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BACKGROUND: The comparative efficacy and safety of first-generation flow diverters (FDs), Pipeline Embolization Device (PED) (Medtronic, Irvine, California), Silk (Balt Extrusion, Montmorency, France), Flow Re-direction Endoluminal Device (FRED) (Microvention, Tustin, California), and Surpass Streamline (Stryker Neurovascular, Fremont, California), is not directly established and largely inferred. PURPOSE: This study aimed to compare the efficacy of different FDs in treating sidewall ICA intracranial aneurysms. METHODS: We conducted a retrospective review of prospectively maintained databases from eighteen academic institutions from 2009-2016, comprising 444 patients treated with one of four devices for sidewall ICA aneurysms. Data on demographics, aneurysm characteristics, treatment outcomes, and complications were analyzed. Angiographic and clinical outcomes were assessed using various imaging modalities and modified Rankin Scale (mRS). Propensity score weighting was employed to balance confounding variables. The data analysis used Kaplan-Meier curves, logistic regression, and Cox proportional-hazards regression. RESULTS: While there were no significant differences in retreatment rates, functional outcomes (mRS 0-1), and thromboembolic complications between the four devices, the probability of achieving adequate occlusion at the last follow-up was highest in Surpass device (HR: 4.59; CI: 2.75-7.66, pâ¯< 0.001), followed by FRED (HR: 2.23; CI: 1.44-3.46, pâ¯< 0.001), PED (HR: 1.72; CI: 1.10-2.70, pâ¯= 0.018), and Silk (HR: 1.0 ref. standard). The only hemorrhagic complications were with Surpass (1%). CONCLUSION: All the first-generation devices achieved good clinical outcomes and retreatment rates in treating ICA sidewall aneurysms. Prospective studies are needed to explore the nuanced differences between these devices in the long term.
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BACKGROUND AND IMPORTANCE: Neurointervention is a very competitive specialty in the United States due to the limited number of training spots and the larger pool of applicants. The training standards are continuously updated to ensure solid training experiences. Factors affecting candidate(s) selection have not been fully established yet. Our study aims to investigate the factors influencing the selection process. METHODS: A 52-question survey was distributed to 93 program directors (PDs). The survey consisted of six categories: (a) Program characteristics, (b) Candidate demographics, (c) Educational credentials, (d) Personal traits, (e) Research and extracurricular activities, and (f) Overall final set of characteristics. The response rate was 59.1%. As per the programs' characteristics, neurosurgery was the most involved specialty in running the training programs (69%). Regarding demographics, the need for visa sponsorship held the greatest prominence with a mean score of 5.9 [standard deviation (SD) 2.9]. For the educational credentials, being a graduate from a neurosurgical residency and the institution where the candidate's residency training is/was scored the highest [5.4 (SD = 2.9), 5.4 (SD = 2.5), respectively]. Regarding the personal traits, assessment by faculty members achieved the highest score [8.9 (SD = 1)]. In terms of research/extracurricular activities, fluency in English had the highest score [7.2 (SD = 1.9)] followed by peer-reviewed/PubMed-indexed publications [6.4 (SD = 2.2)]. CONCLUSION: Our survey investigated the factors influencing the final decision when choosing the future neurointerventional trainee, including demographic, educational, research, and extracurricular activities, which might serve as valuable guidance for both applicants and programs to refine the selection process.
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BACKGROUND AND OBJECTIVES: Endovascular thrombectomy has previously been reserved for patients with small to medium acute ischemic strokes. Three recent randomized control trials have demonstrated functional benefit and risk profiles for thrombectomy in large-volume ischemic strokes. The primary objective of the meta-analysis was to determine the combined benefit of endovascular thrombectomy in patients with large-volume ischemic strokes and to determine the risk of adverse events after treatment. METHODS: We systematically searched Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Scopus, the Cochrane Central Register, and Google Scholar for randomized trials published between January 1, 2010, and February 19, 2023. We included trials specifically comparing endovascular thrombectomy with medical therapy in adults with acute ischemic stroke with large-volume infarctions (defined by Alberta Stroke Program Early Computed Tomography Score 3-5 or a calculated infarct volume of >50 mL). Data were extracted based on prespecified variables on study methods and design, participant characteristics, analysis approach, and efficacy/safety outcomes. Results were combined using a restricted maximum-likelihood estimation random-effects model. Studies were assessed for potential bias and quality of evidence. The primary outcome was an overall ordinal shift across modified Rankin scale scores toward a better outcome at 90 days after either treatment arm. RESULTS: Three thousand forty-four studies were screened, and 29 underwent full-text review. Three randomized trials (N = 1011) were included in the analysis. The pooled random-effects model for the primary outcome favored endovascular thrombectomy over medical management, with a generalized odds ratio of 1.55 (95% CI 1.25-1.91, I 2 = 42.84%). There was a trend toward increased risk of symptomatic intracranial hemorrhage in the thrombectomy group, with a relative risk of 1.85 (95% CI 0.94-3.63, I 2 = 0.00%). CONCLUSION: In patients with large-volume ischemic strokes, endovascular thrombectomy has a clear functional benefit and does not confer increased risk of significant complications compared with medical management alone.
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Isquemia Encefálica , Procedimentos Endovasculares , AVC Isquêmico , Acidente Vascular Cerebral , Adulto , Humanos , AVC Isquêmico/cirurgia , Isquemia Encefálica/etiologia , Resultado do Tratamento , Procedimentos Endovasculares/métodos , Acidente Vascular Cerebral/etiologia , Trombectomia/métodosRESUMO
Importance: Endovascular thrombectomy (ET) has previously been reserved for patients with small to medium acute ischemic strokes. Three recent randomized control trials (RCTs) have demonstrated functional benefit and risk profiles for ET in large volume ischemic strokes. Objective: The primary objective of the meta-analysis was to determine the combined benefit of ET in adult patients with large volume acute ischemic strokes and to better determine the risk of adverse events following ET. Data Sources: We systematically searched MEDLINE, EMBASE, SCOPUS, the Cochrane Central Register of Controlled, and Google Scholar for all RCTs published in English language between January 1, 2010, to February 19, 2023. Study Selection: We included only RCTs specifically comparing ET to medical therapy in patients with acute ischemic stroke with large volume infarctions as defined by Alberta Stroke Program Early Computed Tomography Score (ASPECTS) 3-5 or calculated infarct volume of > 50-70mL. Two independent reviewers screened potential studies for full text review and metaanalysis inclusion with conflicts being resolved by consensus or third reviewer. Data Extraction and Synthesis: Data was extracted based on pre-specified variables on study methods and design, participant characteristics, analysis approach, as well as efficacy and safety outcomes. Results were combined using a restricted maximum-likelihood estimation random-effects model. Studies were assessed for potential bias and quality of evidence. Main Outcomes and Measures: The prespecified primary outcome was an overall ordinal shift across the range of modified Rankin scale scores toward a better outcome at 90 days following either ET or medical management for patients with large volume ischemic strokes. Results: A total of 3044 studies were screened, and 29 underwent full text review. 3 RCTs (1011 patients) were included in the analysis. The pooled random effects model for the primary outcome of mRS improvement favored ET over medical management, generalized odds ratio 1.55 [95% CI 1.25 - 1.91, T 2 = 0.01, I 2 = 42.84%]. There was a trend toward increased risk of symptomatic ICH in the ET group, relative risk 1.85 [95% CI 0.94 - 3.63, T 2 = 0.00, I 2 = 0.00%]. Conclusions and Relevance: In patients with large volume ischemic strokes, ET has a clear functional benefit and does not confer increased risk of significant complications compared to medical management alone.
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BACKGROUND: A teenage boy who had been stabbed in the neck presented with an extracranial traumatic functional carotid artery occlusion that could not be crossed in an antegrade fashion. Endovascular repair depends on obtaining catheter access proximal and distal to an injury within the true lumen. OBSERVATIONS: The occlusion was treated with flossing technique via the posterior communicating artery. After successful recanalization from a retrograde approach, the carotid artery occlusion was treated with a covered stent. LESSONS: The flossing technique is well established in peripheral vascular disease and may be beneficial in certain cases in the neck vasculature when antegrade access is difficult to obtain. Recanalization of an occluded carotid artery from retrograde approach may be successful in cases of trauma from knife wounds.
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OBJECTIVE: Carotid webs (CWs) are an increasingly recognized source of recurrent stroke among young patients without conventional vascular risk factors. There have been no previous studies demonstrating that specific web morphological characteristics correlate with a higher stroke risk. The authors aim to report distinct morphological features of symptomatic and asymptomatic CWs. METHODS: The authors performed a cross-sectional study of patients with CWs detected on CT angiography (CTA) of the neck. Patients were categorized based on whether or not they presented with stroke ipsilaterally and if it was likely to be attributable to their web. The following CW morphological variables were recorded and compared based on CTA: length, thickness, angle, and the proportion of carotid bulb lumen occupied by the web (web-to-bulb ratio [WBR]). RESULTS: A total of 86 CWs were identified, 14 of which presented with stroke (16.3%). Patients presenting with stroke had webs that were significantly longer (4.18 mm vs 2.20 mm, p = 0.001) and were situated at more acute angles relative to the carotid wall (73.2° vs 94.9°, p = 0.004). Additionally, patients presenting with stroke had higher WBRs compared to the asymptomatic cohort (0.50 vs 0.36, p = 0.008). The optimal threshold associated with stroke was web length ≥ 3.1 mm (OR 15.2, 95% CI 3.73-61.8; p < 0.001), web angle ≤ 90.1° (OR 5.00, 95% CI 1.42-17.6; p = 0.012), and WBR ≥ 0.50 (OR 30.0, 95% CI 5.94-151; p < 0.001). CONCLUSIONS: Patients with CWs that occupy more than half of the diameter of the carotid bulb lumen and are situated at acute angles relative to the carotid wall are more likely to present with acute ischemic stroke. Additional studies are needed to determine the long-term outcomes of these lesions.
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Isquemia Encefálica , Estenose das Carótidas , AVC Isquêmico , Acidente Vascular Cerebral , Humanos , Estudos Transversais , Artérias Carótidas/diagnóstico por imagem , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Fatores de Risco , Estudos RetrospectivosRESUMO
OBJECTIVES: In the United States, Black individuals have higher stroke incidence and mortality when compared to white individuals and are also at risk of having lower stroke knowledge and awareness. With the need to implement focused interventions to decrease stroke disparities, the objective of this study is to evaluate the feasibility and efficacy of an emergency department-based educational intervention aimed at increasing stroke awareness and preparedness among a disproportionately high-risk group. MATERIALS AND METHODS: Over a three-month timeframe, an emergency department-based, prospective educational intervention was implemented for Black patients in an urban, academic emergency department. All participants received stroke education in the forms of a video, written brochure and verbal counseling. Stroke knowledge was assessed pre-intervention, immediately post-intervention, and at one-month post-intervention. RESULTS: One hundred eighty-five patients were approached for enrollment, of whom 100 participants completed the educational intervention as well as the pre- and immediate post- intervention knowledge assessments. Participants demonstrated increased stroke knowledge from baseline knowledge assessment (5.35 ± 1.97) at both immediate post-intervention (7.66 ± 2.42, p < .0001) and one-month post-intervention assessment (7.21 ± 2.21, p < .0001). CONCLUSIONS: Emergency department-based stroke education can result in improved knowledge among this focused demographic. The emergency department represents a potential site for educational interventions to address disparities in stroke knowledge.
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Serviços Médicos de Emergência , Acidente Vascular Cerebral , Serviço Hospitalar de Emergência , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Folhetos , Estudos Prospectivos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapiaRESUMO
OBJECTIVE: The Pipeline Embolization Device (PED) has prompted a paradigm shift in the approach to posterior circulation aneurysms. The year 2021 marks a decade since FDA approval of this flow diverter, and during this time operators have adapted to its off-label uses. The authors examined whether case selection, practice trends, and patient outcomes have changed over this 10-year period. METHODS: This study is a retrospective review of consecutive posterior circulation aneurysms managed with the PED at four academic institutions in the US between January 1, 2011, and January 1, 2021. Factors related to case selection, rates of aneurysm occlusion, or complications were identified and evaluated. Angiographic outcomes as well as thromboembolic and hemorrhagic complications were investigated. RESULTS: This study included 117 patients (median age 60 years). At a median follow-up of 12 months, adequate occlusion (> 90%) was attained in 73.2% of aneurysms. Aneurysm occlusion rates were similar over the study interval. Thromboembolic and hemorrhagic complications were reported in 12.0% and 6.0% of the procedures, respectively. There was a nonsignificant trend toward a decline in the rate of thromboembolic (14.1% in 2011-2015 vs 9.4% in 2016-2021, p = 0.443) and hemorrhagic (9.4% in 2011-2015 vs 1.9% in 2016-2021, p = 0.089) complications. CONCLUSIONS: The authors observed a trend toward a decline in the rate of thromboembolic and hemorrhagic complications with improved operator experience in using the PED for posterior circulation aneurysms. The use of single-device PED flow diversion significantly increased, as did the tendency to treat smaller aneurysms and observe large unruptured fusiform/dolichoectatic lesions. These findings reflect changes attributable to evolving judgment with maturing experience in PED use.
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BACKGROUND: The timing of stroke onset among patients with blunt cerebrovascular injury (BCVI) is not well understood. All blunt trauma patients at our institution undergo a screening computed tomographic angiography (CTA) of the neck. Most patients with CTA evidence of BCVI are treated with aspirin, and all patients with clinical evidence of stroke are treated with aspirin and undergo magnetic resonance imaging (MRI) of the brain. We conducted a retrospective review to determine the incidence of stroke upon admission and following admission. METHODS: All neck CTAs and head MRIs obtained in blunt trauma patients were reviewed from August 2017 to August 2019. All CTAs that were interpreted as showing BCVI were individually reviewed to confirm the diagnosis of BCVI. Stroke was defined as brain MRI evidence of new ischemic lesions, and each MRI was reviewed to identify the brain territory affected. We extracted the time to aspirin administration and the timing of stroke onset from patients' electronic health records. RESULTS: Of the 6,849 blunt trauma patients, 479 (7.0%) had BCVIs. Twenty-four patients (5.0%) with BCVI had a stroke on admission. Twelve (2.6%) of the remaining 455 patients subsequently had a stroke during their hospitalization. The incidence of stroke among patients with BCVI was 7.5%; 2.6% were potentially preventable. Only 5 of the 12 patients received aspirin before the onset of stroke symptoms. All 36 patients with BCVI and stroke had thromboembolic lesions in the territory supplied by an injured vessel. CONCLUSION: With universal screening, CTA evidence of BCVI is common among blunt trauma patients. Although acute stroke is also relatively common in this population, two thirds of strokes are already evident on admission. One third of BCVI-related strokes occur after admission and often relatively early, necessitating rapid commencement of preventative treatment. Further studies are required to demonstrate the value of antithrombotic administration in preventing stroke in BCVI patients. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.
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Traumatismo Cerebrovascular , AVC Isquêmico , Acidente Vascular Cerebral , Ferimentos não Penetrantes , Aspirina/uso terapêutico , Traumatismo Cerebrovascular/complicações , Traumatismo Cerebrovascular/diagnóstico por imagem , Traumatismo Cerebrovascular/epidemiologia , Humanos , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/epidemiologiaRESUMO
BACKGROUND: Aneurysmal persistence after flow diversion (FD) occurs in 5% to 25% of aneurysms, which may necessitate retreatment. There are limited data on safety/efficacy of repeat FD-a frequently utilized strategy in such cases. METHODS: A series of consecutive patients undergoing FD retreatment from 15 centers were reviewed (2011-2019), with inclusion criteria of repeat FD for the same aneurysm at least 6 months after initial treatment, with minimum of 6 months post-retreatment imaging. The primary outcome was aneurysmal occlusion, and secondary outcome was safety. A multivariable logistic regression model was constructed to identify predictors of incomplete occlusion (90%-99% and <90% occlusion) versus complete occlusion (100%) after retreatment. RESULTS: Ninety-five patients (median age, 57 years; 81% women) harboring 95 aneurysms underwent 198 treatment procedures. Majority of aneurysms were unruptured (87.4%), saccular (74.7%), and located in the internal carotid artery (79%; median size, 9 mm). Median elapsed time between the first and second treatment was 12.2 months. Last available follow-up was at median 12.8 months after retreatment, and median 30.6 months after the initial treatment, showing complete occlusion in 46.2% and near-complete occlusion (90%-99%) in 20.4% of aneurysms. There was no difference in ischemic complications following initial treatment and retreatment (4.2% versus 4.2%; P>0.99). On multivariable regression, fusiform morphology had higher nonocclusion odds after retreatment (odds ratio [OR], 7.2 [95% CI, 1.97-20.8]). Family history of aneurysms was associated with lower odds of nonocclusion (OR, 0.18 [95% CI, 0.04-0.78]). Likewise, positive smoking history was associated with lower odds of nonocclusion (OR, 0.29 [95% CI, 0.1-0.86]). History of hypertension trended toward incomplete occlusion (OR, 3.10 [95% CI, 0.98-6.3]), similar to incorporated branch into aneurysms (OR, 2.78 [95% CI, 0.98-6.8]). CONCLUSIONS: Repeat FD for persistent aneurysms carries a reasonable success/safety profile. Satisfactory occlusion (100% and 90%-99% occlusion) was encountered in two-thirds of patients, with similar complications between the initial and subsequent retreatments. Fusiform morphology was the strongest predictor of retreatment failure.
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Embolização Terapêutica , Procedimentos Endovasculares , Aneurisma Intracraniano , Mordida Aberta , Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Estudos de Viabilidade , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/etiologia , Aneurisma Intracraniano/cirurgia , Masculino , Pessoa de Meia-Idade , Mordida Aberta/etiologia , Mordida Aberta/terapia , Estudos Retrospectivos , Stents , Resultado do TratamentoRESUMO
BACKGROUND: Blunt cerebrovascular injuries (BCVI) remain a significant source of disability and mortality among trauma patients. The purpose of the present study was to determine whether knowledge silos exist in the overall BCVI literature. METHODS: An object-oriented programmatic script written in Python programming language was used to extract and categorize articles and references on the topic of BCVI. Additionally, each BCVI article was searched for by digital object identifier in the other BCVI references to build a network analysis and visualize topic reference patterns. Analyses were performed using Stata V.14.2 (StataCorp). RESULTS: A total of 306 articles with 10 282 references were included for analysis. Of these, 24% (74) were published in neurosurgery journals, 45% (137) were published in trauma journals, and 31% (95) were published in a journal of another specialty. Similar proportions were found when categorized by author departmental affiliation. Trauma surgery authors disproportionately referenced articles in the trauma literature, compared with neurosurgeons (73.5% vs. 48.0%, p<0.0001), and other authors. The biggest factor influencing reference proportions was the specialty of the publishing journal. Finally, a network analysis revealed that there are more trauma BCVI articles, and there are more frequently cited trauma BCVI articles by all specialties. CONCLUSIONS: This study revealed the existence of a one-way knowledge silo in the BCVI literature. However, a robust preference by both trauma and neurosurgery to cite trauma references when publishing in trauma journals may indicate a possible conscious curating of citations by authors to increase the likelihood of publication. These observations highlight the need for an active role by journal editors, peer reviewers, and authors to actively foster diversity of citations and cross-specialty collaboration to improve dissemination of information between these specialties. LEVEL OF EVIDENCE: Level IV. Observational study.
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Transtornos Cerebrovasculares , Aneurisma Intracraniano , Acidente Vascular Cerebral , Transtornos Cerebrovasculares/epidemiologia , Transtornos Cerebrovasculares/prevenção & controle , Humanos , Aneurisma Intracraniano/cirurgia , Convulsões , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/prevenção & controleRESUMO
INTRODUCTION: The COVID-19 pandemic has resulted in unprecedented strain on the health care system. An adaptive strategy for the handling of thrombectomy for patients with large vessel occlusion has evolved at our center to optimize patient care while also minimizing risk of virus transmission. The purpose of this study was to evaluate the effects of the new thrombectomy protocol by comparing thrombectomy times and patient outcomes during the pandemic and pre pandemic period. METHODS: A retrospective cohort study was conducted on patients who underwent emergent thrombectomy from April 4th, 2020 to August 25th, 2020 (pandemic period) and between December 2nd, 2019 to April 3rd, 2020 (pre-pandemic period). The new protocol centered on a standardized approach to airway management in patients considered 'high-risk' for infection. An array of patient-specific factors and outcomes were compared between the two groups. RESULTS: A total of 126 patients were included in the study. There was no significant difference in door-to-recanalization or other time parameters between the two groups (138 minutes during the pandemic vs. 129 minutes pre-pandemic; p=0.37). However, outcomes measured as discharge modified Rankin Scale (mRS) were worse for patients during the pandemic (mRS ≤ 2, 10/58; 17.2% during pandemic vs. 24/68; 35.3% pre-pandemic, pâ¯=â¯0.02). No neurointerventional providers have been found to contract COVID-19. CONCLUSION: Our approach to mechanical thrombectomy during the COVID-19 era was associated with similar recanalization rates but worse clinical outcomes compared to pre pandemic period. Further studies are necessary to identify factors contributing to worse outcomes during this ongoing pandemic.
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Arteriopatias Oclusivas/cirurgia , COVID-19 , Transtornos Cerebrovasculares/cirurgia , Procedimentos Endovasculares/métodos , Pandemias , Acidente Vascular Cerebral/cirurgia , Idoso , Idoso de 80 Anos ou mais , Manuseio das Vias Aéreas , Circulação Cerebrovascular , Protocolos Clínicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Trombectomia , Tempo para o Tratamento , Resultado do TratamentoRESUMO
BACKGROUND: The extent of intracerebral hemorrhage (ICH) removal conferred survival and functional benefits in the minimally invasive surgery with thrombolysis in intracerebral hemorrhage evacuation (MISTIE) III trial. It is unclear whether this similarly impacts outcome with craniotomy (open surgery) or whether timing from ictus to intervention influences outcome with either procedure. OBJECTIVE: To compare volume evacuation and timing of surgery in relation to outcomes in the MISTIE III and STICH (Surgical Trial in Intracerebral Hemorrhage) trials. METHODS: Postoperative scans were performed in STICH II, but not in STICH I; therefore, surgical MISTIE III cases with lobar hemorrhages (n = 84) were compared to STICH II all lobar cases (n = 259) for volumetric analyses. All MISTIE III surgical patients (n = 240) were compared to both STICH I and II (n = 722) surgical patients for timing analyses. These were investigated using cubic spline modeling and multivariate risk adjustment. RESULTS: End-of-treatment ICH volume ≤28.8 mL in MISTIE III and ≤30.0 mL in STICH II had increased probability of modified Rankin Scale (mRS) 0 to 3 at 180 d (P = .01 and P = .003, respectively). The effect in the MISTIE cohort remained significant after multivariate risk adjustments. Earlier surgery within 62 h of ictus had a lower probability of achieving an mRS 0 to 3 at 180 d with STICH I and II (P = .0004), but not with MISTIE III. This remained significant with multivariate risk adjustments. There was no impact of timing until intervention on mortality up to 47 h with either procedure. CONCLUSION: Thresholds of ICH removal influenced outcome with both procedures to a similar extent. There was a similar likelihood of achieving a good outcome with both procedures within a broad therapeutic time window.
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Hemorragia Cerebral , Procedimentos Cirúrgicos Minimamente Invasivos , Terapia Trombolítica , Tempo para o Tratamento , Hemorragia Cerebral/mortalidade , Hemorragia Cerebral/cirurgia , Craniotomia , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/mortalidade , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Terapia Trombolítica/mortalidade , Terapia Trombolítica/estatística & dados numéricos , Resultado do TratamentoRESUMO
BACKGROUND: Blunt cerebrovascular injury (BCVI) can result in thromboembolic stroke. Many trauma centers selectively screen patients with cervical computed tomographic angiography (CTA) based on clinical criteria. In 2016, our institution adopted universal screening for BCVI for all blunt trauma patients. The aim of this study was to accurately determine the incidence of BCVI and to evaluate the diagnostic performance of the Denver criteria (DC), expanded Denver criteria (eDC), and Memphis criteria (MC) in selecting patients for screening. METHODS: Retrospective cohort study of adult (≥16 years) blunt trauma patients who presented to the Level I trauma center at University of Alabama at Birmingham. We reviewed all CTA reports and selected CTA images to obtain the true incidence rate of BCVI. We then evaluated the diagnostic performance of the DC, eDC, and MC. RESULTS: A total of 6,800 patients who had suffered blunt trauma were evaluated, of whom 6,287 (92.5%) had a neck CTA. Of these, 480 (7.6%) patients had CTA evidence of BCVI. The eDC identified the most BCVI cases (sensitivity 74.7%) but had the lowest positive predictive value (14.6%). The DC and MC had slightly greater positive predictive values (19.6% and 20.6%, respectively) and had the highest diagnostic ability in terms of likelihood ratio (2.8 and 2.9) but had low sensitivity (57.5% and 47.3%). Consequently, if relying on the traditional screening criteria, the DC, eDC, and MC would have respectively resulted in 42.5%, 25.3%, and 52.7% of patients with BCVI identified by universal screening not receiving a neck CTA to screen for BCVI. CONCLUSION: Blunt cerebrovascular injury is even more common than previously thought. The diagnostic performance of selective clinical screening criteria is poor. Consideration should be given to the implementation of universal screening for BCVI using neck CTA in all blunt trauma patients. LEVEL OF EVIDENCE: Diagnostic, level III.
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Angiografia Cerebral , Traumatismo Cerebrovascular/prevenção & controle , Traumatismos Cranianos Fechados/prevenção & controle , Embolia Intracraniana/prevenção & controle , Programas de Rastreamento , Tomografia Computadorizada por Raios X , Adolescente , Adulto , Idoso , Alabama , Traumatismo Cerebrovascular/complicações , Traumatismo Cerebrovascular/epidemiologia , Estudos de Coortes , Traumatismos Cranianos Fechados/complicações , Traumatismos Cranianos Fechados/epidemiologia , Humanos , Incidência , Embolia Intracraniana/epidemiologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Sensibilidade e Especificidade , Adulto JovemRESUMO
BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. Among the most common sequelae of aSAH is delayed cerebral ischemia. Hyperdynamic therapy (fluid supplementation and hypertension) is used to increase cerebral perfusion. However, the safety of hyperdynamic therapy in patients with separate unruptured, unsecured intracranial aneurysms is not well-established. Herein, a rare case demonstrating the rapid evolution and rupture of an incidental unsecured aneurysm in the setting of hyperdynamic therapy is presented. CASE DESCRIPTION: A 56-year-old woman without significant medical history presented with aSAH secondary to rupture of a 3-mm left posterior inferior cerebellar artery aneurysm. After endovascular treatment of this aneurysm, she developed symptomatic vasospasm prompting initiation of hyperdynamic therapy. Seven days after initiation of hyperdynamic therapy, she experienced rupture of an incidental pericallosal artery aneurysm that was found to have increased in size during the hyperdynamic therapy. She ultimately survived and was functionally independent approximately 1 year after her initial ictus. CONCLUSIONS: This case demonstrates that enlargement and rupture of an incidental, previously unruptured aneurysm may occur during hyperdynamic therapy.
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Aneurisma Roto/etiologia , Hidratação/efeitos adversos , Hipertensão , Hemorragia Subaracnóidea/etiologia , Vasoespasmo Intracraniano/complicações , Vasoespasmo Intracraniano/terapia , Aneurisma Roto/diagnóstico por imagem , Angiografia Digital , Doenças Cerebelares/etiologia , Feminino , Humanos , Pessoa de Meia-Idade , Hemorragia Subaracnóidea/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
BACKGROUND: Most of the published literature pertaining to blunt traumatic cerebrovascular injury (BCVI) is focused on extracranial arterial injury. Studies of intracranial arterial injury are relatively uncommon. OBSERVATIONS: The clinical course of a patient who sustained an injury to the right posterior communicating artery followed by infarction due to vasospasm after severe traumatic brain injury is presented, along with a focused literature review. LESSONS: Intracranial BCVI is uncommon, and this report may serve to raise awareness of BCVI management and the importance of recognizing symptomatic vasospasm due to BCVI.
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BACKGROUND: Flow diversion is a common endovascular treatment for cerebral aneurysms, but studies comparing different types of flow diverters are scarce. OBJECTIVE: To perform a propensity score matched cohort study comparing the Pipeline Embolization Device (PED) and Flow Redirection Intraluminal Device (FRED) for posterior circulation aneurysms. METHODS: Consecutive aneurysms of the posterior circulation treated at 25 neurovascular centers with either PED or FRED were collected. Propensity score matching was used to control for age, duration of follow-up imaging, adjunctive coiling, and aneurysm location, size, and morphology; previously ruptured aneurysms were excluded. The two devices were compared for the following outcomes: procedural complications, aneurysm occlusion, and functional outcome. RESULTS: A total of 375 aneurysms of the posterior circulation were treated in 369 patients. The PED was used in 285 (77.2%) and FRED in 84 (22.8%) procedures. Aneurysms treated with the PED were more commonly fusiform and larger than those treated with FRED. To account for these important differences, propensity score matching was performed resulting in 33 PED and FRED unruptured aneurysm pairs. No differences were found in occlusion status and neurologic thromboembolic or hemorrhagic complications between the two devices. The proportion of patients with favorable functional outcome was higher with FRED (100% vs 87.9%, p=0.04). CONCLUSION: Comparative analysis of PED and FRED for the treatment of unruptured posterior circulation aneurysms did not identify significant differences in aneurysm occlusion or neurologic complications. Variations in functional outcomes warrant additional investigations.
Assuntos
Aneurisma Roto/terapia , Prótese Vascular/normas , Embolização Terapêutica/normas , Aneurisma Intracraniano/terapia , Pontuação de Propensão , Stents Metálicos Autoexpansíveis/normas , Adulto , Idoso , Aneurisma Roto/diagnóstico por imagem , Estudos de Coortes , Embolização Terapêutica/métodos , Feminino , Seguimentos , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) procedure was recently tested in a large phase III randomized trial showing a significant probability of functional benefit in those cases that reached the goal hematoma evacuation of ≤15 mL residual (or ≥70% removal). Benefit of thrombolysis was also identified in cases with large intraventricular hemorrhage, and achieving at least 85% volume reduction in the Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III trial. OBJECTIVE: To protocolize steps in the MISTIE and CLEAR procedures in order to maximize hematoma evacuation and minimize complications. METHODS: We articulate data-driven lessons and expert opinions surrounding the factors of patient selection, catheter placement, and dosing, which impacted safety and surgical performance in the MISTIE and CLEAR trials. RESULTS: Modifiable factors to maximize evacuation efficiency include optimizing catheter placement and pursuing aggressive dosing to achieve treatment goals, while strictly adhering to the safety steps as articulated in the respective trials. Prognostic factors that are viewed as nonmodifiable include greater initial intracerebral hemorrhage volume with irregular shape, smaller intraventricular bleeds, and the uncommon but consequential development of new bleeding during the dosing period despite strict protocol adherence. CONCLUSIONS: Surgeon education in this tutorial is aimed at maximizing the benefit of the MISTIE and CLEAR procedures by reviewing case selection, safety steps, treatment objectives, and technical nuances. Key lessons include stability imaging, etiology screening, and technical adherence to the protocol in order to achieve defined thresholds of evacuation.