Predictive value of ischemia location on multimodal CT in thrombectomy-treated patients

Objective

Alberta Stroke Program Early CT Score (ASPECTS) applied to CT-perfusion (CTP) and CT-angiography-source-images (CTA-SI) may improve outcome prediction in large vessel occlusion (LVO) stroke if compared to non-contrast CT (NCCT) alone. Besides, ischemia location may have enhanced capabilities, compared to ischemia volume alone, in predicting stroke outcomes. We aim to evaluate the association between ischemia location as measured by ASPECTS regions in NCCT, CTP maps and CTA-SI and 3 months outcome in patients with LVO treated with mechanical thrombectomy (MT).

Material and methods

Consecutive patients with anterior circulation stroke treated with MT were recorded in a prospectively maintained database at a single center. Modified Rankin scale (mRS) at 3 months >2 was considered a poor outcome. Association of patients’ characteristics, NCCT, CTP, and CTA-SI parameters with outcome was evaluated using single-variable analysis and binary logistic regression multivariate analysis for each imaging technique.

Results

177 patients were included. 115 (65%) patients reached a favorable outcome. The involvement of lenticular, caudate, M1, or M2 in all imaging techniques, insula in NCCT and CTA-SI and M5 in CBV maps and CTA-SI was related to functional outcome in bivariate analysis. However, in the multivariate analysis, none ischemia location was independently related to outcome, no matter the imaging technique studied. This finding remained unchanged when restricted to patients with good recanalization and when analyzing subpopulations according to hemisphere involvement or territories association.

Conclusions

Our study suggests ischemia location shouldn’t be used solely for decision-making in LVO stroke patients. Its predictive value may be taken in consideration together with other clinical and radiological variables.

Clinical Predictors of Hyperperfusion Syndrome Following Carotid Stenting: Results From a National Prospective Multicenter Study

OBJECTIVES

The aim of the HISPANIAS (HyperperfusIon Syndrome Post-carotid ANgIoplasty And Stenting) study was to define CHS rates and develop a clinical predictive model for cerebral hyperperfusion syndrome (CHS) after carotid artery stenting (CAS).

BACKGROUND

CHS is a severe complication following CAS. The presence of clinical manifestations is estimated on the basis of retrospective reviews and is still uncertain.

METHODS

The HISPANIAS study was a national prospective multicenter study with 14 recruiting hospitals. CHS was classified as mild (headache only) and moderate-severe (seizure, impaired level of consciousness, or development of focal neurological signs).

RESULTS

A total of 757 CAS procedures were performed. CHS occurred in 22 (2.9%) patients, in which 16 (2.1%) had moderate-severe CHS and 6 (0.8%) had mild CHS (only headache). The rate of hemorrhages was 0.7% and was associated with high mortality (20%). Pre-operative predictors of moderate-severe CHS in multivariate analysis were female sex (odds ratio [OR]: 3.24; 95% confidence interval [CI]: 1.11 to 9.47; p = 0.03), older patients (OR: 1.09; 95% CI: 1.01 to 1.17; p = 0.02), left carotid artery treated (OR: 4.13; 95% CI: 1.11 to 15.40; p = 0.03), and chronic renal failure (OR: 6.29; 95% CI: 1.75 to 22.57; p = 0.005). The area under the curve of this clinical and radiological model was 0.86 (95% CI: 0.81 to 0.92; p = 0.001).

CONCLUSIONS

The rate of CHS in the HISPANIAS study was 2.9%, with moderate-severe CHS of 2.1%. CHS was independently associated with female sex, older age, history of chronic kidney disease, and a treated left carotid artery. Although further investigations are needed, the authors propose a model to identify high-risk patients and develop strategies to decrease CHS morbidity and mortality in the future.

Endovascular treatment of intracranial aneurysms using the Pipeline Flex embolization device: a case series of 30 consecutive patients

BACKGROUND

The Pipeline Flex embolization device has some peculiarities in comparison with the previous generation device. Despite recent reports of the modified delivery system, its safety is still unknown.

OBJECTIVE

To illustrate the intraprocedural and periprocedural complication rate with this new device in 30 consecutive patients.

MATERIAL AND METHODS

Clinical, procedural, and angiographic data, including aneurysm size and location, device or devices used, angiographic and clinical data were analyzed.

RESULTS

30 patients harboring 30 aneurysms were analyzed. 39 devices were placed properly. Multiple Pipeline embolization devices (PEDs) were used in 7 cases. In 28 devices the distal end opened fully from the beginning with a complete wall apposition. In the remaining 11 devices, distal-end opening of the devices was instant but partial, but fully opened easily after recapture. Among the 30 procedures, recapture and reposition of the Pipeline Flex was performed four times owing to proximal migration/malposition of the device during delivery. Four intraprocedural/periprocedural complications occurred, of which 2 resulted in major complications, with neurologic deficits persisting for longer than 7 days. The 30-day morbidity rate was 6.6%, with no deaths. No aneurysm rupture or parenchymal hemorrhage was seen.

CONCLUSIONS

The Pipeline Flex embolization device allows more precise and controlled deployment than the first-generation device. The number of devices and the complication rate during the learning curve are lower than reported with the first-generation PED. The new delivery system and the resheathing maneuvers do not seem to increase the intraprocedural complication rate in comparison with the first-generation PED.

Preliminary experience with the Pipeline Flex Embolization Device: technical note

BACKGROUND

Clinical experience with the Pipeline Embolization Device (PED) has been widely described in the literature since it obtained its European CE and FDA approvals in 2008 and 2011, respectively. The new generation of PED, the Pipeline Flex Embolization Device, received the CE mark of approval in March 2014. While the implant composition has not changed, its new delivery system has some differences. One of the main changes from the previous generation is a new delivery system that makes the device resheathable until deployed over 90% of its length. We present our preliminary experience using this device.

METHODS

Between May and June 2014, six patients with six aneurysms were treated with the Pipeline Flex device.

RESULTS

All devices were placed properly, without technical difficulties. We successfully resheathed and repositioned the device in two cases. Minor and major intraprocedural or periprocedural events were noted.

CONCLUSIONS

The Pipeline Flex device allows more precise and controlled deployment than the current PED device. Although this preliminary experience seems positive, multicenter larger series will be needed to confirm the safety and durability of this new device.

[Neurovascular intervention in the acute phase of cerebral infarction]

BACKGROUND AND PURPOSE

Endovascular therapies in acute ischaemic stroke may offer benefits to patients that are not eligible for standard use of intravenous tissue activator plasminogen (iv t-PA) or when this is not effective. Our aim is to present the initial experience in with endovascular techniques in the Community of Madrid.

METHODS

We present data from our registry of acute ischaemic strokes treated with endovascular re-perfusion therapies in five University Hospitals in Madrid (Spain) during the period 2005-2009. We recorded demographic data, vascular risk factors, risk severity with the NIHSS (National Institute of Health Stroke Scale), endovascular techniques, complications and mortality rates. Functional outcome and neurological disability at 90 days was defined by the modified Rankin scale (mRs).

RESULTS

A total of 41 patients were treated with endovascular therapies. Mean age was 58.6 ± 19.9, and 56.1% were males. Of those 22 patients had an anterior circulation stroke and 19 had a posterior circulation stroke. Baseline NIHSS score was: median, 17 [range, 2-34]; 7 patients had previously received iv t-PA. The following endovascular techniques were performed: mechanical disruption (26 patients), intra-arterial infusion of t-PA (26 patients), angioplasty and stenting (5 patients), mechanical use of MERCI device (3 patients). Partial or total re-canalization was achieved in 32 patients (78%). Only one patient had a symptomatic cerebral haemorrhage. Three months after stroke, 53.6% of the patients were independent (mRs ≤ 2) and overall mortality rate was 19.5%.

CONCLUSIONS

Acute ischaemic stroke is a potentially treatable medical emergency within the first hours after the onset of symptoms. Stroke endovascular procedures constitute an alternative for patients with iv t-PA exclusion criteria or when this is not effective.

Arteriovenous fistula after temporomandibular joint arthroscopy successfully treated with embolization

Temporomandibular joint arthoscopy is a minimal invasive surgical procedure commonly used to effectively treat some internal derangement of the TMJ. However, this method is not free of complications. Arteriovenous fistula (AVF) is a lesion that communicates the high flow arterial system and the low flow venous network. We describe a new case of preauricular traumatic AVF successfully treated with external carotid embolization, along with a review of the medical literature.

[Fusiform aneurysm of the middle cerebral artery]

Introduction. The main objective of the treatment of intracranial aneurysms is to isolate them from the cerebral blood circulation. A fusiform aneurysm, because of its shape, cannot be treated using the usual techniques and usually requires techniques of arterial reconstruction and revascularization using by pass. Currently it is possible to find the vascular territories with the greatest risk of causing neurological defects and where revascularization is necessary. CASE REPORT. A 20 year old man with no previous history of illness who had several transient ischaemic episodes. Emergency laboratory tests, ECG and plain chest Xray were all normal. Imaging investigations showed the presence of a fusiform aneurysm of the anterosuperior division of the right middle cerebral artery. No associated systemic disease was detected. Wada s test showed the vascular territory with the greatest risk of neurological deficit. Extra intra cranial by pass was done from the right superficial temporal artery to the distal portion of the anteriorsuperior branch of this artery. The operation was done using a right pterion approach with dissection of the superficial temporal artery, and the aneurysm, trapping and termino lateral anastomosis. Cerebral protectors and mild hypothermia were used during the operation. The post operative course was uneventful. Anatomo pathological diagnosis was of an atherosclerotic fusiform aneurysm with osseous and chondroid metaplasia. After six months follow up the patient remains asymptomatic. Discussion and conclusions. Treatment of fusiform cerebral aneurysms is complex and usually requires procedures for cerebral revascularization. Correct pre operative evaluation is essential to identify the vascular territory with the greatest risk of causing neurological deficit. Wada s test is useful for this, since it permits selective evaluation of the different vascular territories safely and quickly. High or low flow by pass of these territories prevents cerebral ischaemia and permits the treatment of choice for these aneurysms.

[The rupture of a cardiac hydatid cyst located in the right ventricle]

Heart involvement in echinococcal disease is rare, but it is more infrequent the location of cysts in the right ventricle. We report a case of a male 35 years old with hydatid cysts located in the right ventricle. The condition was diagnosed by two-dimensional echocardiogram performed after the rupture of the cysts leading to massive pulmonary embolism and subsequently right heart failure. Early diagnosis appears mandatory in an attempt to modify, applying the appropriate therapy, the natural evolution of this potentially lethal condition.