The PHASES score: To treat or not to treat? Retrospective evaluation of the risk of rupture of intracranial aneurysms in patients with aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: The PHASES score was formulated to predict the 5-year risk of rupture for intracranial aneurysms. We retrospectively analyzed all patients treated in our institution for aneurysmal SAH and applied the PHASES score to estimate the probable predicted risk of bleeding in this group of patients. METHODS: Between February 2015 and August 2018, all patients with aneurysmal SAH were retrospectively analyzed and the PHASES score was applied. A total of 155 patients were included with a mean age of 53.8years, including 60 males and 95 females. RESULTS: Of our patients 110 (70.9%) had a PHASES score of below or equal to 5, with a hemorrhagic risk of up to 1.3% over 5years. If we analyze the patients with a risk of below 2% this figure increases to 122 patients (78.7%). Of these 99.3% were European and 0.6% were Japanese (1 patient). In 86 patients (55.4%), the aneurysm was smaller than 5mm and in 10 patients (6.4%) the aneurysm was located in the posterior circulation. CONCLUSION: Of our patients 78.7% had less than a 2% 5-year rupture risk based on their PHASES score, highlighting the discrepancy of the rupture risk calculated with the PHASES score when hypothetically applied to this group of patients. In the hypothetical scenario that our patients had unruptured aneurysms, our retrospective analysis shows that the PHASES score may only provide a weak tool for clinicians to use in the decision-making process as to whether or not to treat these aneurysms.

How to differentiate intracranial atherosclerotic disease or vasospasms after mechanical thrombectomy. Be patient or vasodilator is the secret?

Here we describe a successful mechanical thrombectomy (MT) for acute large vessel occlusion in stroke treatment with one passage (thrombolysis in cerebral infarction, TICI 3). Immediately after the withdrawing of the stent retriever, a narrowing of the middle cerebral artery was diagnosed. The rate of vasospasms during this procedure can be as higher as 41% (range from 6-41%). Here we describe our protocol when a narrowing of the artery is visualized after a stent retriever is withdrawn. A patient presented in our emergency room with National Institute of Health Stroke Scale (NIHSS) of 21, Alberta Stroke Program Early CT Score (ASPECTS) 8, computed tomography angiography revealed occlusion of the M1 segment and MT was indicated. One passage TICI Ⅲ was achieved. After that, the image showed a narrowing of the artery. We present one case of a spasm after stent retriever technique for MT, we injected vasodilator and the artery became normal in a few minutes differentiating between atheromatous stenosis and vasospasm. We present a technical note that can help to make the differentiation of vasospasm or atheromatous disease after MT with the stent retriever technique.

Is the retrograde access for endovascular treatment of a traumatic carotid cavernous fistula associated with dissection of the ipsilateral carotid possible?

This is a case demonstrating a combined traumatic lesion of the internal carotid artery (dissection and a carotid cavernous fistula [CCF]) in a patient who was beaten during a robbery and, while trying to escape, was hit by a vehicle. Endovascular approach for the treatment was chosen using the retrograde access from the vertebral artery to the cavernous sinus by posterior communicating (Pcom) artery due to the occlusion of the ipsilateral internal carotid. Because the artery access by the internal carotid was impossible, retrograde approach by vertebral artery and Pcom artery was done to treat the direct CCF. A patient presented with left hemiplegia and proptosis, chemosis, right eye ptosis. Computed tomography (CT) and CT angiography revealed a CCF of the right carotid. An arterial retrograde endovascular approach by the vertebral artery was used for CCF occlusion with coils. We present a rare case of a combined traumatic cerebrovascular lesion, right carotid artery dissection and a right direct CCF treated by a retrograde endovascular approach by the vertebral artery through the Pcom artery to reach the fistula point and achieved a complete cure of the CCF.

Follow-up of endovascular treatment of direct carotid-cavernous fistulas.

INTRODUCTION: Direct carotid-cavernous fistula (CCF) is a direct communication between the internal carotid artery (ICA) and the cavernous sinus. Some patients treated with detachable balloons develop pseudoaneurysms or present with a true aneurysm recanalization in the cavernous ICA with poorly known long-term radiological and clinical progression. The objective of the present study was to evaluate the long-term clinical and radiological progression of patients treated with detachable balloons. METHODS: The present study evaluated 13 patients previously treated for direct CCF by an endovascular approach. RESULTS: The follow-up period ranged between 19 and 128 months. Ophthalmological evaluation demonstrated alterations in eight patients (61.5%). All of these alterations were already present from the moment of the treatment and displayed no signs of progression. Cranial magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) were performed in all patients, and 11 pseudoaneurysms were demonstrated in ten of the 11 patients in whom ICA patency had been preserved. Five patients were submitted for cerebral digital subtraction angiography (DSA) to characterize the pseudoaneurysms previously observed on MRA studies, with no significant differences in morphology, size, aneurismal neck, and number of lesions. CONCLUSION: Endovascular treatment of direct CCF with detachable balloons has been shown to be a long-term effective and stable therapeutic method. The authors found asymptomatic pseudoaneurysms in 91% of cases where the ICA patency was preserved. MRI and MRA demonstrated an accuracy similar to that of DSA in the diagnosis of pseudoaneurysms of cavernous ICA.

Republished: Spinal arteriovenous malformation without endovascular arterial access: is a combined neurosurgical approach and direct venous puncture an option?

This case report describes a combined neurosurgical and endovascular approach for the treatment of a conus medullaris arteriovenous malformation resulting in considerable improvement in the patient's neurological condition (modified Rankin Scale score 2).

Spinal arteriovenous malformation without endovascular arterial access: is a combined neurosurgical approach and direct venous puncture an option?

This case report describes a combined neurosurgical and endovascular approach for the treatment of a conus medullaris arteriovenous malformation resulting in considerable improvement in the patient's neurological condition (modified Rankin Scale score 2).

[Reference values for measures of blood flow velocities and impedance indexes in healthy individuals through conventional transcranial Doppler]. / Doppler transcraniano convencional em voluntários assintomáticos: variabilidade e valores de referência para parâmetros de fluxo sanguíneo.

OBJECTIVE: To establish reference values for measures of blood flow velocities and impedance indexes in healthy individuals through conventional transcranial Doppler (TCD) and to observe their variations in relation to the age and sex. METHOD: 88 asymptomatic volunteers were examined without antecedents of cardiac, peripheral or cerebrovascular diseases. The TCD were accomplished by the same examiner. The middle, anterior and posterior cerebral arteries were studied through the temporal acoustic window and the vertebral and basilar arteries through the suboccipital acoustic window. The values of mean velocity (MV), peak-systolic velocity (PSV), final diastolic velocity (FDV), resistance index (RI) and pulsatility index (PI) of each examined arterial segment were filed. RESULTS: The reference limits found by us were similar to the described by other authors for all of the studied parameters. There was tendency of the flow velocities decrease and of the impedance indexes increase with moving forward of the age. The values of velocities in the women were superior to the found in men. CONCLUSION: TCD was shown useful in the evaluation of hemodynamic cerebral for our population. Our results are similar to the other studies, so much in the reference values as in relationship with the age and the sex.

Preliminary evaluation of the endovascular treatment of intracranial aneurysms with detachable coils in vigil patients.

UNLABELLED: Endovascular treatment of intracranial aneurysms with coil embolization became the most important therapeutic option with better morbidity and mortality rates and quality of life. Following immobility, patients are treated with general anaesthesia. OBJECTIVE: To test viability of endovascular treatment on wake patients. METHOD: Considering clinical symptoms, psychological characteristics and aneurysmal morphology, four patients with five intracranial aneurysms were selected. RESULTS: Four among five cases were completed with this technique. Patient 1 was partially treated after 75 minutes presenting vesical stress. Patient 2 presented subarachnoid hemorrhage after aneurysmal re-rupture, and the procedure was completed under general anaesthesia. The other three patients presented no intercurrences during the treatment. CONCLUSION: Endovascular treatment on wake patients with intracranial aneurysm can be an alternative to a selected group of patients.

[Dissecting aneurysm of the intracranial fenestrated vertebral artery submited to endovascular treatment: case report]. / Aneurisma dissecante de artéria vertebral intracraniana fenestrada submetido ao tratamento endovascular: relato de caso.

Dissecting aneurysms of the vertebral artery at its intracranial segment are uncommon lesions, mainly when associated to subarachnoid hemorrhage, being also rare fenestrations of the vertebral artery. They present high morbidity and mortality, with high rebleeding rate and difficulty of surgical approach. We present a 19 years old man who was victim of physical aggression in the occipto-cervical region, presenting subarachnoid hemorrhage and a dissecting aneurysm of the right vertebral artery, which had a fenestration, being submitted to endovascular treatment. We accomplished a literature review about this subject, proposing endovascular treatment as a therapeutic option for these cases.

[Ischemic stroke after chemotherapy with cisplatin, etoposide and bleomycin: case report]. / Acidente vascular cerebral isquêmico após quimioterapia com cisplatina, etoposide e bleomicina: relato de caso.

A 20-year-old man with a germ cell tumor who experienced an ischemic stroke as a complication of cisplatin/etoposide/bleomycin based chemotherapy is reported. The previously reported cases are reviewed as well as the different physiopathologic mechanisms associated with vascular toxicity of this regimen.

Doppler transcraniano convencional em voluntários assintomáticos: variabilidade e valores de referência para parâmetros de fluxo sanguíneo / Reference values for measures of blood flow velocities and impedance indexes in healthy individuals through conventional transcranial Doppler

OBJETIVO: Estabelecer valores de referência para medidas de velocidade sanguínea e índices de impedância em indivíduos saudáveis por meio do Doppler transcraniano convencional (DTC) e observar suas variações em relação à idade e sexo. MÉTODO: Foram examinados 88 voluntários assintomáticos, sem antecedentes de doença cerebrovascular, cardíaca ou vascular periférica. Os exames de DTC foram realizados pelo mesmo examinador, sendo as artérias cerebrais médias, anteriores e posteriores estudadas por meio da janela temporal e as artérias vertebrais e basilar por meio da janela suboccipital. Foram arquivados os valores de velocidade média (VM), velocidade de pico sistólico (VPS), velocidade diastólica final (VDF) e índices de resistência (IR) e pulsatilidade (IP) de cada segmento arterial examinado. RESULTADOS: Os limites de referência encontrados por nós foram semelhantes aos descritos por outros autores para todos os parâmetros estudados. Houve tendência das velocidades de fluxo diminuírem e dos índices de impedância aumentarem com o avançar da idade. Os valores de velocidade nas mulheres foram superiores aos encontrados em homens. CONCLUSÃO: O DTC se mostrou útil na avaliação hemodinâmica cerebral de nossa população. Os nossos resultados são semelhantes aos de outros estudos, tanto nos valores de referência quanto na sua relação com a idade e o sexo.

OBJECTIVE: To establish reference values for measures of blood flow velocities and impedance indexes in healthy individuals through conventional transcranial Doppler (TCD) and to observe their variations in relation to the age and sex. METHOD: 88 asymptomatic volunteers were examined without antecedents of cardiac, peripheral or cerebrovascular diseases. The TCD were accomplished by the same examiner. The middle, anterior and posterior cerebral arteries were studied through the temporal acoustic window and the vertebral and basilar arteries through the suboccipital acoustic window. The values of mean velocity (MV), peak-systolic velocity (PSV), final diastolic velocity (FDV), resistance index (RI) and pulsatility index (PI) of each examined arterial segment were filed. RESULTS: The reference limits found by us were similar to the described by other authors for all of the studied parameters. There was tendency of the flow velocities decrease and of the impedance indexes increase with moving forward of the age. The values of velocities in the women were superior to the found in men. CONCLUSION: TCD was shown useful in the evaluation of hemodynamic cerebral for our population. Our results are similar to the other studies, so much in the reference values as in relationship with the age and the sex.

Preliminary evaluation of the endovascular treatment of intracranial aneurysms with detachable coils in vigil patients / Avaliação preliminar do tratamento endovascular de aneurismas intracranianos com espirais destacáveis em pacientes no estado de vigília

Endovascular treatment of intracranial aneurysms with coil embolization became the most important therapeutic option with better morbidity and mortality rates and quality of life. Following immobility, patients are treated with general anaesthesia. OBJECTIVE: To test viability of endovascular treatment on wake patients. METHOD: Considering clinical symptoms, psychological characteristics and aneurysmal morphology, four patients with five intracranial aneurysms were selected. RESULTS: Four among five cases were completed with this technique. Patient 1 was partially treated after 75 minutes presenting vesical stress. Patient 2 presented subarachnoid hemorrhage after aneurysmal re-rupture, and the procedure was completed under general anaesthesia. The other three patients presented no intercurrences during the treatment. CONCLUSION: Endovascular treatment on wake patients with intracranial aneurysm can be an alternative to a selected group of patients.

O tratamento endovascular de aneurismas intracranianos com espirais destacáveis estabeleceu-se como principal opção terapêutica na maioria dos pacientes, por menores taxas de morbidade e mortalidade. De forma geral, os pacientes são tratados sob anestesia geral, pela necessidade de imobilidade. OBJETIVO: Avaliar a viabilidade do tratamento endovascular de aneurismas intracranianos em pacientes no estado de vigília. MÉTODO: Cinco aneurismas foram tratados em quatro pacientes selecionados, considerando-se quadro clínico, a intenção de colaboração do paciente e características morfológicas do aneurisma. RESULTADOS: A abordagem proposta foi possível em quatro dos cinco casos. O paciente 1 obteve compactação parcial do aneurisma, pois o tratamento foi interrompido por desconforto vesical. O paciente 2 apresentou hemorragia subaracnóidea por re-ruptura do aneurisma, e o tratamento foi completado no mesmo tempo sob anestesia geral. Nos demais casos, não houve intercorrências. CONCLUSÃO: O tratamento endovascular de aneurismas intracranianos em pacientes no estado de vigília é viável em grupo selecionado de pacientes.

Aneurisma dissecante de artéria vertebral intracraniana fenestrada submetido ao tratamento endovascular: relato de caso / Dissecting: aneurysm of the intracranial fenestrated vertebral artery submited to endovascular treatment case report

Aneurismas dissecantes da artéria vertebral em seu segmento intracraniano são lesões pouco comuns, principalmente quando associadas a hemorragia subaracnóidea, sendo também raras as fenestrações da artéria vertebral. Apresentam elevada morbidade e mortalidade, com elevado índice de ressangramento e dificuldade de abordagem cirúrgica. Apresentamos o caso de um homem de 19 anos, o qual foi vitima de agressão física em região occipto-cervical, apresentando hemorragia subaracnóidea e aneurisma dissecante na artéria vertebral direita, a qual era fenestrada, sendo submetido ao tratamento endovascular. Realizamos revisão da literatura sobre o assunto, sendo colocado o tratamento endovascular como uma opção terapêutica para estes casos.

Acidente vascular cerebral isquêmico após quimioterapia com cisplatina, etoposide e bleomicina. Relato de caso / Ischemic stroke after chemotherapy with cisplatin, etoposide and bleomycin: case report

Relatamos o caso de um homem de 20 anos, com diagnóstico de tumor de células germinativas, que apresentou acidente vascular cerebral isquêmico durante quimioterapia com cisplatina, etoposide e bleomicina. Os casos relatados na literatura foram revisados, bem como os diferentes mecanismos fisiopatológicos implicados na toxicidade vascular deste esquema quimioterápico

Uma nova técnica de utilização de balões destacáveis para oclusão carotídea / A new technique for detachable balloons utilization for carotid occlusion

O objetivo deste trabalho é apresentar uma modificação técnica do uso de balões destacáveis para oclusão carotídea, visando aumentar a segurança do procedimento. Pela via femoral, e pelo mesmo cateter-guia, são introduzidos, simultaneamente, dois balões destacáveis até a artéria carótida interna, permitindo obter-se controle do fluxo proximal da artéria carótida interna em caso de esvaziamento prematuro do primeiro balão.

Meningeoma lipomatoso em localizacao extradural da coluna toracica: relato de um caso / Meningioma lipomatosus localizeded in extradural thoracic spine: a case report

Os autores apresentam um caso de meningeoma lipomatoso toracico ocorrendo em mulher de 56 anos de idade, com descricao de seus aspectos tomograficos, e salientam a raridade desta histologica de sua localizacao

Meningocele toracica nao-associada a neurofibromatose: relato de um caso / Toraxic meningocele non-associated with neurofibromatosis: a case report

Os autores apresentam um caso de meningocele toracica nao-associada a neurofibromatose ocorrendo em mulher de 30 anos de idade, e mostram a importancia dos metodos de imagem no diagnostico diferencial das massas mediastinais posteriores