Regional Mechanical Thrombectomy Imaging Protocol in Patients Presenting with Acute Ischemic Stroke during the COVID-19 Pandemic.

BACKGROUND AND PURPOSE: Chest CT is a rapid, useful additional screening tool for coronavirus disease 2019 (COVID-19) in emergent procedures. We describe the feasibility and interim outcome of implementing a modified imaging algorithm for COVID-19 risk stratification across a regional network of primary stroke centers in the work-up of acute ischemic stroke referrals for time-critical mechanical thrombectomy. MATERIALS AND METHODS: We undertook a retrospective review of 49 patients referred to the regional neuroscience unit for consideration of mechanical thrombectomy between April 14, 2020, and May 21, 2020. During this time, all referring units followed a standard imaging protocol that included a chest CT in addition to a head CT and CT angiogram to identify Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infective pulmonary changes. RESULTS: Overall, 2 patients had typical COVID-19 radiologic features and tested positive, while 7 patients had indeterminate imaging findings and tested negative. The others had normal or atypical changes and were not diagnosed with or suspected of having COVID-19. There was an overall sensitivity of 100%, specificity of 74.1%, negative predictive value of 100%, and positive predictive value of 22.2% when using chest CT to diagnose COVID-19 in comparison with the real-time reverse transcriptase-polymerase chain reaction test. The mean additional time and radiation dose incurred for the chest CT were 184 ± 65.5 seconds and 2.47 ± 1.03 mSv. Multiple cardiovascular and pulmonary incidental findings of clinical relevance were identified in our patient population. CONCLUSIONS: Chest CT provides a pragmatic, rapid additional tool for COVID-19 risk stratification among patients referred for mechanical thrombectomy. Its inclusion in a standardized regional stroke imaging protocol has enabled efficient use of hospital resources with minimal compromise or delay to the overall patient treatment schedule.

Mechanical thrombectomy for acute ischaemic stroke during the COVID-19 pandemic: changes to UK practice and lessons learned.

AIM: To describe evolving practices in the provision of mechanical thrombectomy (MT) services across the UK during the COVID-19 pandemic, the responses of and impact on MT teams, and the effects on training. MATERIALS AND METHODS: The UK Neurointerventional Group (UKNG) and the British Society of Neuroradiologists (BSNR) sent out a national survey on 1 May 2020 to all 28 UK neuroscience centres that have the potential capability to perform MT. RESULTS: Responses were received from 27/28 MT-capable centres (96%). Three of the 27 centres do not currently provide MT services. There was a 27.7% reduction in MTs performed during April 2020 compared with the first 3 months of the year. All MT patients in 20/24 centres that responded were considered as COVID-19 suspicious/positive unless or until proven otherwise. Twenty-two of the 24 centres reported delays to the patient pathway. Seventeen of the 24 centres reported that the COVID-19 pandemic had reduced training opportunities for specialist registrars (SpR). Fourteen of the 24 centres reported that the pandemic had hampered their development plans for their local or regional MT service. CONCLUSION: The present survey has highlighted a trend of decreasing cases and delays in the patient pathway during the early stages of the COVID-19 pandemic across UK centres.

Is there a causal relationship between the hypoxia-ischaemia associated with cardiorespiratory arrest and subdural haematomas? An observational study.

The aim of this study was to determine the frequency of subdural haematomas (SDHs) occurring in infants presenting following atraumatic cardiorespiratory collapse. This study was a review of retrospective case notes, brain imaging and post-mortem examinations carried out in the paediatric intensive care unit (PICU) and emergency department (ED) in a tertiary paediatric centre in the UK. The study included infants and children less than 4 years old dying in the ED or admitted to the PICU after atraumatic cardiorespiratory arrest. We identified macroscopic SDHs on brain imaging or post-mortem examination. Of those children who experienced a cardiorespiratory arrest from a non-traumatic cause and met inclusion criteria, 33 presented and died in the ED and 17 were admitted to the PICU. These children had a post-mortem examination, brain imaging or both. None of these infants had a significant SDH. One child had a small clot adherent to the dura found on post-mortem and two had microscopic intradural haemorrhage, but it is unclear in each case whether this was artefact, as each had otherwise normal brains. Subdural haematoma arising in infants or young children in the context of catastrophic cardiorespiratory compromise from a non-traumatic cause was not observed.

Isolated cerebral cortical tears in children: aetiology, characterisation and differentiation from non-accidental head injury.

A wide spectrum of intracranial injuries has been described as complicating difficult birth, particularly following instrumental delivery. We describe five children in whom isolated cortical tears were observed on MRI. Four cases were characterised by a difficult instrumental delivery. None of the children developed long-term neurological sequelae. As far as we are aware, isolated cerebral cortical tears have not been reported previously although recognition of this injury pattern is important because of its possible misinterpretation as a marker of a non-accidental head injury. Other differential diagnoses that should be considered include cerebral infarcts, schizencephaly and accidental head injury. The importance of high-quality cross-sectional brain imaging in newborn infants with seizures is emphasised.

Spinal subdural haematomas in children with non-accidental head injury.

OBJECTIVE: To examine the incidence of spinal pathology in infants with non-accidental head injury. METHODS: 18 infants with non-accidental head injury were investigated between 2000 and 2007 with dedicated MRI of the brain and spine. During the earlier years, the spine was imaged only when there were suspicious features on other imaging to suggest a spinal injury (seven cases). After 2005, all suspected cases of non-accidental head injury were routinely investigated with MRI of the whole spine in addition to the brain. The spinal imaging at initial investigation and at follow-up was reviewed. RESULTS: There was a high incidence (8/18 cases, 44%) of subdural collections in the spine. They were all clinically occult and in six cases large. All eight cases were associated with subdural haematomas in the supratentorial and infratentorial compartment. The signal characteristics were analysed and compared with those of the intracranial collections. One had a small epidural haematoma. Other depicted abnormalities and appearances at follow-up were also reviewed. CONCLUSION: There is a high incidence of previously unsuspected spinal subdural haematomas associated with intracranial collections in children with non-accidental head injury. Further work is required to evaluate the clinical implications.

Profuse epistaxis following sphenoid surgery: a ruptured carotid artery pseudoaneurysm and its management.

OBJECTIVE: We report a rare case of iatrogenic pseudoaneurysm of the internal carotid artery secondary to endoscopic sphenoid surgery. METHOD: The management of this unusual complication and a review of the literature are presented. RESULTS: A 65-year-old woman presented with intractable epistaxis four days following endoscopic sphenoid sinus surgery. Initial, conservative measures were unsuccessful in controlling bleeding. The clinical picture of delayed, severe epistaxis after a sphenoid sinus exploration raised the possibility of injury to the internal carotid artery and subsequent formation of a false aneurysm. The patient's pseudoaneurysm was managed, without visualising it, by packing the sphenoid sinus (achieved by palpating 1 cm above the shoulder of the posterior choana) in order to gain control of the haemorrhage, followed by endovascular occlusion. CONCLUSION: An awareness of this rare complication is essential in order to manage this life-threatening condition efficiently.

Retreatment of previously embolized cerebral aneurysms: the risk of further coil embolization does not negate the advantage of the initial embolization.

BACKGROUND AND PURPOSE: A significant minority of aneurysms treated by endovascular means undergo additional subsequent therapy to treat aneurysm recurrence. Our study was undertaken to determine the risk of additional coil embolization of aneurysms recurring following endovascular therapy. MATERIALS AND METHODS: Patients were identified during a 10-year period from prospectively collated data bases at 2 different neuroscience institutions. Patient outcome was obtained from the data bases or the patient's neurosurgical records. Occlusion grade was assessed at the time of treatment and at follow-up angiography as complete, near-complete, or incomplete. RESULTS: Of a total of 1834 aneurysms in 1631 patients, 100 aneurysms in 99 patients treated between January 1996 and December 2005 required additional coiling because of an enlarging remnant and subtotal occlusion. This comprised 6% of the patients treated and 8% of the total followed. Thromboembolic events complicated 3 retreatment procedures, but all 3 patients remain independent. Ninety-five patients were followed for 8-103 months (mean, 42.3 months) by conventional or MR angiography. CONCLUSION: Coil embolization of aneurysm recurrences has a low complication rate and leads to satisfactory occlusion in most cases. The risk from additional coil embolization does not negate the advantage of the initial embolization.

Corpus callosum changes following shunting for hydrocephalus: case report and review of the literature.

Diffuse callosal signal changes can rarely occur following successful shunting for obstructive hydrocephalus. We report on a patient who underwent ventriculoperitoneal shunting for aqueductal stenosis and required two revisions for neurological deterioration and presumed shunt malfunction. Extensive changes involving the corpus callosum, periventricular white matter and optic chiasm were noted after the first, and were prominent after second shunt revision. Thus, post-shunting callosal changes may be associated with more extensive white matter disease, and may not imply wide pressure fluctuations. However, they need not prompt further intervention.

The 'unified hypothesis' of Geddes et al. is not supported by the data.

Inflicted head injury to the developing brain frequently results in serious disability. The pathogenesis of the neuraxial and ocular findings in infants believed to have suffered inflicted head injury remains the subject of considerable debate. Recent neuropathology studies of fatal cases of inflicted head injury and of a foetal/perinatal non-traumatic model have led to the proposal that there is a 'unified hypothesis', the essential feature of which is hypoxic brain swelling secondary to cervicomedullary injury. It has been suggested that less than violent forces may be involved and even that some cases may not be due to trauma at all. The purpose of this paper is to provide a critical review of the data upon which these suppositions are based on a background of what is already known. It is submitted that there are serious flaws in the methodology; the conclusions reached cannot logically be drawn from the data; and the 'unified hypothesis' is not supported by the evidence. On the basis of the data presented, it is also difficult to sustain the secondary hypothesis purporting to describe a minority cohort with 'infantile encephalopathy with subdural and retinal bleeding' of non-traumatic causation.

Neuroimaging for non-accidental head injury in childhood: a proposed protocol.

Non-accidental head injury (NAHI) is a major cause of neurological disability and death during infancy. Radiological imaging plays a crucial role in evaluating craniospinal injury, both for guiding medical management and the forensic aspects of abusive trauma. The damage sustained is varied, complex and may be accompanied by an evolving pattern of brain injury secondary to a cascade of metabolic and physiological derangements. Regrettably, many cases are poorly or incompletely evaluated leading to diagnostic errors and difficulties in executing subsequent child care or criminal proceedings. It is evident, from cases referred to the authors, that imaging protocols for NAHI are lacking (or only loosely adhered to, if present) in many centres throughout the U.K. Future research in this field will also be hampered if there is a lack of consistent and reliable radiological data. There is no nationally agreed protocol for imaging NAHI. We propose such a protocol, based upon a wide experience in the medical management of child abuse and extensive involvement in the medicolegal aspects of NAHI.

Neuroendoscopic third ventriculostomy in dysmorphic brains.

Neuroendoscopic third ventriculostomy (NTV) has superseded shunting as the treatment of choice in non-communicating hydrocephalus. Intracranial developmental anomalies have been considered to be relative contraindications for this procedure. We present one patient with a Dandy-Walker malformation and another with septo-optic dysplasia who presented with hydrocephalus. An NTV was performed successfully in both patients using a flexible neuroendoscope and utilising transendoscopic Doppler ultrasound to ensure a safe target area for ventriculostomy.

Delayed reconfiguration of a Guglielmi detachable coil mass associated with late occlusion of an adjacent aneurysm and parent vessel.

We present a case of asymptomatic, progressive, late occlusion of the left superior cerebellar artery (SCA) and an aneurysm arising from the junction of the SCA and basilar artery after embolization of an adjacent aneurysm arising between the left posterior cerebral artery and the left SCA. The delayed occlusion was associated with reconfiguration of the Guglielmi detachable coils at the neck of the treated aneurysm.

Amphetamine abuse and intracranial haemorrhage.

Amphetamines taken by any route can cause cerebral vasculitis and intracranial haemorrhage. 8 cases were seen in a neurosurgical unit over 3.5 years. The published work indicates that those who experience these complications, mainly young adults, have poor outcomes.