Intrasaccular flow disruption for ruptured aneurysms: an international multicenter study

BACKGROUND

The Woven EndoBridge (WEB) device is a novel intrasaccular flow disruptor tailored for bifurcation aneurysms. We aim to describe the degree of aneurysm occlusion at the latest follow-up, and the rate of complications of aneurysms treated with the WEB device stratified according to rupture status.

METHODS

Our data were taken from the WorldWideWeb Consortium, an international multicenter cohort including patients treated with the WEB device. Aneurysms were classified into two groups: ruptured and unruptured. We compared clinical and radiologic outcomes of both groups. Propensity score matching (PSM) was done to match according to age, gender, bifurcation, location, prior treatment, neck, height, dome width, daughter sac, incorporated branch, pretreatment antiplatelets, and last imaging follow-up.

RESULTS

The study included 676 patients with 691 intracranial aneurysms (529 unruptured and 162 ruptured) treated with the WEB device. The PSM analysis had 55 pairs. In both the unmatched (85.8% vs 84.3%, p=0.692) and matched (94.4% vs 83.3%, p=0.066) cohorts there was no significant difference in the adequate occlusion rate at the last follow-up. Likewise, there were no significant differences in both ischemic and hemorrhagic complications between the two groups. There was no documented aneurysm rebleeding after WEB device implantation.

CONCLUSION

There was no significant difference in both the radiologic outcomes and complications between unruptured and ruptured aneurysms. Our findings support the feasibility of treatment of ruptured aneurysms with the WEB device.

Management of refractory bacterial meningitis-associated cerebral vasospasm: illustrative case

BACKGROUND

Cerebral vasospasm is an alarming complication of acute bacterial meningitis with potentially devastating consequences. It is essential for providers to recognize and treat it appropriately. Unfortunately, there is no well-established approach to the management of postinfectious vasospasm, which makes it especially challenging to treat these patients. More research is needed to address this gap in care.

OBSERVATIONS

Here, the authors describe a patient with postmeningitis vasospasm that was refractory to induced hypertension, steroids, and verapamil. He eventually responded to a combination of intravenous (IV) and intra-arterial (IA) milrinone followed by angioplasty.

LESSONS

To our knowledge, this is the first report of successfully using milrinone as vasodilator therapy in a patient with postbacterial meningitis-associated vasospasm. This case supports the use of this intervention. In future cases of vasospasm after bacterial meningitis, IV and IA milrinone should be trialed earlier with consideration of angioplasty.

Flow diversion for cerebral aneurysms

The treatment of cerebral aneurysms includes open microsurgical options (e.g., clipping, trapping/bypass) and evolving endovascular techniques. Following the landmark trials that propelled endovascular treatment to the forefront, flow diversion has shown high aneurysm cure rates with minimal complications. Flow diversion stents are placed in the parent vessel, redirecting blood flow from the aneurysm, promoting reendothelization across the neck, and resulting in complete occlusion of the aneurysm. As a result, flow diversion has become increasingly used as the primary treatment for unruptured aneurysms; however, its applications are being pushed to new frontiers. Here, the authors present three cases showcasing the treatment of intracranial aneurysms with flow diversion. The video can be found here: https://stream.cadmore.media/r10.3171/2022.7.FOCVID2253.

Angiographic Blush after Mechanical Thrombectomy is Associated with Hemorrhagic Transformation of Ischemic Stroke

BACKGROUND AND PURPOSE

Risk factors for hemorrhagic transformation of ischemic stroke after mechanical thrombectomy (MT) are not well established. We conducted a study to determine if prominent angiographic cerebral vascularity following recanalization with thrombectomy (angiographic blush) is associated with hemorrhagic transformation.

METHODS

Using the Cornell AcutE Stroke Academic Registry, we identified stroke patients who had thrombectomy and achieved recanalization of anterior circulation large-vessel occlusion between 2012 and 2015. The exposure variable was presence of angiographic blush after recanalization, defined as capillary blush with or without early venous drainage. The primary outcome was volume of hemorrhagic transformation on brain imaging after thrombectomy, as determined by semiautomated volumetric analysis on computed tomography or magnetic resonance imaging among those adjudicated to have hemorrhagic conversion by neuroradiology investigators blinded to angiography results. Using a doubly robust estimator with propensity scores and outcome regression adjusting for demographics and known risk factors for hemorrhagic transformation, we evaluated whether angiographic blush after recanalization is associated with an increased volume of hemorrhagic transformation.

RESULTS

Among 48 eligible patients, 31 (64.6%) had angiographic blush and 26 (54.2%) had radiographic hemorrhagic transformation (mean volume, 7.6 ml). Patients with angiographic blush averaged lower thrombolysis in cerebral infarction scores and more often received intravenous thrombolysis. In adjusted analysis, angiographic blush was associated with an increased volume of hemorrhagic transformation: mean volume, 10.3ml (95% CI, 3.7-16.9 ml) with blush versus 1.8ml (95% Confidence Interval (CII = Confidence Interval), 0.1-3.4 ml) without (P = .01).

CONCLUSIONS

Presence of angiographic blush after MT was independently associated with the volume of hemorrhagic transformation.

Abstract WP24: Angiographic Blush After Mechanical Thrombectomy is Associated With Hemorrhagic Conversion of Ischemic Stroke

Introduction: Risk factors for hemorrhagic transformation of ischemic stroke after mechanical thrombectomy are not well established.

Hypothesis: Prominent cerebral tissue vascularity on angiography after recanalization with thrombectomy (angiographic blush) is associated with hemorrhagic transformation.

Methods: Among patients in the Cornell AcutE Stroke Academic Registry (CAESAR), we identified those who underwent stent-retriever-based thrombectomy for anterior circulation occlusion between 2012 and 2015. The presence of hemorrhagic transformation and angiographic blush were determined by neuroradiologists and neurointerventionalists. We identified angiographic blush as hypervascularity with or without early venous drainage. Hemorrhagic transformation was defined using CT or MRI studies performed within 7 days of thrombectomy. Our primary outcome was the volume of hemorrhagic transformation, determined using 3D-Slicer software. Our secondary outcome was the presence of any hemorrhagic transformation. Using a doubly robust estimator, we analyzed whether the presence of angiographic blush after recanalization was associated with an increased volume of hemorrhagic transformation after adjustment for demographics and previously published risk factors for hemorrhagic transformation.

Results: Among 48 eligible patients (median age, 68 years; median NIHSS score, 18), 31 (64.6%) had angiographic blush and 26 (54.2%) had hemorrhagic transformation (mean volume, 7.6 cc). Patients with angiographic blush had lower TICI scores and had more often received alteplase. After adjustment for demographics and risk factors for hemorrhagic transformation, the presence of angiographic blush was significantly associated with an increased volume of hemorrhagic transformation: mean volume, 10.3 (95% CI, 3.7-16.9) cc with any blush versus 1.8 (95% CI, 0.1-3.4) cc without any blush (p=0.01). Angiographic blush was nonsignificantly associated with the presence of any hemorrhagic transformation (odds ratio, 1.5; 95% CI, 0.9-2.5).

Conclusions: In a single-center study, we found that the presence of angiographic blush after mechanical thrombectomy was independently associated with an increased volume of hemorrhagic transformation.

Fluoroscopic-guided lumbar puncture: fluoroscopic time and implications of body mass index--a baseline study

BACKGROUND AND PURPOSE

Fluoroscopic-guided lumbar puncture is an effective alternative to bedside lumbar puncture in challenging patients. However, no published guidelines are available for an acceptable range of fluoroscopic time for this procedure. The purpose of this study was to set department benchmark fluoroscopic times for lumbar puncture, accounting for body mass index in our patient population.

MATERIALS AND METHODS

We identified and reviewed all patients who underwent fluoroscopic-guided lumbar puncture at 4 hospitals during a 2-year period (July 2011 to June 2013). Data collection included patient information (demographics, body mass index, history of prior lumbar surgery and/or lumbar hardware, scoliosis); procedure details (fluoroscopic time, level of access, approach, needle gauge and length); level of operator experience; and hospital site. A generalized linear model was used to test whether body mass index influenced fluoroscopic time while controlling other factors.

RESULTS

Five hundred eighty-four patients (mean age, 47.8 ± 16.2 years; range, 16-92 years; 33% male) had successful fluoroscopic-guided lumbar puncture s. Mean body mass index and fluoroscopic time were higher in female patients (34.4 ± 9.9 kg/m(2) and 1.07 minutes; 95% CI, 0.95-1.20) than in male patients (29.2 ± 7.3 kg/m(2) and 0.91 minutes; 95% CI, 0.79-1.03). Body mass index (P = .001), hospital site (P < .001), and level of experience (P = .03) were factors significantly affecting fluoroscopic time on multivariate analysis. Benchmark fluoroscopic times in minutes were the following: 0.48 (95% CI, 0.40-0.56) for normal, 0.61 for overweight (95% CI, 0.52-0.71), 0.63(95% CI, 0.58-0.73) for obese, and 0.86 (95% CI, 0.74-1.01) in extremely obese body mass index categories.

CONCLUSIONS

In patients undergoing fluoroscopic-guided lumbar punctures, fluoroscopy time increased with body mass index We established benchmark fluoroscopic-guided lumbar puncture time ranges as related to body mass index in our patient population.

Contrast-enhanced time-resolved MRA for follow-up of intracranial aneurysms treated with the pipeline embolization device

BACKGROUND AND PURPOSE

Endovascular reconstruction and flow diversion by using the Pipeline Embolization Device is an effective treatment for complex cerebral aneurysms. Accurate noninvasive alternatives to DSA for follow-up after Pipeline Embolization Device treatment are desirable. This study evaluated the accuracy of contrast-enhanced time-resolved MRA for this purpose, hypothesizing that contrast-enhanced time-resolved MRA will be comparable with DSA and superior to 3D-TOF MRA.

MATERIALS AND METHODS

During a 24-month period, 37 Pipeline Embolization Device-treated intracranial aneurysms in 26 patients underwent initial follow-up by using 3D-TOF MRA, contrast-enhanced time-resolved MRA, and DSA. MRA was performed on a 1.5T unit by using 3D-TOF and time-resolved imaging of contrast kinetics. All patients underwent DSA a median of 0 days (range, 0-68) after MRA. Studies were evaluated for aneurysm occlusion, quality of visualization of the reconstructed artery, and measurable luminal diameter of the Pipeline Embolization Device, with DSA used as the reference standard.

RESULTS

The sensitivity, specificity, and positive and negative predictive values of contrast-enhanced time-resolved MRA relative to DSA for posttreatment aneurysm occlusion were 96%, 85%, 92%, and 92%. Contrast-enhanced time-resolved MRA demonstrated superior quality of visualization (P = .0001) and a higher measurable luminal diameter (P = .0001) of the reconstructed artery compared with 3D-TOF MRA but no significant difference compared with DSA. Contrast-enhanced time-resolved MRA underestimated the luminal diameter of the reconstructed artery by 0.965 ± 0.497 mm (27% ± 13%) relative to DSA.

CONCLUSIONS

Contrast-enhanced time-resolved MRA is a reliable noninvasive method for monitoring intracranial aneurysms following flow diversion and vessel reconstruction by using the Pipeline Embolization Device.

Pulmonary blastoma — a rare tumor with variable presentation

BACKGROUND

Pulmonary blastoma is a rare primary lung tumor with poor prognosis that commonly presents at a younger age than the non-small cell lung carcinoma (NSCLC). Classically they are large, symptomatic tumors with lymph nodal metastasis and carry poor prognosis. We report our experience of 7 patients with pulmonary blastoma who presented with varying clinical features.

METHODS

Retrospective analysis of our database revealed seven patients with pulmonary blastoma that were operated between January 1993 and December 2004. During the same time, 889 lung resections were performed for primary NSCLC. Demographic and clinical details were obtained from hospital notes. The histopathology reports were reviewed with the department of pathology and the radiological images were reported.

RESULTS

The tumors showed a bimodal pattern in age at incidence being (four patients were less than 49 years and three more than 66 years). All patients were symptomatic and demonstrated variable sized tumors. Lesions were common in lower lobes (lower:other lobes -4:3) and were staged T2N0 pathologically. All of the patients underwent surgical resections and had no chemotherapy/radiotherapy following surgery. Three of the seven patients died during follow-up due to unrelated causes between 24 and 29 months. The longest follow-up was more than 9 years and the survivor continues to do well.

CONCLUSIONS

Pulmonary blastomas are rare tumors but can present with differing clinical features. Early detection and treatment may improve prognosis. Further larger series are needed to evaluate the characteristics of the tumor.