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Bandlamuri S, Custozzo A, Silva J, Bandlamuri SK, Qian J, Paul AR. Systematic Review and Case of Thrombectomy for Pediatric Stroke Due to Myxoma Embolism. World Neurosurg 2024; 183:e761-e771. [PMID: 38211812 DOI: 10.1016/j.wneu.2024.01.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/04/2024] [Indexed: 01/13/2024]
Abstract
BACKGROUND Stroke presentation secondary to a cardiac myxoma thromboembolism is rare in the pediatric population. Because of such rarity, the reported cases in the literature are primarily case reports. Additionally, general pediatric stroke management lacks evidence-based guidelines because of its low incidence and lack of clinical trials. In pediatric strokes identified from a cardiac myxoma, the incidence favors boys with the classical presentation of unilateral weakness and aphasia. We present a pediatric patient who presented with strokelike symptoms secondary to an intracranial embolus from a previously undiagnosed cardiac myxoma. METHODS We performed a systematic review by searching PubMed, Google Scholar, Web of Science, and Embase databases for cases of pediatric myxoma causing stroke (n = 2431) and identified 19 reported uses of surgical management in treating pediatric patients who present with stroke symptoms secondary to a cardiac myxoma thromboembolism. RESULTS The most common imaging modality was magnetic resonance imaging in 42% of cases, computed tomography in 36.8%, followed by computed tomography angiography in 31.6% of cases. Of these 19 children treated with procedures, 36.8% of pediatric patients aged between 4 and 14 years underwent neurosurgery (n = 7). CONCLUSIONS We describe an urgent mechanical thrombectomy and share preoperative and postoperative images and pathology slides confirming a stroke from myxoma origin. We provide added insight in the safe use of mechanical thrombectomy as treatment for pediatric strokes secondary to a thromboembolism.
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Affiliation(s)
- Sruti Bandlamuri
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Amanda Custozzo
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Jonathan Silva
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | | | - Jiang Qian
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, New York, USA
| | - Alexandra R Paul
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA.
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2
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Almawi AS, Alhammad AS, Alshammari ZA, Althubait S, Alqahtani S. Salvageable Intra-stent Coil Embolization Treatment for Spinal Dural Arteriovenous Fistula in a Child. Cureus 2023; 15:e42425. [PMID: 37637553 PMCID: PMC10448778 DOI: 10.7759/cureus.42425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
Spinal dural arteriovenous fistulae (SDAVF) are rare diseases that exhibit abnormal connections between arteries and veins. They are even rarer in the pediatric population and pose diagnostic and treatment challenges for physicians. Its presentation varies depending on the site and size of the SDAVF. Multiple management options are available, which are usually tailored depending on the patient's condition. Here, we present a rare case of SDAF in a four-year-old girl who initially presented with bilateral lower limb weakness. The patient was then treated successfully using primary major fistula point stenting and intra-stent coiling, with complete closure achieved. Full recovery was achieved over the course of follow-ups. The deep analysis of SDAVF, its classification, and the utilization of the best available endovascular tools by a dedicated neurovascular team offer the best outcome in dealing with complex spinal neurovascular pathologies.
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Affiliation(s)
| | | | | | - Shorog Althubait
- Interventional Neuroradiology, King Fahad Medical City, Riyadh, SAU
| | - Sultan Alqahtani
- Interventional Neuroradiology, King Fahad Medical City, Riyadh, SAU
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3
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Northam WT, Slingerland AL, Orbach DB, Smith ER. Magnetic Resonance Imaging/Angiography Versus Catheter Angiography for Annual Follow-up of Pediatric Moyamoya Patients: A Cost Outcomes Analysis. Neurosurgery 2023; 92:1243-1248. [PMID: 36744923 DOI: 10.1227/neu.0000000000002357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/08/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Digital subtraction angiography (DSA) assesses revascularization in pediatric moyamoya patients after surgery, but MRI and angiography (MRI/A) may provide comparable data. OBJECTIVE To evaluate DSA and MRI/A with respect to clinical utility in postoperative follow-up, complication profile, and relative cost at 1 year. METHODS All pediatric moyamoya patients who received bilateral indirect revascularization between 2011 and 2020 were retrospectively reviewed at 1 institution. Patients who underwent MRI/A-only, DSA-only, or both after 1 year were compared. RESULTS Eighty-two patients were included. At 1 year, patients who underwent either MRI/A (n = 29) or DSA (n = 40) had no significant differences in detection rate of new at-risk hypovascular territories (6.9% vs 2.5%, P = .568) or need for subsequent revascularization beyond the mean 40 ± 24-month follow-up period (3.4% vs 5.0%, P > .9). Among patients who underwent both MRI/A and DSA (n = 13), both studies identified the same at-risk territories. No patients experienced MRI/A-related complications, compared with 3 minor DSA-related complications. The use of MRI/A yielded a 6.5-fold reduction in cost per study vs DSA at 1 year. CONCLUSION Using DSA to follow moyamoya patients after indirect revascularization is generally safe but associated with a low rate of minor complications and a 6.5-fold greater financial cost relative to MRI/A. These data support changing practice to eliminate the use of DSA when following routine bilateral moyamoya cases in the absence of clinical symptoms or specific concerns. Using MRI/A as the primary postoperative follow-up modality in this select population provides noninferior care and greater patient access, while reducing cost and potentially decreasing risk.
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Affiliation(s)
- Weston T Northam
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Anna L Slingerland
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Darren B Orbach
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
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4
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Oulasvirta E, Koroknay-Pál P, Numminen J, Hafez A, Raj R, Jahromi BR, Niemelä M, Laakso A. Recurrence of brain arteriovenous malformations in pediatric patients: a long-term follow-up study. Acta Neurochir (Wien) 2023; 165:1565-1573. [PMID: 37140647 DOI: 10.1007/s00701-023-05612-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/19/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Previously thought to be congenital, AVMs have shown evidence of de-novo formation and continued growth, thus shifting thoughts on their pathophysiology. Pediatric AVM patients have been reported to be more prone to develop AVM recurrence after a seemingly complete cure. Therefore, we assessed the risk of AVM treated in childhood to recur in adulthood after a long-term follow-up in our own cohort. METHODS Control DS-angiography was arranged during 2021-2022 as part of a new protocol for all AVM patients who were under 21 years of age at the time of their treatment and in whom the treatment had occurred at least five years earlier. Angiography was offered only to patients under 50 years of age at the time of the new protocol. The complete eradication of AVM after the primary treatment had been originally confirmed with DSA in every patient. RESULTS A total of 42 patients participated in the late DSA control, and 41 of them were included in this analysis after excluding the patient diagnosed with HHT. The median age at the time of admission for AVM treatment was 14.6 (IQR 12-19, range 7-21 years) years. The median age at the time of the late follow-up DSA was 33.8 years (IQR 29.8-38.6, range 19.4-47.9 years). Two recurrent sporadic AVMs and one recurrent AVM in a patient with hereditary hemorrhagic telangiectasia (HHT) were detected. The recurrence rate was 4.9% for sporadic AVMs and 7.1% if HHT-AVM was included. All the recurrent AVMs had originally bled and been treated microsurgically. The patients with sporadic AVM recurrence had been smoking their whole adult lives. CONCLUSIONS Pediatric and adolescent patients are prone to develop recurrent AVMs, even after complete AVM obliteration verified by angiography. Therefore, imaging follow-up is recommended.
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Affiliation(s)
- Elias Oulasvirta
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Päivi Koroknay-Pál
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jussi Numminen
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ahmad Hafez
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Behnam Rezai Jahromi
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Aki Laakso
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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5
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Varney ET, Taylor CS, Crosthwait AG, Weaver K, Nichols T. A deceptive mass on neonatal ultrasound and a fetal brain MRI-confirmed complex dural arteriovenous fistula postnatally: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22318. [PMID: 36471579 PMCID: PMC9724006 DOI: 10.3171/case22318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/06/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Dural arteriovenous fistulas (dAVFs) are direct, aberrant connections between dural arteries and cerebral veins. In neonates, delayed diagnosis results in grim outcomes. Treatment involves endovascular management because of its success and tolerability. Here, the authors present a case of a complex dAVF initially recognized with an in utero neurosonogram and fetal magnetic resonance imaging (MRI). OBSERVATIONS A 21-week fetal ultrasound of a nonspecific brain mass was confirmed with fetal MRI as a 2.7-cm T1-hyperintense posterior fossa mass. Although a large flow void in the left middle cranial fossa was present, postnatal computed tomography angiography ultimately revealed a high-flow dAVF communicating with the left transverse sinus. In the early postnatal period, the patient developed hydrocephalus. After successful partial embolization, 6-week postangiogram brain MRI indicated disease progression with the development of a venous varix causing brainstem compression. Repeat embolization resulted in complete cessation of early venous drainage. LESSONS Neonatal dAVFs are exceedingly rare and result in futile outcomes; however, detection in utero is possible. Although definitive therapy must be performed postnatally, constant monitoring and early delivery can prevent complications. Attention to fetal ultrasound is essential, and knowledge of fetal MRI in the detection of these complex lesions can significantly improve outcomes.
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Affiliation(s)
| | | | | | - Kristin Weaver
- Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi
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6
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The use of the Safeguard pressure-assisted device for maintenance of hemostasis following angiography in children. J Vasc Interv Radiol 2022; 33:1084-1088. [DOI: 10.1016/j.jvir.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/29/2022] [Accepted: 04/07/2022] [Indexed: 11/22/2022] Open
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7
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Aldea CC, Florian IA, Timiș TL, Andrașoni Z, Florian IS. Ruptured AComA aneurysm and asymptomatic bilateral ACA vasospasm in an infant: surgical case report. Childs Nerv Syst 2022; 38:633-641. [PMID: 34021372 DOI: 10.1007/s00381-021-05215-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/13/2021] [Indexed: 11/27/2022]
Abstract
Intracranial aneurysms (IAs) are localized dilations of the cerebral vasculature, representing the leading cause for non-traumatic subarachnoid hemorrhage and an important source of morbidity and mortality. Despite it being a frequent pathology and most often diagnosed incidentally, IAs in infants are a very rare occurrence, and the ruptured variant is exceptional. A 4-month-old boy with a negative family history was brought to our department because of several episodes of incoercible vomiting and fever. Upon examination, the child was somnolent, without any noticeable deficit. Transfontanellar ultrasonography and CT angiography revealed a ruptured aneurysm of the anterior communicating artery (AComA), whereas the pre-clipping MRI showed thin, almost angiographically invisible anterior cerebral arteries (ACAs) on both sides due to vasospasm. We intervened surgically by placing an external ventricular shunt in an emergency setting, followed by clipping of the IA in a delayed manner. The child was discharged a month after admission with no deficit, despite the paradoxical aspect of the ACA. Ruptured IAs can be safely treated via microsurgery, even in infants. However, this requires a great amount of experience and surgical expertise. Furthermore, the lack of proper management would most likely result in a severe deficit in the long term. Lastly, the lack of visibility of the ACA on angiographic studies may not have neurological consequences if they occur in this age group.
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Affiliation(s)
| | - Ioan Alexandru Florian
- Clinic of Neurosurgery, Cluj County Emergency Clinical Hospital, Cluj-Napoca, Romania. .,Department of Neurosurgery, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
| | - Teodora Larisa Timiș
- Department of Physiology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Zorinela Andrașoni
- Clinic of Neurosurgery, Cluj County Emergency Clinical Hospital, Cluj-Napoca, Romania
| | - Ioan Stefan Florian
- Clinic of Neurosurgery, Cluj County Emergency Clinical Hospital, Cluj-Napoca, Romania.,Department of Neurosurgery, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Lauzier DC, Osbun JW, Chatterjee AR, Moran CJ, Kansagra AP. Safety of pediatric cerebral angiography. J Neurosurg Pediatr 2022; 29:192-199. [PMID: 34740194 DOI: 10.3171/2021.8.peds21301] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/13/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Catheter-based cerebral angiography is commonly used for neurovascular diagnosis in children. In this work, the authors aimed to quantify the complication rate of cerebral angiography in children, characterize these complications, and identify risk factors for complications. METHODS Relevant clinical data were retrospectively obtained for 587 consecutive cerebral angiography procedures performed in 390 children from March 2002 to March 2020. Complications were categorized as neurological or nonneurological, and severity was graded using a standard schema. Incidences of complications were reported as point estimates. Associations between risk factors and complications were characterized in univariate analysis using the two-tailed Fisher exact test and in multivariate analysis using multiple logistic regression with bidirectional elimination based on the Akaike information criterion. In both univariate and multivariate analyses, statistical significance was corrected for multiple comparisons using the Benjamini-Hochberg method. RESULTS Complications occurred in 6.5% of procedures, including neurological complications in 1.9% and nonneurological complications in 4.8%. Permanent deficits occurred in only 0.2% of cases. Overall, 0.5% of procedures resulted in major complications, while 6.0% resulted in minor complications. Female sex and a history of hypertension or ischemic stroke were associated with an increased risk of complications, while femoral artery access was associated with a decreased risk of complications. CONCLUSIONS Pediatric cerebral angiography was shown to have a low rate of major or permanent complications. Children who were female and those with a history of hypertension or ischemic stroke were shown to be at higher risk of complications, while the use of femoral access carried a lower risk of complications.
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Affiliation(s)
- David C Lauzier
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis
| | - Joshua W Osbun
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis
- 3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Arindam R Chatterjee
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis
- 3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Christopher J Moran
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis; and
| | - Akash P Kansagra
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis
- 3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
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9
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Dandapat S, Guerrero WR, Ortega-Gutierrez S. Acute StrokeTreatment in Children: Are Adult Guidelines Applicable? Curr Treat Options Neurol 2022; 24:41-54. [PMID: 35509674 PMCID: PMC9060549 DOI: 10.1007/s11940-022-00707-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose of this Review This article provides an overview into acute treatments in stroke which are widely studied and available for adults and their applicability in the pediatric population. Recent Findings Arterial ischemic stroke is an important cause of morbidity and mortality in the pediatric population. Neurological deficits and etiologies are age-dependent and more challenging to diagnose than in the adult population. Advancements in imaging and treatment modalities including increased treatment windows in acute stroke have led to improvement in the diagnosis and management of pediatric arterial ischemic disease. Accordingly, hyperacute treatments, such as endovascular therapy, are becoming increasingly available in an attempt to improve outcomes in children. Summary Significant scientific and technological advances have transformed the hyperacute treatment of stroke in the recent years, allowing for improvement in the diagnosis and treatment of cerebrovascular pathologies in children. Optimization in the approach, and validation of existing stroke pathways/protocols is expected to further advance acute stroke therapy in pediatric patient care. Given that the lifelong individual, family, and societal burden of acute stroke is likely to be greater than in adults because infants and children surviving stroke live more years with disability, we must be knowledgeable about this pathology and the medical and therapeutic options available for this unique population as detailed in this review.
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Affiliation(s)
- Sudeepta Dandapat
- Department of Neurosciences, Aurora Neuroscience Innovation Institute, St.Luke’s Hospital, Milwaukee, WI
| | - Waldo R. Guerrero
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Radiology and Neurosurgery, University of Iowa Comprehensive Stroke Center, Iowa City, IA
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10
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Chen K, Dawkins D, Orbach DB, Aagaard-Kienitz B. Low profile sheaths in pediatric neurointervention: a multicenter experience. J Neurointerv Surg 2021; 14:1135-1138. [PMID: 34625510 DOI: 10.1136/neurintsurg-2021-017936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/03/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pediatric neurointervention is challenged by the appropriateness of adult catheters and devices. This multicenter report on the smallest groin access sheaths offers technical notes and clinical outcomes in the pediatric neurointerventional population. METHODS All pediatric neurointerventional cases from 2019 to 2021 were reviewed for use of a 3.3F Pediavascular or a 4F Merit Prelude Ideal low profile sheath. Hospital records were reviewed for complications and technical notes and compared with arterial groin access with the 4F Terumo Pinnacle in infants less than 1 year old, before the low profile sheaths at one author's institution were introduced. RESULTS From January 1, 2019 to March 31, 2021 there were 347 procedures performed at Boston Children's Hospital and University of Wisconsin. Forty-four procedures in 26 patients were identified in which a 3.3F (38 cases, 20 patients) or 4F (6 cases, 6 patients) sheath was used. The average age was 2.2 years (1.5 days to 18 years). Retinoblastoma intra-arterial chemotherapy infusion (18 of 44) was the most common indication. The remaining procedures comprised vein of Galen embolization (12), diagnostic cerebral angiography (13), and one preoperative tumor embolization. Morbidity included a groin hematoma and decreased pulses (4.5%). No major groin complications occurred. There was no statistically significant difference compared with the historical cohort (132 procedures), which had seven instances of decreased pulses (5.3%, p>0.05). CONCLUSION The 3.3F Pediavascular and 4F Merit Prelude Ideal sheaths are easily incorporated into the pediatric neurointerventionalist's armamentarium for infants and readily accommodate various microcatheters for distal embolization and catheterization.
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Affiliation(s)
- Karen Chen
- Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Demi Dawkins
- Neurosurgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Darren B Orbach
- Neurointerventional Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Beverly Aagaard-Kienitz
- Radiology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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Alshehri H, Dmytriw AA, Bhatia K, Bickford S, Rea V, Shkumat N, Muthusami P. Transradial Neuroendovascular Procedures in Adolescents: Initial Single-Center Experience. AJNR Am J Neuroradiol 2021; 42:1492-1496. [PMID: 33958331 DOI: 10.3174/ajnr.a7142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/23/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The feasibility and safety of transradial angiography is not established outside the adult literature. The objective of this study was to assess the feasibility and safety of transradial access for neuroangiography in adolescents. MATERIALS AND METHODS A retrospective case-control study was performed, comparing transradial neuroendovascular procedures in adolescents (age range, 10-18 years) with an age- and procedure-matched cohort of transfemoral neuroendovascular procedures. Clinical and procedural details, including type of procedure, conversion rate, fluoroscopy time, radiation dose, complications, and readmissions, were reported by descriptive statistics or measures of central tendency and compared using a t test or nonparametric equivalent. A P value < .05 was considered statistically significant. RESULTS Twenty adolescents (mean age, 14.6 [SD, 1.7] years, M/F ratio = 9:11) who underwent transradial neuroangiography were compared against 20 adolescents (mean age, 14.4 [SD, 2.1 ] years, M/F ratio = 12:8) who underwent transfemoral neuroangiography. We found no significant difference in procedural success (0% conversion rate), fluoroscopy times (33.7 [SD, 40.2] minutes versus 23.3 [SD, 26.2] minutes, P = .34) and radiation dose (150.9 [SD, 133.7] Gy×cm2 and 122.9 [SD, 79.7] Gy×cm,2 P = .43) There were 2 self-limiting postprocedural complications in the transradial group. There were no major hemorrhages, need for further interventions, or readmissions in either group. CONCLUSIONS The benefits of transradial angiography described for adults can likely be safely extended to adolescents. These are important data before transitioning to smaller children and should be prospectively evaluated in a larger cohort.
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Affiliation(s)
- H Alshehri
- From the Divisions of Neuroradiology and Image-Guided Therapy (H.A., A.A.D., S.B., V.R., N.S., P.M.), Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - A A Dmytriw
- From the Divisions of Neuroradiology and Image-Guided Therapy (H.A., A.A.D., S.B., V.R., N.S., P.M.), Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - K Bhatia
- Department of Medical Imaging (K.B.), Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - S Bickford
- From the Divisions of Neuroradiology and Image-Guided Therapy (H.A., A.A.D., S.B., V.R., N.S., P.M.), Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - V Rea
- From the Divisions of Neuroradiology and Image-Guided Therapy (H.A., A.A.D., S.B., V.R., N.S., P.M.), Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - N Shkumat
- From the Divisions of Neuroradiology and Image-Guided Therapy (H.A., A.A.D., S.B., V.R., N.S., P.M.), Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - P Muthusami
- From the Divisions of Neuroradiology and Image-Guided Therapy (H.A., A.A.D., S.B., V.R., N.S., P.M.), Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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12
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Dmytriw AA, Ha W, Bickford S, Bhatia K, Shroff M, Dirks P, Muthusami P. Long Vascular Sheaths for Transfemoral Neuroendovascular Procedures in Children. Neurointervention 2021; 16:149-157. [PMID: 34078026 PMCID: PMC8261116 DOI: 10.5469/neuroint.2021.00192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 05/21/2021] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To evaluate the safety and efficacy of long vascular sheaths for transfemoral neuroendovascular procedures in children. MATERIALS AND METHODS A retrospective evaluation of transfemoral neuroendovascular procedures in children <18 years, using long sheaths was undertaken analyzing procedure type, fluoroscopic times, technical success, access site and systemic complications. Twenty-seven consecutive procedures were included over a 2-year period. Mean age was 8.4 years (standard deviation [SD] 6.3) (range 17.0 months-16.3 years). RESULTS Patients were 44% female and mean weight was 35.0 kg (SD 22.8) (range 9.8-72.2 kg). A third of the procedures were performed in ≤15 kg children. The most common procedure was for embolization (n=13, 48.1%) and the most common indication was dual microcatheter technique (52%). The most common device used was the 5 Fr Cook Shuttle sheath. Mean fluoroscopy time was 61.9 minutes (SD 43.1). Of these procedures, 93% were technically successful. Femoral vasospasm, when present, was self-limiting. Complications (3/27, 11.1%) included groin hematoma (n=1), neck vessel spasm that resolved with verapamil (n=1), and intracranial thromboembolism (n=1), with no significant difference between the ≤15 kg and >15 kg subcohorts. There were no aorto-femoro-iliac or limb-ischemic complications. CONCLUSION Long vascular sheaths without short femoral sheaths can be safely used for pediatric neuroendovascular procedures as they effectively increase inner diameter access without increasing the outer sheath diameter. This property increases the range of devices used and intracranial techniques that can be safely performed without arterial compromise, thus increasing the repertoire of the neurointerventionist.
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Affiliation(s)
- Adam A Dmytriw
- Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada
| | - Winston Ha
- Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada
| | - Suzanne Bickford
- Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada
| | - Kartik Bhatia
- Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada
| | - Manohar Shroff
- Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada
| | - Peter Dirks
- Department of Neurosurgery, Hospital for Sick Children, Toronto, ON, Canada
| | - Prakash Muthusami
- Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada
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13
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Bertoli MJ, Parikh K, Klyde D, Mazzola CA, Pandya Shah S. Spinal arteriovenous malformation in a pediatric patient with a history of congenital syphilis: a case report. BMC Pediatr 2021; 21:242. [PMID: 34011293 PMCID: PMC8132029 DOI: 10.1186/s12887-021-02707-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 05/06/2021] [Indexed: 11/20/2022] Open
Abstract
Background Spinal arteriovenous malformations in children are extremely rare and pose great risk for intraoperative hemorrhage. Congenital syphilis sometimes presents with vascular symptoms, however, there is little published on patients with a history of congenital syphilis presenting with spinal arteriovenous malformations. Case presentation A 15-month-old female with a history of congenital syphilis presented with urinary retention, fever, and subacute onset of paraplegia. MRI showed a lesion at T8-L1, angiogram was performed which confirmed the presence of a complex type IVc arteriovenous malformation and fistula from Artery of Adamkiewicz at L1-L2. It also showed peri medullary dilated veins and a pseudoaneurysm that compressed the spinal cord at T8-T10. Somatosensory evoked potentials and motor-evoked potentials were not recordable on the bilateral lower extremities prior to surgery. Once the patient was optimized for surgery, osteoplastic laminotomies from T6-T12 were performed. The dura was opened and the intradural, intramesenchymal hematoma was evacuated. There were two episodes of brisk arterial bleeding with hypotension during resection of the hematoma. The patient was taken to the angiography suite from the OR to successfully coil the large aneurysm. Intraoperative spinal cord monitoring remained undetectable in the bilateral lower extremities. The patient’s paraplegia remained unchanged from preoperative presentation. Conclusion Congenital syphilis may present with vascular changes that might impact surgical approaches and treatment outcomes in patients with spinal arteriovenous malformations. Preparation for massive transfusion and intraoperative monitoring are imperative in ensuring a safe perioperative experience.
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Affiliation(s)
| | - Kruti Parikh
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - David Klyde
- Department of Radiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Catherine A Mazzola
- Department of Neurosurgery, New Jersey Pediatric Neuroscience Institute, Morristown, NJ, USA
| | - Shridevi Pandya Shah
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA.
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14
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Chaudhary N, Elijovich L, Martinez M, Fifi JT, Ortega-Gutierrez S, Shaibani A, Pandey AS, Suzuki S, Field RR, Gemmete JJ, Cooke DL, Narayanan S, Hetts SW, Orbach DB, Pearl MS. Pediatric diagnostic cerebral angiography: practice recommendations from the SNIS Pediatric Committee. J Neurointerv Surg 2021; 13:762-766. [PMID: 33875551 DOI: 10.1136/neurintsurg-2021-017389] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/25/2021] [Accepted: 03/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Neeraj Chaudhary
- Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Lucas Elijovich
- Departments of Neurology and Neurosurgery, Semmes-Murphey Clinic, Memphis, Tennessee, USA
| | - Mesha Martinez
- Neurointerventional Radiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Johanna T Fifi
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Santiago Ortega-Gutierrez
- Division of Neurointerventional Surgery-Interventional Neuroradiology, University of Iowa, Iowa City, Iowa, USA
| | - Ali Shaibani
- Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Radiology, Northwestern Memorial HealthCare Corp, Chicago, Illinois, USA
| | - Aditya S Pandey
- Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Shuichi Suzuki
- Neurosurgery, University of California Irvine, Orange, California, USA
| | - R Ryan Field
- Anesthesia, Neurosurgery, University of California Irvine, Orange, California, USA
| | - Joseph J Gemmete
- Radiology and Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Daniel L Cooke
- Radiology and Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | - Sandra Narayanan
- Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Darren B Orbach
- Neurointerventional Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Monica S Pearl
- Radiology, Children's National Hospital, Washington, District of Columbia, USA .,Radiology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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15
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Sun LR, Harrar D, Drocton G, Castillo-Pinto C, Gailloud P, Pearl MS. Endovascular therapy for acute stroke in children: age and size technical limitations. J Neurointerv Surg 2021; 13:794-798. [PMID: 33832970 DOI: 10.1136/neurintsurg-2021-017311] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/23/2021] [Accepted: 03/29/2021] [Indexed: 01/18/2023]
Abstract
Endovascular therapies for acute childhood stroke remain controversial and little evidence exists to determine the minimum age and size cut-off for thrombectomy in children. Despite this, an increasing number of reports suggest feasibility of thrombectomy in at least some children by experienced operators. When compared with adults, technical modifications may be necessary in children owing to differences in vessel sizes, tolerance of blood loss, safety of contrast and radiation exposure, and differing stroke etiologies. We review critical considerations for neurologists and neurointerventionalists when treating pediatric stroke with endovascular therapies. We discuss technical factors that may limit feasibility of endovascular therapy, including size of the femoral and cervicocerebral arteries, which contributes to vasospasm risk. The risk of femoral vasospasm can be assessed by comparing catheter outer diameter with estimated femoral artery size, which can be estimated based on the child's height. We review evidence supporting specific strategies to mitigate cervicocerebral arterial injury, including technique (stent retrieval vs direct aspiration) and device size selection. The importance of and strategies for minimizing blood loss, radiation exposure, and contrast administration are reviewed. Attention to these technical limitations is critical to delivering the safest possible care when thrombectomy is being considered for children with acute stroke.
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Affiliation(s)
- Lisa R Sun
- Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dana Harrar
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
| | - Gerald Drocton
- Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Philippe Gailloud
- Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Monica S Pearl
- Radiology, Children's National Hospital, Washington, District of Columbia, USA.,Radiology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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16
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Hirano Y, Ono H, Inoue T, Mitani T, Tanishima T, Tamura A, Saito I. Emergent surgical embolectomy for middle cerebral artery occlusion related to cerebral angiography followed by neck clipping for an unruptured aneurysm in the anterior communicating artery. Surg Neurol Int 2020; 11:420. [PMID: 33365183 PMCID: PMC7749952 DOI: 10.25259/sni_627_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/20/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Intracranial embolism related to cerebral angiography is rare but one of the complications of the procedure. However, the standard management of acute intracranial embolism for this etiology has not been established, and there have been very few reports in the past. Case Description: A 68-year-old male was incidentally found to have an unruptured aneurysm of anterior communicating artery (ACoA). Immediately after the cerebral angiography for the purpose of detailed examination of the aneurysm, the right partial hemiparalysis and mild aphasia developed. Magnetic resonance imaging/angiography (MRI/A) revealed an occlusion in the peripheral part of the left middle cerebral artery (MCA). Due to the existence of magnetic resonance angiography-diffusion mismatch, emergent craniotomy was immediately performed to remove intra-arterial thrombus. We also performed clipping for an unruptured ACoA aneurysm with this approach. Postoperative MRI/A showed that the occluded artery was recanalized and a slight infarction was observed in the left cerebral hemisphere. The patient was discharged on foot and followed at outpatient clinic over 4 years without no neurological deficit. Conclusion: Emergent surgical embolectomy for distal MCA occlusion related to cerebral angiography followed by neck clipping for an unruptured aneurysm of the ACoA was successful in treating acute occlusion of the peripheral part of the MCA in a patient with an unruptured aneurysm. As there are few similar cases, there is controversy about the best management, but this surgical method can be a safe and effective treatment.
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Affiliation(s)
- Yudai Hirano
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka
| | - Hideaki Ono
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center, Shinagawa
| | - Tomohiro Mitani
- Department of Neurosurgery, The University of Tokyo Hospital, Bunkyo, Tokyo, Japan
| | - Takeo Tanishima
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka
| | - Akira Tamura
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka
| | - Isamu Saito
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka
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17
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Robertson RL, Palasis S, Rivkin MJ, Pruthi S, Bartel TB, Desai NK, Kadom N, Kulkarni AV, Lam HFS, Maheshwari M, Milla SS, Mirsky DM, Myseros JS, Partap S, Radhakrishnan R, Soares BP, Trout AT, Udayasankar UK, Whitehead MT, Karmazyn B. ACR Appropriateness Criteria® Cerebrovascular Disease-Child. J Am Coll Radiol 2020; 17:S36-S54. [PMID: 32370977 DOI: 10.1016/j.jacr.2020.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 10/24/2022]
Abstract
Stroke is an uncommon but an important and under-recognized cause of morbidity and mortality in children. Strokes may be due to either brain ischemia or intracranial hemorrhage. Common symptoms of pediatric acute stroke include headache, vomiting, focal weakness, numbness, visual disturbance, seizures, and altered consciousness. Most children presenting with an acute neurologic deficit do not have an acute stroke, but have symptoms due to stroke mimics which include complicated migraine, seizures with postictal paralysis, and Bell palsy. Because of frequency of stroke mimics, in children and the common lack of specificity in symptoms, the diagnosis of a true stroke may be delayed. There are a relatively large number of potential causes of stroke mimic and true stroke. Consequently, imaging plays a critical role in the assessment of children with possible stroke and especially in children who present with acute onset of stroke symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Susan Palasis
- Panel Chair, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Michael J Rivkin
- Boston Children's Hospital, Boston, Massachusetts; American Academy of Neurology
| | - Sumit Pruthi
- Panel Vice Chair, Vanderbilt Children's Hospital, Nashville, Tennessee
| | | | | | - Nadja Kadom
- Emory University and Children's of Atlanta (Egleston), Atlanta, Georgia
| | - Abhaya V Kulkarni
- Hospital for Sick Children, Toronto, Ontario, Canada; Neurosurgery expert
| | - H F Samuel Lam
- Sutter Medical Center, Sacramento, California; American College of Emergency Physicians
| | | | - Sarah S Milla
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - John S Myseros
- Children's National Health System, Washington, District of Columbia; Neurosurgery expert
| | - Sonia Partap
- Stanford University, Stanford, California; American Academy of Pediatrics
| | | | - Bruno P Soares
- The University of Vermont Medical Center, Burlington, Vermont
| | - Andrew T Trout
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Boaz Karmazyn
- Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana
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18
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Lv X, Jiang C, Wang J. Pediatric intracranial arteriovenous shunts: Advances in diagnosis and treatment. Eur J Paediatr Neurol 2020; 25:29-39. [PMID: 31996298 DOI: 10.1016/j.ejpn.2019.12.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/24/2019] [Accepted: 12/29/2019] [Indexed: 02/07/2023]
Abstract
Pediatric intracranial arteriovenous shunts (IAVSs) comprise a wide range of lesions, including pial arteriovenous malformation (AVM) and arteriovenous fistula (AVF), dural arteriovenous fistula (DAVF) and vein of Galen aneurysmal malformation (VGAM). We provide an overview of pediatric IAVSs, encompassing both diagnosis and endovascular treatment. We include references from pertinent literature and representative cases from our hospital. Pediatric IAVS are frequently associated two broader conditions, such as capillary malformation-arteriovenous malformation (CM-AVM) and hereditary hemorrhagic telangiectasia (HHT). These conditions and the associated genetic mutations have only recently been described. Their impact on the brain will be different in the prenatal period, in neonates, in infants, and in children, with variable symptoms according to each age group and the current strategies of endovascular treatment in the management of these vascular lesions will be discussed. This review could improve the understanding of pediatric IAVSs and their diagnosis and treatment.
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Affiliation(s)
- Xianli Lv
- Neurosurgery Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.
| | - Chuhan Jiang
- Neurosurgery Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - James Wang
- Neurosurgery Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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19
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Bhatia K, Kortman H, Blair C, Parker G, Brunacci D, Ang T, Worthington J, Muthusami P, Shoirah H, Mocco J, Krings T. Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series. J Neurosurg Pediatr 2019; 24:558-571. [PMID: 31398697 DOI: 10.3171/2019.5.peds19126] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 05/24/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The role of mechanical thrombectomy in pediatric acute ischemic stroke is uncertain, despite extensive evidence of benefit in adults. The existing literature consists of several recent small single-arm cohort studies, as well as multiple prior small case series and case reports. Published reports of pediatric cases have increased markedly since 2015, after the publication of the positive trials in adults. The recent AHA/ASA Scientific Statement on this issue was informed predominantly by pre-2015 case reports and identified several knowledge gaps, including how young a child may undergo thrombectomy. A repeat systematic review and meta-analysis is warranted to help guide therapeutic decisions and address gaps in knowledge. METHODS Using PRISMA-IPD guidelines, the authors performed a systematic review of the literature from 1999 to April 2019 and individual patient data meta-analysis, with 2 independent reviewers. An additional series of 3 cases in adolescent males from one of the authors' centers was also included. The primary outcomes were the rate of good long-term (mRS score 0-2 at final follow-up) and short-term (reduction in NIHSS score by ≥ 8 points or NIHSS score 0-1 at up to 24 hours post-thrombectomy) neurological outcomes following mechanical thrombectomy for acute ischemic stroke in patients < 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3). RESULTS The authors' review yielded 113 cases of mechanical thrombectomy in 110 pediatric patients. Although complete follow-up data are not available for all patients, 87 of 96 (90.6%) had good long-term neurological outcomes (mRS score 0-2), 55 of 79 (69.6%) had good short-term neurological outcomes, and 86 of 98 (87.8%) had successful angiographic recanalization (mTICI score 2b/3). Death occurred in 2 patients and symptomatic intracranial hemorrhage in 1 patient. Sixteen published thrombectomy cases were identified in children < 5 years of age. CONCLUSIONS Mechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M1, basilar artery) in patients aged 1-18 years (Level C evidence; Class IIb recommendation). The existing evidence base is likely affected by selection and publication bias. A prospective multinational registry is recommended as the next investigative step.
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Affiliation(s)
- Kartik Bhatia
- 1Department of Neuroradiology, Toronto Western Hospital
- Departments of2Interventional Neuroradiology and
| | - Hans Kortman
- 1Department of Neuroradiology, Toronto Western Hospital
| | - Christopher Blair
- 3Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | | | | | - Timothy Ang
- Departments of2Interventional Neuroradiology and
- 3Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - John Worthington
- 3Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Prakash Muthusami
- 4Department of Interventional Radiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hazem Shoirah
- 5Department of Neurosurgery, Icahn School of Medicine at Mount Sinai; and
| | - J Mocco
- 6Department of Neurosurgery, The Mount Sinai Health System, New York, New York
| | - Timo Krings
- 1Department of Neuroradiology, Toronto Western Hospital
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20
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Huang Y, Singer TG, Iv M, Lanzman B, Nair S, Stadler JA, Wang J, Edwards MSB, Grant GA, Cheshier SH, Yeom KW. Ferumoxytol-enhanced MRI for surveillance of pediatric cerebral arteriovenous malformations. J Neurosurg Pediatr 2019; 24:407-414. [PMID: 31323627 DOI: 10.3171/2019.5.peds1957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 05/03/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Children with intracranial arteriovenous malformations (AVMs) undergo digital DSA for lesion surveillance following their initial diagnosis. However, DSA carries risks of radiation exposure, particularly for the growing pediatric brain and over lifetime. The authors evaluated whether MRI enhanced with a blood pool ferumoxytol (Fe) contrast agent (Fe-MRI) can be used for surveillance of residual or recurrent AVMs. METHODS A retrospective cohort was assembled of children with an established AVM diagnosis who underwent surveillance by both DSA and 3-T Fe-MRI from 2014 to 2016. Two neuroradiologists blinded to the DSA results independently assessed Fe-enhanced T1-weighted spoiled gradient recalled acquisition in steady state (Fe-SPGR) scans and, if available, arterial spin labeling (ASL) perfusion scans for residual or recurrent AVMs. Diagnostic confidence was examined using a Likert scale. Sensitivity, specificity, and intermodality reliability were determined using DSA studies as the gold standard. Radiation exposure related to DSA was calculated as total dose area product (TDAP) and effective dose. RESULTS Fifteen patients were included in this study (mean age 10 years, range 3-15 years). The mean time between the first surveillance DSA and Fe-MRI studies was 17 days (SD 47). Intermodality agreement was excellent between Fe-SPGR and DSA (κ = 1.00) but poor between ASL and DSA (κ = 0.53; 95% CI 0.18-0.89). The sensitivity and specificity for detecting residual AVMs using Fe-SPGR were 100% and 100%, and using ASL they were 72% and 100%, respectively. Radiologists reported overall high diagnostic confidence using Fe-SPGR. On average, patients received two surveillance DSA studies over the study period, which on average equated to a TDAP of 117.2 Gy×cm2 (95% CI 77.2-157.4 Gy×cm2) and an effective dose of 7.8 mSv (95% CI 4.4-8.8 mSv). CONCLUSIONS Fe-MRI performed similarly to DSA for the surveillance of residual AVMs. Future multicenter studies could further investigate the efficacy of Fe-MRI as a noninvasive alternative to DSA for monitoring AVMs in children.
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Affiliation(s)
| | | | - Michael Iv
- 2Department of Radiology, Lucile Packard Children's Hospital, Stanford University School of Medicine
| | - Bryan Lanzman
- 2Department of Radiology, Lucile Packard Children's Hospital, Stanford University School of Medicine
| | | | - James A Stadler
- 5Department of Neurosurgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jia Wang
- 3Environmental Health and Safety, Stanford University, Stanford, California
| | | | | | - Samuel H Cheshier
- 4Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah; and
| | - Kristen W Yeom
- 2Department of Radiology, Lucile Packard Children's Hospital, Stanford University School of Medicine
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21
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Miao TL, Figueroa EL, Bajunaid K, Mayich M, de Ribaupierre S, Pandey SK. Use of a radial artery 'slender' sheath for facilitating transfemoral arterial access for neuroendovascular embolization in a very young infant. Interv Neuroradiol 2018; 25:353-356. [PMID: 30463500 DOI: 10.1177/1591019918813212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pediatric neuroendovascular procedures are increasingly performed as several studies have shown the safety of these interventions. In the literature, an upper limit of 4 French catheter size is conventionally used for femoral access in neuroangiography of very young infants. However, this constraint in luminal size may not allow for more complex procedures. We present the previously unreported use of a radial 5 French slender catheter with ultrathin walls for femoral access for aneurysm embolization in a 3-month-old boy presenting with left M2 aneurysm rupture.
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Affiliation(s)
- Timothy L Miao
- 1 Department of Medical Imaging, University Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Enriqueta Lucar Figueroa
- 2 Clinical Neurological Sciences, Division of Neurosurgery, University Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Khalid Bajunaid
- 1 Department of Medical Imaging, University Hospital, London Health Sciences Centre, London, Ontario, Canada.,3 Division of Neurosurgery, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Michael Mayich
- 1 Department of Medical Imaging, University Hospital, London Health Sciences Centre, London, Ontario, Canada.,2 Clinical Neurological Sciences, Division of Neurosurgery, University Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Sandrine de Ribaupierre
- 2 Clinical Neurological Sciences, Division of Neurosurgery, University Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Sachin K Pandey
- 1 Department of Medical Imaging, University Hospital, London Health Sciences Centre, London, Ontario, Canada.,2 Clinical Neurological Sciences, Division of Neurosurgery, University Hospital, London Health Sciences Centre, London, Ontario, Canada
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22
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Abstract
Intracerebral hemorrhage (ICH) is a subset of stroke due to spontaneous bleeding within the parenchyma of the brain. It is potentially lethal, and survival depends on ensuring an adequate airway, proper diagnosis, and early management of several specific issues such as blood pressure, coagulopathy reversal, and surgical hematoma evacuation for appropriate patients. ICH was chosen as an Emergency Neurological Life Support (ENLS) protocol because intervention within the first hours may improve outcome, and it is critical to have site-specific protocols to drive care quickly and efficiently.
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23
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Bashir Q, Ishfaq A, Baig AA. Safety of Diagnostic Cerebral and Spinal Digital Subtraction Angiography in a Developing Country: A Single-Center Experience. INTERVENTIONAL NEUROLOGY 2018; 7:99-109. [PMID: 29628949 PMCID: PMC5881143 DOI: 10.1159/000481785] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Digital subtraction angiography (DSA) remains the gold standard imaging modality for cerebrovascular disorders. In contrast to developed countries, the safety of the procedure is not extensively reported from the developing countries. Herein, we present a retrospective analysis of the basic technique, indications, and outcomes in 286 patients undergoing diagnostic cerebral and spinal angiography in a developing country, Pakistan. METHODS A retrospective review of patient demographics, procedural technique and complication rates of 286 consecutive patients undergoing the diagnostic cerebral/spinal angiography procedure at one institution from May 2013 to December 2015 was performed. Neurological, systemic, or local complications occurring within and after 24 h of the procedure were recorded. RESULTS Mean age reported for all patients was 49.7 years. Of all the 286 cases, 175 were male (61.2%) and the rest female (111, 38.8%). Cerebral DSA was performed in 279 cases (97.6%), with 7 cases of spinal DSA (2.4%). Subarachnoid hemorrhage was the most common indication for DSA accounting for 88 cases (30.8%), closely followed by stroke (26.6%) and arteriosclerotic vascular disease (23.1%). No intra- or post-procedural neurological complications of any severity were seen in any of the 286 cases. One case of asymptomatic aortic dissection was reported (0.3%) in the entire cohort of patient population. CONCLUSION Diagnostic cerebral/spinal digital subtraction angiography was found to be safe in Pakistan, with complication rates at par with and comparable to those reported in the developed world.
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Affiliation(s)
- Qasim Bashir
- Department of Neurointervention, Bahria Town Hospital, Lahore, Pakistan
- Department of Clinical and Interventional Neurology, Lahore, Pakistan
| | - Asim Ishfaq
- Department of Neurosurgery, CMH Lahore Medical College, Lahore, Pakistan
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24
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Jauch EC, Pineda JA, Hemphill JC. Emergency Neurological Life Support: Intracerebral Hemorrhage. Neurocrit Care 2016; 23 Suppl 2:S83-93. [PMID: 26438461 DOI: 10.1007/s12028-015-0167-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Intracerebral hemorrhage (ICH) is a subset of stroke due to bleeding within the parenchyma of the brain. It is potentially lethal, and survival depends on ensuring an adequate airway, reversal of coagulopathy, and proper diagnosis. ICH was chosen as an Emergency Neurological Life Support protocol because intervention within the first critical hour may improve outcome, and it is critical to have site-specific protocols to drive care quickly and efficiently.
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Affiliation(s)
- Edward C Jauch
- Division of Emergency Medicine and Department of Neurosciences, Medical University of South Carolina, Charleston, USA.
| | - Jose A Pineda
- Department of Pediatrics and Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - J Claude Hemphill
- Department of Neurology, University of California, San Francisco, USA
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25
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Choudhri O, Schoen M, Mantha A, Feroze A, Ali R, Lawton MT, Do HM. Increased risk for complications following diagnostic cerebral angiography in older patients: Trends from the Nationwide Inpatient Sample (1999-2009). J Clin Neurosci 2016; 32:109-14. [PMID: 27430411 DOI: 10.1016/j.jocn.2016.04.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 04/20/2016] [Indexed: 02/08/2023]
Abstract
The full utility of diagnostic cerebral angiography, an invasive cerebrovascular imaging technique, is currently debated. Our goal was to determine trends in diagnostic cerebral angiography utilization and associated complications from 1999 through 2009. The National Inpatient Sample (NIS) was used to identify patients who received primary cerebral angiography from 1999-2009 in the United States. We observed trends in discharge volume, total mean charge, and post-procedural complications for this population. Data was based on sample projections and analyzed using univariate and multivariate regression. There were a total of 424,105 discharges indicating primary cerebral angiography nationwide from 1999-2009. The majority of these cases (65%) were in patients older than 55years. Embolic stroke was the most frequent complication, particularly in the oldest age bracket, occurring in 16,304 patients. The risk for complications increased with age (p<0.0001) and with other underlying health conditions. Pulmonary, deep vein thrombosis, and renal associated comorbidities resulted in the greatest risk for developing post-procedural complications. Throughout the study period case volume for cerebral angiography remained constant while total charge per patient increased from $17,365 in 1999 to $45,339 in 2009 (p<0.001). While the overall complication rate for this invasive procedure is relatively low, the potential risk for embolic stroke in older patients is significant. It is worth considering less invasive diagnostic techniques for an older and at risk patient population.
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Affiliation(s)
- Omar Choudhri
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Ave. Rm. M779, San Francisco, CA 94143-0112, USA.
| | - Matthew Schoen
- Department of Neurosurgery, Stanford University School of Medicine, CA 94305, USA
| | - Aditya Mantha
- Department of Neurosurgery, Stanford University School of Medicine, CA 94305, USA
| | - Abdullah Feroze
- Department of Neurosurgery, Stanford University School of Medicine, CA 94305, USA
| | - Rohaid Ali
- Department of Neurosurgery, Stanford University School of Medicine, CA 94305, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Ave. Rm. M779, San Francisco, CA 94143-0112, USA
| | - Huy M Do
- Department of Neurosurgery, Stanford University School of Medicine, CA 94305, USA; Department of Radiology, Stanford University School of Medicine, Stanford, CA 94305, USA
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Morgenstern PF, Hoffman CE, Kocharian G, Singh R, Stieg PE, Souweidane MM. Postoperative imaging for detection of recurrent arteriovenous malformations in children. J Neurosurg Pediatr 2016; 17:134-140. [PMID: 26517058 DOI: 10.3171/2015.6.peds14708] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Peter F Morgenstern
- Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical Center; and
| | - Caitlin E Hoffman
- Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical Center; and
| | | | | | - Philip E Stieg
- Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical Center; and.,Weill Cornell Medical College, New York, New York
| | - Mark M Souweidane
- Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical Center; and.,Weill Cornell Medical College, New York, New York
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He L, Ladner TR, Pruthi S, Day MA, Desai AA, Jordan LC, Froehler MT. Rule of 5: angiographic diameters of cervicocerebral arteries in children and compatibility with adult neurointerventional devices. J Neurointerv Surg 2015; 8:1067-71. [DOI: 10.1136/neurintsurg-2015-012034] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Accepted: 10/16/2015] [Indexed: 11/04/2022]
Abstract
Background and purposeThe safety of using adult-sized neuroendovascular devices in the smaller pediatric vasculature is not known. In this study we measure vessel diameters in the cervical and cranial circulation in children to characterize when adult-approved devices might be compatible in children.MethodsFor 54 children without vasculopathy (mean age 9.5±4.9 years (range 0.02–17.8), 20F/34M) undergoing catheter angiography, the diameters of the large vessels in the cervical and cranial circulation (10 locations, 611 total measurements) were assessed by three radiologists. Mean±SD diameter was calculated for the following age groups: 0–6 months, 1, 2, 3, 4, 5–9, 10–14, and 15–18 years. To compare with adult sizes, each vessel measurement was normalized to the respective region mean diameter in the oldest age group (15–18 years). Normalized measurements were compared with age and fitted to a segmented regression.ResultsVessel diameters increased rapidly from 0 to 5 years of age (slope=0.069/year) but changed minimally beyond that (slope=0.005/year) (R2=0.2). The regression model calculated that, at 5 years of age, vessels would be 94% of the diameter of the oldest age group (compared with 59% at birth). In addition, most vessels in children under 5, while smaller, were still potentially large enough to be compatible with many adult devices.ConclusionsThe growth curve of the cervicocerebral vasculature displays rapid growth until age 5, at which point most children's vessels are nearly adult size. By age 5, most neuroendovascular devices are size-compatible, including thrombectomy devices for stroke. Under 5 years of age, some devices might still be compatible.
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Lin N, Smith ER, Scott RM, Orbach DB. Safety of neuroangiography and embolization in children: complication analysis of 697 consecutive procedures in 394 patients. J Neurosurg Pediatr 2015; 16:432-8. [PMID: 26114994 DOI: 10.3171/2015.2.peds14431] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Ning Lin
- Department of Neurosurgery, Weill Cornell Medical Center, New York, New York; and.,Department of Neurosurgery and
| | | | | | - Darren B Orbach
- Division of Interventional and Neurointerventional Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Common procedures and strategies for anaesthesia in interventional radiology. Curr Opin Anaesthesiol 2015; 28:458-63. [DOI: 10.1097/aco.0000000000000208] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Kato MA, Green N, O'Connell K, Till SD, Kramer DJ, Al-Khelaifi M, Han JH, Pryor KO, Gobin YP, Proekt A. A retrospective analysis of severe intraoperative respiratory compliance changes during ophthalmic arterial chemosurgery for retinoblastoma. Paediatr Anaesth 2015; 25:595-602. [PMID: 25565164 DOI: 10.1111/pan.12603] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Ophthalmic arterial chemosurgery for retinoblastoma has been associated with intraoperative decreases in respiratory compliance. Through the analysis of data from computerized records, we objectively defined severe respiratory compliance events and correlated them with demographic and clinical information in patients undergoing this procedure. METHODS Data were collected from ophthalmic arterial chemosurgery cases from 2006 to 2013. Intraoperative PIP, PEEP, TV, SpO2 , and EtCO2 were analyzed. Compliance changes, desaturations, decreases in EtCO2 , and clinical outcomes were assessed. RESULTS Respiratory compliance decreases with a bimodal distribution. Severe events were defined as exhibiting a minimum compliance decrease of 40%. Seventy-eight of 122 children (64%) experienced a severe compliance event during at least one treatment, and it occurred in 137/468 cases (29%). A subset of 94 children had complete or at least the first three records. The incidence of a severe respiratory compliance event in this subgroup was 17/94 (18%) on the first and 84/261 (32%) on subsequent procedures. The probability of developing a severe respiratory compliance event on a subsequent procedure was 0.40 if the child developed it on the first procedure, 0.30 if he did not; this difference was not significant. The incidence of desaturation below 90% with severe respiratory compliance events was 0.20; the incidence of a 30% drop in EtCO2 was 0.34. No morbidity, no extended recovery, and no admissions were associated with intraoperative severe respiratory compliance events. We found no correlation between history, age, sex, weight or allergies, and intraoperative severe respiratory compliance events. CONCLUSIONS Here, most patients experienced a severe respiratory compliance event during at least one of their procedures. Overall incidence was 29% and was more likely on subsequent procedures. A severe respiratory compliance event at the initial procedure was poorly predictive of its occurrence on subsequent procedures. No morbidity was associated with intraoperative severe respiratory compliance events.
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Affiliation(s)
- Meredith A Kato
- Department of Anesthesiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
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