Superficial siderosis of the central nervous system secondary to spinal ependymoma

Superficial siderosis of the central nervous system is a syndrome caused by deposition of hemosiderin in the subpial layers of the central nervous system, occurring as a result of recurrent asymptomatic or symptomatic bleeding into the subarachnoid space. We report a rare case of superficial siderosis in a 33-year-old man who presented with sensorineural hearing loss. The diagnosis of superficial siderosis on MRI brain studies led to further investigations with detection of a spinal ependymoma at L1-L2, compressing the cauda equina. Gross total resection of the tumor arrested the progression of the neurological deterioration. Our report underlies the importance of early diagnosis and surgical management, with imaging examination of the full neuroaxis to identify the source of bleeding, to halt disease progression and improve prognosis.

Urgent off-label use of the pipeline flow diverter stent in selected ischemic cerebrovascular conditions: thrombotic segments and tortuous arteries

OBJECTIVE

Flow diverter stents were originally designed for the endovascular management of certain types of cerebral aneurysms; however, these devices present characteristics that make them more suitable that regular carotid stents or neurostents for the management of selected ischemic cerebrovascular conditions.

METHODS

Eight patients with steno-occlusive disease of the internal carotid (ICA) or vertebral (VA) arteries underwent endovascular reconstruction by means of flow diverter stent implant at our center. Five patients presented with ICA steno-occlusive lesions that involved tortuous segments not amenable to regular carotid stent placement and three patients presented with severe and complex proximal VA dissections.

RESULTS

In all cases the procedures were considered technically successful. Flow diverter stent implant allowed recanalization of the treated vessels (stenosis of 89±10.5% was improved to 26±13%) without procedure related complications. At the 3 month clinical and radiological follow-up, patients either improved or remained stable, and showed stent patency. One patient presented with asymptomatic occlusion of the revascularized artery at 13 months, emphasizing the need for prolonged antiplatelet therapy.

CONCLUSIONS

This preliminary series of patients with high risk steno-occlusive lesions affecting tortuous arterial segments or presenting with heavy thrombotic load managed by the implant of flow diverter stents shows that this approach is feasible, safe, and effective in achieving arterial recanalization. Further studies will elucidate the role of this technique in ischemic cerebrovascular settings.

Efficacy and safety of vertebral stenting for painful vertebral compression fractures in patients with metastatic disease

BACKGROUND AND PURPOSE

Painful vertebral compression fractures in cancer patients reduce quality of life and may limit survival. We assessed pain relief, vertebral height restoration, and kyphosis correction following vertebral augmentation using a novel expandable titanium stent implant in cancer patients with painful vertebral compression fractures.

MATERIALS AND METHODS

Patients >18 years of age with metastatic disease who presented symptomatic compression fractures of vertebral bodies T5-L5, with or without a history of osteoporosis, were included in the study. Back pain at presentation, immediately after vertebral stenting, and at 1-, 3-, 6-, and 12-month follow-up was estimated using the visual analog scale (VAS). Vertebral height and local kyphotic angle (alpha angle) were measured on lateral standing X-ray before and 1-3 months after stenting.

RESULTS

Forty-one cancer patients with painful vertebral compression fractures underwent vertebral stenting procedures at 55 levels. There was no perioperative mortality and no significant complication. Median preoperative VAS was 8.0 (range 8-10), falling to 2.0 immediately postop (range 1-6, P  =  0.000) and 0 at all subsequent follow-up (P ≤ 0.012). Mean preoperative vertical height loss was 25.8% (range 0-84.0%) versus a postoperative mean of 18.0% (range 0-66.0%, P  =  0.000). Median pre- and postoperative kyphotic angle improved from 8.3° (range 0.2°-54.0°) to 7.1° (range 0.2°-25.0°, P  =  0.000). Wilcoxon signed rank test or student's t-test was used for comparisons.

CONCLUSIONS

Vertebral augmentation using a novel vertebral stenting system provided immediate and enduring pain relief and improved vertebral height loss and kyphotic angle.

Extracranial carotid artery stenting followed by intracranial stent-based thrombectomy for acute tandem occlusive disease

OBJECTIVE

Acute tandem occlusions of the extracranial internal carotid artery (ICA) and a major intracranial artery respond poorly to intravenous tissue plasminogen activator (tPA) and present an endovascular challenge. We describe our experience with emergency stent-assisted ICA angioplasty and intracranial stent-based thrombectomy of tandem occlusions.

METHODS

Procedures were performed from March 2010 to December 2013. National Institutes of Health Stroke Score (NIHSS) and Alberta Stroke Program Early CT Score (ASPECTS), occlusion sites, collateral supply, procedural details, and outcomes were retrospectively reviewed with IRB waiver of informed consent.

RESULTS

24 patients, mean age 66 years, mean admission NIHSS 20.4, and mean ASPECTS 9 were included. Occlusion sites were proximal ICA-middle cerebral artery (MCA) trunk in 17 patients, proximal ICA-ICA terminus in six, and ICA-MCA-anterior cerebral artery in one. Stent-assisted cervical ICA recanalization was achieved in all patients, with unprotected pre-angioplasty in 24/24, unprotected stenting in 16/24 (67%), and protected stenting in 8/24 (33%), followed by stent-thrombectomy in 25 intracranial occlusions. There was complete recanalization/complete perfusion in 19/24 (79%), complete recanalization/partial perfusion in 3/24 (13%), and partial recanalization/partial perfusion in 2/24 (8%) with no procedural morbidity/mortality. Mean time to therapy was 3.8 h (range 2-5.5) and mean time to recanalization was 51 min (range 38-69). At 3-month follow-up, among 17/22 surviving patients (77%), 13/17 (76%) were modified Rankin Scale (mRS) 0-2 and 3/17 (18%) were mRS 3.

CONCLUSIONS

In acute tandem ICA-MCA/distal ICA occlusions, extracranial stenting followed by intracranial stent-based thrombectomy appears feasible, effective, and safe. Further evaluation of this treatment strategy is warranted.

Revascularization-outcome paradox: not only time and collaterals status, but also complete recanalization contribute to good neurological outcome

The rate of successful recanalization in endovascular trials has not always mirrored the rate of good clinical outcomes, creating a revascularization-outcome paradox. In early experience with the new generation of stent-based thrombectomy devices, 45-77% of patients have achieved good 90-day outcomes despite treatment up to eight-hours after symptom onset. These rates of good functional outcome are clearly higher than those previously reported with other endovascular strategies. We propose that among the factors influencing this difference is the far higher complete recanalization rate and the high ratio of Thrombolysis in Myocardial Infarction 3/Thrombolysis in Myocardial Infarction 2 recanalization obtained with stent retrievers in comparison with previous generation mechanical thrombectomy devices. Recently, we achieved Thrombolysis in Myocardial Infarction 3 in 94% of patients and Thrombolysis in Myocardial Infarction 2 in 6% in a series of patients with acute middle cerebral artery occlusions who were managed with stent-thrombectomy within eight-hours of symptom onset. Good outcomes were achieved in 77%. Extent of recanalization appears to interact with time and collateral supply in determining clinical outcomes.

Isolated cortical vein thrombosis: a rare cause of venous stroke with good prognosis after timely diagnosis and treatment

BACKGROUND

Isolated cortical vein thrombosis (ICoVT) is a rare condition representing approximately 6% of cerebral vein thromboses (CVT). In all its forms, CVT is more prevalent in women. ICoVT shares the same group of predisposing conditions typical of other CVT. It may thus be easily missed due to its non-specific clinical presentation and confounding radiological findings, which may lead to a delay in appropriate diagnosis and treatment.

METHODS

A comprehensive literature search was conducted to identify manuscripts discussing epidemiology, risk factors, clinical presentation, radiological techniques and presentation, management, and outcome in patients with ICoVT.

RESULTS

We identified 40 papers published between 1991 and 2012 that met our criteria for review.

DISCUSSION

MR techniques are essential in the diagnosis of this entity. Without appropriate therapy, these thromboses may extend bidirectionally and even compromise the dural sinuses. Correction of predisposing factors for venous thrombosis and anticoagulation is the therapy of choice for most patients. The overall prognosis with adequate and timely therapy is very good.

Bilateral acute epidural hematoma after evacuation of acute subdural hematoma: brain shift and the dynamics of extraaxial collections

Acute epidural hematoma following supratentorial decompressive craniectomy is a very seldom described but serious complication. The occurrence of intraoperative brain swelling may suggest the development of a contralateral hematoma. A unique case of bilateral acute epidural following decompressive craniectomy and evacuation of acute subdural hematoma is presented. Awareness of unexplained elevation of intracranial pressure is of paramount importance when routine immediate postoperative computed tomography is not performed. This case provides insight into the well-known but poorly understood dynamic process of brain shift and extraaxial collections.

X-microstenting and transmesh coiling in the management of wide-necked tent-like anterior communicating artery aneurysms

Anterior communicating artery (AcomA) aneurysms frequently have wide necks and an irregular shape, incorporate parent vessels, and are associated with significant variations in vascular anatomy. Safe and complete endovascular occlusion of these aneurysms usually requires the assistance of combined approaches using balloons and stents in an individually tailored strategy. We describe a technique for X-configured stent-assisted coiling in the management of a small tricuspid tent-like wide-necked AcomA aneurysm by means of two crossed nitinol self-expandable Leo+ Baby stents (Balt Therapeutics, Montmorency, France) followed by "in stent" transmesh coiling. The addition of a low-profile stent into the neurointerventional armamentarium will substantially enhance our capability to treat previously uncoilable tent-like AcomA aneurysms.

Pharyngo-occipital artery variant arising proximal to occluded internal carotid artery: the risk of an unnecessary endarterectomy

Collateral branches originating from the cervical internal carotid artery (ICA) are rare but can have significant clinical and surgical implications. We present a case of pharyngo-occipital artery arising proximal from an occluded ICA that was missed and confused for severe stenosis of the ICA, leading to the misguided indication for carotid endarterectomy. Advanced preoperative studies allowed timely recognition of this anomaly and reconsideration of the therapeutic plan. We stress the importance of recognizing these variants by careful examination of multimodal pre-surgical exams. Awareness of these variants will allow a more precise diagnosis, and more appropriate management of patients with carotid artery disease.

Single-staged sequential endovascular stenting in patients with in tandem carotid stenoses

BACKGROUND AND PURPOSE

Simultaneous stenoses at the origin of the internal carotid artery and the carotid siphon, also known as 'in tandem stenoses', are not uncommon. However, the clinical importance of this condition is still a subject of controversy. Surgical and endovascular approaches have been proposed to manage symptomatic patients who fail antithrombotic therapy.

METHODS

We present a series of eight patients with symptomatic in tandem carotid artery stenoses treated by sequential endovascular stent-assisted angioplasty. In all the cases, the intracranial stenosis was equal to, or greater, than the extracranial stenosis.

RESULTS

Procedural success, defined as residual stenosis of less than 30% in extracranial and intracranial lesions, was obtained in all the cases. No patient sustained myocardial infarction, stroke or transient ischemic attack (TIA) during the procedure or hospital stay. During a mean clinical follow-up of 12 +/- 3.4 months (range: 7-20 months), there were no neurological events and on angiographic follow-up after 6 months, no patient presented in-stent de novo stenosis.

CONCLUSION

Endovascular stent-assisted angioplasty appears to be a valid alternative for selected patients with symptomatic in tandem carotid stenoses that are refractory to medical treatment. In most of the cases, the characteristics of intracranial stenoses determine the feasibility of the procedure.

Protected stent-assisted carotid angioplasty in symptomatic high-risk NASCET-ineligible patients

BACKGROUND AND OBJECTIVES

The North American Symptomatic Carotid Endarterectomy Trial (NASCET) excluded patients with severe medical, angiographic and neurological risk factors. The aim of this study is to determine the safety and efficacy of protected stent angioplasty in these high-risk patients.

METHODS

Sixty-eight consecutive symptomatic NASCET-ineligible patients underwent protected stent-assisted carotid angioplasty. Patients were classified according to surgical risk based on Sundt criteria, and stratified for medical therapy according to stroke risk. Twenty-one patients were classified as Sundt grade 3 (30.8%) and 36 patients as grade 4 (52.9%).

RESULTS

The procedure was technically successful in all patients, with stenosis averaging 82.1% (range 70-99%) before the procedure and 6.3% (range 0-30%) after treatment. There were no periprocedural deaths or major strokes, but two patients had minor, non-embolic stokes (2.9%). During a mean clinical follow-up of 14.4 months (range 1-30 months), no new neurological events occurred in relation to the treated vascular territory.

CONCLUSIONS

Carotid angioplasty with cerebral protection can be performed safely in high-risk patients. During the follow-up period, angioplasty was highly effective in terms of stroke prevention and arterial patency.

Endovascular stenting for the treatment of post-traumatic aneurysms of the extracranial internal carotid artery

Aneurysmal dilatations occur at any level of carotid dissection, but typically at the distal subcranial segment. These aneurysms may grow, compress cervical structures, rupture or constitute a potential source of thrombo-embolic complications. When conservative and/or medical treatment failed or is contraindicated, a more aggressive therapy, such as endovascular stenting should be considered. We report the successful use endovascular stenting for the treatment of post-traumatic dissecting aneurysms of the extracranial internal carotid artery and discuss the potential of different stents types.