Flow-diversion panacea or poison?

Endovascular therapy is now the treatment of choice for intracranial aneurysms (IAs) for its efficacy and safety profile. The use of flow diversion (FD) has recently expanded to cover many types of IAs in various locations. Some institutions even attempt FD as first line treatment for unruptured IAs. The most widely used devices are the pipeline embolization device (PED), the SILK flow diverter (SFD), the flow redirection endoluminal device (FRED), and Surpass. Many questions were raised regarding the long-term complications, the optimal regimen of dual antiplatelet therapy, and the durability of treatment effect. We reviewed the literature to address these questions as well as other concerns on FD when treating IAs

Rare Case of Diffuse Spinal Arachnoiditis Following a Complicated Vertebral Artery Dissection

Spinal arachnoiditis (SA) is an extremely rare and delayed complication of intracranial subarachnoid hemorrhage (SAH). SA is an inflammatory process leading to chronic fibrosis of the spinal cord. Possible pathophysiology is a two-staged disease of initial inflammatory reaction secondary to SAH, followed by a “free interval phase” prior to delayed adhesive phase (i.e. SA). The clinical course can be complicated and is the cause of major morbidity.https://jdc.jefferson.edu/neurosurgeryposters/1009/thumbnail.jp

Management of head and neck pseudoaneurysms: a review of 33 consecutive cases.

Background. Endosaccular coiling, vessel occlusion, stenting, stent-assisted coiling, and flow diversion are all endovascular treatment options for pseudoaneurysms (PAs) of the head and neck. We explore different clinical situations in which these were selected for PA management at a single institution. Methods. Over a period of ten years, 33 patients presented to our hospital with PAs of the head and neck. Their outcomes and procedural complications are discussed. Results. We observed a complication rate of 18.2% (6 of 33), consisting predominantly of infarcts following vessel occlusion. As measured by the modified Rankin Scale, 25 (75.8%) patients had achieved favorable outcomes on discharge. A single patient who was treated with stent-assisted coiling expired following procedural complications. Conclusions. In our series, most patients with traumatic/iatrogenic PAs were successfully treated with parent vessel sacrifice. When parent vessel occlusion is not an option, stenting with or without coiling, or flow diversion, may also be safe and effective alternatives

Extending the indications of flow diversion to small, unruptured, saccular aneurysms of the anterior circulation.

BACKGROUND AND PURPOSE: Flow diverters are currently indicated for treatment of large and complex intracranial aneurysms. The purpose of this study was to determine whether the indications of flow diversion can be safely extended to unruptured, small, saccular aneurysms (\u3c10 \u3emm) of the anterior circulation. METHODS: Forty patients treated with the pipeline embolization device (PED) were matched in a 1:4 fashion with 160 patients treated with stent-assisted coiling based on patient age, sex, aneurysm location, and aneurysm size. Procedural complications, angiographic results, and clinical outcomes were analyzed and compared. RESULTS: The rate of periprocedural complications was 5% in the PED group and 3% in the stent-coil group (P=0.7). In multivariable analysis, increasing age was the only predictor of complications. At follow-up, a higher proportion of aneurysms treated with PED (80%) achieved complete obliteration compared with stent-coiled aneurysms (70%) but the difference did not reach statistical significance (P=0.2). In multivariable analysis, increasing aneurysm size and aneurysm location were predictors of nonocclusion. The rate of favorable outcome (modified Rankin Scale, 0-2 and modified Rankin Scale, 0-1) was similar in the PED group and the coil group. CONCLUSIONS: The PED was associated with similar periprocedural risks, clinical outcomes, and angiographic results compared with stent-assisted coiling. These findings suggest that the indications of PED can be safely extended to small intracranial aneurysms that are amenable to conventional endovascular techniques. Larger studies with long-term follow-up are necessary to determine the optimal treatment that leads to the highest rate of obliteration and best clinical outcomes

Selection Criteria for Posterior Circulation Stroke and Functional Outcome Following Mechanical Thrombectomy

Objective: 20% of all acute ischemic strokes (AIS) are caused by posterior circulation strokes, which carry an intensified mortality touching 95%. Early recanalization improves outcome as shown by several reports; however, safety, patient selection, and prognostic factors remain lacking. An investigation of the safety and prognostic factors for posterior circulation mechanical thrombectomy (MT) was performed. Methods: A retrospective review of patients presenting with posterior circulation AIS, who underwent MT between 2010 and 2018. Results: Of 443 patients who underwent MT for AIS, 83 patients had posterior circulation strokes. 95% of procedures were conducted under general anesthesia. The median NIHSS upon admission was 19.1. Half of the patients underwent MT 8 hours from symptom onset, and half required a salvage contact thrombus aspiration after a stent retriever trial with an average of two passes for successful recanalization. The time to achieve revascularization was 61.6 minutes. Mortality rate was 28%, and modified Rankin Scale (mRS) \u3c 2 at three months was seen in 40.1% of surviving patients. A higher functional outcome trend (mRS\u3c2) was seen in patients who underwent MT within 8 hours of symptom onset. The overall complication rate was 28%. Regression analysis showed that stroke subtype, baseline NIHSS, and posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) before thrombectomy were independent predictive factors of positive clinical outcomes. Conclusions: MT is an effective intervention for posterior circulation strokes, and long-term functional independence relies upon proper patient selection. Baseline NIHSS and pc-ASPECTS are independent predictive factors

Mechanical Thrombectomy in Acute Ischemic Stroke Patients Greater than 90 years of age experience in 26 patients in a Large Tertiary Care Center: Outcome comparison with younger patients

Introduction: Several independent randomized control trials have shown the superior efficacy of mechanical thrombectomy for acute ischemic stroke (AIS). However, the elderly has been underrepresented or excluded in these trials. In this study, we investigated the feasibility and safety of mechanical thrombectomy in patients with AIS aged 90 years or greater. Methods: A retrospective review of patients age 90 years or older presenting with AIS who underwent mechanical thrombectomy between 2010 and 2018. Results: Of total 453 patients with AIS, 5.74 % (26) were aged 90 or older, and 69.32 % (314) ranged from 60-89 years of age. Of all baseline characteristics between both groups, there is a significant difference in age, gender, body mass index (BMI), smoking, hyperlipidemia (HLD), atrial fibrillation, and diabetes mellitus. The mean NIHSS upon admission was higher in the nonagenarians (17 vs. 15). Similar proportions of both groups received tPA (57.69%, 15 vs. 42.68%, 134, p=0.14). There was no difference in peri & post-procedural complications, good TICI score (88.46%, 23 vs. 87.58%, 275, p=1.00), “good” mRS scores (34.62%, 4 vs. 49.36%, 155, p=0.40), and mortality (11.54%, 3 vs. 13.06%, 41, p= 0.82). Discussion: Age is one of the factors that affect functional outcome following mechanical thrombectomy. Advancements in catheter techniques, technical experience, and great outcomes with mechanical thrombectomy allow for pushing the envelope to deal with age as one of the factors, rather, than an exclusion criterion. Our results show that mechanical thrombectomy is safe and feasible in nonagenarians

Access-Site Complications in Transfemoral Neuroendovascular Procedures: A Systematic Review of Incidence Rates and Management Strategies

BACKGROUND: The femoral artery is the most common access route for cerebral angiography and neurointerventional procedures. Complications of the transfemoral approach include groin hemorrhages and hematomas, retroperitoneal hematomas, pseudoaneurysms, arteriovenous fistulas, peripheral artery occlusions, femoral nerve injuries, and access-site infections. Incidence rates vary among different randomized and nonrandomized trials, and the literature lacks a comprehensive review of this subject. OBJECTIVE: To gather data from 16 randomized clinical trials (RCT) and 17 nonrandomized cohort studies regarding femoral access-site complications for a review paper. We also briefly discuss management strategies for these complications based on the most recent literature. METHODS: A PubMed indexed search for all neuroendovascular clinical trials, retrospective studies, and prospective studies that reported femoral artery access-site complications in neurointerventional procedures. RESULTS: The overall access-site complication rate in RCTs is 5.13%, while in in non-RCTs, the rate is 2.78%. The most common complication in both groups is groin hematoma followed by access-site hemorrhage and femoral pseudoaneurysm. On the other hand, wound infection was the least common complication. CONCLUSION: The transfemoral approach in neuroendovascular procedures holds risk for several complications. This review will allow further studies to compare access-site complications between the transfemoral approach and other alternative access sites, mainly the transradial approach, which is gaining a lot of interest nowadays

Improving Serial Imaging Protocols in Spontaneous Intracerebral Hemorrhage

There is no universally agreed upon protocol to image patient presenting with intra-parenchymal hemorrhage of non-traumatic etiology (sICH). At our institution, it is common practice for a patient to have 3 CT’s done within 24 hours. They are often at onset of symptoms or presentation, 6 hours post onset of symptoms, and finally 24 hours post bleed onset. The goal of this project will be to assess the safety and efficacy of obtaining this repeat imaging in our patients in the hopes that limiting unnecessary CT head studies will decrease resource utilization, decrease patient radiation, expedite movement of stable patients out of the ICU and/or disposition

Standardizing Postoperative Handoffs Using the Evidence-Based IPASS Framework Improves Handoff Communication for Postoperative Neurosurgical Patients in the Neuro-Intensive Care Unit

Aims for Improvement Within one year of initiation of the process improvement plan, we wanted to improve: Direct communication of airway and hemodynamic concerns Direct communication of operative events, complications, and perioperative management goals. Attendance at postoperative handoffs Confirmation of information by receiving teams Staff perceptions of handoff efficacy and teamwork

Surgical Evacuation for Chronic Subdural Hematoma: Predictors of Reoperation and Functional Outcomes

Background Although chronic subdural hematoma (CSDH) incidence has increased, there is limited evidence to guide patient management after surgical evacuation. Objective To identify predictors of reoperation and functional outcome after CSDH surgical evacuation. Methods We identified all patients with CSDH between 2010 and 2018. Clinical and radiographic variables were collected from the medical records. Outcomes included reoperation within 90 days and poor (3–6) modified Rankin Scale score at 3 months. Results We identified 461 surgically treated CSDH cases (396 patients). The mean age was 70.1 years, 29.7 % were females, 298 (64.6 %) underwent burr hole evacuation, 152 (33.0 %) craniotomy, and 11 (2.4 %) craniectomy. Reoperation rate within 90 days was 12.6 %, whereas 24.2 % of cases had a poor functional status at 3 months. Only female sex was associated with reoperation within 90 days (OR = 2.09, 95 % CI: 1.17–3.75, P = 0.013). AMS on admission (OR = 5.19, 95 % CI: 2.15–12.52, P \u3c 0.001) and female sex (OR = 3.90, 95 % CI: 1.57–9.70, P = 0.003) were independent predictors of poor functional outcome at 3 months. Conclusion Careful management of patients with the above predictive factors may reduce CSDH reoperation and improve long-term functional outcomes. However, larger randomized studies are necessary to assess long-term prognosis after surgical evacuation