Leptomeningeal Collaterals Strongly Correlate with Reduced Cerebrovascular Reactivity Measured by Acetazolamide-challenged Single-photon Emission Computed Tomography Using a Stereotactic Extraction Estimation Analysis in Patients with Unilateral Internal Carotid Artery Stenosis

Objective To assess the correlation between the angiographic appearance of cerebral collateral pathways or the degree of internal carotid artery stenosis (ICAS) and reduced cerebrovascular reactivity (CVR) estimated by single-photon emission computed tomography (SPECT) image analysis in patients with unilateral ICAS. Methods A retrospective analysis was performed in 42 patients with unilateral ICAS who underwent cerebral angiography and acetazolamide-challenged SPECT of the brain. Cerebral blood flow quantitation was performed using the quantitative SPECT/dual-table autoradiography method. The CVR in the middle cerebral artery (MCA) territory was evaluated using the stereotactic extraction estimation based on the Japanese extracranial-intracranial bypass trial (SEE-JET) program and classified as reduced (<18.4%) or non-reduced (≥18.4%). Angiographic collateralization was classified as circle of Willis (type 1), extracranial-intracranial (type 2), and leptomeningeal (type 3). The degree of ICAS was defined as severe (≥70% stenosis) or non-severe (<70%). Results Eight patients showed reduced CVR, including 6 (46%) of 13 with type 3 collaterals and 2 (7%) of 29 without type 3 collaterals (p=0.006). In contrast, type 1 and type 2 collaterals and severe ICAS were not significantly associated with reduced CVR. Conclusion In patients with unilateral ICAS, leptomeningeal collaterals are strongly correlated with reduced CVR in the MCA territory, which presumably increases the risk of cerebral hyperperfusion after carotid artery stenting (CAS). Therefore, these findings may be clinically applicable to the perioperative management of CAS.

Risk factors for vasovagal reaction associated with cerebral angiography via femoral catheterisation

Objective To analyse the related risk factors for vasovagal reaction associated with cerebral angiography via femoral catheterisation and discuss treatment measures and prevention and control methods. Methods The data of 3107 patients on whom cerebral angiography was performed in two high-volume interventional neuroradiology centres within 8 years were retrospectively analysed. Patients were divided into the vasovagal reaction and non-vasovagal reaction groups according to whether vasovagal reaction developed. The two groups' clinical data were analysed using univariate and multivariate logistic regression analysis to examine vasovagal reaction-related factors. Results Of the 3107 patients included, 127 developed vasovagal reaction (4.09%). Of the 127 patients who developed vasovagal reaction, 123, three and one had vasovagal reaction after sheath removal, during cerebral angiography and upon femoral artery compression device removal, respectively. Differences in age, body mass index, sex ratios, proportions of patients with hypertension, diabetes and hyperlipemia, and adoption rate of femoral artery compression device were not statistically significant between the two groups ( P > 0.05). Compared with the control group, the vasovagal reaction group had a significantly longer preoperative fasting time ( P < 0.05). Multivariate logistic regression analysis revealed preoperative fasting time as the only risk factor for vasovagal reaction that was associated with cerebral angiography ( P < 0.001). Conclusion Excessive fasting time before cerebral angiography is the most important risk factor for vasovagal reaction associated with cerebral angiography.

Diagnostic Work-Up of a Giant Calcified Intracranial Aneurysm: Comparing 4D-CTA and Cerebral Angiogram Findings

The risks associated with unruptured intracranial aneurysms can be neurologically debilitating and even fatal. Evaluation of these aneurysms is critical for determining what type of intervention is warranted, if at all. Cerebral angiography has long been the gold standard in the evaluation of intracranial aneurysms. However, this diagnostic modality is accompanied by several risks that are made clear to the patient before they consent to the procedure. These risks include the possibility of stroke, groin hematomas, contrast-induced anaphylaxis, contrast nephropathy, and catheter-associated infections. Dynamic CT angiography (4D-CTA) has been studied as an assessment tool for cerebral vasculopathies such as stroke, arteriovenous malformations, and aneurysms. It has been shown that 4D-CTA has the advantage of being less invasive and has a shorter examination time than cerebral angiography. In this article, we present a rare case of a giant calcified aneurysm and compare the findings of a cerebral angiogram and a 4D-CTA study.

Primary Intraventricular Hemorrhage: Clinical Characteristics and Outcomes

BACKGROUND

Primary intraventricular hemorrhage (IVH) in adults is a rare neurologic disorder. The typical course, etiology, complications, and outcomes have not been well established.

MATERIALS AND METHODS

Consecutive patient records with a diagnosis of intracerebral hemorrhage admitted between May 2009 and June 2014 at a tertiary care center were retrospectively reviewed. Subjects were included in the study cohort if all neurologists and the radiology report agreed that the subject had an isolated IVH. Patients with intraparenchymal hemorrhage, subarachnoid hemorrhage, malignancy with hemorrhagic components, and hemorrhagic transformation of ischemic stroke were excluded. The electronic medical record, imaging report, and imaging studies were reviewed.

FINDINGS

Of 1692 cases reviewed, 33 (1.9%) had primary IVH. The most common presenting symptoms included altered mental status (48.5%), headache, (39.4%), and nausea (24.2%). In 36.3%, hypertension was found to be a contributing factor; 27.2% were attributed solely to hypertension. Vascular abnormalities were the primary etiology in 21.3% of patients. When observing outcomes, 61.8% were discharged home or to rehab, whereas 20.5% died or were placed in hospice care. A higher Graeb score was associated with an increased likelihood of death or hospice (8 versus 5, P = .02) CONCLUSION: This study is one of few to describe the etiology, contributing factors, and outcomes of primary IVH. As in prior studies, hypertension was a contributing factor, and vascular lesions were less common than expected. More research is necessary to further define the course and characteristics of this rare type of intracerebral hemorrhage.

Arterial Obstruction on Computed Tomographic or Magnetic Resonance Angiography and Response to Intravenous Thrombolytics in Ischemic Stroke

BACKGROUND AND PURPOSE

Computed tomographic angiography and magnetic resonance angiography are used increasingly to assess arterial patency in patients with ischemic stroke. We determined which baseline angiography features predict response to intravenous thrombolytics in ischemic stroke using randomized controlled trial data.

METHODS

We analyzed angiograms from the IST-3 (Third International Stroke Trial), an international, multicenter, prospective, randomized controlled trial of intravenous alteplase. Readers, masked to clinical, treatment, and outcome data, assessed prerandomization computed tomographic angiography and magnetic resonance angiography for presence, extent, location, and completeness of obstruction and collaterals. We compared angiography findings to 6-month functional outcome (Oxford Handicap Scale) and tested for interactions with alteplase, using ordinal regression in adjusted analyses. We also meta-analyzed all available angiography data from other randomized controlled trials of intravenous thrombolytics.

RESULTS

In IST-3, 300 patients had prerandomization angiography (computed tomographic angiography=271 and magnetic resonance angiography=29). On multivariable analysis, more extensive angiographic obstruction and poor collaterals independently predicted poor outcome (P<0.01). We identified no significant interaction between angiography findings and alteplase effect on Oxford Handicap Scale (P≥0.075) in IST-3. In meta-analysis (5 trials of alteplase or desmoteplase, including IST-3, n=591), there was a significantly increased benefit of thrombolytics on outcome (odds ratio>1 indicates benefit) in patients with (odds ratio, 2.07; 95% confidence interval, 1.18-3.64; P=0.011) versus without (odds ratio, 0.88; 95% confidence interval, 0.58-1.35; P=0.566) arterial obstruction (P for interaction 0.017).

CONCLUSIONS

Intravenous thrombolytics provide benefit to stroke patients with computed tomographic angiography or magnetic resonance angiography evidence of arterial obstruction, but the sample was underpowered to demonstrate significant treatment benefit or harm among patients with apparently patent arteries.

CLINICAL TRIAL REGISTRATION

URL: http://www.isrctn.com. Unique identifier: ISRCTN25765518.

Common carotid artery dissection caused by radiotherapy: A case report

In the present study, a case of acute cerebral infarction with radiation-induced carotid artery dissection is reported. Carotid artery dissection is generally asymptomatic at the early stages. Due to the non-specific clinical manifestations of carotid artery dissection, a detailed inquiry of the past history of a patient has a critical role in making a diagnosis of radiation-induced common carotid artery dissection. Onset of acute ischemic stroke is the predominant manifestation, and for patients with a history of head-and-neck radiotherapy, dissection should be considered. The condition may progress rapidly, and result in a poor prognosis. Therefore, a correct early diagnosis and initiation of appropriate therapy may lead to rapid recovery, and influence the overall prognosis.

Cerebral Misery Perfusion on Susceptibility Weighted Imaging in Acute Carotid Dissection

The cerebral vasculature incorporates several fail-safes that must be breached before an irreversible ischemic event takes place. In particular, when autoregulatory vasodilatation fails secondary to falling cerebral perfusion pressure (CPP; stage I hemodynamic failure), increases in the oxygen extraction fraction work to maintain the cerebral metabolic rate of oxygen. Previously, failure of this mechanism, stage II hemodynamic failure, or misery perfusion, has been imaged via positron emission tomography/computed tomography (PET/CT). Current susceptibility-weighted sequences (SWI) allow for more efficient imaging of this physiology. In this case, we identify an incident of reversible ischemia caused by spontaneous carotid artery dissection using a combination of diffusion weighted imaging (DWI) and SWI. The level of hemodynamic failure identified by the imaging sequences elevated the urgency of neurointervention, expediting the patient's arrival to the neurointerventional table and thus avoiding impending irreversible ischemia.

Postoperative imaging for detection of recurrent arteriovenous malformations in children

OBJECT The optimal method for detecting recurrent arteriovenous malformations (AVMs) in children is unknown. An inherent preference exists for MR angiography (MRA) surveillance rather than arteriography. The validity of this strategy is uncertain. METHODS A retrospective chart review was performed on pediatric patients treated for cerebral AVMs at a single institution from 1998 to 2012. Patients with complete obliteration of the AVM nidus after treatment and more than 12 months of follow-up were included in the analysis. Data collection focused on recurrence rates, associated risk factors, and surveillance methods. RESULTS A total of 45 patients with a mean age of 11.7 years (range 0.5-18 years) were treated for AVMs via surgical, endovascular, radiosurgical, or combined approaches. Total AVM obliteration on posttreatment digital subtraction angiography (DSA) was confirmed in 27 patients, of whom the 20 with more than 12 months of follow-up were included in subsequent analysis. The mean follow-up duration in this cohort was 5.75 years (median 5.53 years, range 1.11-10.64 years). Recurrence occurred in 3 of 20 patients (15%). Two recurrences were detected by surveillance DSA and 1 at the time of rehemorrhage. No recurrences were detected by MRA. Median time to recurrence was 33.6 months (range 19-71 months). Two patients (10%) underwent follow-up DSA, 5 (25%) had DSA and MRI/MRA, 9 (45%) had MRI/MRA only, 1 (5%) had CT angiography only, and 3 (15%) had no imaging within the first 3 years of follow-up. After 5 years posttreatment, 2 patients (10%) were followed with MRI/MRA only, 2 (10%) with DSA only, and 10 (50%) with continued DSA and MRI/MRA. CONCLUSIONS AVM recurrence in children occurred at a median of 33.6 months, when MRA was more commonly used for surveillance, but failed to detect any recurrences. A recurrence rate of 15% may be an underestimate given the reliance on surveillance MRA over angiography. A new surveillance strategy is proposed, taking into account exposure to diagnostic radiation and the potential for catastrophic rehemorrhage.

Safety of neuroangiography and embolization in children: complication analysis of 697 consecutive procedures in 394 patients

OBJECT

The safe treatment of children using catheter-based angiography and embolization poses unique challenges because of the technical factors regarding the size and fragility of access and target vessels, as well as unique pediatric cerebrovascular pathologies. The complication rates for neurointerventional procedures in children have not been established.

METHODS

The records of a consecutive cohort of pediatric patients who underwent neuroangiography and/or embolization between 2007 and 2013 were reviewed retrospectively to identify both intraprocedural and postprocedural complications. Demographic and clinical risk factors were analyzed with a multivariate logistic regression model.

RESULTS

The 697 consecutive procedures consisted of 429 diagnostic angiograms and 268 embolizations (mean age of patients 11.1 years; range 4 days to 18 years; 217 females). There were 130 intracranial, 122 extracranial, and 16 spinal embolizations. Pathologies included 28 intracranial arteriovenous malformations (AVMs), 12 spinal AVMs, 19 aneurysms, 29 vein of Galen malformations, 29 dural arteriovenous fistulas, 96 extracranial AVMs, 39 tumors, 3 strokes, and 13 others. Overall, 2 intraprocedural and 1 postprocedural complication (0.7%) occurred in the diagnostic group, all of which were nonneurological events. In the embolization group, 7 intraprocedural and 11 postprocedural complications (6.7%) were observed. Of these complications, 15 were nonneurological events (5.6%), 1 was a short-term neurological event (0.4%), and 2 were long-term neurological events (0.7%).

CONCLUSIONS

Neither the technical challenges posed by children's access and target vessels nor the unique neuro-vascular pathologies seen in children need result in an elevated morbidity rate related to neuroangiography and embolization. At a dedicated high-volume center, the complication rates may be lower than those for comparable procedures performed in adults.

Qureshi-5 Catheter for Complex Supra- and Abdominal-Aortic Catheterization

BACKGROUND

The use of previously described catheter technique was expanded to complex supra- and abdominal- aortic catheterizations.

METHODS

A new (Qureshi 5) catheter with curved shape at the distal end that has two lumens was used. One of lumens can accommodate a 0.035-inch guide wire and the second lumen can accommodate a 0.018-inch guide wire and terminates at the beginning of the distal curve of the first lumen. The manipulation and engagement of the curved distal end catheter was facilitated by rotation and movement of the J-shaped 0.018-inch guide wire extended coaxial and beyond the distal end of catheter. Subsequently, either contrast was injected or a 0.035-inch guide wire advanced into the target artery.

RESULTS

The catheters were used in one patient to perform diagnostic cerebral and abdominal angiography through a 6F introducer sheath placed in the right common femoral artery. The catheterization was complex because of severe tortuosity of arch and descending aorta secondary to kyphosis. The left and right internal carotid arteries and left and right vertebral arteries, left renal artery, and superior mesenteric artery were catheterized in patient (fluoroscopy time 19:46 min). No complications were observed in the patient.

CONCLUSIONS

The Qureshi-5 catheter was successful in complex supra- and abdominal-aortic catheterizations.

Defending a traditional practice in the modern era: The use of lumbar puncture in the investigation of subarachnoid haemorrhage

INTRODUCTION

Acute severe headache is a common medical presentation, and a common area of diagnostic uncertainty. Subarachnoid haemorrhage (SAH) is the cause in a minority of patients and has a high rate of morbidity and mortality. Therefore, its conclusive diagnosis with computed tomography (CT) or lumbar puncture (LP) is paramount. With advancement in imaging technology, emerging evidence now suggests that LP is no longer required for a subset of patients as CT has 100% sensitivity in detecting SAH, when performed under specific conditions.

OBJECTIVES

To assess the proportion of patients with conclusive CSF xanthochromia results following a negative CT scan in suspected SAH to determine the diagnostic efficacy of LP.

METHODS

CSF bilirubin and oxyhaemoglobin spectrophotometric absorbance data from all centres in a regional health board were identified for consecutive patients over a 6-month period. Results were stratified as conclusive (positive or negative), or inconclusive according to national guidelines.

RESULTS

239 of 255 (93.7%) results were conclusive: 89.0% were negative (227 of 255). 4.7% of results were positive (12 of 255), revealing 4 cerebral aneurysms requiring treatment. 16 out of 255 (6.3%) samples were inconclusive, yielding 1 aneurysm requiring treatment. In the same period, there were 27 CT-positive cases of SAH.

CONCLUSIONS

LP has a high diagnostic yield, eliminating the need for neurosurgical opinion or investigation in almost 90% of cases. The test is both cost and time efficient and subjects only a small number of patients to the radiation and contrast risks of angiography.

Case Report: Traumatic anterior cerebral artery aneurysm in a 4-year old child

Traumatic intracranial aneurysm in the proximal part of the anterior cerebral artery in the pediatric population has not been documented so far. Here we report the case of a 4 year-old child who developed a pseudo-aneurysm after minor head trauma and was managed successfully with trapping of the aneurysm. A ventriculo-peritoneal shunt was placed as the child became dependent on extraventricular drain during the post-operative period. The patient made excellent recovery in neurological status within 1 month of post-operative clinical follow up.

Clinical Presentation, Imaging, and Management of Complications due to Neurointerventional Procedures

Neurointervention is a rapidly evolving and complex field practiced by clinicians with backgrounds ranging from neurosurgery to radiology, neurology, cardiology, and vascular surgery. New devices, techniques, and clinical applications create exciting opportunities for impacting patient care, but also carry the potential for new iatrogenic injuries. Every step of every neurointerventional procedure carries risk, and a thorough appreciation of potential complications is fundamental to maximizing safety. This article presents the most frequent and dangerous iatrogenic injuries, their presentation, identification, prevention, and management.

Preliminary Experience with use of Qureshi-5 Catheters for Diagnostic Cerebral Angiography

BACKGROUND

A catheter technique was developed to overcome current challenges in the stabilization and manipulation of catheter in tortuous arteries such as right subclavian artery and left common carotid artery.

METHODS

The new catheter has the following two lumens: first lumen can accommodate a 0.035-inch guide wire (lumen A) and a curved shape at the distal end; the second lumen can accommodate a 0.018-inch guide wire and terminates at the beginning of the distal curve of the first lumen (lumen B). The catheter is withdrawn or advanced over the 0.018-inch guide wire and the curved free end of catheter manipulated until the end engages the origin of the target artery. Subsequently, either contrast can be injected or a 0.035-inch guide wire advanced into the target artery.

RESULTS

The catheters were used in two patients to perform diagnostic cerebral angiography through a 6F introducer sheath placed in the right common femoral artery. The left and right common carotid arteries and left and right vertebral arteries were catheterized in first patient (contrast used 50 ml; fluoroscopy time 20:09 min). The left and right internal carotid arteries, left and right subclavian arteries, and left external carotid artery were catheterized in second patient (contrast used 40 ml; fluoroscopy time 13:56 min). No complications were observed in either of the two patients.

CONCLUSIONS

The performance of the new catheter for catheterization of multiple arteries in two patients was considered adequate with high-quality angiographic image acquisitions.

Recognizing the signs and symptoms of aneurysmal subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) is a devastating neurologic condition with a high mortality and long term neurological morbidity in 50% of survivors. In addition, SAH commonly affects young patients causing substantial loss of productive life years and resulting in significant long term healthcare costs. Early recognition of the signs and symptoms of SAH is absolutely critical to earlier intervention, and delays in diagnosis can have devastating consequences. To avoid such delays in SAH diagnosis, the medical provider should recognize its signs and symptoms. Neuroimgaging, cerebrospinal fluid examination and angiography (invasive or non-invasive) facilitate early diagnosis of SAH. The purpose of this review is not to provide an exhaustive critique of the available literature, rather, it is to provide an overview that will better enable a provider to recognize and initiate the workup of patients with SAH.

Carotid artery stenting

Carotid artery stenting (CAS) has achieved clinical equipoise with carotid endarterectomy (CEA), as evidenced by 2 large U.S. randomized clinical trials, multiple pivotal registry trials, and 2 multispecialty guideline documents endorsed by 14 professional societies. The largest randomized trial conducted in patients at average surgical risk of CEA, CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) found no difference between CAS and CEA for the combined endpoint of stroke, death, and myocardial infarction (MI) after 4 years of follow-up. The largest randomized trial comparing CAS and CEA in patients at increased surgical risk, SAPPHIRE (Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy), looked at 1-year stroke, death, and MI incidence and found no difference in symptomatic patients, but a significantly better outcome in asymptomatic patients for CAS (9.9% vs. 21.5%; p = 0.02). Given that >70% of carotid revascularization procedures are performed in asymptomatic patients for primary prevention of stroke, it is incumbent upon clinicians to demonstrate that revascularization has an incremental benefit over highly effective modern medical therapy alone.

Dural Arteriovenous Fistula of the Transverse and Sigmoid Sinus Manifesting Ascending Dysesthesia: Case Report and Literature Review

Cases involving intracranial dural arteriovenous fistulas (AVFs) with spinal perimedullary venous drainage exhibit variable presentations, which results in delayed diagnoses. We describe a case of a 66-year-old female with a transverse-sigmoid sinus dural AVF with spinal perimedullary venous drainage who developed dysesthesia and hypalgesia that ascended from the peripheral lower extremities. Sixty cases of intracranial dural AVFs resulting in myelopathy have been reported, and an absence of brainstem signs significantly correlated with a delay in diagnosis (positive group: 3.4 months vs. negative group: 9.6 months, P < 0.05). Intracranial dural AVFs with brainstem signs should be diagnosed without delay because the myelopathy and bulbar symptoms could progress aggressively without alternative drainage routes besides the perimedullary veins. We emphasize that intracranial dural AVFs should be considered as a differential diagnosis in case presenting with symptoms, such as atypical dysesthesia and hypalgesia ascending from the toes, without brainstem signs. Moreover, we should perform cerebral angiography as early as possible because dural AVFs with slow-flow venous drainage can produce false negatives on magnetic resonance angiography.

Vertebral artery dissection in patients with autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited renal cystic disease, and it is associated with various extrarenal manifestations, including vascular complications, such as intracranial aneurysms, and aortic root dilatation and aneurysms. However, intracranial arterial dissection has rarely been reported. We herein report the cases of 2 patients with ADPKD who developed a vertebral artery (VA) dissection. Dissection was also observed on the other side of the VA and in the internal carotid artery in the first and second patient, respectively. Both patients also had a history of hypertension, which is frequently accompanied by ADPKD, and their serum creatinine levels were normal. Our report supports the importance of considering ADPKD as one of the possible pathogenic factors in arterial dissection.

Prediction and observation of post-admission hematoma expansion in patients with intracerebral hemorrhage

Post-admission hematoma expansion in patients with intracerebral hemorrhage (ICH) comprises a simultaneous major clinical problem and a possible target for medical intervention. In any case, the ability to predict and observe hematoma expansion is of great clinical importance. We review radiological concepts in predicting and observing post-admission hematoma expansion. Hematoma expansion can be observed within the first 24 h after symptom onset, but predominantly occurs in the early hours. Thus capturing markers of on-going bleeding on imaging techniques could predict hematoma expansion. The spot sign observed on computed tomography angiography is believed to represent on-going bleeding and is to date the most well investigated and reliable radiological predictor of hematoma expansion as well as functional outcome and mortality. On non-contrast CT, the presence of foci of hypoattenuation within the hematoma along with the hematoma-size is reported to be predictive of hematoma expansion and outcome. Because patients tend to arrive earlier to the hospital, a larger fraction of acute ICH-patients must be expected to undergo hematoma expansion. This renders observation and radiological follow-up investigations increasingly relevant. Transcranial duplex sonography has in recent years proven to be able to estimate hematoma volume with good precision and could be a valuable tool in bedside serial observation of acute ICH-patients. Future studies will elucidate, if better prediction and observation of post-admission hematoma expansion can help select patients, who will benefit from hemostatic treatment.

Moderately elevated intracranial pressure produces greater cross-filling of the anterior communicating artery

This study aimed to investigate whether moderately elevated intracranial pressure is associated with greater cross-filling of the anterior communicating artery on diagnostic cerebral angiography. A retrospective study of 12 patients with subarachnoid hemorrhage was performed. Data on sequential cerebral angiograms and clinical data were used to indirectly estimate intracranial pressure (ICP). Cross-filling of the anterior communicating artery (ACom) was recorded according to our scoring system. Our study included 12 patients with mean age 43 ± 11 yrs. Six patients demonstrated greater ICP associated with greater cross-filling of the ACom on initial angiogram. One patient had greater ICP with greater cross-filling on follow-up angiogram secondary to infarction and midline shift. Two patients had lower ICP yet greater cross-filling on follow-up angiogram due to higher injection rate and volume. One patient with no change in ICP demonstrated the same degree of cross-filling. A markedly elevated ICP is traditionally associated with no cross-filling across the ACom. We propose a counter-intuitive model in which moderately elevated ICP produces greater cross-filling of the ACom. This diagnostic angiographic finding should make the angiographer consider that the patient has moderately elevated ICP, and facilitate more timely clinical management.

An institutional experience of 26 patients with Moyamoya disease: A study from Northwest India

Aim:

Moyamoya disease (MMD) is a slowly progressive bilateral stenocclusive process of the distal internal carotid and proximal portions of the anterior and middle cerebral arteries and the formation of an abnormal vascular network at the base of the brain. The purpose of this retrospective study was to identify clinical features, salient features, radiological features and yield of diagnostic cerebral angiography in MMD.

Materials and Methods:

We analyzed the records of 26 patients with MMD evaluated and treated at our institute from August 2010 until March 2013. Diagnosis of MMD was made on the basis of features of angiographic findings. Cerebral angiography showed typically fine network of vessels at the base of the brain with puff of smoke appearance suggestive of MMD. CT angiography (CTA) was done in 25 (96.15%) patients where as Digital substraction angiography (DSA) was done in 18 (69.23%) patients.

Results:

Out of the 26 patients 13 were in the pediatric age group and 13 were adults. At presentation 14 patients had infarcts and 10 patients had hemorrhages. Among the hemorrhagic group 20% had isolated intracerebral hemorrhage (ICH), 50% patients had ICH with intraventricular extension (IVE) and 30% patients had primary intraventricular hemorrhage (PIVH). 50 % of the patients had involvement of the posterior circulation.

Conclusion:

Posterior circulation involvement is frequent in MMD. Though parenchymal bleed with/without intraventricular extension is the usual presentation of hemorrhagic MMD, isolated intraventricular hemorrhage could also be the mode of presentation.

Anesthesia for interventional radiology

Pediatric patients in the neurointerventional radiology setting pose the dual challenges of caring for relatively sick patients in the outfield environment. For safe and successful practice, the anesthesiologist must not only understand the nuances of pediatric anesthesia and the physiologic demands of the cerebral lesions. They must also help maintain a team-based approach to safe, compassionate care of the child in this challenging setting. In this review article, we summarize key aspects of success for several of these topics.

Endovascular treatment of intracranial aneurysms by interventional neurologists: first year single-center experience

BACKGROUND

Endovascular embolization of ruptured intracranial aneurysms provides an adequate treatment and long-term results with less morbidity and mortality (M&M) compared with surgical treatment. Since the last decade more and more ruptured and unruptured intracranial aneurysms (IA) undergo endovascular embolization in the United States. We present our experience of the initial one year periprocedural M&M at Paul L. Foster School of Medicine (PLFSM), Texas Tech Health Science Center (TTUHSC) in El Paso, Texas.

METHODS

Demographics, technical aspects of the endovascular procedure and clinical assessment, including several commonly used scales to assess the severity in case of subarachnoid hemorrhage were collected. Perioperative complications were classified as minor and major. All data is prospectively collected in a local database. Only endovascular treated aneurysms were included in the study.

RESULTS

During the first year of opening of the interventional neurology program at our school of medicine (March 2011 and March 2012), a total 45 ruptured and unruptured intracranial aneurysms were treated with endovascular embolization. Two thirds of the patients (n = 27) presented with a ruptured IA. Within those with a ruptured aneurysm, the most median Hunt and Hess grade was 3. By large the vast majority of treated IA were in the anterior circulation and more than half measured 7-12 mm. Only three unruptured IA were <7 mm (average 5.5 mm). Complications occurred in seven patients (15%), four of them were minor without any clinical sequelae. The remaining three included; intracranial dissection and aneurysmal rupture resulting in both hemorrhagic or ischemic stroke and death in only one patient.

CONCLUSION

The first year experience of interventional neurology services at Paul L. Foster School of Medicine in El Paso, Texas demonstrates successful treatments with comparable national rates of morbidity and mortality.

ABBREVIATIONS

ACAAnterior cerebral arteryAcommAnterior communicating arteryESNEndovascular surgical neuroradiologyH&HHunt and Hess scaleIAIntracranial aneurysmICAInternal carotid arteryMCAMiddle cerebral arteryM&MMorbidity and mortalitySAHSubarachnoid hemorrhagePcommPosterior communicating arteryPLFSMPaul L. Foster School of MedicineTTUHSCTexas Tech University Health Science CenterVAVertebral artery.

Use of low-dose contrast agent in cerebral angiography produces high-quality diagnostic images

The present study was aimed to study feasibility of low-dose contrast agent in cerebral CT angiography (CTA) to alleviate some side effects and costs associated with routine doses of contrast agent. Sixty patients suspected to have cerebral artery disease were randomly selected to receive either low-dose (60 mL) contrast agent or routine-dose (100 mL) contrast agent. CTA included transverse images, volume rendering (VR), and maximum intensity projection (MIP) images. Developing strength, image noise, and structure display effects of the cerebral artery were compared between groups. The developing strength and image noise of the cerebral artery were equivalent between groups (P > 0.05). No statistical differences were observed in structure display effects of the cerebral artery or in radiological diagnosis between groups (P > 0.05). Application of the low-dose contrast agent is feasible and offers comparable diagnostic capabilities in cerebral CT angiography.

Multiple intracranial aneurysms followed left atrial myxoma: case report and literature review

Cerebral aneurysms follows atrial myxoma is a rare neurological complication. We report a patient with multiple cerebral aneurysms three years after resection of left atrial myxoma and further review the literature. The characteristics of these aneurysms are indefinite and variable. They can occur prior or post the resection of cardiac myxoma. "Metastasize and Infiltrate" theory may be the key mechanism in the formation of these aneurysms. Magnetic resonance imaging (MRI), computed tomography (CT) and angiography are useful in the diagnosis while digital subtraction angiography (DSA) is the best choice. There are no definite guidelines for therapy of these aneurysms. Resection of the cardiac myxomas, chemotherapy, radiotherapy, coil embolization and surgical treatment could be helpful.

Endovascular neurointervention success and complication rates in the first year of independent practice in a suburban hospital setup

CONTEXT

Endovascular neurointervention (interventional neuroradiology) is a highly demanding science requiring deep understanding of disease, anatomy, clinical skills and manual dexterity, consequently with a long learning curve and thus posing significant challenges to a physician entering new into the competitive arena.

AIM

To evaluate the procedural success, complications and outcome in the first year of independent endovascular neurointervention practice in a suburban hospital.

MATERIALS AND METHODS

Retrospective analysis of prospectively maintained data of all diagnostic and therapeutic neurointerventional cases performed by the author between the period of January 02, 2012 and December 31, 2012.

RESULTS

A total of 61 procedures were performed. The performance success rate of the diagnostic procedures was 100% (38/38) and that of therapeutic procedures was 82.6% (19/23). The periprocedural complication rates were nil and 13%, respectively, for diagnostic and therapeutic procedures. The 3-month patient outcome for therapeutic procedures was good outcome (Modified Rankin Scale <2) in 87% cases (20/23), and poor outcome in 13% (2 dead and 1 debilitated with Modified Rankin Scale of 3).

CONCLUSION

For a well-trained endovascular neurointerventionalist, the first year of practice had high procedural success rate and acceptable complication with patient outcome rates comparable to the existing literature.

Dural arteriovenous fistula discovered in patient presenting with recent head trauma

Patient

Male, 32

Final Diagnosis: Dural arterio-venous fistula

Symptoms: Eye redness • post-trauma headache • tinnitus

Medication: —

Clinical Procedure: Fistula embolization

Specialty: Neurology

Successful treatment of bilateral symmetrical skeletal haemangiomata: a case report

We describe a case of giant bilateral skull vault haemangiomas in a patient with diffuse skeletal haemangiomatosis. The clinical details, histological and radiographic findings and surgical management are reviewed. This is the first described case of radical surgical management of bilateral giant haemangiomas with relief of intractable headache.

Recent advances in intra-arterial thrombolysis

Thrombolytic therapy has revolutionized acute ischemic stroke (AIS) treatment; however it is clear that intravenous (IV) thrombolytic therapy has certain limitations, including a short-time window for use, poor specificity for the site of arterial occlusion, and suboptimal recanalization rates. Some of these problems may be circumvented by using intra-arterial (IA) thrombolysis. In this article, we will discuss the various thrombolytic agents being used in AIS, their mechanisms of actions and doses, and the rationale for use of IA therapy as opposed to IV thrombolysis, and review the clinical trials using IA thrombolysis. We will also discuss other approaches to IA thrombolysis, including mechanical and other endovascular techniques.

Spontaneous intracerebral hematoma from transient occult carotid-cavernous fistula: a case report

After the spontaneous relief of initial symptoms by traumatic carotid-cavernous fistula (CCF), paradoxical worsening of patient's condition can be followed. We present a case of a 60-yr-old man whose audible bruit from a traumatic CCF had completely disappeared. A few days later, however, the patient had spontaneous intracerebral hematoma with cortical venous drainage. Complete obliteration of the fistula was achieved after embolization. When initial audible bruit in traumatic CCF disappears suddenly, cerebral angiography should be performed to differentiate venous hypertension by the hemodynamic changes of the cavernous sinus channels from spontaneous resolution of CCF.