Dural venous sinus stenting technique for idiopathic intracranial hypertension in patients with tortuous venous anatomy.

Venous sinus stenting (VSS) for medically refractory idiopathic intracranial hypertension (IIH) is emerging as a safe and effective alternative to shunting. However, stent navigation past the jugular bulb with commonly used carotid stenting systems via femoral access in cases with tortuous venous anatomy can present a challenge, leading to procedural failure. We present a technical refinement using a cervical access and peripheral vascular stent with a more stable 0.035-in. delivery platform as an alternative to the traditional approach to simplify the procedure and overcome the technical difficulties in cases with tortuous venous anatomy. Our institutional database for patients who had IIH and undergone VSS using the peripheral vascular stent between 2013 and 2023 was retrospectively reviewed. Data on 36 patients (33 women, 3 men, mean age 32 years) was collected. VSS was technically successful in all patients (100%) without major complications or thrombosis. There was one case of minor neck cellulitis treated with oral antibiotics. Three patients underwent repeat stenting, and 2 patients had ventriculoperitoneal shunt placement after stenting due to persistent or recurrent symptoms. All patients (100%) had improvement or resolution of papilledema; however, six patients had evidence of optic atrophy and persistent vision loss. Headache was resolved or improved in 91% of patients. In the presence of tortuous venous anatomy, VSS using cervical access and a peripheral vascular stent with a more stable 0.035-in. delivery platform can be considered as a safe and effective alternative approach with shorter procedure time. This approach is particularly advantageous in situations where the procedure is prolonged or high dose of contrast has been administered due to the technical challenges associated with the traditional use of carotid systems via femoral access for stent delivery.

A Single-Center Retrospective Analysis Investigating the Effect of Timing of Vertebral Augmentation on Pain Outcomes.

BACKGROUND: Approximately 700,000 individuals experience osteoporotic vertebral compression fractures (OVCF) every year in the United States. Chronic complications from patients and increasing economic burdens continue to be major problems with OVCFs. Multiple treatment options for OVCF are available, including conservative management, surgical intervention, and minimally invasive vertebral augmentation. Prior studies have investigated the utility of vertebral augmentation techniques such as percutaneous vertebroplasty (PVP), balloon vertebroplasty (BVP), and vertebral augmentation with the KivaTM implant on patient mortality with favorable results. The optimal time from OVCF occurrence to vertebral augmentation continues to be a topic of investigation. OBJECTIVES: To further investigate the effect of the timing of vertebral augmentation on pain outcomes. STUDY DESIGN: A retrospective cohort chart review study. SETTING: A single academic center in Albuquerque, New Mexico. METHODS: One hundred twenty-six consecutive patient encounters with OVCF diagnosed on imaging and treated with PVP, BVP, or vertebral augmentation with a KivaTM implant between 01/01/2004 and 11/28/2016 were analyzed. The time between fracture and intervention was categorized into < 6 weeks, 6-12 weeks, and >= 12 weeks. Pain scores were measured before and after treatment using the numeric pain rating scale. Statistical analysis using Wilcoxon-Mann-Whitney and Kruskal-Wallis tests were used as appropriate, and effect sizes were described with the Hodges-Lehmann estimates of difference. RESULTS: The 3 vertebral augmentation procedures compared in this study did not demonstrate statistically significant differences in pain score reduction (P = 0.949). The < 12 weeks group had a median and interquartile range (IQR) pain improvement of 3 (IQR 1,6) versus 1 (IQR 0,4) in the >= 12 weeks group (P = 0.018). Further analysis showed that the median and IQR pain improvement for the < 6 weeks group was 3 (IQR 1,7), for the 6-12 weeks group was 3 (IQR 1,4), and for the >= 12 weeks group was 1 (IQR 0,4). The overall effect of the time category on pain improvement was statistically significant for these groups (P = 0.040). Comparisons between groups only showed differences between the < 6 weeks and >= 12 weeks groups (P = 0.013), with an estimated median difference of 2 (95% CI 0,3). There was no statistically significant relationship between fill percentage and pain relief (P = 0.291). LIMITATIONS: This is a retrospective cohort study from a single academic center with a limited sample size that lacked a control group and procedural blinding. There was also substantial heterogeneity among patients, fractures, operators, and techniques. Pain relief outcomes are subjective and can be biased by patients as well as physician reporting. CONCLUSIONS: Early intervention (< 12 weeks) with vertebral augmentation in patients with OVCF is associated with improved pain scores when compared to later intervention (> 12 weeks). Very early intervention (< 6 weeks) confers a greater advantage when compared to later intervention (> 12 weeks).

Blunt cerebrovascular injury in pediatric trauma: a national database study.

OBJECTIVE: The incidence of blunt cerebrovascular injury (BCVI) has not been well characterized in the pediatric population. The goal of this study was to describe the incidence, patient characteristics, and risk factors for pediatric patients with cerebrovascular injuries. METHODS: The authors collected data from the Kids' Inpatient Database (KID), a nationally representative database of pediatric admissions, for years 2000, 2003, 2006, 2009, and 2012. RESULTS: Among an estimated 646,549 admissions for blunt trauma, 2150 were associated with BCVI, an overall incidence of 0.33%. The incidence of BCVI nearly doubled from 0.24% in 2000 to 0.49% in 2012. Patients 4 to 13 years of age were less likely to have BCVI than those in the youngest (0-3 years) and oldest age groups comprising adolescents (14-17 years) and young adults (18-20 years). BCVIs were associated with cervical (adjusted OR [aOR] 4.6, 95% CI 3.8-5.5), skull base (aOR 3.0, 95% CI 2.5-3.6), clavicular (aOR 1.4, 95% CI 1.1-1.8), and facial (aOR 1.2, 95% CI 1.0-1.5) fractures, as well as intracranial hemorrhage (aOR 2.7, 95% CI 2.2-3.2) and traumatic brain injury (aOR 2.0, 95% CI 1.7-2.3). Mechanism of injury was also independently associated with BCVI: motor vehicle collision (aOR 1.7, 95% CI 1.3-2.2) and struck pedestrian (aOR 1.4, 95% CI 1.0-1.9). Among pediatric patients with BCVI, 37.4% had cerebral ischemic infarction with an in-hospital mortality of 12.7%, and patients with stroke had 20% mortality. CONCLUSIONS: The incidence of pediatric BCVI is increasing, likely due to increased use of screening, but remains lower than that in the adult population. Risk factors include the presence of cervical, facial, clavicular, and skull base fractures, similar to that of the adult population. Diagnosed BCVI is associated with a relatively high incidence of stroke with increased morbidity and mortality. The use of adult screening criteria is likely reasonable given the similarity in the risk factors identified in this study. Further studies are needed to investigate the role of treatment with antiplatelet agents or anticoagulation.

Restrictive cerebral cortical venopathy: A new clinicopathological entity.

We present a case of a novel restrictive cerebral venopathy in a child, consisting of a bilateral network of small to medium cortical veins without evidence of arteriovenous shunting, absence of the deep venous system, venous ischemia, elevated intracranial pressure, and intracranial calcifications. The condition is unlike other diseases characterized by networks of small veins, including cerebral proliferative angiopathy, Sturge-Weber syndrome, or developmental venous anomaly. While this case may be the result of an anatomic variation leading to the congenital absence of or early occlusion of the deep venous system, the insidious nature over many years argues against this. The absence of large cortical veins suggests a congenital abnormality of the venous structure. The child's presentation with a seizure-like event followed by protracted hemiparesis is consistent with venous ischemia. We propose that this is likely to represent a new clinicopathological entity.

Recurrent posterior circulation infarcts secondary to vertebral artery external compression treated with endovascular deconstruction.

When multiple, recurrent infarcts occur in spite of maximal medical management, the level of suspicion for atypical vascular injury should be heightened. We present a case of a patient who presented with recurrent posterior circulation infarcts despite optimized medical management. On imaging, he was found to have external anatomical vertebral artery muscular and/or osseous compression leading to repetitive vascular injury and strokes. Recurrent intimal injury and vertebral artery to intracranial emboli despite anticoagulation and subsequent dual antiplatelet therapy necessitated definitive operative management. Surgical bypass, external surgical decompression, reconstructive endovascular, and deconstructive endovascular techniques were carefully considered. A deconstructive endovascular approach was chosen as the least morbid option. The use of endovascular plugs such as a microvascular plug provides a quick and effective means of achieving a therapeutic parent artery occlusion in lieu of traditional coil occlusion. Although reserved as a last resort, parent artery occlusion can be a viable option to treat recurrent strokes, particularly in a nondominant vertebral artery.

Intraoperative spinal digital subtraction angiography: indications, technique, safety, and clinical impact.

BACKGROUND: Cerebral intraoperative DSA (IODSA) is a well-described, routinely performed procedure that allows the effectiveness of cerebrovascular interventions to be evaluated in the operating room. Spinal IODSA, on the other hand, is infrequently obtained and has received less attention. OBJECTIVE: To discuss the indications, technique, safety, and clinical impact of spinal IODSA. MATERIALS AND METHODS: Twenty-three patients underwent 45 thoracic and/or lumbar spinal IODSA between 2005 and 2016, either immediately before surgery for lesion localization or after the intervention to evaluate its effectiveness. Indications included 21 vascular malformations and 2 diaphragmatic crus compression syndromes. A long femoral arterial sheath with its hub positioned on the lateral surface of the thigh was used to allow catheter manipulations in the prone position. RESULTS: All targeted intersegmental arteries (ISAs) were successfully catheterized. The course of surgery was changed in 6 instances (26.1%). In 4 cases of epidural or perimedullary arteriovenous fistulae (AVFs), a residual lesion required additional intervention. In one case of epidural AVF, initial IODSA revealed spontaneous resolution of the lesion, preventing unnecessary surgery. Finally, angiography performed in a case of diaphragmatic crus syndrome showed thrombosis of the ISA and non-visualization of the artery of Adamkiewicz. Recanalization was obtained by IA thrombolysis, with excellent clinical outcome. No intraprocedural or postprocedural complication was noted. CONCLUSIONS: Spinal IODSA is a safe technique that offers an immediate assessment of the effectiveness of a spinovascular surgical procedure, notably epidural and perimedullary AVFs. Spinal IODSA was technically successful in all cases, influencing the surgical strategy in 6 of 23 patients, including one patient who benefited from intraoperative endovascular therapy.

Angiographic suppression of the artery of Adamkiewicz by venous hypertension resolving after embolization in a case of spinal epidural arteriovenous fistula.

A case of complete angiographic suppression of the artery of Adamkiewicz and anterior spinal artery in a patient with a spinal epidural arteriovenous fistula (AVF) is reported. Slow flow AVFs typically present with progressive myelopathy secondary to spinal venous hypertension (SVH). The lack of a normal venous phase during angiography and its restoration after treatment is commonly observed with these lesions, yet a similar phenomenon seems exceptional at the arterial level. Right T11 intercostal artery angiograms obtained before and after treatment of a left L4 epidural AVF documented the initial suppression of the artery of Adamkiewicz and anterior spinal artery, and their normal appearance immediately after correction of the SVH by embolization. This report confirms that SVH can angiographically suppress prominent and functionally important spinal arteries, re-emphasizing the potential role played by secondary arterial changes in SVH induced myelopathy. This hemodynamic phenomenon also represents a potential pitfall during diagnostic and therapeutic endovascular procedures.

Longitudinally extensive myelopathy in children.

When children present with acute myelopathy manifested by sensory, motor, or bowel and bladder symptoms, MRI of the neuraxis with contrast agent is the most important imaging study to obtain. Although occasionally normal, MRI often demonstrates signal abnormality within the spinal cord. Classically, longitudinally extensive transverse myelitis (≥3 vertebral bodies in length) has been described with neuromyelitis optica (NMO), but alternative diagnoses should be considered. This pictorial essay reviews the differential diagnoses that may present with longitudinally extensive spinal cord signal abnormalities. Multiple inflammatory, infectious, vascular, metabolic and neurodegenerative etiologies can present with a myelopathy. Thus, radiologists can assist in the diagnosis by familiarizing themselves with the spectrum of diseases in childhood that result in longitudinally extensive signal abnormalities in the absence of trauma.

Angiographic suppression of the artery of Adamkiewicz by venous hypertension resolving after embolization in a case of spinal epidural arteriovenous fistula.

A case of complete angiographic suppression of the artery of Adamkiewicz and anterior spinal artery in a patient with a spinal epidural arteriovenous fistula (AVF) is reported. Slow flow AVFs typically present with progressive myelopathy secondary to spinal venous hypertension (SVH). The lack of a normal venous phase during angiography and its restoration after treatment is commonly observed with these lesions, yet a similar phenomenon seems exceptional at the arterial level. Right T11 intercostal artery angiograms obtained before and after treatment of a left L4 epidural AVF documented the initial suppression of the artery of Adamkiewicz and anterior spinal artery, and their normal appearance immediately after correction of the SVH by embolization. This report confirms that SVH can angiographically suppress prominent and functionally important spinal arteries, re-emphasizing the potential role played by secondary arterial changes in SVH induced myelopathy. This hemodynamic phenomenon also represents a potential pitfall during diagnostic and therapeutic endovascular procedures.