Clinical and experimental aspects of aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) continues to be associated with significant morbidity and mortality despite advances in care and aneurysm treatment strategies. Cerebral vasospasm continues to be a major source of clinical worsening in patients. We intended to review the clinical and experimental aspects of aSAH and identify strategies that are being evaluated for the treatment of vasospasm. A literature review on aSAH and cerebral vasospasm was performed. Available treatments for aSAH continue to expand as research continues to identify new therapeutic targets. Oral nimodipine is the primary medication used in practice given its neuroprotective properties. Transluminal balloon angioplasty is widely utilized in patients with symptomatic vasospasm and ischemia. Prophylactic “triple‐H” therapy, clazosentan, and intraarterial papaverine have fallen out of practice. Trials have not shown strong evidence supporting magnesium or statins. Other calcium channel blockers, milrinone, tirilazad, fasudil, cilostazol, albumin, eicosapentaenoic acid, erythropoietin, corticosteroids, minocycline, deferoxamine, intrathecal thrombolytics, need to be further investigated. Many of the current experimental drugs may have significant roles in the treatment algorithm, and further clinical trials are needed. There is growing evidence supporting that early brain injury in aSAH may lead to significant morbidity and mortality, and this needs to be explored further.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/151874/1/cns13222_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/151874/2/cns13222.pd

Stroke recurrence in pregnancy: Experience at a regional referral center

BACKGROUND: Although stroke is more common with advancing age, especially in the elderly, women of reproductive age may still suffer from stroke, and from its deleterious consequences. Women of reproductive age who suffer a stroke may do so either due to a specific predisposition, or due to pregnancy-related hypertensive emergencies. OBJECTIVE: To assess the risk of stroke recurrence in pregnancy and the postpartum period in women who have suffered a stroke before pregnancy. STUDY DESIGN: This was a retrospective cohort study conducted at Thomas Jefferson University Hospital from January 2005 to December 2015. This is a tertiary referral center for high-risk obstetrics and one of the largest stroke referral centers for neurosurgery. All consecutive pregnant women that had a viable pregnancy (≥24 weeks of gestation) and a history of stroke prior to pregnancy were identified. The primary outcome of this study was stroke recurrence in pregnancy or the postpartum period defined as 6 weeks after delivery. RESULTS: Forty-eight pregnancies with a history of stroke before pregnancy were identified in 24 women. Thirty-one pregnancies (64.6%) had a history of an ischemic stroke, 11 (22.9%) had a history of transient ischemic attack, and 6 (12.5%) had a history of a hemorrhagic stroke. There was no stroke recurrence during pregnancy or the postpartum period for the three groups of stroke. In the ischemic stroke group, 8 (25.8%) had recurrence in the non-pregnant state compared to none in the TIA and the hemorrhagic stroke group. CONCLUSION: There was no stroke recurrence during pregnancy or the postpartum period for the three groups of stroke

Decompressive Hemicraniectomy: Predictors and Functional Outcome In Patients With Ischemic Stroke

BACKGROUND Patients presenting with large ischemic strokes may develop uncontrollable, progressive brain edema that risks compression of brain parenchyma and cerebral herniation.1 Edema that does not respond to medical treatment necessitates decompressive hemicraniectomy (DH) as a life-saving procedure. The functional outcome of patients is uncertain and the patient’s family is presented with the difficult decision of intervention with DH. While the functional outcome of patients is not worsened by DH,2 neurological deficit is likely as a result of initial large-territory ischemia. The correlation of specific clinical variables preceding DH to patient outcome helps inform clinicians and families about prognosis.3 This study identifies an array of clinical variables in patients who underwent DH for ischemic stroke in order to investigate potential predictors of functional outcome. METHOD A total of 1,624 subjects that underwent any type of craniectomy from 2006 to 2014 were retrospectively screened via electronic medical record. The specific selection criterion was DH secondary to ischemic stroke involving the middle cerebral artery (MCA), internal carotid artery (ICA), or both. Subjects were excluded if they underwent craniectomy for any reason other than DH for ischemic stroke; or if the MCA or ICA were not implicated. The clinical variables that were collected may be divided into pre-DH and post-DH. The pre-DH variables involve patient demographics and past medical history, in addition to clinical variables during the period of presentation and clinical management leading up to DH. The post-DH variables describe the in-patient recovery period and discharge status. The primary outcome was functional status assessed by the Modified Rankin Scale (MRS) score at 90 days post-DH. The MRS ranges from 0 (no symptoms) to 6 (death) with intermediate values (1-5) representing increasing functional and cognitive disability

Clinical Applications of the Pipeline Embolization Device

No abstract availabl

A New Protocol for Anticoagulation With Tirofiban During Flow Diversion

Abstract BACKGROUND: Flow diversion is increasingly used to treat intracranial aneurysms. In previous reports, patients were pretreated with aspirin and clopidogrel before the intervention for the prevention of thromboembolic complications. OBJECTIVE: To assess the safety and efficacy of a new protocol for anticoagulation using tirofiban during flow diversion. METHODS: All patients received a 0.10–μg.kg−1.min−1 maintenance infusion of tirofiban intraoperatively without a loading dose. All patients were loaded with aspirin (325 mg) and clopidogrel (600 mg) just before the procedure or intraoperatively. No patient was pretreated with aspirin or clopidogrel. Thromboembolic and hemorrhagic complications were recorded. RESULTS: A total of 46 patients were treated with this protocol. Six patients (13%) had sustained a subarachnoid hemorrhage and were treated with the Pipeline Embolization Device within 24 hours of aneurysm rupture. The mean number of devices was 1.2 ± 0.66; adjunctive coiling was performed in 3 patients (6.5%). There were 2 complications (4.3%), 1 thromboembolic (2.2%) and 1 hemorrhagic (2.2%; monocular vision loss from occlusion of the central retinal artery in 1 patient and a parenchymal hemorrhage managed conservatively in another patient). No patient developed thrombocytopenia or retroperitoneal, gastrointestinal, or genitourinary bleeding. Of 46 patients, 44 (95.7%) had a modified Rankin Scale score of 0 to 2 at their follow-up visit. CONCLUSION: A protocol of anticoagulation with tirofiban during flow diversion has an excellent safety profile. This protocol provides a reasonable alternative to pretreatment with aspirin and clopidogrel and is useful in patients with ruptured aneurysms or when the use of a stent is unexpected

Dissecting pseudoaneurysms: predictors of symptom occurrence, enlargement, clinical outcome, and treatment

OBJECTIVE Dissection of the carotid and vertebral arteries can result in the development of aneurysmal dilations. These dissecting pseudoaneurysms can enlarge and cause symptoms. The objective of this study is to provide insight into the progression of dissecting pseudoaneurysms and the treatments required to manage them. METHODS A review of the electronic medical records was conducted to detect patients with carotid and vertebral artery dissection. An imaging review was conducted to identify patients with dissecting pseudoaneurysms. One hundred twelve patients with 120 dissecting pseudoaneurysms were identified. Univariate and multivariate analyses were conducted to assess the factors associated with undergoing further interventions other than medical treatment, pseudoaneurysm enlargement, pseudoaneurysms resulting in ischemic and nonischemic symptoms, and clinical outcome. RESULTS Overall, 18.3% of pseudoaneurysms were intracranial and 81.7% were extracranial, and the average size was 7.3 mm. The mean follow-up time was 29.3 months; 3.3% of patients had a recurrent transient ischemic attack, no patients had a recurrent stroke, and 14.2% of patients had recurrence of nonischemic symptoms (headache, neck pain, Horner syndrome, or cranial nerve palsy). Follow-up imaging demonstrated that 13.8% of pseudoaneurysms had enlarged, 30.2% had healed, and 56% had remained stable. In total, 20.8% of patients had an intervention other than medical treatment. Interventions included stenting, coiling, flow diversion, and clipping. Predictors of intervention included increasing size, size > 10 mm, location in the C (petrous) segment of the internal carotid artery (ICA), younger age, hyperlipidemia, pseudoaneurysm enlargement, and any symptom development. Significant predictors of enlargement included smoking, history of trauma, C location, hyperlipidemia, and larger initial pseudoaneurysm size. Predictors of pseudoaneurysm resulting in recurrent ischemic and nonischemic symptoms included increasing size and location in the petrous segment of the ICA. Smoking was a predictor of unfavorable outcome. CONCLUSIONS Dissecting pseudoaneurysms have a benign course and most will not cause symptoms or enlarge on follow-up. Medical treatment can be a sufficient, initial treatment for dissecting pseudoaneurysms

P2Y12 Reaction Units: Effect on Hemorrhagic and Thromboembolic Complications in Patients With Cerebral Aneurysms Treated With the Pipeline Embolization Device

The main concern with the use of the pipeline embolization device (PED) in treating cerebral aneurysms is the risk of hemorrhagic and thromboembolic complications. To investigate if P2Y12 reaction unit (PRU) values are associated with hemorrhagic and thromboembolic complications after treatment with the PED and to find an optimal range of preprocedural PRU values. Two hundred thirty-one patients with 248 cerebral aneurysms treated with the PED were retrospectively identified. Patients were started on dual-antiplatelet treatment at least 10 days before the intervention. PRU values were checked. Univariate and multivariate logistic regression were performed. Youden Indices were calculated to determine cutoffs for optimal PRU values. Mean patient age was 57 years. Mean last preprocedural PRU was 132 (range: 1-382). The combined rate of major hemorrhagic complications (4%) and major thromboembolic complications (5.6%) was 9.6%. Analysis using Youden indices suggested an optimal PRU range of 70 to 150 with higher odds of complications outside this range (P = .01, odds ratio [OR] = 3 [1.2-7.5]). PRU 240 was a significant predictor of any thromboembolic complication (P = .04, OR = 3.6 [1.04-12]) and cerebral thromboembolic complications (P = .02, OR = 4 [1.2-14]). Target preoperative PRU values should be between 60 and 240 and ideally between 70 and 150. Values below this range and above it carry higher odds of hemorrhagic and thromboembolic complications, respectively

Predictors of Outcome, Complications, and Recanalization of the Solitaire Device: A Study of 89 Cases

The use of mechanical thrombectomy in the management of acute ischemic stroke is becoming increasingly popular. To identify notable factors that affect outcome, revascularization, and complications in patients with acute ischemic stroke treated with the Solitaire Flow Restoration Revascularization device. Eighty-nine patients treated with the Solitaire Flow Restoration Revascularization device (ev3/Covidien Vascular Therapies, Irvine, California) were retrospectively analyzed. Three endpoints were considered: revascularization (Thrombolysis In Cerebral Infarction), outcome (modified Rankin Scale score), and complications. Univariate analysis and multivariate logistic regression were conducted to determine significant predictors. The mean time from onset of symptoms to the start of intervention was 6.7 hours. The average procedure length was 58 minutes. The mean NIH Stroke Scale (NIHSS) score was 16 on arrival and 8 at discharge. Of the patients, 6.7% had a symptomatic intracerebral hemorrhage, 16.8% had fatal outcomes within 3 months post-intervention, and 81.4% had a successful recanalization. Thrombus location in the M1 segment of the middle cerebral artery was associated with successful recanalization (thrombolysis in cerebral infarction 2b/3) (P = .003). Of the patients, 56.6% had a favorable outcome (modified Rankin Scale score at 3 months: 0-2). In patients younger than 80 years of age, 66.7% had favorable outcome. Increasing age (P = .01) and NIHSS score (P = .002) were significant predictors of a poor outcome. On multivariate analysis, NIHSS score on admission (P = .05) was a predictor of complications. On univariate analysis, increasing NIHSS score from admission to 24 hours after the procedure (P = .05) and then to discharge (P = .04) was a predictor of complications. Thrombus location in the posterior circulation (P = .04) and increasing NIHSS score (P = .04) predicted mortality. The Solitaire device is safe and effective in achieving successful recanalization after acute ischemic stroke. Important factors to consider include age, NIHSS score, and location

Predictors of restenosis after carotid artery stenting in 241 cases

Variable rates of restenosis after carotid artery stenting (CAS) have been reported, and few predictors have been suggested. Because CAS is being performed with increasing frequency, more data are needed to evaluate the rate and predictors of restenosis and possibly identify new risk factors for restenosis after CAS. The aim of this study was to analyze the rate and predictors of restenosis after CAS. 241 patients with carotid artery stenosis treated with stenting were analyzed retrospectively to identify patients who had restenosis after stenting. Univariate analysis and multivariate logistic regression were conducted to determine the predictors of restenosis. Mean patient age was 67.5 years. 8.3% of patients who underwent CAS had carotid restenosis of ≥50% during follow-up. 3.7% of patients required retreatment. Mean duration from CAS to retreatment was 11 months. In multivariate analysis, the predictors of restenosis included history of cardiovascular disease (OR=8.88, p<0.001) and having a cerebrovascular accident (CVA) prior to stenting (OR=1.87, p=0.034). A higher percentage of preoperative carotid stenosis was associated with higher odds of restenosis in univariate analysis (p=0.04, OR stenosis ≥80%=5.7). Our results suggest that the rate of carotid restenosis after stenting is low. Patients with cardiovascular disease, patients who had a CVA prior to stenting, and patients with higher percentages of preoperative stenosis had higher odds of restenosis. Higher rates of restenosis should be kept in mind when opting for CAS in these patients