Endovascular management of intracranial aneurysms at Chris Hani Baragwanath Academic Hospital

Background

Worldwide, intracranial aneurysms are associated with a high mortality rate. While endovascular management has proven to be the choice of treatment in selected patients, patient demographics and aneurysm characteristics differ between study populations.

Objectives

This study aimed to investigate the profile of patients with intracranial aneurysms who underwent endovascular management in the Interventional Neuroradiology Unit at Chris Hani Baragwanath Academic Hospital. Patient demographics, risk factors, indications, aneurysm characteristics and intra-operative complications were studied.

Method

This was a 3-year retrospective study of all adult patients between 01 January 2018 and 31 January 2021. The Chi-square test was used to compare categorical variables.

Results

A total of 77 patients were included in this study. The mean age of the patients was 47 ± 11.6 with a male-to-female ratio of 1:1.8. Hypertension was the most reported risk factor in 27% of patients. There was no statistical correlation between the gender groups according to presentation, multiplicity, aneurysmal size dimensions and locations. According to the presentation, there was statistical significance in ruptured intracranial aneurysms (p = 0.020), neck size dimensions less than 4 mm (p = 0.010), and aneurysms located in the internal cerebral artery (ICA) circulation (p = 0.001).

Conclusion

The study findings support known parameters including females and anterior circulation aneurysm preponderance, and the low complication risk of endovascular management. Interestingly, intracranial aneurysms presented with rupture at smaller size dimensions.

Contribution

This study provides valuable insights into intracranial aneurysm characteristics and endovascular management efficacy in a resource-limited setting.

Understanding development of jugular bulb stenosis in vein of galen malformations: identifying metrics of complex flow dynamics in the cerebral venous vasculature of infants

Introduction: Computational fluid dynamics (CFD) assess biological systems based on specific boundary conditions. We propose modeling more advanced hemodynamic metrics, such as core line length (CL) and critical points which characterize complexity of flow in the context of cerebral vasculature, and specifically cerebral veins during the physiologically evolving early neonatal state of vein of Galen malformations (VOGM). CFD has not been applied to the study of arteriovenous shunting in Vein of Galen Malformations but could help illustrate the pathophysiology of this malformation. Methods: Three neonatal patients with VOGM at Boston Children's Hospital met inclusion criteria for this study. Structural MRI data was segmented to generate a mesh of the VOGM and venous outflow. Boundary condition flow velocity was derived from PC-MR sequences with arterial and venous dual velocity encoding. The mesh and boundary conditions were applied to model the cerebral venous flow. We computed flow variables including mean wall shear stress (WSSmean), mean OSI, CL, and the mean number of critical points (nCrPointsmean) for each patient specific model. A critical point is defined as the location where the shear stress vector field is zero (stationary point) and can be used to describe complexity of flow. Results: The division of flow into the left and right venous outflow was comparable between PC-MR and CFD modeling. A high complexity recirculating flow pattern observed on PC-MR was also identified on CFD modeling. Regions of similar WSSmean and OSImean (<1.3 fold) in the left and right venous outflow channels of a single patient have several-fold magnitude difference in higher order hemodynamic metrics (> 3.3 fold CL, > 1.7 fold nCrPointsmean). Specifically, the side which developed JBS in each model had greater nCrPointsmean compared to the jugular bulb with no stenosis (VOGM1: 4.49 vs. 2.53, VOGM2: 1.94 vs. 0, VOGM3: 1 vs. 0). Biologically, these regions had subsequently divergent development, with increased complexity of flow associating with venous stenosis. Discussion: Advanced metrics of flow complexity identified in computational models may reflect observed flow phenomena not fully characterized by primary or secondary hemodynamic parameters. These advanced metrics may indicate physiological states that impact development of jugular bulb stenosis in VOGM.

Primary central nervous system vasculitis: a diagnostic and therapeutic challenge. A series of 7 patients

INTRODUCTION

Primary central nervous system vasculitis (PCNSV) is a rare disease affecting medium- and small-calibre blood vessels of the central nervous system.

OBJECTIVE

The aim of this study was to analyse clinical findings and diagnostic aspects, with special attention to histopathological findings, as well as the treatments used and treatment response in patients diagnosed with PCNSV at our hospital.

PATIENTS AND METHODS

We conducted a retrospective descriptive analysis of patients with a diagnosis of PCNSV at discharge from our centre and meeting the 1988 Calabrese criteria. To this end, we analysed the hospital discharge records of Hospital General Universitario de Castellón between January 2000 and May 2020.

RESULTS

We analysed a series of 7 patients who were admitted with transient focal alterations and other less specific symptoms such as headache or dizziness; diagnosis was based on histological findings in 5 cases and on suggestive arteriographic findings in the remaining 2. Neuroimaging results were pathological in all cases, and CSF analysis detected alterations in 3 of the 5 patients who underwent lumbar puncture. All patients received initial treatment with megadoses of corticosteroids followed by immunosuppressive treatment. Progression was unfavorable in 6 cases, with fatal outcomes in 4.

CONCLUSIONS

Despite the diagnostic challenge of PCNSV, it is essential to attempt to reach a definitive diagnosis using such tools as histopathology and/or arteriography studies, in order to promptly establish appropriate treatment and thus reduce the morbidity and mortality of this condition.

[Rapidly progressive intracranial large artery aterosclerosis, a rare stroke etiology]

INTRODUCTION

Intracranial atheromatosis is one of the most frequent causes of stroke. It is usually a slowly progressive process and normally associated with the sum of vascular risk factors.

CASE REPORT

In this case we present a rapidly progressive development of intracranial atheromatosis demonstrated by serial neuroimaging techniques and sample analysis in a 72-year-old female patient with high levels of interleukin-6 and C-reactive protein, with no signs of vasculitis.

CONCLUSION

Rapidly progressive intracranial atheromatosis should be considered in adult patients over 50 years of age with recurrent stroke.

The Clinical Impact of Recent Methamphetamine Exposure in Aneurysmal Subarachnoid Patients

Background

Methamphetamines (MA) are a frequently used drug class with potent sympathomimetic properties that can affect cerebral vasculature. Conflicting reports in literature exist about the effect of exposure to MA on vasospasm risk and clinical outcomes in aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to characterize the impact of recent MA use on the timing, severity and features of vasospasm in aneurysmal subarachnoid as well as neurological outcomes.

Methods

We retrospectively screened 441 consecutive patients admitted to a tertiary care hospital with a diagnosis of SAH who underwent at least one cerebral digital subtraction angiogram (DSA). Patients were excluded if no urinary toxicology screen was performed within 24 hours of admission, if there was a diagnosis of non-aneurysmal SAH, or if ictus was greater than 72 hours from hospital admission. Vasospasm characteristics were collected from DSA and transcranial doppler (TCD) studies and demographic as well as clinical outcome data was abstracted from the chart.

Results

129 patients were included and 24 tested positive for MA. Among the 312 excluded patients, 281 did not have a urinary toxicology screen and 31 had a non-aneurysmal pattern of SAH or ictus occurring greater than 72 hours from hospital admission. No significant differences were found in respect to patient age, sex, or admission Hunt and Hess Score or Modified Fisher Scale based on MA use. There was no difference in the severity of vasospasm or time to peak severity using either TCD or DSA criteria on multivariate analysis. Aneurysms were more likely to be in the anterior circulation for both groups, however the MA cohort experienced less vasospasm involving the anterior circulation and more isolated posterior circulation vasospasm. There was no difference in delayed cerebral ischemia (DCI) incidence, length of ICU stay, need for ventriculoperitoneal shunt placement, functional outcome at discharge or hospital mortality.

Interpretation

Recent MA use was not associated with worse vasospasm severity, time to vasospasm, or DCI in aSAH patients. Further investigations about localized MA effects in the posterior circulation and impact on long-term functional outcomes are warranted.

Development of technical skills in simulated cerebral aneurysm coiling

Endovascular surgical procedures require visual-spatial coordination in workspaces with restricted motions and temporally limited imaging. The development of the skills needed for these procedures can be facilitated by 3D simulator-based training. Cerebral angiography (CA) has lagged behind in this training approach due to the lack of validated, realistic training models, relying strictly on clinical case exposure frequency ("number of hours logged") as a means of assessing proficiency. The ANGIO Mentor visual-haptic simulator is regarded as an effective training tool, however, this simulator has not been tested thoroughly in its ability to train interventional skills. In particular, the details of the aneurysm coiling process during simulation-based training have not been assessed. In this study, 12 novice medical students were given simulation-based diagnostic CA training until a procedural plateau in performance, established in our previous work. Subsequently, they were trained using video tutorials and written instructions to identify, measure and intervene with cerebral aneurysms using endovascular coils. Over the span of 6 sessions, participants were assessed on their procedural task time, coiling quantity and quality, and perforation rates. Prior to commencing the study, participant spatial ability was assessed using a mental rotation test (MRT) and used as a comparative baseline for the performance analysis. We found that all individuals were able to perform the procedure faster after 6 sessions, reducing their average time from 42 to 24 minutes. Coil success rate improved over from 82% to 88% and coil packing rate remained consistent at 30% throughout testing. High perforation rate seen at the start of the study showed a trend of decreasing over the latter sessions, however, over half of aneurysms were still being perforated by the novice participants. No change in aneurysm coiling quality was found, with a slight decrease in number of parent artery coil protrusions. High MRT individuals were better able to establish necessary tools prior to coiling, however, no other MRT-specific changes were seen. This work identifies the utility of simulation-based CA training in identifying the particular difficulties trainees experience in learning procedural skills, including prevention of perforations, proper positioning and success of coils within the aneurysm.

Comparing Radiation Dose of Cerebral Angiography Using Conventional and High kV Techniques: A Retrospective Study on Intracranial Aneurysm Patients and a Phantom Study

Evaluation of patient radiation dose after the implementation of a high kV technique during a cerebral angiographic procedure is an important issue. This study aimed to determine and compare the patient radiation dose of intracranial aneurysm patients undergoing cerebral angiography using the conventional and high kV techniques in a retrospective study and a phantom study. A total of 122 cases (61 cases with conventional technique and 61 cases with high kV technique) of intracranial aneurysm patients, who underwent cerebral angiographic procedure and met the inclusion criteria, were recruited. The radiation dose and the angiographic exposure parameters were reviewed retrospectively. The radiation dose in the phantom study was conducted using nanoDot^TM optically stimulating luminescence (OSLD), which were placed on the scalp of the head phantom, the back of the neck, and the phantom skin at the position of the eyes. The standard cerebral angiographic procedure using the conventional and high kV techniques was performed following the standard protocol. The results showed that the high kV technique significantly reduced patient radiation dose and phantom skin dose. This study confirms that the implementation of a high kV technique in routine cerebral angiography for aneurysm diagnosis provides an effective reduction in radiation dose. Further investigation of radiation dose in other interventional neuroradiology procedures, particularly embolization procedure, should be performed.

Diagnosis, Workup, Risk Reduction of Transient Ischemic Attack in the Emergency Department Setting: A Scientific Statement From the American Heart Association

At least 240 000 individuals experience a transient ischemic attack each year in the United States. Transient ischemic attack is a strong predictor of subsequent stroke. The 90-day stroke risk after transient ischemic attack can be as high as 17.8%, with almost half occurring within 2 days of the index event. Diagnosing transient ischemic attack can also be challenging given the transitory nature of symptoms, often reassuring neurological examination at the time of evaluation, and lack of confirmatory testing. Limited resources, such as imaging availability and access to specialists, can further exacerbate this challenge. This scientific statement focuses on the correct clinical diagnosis, risk assessment, and management decisions of patients with suspected transient ischemic attack. Identification of high-risk patients can be achieved through use of comprehensive protocols incorporating acute phase imaging of both the brain and cerebral vasculature, thoughtful use of risk stratification scales, and ancillary testing with the ultimate goal of determining who can be safely discharged home from the emergency department versus admitted to the hospital. We discuss various methods for rapid yet comprehensive evaluations, keeping resource-limited sites in mind. In addition, we discuss strategies for secondary prevention of future cerebrovascular events using maximal medical therapy and patient education.

A novel simulator-based checklist for evaluating residents' competence in cerebral angiography in China

Background

Nowadays, with the fast-increasing demand for neuro-endovascular therapy, surgeons in this field are in urgent need. Unfortunately, there is still no formal skill assessment in neuro-endovascular therapy in China.

Methods

We used a Delphi method to design a newly objective checklist for standards of cerebrovascular angiography in China and evaluated its validity and reliability. A total of 19 neuro-residents with no interventional experience and 19 neuro-endovascular surgeons from two centers (Guangzhou and Tianjin) were recruited; they were divided into two groups: residents and surgeons. Residents completed a simulation-based cerebrovascular angiography operation training before assessment. Assessments were under live and video record forms with two tools: the existing global rating scale (GRS) of endovascular performance and the new checklist.

Results

The average scores of residents were significantly increased after training in two centers (p < 0.05). There is good consistency between GRS and the checklist (p = 0.856). Intra-rater reliability (Spearman's rho) of the checklist was >0.9, and the same result was also observed in raters between different centers and different assessment forms (p < 0.001, rho > 0.9). The reliability of the checklist was higher than that of the GRS (Kendall's harmonious coefficient is 0.849, while GRS is 0.684).

Conclusion

The newly developed checklist appears reliable and valid for evaluating the technical performance of cerebral angiography and differentiating between trained and untrained trainees' performance well. For its efficiency, our method has been proven to be a feasible tool for resident angiography examination in certification nationwide.

Aberrant Origin of the Distal Anterior Cerebral Artery from the Middle Cerebral Artery Related to Obstruction of Bilateral Proximal Anterior Cerebral Arteries: A Case Report

BACKGROUND

Aberrant origin of the distal anterior cerebral artery (ACA) arising from the middle cerebral artery (MCA) is extremely rare.

CASE PRESENTATION

A 74-year-old woman with a sudden onset of left-sided weakness was admitted to the emergency department. Angiography revealed an unusual course of the distal ACA originating from the MCA with bilateral obstruction of the proximal segment of the ACA and simultaneous occurrence of infarction in the ACA and MCA territories.

CONCLUSION

Knowledge of a rare vascular variation or anomaly could help understand brain imaging, which has an unusual involvement of vascular territories, performed in patients with acute ischemic stroke.

Congenital internal carotid artery hypoplasia: A systematic review

This review evaluates the current evidence for the clinical management of congenital internal carotid artery hypoplasia (CICAH). We summarise clinical presentations diagnostic standards, imaging recommendations, treatment and follow-up. The review was prompted by a case of CICAH in a 50-year-old female who presented to our neurosurgery clinic with an acute episode of vertigo. The patient underwent CT angiogram, which showed an unusually low right carotid bifurcation. The right internal carotid artery (ICA) was hypoplastic, and the A1 segment of the anterior cerebral artery (ACA) was absent. Skull base CT showed an ipsilateral hypoplastic carotid canal. To summarise current evidence for clinical management of CICAH we followed PRISMA guidelines to identify papers meeting our predefined inclusion criteria. We searched three databases using the terms 'ICA' and 'Hypoplasia'. We reviewed 41 papers meeting our criteria. 34 were clinical reports. We performed a data extraction and quality appraisal on these reports. We found that CICAH may be less rare than previously described. Blood pressure control in CICAH is crucial due to the increased risk of stroke and aneurysm formation. Follow-up imaging is strongly recommended. Carotid doppler sonography is a powerful and underutilised diagnostic tool, and carotid canal hypoplasia is not a pathognomic sign. In conclusion, clinicians should be alert to anatomic variations such as CICAH because these produce haemodynamic changes that may have serious clinical consequences. We recommend a central registry of patients with CICAH in order to understand the longer-term natural history of the condition.

Thalamic structure and anastomosis in different hemispheres of moyamoya disease

Objective

The progression of the asymptomatic hemisphere of moyamoya disease (MMD) is largely unknown. In this study, we investigated the differences in subcortical gray matter structure and angiographic features between asymptomatic and symptomatic hemispheres in patients with MMD.

Methods

We retrospectively reviewed patients with MMD in consecutive cases in our center. We compared subcortical gray matter volume and three types of collaterals (lenticulostriate anastomosis, thalamic anastomosis, and choroidal anastomosis) between symptomatic and asymptomatic hemispheres. Symptomatic hemispheres were classified as ischemic hemisphere (i-hemisphere) and hemorrhagic hemisphere (h-hemisphere). Asymptomatic hemispheres were classified as contralateral asymptomatic hemisphere of i-hemisphere (ai-hemisphere), contralateral asymptomatic hemisphere of h-hemisphere (ah-hemisphere), bilateral asymptomatic hemispheres in asymptomatic group (aa-hemisphere).

Results

A total of 117 MMD patients were reviewed, and 49 of them met the inclusion criteria, with 98 hemispheres being analyzed. The thalamic volume was found to differ significantly between the i- and ai-hemispheres (P = 0.010), between the i- and ah-hemispheres (P = 0.004), as well as between the h- and ai-hemispheres (P = 0.002), between the h- and ah-hemispheres (P < 0.001). There was a higher incidence of thalamic anastomosis in the ai-hemispheres than i-hemispheres (31.3% vs. 6.3%, P = 0.070), and in the ah-hemispheres than h-hemispheres (29.6% vs. 11.1%, P = 0.088). Additionally, the hemispheres with thalamic anastomosis had a significantly greater volume than those without thalamic anastomosis (P = 0.024). Univariate and multivariate logistic regression analysis showed that thalamic volume was closely associated with thalamic anastomosis.

Conclusion

The thalamic volume and the incidence of thalamic anastomosis increase in asymptomatic hemispheres and decrease in symptomatic hemispheres. Combining these two characteristics may be helpful in assessing the risk of stroke in the asymptomatic hemispheres of MMD as well as understanding the pathological evolution of the disease.

Contrast-induced encephalopathy and permanent neurological deficit following cerebral angiography: A case report and review of the literature

Contrast-induced encephalopathy (CIE) is an uncommon complication associated with contrast exposure during angiographic procedures that is usually transient but occasionally leads to permanent complications or death. Due to the low incidence of CIE, there are still insufficient reports. This study was used to summarize the clinical features of CIE through a case report and systematic review. We summarized and reviewed 127 patients with CIE, and we found that the total incidence of CIE between men and women had no difference (49.61 and 50.39%, respectively), but the average age in female patients with CIE was older than that in male patients (62.19 and 58.77 years, respectively). Interestingly, the incidence of female patients with CIE in the poor prognosis group was significantly higher than that in the good prognosis group (62.50 and 36.51%, respectively), and the average age of these female patients in the poor prognosis group was younger than that in the good prognosis group (61.39 and 62.82 years, respectively). The contrast medium types were mainly nonionic (79.69 and 73.02%, respectively) and low-osmolar (54.69 and 71.43%, respectively) in both groups. Importantly, the total contrast media administrated in patients with poor prognoses was greater than that administrated in patients with good prognoses (198.07 and 188.60 ml, respectively). In addition, comorbidities in both groups included hypertension (55.91%), diabetes mellitus (20.47%), previous contrast history (15.75%), renal impairment (11.81%), and hyperlipidemia (3.15%). The percentage of patients with cerebral angiography was significantly higher in the poor prognosis group than that in the good prognosis group (37.50 and 9.52%, respectively), whereas the percentage of patients with coronary angiography in both groups had the opposite results (35.94 and 77.78%, respectively). In conclusion, CIE may not always have a benign outcome and can cause permanent deficits. Female gender, younger age, the higher dose of contrast medium, and the procedure of cerebral angiography may be related to the patient's poor prognosis.

Case report: An overlooked complication of the dural suture after craniotomy: pseudoaneurysm of the middle meningeal artery with endovascular resolution

Aneurysms of the middle meningeal artery (MMA) are exceedingly uncommon and mainly result from traumatic brain damage, but this report describes a case of MMA aneurysm induced by cranial surgery. Surgery was performed on a 34-year-old male with cerebrovascular malformation and cerebral hemorrhage. Cerebral angiography revealed no MMA aneurysm before craniocerebral surgery; however, a postoperative angiogram revealed a new MMA aneurysm. Aneurysms of the MMA are uncommon consequences of brain surgery. Based on our findings, the MMA as well as other meningeal arteries should be avoided while suturing the dura mater tent to prevent aneurysms.

Fluorescently-tagged magnetic protein nanoparticles for high-resolution optical and ultra-high field magnetic resonance dual-modal cerebral angiography

Extremely small paramagnetic iron oxide nanoparticles (FeMNPs) (<5 nm) can enhance positive magnetic resonance imaging (MRI) contrast by shortening the longitudinal relaxation time of water (T₁), but these nanoparticles experience rapid renal clearance. Here, magnetic protein nanoparticles (MPNPs) are synthesized from protein-conjugated citric acid coated FeMNPs (c-FeMNPs) without loss of the T₁ MRI properties and tagged with fluorescent dye (f-MPNPs) for optical cerebrovascular imaging. The c-FeMNPs shows average size 3.8 ± 0.7 nm with T₁ relaxivity (r₁) of 1.86 mM^-1 s^-1 and transverse/longitudinal relaxivity ratio (r₂/r₁) of 2.53 at 11.7 T. The f-MPNPs show a higher r₁ value of 2.18 mM^-1 s^-1 and r₂/r₁ ratio of 2.88 at 11.7 T, which generates excellent positive MRI contrast. In vivo cerebral angiography with f-MPNPs enables detailed microvascular contrast enhancement for differentiation of major blood vessels of murine brain, which corresponds well with whole brain three-dimensional time-of-flight MRI angiograms (17 min imaging time with 60 ms repetition time and 40 μm isotropic voxels). The real-time fluorescence angiography enables unambiguous detection of brain capillaries with diameter < 40 μm. Biodistribution examination revealed that f-MPNPs were safely cleared by the organs like the liver, spleen, and kidneys within a day after injection. Blood biochemical assays demonstrated no risk of iron overload in both rats and mice. With hybrid neuroimaging technologies (e.g., MRI-optical) on the rise, f-MPNPs built on this platform can generate exciting neuroscience applications.

Duplication of the internal maxillary artery: Anatomical and clinical considerations

Duplication of the internal maxillary artery (IMAX) results from a failed regression of either the embryological superficial or deep ring and is reported to be exceedingly rare. We present a patient with this rare anatomical variant who was treated by endovascular technique in the clinical context of an acute oropharyngeal hemorrhage.

Development of a Nomogram for Predicting Asymptomatic Coronary Artery Disease in Patients with Ischemic Stroke

BACKGROUND

Coronary artery stenosis (CAS) ≥50% often coexists in patients with ischemic stroke, which leads to a significant increase in the occurrence of major vascular events after stroke. This study aimed to develop a nomogram for diagnosing the presence of ≥50% asymptomatic CAS in patients with ischemic stroke.

METHODS

A primary cohort was established that included 275 non-cardioembolic ischemic stroke patients who were admitted from January 2011 to April 2013 to a teaching hospital in southern China. The preoperative data were used to construct two models by the best subset regression and the forward stepwise regression methods, and a nomogram between these models was established. The assessment of the nomogram was carried out by discrimination and calibration in an internal cohort.

RESULTS

Out of the two models, model 1 contained eight clinical-related variables and exhibited the lowest Akaike Information Criterion value (322.26) and highest concordance index 0.716 (95% CI, 0.654-0.778). The nomogram showed good calibration and significant clinical benefit according to calibration curves and the decision curve analysis.

CONCLUSION

The nomogram, composed of age, sex, NIHSS score on admission, hypertension history, fast glucose level, HDL cholesterol level, LDL cholesterol level, and presence of ≥50% cervicocephalic artery stenosis, can be used for prediction of ≥50% asymptomatic coronary artery disease (CAD). Further studies are needed to validate the effectiveness of this nomogram in other populations.

Hidden Telltale Signs in Hyperacute Ischemic Stroke Caused by Aortic Dissection: A Case Report and Post Hoc Analysis

INTRODUCTION

Rapid identification of hidden telltale signs in hyperacute ischemic stroke caused by aortic dissection (AD) is challenging, mainly owing to the narrow time window for bridging therapy.

CASE REPORT

A 63-year-old man was referred for sudden right-side weakness accompanied by a decreased level of consciousness for almost 1 hour and 37 minutes. He had a history of hypertension. His skin was clammy, and on physical examination, there was involuntary chest thumping in the left upper limb. Hyperacute cerebral infarction was considered after no bleeding was observed on emergency head computed tomography, and intravenous thrombolysis with alteplase was administered immediately after. The patient was then taken to the catheter room, ready for endovascular thrombectomy. Stanford type A AD was found by cerebral angiography before endovascular thrombectomy. The infusion of alteplase was stopped immediately during cerebral angiography, but the patient's blood pressure, heart rate, and blood oxygen were still declining progressively, and the degree of consciousness disturbance deepened. The patient died after the combined but failed rescue attempts of multiple departments.

CONCLUSION

Hyperacute ischemic stroke caused by AD often hides some telltale signs. Clinicians should master basic clinical skills to exclude AD by looking for these telltale signs hidden in hyperacute ischemic stroke to avoid the fatal consequences of intravenous thrombolysis and/or cerebral angiography within the narrow window of time.

Vertebral artery dissection induced lateral medullary syndrome characterized with severe bradycardia: a case report and review of the literature

BACKGROUND

Lateral medullary syndrome is the most common type of brainstem infarction. Lateral medullary syndrome results in damage to the corresponding cranial nerve nuclei and the nucleus tractus solitarius, with vertigo, ipsilateral ataxia, crossed sensory disturbances, Horner's sign, bulbar palsy, and other underlying symptoms or signs. However, cases with cardiac arrhythmia and other autonomic dysfunctions as the primary manifestations are less common. Clinically, sudden death occasionally occurs in patients with lateral medullary syndrome, which may be associated with severe cardiac arrhythmia. These patients may suffer in life-threatening arrhythmia and even cardiac arrest, and vital signs should be closely monitored to prevent sudden death. In younger patients, vertebral artery dissection is the most common cause.

CASE DESCRIPTION

Here, we present a case of lateral medullary syndrome caused by vertebral artery dissection with severe bradycardia. The patient was a 49-year-old man who was admitted with "sudden onset of numbness in the left limbs and right side of the face for 1 hour". Electrocardiogram (ECG) monitoring showed a repeated heart rate decrease to as low as 23 beats/min, followed by a gradual increase in heart rate to 35-55 beats/min after 2-3 seconds. Head magnetic resonance imaging (MRI) examination revealed right dorsolateral cerebral infarction of the medulla oblongata. Digital subtraction angiography (DSA) revealed a right vertebral artery dissecting aneurysm. We performed an emergency placement of a temporary pacemaker, followed by conservative treatment with platelet aggregation inhibitors, vascular softening agents and improved collateral circulation. Elective spring coil embolization of the vertebral artery dissecting aneurysm and stent implantation were performed. At outpatient follow-up, the patient had a good prognosis.

CONCLUSIONS

Clinical management of patients with lateral medullary syndrome should be prioritized, with close cardiac monitoring at the early stages of observation and pacemaker placement and tracheal intubation as required to prevent adverse events.

Sequential Flow Diversion After Nitinol Stent Placement for a Large, Matricidal Cavernous Internal Carotid Artery Aneurysm: Technical Video

The Surpass Evolve flow diverter is a novel 64-wire braided intravascular stent approved to treat unruptured large or giant saccular wide-neck or fusiform intracranial aneurysms of the intracranial internal carotid artery.1-3 Flow diverting stents have been used for the treatment of previously stented aneurysms, including residual aneurysms following prior flow diversion.5-8 This patient initially presented with a large symptomatic matricidal cavernous ICA aneurysm4 that was treated with stand-alone Neuroform Atlas stenting at an outside hospital. Here we present a video demonstrating the placement of sequential Surpass Evolve flow diverter stents within a Neuroform Atlas nitinol stent.

Transradial access for cerebral angiography and neurointerventional procedures: A meta-analysis and systematic review

PURPOSE

Transradial access (TRA) for diagnostic and interventional neurointerventional procedures has recently gained traction over transfemoral access (TFA) in the neurointerventional community. This meta-analysis aims to assess and summarize the utility of TRA in cerebral angiography and neurointerventional procedures.

METHODS

A systematic literature review was performed utilizing Pubmed, Embase, and Scopus databases. Using PRISMA guidelines, records were extracted with the following search terms: transradial approach, transradial access, radial access, cerebral angiogram, cerebral angiography, neurointervention, and neuroendovascular. The primary outcomes assessed were case success rate, complication rate, and crossover rate from TRA to TFA. Secondary analysis was performed on procedure time, fluoroscopy time, fluoroscopy time per vessel (diagnostic procedures only), contrast dose, radial artery diameter, distal radial artery diameter, and patient preference for TRA over TFA.

RESULTS

Sixty-two full-text articles were analyzed for this meta-analysis, representing 12,927 diagnostic and interventional TRA access patients. Our analysis revealed a combined diagnostic and interventional case success rate of 95.9% and complication rate of 3.5%, with crossover to TFA occurring in 4.9% of cases.

CONCLUSION

This meta-analysis demonstrates that TRA access for diagnostic angiography and neurointerventional procedures is a safe and effective approach, though determining a true complication rate is challenging as the definition of TRA complications has changed in various publications over time.

Diagnostic Criteria for Moyamoya Disease - 2021 Revised Version

In this report, we, the Research Committee on Moyamoya Disease (Spontaneous Occlusion of the circle of Willis), describe in detail the changes in the new “Diagnostic Criteria 2021” for moyamoya disease and its scientific basis to make it widely known to the world. The revised criteria cover all aspects of the disease, including a definition of the disease concept, diagnostic imaging, and the concept of quasi-moyamoya disease (moyamoya syndrome).

Transdural Revascularization by Multiple Burrhole After Erythropoietin in Stroke Patients With Cerebral Hypoperfusion: A Randomized Controlled Trial

In patients with acute symptomatic stroke, reinforcement of transdural angiogenesis using multiple burr hole (MBH) procedures after EPO (erythropoietin) treatment has rarely been addressed. We aimed to investigate the efficacy and safety of cranial MBH procedures under local anesthesia for augmenting transdural revascularization after EPO treatment in patients with stroke with perfusion impairments.

Contrast-induced encephalopathy following cerebral angiography: A case report

The present study describes the case of patient with contrast-induced encephalopathy following cerebrovascular angiography, and presents the clinical and imaging features, as well as the treatment and prognosis of this patient. Following digital subtraction angiography, cortical blindness and cognitive dysfunction were the main complaints of the patient. The emergency craniocerebral CT scan revealed hyperdense areas in the bilateral cerebellum, thalamus, sulcus and cistern, and a review of the CT scan 24 h following the procedure revealed that the hyperintense lesions were reduced or resolved in these areas. The patient obtained a good prognosis following treatment anti-inflammatory and intracranial pressure reduction treatment. On the whole, the present study demonstrates that cognitive dysfunction may be a clinical manifestation of contrast-induced encephalopathy. Thus, the earlier diagnosis and earlier treatment are crucial for the prognosis of patients.

Planning of gamma knife radiosurgery (GKR) for brain arteriovenous malformations using triple magnetic resonance angiography (triple-MRA)

PURPOSE

Intra-arterial Digital Subtraction Angiography (DSA) is the gold standard technique for radiosurgery target delineation in brain Arterio-Venous Malformations (AVMs). This study aims to evaluate whether a combination of three Magnetic Resonance Angiography sequences (triple-MRA) could be used for delineation of brain AVMs for Gamma Knife Radiosurgery (GKR).

METHODS

Fifteen patients undergoing DSA for GKR targeting of brain AVMs also underwent triple-MRA: 4D Arterial Spin Labelling based angiography (ASL-MRA), Contrast-Enhanced Time-Resolved MRA (CE-MRA) and High Definition post-contrast Time-Of-Flight angiography (HD-TOF). The arterial phase of the AVM nidus was delineated on triple-MRA by an interventional neuroradiologist and a consultant neurosurgeon (triple-MRA volume). Triple-MRA volumes were compared to AVM targets delineated by the clinical team for delivery of GKR using the current planning paradigm, i.e., stereotactic DSA and volumetric MRI (DSA volume). Difference in size, degree of inclusion (DI) and concordance index (CcI) between DSA and triple-MRA volumes are reported.

RESULTS

AVM target volumes delineated on triple-MRA were on average 9.8% smaller than DSA volumes (95%CI:5.6-13.9%; SD:7.14%; p = .003). DI of DSA volume in triple-MRA volume was on average 73.5% (95%CI:71.2-76; range: 65-80%). The mean percentage of triple-MRA volume not included on DSA volume was 18% (95%CI:14.7-21.3; range: 7-30%).

CONCLUSION

The technical feasibility of using triple-MRA for visualisation and delineation of brain AVMs for GKR planning has been demonstrated. Tighter and more precise delineation of AVM target volumes could be achieved by using triple-MRA for radiosurgery targeting. However, further research is required to ascertain the impact this may have in obliteration rates and side effects.