Clinical and Angioarchitectural Features of Hemorrhagic Brain Arterio-Venous Malformations in Adults and Children: Contrasts and Implications on Outcome.

BACKGROUND: Hemorrhage from brain arteriovenous malformations (bAVMs) is estimated at 3% per annum. Features influencing risk of hemorrhage include perforator/posterior circulation supply, associated aneurysms, and deep drainage. Children are more likely to present with bAVM bleeds. OBJECTIVE: To analyze differences in bAVM angioarchitecture between children and adults and describe predictors of poor outcome. METHODS: Data were collected from adult and pediatric tertiary referral hospitals. Demographic data, bleed location, treatment, and follow-up modified Rankin Scale (mRS) were collected. Angioarchitectural assessment included aneurysm presence, nidus morphology, perinidal angiogenesis, intranidal shunting, steal phenomenon, venous ectasia, venous stenosis, venous reflux, and pseudophlebitic pattern. Regression analyses conducted to determine predictors of mRS > 2. RESULTS: A total of 270 adult and 135 pediatric ruptured bAVMs were assessed. Median age was 42 (adults) and 10.9 (children) yr. Intranidal aneurysms were more frequent in children (P = .012), whereas prenidal aneurysms were more common in adults (P < .01). Children demonstrated more perinidal angiogenesis (P = .04), whereas steal phenomenon was commoner in adults (P < .01). Venous ectasia (P < .01), reflux (P < .01), and pseudophlebitic pattern (P = .012) were more frequent in adults. Children had better outcome (mRS score ≤ 2) (P < .01). Older age (odds ratio [OR] = 1.02), eloquent location (OR = 2.5), multicompartmental hemorrhage (OR = 1.98), venous reflux (OR = 2.5), diffuse nidus (OR = 1.83), pseudophlebitic pattern (OR = 1.96), intranidal shunts (OR = 2), and no treatment (OR = 3.68) were significant predictors of mRS > 2. CONCLUSION: Children are more likely to have intranidal aneurysms and perinidal angiogenesis, whereas adults have more prenidal aneurysms, venous ectasia, corticovenous reflux, and pseudophlebitic pattern. Eloquent location, diffuse nidus, intranidal shunts, venous reflux, and pseudophlebitic pattern predict poorer outcome.

Subarachnoid Hemorrhage in Mechanical Thrombectomy for Acute Ischemic Stroke: Analysis of the STRATIS Registry, Systematic Review, and Meta-Analysis.

Background: The indications for mechanical thrombectomy in acute ischemic stroke continue to broaden, leading neurointerventionalists to treat vessel occlusions at increasingly distal locations farther in time from stroke onset. Accessing these smaller vessels raises the concern of iatrogenic subarachnoid hemorrhage (SAH) owing to increasing complexity in device navigation and retrieval. This study aims to determine the prevalence of SAH following mechanical thrombectomy, associated predictors, and resulting functional outcomes using a multicenter registry and compare this with a systematic review and meta-analysis of the literature. Methods: Data from STRATIS (The Systematic Evaluation of Patients Treated with Neurothrombectomy Devices for Acute Ischemic Stroke) registry were analyzed dichotomized by the presence or absence of SAH after thrombectomy. Only patients with 24-h post-procedural neuroimaging were included (n = 841). Multivariable logistic regression was performed to identify significant predictors of SAH. A systematic review and random-effects meta-analysis was also conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) protocol. Results: The prevalence of post-thrombectomy SAH was 5.23% in STRATIS with 15.9% (1.84% overall) experiencing neurological decline. Distal location of vessel occlusion (OR 3.41 [95% CI: 1.75-6.63], p < 0.001) and more than 3 device passes (OR 1.34 [95% CI: 1.09-1.64], p = 0.01) were associated with a higher probability of SAH in contrast to a reduction with administration of intravenous tissue plasminogen activator (tPA) (OR 0.48 [95% CI: 0.26-0.89], p = 0.02). There was a trend toward a higher discharge NIHSS (8.3 ± 8.7 vs. 5.3 ± 6.6, p = 0.07) with a significantly reduced proportion achieving functional independence at 90 days (modified Rankin Score 0-2: 32.5% vs. 57.8%, p = 0.002) in SAH patients. Pooled analysis of 10,126 patients from 6 randomized controlled trials and 64 observational studies demonstrated a prevalence of 5.85% [95% CI: 4.51-7.34%, I 2: 85.2%]. Only location of vessel occlusion was significant for increased odds of SAH at distal sites (OR 2.89 [95% CI: 1.14, 7.35]). Conclusions: Iatrogenic SAH related to mechanical thrombectomy is more common with treatment of distally-situated occlusions and multiple device passes. While low in overall prevalence, its effect is not benign with fewer patients reaching post-procedural functional independence, particularly if symptomatic.

Occult posterior inferior cerebellar artery dissection requiring endovascular treatment following pediatric head trauma: case report.

This is the eighth case report of a pediatric dissecting posterior inferior cerebellar artery aneurysm. The authors present the case of a 13-year-old boy who presented with posttraumatic posterior fossa subdural, subarachnoid, and intraventricular hemorrhage with hydrocephalus. Initial vascular imaging findings were negative; however, a high level of suspicion is necessary. The aneurysm was identified on day 20, after recurrence of hydrocephalus, and was treated with endovascular vessel sacrifice. The patient made a good recovery. It is important to consider arterial dissection in pediatric traumatic brain injury, especially with suspicious findings on initial CT scan and clinical presentation out of proportion to the mechanism of injury. Delayed vascular imaging is imperative for appropriate management.

Clinical and Angioarchitectural Features of Ruptured Dural Arteriovenous Fistulas.

BACKGROUND: Hemorrhage is a feared complication of cranial dural arteriovenous fistulas (DAVFs). Traditional grading systems including the Cognard and Borden classifications assess for this risk. We sought to define the specific angioarchitecture of ruptured lesions. METHODS: A total of 41 cases between 2004 and 2019 with ruptured cranial DAVFs were retrospectively analyzed. Information reviewed from records and imaging included hematoma location, fistula anatomy and architecture, classification, venous pouches, common collecting veins, downstream stenosis, treatment, and outcomes. RESULTS: Mean age at presentation was 60 years, and 61% of patients were male. Hemorrhage was most commonly intraparenchymal, and the majority of fistulae were transverse-sigmoid, tentorial, or convexity. We noted that 71% of lesions had a multi-feeder-common-hole configuration. Venous aneurysms (present in 64% of patients) were in direct communication with the hematoma in 88%; 72% of cases were treated by endovascular means; 64% of patients were treated within 7 days. Five patients re-bled between diagnosis and treatment. A total of 83% of patients were functionally independent at last follow-up. CONCLUSIONS: Hemorrhage from cranial DAVFs is mostly intraparenchymal. Venous aneurysms are common and very often responsible for the bleed. Embolization yields high cure rates and should be performed early because of risk of re-hemorrhage. However, in spite of hemorrhage, DAVFs have a relatively favorable clinical outcome.

Prostate-specific Antigen as a Risk Factor for Skeletal Metastasis in Native Ethnic African Men with Prostate Cancer: A Case-control Study.

Prostate cancer is the most common noncutaneous cancer in males. Men of African origin are at a significantly higher risk as reflected in the higher incidence and mortality rates in this racial group. Metastases incidence increases parallel to serum levels of prostate-specific antigen (PSA), contributing significantly to morbidity and mortality. Staging of the disease involves bone scans, which are sensitive in detecting skeletal metastases. Suggestions that these scans may be omitted in some situations in patients with low prostate specific antigen levels have drawn attention to the matter. In this case-control study, using radiology and pathology records, a registry of prostate cancer patients recorded as being of dark-skinned ethnicity was obtained. Images were presented to image reviewers blinded to the PSA level, to determine the presence of skeletal metastases. The risk factor for the outcome of interest (skeletal metastases) was PSA level above 20 ng/mL. The reliability of image reporting was also assessed. Of the 122 patients, skeletal metastases were present in 50 (41%) while these were absent in 72 (59%). The prevalence of metastases among the high PSA group was 55.9% [95% confidence interval (CI) 44.1-67.7%] and among the normal/low PSA group was 22.2% (95% CI 11.1-33.3%). The odds ratio (OR) for skeletal metastases in the exposed (high PSA) group was 4.4 (95% CI, 2.01-9.78.) Intraobserver agreement on image interpretation was 88.5% with a Kappa statistic of 0.76. A relatively higher prevalence of skeletal metastasis is seen in regional dark-skinned African males with prostate cancer at both low and high prostate specific antigen levels. Bone scanning in this population should therefore, be considered even at PSA levels below 20 ng/mL.