Microsurgical and endovascular treatment of un-ruptured cerebral aneurysms by European hybrid neurosurgeons to balance surgical skills and medical staff management.

BACKGROUND: In Europe, aneurysm treatment performed by dually trained neurosurgeons is extremely scarce. We provide outcome data for un-ruptured aneurysm patients treated at a European hybrid center to prove that hybrid neurosurgeons achieve clinical and angiographical results allowing to integrate hybrid neurosurgery into routine aneurysm treatment. This will not only help to maintain neurovascular microsurgical skills but will influence staff costs in related hospitals. METHODS: We retrospectively analyzed all consecutively treated un-ruptured aneurysm patients between 2000 and 2016. The decision-making took into account the pros and cons of both modalities and considered patient and aneurysm characteristics. Clinical outcome was assessed by the modified Rankin scale (mRS). Occlusion rates were stratified into grade I for 100%, grade II for 99-90%, and grade III for <90% occlusion. To account for the introduction of stents, two treatment periods (p1, 2000 to 2008; p2, 2009 to 2016) were defined. RESULTS: The study population consisted of 274 patients (median age 55 years) harboring 338 un-ruptured aneurysms. Microsurgery (MS) was performed in 51.8% and endovascular therapy (EVT) in 43.1%; 5.1% required combined treatment. Overall, 93% showed a favorable clinical outcome (mRS 0-2), 94.3% after MS and 91.5% after EVT. Grade I aneurysm occlusion was achieved in 82.6% patients, 91.9% after MS and 72.9% after EVT. Procedure-related complications occurred after MS in 5.6% and after EVT in 4.4% patients. Mortality was recorded for five (1.8%) patients, one patient after MS and four after EVT. For the EVT cohort, significant improvement from p1 to p2 was seen with clinical outcomes (P=0.030, RR = 0.905, CI: 0.8351-0.9802) and occlusion rates (P=0.039, RR = 0.6790, CI: 0.499-0.923). CONCLUSION: Hybrid neurosurgeons achieve qualified clinical and angiographic results. Dual training will allow to maintain neurovascular caseloads and preserve future aneurysm treatment within neurosurgery. Furthermore economic benefits could be observed in hospital management.

Neutrophil to lymphocyte ratio predicts intracranial hemorrhage after endovascular thrombectomy in acute ischemic stroke.

BACKGROUND: The development of intracranial hemorrhage (ICH) in acute ischemic stroke is associated with a higher neutrophil to lymphocyte ratio (NLR) in peripheral blood. Here, we studied whether the predictive value of NLR at admission also translates into the occurrence of hemorrhagic complications and poor functional outcome after endovascular treatment (EVT). METHODS: We performed a retrospective analysis of consecutive patients with anterior circulation ischemic stroke who underwent EVT at a tertiary care center from 2012 to 2016. Follow-up scans were examined for non-procedural ICH and scored according to the Heidelberg Bleeding Classification. Demographic, clinical, and laboratory data were correlated with the occurrence of non-procedural ICH. RESULTS: We identified 187 patients with a median age of 74 years (interquartile range [IQR] 60-81) and a median baseline National Institutes of Health Stroke scale (NIHSS) score of 18 (IQR 13-22). A bridging therapy with recombinant tissue-plasminogen activator (rt-PA) was performed in 133 (71%). Of the 31 patients with non-procedural ICH (16.6%), 13 (41.9%) were symptomatic. Patients with ICH more commonly had a worse outcome at 3 months (p = 0.049), and were characterized by a lower body mass index, more frequent presence of tandem occlusions, higher NLR, larger intracranial thrombus, and prolonged rt-PA and groin puncture times. In a multivariate analysis, higher admission NLR was independently associated with ICH (OR 1.09 per unit increase, 95% CI (1.00-1.20, p = 0.040). The optimal cutoff value of NLR that best distinguished the development of ICH was 3.89. CONCLUSIONS: NLR is an independent predictor for the development of ICH after EVT. Further studies are needed to investigate the role of the immune system in hemorrhagic complications following EVT, and confirm the value of NLR as a potential biomarker.

Intracranial Thrombus Morphology and Composition Undergoes Time-Dependent Changes in Acute Ischemic Stroke: A CT Densitometry Study.

The aim of our study was to assess whether cerebral artery clots undergo time-dependent morphological and compositional changes in acute ischemic stroke. We performed a retrospective chart review of patients admitted within 5 h from symptom onset to three European stroke centers and evaluated non-contrast-enhanced CT (NECT) for hyperdense artery signs (HAS) in 2565 scans. The occlusion site, density of HAS expressed in Hounsfield units (HU), area of HAS, and relative density (rHU) (HU clot/HU non-affected artery) were studied and related to time from symptom onset, clinical severity, stroke etiology, and laboratory parameters. A HAS was present in the middle cerebral artery (MCA) in 185 (7.2%) and further explored. The mean time from symptom onset to CT was 100 min (range 17-300). We found a time-dependent loss of density in the occluded M1 segment within the first 5 h (N = 118, 95% CI [-15, -2], p = 0.01). Further, the thrombus area in the M2 segment decreased with time (cubic trend N = 67, 95% CI [-63, -8], p = 0.02). Overall, and especially in the M2 segment, a lower clot area was associated with higher fibrinogen (-21.7%, 95% CI [-34.8, -5.8], p = 0.009). In conclusion, our results disclosed time-dependent changes of intracranial thrombi with regard to occlusion site, density and area.

Fracture of a Flow Diverter in the Cervical Internal Carotid Artery Due to Eagle Syndrome.

In Eagle syndrome, elongated styloid processes may provoke internal carotid dissection and pseudoaneurysm causing stroke and data regarding possible complications or long-term results of pseudoaneurysm treatment using a flow diverter are limited. We report a case of a dissection-related pseudoaneurysm in the left cervical carotid artery treated by implantation of a flow diverter. Follow-up imaging of the flow diverter showed fracture of a continuous radiopaque marker at 3 months and fracture of a second continuous radiopaque marker at 7 months, while contrasting of the vessel was preserved. At the time of angiographic control (8 months after implantation), the flow diverter and the extracranial left internal carotid artery were occluded, and the patient did not experience any symptoms throughout the period.

The role of MRI in spinal stab wounds compared with intraoperative findings.

INTRODUCTION: Spinal stab wound injuries are quite rare and only few patients have been reported on the basis of MRI scan. METHODS: A 25-year-old man was stabbed at C1/2 and had an incomplete Brown-Sequard syndrome. He underwent surgical exploration because of CSF leakage on the fourth day. RESULTS: After a follow-up period of 32 months, he was left with a remaining loss of the proprioception of the right foot. We show detailed CT and MR images with the focus on the lesions of the dura and myelon and compared them with intraoperative images. In addition, we contrast our findings with a review of literature published over the last three decades. CONCLUSION: MRI gives the most detailed view of soft tissue lesions in SSWs and is in accordance with our intraoperative findings.

Contribution of Serum Lipid Profiles to Outcome After Endovascular Thrombectomy for Anterior Circulation Ischemic Stroke.

The contribution of lipids, including low- and high-density lipoprotein cholesterol (LDL-C and HDL-C, respectively) and triglycerides (TG), to stroke outcomes is still debated. We sought to determine the impact of LDL-C concentrations on the outcome of patients with ischemic stroke in the anterior circulation who received treatment with endovascular thrombectomy (EVT). We performed a retrospective analysis of consecutive patients with acute ischemic stroke treated at a tertiary center between 2012 and 2016. Patients treated with EVT for large artery occlusion in the anterior circulation were selected. The primary endpoint was functional outcome at 3 months as measured with the modified Rankin Scale (mRS). Secondary outcome measures included hospital death and final infarct volume (FIV). Blood lipid levels were determined in a fasting state, 1 day after admission. We studied a total of 174 patients (44.8% men) with a median age of 74 years (interquartile range [IQR] 61-82) and median National Institutes of Health Stroke Scale at admission of 18 (14-22). Bridging therapy with intravenous tissue-plasminogen activator (t-PA) was administered in 122 (70.5%). The median LDL-C was 90 mg/dl (72-115). LDL-C demonstrated a U-type relationship with FIV (p = 0.036). Eighty-three (50.0%) patients had an mRS of 0-2 at 3 months. This favorable outcome was independently associated with younger age (OR 0.944, 95% CI 0.90-0.99, p = 0.012), thrombolysis in cerebral infarction 2b-3 reperfusion (OR 5.12, 95% CI 1.01-25.80, p = 0.015), smaller FIV (0.97 per cm3, 95% CI 0.97-0.99, p < 0.001), good leptomeningeal collaterals (OR 5.29, 95% CI 1.48-18.9, p = 0.011), and LDL-C more than 77 mg/dl (OR 0.179, 95% CI 0.04-0.74, p = 0.018). A higher LDL-C concentration early in the course of a stroke caused by large artery occlusion in the anterior circulation is independently associated with a favorable clinical outcome at 3 months. Further studies into the pathophysiological mechanisms underlying this observation are warranted.

Intravenous thrombolysis in acute ischemic stroke after dabigatran reversal with idarucizumab - a case report.

Much excitement has been generated with the approval of idarucizumab, a humanized monoclonal antigen-binding antibody fragment that is capable of reversing the anticoagulant activity of dabigatran. Here, we describe our initial experience of using tissue plasminogen activator (tPA) in an acute posterior circulation ischemic stroke after dabigatran reversal with idarucizumab. Both treatments were well tolerated and no hemorrhagic or procoagulatory complications were observed. We propose that the option of dabigatran reversal needs to be considered for contemporary treatment concepts of acute ischemic stroke.