Traumatic cervical internal carotid artery pseudoaneurysm in a child refractory to initial endovascular treatment: case report and technical considerations.

PURPOSE: Optimal management of extracranial carotid artery dissections (eCAD) in pediatric patients is not well documented, and endovascular interventions are rarely reported. METHODS: A 10-year-old girl sustained multiple systemic injuries in a motor vehicle accident, including an eCAD with pseudoaneurysm. She initially failed both aspirin and endovascular stenting with progressive enlargement of a traumatic cervical carotid pseudoaneurysm and stenosis. RESULTS: Second-stage endovascular stent placement with coiling resulted in successful occlusion of the pseudoaneurysm. At 30-month imaging follow-up, the parent vessel remained patent with no evidence of the pseudoaneurysm. CONCLUSION: In the setting of poly-trauma, management of eCAD can be complex especially in the pediatric population. There is little data on the endovascular treatment of eCAD in children. Failed endovascular therapies are extremely rare. Our report supports surveillance imaging as repeat endovascular treatment may be necessary.

Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society and Society of Critical Care Medicine.

BACKGROUND: The use of antithrombotic agents, including anticoagulants, antiplatelet agents, and thrombolytics has increased over the last decade and is expected to continue to rise. Although antithrombotic-associated intracranial hemorrhage can be devastating, rapid reversal of coagulopathy may help limit hematoma expansion and improve outcomes. METHODS: The Neurocritical Care Society, in conjunction with the Society of Critical Care Medicine, organized an international, multi-institutional committee with expertise in neurocritical care, neurology, neurosurgery, stroke, hematology, hemato-pathology, emergency medicine, pharmacy, nursing, and guideline development to evaluate the literature and develop an evidence-based practice guideline. Formalized literature searches were conducted, and studies meeting the criteria established by the committee were evaluated. RESULTS: Utilizing the GRADE methodology, the committee developed recommendations for reversal of vitamin K antagonists, direct factor Xa antagonists, direct thrombin inhibitors, unfractionated heparin, low-molecular weight heparin, heparinoids, pentasaccharides, thrombolytics, and antiplatelet agents in the setting of intracranial hemorrhage. CONCLUSIONS: This guideline provides timely, evidence-based reversal strategies to assist practitioners in the care of patients with antithrombotic-associated intracranial hemorrhage.

Modern endovascular treatments of occlusive pediatric acute ischemic strokes: case series and review of the literature.

PURPOSE: Literature on the endovascular treatment of occlusive acute ischemic stroke (AIS) in the pediatric population remains nebulous. Clinical trials evaluating the role of systemic and intra-arterial thrombolysis, and mechanical thrombectomy have been strictly isolated to the adult population and largely unknown in their safety and efficacy in the pediatric group. METHODS: The authors present a review of the literature and their own two cases of occlusive acute ischemic stroke in children younger than the age of 10 years who were treated with modern endovascular devices, specifically with stent retrievers, and discuss their clinical and technical considerations as well as their limitations. RESULTS: In both pediatric patients, a combination of stent retriever and Penumbra aspiration were used to achieve Thrombolysis In Cerebral Infarction (TICI) 2a or greater with reduction of overall stroke burden. A reduction of National Institutes of Health Stroke Scale (NIHSS) of 8 or greater was achieved at discharge. At 3-month follow-up, the patients had a NIHSS of 6 and 2, respectively. One patient continued to improve from NIHSS of 6 to 3 at 6 months. CONCLUSION: In carefully, selected pediatric patients, modern endovascular techniques may be used to treat occlusive pediatric AIS. However, larger clinical trials are needed to evaluate the overall safety and effectiveness.

Thrombectomy and stenting of pseudoaneurysm from transcarotid artery revascularization.

Background: Transcarotid artery revascularization (TCAR) is becoming an increasingly popular treatment of carotid stenosis. Despite this rapid adoption, little in the literature describes the associated complications of this procedure. Case Description: We report a case of a left M1 large-vessel occlusion following treatment of symptomatic, high-grade carotid stenosis with a TCAR procedure approximately three weeks earlier. The initial angiography demonstrated a pseudoaneurysm in the left common carotid artery at the site of TCAR access with a distal clot in the carotid stent. The clot within the stent was aspirated, and a mechanical thrombectomy was performed with a combination of a stent-retriever and aspiration catheter for thrombolysis in cerebral infarction 2B revascularization. Conclusion: The TCAR procedure offers a novel method for revascularization of carotid lesions; it does include its complications. While generally safe, access site complications such as pseudoaneurysms can always occur. Knowledge of this risk allows for appropriate surveillance and management should it occur.

Response of brain oxygen to therapy correlates with long-term outcome after subarachnoid hemorrhage.

BACKGROUND: Brain oxygen (PbtO2) monitoring can help guide care of poor-grade aneurysmal subarachnoid hemorrhage (aSAH) patients. The relationship between PbtO2-directed therapy and long-term outcome is unclear. We hypothesized that responsiveness to PbtO2-directed interventions is associated with outcome. METHODS: Seventy-six aSAH patients who underwent PbtO2 monitoring were included. Long-term outcome [Glasgow Outcome Score-Extended (GOS-E) and modified Rankin Scale (mRS)] was ascertained using the social security death database and structured telephone interviews. Univariate and multivariate regression were used to identify variables that correlated with outcome. RESULTS: Data from 64 patients were analyzed (12 were lost to follow-up). There were 530 episodes of compromised PbtO2 (<20 mmHg) during a total of 7,174 h of monitor time treated with 1,052 interventions. Forty-two patients (66 %) survived to discharge. Median follow-up was 8.5 months (range 0.1-87). At most recent follow-up 35 (55 %) patients were alive, and 28 (44 %) had a favorable outcome (mRS ≤3). In multivariate ordinal regression analysis, only age and response to PbtO2-directed intervention correlated significantly with outcome. Increased age was associated with worse outcome (coeff. 0.8, 95 % CI 0.3-1.3, p = 0.003), and response to PbtO2-directed intervention was associated with improved outcome (coeff. -2.12, 95 % CI -4.0 to -0.26, p = 0.03). Patients with favorable outcomes had a 70 % mean rate of response to PbtO2-directed interventions whereas patients with poor outcomes had a 45 % response rate (p = 0.005). CONCLUSIONS: Response to PbtO2-directed intervention is associated with improved long-term functional outcome in aSAH patients.

Novel endovascular treatment of enlarging facial artery pseudoaneurysm resulting from molar extraction: a case report.

PURPOSE: A novel endovascular therapy to treat a pseudoaneurysm as a complication of molar tooth extraction is described. PATIENTS AND METHODS: A 20-year-old man presented 2 weeks after third molar tooth extraction with an enlarging pulsatile jaw mass, identified as a facial artery pseudoaneurysm. Endovascular embolization with microcoils and a liquid embolic agent, Onyx, was performed. The use of Onyx in this manner is an off-label use. RESULTS: Immediately after treatment, the pulsatile mass resolved and remained obliterated at 2 months of follow-up. CONCLUSIONS: Onyx embolization of facial artery vascular lesions can be safely accomplished while avoiding microvascular complications and provides a satisfactory and durable result.

Reduced brain tissue oxygen in traumatic brain injury: are most commonly used interventions successful?

BACKGROUND: Brain tissue oxygenation (PbtO2)-guided management facilitates treatment of reduced PbtO2 episodes potentially conferring survival and outcome advantages in severe traumatic brain injury (TBI). To date, the nature and effectiveness of commonly used interventions in correcting compromised PbtO2 in TBI remains unclear. We sought to identify the most common interventions used in episodes of compromised PbtO2 and to analyze which were effective. METHODS: A retrospective 7-year review of consecutive severe TBI patients with a PbtO2 monitor was conducted in a Level I trauma center's intensive care unit or neurosurgical registry. Episodes of compromised PbtO2 (defined as <20 mm Hg for 0.25-4 hours) were identified, and clinical interventions conducted during these episodes were analyzed. Response to treatment was gauged on how rapidly (ΔT) PbtO2 normalized (>20 mm Hg) and how great the PbtO2 increase was (ΔPbtO2). Intracranial pressure (ΔICP) and cerebral perfusion pressure (ΔCPP) also were examined for these episodes. RESULTS: Six hundred twenty-five episodes of reduced PbtO2 were identified in 92 patients. Patient characteristics were: age 41.2 years, 77.2% men, and Injury Severity Score and head or neck Abbreviated Injury Scale score of 34.0 ± 9.2 and 4.9 ± 0.4, respectively. Five interventions: narcotics or sedation, pressors, repositioning, FIO2/PEEP increases, and combined sedation or narcotics + pressors were the most commonly used strategies. Increasing the number of interventions resulted in worsening the time to PbtO2 correction. Triple combinations resulted in the lowest ΔICP and dual combinations in the highest ΔCPP (p < 0.05). CONCLUSION: Clinicians use a limited number of interventions when correcting compromised PbtO2. Using strategies employing many interventions administered closely together may be less effective in correcting PbO2, ICP, and CPP deficits. Some PbtO2 deficits may be self-limited.

Medical management of compromised brain oxygen in patients with severe traumatic brain injury.

BACKGROUND: Brain tissue oxygen (PbtO(2)) monitoring is used in severe traumatic brain injury (TBI) patients. How brain reduced PbtO(2) should be treated and its response to treatment is not clearly defined. We examined which medical therapies restore normal PbtO(2) in TBI patients. METHODS: Forty-nine (mean age 40 ± 19 years) patients with severe TBI (Glasgow Coma Scale [GCS] ≤ 8) admitted to a University-affiliated, Level I trauma center who had at least one episode of compromised brain oxygen (PbtO(2) <25 mmHg for >10 min), were retrospectively identified from a prospective observational cohort study. Intracranial pressure (ICP), cerebral perfusion pressure (CPP), and PbtO(2) were monitored continuously. Episodes of compromised PbtO(2) and brain hypoxia (PbtO(2) <15 mmHg for >10 min) and the medical interventions that improved PbtO(2) were identified. RESULTS: Five hundred and sixty-four episodes of compromised PbtO2 were identified from 260 days of PbtO2 monitoring. Medical management used in a "cause-directed" manner successfully reversed 72% of the episodes of compromised PbtO(2), defined as restoration of a "normal" PbtO(2) (i.e. ≥ 25 mmHg). Ventilator manipulation, CPP augmentation, and sedation were the most frequent interventions. Increasing FiO(2) restored PbtO(2) 80% of the time. CPP augmentation and sedation were effective in 73 and 66% of episodes of compromised brain oxygen, respectively. ICP reduction using mannitol was effective in 73% of treated episodes, though was used only when PbtO(2) was compromised in the setting of elevated ICP. Successful medical treatment of brain hypoxia was associated with decreased mortality. Survivors (n = 38) had a 71% rate of response to treatment and non-survivors (n = 11) had a 44% rate of response (P = 0.01). CONCLUSION: Reduced PbtO(2) may occur in TBI patients despite efforts to maintain CPP. Medical interventions other than those to treat ICP and CPP can improve PbtO(2). This may increase the number of therapies for severe TBI in the ICU.

Unenhanced dynamic MR angiography: high spatial and temporal resolution by using true FISP-based spin tagging with alternating radiofrequency.

PURPOSE: To present an unenhanced four-dimensional time-resolved dynamic magnetic resonance (MR) angiography technique with true fast imaging with steady-state precession-based spin tagging with alternating radiofrequency (STAR), also called TrueSTAR. MATERIALS AND METHODS: This study received Institutional Review Board approval and was HIPAA compliant. Informed consent was obtained from all study subjects. In eight healthy volunteers, the spatial and temporal resolution of the TrueSTAR technique were optimized. In another six healthy volunteers, the contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) of the TrueSTAR dynamic MR angiography images were compared with those acquired by using a standard Look-Locker echo-planar technique by using the Wilcoxon signed rank test. Finally, one patient with an arteriovenous malformation (AVM) was studied by using this technique. RESULTS: The SNR and CNR of the TrueSTAR dynamic MR angiography images were 29% and 39% higher, respectively, compared with those acquired by using a standard Look-Locker echo-planar imaging sequence (both P = .028). In the AVM patient, TrueSTAR dynamic MR angiography delineated the dynamic course of labeled blood flowing through feeding arteries into the nidus and draining veins. CONCLUSION: The results suggest that TrueSTAR is a promising unenhanced dynamic MR angiography technique for clinical evaluation of cerebrovascular disorders such as AVM, steno-occlusive disease, and aneurysm.

Diagnosis and treatment of vein of Galen aneurysmal malformations.

INTRODUCTION: Vein of Galen aneurysmal malformations (VGAM) are rare but clinically significant intracranial arteriovenous shunt lesions that most often present in neonates and infants. METHODS: Retrospective clinical data were collected for patients evaluated with a diagnosis of VGAM from 1994 to 2007. RESULTS: Thirteen patients with VGAM were evaluated from 1994 to 2007. Seven patients presented emergently with medically intractable cardiac failure, and six were treated in the first 2 weeks of life. Five children treated after this period (1.5-31 months of age) manifested enlarging head circumference, abnormal development, or subarachnoid hemorrhage. Eleven patients were managed endovascularly. Four disease or procedure-related complications occurred. Two complications were associated with poor outcome, both of which occurred in patients treated at less than 2 weeks of age. Two other patients experienced transient neurological deficits with no evidence of permanent sequelae. Outcome in the six patients treated emergently in the first 2 weeks of life included two patients who developed normally, one with mild to moderate neurological deficits, one with severe neurological deficits, and two deaths. Outcome in the five older patients (treated between 1.5 and 31 months) was considerably better than in the group treated early and included three with normal outcome and two with mild neurological deficits. CONCLUSIONS: Contemporary endovascular techniques remain the preferred treatment for VGAM in all age groups. Early diagnosis and multimodality treatment are essential for the best management and treatment of the complex constellation of clinical problems often arising from this disorder.

Operative intracranial infection following craniotomy.

OBJECT: Postoperative infection after cranial surgery is a serious complication that requires immediate recognition and treatment. In certain cases such as postoperative meningitis, the patient can be treated with antibiotics only. In cases that involve a bone flap infection, subdural empyema, or cerebral abscess, however, reoperation is often needed. There has been significant disagreement regarding the incidence of postoperative central nervous system (CNS) infections following cranial surgery. In this paper the authors' goal was to perform a retrospective review of the incidence of CNS infection after cranial surgery at their institution. They focused their review on those patients who required repeated surgery to treat the infection. METHODS: The authors reviewed the medical records and imaging studies in all patients who underwent a craniotomy or stereotactic drainage for CNS infection over the past 10 years. Subgroup analysis was then performed in patients whose infection was a result of a previous cranial operation to determine the incidence, factors associated with infection, and the type of infectious organism. Patients treated nonoperatively (that is, those who received intravenous antibiotics for postoperative meningitis or cellulitis) were not included. Patients treated for wound infection without intracranial pus were also not included. RESULTS: During the study period from January 1997 through December 2007, approximately 16,540 cranial surgeries were performed by 25 neurosurgeons. These included elective as well as emergency and trauma cases. Of these cases 82 (0.5%) were performed to treat postoperative infection in 50 patients. All 50 patients underwent their original surgery at the authors' institution. The median age was 51 years (range 2-74 years). There were 26 male and 24 female patients. The most common offending organism was methicillin-sensitive Staphylococcus aureus, which was found in 10 of 50 patients. Gram-negative rods were found in 15 patients. Multiple organisms were identified in specimens obtained in 5 patients. Six patients had negative cultures. Most craniotomies leading to subsequent infection were performed for tumors or other mass lesions (23 of 50 patients), followed by craniotomies for hemorrhage and vascular lesions. Almost half of the patients underwent > 1 cranial operation before presenting with infection. CONCLUSIONS: Postoperative infection after cranial surgery is an important phenomenon that needs immediate recognition. Even with strict adherence to sterile techniques and administration of antibiotic prophylaxis, a small percentage of these patients will develop an infection severe enough to require reoperation.

Brain abscess formation at the site of intracerebral hemorrhage secondary to central nervous system vasculitis.

Brain abscess is a rare but very dangerous neurosurgical lesion. Prompt diagnosis and emergency surgical evacuation are the hallmarks of therapy. Brain abscess following ischemic and hemorrhagic stroke is a rare entity. These cases are often preceded by episodes of bacteremia, sepsis, and local infection. The authors report the case of a 30-year-old woman who presented with a cerebral abscess at the site of a recent intraparenchymal hemorrhage.

Symptomatic high-flow arteriovenous fistula after a C-2 fracture. Case report.

Spinal arteriovenous fistulas (AVFs) are relatively uncommon lesions that are often diagnosed in a delayed fashion. The authors present a cause of a symptomatic high-flow AVF that developed in a patient after traumatic injury to the upper cervical spine. The patient presented to the trauma bay after a motor vehicle collision, and was found to have a C-2 fracture involving the transverse foramen. Although the patient was neurologically intact on presentation, 6 hours after admission weakness developed on his left side. Imaging studies demonstrated complete transection of the distal cervical aspect of the right vertebral artery (VA) at the base of C-2, with antegrade and retrograde flow into a direct AVF, resulting in early filling of the right internal jugular vein and other external draining veins. The patient was treated endovascularly with coil occlusion of the VA both proximal and distal to the transection. The patient's weakness improved over the next 7 days. At the 12-week follow-up examination, the patient's fractures had healed and he was neurologically intact.

Successful microsurgical extraction of a migrated coil in a pediatric patient after failed endovascular closure of a Blalock-Taussig shunt. Case report.

Coil migration is a rare but potentially serious complication of endovascular procedures. Occasionally coils can be retrieved via endovascular techniques. The authors describe the microsurgical management of a case in which endovascular techniques failed. A 2-year-old girl with pulmonary atresia and a Blalock-Taussig shunt underwent attempted endovascular closure of the shunt with Gianturco steel coils. During deployment, a coil was lost in the aorta and an angiogram showed that it had lodged in the proximal M1 segment of the middle cerebral artery. The coil could not be retrieved by endovascular techniques, and the patient was taken to the operating room to undergo a craniotomy. After the sylvian fissure was split, the coil was visible through the vessel wall. Temporary clips were placed on the proximal M1 and the proximal M2 segments, trapping the coil. A small arteriotomy was performed, the coil was removed, and the arteriotomy was closed. A cerebral angiogram showed excellent perfusion with no dissections. The patient's motor examination demonstrated a mild hemiparesis on the left with no tremulousness. Coil migration can be treated by microsurgical techniques in pediatric patients with a good clinical outcome.

Brain tissue oxygen tension in clinical brain death: a case series.

OBJECTIVES: Brain death is a clinical diagnosis often confirmed with supplementary tests. In this study, we examined the relationship between brain death and the partial pressure of brain tissue oxygen (PbtO(2)). We hypothesized that a sustained PbtO(2) of 0 is associated with brain death. METHODS: One hundred and twenty-six patients (Glasgow coma scale < or = 8, median age: 50 years) who underwent PbtO(2) monitoring were studied prospectively during a 2 year period in the neurointensive care unit at a university-based level I trauma center. PbtO(2), intracranial pressure (ICP), mean arterial pressure (MAP), cerebral perfusion pressure (CPP) and brain temperature (BT) were compared before and after the diagnosis of brain death. RESULTS: Six patients (median age: 52 years) experienced brain death. In these patients, PbtO(2) decreased toward 0 mmHg as ICP increased and CPP decreased. PbtO(2) reached 0 only when there was clinical evidence for brain death. During the subsequent 12 hours until the second brain death examination, PbtO(2) remained 0 mmHg and did not respond to oxygen challenge. In addition, TCD examination demonstrated a 'to and fro' pattern consistent with brain death and cerebral circulatory arrest. PbtO(2) of 0 mmHg was observed in five non-brain dead patients. These episodes were transient (>30 minutes) and responded to an oxygen challenge, directed treatment or catheter replacement. DISCUSSION: A sustained (>30 minutes) brain PbtO(2) of 0 is consistent with brain death. We suggest that a sustained 'zero' PbtO(2) may be used to determine when a brain death examination is appropriate in the pharmacologically suppressed patient.

De novo aneurysm formation and regression after brain arteriovenous malformation embolization: case report.

BACKGROUND: The formation of de novo aneurysms is a known complication of vessel occlusion (Wright RL, Sweet WH. Carotid or vertebral occlusion in the treatment of intracranial aneurysms: value of early and late readings of carotid and retinal pressures. Clin Neurosurg 1962:9;163-192). Aneurysms most commonly develop on newly formed primary collateral routes as a result of increased flow through these collaterals. Development of aneurysms is not commonly seen in vessels whose flow has been directly decreased by therapeutic or natural occlusion. CASE DESCRIPTION: A 53-year-old woman with an intracerebral hemorrhage underwent cerebral angiography which demonstrated a right parietal AVM. An enlarged right ACA gave rise to 3 direct feeding pedicles. Leptomeningeal collaterals from the right MCA as well as the right PCA also gave collateral supply to the AVM. The lesion had superficial drainage into the superior sagittal sinus and deep venous drainage into the right posterior pericallosal vein. No feeding artery aneurysms or intranidal aneurysms were present. Treatment plan included preoperative embolization followed by surgical resection. CONCLUSION: To our knowledge, this is the first reported case of a de novo aneurysm forming and regressing in an artery hemodynamically related to an embolized AVM. The short timescale of its development (6 weeks) is also noteworthy. The spontaneous regression suggests that at least some aneurysms forming in vessels after abrupt decrease in distal runoff may have a self-limited course. Such lesions may do best if not subjected to direct endovascular or surgical treatment.

Acute paraparesis from hemorrhagic spinal ependymoma: diagnostic dilemma and surgical management. Report of two cases and review of the literature.

Spinal ependymomas are a common type of primary spinal cord neoplasm that frequently occurs in the lumbar spine. The authors report on two patients who presented with acute neurological decline after hemorrhage into ependymomas of the filum terminale. Both were transferred to the authors' institution because of diagnostic uncertainty and a concern about possible intradural vascular abnormalities. Both patients underwent lumbar laminectomies for tumor resection. The pathological finding in each case was myxopapillary ependymoma. Both patients made a significant recovery and were ambulatory and continent at follow-up review. These cases illustrate the rare but clinically significant incidence of acute neurological decline caused by hemorrhagic cauda equina ependymomas, including the potential for delayed diagnosis and treatment.

Pipeline embolization device as primary treatment for cervical internal carotid artery pseudoaneurysms.

BACKGROUND: Limited data exists on the durability and occlusion rate of treating extracranial cervical internal carotid artery pseudoaneurysms using the pipeline embolization device (PED) flow-diverting stent. METHODS: Three patients presenting with dissecting cervical internal carotid artery pseudoaneurysms were treated with the PED as the sole treatment modality. RESULTS: In all three patients, successful aneurysmal occlusion and parent vessel reconstruction occurred on immediate angiography and continued on 6-month follow-up. No immediate or delayed complications were seen, and all patients remained neurologically intact. CONCLUSION: Complete aneurysmal occlusion and long-term angiographic occlusion can occur after PED treatment of cervical carotid pseudoaneurysms. In select patients, the PED can be a suitable primary treatment modality with good neurological outcome for cervical carotid pseudoaneurysms.