Stratification of a population of intracranial aneurysms using blood flow metrics.

Indices of the intra-aneurysm hemodynamic environment have been proposed as potentially indicative of their longitudinal outcome. To be useful, the indices need to be used to stratify large study populations and tested against known outcomes. The first objective was to compile the diverse hemodynamic indices reported in the literature. Furthermore, as morphology is often the only patient-specific information available in large population studies, the second objective was to assess how the ranking of aneurysms in a population is affected by the use of steady flow simulation as an approximation to pulsatile flow simulation, even though the former is clearly non-physiological. Sixteen indices of aneurysmal hemodynamics reported in the literature were compiled and refined where needed. It was noted that, in the literature, these global indices of flow were always time-averaged over the cardiac cycle. Steady and pulsatile flow simulations were performed on a population of 198 patient-specific and 30 idealised aneurysm models. All proposed hemodynamic indices were estimated and compared between the two simulations. It was found that steady and pulsatile flow simulations had a strong linear dependence (r ≥ 0.99 for 14 indices; r ≥ 0.97 for 2 others) and rank the aneurysms in an almost identical fashion (ρ ≥ 0.99 for 14 indices; ρ ≥ 0.96 for other 2). When geometry is the only measured piece of information available, stratification of aneurysms based on hemodynamic indices reduces to being a physically grounded substitute for stratification of aneurysms based on morphology. Under such circumstances, steady flow simulations may be just as effective as pulsatile flow simulation for estimating most key indices currently reported in the literature

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

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

Rapid Decline in Telestroke Consults in the Setting of COVID-19.

Background and Purpose: As coronavirus disease 2019 (COVID-19) continues to be a global pandemic, there is a growing body of evidence suggesting that incidence of diseases that require emergent care, particularly myocardial infarction and ischemic stroke, has declined rapidly. The objective of this study is to quantify our experience of telestroke (TS) consults at a large tertiary comprehensive stroke center during the COVID-19 pandemic. Methods: We retrospectively reviewed TS consults of patients presenting to our neuroscience network. Those with a confirmed diagnosis of acute ischemic stroke or transient ischemia attack were included. Data were compared from April 1, 2019, to June 30, 2020, which include consults prepandemic and during the crisis. Results: A total of 1,982 TS consults were provided in 1 year. Prepandemic, the mean monthly consults were 148. In April 2020, only 59 patients were seen (49% decline). Mobile stroke unit consults decreased by 72% in the same month. The 30-day moving average of patients seen per day was between five and six prepandemic declined to between two and three in April, and then began to uptrend during May. The mean percentage of patients receiving intravenous tissue plasminogen activator was 16% from April 2019 to March 2020 and increased to 31% in April 2020. The mean percentage of patients receiving endovascular therapy was 10% from April 2019 to March 2020 and increased to 19% in April 2020. Conclusions: At our large tertiary comprehensive stroke center, we observed a significant and rapid decline in TS consults during the COVID-19 pandemic. We cannot be certain of the reasons for the decline, but a fear of contracting coronavirus, social distancing, and isolation likely played a major role. Further research must be done to elucidate the etiology of this decline

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

Gastric Perforation From a Migrating Ventriculoperitoneal Shunt: A Case Report and Review of Literature

Ventriculoperitoneal (VP) shunts represent a surgical option for patients affected by increased intracranial hypertension when medical management fails or is contraindicated. Complications following implantation include shunt obstruction, infection, over and under drainage, migration or disconnection of the tube, formation of a pseudocyst, and allergy to the silicone tube. We report the case of a 31-year-old woman who presented to the emergency room with nausea and generalized malaise, found to have the distal segment of the VP catheter perforating her gastric wall into the stomach lumen which required surgical intervention. In this report, we describe a rare complication associated with the implantation of ventriculoperitoneal shunt (VPS) catheters and the subsequent management plan

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

Management of patients with isolated acute cervical carotid artery occlusion and normal neurological exam: Technical note and case series

Objectives Limited data exists on the management and outcome of patients with isolated acute cervical internal carotid artery (cICA) occlusion presenting with normal neurologic exam after experiencing a period of neurological deficits. These patients are at risk for progressive neurologic deterioration but have not yet progressed to stroke. Current management is no intervention due to intervention risk of embolization. We aim to determine the optimal management of patients with isolated acute cICA occlusion presenting with a normal neurological exam after experiencing neurological deficits. Patients and methods Data was collected on 3 patients with acute cICA occlusion that presented with a normal neurological exam to our institution. Patient 1 was treated according to standard protocol, while patients 2 and 3 were treated according to the management discussed. Associations between perfusion imaging studies and clinical outcome were analyzed to determine stroke risk. A revascularization technique to minimize risk of distal embolization is described. Results A total of 3 consecutive patients with acute cICA occlusion were successfully revascularized. Patients 2 and 3 (66.67%) were neurologically intact post-operatively, while patient 1 (33.33%) had residual hemiparesis. It seems that MTT ≥ 200% or Tmax \u3e 6 s is the optimal penumbra threshold predicting infarction and neurologic deterioration. There were no embolic complications as a result of endovascular therapy (EVT). Conclusion Cerebral perfusion imaging of patients presenting with normal neurological exam after experiencing neurological deficits is warranted to help identify patients at risk for stroke due to collateral failure. These patients should be monitored in the ICU for neurologic deterioration and given the option of intervention if mismatch is noted on CT perfusion imaging. Perfusion studies identifying penumbra and delayed MTT ≥ 200% or Tmax \u3e 6 s are indicators for possible collateral failure. In patients undergoing intervention, we suggest a technique using proximal flow arrest to minimize risk of shower emboli. Further studies are needed to verify our findings

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