Introduction
Delayed aneurysm rupture and delayed intraparenchymal hemorrhages (DIPH) are poorly understood and often fatal complications of flow diversion (FD) for intracranial aneurysms. The ...purpose of this study was to identify risk factors for these complications.
Methods
We performed a systematic review on post-FD delayed aneurysm rupture and DIPH. For each reported case, we collected the following information: aneurysm location, size and rupture status, type of flow diverter used, timing of the hemorrhage, and neurological outcome. We reported descriptive statistics of patients suffering DIPH and delayed aneurysm rupture to determine if there were any characteristics consistently present among patients with these complications.
Results
We identified 81 delayed aneurysm ruptures and 101 DIPH. Of the delayed ruptures, 76.6 % (45/58) occurred within 1 month. The prognosis of delayed ruptures was poor, with 81.3 % (61/75) experiencing death or poor neurological outcome. Giant aneurysms accounted for 46.3 % of ruptures (31/67). Of these aneurysms, 80.9 % (55/68) were initially unruptured. Of the delayed ruptured aneurysms, 17.8 % (13/73) had prior or concomitant coiling. DIPHs were ipsilateral to the treated aneurysm in 82.2 % (60/73) of cases. Of the DIPH, 86.0 % (43/50) occurred within 1 month after FDS. Combined morbidity/mortality rate was 68.5 % (50/73) following DIPH. Of DIPHs, 23.0 % (14/61) occurred in patients with giant aneurysms.
Conclusions
Our study demonstrates that giant aneurysms represent almost 50 % of delayed aneurysm ruptures in the flow diverter literature. About 20 % of delayed ruptures occurred despite associated coiling. A substantial proportion of DIPHs occur early following FDS treatment of giant aneurysms.
OBJECTIVE To identify and define clinical associations and radiologic findings of posterior reversible encephalopathy syndrome (PRES). PATIENTS AND METHODS Patients prospectively diagnosed as having ...PRES from October 1, 2005, through April 30, 2009, were pooled with retrospectively identified patients admitted from August 1, 1999, through September 30, 2005. We performed a detailed review of clinical information, including demographics, presenting symptoms, medical history, and risk factors. All patients underwent computed tomography of the brain or magnetic resonance imaging. Findings on magnetic resonance imaging were analyzed independently by 2 neuroradiologists. RESULTS We identified 120 cases of PRES in 113 patients (mean age, 48 years). Mean peak systolic blood pressure was 199 mm Hg (minimum-maximum, 160-268 mm Hg), and mean peak diastolic blood pressure was 109 mm Hg (minimum-maximum, 60-144 mm Hg). Etiologies of PRES included hypertension (n=69 61%), cytotoxic medications (n=21 19%), sepsis (n=8 7%), preeclampsia or eclampsia (n=7 6%), and multiple organ dysfunction (n=1 1%). Autoimmune disease was present in 51 patients (45%). Clinical presentations included seizures (n=84 74%), encephalopathy (n=32 28%), headache (n=29 26%), and visual disturbances (n=23 20%). In the 115 cases (109 patients) for which magnetic resonance imaging findings were available, the parieto-occipital regions were the most commonly involved (n=108 94%), followed by the frontal lobe (n=88 77%), temporal lobe (n=74 64%), and cerebellum (n=61 53%). Cerebellar involvement was significantly more frequent in patients with a history of autoimmunity ( P =.008), and patients with sepsis were more likely to have cortical involvement ( P <.001). CONCLUSION A substantial proportion of patients with PRES have underlying autoimmune conditions that may support endothelial dysfunction as a pathophysiologic mechanism. On brain imaging, the location and severity of vasogenic edema were mostly similar for the different clinical subgroups.
Flow diverters are important tools in the treatment of intracranial aneurysms. However, their impact on aneurysmal occlusion rates, morbidity, mortality, and complication rates is not fully examined.
...We conducted a systematic review of the literature searching multiple databases for reports on the treatment of intracranial aneurysms with flow-diverter devices. Random effects meta-analysis was used to pool outcomes of aneurysmal occlusion rates at 6 months, and procedure-related morbidity, mortality, and complications across studies.
A total of 29 studies were included in this analysis, including 1451 patients with 1654 aneurysms. Aneurysmal complete occlusion rate was 76% (95% confidence interval CI, 70%-81%). Procedure-related morbidity and mortality were 5% (95% CI, 4%-7%) and 4% (95% CI, 3%-6%), respectively. The rate of postoperative subarachnoid hemorrhage was 3% (95% CI, 2%-4%). Intraparenchymal hemorrhage rate was 3% (95% CI, 2%-4%). Perforator infarction rate was 3% (95% CI, 1%-5%), with significantly lower odds of perforator infarction among patients with anterior circulation aneurysms compared with those with posterior circulation aneurysms (odds ratio, 0.01; 95% CI, 0.00-0.08; P<0.0001). Ischemic stroke rate was 6% (95% CI, 4%-9%), with significantly lower odds of perforator infarction among patients with anterior circulation aneurysms compared with those with posterior circulation aneurysms (odds ratio, 0.15; 95% CI, 0.08-0.27; P<0.0001).
This meta-analysis suggests that treatment of intracranial aneurysms with flow-diverter devices is feasible and effective with high complete occlusion rates. However, the risk of procedure-related morbidity and mortality is not negligible. Patients with posterior circulation aneurysms are at higher risk of ischemic stroke, particularly perforator infarction. These findings should be considered when considering the best therapeutic option for intracranial aneurysms.
In this study the authors determined the patency rate of the ophthalmic artery (OphA) after placement of 1 or more flow diversion devices across the arterial inlet for treatment of proximal internal ...carotid artery (ICA) aneurysms, and correlated possible risk factors for OphA occlusion.
Nineteen consecutive patients were identified (mean age 53.9 years, range 23-74 years, all female) who were treated for 20 ICA aneurysms. In all patients a Pipeline Embolization Device (PED) was placed across the ostium of the OphA while treating the target aneurysm. Flow through the OphA after PED placement was determined by immediate angiography as well as follow-up angiograms (mean 8.7 months), compared with the baseline study. Potential risk factors for OphA occlusion, including age, immediate angiographic flow through the ophthalmic branch, status of flow within the aneurysm after placement of PEDs, whether the ophthalmic branch originated from the aneurysm dome, and number of PEDs placed across the ophthalmic branch inlet were correlated with patency rate.
Patients were treated with 1-3 PEDs (3 aneurysms treated with placement of 1 PED, 12 with 2 PEDs, and 5 with 3 PEDs). In 17 (85%) of 20 treated aneurysms, no changes in the OphA flow were noted immediately after placement of the device. Two (10%) of 20 patients had delayed antegrade filling immediately following PED placement and 1 patient (5%) had retrograde flow from collaterals to the OphA immediately after placement of the device. One patient (5%) experienced delayed asymptomatic ICA occlusion; this patient was excluded from analysis at follow-up. At follow-up the OphA remained patent with normal antegrade flow in 13 (68%) of 19 patients, patent but with slow antegrade flow in 2 patients (11%), and was occluded in 4 patients (21%). No visual changes or clinical symptoms developed in patients with OphA flow compromise. The mean number of PEDs in the patients with occluded OphAs or change in flow at angiographic follow-up was 2.4 (SEM 0.2) compared with 1.9 (SEM 0.18) in the patients with no change in OphA flow (p = 0.09). There was no significant difference between the patients with occluded OphAs compared with nonoccluded branches based on patient age, immediate angiographic flow through the ophthalmic branch, status of flow through the aneurysm after placement of PEDs, whether the ophthalmic branch originated from the aneurysm dome, or number of PEDs placed across the ophthalmic branch inlet.
Approximately one-quarter of OphAs will undergo proximal thrombosis when covered with flow diversion devices. Even though these events were well-tolerated clinically, our findings suggest that coverage of branch arteries that have adequate collateral circulation may lead to spontaneous occlusion of those branches.
Objective:
Stroke risk due to intracranial atherosclerosis increases with degree of arterial stenosis. We evaluated the previously unexplored role of collaterals in modifying stroke risk in ...intracranial atherosclerosis and impact on subsequent stroke characteristics.
Methods:
Collateral flow was graded in blind fashion on 287 of 569 baseline angiograms (stenoses of 50–99% and adequate collateral views) in the Warfarin–Aspirin Symptomatic Intracranial Disease (WASID) trial. Statistical models predicted stroke in the symptomatic arterial territory based on collateral flow grade, percentage of stenosis, and previously demonstrated independent covariates.
Results:
Across all stenoses, extent of collaterals was a predictor for subsequent stroke in the symptomatic arterial territory (hazard ratio HR none vs good, 1.14; 95% confidence interval CI, 0.39–3.30; poor vs good, 4.36; 95% CI, 1.46–13.07; p < 0.0001). For 70 to 99% stenoses, more extensive collaterals diminished risk of subsequent territorial stroke (HR none vs good, 4.60; 95% CI, 1.03–20.56; poor vs good, 5.90; 95% CI, 1.25–27.81; p = 0.0427). At milder degrees of stenoses (50–69%), presence of collaterals was associated with greater likelihood of subsequent stroke (HR none vs good, 0.18; 95% CI, 0.04–0.82; poor vs good, 1.78; 95% CI, 0.37–8.57; p < 0.0001). In multivariate analyses, extent of collaterals was an independent predictor for subsequent stroke in the symptomatic arterial territory (HR none vs good, 1.62; 95% CI, 0.52–5.11; poor vs good, 4.78; 95% CI, 1.55–14.7; p = 0.0019).
Interpretation:
Collateral circulation is a potent determinant of stroke risk in intracranial atherosclerosis, demonstrating a protective role with severe stenoses and identifying more unstable milder stenoses. ANN NEUROL 2010;
Antithrombotic therapy for intracranial arterial stenosis was recently evaluated in the Warfarin versus Aspirin for Symptomatic Intracranial Disease (WASID) trial. A prespecified aim of WASID was to ...identify patients at highest risk for stroke in the territory of the stenotic artery who would be the target group for a subsequent trial comparing intracranial stenting with medical therapy.
WASID was a randomized, double-blinded, multicenter trial involving 569 patients with transient ischemic attack or ischemic stroke due to 50% to 99% stenosis of a major intracranial artery. Median time from qualifying event to randomization was 17 days, and mean follow-up was 1.8 years. Multivariable Cox proportional hazards models were used to identify factors associated with subsequent ischemic stroke in the territory of the stenotic artery. Subsequent ischemic stroke occurred in 106 patients (19.0%); 77 (73%) of these strokes were in the territory of the stenotic artery. Risk of stroke in the territory of the stenotic artery was highest with severe stenosis > or =70% (hazard ratio 2.03; 95% confidence interval 1.29 to 3.22; P=0.0025) and in patients enrolled early (< or =17 days) after the qualifying event (hazard ratio 1.69; 95% confidence interval 1.06 to 2.72; P=0.028). Women were also at increased risk, although this was of borderline significance (hazard ratio 1.59; 95% confidence interval 1.00 to 2.55; P=0.051). Location of stenosis, type of qualifying event, and prior use of antithrombotic medications were not associated with increased risk.
Among patients with symptomatic intracranial stenosis, the risk of subsequent stroke in the territory of the stenotic artery is greatest with stenosis > or =70%, after recent symptoms, and in women.
Atherosclerotic intracranial arterial stenosis is an important cause of stroke that is increasingly being treated with percutaneous transluminal angioplasty and stenting (PTAS) to prevent recurrent ...stroke. However, PTAS has not been compared with medical management in a randomized trial.
We randomly assigned patients who had a recent transient ischemic attack or stroke attributed to stenosis of 70 to 99% of the diameter of a major intracranial artery to aggressive medical management alone or aggressive medical management plus PTAS with the use of the Wingspan stent system. The primary end point was stroke or death within 30 days after enrollment or after a revascularization procedure for the qualifying lesion during the follow-up period or stroke in the territory of the qualifying artery beyond 30 days.
Enrollment was stopped after 451 patients underwent randomization, because the 30-day rate of stroke or death was 14.7% in the PTAS group (nonfatal stroke, 12.5%; fatal stroke, 2.2%) and 5.8% in the medical-management group (nonfatal stroke, 5.3%; non-stroke-related death, 0.4%) (P=0.002). Beyond 30 days, stroke in the same territory occurred in 13 patients in each group. Currently, the mean duration of follow-up, which is ongoing, is 11.9 months. The probability of the occurrence of a primary end-point event over time differed significantly between the two treatment groups (P=0.009), with 1-year rates of the primary end point of 20.0% in the PTAS group and 12.2% in the medical-management group.
In patients with intracranial arterial stenosis, aggressive medical management was superior to PTAS with the use of the Wingspan stent system, both because the risk of early stroke after PTAS was high and because the risk of stroke with aggressive medical therapy alone was lower than expected. (Funded by the National Institute of Neurological Disorders and Stroke and others; SAMMPRIS ClinicalTrials.gov number, NCT00576693.).
There is currently controversy on the ideal anesthesia strategy during mechanical thrombectomy for acute ischemic stroke. We performed a systematic review and meta-analysis of studies comparing ...clinical and angiographic outcomes of patients undergoing general anesthesia (GA group) and those receiving either local anesthesia or conscious sedation (non-GA group).
A literature search on anesthesia and endovascular treatment of acute ischemic stroke was performed. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome at 90 days (modified Rankin Score≤2), symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, and time to groin puncture.
Twenty-two studies (3 randomized controlled trials and 19 observational studies), including 4716 patients (1819 GA and 2897 non-GA) were included. In the nonadjusted analysis, patients in the GA group had higher odds of death (odds ratio OR, 2.02; 95% confidence interval CI, 1.66-2.45) and respiratory complications (OR, 1.70; 95% CI, 1.22-2.37) and lower odds of good functional outcome (OR, 0.58; 95% CI, 0.48-0.64) compared with the non-GA group. There was no difference in procedure time between the 2 primary comparison groups. When adjusting for baseline National Institutes of Health Stroke Scale, GA was still associated with lower odds of good functional outcome (OR, 0.59; 95% CI, 0.29-0.94). When considering studies performed in the stent-retriever/aspiration era, there was no significant difference in good neurological outcome rates (OR, 0.84; 95% CI, 0.67-1.06).
Acute ischemic stroke patients undergoing intra-arterial therapy may have worse outcomes when treated with GA as compared with conscious sedation/local anesthesia. However, major limitations of current evidence (ie, retrospective studies and selection bias) indicate a need for adequately powered, multicenter randomized controlled trials to answer this question.
We report a preclinical study of a new endoluminal device for aneurysm occlusion to test the hypothesis that the device, even without use of intrasaccular coil placement, could occlude saccular ...aneurysms without causing substantial parent artery compromise or compromise of adjacent, small branch arteries.
The Pipeline Neuroendovascular Device (Pipeline NED; Chestnut Medical Technologies, Inc) is a braided, tubular, bimetallic endoluminal implant aimed at occlusion of saccular aneurysms through flow disruption along the aneurysm neck. The device was implanted across the necks of 17 elastase-induced aneurysms in the New Zealand white rabbit model and followed for 1 month (n=6), 3 months (n=5), and 6 months (n=6). In each subject, a second device was implanted in the abdominal aorta to cover the origins of lumbar arteries. Aneurysm occlusion rates by angiography (grade 1, complete occlusion; grade 2, near-complete occlusion; and grade 3, incomplete occlusion) were documented. Percent area stenosis of the parent arteries was calculated. Presence of distal emboli in the downstream vessels in the parent artery and branch artery stenosis or occlusion was noted.
Grades 1, 2, and 3 occlusion rates were noted in 9 (53%), 6 (35%), and 2 (12%) of 17 aneurysms, respectively, indicating an 88% rate of complete or near complete occlusion. No cases of branch artery occlusion or distal emboli in the downstream vessels of the parent artery, specifically the subclavian artery, were seen. Parent artery compromise from neointimal hyperplasia was minimal in most cases.
The Pipeline NED is a trackable, bio- and hemocompatible device able to occlude saccular aneurysms with preservation of the parent artery and small, adjacent branch vessels.
Abstract
BACKGROUND
Spinal epidural arteriovenous fistulas (SEDAVFs) are an increasingly recognized form of spinal vascular malformation and are distinct from spinal dural arteriovenous fistulas ...(SDAVFs). Differentiating between these 2 entities is important as operative strategies often differ based on angioarchitecture.
OBJECTIVE
To compare demographic, clinical, anatomic, and imaging findings of SDAVFs and SEDAVFs.
METHODS
Consecutive patients diagnosed and/or treated for SDAVF or SEDAVF at our institution between January 2000 and November 2018 were included. Data were collected on demographics, clinical presentation, and imaging findings. All cross-sectional and angiographic imaging were reviewed. To compare continuous variables, t-test was used Chi-squared was used for categorical variables.
RESULTS
A total of 169 patients were included. In total 47 patients had SEDAVFs and 122 patients had SDVAFs. Clinical presentation and magnetic resonance imaging (MRI) imaging findings were similar between the 2 groups. SEDAVF patients were significantly more likely to have an epidural venous pouch on gadolinium bolus MR angiography (MRA) (0.0% vs 92.1%, P < .0001). SEDAVFs were more commonly located in the lumbar and sacral spine than SDAVFs (85.1% vs 34.4%, P < .0001). When in the lumbar spine, SEDAVFs unlike SDAVFs were more likely to involve the most caudal segments (L4 and L5, P = .02).
CONCLUSION
SEDAVF share clinical and radiological findings similar to SDAVFS, including high T2 cord signal, cord enhancement, and perimedullary flow voids on conventional MRI. However, they have a characteristic appearance on spinal MRA and DSA with a pouch of epidural contrast. SEDAVFs are more commonly located in the lumbosacral spine.
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