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INTRODUCTION: Intracranial artery calcification (ICAC) is a common finding on computed tomography (CT) in patients presenting with large vessel occlusion acute ischemic stroke (LVO-AIS) and could serve as a useful biomarker of intracranial atherosclerosis and altered intracranial vessel pliability in patients undergoing endovascular thrombectomy (EVT). METHODS: This was a retrospective cohort study analyzing consecutive patients undergoing CT head prior to EVT between 2016 and 2020. Extent of ICAC proximal to the target vessel was scored using a validated grading scale examining thickness and circumferential extent of calcifications. The relationship between 3 levels of ICAC burden and procedural, clinical, and safety outcomes was analyzed. RESULTS: Among 86 patients meeting inclusion criteria, ICAC of any degree was present in 72.1%. Median ICAC score was 3 [IQR 0-4]. There was a U-shaped association between ICAC score and successful reperfusion: 90.9%, 65.7%, and 94.4% in the low, intermediate, and high ICAC score groups, respectively (pâ¯=â¯0.008). Use of rescue intervention, most often angioplasty and stenting, was greatest in the high ICAC score group: 3.0% vs. 5.7% vs. 22.2% (pâ¯=â¯0.05). Functional independence at 90 days did not differ significantly among groups (41.7% vs. 31.0% vs. 15.4%, pâ¯=â¯0.26), nor did rates of symptomatic intracranial hemorrhage (15.2% vs. 14.3% vs. 16.7%, pâ¯=â¯0.97). CONCLUSIONS: ICAC is seen on CT in nearly three-quarters of patients with LVO-AIS. Extent of ICAC has a U-shaped association with successful reperfusion, in part due to more frequent use of rescue interventions in patients with extensive ICAC.
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BACKGROUND: Hemodynamic factors have been implicated in hemorrhage from cerebral arteriovenous malformations (AVMs). The goal of this endovascular study is to analyze the hemodynamic variability in AVM feeders in a balanced group of ruptured and unruptured AVMs of various sizes and at both superficial and deep locations. METHODS: We monitored feeder artery pressure (FP) using microcatheters in 45 patients with AVMs (16 with hemorrhage, 29 without) during superselective angiography and AVM embolization. RESULTS: Mean FP was 49 mm Hg. Significant determinants of FP were the systemic pressure (p < 0.001), AVM size (p = 0.03), and the distance of the microcatheter tip from the Circle of Willis (p = 0.06), but not the presence of hemorrhage, patient age, or feeder artery diameter. The FP in ruptured AVMs was 7 mm Hg higher than in unruptured ones (53.8 mm Hg vs. 47.1 mm Hg, p = 0.032). The presence or absence of venous outflow stenosis and the position of the AVM nidus (superficial or deep to the cortical surface) were important anatomical predictors of AVM presentation. CONCLUSION: The pressure in the feeding artery supplying an AVM is the result of factors which include the systemic arterial pressure, the size of the AVM nidus, and the distance of the AVM from the Circle of Willis. The correlation between these variables makes it difficult to study the risk of hemorrhage as a function of a single factor, which may account for the variation in the conclusions of previous studies.
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Embolización Terapéutica , Malformaciones Arteriovenosas Intracraneales , Humanos , Malformaciones Arteriovenosas Intracraneales/terapia , Hemodinámica , Arterias , Estudios RetrospectivosRESUMEN
PURPOSE: One of the most devastating complications of facial filler injection is sudden ischemic blindness. However, its mechanisms and predisposing factors are poorly understood. The purpose of this study was to investigate the prevalence of external carotid artery (ECA) to ophthalmic artery (OA) anterograde flow in patients with internal carotid artery (ICA) stenosis and in a control population without carotid disease. METHODS: In this cross-sectional cohort study, two groups of patients who underwent catheter cerebral angiography over a 5-year period were identified: patients with symptomatic ICA stenosis and a control group of patients with refractory epistaxis undergoing embolization. Angiograms were reviewed by an interventional neuroradiologist. The primary outcome measure was the presence of ECA to OA flow, defined as choroidal blush before filling of the circle of Willis. Secondary outcome measures included the percentage and location of ICA stenosis and ECA anastomotic branches involved. RESULTS: The study included 149 patients with ICA stenosis and 69 control patients. ECA to OA flow was more prevalent in patients with ICA stenosis (34.9%) compared to controls (2.9%) (p < .001). Logistic regression demonstrated that for each 10% increase in ICA stenosis over 70%, there was 2.8 times increased risk of ECA to OA flow (p < .001). CONCLUSIONS: ECA to ICA anterograde flow can be demonstrated in approximately 3% of control patients and in over 1/3 of patients with symptomatic carotid stenosis. This provides a plausible pathway for small filler particles to pass with blood flow from the facial to the ophthalmic circulation.
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Arteria Carótida Externa , Estenosis Carotídea , Humanos , Arteria Carótida Externa/diagnóstico por imagen , Arteria Carótida Externa/cirugía , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/complicaciones , Arteria Oftálmica/diagnóstico por imagen , Arteria Carótida Interna/diagnóstico por imagen , Arteria Carótida Interna/cirugía , Constricción Patológica , Estudios TransversalesRESUMEN
Background and Purpose: Clot fragmentation and distal embolization during endovascular thrombectomy for acute ischemic stroke may produce emboli downstream of the target occlusion or in previously uninvolved territories. Susceptibility-weighted magnetic resonance imaging can identify both emboli to distal territories (EDT) and new territories (ENT) as new susceptibility vessel signs (SVS). Diffusion-weighted imaging (DWI) can identify infarcts in new territories (INT). Methods: We studied consecutive acute ischemic stroke patients undergoing magnetic resonance imaging before and after thrombectomy. Frequency, predictors, and outcomes of EDT and ENT detected on gradient-recalled echo imaging (EDT-SVS and ENT-SVS) and INT detected on DWI (INT-DWI) were analyzed. Results: Among 50 thrombectomy-treated acute ischemic stroke patients meeting study criteria, mean age was 70 (±16) years, 44% were women, and presenting National Institutes of Health Stroke Scale score 15 (interquartile range, 819). Overall, 21 of 50 (42%) patients showed periprocedural embolic events, including 10 of 50 (20%) with new EDT-SVS, 10 of 50 (20%) with INT-DWI, and 1 of 50 (2%) with both. No patient showed ENT-SVS. On multivariate analysis, model-selected predictors of EDT-SVS were lower initial diastolic blood pressure (odds ratio, 1.09 [95% CI, 1.021.16]), alteplase pretreatment (odds ratio, 5.54 [95% CI, 0.9432.49]), and atrial fibrillation (odds ratio, 7.38 [95% CI, 1.0253.32]). Classification tree analysis identified pretreatment target occlusion SVS as an additional predictor. On univariate analysis, INT-DWI was less common with internal carotid artery (5%), intermediate with middle cerebral artery (25%), and highest with vertebrobasilar (57%) target occlusions (P=0.02). EDT-SVS was not associated with imaging/functional outcomes, but INT-DWI was associated with reduced radiological hemorrhagic transformation (0% versus 54%; P<0.01). Conclusions: Among acute ischemic stroke patients treated with thrombectomy, imaging evidence of distal emboli, including EDT-SVS beyond the target occlusion and INT-DWI in novel territories, occur in about 2 in every 5 cases. Predictors of EDT-SVS are pretreatment intravenous fibrinolysis, potentially disrupting thrombus structural integrity; atrial fibrillation, possibly reflecting larger target thrombus burden; lower diastolic blood pressure, suggestive of impaired embolic washout; and pretreatment target occlusion SVS sign, indicating erythrocyte-rich, friable target thrombus.
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Isquemia Encefálica/diagnóstico por imagen , Embolia Intracraneal/diagnóstico por imagen , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Imagen por Resonancia Magnética/tendencias , Complicaciones Cognitivas Postoperatorias/diagnóstico por imagen , Trombectomía/efectos adversos , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/cirugía , Femenino , Humanos , Embolia Intracraneal/etiología , Accidente Cerebrovascular Isquémico/cirugía , Masculino , Persona de Mediana Edad , Complicaciones Cognitivas Postoperatorias/etiología , Estudios Prospectivos , Sistema de Registros , Trombectomía/tendencias , Factores de Tiempo , Resultado del TratamientoRESUMEN
PURPOSE: To compare coil embolotherapy outcomes of feeding-artery-only versus nidus-plus-feeding-artery technique for treating pulmonary arteriovenous malformations (PAVMs). MATERIALS AND METHODS: A total of 219 treatment-naïve PAVMs embolized in 90 patients at a single center from 2008 to 2018 met inclusion criteria for retrospective evaluation. Of the patients, 87% had a diagnosis of hereditary hemorrhagic telangiectasia (HHT). Feeding artery (FA) diameters ≥2 mm were treated. Coil embolization techniques were classified on the basis of embolic deployment zone: (i) distal feeding artery (DFA) technique (coil-to-nidus distance ≤ 1 cm) or (ii) nidus plus feeding artery (NiFA) technique. Successful embolization predictors were assessed using a multivariate linear regression model with input from patient- and PAVM-specific variables. RESULTS: Treatment success was achieved in 192 of 219 PAVMs (87.7%) over a mean follow-up period of 19 months. Statistically significant predictors of success in the linear regression model included simple angioarchitecture, NiFA embolization technique, and shorter follow-up duration. Stratified by technique, success rates were 99 of 105 (94.3%) and 93 of 114 (81.6%) PAVMs for NiFA and DFA, respectively (P = .007). On average, NiFA-embolized PAVMs had a larger FA diameter (3.6 mm vs 2.7 mm, P < .001) and comprised more complex PAVMs (48% vs 22%, P < .001) than DFA. Treatment success was not significantly associated with sac size or FA diameter. CONCLUSIONS: Coil embolization of both the nidus and FA was associated with a higher persistent occlusion rate than FA embolization alone.
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Malformaciones Arteriovenosas , Embolización Terapéutica , Venas Pulmonares , Telangiectasia Hemorrágica Hereditaria , Malformaciones Arteriovenosas/diagnóstico por imagen , Malformaciones Arteriovenosas/terapia , Embolización Terapéutica/efectos adversos , Humanos , Arteria Pulmonar/diagnóstico por imagen , Venas Pulmonares/diagnóstico por imagen , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND AND PURPOSE: More than half of patients with acute ischemic stroke have minor neurological deficits; however, the frequency and outcomes of reperfusion therapy in regular practice has not been well-delineated. METHODS: Analysis of US National Inpatient Sample of hospitalizations with acute ischemic stroke and mild deficits (National Institutes of Health Stroke Scale [NIHSS] score 0-5) from October 1, 2016, to December 31, 2017. Patient- and hospital-level characteristics associated with use and outcome of reperfusion therapies were analyzed. Primary outcomes included excellent discharge disposition (discharge to home without assistance); poor discharge disposition (discharge to facility or death); in-hospital mortality; and radiological intracranial hemorrhage. RESULTS: Among 179 710 acute ischemic stroke admissions with recorded NIHSS during the 15-month study period, 103 765 (57.7%) had mild strokes (47.3% women; median age, 69 [interquartile range, 59-79] years; median NIHSS score of 2 [interquartile range, 1-4]). Considering reperfusion therapies among strokes with documented NIHSS, mild deficit hospitalizations accounted for 40.0% of IVT and 10.7% of mechanical thrombectomy procedures. Characteristics associated with IVT and with mechanical thrombectomy utilization were younger age, absence of diabetes, higher NIHSS score, larger/teaching hospital status, and Western US region. Excellent discharge outcome occurred in 48.2% of all mild strokes, and in multivariable analysis, was associated with younger age, male sex, White race, lower NIHSS score, absence of diabetes, heart failure, and kidney disease, and IVT use. IVT was associated with increased likelihood of excellent outcome (odds ratio, 1.90 [95% CI, 1.71-2.13], P<0.001) despite an increased risk of intracranial hemorrhage (odds ratio, 1.41 [95% CI, 1.09-1.83], P<0.001). CONCLUSIONS: In national US practice, more than one-half of acute ischemic stroke hospitalizations had mild deficits, accounting for 4 of every 10 IVT and 1 of every 10 mechanical thrombectomy treatments, and IVT use was associated with increased discharge to home despite increased intracranial hemorrhage.
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Mortalidad Hospitalaria , Hospitales/estadística & datos numéricos , Accidente Cerebrovascular Isquémico/terapia , Trombectomía/estadística & datos numéricos , Terapia Trombolítica/estadística & datos numéricos , Factores de Edad , Anciano , Anciano de 80 o más Años , Comorbilidad , Diabetes Mellitus/epidemiología , Servicio de Urgencia en Hospital , Procedimientos Endovasculares/estadística & datos numéricos , Etnicidad/estadística & datos numéricos , Femenino , Tamaño de las Instituciones de Salud , Hospitalización , Hospitales Rurales , Hospitales de Enseñanza , Hospitales Urbanos , Humanos , Accidente Cerebrovascular Isquémico/epidemiología , Accidente Cerebrovascular Isquémico/fisiopatología , Masculino , Persona de Mediana Edad , Alta del Paciente/estadística & datos numéricos , Transferencia de Pacientes , Recuperación de la Función , Insuficiencia Renal Crónica/epidemiología , Reperfusión/estadística & datos numéricos , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND AND PURPOSE: We aimed to delineate the determinants of the initial speed of infarct progression and the association of speed of infarct progression (SIP) with procedural and functional outcomes. METHODS: From a prospectively maintained stroke center registry, consecutive anterior circulation ischemic stroke patients with large artery occlusion, National Institutes of Health Stroke Scale score ≥4, and multimodal vessel, ischemic core, and tissue-at-risk imaging within 24 hours of onset were included. Initial SIP was calculated as ischemic core volume at first imaging divided by the time from stroke onset to imaging. RESULTS: Among the 88 patients, SIP was median 2.2 cc/h (interquartile range, 0-8.7), ranging most widely within the first 6 hours after onset. Faster SIP was positively independently associated with a low collateral score (odds ratio [OR], 3.30 [95% CI, 1.25-10.49]) and arrival by emergency medical services (OR, 3.34 [95% CI, 1.06-10.49]) and negatively associated with prior ischemic stroke (OR, 0.12 [95% CI, 0.03-0.50]) and coronary artery disease (OR, 0.32 [95% CI, 0.10-1.00]). Among the 67 patients who underwent endovascular thrombectomy, slower SIP was associated with a shift to reduced levels of disability at discharge (OR, 3.26 [95% CI, 1.02-10.45]), increased substantial reperfusion by thrombectomy (OR, 8.30 [95% CI, 0.97-70.87]), and reduced radiological hemorrhagic transformation (OR, 0.34 [95% CI, 0.12-0.94]). CONCLUSIONS: Slower SIP is associated with a high collateral score, prior ischemic stroke, and coronary artery disease, supporting roles for both collateral robustness and ischemic preconditioning in fostering tissue resilience to ischemia. Among patients undergoing endovascular thrombectomy, the speed of infarct progression is a major determinant of clinical outcome.
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Isquemia Encefálica/diagnóstico por imagen , Progresión de la Enfermedad , Recuperación de la Función/fisiología , Accidente Cerebrovascular/diagnóstico por imagen , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/epidemiología , Isquemia Encefálica/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Sistema de Registros , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/terapia , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Detection of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) in patients with a poor clinical exam is challenging. Brain tissue oxygen tension monitoring (PbtO2) and cerebral microdialysis (CMD) can detect ischemia and metabolic derangements. Our aim was to evaluate efficacy of these modalities in real-time detection of DCI. METHODS: All patients with aSAH who underwent with multimodality monitoring (MMM) with PbtO2 and/or CMD between the years of 2013 and 2015 at our institution were retrospectively studied. Mean PbTO2, lactate to pyruvate ratio (LPR), and glucose over the 24-h period prior to each angiogram for evaluation and treatment of vasospasm were correlated to the extent of vasospasm observed in the hemisphere with the monitors. The average measurements were also compared in the setting of presence and absence of angiographically significant vasospasm. RESULTS: A total of ten patients with aSAH who underwent MMM were identified. PbtO2 decline correlates with severity of proximal vasospasm (r = -0.66). PbtO2 was significantly lower in the setting of vasospasm (17.6 vs. 25.8, p = 0.003), but LPR (34.5 vs. 26.8, p = 0.1) and glucose (0.8 vs. 1.1, p = 0.6) were not significantly different. CONCLUSION: Proximal vasospasm after aSAH is associated with MMM indicator of tissue ischemia and/or metabolic derangement. PbtO2 and CMD help in real-time detection and management of DCI.
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Isquemia Encefálica , Pruebas en el Punto de Atención , Hemorragia Subaracnoidea , Vasoespasmo Intracraneal , Humanos , Estudios Retrospectivos , Hemorragia Subaracnoidea/complicaciones , Vasoespasmo Intracraneal/diagnóstico , Vasoespasmo Intracraneal/etiologíaRESUMEN
BACKGROUND: MRI and CT modalities are both current standard-of-care options for initial imaging in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). MR provides greater lesion conspicuity and spatial resolution, but few series have demonstrated multimodal MR may be performed efficiently. METHODS: In a prospective comprehensive stroke center registry, we analyzed all anterior circulation LVO thrombectomy patients between 2012-2017 who: (1) arrived directly by EMS from the field, and (2) had initial NIHSS ≥6. Center imaging policy was multimodal MRI (including DWI/GRE/MRA w/wo PWI) as the initial evaluation in all patients without contraindications, and multimodal CT (including CT with CTA, w/wo CTP) in the remainder. RESULTS: Among 106 EMS-arriving endovascular thrombectomy patients, initial imaging was MRI 62.3%, CT in 37.7%. MRI and CT patients were similar in age (72.5 vs 71.3), severity (NIHSS 16.4 v 18.2), and medical history, though MRI patients had longer onset-to-door times. Overall, door-to-needle (DTN) and door-to-puncture (DTP) times did not differ among MR and CT patients, and were faster for both modalities in 2015-2017 versus 2012-2014. In the 2015-2017 period, for MR-imaged patients, the median DTN 42m (IQR 34-55) surpassed standard (60m) and advanced (45m) national targets and the median DTP 86m (IQR 71-106) surpassed the standard national target (90m). CONCLUSIONS: AIS-LVO patients can be evaluated by multimodal MR imaging with care speeds faster than national recommendations for door-to-needle and door-to-puncture times. With its more sensitive lesion identification and spatial resolution, MRI remains a highly viable primary imaging strategy in acute ischemic stroke patients, though further workflow efficiency improvements are desirable.
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Isquemia Encefálica/terapia , Angiografía Cerebral , Angiografía por Tomografía Computarizada , Imagen de Difusión por Resonancia Magnética , Procedimientos Endovasculares , Angiografía por Resonancia Magnética , Accidente Cerebrovascular/terapia , Trombectomía , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/fisiopatología , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Imagen Multimodal , Valor Predictivo de las Pruebas , Estudios Prospectivos , Sistema de Registros , Reproducibilidad de los Resultados , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/fisiopatología , Trombectomía/efectos adversos , Factores de Tiempo , Tiempo de Tratamiento , Resultado del Tratamiento , Flujo de TrabajoRESUMEN
PURPOSE: To review a representative case series and share a stepwise approach to the diagnosis and treatment of periorbital venolymphatic malformations. METHODS: A case series of 9 patients with representative periorbital venolymphatic malformations. All patients managed at the University of California, Los Angeles Orbital Center for a vascular malformation over the last 5 years were reviewed. Cases representative of the varied pathologic findings and techniques were selected. The clinical, radiologic, and intraoperative findings are presented and a survey of techniques composed. RESULTS: Venolymphatic malformations can have protean manifestations. Characteristics vital to the understanding and management of these lesions are the classification and vascular composition of the lesion, internal flow and drainage patterns, anatomic localization and association with distant components. Options for treatment include sclerotherapy, biologic therapy, embolization, surgical excision, or some combination thereof. CONCLUSIONS: A comprehensive understanding of each patient's unique lesion is critical to a rational treatment approach. Teamwork and creativity are key to effectively managing these lesions.
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Factores Biológicos/uso terapéutico , Embolización Terapéutica/métodos , Vasos Linfáticos/anomalías , Procedimientos Quirúrgicos Oftalmológicos/métodos , Órbita/irrigación sanguínea , Escleroterapia/métodos , Malformaciones Vasculares/terapia , Adulto , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Malformaciones Vasculares/diagnóstico , Adulto JovenRESUMEN
PURPOSE: Hyaluronic acid gel filler-associated blindness is an uncommon but devastating complication. Hyaluronidase can potentially dissolve intravascular filler and improve perfusion; however, its role in filler-associated blindness has yet to be determined. The purpose of this study is to determine the effect of retrobulbar hyaluronidase on hyaluronic acid gel-induced ophthalmic artery occlusion in a rabbit model. METHODS: New Zealand red rabbits were used to simulate hyaluronic acid gel filler-associated vascular occlusive blindness. Ophthalmic artery occlusion and subsequent ischemia were confirmed by both retinal fundus photography and electroretinogram changes. Retrobulbar hyaluronidase 1,000 IU was injected 30 minutes after occlusion. Fundus photography and electroretinogram changes were recorded at 30, 60, 90, and 120 after administration of retrobulbar hyaluronidase. RESULTS: A total of 6 rabbits were used, for a total of 12 eyes. Four eyes were used as controls. Of the 8 experimental eyes, 2 eyes had recorded partial occlusion and 6 eyes had fully occluded ophthalmic arteries by angiographic evaluation. One of the partially occluded eyes demonstrated some improvement in perfusion 60 minutes after injection of retrobulbar hyaluronidase; however, electroretinogram readings remained flat over the 120-minute period of observation. Six eyes with completely occluded ophthalmic arteries showed no improvement in retinal perfusion with corresponding flat electroretinogram readings at 120 minutes following retrobulbar hyaluronidase injection. CONCLUSIONS: In this rabbit model, 1,000 IU of retrobulbar hyaluronidase administered 30 minutes after occlusion failed to reverse obstruction or restore function following hyaluronic acid gel occlusion of the ophthalmic artery.
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Ceguera/tratamiento farmacológico , Rellenos Dérmicos/efectos adversos , Electrorretinografía/métodos , Hialuronoglucosaminidasa/administración & dosificación , Oclusión de la Arteria Retiniana/complicaciones , Agudeza Visual , Animales , Ceguera/etiología , Ceguera/fisiopatología , Modelos Animales de Enfermedad , Estudios de Seguimiento , Fondo de Ojo , Inyecciones , Órbita , Estudios Prospectivos , Conejos , Retina/diagnóstico por imagen , Oclusión de la Arteria Retiniana/inducido químicamenteRESUMEN
PURPOSE: Soft tissue dermal fillers, both temporary and permanent, are used frequently in facial rejuvenation. As the use of fillers increases, ischemic complications including skin necrosis are becoming more prevalent. In the literature, topical nitroglycerin paste has been recommended in the early treatment of patients presenting with ischemia. The purpose of this study was to evaluate the vascular perfusion effects of topical nitroglycerin paste in an animal model using indocyanine green (ICG) imaging. METHODS: After Animal Research Committee approval, a rabbit ear model was used to create filler-associated skin ischemia. Ischemia was confirmed to occur after intra-arterial occlusion. Four commonly used soft tissue fillers were injected intra-arterially: Radiesse (Merz USA, Greensboro NC), Restylane (Galderma, Ft. Worth, TX), Juvederm Ultra (Allergan, Irvine CA), Belotero (Merz USA, Greensboro NC) (0.1 ml). A total of 15 ears were used, 1 control and 4 experimental per product. Thirty minutes after occlusion, nitroglycerin ointment USP, 2%(Nitro-Bid) was applied topically to the experimental ears. Vascular perfusion was evaluated with the SPY System (Novadaq Inc.) using ICG imaging. Perfusion images were obtained at baseline, immediately after, and 30 minutes after intra-arterial filler injection, and at 30, 60, 90, and 120 minutes after application of topical nitroglycerin ointment. RESULTS: In this rabbit ear model, no statistically significant improvement in perfusion was noted after topical application of nitroglycerin paste with ICG imaging. In addition, the skin of the rabbit ear post-nitroglycerin ointment appeared to have more of a congested appearance than the controls. CONCLUSIONS: Ischemic filler complications are becoming increasingly prevalent. Practitioners often treat these complications with topical nitroglycerin paste based on the knowledge that topical nitroglycerin causes vasodilation. In filler-induced tissue ischemia, however, filler product is present within arterioles. Theoretically, applying nitroglycerin paste, at least early, may not improve perfusion and could worsen ischemia with dilation of vessels and further propagation of product into the smaller arterioles and capillaries. In addition, nitroglycerin paste has systemic effects, including hypotension and dizziness, which may not be tolerated by some patients. Therefore, the authors caution the use of topical nitroglycerin paste in patients presenting with filler-associated ischemia. Further studies in the best treatment algorithms for patients presenting with ischemic complications need to be performed.
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Rellenos Dérmicos/efectos adversos , Modelos Animales de Enfermedad , Isquemia/inducido químicamente , Nitroglicerina/efectos adversos , Piel/irrigación sanguínea , Vasodilatadores/efectos adversos , Animales , Velocidad del Flujo Sanguíneo , Colorantes/administración & dosificación , Técnicas Cosméticas , Ácido Hialurónico/análogos & derivados , Verde de Indocianina/administración & dosificación , Isquemia/diagnóstico , Isquemia/fisiopatología , Pomadas , Conejos , Flujo Sanguíneo RegionalRESUMEN
BACKGROUND AND PURPOSE: Degree of stent retriever engagement with target thrombi may be reflected by (1) immediate reperfusion (IR) on first deployment, indicating displacement of clot toward the vessel wall, and (2) by early loss of IR (ELOIR), indicating penetration of retriever struts through the thrombus. The relation of these early findings to final reperfusion and clinical outcomes has not been well delineated. METHODS: We investigated IR and ELOIR in patients undergoing stent retriever mechanical thrombectomy at an academic medical center between March 2012 and June 2014. RESULTS: Among 56 patients, IR itself was not associated with final successful reperfusion, which occurred in 66.7% of IR patients and 71.4% of non-IR patients (P=0.999). However, ELOIR was associated with a higher rate of final successful reperfusion (92% versus 44%; P=0.046). Patients with ELOIR had a higher nominal rate of final favorable outcome (42% versus 22%; P=0.64). CONCLUSIONS: ELOIR during the embedding period after deployment of stent retrievers is associated with successful final reperfusion, likely because of greater thrombus engagement with the stent retriever. ELOIR may be a useful finding to guide duration of embedding time in clinical practice and design of novel stent retrievers.
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Trombosis de las Arterias Carótidas/cirugía , Infarto de la Arteria Cerebral Media/cirugía , Sistema de Registros , Stents , Accidente Cerebrovascular/cirugía , Trombectomía/métodos , Centros Médicos Académicos , Anciano , Isquemia Encefálica/complicaciones , Isquemia Encefálica/cirugía , Trombosis de las Arterias Carótidas/complicaciones , Arteria Carótida Interna/cirugía , Femenino , Humanos , Infarto de la Arteria Cerebral Media/complicaciones , Trombosis Intracraneal/complicaciones , Trombosis Intracraneal/cirugía , Masculino , Estudios Prospectivos , Reperfusión/métodos , Accidente Cerebrovascular/etiología , Resultado del TratamientoRESUMEN
PURPOSE: The aim of this updated statement is to provide comprehensive and evidence-based recommendations for management of patients with unruptured intracranial aneurysms. METHODS: Writing group members used systematic literature reviews from January 1977 up to June 2014. They also reviewed contemporary published evidence-based guidelines, personal files, and published expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulated recommendations using standard American Heart Association criteria. The guideline underwent extensive peer review, including review by the Stroke Council Leadership and Stroke Scientific Statement Oversight Committees, before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. RESULTS: Evidence-based guidelines are presented for the care of patients presenting with unruptured intracranial aneurysms. The guidelines address presentation, natural history, epidemiology, risk factors, screening, diagnosis, imaging and outcomes from surgical and endovascular treatment.
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Manejo de la Enfermedad , Personal de Salud/normas , Aneurisma Intracraneal/diagnóstico , Aneurisma Intracraneal/terapia , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/epidemiología , Femenino , Humanos , Aneurisma Intracraneal/epidemiología , Masculino , Accidente Cerebrovascular/terapia , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND AND PURPOSE: High revascularization rates in large-vessel occlusion strokes treated by mechanical thrombectomy are not always associated with good clinical outcomes. We evaluated predictors of functional dependence despite successful revascularization among patients with acute ischemic stroke treated with thrombectomy. METHODS: We analyzed the pooled data from the Multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI), Thrombectomy Revascularization of Large Vessel Occlusions in Acute Ischemic Stroke (TREVO), and TREVO 2 trials. Successful revascularization was defined as thrombolysis in cerebral infarction score 2b or 3. Functional dependence was defined as a score of 3 to 6 on the modified Rankin Scale at 3 months. We assessed relationship of demographic, clinical, angiographic characteristics, and hemorrhage with functional dependence despite successful revascularization. RESULTS: Two hundred and twenty-eight patients with successful revascularization had clinical outcome follow-up. The rates of functional dependence with endovascular success were 48.6% for Trevo thrombectomy and 58.0% for Merci thrombectomy. Age (odds ratio, 1.04; 95% confidence interval, 1.02-1.06 per 1-year increase), National Institutes of Health Stroke Scale score (odds ratio, 1.08; 95% confidence interval, 1.02-1.15 per 1-point increase), and symptom onset to endovascular treatment time (odds ratio, 1.11; 95% confidence interval, 1.01-1.22 per 30-minute delay) were predictors of functional dependence despite successful revascularization. Symptom onset to reperfusion time beyond 5 hours was associated with functional dependence. All subjects with symptomatic intracranial hemorrhage had functional dependence. CONCLUSIONS: One half of patients with successful mechanical thrombectomy do not have good outcomes. Age, severe neurological deficits, and delayed endovascular treatment were associated with functional dependence despite successful revascularization. Our data support efforts to minimize delays to endovascular therapy in patients with acute ischemic stroke to improve outcomes. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00318071, NCT01088672, and NCT01270867.
Asunto(s)
Isquemia Encefálica/epidemiología , Revascularización Cerebral , Recuperación de la Función/fisiología , Accidente Cerebrovascular/epidemiología , Trombectomía , Terapia Trombolítica , Anciano , Anciano de 80 o más Años , Infarto Encefálico/epidemiología , Infarto Encefálico/fisiopatología , Isquemia Encefálica/tratamiento farmacológico , Isquemia Encefálica/fisiopatología , Revascularización Cerebral/normas , Revascularización Cerebral/estadística & datos numéricos , Ensayos Clínicos como Asunto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Multicéntricos como Asunto , Valor Predictivo de las Pruebas , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/tratamiento farmacológico , Accidente Cerebrovascular/fisiopatología , Trombectomía/normas , Trombectomía/estadística & datos numéricos , Terapia Trombolítica/normas , Terapia Trombolítica/estadística & datos numéricosRESUMEN
BACKGROUND: Spinal epidural arteriovenous fistulas (SEDAVFs) are rarely diagnosed vascular malformations that can cause spinal cord compression and congestive myelopathy. METHODS: This is a single-center, retrospective case series of patients with SEDAVFs who underwent observation or treatment at UCLA medical center between 1993 and 2023. RESULTS: Between 1993 and 2023 a total of 26 patients at UCLA were found to have a SEDAVF. The median age at treatment was 59 years (range 4 months to 91 years). Compared with sacral, lumbar, and thoracic SEDAVFs, patients with cervical SEDAVF were younger (41 years vs 63 years, P=0.016) and more likely to be female (66.7% vs 14.3%, P=0.006). Possible triggers for development of SEDAVFs may be prior spinal surgery or trauma (n=4), turning the neck (n=1), lifting a heavy box (n=1), a prolonged period of bending over (n=1), and neurofibromatosis type 1 (n=1). Of the 22 patients treated endovascularly, 18 (82%) were angiographically cured on the first attempt without complications. One patient underwent surgical treatment alone and had a failed surgery on the first attempt, and developed a surgical site infection after the second successful attempt at treatment. Of the 16 patients with adequate clinical follow-up, 11 (69%) demonstrated early improved clinical outcome (eg, improved strength on examination, absent bruit). CONCLUSIONS: SEDAVFs are a rarely diagnosed disease that can be treated effectively and safely with endovascular embolization in most cases. Patients with sacral, lumbar, and thoracic SEDAVFs were older and more often male compared to patients with cervical SEDAVFs.
RESUMEN
OBJECTIVE: Complex middle cerebral artery (MCA) aneurysms incorporating parent or branching vessels are often not amenable to standard microsurgical clipping or endovascular embolization treatments. We aim to discuss the treatment of such aneurysms via a combination of surgical revascularization and aneurysm exclusion based on our institutional experience. METHODS: Thirty-four patients with complex MCA aneurysms were treated with bypass and aneurysm occlusion, 5 with surgical clipping or wrapping only, and 1 with aneurysm excision and primary reanastomosis. Bypasses included superficial temporal artery (STA)-MCA, double-barrel STA-MCA, occipital artery-MCA, and external carotid artery-MCA. After bypass, aneurysms were treated by surgical clipping, Hunterian ligation, trapping, or coil embolization. RESULTS: The average age at diagnosis was 46 years. Of the aneurysms, 67% were large and most involved the MCA bifurcation. Most bypasses performed were STA-MCA bypasses, 12 of which were double-barrel. There were 2 wound-healing complications. All but 2 of the aneurysms treated showed complete occlusion at the last follow-up. There were 3 hemorrhagic complications, 3 graft thromboses, and 4 ischemic insults. The mean follow-up was 73 months. Of patients, 83% reported stable or improved symptoms from presentation and 73% reported a functional status (Glasgow Outcome Scale score 4 or 5) at the latest available follow-up. CONCLUSIONS: Cerebral revascularization by bypass followed by aneurysm or parent artery occlusion is an effective treatment option for complex MCA aneurysms that cannot be safely treated by standard microsurgical or endovascular techniques. Double-barrel bypass consisting of 2 STA branches to 2 MCA branches yields adequate flow replacement in most cases.
Asunto(s)
Revascularización Cerebral , Aneurisma Intracraneal , Humanos , Persona de Mediana Edad , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/cirugía , Revascularización Cerebral/métodos , Arteria Cerebral Media/cirugía , Resultado del Tratamiento , Arterias Temporales/cirugíaRESUMEN
BACKGROUND: Abnormal intracranial aneurysm (IA) wall motion has been associated with IA growth and rupture. Recently, a new image processing algorithm called amplified Flow (aFlow) has been used to successfully track IA wall motion by combining the amplification of cine and four-dimensional (4D) Flow MRI. We sought to apply aFlow to assess wall motion as a potential marker of IA growth in a paired-wise analysis of patients with growing versus stable aneurysms. METHODS: In this retrospective case-control study, 10 patients with growing IAs and a matched cohort of 10 patients with stable IAs who had baseline 4D Flow MRI were included. The aFlow was used to amplify and extract IA wall displacements from 4D Flow MRI. The associations of aFlow parameters with commonly used risk factors and morphometric features were assessed using paired-wise univariate and multivariate analyses. RESULTS: aFlow quantitative results showed significantly (P=0.035) higher wall motion displacement depicted by mean±SD 90th% values of 2.34±0.72 in growing IAs versus 1.39±0.58 in stable IAs with an area under the curve of 0.85. There was also significantly (P<0.05) higher variability of wall deformation across IA geometry in growing versus stable IAs depicted by the dispersion variables including 121-150% larger standard deviation ([Formula: see text]) and 128-161% wider interquartile range [Formula: see text]. CONCLUSIONS: aFlow-derived quantitative assessment of IA wall motion showed greater wall motion and higher variability of wall deformation in growing versus stable IAs.
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PURPOSE: To characterize the relationship between aneurysm size and epidemiologic risk factors with growth and rupture by using computed tomographic (CT) angiography. MATERIALS AND METHODS: In this HIPAA-compliant, institutional review board approved study, patients with known asymptomatic unruptured intracerebral aneurysms were followed up longitudinally with CT angiographic examinations. Growth was defined as an increase in one or more dimensions above the measurement error, and at least 5% volume by using the ABC/2 method. Associations of epidemiologic factors with aneurysm growth and rupture were analyzed by using logistic regression analysis. Intra- and interobserver agreement coefficients for dimension, volume, and growth were evaluated by using the Pearson correlation coefficient and difference of means with 95% confidence intervals, the agreement statistic, and the McNemar χ(2). RESULTS: Patients (n = 165) with aneurysms (n = 258) had a mean follow-up time of 2.24 years from time of diagnosis. Forty-six of 258 (18%) aneurysms in 38 patients grew larger. Spontaneous rupture occurred in four of 228 (1.8%) intradural aneurysms of average size (6.2 mm). Risk of aneurysm rupture per patient-year was 2.4% (95% CI: 0.5%, 7.12%) with growth and 0.2% (95% CI: 0.006%, 1.22%) without growth (P = .034). There was a 12-fold higher risk of rupture for growing aneurysms (P < .002), with high intra- and interobserver correlation coefficients for size, volume, and growth. Tobacco smoking (3.806, one degree of freedom; P < .015,) and initial size (5.895, two degrees of freedom; P < .051) were independent covariates, predicting 78.4% of growing aneurysms. CONCLUSION: These results support imaging follow-up of all patients with aneurysms, including those whose aneurysms are smaller than the current 7-mm treatment threshold. Aneurysm growth, size, and smoking were associated with increased rupture risk.