HEMORRHAGIC PROGRESSION OF CONTUSION IN PATIENTS WITH MILD TRAUMATIC BRAIN INJURY ON THE ROUTINE REPEAT HEAD COMPUTED TOMOGRAPHY

Computed tomography (CT) scan is a standard for the diagnosis of intracranial pathology after traumatic brain injury (TBI). Hemorrhagic progression of contusion (HPC) is frequently seen on repeat CT, but its clinical and radiological significance in case of mild TBI is not well define. The aim of the study: to evaluate the result of routine repeat head CT in patients with mild TBI and brain contusions. Materials and methods: retrospective analysis of management of patients with mild TBI (Glasgow Coma Scale (GCS) score – 13 to 15) and cerebral contusion. All patients were treated at the Kyiv City Clinical Emergency Hospital between 2016 and 2017. Results: within 202 patients with mild TBI, 87 (43.1 %) met the inclusion criteria and were selected for detailed analysis. There were 69 (79.3 %) men and 18 (20.7 %) women. The mean age of the patients was 43.8±12.7 years (17–82 years). The average time between trauma and CT was 3.3 hours. The average volume of contusion on the initial CT was 1.9±0.6 cm3 (0.2–9.6 cm3). The average time of routine CT was 6.8 hours (range 4–24 hours) after the initial scans. HPC was found in 24 (30.7 %) of 87 cases. The average volume of brain contusion on the repeat CT was 2.3±0.5 cm3 (0.2-17.1 cm3). In 3 (3.4 %) patients the size of the hematoma increased. Clinical deterioration occurred in 10 (11.5 %) patients. Six (6.9 %) patients were operated after a CT scan due to HPC with midline shift in 4 cases and increasing of subdural hematoma – 2 cases. Four of these patients had clinical deterioration, and 2 patients were neurological stable. Patients with HPC at admission had lower points of GCS, fractures of the skull (both p <0.001), subdural blood collection (p=0.002), a higher average duration of treatment 8.1±4.2 vs 14.3±5.2 days (p=0.0001), and mortality rate 0 vs. 3 (12.5 %) (p=0.02). Conclusions: Routine repeat CT in patients with mild TBI with brain contusions is aimed to find a patients with s high risk for clinical deterioration. One third of patients with mild TBI and brain contusion experienced HPC. Patients with HPC often have unfavorable clinical course with higher average duration of treatment, delay surgical treatment and mortality rate

Thrombectomy Outcomes for Anterior Circulation Stroke in the 6–24 h Time Window Solely Based On NCCT and CTA: A Single Center Study

Purpose Since perfusion imaging may be unavailable in smaller hospitals, alternative imaging selection methods for acute ischemic stroke can improve outcomes and optimize resources. This study assessed the safety and effectiveness of using imaging criteria other than DEFUSE 3 and DAWN for thrombectomy beyond 6 h from symptom onset in patients stroke in the anterior circulation. Methods This is a retrospective, single-center analysis of consecutive patients with large vessel occlusion in the anterior circulation undergoing thrombectomy. Patients were categorized into two groups based on the collateral status (moderate collaterals and good collaterals). Results Among 198 patients, 106 (54%) met the inclusion criteria and were analyzed. Good collateral status was observed in 78 (74%) patients. Patients with good collaterals showed significantly lower mRS scores at discharge and at 90 days compared to their counterparts with moderate collateral status (4 (3–4) vs. 4 (4–5); p = 0.001 and 2 (0–4) vs. 6 (3–6); p < 0.001, respectively). More patients with good collateral status achieved favorable outcomes at 90 days compared to those with moderate status (48 (61.5%) vs. 5 (17.9%); p < 0.001). Good collaterals were an independent predictor of good clinical outcomes at 90 days (OR = 1.31, 95% CI: 1.13–1.53, p < 0.001). Conclusion Selecting patients for endovascular treatment of acute ischemic stroke using non-contrast CT and CT angiography shows 90-day outcomes similar to the DAWN and DEFUSE-3 trials. Using collateral status on CT angiography can predict favorable outcomes after mechanical thrombectomy in resource-limited settings where perfusion imaging is unavailable

Results of the Treatment and Evaluation of Quality of Life in Patients with High-Grade Cerebral Arteriovenous Malformations after Endovascular Embolization

Treatment options for cerebral arteriovenous malformations (cAVMs) may include radiosurgery, endovascular embolization, microsurgical removal, or a combination thereof. However, treatment of high-grade (Spetzler–Martin grades IV and V) cAVMs remains extremely challenging when aiming complete occlusion. The aim. To study the safety of the endovascular embolization in patients with high-grade cAVMs and its impact on the quality of life (QoL). Materials and methods. Between 2012 and 2022, 174 patients with cAVMs were endovascularly treated at Research and Practical Center for Endovascular Neuroradiology of the National Academy of Medical Sciences of Ukraine with an average follow-up of more than 9 months. Of these patients, 11 (6.3%) and 6 (3.4%) had Spetzler–Martin grade IV and grade V cAVM, respectively. Outcomes after surgical procedures were assessed and QoL was evaluated using standardized EQ-5D-3L questionnaire. Results. Five (29.4%) patients had intracerebral hemorrhage, 6 (35.3%) had seizures, 5 (29.4%) had other non-hemorrhagic manifestations and 1 (5.9%) patient had a neurological deficit as a result of cerebral steal. In 17 patients, 28 embolization sessions were performed, and in nearly all of them (96%) N-butyl cyanoacrylate was used as the preferred embolic agent. There were no procedural complications. After embolization, three (17.6%) patients had neurologic deterioration (temporary in 2 patients and persistent in 1 patient). All the patients were alive at the nearest follow-up. After embolization, 2 (11.7%) patients had recurrent hemorrhage, but without additional morbidity. Two of the five patients after cAVM rupture had some degree of disability. With regard to non-hemorrhagic debut, 8 (72%) patients reported symptom reduction. QoL assessment with EQ-5D-3L questionnaire revealed that severe problems were present in 2 (33.3%) of 6 patients after intracerebral hemorrhage and 2 (18.2%) of 11 patients with non-hemorrhagic manifestation. The mean Visual Analogue Scale score for the hemorrhagic group was 76.4 ± 15 points, while the non-hemorrhagic group’s score was 85.2 ± 14 points. Conclusions. Endovascular embolization, which aims to occlude the bleeding site or improve cerebral steal with a manageable consequence profile, can be used safely in carefully selected patients with high-grade cAVMs. Our experience shows that QoL can be satisfactory in 3/4 of patients after high-grade cAVM embolization, and more data from real-world practice are highly needed to determine the best method and time for improving patient outcomes

HEMORRHAGIC PROGRESSION OF CONTUSION IN PATIENTS WITH MILD TRAUMATIC BRAIN INJURY ON THE ROUTINE REPEAT HEAD COMPUTED TOMOGRAPHY

Computed tomography (CT) scan is a standard for the diagnosis of intracranial pathology after traumatic brain injury (TBI). Hemorrhagic progression of contusion (HPC) is frequently seen on repeat CT, but its clinical and radiological significance in case of mild TBI is not well define. The aim of the study: to evaluate the result of routine repeat head CT in patients with mild TBI and brain contusions. Materials and methods: retrospective analysis of management of patients with mild TBI (Glasgow Coma Scale (GCS) score – 13 to 15) and cerebral contusion. All patients were treated at the Kyiv City Clinical Emergency Hospital between 2016 and 2017. Results: within 202 patients with mild TBI, 87 (43.1 %) met the inclusion criteria and were selected for detailed analysis. There were 69 (79.3 %) men and 18 (20.7 %) women. The mean age of the patients was 43.8±12.7 years (17–82 years). The average time between trauma and CT was 3.3 hours. The average volume of contusion on the initial CT was 1.9±0.6 cm3 (0.2–9.6 cm3). The average time of routine CT was 6.8 hours (range 4–24 hours) after the initial scans. HPC was found in 24 (30.7 %) of 87 cases. The average volume of brain contusion on the repeat CT was 2.3±0.5 cm3 (0.2-17.1 cm3). In 3 (3.4 %) patients the size of the hematoma increased. Clinical deterioration occurred in 10 (11.5 %) patients. Six (6.9 %) patients were operated after a CT scan due to HPC with midline shift in 4 cases and increasing of subdural hematoma – 2 cases. Four of these patients had clinical deterioration, and 2 patients were neurological stable. Patients with HPC at admission had lower points of GCS, fractures of the skull (both p &lt;0.001), subdural blood collection (p=0.002), a higher average duration of treatment 8.1±4.2 vs 14.3±5.2 days (p=0.0001), and mortality rate 0 vs. 3 (12.5 %) (p=0.02). Conclusions: Routine repeat CT in patients with mild TBI with brain contusions is aimed to find a patients with s high risk for clinical deterioration. One third of patients with mild TBI and brain contusion experienced HPC. Patients with HPC often have unfavorable clinical course with higher average duration of treatment, delay surgical treatment and mortality rate.</jats:p

Вторинна геморагічна прогресія вогнищ забою головного мозку у пацієнтів при черепно-мозковій травмі

Introduction. Secondary posttraumatic changes of the brain often are determining in the clinical flow of traumatic brain injury (TBI). Prevention, detection and determination of treatment strategy at secondary hemorrhagic progression of contusion (SHPC) are very actual for neurotraumatology.Materials and methods. The results of 110 injured persons with TBI were analyzed.Results. It was found that SHPC occurs in 50% patients with TBI, as in areas of primary brain damage as in remote areas on the other side of the brain during 12 h ad also after 3–4 days. SHPC often is revealed in patients with subdural hematoma. The bigger contusion foci, the higher the probability of their progression and the need of surgical decompression.Conclusions. SHPC is one of most important TBI complications associated with considerable risk of clinical deterioration and serious cause of morbidity and lethality. Treatment tactics depends on severity of volumetric effect on surrounding brain structures and manifestations of compression-dislocation syndrome.Вступление. Вторичные послетравматические изменения головного мозга (ГМ) часто являются определяющими в клиническом течении черепно-мозговой травмы (ЧМТ). Предупреждение, выявление и определение лечебной тактики при вторичной геморрагической прогрессии ушиба (ВГПУ) ГМ актуально для нейротравматологии.Материалы и методы. Проанализированы результаты лечения 110 пострадавших с ЧМТ.Результаты. Установлено, что ВГПУ ГМ возникает у 50% пациентов при ЧМТ как в местах первичного повреждения ГМ, так и в отдаленных зонах по принципу противоудара в течение 12 ч, хотя может возникать и через 3–4 сут после травмы. ВГПУ часто выявляют у пациентов с субдуральной гематомой. Чем больше очаг ушиба, тем большая вероятность его прогрессии и необходимости хирургической декомпрессии.Выводы. ВГПУ является одним из важнейших осложнений после травмы ГМ, связана со значительным риском клинического ухудшения и серьезной причиной заболеваемости и смертности населения. Лечебная тактика зависит от выраженности объемного действия очага ушиба ГМ на окружающие структуры и проявлений компрессионно-дислокационного синдрома.Вступ. Вторинні післятравматичні зміни головного мозку (ГМ) часто є визначальними в клінічному перебігу черепно-мозкової травми (ЧМТ). Попередження, виявлення та визначення лікувальної тактики при вторинній геморагічній прогресії забою (ВГПЗ) ГМ актуальні для нейротравматології.Матеріали і методи. Проаналізовані результати лікування потерпілих з ЧМТ, у яких діагностований забій ГМ.Результати. Встановлено, що ВГПЗ виникає у 50% пацієнтів при ЧМТ, як у місцях первинного ушкодження ГМ, так і у віддалених зонах за принципом протиудару протягом 12 год, хоча може виникати і через 3–4 доби після травми. ВГПЗ часто виявляють у пацієнтів з субдуральною гематомою (СДГ). Чим більше вогнище забою, тим більша ймовірність його прогресії та необхідності хірургічної декомпресії.Висновки. ВГПЗ є одним з найважливіших ускладнень після ЧМТ, пов’язана з значним підвищенням ризику клінічного погіршення. Лікувальна тактика залежить від вираженості впливу на навколишні структури та проявів компресійно-дислокаційного синдрому

Secondary hemorrhagic progression of contusion foci in patients with traumatic brain injury

Introduction. Secondary posttraumatic changes of the brain often are determining in the clinical flow of traumatic brain injury (TBI). Prevention, detection and determination of treatment strategy at secondary hemorrhagic progression of contusion (SHPC) are very actual for neurotraumatology.Materials and methods. The results of 110 injured persons with TBI were analyzed.Results. It was found that SHPC occurs in 50% patients with TBI, as in areas of primary brain damage as in remote areas on the other side of the brain during 12 h ad also after 3–4 days. SHPC often is revealed in patients with subdural hematoma. The bigger contusion foci, the higher the probability of their progression and the need of surgical decompression.Conclusions. SHPC is one of most important TBI complications associated with considerable risk of clinical deterioration and serious cause of morbidity and lethality. Treatment tactics depends on severity of volumetric effect on surrounding brain structures and manifestations of compression-dislocation syndrome

Angioplasty and Stenting for Carotid Artery Near-Occlusion

Carotid near-occlusion (CNO) is the type of severe atherosclerotic stenosis of the internal carotid artery (ICA) with or without collapse of the vessel distally to the narrow part. According to the North American Symptomatic Carotid Endarterectomy Trial (NASCET), severity of ICA stenosis highly correlates with the risk of stroke, except for cases of extremely critical stenosis &gt; 94%, where the risk is lower, and, according to recent guidelines, conservative treatment is preferable. This consideration is questionable due to the recent data about early stroke recurrence and worldwide practice. Rapid improvement of endovascular technique during the last decade makes carotid angioplasty and stenting (CAS) a feasible option for the treatment of patients with CNO and is widely reported in the literature. However, in uncertain circumstances, more scientific data are necessary to fulfill the gap in indications, terms and risks of CAS for CNO.&#x0D; The aim. To evaluate the results of the treatment of patients with CNO after CAS.&#x0D; Materials and methods. Three hundred and fifteen patients were surgically treated at Scientific-Practical Center of Endovascular Neuroradiology of the National Academy of Medical Sciences of Ukraine due to ICA stenosis between 2010 and 2020. Among them, 39 (12.4%) patients (11 woman / 28 men (age 57.9±2.1 years) had CNO and underwent CAS at our Center. Patient population, clinical and radiological investigations, procedure compli-cations were investigated. Procedure complications (stroke, hemodynamic depression [HD] and hyperperfusion syndrome [HPS]) were meticulously studied. All the patients had routine ultrasound and clinical check 30 days after the procedure.&#x0D; Results. All the patients with CNO were successfully stented with the improvement of the site of stenosis after CAS, with only minimal residual stenosis in cases of severe HD. We observed two procedural vascular accidents, first patient had transient ischemic attack (TIA) and one had stroke due to middle cerebral artery occlusion after stent placement and further urgent mechanical thrombectomy. The patient had no neurologic decline and was discharged home. We didn’t observe any cases of myocardial infarction (MI) or death in our series during the hospital stay. HD was seen in 13 (33.3%) patients, and mostly resolved after the procedure except for 3 casesthat required prolonged intensive care unit stay. HPS was diagnosed in 2 (5.1%) patients and also didn’t have anyneurologic consequences after supportive care. During 30 days of follow-up, one (2.6%) patient had TIA because of anti-platelets cessation and 1 (2.6%) patient had MI after 1 week since discharge. All control images revealedstents patency without the evidence of critical residual stenosis.&#x0D; Conclusions. CNO remains important diagnostic and therapeutic challenge. Recent data showed high risk ofrecurrent stroke in case of CNO on best medical therapy, especially at an early stage, but it remains a preferred option according to guidelines. Considering worldwide improvement of stroke rates after CAS in patients with symptomatic ICA stenosis, further studies are warranted to evaluate its risk-benefit in case of CNO, especially with full collapse. Our data shows that CAS with careful preoperative diagnosis and planning is an effective procedure for selected patients with CNO.</jats:p

Endovascular Treatment of the Tentorial Dural Arteriovenous Fistulas. Case Series and Literature Review

Dural arteriovenous fistulas (DAVFs) are vascular anomalies where arteries from the carotid or vertebral arteries directly drain into the dural venous sinuses. Symptoms can range from asymptomatic to severe, including hemorrhage, venous hypertension, and neurological deficits. Tentorial dural arteriovenous fistulas (TDAVFs), a rare subset occurring in the tentorium, represent up to 4% of all DAVFs. Traditionally, DAVFs have been treated surgically, but recent advancements in endovascular embolization have made it a first-line treatment, although the optimal approach is still debated. The aim. To evaluate the efficacy and outcomes of endovascular treatment for TDAVFs. Materials and methods. Between 2012 and 2024, 174 patients with DAVFs were treated at the ScientificPractical Center of Endovascular Neuroradiology of the NAMS of Ukraine, including 8 patients with TDAVFs (mean age 58.5 years). All the patients with TDAVFs were symptomatic, with symptoms including hemorrhage (37.5%), headache, tinnitus, and seizures (62.5%). Endovascular treatment used liquid embolic agents and coils when required. Outcomes were assessed using postoperative angiograms and the modified Rankin Scale. Results. Nine embolization sessions were performed; of these, 8 (88.9%) using n-butyl cyanoacrylate Histoacryl and 1 (11.1%) using Onyx. Complete shunt elimination was achieved in 75% of sessions; 25% had residual lowflow shunting, with vessels unsuitable for further catheterization. No neurological deterioration occurred. The mean length of hospital stay was 5.5 days. Follow-up angiography in 7 patients showed one case of symptom worsening and vessel recruitment, which was later fully treated with repeat transvenous embolization. Conclusions. Endovascular embolization is an effective and safe treatment for TDAVFs. This case series indicates its efficacy but underscores the need for further randomized trials to compare all treatment modalities for tentorial and other deep-seated dural vascular lesions

Silk Vista Baby for the treatment of distal anterior cerebral artery aneurysms

Purpose: Treating small-caliber vessel aneurysms with flow diverters poses challenges due to narrow luminal diameters and tortuous vasculature, which complicate the navigation and deployment of conventional devices using standard microcatheters. The Silk Vista Baby (SVB, Balt, Montmorency, France) flow diverter was developed to treat intracranial aneurysms located in smaller vessels or more distal segments and is compatible with 0.017″ microcatheters. We present the largest multicenter analysis to date evaluating the outcomes of SVB use in unruptured distal anterior cerebral artery (DACA) aneurysms. Methods: Retrospective data from 20 centers were reviewed for patients with unruptured DACA aneurysms treated with the SVB. Demographic information, clinical presentation, radiographic characteristics, complications, and outcomes were recorded. Results: Seventy-nine patients (79 DACA aneurysms) were treated between January 2018 and December 2022; 59 were female (74.7%), and the median age was 61 years (IQR 53-67). Most aneurysms were saccular (89.9%), and 65.8% involved a branch. The median parent vessel diameter was 1.9 mm (IQR 1.7-2.1). A single stent was implanted in 97.5% of cases; 2.5% required two stents. The median imaging follow-up duration was 12 months (IQR 9.5-24). At the last follow-up, 76% of aneurysms showed complete or near-complete occlusion (O'Kelly-Marotta scale C or D, Raymond-Roy 1 or 2). Overall, thromboembolic or hemorrhagic complications occurred in 14% of patients, with two cases being symptomatic. The mortality rate was 0%, and the retreatment rate was 1.3%. Conclusion: In this multicenter series, the SVB flow diverter represented a valuable treatment option for distal anterior cerebral artery (DACA) aneurysms.No embarg