Analysis of cerebral venous sinus stenosis by flat panel angiographic CT (FP-CT) to guide treatment for idiopathic intracranial hypertension.

INTRODUCTION: Cerebral venous sinus stenting (CVSS) is an effective treatment for idiopathic intracranial hypertension (IIH) secondary to dural venous sinus stenosis. Traditional selection of patients for CVSS has been made by microcatheter manometry, but pressure measurements are often equivocal. Here we present the results of a series of cases in which venous flat-panel CT (FP-CT) was used as an adjunct to microcatheter manometry to improve decision making and precise stent placement during CVSS. METHODS: Ten consecutive patients with IIH underwent angiography with microcatheter manometry and venous FP-CT, with CVSS if indicated by the results. Cross-sectional measurements of the narrowed sinus were obtained on FP-CT before and after stenting. After the procedure, clinical outcomes were tracked. Follow-up with quantitative MRA with sinus flow measurements was also performed, when available. RESULTS: There was an exponential correlation between measured pressure gradient and degree of stenosis calculated using venous FP-CT. All patients with both a high degree of stenosis measured by FP-CT and a high pressure gradient across the stenosis showed a clinical benefit from stenting. CONCLUSIONS: True measurement of the cross-sectional area of the dural sinus, made by venous phase FP-CT, has a high degree of correlation with elevated venous pressure gradient across the point of stenosis. Even in a limited series of cases, we found an exponential decrease in flow with increasing severity of stenosis. Furthermore, patients with both an elevated venous pressure gradient and critical stenosis of the sinus on FP-CT showed symptomatic improvement after stenting.

Hemorrhagic versus non-hemorrhagic presentation of presumed reversible cerebral vasoconstriction syndrome (RCVS): Presentations and outcomes.

INTRODUCTION: Reversible cerebral vasoconstriction syndrome (RCVS) can present with hemorrhage, ischemia, or both. We aim to compare the differences in presentation and outcomes between patients with RCVS. METHODS: The hemorrhagic presentation group had 58 patients, and the non-hemorrhagic presentations had 30 patients. Subgroup analysis compared patients with evidence of one or more types of hemorrhage (n = 53), no evidence of hemorrhage or infarction (n = 23), evidence of infarction only (n = 7), and combination of hemorrhage and infarction (n = 5). Clinical and radiographic data were analyzed. RESULTS: Migraine (p = 0.030) and intracranial tumors (p = 0.004) were more frequent in non-hemorrhagic presentation. Seizures on admission (p = 0.047) and higher than average C-reactive protein (CRP) (p = 0.037) were seen at a higher rate in patients with hemorrhagic presentation. RCVS2 scores were not unexpectedly higher in patients with hemorrhage than non-hemorrhagic presentations (p = 0.010). Outcomes between the hemorrhagic and non-hemorrhagic groups were comparable. Subgroup analysis found a higher subset of patients with opiate use (p = 0.046) in the hemorrhage-only group. Patients with hemorrhage presented with a thunderclap headache (p < 0.001) more often when compared to the other three groups. RCVS2 score was not unexpectedly higher in the hemorrhage-only group compared with the other groups (p = 0.004). CONCLUSION: A history of migraines was associated with ischemia, while intracranial tumor was significantly associated with evidence of either an infarct, or no changes on imaging. Exposure to opiates, and seizures or thunderclap headache on presentation were associated with hemorrhage. If our data are reproducible, the RCVS2 score may benefit from inclusion of other, small hemorrhages as criterion for diagnosis for RCVS.

Part 1: Pushing the boundaries of neurointerventional surgery: A historical review of the work of Dr Gerard Debrun.

French-American neurointerventionalist and pioneer, Dr Gerard Debrun, laid the groundwork for treatments which have become irreplaceable in neurointerventional surgery today. This article aims to outline the career of Dr Debrun while highlighting his accomplishments and contributions to the field of neurointerventional surgery. We selected relevant articles from PubMed authored or co-authored by Dr Debrun between 1941 and 2023. All included articles discuss the accomplishments and contributions of Dr Debrun. Dr Debrun began his career in France by investigating neurointerventional techniques, most notably the intravascular Detachable Balloon Catheter (DBC). His work was recognized by renowned neurosurgeon Dr Charles Drake, who recruited him to London, Ontario. Dr Debrun created the foundation for homemade manufacturing of DBCs, building on one of the largest series for use of DBCs in cerebrovascular disease. Dr Debrun spent time as faculty at Massachusetts General Hospital (MGH) and Johns Hopkins Hospital, before arriving at the University of Illinois Chicago (UIC) where he remained until his retirement. Dr Debrun's subsequent contributions included the calibrated-leak balloon catheter, pioneering of glue embolization, setting the foundation for preoperative AVM embolizations, and as an early adopter of the Guglielmi detachable coil (GDC), including mastering the balloon remodeling technique for wide neck aneurysms. Dr Debrun established the first integrated neurointerventional surgery program at UIC, establishing a well sought-after fellowship program. Dr Debrun lectured extensively and was a prolific writer on neurointerventional surgery throughout this career. His contributions established the foundation for several techniques which have since become standard practice in present-day neurointerventional surgery.

Part 2: The development and advancement of the detachable balloon catheter; a historical and technical review.

The detachable balloon catheter (DBC) was a revolutionary technique for the treatment of cerebrovascular pathologies. It was used to treat carotid cavernous fistulas (CCFs), vertebro-jugular fistulas, arteriovenous malformations (AVMs), and aneurysms. The DBC became the foundation for neurointerventional techniques, leading to the development of coil embolization and bioactives. Our team selected relevant articles from PubMed published between 1974 and 2023. Articles were excluded if they did not discuss the use or development of the detachable balloon catheter or subsequent technologies. The DBC was used to occlude vessels, either temporarily or permanently. Dr Gerard Debrun implemented findings from Dr Fedor Serbinenko's research to develop an intravascular detachable balloon technique. He developed many variations using type I and type II balloon catheters that differed in size, length, and material, allowing for the personalization of treatment based on the lesion. This revolutionary thinking showed that every pathology has a different shape and anatomy that require a unique approach. The DBC would offer the first alternative to the conventional practice of carotid occlusion in CCF treatment at the time. The DBC would later be used in aneurysm occlusion and the embolization of AVMs, with additional benefit in traumatic vascular sacrifice. Although the DBC has largely been replaced, it is still useful in a small subset of patients, and has financial incentive as it is more affordable than coils. This technique was a monumental stride in the history of neurointervention and helped propel the specialty to the current era of patient-specific interventions.

Glue embolization of ruptured pseudoaneurysm secondary to reversible cerebral vasoconstriction syndrome: An illustrative case.

BACKGROUND: Reversible cerebral vasoconstriction syndrome (RCVS) is an increasingly recognized condition characterized by thunderclap headache with or without other neurological deficits and diffuse vasoconstriction of cerebral arteries. Altered cerebrovascular tone may produce hemorrhage or stroke. METHODS: A retrospective review of patients with RCVS at our institution (2000-2023) yielded one case of pseudoaneurysm secondary to RCVS. RESULTS: Diagnostic cerebral angiogram demonstrated diffuse multifocal segmental narrowing consistent with RCVS and a left M4 pseudoaneurysm in proximity to the cortical hemorrhage. The pseudoaneurysm was treated with branch vessel sacrifice using nBCA glue in a 1 : 3 ratio with ethiodized oil. After securing the source of hemorrhage, the patient received an intra-arterial infusion of Verapamil. CONCLUSION: This unique presentation of pseudoaneurysm secondary to RCVS in this patient highlights the impact of hemodynamic alteration as a possible source of bleeding and demonstrates a potential management strategy. Endovascular management with nBCA glue embolization successfully treated this lesion.

Predictors of angiographic resolution in patients with presumed reversible cerebral vasoconstriction syndrome.

INTRODUCTION: Reversible cerebral vasoconstriction syndrome is a complex neurovascular syndrome that presents with varying neurological deficits as well as segmental vasoconstriction of the small and medium cerebral arteries. There is limited literature on pathologies that mimic reversible cerebral vasoconstriction syndrome, so this study aims to understand what factors may impact the angiographic confirmation of reversible cerebral vasoconstriction syndrome on follow-up and play a role in establishing the diagnosis. METHODS: The Clinical Research Data Warehouse at this institution was employed to search the medical records for patients with diagnosis and treatment of reversible cerebral vasoconstriction syndrome between January 2010 and May 2021. After screening, 32 patients met the inclusion criteria for a presumed diagnosis of reversible cerebral vasoconstriction syndrome with both angiography on presentation and at three-month follow-up after treatment. Patients were divided into two categories: those with complete angiographic resolution, versus partial or no improvement on follow-up. Clinical and radiographic data were analyzed. RESULTS: Patients who had partial or no resolution were more likely to have a history of hypertension (p = 0.001), higher systolic blood pressure on admission (p = 0.047), and present with a recurrent thunderclap headache (p = 0.038). Binary logistic regression selected for hypertension (odds ratio [OR] 18.35 [95% CI, 1.37-245.1]) as predictive of not having reversible cerebral vasoconstriction syndrome, as can be seen by partial or no resolution on follow-up angiography (p = 0.028). CONCLUSION: Complete resolution on follow-up angiography is a distinguishing factor of reversible cerebral vasoconstriction syndrome. Our analysis revealed that a history of hypertension is the most significant predictor of confirming that a patient may not have reversible cerebral vasoconstriction syndrome. This is due, in part, to increased atherosclerotic or hypertensive cerebral arterial changes, which can mimic reversible cerebral vasoconstriction syndrome and present as partial or no resolution on angiography.

Refinement of nBCA embolization technique in treatment of metastatic spinal tumors: Case series and technical report.

BACKGROUND AND OBJECTIVES: Preoperative embolization of metastatic spinal tumors (MSTs) has proven advantageous in limiting intraoperative blood loss (IBL) during resection. N-butyl cyanoacrylate (nBCA) is a liquid embolic agent known for its rapid hemostatic effects. However, nBCA is associated with a higher risk of distal nontarget embolization. This study highlights the refinement of the embolization technique and assesses its efficacy in performing an initial distal segmental artery plug with concentrated nBCA followed by proximal diluted nBCA for MSTs. METHODS: A retrospective review of patients with MST (2018-2023) was performed. Patients who underwent preoperative nBCA endovascular embolization prior to tumor resection and spinal instrumentation were included. Baseline standard spinal angiography was performed. RESULTS: Sixteen patients (13 men, 3 women; 56.0 ± 12.4 years) met inclusion criteria. And 43.75% (7 of 16) had thoracic levels, 37.5% (6 of 16) lumbar, and 18.75% (3 of 16) sacral. The most common primary tumor was renal cell carcinoma (43.75%, 7 of 16). A total of 43 pedicles were embolized (median 3), resulting in complete/near complete obliteration of the tumor blush. Most pedicles (83.7%, 36 of 43) received a single dilute concentration of nBCA; however, 16.3% (7 of 43) received two separate concentrations of nBCA, a denser concentration distally into the segmental artery and a diluted concentration proximally into the tumor bed. Mean IBL was 1150 ± 1201 mL in 3 distal plug patients distal plug patients versus 1625 ± 681 mL in 12 other patients. There were no complications related to embolization. CONCLUSION: Performing a distal, concentrated nBCA plug during preoperative nBCA embolization of MSTs may increase tumor penetration and reduce IBL.

Anticoagulation Options for Cranial Procedures: A Comparative Review of Aspirin, Plavix, and Aggrastat.

Anticoagulation therapy is critical to avoiding thrombotic events in patients following cranial surgery. Although Aspirin, Plavix, and Aggrastat are used as anticoagulants for this purpose, there is no consensus on which agent is the most effective and safe. In this comparative study, we analyze the current evidence on the efficacy and safety of these three anticoagulants in the context of cranial surgeries. This review focuses on the advantages and disadvantages of each anticoagulant, such as its pharmacokinetics, indications, contraindications, and possible consequences. The outcomes of this study will help physicians choose the best anticoagulant for their patients based on individual patient characteristics and the kind of cranial procedure. Aggrastat's potential to be included as a recommended anticoagulant for cranial procedures warrants further study.