Cerebral Arteriovenous Malformations: Evaluation and Management.

There has been increased detection of incidental AVMs as result of the frequent use of advanced imaging techniques. The natural history of AVM is poorly understood and its management is controversial. This review provides an overview of the epidemiology, pathophysiology, natural history, clinical presentation, diagnosis, and management of AVMs. The authors discussed the imaging techniques available for detecting AVMs with regard to the advantages and disadvantages of each imaging modality. Furthermore, this review paper discusses the factors that must be considered for the most appropriate management strategy (based on the current evidence in the literature) and the risks and benefits of each management option

Cerebral Arteriovenous Malformations: Evaluation and Management

There has been increased detection of incidental AVMs as result of the frequent use of advanced imaging techniques. The natural history of AVM is poorly understood and its management is controversial. This review provides an overview of the epidemiology, pathophysiology, natural history, clinical presentation, diagnosis, and management of AVMs. The authors discussed the imaging techniques available for detecting AVMs with regard to the advantages and disadvantages of each imaging modality. Furthermore, this review paper discusses the factors that must be considered for the most appropriate management strategy (based on the current evidence in the literature) and the risks and benefits of each management option

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Abstract Number ‐ 114: Deep Cerebral Venous Thrombosis requiring Venous Thrombectomy and Intra‐arterial Thrombolysis in Young Pregnant Female

Introduction Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke and mortality especially in young women and children (1). Even though, first‐line treatment remains anticoagulation, some patients deteriorate and endovascular treatment is needed. Currently there are no randomized controlled trials comparing the efficacy and safety of intracranial thrombolysis and mechanical thrombectomy to standard‐of‐care anticoagulation therapy (2). We present a case of a pregnant lady with CVST with successful clinical outcomes with venous thrombectomy and intraarterial thrombolysis. Methods Case Report Results 30 year old lady with no past medical history, 7 weeks and 4 days pregnant presented with acute progressive encephalopathy associated with nausea, vomiting and headaches. On admission, she was stuporous, had dysarthria, severe hemiparesis, and hemineglect on the right side. She had COVID‐19 infection and her fetus had subchorionic hematoma by ultrasound. Initial CT brain showed extensive cerebral venous sinus thrombosis (CVST). She was intubated and MRI showed venous infarcts. MR venography revealed acute extensive CVST of superior sagittal sinus, vein of galen, right transverse sinus, right sigmoid sinus, and right jugular vein. IV Heparin drip was initiated. Her follow‐up neurological exam deteriorated despite maximal medical therapy. The decision was made for endovascular recanalization. The cerebral angiogram confirmed the occlusion of deep venous system. Thrombectomy of bilateral internal jugular vein and sigmoid sinus was performed with retrieval of thrombi. Post‐thrombectomy runs demonstrated persistent extensive CVST and decision was made for intra‐arterial thrombolysis. A diagnostic catheter was secured in the right internal carotid artery catheter (ICA). Thombolysis was performed with 4 mg/hr recombinant tissue‐plasminogen activator (rt‐PA). Heparin drip IV was continued. Subsequently, the repeat CT brain showed significant improvement in the CVST and interval development of intraparenchymal hemorrhages and subarachnoid hemorrhages. Heparin and rt‐PA were held. The patient was found to have Factor V Leiden mutation and she was started on Enoxaparin 1mg/kg throughout her pregnancy and 6 weeks postpartum. Clinically she demonstrated significant neurologic improvement and was discharged to home from rehabilitation center. Currently, she is thirty‐ four weeks pregnant and neurologically intact without any deficits. Conclusions Pharmacological and mechanical endovascular interventions can have significantly successful clinical outcomes in deep cerebral venous thrombosis. Controlled studies are required to assess the safety and efficacy of these interventions when compared to standard systemic anticoagulation

Abstract Number ‐ 136: Aspirin Desensitization in Cerebral Aneurysms and Management for the Neurointerventionalist

Introduction Aspirin (ASA) is the pillar of cerebrovascular and systemic vascular disease management. ASA allergy/hypersensitivity presents a challenge to the NeuroInterventionalist due to difficulties achieving optimum medical management prior to and after neurointerventional treatment. Currently there is vast cardiovascular literature describing successful ASA desensitization protocols, however the same cannot be said for neurointervention.The purpose of our study was to describe our experience with ASA hypersensitivity management in cerebrovascular disease and review of the relevant literature in patients with aneurysms. We present two cases of patients with cerebrovascular aneurysms requiring neurointervention with a pipeline embolization device who were successfully desensitized to their ASA hypersensitivity prior to treatment and the different variables encountered/approach for each patient. Methods N/A Results 37 yo F with history of pre‐eclampsia while pregnant with twins presented with complaints of a severe headache 22 days after delivery and on MRA head and neck had unruptured bilateral paraclinoid para‐ophthalmic internal carotid artery aneurysms. She was placed on Brilinta instead of Plavix due to subtherapeutic PruTest. She underwent successful endovascular coil embolization of the unruptured RIGHT paraclinoid para‐ophthalmic internal carotid artery aneurysm. Post coil embolization she underwent desensitization in the ICU for ASA under the care of the ICU physician and the allergist; 1mg, 5mg, 10mg, 20mg, 45mg ‐ each given 30 min apart. The protocol was followed by ASA 81mg the next morning and had successful endovascular flow diversion with Pipeline Flex Embolization Device for LEFT paraclinoid para‐ophthalmic internal carotid artery aneurysm. 71 yo F with history of uncontrolled HTN. During her hypertensive work‐up was found to have an approximately 6 mm unruptured right internal carotid artery aneurysm on CTA. She was successfully desensitized to ASA and optimized with Aspirin and Brilinta. She underwent successful endovascular flow diversion with Microvention FRED X Flow Diverter of the unruptured medially directed right paraclinoid ophthalmic segment internal carotid artery aneurysm. Conclusions There are few reports of ASA desensitization in patients with cerebral aneurysms ‐ due to this there are few established set protocols. We describe our protocol for high risk patients and post‐op management of patients undergoing neurointerventional procedures.We report these 2 case reports to help add to the current literature of ASA desensitization utilization in patients with CNS aneurysms and may help create more standardized protocols

Unruptured Cerebral Aneurysms: Evaluation and Management

The evolution of imaging techniques and their increased use in clinical practice have led to a higher detection rate of unruptured intracranial aneurysms. The diagnosis of an unruptured intracranial aneurysm is a source of significant stress to the patient because of the concerns for aneurysmal rupture, which is associated with substantial rates of morbidity and mortality. Therefore, it is important that decisions regarding optimum management are made based on the comparison of the risk of aneurysmal rupture with the risk associated with intervention. This review provides a comprehensive overview of the epidemiology, pathophysiology, natural history, clinical presentation, diagnosis, and management options for unruptured intracranial aneurysms based on the current evidence in the literature. Furthermore, the authors discuss the genetic abnormalities associated with intracranial aneurysm and current guidelines for screening in patients with a family history of intracranial aneurysms. Since there is significant controversy in the optimum management of small unruptured intracranial aneurysms, we provided a systematic approach to their management based on patient and aneurysm characteristics as well as the risks and benefits of intervention

Abstract 109: Flow-Diversion Versus Conventional Endovascular Techniques for Carotid Cavernous Aneurysms

Background and Purpose: Several endovascular treatment options are available for cavernous carotid aneurysms (CCA). We compared PED versus conventional endovascular treatment in terms of evolution of mass effect, complications, recurrence and retreatment rate. Methods: One hundred fifty-seven patients harboring 167 CCA were treated using PED placement, coiling, stent assisted coiling (SAC), and carotid vessel destruction (CVD). Procedural complications, angiographic results, and clinical outcomes were analyzed and compared. Results: There were no difference in age, gender, and mean aneurysm size between those treated with PED and those treated with conventional endovascular procedures. The patients treated with PED had a significantly lower proportion of small size aneurysms(15mm (OR=4.27; p=0.003) to be predictors of none improvement in symptoms. The rate of complete occlusion was 81.36% (48/59) for PED, 42.25% (39/71) for SAC, 27.27% (6/22) for coiling and 73.33% (11/15) for CVD. Retreatment was needed in patients with aneurysm size >15 mm (OR=2.67;p=0.037) and those who were not treated with PED (PED: OR = 0.16; p=0.006). The rate of major complications was 6.6% (11/167). Patients that were treated with PED or SAC had 3.84 lower odds to develop complications (OR=0.26 p<0.05). Conclusion: The use of PED should be encouraged, especially in symptomatic patients. We found PED to be associated with less need for future treatment, higher improvement in symptoms rate and lower rate of complications

Endovascular stroke intervention in the very young

•Data on stroke in the very young is lacking and insufficient.•Endovascular therapy can achieve a high recanalization rate and favorable outcome.•Endovascular therapy can have limited complications.•We advise aggressive management for very young patients. Object: This study aims to evaluate the use of endovascular therapy to treat very young (≤35 years) patients with acute ischemic stroke from large vessel occlusion. We identified from a prospectively maintained database young patients (≤35 years) undergoing endovascular intervention for AIS at two cerebrovascular referral centers. The study only included patients with a confirmed large vessel occlusion. Modified Rankin scale (mRS) scores were determined at 90 days during a follow-up visit. A total of 15 patients met the inclusion criteria. Mean age was 27.93 years±6.75 years (range: 9–35 years). On admission, the mean NIHSS score was 14.07±9.16. Mechanical thrombectomy was performed using the Solitaire FR device in 4 of 15 (26.67%) patients and the Merci/Penumbra systems in 11 (73.33%) patients. Successful recanalization (TICI 2–3) was achieved in all but one patient (14/15; 93.33%). Only one patient (6.67%) had a hemorrhagic conversion following intervention; he later expired. The rate of 90-day favorable outcome (mRS 0–2) was 86.67% (13/15). Endovascular treatment in the very young population may be carried out with limited complications and attain remarkably high rate of recanalization and favorable outcome. This study supports the role of aggressive management strategies for very young patients with large vessel occlusion

Flow Diversion Versus Conventional Treatment for Carotid Cavernous Aneurysms

Several endovascular treatment options are available for cavernous carotid aneurysms. We compared pipeline embolization device (PED) versus conventional endovascular treatment in terms of evolution of mass effect, complications, recurrence, and retreatment rate. One hundred fifty-seven patients harboring 167 cavernous carotid aneurysms were treated using PED placement, coiling, stent-assisted coiling, and carotid vessel destruction. Procedural complications, angiographic results, and clinical outcomes were analyzed and compared. There were no difference in age, sex, and mean aneurysm size between those treated with PED and those treated with conventional endovascular procedures. The patients treated with PED had a significantly lower proportion of small-size aneurysms (15 mm (OR, 4.27; P=0.003) to be predictors of no improvement in symptoms. The rate of complete occlusion was 81.36% (48 of 59) for PED, 42.25% (39 of 71) for stent-assisted coiling, 27.27% (6 of 22) for coiling, and 73.33% (11 of 15) for carotid vessel destruction. Retreatment was needed in patients with aneurysm size >15 mm (OR, 2.67; P=0.037) and those who were not treated with PED (PED: OR, 0.16; P=0.006). The rate of major complications was 6.6% (11 of 167). Patients who were treated with PED or stent-assisted coiling had 3.84 lower odds to develop complications (OR, 0.26; P<0.05). The use of PED should be encouraged, especially in symptomatic patients. We found PED to be associated with less need for future treatment, higher improvement in symptoms rate, and lower rate of complications

Epidural cylinder electrodes for presurgical evaluation of intractable epilepsy: technical note

This is a technical report describing a different technique for the insertion of epidural electrodes in the preoperative evaluation of epilepsy surgery. Our experience in 67 cases using this technique is analyzed. Cylinder electrodes with multiple recording nodes spaced 1 cm apart along a Silastic core are placed into the epidural space under general anesthesia through single or multiple burr holes. We reviewed the data on 67 cases of medically intractable epilepsy requiring intracranial monitoring that had epidural cylinder electrodes placed. The electrodes were placed bilaterally or contralateral to subdural grids in 64 of the 67 cases. Continuous monitoring was performed from 1 to 3 weeks. This method was most useful when used bilaterally or contralateral to subdural grids. Definitive surgery was rendered in 48 of 67 cases. After monitoring, all electrodes were removed at bedside or upon return to the operating room for definitive surgery. There were no mortalities, infections, cerebrospinal fluid leaks, neurologic deficits, or electrode malfunctions. Two patients (2/67, 3%) did develop subdural hematomas early in our series after dural injury near the pterion; however, these patients did not sustain permanent deficit. Epidural cylinders are another option for preoperative monitoring, useful for determining lobe or laterality of seizure genesis. They offer an alternate method to EPEs in cases where epidural recording is desirable. The cylinder electrodes are easy to place and can be removed without a return to the operating theater. The electrodes' minimal mass effect allows them to be safely placed bilaterally or contralateral to subdural grids. The epidural cylinders can monitor cortex with a greater density of nodes and can access regions not amenable to EPEs