Editorial: Stent-assisted coil embolization

Staged treatment for ruptured wide-neck intracranial aneurysm with intentional partial coiling in the acute phase followed by definitive treatment

Background:

Evidence supports endovascular coiling for ruptured intracranial aneurysms (RIAs). However, in some cases, it is difficult to achieve complete occlusion by coiling, such as with wide-neck aneurysms. We report our experience with intentional staged RIA treatment using targeted endovascular coiling at the rupture point in the acute phase, followed by delayed stent-assisted coiling, flow diverter stenting, or surgical clipping.

Methods:

Consecutive patients with RIAs treated between April 2015 and June 2021 were retrospectively investigated. Clinical characteristics, treatment complications, and patient outcomes data were collected.

Results:

Among 108 RIAs treated in our hospital, 60 patients underwent initial coiling; 10 patients underwent staged treatment. The aneurysm locations were the anterior communicating artery (n = 5), internal carotid-posterior communicating artery (n = 3), internal carotid-paraclinoid (n = 1), and vertebral artery-posterior inferior cerebellar artery (n = 1). The mean ± standard deviation aneurysmal diameter was 9.6 ± 5.4 mm and the mean aspect ratio was 1.2 ± 0.7. As the second treatment to obliterate blood flow to the neck area, we performed five stent-assisted coiling, two flow-diverter stentings, and three surgical clippings. Only one minor perioperative complication occurred. The median duration between the first and second treatments was 18 days (range, 14– 42 days). Good clinical outcome (modified Rankin scale score 0–2) at 90 days was achieved in 5 (50%) cases. The median follow-up duration was 6.5 months (range, 3–35 months); no rerupture occurred.

Conclusion:

Intentional staged treatment with a short time interval for RIA was effective and feasible.

Insights into the natural history of spontaneous intracranial hypotension from infusion testing

Objective

To assess the pathophysiologic changes in patients with spontaneous intracranial hypotension (SIH) based on measures of CSF dynamics, and on the duration of symptoms, in a retrospective case-controlled study.

Methods

We included consecutive patients investigated for SIH at our department from January 2012 to February 2018. CSF leak was considered confirmed if extrathecal contrast spillage was seen on imaging (CT or MRI) after intrathecal contrast application, or dural breach was detected by direct intraoperative visualization. We divided patients with a confirmed CSF leak into 3 groups depending on the symptom duration, as follows: ≤10, 11–52, and >52 weeks. Clinical characteristics and measures of CSF fluid dynamics obtained by computerized lumbar infusion testing were analyzed over time and compared with a reference population.

Results

Among the 137 patients included, 69 had a confirmed CSF leak. Whereas 93.1% with <10 weeks of symptoms displayed typical orthostatic headache, only 62.5% with >10 weeks of symptoms did (p = 0.004). Analysis of infusion tests revealed differences between groups with different symptom duration for CSF outflow resistance (p < 0.001), lumbar baseline pressure (p = 0.013), lumbar plateau pressure (p < 0.001), baseline pressure amplitude (p = 0.021), plateau pressure amplitude (p = 0.001), pressure–volume index (p = 0.001), elastance (p < 0.001), and CSF production rate (p = 0.001). Compared to the reference population, only patients with acute symptoms showed a significantly altered CSF dynamics profile.

Conclusion

A CSF leak dramatically alters CSF dynamics acutely, but the pattern changes over time. There is an association between the clinical presentation and changes in CSF dynamics.

Coagulopathy reversal in intracerebral haemorrhage

As intracerebral hemorrahge becomes more frequent as a result of an aging population with greater comorbidities, rapid identification and reversal of precipitators becomes increasingly paramount. The aformentioned population will ever more likely be on some form of anticoagulant therapy. Understanding the mechanisms of these agents and means by which to reverse them early on is critical in managing the acute intracerebral hemorrhage.

Prediction of pediatric meningioma recurrence by preoperative MRI assessment

Preoperative identification of high-recurrent pediatric meningiomas with MRI features would help clinicians to make optimal treatment strategies; however, the relationships between radiological features and recurrence of meningiomas in pediatric population have not been clearly demonstrated yet. The aim of this study is to identify preoperative MRI features which are significant risk factors for recurrence of pediatric meningiomas. From January 2005 to December 2012, we retrospectively reviewed 52 pediatric meningiomas in terms of preoperative MRI features and their clinical data and followed them up from 22 to 128 months (mean 63 months) after the initial surgery. The relationships between these radiological findings and relapse-free survival (RFS) time were assessed initially with univariate Cox analysis and then corrected by multivariate Cox analysis. According to univariate analysis, irregular shape, narrow-based attachment, and skull base location were significantly correlated with shorter time to recurrences of meningiomas in pediatric patients. When corrected by multivariate analysis, irregular shape (P = 0.05; OR 3.442, 95 % CI 1.001-11.831) and narrow-based attachment (P = 0.004; OR 7.164, 95 % CI 1.894-27.09) were strong independent predictive factors for worse RFS of pediatric meningiomas. In pediatric population, narrow-based attachment and irregular shape were significantly correlated with recurrences of meningiomas. Our results could help clinicians to make optimal therapeutic strategies for pediatric patients with intracranial meningiomas before surgery.

Chronic subdural haematoma associated with disturbance of consciousness: significance of acute-on-chronic subdural haematoma

OBJECTIVE

Detailed features of chronic subdural haematoma (cSDH) associated with disturbance of consciousness and acute-on-chronic subdural haematoma (a/cSDH), in which acute subdural haematoma overlaps cSDH, remain poorly understood. The object of this study was to clarify both characteristics of cSDH associated with disturbance of consciousness and the significance of a/cSDH.

METHODS

Clinical factors and computed tomography (CT) findings were retrospectively investigated in 349 consecutive patients admitted between 2006 and 2013 and diagnosed with cSDH.

RESULTS

Glasgow Coma Scale (GCS) was ≤ 8 in 21 patients (6.0%) and 9-14 in 29 patients excluding aphasia and/or dementia (8.3%). Multiple logistic regression analysis indicated that a/cSDH, female sex and haemodialysis were significantly related to severe disturbance of consciousness (GCS ≤ 8). Predictors for a/cSDH observed in 29 patients (8.3%) were trauma history within 7 days before admission, high prothrombin time-international rate, and use of anticoagulants and/or antiplatelets. Unfavourable outcomes were observed in 29 of 299 patients (9.7%) without consciousness disturbance, compared to 27 of 50 patients (54%) with consciousness disturbance. Predictors of unfavourable outcome were consciousness disturbance, increase in age, malignancy, trauma history within 7 days and haemodialysis.

DISCUSSION

Disturbance of consciousness associated with cSDH, often caused by either a/cSDH or concomitant disease, frequently resulted in unfavourable outcomes. As a result, in cSDH patients associated with disturbance of consciousness, underlying conditions, especially a/cSDH, which is often caused by haemostatic abnormality, should be clarified and managed.