Cerebral Arteriovenous Malformations: Evaluation and Management.

There has been increased detection of incidental AVMs as result of the frequent use of advanced imaging techniques. The natural history of AVM is poorly understood and its management is controversial. This review provides an overview of the epidemiology, pathophysiology, natural history, clinical presentation, diagnosis, and management of AVMs. The authors discussed the imaging techniques available for detecting AVMs with regard to the advantages and disadvantages of each imaging modality. Furthermore, this review paper discusses the factors that must be considered for the most appropriate management strategy (based on the current evidence in the literature) and the risks and benefits of each management option

Cerebrospinal Fluid Leakage and Cerebral Venous Sinus Thrombosis: A Case Report

Cerebrovascular venous thrombosis is an uncommon entity that may occur in the sinuses of the dura, the cortical veins, or the deep venous system. Common etiologies include states of hypercoagulability, such as oral contraceptives intake, malignancy, and trauma. Additional causes include inherent thrombophilic states, such as those caused by systemic lupus erythematosus, protein C or S deficiency, and antithrombin III deficiency. The pathogenesis of cerebral venous sinus thrombosis stems from the obstruction of venous outflow. Consequently, venous engorgement occurs, leading to decreased effective blood flow and white matter edema. Infarction or hemorrhage are not uncommon in the setting of venous thrombosis. Intracranial pressure also rises. The most common presenting symptom is headache.2,3 The impact of intracranial hypotension due to cerebrospinal fluid (CSF) leak on venous flow and thrombosis is not clear.1, 4-8, 10, 11 We present the case and treatment course of a patient who initially presented with an acute venous sinus thrombosis and in was later found to have a CSF leak and intracranial hypotension

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

Moyamoya: A Review of the Disease and Current Treatments

INTRODUCTION Moyamoya disease is a rare progressive cerebrovascular disease characterized by bilateral stenosis of vasculature of the Circle of Willis, specifically the distal internal carotid arteries, that leads to extensive collateral circulation. These dilated collateral vessels are described as having a hazy “puff of smoke” appearance on angiography. “Moyamoya” is the Japanese word for this characteristic appearance. The disease was originally described in Japan in 1957 1 and introduced to the English literature in 1969.2 The disease is most known for its distribution in Asian populations, but recently there has been more research and attention given to moyamoya in Europe and North American Moyamoya disease presents clinically due to the ischemic and hemorrhagic complications of abnormal cerebral vascularity.3,4 Epidemiology Moyamoya disease was originally described in Japanese populations but is present in a variety of ethnicities.3,5,6 In Japan, the incidence per 100,000 patient years is between 0.35 to 0.943 with a male: female ratio of 1:1.87. In the US, incidence ranged from 0.05 to 0.17 per 100,000 patient years with a similar gender distribution.3,6 Other population studies have not been as robust but European studies show moyamoya statistics that are more similar to American findings than those of Asian moyamoya findings.4 There is a bimodal distribution of incidence: in early childhood and adulthood, but the doublepeaked incidence is less dramatic in the US and Europe.4,8 Children typically present with the ischemic symptoms and adults can present with either ischemic or hemorrhagic type, with the ischemic type predominating.5,9 Overall, the hemorrhagic type is more common in Asia than the U.S.9 The incidence has been increasing with time, which may be due to increased awareness.

The Use of Prasugrel and Ticagrelor in Pipeline Flow Diversion

Background: Despite the routine clopidogrel/aspirin anti-platelet therapy, complications like thromboembolism, continue to be encountered with PED. We studied the safety and the efficacy of prasugrel in the management of clopidogrel non-responders treated for intracranial aneurysms. Methods: 437 consecutive neurosurgery patients were identified between January 2011 and May 2016. Patients allergic or having \u3c30% platelet-inhibition with a daily 75mg of clopidogrel were dispensed 10mg of prasugrel daily (n=20) or 90mg of ticagrelor twice daily (n=2). The average follow-up was 15.8 months (SD=12.4 months). Patient clinical well being was evaluated with the modified Rankin Scale (mRS) registered before the discharge and at each follow-up visit. To control confounding we used multivariable mixed-effects logistic regression and propensity score conditioning. Results: 26 of 437(5.9%) patients (mean of age 56.3 years; 62 women [14,2%]) presented with a sub-arachnoid hemorrhage. 1 patient was allergic to clopidogrel and prasugrel simultaneously. All the patients receiving prasugrel (n=22) had a mRS\u3c2 on their latest follow-up visit (mean=0.67; SD=1.15). In a multivariate analysis, clopidogrel did not affect the mRS on last follow-up, p=0.14. Multivariable logistic regression showed that clopidogrel was not associated with an increased long-term recurrence rate (odds ratio[OR], 0.17; 95%Confidence Interval [CI95%], 0.01-2.70; p=0.21) neither with an increased thromboembolic accident rate (OR, 0.46; CI95%, 0.12-1.67; p=0.36) nor with an increased hemorrhagic event rate (OR, 0.39; CI95%,0.91-1.64; p=0.20). None of the patients receiving prasugrel deceased or had a long-term recurrence nor a hemorrhagic event, only 1 patient suffered from mild aphasia subsequent to a thromboembolic event. 3 patients on clopidogrel passed during the study: (2) from acute SAH and (1) from intra-parenchymal hemorrhage. Clopidogrel was not associated with an increased mortality rate (OR, 2.18; CI95%,0.11-43.27; p=0.61). The same associations were present in propensity score adjusted models. Conclusion: In a cohort of patients treated with PED for their intracranial aneurysms, prasugrel (10mg/day) is a safe alternative to clopidogrel resistant, allergic or non-responders

Stereotactic Radiosurgery for Management of Cavernous Malformations

Cavernous malformations (CMs) are abnormal vascular formations of the brain with an estimated incidence of 0.4%-0.8% in the general population.1 CMs have the potential to cause significant morbidity, and have been associated with epileptic seizures, intracranial hemorrhage, and focal neurological deficits.2 Management options include non-treatment, surgical resection, and radiosurgery. We review here the efficacy of different management strategies for cavernous malformations and highlight the specific role of radiosurgery. One of the major complications of cerebral cavernous malformations is intracranial hemorrhage. To optimize patient treatment, it is beneficial to be able to identify patients that are at an increased risk of developing a hemorrhage and would most benefit from intervention. The overall rate of hemorrhage in patients with CMs has been estimated to be 2.25%.3 The rate of hemorrhage, however, is significantly affected by the initial symptom presentation. Patients presenting with a hemorrhage have significantly higher rates of rehemorrhage compared to patients presenting due to incidental findings.3,4 Flemming et al. found that patients presenting with hemorrhage had an overall annual rate of hemorrhage of 6.19% compared to patients presenting without hemorrhage of 0.33%. With increasing use of MR imaging, the percentage of cavernous malformations found incidentally approaches 40%.1 Because the risk of hemorrhage is low in patients with CMs found incidentally, surgical or radiosurgery management may not be indicated. In contrast, patients presenting with symptoms of hemorrhage should be considered for therapeutic intervention due to a high risk for subsequent hemorrhage. One option for the management of cavernous malformations is surgical intervention by CM resection. There is conflicting evidence in the literature regarding the effectiveness of CM resection, likely due to different methodologies used for determining efficacy. When post-operative outcomes are compared to pre-operative values, significant improvement is observed as demonstrated by improvements in the modified Rankin scale and decreased annual hemorrhage rate.5,6 However, the results are limited by the fact that studies did not include a control group of patients that did not receive surgery. A recent retrospective study by Moultrie and colleagues compared the outcome of patients treated with surgical to conservative management. Patients who underwent CM resection had worsened short-term disability scores, increased risk of developing intracranial hemorrhage, and new focal neurologic deficits.

Assessing a 600-mg Loading Dose of Clopidogrel 24 Hours Prior to Pipeline Embolization Device Treatment

Background: Clopidogrel/aspirin antiplatelet therapy routinely is administered 7-10 days before pipeline aneurysm treatment. Our study assessed the safety and efficacy of a 600-mg loading dose of clopidogrel 24 hours before Pipeline Embolization Device (PED) treatment. Methods: In this retrospective cohort study, we included patients treated with PED from October 2010 to May 2016. A total of 39.7% (n = 158) of patients were dispensed a loading dose of 650 mg of aspirin plus at least 600 mg of clopidogrel 24 hours preceding PED deployment, compared to 60.3% (n = 240) of patients who received 81-325 mg of aspirin daily for 10 days with 75 mg of clopidogrel daily preprocedurally. The mean follow-up was 15.8 months (standard deviation [SD] 12.4 months). modified Rankin Scale (mRS) was registered before the discharge and at each follow-up visit. To control confounding, we used multivariable logistic regression and propensity score conditioning. Results: Of 398 patients, the proportion of female patients was ~16.5% (41/240) in both groups and shared the same mean of age ~56.46 years. ~12.2% (mean = 0.09; SD = 0.30) had a subarachnoid hemorrhage. 92% (mean = 0.29; SD = 0.70) from the pretreatment group and 85.7% (mean = 0.44; SD = 0.91) of the bolus group had a mRS ≤2. In multivariate analysis, bolus did not affect the mRS score, P = 0.24. Seven patients had a long-term recurrence, 2 (0.83%; mean = 0.01; SD = 0.10) of which from the pretreatment group. In a multivariable logistic regression, bolus was not associated with a long-term recurrence rate (odds ratio [OR] 1.91; 95% confidence interval [CI] 0.27-13.50; P = 0.52) or with thromboembolic accidents (OR 0.99; 95% CI 0.96-1.03; P = 0.83) nor with hemorrhagic events (OR 1.00; 95% CI 0.97-1.03; P = 0.99). Three patients died: one who received a bolus had an acute subarachnoid hemorrhage. The mean mortality rate was parallel in both groups ~0.25 (SD = 0.16). Bolus was not associated with mortality (OR 1.11; 95% CI 0.26-4.65; P = 0.89). The same associations were present in propensity score-adjusted models. Conclusions: In a cohort receiving PED, a 600-mg loading dose of clopidogrel should be safe and efficacious in those off the standard protocol or showing \u3c30% platelet inhibition before treatment

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