Low-Profile Visualized Intraluminal Support Device for Y-Stent-Assisted Coiling of Wide-Neck Intracranial Aneurysms: A Single-Center Experience.

BACKGROUND: The Low-Profile Visualized Intraluminal Support (LVIS) device has been frequently used as an intracranial stent for treating intracranial aneurysms. However, the feasibility and efficacy of LVIS devices in Y-stent-assisted coiling (Y-SAC) have remained contentious. This study aimed to evaluate long-term angiographic and clinical outcomes of Y-SAC using LVIS devices. METHODS: We retrospectively reviewed the clinical presentation and angiography data of patients treated with Y-SAC using LVIS stents. The vascular angle geometry between the parent and the 2 branch vessels, before and after stent deployment and after coiling, were analyzed. Based on the Raymond-Roy Occlusion Classification (RROC), aneurysm occlusion status was classified. Clinical outcomes were assessed using the modified Rankin Scale. RESULTS: Forty patients with 40 aneurysms were included in this study. Immediate postprocedural angiograms showed complete/near-complete occlusion (RROC 1 and 2) in 31 aneurysms (77.5%). The long-term follow-up angiographic studies were available in 32 patients and showed RROC class 1 and 2 in 93.8% of patients. Y-SAC with LVIS devices significantly decreased the angle between the bifurcation branches from 171.90° ± 48.0° (standard deviation) to 130.21° ± 46.3° (standard deviation) (P < 0.0001). Periprocedural complications occurred in 5 patients (12.5%) including 4 in-stent thromboses (10.5%). Thirty-six patients (90.0%) had favorable clinical outcomes at the final follow-up. Univariate analysis showed that World Federation of Neurological Societies grade 3-5, thickness of subarachnoid hemorrhage on head computed tomography, intraprocedural complications, and in-stent thrombosis were predictors of poor outcome. CONCLUSIONS: Y-SAC using the LVIS device for intracranial bifurcation aneurysms is a feasible and relatively safe procedure with favorable long-term angiographic and clinical outcomes.

Safety of dual antiplatelet therapy in the acute phase of aneurysmal subarachnoid hemorrhage: a propensity score-matched study.

OBJECTIVE: With the evolution of neuroendovascular treatments, there is a great trend to treat acutely ruptured wide-necked aneurysms with stent-assisted coiling (SAC) and flow diverters (FDs), which inevitably requires dual antiplatelet therapy (DAPT). This therapy can increase the rate of hemorrhagic complications following other neurosurgical maneuvers, such as external ventricular drain (EVD) placement or removal. In this study, the authors aimed to evaluate the safety of DAPT in patients with aneurysmal subarachnoid hemorrhage (SAH) treated with SAC or FDs and the therapy's potential benefit in reducing cerebral ischemia and cerebral vasospasm. METHODS: In this retrospective study, the authors reviewed the records of patients who had been admitted to their hospital with acute aneurysmal SAH and treated with SAC, FDs, and/or coiling between 2012 and 2022. Patients were classified into two groups: a DAPT group, including patients who had received DAPT for SAC or FDs, and a non-DAPT group, including patients who had not received any antiplatelet regimen and had been treated with coiling. Perioperative hemorrhagic and ischemic complications and clinical outcomes were compared between the two groups. RESULTS: From among 938 cases of acute ruptured aneurysms treated during 10 years of study, 192 patients were included in this analysis, with 96 patients in each treatment group, after propensity score matching. All basic clinical and imaging characteristics were equivalent between the two groups except for the neck size of aneurysms (p < 0.001). EVD-related hemorrhage was significantly higher in the DAPT group than in the non-DAPT group (p = 0.035). In most patients, however, the EVD-related hemorrhage was insignificant. Parent artery or stent-induced thrombosis was higher in the DAPT group than in the non-DAPT group (p = 0.003). The rate of cerebral ischemia was slightly lower in the DAPT group than in the non-DAPT group (11.5% vs 15.6%, p = 0.399). In the multivariate analysis, cerebral ischemia, rebleeding before securing the aneurysm, extracranial hemorrhage, and cerebral vasospasm were the predictive factors of a poor clinical outcome (p < 0.001, p < 0.001, p = 0.038, and p = 0.038, respectively). CONCLUSIONS: The DAPT regimen may be safe in the setting of acute aneurysmal SAH. Although EVD-related hemorrhage is more common in the DAPT group than the non-DAPT group, it is usually insignificant without any neurological deficit.

Transradial access for neurointerventional procedures: A practical approach.

INTRODUCTION: Transradial approach (TRA) is a new technique proposed for performing cerebral angiography and neuro-interventional procedures. In this article, we sought to provide a step-by-step guide for carrying out a diagnostic cerebral angiography using this approach and summarize our center's experience. MATERIAL AND METHODS: Records of patients since January 2020 were investigated, and data on demographic indices, reports of the procedures, outcomes, and complications were extracted. Then, these data were used to develop a step-by-step instruction for TRA cerebral angiography. RESULTS: Two hundred eighty-nine patients matched our eligibility criteria with a mean age of 50 years and a female-to-male ratio of 1.18. Overall, TRA was carried out successfully for 97.2% (281 patients). In case TRA failed, transfemoral approach was considered for the procedure. Three minor complications (two vasospasm and one small hematoma) and two major complications (one pseudoaneurysm of the radial artery and one radial artery avulsion) were observed. CONCLUSION: This article covers challenges a neurointerventionalist may face during a diagnostic cerebral angiography using TRA. Furthermore, our findings indicated that cerebral angiography with TRA might be performed safely and with a great success rate.

HIV-associated multiple intracranial aneurysms and stroke in an adult patient: successful treatment with a combination of glucocorticoid and antiviral agents.

A 35-year-old Iranian man with an 18-year history of human immunodeficiency virus (HIV) infection developed sudden left-sided hemiparesis and mild dysarthria. Based on laboratory results, brain and neck computerized tomography angiography (CTA), echocardiography, hypercoagulability tests, and vasculitis tests, the patient was diagnosed with a stroke with multiple intracranial aneurysms secondary to HIV. Cerebral aneurysms and stroke are uncommon in HIV-infected patients, and the aneurysms' exact cause and risk factors are unknown. There is currently no effective regimen or definitive treatment for HIV-associated vasculitis. In the present study, the patient recovered without any neurological deficits following treatment with oral prednisolone, combined with combination antiretroviral therapy (cART), valacyclovir, and antiplatelet medication. Furthermore, after 2 months of immunosuppressive treatment, all imaging abnormalities improved, and no new events were observed at the 20-month follow-up. To the best of our knowledge, this is the first case in which a patient with HIV-associated vasculopathy and stroke has survived successfully, and all angiographic abnormalities completely eliminated.

Endovascular treatment as the first-line approach for cure of low-grade brain arteriovenous malformation.

OBJECTIVE: While microsurgery has been proposed as the first-line treatment for patients with low-grade (Spetzler-Martin grade I or II) brain arteriovenous malformations (bAVMs), recent studies have shown promising results for endovascular treatment (EVT) as a single proper choice for the management of this group of bAVMs. In this study, the authors evaluated the safety and efficacy of EVT as a first-line strategy for curing low-grade bAVMs at their center. METHODS: All patients with low-grade bAVMs managed primarily by EVT between 2015 and 2021 were enrolled in this study. Patients were evaluated and treated by the same team and followed with the same protocol. The primary endpoint was the efficacy of EVT on the cure of low-grade bAVMs. The second endpoint was the safety of EVT for the treatment of low-grade bAVMs, including procedural complications and long-term clinical outcomes. RESULTS: A total of 109 patients were enrolled and represented in the study population. The mean patient age was 31.6 ± 14.8 years. Forty-eight AVMs (44%) were Spetzler-Martin grade I and 61 (56%) were grade II. Of 99 patients who completed their EVT sessions, complete exclusion was achieved in 89 patients (89.9%). Overall, complete exclusion was achieved in 59.6% of patients after a single EVT session. At the 6-month follow-up, 106 patients (97.2%) had a favorable outcome. Four patients (4.6%) experienced transient neurological deficits, and 1 patient (0.9%) had a permanent neurological deficit. CONCLUSIONS: EVT can be offered as the first choice of treatment for select patients with low-grade bAVMs, with a high cure rate and low morbidity.

Association of 5-lipoxygenase activating protein gene polymorphism and stroke: A study from north east of Iran.

Background: Stroke is a multifactorial disorder and a major cause of morbidity and mortality around the world. There are growing numbers of candidate gene pathways which are thought to be associated with stroke. Genes involved in lipid metabolism are important issues in stroke studies. Studying different polymorphisms in these genes are becoming an interest for researchers. 5-lipoxygenase activating protein (ALOX5AP) is one of these genes. Different studies have provided different relations between ALOX5AP promoter polymorphism (rs17222919) and stroke. In the present study, we have evaluated this gene polymorphism in a population in north east of Iran. Methods: This case-control study took place in Ghaem Hospital, Mashhad, Iran. Patients with computed tomography (CT) or magnetic resonance imaging (MRI) confirmation for ischemic stroke were enrolled in this study and considered as case group. Healthy persons without ischemic stroke were control group. During 1-year period of this study, ALOX5AP gene polymorphism in 200 healthy patients (control group) as well as 228 patients with stroke (case group) was evaluated by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Results: All of 428 persons (228 cases and 200 healthy controls) enrolled in this study. The genotype and allele frequency was significantly different between both groups (P = 0.001 and P = 0.003, respectively). A total number of 54 patients had G allele in case group in contrast to 27 ones in control group. Also, 174 patients in case group had T allele and 173 persons had this allele in control group. In compression of TT genotype, the risk of developing stroke in GG and TG genotypes increased by 3.998 and 1.643, respectively. Also the risk of ischemic stroke with G allele would increase by 2.128. Conclusion: According to our results, ALOX5AP promoter polymorphism (rs17222919) is related to increased ischemic stroke in Iranian population.

Malignant Cerebral Venous Infarction: Decompressive Craniectomy versus Medical Treatment.

BACKGROUND: Cerebral venous thrombosis (CVT) is a common type of stroke in young adults and associated with 8% mortality. High intracranial pressure (ICP) and brain herniation are the most common causes of death in these patients. In contrast with malignant arterial middle cerebral infarction, there are few studies reporting the efficacy of decompressive craniectomy (DC) for treatment of high ICP in patients with CVT. In this study, we assess the clinical outcome of patients with CVT with impending brain herniation treated with DC versus medical management. METHODS: In this retrospective study, medical records of all patients with CVT admitted to our hospital were reviewed. Patients with the following inclusion criteria were entered into the study: 1) CVT proven by contrast-enhanced magnetic resonance venogram and/or computed tomography venogram, 2) malignant CVT (impending brain herniation according to imaging and clinical finding), and 3) age between 16 and 80 years. Patients with deep venous system thrombosis, Glasgow Coma Scale (GCS) score of 3, and bilateral nonreactive midposition pupils or mydriasis on admission were excluded. Patients were classified into 2 groups: surgical group (DC group) including patients who received medical treatment and DC and medical group (MG) including patients who received only medical treatment. Outcomes and complications were assessed and compared between the 2 groups. RESULTS: Of 357 patients with CVT hospitalized in our center, 48 patients entered into the study. Twenty-three patients were managed medically, and 25 patients were managed surgically. There was no significant difference between the groups concerning age, sex, presenting symptoms, transient and permanent risk factors of CVT, GCS score on admission, and pupils' reactivity on admission. All patients in the MG died during hospitalization in comparison with 8 patients in the DC group (100% vs. 32%, P < 0.001). Favorable outcome (modified Rankin scale score 0-2) was achieved in 52% of the DC group and 0% of the MG group (P < 0.001). CONCLUSIONS: The results of our study confirmed that in contrast with DC, medical treatment could not prevent transtentorial herniation. DC is not only lifesaving for patients with CVT with impending brain herniation but also results in favorable outcome in most patients.

Rare Presentation of Moyamoya Disease with Sub acute Presentation in Iran.

Moyamoya disease is a chronic progressive vascular disease of brain characterized by bilateral stenosis or occlusion of the arteries around the circle of Willis with prominent arterial collateral circulation. We introduce here a patient with Moyamoya who was misdiagnosed. She was a 16-yr-old female from north east of Iran who complained left hemiparesis and was diagnosed Moyamoya disease by brain and cervical CT-Angiography. There was still great difficulty in the diagnosis of diffuse white matter lesions. The CT-Angiography showed bilateral internal carotid stenosis with "puff of smoke" collateralization arising from the circle of Willis, therefore Moyamoya disease was raised. The clinical diagnosis of Moyamoya is challenging and misdiagnosis is probable. Therefore, the physicians should know this disease and think about it in patients with Juvenile stroke. This shows that Moyamoya disease should be considered in differential diagnoses especially among young patients presenting with unexplained cerebrovascular syndromes.

Cognitive function, depression, and quality of life in patients with ruptured cerebral aneurysms.

Background: Neuropsychiatric dysfunction is one of the most common complications after aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to evaluate cognitive function, depression, and quality of life (QOL) in patients with aSAH. Methods: In this study, we prospectively enrolled patients with SAH due to rupture of anterior circulation aneurysms who referred to Ghaem hospital, Mashhad, Iran, and who had good function outcome [modified Rankin scale (mRS) > 2]. They underwent microsurgery or endovascular treatment. Cognitive function, depression, and QOL were evaluated 6 months after surgery with standard psychiatric examinations, including Mini-Mental State Examination (MMSE) for cognitive function, Hospital Anxiety and Depression Scale (HADS) for depression, and 36-Item Short Form Health Survey (SF-36) for QOL. Risk factors for cognitive dysfunction were assessed. Results: Fifty-three patients were entered the study. The mean of age was 50.9 ± 13.6 years. QOL and its components were affected in most patients. Fifty-five percent of patients suffered from depression. Cognitive impairment was found in 57% of patients. Older patients experienced more cognitive impairment (P < 0.001). Conclusion: Neuropsychological sequels are common in patients with aSAH, even if they classified as good functional outcome (mRS > 2). These complications could be found with appropriate neuropsychological evaluation of these patients to be managed as soon as possible.

Gaps and hurdles deter against following stroke guidelines for thrombolytic therapy in Iran: exploring the problem.

BACKGROUND: Insufficient information is available on the barriers that explain low rates of thrombolytic therapy for acute ischemic stroke (AIS) in developing countries compared with rates in developed societies. By the present study, we aimed to assess the implementation of thrombolytic therapy in the northeast of Iran to explore the gaps and hurdles against thrombolysis as the generally accepted treatment for AIS. METHODS: In a 1-year cohort study among AIS patients admitted to the second largest tertiary neurologic referral center in Iran, those who met the prespecified selection criteria were treated with intravenous recombinant tissue plasminogen activator (rtPA). RESULTS: Among 1,144 patients admitted with AIS, only 14 (1.2%) were treated with rtPA. The mean onset-to-needle and door-to-needle times were 172 and 58 minutes, respectively; 980 (85.6%) patients were initially excluded from the study because of late arrival. Additionally, 60 patients in total were omitted because of either their high age (3.7%) or passing the gold standard time limit for rtPA therapy after preliminary evaluations (1.6%), and 90 more patients (7.9%) were considered not suitable for thrombolysis because of the severity of the symptoms or the higher risk of bleeding on rtPA. CONCLUSIONS: Access to thrombolytic therapy for AIS in Iran is less than in most developed countries but comparable with other developing countries. Awareness campaigns are needed to minimize barriers and improve access to thrombolysis and specialized stroke care in Iran.

Decompressive craniectomy after unsuccessful intravenous thrombolysis of malignant cerebral infarction.

BACKGROUND: Intravenous recombinant tissue plasminogen activator (rt-PA) is an approved treatment for acute ischemic stroke within 4.5 h of symptoms onset. Decompressive craniectomy (DC) has been shown as an effective therapeutic modality in malignant middle cerebral artery (MCA) infarction. As rt-PA could result in hemorrhagic complication during or after any surgery DC may be associated with severe bleeding after intravenous thrombolysis. CASE DESCRIPTION: A 57-year-old woman was presented 90 min after the sudden onset of left hemiplegia. Despite intravenous thrombolytic therapy, she lost consciousness within 48 h and brain CT scan showed a right malignant MCA infarction associated with a small bleeding. DC was performed without any complication. The patient improved dramatically. CONCLUSION: DC could be done safety for malignant MCA infarction after unsuccessful intravenous thrombolytic therapy even the later was complicated with intra-infarction hemorrhage.

Guillain-Barré-like Syndrome, as a Rare Presentation of Adult T-cell Leukemia-Lymphoma (ATLL): A Case Report.

We report a 21-year-old woman who was admitted because of unilateral facial paresis and then developed progressive ascending flaccid tetraparesis with generalized areflexia. Electrodiagnostic studies revealed acute motor axonal polyradiculoneuropathy (AMAN type of Guillain-Barré Syndrome). Further evaluations revealed severe leukocytosis, increased erythrocyte sedimentation rate (ESR), increased protein content and presence of a few lymphocytes in cerebrospinal fluid (CSF), and then presence of human T-cell lymphotropic virus type 1 (HTLV-I) in serum and CSF. Finally, biopsy of the enlarged lymph nodes resulted in the diagnosis of Adult T-cell Leukemia-Lymphoma. The HTLV-1 has been endemic to certain parts of Iran like Khorasan province in the northeast since 1985 with 2.3% prevalence rate of infection. Thus, some rare neurologic complications occasionally occur in this area as a result of being infected with HTLV-1.

Lavender essential oil in the treatment of migraine headache: a placebo-controlled clinical trial.

UNLABELLED: Lavender essential oil has been used as an anxiolytic drug, a mood stabilizer, a sedative, spasmolytic, antihypertensive, antimicrobial, analgesic agent as well as a wound healing accelerator. We have studied for the first time the efficacy of lavender essential oil inhalation for the treatment of migraine in a placebo-controlled clinical trial. METHODS: Forty-seven patients with definite diagnosis of migraine headache were divided into cases and controls. Cases inhaled lavender essential oil for 15 min, whereas the control group used liquid paraffin for the same time period. Patients were asked to record their headache severity and associated symptoms in 30-min intervals for a total of 2 h. We matched the two groups for key confounding factors. RESULTS: The mean reduction of headache severity in cases was 3.6 ± 2.8 based on Visual Analogue Scale score. The reduction was 1.6 ± 1.6 in controls. This difference between the controls and cases was statistically significant with p < 0.0001. From 129 headache attacks in cases, 92 responded entirely or partially to lavender. In the control group, 32 out of 68 recorded headache attacks responded to placebo. The percentage of responders was significantly higher in the lavender group than the placebo group (p = 0.001). CONCLUSION: The present study suggests that inhalation of lavender essential oil may be an effective and safe treatment modality in acute management of migraine headaches.

Cerebral vein thrombosis in women using short course oral contraceptive consumption.

BACKGROUND: Muslim women tend to postpone their menstrual period using short course oral contraceptives (OC) during Ramadan, Muslims fasting month. Recently, many cases of stroke, particularly cerebral vein thrombosis (CVT), have been reported in Ramadan. OBJECTIVE: This work studies the incidence of CVT and its relation to Ramadan. MATERIALS AND METHODS: This is a cohort study conducted from October 2006 to October 2009 and included 4 consecutive Ramadan's. All patients with definite diagnosis of CVT who were referred to the neurology department of Ghaem Hospital, Mashhad, Iran in this four-year period were included in the study. RESULTS: During the study period, 70 cases with CVT (11 males and 59 females) were recruited. Twenty five cases were admitted during Ramadan months which was significantly higher than all the other 32 months (p=1.9×10(-7)). The higher frequency of females (6 times more) among CVT cases probed by investigating possible risk factors and short term OC consumption was revealed as the major risk factor (p=0.00071). CONCLUSION: Higher incidence of CVT in females during Ramadan suggests the presence of specific risk factors in this group. Our study revealed that short-term use of OCs may be a major risk factor for CVT.

Prevalence of peripheral neuropathy in patients with HTLV-1 associated myelopathy/tropical spastic paraparesis (HAM/TSP).

UNLABELLED: While the most common neurological disorder associated with Human T lymphotropic virus type-1 (HTLV-1) infection in the endemic areas is HTLV-1 associated myelopathy also know as tropical spastic paraparesis (HAM/TSP), other disorders such as optic neuropathy, peripheral neuropathy and cerebellar diseases have also been reported in patient with this infection. In this paper, we studied the prevalence of peripheral nerve involvement in patients with HAM/TSP. METHODS: Seventy three patients diagnosed with HAM/TSP in accordance to criteria set by the World Health Organization (WHO) were evaluated in this cross-sectional study. Clinical and electrodiagnostic criteria were used for the diagnosis of peripheral neuropathy. RESULTS: Electrodiagnostic studies showed that 30.1% of patients with HAM/TSP had peripheral nerve involvement. All patients had predominantly axonal neuropathy with sensory-motor polyneuropathy being the most common neuropathy observed in our patients. DISCUSSION AND CONCLUSION: Peripheral neuropathy may be more common than previously thought and should be checked systematically in all patients with HAM/TSP.