Tortuous occipital emissary vein combined with dural venous sinus stenosis in contrast-enhanced MRV for evaluation of idiopathic intracranial hypertension

PURPOSE

Venous outflow impediment is increasingly recognized in idiopathic intracranial hypertension (IIH). We aim to search for the value of tortuous occipital emissary vein (OEV) in IIH by integrating measurable transverse sinus (TS) stenosis in contrast-enhanced MR venography (CE-MRV).

METHODS

Twenty-one IIH patients were evaluated with CE-MRV. Each patient had high LP opening pressure (> 25 cm.H2O), and presented papilledema. Age- and sex-matched 21 control subjects who underwent cranial CE-MRV were selected. The OEV and the following features: intraosseous diameter of more than 3 mm, twisted course, and continuous with prominent sub-occipital extracranial veins were named tortuous OEV. TS stenosis was measured by utilizing the coronal T1-VIBE series to calculate quantitative metrics such as TS max./min.. The tortuous OEV and TS max./min. were registered to create a bivariate logistic regression model to assess the performance of tortuous OEV for IIH when accompanied by TS stenosis.

RESULTS

Six (29%) tortuous OEVs were observed in the IIH group, while no tortuous OEV was identified in the control group (p = 0.021). The mean TSmax./min. was 2.48 ± 1.19 in patients with IIH and 1.23 ± 0.33 in the control group (p < 0.001). According to regression analysis, tortuous OEV is not predictive of IIH (p = 0.999), while the higher TSmax./min. (> 1.69) is predictive of IIH (p = 0.022, OR: 8.9; %95 CI; 1.4-59.0) when accompanied together.

CONCLUSION

Tortuous occipital emissary vein is more frequently seen in patients with IIH. However, the tortuous appearance alone does not predict idiopathic intracranial hypertension unless associated with measurable transverse sinus narrowing in CE-MRV.

Prediction of mortality and the development of critical illness in the course of COVID-19 with tertiary hospital data: vaccines? Critical illness scores? Mortality scores?

OBJECTIVE

Even though COVID-19 affects some risk groups more severely than others, there are still unknowns concerning the intensive care procedure and death in non-risk categories, making it vital to identify critical sickness and fatality risk factors at this time. The purpose of this study was to look into the efficacy of critical illness and mortality scores, as well as other risk factors in COVID-19.

PATIENTS AND METHODS

Two hundred twenty-eight inpatients diagnosed with COVID-19 were included in the study. Sociodemographic, clinical, and laboratory data were recorded and risk calculations were made with the help of web-based patient data-based calculation programs called COVID-GRAM Critical Illness and 4C-Mortality score.

RESULTS

The median age of 228 patients included in the study was 56.5 years, 51.3% of them were males, and ninety-six (42.1%) were unvaccinated. According to the multivariate analysis, the factors affecting the development of critical illness were cough [odds ratio=0.303, 95% CI (0.123,0.749), p=0.010], creatinine [odds ratio=1.542, 95% CI (1.100, 2.161), p=0.012], respiratory rate [odds ratio=1.484, 95% CI (1.302, 1.692), p=0.000], COVID-GRAM Critical Illness Score [odds ratio=3.005, 95% CI (1.288, 7.011), p=0.011]. Factors affecting survival were vaccine status [odds ratio=0.320, 95% CI (0.127,0.802), p=0.015], blood urea nitrogen (BUN) [odds ratio=1.032, 95% CI (1.012, 1.053), p=0.002], respiratory rate [odds ratio=1.173, 95% CI (1.070, 1.285), p=0.001], COVID-GRAM-critical-illness score [odds ratio=2.714, 95% CI (1.123, 6.556), p=0.027].

CONCLUSIONS

The findings suggested that risk assessment might employ risk scoring, such as COVID-GRAM Critical Illness, and that immunization against COVID-19 will reduce the occurrence of mortality.

The Angiographic and Clinical Follow-up Outcomes of the Wide-Necked and Complex Intracranial Aneurysms Treated With LVIS EVO-Assisted Coiling

BACKGROUND

The Low Profile Visible Intraluminal Support EVO (LVIS EVO) is a self-expandable braided stent, which was recently introduced for the treatment of intracranial aneurysms. Full visibility of the stent and a relatively high metal coverage ratio are the unique features of the LVIS EVO.

OBJECTIVE

To assess the safety, efficacy, and midterm durability of LVIS EVO stent-assisted coiling for the treatment of wide-necked intracranial aneurysms.

METHODS

The endovascular databases were reviewed to identify patients treated with LVIS EVO-assisted coiling. The technical success and immediate clinical/angiographic outcomes were assessed. Periprocedural and delayed complications were evaluated. The follow-up angiographic/clinical outcomes were investigated. The preprocedural/follow-up neurological statuses were assessed with the modified Rankin Scale.

RESULTS

One hundred three aneurysms in 103 patients (63 females) with a mean age of 54.9 ± 11.3 years were included. The mean maximum sac diameter was 6.2 ± 2.9 mm. The procedural technical success rate was 100%. Immediate postprocedural angiography showed complete occlusion in 77.7%. The mean duration of the angiographic follow-up was 8.8 ± 3.6 months. Follow-up angiography showed complete aneurysm occlusion in 89% of the 82 patients with angiographic follow-up. Recanalization was observed in 7.3% of 82 patients. Two patients (2.4%) required retreatment. In addition, 8.7% of the patients had at least 1 complication, and 2.9% of the patients developed a permanent morbidity. All patients had mRS scores ≤2.

CONCLUSION

The results of this study demonstrate that SAC with LVIS EVO is a relatively safe, efficient, and durable treatment for wide-necked and complex intracranial aneurysms.

Basilar artery occlusion management: An international survey of middle versus high-income countries

BACKGROUND AND PURPOSE

Two early basilar artery occlusion (BAO) randomized controlled trials (RCTs) did not establish the superiority of endovascular thrombectomy (EVT) over medical management. Yet many providers continued to recommend EVT. The goal of the present article is to compare physicians' diagnostic and management strategies of BAO among middle-income and high-income countries (MICs and HICs, respectively).

METHODS

We conducted an international survey from January to March 2022 regarding management strategies in acute BAO, to examine clinical and imaging parameters influencing clinician management of patients with BAO. We compared responses between physicians from HIC and MIC.

RESULTS

Among the 1245 respondents from 73 countries, 799 (64.2%) were from HIC, with the remaining 393 (31.6%) from MIC. Most respondents perceived that EVT was superior to medical management for acute BAO, but more so in respondents from HIC (98.0% vs. 94.2%, p < 0.01). MIC respondents were more likely to believe further RCTs were warranted (91.6% vs. 74.0%, p < 0.01) and were more likely to find it acceptable to enroll any patient who met a trial's criteria in the standard medical treatment arm (58.8% vs. 38.5%, p < 0.01).

CONCLUSIONS

In an area where clinical equipoise was called into question despite the lack of RCT evidence, we found that respondents from MIC were more likely to express willingness to enroll patients with BAO in an RCT than their HIC counterparts.

Safety, Efficacy, and Durability of Stent-Assisted Coiling Treatment of M2 (Insular) Segment MCA Aneurysms

BACKGROUND AND PURPOSE

Most distal MCA aneurysms are located within the insular segment, which lies between the limen insulae and circular sulcus. However, experience is limited in the microsurgical and endovascular management of insular segment MCA aneurysms. In this multicenter retrospective case series, we aimed to investigate the safety, efficacy, and durability of stent-assisted coiling for treatment of insular segment MCA aneurysms.

MATERIALS AND METHODS

A retrospective review was performed to identify patients with insular MCA aneurysms that were treated with stent-assisted coiling. The technical success of the procedures and the initial and follow-up clinical and angiographic outcomes were assessed. Periprocedural and delayed complications were reviewed.

RESULTS

Twenty-seven aneurysms in 27 patients with a mean age of 53.3 (SD,11.3) years were included. The mean size of the aneurysms was 6.3 (SD 2.6) mm. Endovascular procedures were successfully performed in all patients. Immediate postprocedural angiography revealed complete aneurysm occlusions in 81.5%. Periprocedural complications developed in 7.4% without causing permanent morbidity. A delayed thromboembolic complication resulted in a minor permanent morbidity in 1 patient (3.7%). There was no mortality. The mean duration of angiographic follow-up was 19.5 (SD, 9.8)  months. The last follow-up examinations showed complete occlusion in 92.6%. During the follow-up period, none of the treated aneurysms showed recanalization.

CONCLUSIONS

The results of this study demonstrate that stent-assisted coiling with a low-profile self-expandable stent is a feasible and relatively safe technique for endovascular treatment of insular segment complex MCA aneurysms. Additionally, it provides an effective and durable treatment for insular MCA aneurysms.

Comparison of 2017 ILAE and Semiological seizure classifications before and after video-EEG monitoring in childhood epilepsy

OBJECTIVE

Our aim in this study is to evaluate epilepsy classification in children with epilepsy before monitoring (based on information received from the family) and after monitoring (based on video-EEG) by comparing two separate classification systems, namely the 2017 International League Against Epilepsy (ILAE) and Semiological Seizure Classification (SSC) systems. Classifications and methods were compared in terms of simplicity, intelligibility, and applicability during daily outpatient care.

PATIENTS AND METHODS

The study was performed with 230 recorded seizures of 173 patients aged between 1 and 18 years who underwent video-EEG monitoring and clinical seizure recordings. Seizure types and video-EEG data of the patients were recorded. Seizures were first classified based on information obtained from the parents of the patients in interviews, recorded as "before video-EEG monitoring classification," and a second characterization, based on video EEG-monitoring, was subsequently recorded as "after video-EEG monitoring classification". The consistency of both seizure classifications was evaluated.

RESULTS

For both classifications, autonomic seizures were the least congruent seizures (κ=0.27, κ=-0.005). The families generally described the seizures very well; the consistency before and after video-EEG monitoring was good. Focal seizures with impaired awareness were most common in the 2017 ILAE classification (κ=0.6), while for the SSC simple motor seizures were most common (κ=0.84). Among subtypes, clonic-tonic seizures were the most common, and the second most common subtype was dialeptic (κ=0.67). Overall, the harmony between the SSC and ILAE systems was good. The rate of good and excellent coefficients of concordance for both the SSC and 2017 ILAE was determined as 77.8% for the expanded SSC, 48% for the 2017 ILAE, 71.4% for the basic SSC, and 60% for the 2017 ILAE.

CONCLUSIONS

In practice, it is difficult to determine seizure patterns reliably in cases of childhood epilepsy. Parents, however, can generally describe seizures very well. Although the SSC seems to be superior, both the SSC and 2017 ILAE systems can be applied in daily use. Such classification enables the rise of new concepts and a better understanding of disease groups. The continuing development of classification systems will lead to advancements for patients.

Electrical status epilepticus during sleep (ESES) in benign childhood epilepsy with Centrotemporal spikes (BCECTS): insights into predictive factors, and clinical and EEG outcomes

OBJECTIVE

Benign childhood epilepsy with centro-temporal spikes (BCECTS), otherwise known as benign rolandic epilepsy, is the most common focal epilepsy in childhood. This study aimed to evaluate the development and resolution of ESES in children with BCECTS and evaluate the clinical and electroencephalography (EEG) parameters associated with prognosis.

PATIENTS AND METHODS

Resolution of ESES was defined as the reduction of the spike-wave index (SWI) to <50%. The SWI short method, measurements from the first 180 s of non-rapid eye movement; and the conventional method, measurements from total NREM stage 2, SW count during the first 60 and 180 s of NREM, SW localization, and ESES type were determined.

RESULTS

Of a total of 126 BCECTS patients, 33, including 13 females, 20 males, who developed ESES during follow-up, were included in the study. ESES remission was observed in 42.4% (n = 14) of the patients. The median time to remission was 10.5 months. The rate of resolution was 87.9 % for the entire population. The mean age at resolution was 9.8 ± 2.05 years and the mean time to resolution was 8.8 months.

CONCLUSIONS

The data demonstrated that age at ESES diagnosis, the time between BCECTS diagnosis and the onset of ESES, time to resolution of ESES, ESES remission, and seizure freedom after ESES were significantly associated with prognosis. The early recognition of ESES evolution in children with BECTS, the better understanding of the relationship between age at ESES diagnosis and remission and prognosis, and timely intervention can prevent long-term sequelae.

Safety, Efficacy, and Durability of Stent Plus Balloon-Assisted Coiling for the Treatment of Wide-Necked Intracranial Bifurcation Aneurysms

BACKGROUND

Wide-necked bifurcation aneurysms remain a challenge for endovascular surgeons. Dual-stent-assisted coiling techniques have been defined to treat bifurcation aneurysms with a complex neck morphology. However, there are still concerns about the safety of dual-stenting procedures. Stent plus balloon-assisted coiling is a recently described endovascular technique that enables the coiling of wide-necked complex bifurcation aneurysms by implanting only a single stent.

OBJECTIVE

To investigate the feasibility, efficacy, safety, and durability of this technique for the treatment of wide-necked bifurcation aneurysms.

METHODS

A retrospective review was performed of patients with wide-necked intracranial bifurcation aneurysms treated with stent plus balloon-assisted coiling. The initial and follow-up clinical and angiographic outcomes were assessed. Preprocedural and follow-up clinical statuses were assessed using modified Rankin scale.

RESULTS

A total of 61 patients (mean age: 54.6 ± 10.4 yr) were included in the study. The immediate postprocedural digital subtraction angiography revealed complete aneurysm occlusion in 86.9% of the cases. A periprocedural complication developed in 11.5% of the cases. We observed a delayed ischemic complication in 4.9%. There was no mortality in this study. The permanent morbidity rate was 3.3%. The follow-up angiography was performed in 55 of 61 patients (90.1%) (the mean follow-up period was 25.5 ± 27.3 mo). The rate of complete aneurysm occlusion at the final angiographic follow-up was 89.1%. The retreatment rate was 1.8%.

CONCLUSION

The results of this study showed that stent plus balloon-assisted coiling is a feasible, effective, and relatively safe endovascular technique for the treatment of wide-necked bifurcation aneurysms located in the posterior and anterior circulation.

Flow diverter stents in the treatment of recanalized intracranial aneurysms

BACKGROUND

We assessed the safety and efficacy of flow diverter stents (FDSs) in the treatment of recanalized or residual intracranial aneurysms treated endovascularly.

MATERIALS & METHODS

Patients whose recanalized or residual aneurysms were treated with FDSs in five tertiary hospitals were reviewed retrospectively. The patients' demographic data, aneurysm characteristics, types of previous treatment, and clinical complications, or serious adverse events associated with FDSs, as well as the results of neurological and angiographic follow-up assessments, were recorded.

RESULTS

Eighty-six patients (37 males) with 87 aneurysms were included in this study. Eighty (91.9%) aneurysms were in the anterior and seven (8.1%) in the posterior circulation. The initial treatment methods were the primary coiling or balloon remodeling technique in 69 (79.3%) and stent-assisted coiling in 18 (20.7%) aneurysms. The endovascular procedure was successful in all patients. Complications occurred in four patients, for a total complication rate of 4.6%. A technical complication developed in one patient (1.2%). An in-stent thrombosis treated with tirofiban was seen in two cases. Late in-stent stenosis exceeding 50% was treated with balloon angioplasty in one patient. The mean length of follow-up was 21.0 months. The first angiographic follow-up (3-6 months) revealed the complete occlusion of 74 aneurysms (85.1%). While 76 aneurysms (87.4%) were occluded at the last angiographic follow-up (mean: 26.0 months), 11 aneurysms (12.6%) were still filling. Morbimortality was zero.

CONCLUSION

The drawback of endovascular treatment is aneurysmal remnants or recurrences, which is safely and durably amenable to flow diversion.

A new COVID-19 prediction scoring model for in-hospital mortality: experiences from Turkey, single center retrospective cohort analysis

OBJECTIVE

Although many studies reported prognostic factors proceeding to severity of COVID-19 patients, in none of the article a prediction scoring model has been proposed. In this article a new prediction tool is presented in combination of Turkish experience during pandemic.

MATERIALS AND METHODS

Laboratory and clinical data of 397 over 798 confirmed COVID-19 patients from Gülhane Training and Research Hospital electronic medical record system were included into this retrospective cohort study between the dates of 23 March to 18 May 2020. Patient demographics, peripheral venous blood parameters, symptoms at admission, in hospital mortality data were collected. Non-survivor and survivor patients were compared to find out a prediction scoring model for mortality.

RESULTS

There was 34 [8.56% (95% CI:0.06-0.11)] mortality during study period. Mean age of patients was 57.1±16.7 years. Older age, comorbid diseases, symptoms, such as fever, dyspnea, fatigue and gastrointestinal and WBC, neutrophil, lymphocyte count, C-reactive protein, neutrophil-to-lymphocyte ratio of patients in non-survivors were significantly higher. Univariate analysis demonstrated that OR for prognostic nutritional index (PNI) tertile 1 was 18.57 (95% CI: 4.39-78.65, p<0.05) compared to tertile 2. Performance statistics of prediction scoring method showed 98% positive predictive value for criteria 1.

CONCLUSIONS

It is crucial to constitute prognostic clinical and laboratory parameters for faster delineation of patients who are prone to worse prognosis. Suggested prediction scoring method may guide healthcare professional to discriminate severe COVID-19 patients and provide prompt intensive therapies which is highly important due to rapid progression leading to mortality.

Ecosystem-based fisheries management forestalls climate-driven collapse

Climate change is impacting fisheries worldwide with uncertain outcomes for food and nutritional security. Using management strategy evaluations for key US fisheries in the eastern Bering Sea we find that Ecosystem Based Fisheries Management (EBFM) measures forestall future declines under climate change over non-EBFM approaches. Yet, benefits are species-specific and decrease markedly after 2050. Under high-baseline carbon emission scenarios (RCP 8.5), end-of-century (2075–2100) pollock and Pacific cod fisheries collapse in >70% and >35% of all simulations, respectively. Our analysis suggests that 2.1–2.3 °C (modeled summer bottom temperature) is a tipping point of rapid decline in gadid biomass and catch. Multiyear stanzas above 2.1 °C become commonplace in projections from ~2030 onward, with higher agreement under RCP 8.5 than simulations with moderate carbon mitigation (i.e., RCP 4.5). We find that EBFM ameliorates climate change impacts on fisheries in the near-term, but long-term EBFM benefits are limited by the magnitude of anticipated change.

Ecosystem Based Management measures developed to prevent overfishing could be particularly important under climate change. Here the authors combine climate and fish stock modelling to show that EBM cap implementation reduces climate-driven fishery declines under RCP 4.5 and 8.5 before midcentury. However, there are thermal tipping points beyond which potential collapses are predicted.

Y-Stent-Assisted Coiling With Low-Profile Neuroform Atlas Stents for Endovascular Treatment of Wide-Necked Complex Intracranial Bifurcation Aneurysms

BACKGROUND

Y-stent-assisted coiling is one of the eligible techniques for the treatment of complex bifurcation aneurysms. In majority of previous literature, Y-stenting has been performed using stents that could be delivered through large profile microcatheters that are often difficult to manipulate during navigation through sharply angled side branches. Attempts to navigate with these large profile catheters might cause serious complications during Y-stenting procedure.

OBJECTIVE

To investigate the safety, feasibility, and efficacy of Y-stent-assisted coiling procedure with Neuroform Atlas stents for the treatment of complex bifurcation aneurysms; Neuroform Atlas is a recently introduced open-cell stent that can be delivered though low-profile microcatheters.

METHODS

We identified the patients with intracranial bifurcation aneurysms treated by Y-stent-assisted coiling procedure with Neuroform Atlas stents. We assessed the immediate postoperative and follow-up clinical and angiographic outcomes. We also investigated the periprocedural and delayed complications.

RESULTS

A total of 30 aneurysms in 30 patients were included in the study. Y-stenting was successfully performed without any technical complications in all cases (100%). Immediate postprocedural angiography revealed total aneurysm occlusion in 83.3% of patients. The mean angiographic follow-up time was 11.8 mo. The last follow-ups showed complete occlusion in 93.3% of patients. There was no mortality in this study. A procedure-related complication developed in 6.7% and resulted in permanent morbidity in 3.3% of patients.

CONCLUSION

Neuroform Atlas stent combines the advantages of low-profile deployment microcatheters with an open-cell structure to achieve a successful Y-stenting procedure. Y-stent-assisted coiling with Neuroform Atlas stents provides a safe and effective endovascular treatment for wide-necked complex bifurcation aneurysms.

Long-term outcomes of wide-necked intracranial bifurcation aneurysms treated with T-stent-assisted coiling

OBJECTIVE

The endovascular treatment of complex bifurcation aneurysms possessing a neck that incorporates multiple side branches remains a surgical challenge. Double-stent-assisted coiling techniques, such as those with stents in an X and Y configuration, enable the endovascular treatment of wide-necked complex intracranial bifurcation aneurysms. However, the intraluminal struts at the intersection point in X- and Y-stents are not amenable to endothelialization, which may lead to thromboembolic complications. Stenting in the T configuration is a relatively new double-stent coiling technique. T-stenting differs from X- or Y-stenting in that there are no overlapping or intersecting stent segments. Promising short-term results of T-stent-assisted coiling were recently reported. However, the long-term results have not yet been demonstrated. This retrospective study investigated the long-term angiographic and clinical results in patients with wide-necked complex intracranial bifurcation aneurysms treated with T-stent-assisted coiling.

METHODS

A retrospective review was performed to identify patients with wide-necked complex intracranial bifurcation aneurysms treated with T-stent-assisted coiling at 4 institutions. The technical success and the initial and follow-up clinical and angiographic outcomes were assessed. Aneurysm filling status was assessed according to the Raymond classification. Periprocedural and delayed complications were reviewed. The neurological status of the patients was evaluated using the modified Rankin Scale (mRS).

RESULTS

One hundred two aneurysms in 102 patients (54 females), whose mean age was 57.9 ± 13.0 years, were included in the study. T-stenting was performed successfully in all patients. Immediate postprocedural angiography revealed complete occlusion in 83.3% of patients. Periprocedural complications developed in 13.7%, resulting in permanent morbidity in 1.9% and death in 1%. Eighty patients (78.4%) had at least one follow-up DSA examination performed at 6 months or later following the endovascular procedure. The mean duration of angiographic follow-up was 30.0 ± 16.3 months. The last follow-up examinations showed complete occlusion in 90.0% of patients. During the follow-up period, only 1 patient (1.3%) required retreatment. Delayed thromboembolic complications were observed in 4 patients (3.9%) without permanent morbidity. The mRS scores of all patients at the last clinical follow-up were between 0 and 2.

CONCLUSIONS

The short-term angiographic findings showed that T-stent-assisted coiling is a feasible and effective endovascular method to treat wide-necked complex bifurcation aneurysms. The long-term angiographic follow-up results suggest that T-stent-assisted coiling provides a durable treatment for wide-necked complex bifurcation aneurysms with favorable clinical outcomes, demonstrating the long-term safety of T-stent-assisted coiling.

Metabolic syndrome is not uncommon in treatment-naïve rheumatoid arthritis patients

OBJECTIVES

Rheumatoid arthritis (RA) is an independent risk factor for cardiovascular disease (CVD). Glucocorticoids are often used in the management of RA and might also contribute to the increased risk of metabolic syndrome (metS). Identifying metabolic alterations earlier and treating them together with disease-modifying therapy may be associated with better outcomes. Here, we aimed to investigate the frequency of metS and its components in treatment-naïve RA patients.

METHODS

Fifty-three newly diagnosed treatment-naïve RA patients and 55 control subjects were enrolled. MetS was diagnosed using Adult Treatment Panel III report-defined criteria. We evaluated the metS-related metabolic and anthropometric alterations between the groups. RA patients were subdivided and those with and without metS were also compared with respect to disease-related parameters.

RESULTS

MetS was more common in treatment-naïve newly diagnosed RA patients compared to controls (25 of 53 (47.1%) vs 9 of 55 (16.4%), respectively (p = 0.001; OR, 4.56; 95% CI 1.86-11.16). All evaluated anthropometric and metabolic parameters were similar in both groups. However, there was a trend to lower LDL and HDL cholesterol levels in RA patients. Furthermore, among those with metS, the number of fulfilled metS criteria items were higher in RA patients, compared to controls (p < 0.001). Interestingly, more RA patients fulfilled metS criteria with a glucose measurements item compared to controls (p < 0.001).

CONCLUSION

MetS was more common in newly diagnosed and treatment-naïve RA patients compared to controls. MetS, along with tendency to present paradoxical and atherogenic lipid profiles in RA patients, may be among the underlying mechanisms of increased CVD.

Anticoagulation strategy in patients with atrial fibrillation after carotid endarterectomy

Aim: Carotid artery stenosis and atrial fibrillation are diseases of the aging patient population. Literature lacks precise anticoagulation treatment protocols for patients with atrial fibrillation following carotid endarterectomy. We present our experiences with anticoagulation strategy in this particular patient population. Patients and methods: Between June 2001-September 2017, 165 patients with chronic or paroxysmal atrial fibrillation out of 1594 cases from three different institutions whom received Coumadin and aspirin and required carotid endarterectomy were reviewed, respectively. Mean age was 63.4 ± 7.9 years. Male/female ratio was 102/63. There were 67 diabetic and 138 hypertensive cases. Results: Patients are followed a mean of 64.4 ± 16.9 months. Early mortality occurred in two patients due to intracranial bleeding and heart failure. Another patient was lost due to intracerebral hemorrhage and 16 other patients died due to various causes in the late follow-up. Three patients required exploration against bleeding. Conclusion: Combination of warfarin with an aim to keep the INR value between 2 and 3, and aspirin at a dosage of 100 mg per day seemed feasible and in our modest patient cohort. Further studies including multicenter larger data are warranted in order to establish a precise anticoagulation treatment protocol for patients with atrial fibrillation after carotid endarterectomy.

Initial and Long-Term Outcomes of Complex Bifurcation Aneurysms Treated by Y-Stent-Assisted Coiling with Low-Profile Braided Stents

BACKGROUND AND PURPOSE

Coiling complex intracranial bifurcation aneurysms often necessitates the implantation of double stents in various configurations, such as Y-stent placement. Low-profile braided stents have been introduced recently to facilitate the endovascular treatment of wide-neck aneurysms. We aimed to investigate the feasibility, safety, efficacy, and durability of Y-stent-assisted coiling with double low-profile braided stents for the treatment of complex bifurcation aneurysms.

MATERIALS AND METHODS

A retrospective review was performed to identify patients who were treated using Y-stent-assisted coiling with low-profile braided stents. Technical success was assessed, as were initial and follow-up clinical and angiographic outcomes. Periprocedural and delayed complications were reviewed. Preprocedural and follow-up clinical statuses were assessed using the modified Rankin Scale.

RESULTS

Forty patients with 40 intracranial aneurysms were included in the study. Y-stent placement was successfully performed in all cases. Immediate postprocedural digital subtraction angiography images revealed total aneurysm occlusion in 72.5% of cases. The mean angiographic follow-up time was 24.8 months. The last follow-up angiograms showed complete occlusion in 85% of patients. During follow-up, only 1 patient showed an increase in the filling status of the aneurysm and that patient did not require retreatment. There was no mortality in this study. The overall procedure-related complication rate, including asymptomatic complications, was 17.5%. A permanent morbidity developed in 1 patient (2.5%).

CONCLUSIONS

The long-term angiographic and clinical outcomes of this retrospective study demonstrate that Y-stent-assisted coiling using low-profile braided stents is an effective, relatively safe, and durable endovascular treatment for wide-neck and complex bifurcation aneurysms.

Crossing Y-Solitaire thrombectomy as a rescue treatment for refractory acute occlusions of the middle cerebral artery

Background

Mechanical thrombectomy using a stent retriever has become the standard of care for acute large-vessel occlusions in the anterior circulation. Clots that are refractory to single stent retriever thrombectomy remain a challenge for neurointerventionalists.

Objective

To assess the efficacy and safety of double stent retriever (crossing Y-Solitaire) thrombectomy as a rescue treatment for acute middle cerebral artery (MCA) occlusions that are refractory to single stent retriever thrombectomy.

Methods

We retrospectively reviewed the databases of our hospitals to identify patients who presented with an acute MCA occlusion and were treated with crossing Y-Solitaire thrombectomy. The angiographic (Thrombolysis in Cerebral Infarction (TICI) scale) and clinical outcomes (National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores) and complications were assessed.

Results

Ten patients were included in the study. The median initial NIHSS score and Alberta Stroke Program Early CT Score (ASPECTS) were 19.0 and 9.6, respectively. Crossing Y-Solitaire thrombectomy was performed as a rescue technique after unsuccessful single Solitaire thrombectomy passes in all cases. Successful recanalization (TICI 2b/3) was achieved in 8 (80%) patients. We observed asymptomatic reperfusion hemorrhages in 2 (20%) patients. No procedural related complications were seen other than reversible vasospasms in 5 (50%) patients. Sixty percent of the patients had a mRS score of between 2 and 0 at 90 days after the procedure. There was no mortality.

Conclusion

Crossing Y-Solitaire thrombectomy seems to be an effective and safe alternative rescue technique to treat refractory MCA bifurcation occlusions that are refractory to standard thrombectomy procedures.

Inverse-Designed Broadband All-Dielectric Electromagnetic Metadevices

This paper presents a platform combining an inverse electromagnetic design computational method with additive manufacturing to design and fabricate all-dielectric metadevices. As opposed to conventional flat metasurface-based devices that are composed of resonant building blocks resulting in narrow band operation, the proposed design approach creates non-resonant, broadband (Δλ/λ up to >50%) metadevices based on low-index dielectric materials. High-efficiency (transmission >60%), thin (≤2λ) metadevices capable of polarization splitting, beam bending, and focusing are proposed. Experimental demonstrations are performed at millimeter-wave frequencies using 3D-printed devices. The proposed platform can be readily applied to the design and fabrication of electromagnetic and photonic metadevices spanning microwave to optical frequencies.

Comparing SARC-F with SARC-CalF to Screen Sarcopenia in Community Living Older Adults

OBJECTIVE

To compare the diagnostic value of the SARC-F combined with calf circumference (SARC-CalF) with the standard SARC-F to screen sarcopenia in community-dwelling older adults.

DESIGN

Cross-sectional, diagnostic accuracy study.

SETTING

Geriatric outpatient clinic of a university hospital.

PARTICIPANTS

Older adults >= 65 years.

MEASUREMENTS

Muscle mass (bioimpedance analysis device), muscle strength (hand grip strength-Jamar hydraulic hand dynamometer), and physical performance (usual gait speed). Four currently used diagnostic criteria [European Working Group on Sarcopenia in Older People (EWGSOP), Foundation for the National Institutes of Health (FNIH), International Working Group on Sarcopenia (IWGS), and Society on Sarcopenia Cachexia and Wasting Disorders (SCWD) criteria] were applied. SARC-CalF was performed by using two different calf circumference threshold: standard cut-off 31 cm (SARC-CalF-31) and national cut-off 33 cm (SARC-CalF-33). The sensitivity/specificity analyses of the SARC-CalF and SARC-F tools were run. We used the receiver operating characteristics curves and the area under the receiver operating characteristics curves (AUC) to compare the diagnostic accuracy to identify sarcopenia.

RESULTS

We included 207 subjects; 67 male and 140 female with a mean age of 74.6±6.7 years. The prevalence of sarcopenia ranged from 1.9% to 9.2%. The sensitivity of SARC-F was between 25% (EWGSOP) and 50% (IWGS); specificity was about 82%. For SARC-CalF-31 and SARC-CalF-33 sensitivity was in general similar -between 25-50%- which pointed out that SARC-CalF was not superior to SARC-F for sensitivity in this sample. Corresponding specificities for SARC-CalF-31 and SARC-CalF-33 were higher than SARC-F and were between 90-98%. Additionally, the AUC values, which indicates the diagnostic accuracy of a screening test, were in general higher for SARC-CalF-33 than the SARC-F and SARC-CalF-31.

CONCLUSIONS

We reported that addition of calf circumference item to SARC-F tool improved the specificity and diagnostic accuracy of SARC-F but it did not improve the sensitivity in a community-dwelling Turkish older adult population sample that had low prevalence of sarcopenia. The performance of SARC-CalF tool to screen sarcopenia is to be studied in different populations and living settings.

A Case of Spontaneous Spinal Epidural Haematoma in the Emergency Department Associated with Warfarin Therapy

Spontaneous spinal epidural haematoma (SSEH) is a neurosurgical emergency that requires early diagnosis and treatment. An 88-year-old man presented to the emergency department with complaints of weakness in the legs, walking deficit, incontinence and back pain for the last two days. He had been on warfarin therapy for 5 years for atrial fibrillation. There was no antecedent trauma. The neurological examination revealed hypoesthesia below the T6 level, anaesthesia below the T10 level and complete paraplegia of both lower extremities. The INR level was 7.81 on admission. Magnetic resonance imaging revealed a posterolateral epidural haematoma extending from T2 to L5. He was given fresh frozen plasma and vitamin K in the emergency department. Emergency thoracic and lumbar laminectomy was performed by neurosurgeons. The probability of SSEH should be investigated in any patient under anticoagulation therapy who presents with signs of spinal compression in the emergency department.

Midterm results of T-stent–assisted coiling of wide-necked and complex intracranial bifurcation aneurysms using low-profile stents

OBJECTIVE

Coiling of wide-necked and complex bifurcation aneurysms frequently requires implantation of double stents in various configurations. T-stent–assisted coiling involves the nonoverlapping implantation of 2 stents to protect the daughter vessels of bifurcation and is followed by coiling of the aneurysm. The authors studied the feasibility, efficacy, and safety of the T-stent–assisted coiling procedure as well as the midterm angiographic/clinical outcomes of patients with wide-necked bifurcation intracranial aneurysms treated using this technique.

METHODS

The authors retrospectively identified patients with wide-necked bifurcation intracranial aneurysms treated using double-stent–assisted coiling with a T-stent configuration.

RESULTS

Twenty-four patients with 24 aneurysms and a mean of age of 51.91 years were identified. The most common locations were the middle cerebral bifurcation (45.8%) and anterior communicating artery (35.7%). T stentings were performed using low-profile stents. The procedures were performed with a technical success rate of 95.8%, and an immediate total occlusion rate of 79.2% was achieved. We observed periprocedural complications in 16.7% of cases and a delayed thromboembolic event in 4.2%. The complications caused permanent morbidity in 1 patient (4.2%). No deaths occurred. The mean angiographic follow-up duration was 9.3 months. The total occlusion rate at the last follow-up was 81.2%. The recanalization rate was 4.5%. Modified Rankin Scale scores of all patients at the last follow-ups were between zero and 2.

CONCLUSIONS

T-stent–assisted coiling using low-profile stents is a feasible, effective, and relatively safe endovascular technique used to treat wide-necked and complex intracranial aneurysms. The midterm angiographic and clinical outcomes are outstanding.