Vertebro-Vertebral Arteriovenous Fistulae: A Case Series of Endovascular Management at a Single Center.

OBJECTIVE: Vertebro-vertebral arteriovenous fistulae (VVFs) are a rare disorder characterized by a direct shunt between the extracranial vertebral artery and the veins of the vertebral venous plexus. This study aims to comprehensively review the characteristics and outcomes of endovascular treatments for VVFs at our center. METHODS: A retrospective review was conducted on 14 patients diagnosed with a VVF who underwent endovascular treatment at Siriraj Hospital from January 2000 to January 2023. The study assessed patient demographics, presentation, fistula location, treatment strategies, endovascular techniques employed, and treatment outcomes. RESULTS: Among the 14 patients, 11 (78.6%) were female, with an age range from 25 to 79 years (median: 50 years). Spontaneous VVFs were observed in 64.3% of the cases, including three associated with neurofibromatosis type 1 (NF-1). Iatrogenic injury accounted for two cases, and three patients had VVFs resulting from traffic accidents. A pulsatile neck mass and tinnitus, with or without neurological deficits, were common presenting symptoms. Active bleeding was observed in three cases with vascular injury, while unilateral proptosis, congestive heart failure, and incidental findings each presented in one patient. All the VVFs were successfully obliterated without major treatment complications. Parent vessel sacrifice was performed in 85.7% of the cases, while vertebral artery preservation was achieved in the remaining two patients. Embolic materials included detachable balloons, detachable coils, and n-butyl cyanoacrylate (NBCA) glue. All the presenting symptoms showed improvement, and no morbidity or mortality was observed. CONCLUSIONS: Endovascular embolization is a feasible and effective approach for achieving complete VVF obliteration with safety. Parent artery sacrifice should not be reluctantly performed, particularly when adequate collateral circulation is demonstrated.

World federation of interventional and therapeutic neuroradiology (WFITN) federation assembly neurointerventional surgery safety checklist.

Over the last 10 years, there has been a rise in neurointerventional case complexity, device variety and physician distractions. Even among experienced physicians, this trend challenges our memory and concentration, making it more difficult to remember safety principles and their implications. Checklists are regarded by some as a redundant exercise that wastes time, or as an attack on physician autonomy. However, given the increasing case and disease complexity along with the number of distractions, it is even more important now to have a compelling reminder of safety principles that preserve habits that are susceptible to being overlooked because they seem mundane. Most hospitals have mandated a pre-procedure neurointerventional time-out checklist, but often it ends up being done in a cursory fashion for the primary purpose of 'checking off boxes'. There may be value in iterating the checklist to further emphasize safety and communication. The Federation Assembly of the World Federation of Interventional and Therapeutic Neuroradiology (WFITN) decided to construct a checklist for neurointerventional cases based on a review of the literature and insights from an expert panel.

Treatment Outcomes of Mechanical Thrombectomy in Patients with Acute Posterior Circulation Stroke.

Objective The benefits of mechanical thrombectomy (MT) in patients with acute posterior circulation stroke remain unclear. Currently, there is no evidence from randomized control trials to show the safety and effectiveness of MT in patients with posterior circulation stroke. This study was to evaluate the treatment outcomes of MT in posterior circulation stroke patients enrolling in our hospital during 2010 to 2020. Materials and Methods Between January 2010 and December 2020, 66 patients with acute posterior circulation stroke underwent MT. Data collected and analyzed included demographics, comorbidity, National Institutes of Health Stroke Scale (NIHSS), procedure time, site of occlusion, presence of posterior communicating artery (PCoA), endovascular technique, and modified Rankin Scale (mRS). Good clinical outcome was defined by mRS at 2 or less at 90 days after MT. Statistical Analysis Variables with normal distribution were reported with mean ± standard deviation, meanwhile those with nonnormal distribution were demonstrated with median and range. Fisher's exact test for categorical variables or Mann-Whitney U test for continuous variables was performed. Multivariate logistic regression analysis with binary logistic regression method was used analyze the association between the prognosis factor and good outcome. Statistical significance was defined when p -value less than 0.05. Results The mean age of patients was 65.2 years with male predominance. The median NIHSS was 18.5. Successful recanalization (modified thrombolysis in cerebral infarction 2b-3) was achieved in 61/66 cases (92.42%) and postprocedure symptomatic intracerebral hemorrhage occurred in 5/66 cases (7.60%). Successful recanalization with good clinical outcome was obtained from 30 of 61 cases (49.18%); it was also associated with distal basilar artery occlusion ( p = 0.035) and PCoA patency presence ( p = 0.024). Our study showed the correlation between good treatment outcomes with initial NIHSS less than 20, intravenous recombinant tissue-type plasminogen activator, pre-MT magnetic resonance imaging Q5 brain, and contact aspiration MT technique. Conclusion MT is beneficial to patients with posterior circulation stroke. A good clinical outcome was significantly associated with distal basilar artery occlusion and PCoA patency presence within a group of successful recanalization.

Stroke services in the Middle East and adjacent region: A survey of 34 hospital-based stroke services.

Background: Acute stroke care is complex and requires multidisciplinary networking. There are insufficient data on stroke care in the Middle East and adjacent regions in Asia and Africa. Objective: Evaluate the state of readiness of stroke programs in the Middle East North Africa and surrounding regions (MENA+) to treat acute stroke. Method: Online questionnaire survey on the evaluation of stroke care across hospitals of MENA+ region between April 2021 and January 2022. Results: The survey was completed by 34/50 (68%) hospitals. The median population serviced by participating hospitals was 2 million. The median admission of patients with stroke/year was 600 (250-1,100). The median length of stay at the stroke units was 5 days. 34/34 (100%) of these hospitals have 24/7 CT head available. 17/34 (50%) have emergency guidelines for prehospital acute stroke care. Mechanical thrombectomy with/without IVT was available in 24/34 (70.6%). 51% was the median (IQR; 15-75%) of patients treated with IVT within 60 min from arrival. Thirty-five minutes were the median time to reverse warfarin-associated ICH. Conclusion: This is the first large study on the availability of resources for the management of acute stroke in the MENA+ region. We noted the disparity in stroke care between high-income and low-income countries. Concerted efforts are required to improve stroke care in low-income countries. Accreditation of stroke programs in the region will be helpful.

Efficiency of Endovascular Therapy for Bilateral Cavernous Sinus Dural Arteriovenous Fistula.

BACKGROUND: The principles of endovascular treatment of bilateral cavernous sinus dural arteriovenous fistula (CS-dAVF) are not well established because of the complexity in the number of fistula tracts and their behavior, which seems to be more aggressive. We aimed to determine an efficient technique for endovascular treatment of bilateral CS-dAVF and the associated factors to achieve good clinical and angiographic outcomes. METHODS: The data were analyzed from 165 consecutive patients diagnosed with CS-dAVF from January 2005 to September 2018. The demographic data included approaching route, embolization times, embolization material, sequence of embolization, number of embolization sessions, and angiographic and clinical outcomes. Interrater agreement of bilateral CS-dAVF diagnosis was performed using the κ coefficient. The factors associated with treatment outcome were analyzed using a Pearson χ2 test. RESULTS: Bilateral CS-dAVF was detected in 43 patients (26%). Angiographic presentations that showed evidence of sinus thrombosis, dangerous venous drainage, and higher Satomi classification were more commonly found in bilateral CS-dAVF than in unilateral CS-dAVF. Good clinical outcome and cure from angiography were obtained in 90% and 74%, respectively. Ipsilateral inferior petrosal sinus-intercavernous sinus-contralateral cavernous sinus catheterization was the major approach route of treatment. The factors associated with improved clinical outcome were transvenous approach, shunt closure, coil embolization, and sequencing the embolization (P < 0.001). CONCLUSIONS: Dangerous venous drainage tends to increase in bilateral CS-dAVF. Retrograde ipsilateral inferior petrosal sinus catheterization using coil embolization and sequencing the embolization are the major concerns for treatment.

Success Rate of Simple Coil Embolization in Wide-Neck Aneurysm with Aneurysmal Shoulder.

BACKGROUND AND OBJECTIVE: Wide-necked intracranial aneurysm (WIA) is one of the challenging diseases for neuro-interventionist to treat by simple coiling technique. The purpose of this study is to identify the morphology associated with successful simple coil embolization in wide neck aneurysm patients. MATERIALS AND METHODS: Between January 2002 and August 2018, 102 patients with total 115 ruptured or unruptured WIA which received endovascular treatment were retrospective reviewed. Data were analyzed including demographics, aneurysm morphology, endovascular technique, angiographic outcome, complication, regrowth, and retreatment rate. RESULTS: The mean age of patients was 61.6 years with female predominant (72.5%). Ruptured WIA was diagnosed in 71 patients (61.7%). Majority of aneurysms were located in an anterior circulation which were 74 cases (64.3%), mainly paraclinoid aneurysm (30/115). Endovascular treatment was successful in 113 cases (98.3%) which can be mainly divided into simple coil embolization 50 cases (43.5%), balloon-assisted coil embolization 26 cases (22.6%), and stent-assisted coil embolization 32 cases (27.8%). Complete, subtotal, and incomplete occlusion of WIA was achieved in 32 cases (27.8%), 62 cases (53.9%), and 18 cases (15.7%), respectively. There was 9.6% complication occurred. Regrowth and retreatment were found 20% and 15.7%, respectively. CONCLUSION: WIA with two-sided aneurysmal shoulder or neck width <3.6 mm. are significantly associated with successful coil embolization using simple coiling technique.

Current state of acute stroke care in Southeast Asian countries.

Acute stroke care systems in Southeast Asian countries are at various stages of development, with disparate treatment availability and practice in terms of intravenous thrombolysis and endovascular therapy. With the advent of successful endovascular therapy stroke trials over the past decade, the pressure to revise and advance acute stroke management has greatly intensified. Southeast Asian patients exhibit unique stroke features, such as increased susceptibility to intracranial atherosclerosis and higher prevalence of intracranial haemorrhage, likely secondary to modified vascular risk factors from differing dietary and lifestyle habits. Accordingly, the practice of acute endovascular stroke interventions needs to take into account these considerations. Acute stroke care systems in Southeast Asia also face a unique challenge of huge stroke burden against a background of ageing population, differing political landscape and healthcare systems in these countries. Building on existing published data, further complemented by multi-national interaction and collaboration over the past few years, the current state of acute stroke care systems with existing endovascular therapy services in Southeast Asian countries are consolidated and analysed in this review. The challenges facing acute stroke care strategies in this region are discussed.

Favorable Outcome of Endovascular Treatment for Intracranial Aneurysms: A Single-Center Study in Thailand.

PURPOSE: The purpose of this study is to collect the information on patients with intracranial aneurysm (IA) receiving endovascular management in Siriraj Hospital, Mahidol University, Thailand. MATERIALS AND METHODS: We retrospectively reviewed data from patients with IA who underwent endovascular treatment from January 1997 through July 2013. We collected patients' demographic data including age, sex, clinical presentations, and aneurysmal profiles, as well as endovascular treatment technique, complications, angiographic results, and regrowth rate. Treatment results included success rate, clinical findings during follow-up, and regrowth rate. RESULTS: We reviewed data from 497 patients with 636 aneurysms (female:male ratio, 1.9:1; age range, 15-90 years; mean age, 59.18 years) and 69% presented with rupture. One hundred and twenty patients with 127 aneurysms received endovascular treatment. The most common location for endovascular treatment was the posterior communicating artery (15.8%), and endovascular techniques were used most often for posterior circulation and paraclinoid aneurysms. The success rate was approximately 99.2% with a 16.5% regrowth rate and no rebleeding. Regrowth rate did not correlate with immediate postoperative angiographic findings. We encountered 23 complications (18.1%); most commonly, intra-procedural rupture (7/23). Good outcomes occurred in approximately 95.9% of the patients. CONCLUSIONS: The success rate for endovascular treatment was >90%. Regrowth rate and clinical outcomes were within standard limits. Posterior circulation and paraclinoid aneurysms were our main targets. We tended to use fewer devices and simpler techniques to secure ruptured IA; however, the regrowth rate was similar to that using device-assisted techniques in other studies. We found no significant factors affecting regrowth rate, including immediate posttreatment angiographic results.

The Effectiveness of Dural Venous Sinus Sacrifice as a Treatment of Aggressive Type Cranial Dural Arteriovenous Fistulas.

OBJECTIVE: To evaluate the effectiveness of dural venous sinus sacrifice as a treatment of aggressive type cranial dural arteriovenous fistulas (dAVFs) in terms of both clinical outcome and angiographic outcome. MATERIALS AND METHODS: One hundred and twenty-eight patients with 163 aggressive type cranial dAVFs who were treated with dural sinus sacrifice were retrospectively reviewed. Clinical and angiographic outcomes were analyzed. Procedural complications were also recorded. Only 103 patients (80.5%) who had been following up for at least 90 days were analyzed for clinical outcome. RESULTS: There were 53 males and 75 females with age ranging from 20 years to 93 years (mean age 55.44 years). The overall angiographic cure rate of dural venous sinus sacrifice as a part of the treatment of aggressive dAVFs was 81.6%. Considering clinical outcome (average duration of follow-up was 2 years and 6 months), 75 patients (72.8%) had clinical improvement and 21 (20.4%) were clinically stable. Worsening of the presenting symptoms was observed in 7 patients (6.8%). Procedural complications were found in 5 patients (3.9%). CONCLUSION: Dural venous sinus sacrifice is a safe and effective treatment strategy with high angiographic cure rate, good clinical outcome, and low incidence of procedural-related complication.

Treatment outcomes in cerebral artery dissection and literature review.

Methods Patients with cerebral artery dissections were reviewed in a hospital setting from 2008 to 2015. Clinical presentations, lesion locations, treatment modalities, functional outcomes, and mortality were reviewed. Parent artery occlusion was the first choice for surgery or endovascular treatment of a hemorrhagic dissecting cerebral artery. Endovascular or surgical reconstructive treatment was indicated in patients whose parent artery could not be occluded. Favorable functional outcomes were determined using modified Rankin Scale (mRS) scores of 0-2. Results In total, 61 patients with cerebral artery dissections were admitted to the hospital. Seven (11.5%) had traumatic dissections. All traumatic dissections were located in the internal carotid arteries. Overall favorable outcome rate was about 57% (4/7). Spontaneous cerebral artery dissections were found in 54 patients. No difference in favorable outcomes was observed between parent vessel occlusion and selective occlusion with parent vessel preservation (or vessel reconstruction) (70% and 63%, respectively, p = 1.000). Patients who presented with spontaneous dissection without intracranial hemorrhage had more favorable outcomes than those with intracranial hemorrhage (79% and 52%, respectively, p = 0.045). The mortality rate of patients with spontaneous dissection was 7.4%. Conclusions Most of the traumatic dissections were located on the internal carotid arteries and spontaneous dissections were commonly located on vertebral arteries. Nonhemorrhagic spontaneous cerebral dissections had better functional outcomes after treatment. Endovascular and surgical management were effective treatments by parent vessel occlusion or reconstructions.

Comparative outcomes for sclerotherapy of head and neck venous vascular malformation between alcohol and bleomycin.

OBJECTIVE: To assess and compare the effectiveness of the two sclerosing agents (95% alcohol and Bleomycin) for the treatment of head and neck venous malformation (VM). MATERIAL AND METHOD: The authors retrospectively reviewed our experience in treating VM of the head and neck region using two sclerosing agents, 95% alcohol (November 2001 to June 2008) and bleomycin (July 2008 to July 2010). Patients' demography (age, sex), lesion number location, type (focal/extensive), and characteristic features (cystic/tubular/mixed) were recorded. The treatment outcome was determined by decrease in size of VM in photographs taken at one month and at final clinical follow-up. These were analyzed by two radiologists using visual rating scale (worst or not improved, <50%, 50-75%, >75% of size reduction). One-way Anova test (p < 0.1) was used to show the differences in treatment effectiveness of the two sclerosing agents at short- and long-term intervals. RESULTS: Thirty-three patients, age ranged from 11 to 62 years (mean 25.1 years), with 27 female and six male patients were included in this study. The majority of patients were less than 16 years (17 patients, 51%). The 43 lesions were categorized as 28 VMs were focal (65.1%), 15 (34.9%) diffuse, and30 (69.7%) were of the mixed type. Sixteen lesions were treated with 95% alcohol, 23 lesions with bleomycin, and four lesions with a combination of the two sclerosants. The range of number of procedures was 1 to 16 (mean 3.76 procedures per patient) for alcohol, and 1 to 5 (mean 2.27 procedures per patient) for bleomycin. The cumulative dose ofsclerosant used was 101 ml for alcohol and 32.11 mg for bleomycin. Total follow-up at 1-month and at final was 43/43.(100%) and 35/43 (81.4%) respectively. Mean follow-up interval was 14.7 months. Differences in size reduction after treatment by different sclerosing agents were found. At more than 1-year follow-up, those treated with bleomycin gained graded 3 (> 75%) size reduction more than treated by 95% alcohol. No VM treated with 95% alcohol obtained grade 3 of size reduction at 1-year follow-up. Multiple regression analysis showed VM's favorable character for bleomycin treatment by decreasing mixed, cystic, and tubular Pediatrics had relatively more benefit with bleomycin treatment. CONCLUSION: Sclerotherapy using either alcohol or bleomycin is an effective treatment for VMs. Different treatment outcomes were significant at long-term with group of VM those treated with bleomycin but not at short-term (p < 0.1).

Is intervertebral cement leakage a risk factor for new adjacent vertebral collapse?

This retrospective study evaluated the relationship between intervertebral cement leakage and new adjacent vertebral fracture and describes the different characteristics of cement leakage. Increased risk of new adjacent vertebral fracture (NF) has been reported to be a complication of cement leakage in vertebroplasty. In our observation, an incidental intervertebral cement leakage may occur during vertebroplasty but is commonly asymptomatic. The study focused on osteoporotic collapse patients who had percutaneous vertebroplasty (PV) between 2005 and 2007. We divided patients into leakage and non-leakage groups and compared the incidence of NF. Leakage characteristics were divided into three types: Type I intervertebral-extradiscal leakage, Type II intradiscal leakage and Type III combined leakage. Visual analog scale for pain and the Karnofsky Performance Status at 24 h, three months, six months and one year were compared between groups and types of leakages. Among 148 PVs (102 patients) there were 30 leakages (20.27%) and 21(14.19%) NFs. The incidence of NF did not significantly differ between leakage and non-leakage groups (P<0.05). Type II was the most common type of leakage (15/30). Reduction of average pain and improvement of Karnofsky Performance Status score did not differ between groups (P< 0.05). Type II had decreased pain score < type I and III at 24 h (P < 0.01), three months and six months (P < 0.1) but not at one year (P<0.10). Type II also had decreased pain score < non-leakage group only at 24 h (P<0.05). Intervertebral cement leakage is not an increased risk for NF, influenced outcomes of pain relief or improvement of physical function. Intradiscal leakage (Type II) is the most common characteristic of cement leakage and probably related to delayed pain relief.

Complications in vertebroplasty.

BACKGROUND: Vertebroplasty is one of the minimally invasive surgery that benefit in pain relief from the osteoporotic or malignancy related vertebral compression fractures. However, many literatures reported both asymptomatic and serious complications. The aim of the present study was to summarize, collect data and report the complication ofvertebroplastyfrom our experience at a single institute. MATERIAL AND METHOD: Three hundred and twenty five vertebroplasty procedures from 236 patients performed in our institute were retrospectively reviewed. Data of diagnosis, age at the time of procedure were collected. All complications found were reviewed in detail. RESULTS: Commonly performed procedures were at thoracolumbar junction (51.4%). Osteoporosis was the most common cause of fracture. The present study found 88 (27%) complications with 26 (8%) symptomatic patients. Most common complication was cement leakage, which intervertebral disc was the most common site (42.9). Spinal canal leakage was found in 14 cases (20%). Four out of 14 cases had neurological complications and need further managements. Two cases had neurologic complications from needle injury.Adjacent level collapse found in 13 patients (4%) and remote segment collapse occurred in 5 patients (1.5%). Three had progressive kyphosis required later surgical treatment. One asymptomatic cement pulmonary embolism was found in the present study. CONCLUSION: The complications of vertebroplasty were mostly asymptomatic, but serious complication such as neurologic injury could occur. Vertebroplasty could be considered a quite safe treatment for osteoporotic vertebral fracture. Meticulous technique should be executed during the procedure to avoid the leakage complication.

The limited protocol MRI in diagnosis of lumbar disc herniation.

OBJECTIVE: To assess agreement in detection of lumbar disc herniation (LDH) between limited and full protocol MRI. MATERIAL AND METHOD: 123 patients who requested lumbar MRI for diagnosis of disc herniation were assessed The full protocol MRI composed of sagittal T1-wi, sagittal T2-wi and axial T2-wi was performed on each patient. The sagittal T2-wi was selected as the limited protocol MRI. The limited and full protocols MRI of each patient were separately interpreted by three neuroradiologists to assess disc herniation and nerve root compression. The consensus results of limited and full protocol were compared. The diagnostic performance of each protocol was analyzed using surgery as the gold standard. RESULTS: There were 62 females and 61 males enrolled into the study between the age of 21-60 years old (means = 42.91 years). The duration of pain was 1-204 months (mean = 31.20 months). The degree of severity was mild in 23.58%, moderate 45.52% and severe 30.89% of cases. Thirty-three cases were operated on. For detection of LDH, the limited protocol gave the same interpretation results as the full protocol (0 = 1.04, 95%CI = 0.94, 1.14 with accepted range of 0.95-1.05). In nerve root compression, the limited protocol was not accurate as the full protocol (0 = 0.75, 95%CI = 0.87, 0.63). The sensitivity, specificity, accuracy, PPV, NPV, and LR+ in the surgical group of limited protocol in diagnosis of LDH were 82.61%, 80%, 81.82%, 90.48%, 60.67%, 4.13 and in nerve root compression were 54.84%, 100%, 57.58%, 100%, 12.5% respectively. The same statistics of full protocol MRI in diagnosis of LDH were 82.61%, 70.80%, 78.79%, 86.36%, 63.64%, 2.75 and of nerve root compression were 80.65%, 100%, 81.82%, 100%, 25% respectively. The sensitivity and specificity in diagnosis of LDH were not different in both protocols but the sensitivity of nerve root compression was statistically significant different (p < 0.013, 95%CI = -0.33, -0.25). CONCLUSION: The authors concluded that limited protocol MRI may replace full protocol MRI in diagnosis of LDH but not in nerve root compression.

Vascular loop compressing facial nerve in hemifacial spasm: demonstrated by 3D-phase contrast magnetic resonance angiography in 101 patients.

BACKGROUND: Vascular compression of the facial nerve is deemed to be the common cause of hemifacial spasm producing emphatic transmission. Although facial nucleus supersensitivity is more accepted as the main cause of hemifacial spasm. PURPOSE: To determine the vascular loop compression of the facial nerve in patients with hemifacial spasm by 3D-phase contrast (PC) magnatic resonance imaging (MRI). MATERIAL AND METHOD: A retrospective study of 101 patients with hemifacial spasm who went MRI and magnetic resonance angiography (MRA) of the brain was done. The magnitude images of the 3D-PC MRA was evaluated in axial and oblique coronal reconstruction planes blindly from symptomatic information. RESULTS: Among 101 patients, 53 affected the left side, 48 patients were right sided and none had bilateral involvement. Vascular loop compressing on the symptomatic side was found in 61 (60.4%) patients. For the asymptomatic side, there were 14 (13.86%) with vascular loop contact. Five patients (4.9%) had bilateral vascular compression. The proportion of vascular contact of the symptomatic and asymptomatic side was significantly different (with p < 0.001). The offending vessels were vertebral artery (32, 52.46%), posterior inferior cerebellar artery (7, 6.93%), anterior inferior cerebellar artery (6, 5.94%) and artery of uncertain origin (16, 26.23%). CONCLUSION: The study implied the usefulness of this simple technique to demonstrate the neurovascular contact of the facial nerve.