Postreperfusion Blood Pressure Variability After Endovascular Thrombectomy Affects Outcomes in Acute Ischemic Stroke Patients With Poor Collateral Circulation

Background and Purpose: We evaluated the effect of 24 h blood pressure variability (BPV) on clinical outcomes in acute ischemic stroke patients with successful recanalization after endovascular recanalization therapy (ERT).Methods: Patients with anterior circulation occlusion were evaluated if they underwent ERT based on multiphase computed tomography angiography and achieved successful recanalization (≥thrombolysis in cerebral ischemia 2b). Collateral degrees were dichotomized based on the pial arterial filling score, with a score of 0–3 defined as a poor collateral status. BPV parameters include mean, standard deviation, coefficient of variation, and variation independent of the mean (VIM) for systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure, and pulse rate (PR). These parameters were measured for 24 h after ERT and were analyzed according to occlusion sites and stroke mechanisms. Associations of BPV parameters with clinical outcomes were investigated with stratification based on the baseline collateral status.Results: BPV was significantly different according to the occlusion sites and stroke mechanisms, and higher BPV was observed in patients with internal carotid artery occlusion or cardioembolic occlusion. After adjustment for confounders, most BPV parameters remained significant to predict functional outcomes at 3 months in patients with poor collateral circulation. However, no significant association was found between BPV parameters and clinical outcomes in patients with good collateral circulation.Conclusion: Postreperfusion BP management by decreasing BPV may have influence on improving clinical outcome in cases of poor collateral circulation among patients achieving successful recanalization after ERT

Dichotomizing Level of Pial Collaterals on Multiphase CT Angiography for Endovascular Treatment in Acute Ischemic Stroke: Should It Be Refined for 6-Hour Time Window?

Purpose Although endovascular treatment is currently thought to only be suitable for patients who have pial arterial filling scores >3 as determined by multiphase computed tomography angiography (mpCTA), a cut-off score of 3 was determined by a study, including patients within 12 hours after symptom onset. We aimed to investigate whether a cut-off score of 3 for endovascular treatment within 6 hours of symptom onset is an appropriate predictor of good functional outcome at 3 months. Materials and Methods From April 2015 to January 2016, acute ischemic stroke patients treated with mechanical thrombectomy within 6 hours of symptom onset were enrolled into this study. Pial arterial filling scores were semi-quantitatively assessed using mpCTA, and clinical and radiological parameters were compared between patients with favorable and unfavorable outcomes. Multivariate logistic regression analysis was then performed to investigate the independent association between clinical outcome and pial collateral score, with the predictive power of the latter assessed using C-statistics. Results Of the 38 patients enrolled, 20 (52.6%) had a favorable outcome and 18 had an unfavorable outcome, with the latter group showing a lower mean pial arterial filling score (3.6±0.8 vs. 2.4±1.2, P=0.002). After adjusting for variables with a P-value of 2 vs. ≤2. Conclusion A pial arterial filling cut-off score of 2 as determined by mpCTA appears to be more suitable for predicting clinical outcomes following endovascular treatment within 6 hours of symptom onset than the cut-off of 3 that had been previously suggested

Intra-arterial Thrombolysis for Central Retinal Artery Occlusion: Two Cases Report

Central retinal artery occlusion (CRAO) causes severe visual loss in affected eye and vision does not recover in more than 90% of the patients. It is believed that it occurs by occlusion of the central retinal artery with small emboli from atherosclerotic plaque of internal cerebral artery. Retina is a part of the brain, thus basically CRAO is corresponding to acute occlusion of intracerebral artery and retinal ischemia is to cerebral stroke. Therefore, intra-arterial thrombolysis (IAT) has been considered as a treatment method in CRAO. Recently, we treated 2 patients diagnosed as CRAO and could achieve complete recanalization on fundus fluorescein angiogram with IAT. Of them, one recovered visual acuity to 20/25. We report our 2 CRAO cases treated with IAT and discuss technical aspects for IAT and management of patient. To the best of our knowledge, this is the first Korean report of IAT for CRAO

Protection filter-related events in extracranial carotid artery stenting: a single-center experience

PURPOSE: To report the complications, rescue procedures, and consequences related to the use of an embolus protection filter during carotid artery stenting (CAS). METHODS: A retrospective review was undertaken of 72 patients (58 men; mean age 70.0+/-8.2 years, range 56-87) with extracranial atherosclerotic carotid stenosis who underwent 77 CAS procedures under filter protection. Filter-related events and rescue procedures according to each procedural step were retrospectively evaluated on CAS angiograms. In addition, neurological events and outcomes were also assessed. RESULTS: CAS using a filter was successful in 99% of cases, and the overall rate of minor stroke (n=1), major stroke (0), or mortality (n=1) was 2.6% at 30 days. Filter placement was successful in all cases. However, arterial tortuosity made it difficult for a filter to pass through the stenosis in 1 case; this was overcome with an additional supportive wire (0.018-inch). Filter-related events were flow impairment in 6 (7.8%), filter wedging in the catheter tip in 4 (5.2%), vasospasm >50% narrowing in 7 (9.1%), filling defects within the filter membrane in 5 (6.5%), retrieval failure with the provided retriever in 3 (3.9%), and insecure retrieval without filter collapse in 2 (2.6%). Flow impairment caused drowsy mentality and impaired verbal response in 4, which resolved after prompt filter retrieval. All the cases of filter wedging were resolved with a catheter pulled down into the stented segment to separate the filter element from the catheter tip. Significant vasospasm and filling defects were spontaneously resolved in all cases after filter retrieval. Inability to pass a retriever catheter through a stent was overcome with curved 5-F catheter manipulation in all 3 cases. CONCLUSION: The use of a filter during CAS may induce various angiographic or technical events at each step. For a severely stenotic and tortuous carotid lesion with difficult access, a filter may become trapped or irretrievable during flow arrest. Physicians should be aware of the preventive and rescue maneuvers to counter filter-related events, perhaps even considering another type of protection mechanism or carotid endarterectom

Cases of Common Carotid Artery Pseudoaneurysm Treated by Stent Graft

Common carotid artery (CCA) pseudoaneurysms are rare and potentially lethal, and adequate treatment is warranted in order to prevent rupture or neurologic sequelae. The causes of CCA pseudoaneurysm include blunt or penetrating trauma, infection, and vasculitis, as well as iatrogenic and unknown causes. Previously, surgery was the standard treatment for pseudoaneurysm. However, endovascular surgical approaches such as stent graft or coiling have become effective alternatives with minimal morbidity and high success rates. Here, we report two cases of CCA pseudoaneurysms that were successfully treated by stent graft and review the current literature

Venous-predominant parenchymal arteriovenous malformation: a rare subtype with a venous drainage pattern mimicking developmental venous anomaly

OBJECT: Considerable confusion exists in the literature regarding the classification of cerebrovascular malformations and their clinical significance. One example is provided by the atypical developmental venous anomaly (DVA) with arteriovenous shunt, because it remains controversial whether these lesions should be classified as DVAs or as atypical cases of other subtypes of cerebrovascular malformations. The purpose of this study was to clarify the classification of these challenging vascular lesions in an effort to suggest an appropriate diagnosis and management strategy. METHODS: The authors present a series of 15 patients with intracranial vascular malformations that were angiographically classified as atypical DVAs with arteriovenous shunts. This type of vascular malformation shows a fine arterial blush without a distinct nidus and early filling of dilated medullary veins that drain these arterial components during the arterial phase on angiography. Those prominent medullary veins converge toward an enlarged main draining vein, which together form the caput medusae appearance of a typical DVA. RESULTS: Based on clinical, angiographic, surgical, and histological findings, the authors propose classifying these vascular malformations as a subtype of an arteriovenous malformation (AVM), rather than as a variant of DVA or as a combined vascular malformation. CONCLUSIONS: Correct recognition of this AVM subtype is required for its proper management, and its clinical behavior appears to follow that of a typical AVM. Gamma Knife radiosurgery appears to be a good alternative to resection, although long-term follow-up results require verification.This study was supported in part by a grant from the Korea Health 21 R&D Project, Ministry of Health & Welfare, Republic of Korea (Grant No. A06-0171-B51004-06N1-00040B)

Endovascular coil embolization of anterior choroidal artery aneurysms

Object. Anterior choroidal artery (AChA) aneurysms are difficult to treat, and the clinical outcome of patients is occasionally compromised by ischemic complications after clipping operations. The purpose of this study was to document the outcome and follow-up results of endovascular coil embolization in patients with AChA aneurysms. Methods. Between July 1999 and March 2008, 88 patients with 90 AChA aneurysms ( 31 ruptured and 59 unruptured aneurysms) were treated with endovascular coil embolization in 91 sessions. There were 87 small aneurysms (< 10 mm) and 3 large aneurysms, with a mean aneurysm volume of 60.9 +/- 83.3 mm(3). Preprocedural oculomotor nerve palsy associated with AChA aneurysms was noted in 8 patients. Efficacy and safety were evaluated based on the degree of initial occlusion, procedure-related complications, patient outcome based on the Glasgow Outcome Scale score, and follow-up results. Results. The degree of angiographic occlusion of the aneurysms was complete for 15 aneurysms (17%), near complete for 69 aneurysms (77%) and partial for 6 aneurysms (7%). There were 4 (4.4%) symptomatic procedure-related complications ( 3 thromboembolic events and 1 procedural hemorrhage). The procedural hemorrhage resulted in death; however, the thromboembolic events only caused transient deficits. A favorable outcome ( Glasgow Outcome Scale score of 5 or 4) was achieved in 90% ( 79 of 88) of the patients at the time of discharge. No patient showed signs of bleeding or rebleeding during the follow-up period ( mean 25 months). Major aneurysm recanalization occurred in 2 cases. The AChA aneurysm-associated oculomotor nerve palsy tended to become aggravated transiently after coil embolization and then completely recovered over the course of 2-9 months. Conclusions. Coil embolization is a safe and effective treatment modality in cases of AChA aneurysms. Coil embolization enables procedural recognition of arterial compromise and immediate reestablishment of flow, thus contributing to a favorable outcome. (DOI: 10.3171/2009.4.JNS08934)Kang HS, 2008, NEUROSURGERY, V63, P230, DOI 10.1227/01.NEU.0000320440.85178.CCKim BM, 2008, AM J NEURORADIOL, V29, P286, DOI 10.3174/ajnr.A0806Kang HS, 2008, NEURORADIOLOGY, V50, P171, DOI 10.1007/s00234-007-0320-3Mansour N, 2007, SURG NEUROL, V68, P500, DOI 10.1016/j.surneu.2006.12.061Bulsara KR, 2007, NEUROSURG REV, V30, P307, DOI 10.1007/s10143-007-0089-1Kang HS, 2007, NEUROSURGERY, V61, P51, DOI 10.1227/01.NEU.0000255511.89214.65Kwon OK, 2006, ACTA NEUROCHIR, V148, P1139, DOI 10.1007/s00701-006-0876-4Chen PR, 2006, NEUROSURGERY, V58, P1040, DOI 10.1227/01.NEU.0000215853.95187.5EAntonietti LCL, 2006, CEREBROVASC DIS, V22, P450, DOI 10.1159/000095382Kang HS, 2005, AM J NEURORADIOL, V26, P1921Kwon OK, 2005, AM J NEURORADIOL, V26, P894Kang HS, 2005, AM J NEURORADIOL, V26, P306Kang HS, 2004, AM J NEURORADIOL, V25, P1463Piotin M, 2004, AM J NEURORADIOL, V25, P314Kwon BJ, 2003, NEURORADIOLOGY, V45, P562, DOI 10.1007/s00234-003-1028-7Baldi S, 2003, AM J NEURORADIOL, V24, P1222Kwon BJ, 2002, INTERV NEURORADIOL, V8, P367Kwon OK, 2002, AM J NEURORADIOL, V23, P447Friedman JA, 2001, J NEUROSURG, V94, P565Das K, 1998, J NEUROSURG, V89, P865MORET J, 1997, INTERV NEURORADIOL, V3, P21TAKAHASHI S, 1990, AM J NEURORADIOL, V11, P719HUSSEIN S, 1988, ACTA NEUROCHIR, V92, P19YASARGIL MG, 1984, MICRONEUROSURGERY, V2, P99TAKAHASHI M, 1980, AM J NEURORADIOL, V1, P537VIALE GL, 1979, SURG NEUROL, V11, P141YASARGIL MG, 1978, SURG NEUROL, V9, P129JENNETT B, 1975, LANCET, V1, P480PERRIA L, 1971, ACTA NEUROCHIR, V24, P253DRAKE CG, 1968, J NEUROSURG, V29, P32GALATIUSJENSEN F, 1963, RADIOLOGY, V81, P942MORELLO A, 1955, AM J OPHTHALMOL, V40, P796CARPENTER MB, 1954, AMA ARCH NEUROL PSY, V71, P714

Is Clopidogrel Premedication Useful to Reduce Thromboembolic Events During Coil Embolization for Unruptured Intracranial Aneurysms?

BACKGROUND: Thromboembolism is a common complication related to coil embolization of intracranial aneurysms. OBJECTIVE: To identify factors related to thromboembolic events during coil embolization for unruptured intracranial aneurysms and to evaluate the role of clopidogrel premedication to prevent thromboembolisms. METHODS: Since March 2006, clopidogrel has been administered to patients with unruptured aneurysms before coil embolization (the clopidogrel group) in our institution. The clopidogrel group (416 patients with 485 aneurysms) and the historical control group (140 patients with 159 aneurysms who received no antiplatelet premedication) were compared to find the efficacy of clopidogrel premedication. Various factors, including age, sex, body weight, and medical history of hypertension, diabetes mellitus, hyperlipidemia, smoking, previous stroke, and heart disease, as well as clopidogrel premedication, were analyzed in relationship to the development of a procedure-related thromboembolism. RESULTS: Procedure-related thromboembolic events tended to occur less frequently in the clopidogrel group compared with the control group (7.4% vs 12.6%; P = .05), and clopidogrel premedication could modify the risk in female patients from 11.1% to 5.2% (P = .04). The use of multiple logistic regression analysis identified clopidogrel premedication (P = .03), smoking (P = .002), and hyperlipidemia (P = .02) as significant factors related to the formation of thromboembolism. CONCLUSION: Clopidogrel premedication seems to have a beneficial effect in reducing the number of procedure-related thromboembolisms during coil embolization for unruptured intracranial aneurysms, especially in female patients. Smoking and hyperlipidemia were independent risk factors related to thromboembolism.Mocco J, 2009, J NEUROSURG, V110, P35, DOI 10.3171/2008.7.JNS08322Bhindi R, 2008, QJM-INT J MED, V101, P915, DOI 10.1093/qjmed/hcn089Kang HS, 2008, NEUROSURGERY, V63, P230, DOI 10.1227/01.NEU.0000320440.85178.CCLee DH, 2008, AM J NEURORADIOL, V29, P1389, DOI 10.3174/ajnr.A1070Yousef AM, 2008, J CLIN PHARM THER, V33, P439Tumialan LM, 2008, J NEUROSURG, V108, P1122, DOI 10.3171/JNS/2008/108/6/1122Brooks NP, 2008, J NEUROSURG, V108, P1095, DOI 10.3171/JNS/2008/108/6/1095Prabhakaran S, 2008, AM J NEURORADIOL, V29, P281, DOI 10.3174/ajnr.A0818Yamada NK, 2007, AM J NEURORADIOL, V28, P1778, DOI 10.3174/ainr.A0641Kang HS, 2007, NEUROSURGERY, V61, P51, DOI 10.1227/01.NEU.0000255511.89214.65Kwon OK, 2006, ACTA NEUROCHIR, V148, P1139, DOI 10.1007/s00701-006-0876-4Ihn YK, 2006, ACTA NEUROCHIR, V148, P1045, DOI 10.1007/s00701-006-0881-7Mirkhel A, 2006, AM J CARDIOL, V98, P577, DOI 10.1016/j.amjcard.2006.03.029Ries T, 2006, STROKE, V37, P1816, DOI 10.1161/01.STR.0000226933.44962.a6Kang HS, 2005, AM J NEURORADIOL, V26, P1921Ross IB, 2005, SURG NEUROL, V64, P12, DOI 10.1016/j.surneu.2004.09.045Kwon OK, 2005, AM J NEURORADIOL, V26, P894Park HK, 2005, AM J NEURORADIOL, V26, P506Serebruany VL, 2004, ARCH INTERN MED, V164, P2051Kang HS, 2004, AM J NEURORADIOL, V25, P1463Neubauer H, 2003, EUR HEART J, V24, P1744, DOI 10.1016/S0195-668X(03)00442-1Kwon BJ, 2003, NEURORADIOLOGY, V45, P562, DOI 10.1007/s00234-003-1028-7Kwon BJ, 2002, INTERV NEURORADIOL, V8, P367Derdeyn CP, 2002, J NEUROSURG, V96, P837Pelz DM, 1998, AM J NEURORADIOL, V19, P1541Higashida RT, 1997, J NEUROSURG, V87, P944Moret J, 1997, J NEURORADIOLOGY, V24, P30DOTEVALL A, 1987, EUR J HAEMATOL, V38, P55LEVINE PH, 1973, CIRCULATION, V48, P619KANG HS, AM J NEUROR IN PRESS