (S.W.H., D.L.C., P.J., M.R.A., C.F.D., R.T.H., V.V.H.).,Departments of Anesthesia and Perioperative Care (J.N., P.J., C.F.D., R.T.H., H.K., V.V.H.).,Neurological Surgery (C.F.D., R.T.H., M.T.L., V.V.H.).,Neurology (C.F.D., R.T.H., V.V.H.), University of California, San Francisco, San Francisco, California
| |
Collapse
|
36
|
Alexander MD, Nicholson AD, Darflinger RJ, Settecase F, Cooke DL, Dowd CF, Amans MR, Higashida RT, Hetts SW, Halbach VV. Effects on vessel measurement accuracy and subsequent occlusion after calcium channel blocker infusion during treatment of cerebral aneurysms with the Pipeline embolization device. Interv Neuroradiol 2017; 23:47-51. [DOI: 10.1177/1591019916674916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction/Purpose To achieve aneurysm occlusion, flow diverters (FDs) must be accurately sized to maximize coverage over the neck and induce thrombosis. Catheterization for diagnostic angiography can cause vasospasm that may affect vessel measurements. This study evaluates impacts of intra-arterial infusion of a calcium channel blocker (CCB) on angiographic measurements in patients treated with FDs to determine effects on final diameter of the FD and subsequent occlusion. Materials and methods Pre-treatment measurements were recorded for diameter of the distal and proximal landing zones and maximum and minimum diameters between these segments. Post-treatment measurements of the stent following deployment were recorded at these locations. When CCB was infused, post-infusion pre-treatment measurements were recorded. Rates of occlusion were noted for all patients. T-tests were performed to assess for differences in pre- and post-treatment measurements and rates of occlusion between groups with and without CCB infusion. Results Twenty-eight FDs were deployed to treat 25 aneurysms in 24 patients. CCB infusion was performed prior to deployment of 12 (42.9%) devices. No significant difference was noted between groups for pre- and post-treatment measurement changes. Confirmed aneurysm occlusion was more likely to occur in the CCB infusion group (88.9% vs. 36.4%, p = 0.009). Conclusion Optimization of device sizing is important to increase FD density over the aneurysm neck and promote thrombosis. To improve measurement accuracy, CCB infusion can reduce effects of mild vasospasm. Subsequent aneurysm occlusion was more likely to occur following FD treatment when device size selection was based on measurements performed following CCB infusion.
Collapse
Affiliation(s)
- MD Alexander
- University of California San Francisco, Department of Radiology and Biomedical Imaging, USA
| | - AD Nicholson
- University of California San Francisco, Department of Radiology and Biomedical Imaging, USA
| | - RJ Darflinger
- University of California San Francisco, Department of Radiology and Biomedical Imaging, USA
| | - F Settecase
- University of California San Francisco, Department of Radiology and Biomedical Imaging, USA
| | - DL Cooke
- University of California San Francisco, Department of Radiology and Biomedical Imaging, USA
| | - CF Dowd
- University of California San Francisco, Department of Radiology and Biomedical Imaging, USA
| | - MR Amans
- University of California San Francisco, Department of Radiology and Biomedical Imaging, USA
| | - RT Higashida
- University of California San Francisco, Department of Radiology and Biomedical Imaging, USA
| | - SW Hetts
- University of California San Francisco, Department of Radiology and Biomedical Imaging, USA
| | - VV Halbach
- University of California San Francisco, Department of Radiology and Biomedical Imaging, USA
| |
Collapse
|
37
|
Smith EE, Saposnik G, Biessels GJ, Doubal FN, Fornage M, Gorelick PB, Greenberg SM, Higashida RT, Kasner SE, Seshadri S. Prevention of Stroke in Patients With Silent Cerebrovascular Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2016; 48:e44-e71. [PMID: 27980126 DOI: 10.1161/str.0000000000000116] [Citation(s) in RCA: 223] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Two decades of epidemiological research shows that silent cerebrovascular disease is common and is associated with future risk for stroke and dementia. It is the most common incidental finding on brain scans. To summarize evidence on the diagnosis and management of silent cerebrovascular disease to prevent stroke, the Stroke Council of the American Heart Association convened a writing committee to evaluate existing evidence, to discuss clinical considerations, and to offer suggestions for future research on stroke prevention in patients with 3 cardinal manifestations of silent cerebrovascular disease: silent brain infarcts, magnetic resonance imaging white matter hyperintensities of presumed vascular origin, and cerebral microbleeds. The writing committee found strong evidence that silent cerebrovascular disease is a common problem of aging and that silent brain infarcts and white matter hyperintensities are associated with future symptomatic stroke risk independently of other vascular risk factors. In patients with cerebral microbleeds, there was evidence of a modestly increased risk of symptomatic intracranial hemorrhage in patients treated with thrombolysis for acute ischemic stroke but little prospective evidence on the risk of symptomatic hemorrhage in patients on anticoagulation. There were no randomized controlled trials targeted specifically to participants with silent cerebrovascular disease to prevent stroke. Primary stroke prevention is indicated in patients with silent brain infarcts, white matter hyperintensities, or microbleeds. Adoption of standard terms and definitions for silent cerebrovascular disease, as provided by prior American Heart Association/American Stroke Association statements and by a consensus group, may facilitate diagnosis and communication of findings from radiologists to clinicians.
Collapse
|
38
|
Lum MA, Martin AJ, Alexander MD, McCoy DB, Cooke DL, Lillaney P, Moftakhar P, Amans MR, Settecase F, Nicholson A, Dowd CF, Halbach VV, Higashida RT, McDermott MW, Saloner D, Hetts SW. Intra-Arterial MR Perfusion Imaging of Meningiomas: Comparison to Digital Subtraction Angiography and Intravenous MR Perfusion Imaging. PLoS One 2016; 11:e0163554. [PMID: 27802268 PMCID: PMC5089755 DOI: 10.1371/journal.pone.0163554] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 09/11/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND PURPOSE To evaluate the ability of IA MR perfusion to characterize meningioma blood supply. METHODS Studies were performed in a suite comprised of an x-ray angiography unit and 1.5T MR scanner that permitted intraprocedural patient movement between the imaging modalities. Patients underwent intra-arterial (IA) and intravenous (IV) T2* dynamic susceptibility MR perfusion immediately prior to meningioma embolization. Regional tumor arterial supply was characterized by digital subtraction angiography and classified as external carotid artery (ECA) dural, internal carotid artery (ICA) dural, or pial. MR perfusion data regions of interest (ROIs) were analyzed in regions with different vascular supply to extract peak height, full-width at half-maximum (FWHM), relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), and mean transit time (MTT). Linear mixed modeling was used to identify perfusion curve parameter differences for each ROI for IA and IV MR imaging techniques. IA vs. IV perfusion parameters were also directly compared for each ROI using linear mixed modeling. RESULTS 18 ROIs were analyzed in 12 patients. Arterial supply was identified as ECA dural (n = 11), ICA dural (n = 4), or pial (n = 3). FWHM, rCBV, and rCBF showed statistically significant differences between ROIs for IA MR perfusion. Peak Height and FWHM showed statistically significant differences between ROIs for IV MR perfusion. RCBV and MTT were significantly lower for IA perfusion in the Dural ECA compared to IV perfusion. Relative CBF in IA MR was found to be significantly higher in the Dural ICA region and MTT significantly lower compared to IV perfusion.
Collapse
Affiliation(s)
- Mark A. Lum
- School of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Alastair J. Martin
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, United States of America
| | - Matthew D. Alexander
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, United States of America
| | - David B. McCoy
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, United States of America
| | - Daniel L. Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, United States of America
| | - Prasheel Lillaney
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, United States of America
| | - Parham Moftakhar
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, United States of America
| | - Matthew R. Amans
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, United States of America
| | - Fabio Settecase
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, United States of America
| | - Andrew Nicholson
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, United States of America
| | - Christopher F. Dowd
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, United States of America
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America
- Department of Neurology, University of California San Francisco, San Francisco, California, United States of America
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
| | - Van V. Halbach
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, United States of America
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America
- Department of Neurology, University of California San Francisco, San Francisco, California, United States of America
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
| | - Randall T. Higashida
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, United States of America
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America
- Department of Neurology, University of California San Francisco, San Francisco, California, United States of America
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, United States of America
| | - Michael W. McDermott
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, United States of America
| | - David Saloner
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, United States of America
| | - Steven W. Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| |
Collapse
|
39
|
Hetts SW, Moftakhar P, Maluste N, Fullerton HJ, Cooke DL, Amans MR, Dowd CF, Higashida RT, Halbach VV. Pediatric intracranial dural arteriovenous fistulas: age-related differences in clinical features, angioarchitecture, and treatment outcomes. J Neurosurg Pediatr 2016; 18:602-610. [PMID: 27540826 DOI: 10.3171/2016.5.peds15740] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intracranial dural arteriovenous fistulas (DAVFs) are rare in children. This study sought to better characterize DAVF presentation, angioarchitecture, and treatment outcomes. METHODS Children with intracranial DAVFs between 1986 and 2013 were retrospectively identified from the neurointerventional database at the authors' institution. Demographics, clinical presentation, lesion angioarchitecture, treatment approaches, angiographic outcomes, and clinical outcomes were assessed. RESULTS DAVFs constituted 5.7% (22/423) of pediatric intracranial arteriovenous shunting lesions. Twelve boys and 10 girls presented between 1 day and 18 years of age; boys presented at a median of 1.3 years and girls presented at a median of 4.9 years. Four of 8 patients ≤ 1 year of age presented with congestive heart failure compared with 0/14 patients > 1 year of age (p = 0.01). Five of 8 patients ≤ 1 year old presented with respiratory distress compared with 0/14 patients > 1 year old (p = 0.0021). Ten of 14 patients > 1 year old presented with focal neurological deficits compared with 0/8 patients ≤ 1 year old (p = 0.0017). At initial angiography, 16 patients harbored a single intracranial DAVF and 6 patients had 2-6 DAVFs. Eight patients (38%) experienced DAVF obliteration by the end of treatment. Good clinical outcome (modified Rankin Scale score 0-2) was documented in 77% of patients > 1 year old at presentation compared with 57% of patients ≤ 1 year old at presentation. Six patients (27%) died. CONCLUSIONS Young children with DAVFs presented predominantly with cardiopulmonary symptoms, while older children presented with focal neurological deficits. Compared with other pediatric vascular shunts, DAVFs had lower rates of angiographic obliteration and poorer clinical outcomes.
Collapse
Affiliation(s)
| | | | - Neil Maluste
- Department of Neurology, University of California, Los Angeles, California
| | | | | | | | - Christopher F Dowd
- Departments of 1 Radiology and Biomedical Imaging.,Neurology.,Neurological Surgery, and.,Anesthesia and Perioperative Care, University of California, San Francisco; and
| | - Randall T Higashida
- Departments of 1 Radiology and Biomedical Imaging.,Neurology.,Neurological Surgery, and.,Anesthesia and Perioperative Care, University of California, San Francisco; and
| | - Van V Halbach
- Departments of 1 Radiology and Biomedical Imaging.,Neurology.,Neurological Surgery, and.,Anesthesia and Perioperative Care, University of California, San Francisco; and
| |
Collapse
|
40
|
Abstract
Purpose: To report the safety and efficacy of local, direct, intra-arterial and intravenous fibrinolysis treatment in selected cases of clinically symptomatic patients with acute occlusion of the intracranial cerebral arteries and dural sinuses. Methods: Patients with acute progressive neurological deterioration, in spite of systemic anticoagulation and/or antiplatelet medications, presenting with occlusion of a major intracranial cerebral artery or dural sinus were treated. From a transfemoral approach through a guiding catheter, a 2.5F microcatheter was guided directly into the intracranial cerebral circulation and embedded within the clot. Infusion of urokinase was then performed directly into the thrombus until lysis was attained. Results: In 36 total patients, 27 cases were treated for an acute arterial occlusion in 45 vascular territories. Clinically, there was neurological improvement in 18 (66.7%) cases. Complications directly related to therapy included symptomatic intracranial hemorrhage in three cases (11.1%), which included 1 case (3.7%) of vessel perforation. In 8 (29.6%) patients, there was no evidence of clinical improvement, and in long-term follow-up there were 9 (33.3%) patient deaths. Nine patients were treated for an intracerebral dural sinus thrombosis in ten vascular territories by local urokinase infusion. In 7 (77.8%) cases, there was angiographic evidence of clot lysis and clinical improvement of the patient's neurological condition. Minor complications including infection and noncerebral sites of bleeding occurred in 3 (33.3%) patients, requiring adjustment in urokinase infusion therapy. Conclusions: Local, direct intra-arterial or intravenous infusion of thrombolytic drugs for treatment of stroke patients may improve overall patient morbidity and mortality related to acute thromboembolic disease in the central nervous system. Further clinical studies are warranted to evaluate this form of therapy.
Collapse
Affiliation(s)
| | | | - Stanley L. Barnwell
- Department of Neurological Surgery and Neuroradiology, University of Oregon Health Sciences Center, Portland, Oregon
| | | | | |
Collapse
|
41
|
Abstract
Purpose: The endovascular surgical approach to complex disorders of the central nervous system has made rapid and significant advancements over the past decade. Patients with intracranial arterial aneurysms, traumatic carotid and vertebral artery lesions, including fistulas and pseudoaneurysms, hemodynamically significant atherosclerotic lesions, vasospasm, and acute stroke are now being approached and treated by newer and less invasive techniques, including cerebral angioplasty and thrombolytic therapy. Methods: All procedures are usually performed from a transfemoral approach utilizing a variety of occlusion devices, including detachable silicone balloons, microcoils, electrolytic detachable coils, liquid tissue adhesives, and particulate emboli for vessel occlusion. For dilatation and reperfusion of vessels, balloon angioplasty catheters, stents, and thrombolytic drugs are being used. Results: For the treatment of traumatic vascular injuries, such as carotid cavernous sinus fistulas and vertebral arteriovenous fistulas and pseudoaneurysms, endovascular therapy has become the treatment of choice. The endovascular approach for intracranial aneurysms is emerging as a therapeutic option in selected cases. For occlusive disorders in patients presenting with acute cerebral ischemia, extracranial angioplasty and cerebral thrombolysis techniques are currently under investigation. Conclusions: As these techniques continue to evolve, the field of interventional neuroradiology will expand the therapeutic options for managing complex cerebrovascular disorders and improve patient outcome in acute stroke therapy.
Collapse
Affiliation(s)
- Randall T. Higashida
- Department of Radiology and Neurological Surgery, Division of Interventional Neurovascular Radiology, University of California-San Francisco Medical Center, San Francisco, California, USA
| | - Van V. Halbach
- Department of Radiology and Neurological Surgery, Division of Interventional Neurovascular Radiology, University of California-San Francisco Medical Center, San Francisco, California, USA
| | - Christopher F. Dowd
- Department of Radiology and Neurological Surgery, Division of Interventional Neurovascular Radiology, University of California-San Francisco Medical Center, San Francisco, California, USA
| | - Grant B. Hieshima
- Department of Radiology and Neurological Surgery, Division of Interventional Neurovascular Radiology, University of California-San Francisco Medical Center, San Francisco, California, USA
| |
Collapse
|
42
|
Settecase F, Hetts SW, Nicholson AD, Amans MR, Cooke DL, Dowd CF, Higashida RT, Halbach VV. Superselective Intra-Arterial Ethanol Sclerotherapy of Feeding Artery and Nidal Aneurysms in Ruptured Cerebral Arteriovenous Malformations. AJNR Am J Neuroradiol 2016; 37:692-7. [PMID: 26564434 DOI: 10.3174/ajnr.a4584] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 08/10/2015] [Indexed: 01/19/2023]
Abstract
In the endovascular treatment of cerebral arteriovenous malformations, ethanol sclerotherapy is seldom used due to safety concerns. However, when limited reflux of an embolic agent is permissible or when there is a long distance to the target, ethanol may be preferable. We reviewed 10 patients with 14 cerebral AVM feeding artery aneurysms or intranidal aneurysms treated with intra-arterial ethanol sclerotherapy at our institution between 2005 and 2014. All patients presented with acute intracranial hemorrhage. Thirteen of 14 aneurysms were treated primarily with 60%-80% ethanol into the feeding artery. Complete target feeding artery and aneurysm occlusion was seen in all cases; 8/13 (62%) were occluded by using ethanol alone. No retreatments or recurrences were seen. One permanent neurologic deficit (1/13, 7.7%) and no deaths occurred. In a subset of ruptured cerebral AVMs, ethanol sclerotherapy of feeding artery aneurysms and intranidal aneurysms can be performed with a high degree of technical success and a low rate of complication.
Collapse
Affiliation(s)
- F Settecase
- From the Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California.
| | - S W Hetts
- From the Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - A D Nicholson
- From the Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - M R Amans
- From the Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - D L Cooke
- From the Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - C F Dowd
- From the Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - R T Higashida
- From the Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - V V Halbach
- From the Division of Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| |
Collapse
|
43
|
Abstract
OBJECT
Retroclival hematomas are rare, appearing mostly as posttraumatic phenomena in children. Spontaneous retroclival hematoma (SRH) in the absence of trauma also has few descriptions in the literature. None of the reported clinical cases features the combination of an SRH and intraventricular hemorrhage (IVH). Nevertheless, despite extensive cases of idiopathic or angiographically negative subarachnoid hemorrhage (SAH) of the posterior fossa, only a single case report of a patient with a unique spontaneous retroclival hematoma has been identified. In this study, the authors reviewed the presentation, management, and clinical outcome of this rare entity.
METHODS
The authors performed a retrospective analysis of all patients with diagnosed SRH at their institution over a 3-year period. Collected data included clinical history, laboratory results, treatment, and review of all imaging studies performed.
RESULTS
Four patients had SRH. All were appropriately evaluated for coagulopathic and/or traumatic etiologies of hemorrhage, though no etiology could be found. Moreover, all of the patients demonstrated SRH that both clearly crossed the basioccipital synchondrosis and was contained within a nondependent configuration along the retroclival dura mater.
CONCLUSIONS
Spontaneous retroclival hematoma, often associated with IVH, is a rare subtype of intracranial hemorrhage frequently recognized only when MRI demonstrates compartmentalization of the posterior fossa hemorrhage. When angiography fails to reveal an underlying lesion, SRH patients, like patients with traditional angiographically negative SAH, enjoy a remarkably good prognosis.
Collapse
Affiliation(s)
| | - Matthew R. Amans
- 2Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Daniel L. Cooke
- 2Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Steven W. Hetts
- 2Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | | | - Randall T. Higashida
- 2Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Christopher F. Dowd
- 2Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Van V. Halbach
- 2Interventional Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| |
Collapse
|
44
|
Settecase F, Nicholson AD, Amans MR, Higashida RT, Halbach VV, Cooke DL, Dowd CF, Hetts SW. Onyx embolization of an intraosseous pseudoaneurysm of the middle meningeal artery in a patient with meningiomatosis, McCune-Albright syndrome, and gray platelet syndrome. J Neurosurg Pediatr 2016; 17:324-9. [PMID: 26588455 DOI: 10.3171/2015.9.peds15267] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A 13-year-old boy with meningiomatosis, McCune-Albright syndrome, and gray platelet syndrome presented with an enlarging "lump" on his right forehead. A head CT scan revealed a polyostotic fibrous dysplasia involving the entire skull. A 3.4-cm right frontal osseous cavity and an overlying right forehead subcutaneous soft-tissue mass were seen, measuring 5.2 cm in diameter and 1.6 cm thick. Ultrasound of the cavity and overlying mass showed swirling of blood and an arterialized waveform. MRI revealed an en plaque meningioma underlying the cavity. An intraosseous pseudoaneurysm fed by 3 distal anterior division branches of the right middle meningeal artery (MMA) with contrast extravasation was found on angiography. Two MMA feeders were embolized with Onyx, with anterograde filling of the intraosseous cavity with Onyx. A small pocket of residual intracavity contrast filling postembolization from a smaller third MMA feeder eventually thrombosed and the forehead lump regressed.
Collapse
Affiliation(s)
- Fabio Settecase
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Andrew D Nicholson
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Matthew R Amans
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Randall T Higashida
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Van V Halbach
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Christopher F Dowd
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| |
Collapse
|
45
|
Causey MW, Amans MR, Han S, Higashida RT, Conte M. Reversible cerebral vasoconstriction syndrome is a rare cause of stroke after carotid endarterectomy. J Vasc Surg 2016; 64:1847-1850. [PMID: 26924717 DOI: 10.1016/j.jvs.2016.01.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 01/10/2016] [Indexed: 11/19/2022]
Abstract
Neurologic events after carotid endarterectomy (CEA) require prompt diagnosis and management to avoid potentially catastrophic sequelae. This report describes a 69-year-old gentleman who underwent a left CEA for a high-grade asymptomatic carotid stenosis with concomitant contralateral carotid occlusion. He had transient and crescendo neurologic events in the first 3 postoperative weeks that culminated in right hand weakness and paresthesia, despite dual antiplatelet therapy, maximal anticoagulation, and undergoing stenting of the endarterectomy site. Neurologic events recurred despite these measures and subsequent angiography showed reversible cerebral vasoconstriction syndrome that was successfully managed without further events. Reversible cerebral vasoconstriction syndrome is an unusual but important cause of neurologic events after CEA that requires aggressive and directed medical therapy.
Collapse
Affiliation(s)
- Marlin Wayne Causey
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, Calif.
| | - Matthew R Amans
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, Calif
| | - Sukgu Han
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, Calif
| | - Randall T Higashida
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, Calif
| | - Michael Conte
- Department of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, Calif
| |
Collapse
|
46
|
Seymour ZA, Sneed PK, Gupta N, Lawton MT, Molinaro AM, Young W, Dowd CF, Halbach VV, Higashida RT, McDermott MW. Volume-staged radiosurgery for large arteriovenous malformations: an evolving paradigm. J Neurosurg 2016; 124:163-74. [DOI: 10.3171/2014.12.jns141308] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Large arteriovenous malformations (AVMs) remain difficult to treat, and ideal treatment parameters for volume-staged stereotactic radiosurgery (VS-SRS) are still unknown. The object of this study was to compare VS-SRS treatment outcomes for AVMs larger than 10 ml during 2 eras; Era 1 was 1992-March 2004, and Era 2 was May 2004–2008. In Era 2 the authors prospectively decreased the AVM treatment volume, increased the radiation dose per stage, and shortened the interval between stages.
METHODS
All cases of VS-SRS treatment for AVM performed at a single institution were retrospectively reviewed.
RESULTS
Of 69 patients intended for VS-SRS, 63 completed all stages. The median patient age at the first stage of VS-SRS was 34 years (range 9–68 years). The median modified radiosurgery-based AVM score (mRBAS), total AVM volume, and volume per stage in Era 1 versus Era 2 were 3.6 versus 2.7, 27.3 ml versus 18.9 ml, and 15.0 ml versus 6.8 ml, respectively. The median radiation dose per stage was 15.5 Gy in Era 1 and 17.0 Gy in Era 2, and the median clinical follow-up period in living patients was 8.6 years in Era 1 and 4.8 years in Era 2. All outcomes were measured from the first stage of VS-SRS. Near or complete obliteration was more common in Era 2 (log-rank test, p = 0.0003), with 3- and 5-year probabilities of 5% and 21%, respectively, in Era 1 compared with 24% and 68% in Era 2. Radiosurgical dose, AVM volume per stage, total AVM volume, era, compact nidus, Spetzler-Martin grade, and mRBAS were significantly associated with near or complete obliteration on univariate analysis. Dose was a strong predictor of response (Cox proportional hazards, p < 0.001, HR 6.99), with 3- and 5-year probabilities of near or complete obliteration of 5% and 16%, respectively, at a dose < 17 Gy versus 23% and 74% at a dose ≥ 17 Gy. Dose per stage, compact nidus, and total AVM volume remained significant predictors of near or complete obliteration on multivariate analysis. Seventeen patients (25%) had salvage surgery, SRS, and/or embolization. Allowing for salvage therapy, the probability of cure was more common in Era 2 (log-rank test, p = 0.0007) with 5-year probabilities of 0% in Era 1 versus 41% in Era 2. The strong trend toward improved cure in Era 2 persisted on multivariate analysis even when considering mRBAS (Cox proportional hazards, p = 0.055, HR 4.01, 95% CI 0.97–16.59). The complication rate was 29% in Era 1 compared with 13% in Era 2 (Cox proportional hazards, not significant).
CONCLUSIONS
VS-SRS is an option to obliterate or downsize large AVMs. Decreasing the AVM treatment volume per stage to ≤ 8 ml with this technique allowed a higher dose per fraction and decreased time to response, as well as improved rates of near obliteration and cure without increasing complications. Reducing the volume of these very large lesions can facilitate a surgical approach for cure.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Christopher F. Dowd
- 2Neurological Surgery,
- 6Radiology, University of California, San Francisco, California
| | - Van V. Halbach
- 2Neurological Surgery,
- 6Radiology, University of California, San Francisco, California
| | - Randall T. Higashida
- 2Neurological Surgery,
- 6Radiology, University of California, San Francisco, California
| | | |
Collapse
|
47
|
Sun Z, Su H, Long B, Sinclair E, Hetts SW, Higashida RT, Dowd CF, Halbach VV, Cooke DL. Endothelial cell high-enrichment from endovascular biopsy sample by laser capture microdissection and fluorescence activated cell sorting. J Biotechnol 2015; 192 Pt A:34-9. [PMID: 25450638 DOI: 10.1016/j.jbiotec.2014.07.434] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 07/07/2014] [Accepted: 07/18/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular sampling and characterization from patients can provide very useful information about the pathogenesis of different vascular diseases, but it has been limited by the lack of an effective method of endothelial cell (EC) enrichment. We optimized the EC yield and enrichment from conventional guide wires by laser capture microdissection (LCM) and fluorescence activated cell sorting (FACS) technique, and addressed the feasibility of using these enriched ECs for downstream gene expression detection. METHODS Iliac artery endovascular samples from 10 patients undergoing routine catheter angiography were collected using conventional 0.038 in. J-shape guide wires. Each of these samples was equally divided into two parts, which were respectively used for EC enrichment by immunocytochemistry-coupled LCM or multiple color FACS. After RNA extraction and reverse transcription, the amplified cDNA was used for quantitative polymerase chain reaction (qPCR). RESULTS Fixed ECs, with positive CD31 or vWF fluorescent signal and endothelial like nucleus, were successfully separated by LCM and live single ECs were sorted on FACS by a seven color staining panel. EC yields by LCM and FACS were 51 ± 22 and 149 ± 56 respectively (P < 0.001). The minimum number of fixed ECs from ICC-coupled LCM for acceptable qPCR results of endothelial marker genes was 30, while acceptable qPCR results as enriched by FACS were attainable from a single live EC. CONCLUSION Both LCM and FACS can be used to enrich ECs from conventional guide wires and the enriched ECs can be used for downstream gene expression detection. FACS generated a higher EC yield and the sorted live ECs may be used for single cell gene expression detection.
Collapse
|
48
|
Affiliation(s)
- Philip M Meyers
- Departments of Radiology and Neurological Surgery, Columbia University, Neurological Institute of New York, New York
| | - Randall T Higashida
- Departments of Radiology, Neurological Surgery, Neurology, and Anesthesiology, University of California, San Francisco, California
| | | | | | - Joshua A Hirsch
- Department of Radiology, Harvard University and Massachusetts General Hospital, Boston, Massachusetts
| | | |
Collapse
|
49
|
Sun Z, Lawson DA, Sinclair E, Wang CY, Lai MD, Hetts SW, Higashida RT, Dowd CF, Halbach VV, Werb Z, Su H, Cooke DL. Endovascular biopsy: Strategy for analyzing gene expression profiles of individual endothelial cells obtained from human vessels ✩. ACTA ACUST UNITED AC 2015; 7:157-165. [PMID: 26989654 PMCID: PMC4792280 DOI: 10.1016/j.btre.2015.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The combination of guide wire sampling, FACS and high throughput microfluidic single-cell quantitative RT-PCR, is an effective strategy for analyzing molecular changes of ECs in vascular lesions. Although heterogeneous, the ECs in normal iliac artery fall into two classes.
Purpose To develop a strategy of achieving targeted collection of endothelial cells (ECs) by endovascular methods and analyzing the gene expression profiles of collected single ECs. Methods and results 134 ECs and 37 leukocytes were collected from four patients' intra-iliac artery endovascular guide wires by fluorescence activated cell sorting (FACS) and analyzed by single-cell quantitative RT-PCR for expression profile of 48 genes. Compared to CD45+ leukocytes, the ECs expressed higher levels (p < 0.05) of EC surface markers used on FACS and other EC related genes. The gene expression profile showed that these isolated ECs fell into two clusters, A and B, that differentially expressed 19 genes related to angiogenesis, inflammation and extracellular matrix remodeling, with cluster B ECs have demonstrating similarities to senescent or aging ECs. Conclusion Combination of endovascular device sampling, FACS and single-cell quantitative RT-PCR is a feasible method for analyzing EC gene expression profile in vascular lesions.
Collapse
Affiliation(s)
- Zhengda Sun
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Devon A Lawson
- Department of Anatomy, University of California, San Francisco, CA, USA
| | - Elizabeth Sinclair
- Division of Experimental Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Chih-Yang Wang
- Department of Anatomy, University of California, San Francisco, CA, USA; Department of Biochemistry and Molecular Biology, Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Derg Lai
- Department of Biochemistry and Molecular Biology, Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Steven W Hetts
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Randall T Higashida
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Christopher F Dowd
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Van V Halbach
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Zena Werb
- Department of Anatomy, University of California, San Francisco, CA, USA
| | - Hua Su
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Daniel L Cooke
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| |
Collapse
|
50
|
Hetts SW, Tsai T, Cooke DL, Amans MR, Settecase F, Moftakhar P, Dowd CF, Higashida RT, Lawton MT, Halbach VV. Progressive versus Nonprogressive Intracranial Dural Arteriovenous Fistulas: Characteristics and Outcomes. AJNR Am J Neuroradiol 2015. [PMID: 26206813 DOI: 10.3174/ajnr.a4391] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE A minority of intracranial dural arteriovenous fistulas progress with time. We sought to determine features that predict progression and define outcomes of patients with progressive dural arteriovenous fistulas. MATERIALS AND METHODS We performed a retrospective imaging and clinical record review of patients with intracranial dural arteriovenous fistula evaluated at our hospital. RESULTS Of 579 patients with intracranial dural arteriovenous fistulas, 545 had 1 fistula (mean age, 45 ± 23 years) and 34 (5.9%) had enlarging, de novo, multiple, or recurrent fistulas (mean age, 53 ± 20 years; P = .11). Among these 34 patients, 19 had progressive dural arteriovenous fistulas with de novo fistulas or fistula enlargement with time (mean age, 36 ± 25 years; progressive group) and 15 had multiple or recurrent but nonprogressive fistulas (mean age, 57 ± 13 years; P = .0059, nonprogressive group). Whereas all 6 children had fistula progression, only 13/28 adults (P = .020) progressed. Angioarchitectural correlates to chronically elevated intracranial venous pressures, including venous sinus dilation (41% versus 7%, P = .045) and pseudophlebitic cortical venous pattern (P = .048), were more common in patients with progressive disease than in those without progression. Patients with progressive disease received more treatments than those without progression (median, 5 versus 3; P = .0068), but as a group, they did not demonstrate worse clinical outcomes (median mRS, 1 and 1; P = .39). However, 3 young patients died from intracranial venous hypertension and intracranial hemorrhage related to progression of their fistulas despite extensive endovascular, surgical, and radiosurgical treatments. CONCLUSIONS Few patients with dural arteriovenous fistulas follow an aggressive, progressive clinical course despite treatment. Younger age at initial presentation and angioarchitectural correlates to venous hypertension may help identify these patients prospectively.
Collapse
Affiliation(s)
- S W Hetts
- From the Departments of Radiology and Biomedical Imaging (S.W.H., T.T., D.L.C., M.R.A., F.S., P.M., C.F.D., R.T.H., V.V.H.)
| | - T Tsai
- From the Departments of Radiology and Biomedical Imaging (S.W.H., T.T., D.L.C., M.R.A., F.S., P.M., C.F.D., R.T.H., V.V.H.)
| | - D L Cooke
- From the Departments of Radiology and Biomedical Imaging (S.W.H., T.T., D.L.C., M.R.A., F.S., P.M., C.F.D., R.T.H., V.V.H.)
| | - M R Amans
- From the Departments of Radiology and Biomedical Imaging (S.W.H., T.T., D.L.C., M.R.A., F.S., P.M., C.F.D., R.T.H., V.V.H.)
| | - F Settecase
- From the Departments of Radiology and Biomedical Imaging (S.W.H., T.T., D.L.C., M.R.A., F.S., P.M., C.F.D., R.T.H., V.V.H.)
| | - P Moftakhar
- From the Departments of Radiology and Biomedical Imaging (S.W.H., T.T., D.L.C., M.R.A., F.S., P.M., C.F.D., R.T.H., V.V.H.)
| | - C F Dowd
- From the Departments of Radiology and Biomedical Imaging (S.W.H., T.T., D.L.C., M.R.A., F.S., P.M., C.F.D., R.T.H., V.V.H.) Neurological Surgery (C.F.D., R.T.H., M.T.L., V.V.H.) Neurology (C.F.D., R.T.H., V.V.H.) Anesthesia and Perioperative Care (C.F.D., R.T.H., V.V.H.), University of California, San Francisco, San Francisco, California
| | - R T Higashida
- From the Departments of Radiology and Biomedical Imaging (S.W.H., T.T., D.L.C., M.R.A., F.S., P.M., C.F.D., R.T.H., V.V.H.) Neurological Surgery (C.F.D., R.T.H., M.T.L., V.V.H.) Neurology (C.F.D., R.T.H., V.V.H.) Anesthesia and Perioperative Care (C.F.D., R.T.H., V.V.H.), University of California, San Francisco, San Francisco, California
| | - M T Lawton
- Neurological Surgery (C.F.D., R.T.H., M.T.L., V.V.H.)
| | - V V Halbach
- From the Departments of Radiology and Biomedical Imaging (S.W.H., T.T., D.L.C., M.R.A., F.S., P.M., C.F.D., R.T.H., V.V.H.) Neurological Surgery (C.F.D., R.T.H., M.T.L., V.V.H.) Neurology (C.F.D., R.T.H., V.V.H.) Anesthesia and Perioperative Care (C.F.D., R.T.H., V.V.H.), University of California, San Francisco, San Francisco, California
| |
Collapse
|