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1.
J Neurointerv Surg ; 2021 Nov 03.
Artigo em Inglês | MEDLINE | ID: mdl-34732531

RESUMO

BACKGROUND: Data regarding the safety and efficacy of flow diverting stents (FDS) in the treatment of middle cerebral artery (MCA) bifurcation aneurysms are scarce and limited to small single center series, with particular concern for increased risk of ischemic complications with jailing one of the M2 branches. METHODS: Prospectively-maintained databases at six North American and European centers were queried for patients harboring MCA bifurcation aneurysms undergoing treatment with FDS (2011-2018). The pertinent clinical and radiographic data were collected and analyzed. RESULTS: 87 patients (median age 60 years, 69% females) harboring 87 aneurysms were included. The majority of aneurysms were unruptured (79%); 75.9% were saccular with a median maximal diameter of 8.5 mm. Radiographic imaging follow-up was available in 88.5% of cases at a median of 16.3 months post-treatment, showing complete occlusion in 59% and near complete occlusion (90-99%) in 18% of aneurysms. The overall rate of ischemic and hemorrhagic complications was 8% and 1.1%, respectively. Symptomatic and permanent complications were encountered in 5.7% and 2.3% of patients respectively, with retreatment pursued in 2.3% of patients. Jailed branch occlusion was detected in 11.5% of cases, with clinical sequelae in 2.3%. Last follow-up modified Rankin Scale of 0-2 was noted in 96.8% of patients. On multivariate analysis, male sex was the only independent predictor of aneurysmal persistence at last follow-up imaging (p=0.019). CONCLUSION: FDS treatment for MCA bifurcation aneurysms is feasible, with comparable safety and efficacy profiles to other available endovascular options when utilized in carefully selected aneurysms. Jailing of M2 branches was not associated with a higher risk of post-procedural ischemic complications.

2.
Neurosurg Rev ; 2021 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-34480649

RESUMO

The Woven EndoBridge (WEB) device is becoming increasingly popular for treatment of wide-neck aneurysms. As experience with this device grows, it is important to identify factors associated with occlusion following WEB treatment to guide decision making and screen patients at high risk for recurrence. The aim of this study was to identify factors associated with adequate aneurysm occlusion following WEB device treatment in the neurosurgical literature and in our case series. A systematic review of the present literature was conducted to identify studies related to the prediction of WEB device occlusion. In addition, a retrospective review of our institutional data for patients treated with the WEB device was performed. Demographics, aneurysm characteristics, procedural variables, and 6-month follow-up angiographic outcomes were recorded. Seven articles totaling 450 patients with 456 aneurysms fit our criteria. Factors in the literature associated with inadequate occlusion included larger size, increased neck width, partial intrasaccular thrombosis, irregular shape, and tobacco use. Our retrospective review identified 43 patients with 45 aneurysms. A total of 91.1% of our patients achieved adequate occlusion at a mean follow-up time of 7.32 months. Increasing degree of contrast stasis after WEB placement on the post-deployment angiogram was significantly associated with adequate occlusion on follow-up angiogram (p = 0.005) and with Raymond-Roy classification (p = 0.048), but not with retreatment (p = 0.617). In our systematic review and case series totaling 450 patients with 456 aneurysms, contrast stasis on post-deployment angiogram was identified as a predictor of adequate aneurysm occlusion, while morphological characteristics such as larger size and wide neck negatively impact occlusion.

3.
World Neurosurg ; 156: e77-e84, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34500100

RESUMO

OBJECTIVES: We aim to determine the incidence of decompressive hemicraniectomy (DHC) in the modern era of mechanical thrombectomy techniques and improved revascularization outcomes. METHODS: We performed a retrospective analysis of 512 patients admitted with acute ischemic strokes with anterior circulation large-vessel occlusion that were treated by mechanical thrombectomy from 2010-2019. The primary endpoint was the need for surgical decompression. Secondary endpoints were infarct size, hemorrhagic conversion, and functional outcome at hospital discharge. RESULTS: Of the 512 patients, 18 (3.5%) underwent DHC at a median 2.0 days from stroke onset. The DHC group was significantly younger than the non-DHC group (P < 0.001), had worse reperfusion rates (P = 0.024) and larger infarct size (P < 0.001). Hemorrhagic conversion was more frequent in the DHC group but did not reach statistical significance (P = 0.08). From 2010-2015, 196 patients underwent a mechanical thrombectomy, 13 of whom (6.6%) required a DHC, while 316 patients underwent mechanical thrombectomy from 2016-2019 and only 5 patients required a DHC (1.6%; P = 0.002). Younger age (P < 0.001), urinary tract infection (P < 0.001) and increasing infarct size were significantly associated with needing a DHC. When controlling for other risk factors, higher thrombolysis in cerebral infarction score significantly reduced the need for decompressive hemicraniectomy (P = 0.004). CONCLUSIONS: This is one of the largest single-center experiences demonstrating that improved recanalization decreased the need for DHC without increasing the risk of hemorrhagic conversion.

4.
J Clin Neurosci ; 92: 67-74, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34509265

RESUMO

Errors in communication are a major source of preventable medical errors. Neurosurgical patients frequently present to the neuro-intensive care unit (NICU) postoperatively, where handoffs occur to coordinate care within a large multidisciplinary team. A multidisciplinary working group at our institution started an initiative to improve postoperative neurosurgical handoffs using validated quality improvement methodology. Baseline handoff practices were evaluated through staff surveys and serial observations. A formalized handoff protocol was implemented using the evidence based IPASS format (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, Synthesis by receiver). Cycles of objective observations and surveys were employed to track practice improvements and guide iterative process changes over one year. Surveys demonstrated improved perceptions of handoffs as organized (17.1% vs 69.7%, p < 0.001), efficient (27.0% vs. 72.7%, p < 0.001), comprehensive (17.1% vs. 66.7%, p < 0.001), and safe (18.0% vs. 66.7%, p < 0.001), noting improved teamwork (31.5% vs. 69.7%, p < 0.001). Direct observations demonstrated improved communication of airway concerns (47.1% observed vs. 92.3% observed, p < 0.001), hemodynamic concerns (70.6% vs. 97.1%, p = 0.001), intraoperative events (52.9% vs. 100%, p < 0.001), neurological examination (76.5% vs. 100%, p < 0.001), vital sign goals (70.6% vs. 100%, p < 0.001), and required postoperative studies (76.5% vs. 100%, p < 0.001). Receiving teams demonstrating improved rates of summarization (47.1% vs. 94.2%, p = 0.005) and asking questions (76.5% vs 98.1%, p = 0.004). The mean handoff time during long-term follow-up was 4.4 min (95% confidence interval = 3.9-5.0 min). Standardization of handoff practices yields improvements in communication practices for postoperative neurosurgical patients.


Assuntos
Transferência da Responsabilidade pelo Paciente , Comunicação , Humanos , Unidades de Terapia Intensiva , Erros Médicos , Período Pós-Operatório
5.
J Neurointerv Surg ; 2021 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-34244337

RESUMO

BACKGROUND: The purpose of this guideline is to summarize the data available for performing mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) stroke in special populations not typically included in large randomized controlled clinical trials, including children, the elderly, pregnant women, patients who have recently undergone surgery, and patients with thrombocytopenia, collagen vascular disorders, and endocarditis. METHODS: We performed a literature review for studies examining the indications, efficacy, and outcomes for patients undergoing MT for ischemic stroke aged <18 years and >80 years, pregnant patients, patients who have recently undergone surgery, and those with thrombocytopenia, collagen vascular diseases, or endocarditis. We graded the quality of the evidence. RESULTS: MT can be effective for the treatment of ELVO in ischemic stroke for patients over age 80 years and under age 18 years, thrombocytopenic patients, pregnant patients, and patients with endocarditis. While outcomes are worse compared to younger patients and those with normal platelet counts (respectively), there is still a benefit in the elderly (in both mRS and mortality). Data are very limited for patients with collagen vascular diseases; although diagnostic cerebral angiography carries increased risks, MT may be appropriate in carefully selected patients in whom untreated ELVO would likely result in disabling or fatal outcome.

6.
World Neurosurg ; 154: 13-20, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34245882

RESUMO

The treatment of orbital lymphaticovenous malformations (OLVMs) has evolved from simple surgical resection to a multimodal approach consisting of sclerosing agents, embolization, and resection depending on the specific components that compose the lesion. Here we present a representative case series of 5 nonconsecutive patients who underwent percutaneous embolization of OLVMs with the Onyx Liquid Embolic System (Medtronic, Dublin, Ireland) before surgical resection between 2019 and 2021. OLVMs are rare, benign, congenital lesions that grow with age and can become symptomatic and disabling. Treatment can be conservative or invasive; depending on the clinical presentation and characteristics of the lesions, treatment modalities can vary. Preoperative percutaneous embolization of OLVMs with the Onyx system is a promising technique, as demonstrated in this case series.

7.
World Neurosurg ; 153: e237-e243, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34175489

RESUMO

BACKGROUND: Tandem occlusion (TO) describes not only occlusion of the middle cerebral artery but a contemporaneous occlusion of the cervical internal carotid artery. There is a paucity of data over whether mechanical thrombectomy (MT) alone, MT with angioplasty, or MT with carotid artery stent placement is superior. We aim to address a gap in the literature comparing carotid stenting with mechanical thrombectomy (CSMT) and carotid angioplasty with mechanical thrombectomy (CAMT) in patients presenting with acute anterior circulation TOs. METHODS: This is a multicenter, retrospective study from 2012 to 2020 comparing CSMT and CAMT presenting with acute anterior circulation TOs. Primary outcomes of interest were functional status, perioperative stroke, mortality, and symptomatic intracranial hemorrhage (sICH). A total of 92 patients (66 vs. 26 in CSMT and CAMT, respectively) met inclusion criteria for analysis. RESULTS: There was no statistically significant difference in functional outcomes at 90-day follow-up (adjusted odds ratio [aOR] 0.82; 95% confidence interval [CI] 0.20-3.5; P = 0.46). In addition, there was no statistically significant difference in 90-day mortality (aOR 0.361; 95% CI 0.016-2.92; P = 0.532) and perioperative stroke rate (aOR 1.76; 95% CI 0.160-15.6; P = 0.613). However, sICH risk was significantly greater in the stent-treated cohort (aOR 3.94; 95% CI 0.529-37.4; P = 0.003). CONCLUSIONS: Functional outcomes, mortality, and perioperative stroke rates do not significantly differ in CSMT and CAMT procedures in the acute setting. However, CSMT-treated patients do appear to have an increased risk of sICH, potentially due to the use of additional antiplatelet agents following stent placement.


Assuntos
Angioplastia/métodos , Artéria Carótida Interna/cirurgia , Estenose das Carótidas/cirurgia , Infarto da Artéria Cerebral Média/cirurgia , Complicações Pós-Operatórias/epidemiologia , Stents , Trombectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Estenose das Carótidas/complicações , Feminino , Estado Funcional , Humanos , Infarto da Artéria Cerebral Média/complicações , Hemorragias Intracranianas/epidemiologia , Masculino , Pessoa de Meia-Idade , Mortalidade , Hemorragia Pós-Operatória/epidemiologia , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia
8.
Stroke ; 52(6): e282-e294, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33677974

RESUMO

PURPOSE: Central retinal artery occlusion (CRAO) is a form of acute ischemic stroke that causes severe visual loss and is a harbinger of further cerebrovascular and cardiovascular events. There is a paucity of scientific information on the appropriate management of CRAO, with most strategies based on observational literature and expert opinion. In this scientific statement, we critically appraise the literature on CRAO and provide a framework within which to consider acute treatment and secondary prevention. METHODS: We performed a literature review of randomized controlled clinical trials, prospective and retrospective cohort studies, case-control studies, case reports, clinical guidelines, review articles, basic science articles, and editorials concerning the management of CRAO. We assembled a panel comprising experts in the fields of vascular neurology, neuro-ophthalmology, vitreo-retinal surgery, immunology, endovascular neurosurgery, and cardiology, and document sections were divided among the writing group members. Each member received an assignment to perform a literature review, synthesize the data, and offer considerations for practice. Multiple drafts were circulated among the group until consensus was achieved. RESULTS: Acute CRAO is a medical emergency. Systems of care should evolve to prioritize early recognition and triage of CRAO to emergency medical attention. There is considerable variability in management patterns among practitioners, institutions, and subspecialty groups. The current literature suggests that treatment with intravenous tissue plasminogen activator may be effective. Patients should undergo urgent screening and treatment of vascular risk factors. There is a need for high-quality, randomized clinical trials in this field.

9.
J Neurointerv Surg ; 13(4): 378-383, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33443128

RESUMO

BACKGROUND: Intraoperative neuromonitoring (IONM) is often used during cerebral endovascular procedures. OBJECTIVE: To investigate the relationship between intraoperative vascular complications and IONM signal changes, and the impact of interventions on signal resolution and postoperative outcomes. METHODS: A series of 2278 cerebral endovascular procedures conducted under general anesthesia and using electroencephalography and somatosensory evoked potential monitoring were retrospectively reviewed. A subset of 763 procedures also included motor evoked potentials (MEPs). IONM alerts were categorized as either a partial attenuation or complete loss of signal. Vascular complications were subcategorized as due to rupture, emboli, instrumentation, or vasospasm. Odds ratios (ORs) for new postoperative motor deficits were calculated and diagnostic accuracy was measured using sensitivity, specificity, and likelihood ratios. RESULTS: The overall incidence of new postoperative motor deficit was 1.2%; 20.4% in cases with an IONM alert and 0.09% in cases without an alert. Relative to procedures with no alerts, odds of a new deficit increased if there was partial signal attenuation (OR=210.9, 95% CI 44.3 to 1003.5, p<0.0001) and increased further with complete loss of signal (OR=1437.3, 95% CI 297.3 to 6948.2, p<0.0001). Relative to procedures with unresolved alerts, odds of a new deficit decreased if the alert was fully resolved (OR=0.039, 95% CI 0.005 to 0.306, p<0.002). Procedures using MEPs had slightly higher sensitivity (92.3% vs 85.7%) but slightly lower specificity (96.7% vs 98.2%). CONCLUSIONS: An IONM alert associated with an arterial complication is associated with a dramatic increase in odds of a new postoperative deficit; however, if there is resolution of the alert prior to closure, odds of a new deficit decrease significantly.


Assuntos
Procedimentos Endovasculares/efeitos adversos , Potencial Evocado Motor/fisiologia , Potenciais Somatossensoriais Evocados/fisiologia , Complicações Intraoperatórias/diagnóstico por imagem , Complicações Intraoperatórias/etiologia , Monitorização Neurofisiológica Intraoperatória/métodos , Adulto , Anestesia Geral/efeitos adversos , Procedimentos Endovasculares/métodos , Feminino , Humanos , Complicações Intraoperatórias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Imagem Multimodal/métodos , Procedimentos Neurocirúrgicos/efeitos adversos , Procedimentos Neurocirúrgicos/métodos , Estudos Retrospectivos , Resultado do Tratamento
10.
J Neurointerv Surg ; 13(4): 304-307, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33408256

RESUMO

BACKGROUND: The coronavirus disease (COVID-19) pandemic has affected stroke care globally. In this study, we aim to evaluate the impact of the current pandemic on racial disparities among stroke patients receiving mechanical thrombectomy (MT). METHODS: We used the prospectively collected data in the Stroke Thrombectomy and Aneurysm Registry from 12 thrombectomy-capable stroke centers in the US and Europe. We included acute stroke patients who underwent MT between January 2017 and May 2020. We compared baseline features, vascular risk factors, location of occlusion, procedural metrics, complications, and discharge outcomes between patients presenting before (before February 2020) and those who presented during the pandemic (February to May 2020). RESULTS: We identified 2083 stroke patients: of those 235 (11.3%) underwent MT during the COVID-19 pandemic. Compared with pre-pandemic, stroke patients who received MT during the pandemic had longer procedure duration (44 vs 38 min, P=0.006), longer length of hospitalization (6 vs 4 days, P<0.001), and higher in-hospital mortality (18.7% vs 11%, P<0.001). Importantly, there was a lower number of African American patients undergoing MT during the COVID-19 pandemic (609 (32.9%) vs 56 (23.8%); P=0.004). CONCLUSION: The COVID-19 pandemic has affected the care process for stroke patients receiving MT globally. There is a significant decline in the number of African American patients receiving MT, which mandates further investigation.


Assuntos
Afro-Americanos/etnologia , COVID-19/etnologia , Disparidades em Assistência à Saúde/tendências , Pandemias , Acidente Vascular Cerebral/etnologia , Trombectomia/tendências , Idoso , Idoso de 80 Anos ou mais , COVID-19/terapia , Feminino , Mortalidade Hospitalar/tendências , Hospitalização/tendências , Humanos , Internacionalidade , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Acidente Vascular Cerebral/terapia , Trombectomia/métodos , Resultado do Tratamento
11.
J Neurointerv Surg ; 13(11): 1012-1016, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33483455

RESUMO

BACKGROUND: The Woven EndoBridge (WEB) device is approved in the USA for treatment of unruptured wide-neck bifurcation aneurysms. However, the safety and effectiveness of the WEB device in the treatment of ruptured intracranial aneurysms is not clear. We aim to evaluate the perioperative safety and effectiveness of the WEB device in patients with ruptured intracranial aneurysms. METHODS: This retrospective study, conducted at eight centers in the USA, included patients with ruptured intracranial aneurysms treated with the WEB device in the setting of subarachnoid hemorrhage (SAH). Safety outcomes included intraoperative complications such as vessel perforation, thromboembolic events, and postoperative hemorrhagic or thromboembolic complications based on radiologic imaging. The primary effectiveness outcome was adequate (complete and neck remnant) aneurysm occlusion, according to the Raymond-Roy classification. RESULTS: A total of 91 patients with 94 ruptured intracranial aneurysms were included (mean age 57.7±15.2 years; 68.1% women; 82.9% wide-necked). Aneurysms were located in the anterior communicating artery (42/94, 44.6%), middle cerebral artery (16/94, 17%), and basilar artery (15/94, 16%). Adequate occlusion was achieved in 48.8% (41/84) and 80.0% (40/50) at discharge and last follow-up (mean of 3.4 months), respectively. At discharge, procedural-related morbidity was 3.3% (3/91) and there was no procedure-related mortality. No re-rupture or delayed aneurysm rupture was observed. CONCLUSIONS: This study demonstrates the perioperative safety and effectiveness of the WEB device for the treatment of patients with ruptured intracranial aneurysms in the setting of SAH, with low periprocedural morbidity and mortality. Long-term follow-up is warranted.


Assuntos
Aneurisma Roto , Embolização Terapêutica , Procedimentos Endovasculares , Aneurisma Intracraniano , Adulto , Idoso , Aneurisma Roto/diagnóstico por imagem , Aneurisma Roto/cirurgia , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
12.
J Neurointerv Surg ; 13(7): 652-656, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33122349

RESUMO

BACKGROUND: Retinoblastoma is the most common primary intraocular malignancy in children. OBJECTIVE: To determine the incidence of ophthalmic artery (OA) occlusion in patients treated with selective ophthalmic artery catheterization (OAC) for chemotherapy infusion for retinoblastoma. Also, to evaluate technical, anatomical, tumorous, and patient-related factors that are predictors of OA occlusion. METHODS: A retrospective chart review was performed for patients diagnosed with intraocular retinoblastoma and managed with intra-arterial chemotherapy (IAC). RESULTS: The total study cohort included 208 retinoblastoma tumors of 208 eyes in 197 consecutive patients who underwent 688 attempted IAC infusions overall with a total of 624 successful OAC infusions. The total incidence of ophthalmic artery thrombosis was 11.1% (23/208). The numbers of successful OAC procedures before diagnosing OA occlusion were one OAC in six cases (27.3%), two in seven cases (31.8%), three in four cases (18.2%), four in one case (4.5%), five in two cases (9.1%), and six in one case (4.5%). CONCLUSIONS: Local factors relating to the chemotherapy and selective microcatheterization of the OA are essential factors in the development of OA thrombosis, as seen by the association of OA thrombosis with the frequency of IAC.


Assuntos
Infusões Intra-Arteriais/métodos , Artéria Oftálmica/diagnóstico por imagem , Neoplasias da Retina/diagnóstico por imagem , Neoplasias da Retina/tratamento farmacológico , Retinoblastoma/diagnóstico por imagem , Retinoblastoma/tratamento farmacológico , Antineoplásicos/administração & dosagem , Cateterismo/métodos , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Incidência , Lactente , Masculino , Artéria Oftálmica/efeitos dos fármacos , Valor Preditivo dos Testes , Neoplasias da Retina/epidemiologia , Retinoblastoma/epidemiologia , Estudos Retrospectivos , Resultado do Tratamento
13.
World Neurosurg ; 146: e607-e617, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33130285

RESUMO

BACKGROUND: Aneurysms associated with fenestrations of intracranial arteries are exceptionally rare findings. Management strategies for these aneurysms are not well-defined, especially regarding endovascular treatment. We sought to investigate the strategies and feasibility of endovascular treatment approaches for various fenestration-associated intracranial aneurysms. METHODS: We performed a retrospective chart review of 2000 aneurysms treated endovascularly, identifying 8 aneurysms located at arterial fenestrations. The technical details and procedural outcomes were reviewed to identify common management approaches, technical nuances, and treatment outcomes. RESULTS: There were 3 (37.5%) aneurysms associated with fenestrations of the basilar artery or vertebrobasilar junction. All 3 were successfully treated with a previously undescribed coil-assisted flow-diversion technique, resulting in complete obliteration. Three (37.5%) aneurysms were associated with fenestrations of the anterior communicating artery. Of those, 2 were successfully treated with stent-assisted coil embolization and 1 with coil embolization alone. One (12.5%) aneurysm was associated with a fenestration of the paraclinoid internal carotid artery and 1 (12.5%) aneurysm found was at the takeoff of the posterior inferior cerebellar artery at a fenestration of the vertebral artery. Both were successfully treated with coil-assisted flow diversion. There were no permanent procedural complications. Major considerations for endovascular management of these aneurysms were the dominance of fenestration trunks, aneurysms arising from the fenestration apex or a fenestration limb, amenability to flow diversion, and anticipation of vascular remodeling. CONCLUSIONS: Fenestration-associated aneurysms are very rare. We have identified common factors to help guide decision-making for endovascular approaches and demonstrate successful aneurysm treatment using these methods.


Assuntos
Artéria Carótida Interna/cirurgia , Angiografia Cerebral , Embolização Terapêutica , Aneurisma Intracraniano/terapia , Adulto , Idoso , Angiografia Cerebral/efeitos adversos , Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Feminino , Humanos , Imageamento Tridimensional/métodos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Artéria Vertebral/cirurgia
14.
Clin Neurol Neurosurg ; 201: 106440, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33383464

RESUMO

BACKGROUND AND IMPORTANCE: Additional time is needed to determine the exact impact of COVID-19 on acute cerebrovascular disease incidence, but recently published data has correlated COVID-19 to large vessel occlusion strokes. CLINICAL PRESENTATION: We report the first case of central retinal artery occlusion (CRAO) as the initial manifestation of COVID-19 infection. Subsequent neuroimaging revealed a large thrombus extending into the internal carotid artery. CONCLUSION: This case illustrates the need to suspect COVID-19 infection in patients presenting with retinal arterial occlusion, including individuals who are asymptomatic or minimally symptomatic for COVID-19 infection.


Assuntos
COVID-19/diagnóstico por imagem , Oclusão da Artéria Retiniana/diagnóstico por imagem , Transtornos da Visão/diagnóstico por imagem , Visão Monocular/fisiologia , COVID-19/complicações , Diagnóstico Diferencial , Humanos , Masculino , Pessoa de Meia-Idade , Oclusão da Artéria Retiniana/etiologia , Transtornos da Visão/etiologia
15.
J Neurointerv Surg ; 12(12): 1235-1241, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32769110

RESUMO

BACKGROUND: The transradial approach (TRA) reduces mortality, morbidity, access site complications, hospital cost, and length of stay while maximizing patient satisfaction. We aimed to assess the technical success and safety of TRA for elderly patients (aged ≥75 years). METHODS: A retrospective chart review and comparative analysis was performed for elderly patients undergoing a diagnostic cerebral angiogram performed via TRA versus transfemoral approach (TFA). Also, a second comparative analysis was performed among the TRA cohort between elderly patients and their younger counterparts. RESULTS: Comparative analysis in the elderly (TRA vs TFA) showed no significant differences for contrast dose per vessel (43.7 vs 34.6 mL, P=0.106), fluoroscopy time per vessel (5.7 vs 5.2 min, P=0.849), procedure duration (59.8 vs 65.2 min, P=0.057), conversion rate (5.8% vs 2.9%, P=0.650), and access site complications (2.3% vs 2.9%, P=1.00). Radiation exposure per vessel (18.9 vs 51.9 Gy cm2, P=0.001) was significantly lower in the elderly TRA group.The second comparison (TRA in elderly vs TRA in the young) showed no significant differences for contrast dose per vessel (43.7 vs 37.8 mL, P=0.185), radiation exposure per vessel (18.9 vs 16.5 Gy cm2, P=0.507), procedure duration (59.8 vs 58.3 min, P=0.788), access site complication (2.3% vs 1.7%, P=0.55), and conversation rate (5.8% vs 1.8%, P=0.092). A trend for prolonged fluoroscopy time per vessel (5.7 vs 4.7 min, P=0.050) was observed in the elderly TRA group. CONCLUSIONS: TRA is a technically feasible and safe option for diagnostic neurointerventional procedures in the elderly. Our small elderly cohort was not powered enough to show a significant difference in terms of access site complications between TRA and TFA.


Assuntos
Cateterismo Periférico/métodos , Angiografia Cerebral/métodos , Artéria Radial/diagnóstico por imagem , Artéria Radial/cirurgia , Fatores Etários , Idoso , Estudos de Coortes , Feminino , Fluoroscopia/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
16.
J Neurointerv Surg ; 12(11): 1039-1044, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32843359

RESUMO

BACKGROUND: In response to the COVID-19 pandemic, many centers altered stroke triage protocols for the protection of their providers. However, the effect of workflow changes on stroke patients receiving mechanical thrombectomy (MT) has not been systematically studied. METHODS: A prospective international study was launched at the initiation of the COVID-19 pandemic. All included centers participated in the Stroke Thrombectomy and Aneurysm Registry (STAR) and Endovascular Neurosurgery Research Group (ENRG). Data was collected during the peak months of the COVID-19 surge at each site. Collected data included patient and disease characteristics. A generalized linear model with logit link function was used to estimate the effect of general anesthesia (GA) on in-hospital mortality and discharge outcome controlling for confounders. RESULTS: 458 patients and 28 centers were included from North America, South America, and Europe. Five centers were in high-COVID burden counties (HCC) in which 9/104 (8.7%) of patients were positive for COVID-19 compared with 4/354 (1.1%) in low-COVID burden counties (LCC) (P<0.001). 241 patients underwent pre-procedure GA. Compared with patients treated awake, GA patients had longer door to reperfusion time (138 vs 100 min, P=<0.001). On multivariate analysis, GA was associated with higher probability of in-hospital mortality (RR 1.871, P=0.029) and lower probability of functional independence at discharge (RR 0.53, P=0.015). CONCLUSION: We observed a low rate of COVID-19 infection among stroke patients undergoing MT in LCC. Overall, more than half of the patients underwent intubation prior to MT, leading to prolonged door to reperfusion time, higher in-hospital mortality, and lower likelihood of functional independence at discharge.


Assuntos
Infecções por Coronavirus , Pandemias , Pneumonia Viral , Acidente Vascular Cerebral/terapia , Trombectomia/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral , COVID-19 , Procedimentos Endovasculares , Feminino , Mortalidade Hospitalar , Humanos , Vida Independente , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reperfusão , Trombectomia/métodos , Resultado do Tratamento , Fluxo de Trabalho
17.
Int J Stroke ; 15(7): 733-742, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32501751

RESUMO

BACKGROUND: The coronavirus disease 2019 is associated with neurological manifestations including stroke. OBJECTIVES: We present a case series of coronavirus disease 2019 patients from two institutions with acute cerebrovascular pathologies. In addition, we present a pooled analysis of published data on large vessel occlusion in the setting of coronavirus disease 2019 and a concise summary of the pathophysiology of acute cerebrovascular disease in the setting of coronavirus disease 2019. METHODS: A retrospective study across two institutions was conducted between 20 March 2020 and 20 May 2020, for patients developing acute cerebrovascular disease and diagnosed with coronavirus disease 2019. We performed a literature review using the PubMed search engine. RESULTS: The total sample size was 22 patients. The mean age was 59.5 years, and 12 patients were female. The cerebrovascular pathologies were 17 cases of acute ischemic stroke, 3 cases of aneurysm rupture, and 2 cases of sinus thrombosis. Of the stroke and sinus thrombosis patients, the mean National Institute of Health Stroke Scale was 13.8 ± 8.0, and 16 (84.2%) patients underwent a mechanical thrombectomy procedure. A favorable thrombolysis in cerebral infarction score was achieved in all patients. Of the 16 patients that underwent a mechanical thrombectomy, the mortality incidence was five (31.3%). Of all patients (22), three (13.6%) patients developed hemorrhagic conversion requiring decompressive surgery. Eleven (50%) patients had a poor functional status (modified Rankin Score 3-6) at discharge, and the total mortality incidence was eight (36.4%). CONCLUSIONS: Despite timely intervention and favorable reperfusion, the mortality rate in coronavirus disease 2019 patients with large vessel occlusion was high in our series and in the pooled analysis. Notable features were younger age group, involvement of both the arterial and venous vasculature, multivessel involvement, and complicated procedures due to the clot consistency and burden.


Assuntos
Betacoronavirus , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/virologia , Infecções por Coronavirus/complicações , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/virologia , Pneumonia Viral/complicações , Doença Aguda , Adulto , Idoso , Isquemia Encefálica/diagnóstico , COVID-19 , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Feminino , Humanos , Hemorragias Intracranianas/diagnóstico , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Estudos Retrospectivos , SARS-CoV-2 , Taxa de Sobrevida
18.
J Neurol Neurosurg Psychiatry ; 91(8): 846-848, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32354770

RESUMO

BACKGROUND: Emergence of the novel corona virus (severe acute respiratory syndrome (SARS)-CoV-2) in December 2019 has led to the COVID-19 pandemic. The extent of COVID-19 involvement in the central nervous system is not well established, and the presence or the absence of SARS-CoV-2 particles in the cerebrospinal fluid (CSF) is a topic of debate. CASE DESCRIPTION: We present two patients with COVID-19 and concurrent neurological symptoms. Our first patient is a 31-year-old man who had flu-like symptoms due to COVID-19 and later developed an acute-onset severe headache and loss of consciousness and was diagnosed with a Hunt and Hess grade 3 subarachnoid haemorrhage from a ruptured aneurysm. Our second patient is a 62-year-old woman who had an ischaemic stroke with massive haemorrhagic conversion requiring a decompressive hemicraniectomy. Both patients' CSF was repeatedly negative on real-time PCR analysis despite concurrent neurological disease. CONCLUSION: Our report shows that patients' CSF may be devoid of viral particles even when they test positive for COVID-19 on a nasal swab. Whether SARS-CoV-2 is present in CSF may depend on the systemic disease severity and the degree of the virus' nervous tissue tropism and should be examined in future studies.


Assuntos
Betacoronavirus/isolamento & purificação , Infecções por Coronavirus/líquido cefalorraquidiano , Infecções por Coronavirus/complicações , Pneumonia Viral/líquido cefalorraquidiano , Pneumonia Viral/complicações , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/virologia , Adulto , COVID-19 , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , SARS-CoV-2 , Acidente Vascular Cerebral/líquido cefalorraquidiano
19.
J Neurosurg ; 134(5): 1500-1504, 2020 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-32357335

RESUMO

OBJECTIVE: The 30-day readmission rate is of increasing interest to hospital administrators and physicians, as it is used to evaluate hospital performance and is associated with increased healthcare expenditures. The estimated yearly cost to Medicare of readmissions is $17.4 billion. The Centers for Medicare and Medicaid Services therefore track unplanned 30-day readmissions and institute penalties against hospitals whose readmission rates exceed disease-specific national standards. One of the most important conditions with potential for improvement in cost-effective care is ischemic stroke, which affects 795,000 people in the United States and is a leading cause of death and disability. Recent widespread adoption of mechanical thrombectomy has revolutionized stroke care, requiring reassessment of readmission causes and costs in this population. METHODS: The authors retrospectively analyzed a prospectively maintained database of stroke patients and identified 561 patients who underwent mechanical thrombectomy between 2010 and 2019 at the authors' institution. Univariate and multivariate analyses were conducted to identify clinical variables and comorbidities related to 30-day readmissions in this patient population. RESULTS: Of the 561 patients, 85.6% (n = 480) survived their admission and were discharged from the hospital to home or rehabilitation, and 8.8% (n = 42/480) were readmitted within 30 days. The median time to readmission was 10.5 days (IQR 6.0-14.3). The most common reasons for readmission were infection (33.3%) and acute cardiac or cerebrovascular events (19% and 20%, respectively). Multivariate analysis showed that hypertension (p = 0.030; OR 2.72) and length of initial hospital stay (p = 0.040; OR 1.032) were significantly correlated with readmission within 30 days, while hemorrhagic conversion (grades 3 and 4) approached significance (p = 0.053; OR 2.23). Other factors, such as unfavorable outcome at discharge, history of coronary artery disease, and discharge destination, did not predict readmission. CONCLUSIONS: The study data demonstrate that hypertension, length of hospital stay, and hemorrhagic conversion were predictors of 30-day hospital readmission in stroke patients after mechanical thrombectomy. Infection was the most common cause of 30-day readmission, followed by cardiac and cerebrovascular diagnoses. These results therefore may serve to identify patients within the stroke population who require increased surveillance following discharge to reduce complications and unplanned readmissions.


Assuntos
Isquemia Encefálica/cirurgia , Trombólise Mecânica , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Hemorragia Cerebral/epidemiologia , Hemorragia Cerebral/etiologia , Transtornos Cerebrovasculares/epidemiologia , Comorbidade , Craniectomia Descompressiva/estatística & dados numéricos , Feminino , Cardiopatias/epidemiologia , Mortalidade Hospitalar , Humanos , Hipertensão/complicações , Infecções/epidemiologia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Prognóstico , Estudos Retrospectivos
20.
J Neurointerv Surg ; 12(9): 915-920, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32277036

RESUMO

BACKGROUND: Intra-arterial chemotherapy (IAC) for retinoblastoma (Rb) has been established as a primary treatment for the disease. To determine whether the presence of reflux into the ICA is associated with tumor response or with any other adverse events in pediatric retinoblastoma patients. METHODS: A retrospective chart review was performed for patients diagnosed with Rb and managed with ophthalmic artery catheterization (OAC). RESULTS: The total study cohort included 205 Rb tumors of 205 eyes in 194 consecutive patients who underwent 624 successful intra-arterial chemotherapy infusions using OAC. Of the 205 eyes, 65 eyes (32.7%) underwent 157 OAC procedures constituted group A (no reflux), 64 eyes (31.2%) underwent 236 OAC procedures constituted group B (variable pattern), and 74 eyes (36.1%) underwent 231 OAC procedures constituted group C (reflux). There was no significant difference in baseline characteristics between the three cohorts. Also, there was no significant difference in tumor characteristics between the three groups, except for genetic status. There was no significant difference between the three groups in terms of tumor response at completion of the treatment regimen. Complete tumor response was achieved at 70.2% in Group A, at 83.3% in Group B, and at 78.5% in group C (P=0.39). Similarly, eye enucleation occurred at 38.5% in group A, 31.8% in group B, and 31.5% in group C. None of the patients in both groups had any neurological adverse events or new onset of seizures. CONCLUSIONS: The presence of reflux, which may complicate the procedure and prolong it, was not associated with poor outcomes in our analysis.


Assuntos
Cateterismo/métodos , Artéria Oftálmica/diagnóstico por imagem , Neoplasias da Retina/diagnóstico por imagem , Neoplasias da Retina/terapia , Retinoblastoma/diagnóstico por imagem , Retinoblastoma/terapia , Antineoplásicos/administração & dosagem , Pré-Escolar , Estudos de Coortes , Feminino , Seguimentos , Humanos , Lactente , Infusões Intra-Arteriais/efeitos adversos , Masculino , Estudos Retrospectivos , Resultado do Tratamento
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