Vein of Galen malformation (VOGM) is a fistulous arteriovenous malformation presenting in the early childhood. Hydrocephalus with VOGM develops in one half of patients during the course of the ...disease. The concept of hydrodynamic disorders is the key to understand the development of hydrocephalus. VOGM results in venous hypertension that secondarily disturbs cerebrospinal fluid (CSF) absorption leading to hydrocephalus and occurs frequently in infants and young children. The medullary veins are thought to be the main pathway for absorption of CSF by the cerebrofugal gradient act as the driving force. In neonates, the cavernous sinus is poorly developed and brain does not use it for venous drainage along with poor jugular bulb maturation results in poor venous drainage reserve. The presence of high flow vascular malformation with poor venous drainage reserve leads to hydrodynamic disorder, poor CSF absorption, and hydrocephalus. Apart from this, hydrocephalus secondary to intraventricular hemorrhage and physical obstruction of the enlarged VOGM at the aqueduct has been proposed. The management strategy is to perform timely endovascular treatment to correct the hydrodynamic disorder and avoid ventricular shunting. Trans-arterial embolization is the effective way, as it decreases flow in the malformation, secondarily the venous hypertension, and thereby improving the clinical symptoms related to hydrodynamic disorder. Ventricular diversion procedure is indicated in symptomatic hydrocephalus after exhausting our effort to reduce hydrodynamic pressure by endovascular embolization.
Abstract
BACKGROUND
Vein of Galen aneurysmal malformation (VGAM) is a rare congenital vascular malformation representing <1% of all arteriovenous malformations. The knowledge and strategies in the ...management are constantly evolving.
OBJECTIVE
To review our series of postneonatal VGAM patients treated over 11-yr period.
METHODS
Retrospective analysis of 113 VGAM treated between January 2004 and April 2015. After exclusions, 45 patients were included: 33 choroidal and 12 mural types.
RESULTS
Presenting symptom in the order of frequency: enlarged head circumference, antenatal diagnosis, mild CHF, and PHT at birth. Older patients were diagnosed following trauma, headache, cognitive decline, and incidentally during workup for other diseases. Hydrocephalus due to hydrodynamic disorder was present in 70% of choroidal and 58% of mural types. Only a quarter needed cerebrospinal fluid diversion procedure. Radiological cure was achieved in 82%; the outcome graded on a 5-point scale: 0 (death) to 4 (normal). A total of 66.6% are neurologically and developmentally intact with outcome score 4, 20% had outcome score of 3, and 8.9% had outcome score of 2. There was 4.4% mortality. Dural feeders to VGAM were found either in the initial or during the treatment in 22.2% in the current series. Angiogenesis from pial vessels developed after partial embolization in 17.7% that resolved completely following complete obliteration of VGAM.
CONCLUSION
Technical and technological advancements in endovascular embolization along with better understanding of clinical, anatomic, and pathophysiological aspects have resulted in significantly improved outcome and prognosis in VGAM. Most patients with proper treatment can now survive and most develop normally following appropriately timed treatment.
Endovascular recanalization treatment for acute ischemic stroke is a complex, time-sensitive intervention. Trip-and-treat is an interhospital service delivery model that has not previously been ...evaluated in the literature and consists of a shared mobile interventional stroke team that travels to primary stroke centers to provide on-site interventional capability. We compared treatment times between the trip-and-treat model and the traditional drip-and-ship model.
We performed a retrospective analysis on 86 consecutive eligible patients with acute ischemic stroke secondary to large vessel occlusion who received endovascular treatment at 4 hospitals in Manhattan. Patients were divided into 2 cohorts: trip-and-treat (n=39) and drip-and-ship (n=47). The primary outcome was initial door-to-puncture time, defined as the time between arrival at any hospital and arterial puncture. We also recorded and analyzed the times of last known well, IV-tPA (intravenous tissue-type plasminogen activator) administration, transfer, and reperfusion.
Mean initial door-to-puncture time was 143 minutes for trip-and-treat and 222 minutes for drip-and-ship (
<0.0001). Although there was a trend in longer puncture-to-recanalization times for trip-and-treat (
=0.0887), initial door-to-recanalization was nonetheless 79 minutes faster for trip-and-treat (
<0.0001). There was a trend in improved admission-to-discharge change in National Institutes of Health Stroke Scale for trip-and-treat compared with drip-and-ship (
=0.0704).
Compared with drip-and-ship, the trip-and-treat model demonstrated shorter treatment times for endovascular therapy in our series. The trip-and-treat model offers a valid alternative to current interhospital stroke transfers in urban environments.
Summary Introduction Onyx as an embolization agent for the management of vascular malformation is well established. We report our initial experience with dimethyl-sulphoxide (DMSO) compatible double ...lumen balloon catheters used for Onyx embolization. Methods and technique Between December 2011 and March 2013, we treated 22 patients aged between 1.5 to 70 years with two types of DMSO compatible dual-lumen balloon catheters (Scepter C and Ascent) to treat dural arteriovenous fistulas, brain arteriovenous malformation (AVM) with dural feeders, mandibular, facial, lingual, vertebral and paravertebral AVMs. The catheter has good navigability, compliant balloon on inflation formed a “plug” that has more resistance than Onyx plug enhancing better penetration. During injection, the balloon remained stable without spontaneous deflation or rupture and withstood the pressure build-up well. The retrieval of the catheter in most cases took less than a minute (19/28) while in five, it was less than five minutes and in the remaining four, it was longer that includes a trapped catheter on prolonged attempted retrieval resulted in an epidural hematoma, requiring emergent surgical evacuation. The fluoroscopy time is reduced, as we do not form a proximal onyx plug, the injection time is shorter along with easy and instantaneous removal of the catheter after balloon deflation in most cases. Conclusion Dual-lumen balloon catheter Onyx embolization is a safe and effective technique. Currently, an important tool to circumvent some of the shortcomings associated with Onyx embolization. The catheter has good navigability, the balloon has stability, tolerance, enhances penetrability. It is easy to retrieve the microcatheter. With the experience gained, and with more compliant balloon catheters available, this technique can be applied to cerebral vessels in near future.
The rapid development and wider use of neurointerventional procedures have increased the demand for a comprehensive training program for the trainees, in order to safely and efficiently perform these ...procedures. Artificial vascular models are one of the dynamic ways to train the new generation of neurointerventionists to acquire the basic skills of material handling, tool manipulation through the vasculature, and development of hand-eye coordination. Herein, the authors present their experience regarding a long-established training program and review the available literature on the advantages and disadvantages of vascular silicone model training. Additionally, they present the current research applications of silicone replicas in the neurointerventional arena.
BACKGROUND AND IMPORTANCE:Distal extracranial posterior inferior cerebellar artery (PICA) aneurysms are very rare lesions and have not been previously reported in association with a Chiari type I ...malformation (CMI).
CLINICAL PRESENTATION:A 56-year-old woman with a distal, low-lying, intradural-extracranial PICA aneurysm presented with a subarachnoid hemorrhage and was treated with coil embolization. The patient presented again 1 month later with symptoms of a CMI and was found to have tonsillar herniation and a large syrinx that appeared to be exacerbated by the coil mass. The patient was re-treated with a suboccipital craniectomy, C1-2 laminectomy, aneurysm trapping and excision, end-to-end PICA anastomosis, and expansile duraplasty.
CONCLUSION:Although just a single case, important teaching points regarding the angiographic appearance of a CMI and treatment options for distal PICA aneurysms that are situated below the foramen magnum can be learned. A low-lying caudal PICA loop should trigger a workup for a CMI. Caution should be taken when using coil embolization for aneurysms in the high cervical spinal canal. Bypass with aneurysm trapping and excision may be a superior treatment option in these cases because the posterior fossa and high cervical canal can be concomitantly decompressed. To our knowledge, this is the only case reported of a distal intradural-extracranial PICA aneurysm associated with a CMI.
ABBREVIATIONS:CMI, Chiari type I malformationFM, foramen magnumPICA, posterior inferior cerebellar arterySAH, subarachnoid hemorrhage
ADAPT (a direct aspiration first pass technique) has been shown to be fast, cost-effective, and associated with excellent angiographic and clinical outcomes in the treatment of acute ischemic stroke ...(AIS).
To identify any and all preoperative factors that are associated with successful revascularization using aspiration alone.
A retrospective review of 76 patients with AIS treated with thrombectomy was carried out. Cohort 1 included cases in which aspiration alone was successful (Thrombolysis in Cerebral Infarction 2b or 3). Cohort 2 included cases in which aspiration was unsuccessful or could not be performed despite an attempt.
There was no difference between cohorts in gender, race, medications, National Institute of Health Stroke Scale score, IV tissue plasminogen activator, site or side of the occlusion, dense vessel sign, aortic arch type, severe stenosis, clot length, operator years of experience, and guide/aspiration catheters used. Patients in cohort 1 were on average younger (66.5 vs 74.1 years, p=0.025). There was a trend for more patients in cohort 2 to have atrial fibrillation/arrhythmias (62.5% vs 45.5%, p=0.168) and have a cardiogenic stroke etiology (78.1% vs 56.8%, p=0.086). There was also a trend for more reverse curves (2.3 vs 1.7, p=0.107), larger vessel diameter (3.26 mm vs 2.88 mm, p=0.184), larger vessel-to-catheter ratio (2.09 vs 1.87, p=0.192), and worse clot burden score (5.38 vs 6.68, p=0.104) in cohort 2.
Aspiration success was associated with younger age. Our findings suggest that ADAPT can be used for the vast majority of patients but it may be beneficial to use a different method first in the elderly.
Failed mechanical thrombectomy due to a refractory emergent large vessel occlusion (RELVO) in patients presenting with an acute stroke poses a major challenge to the outcomes.
We demonstrate the ...use of coronary stents in the intracranial circulation as rescue stenting for an already expensive mechanical thrombectomy procedure in a mid-low socioeconomic setting.
A retrospective, multicenter study was conducted between December 2015 and January 2021. The studied cohort were patients who required the use of a rescue stenting using a coronary stent for emergent large vessel occlusion to avoid failed recanalization. Failed recanalization was defined as failed vessel recanalization after at least two passes. Patient demographic data, procedure specifics, type of stent used, and procedural outcomes were collected.
A total of 26 patients with acute ischemic stroke were included from eight different centers across India. Out of 26 patients, 19 (73.0%) were male and seven were female (26.9%). The mean age was 53.6 years, the youngest patient was 23 years old and the eldest was 68 years old. Seven patients (26.9%) had posterior circulation stroke due to occlusion of the vertebral or basilar artery and 19 patients (73.0%) had anterior circulation stroke median NIHSS at presentation was 16 (range 10 to 28) in anterior circulation stroke and 24 (range 16 to 30) in posterior circulation stroke. Intravenous thrombolysis with tissue plasminogen activator (IV tPA) was given in three patients (11.5%). The hospital course of two patients was complicated by symptomatic intracranial hemorrhage (sICH), which was fatal. Favorable revascularization outcome and favorable functional outcome was achieved in 22 patients (84.6%), three patients passed away (11.5%), and one patient was lost to follow up.
Overall, our study finds that rescue stenting using coronary stents can potentially improve outcomes in refractory large vessel occlusions while minimizing costs in low-mid economic settings.
Stroke is the leading cause of disability and most of the cases are those of ischemic stroke. Management strategies especially for large vessel occlusive stroke have undergone a significant change in ...the recent years that include widespread use of thrombolytic medications followed by endovascular clot removal. For successful treatment by endovascular thrombectomy, the important factors are patient selection based on clinical criterion including age, time of onset, premorbid clinical condition, co-morbidities, National Institute of Health Stroke Scale, and imaging criterion including computed tomography (CT) head, CT angiogram and CT perfusion. Patients presenting within 4.5 hours of onset are considered for intravenous (IV) recombinant tissue plasminogen activator treatment. Mechanical clot retrieval devices have evolved over the past decade. The Mechanical Embolus Removal in Cerebral Ischemia device was approved first followed by the penumbra revascularization system. They have proven in various studies to improve recanalization with acceptable rates of symptomatic intra-cerebral hemorrhage. Introduction of stent retrievers has led to a new era in the interventional management of acute ischemic stroke (AIS). Recent trials namely MRCLEAN, ESCAPE, SWIFT PRIMEs, and EXTEND-IA have used the stent retriever predominantly and have shown unequivocal benefit in the outcome at 90 days for AIS patients with large vessel occlusion. More recently, a new catheter namely 5 MAX ACE was introduced along with improvement in the suction device. This has led to a direct aspiration first pass technique resulting in faster recanalization. Advancements in the endovascular management of AIS with large vessel occlusion have resulted in a paradigm shift in the way this disease is managed. Improvements in patient selection using clinical and imaging criterion along with technical and technological advancements in mechanical thrombectomy have made possible a significantly improved outcome in stroke patients.
Spine and spinal cord injury in children Jayakumar, Indira; Pandian, NSaravana; Venkatachalapathy, Priyavardhini ...
Journal of Pediatric Critical Care,
2017, Letnik:
4, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Trauma to the spine can cause injuries involving spinal cord, vertebra or both. Although less frequent compared to adults, Traumatic Spinal Cord Injury (TSCI) in the pediatric population is not rare ...and has high morbidity and mortality with significant physiological and psychological consequences. Pediatric patients with TSCI have different mechanisms of injury but better neurological recovery potential when compared to adults. TSCI should be strongly suspected in the presence of neck pain, abnormal neurological exam, high-risk mechanism ofinjury or a distracting injury, even in the absence ofradiological abnormality A high index of suspicion should be maintained in trauma victims until a spinal injury is identified or ruled out. As in Traumatic Brain Injury (TBI), hypoxia and hypotension can worsen secondary injury to the spinal cord and adversely affect neurologic outcome.
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