Early and Intermediate-Term Outcome of Balloon Aortic Valvuloplasty in Children With Aortic Stenosis and Left Ventricular Dysfunction at Tertiary Care Hospital.

Background Left ventricular (LV) dysfunction in patients with aortic valve stenosis (AVS) is seen in two scenarios: in neonates and in elderly patients. Neonatal AVS may present as a congestive cardiac failure (CCF), while older children rarely present with CCF if they have not been diagnosed early. Only a few reports of LV dysfunction with AVS have been described in the literature. However, there is a paucity of data regarding the safety and effectiveness of balloon aortic valvuloplasty (BAV) in children with AVS with LV dysfunction. Therefore, the aim of this study was to evaluate outcomes to establish the safety and effectiveness of BAV in children with AVS and LV dysfunction in improving LV function and survival. Methods A total of 160 BAVs were performed from 2004 to 2017; of these, 41 (25.6%) patients had LV dysfunction. We reviewed these cases, and data were obtained on clinical features, echocardiographic parameters including LV ejection fraction (LVEF) and LV dimensions, LV posterior wall, interventricular septal thickness, pressure gradient across the valve, aortic valve morphology and annulus and aortic insufficiency (AI), and angiographic parameters such as aortic and LV pressures, AI and annulus size, and balloon size. Echocardiography was done before the procedure, one day after intervention, at three months, at six months, and on regular follow-up. Mortality during and after the procedure and at follow-up was reported. Results Children who had undergone BAV for AVS and LV dysfunction within the age range of six to 192 months showed a significant reduction in peak-to-peak pressure gradient (PPG) from 73.5 ± 30 mmHg to 26.7 ± 6.7 mmHg and improvement in LVEF from 32.8 ± 11% to 54.3 ± 12.7% after 24 hours. Instantaneous gradient on echocardiography after three months showed PPG was 29.8 ± 7.7 mmHg and mean LVEF was 63 ± 8.6%. Mean LV end-diastolic pressure was 20.8 ± 4.7 mmHg and decreased to 13 ± 2.4 mmHg. Four patients died, all of whom had severe LV dysfunction - one died during the procedure and three died within six to 20 hours after successful BAV. On average follow-up of 6.4 ± 3.8 years, with a range of three months to 13 years, there was no mortality, pressure gradient increased to 40 ± 16.3 mmHg (range, 20 to 90 mmHg), and three had BAV after one, four, and six years, respectively. There was an increase in AI from mild to moderate in five patients, but they did not require any intervention. Four patients had aortic valve replacement (AVR) with two patients having an increase in pressure gradient and AI after eight and 13 years, respectively. One patient had AI (+3) after BAV had AVR after three years, and one patient who had a very thick and dysplastic aortic valve with LVEF of 20% and pulmonary hypertension (PH) had AVR after six months. Conclusion Patients with AVS who develop LV dysfunction deteriorate and die soon without treatment. Our data suggest that BAV in children with aortic stenosis and LV dysfunction is safe and effective in the normalization of LV function.

Concurrent Angioplasty Balloon Placement for Stent Delivery through Jugular Venous Bulb for Treating Cerebral Venous Sinus Stenosis. Technical Report.

OBJECTIVE: To report upon technique of concurrent placement of angioplasty balloon at the internal jugular vein and sigmoid venous sinus junction to facilitate stent delivery in two patients in whom stent delivery past the jugular bulb was not possible. CLINICAL PRESENTATION: A 21-year-old woman and a 41-year-old woman with worsening headaches, visual obscuration or diplopia were treated for pseudotumor cerebri associated with transverse venous stenosis. Both patients had undergone primary angioplasty, which resulted in improvement in clinical symptoms followed by the recurrence of symptoms with restenosis at the site of angioplasty. INTERVENTION: After multiple attempts at stent delivery through jugular venous bulb were unsuccessful, a second guide catheter was placed in the ipsilateral internal jugular vein through contralateral femoral venous approach. A 6 mm × 20 mm (left) or 5 × 15 mm (right) angioplasty balloon was placed across the internal jugular vein and sigmoid sinus junction and partially inflated until the inflation and relative straightening of the junction was observed. In both patients, the internal jugular vein and sigmoid sinus junction was successfully traversed by the stent delivery system in a parallel alignment to inflated balloon. Balloon mounted stent was deployed at the site of restenosis with near complete resolution of lumen narrowing delivery and improvement in clinical symptoms. CONCLUSION: We report a technique for realignment and diameter change with concurrent placement and partial inflation of angioplasty balloon at the jugular venous bulb to facilitate stent delivery into the sigmoid and transverse venous sinuses in circumstances where multiple attempts at stent delivery are unsuccessful.

Lumbar Catheter Placement Using Paramedian Approach Under Fluoroscopic Guidance.

BACKGROUND: Lumbar catheter placement under fluoroscopic guidance may reduce the rate of technical failures and associated complications seen with insertion guided by manually palpable landmarks. METHODS: We reviewed our experience with 43 attempted lumbar catheter placements using paramedian approach under fluoroscopic guidance and ascertained rates of technical success, and clinical events. RESULTS: Among the 43 patients, 18, 1, and 1 patients were on aspirin (with dipyrimadole in 2), clopidogrel, and combination of both, respectively. Lumbar catheter placement was successful in 42 of 43 attempted placements. Floroscopic guidance was critical in three patients; one patient had severe cerebrospinal fluid (CSF) depletion (empty thecal sac phenomenon) following pituitary surgery leading to no cerebrospinal fluid return despite correct placement confirmation under fluoroscopy. Two patients had spinal needle placement at the junction between epidural and cerebrospinal fluid spaces (junctional position) leading to cerebrospinal fluid return but inability to introduce the lumbar catheter. After confirmation of position by the injection of contrast or radiographic landmarks the needle was advanced by indenting the subcutaneous tissue or reinserting at a spinal level above the first insertion. The lumbar catheter remained in position over a mean period (±standard deviation) of 4.1(±2.3) days. Improvement in hydrocephalus was seen in two patients with intracranial mass lesions. One patient developed cerebrospinal fluid leakage through the insertion track following removal of catheter and required skin suturing at the site of insertion. CONCLUSIONS: We observed a high technical success rate with low rate of complications even in patients with intracranial mass lesions, those on ongoing antiplatelet medications or in whom insertion would not be possible guided by manually palpable landmarks.

Exercise Induced Transient Neurological Deficit in a Patient with Cerebellar Developmental Venous Anomaly.

BACKGROUND: The association of venous angiomas or developmental venous anomalies (DVA) with transient neurological deficit is rare. We present a rare case of a cerebellar developmental venous anomaly resulting in transient neurological deficits. CASE DESCRIPTION: A 58-year-old man with recurrent left sided facial dysesthesia, hemiparesis, and mild difficulty ambulating after exercise. A similar episode was experienced six months earlier under the same circumstances. Computed tomographic (CT) scan demonstrated an ill-defined hyperdensity in the right cerebellar hemisphere. Cerebral angiography demonstrated a venous angioma that dilated with valsalva maneuver. CONCLUSION: We report the first case of a cerebellar venous angioma causing exercise induced transient neurologically deficits. Limiting strenuous exercise may be needed to avoid symptom recurrence. Further research is warranted on the hemodynamic effects of intracranial DVA's.

Internal carotid artery stenosis associated with giant cell arteritis: case report and discussion.

BACKGROUND: Cerebrovascular ischemic events associated with giant cell arteritis (GCA) are uncommon and have been reported in 3%-4% of patients. We describe a case report of GCA associated with intracranial stenosis and review various angiographic findings. CASE PRESENTATION: A 66-year-old man presented with worsening headache and vision loss. A recent magnetic resonance angiogram of the head and neck showed multiple intracranial stenosis. Cerebrospinal fluid (CSF) analysis demonstrated increased protein of 135.6 mg/dL, with two white blood cells/µL. No bacteria were observed in the CSF on gram staining, and cultures were negative for bacterial growth. Erythrocyte sedimentation rate was noted to be 14 mm/h, and C-reactive protein was 1.514 mg/L at admission. Human immunodeficiency virus (HIV) and hepatitis panels were negative. On digital subtraction angiography, patient had predominantly narrowing and irregularities in petrous and cavernous segments of the internal carotid arteries bilaterally. The diagnosis of GCA was confirmed by temporal artery biopsy. He was treated with steroids, and a followup angiogram 6 weeks later showed minimal resolution of the angiographic findings. Patient reported complete resolution of headaches and visual loss. CONCLUSION: Bilateral internal carotid arteries stenosis may be seen in patients presenting with typical symptoms of GCA and may persist after steroid treatment despite resolution of clinical symptoms.

Liquid embolization of brain arteriovenous malformation using novel detachable tip micro catheter: a technical report.

BACKGROUND AND IMPORTANCE: Liquid embolization using Onyx® of brain arteriovenous malformations (AVMs) is sometimes limited by micro catheter retention by Onyx® cast during the disengagement process. Use of the new detachable tip micro catheter is presented in this report. CLINICAL PRESENTATION: Two feeding arteries of a previously ruptured brain AVM in a 62-year-old man were embolized by Onyx 18 prior to surgery using the new Apollo™ micro catheter with the detachable-tip (30 mm) was utilized. The arterial feeders were accessed without difficulty by micro catheter, guided by 0.010" microwire. Onyx reflux around the distal end of the micro catheter was necessary for effective embolization of arteriovenous fistulous components of brain AVM. The micro catheter was successfully retracted after embolization in both feeding arteries, with distal end detachment seen in one but not the other arterial embolization. No arterial thrombosis, vasospasm, dissection, or rupture was seen at respective sites of disengagement. CONCLUSION: Use of the new micro catheters with detachable-tip design allowed prolonged Onyx® injection times, safe micro catheter disengagement, without any limitations in accessing target arterial feeders.

MRI findings of bilateral posterior ischemic optic neuropathy in postcardiac transplant patient.

INTRODUCTION: Posterior ischemic optic neuropathy (PION) is a rare complication of prolonged surgical hypotension. It can occur in patients who have undergone nonocular surgery, particularly associated with significant blood loss, prolonged anesthesia time, and hypotension. CASE REPORT: We report a 48-year-old female patient who developed postoperative visual loss after cardiac transplantation. Her operative course was marked by prolonged hypotension. The patient's symptoms did not manifest until she was off sedatives. The initial ophthalmoscopic examination performed was normal. Magnetic resonance imaging confirmed the presence of restricted diffusion in both optic nerves consistent with bilateral PION. CONCLUSIONS: PION remains a difficult clinical diagnosis to prove. We report a magnetic resonance imaging-confirmed case of bilateral PION. Radiologic findings, especially diffusion-weighted images, can assist in the early identification of diffusion changes in ischemic optic nerves.

Potential synergy between advanced primary stroke centers and level I or II trauma centers in the United States.

OBJECTIVE: The objective of this study is to determine the number of primary stroke centers (PSCs) that exist concurrently (synergic relationship) with designated higher level trauma centers (level I or level II trauma centers) and associated characteristics. METHODS: We identified all PSCs certified by the Joint Commission or local state authorities in 2010. Concurrently, all the higher level trauma centers (designated level I or level II) were identified using data collected from the trauma information exchange program. Additional data was collected from the Accreditation Council for Graduate Medical Education and the American hospital directory. RESULTS: A total of 788 existing designated PSCs were identified in 2010; coexisting PSC-trauma centers were found in 252 centers (32%) with PSCs coexisting with level I trauma centers in 138 hospitals (17.5%). The remaining 536 PSCs (68%) are based in hospitals without trauma centers. There was a higher proportion of residency training programs including neurology, neurosurgery, and general surgery in coexisting PSC-trauma centers (P < .001). In a proof-of-concept analysis in 1 state, PSCs with level I trauma facilities were found to have the highest rates of thrombolytic administration as compared with PSCs with level II trauma centers and PSCs without trauma facilities (12.8% vs 3.8% vs 4.9%)(P < .0001). Primary stroke centers with level I trauma facilities were also more likely to follow the drip-and-ship paradigm (5.7% vs 1.8% vs 0.9%) (P < .0001). CONCLUSIONS: Despite evidence of higher capability among institutions with coexisting PSC-trauma centers, two thirds of PSCs are in hospitals without advanced trauma systems. These findings have implications for establishing stroke systems in the United States.