Clinical diagnosis and successful treatment of inflammatory cerebral amyloid angiopathy

INTRODUCTION

Cerebral amyloid angiopathy is a major cause of lobar hemorrhage in older adults, and of microvascular ischemic disease. The rarest form of this disease is an inflammatory form causing seizures. It is important to recognize because the patients usually respond to a brief course of immunosuppression.

METHODS

Case report.

RESULTS

A 66-year-old man developed gradual cognitive decline, insidiously increasing headaches, and then had a likely seizure. MRI showed diffuse white matter edema, and innumerable superficial microhemorrhages characteristic of amyloid angiopathy. He was empirically treated with oral prednisone and an anticonvulsant. His symptoms improved and the white matter edema resolved over several months. ApoE genotype was 4/4, which is commonly found in inflammatory amyloid angiopathy.

CONCLUSIONS

Inflammatory cerebral amyloid angiopathy can be clinically diagnosed and treated without brain biopsy. Clinical diagnosis is important because of the good response to a brief course of steroids in most cases.

Idiopathic pontine Streptococcus salivarius abscess in an immunocompetent patient: management lessons through case illustration and literature review

A 55-y-old woman with no previous medical history presented with a 3-day history of progressive headache, nausea, emesis, right-sided facial numbness, and right-sided extremity weakness. Serial magnetic resonance imaging demonstrated rapid enlargement of a left-sided ring-enhancing dorsal pontine lesion with an exophytic portion, raising concern for an abscess. A stereotactically guided left-sided retrosigmoid craniotomy for abscess incision and decompression was performed given the rapid progression of her neurological deficits. Streptococcus salivarius was isolated from the intra-operative samples. After an extensive evaluation, no source for the S. salivarius was identified. Solitary brainstem abscesses are uncommon intracranial infections with high morbidity and mortality. Patients can present with non-specific symptoms and often have no previous medical history. Since 1974, 40 patients with solitary brainstem abscess have survived to hospital discharge. We outline management strategies for solitary brainstem abscess based on a literature review of survivors.

Intraventricular hemorrhage secondary to intranidal aneurysm rupture-successful management by arteriovenous malformation embolization followed by intraventricular tissue plasminogen activator: case report

BACKGROUND AND IMPORTANCE

Intraventricular hemorrhage related to arteriovenous malformation (AVM) rupture is associated with significant morbidity and mortality. Intraventricular tissue plasminogen activator (tPA) has been used to treat spontaneous intraventricular hemorrhage. We demonstrate the successful application of endovascular occlusion to seal the rupture site of an AVM followed by intraventricular tPA.

CLINICAL PRESENTATION

A 32-year-old woman presented with a right frontoparietal parasagittal AVM abutting the motor cortex. The AVM was diagnosed when the patient was 13 years old, and she initially underwent conservative management. At the age of 30, the patient suffered an intracranial hemorrhage, leaving her with left hemiparesis. After rehabilitation, the patient regained ambulation; however, she remained spastic and hyperreflexic on the left side. Two years after her major hemorrhage, she presented for elective treatment of her AVM. The patient was advised to undergo staged embolization before surgical resection of her AVM. The initial embolization was uneventful. A second embolization was complicated by intraventricular hemorrhage and coma. The patient was treated with placement of an external ventricular drain followed by embolization of intranidal aneurysm. After embolization of the intranidal aneurysm the ruptured, the patient was treated with intraventricular tPA. The patient had rapid clearance of the intraventricular hemorrhage and significant improvement in her neurological examination, following commands 24 hours later and returning almost to baseline.

CONCLUSION

This case demonstrates the feasibility of treating AVM-related intraventricular hemorrhage with tPA if the rupture source can be confidently sealed interventionally. This strategy can be lifesaving but needs further study to ensure its safety.

Moyamoya disease: a review of histopathology, biochemistry, and genetics

Object

Moyamoya disease (MMD) is a rare cerebrovascular disorder involving stenosis of the major vessels of the circle of Willis and proximal portions of its principal branches. Despite concerted investigation, the pathophysiology of the disorder has not been fully elucidated. Currently, the major proteins believed to play an active role in the pathogenesis include vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), hepatocyte growth factor (HGF), transforming growth factor–β1 (TGFβ1), and granulocyte colony-stimulating factor (G-CSF). In terms of the genetics, recent literature suggests a low penetrance autosomal dominant or polygenic mode of transmission involving chromosomes 3, 6, 8, 12, and 17 for familial MMD. This review summarizes the current knowledge on the histopathology, pathophysiology and genetics of MMD.

Methods

A PubMed/Medline systematic study of the literature was performed, from which 45 articles regarding MMD pathophysiology were identified and analyzed.

Conclusions

Moyamoya disease is characterized by the intimal thickening and media attenuation of the proximal vessels of the circle of Willis as well as the development of an aberrant distal vascular network. The primary proteins that are currently implicated in the pathophysiology of MMD include VEGF, bFGF, HGF, TGFβ1, and G-CSF. Furthermore, the current literature on familial MMD has pointed to a low penetrance autosomal dominant or polygenic mode of transmittance at loci on chromosomes 3, 6, 8, 12, and 17.

Decompressive hemicraniectomy after malignant middle cerebral artery infarction: rationale and controversies

Malignant middle cerebral artery stroke carries a very poor prognosis. Significant retrospective data support the hypothesis that decompressive hemicraniectomy decreases mortality rates due to this disease entity. Recently, 3 randomized controlled studies have been published and shed light on these issues and enhance the quality of evidence revolving around this procedure. In this review, the rationale, risks, benefits, and unanswered questions related to hemicraniectomy for acute ischemic stroke are reviewed with an emphasis on how 3 randomized trials have influenced knowledge on this life-saving yet controversial procedure. Further randomized studies are needed to clarify lingering questions regarding age indications and impact on quality of life.

Relationship of Growth to Aneurysm Rupture in Asymptomatic Aneurysms ≤ 7 mm: A Systematic Analysis of the Literature

BACKGROUND:

The apparent paradox of natural history data suggesting low rupture risk of small asymptomatic aneurysms and the median size of aneurysm rupture remains unexplained. Aneurysm growth rates and their potential relationship with rupture risk have not been well examined in natural history studies.

OBJECTIVE:

To examine the question of whether small asymptomatic aneurysms ≤ 7 mm that are followed up over time rupture and to determine the relationship between aneurysm growth and rupture.

METHODS:

We reviewed all publications on unruptured aneurysms published from 1966 to 2009. We then selected all aneurysms ≤ 7 mm for which measurements were reported for at least 2 time points and for which initial asymptomatic status and ultimate outcome (rupture vs unruptured) were reported. Using the Mann-Whitney U test, we compared absolute diameter annual growth rate.

RESULTS:

Our search retrieved 64 aneurysms. Thirty aneurysms ruptured during follow-up, of which 27 were enlarged before rupture (90%). Thirty-four aneurysms did not rupture, of which 24 enlarged during follow-up (71%). There was a statistically significant trend toward larger absolute diameter growth for ruptured aneurysms vs unruptured aneurysms (3.89 ± 2.34 vs 1.79 ± 1.02 mm; P < .001), respectively. Annual growth rates for aneurysms for the 2 groups, however, were not statistically different (27.46 ± 18.76 vs 32.00 ± 29.30; P = .92).

CONCLUSION:

Small aneurysms are prone to growth and rupture. Aneurysm rupture is more likely to occur in aneurysms with larger absolute diameter growth, but rupture can also occur in the absence of growth. The annual growth rate in both groups suggests that rate of growth of aneurysms is highly variable and unpredictable, justifying treatment or close diagnostic follow-up.

Endovascular Stenting of Extracranial Carotid and Vertebral Artery Dissections: A Systematic Review of the Literature

BACKGROUND:

Carotid and vertebral artery dissections are a leading cause of stroke in young individuals.

OBJECTIVE:

To examine the published safety and efficacy of endovascular stenting for extracranial artery dissection.

METHODS:

We conducted a systematic review of the literature to identify all cases of endovascular management of extracranial carotid and vertebral artery dissections.

RESULTS:

For carotid dissections, our review yielded 31 published reports including 140 patients (153 vessels). Reported etiologies were traumatic (48%, n = 64), spontaneous (37%, n = 49), and iatrogenic (16%, n = 21). The technical success rate of stenting was 99%, and the procedural complication rate was 1.3%. Mean angiographic follow-up was 12.8 months (range, 2-72 months) and revealed in-stent stenosis or occlusion in 2% of patients. Mean clinical follow-up was 17.7 months (range, 1-72 months), and neurological events were seen in 1.4% of patients. For vertebral artery dissections, our review revealed 8 reports including 10 patients (12 vessels). Etiologies were traumatic (60%, n = 6), spontaneous (20%, n = 2), and iatrogenic (20%, n = 2). There was a 100% technical success rate. The mean angiographic follow-up period was 7.5 months (range, 2-12 months). No new neurological events were reported during a mean clinical follow-up period of 26.4 months (range, 3-55 months).

CONCLUSION:

Endovascular management of extracranial arterial dissection continues to evolve. Current experience shows that this treatment option is safe and technically feasible. Prospective randomized trials compared with medical management are needed to further elucidate the role of stenting.

Association of Intracranial Aneurysm and Loeys-Dietz Syndrome: Case Illustration, Management, and Literature Review

BACKGROUND AND IMPORTANCE:

Loeys-Dietz syndrome (LDS) is a newly described connective tissue disease associated with aortic aneurysms. A strong association between LDS and intracranial aneurysms has not yet been documented in the literature. We present the first detailed report of an intracranial aneurysm finding in an LDS patient.

CLINICAL PRESENTATION:

The patient is a 20-year-old female recently diagnosed with LDS and found to harbor 2 incidental intracranial aneurysms on a screening magnetic resonance angiography: a 3-mm right carotid ophthalmic aneurysm and an 8-mm partially fusiform paraclinoid carotid artery aneurysm. A standard left pterional craniotomy was performed. Intraoperative adenosine was used instead of temporary clipping because her vessels were extremely friable. After reconstruction, an intraoperative indocyanine green angiogram was obtained, confirming complete aneurysmal obliteration and internal carotid artery patency.

CONCLUSION:

This is the first detailed report of a clear association between intracranial aneurysms and LDS. An association between LDS and intracranial aneurysms, if substantiated in a larger study, has implications for aneurysm screening in this population. Such an association may shed light on mechanisms of aneurysm formation, growth, and rupture.

Accelerating time-resolved MRA with multiecho acquisition

A new four-dimensional magnetic resonance angiography (MRA) technique called contrast-enhanced angiography with multiecho and radial k-space is introduced, which accelerates the acquisition using multiecho while maintaining a high spatial resolution and increasing the signal-to-noise ratio (SNR). An acceleration factor of approximately 2 is achieved without parallel imaging or undersampling by multiecho (i.e., echo-planar imaging) acquisition. SNR is gained from (1) longer pulse repetition times, which allow more time for T(1) regrowth; (2) decreased specific absorption rate, which allows use of flip angles that maximize contrast at high field; and (3) minimized effects of a transient contrast bolus signal with a shorter temporal footprint. Simulations, phantom studies, and in vivo scans were performed. Contrast-enhanced angiography with multiecho and radial k-space can be combined with parallel imaging techniques such as Generalized Autocalibrating Partially Parallel Acquisitions (GRAPPA) to provide additional 2-fold acceleration in addition to higher SNR to trade off for parallel imaging. This technique can be useful in diagnosing vascular lesions where accurate dynamic information is necessary.

True Aneurysm on the Posterior Meningeal Artery Associated With a Dural Arteriovenous Fistula

BACKGROUND

We report an unusual case of a true dural aneurysm arising from the posterior meningeal artery that fed a symptomatic dural arteriovenous fistula located at the right transverse-sigmoid sinus junction.

CLINICAL PRESENTATION

A 29-year-old right-handed white woman presented with aneurysmal dilatation of hypertrophied posterior meningeal artery feeding a partially treated dural arteriovenous fistula.

INTERVENTION

The aneurysm, which measured approximately 3 mm in width and 5 mm in length, was located in the intracranial space with a thin-walled dome projecting toward the cerebellum. Its afferent and efferent vessels were identified, secured, and the lesion was excised en bloc.

CONCLUSION

A thorough evaluation of all diagnostic studies should be performed for patients with vascular malformations to help identify these or other unusual lesions that may aid in the risk stratification process and management plan.