One-Year Risk of Recurrent Stroke and Death Associated with Vertebrobasilar Artery Stenosis and Occlusion in a Cohort of 10,515 Patients.

BACKGROUND: The natural history of vertebrobasilar artery (VBA) stenosis or occlusion remains understudied. METHODS: Patients with diagnosis of ischemic stroke or transient ischemic attack (TIA) who were noted to have VBA stenosis based on computed tomography or magnetic resonance imaging or catheter-based angiogram were selected from Taiwan Stroke Registry. Cox proportional hazards model was used to determine the hazards ratio (HR) of recurrent stroke and death within 1 year of index event in various groups based on severity of VBA stenosis (none to mild: 0-49%; moderate to severe: 50-99%: occlusion: 100%) after adjusting for differences in demographic and clinical characteristics between groups at baseline evaluation. RESULTS: None to mild or moderate to severe VBA stenosis was diagnosed in 6972 (66%) and 3,137 (29.8%) among 10,515 patients, respectively, and occlusion was identified in 406 (3.8%) patients. Comparing with patients who showed none to mild stenosis of VBA, there was a significantly higher risk of recurrent stroke (HR 1.21, 95% CI 1.01-1.45) among patients with moderate to severe VBA stenosis. There was a nonsignificantly higher risk of recurrent stroke (HR 1.49, 95% CI 0.99-2.22) and significantly higher risk of death (HR 2.21, 95% CI 1.72-2.83), among patients with VBA occlusion after adjustment of potential confounders. CONCLUSIONS: VBA stenosis or occlusion was relatively prevalent among patients with TIA or ischemic stroke and associated with higher risk of recurrent stroke and death in patients with ischemic stroke or TIA who had large artery atherosclerosis.

Blood Pressure-Attained Analysis of ATACH 2 Trial.

BACKGROUND AND PURPOSE: We compared the rates of death or disability, defined by modified Rankin Scale score of 4 to 6, at 3 months in patients with intracerebral hemorrhage according to post-treatment systolic blood pressure (SBP)-attained status. METHODS: We divided 1000 subjects with SBP ≥180 mm Hg who were randomized within 4.5 hours of symptom onset as follows: SBP <140 mm Hg achieved or not achieved within 2 hours; subjects in whom SBP <140 mm Hg was achieved within 2 hours were further divided: SBP <140 mm Hg for 21 to 22 hours (reduced and maintained) or SBP was ≥140 mm Hg for at least 2 hours during the period between 2 and 24 hours (reduced but not maintained). RESULTS: Compared with subjects without reduction of SBP <140 mm Hg within 2 hours, subjects with reduction and maintenance of SBP <140 mm Hg within 2 hours had a similar rate of death or disability (relative risk of 0.98; 95% confidence interval, 0.74-1.29). The rates of neurological deterioration within 24 hours were significantly higher in reduced and maintained group (10.4%; relative risk, 1.98; 95% confidence interval, 1.08-3.62) and in reduced but not maintained group (11.5%; relative risk, 2.08; 95% confidence interval, 1.15-3.75) compared with reference group. The rates of cardiac-related adverse events within 7 days were higher among subjects with reduction and maintenance of SBP <140 mmHg compared to subjects without reduction (11.2% versus 6.4%). CONCLUSIONS: No decline in death or disability but higher rates of neurological deterioration and cardiac-related adverse events were observed among intracerebral hemorrhage subjects with reduction with and without maintenance of intensive SBP goals. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01176565.

Preprocedure change in arterial occlusion in acute ischemic stroke patients undergoing endovascular treatment by computed tomographic angiography.

BACKGROUND: The American Heart Association/American Stroke Association guidelines strongly recommend a noninvasive intracranial vascular study such as computed tomographic (CT) angiogram in acute stroke patient if endovascular treatment is contemplated. OBJECTIVE: The objective was to determine the frequency of change in occlusion site between CT angiogram and cerebral angiogram in acute ischemic stroke patients undergoing endovascular treatment. METHODS: All acute ischemic stroke patients who underwent a CT angiogram and subsequently underwent endovascular treatment were included. The CT and cerebral angiographic images were reviewed independently to determine presence and location of arterial occlusion. Severity of occlusion was classified by a previously described grading scheme. Clinical outcome at discharge was determined using modified Rankin scale. RESULTS: Computed tomographic angiogram was performed in 150 patients (mean age ± SD, 64.7 ± 16 years) before endovascular treatment. The mean interval (±SD) between CT angiogram and cerebral angiogram was 193 ± 164 minutes, and 65 (43.3%) of 150 patients received intravenous recombinant tissue plasminogen activator before cerebral angiography. Recanalization between CT angiogram and cerebral angiography was seen in 28 (18.7%) patients, whereas worsening of occlusion was seen in 31 (20.7%) patients. We noticed a trend towards higher rates of improvement (60.7% vs 42.0%, P = .07) and favorable outcome at discharge (42.9% vs 28.7%, P = .1) among patients who experienced preprocedure recanalization. After adjusting for age and initial National Institutes of Health Stroke Scale score strata, preprocedure recanalization was not associated with significantly higher rate of favorable outcome (modified Rankin scale, 0-2) at discharge (odds ratio, 2.1; 95% confidence interval, 0.8-5.5). After adjusting for age and National Institutes of Health Stroke Scale score strata, preprocedure worsening was not associated with significantly lower rates of favorable outcomes at discharge (odds ratio,0.4; 95% confidence interval, 0.1-1.4). CONCLUSIONS: A relatively high proportion of patients have preprocedure recanalization or worsening between CT angiogram and cerebral angiogram in acute ischemic stroke patients selected for endovascular treatment.

A population-based study of the incidence and case fatality of non-aneurysmal subarachnoid hemorrhage.

BACKGROUND: There is a paucity of reliable and recent data regarding epidemiology of non-aneurysmal subarachnoid hemorrhage (SAH) in population-based studies. OBJECTIVES: To determine the incidence and case fatality of non-aneurysmal SAH using a population-based design. METHODS: Medical records and angiographic data of all patients from Stearns and Benton Counties, Minnesota, admitted with SAH were reviewed to identify incident case of non-aneurysmal SAH. Patients with a first-time diagnosis of non-aneurysmal SAH (based on two negative cerebral angiograms performed ≥7 days apart) between June 1st, 2012 and June 30th, 2014 were considered incident cases. We calculated the incidences of non-aneurysmal and aneurysmal SAH adjusted for age and sex based on the 2010 US census. RESULTS: Of the 18 identified SAH among 189,093 resident populations, five were true incident cases of non-aneurysmal SAH in this population-based study. The age- and sex-adjusted incidence of non-aneurysmal SAH were 2.8 [95 % confidence interval (CI) 2.7-2·9] per 100,000 person-years which was lower than aneurysmal SAH incidence of 7.2 [95 % CI 7.1-7.4] per 100,000 person-years. The age-adjusted incidence of non-aneurysmal SAH was similar (compared with aneurysmal SAH) among men; 3.2 [95 % CI 3.1-3.3] per 100,000 person-years versus 2.2 [95 % CI 2.1-2.3] per 100,000 person-years, respectively. The age-adjusted case fatality rate at 3 months was 4.46 and 0.0 per 100,000 persons for aneurysmal and non-aneurysmal SAH, respectively. CONCLUSIONS: The incidence of non-aneurysmal SAH was higher than previously reported particularly among men.

Worse in-hospital outcomes in patients with transient ischemic attack in association with acute kidney injury: analysis of nationwide in-patient sample.

OBJECTIVES: The effect of acute kidney injury (AKI) on outcomes of transient ischemic attack (TIA) is largely unknown. We wanted to determine the impact of AKI on the outcomes of patients admitted with TIA. METHODS: Data from all adult patients admitted to the U.S. hospitals between 2005 and 2011 with a primary discharge diagnosis of TIA and secondary diagnosis of AKI were included, using the nationwide in-patient dataset. The association of AKI with TIA-related mortality and discharge outcomes was analyzed after adjusting for potential confounders using logistic regression analysis. RESULTS: Of the 1,173,340 patients admitted with TIA, 45,974 (3.8%) had AKI. Dialysis was required in 29 (0.06%) patients. TIA patients with AKI had higher rates of moderate-to-severe disability (21.2 vs. 13.7%, p ≤ 0.0001), and in-hospital mortality (0.6 vs. 0.1%, p ≤ 0.0001) compared with those without AKI. After adjusting for age, sex, and potential confounders; TIA patients with AKI had higher odds of moderate-to-severe disability [OR 1.3, 95% CI 1.2-1.4, p < 0.0001] and death (OR 4.2, 95% CI 3.0-6.1, p < 0.0001). CONCLUSIONS: AKI in patients with TIA is associated with significantly higher rates of moderate-to-severe disability at discharge and in-hospital mortality compared with those without AKI.

Flow-independent dynamics in aneurysms: intra-aneurysm pressure measurements following complete flow cessation in internal carotid artery aneurysms.

PURPOSE: To determine if complete flow obliteration by covered stents reduces intra-aneurysm pressures in internal carotid artery (ICA) aneurysms. METHODS: A single lumen microcatheter was placed into the aneurysm sac prior to covered stent deployment in 3 patients and connected to a pressure monitoring system. The intra-aneurysm pressure was continuously monitored, and readings were recorded prior to and immediately after stent deployment and at 5-minute intervals up to 20 minutes after stent placement. Complete occlusion of flow into the aneurysms was confirmed by carotid angiography. RESULTS: There was no change in mean pressure within the aneurysm before and immediately after stent placement (80 mmHg) in any patient, nor was there a change in waveform of the intra-aneurysm pressure recording. The average of intra-aneurysm pressures among the 3 patients was higher (99 mmHg) at 10 and 15 minutes after stent placement. In 2 patients, the microcatheter was retracted into the parent arterial lumen; no difference in pressure was noted. CONCLUSION: Our observations suggest no change in the pressures within the aneurysm after complete flow cessation (flow-independent). These findings may assist clinicians in better understanding aneurysm hemodynamics and rupture after covered stent deployment.

Differentiating intraparenchymal hemorrhage from contrast extravasation on post-procedural noncontrast CT scan in acute ischemic stroke patients undergoing endovascular treatment.

INTRODUCTION: This study aimed to identify the imaging characteristics that can help differentiate intraparenchymal hemorrhage from benign contrast extravasation on post-procedural noncontrast CT scan in acute ischemic stroke patients after endovascular treatment. METHODS: We reviewed the clinical and imaging records of all acute ischemic stroke patients who underwent endovascular treatment in two hospitals over a 3.5-year period. The immediate post-procedural CT scan was evaluated for the presence of hyperdense lesion(s). The average attenuation of the lesion(s) was measured. Intraparenchymal hemorrhage was defined as a persistent hyperdensity visualized on follow-up CT scan, 24 h or greater after the procedure. RESULTS: Of the 135 patients studied, 74 (55%) patients had hyperdense lesion(s) on immediate post-procedural CT scan. Follow-up scans confirmed the diagnosis of intraparenchymal hemorrhage in 20 of these 74 patients. A receiver operating characteristic analysis showed that the average attenuation of the most hyperdense lesion can differentiate intraparenchymal hemorrhage from contrast extravasation with an area under the curve of 0.78 (p = 0.001). An average attenuation of <50 Hounsfield units (HU) in the most visually hyperattenuating hyperdense lesion had 100 % specificity and 56% sensitivity for identification of contrast extravasations. Petechial hyperdensity was seen in 46/54 (85%) patients with contrast extravasation versus 9/20 (45%) patients with intraparenchymal hemorrhage on the immediate post-procedural CT scan (p < 0.001). CONCLUSION: An average attenuation <50 HU of the most hyperattenuating hyperdense parenchymal lesion on immediate post-procedural CT scan was very specific for differentiating contrast extravasation from intraparenchymal hemorrhage in acute ischemic stroke patients after endovascular treatment.

Validation of intracerebral hemorrhage-specific intensity of care quality metrics.

BACKGROUND: Given the considerable variation in care of patients with intracerebral hemorrhage (ICH) among centers that results in differences in outcome among these patients, a new intensity of care quality metrics has been proposed. This study aimed to validate the new ICH-specific intensity of care quality metrics. METHODS: A total of 50 consecutive patients with ICH who were admitted within 24 hours of symptom onset were identified. Twenty-six quality indicators related to 18 facets of care were incorporated into a metric providing the variable, definition of the variable, and quality parameter. A score of 1 point was assigned if the quality parameter met the threshold for appropriate performance or if the parameter was not applicable, creating a total score of up to 26 points. The predictive validity of the classification scheme was tested by using the bootstrap method. RESULTS: Fourteen of the 50 patients with ICH died during hospitalization (28%). The intensity of care quality metric score ranged from 17 points to 26 points. The mean score was higher in those who survived compared with those who died (23 ± 3 vs 21 ± 2; P = .02). Survival increased with tertile based on higher scores (100%, 67%, and 55%; P = .017). The receiver operating characteristic curve demonstrated a high discriminating ability of intensity of care quality metrics for in-hospital mortality (0.730, 95% confidence interval, 0.591-0.869) and a C-statistic of 0.91 (95% confidence interval, 0.90-0.92). CONCLUSIONS: Correlation of the new ICH-specific intensity of care quality metric with in-hospital mortality supports its broader use for improving and standardizing medical care among patients with ICH.

Impact of percutaneous transluminal angioplasty for treatment of cerebral vasospasm on subarachnoid hemorrhage patient outcomes.

BACKGROUND: Percutaneous transluminal angioplasty (PTA) has been introduced for treatment of symptomatic cerebral vasospasm in patients with subarachnoid hemorrhage (SAH). While angiographic improvement is consistently reported, clinical improvement following the procedure varies, and limited data is available regarding overall impact on outcome. METHODS: The authors performed a retrospective analysis of all hospital admissions with aneurysmal SAH over a 6 year period. The length of stay, discharge outcomes (measured by modified Rankin scale [mRS] at discharge), and 1-year mortality among patients with SAH before (4 year period) and after (2 year period) institution of PTA for cerebral vasospasm were compared. Embolization for intracranial aneurysm was used as a therapeutic option throughout the study duration. The effect of institution of PTA for vasospasm after adjusting for age, clinical severity, and use of aneurysm embolization on both discharge outcomes and 1-year mortality in multivariate analysis was evaluated. RESULTS: A total of 146 patients with aneurysmal SAH were admitted during the study duration. There was no difference between the 89 patients admitted in pre-angioplasty period and 57 patients admitted in post-angioplasty period in regards to age, medical co-morbidities, and admission clinical severity of patients (measured by Hunt and Hess grade and Glasgow coma scale). A total of 18 (32%) patients underwent PTA with or without intra-arterial vasodilator treatment in the second period of the study. There was a non significant decrease in rates of severe disability and death (mRS 5-6) at discharge (45 vs. 33%, P = 0.09) and 1-year mortality (32 vs. 22%, P = 0.26) after introduction of PTA for cerebral vasospasm after adjusting for potential confounders. There was no significant difference between the two time periods in regards to length of stay. CONCLUSION: A non significant trend was noted with reduced rate of severe disability and mortality at discharge and 1-year mortality after the introduction of PTA for cerebral vasospasm associated with SAH without increasing the length of hospital stay.

When to Consider Prophylactic Antimigraine Therapy in Children with Migraine.

PURPOSE OF REVIEW: Headache is not an uncommon complaint in children, and recognition of migraine is increasing in children and adolescents. Treatment options consist of abortive and preventive medications; however, when to start the preventive treatment is not clear in the pediatric population. This article reviews current guidelines and practices to provide a better clinical approach in the management of migraines in children and adolescents. RECENT FINDINGS: Currently, the only FDA-approved medical treatment option for preventive therapy in chronic migraine in adolescents is topiramate. However, the Childhood and Adolescent Migraine Prevention Study (CHAMP) did not endorse superiority of topiramate or amitriptyline over placebo. At this time, there is no clear consensus on when to start preventive therapy in children and adolescents with migraines. The decision is multifactorial and should be initiated after a thorough discussion with the patient and caregiver(s) about related risks and benefits of treatment. Education regarding various modalities of treatment and ensuring compliance is essential to treatment success.

Acute hypertensive response in patients with intracerebral hemorrhage pathophysiology and treatment.

Acute hypertensive response is a common systemic response to occurrence of intracerebral hemorrhage which has gained unique prominence due to high prevalence and association with hematoma expansion and increased mortality. Presumably, the higher systemic blood pressure predisposes to continued intraparenchymal hemorrhage by transmission of higher pressure to the damaged small arteries and may interact with hemostatic and inflammatory pathways. Therefore, intensive reduction of systolic blood pressure has been evaluated in several clinical trials as a strategy to reduce hematoma expansion and subsequent death and disability. These trials have demonstrated either a small magnitude benefit (second intensive blood pressure reduction in acute cerebral hemorrhage trial and efficacy of nitric oxide in stroke trial) or no benefit (antihypertensive treatment of acute cerebral hemorrhage 2 trial) with intensive systolic blood pressure reduction compared with modest or standard blood pressure reduction. The differences may be explained by the variation in intensity of systolic blood pressure reduction between trials. A treatment threshold of systolic blood pressure of ≥180 mm with the target goal of systolic blood pressure reduction to values between 130 and 150 mm Hg within 6 h of symptom onset may be best supported by current evidence.

Effect of epidural blood injection on upright posture intolerance in patients with headaches due to intracranial hypotension: A prospective study.

BACKGROUND: We performed a prospective study to quantify changes in various aspects of upright posture intolerance in patients with intracranial hypotension. METHODS: Six patients were provided a standard questionnaire before, immediately after epidural blood patch injection and at follow-up visit within 1 month after epidural blood injection inquiring: (a) How long can they stand straight without any support? (b) Do they feel any sense of sickness when they sit or lie down after standing? (c) How long do they have to wait before they are comfortable standing again after they have stood straight? (d) How effectively and fast can they get up from sitting or lying position to stand straight? and (e) Rate their activities in upright posture without support on a standard vertical visual analogue scale between 100 (can do everything) and 0 (cannot do anything). RESULTS: All patients responded that they could not stand straight for ≥30 min (four responding <5 min) on pretreatment evaluation. All patients reported improvement in this measure immediately postprocedure with two reporting ≥30 min. At follow-up, three patients reported further improvement and one patient reported worsening in this measure. The magnitude of improvement ranged from 10 to 80 points increase immediately postprocedure in their ability to perform activities, while they are standing without any support on visual analogue scale. At follow-up, four patient reported additional improvement in their ability to perform activities, while they are standing without any support (ranged from 10 to 20 points increase compared with immediately postprocedure rating). CONCLUSIONS: We present semiquantitative data on various aspects of upright posture intolerance in patients with intracranial hypotension before and after epidural blood injection.

Concurrent Angioplasty Balloon Placement for Stent Delivery through Jugular Venous Bulb for Treating Cerebral Venous Sinus Stenosis. Technical Report.

OBJECTIVE: To report upon technique of concurrent placement of angioplasty balloon at the internal jugular vein and sigmoid venous sinus junction to facilitate stent delivery in two patients in whom stent delivery past the jugular bulb was not possible. CLINICAL PRESENTATION: A 21-year-old woman and a 41-year-old woman with worsening headaches, visual obscuration or diplopia were treated for pseudotumor cerebri associated with transverse venous stenosis. Both patients had undergone primary angioplasty, which resulted in improvement in clinical symptoms followed by the recurrence of symptoms with restenosis at the site of angioplasty. INTERVENTION: After multiple attempts at stent delivery through jugular venous bulb were unsuccessful, a second guide catheter was placed in the ipsilateral internal jugular vein through contralateral femoral venous approach. A 6 mm × 20 mm (left) or 5 × 15 mm (right) angioplasty balloon was placed across the internal jugular vein and sigmoid sinus junction and partially inflated until the inflation and relative straightening of the junction was observed. In both patients, the internal jugular vein and sigmoid sinus junction was successfully traversed by the stent delivery system in a parallel alignment to inflated balloon. Balloon mounted stent was deployed at the site of restenosis with near complete resolution of lumen narrowing delivery and improvement in clinical symptoms. CONCLUSION: We report a technique for realignment and diameter change with concurrent placement and partial inflation of angioplasty balloon at the jugular venous bulb to facilitate stent delivery into the sigmoid and transverse venous sinuses in circumstances where multiple attempts at stent delivery are unsuccessful.

Detection of Intraparenchymal Hemorrhage After Endovascular Therapy in Patients with Acute Ischemic Stroke Using Immediate Postprocedural Flat-Panel Computed Tomography Scan.

PURPOSE: To assess the diagnostic value of parenchymal hyperdense lesions visualized on the flat-panel CT scan in detecting/excluding intraparenchymal hemorrhage (IPH) after the endovascular treatment of acute stroke patients. METHODS: Two separate cohorts of acute ischemic stroke patients who underwent endovascular treatment were evaluated. In the first group, patients were evaluated for hyperdense parenchymal lesions immediately after the treatment with flat-panel CT scan; whereas, in the second group, patients underwent multidetector CT scan post procedure. IPH was defined as hyperdensity that persisted for >24 hours on follow up CT scan. RESULTS: A total of 30 patients were evaluated with flat panel, and 135 with multidetector CT scan immediately after the endovascular treatment. Hyperdense lesions were visualized on 7/30 (23%) of those evaluated with flat-panel CT versus 74/135 (55%) of those evaluated with multidetector CT scan. Based on 24-hour follow up imaging, hyperdense parenchymal lesions on immediate postprocedural flat-panel or multidetector CT studies had 100% sensitivity and negative predictive value for IPH; whereas, the specificity, and positive predictive value of such lesions were 88% and, 57% on the flat panel; and 53% and, 27% on the multidetector CT study, respectively. CONCLUSION: The absence of hyperdense lesions on immediate postprocedural flat-panel CT scan of ischemic stroke patients can exclude IPH with a high sensitivity and negative predictive value. The hyperdense parenchymal lesions visualized on flat-panel versus multidetector CT studies may have comparable sensitivity and negative predictive value for the detection of IPH.

Syncope in Patient with Bilateral Severe Internal Carotid Arteries Stenosis/Near Occlusion: A Case Report and Literature Review.

BACKGROUND: Syncope is commonly worked up for carotid stenosis, but only rarely attributed to it. Considering paucity of such cases in literature, we report a case and discuss the pathophysiology. DESIGN/METHODS: We report a patient with high-grade bilateral severe internal carotid artery (ICA) stenosis who presented with syncopal episodes in the absence of stroke, orthostatic hypotension, significant cardiovascular disease, or vasovagal etiology. We reviewed all literature pertaining to syncope secondary to carotid stenosis and other cerebrovascular disease. RESULTS: A 67-year-old man presented with two brief syncopal episodes. History and physical examination was not suggestive of seizure or vasovagal syncope. Other workup was negative for any stroke or syncope secondary to cardiac or vasovagal etiology. Magnetic resonance angiography (MRA) revealed bilateral ICA severe stenosis. This was confirmed by transfemoral carotid vessels angiography. Internal carotid angioplasty and stenting was performed on one side. After this, the patient remained asymptomatic. After one month, carotid endarterectomy (CEA) of contralateral side was performed. Patient remained symptom free after that. On review of literature, we identified only 12 cases of syncope attributable to carotid stenosis and reviewed 24 cases attributable to other cerebrovascular disease. CONCLUSION: Syncope secondary to carotid stenosis, especially in the absence of any focal ischemic events is rare. It can only be expected in those patients who have bilateral hemodynamically significant carotid disease, which is unlikely in the absence of any focal ischemic events.

Lumbar Catheter Placement Using Paramedian Approach Under Fluoroscopic Guidance.

BACKGROUND: Lumbar catheter placement under fluoroscopic guidance may reduce the rate of technical failures and associated complications seen with insertion guided by manually palpable landmarks. METHODS: We reviewed our experience with 43 attempted lumbar catheter placements using paramedian approach under fluoroscopic guidance and ascertained rates of technical success, and clinical events. RESULTS: Among the 43 patients, 18, 1, and 1 patients were on aspirin (with dipyrimadole in 2), clopidogrel, and combination of both, respectively. Lumbar catheter placement was successful in 42 of 43 attempted placements. Floroscopic guidance was critical in three patients; one patient had severe cerebrospinal fluid (CSF) depletion (empty thecal sac phenomenon) following pituitary surgery leading to no cerebrospinal fluid return despite correct placement confirmation under fluoroscopy. Two patients had spinal needle placement at the junction between epidural and cerebrospinal fluid spaces (junctional position) leading to cerebrospinal fluid return but inability to introduce the lumbar catheter. After confirmation of position by the injection of contrast or radiographic landmarks the needle was advanced by indenting the subcutaneous tissue or reinserting at a spinal level above the first insertion. The lumbar catheter remained in position over a mean period (±standard deviation) of 4.1(±2.3) days. Improvement in hydrocephalus was seen in two patients with intracranial mass lesions. One patient developed cerebrospinal fluid leakage through the insertion track following removal of catheter and required skin suturing at the site of insertion. CONCLUSIONS: We observed a high technical success rate with low rate of complications even in patients with intracranial mass lesions, those on ongoing antiplatelet medications or in whom insertion would not be possible guided by manually palpable landmarks.

Complex Partial Epilepsy Associated with Temporal Lobe Developmental Venous Anomaly.

BACKGROUND: Developmental venous anomalies (DVA) are found incidentally but sometimes patients with these anomalies present with varying degrees of neurologic manifestations. OBJECTIVE: We report a patient with early onset complex partial epilepsy and associated DVA and discuss the natural history, neuroimaging and clinical characteristics, and management. CASE DESCRIPTION: A 21-year-old man presented with a history of complex partial epilepsy with secondary generalization which started at the age of 4 years. An electroencephalogram (EEG) was performed which demonstrated spike and wave discharges predominantly in the left frontotemporal region. A magnetic resonance imaging (MRI) was performed which demonstrated a linear flow void suggestive of a DVA. The angiogram demonstrated DVA that connected with the left transverse venous sinus and an anastomotic vein between the straight sinus and the transverse venous sinus traversing the brain parenchyma. He was started on carbamezipine for the treatment of complex partial seizures. CONCLUSIONS: Temporal lobe DVA may be associated with complex partial seizures and can be diagnosed by MRI and angiographic findings.

Rates and predictors of 5-year survival in a national cohort of asymptomatic elderly patients undergoing carotid revascularization.

BACKGROUND: Current American Heart Association guidelines recommend carotid revascularization for asymptomatic patients on the basis of life expectancy. OBJECTIVE: To determine the rates and predictors of 5-year survival in elderly patients with asymptomatic carotid artery stenosis who underwent either carotid artery stent placement (CAS) or carotid endarterectomy (CEA). METHODS: The rates of 5-year survival were determined by use of Kaplan-Meier survival methods in a representative sample of fee-for-service Medicare beneficiaries ≥65 years of age who underwent CAS or CEA for asymptomatic carotid artery stenosis with postprocedural follow-up of 3.4 ± 1.7 years. Cox proportional hazards analysis was used to assess the relative risk of all-cause mortality for patients in the presence of selected comorbidities, including ischemic heart disease, chronic renal failure, and atrial fibrillation, after adjustment for potential confounders such as age, sex, race/ethnicity, and procedure type. RESULTS: A total of 22,177 patients with asymptomatic carotid artery stenosis were treated with either CAS (n = 2144) or CEA (n = 20,033). The overall estimated 5-year survival rate (±SE) was 95.3 ± 0.00149; it was 95.5% and 93.8% in patients treated with CEA and CAS, respectively. After adjustment for potential confounders, relative risk of all-cause 5-year mortality was significantly higher among patients with atrial fibrillation (relative risk, 1.8; 95% confidence interval, 1.5-2.1) and those with chronic renal failure (relative risk, 2.1; 95% confidence interval, 1.7-2.6). CONCLUSION: Risks and benefits must be carefully weighed before carotid revascularization in elderly patients with asymptomatic carotid artery stenosis who have concurrent atrial fibrillation or chronic renal failure.

Catheter-Based Trans-Epidural Approach to Aspirate Cervical and Thoracic Epidural Abscesses: A Cadaveric Feasibility Study.

BACKGROUND: Approaching and aspirating cervical and high thoracic epidural abscesses through a trans-epidural route from the lumbar region access represents an alternative method for selected patients. OBJECTIVE: We determined the feasibility of catheter-based manipulation and aspiration using the trans-epidural route. MATERIAL AND METHODS: A custom designed infusion-suction catheter system that includes an outer suction catheter and inner infusion catheter in concentric relation with radio-opaque marker bands was tested in a cadaveric preparation to determine (1) the ability to place an aspiration catheter over a guidewire using a percutaneous approach within the posterior lumbar epidural space; (2) the highest vertebral level a catheter can be advanced within the epidural space; and (3) the ability to aspirate artificial purulent-like material placed in the cervical and thoracic level epidural space. RESULTS: We were able to advance two infusion-suction catheter systems from a 14G Touhy spinal needle inserted via an oblique parasagittal approach at the L2-L3 intervertebral space. The infusion-suction catheter was advanced up to the level of the cervical vertebral level of C2 within the epidural space under fluoroscopic guidance. We were able to aspirate artificial purulent-like material directly injected with a 22G Quincke spinal needle at vertebral levels C4-C5 and at vertebral levels T10-T11 by aspiration and manipulation of the outer catheter within the epidural space at levels C3-C7 and T9-L1, respectively. CONCLUSIONS: Our observations support the further exploration of a percutaneous catheter-based trans-epidural approach to treat epidural abscesses. The trans-epidural approach may be used alone or as a staged or concurrent approach with open surgical treatment.

Effect of Carotid Revascularization Endarterectomy Versus Stenting Trial Results on the Performance of Carotid Artery Stent Placement and Carotid Endarterectomy in the United States.

BACKGROUND: CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) results, published in 2010, showed no difference in the rates of composite outcome (stroke, myocardial infarction, or death) between carotid artery stent placement (CAS) and carotid endarterectomy (CEA). OBJECTIVE: To identify any changes in use and outcomes of CAS and CEA subsequent to the CREST results. METHODS: We estimated the frequency of CAS and CEA procedures in the years 2009 (pre-CREST period) and 2011 (post-CREST period), using data from the National Inpatient Sample (NIS). Demographic and clinical characteristics and in-hospital outcomes of pre- and post-CREST CAS-treated and post-CREST CEA-treated patients were compared with pre-CREST CEA-treated patients. RESULTS: A total of 225,191 patients underwent CEA or CAS in the pre- and post-CREST periods. The frequency of CAS among carotid revascularization procedures did not change after publication of the CREST results (12.3% vs. 12.7%, P = .9). In the pre-CREST period, the CAS group (compared with the CEA group) had higher rates of congestive heart failure (P < .001), coronary artery disease (P < .001), and renal failure (P < .001). The post-CREST CAS group had a higher frequency of atrial fibrillation (P = .003), congestive heart failure (P < .0001), coronary artery disease (P < .0001), and renal failure (P = .0001). Discharge with moderate to severe disability (P < .0001) and postprocedure neurological complications (P = .005) were more frequently reported in the post-CREST CAS group. After adjusting for age, sex, and risk factors, the odds ratio (OR) for moderate to severe disability was 1.0 (95% confidence interval [CI]: 0.8-1.2) in the pre-CREST CAS group and 1.4 (95% CI: 1.1-1.7) in the post-CREST CAS group compared with the reference group. The adjusted OR for neurological complications in the pre-CREST CAS group was 1.6 (95% CI: 1.2-2.1, P = .002), and 1.5 (95% CI: 1.1-2.0, P = .01) in the post-CREST CAS group. CONCLUSION: The frequency of CAS and CEA for carotid artery stenosis has not changed after publication of the CREST. The demographics, pretreatment comorbidity profile, and in-hospital complication rates remained unchanged during the 2 time periods.