Imaging of cerebral perfusion in acute stroke

Rapid imaging of cerebral perfusion in acute stroke is needed for timely triage of patients for thrombolytic therapy. Accurate quantitative perfusion imaging is required for proper assessment of penumbral brain parenchyma truly at risk for extension of infarction from the irreversible core infarction. CT and MRI techniques offer rapidity and availability for acute stroke imaging, including that of cerebral perfusion. CT perfusion techniques are readily available, but suffer from limited brain coverage of present multislice scanners. MRI offers whole brain coverage, but suffers from less availability and higher cost than CT. Presently, development is directed towards increasing the quantitative accuracy of cerebral perfusion imaging and validation of surrogate parameters, such as time to peak (TTP). In the future, the need for rapid and frequent assessment of cerebral perfusion and its metabolic correlates, with minimal or no radiation, will probably be met by MRI.

Percutaneous vertebroplasty: Technique and results in 192 procedures

Percutaneous vertebroplasty with acrylic cement (usually polymethylmethacrylate) consists of injecting cement into vertebral bodies weakened by osseous lesions. The objective of this procedure is to obtain an analgesic effect by mechanical stabilization in destructive lesions of the spine. The three major indications are aggressive vertebral hemangiomas, severe or refractory pain related to osteoporotic vertebral fractures, and malignant vertebral tumors. Complications are infrequent, but occur essentially in patients with vertebral malignant tumors. We present our experience with 148 patients that underwent 192 percutaneous PMMA vertebroplasties for the treatment of painful osteoporotic compression fractures (76 patients, 105 vertebral levels), hemangiomas (31 patients, 43 vertebral levels) and neoplasms (31 patients, 43 vertebral levels). In a vast majority of appropriately selected cases and especially in osteoporotic cases, vertebroplasty constitutes a relatively simple procedure with a very high rate of success.

Stent-assisted arterial reconstruction of traumatic extracranial carotid dissections

OBJECTIVES

Dissection of the internal carotid artery is a well-recognized complication of craniocervical trauma with potentially grave neurological outcome in patients with significant ischemic symptoms. Traditional anticoagulation therapy may not be applicable, since anticoagulation is contraindicated in multiple trauma or penetrating injuries. In these circumstances, rapid stenting followed by antiplatelet therapy may be performed.

METHODS

Patients with angiographically proven traumatic carotid artery dissection were prospectively selected for endovascular stenting according to clinical and radiological criteria. Essentially, patients with hemodynamic significant hemispheric hypoperfusion (as indicated by angiography or perfusion MRI), or in whom anticoagulant therapy failed clinically, or anticoagulation was contraindicated, were considered at high risk for stroke and were selected for stenting. Twelve patients were selected for stenting.

RESULTS

In seven patients, multiple stents were implanted. Endovascular treatment reduced mean dissection stenosis from mean 65+/-33% (range, 10-100%) to mean 7+/-9% (range, 20-0%). In a mean clinical follow-up of 11.5+/-6.3 months (range 3-24 months), eight patients improved and four remained stable, and none of the patients had a TIA or stroke. Doppler U/S studies did not detect any signs of de novo in-stent stenosis in any of the patients at a mean follow-up time of 9.2+/-6.4 months.

CONCLUSIONS

In selected cases of traumatic dissections of the carotid artery, endovascular stent-assisted angioplasty may immediately restore the integrity of the vessel lumen, even of acutely occluded arteries. This approach efficiently prevented the occurrence of new ischemic events, without additional anticoagulation.

Symptomatic facet cysts of the subaxial cervical spine

Subaxial cervical facet cysts are uncommon. We report two patients with intraspinal, extradural, subaxial cervical spinal facet cysts, and review the literature to describe the epidemiology, clinical presentation, imaging findings, and treatment options for these lesions. Intraspinal, extradural, cervical spinal cysts should be considered as part of the differential diagnosis in patients presenting with clinical signs of cervical radiculopathy or myelopathy.

Excellent rates of recanalization and good functional outcome after stent-based thrombectomy for acute middle cerebral artery occlusion. Is it time for a paradigm shift?

The natural history of untreated acute middle cerebral artery (MCA) occlusion is poor, with high rates of mortality (5-33%) and severe long-term disability (40-80% of survivors), despite therapy with intravenous tissue plasminogen activator. We analyzed outcomes in 31 consecutive patients with major ischemic stroke due to acute proximal MCA occlusion who were treated at the Hadassah-Hebrew University Medical Center from February 2010 to October 2012 by endovascular means, using the Solitaire stent (Covidien, Irvine, CA, USA) as a thrombectomy device. Patients had a mean age of 63.3±16.2 years (range, 26-92). The admission National Institutes of Health Stroke Scale score was 19.5±4.3 (median 20). Mean time from symptom onset to femoral artery puncture was 3.8±1.1 hours (median 4 hours). Mean time to recanalization was 46.9±11.1 minutes. Successful recanalization by means of stent-based thrombectomy alone was achieved in 90% of cases and reached 100% after combining definitive stent implantation in three patients. There was no arterial rupture or subarachnoid hemorrhage. Hemorrhagic transformation developed in seven patients (23%), but was symptomatic in only one. Post-procedure CT scan or MRI demonstrated >90% sparing of cortex at risk in all patients. Functional outcome at 90 day follow-up was modified Rankin Score 0-2 in 77% of all patients and 88% of patients younger than 80 years. Three patients (10%) died during hospitalization due to mesenteric event, sepsis, or pulmonary embolism. Our experience suggests that stent-based thrombectomy in selected patients for acute MCA occlusions is safe, very effective in terms of arterial recanalization, and associated with improved neurological outcome. If validated by other groups, endovascular treatment may be proposed as the therapy of choice for MCA occlusion.

Pediatric perimedullary arteriovenous fistula of the conus medullaris supplied by the artery of Desproges-Gotteron

The cone artery, or artery of Desproges-Gotteron, is sometimes seen arising from the internal iliac artery. The authors describe a case of a symptomatic perimedullary arteriovenous fistula (AVF) of the conus medullaris in an 8-year-old boy who presented with a protracted history of urinary difficulty and severe sudden-onset right lumbosciatic pain that evolved to severe paraparesis with compromise of the sphincter muscles. The spinal AVF, which was supplied by the cone artery and a thoracic radiculomedullary artery that joined at the fistula site in a large partially thrombosed varix, was completely occluded with Onyx liquid embolic. The patient's clinical condition improved rapidly after embolization. As shown in this patient, urgent endovascular embolization of spinal AVFs can be very rewarding, even in patients with severe neurological presentation. The artery of Desproges-Gotteron appears to be a rare arterial variation. To the authors' knowledge, this is the first pediatric case of a conal AVF supplied by this artery.

Cerebral sinodural thrombosis following minor head injury in children

Cerebral sinodural thrombosis (CSDT) is a rare complication of minor head trauma in children. Despite recommendations, anticoagulation is frequently withheld. We aimed to evaluate the etiology, clinical presentation, risk factors, diagnosis, treatment, and outcome of pediatric CSDT following minor head trauma, and specifically to evaluate factors associated with anticoagulation use following minor head trauma in pediatric patients with CSDT. A literature search from 1990 to 2012 identified manuscripts discussing epidemiology, risk factors, clinical presentation, management, and outcome in pediatric patients with CSDT subsequent to minor head trauma. One pediatric patient diagnosed with CSDT following minor head trauma in our institution was also included in the study. There were 18 pediatric patients with CSDT following minor trauma, including the current patient. Mean patient age was 7.8years (range 23months-15years). There was a strong female predominance (2.4:1). Vomiting and headache were the most common symptoms. Five patients had pre-existing risk factors (gastroenteritis, protein S deficiency, estroprogestenic medication, elevated antiphospholipid antibodies, malnutrition). Anticoagulation was administered to six patients with additional risk factors, severe symptoms, or deterioration. There was no mortality, 12 patients recovered fully, and four patients improved with residual symptoms. One patient required lumboperitoneal shunt placement. Pediatric CSDT is a rare complication of minor head trauma, with variable presentation. Anticoagulation has generally been reserved for patients suffering from severe symptoms, for those who deteriorate neurologically during observation, and for those who suffer from a concomitant prothrombotic disorder.

Acute middle cerebral artery occlusion: reappraisal of the role of endovascular revascularization

Intravenous tissue plasminogen activator was the first successful stroke therapy in acute ischaemic stroke, after innumerable failed attempts at neuroprotection and neurorestoration. However, intravenous tissue type plasminogen activator has been shown to be effective in recanalizing middle cerebral artery occlusions in only about one-third of cases. The natural history of untreated acute middle cerebral artery occlusion is poor, leading to long-term disability in >70% and mortality in 20%. Recanalization alone is not the name of the game. Only timely, very rapid recanalization, achieved within minutes or at most a few hours after stroke has occurred, before irreversible brain damage develops, is effective. Is intravenous tissue type plasminogen activator the best available option we have for these patients? With recently introduced stent-based thrombectomy devices, neurointerventionalists have achieved complete recanalization rates of more than 90% in middle cerebral artery and 'T' occlusions, with a mean procedural recanalization time of less than one-hour and negligible complication rates. More than 80% of patients less than 80 years of age who were treated within eight-hours after stroke onset in our centre achieved a modified Rankin score of 0-2 at three-month follow-up. The site of arterial occlusion is a factor driving the choice between a standard intravenous tissue type plasminogen activator protocol and an alternative intervention such as intravenous and/or mechanical thrombolysis to achieve early recanalization. The role of intravenous tissue type plasminogen activator must be redefined in major occlusions, and the indications for endovascular therapy must also be reappraised.

Assessing the reach of nicotine replacement therapy as a preventive public health measure

INTRODUCTION

Access to Nicotine Replacement Therapy (NRT) is a key public health intervention to reduce smoking. We assessed prevalence and correlates of use of NRT in Ontario, where NRT is available without prescription.

METHODS

Participants were a representative sample of 2262 adult smokers in the Ontario Tobacco Survey cohort. Prospectively measured use of NRT over a 6-month period was reported in relation to smoking behaviour and history, attempts to quit, receipt of other supports for cessation supports and attitudes toward NRT.

RESULTS

Overall, 11% of smokers used NRT over the six-month follow-up period. Prevalence was 25% among the 27% of smokers matching clinical guidelines that recommend NRT as a therapeutic option, and low among smokers not trying to quit.

CONCLUSION

With increasing accessibility of NRT, further surveillance and research are warranted to determine the impact of the reach and benefits of NRT, considering both the general and targeted smoking populations.

Endovascular management of sigmoid sinus dural arteriovenous fistula associated with sinus stenosis in an infant

A 4-month-old female presented with a dural arteriovenous fistula (DAVF), which was successfully managed using endovascular techniques. There are very few case series reporting DAVF in infants younger than 12 months and, to our knowledge, only 60 pediatric patients with DAVF have been reported to date. Although most DAVF have a benign course, they can result in life-threatening hemorrhage. Endovascular therapies are usually indicated in the management of these neurosurgical vascular malformations. Endovascular therapy of DAVF in neonatal patients presents some major issues. Gaining arterial access may be problematic in femoral arteries too small for the introduction of a sizeable guiding catheter. The volumes of contrast and infused fluids must be carefully monitored to prevent fluid overload. Radiation exposure should be restricted as far as possible. This report contributes to the limited body of evidence on neonatal DAVF and its endovascular management.

Life-threatening neurovascular injuries associated with recreational use of "banana" boats

Banana boat rides are a popular form of recreation worldwide. Recommendations that speed should not exceed 15 mph, passengers should wear protective gear, and an observer should be present on the towing boat are generally ignored. Medical personnel at tourist venues and general practitioners may not be attuned to the risk of serious injury. We present our experience in the management carotid- and vertebral artery dissections sustained by 44- and 23-year-old males during banana boat rides. In both cases, the dissections were misdiagnosed until patients presented to the Emergency Department two days after injury. In the first patient, medical management failed and endovascular treatment was required due to neurological deterioration. In patient two, anticoagulation therapy prevented embolic sequelae. Boat operators, passengers, and the medical personnel who are first to see these patients should be aware of the risk of arterial dissection to facilitate early detection of these potentially life-threatening injuries.

Emergent stent-assisted angioplasty of extracranial internal carotid artery and intracranial stent-based thrombectomy in acute tandem occlusive disease: technical considerations

OBJECTIVE

Tandem occlusions of the internal carotid artery (ICA) and a major intracranial artery respond poorly to intravenous thrombolytic therapy, and are usually managed by endovascular means. This study describes experience with stent-assisted endovascular ICA revascularization and stent-based thrombectomy.

METHODS

In patients with tandem ICA-middle cerebral artery (MCA)/distal ICA occlusion, the carotid occlusion was recanalized by primary angioplasty and stent implantation, and the distal occlusion by stent-based thrombectomy. Two variant techniques are described.

RESULTS

Seven consecutive patients, mean age 64.1 years (range 49-75) and mean admission National Institutes of Health Stroke Scale score of 23, were included. Occlusion sites were tandem proximal ICA and MCA trunk (six patients) and tandem proximal left ICA and ICA terminus (one patient). Complete recanalization with complete perfusion (Thrombolysis in Myocardial Infarction [TIMI] 3, Thrombolysis in Cerebral Infarction [TICI] 3) was achieved in six patients and partial recanalization with partial perfusion (TIMI 2, TICI 2A) in one. Mean time to therapy was 4.9 h (range 3-6.5); mean time to recanalization was 55 min (range 38-65 min). CT performed 1 day after recanalization showed cortical sparing (>90% of the cortex at risk) in seven patients. Five patients (72%) presented with good clinical outcome (modified Rankin Scale (mRS) score 0-2) at 1 month; one patient (patient No 7) reached an mRS score of 3 and one patient died.

CONCLUSIONS

In selected cases of acute ICA occlusion and concomitant major vessel embolic stroke, angioplasty and stenting of the proximal occlusion and stent-based thrombectomy of the intracranial occlusion may be feasible, effective and safe, and provide early neurological improvement. Further experience and prospective studies are warranted.

Selective endovascular embolization for refractory idiopathic epistaxis is a safe and effective therapeutic option: technique, complications, and outcomes

Epistaxis generally responds to conservative management, but a more invasive approach, such as superselective embolization, is sometimes justified. We report our experience with endovascular procedures in 19 patients from 2002 to 2011 for the treatment of refractory idiopatic posterior epistaxis. The sphenopalatine artery and distal internal maxillary arteries were embolized in all patients. Unilateral embolization was performed in 12 patients (63%), bilateral embolization in seven (37%). Additional embolization of the descending palatine artery was performed in eight patients (42%) and embolization of the facial artery and palatine arteries in four (21%). In one patient the distal ophthalmic artery was embolized with n-butyl cyanoacrylate. No minor or major complications occurred in relation to the embolization procedures. The average hospital stay was 11.1±8.6 days, including an average 5.2±3.4 days after embolization. Average follow-up after discharge was 21.3±25.7 months. Superselective endovascular embolization proved safe and effective in controlling idiopathic epistaxis, refractory to other maneuvers.

Rehabilitation outcomes of stroke patients treated with multi-modal endovascular reperfusion therapy

AIM

The aim of this study was to investigate the influence of multi-modal endovascular reperfusion therapy (MMRT) on functional outcomes following rehabilitation.

METHODS

Data from 14 MMRT-treated patients were analyzed and compared to MMRT-ineligible, age and stroke severity-matched patients treated at the same Neurological and Rehabilitation departments. Neurological evaluation was assessed with the NIH stroke scale (NIHSS). Activity of daily living was measured using the FIMTM instrument. Functional outcome was measured using the modified Rankin scale (mRS).

RESULTS

The baseline characteristics of both groups were similar. NIHSS scores were lower in the MMRT group and they had slightly better functional and rehabilitation scores on admission to rehabilitation. At the end of rehabilitation, more MMRT-treated patients reached functional independence (mRS≤2; 50% vs. 7% respectively P=0.03). FIM scores were also higher in the MMRT group (mean score 93.3 vs. 87.7, respectively) but the difference did not reach significance. The delta in FIM and NIHSS scores obtained during rehabilitation did not significantly differ between the groups. MMRT remained a significant modifier of good outcome after regression analysis (OR 21.5 95% CI 1.1-410).

CONCLUSION

MMRT-treated patients have better chances of attaining independence after rehabilitation therapy. However, the additional improvements gained while in active rehabilitation were independent of reperfusion status.

Selective endovascular embolization for refractory idiopathic epistaxis is a safe and effective therapeutic option: technique, complications, and outcomes

Epistaxis generally responds to conservative management, but a more invasive approach, such as superselective embolization, is sometimes justified. We report our experience with endovascular procedures in 19 patients from 2002 to 2011 for the treatment of refractory idiopatic posterior epistaxis. The sphenopalatine artery and distal internal maxillary arteries were embolized in all patients. Unilateral embolization was performed in 12 patients (63%), bilateral embolization in seven (37%). Additional embolization of the descending palatine artery was performed in eight patients (42%) and embolization of the facial artery and palatine arteries in four (21%). In one patient the distal ophthalmic artery was embolized with n-butyl cyanoacrylate. No minor or major complications occurred in relation to the embolization procedures. The average hospital stay was 11.1±8.6 days, including an average 5.2±3.4 days after embolization. Average follow-up after discharge was 21.3±25.7 months. Superselective endovascular embolization proved safe and effective in controlling idiopathic epistaxis, refractory to other maneuvers.