The authors performed a study to review outcomes following Gamma Knife radiosurgery for cerebral arteriovenous malformations (AVMs) and to create a practical scale to predict long-term outcome.
...Outcomes were reviewed in 1012 patients who were followed up for more than 2 years. Favorable outcome was defined as AVM obliteration and no posttreatment hemorrhage or permanent, symptomatic, radiation-induced complication. Preradiosurgery patient and AVM characteristics predictive of outcome in multivariate analysis were weighted according to their odds ratios to create the Virginia Radiosurgery AVM Scale.
The mean follow-up time was 8 years (range 2-20 years). Arteriovenous malformation obliteration occurred in 69% of patients. Postradiosurgery hemorrhage occurred in 88 patients, for a yearly incidence of 1.14%. Radiation-induced changes occurred in 387 patients (38.2%), symptoms in 100 (9.9%), and permanent deficits in 21 (2.1%). Favorable outcome was achieved in 649 patients (64.1%). The Virginia Radiosurgery AVM Scale was created such that patients were assigned 1 point each for having an AVM volume of 2-4 cm(3), eloquent AVM location, or a history of hemorrhage, and 2 points for having an AVM volume greater than 4 cm(3). Eighty percent of patients who had a score of 0-1 points had a favorable outcome, as did 70% who had a score of 2 points and 45% who had a score of 3-4 points. The Virginia Radiosurgery AVM Scale was still predictive of outcome after controlling for predictive Gamma Knife radiosurgery treatment parameters, including peripheral dose and number of isocenters, in a multivariate analysis. The Spetzler-Martin grading scale and the Radiosurgery-Based Grading Scale predicted favorable outcome, but the Virginia Radiosurgery AVM Scale provided the best assessment.
Gamma Knife radiosurgery can be used to achieve long-term AVM obliteration and neurological preservation in a predictable fashion based on patient and AVM characteristics.
Delayed cerebral ischemia is a major predictor of poor outcomes in patients who suffer subarachnoid hemorrhage. Treatment options are limited and often ineffective despite many years of investigation ...and clinical trials. Modern advances in basic science have produced a much more complex, multifactorial framework in which delayed cerebral ischemia is better understood and novel treatments can be developed. Leveraging this knowledge to improve outcomes, however, depends on a holistic understanding of the disease process. We conducted a review of the literature to analyze the current state of investigation into delayed cerebral ischemia with emphasis on the major themes that have emerged over the past decades. Specifically, we discuss microcirculatory dysfunction, glymphatic impairment, inflammation, and neuroelectric disruption as pathological factors in addition to the canonical focus on cerebral vasospasm. This review intends to give clinicians and researchers a summary of the foundations of delayed cerebral ischemia pathophysiology while also underscoring the interactions and interdependencies between pathological factors. Through this overview, we also highlight the advances in translational studies and potential future therapeutic opportunities.
Endovascular thrombectomy (ET) for acute ischemic stroke is the current standard of care. Although successful ET has high efficacy in improving functional outcomes, the decision to abort a long ...procedure remains a challenge. Longer procedure time (PT) has been associated with lower rates of functional independence.
The objective of this study was to evaluate the impact of PT on outcomes and complications after ET using different techniques at a multicenter level and to define the risk of procedure extension in different patient cohorts.
Patients undergoing ET with a stent retriever (SR) or a direct aspiration at first pass technique at 7 U.S. centers between June 2013 and February 2018 were reviewed from prospectively maintained databases that include baseline variables and technical and clinical outcomes. Multivariate analyses were used to assess impact of PT on 90-day modified Rankin scores, successful recanalization, post-procedural symptomatic hemorrhage (sICH), and complications.
The study included 1,359 patients and demonstrated a decreased likelihood of good functional outcomes (modified Rankin score 0 to 2) when PT extended beyond 30 min (p < 0.01). Rates of sICH and complications increased exponentially with PT (doubling rates of 26 and 50 min, respectively). The cumulative rate of successful recanalization and good outcomes plateaued after 60 min of PT. In patients with PT >30 min, fewer attempts predicted the success of ET and good outcomes (p < 0.01). Successful recanalization was achieved faster with the direct aspiration at first pass technique than in SR. The direct aspiration technique was more sensitive to PT than SR, and posterior stroke was more sensitive to PT than anterior stroke.
Longer ET procedures lead to lower rates of functional independence and higher rates of sICH and complications. Exceeding 60 min or 3 attempts should trigger careful assessment of futility and risks of continuing the procedure.
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Abstract
BACKGROUND
Although chronic hydrocephalus requiring shunt placement is a known sequela of aneurysmal subarachnoid hemorrhage (aSAH), its effect on long-term functional outcomes is ...incompletely understood.
OBJECTIVE
To identify predictors of shunt-dependent hydrocephalus and shunt complications after aSAH and determine the effect of shunt dependence on functional outcomes in aSAH patients.
METHODS
We evaluated a database of patients treated for aSAH at a single center from 2000 to 2015. Favorable and unfavorable outcomes were defined as modified Rankin Scale grades 0 to 2 and 3 to 6, respectively. We performed statistical analyses to identify variables associated with shunt-dependent hydrocephalus, unfavorable outcome, and shunt complication.
RESULTS
Of the 888 aSAH patients, 116 had shunt-dependent hydrocephalus (13%). Older age (P = .001), intraventricular hemorrhage (IVH) (P = .004), higher World Federation of Neurological Surgeons (WFNS) grade (P < .001), surgical aneurysm treatment (P = .002), and angiographic vasospasm (P = .005) were independent predictors of shunt-dependent hydrocephalus in multivariable analysis. Functional outcome was evaluable in 527 aSAH patients (mean follow-up 18.6 mo), with an unfavorable outcome rate of 17%. Shunt placement (P < .001), shunt infection (P = .041), older age (P < .001), and higher WFNS grade (P = .043) were independently associated with an unfavorable outcome in multivariable analysis. Of the shunt-dependent patients, 18% had a shunt-related complication. Higher WFNS grade (P = .011), posterior circulation aneurysm (P = .018), and angiographic vasospasm (P = .008) were independent predictors of shunt complications in multivariable analysis.
CONCLUSION
aSAH patients with shunt-dependent hydrocephalus have significantly poorer long-term functional outcomes. Patients with risk factors for post-aSAH shunt dependence may benefit from increased surveillance, although the effect of such measures is not defined in this study.
Despite several retrospective studies analyzing the safety and efficacy of transradial access (TRA) versus transfemoral access (TFA) for cerebral angiography, this transition for neurointerventional ...procedures has been gradual. Nonetheless, based on our positive initial institutional experience with TRA for mechanical thrombectomy in acute ischemic stroke patients, we have started transitioning more of our cerebral angiography cases to TRA. Here we present our single institution experience.
We performed a retrospective review of patients receiving TRA cerebral angiography at our institution between January 2016 and February 2017. We present our experience transitioning from TFA to TRA, including our criteria for patient selection, technical nuances, patient experience, complications, and operator learning curve.
We included 148 angiograms performed in 141 people by one of four operators. No major complications were observed, and the technical success of the procedures was consistent with those of TFA. Marked improvement in operator efficiency was achieved in a short number of cases during this transition when looking at operator proficiency as a function of angiograms performed and days of exposure to TRA (4.3 vs 3.6 min/vessel, P<0.05).
Safety and efficiency can be preserved while transitioning to TRA. While further investigation is necessary to support transition to TRA, these findings should call for a re-evaluation of the role of TRA in catheter cerebral angiography.
Abstract
BACKGROUND
A dramatic improvement in obliteration rates of large, wide-necked aneurysms has been observed after the FDA approved the Pipeline Embolization Device (PED) in 2011.
OBJECTIVE
To ...assess the predictors of complications, morbidity, and unfavorable outcomes in a large cohort of patients with aneurysms treated with PED.
METHODS
A retrospective chart review of a prospectively maintained database for subjects treated with flow diversion from 2010 to 2019.
RESULTS
A total of 598 aneurysms were treated during a period extending from 2010 to 2019 (84.28% females, mean age 55.5 yr, average aneurysm size 8.49 mm). Morbidity occurred at a rate of 5.8% and mortality at a rate of 2.2%. Ischemic stroke occurred at a rate of 3%, delayed aneurysmal rupture (DAR) at 1.2%, and distal intraparenchymal hemorrhage (DIPH) at 1.5%. On multivariate analysis, the predictor of stroke was aneurysm size >15 mm. Predictors of DAR were previous subarachnoid hemorrhage (SAH), increasing aneurysm size, and posterior circulation aneurysm. Predictors of DIPH were using more than 1 PED and baseline P2Y12 value. Predictors of in-stent stenosis were the increasing year of treatment and balloon angioplasty, whereas increasing age and previous treatment were negatively associated with in-stent stenosis. Predictors of morbidity were posterior circulation aneurysms, increasing aneurysm size, and hypertension, and incidental aneurysm diagnosis was protective for morbidity.
CONCLUSION
Flow diversion is a safe and effective treatment option for aneurysms. A better understanding of predictive factors of complications, morbidity, and functional outcomes is of high importance for a more accurate risk assessment.
Context:
It is unclear whether endoscopic transsphenoidal surgery (ETSS) or microsurgical transsphenoidal surgery (MTS) is a superior surgical approach for pituitary adenomas.
Objective:
The ...objective of the study was to compare the outcome of surgery with ETSS and MTS by experienced pituitary surgeons using criteria of remission using current consensus criteria for acromegaly.
Design and Setting:
This was a retrospective review of prospectively recorded outcomes. The study was conducted at a tertiary referral center.
Patients, Interventions, and Outcome Measures:
Remission was defined as a normal IGF-I level and either suppressed GH less than 0.4 ng/mL during an oral glucose tolerance test or random GH less than 1.0 ng/mL. The Youden indices were calculated to determine the optimal cutoffs for using immediate postoperative GH levels to predict the results of later testing for remission.
Results:
Preoperative demographics and tumor characteristics were not significantly different between patients undergoing ETSS (72 patients) or MTS (41 patients). Overall, postoperative remission was achieved in 20 of 23 microadenomas (87%) and 59 of 90 macroadenomas (66%). Remission rates and perioperative complications were not significantly different between ETSS and MTS groups, except for self-reported sinusitis and alterations in taste or smell, which were significantly higher in patients treated with ETSS. Preoperative variables predicting remission in multivariate analysis included GH less than 45 ng/mL odds ratio (OR) 6.4, P = .010) and Knosp score of 0–2 (OR 6.8, P < .001). Postoperative in-hospital GH less than 1.15 ng/mL provided the best predictor of remission (OR 7.7, P < .001; sensitivity of 73%, specificity of 85%) defined by follow-up testing.
Conclusions:
Outcomes of transsphenoidal surgery for acromegaly by experienced pituitary surgeons do not differ between endoscopic and microscopic techniques. Regardless of the mode of resection, patients with high preoperative GH levels and Knosp scores are less likely to achieve remission. An immediate postoperative GH level of less than 1.15 ng/mL provides the best immediate predictor of remission, but long-term outcomes are indicated.
Flow diversion has emerged as an important tool for the management of intracranial aneurysms. The purpose of this study was to compare flow diversion and traditional embolization strategies in terms ...of safety, efficacy, and clinical outcomes in patients with unruptured, large saccular aneurysms (≥10 mm).
Forty patients treated with the Pipeline Embolization Device (PED) were matched in a 1:3 fashion with 120 patients treated with coiling based on patient age and aneurysm size. Fusiform and anterior communicating artery aneurysms were eliminated from the analysis. Procedural complications, angiographic results, and clinical outcomes were analyzed and compared.
There were no differences between the 2 groups in terms of patient age, sex, aneurysm size, and aneurysm location. The rate of procedure-related complications did not differ between the PED (7.5%) and the coil group (7.5%; P=1). At the latest follow-up, a significantly higher proportion of aneurysms treated with PED (86%) achieved complete obliteration compared with coiled aneurysms (41%; P<0.001). In multivariable analysis, coiling was an independent predictor of nonocclusion. Retreatment was necessary in fewer patients in the PED group (2.8%) than the coil group (37%; P<0.001). A similar proportion of patients attained a favorable outcome (modified Rankin Scale, 0-2) in the PED group (92%) and in the coil group (94%; P=0.8).
The PED provides higher aneurysm occlusion rates than coiling, with no additional morbidity and similar clinical outcomes. These findings suggest that the PED might be a preferred treatment option for large unruptured saccular aneurysms.
Abstract
BACKGROUND:
Several studies report early results of endoscopic endonasal transsphenoidal surgery; however, none discuss long-term outcome measures such as tumor recurrence rates and the need ...for additional surgical procedures.
OBJECTIVE:
To discuss the long-term outcomes after endoscopic endonasal transsphenoidal surgery for nonfunctioning pituitary macroadenomas.
METHODS:
This is a retrospective study. Patients were included only if they had at least 5 years of clinical and imaging follow-up after surgery.
RESULTS:
Eighty patients met the study criteria. Grossly complete resection was achieved in 71% of patients. Knosp grade 0 to 2 tumors and tumor with volumes <10 cm3 were significantly more likely to have received a grossly complete resection. There were 7 recurrences (12%) in patients who had received grossly complete resections, with a mean time to recurrence of 53 months. Among the 23 patients who had subtotal resections, 11 (61%) progressed radiographically, and 3 (17%) had symptomatic progression. Knosp score, surgical and radiographic evidence of invasion, and preoperative visual deficits were predictive of recurrence in a univariate analysis, but Knosp grade was the only independent predictor in a multivariate analysis. Kaplan-Meier analysis projected a 10-year progression-free survival rate of 80% and 21% for patients with gross total resections and subtotal resections, respectively.
CONCLUSION:
At the long-term follow-up, 12% of patients had recurrent tumors after grossly complete resection. Recurrent or residual tumors were treated with either repeat surgery or Gamma Knife radiosurgery. Rates of complete resection, postoperative surgical and endocrinological complications, and additional surgical procedures are similar to previously published reports after microscopic transsphenoidal surgery.
OBJECT Flow diverters are increasingly used for treatment of intracranial aneurysms. In most series, the Pipeline Embolization Device (PED) was used for the treatment of large, giant, complex, and ...fusiform aneurysms. Little is known about the use of the PED in small aneurysms. The purpose of this study was to assess the safety and efficacy of the PED in small aneurysms (≤ 7 mm). METHODS A total of 100 consecutive patients were treated with the PED at the authors' institution between May 2011 and September 2013. Data on procedural safety and efficacy were retrospectively collected. RESULTS The mean aneurysm size was 5.2 ± 1.5 mm. Seven patients (7%) had sustained a subarachnoid hemorrhage. All except 5 aneurysms (95%) arose from the anterior circulation. The number of PEDs used was 1.2 per aneurysm. Symptomatic procedure-related complications occurred in 3 patients (3%): 1 distal parenchymal hemorrhage that was managed conservatively and 2 ischemic events. At the latest follow-up (mean 6.3 months), 54 (72%) aneurysms were completely occluded (100%), 10 (13%) were nearly completely occluded (≥ 90%), and 11 (15%) were incompletely occluded (< 90%). Six aneurysms (8%) required further treatment. Increasing aneurysm size (OR 3.8, 95% CI 0.99-14; p = 0.05) predicted retreatment. All patients achieved a favorable outcome (modified Rankin Scale Score 0-2) at follow-up. CONCLUSIONS In this study, treatment of small aneurysms with the PED was associated with low complication rates and high aneurysm occlusion rates. These findings suggest that the PED is a safe and effective alternative to conventional endovascular techniques for small aneurysms. Randomized trials with long-term follow-up are necessary to determine the optimal treatment that leads to the highest rate of obliteration and the best clinical outcomes.
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