Endovascular reconstruction of iatrogenic internal carotid artery injury following endonasal surgery: a systematic review.

The objective of this study is to provide an update on endovascular treatments for iatrogenic internal carotid artery (ICA) injuries following endonasal surgery. A systematic review of the literature was performed by using Medline, Cochrane library, and Scopus from 1999 to 2019. We used a combination of the MeSH terms "internal carotid artery," "iatrogenic disease," and "endovascular procedure." Twenty-six articles including 46 patients were identified for in this systematic review. The mean age of the patients was 49 years (CI: ± 4.2). The most common site of ICA injury was in cavernous segment (18 patients; 39%). The most common type of iatrogenic ICA injury was a traumatic pseudoaneurysm documented in 28 patients (60%). Endoluminal reconstruction was performed using covered stents in 28 patients, the Pipeline embolization device (PED) in 13 patients, the Surpass flow diverter device in three, the SILK flow diverter in one, and one case was treated using a combined approach of a covered stent and a PED. Flow diversion and covered stents resulted in a good clinical outcome in 94% and 89% of patients, respectively. This difference did not reach statistical significance (p = 1.0). Even though this systematic review was limited due to articles of small sample sizes and considerable heterogeneity, the results indicate that flow diverting devices and covered stents are good therapeutic options for endoluminal reconstruction of iatrogenic ICA injuries following endonasal surgery.

Aspirin and Risk of Subarachnoid Hemorrhage: Systematic Review and Meta-Analysis.

BACKGROUND AND PURPOSE: Recent studies have suggested that the use of low-dose aspirin may reduce the risk of aneurysmal subarachnoid hemorrhage (aSAH). We aimed to evaluate any association between aspirin use and risk of aSAH based on the literature, and whether this is influenced by duration or frequency of aspirin use. METHODS: A search of electronic databases was done from inception to September 2016. For each study, data on risk of aSAH in aspirin versus nonaspirin users were used to generate odds ratios and 95% confidence intervals, and combined using inverse variance-weighted averages of logarithmic odds ratios in a random-effects models. RESULTS: From 7 included studies, no significant difference was noted between aspirin use of any duration or frequency and nonaspirin users (odds ratio, 1.00; 95% confidence interval, 0.81-1.24; P=0.99). We found a significant association between short-term use of aspirin (<3 months) and the risk of aSAH (odds ratio, 1.61; 95% confidence interval, 1.20-2.18; P=0.002). No significant difference was found in terms of risk of aSAH for 3 to 12 months, 1 to 3 years, and >3 years of durations of use. No significant association was found between infrequent aspirin use (≤2× per week) or frequent use (≥3× per week) with risk of aSAH. CONCLUSIONS: Current evidence suggests that short-term (<3 months) use of aspirin is associated with increased risk of aSAH. Limitations include substantial heterogenity of the included studies. The role of long-term aspirin in reducing risk of aSAH remains unclear and ideally should be addressed by an appropriately designed randomized controlled trial.

A mini-review of intrasaccular flow diverters.

Treatment of wide-necked complex intracranial aneurysms continues to challenge neurointerventionalists. Intrasaccular flow diverters have expanded the armamentarium considerably and are now used extensively. While five types of devices have already obtained the CE mark for use within Europe, only the Woven EndoBridge (WEB) device is approved by the US Food and Drug Administration. Other intrasaccular devices are the Luna/Artisse Aneurysm Embolization System (Medtronic), the Medina Embolic Device (Medtronic), the Contour Neurovascular System (Cerus), and the Neqstent Coil Assisted Flow Diverter (Cerus). This mini review will provide a compact overview of these devices and a summary of the current literature.

Flared non-flow diverting ends of the FRED flow diverter for cerebral aneurysms facilitate device anchoring at the arterial bifurcation.

INTRODUCTION: The Flow Redirection Intraluminal Device (FRED) flow diverter has a unique bilayer design, with the outer scaffolding stent extending beyond the inner flow diverting component by about 3 mm at each end. Here, we describe a technique to utilize these unrestrained flared ends for precise flow diverter placement in cases where the aneurysm and an adjacent branch are in close proximity and branch jailing is not desired, such as in posterior communicating artery aneurysms.Technical note: The distal end of the FRED device is pushed out of the microcatheter at the carotid terminus. Once the distal flared ends are fully open and well situated in the terminus, ideally with at least one of the limbs in the A1 segment of the anterior cerebral artery, the device is unsheathed under gentle forward pressure. This technique stabilizes the device at the distal landing zone and prevents unintended foreshortening at the distal end. This is particularly important for aneurysms located adjacent to the carotid terminus in order to assure adequate neck coverage, as well as avoiding jailing one of the branching parent arteries. An illustrative case is provided. CONCLUSIONS: The non-flow diverting unrestrained flared ends of the FRED stabilize the distal end of the device when deployed directly into the branches at the arterial bifurcation. The technique is useful to provide adequate neck coverage of cerebral aneurysm located directly adjacent to the bifurcation as is frequently the case with posterior communicating artery aneurysms.

Adenosine-induced transient circulatory arrest in transvenous embolization of cerebral arteriovenous malformations.

Due to advances in interventional techniques, the transvenous approach may present an effective treatment option for embolization of brain arteriovenous malformations (AVMs). Contrary to the transarterial method, the transvenous approach can only be utilized in a specific subset of patients and is not suitable as a standard procedure for all AVM lesions. While this technique can be helpful in certain patients, careful patient selection to ensure patient safety and favorable clinical outcomes is important. However, especially in high-flow AVMs, targeted deposition of embolic materials through a transvenous access can be challenging. Therefore, a temporary flow arrest may prove helpful. Transient cardiac arrest by use of adenosine has been applied in cerebrovascular surgery but is not common for endovascular embolization. Adenosine-induced arrest and systemic hypotension may be a feasible, safe method to reduce flow and help endovascular transvenous embolization of certain AVMs. Our study evaluated the efficiency and safety of adenosine-induced circulatory arrest for transvenous embolization of cerebral AVMs.

Impact of aneurysm location and endovascular treatment modality on the improvement of headache in patients with unruptured intracranial aneurysms.

INTRODUCTION: The use of endovascular therapy (EVT) in patients with unruptured intracranial aneurysms (UIA) is associated with a significant reduction of headache severity. It is still unclear how the treatment modality and the aneurysm location affect headache in these patients. This systematic review and meta-analysis aimed to compare the improvement of headache rates based on the endovascular treatment modality and aneurysm location. EVIDENCE ACQUISITION: We conducted a complete search through four databases. Original studies that reported the improvement in headache rates in patients that had undergone EVT for UIA based on the treatment modality and location were included in the analysis. Fixed effect meta-analysis was performed to compare them using the odds ratio (OR). EVIDENCE SYNTHESIS: A total of 180 reports were screened for title and abstract, of which six reports were included in this study. There were 199 patients that underwent stent-assisted coiling and 184 patients who had coiling alone. A total of 75 patients with posterior aneurysms were included as compared to 347 with anterior aneurysms. There was no significant difference between the two treatment modalities regarding the improvement in headache rates (OR=0.591, 95% CI: 0.349-1.003, P=0.051). Additionally, no difference was found in headache improvement rates between posterior and anterior UIA (OR=0.738, 95% CI: 0.434-1.254, P=0.262). CONCLUSIONS: There was no clear statistical difference between stent-assisted coiling and coiling alone for the improvement of headache in patients with UIA, as well as between posterior and anterior UIA. Future well-conducted large trials that use headache severity scores are warranted to investigate that further.

Endovascular Mechanical Thrombectomy in Large-Vessel Occlusion Ischemic Stroke Presenting with Low National Institutes of Health Stroke Scale: Systematic Review and Meta-Analysis.

INTRODUCTION: Mechanical thrombectomy has become the standard of care for management of most large vessel occlusion (LVO) strokes. When patients with LVO present with minor stroke symptomatology, no consensus on the role of mechanical thrombectomy exists. METHODS: A systematic review and meta-analysis were performed to identify studies that focused on mechanical thrombectomy, either as a standalone treatment or with intravenous tissue plasminogen activator (IV tPA), in patients with mild strokes with LVO, defined as a baseline National Institutes of Health Stroke Scale score ≤5 at presentation. Data on methodology, quality criteria, and outcome measures were extracted, and outcomes were compared using odds ratio as a summary statistic. RESULTS: Five studies met the selection criteria and were included. When compared with medical therapy without IV tPA, mechanical thrombectomy and medical therapy with IV tPA were associated with improved 90-day modified Rankin Scale (mRS) score. Among medical patients who were not eligible for IV tPA, those who underwent mechanical thrombectomy were more likely to experience good 90-day mRS than those who were not. There was no significant difference in functional outcome between mechanical thrombectomy and medical therapy with IV tPA, and no treatment subgroup was associated with intracranial hemorrhage or death. CONCLUSIONS: In patients with mild strokes due to LVO, mechanical thrombectomy and medical therapy with IV tPA led to better 90-day functional outcome. Mechanical thrombectomy plays an important role in the management of these patients, particularly in those not eligible for IV tPA.

Medullary Decompression by Sling Repositioning of Vertebral Artery with Operative Video.

BACKGROUND: Vascular compression of the medullary pyramid resulting in neurologic compromise is rare; therefore diagnosis is difficult and ultimately delayed. Most patients present with a combination of cranial nerve, autonomic, and/or motor and sensory dysfunction. Presentation with a single sign such as hemiparesis is rare. The low number of cases reported has made it impossible to define a standard treatment for this unusual disorder. CASE DESCRIPTION: Here, we present a patient with progressive left hemiparesis due to compression of the upper medulla by the vertebral artery, which was treated with repositioning of the artery using a sling. Clinical and radiologic features including upper medullary compression by the left vertebral artery with effacement of the left medullary pyramid and T2/fluid-attenuated inversion recovery signal changes in the right medulla are illustrated. The patient underwent a standard left retrosigmoid craniectomy for mobilization of the left vertebral artery with a Hemashield (Maquet Cardiovascular, San Jose, California, USA) sling (see video). Postoperatively, the patient had significant improvement of the left hemiparesis and follow-up imaging showed decompression of the medulla with edema reduction. CONCLUSIONS: Vascular decompression using a sling has proven to be a valuable option for treatment of symptomatic vascular brainstem compression.

Ex-vivo release of Pipeline Embolization Device polytetrafluoroethylene (PTFE) sleeves for improved distal landing zone accuracy in-vivo: A technical note.

BACKGROUND: Distal landing zone accuracy is critical in some intracranial aneurysms treated with the Pipeline Embolization Device (PED), and delayed opening of the distal end of the device can complicate the procedure. Here, we report a technical nuance that facilitates accurate placement of the distal end of the PED by ex-vivo, pre-implantation release of the PED Flex polytetrafluoroethylene (PTFE) sleeves. TECHNICAL NOTE: The PED Flex is partially pushed out of the introducer sheath ex-vivo, pre-implantation until the distal PED opens entirely and the PTFE sleeves are located distal to the device. Without inverting the PTFE sleeves, the PED is carefully pulled back into the introducer sheath placing the PTFE sleeves inside the device. The PED is loaded into the microcatheter and advanced toward the site of implantation. When the PED is initially deployed and pushed out of the microcatheter, it opens immediately and provides an anchor for the remainder of the deployment process. We present a video (supplementary material) that illustrates the technique along with an illustrative case. CONCLUSION: Ex-vivo, pre-implantation release of the PTFE sleeves is an option in aneurysm treatment where distal landing accuracy is critical. Even without the protection of the PTFE sleeves, our clinical observation shows that the PED can be advanced safely through the microcatheter in selected cases.

Hemispherectomy for treatment of refractory epilepsy in the pediatric age group: a systematic review.

OBJECT: Evidence in support of hemispherectomy stems from a multitude of retrospective studies illustrating individual institutions' experience. A systematic review of this topic, however, is lacking in the literature. METHODS: A systematic review of hemispherectomy for the treatment of refractory epilepsy available up to October 2013 was performed using the following inclusion criteria: reports of a total of 10 or more patients in the pediatric age group (≤ 20 years) undergoing hemispherectomy, seizure outcome reported after a minimum follow-up of 1 year after the initial procedure, and description of the type of hemispherectomy. Only the most recent paper from institutions that published multiple papers with overlapping study periods was included. Two reviewers independently applied the inclusion criteria and extracted all the data. RESULTS: Twenty-nine studies with a total of 1161 patients met the inclusion criteria. Seizure outcome was available for 1102 patients, and the overall rate of seizure freedom at the last follow-up was 73.4%. Sixteen studies (55.2%) exclusively reported seizure outcomes of a single type of hemispherectomy. There was no statistically significant difference in seizure outcome and type of hemispherectomy (p = 0.737). Underlying etiology was reported for 85.4% of patients with documented seizure outcome, and the overall distribution of acquired, developmental, and progressive etiologies was 30.5%, 40.7%, and 28.8%, respectively. Acquired and progressive etiologies were associated with significantly higher seizure-free rates than developmental etiologies (p < 0.001). Twenty of the 29 studies (69%) reported complications. The overall rate of hydrocephalus requiring CSF diversion was 14%. Mortality within 30 days was 2.2% and was not statistically different between types of hemispherectomy (p = 0.787). CONCLUSIONS: Hemispherectomy is highly effective for treating refractory epilepsy in the pediatric age group, particularly for acquired and progressive etiologies. While the type of hemispherectomy does not have any influence on seizure outcome, hemispherotomy procedures are associated with a more favorable complication profile.

Chemoprophylaxis for venous thromboembolism in traumatic brain injury: a review and evidence-based protocol.

Venous thromboembolism (VTE) is a recognized source of morbidity and mortality in patients suffering traumatic brain injury (TBI). While traumatic brain injury is a recognized risk factor for the development of VTE, its presence complicates the decision to begin anticoagulation due to fear of exacerbating the intracranial hemorrhagic injury. The role of chemoprophylaxis in this setting is poorly defined, leading to a wide variability in clinical practice. A comprehensive review of the literature was performed in an effort to summarize relevant data and construct a chemoprophylaxis protocol to be implemented in a Level I Trauma Center. The review reveals robust evidence regarding the safety and efficacy of chemoprophylaxis in the setting of TBI following demonstration of a stable intracranial injury. In light of this data, a protocol is assembled that, in the absence of predetermined exclusion criteria, will initiate chemoprophylaxis within 24h after the demonstration of a stable intracranial injury by computed tomography (CT).

The "bagel head" cosmetic modification: myths and medical complications for dermatologists to consider.

On September 23, 2012, the television program Taboo on the National Geographic Channel featured individuals in Tokyo undergoing the "bagel head" cosmetic modification. Dermatologists may encounter patients who undergo the bagel head procedure and subsequently present with a cutaneous infection. The purpose of this article is to delineate the bagel head procedure, note responses to sensationalist claims made by the media about this procedure, and discuss potential medical complications from this procedure. Specialists and primary care physicians who encounter reports of a specific extreme body modification for the first time should review discussions of the modification by its critics and advocates in order to assess potential medical complications from the procedure more accurately.