During a 5-year period 317 patients presenting with aneurysmal subarachnoid hemorrhage were successfully treated by coil embolization within 30 days of hemorrhage. The authors followed patients to ...assess the stability of aneurysm occlusion and its longer-term efficacy in protecting patients against rebleeding.
Patients were followed for 6 to 65 months (median 22.3 months) by clinical review, angiography performed at 6 months posttreatment, and annual questionnaires. Stable angiographic occlusion was evident in 86.4% of small and 85.2% of large aneurysms with recurrent filling in 38 (14.7%) of 259 aneurysms. Rebleeding was caused by aneurysm recurrence in four patients (between 11 and 35 months posttreatment) and by rupture of a coincidental untreated aneurysm in one patient. Annual rebleeding rates were 0.8% in the 1st year, 0.6% in the 2nd year, and 2.4% in the 3rd year after aneurysm embolization, with no rebleeding in subsequent years. Rebleeding occurred in three (7.9%) of 38 recurrent aneurysms and in one (0.4%) of 221 aneurysms that appeared stable on angiography.
Periodic follow-up angiography after coil embolization is recommended to identify aneurysm recurrence and those patients at a high risk of late rebleeding.
Dural arteriovenous fistulas (DAVFs) in the craniocervical junction are rare but clinically important. DAVFs can be associated with subarachnoid hemorrhage (SAH), a feature distinguishing them from ...DAVFs in the thoracolumbar region. These lesions are often overlooked at cerebral angiography performed to assess SAH and account for a small proportion of angiographically negative SAHs. After managing two cases of cervical spinal DAVF manifesting as SAH, we analyzed all cases in the literature to identify features associated with bleeding at presentation.
CT remains the most commonly used imaging technique in acute stroke but is often delayed after minor stroke. Interobserver reliability in distinguishing hemorrhagic transformation of infarction from ...intracerebral hemorrhage may depend on delays to CT but has not been reported previously despite the clinical importance of this distinction.
Initial CT scans with intraparenchymal hematoma from the first 1000 patients with stroke in the Oxford Vascular Study were independently categorized as intracerebral hemorrhage or hemorrhagic transformation of infarction by 5 neuroradiologists, both blinded and unblinded to clinical history. Thirty scans were reviewed twice. Agreement was quantified by the kappa statistic.
Seventy-eight scans showed intraparenchymal hematoma. Blinded pairwise interrater agreements for a diagnosis of intracerebral hemorrhage ranged from kappa=0.15 to 0.48 with poor overall agreement (kappa=0.35; 95% CI, 0.15 to 0.54) even after unblinding (kappa=0.41; 0.21 to 0.60). Blinded intrarater agreements ranged from kappa=0.21 to 0.92. Lack of consensus after unblinding was greatest in patients scanned >or=24 hours after stroke onset (67% versus 25%, P=0.001) and in minor stroke (National Institutes of Health Stroke Scale <or=5: 56% versus 29%, P=0.04) with disagreement in 75% of patients scanned >or=24 hours after minor stroke and in 48% of all 30-day stroke survivors in whom reliable diagnosis would be expected to influence long-term management.
Reliability of diagnosis of intraparenchymal hematoma on CT brain scan in minor stroke is poor, particularly if scanning is delayed. Immediate brain imaging is justified in patients with minor stroke.
The aim of this study was to evaluate the efficacy of a treatment combination of coil embolization and clot evacuation in patients presenting with an intracerebral hematoma (ICH) caused by the ...rupture of an aneurysm.
Twenty-seven patients were prospectively recruited in this study between 1996 and 2000. Endovascular treatment of the putative ruptured aneurysm was performed as soon as practical after diagnosis and before surgical evacuation of the ICH. The Glasgow Outcome Scale (GOS) was used during follow up. Despite admission World Federation of Neurosurgical Societies grades of IV or V in 25 patients (92%), 13 (48%) recovered well with GOS scores of 1 or 2, whereas six patients (21%) died.
The combined result of a favorable outcome in 48% of the patients and a mortality rate of 21% indicates that this treatment may be a valuable alternative for this patient group and warrants further study.
Object
The aim of this study was to determine the probability of seizures after treatment of a ruptured cerebral aneurysm by clip occlusion and coil embolization, and to identify the risks and ...predictors of seizures over the shortand long-term follow-up period.
Methods
The study population included 2143 patients with ruptured intracranial aneurysms who were enrolled in 43 centers and randomly assigned to clip application or coil placement. Those patients suffering a seizure were identified prospectively at various time points after randomization, as follows: before treatment; after treatment and before discharge; after discharge to 1 year; and annually thereafter.
Results
Two hundred thirty-five (10.9%) of the 2143 patients suffered a seizure after randomization; 89 (8.3%) of 1073 and 146 (13.6%) of 1070 in the endovascular and neurosurgical allocations, respectively (p = 0.014). In 19 patients the seizure was associated with a rehemorrhage. Of those patients who underwent coil placement alone, without additional procedures, 52 suffered a seizure, and in the group with clip occlusion alone, 91 patients suffered a seizure.
The risk of a seizure after discharge in the endovascular group was 3.3% at 1 year and 6.4% at 5 years. In the neurosurgical group it was 5.2% at 1 year and 9.6% at 5 years. The risk of seizure was significantly greater in the neurosurgical group at both 2 years and at up to 14 years (p = 0.005 and p = 0.013, respectively). The significant predictors of increased risk were as follows: neurosurgical treatment allocation, hazard ratio (HR) 1.64 (95% CI 1.19–2.26); younger age, HR 1.54 (95% CI 1.14–2.13); Fisher grade > 1 on CT scans, HR 1.34 (95% CI 0.62–2.87); delayed ischemic neurological deficit due to vasospasm, HR 2.10 (95% CI 1.49–2.94); and thromboembolic complication, HR 5.08 (95% CI 3.00–8.61). A middle cerebral artery (MCA) aneurysm location was also a significant predictor of increased risk in both groups; the HR was 2.23 (95% CI 1.57–3.17), with the probability of seizure at 6.1% and 11.5% at 1 year in the endovascular and neurosurgery groups, respectively.
Conclusions
The risk of seizures after coil embolization is significantly lower than that after clip occlusion. An MCA aneurysm location increased the risk of seizures in both groups.
Coil embolization of berry aneurysms is a relatively new treatment whose long-term efficacy has yet to be established. The purpose of this study was, first, to attempt to identify factors that might ...be important in predicting success both at the time of treatment and at the time of follow-up angiography, and, second, to study changes in the aneurysm between treatment and follow-up to determine the frequency of these changes.
The pretreatment, posttreatment, and follow-up angiograms of the first 63 aneurysms (in 58 patients) treated at our institution between June 1992 and April 1995 were analyzed, and the percentage of occlusion of each aneurysm was calculated. The size of any rest was noted for the posttreatment and follow-up angiograms. Treatment success was defined as a residue of less than 2 mm. Aneurysms were said to have changed if the percentage of occlusion had altered by more than 2.5% or if the difference in rest size was greater than 0.25 mm. Possible factors influencing primary and follow-up success rates were correlated against these calculations.
Success rates at treatment and follow-up were 71% and 65%, respectively. No change occurred in 41% of aneurysms, and 20% had a decrease in size of the residue. Twenty-eight percent had coil compaction, and 11% had aneurysmal growth. Neck size was the only significant variable in primary treatment success. Success at follow-up correlated significantly with neck size, initial treatment success, vasospasm at the time of treatment, and clinical presentation.
Best long-term angiographic results are obtained when the primary treatment is successful, when the aneurysm is small and narrow-necked, when the acutely ruptured aneurysm is treated within 15 days of ictus, and with anterior communicating and basilar-tip aneurysms.
Key points * Nicotine replacement therapy is an effective aid to smoking cessation * Smokers who are motivated to quit and are dependent on nicotine should be offered NRT * The choice of NRT product ...should normally be guided by the patient's preference * NRT should be prescribed for six to eight weeks, in blocks of up to two weeks, contingent on continued abstinence * Obtaining nicotine from NRT is considerably safer than smoking * NRT is safe in stable cardiac disease, but caution is needed in unstable, acute cardiovascular disease, pregnancy, or breast feeding, or in those aged under 18 Young smokers Most adult smokers established their smoking habit as children. ...the recent National Institute for Clinical Excellence guidance on NRT suggests that smokers under 18 who want to quit using NRT should discuss this with a relevant healthcare professional. ...evidence arises to the contrary, it therefore seems reasonable to use NRT in adolescent smokers who are motivated to quit and show evidence of nicotine dependence.
IntroductionThe Woven EndoBridge (WEB) represents a novel intrasaccular therapeutic option for the treatment of intracranial wide-necked bifurcation aneurysms (WNBAs). The WEB-IT Study is a pivotal ...Investigational Device Exemption (IDE) study to determine the safety and effectiveness of the WEB device for the treatment of WNBAs located in the anterior and posterior intracranial circulations. We present the patient demographics, procedural characteristics, and 30-day adverse event data for the US WEB-IT study.MethodsWEB-IT is a prospective multicenter single-arm interventional study conducted at 25 US and 6 international centers. The study enrolled 150 adults with WNBAs of the anterior and posterior intracranial circulations. All patients were intended to receive a WEB device delivered via standard endovascular neurosurgical embolization techniques. The study was conducted under Good Clinical Practices and included independent adjudication effectiveness outcomes and all adverse events.ResultsOne hundred and fifty patients enrolled at 27 investigational sites underwent attempted treatment with the WEB. Mean age was 59 years (range 29–79) and 110 (73.3%) of the patients were female. Treated aneurysms were located at the basilar apex (n=59, 39.3%), middle cerebral artery bifurcation (n=45, 30%), anterior communicating artery (n=40, 26.7%), and internal carotid artery terminus (n=6, 4%). Average aneurysm size was 6.4 mm (range 3.6–11.4) with a mean neck size of 4.8 mm (range 2.0–8.2, mean dome to neck ratio 1.34). Nine patients presented with ruptured aneurysms. Of the enrolled patients, 98.7% were treated successfully with WEB devices. Mean±SD fluoroscopy time was 30.2±15.7 min. One primary safety event (PSE) (0.7%)—a delayed parenchymal hemorrhage 22 days after treatment—occurred between the index procedure and 30-day follow-up. In addition to the single PSE, there were seven (4.7%) minor ischemic strokes (5 resolved without sequelae and 2 had a modified Rankin Scale score of 1 at 30 days), five (2.7%) transient ischemic attacks, and two (1.3%) minor subarachnoid hemorrhages, which did not meet the prospectively established criteria for PSEs.ConclusionsThe WEB device can be used to treat WNBAs with a high level of procedural safety and a high degree of technical success.Trial registration numberNCT02191618; Pre-results.
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