Trends in incidence and treatments of spontaneous subarachnoid hemorrhage- a 10 year hospital based study.

BACKGROUND: Improved endovascular methods make it possible to treat complex ruptured aneurysms, but surgery is still needed in certain cases. We evaluated the effects on the clinical results of the changes in aneurysm treatment. METHODS: The study cohort was 837 patients with spontaneous subarachnoid hemorrhage (SAH) and one or multiple aneurysms, admitted to Dept of Neurosurgery, Uppsala University Hospital from 2012 to 2021. Demography, location and treatment of aneurysms, neurologic condition at admission and discharge, mortality and last tier treatment of high intracranial pressure (ICP) was evaluated. Functional outcome was measured using the Extended Glasgow Outcome Scale (GOSE) Data concerning national incidences of stroke diseases was collected from open Swedish databases. RESULTS: Endovascular methods were used in 666 cases (79.6%). In 111 (13.3%) with stents. Surgery was performed in 115 cases (13.7%) and 56 patients (6.7%) had no aneurysm treatment. The indications for surgery were a hematoma (51 cases, 44.3%), endovascular treatment not considered safe (47 cases, 40.9%), or had been attempted without success (13 cases, 11.3%). Treatment with stent devices increased, and with surgery decreased over time. There was a trend in decrease in hemicraniectomias over time. Both the patient group admitted awake (n = 681) and unconscious (n = 156) improved significantly in consciousness between admission and discharge. Favorable outcome (GOSE 5-8) was seen in 69% for patients admitted in Hunt & Hess I-II and 25% for Hunt & Hess III-V. Mortality at one year was 10.9% and 42.7% for those admitted awake and unconscious, respectively.The number of cases decreased during the study period, which was in line with Swedish national data. CONCLUSIONS: The incidence of patients with SAH gradually decreased in our material, in line with national data. The treatment policy in our unit has been shifting to more use of endovascular methods. During the study period the use of hemicraniectomies decreased.

Prevalence of extended-spectrum beta-lactamase and molecular detection of blaTEM, blaSHV, and blaCTX-M genotypes among gram-negative Bacilli isolates from hospital acquired infections in pediatrics, one institutional study.

BACKGROUND: Gram-negative bacilli represents an important pathogen in hospital-acquired infections (HAIs) worldwide. The emergence of antibiotic resistance in these pathogens warrants attention for the proper management of infections. Extended-spectrum beta-lactamase (ESBL) resistance represents a major therapeutic problem in infections due to Gram-negative bacilli. The present study aimed to study the extended-spectrum beta-lactamase genes blaTEM, blaSHV, and blaCTX-M by multiplex polymerase reaction in isolated Gram-negative bacilli from HAIs in pediatric patients. METHODS: The study included one hundred-five isolates of Gram-negative bacilli from pediatric patients with different types of HAIs. The isolates were subjected to full microbiological identification, antibiotics susceptibility by disc diffusion method, the phenotypic study of ESBL, and the genetic study of ESBL genes by multiplex PCR. RESULTS: Fifty isolates of Gram-Negative bacilli showed ESBL activity by a phenotypic study by double disc diffusion method (50/105). All ESBL producers' isolates were positive by PCR for ESBL genes. The most frequent gene was blaTEM (64%), followed by blaSHV (30%) and CTX-M (22%). Mixed genes were found in 4 isolates (8%) for blaTEM and blaSHV, blaTEM and CTX-M. There was a significant association between PCR for ESBL genes and phenotypic ESBL detection (P = 0.001). There was significant detection of ESBL genes in E. coli (28%), followed by Enterobacter spp. (26%), Klebsiella spp. (24%), Serratia (14%), Pseudomonas spp. (6%) and Proteus (2%), P = 0.01. There Seventy percent of isolates positive for ESBL production had an insignificant association between MDR and PCR for ESBL genes (P = 0.23). CONCLUSION: The present study highlights the prevalence of ESBL activity among clinical isolates of Gram-negative bacilli isolated from hospital-acquired infections in pediatric patients. The most common gene responsible for this activity was blaTEM gee followed by blaSHV and blaCTX-M. There was a high prevalence of multiple antibiotic resistance among isolates with ESBL activity. The finding of the present study denotes the importance of screening extended beta-lactamase among Gram-negative bacilli associated with HAIs in pediatric patients.

Expanded range of indications for Neuroform Atlas stent in the treatment of very small, wide-necked cerebral aneurysms.

The purpose of this study was to investigate the range of indications for using the Neuroform Atlas stent. Between 2016 and 2020, we treated 20 females and 5 males for aneurysms with a diameter of less than 3 mm and an aspect ratio less than 1.5. The diameter of the parent arteries varied from 1.1 mm to 4.5 mm. There were 13 ruptured and 12 unruptured aneurysms. Double stent-assisted coiling was performed in 14 cases, and single stent-assisted coiling was performed in 11 cases. After deployment, the morphology of the Neuroform Atlas stents was analyzed in tapered or Y-shaped silicone tubes that simulated parent arteries. Radiological results were assessed 7 months and 2 years after the intervention using the Raymond-Roy scale. Clinical outcome was assessed 1 year after the intervention using the modified Rankin score. There were three fatal outcomes. One aneurysm was recoiled. The rate of class I aneurysm occlusion was registered in 21 patients at the last follow-up. At the end of the clinical follow-up period, a favorable outcome (modified Rankin scale 0 -1) was registered in nine patients with ruptured aneurysms. An analysis of the morphology of the stents deployed in the silicone tubes provided an explanation for the stability of the coil mass in the treated aneurysms. Our results suggest that the range of indications for use of the Neuroform Atlas stent can be expanded beyond the present range with regard to the diameter of the parent vessels and size of the aneurysms.

Resource utilization in management of spontaneous intracerebral hemorrhage without systemic risk factors. Does early surgical decompression matter?

BACKGROUND: Even though different subtypes of spontaneous ICH are frequently linked to a poor prognosis, their causes, pathological features, and prognoses vary. Atypical intracerebral hemorrhage is the subtype of spontaneous ICH that usually occurs due to an underlying localized vascular lesion. It is unrelated to systemic vascular risk factors, mostly affects children and young adults and is associated with a relatively good outcome. This fact should be considered when planning the evaluation and treatment. Investigating the cause of this subtype is fundamental to providing optimal management. However, if resources do not allow completing the investigations, the cause will be more difficult to discover. Treatment decisions will be made under stress to save the patient's life, especially with rapidly deteriorating patients. METHODS: We described three cases of spontaneous ICH without systemic risk factors where the bleeding source could not be determined before surgery due to a lack of resources, preventing preoperative vascular investigation. Knowing that the atypical ICH has a distinct identity, regarding etiology and prognosis, encouraged the surgeons to resort to early surgical decompression as an alternative plan. We reviewed the literature searching for supporting evidence. RESULTS: The results of treatment of the presented cases were satisfactory. The lack of reported similar cases was brought to light by a literature analysis that sought to provide backing for the proposed management strategy. In the end, we supplied two graphic organizers to help readers remember the different types and treatment of hemorrhagic stroke. CONCLUSION: There isn't enough evidence to show that there are other ways to treat atypical intracerebral haemorrhage when resources are limited. The presented cases highlight the importance of decisionmaking in resource-constrained situations when patient outcomes can be improved.

Use of Distal Intracranial Catheters for Better Working View of Cerebral Aneurysms Hidden by Parent Artery or Its Branches: A Technical Note.

A good working view is critical for safe and successful endovascular treatment of cerebral aneurysms. In a few cases, endovascular treatment of cerebral aneurysms may be challenging due to difficulty in obtaining a proper working view. In this report of 6 cases, we described the advantage of using a distal intracranial catheter (DIC) to achieve better visualization of cerebral aneurysms hidden by a parent artery or its branches. Between September 2017 and January 2021, we treated 390 aneurysms with endovascular techniques. In 6 cases in which it was difficult to obtain a proper working view, the DIC was placed distally close to the aneurysm in order to remove the parent artery projection from the working view and obtain better visualization of the aneurysm. Clinical and procedural outcomes and complications were evaluated. The position of the DIC was above the internal carotid artery siphon in the 6 cases. All aneurysms were successfully embolized. Raymond-Roy class 1 occlusion was achieved in all 4 unruptured aneurysms, while the result was class 2 in the 2 ruptured aneurysms. Placement of the DIC was atraumatic without dissections or significant catheter-induced vasospasm in all patients. Transient dysphasia was seen in 2 cases and transient aphasia in 1. Using this technique, we have found it possible to better visualize the aneurysm sac or neck and thereby treat cases we otherwise would have considered untreatable.

Endovascular treatment of type 1 and type 4 non-saccular aneurysms of cerebral arteries - a single-Centre experience.

AIM OF THE STUDY: The aim of this study was to evaluate our results regarding treatment options, complications, and outcomes in patients with non-saccular aneurysms of cerebral arteries belonging to type 1 and type 4 according to Mizutani's classification. METHODS: A total of 26 aneurysms in 26 patients were treated between 2014 and 2019. There were 13 males (mean age 42.77 ± 11.73 years) and 13 females (mean age 50.84 ± 9.37 years). In 23 cases the onset was haemorrhagic and in three cases non-haemorrhagic. A combination of conventional stents and coils was used in 10 cases, conventional stents and flow diverters in three cases, flow diverters and coils in five cases, and flow diverters only were used in eight cases. Radiological results of treatment were assessed after eight months and clinical after one year. RESULTS: In 24 patients, aneurysms were occluded at the end of the follow-up period. An iatrogenic dissection and two haemorrhagic complications were registered. In three cases, parent arteries were occluded due to re-growth of the aneurysm, which caused middle cerebral artery infarction in one case. A favourable clinical outcome was registered in 19, patients, and non-favourable in five. Two patients died in the early postoperative period due to extensive damage to the brain parenchyma caused by initial bleeding. CONCLUSION: Our results indicate that treatment of type 1 and type 4 non-saccular aneurysms with various combination of stents and flow diverters, with or without coils, is promising, although very challenging and technically demanding.

Neuroform Atlas stent in treatment of iatrogenic dissections of extracranial internal carotid and vertebral arteries: a single-centre experience.

AIM OF THE STUDY: To present our experience in the treatment of iatrogenic dissections of extracranial internal carotid and vertebral arteries with the Neuroform Atlas stent. MATERIALS AND METHODS: Between January 2017 and February 2018 we treated iatrogenic dissections of three internal carotid arteries and three vertebral arteries. These iatrogenic dissections occurred during the endovascular treatment of ruptured and unruptured intracranial aneurysms. The indication for stenting was haemodynamically significant, flow-limiting dissection with threatening flow arrest. In all six cases, the dissections were treated by placement of Neuroform Atlas stents in the dissected segments of internal carotid or vertebral arteries. Deployment of the stent was followed by the usual dual antiplatelet regimen. RESULTS: Single or multiple Neuroform Atlas stents were deployed without any technical difficulties, and blood flow was restored immediately after placement of the stents in all six cases. Midterm follow-up (6-8 months) showed complete reconstruction of the shape and lumen of all treated arteries, with negligible intimal hyperplasia. CONCLUSION: Our results indicate that a favourable outcome can be achieved by treating iatrogenic dissections of extracranial internal carotid and vertebral arteries with the Neuroform Atlas stent.

Dual lumen balloon catheter - An effective substitute for two single lumen catheters in treatment of vascular targets with challenging anatomy.

The aim of this study was to describe our experience in the treatment of various pathological conditions of the cranial and spinal blood vessels and hypervascularized lesions using dual lumen balloon catheters. Twenty-five patients were treated with endovascular techniques: two with vasospasm of cerebral blood vessels caused by subarachnoid hemorrhage, one with a hypervascularized metastasis in the vertebral body, two with spinal dural fistula, four with cerebral dural fistula, three with cerebral arteriovenous malformations, and 13 with aneurysms. The dual lumen balloon catheters were used for remodeling of the coil mesh, injection of various liquid embolic agents, particles and nimodipine, for the prevention of reflux and deployment of coils and stents. The diameter of catheterized blood vessels varied from 0.7 mm to 4 mm. Two complications occurred: perforation of an aneurysm in one case and gluing of the tip of balloon catheter by embolic material in another case. All other interventions were uneventful, and therapeutic goals were achieved in all cases except in the case with gluing of the tip of balloon catheter. The balloons effectively prevented reflux regardless of the type of the embolic material and diameter of blood vessel. The results of our study show that dual lumen balloon catheters allow complex interventions in the narrow cerebral and spinal blood vessels where the safe use of two single lumen catheters is either limited or impossible.

Spot fluoroscopy: a novel innovative approach to reduce radiation dose in neurointerventional procedures.

Background Increased interest in radiation dose reduction in neurointerventional procedures has led to the development of a method called "spot fluoroscopy" (SF), which enables the operator to collimate a rectangular or square region of interest anywhere within the general field of view. This has potential advantages over conventional collimation, which is limited to symmetric collimation centered over the field of view. Purpose To evaluate the effect of SF on the radiation dose. Material and Methods Thirty-five patients with intracranial aneurysms were treated with endovascular coiling. SF was used in 16 patients and conventional fluoroscopy in 19. The following parameters were analyzed: the total fluoroscopic time, the total air kerma, the total fluoroscopic dose-area product, and the fluoroscopic dose-area product rate. Statistical differences were determined using the Welch's t-test. Results The use of SF led to a reduction of 50% of the total fluoroscopic dose-area product (CF = 106.21 Gycm2, SD = 99.06 Gycm2 versus SF = 51.80 Gycm2, SD = 21.03 Gycm2, p = 0.003884) and significant reduction of the total fluoroscopic dose-area product rate (CF = 1.42 Gycm2/min, SD = 0.57 Gycm2/s versus SF = 0.83 Gycm2/min, SD = 0.37 Gycm2/min, p = 0.00106). The use of SF did not lead to an increase in fluoroscopy time or an increase in total fluoroscopic cumulative air kerma, regardless of collimation. Conclusion The SF function is a new and promising tool for reduction of the radiation dose during neurointerventional procedures.

Combined percutaneous and transarterial devascularisation of juvenile nasopharyngeal angiofibroma with protection of internal carotid artery: A modification of the technique.

Juvenile nasal angiofibroma (JNA) is a hypervascularised, benign, but locally aggressive tumour that grows in the posterior, upper part of the nasal cavity and invades surrounding anatomical structures. The treatment of choice is surgical removal, but complete resection of the tumour can be hampered because of profuse perioperative bleeding. Preoperative embolisation of the tumour has been proposed as an effective method for prevention of perioperative bleeding, thereby shortening of the time of the operation. In this report of five cases, we describe successful preoperative devascularisation of the tumour by applying a modified method of direct intratumoural injection of the liquid embolic agent Onyx combined with protection of the internal carotid artery. The control of bleeding during the embolisation and occlusion of the maxillary or sphenopalatine artery was achieved by using a bi-luminal balloon catheter. Such use of the dual-lumen catheter in treatment of JNA has not been reported so far in the medical literature.