RESUMO
AIM: To investigate factors that could impact on recanalisation and reperfusion in patients undergoing mechanical thrombectomy and to assess the technical success over time. MATERIALS AND METHODS: Two hundred consecutive patients who underwent thrombectomy for a proximal anterior circulation occlusion were dichotomised into equal groups (groups 1 and 2) based on the date that immediate access to emergency general anaesthesia (GA) commenced. RESULTS: Recanalisation success using thrombolysis in cerebral infarction (TICI) 2b/3 or TICI 2c/3 significantly improved in group 2 (67% versus 93%, p<0.0001; 52% versus 78%, p=0.0002). Symptomatic haemorrhage also reduced from 9% to 4%. Despite similar presentation Alberta Stroke Program Early (computed tomography) CT Scores (ASPECTS), post-procedural ASPECTS was significantly increased in group 2 (7; [interquartile range {IQR} 4-9] versus 8 [IQR 7-9]; p=0.0034). The number of patients with a post procedural ASPECTS of 8-10 increased (46% versus 64%, p=0.0155) and the difference in ASPECTS between pre- and post-thrombectomy CT was significantly lower (2 [IQR 1-4] versus 1 [IQR 0-2], p<0.0001). GA use increased from 8% to 56% (p=0.0001) as did use of distal aspiration (59% versus 87%, p=0.0001) mostly in combination with a stent-retriever. Failed access fell from 8% to 3%. When GA was used, successful recanalisation (TICI 2b/3) was achieved more frequently (90.5% versus 76.7%; OR 3.04, 1.2-7.69, p=0.0187). CONCLUSION: Technical results for thrombectomy are improving over time. Technique modification, operator experience, and judicious use of GA may be contributing.
Assuntos
Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Idoso , Anestesia/estatística & dados numéricos , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Infarto Cerebral/cirurgia , Revascularização Cerebral/métodos , Revascularização Cerebral/estatística & dados numéricos , Feminino , Humanos , Masculino , Duração da Cirurgia , Estudos Prospectivos , Trombectomia/estatística & dados numéricos , Terapia Trombolítica/métodos , Terapia Trombolítica/estatística & dados numéricos , Resultado do TratamentoRESUMO
We report a case of Erdheim-Chester disease (ECD) with a 25-year history following initial presentation with diabetes insipidus and brainstem involvement. The exceptionally long history is particularly notable, given that ECD is a life-threatening disorder and there is a recognised association between central nervous system involvement and poor outcome. The case is a timely reminder of the presenting features of the condition, given the emergence of potential new treatment options.
Assuntos
Encefalopatias/etiologia , Doença de Erdheim-Chester/complicações , Diabetes Insípido/complicações , Evolução Fatal , Feminino , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-IdadeRESUMO
Ovarioleukodystrophy-the co-occurrence of leukodystrophy and premature ovarian failure-is a rare presentation now recognised to be part of the clinical spectrum of vanishing white matter disease. We describe a woman with epilepsy and neuroimaging changes consistent with leukoencephalopathy who presented with non-convulsive status epilepticus after starting hormone replacement therapy in the context of premature ovarian failure. Genetic testing confirmed her to be a compound heterozygote for EIF2B5 mutations; the gene encodes a subunit of eukaryotic translation initiation factor 2B. Mutations in EIF2B1-5 result in vanishing white matter disease. We highlight the importance of ovarian failure as a diagnostic pointer to eukaryotic translation initiation factor 2B (eIF2B)-related ovarioleukodystrophy and present a brief literature review of ovarioleukodystrophy.
Assuntos
Fator de Iniciação 2B em Eucariotos/genética , Leucoencefalopatias/genética , Doenças Ovarianas/genética , Adulto , Feminino , Humanos , Leucoencefalopatias/diagnóstico , Mutação , Doenças Ovarianas/diagnóstico , Adulto JovemRESUMO
Recent trial evidence suggests that for patients suffering large-vessel occlusive stroke, endovascular therapy based on the stent-retriever technique is associated with superior clinical outcomes when compared to intravenous thrombolysis alone. The challenge now is how this service is to be delivered. This may involve both centralisation of services around large cities and development of robust networks to receive patients from district general hospitals situated further afield. Both diagnostic and interventional neuroradiology will need to expand. Furthermore, we suggest that it would be advantageous for radiology departments in those hospitals receiving hyperacute stroke patients to perform computed tomography (CT) angiography in addition to non-contrast CT, which also has implications for service delivery in these units. This could swiftly aid identification of patients who might benefit from thrombectomy and improve decision-making through demonstration of occlusive thrombus and of collateral status.
Assuntos
Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/terapia , Angiografia Cerebral , Procedimentos Endovasculares , Neuroimagem/métodos , Stents , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/terapia , Tomografia Computadorizada por Raios X , Meios de Contraste , Tomada de Decisões , Humanos , TrombectomiaRESUMO
Idiopathic hypereosinophilic syndrome (IHES) is a primary haematological condition characterised by persistent, otherwise unexplained hypereosinophilia sufficient to cause organ damage. Various neurological complications are reported, but very few have mentioned CNS pathology and none has included CNS vasculitis. Our objective here is to report IHES as a new cause of histopathologically confirmed CNS vasculitis. A 39-year-old man presented with a relapsing sub-acute encephalopathy, with severe headaches, confusion and drowsiness, myoclonus, ataxia and papilloedema. He had a history of nephrotic syndrome 18 years earlier, stable for the past 5 years on low-dose corticosteroids and low-dose tacrolimus (2 mg bd); lichen planus, and (15 years previously) aloplecia totalis. On admission, he had a marked peripheral eosinophilia (up to 9.1 × 10(9)/dL), whichit subsequently became clearhad been intermittently present for 16 years. After extensive investigation, biopsies of brain and bone marrow confirmed diagnoses of cerebral vasculitis, with lymphocytic and macrophage (but not eosinophilic) cellular infiltration of blood vessel walls, and IHES. CNS vasculitis can therefore now be added to the list of neurological complications of IHES. A dramatic and sustained neurological improvement, and likewise of the eosinophilia, following treatment with corticosteroids and cyclophosphamide, emphasises the tractability of this newly described form of CNS vasculitis.
Assuntos
Síndrome Hipereosinofílica/complicações , Vasculite do Sistema Nervoso Central/etiologia , Corticosteroides/uso terapêutico , Adulto , Ciclofosfamida/uso terapêutico , Eosinofilia/patologia , Humanos , Síndrome Hipereosinofílica/tratamento farmacológico , Imunossupressores/uso terapêutico , MasculinoAssuntos
Lesões das Artérias Carótidas/etiologia , Lesões das Artérias Carótidas/terapia , Endoscopia/efeitos adversos , Procedimentos Endovasculares/métodos , Osso Esfenoide/diagnóstico por imagem , Adulto , Lesões das Artérias Carótidas/diagnóstico por imagem , Humanos , Masculino , Radiografia , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: There is controversy as to the best mode of treating MCA aneurysms. We report the results of a large endovascular series of patients treated at our center. MATERIALS AND METHODS: This study was a retrospective analysis of a prospectively acquired data base. All patients with saccular MCA aneurysms treated between November 1996 and June 2012 were included. World Federation of Neurosurgical Societies grade, aneurysm site, size, and aneurysm neck size were recorded, along with clinical outcome assessed with the Glasgow Outcome Scale and radiographic occlusion assessed with the Raymond classification at 6 months and 2.5 years. RESULTS: A total of 295 patients with 300 MCA aneurysms were treated including 244 ruptured aneurysms (80.7%). The technical failure rate was 4.3% (13 patients). Complete occlusion or neck remnant was achieved in 264 (91.4%). Complications included rupture in 15 patients (5%), thromboembolism in 17 patients (5.7%), and early rebleeding in 3 patients (1%). Overall permanent procedural-related morbidity and mortality were seen in 12 patients (7.8%). Of the ruptured aneurysms, 189 (79.4%) had a favorable clinical outcome (Glasgow Outcome Scale score, 4-5). A total of 33 patients (13.6%) died. On initial angiographic follow-up, aneurysm remnant was seen in 18 aneurysms (8.1%). A total of 13 patients (4.3%) were re-treated. CONCLUSIONS: Our experience demonstrates that endovascular treatment of MCA aneurysms has an acceptable safety profile with low rates of technical failure and re-treatment. Therefore, coiling is acceptable as the primary treatment of MCA aneurysms.
Assuntos
Aneurisma Roto/etiologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Infarto da Artéria Cerebral Média/cirurgia , Trombose Intracraniana/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma Roto/diagnóstico por imagem , Aneurisma Roto/mortalidade , Angiografia Cerebral , Feminino , Seguimentos , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/mortalidade , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/mortalidade , Aneurisma Intracraniano/cirurgia , Trombose Intracraniana/diagnóstico por imagem , Trombose Intracraniana/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
A case of thrombus formation occurring within a dilation of the dural venous sinuses following aneurysmal sub-arachnoid haemorrhage is presented. Acute neurological deterioration accompanied propagation of the thrombus. The patient was anticoagulated on day 5 post-SAH with no haemorrhagic complications and made a full recovery. The optimum time to commence anticoagulation is not clear and is discussed.
Assuntos
Anticoagulantes/farmacologia , Cavidades Cranianas/patologia , Hemorragia Subaracnóidea/complicações , Trombose/etiologia , Varfarina/farmacologia , Adulto , Anticoagulantes/administração & dosagem , Angiografia Cerebral , Cavidades Cranianas/diagnóstico por imagem , Feminino , Humanos , Hemorragia Subaracnóidea/diagnóstico por imagem , Trombose/diagnóstico por imagem , Trombose/tratamento farmacológico , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Varfarina/administração & dosagemRESUMO
Thunderclap headache (TCH) is an acute and severe headache that has maximum intensity at onset; TCH can be primary or secondary. Primary TCH is diagnosed when no underlying cause is discovered; however, imaging is crucial in distinguishing secondary causes, which are wide-ranging. The radiologist should be aware of the list of potential diagnoses. Subarachnoid haemorrhage (SAH) is the most common cause of secondary TCH. Aneurysmal SAH accounts for the majority of cases, although other causes should also be considered and these include perimesencephalic haemorrhage, arteriovenous malformations, and dural arteriovenous fistula as well as reversible cerebral vasoconstriction syndrome. Conditions that may present with TCH, with or without SAH include cervical artery dissection and cerebral venous sinus thrombosis. Ischaemic stroke, pituitary apoplexy, and posterior reversible leucoencephalopathy are other potential causes, whereas non-vascular causes include colloid cysts of the third ventricle and spontaneous intracranial hypotension. Imaging features are reviewed with reference to clues gleaned from initial imaging using computed tomography, as well as characteristics that should be sought using magnetic resonance imaging or angiographic imaging.
Assuntos
Transtornos da Cefaleia Primários/diagnóstico , Transtornos da Cefaleia Primários/etiologia , Neuroimagem/métodos , Diagnóstico Diferencial , HumanosRESUMO
Several diverse neurological conditions may be seen during pregnancy and the post partum period. These usually require neuroimaging for definitive diagnosis and range from a predisposition to neurovascular abnormalities, such as acute ischaemic stroke and cerebral venous sinus thrombosis, through to more specific pregnancy-related conditions, such as eclampsia/posterior reversible leukoencephalopathy and post-partum angiopathy. Additionally, the pregnant patient is predisposed to pituitary disease. It is necessary that the radiologist has an awareness of these conditions to allow swift specific diagnoses or suggest the most appropriate diagnosis when imaging findings are non-specific. We describe epidemiological and radiological features to allow the radiologist to guide the clinician in management, and review guidelines for safe cranial imaging of the pregnant patient.
Assuntos
Encefalopatias/diagnóstico , Encéfalo/diagnóstico por imagem , Encéfalo/patologia , Neuroimagem/métodos , Período Pós-Parto , Complicações na Gravidez/diagnóstico , Diagnóstico Diferencial , Feminino , Humanos , Angiografia por Ressonância Magnética/métodos , Imageamento por Ressonância Magnética/métodos , Gravidez , Tomografia Computadorizada por Raios X/métodosRESUMO
A retained microcatheter is a rare complication of endovascular treatment of cerebral aneurysms. We describe such a case that was complicated by delayed microcatheter fracture within the internal carotid artery and subsequent thrombo-embolism resulting in transient ischaemic attacks. We also describe endovascular management of this complication through the use of several carotid stents.
Assuntos
Catéteres/efeitos adversos , Embolização Terapêutica/efeitos adversos , Procedimentos Endovasculares/métodos , Corpos Estranhos/complicações , Ataque Isquêmico Transitório/etiologia , Stents , Artéria Carótida Interna/diagnóstico por imagem , Angiografia Cerebral , Embolização Terapêutica/instrumentação , Procedimentos Endovasculares/instrumentação , Falha de Equipamento , Corpos Estranhos/diagnóstico , Corpos Estranhos/terapia , Humanos , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/prevenção & controle , Masculino , Pessoa de Meia-Idade , Tromboembolia/diagnóstico , Tromboembolia/etiologia , Tromboembolia/prevenção & controle , Tomografia Computadorizada por Raios X , UltrassonografiaAssuntos
Isquemia Encefálica/etiologia , Meningite Pneumocócica/complicações , Adulto , Antibacterianos/uso terapêutico , Isquemia Encefálica/diagnóstico , Ceftriaxona/uso terapêutico , Dexametasona/uso terapêutico , Exotropia/etiologia , Glucocorticoides/uso terapêutico , Cefaleia/etiologia , Humanos , Imageamento por Ressonância Magnética , Masculino , Meningite Pneumocócica/tratamento farmacológico , Mioclonia/etiologiaRESUMO
Basilar artery occlusion is an infrequent form of acute stroke; clinical outcomes are heterogeneous, but the condition can be fatal. There is a lack of randomized controlled trial data in this field. Case series suggest that patients who are recanalized have much better outcomes than those who are not, and it is generally accepted that intra-arterial techniques achieve high rates of recanalization. Controversially, several studies, including a meta-analysis and registry-based investigation, that have compared intravenous thrombolysis (IVT) and intra-arterial treatment suggest similar outcomes. However, there are many potential sources of bias in each of these studies, precluding a firm conclusion. Indeed, there are many confounding factors that can influence the outcome including severity of presentation, site of occlusion, clot load, degree of collateral flow, timing of therapy, agent used for recanalization and dose of thrombolytic agent. Additionally, pretreatment infarct core imaging using diffusion-weighted imaging and the posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) scoring systems have been shown to predict outcome and therefore may be useful in selecting patients for aggressive therapy. Protocols combining intravenous agents such as glycoprotein IIb/IIIa receptor antagonists or thombolytics agents with intra-arterial techniques ('bridging' therapy) have shown encouraging improvements in neurological outcome and survival. Furthermore, initial case series describing the use of mechanical clot extraction devices or aspiration catheters suggest high rates of recanalization. What would be useful is a randomized trial comparing IVT, endovascular approaches and a combined IVT/endovascular approach. However, the small numbers of patients and multiple confounding factors are barriers to the development of such a trial.
Assuntos
Artéria Basilar/patologia , Transtornos Cerebrovasculares/diagnóstico , Transtornos Cerebrovasculares/cirurgia , Procedimentos Endovasculares/métodos , Doença Aguda , Animais , Artéria Basilar/cirurgia , Humanos , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodosRESUMO
OBJECTIVE: We report a rare case of epistaxis resulting from a ruptured internal carotid artery aneurysm, and present a successful treatment method. CASE REPORT: A 72-year-old woman was admitted following recurrent massive epistaxis. There was no history of trauma or surgery. Radiographic imaging demonstrated a large internal carotid artery aneurysm. An attempt was made to occlude the aneurysm with endovascular coils. Despite this, the patient went on to have further epistaxis. Endovascular ablation of the feeding internal carotid artery led to complete resolution. CONCLUSION: This case demonstrates that spontaneous epistaxis from intra-cavernous carotid artery aneurysms can be managed using endovascular techniques. To our knowledge, we report the first use of interventional radiological techniques to assess the collateral circulation to the brain and subsequently undertake endovascular ablation of the internal carotid artery.
Assuntos
Aneurisma Roto/diagnóstico por imagem , Doenças das Artérias Carótidas/diagnóstico por imagem , Procedimentos Endovasculares/métodos , Epistaxe/diagnóstico , Aneurisma Intracraniano/diagnóstico por imagem , Idoso , Aneurisma Roto/complicações , Aneurisma Roto/terapia , Angiografia , Doenças das Artérias Carótidas/complicações , Doenças das Artérias Carótidas/terapia , Artéria Carótida Interna , Embolização Terapêutica , Epistaxe/etiologia , Epistaxe/terapia , Feminino , Humanos , Hipovolemia/etiologia , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/terapia , Radiologia Intervencionista/métodos , Recidiva , Ruptura Espontânea/complicações , Ruptura Espontânea/diagnóstico por imagem , Ruptura Espontânea/terapia , StentsRESUMO
BACKGROUND AND PURPOSE: FD technology enables reconstructive repair of otherwise difficult-to-treat intracranial aneurysms. These stentlike devices may induce progressive aneurysm thrombosis without additional implants and may initiate complete reverse vessel remodeling. The associated vascular biologic processes are as yet only partially understood. MATERIALS AND METHODS: From 12 different centers, 13 cases of delayed postprocedural aneurysm rupture were recorded and analyzed. Symptom, aneurysm location and morphology, and the time elapsed from treatment until rupture were analyzed. RESULTS: There were 10 internal carotid and 3 basilar artery aneurysms. Mean aneurysm diameter was 22 ± 6 mm. Eleven patients were symptomatic before treatment. A single FD was used for all saccular aneurysms, while fusiform lesions were treated by using multiple devices. A supplementary loose coiling of the aneurysm was performed in 1 patient only. Ten patients developed early aneurysm rupture after FD treatment (mean, 16 days; range, 2-48 days); in 3 patients, rupture occurred 3-5 months after treatment. In all cases, most of the aneurysm cavity was thrombosed before rupture. The biologic mechanisms predisposing to rupture under these conditions are reviewed and discussed CONCLUSIONS: FDs alone may modify hemodynamics in ways that induce extensive aneurysm thrombosis. Under specific conditions, however, instead of reverse remodeling and cicatrization, aggressive thrombus-associated autolysis of the aneurysm wall may result in delayed rupture.