Stent-assisted Woven EndoBridge device for the treatment of intracranial aneurysms: an international multicenter study.

OBJECTIVE: The Woven EndoBridge (WEB) device is an intrasaccular flow disruptor designed for wide-necked bifurcation aneurysms. These aneurysms may require the use of a concomitant stent. The objective of this study was to determine the clinical and radiological outcomes of patients undergoing stent-assisted WEB treatment. In addition, the authors also sought to determine the predictors of a concomitant stent in aneurysms treated with the WEB device. METHODS: The data for this study were taken from the WorldWideWEB Consortium, an international multicenter cohort including patients treated with the WEB device. Aneurysms were classified into two groups based on treatment: stent-assisted WEB and WEB device alone. The authors compared clinical and radiological outcomes of both groups. Univariable and multivariable binary logistic regression analyses were performed to determine factors that predispose to stent use. RESULTS: The study included 691 intracranial aneurysms (31 with stents and 660 without stents) treated with the WEB device. The adequate occlusion status did not differ between the two groups at the latest follow-up (83.3% vs 85.6%, p = 0.915). Patients who underwent stenting had more thromboembolic (32.3% vs 6.5%, p < 0.001) and procedural (16.1% vs 3.0%, p < 0.001) complications. Aneurysms treated with a concomitant stent had wider necks, greater heights, and lower dome-to-neck ratios. Increasing neck size was the only significant predictor for stent use. CONCLUSIONS: This study demonstrates that there is no difference in the degree of aneurysm occlusion between the two groups; however, complications were more frequent in the stent group. In addition, a wider aneurysm neck predisposes to stent assistance in WEB-treated aneurysms.

Intrasaccular flow disruption for ruptured aneurysms: an international multicenter study.

BACKGROUND: The Woven EndoBridge (WEB) device is a novel intrasaccular flow disruptor tailored for bifurcation aneurysms. We aim to describe the degree of aneurysm occlusion at the latest follow-up, and the rate of complications of aneurysms treated with the WEB device stratified according to rupture status. METHODS: Our data were taken from the WorldWideWeb Consortium, an international multicenter cohort including patients treated with the WEB device. Aneurysms were classified into two groups: ruptured and unruptured. We compared clinical and radiologic outcomes of both groups. Propensity score matching (PSM) was done to match according to age, gender, bifurcation, location, prior treatment, neck, height, dome width, daughter sac, incorporated branch, pretreatment antiplatelets, and last imaging follow-up. RESULTS: The study included 676 patients with 691 intracranial aneurysms (529 unruptured and 162 ruptured) treated with the WEB device. The PSM analysis had 55 pairs. In both the unmatched (85.8% vs 84.3%, p=0.692) and matched (94.4% vs 83.3%, p=0.066) cohorts there was no significant difference in the adequate occlusion rate at the last follow-up. Likewise, there were no significant differences in both ischemic and hemorrhagic complications between the two groups. There was no documented aneurysm rebleeding after WEB device implantation. CONCLUSION: There was no significant difference in both the radiologic outcomes and complications between unruptured and ruptured aneurysms. Our findings support the feasibility of treatment of ruptured aneurysms with the WEB device.

Ruptured intracranial infectious aneurysms: Single Canadian center experience.

Background: Ruptured intracranial infected aneurysms (IIAs) are relatively rare, but they portend high mortality. To the best of our knowledge, there is no Canadian case series on IIA, as well there is a relative paucity of international published experiences. Our purpose is to share the experience of a single Canadian tertiary center in managing ruptured IIA and to conduct a systematic review. Methods: We did a retrospective case review series of adult patients with ruptured IIA treated at our institution. Second, we conducted a systematic review of the literature on ruptured IIA between 2011 and 2021 inclusive. Results: At our institution, of a total eight cases with ruptured IIA, four were treated endovascularly and two by surgical bypass. For the systematic review, we included nine noncomparative studies with a total of 509 patients (318 males) and at least 437 ruptured IIA aneurysms. Favorable outcome was specified for 63.3% of patients (n = 57). Regarding ruptured IIA, favorable clinical outcome was described in 59.3% (n = 16). Conclusion: This study highlights a single Canadian tertiary center experience in the management of IIA and compares it to the global trends of the past 10 years in a systematic review.

A Protocol for Carotid Artery Stenting in COVID Times. A Single Canadian Centre Experience.

OBJECTIVES: The COVID-19 pandemic has resulted in huge disruption to healthcare delivery worldwide. There is a need to balance the urgent needs of the neurovascular patient population with the desire to preserve critical inpatient hospital capacity. It is incumbent on neurointerventionalists to advocate for their patients to minimise future disability. Patients still require semiurgent carotid revascularisation after ischaemic embolic events. We present a review of a novel protocol for expediting patient flow through the carotid stenting process, in accordance with government directives to minimise nonessential inpatient admissions, ensure its efficacy, and evaluate its safety. We also evaluate the literature regarding complications with attention to the timing of these related to the procedure. METHODS: A retrospective review of 45 consecutive carotid stenting cases performed at London Health Sciences Centre between March 2020 and March 2021 for symptomatic extracranial internal carotid artery stenosis utilising a default same-day discharge policy was performed. Complications were plotted as a function of time. RESULTS: Twenty-four patients underwent carotid artery stenting with same-day discharge and 21 patients underwent stenting with an overnight inpatient stay. A single stent occlusion occurred 27 h post stenting. CONCLUSION: Simple modification of protocol for symptomatic carotid artery stenting during the COVID-19 outbreak with radial access as first approach appears to provide safe, efficacious care.

Acute Hemorrhagic Encephalitis Related to COVID-19.

PURPOSE OF REVIEW: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the most critical public health challenge in recent history. In this report, we present a case of suspected acute hemorrhagic encephalitis with bilateral intracranial hemorrhages associated with coronavirus disease 2019 (COVID-19) infection. RECENT FINDINGS: A 48-year-old female COVID-19-positive patient developed acute changes in her neurologic status. A head CT with CT angiography demonstrated extensive bilateral parietal and occipital intraparenchymal hemorrhage with intraventricular extension and acute hydrocephalus. The patient was treated with an external ventricular drain, and a CSF sample was tested for SARS-CoV-2 but was found to be negative. SUMMARY: The underlying mechanism for developing acute hemorrhagic encephalitis in viral illnesses may be autoimmune in nature and warrants further investigation. The initial neurologic presentation of COVID-19-related hemorrhagic encephalitis is altered level of consciousness, which may prompt further neurologic examination and imaging to exclude this feature.

Interventional Neuroradiology: A Review.

Interventional neuroradiology (INR) has evolved from a hybrid mixture of daring radiologists and iconoclastic neurosurgeons into a multidisciplinary specialty, which has become indispensable for cerebrovascular and neurological centers worldwide. This manuscript traces the origins of INR and describes its evolution to the present day. The focus will be on cerebrovascular disorders including aneurysms, stroke, brain arteriovenous malformations, dural arteriovenous fistulae, and atherosclerotic disease, both intra- and extracranial. Also discussed are cerebral vasospasm, venolymphatic malformations of the head and neck, tumor embolization, idiopathic intracranial hypertension, inferior petrosal venous sinus sampling for Cushing's disease, and spinal interventions. Pediatric INR has not been included and deserves a separate, dedicated review.

Emergent Carotid Endarterectomy with Open Thrombectomy for Acute Carotid Stent Occlusion.

Acute occlusion of a carotid stent is a rare complication that necessitates rapid diagnosis and treatment to prevent devastating neurologic injury. Management options may include thrombolysis, mechanical thrombectomy, or open surgical revascularization; however, the optimal treatment is unclear due to the low reported incidence of this complication. Video 1 illustrates the surgical technique for open revascularization with carotid stent removal, thrombectomy, and endarterectomy. We present the case of a 64-year-old woman who presented with expressive speech and right-sided motor deficits and was identified to have complete occlusion of the distal left M1 and proximal M2 branches, as well as near-occlusion of the left internal carotid artery. She underwent successful mechanical thrombectomy of the intracranial occlusion with complete reperfusion and also angioplasty and stenting of the carotid stenosis. She deteriorated overnight and was identified to have complete carotid stent occlusion but no large infarct, suggestive of collateral flow impairment. Cerebral reperfusion was established by emergent open stent removal and endarterectomy. An extended exposure of the carotid was required, as the stent extended beyond the typical sites of clamping both proximally and distally. Intraoperatively, the clot from the internal carotid artery was manually aspirated via a 5-French catheter. Postoperative imaging demonstrated appropriate vessel patency. In follow-up, the patient made a full neurologic recovery.

Use of a radial artery 'slender' sheath for facilitating transfemoral arterial access for neuroendovascular embolization in a very young infant.

Pediatric neuroendovascular procedures are increasingly performed as several studies have shown the safety of these interventions. In the literature, an upper limit of 4 French catheter size is conventionally used for femoral access in neuroangiography of very young infants. However, this constraint in luminal size may not allow for more complex procedures. We present the previously unreported use of a radial 5 French slender catheter with ultrathin walls for femoral access for aneurysm embolization in a 3-month-old boy presenting with left M2 aneurysm rupture.

Flow diversion with Pipeline Embolic Device as treatment of subarachnoid hemorrhage secondary to blister aneurysms: dual-center experience and review of the literature.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) secondary to blister-type aneurysms (BAs) is associated with high morbidity and mortality. Microsurgical clipping or wrapping and/or use of traditional endovascular techniques to repair the lesion result in frequent regrowth and rebleeds and ultimately high fatality rates. Because of the purely endoluminal nature of arterial reconstruction, flow diversion may represent an ideal option to repair ruptured BAs. METHODS: We performed a retrospective analysis of our database including all consecutive patients with aSAH secondary to BAs treated with the Pipeline Embolic Device (PED) between November 2013 and November 2015 in two institutions. We collected basic patient demographics, aneurysm size, location, number and sizes of PEDs used, use of coiling, 30-day modified Rankin Scale (mRS) score, and follow-up imaging data. RESULTS: Ten cases of aSAH were found as a result of a ruptured BA. Patients had a mean age of 47.2 years (range 27-68). Mean Hunt and Hess score was 1.6 (range 1-4). Lesions were predominantly left-sided, mostly along the dorsal aspect of the internal carotid artery, either paraclinoid or paraophthalmic (8/10). In two patients the BA was located in the left middle cerebral artery. All lesions were very small (mean 1.4×1.5 mm; range 0.75-2.1 mm). Placement of a single PED resulted in immediate occlusion or near-occlusion of the BA in 9 out of 10 patients. Nine patients did very well; eight had a 90-day mRS score of 0 and one had a 90-day mRS score of 1. Follow-up digital subtraction angiography was performed in all patients (mean 15 months; range 7-24). In the surviving nine patients there was complete occlusion of the BA on long-term follow-up angiography. CONCLUSIONS: Repair of ruptured BA with PED may be a safe and durable option.

Clinical applications of dual-energy CT in head and neck imaging.

Dual-energy CT provides insights into the material properties of the tissues and can differentiate between tissues that have similar attenuation on conventional, single energy CT imaging. It has several useful and promising applications in head and neck imaging that an otolaryngologist could use to deliver improved clinical care. These applications include metal artifact reduction, atherosclerotic plaque and tumor characterization, detection of parathyroid lesions, and delineation of paranasal sinus ventilation. Dual-energy CT can potentially improve image quality, reduce radiation dose, and provide specific diagnostic information for certain head and neck lesions. This article reviews some current and potential otolaryngology applications of dual-energy CT.

An analysis of the use of the Kellgren and Lawrence grading system to evaluate peritalar arthritis following total ankle arthroplasty.

BACKGROUND: The Kellgren and Lawrence grading system (KLGS) has been used throughout the literature for the radiographic staging of osteoarthritis (OA) of the peritalar joints. Despite its widespread use, the KLGS has never been validated for use in this clinical circumstance. The purpose of this study was to determine the inter- and intrarater reliability of the KLGS in the assessment of radiographic progression of OA in the peritalar joints following total ankle replacement (TAR). METHODS: One hundred twenty pre- and minimum 5-year postoperative weight-bearing lateral radiographs following 60 consecutive cases of TAR were utilized. Each individual film was considered separately for the purposes of this study. Of those films, 93 and 98 were found to have adequate visualization of the subtalar (STJ) and talonavicular (TNJ) joints, respectively. Three qualified reviewers graded the films according to the KLGS on 2 separate occasions, with 1 month separating the 2 readings. The results were analyzed for intra- and interobserver reliability. The degree of agreement was analyzed using the weighted kappa (κ(w)) statistic, Fleiss's kappa (Fleiss's κ), and percentage agreement RESULTS: Interrater agreements were moderate (κ(w) = 0.37 ± 0.06; Fleiss's κ = 0.21 ± 0.03) for the STJ to fair (κ(w) = 0.43 ± 0.06; Fleiss's κ = 0.25 ± 0.03) for the TNJ. Intrarater agreements for the STJ were moderate (mean κ(w) = 0.43 ± 0.07) and moderate for the TNJ as well (mean κ(w) = 0.46 ± 0.07). The reliability of the KLGS, although not originally designed for use in the setting of inflammatory arthropathy, was not notably affected when being used to grade inflammatory versus noninflammatory arthropathy. CONCLUSIONS: The KLGS is likely not a reliable tool for grading the degree of OA present in the peritalar joints prior to treatment and following TAR for research purposes. Using the KLGS in the setting of inflammatory arthritis versus OA did not produce any notable differences in the observed reliability. It is important to remember this has not been assessed in the clinical environment. Further work is required to determine the optimal method for assessment of peritalar OA. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Effective detection and management of low-velocity Lisfranc injuries in the emergency setting: principles for a subtle and commonly missed entity.

OBJECTIVE: To improve the ability of primary care physicians to recognize the mechanisms and common presentations of low-velocity Lisfranc injuries (LFIs) and to impart an improved understanding of the role of imaging and principles of primary care in low-velocity LFIs. SOURCES OF INFORMATION: A MEDLINE literature review was performed and the results were summarized, reviewing anatomy and mechanisms, clinical and imaging-based diagnoses, and management principles in the primary care setting. MAIN MESSAGE: Low-velocity LFIs result from various mechanisms and can have very subtle findings on clinical examination and imaging. A high degree of suspicion and caution are warranted when managing this type of injury. CONCLUSION: Although potentially devastating if missed, if a few treatment principles for low-velocity LFIs are applied from the initial presentation onward, outcomes from this injury can be optimized.

RAPD and pedigree-based genetic diversity estimates in cultivated diploid potato hybrids.

In this study, RAPD and pedigree data were used to investigate the genetic relationships in a group of 45 diploid hybrid potato clones used in the breeding and genetics program of the Agriculture and Agri-Food Canada Potato Research Centre in Fredericton, New Brunswick, and used for the potato after-cooking darkness program at the Nova Scotia Agricultural College. These hybrids were derived from crossing primitive cultivated South American diploid species such as Solanum phureja or Solanum stenotomum and wild diploid species such as Solanum chacoense and other wild Argentine species with haploids of Solanum tuberosum. These hybrids have subsequently undergone up to 30 years of breeding and selection, for adaptation to local growing and storage conditions, processing traits and pest resistances. The objectives of this study were to estimate the level of genetic similarity (GS) among these sets of clones and to investigate the correlation between RAPD-based GS and f, based on pedigree information. Genetic similarity coefficients varied from 0.29 to 0.90 with a mean of 0.65 when based on the RAPD data, whereas the coefficient of parentage varied from zero to 0.75 with a mean of 0.11. The degree of relationship between the similarity matrices based on RAPD and pedigree was measured by comparing the similarity matrices with the normalized Mantel test. A low positive correlation (R = 0.104, p = 0.999) between the two matrices was observed. Cluster analysis using GS divided the clones into many subgroups that did not correspond well with the grouping based on pedigree. The level of genetic variation present in this set of potato clones is very high. Rigorous selection pressure aimed at different breeding purposes may result in the genetic differentiation of the clones from the same origin.