Contemporary Treatment of Intracranial Blood Blister Aneurysms - A Systematic Review.

INTRODUCTION: Blood blister aneurysms (BBAs) are rare aneurysms affecting non-branched points of intracerebral arteries. Due to their small size and fragility, BBAs are prone to rupture, and can be challenging to diagnose and treat. Several treatment options have been suggested yet there is no consensus regarding the best modality to reduce morbidity and mortality. MATERIALS AND METHODS: A systematic review of the literature was conducted searching for articles discussing the treatment of BBAs. Inclusion criteria included: articles published between January 2010 and August 2020, English language, with each paper including at least 15 patients. Studies included required detailed reporting of patient demographics, treatment, and patient outcomes (including complications, recurrence, neurologic functional status, and mortality). RESULTS AND DISCUSSION: A total of 25 studies with 883 patients were included. Most were female (n = 594, 67.3%) and aneurysms were overwhelmingly located in the supraclinoid internal carotid artery (99%). Aneurysms were variable in size and mostly presented with subarachnoid haemorrhage. Endovascular treatment (n = 518, 58.7%) was more common than microsurgery (n = 365, 41.1%) while only 2 patients were managed conservatively. Complications were more common in patients treated microsurgically. Microsurgical procedures had an unfavorable outcome (mRS 4-6, GOS 1-3) rate of 27.8% (n = 100/360) while that of endovascular procedures was 14.7% (n = 70/477). Endovascular procedures had a lower mortality rate than microsurgical interventions (8.4% vs 11%). CONCLUSION: This review demonstrates that endovascular treatment of blood blister aneurysm has reduced morbidity and mortality when compared with microsurgical treatment. Small sample sizes and substantial study heterogeneity makes strong conclusions difficult.

Y Stent Rendezvous to Treat Symptomatic Innominate Artery Stenosis.

A male in his 60s presented with transient ischemic attacks 5 years after aortic arch branch graft repair for type A aortic dissection. Computed tomographic angiography demonstrated 80% stenosis of the brachiocephalic artery close to the origins of the right common carotid and subclavian arteries. The case was reviewed at our multidisciplinary aortic meeting and a plan for endovascular management was made. Percutaneous endovascular Y stenting from the innominate artery into the left common carotid and subclavian arteries was achieved using self-expanding nitinol stents with a rendezvous technique that included retrograde right radial artery, retrograde right external carotid artery, and retrograde right femoral arterial approaches. At 6 months review, the stents remained widely patent and the patient was symptom-free.

Ultrasound-guided portal vein puncture during Transjugular Intrahepatic Portosystemic Shunt: Technique and experience of a quaternary liver transplant hospital.

INTRODUCTION: Portal hypertension (PH) is associated with complications including refractory ascites and variceal haemorrhage and can be treated endovascularly with a Transjugular Intrahepatic Portosystemic Shunt (TIPS). Portal vein puncture during TIPS using real-time transabdominal ultrasound guidance is one of many portal vein puncture techniques and is seldom used compared with other methods. The purpose of this manuscript is to describe this technique and its associated procedural outcomes at a quaternary liver transplant hospital. METHODS: Clinical data of all patients who underwent ultrasound-guided TIPS at our institution between 1 January 2009 and 1 January 2019 were retrospectively obtained from electronic medical records and reviewed. Patient demographics, indications, procedural outcomes and complications were recorded. RESULTS: Forty-four ultrasound-guided TIPS procedures were performed during the study period. The most common indication for TIPS was refractory ascites (n = 26; 57%) and variceal haemorrhage (n = 12; 26%). Technical success rate was 100%. No intraprocedural complications occurred. Periprocedural complication rate was 35% (n = 16) with encephalopathy (n = 8; 17%) and sepsis (n = 5; 11%) the most common. One patient with sepsis died. No other TIPS-related deaths occurred. Median fluoroscopy time, contrast volume, air kerma and dose area product values for all procedures were 35 minutes (IQR 24-51), 100 ml (IQR 70-160), 0.95 Gy (IQR 0.50-1.53) and 127 Gycm2 (IQR 68.75-206), respectively. CONCLUSION: Transabdominal ultrasound-guided portal vein puncture during TIPS is safe and technically feasible. When compared to fluoroscopically guided methods, it is associated with lower intraprocedural complication rates, fluoroscopy times, contrast volumes and radiation doses in our experience. Radiation doses, FTs and contrast volumes were also considerably lower than recommended limits.

Value of computed tomography scores in complicated acute diverticulitis.

BACKGROUND: Diverticular disease remains one of the most common conditions in the western world. Up to 25% of patients with diverticular disease require hospitalization, 15-30% of those of which require surgical intervention. CT scoring systems have been proposed as means to drive assessment and stratify patients necessitating hospital intervention. To assess and correlate CT scoring systems with clinical and surgical outcomes. METHODS: Retrospective cohort analysis at a single institution. Single institutional assessment with patients presenting to emergency with a CT diagnosed episode of acute diverticulitis. One hundred and eighty-nine patients were included in the study, 61% of which were male. Patient demographics, comorbidities, medications, biochemistry and inflammatory markers, type of complication following acute diverticulitis, operative/procedural intervention, hospital outcome and mortality were measured. CT scoring systems assessed included modified Hinchey, modified Neff, World Society of Emergency Surgery (WSES) and modified Siewert scoring systems. RESULTS: Majority of patients had left-sided diverticulitis (91%) with localized air (88%) and pericolic abscess (49%) the most common radiological findings. 28% of patients required radiological and/or surgical management with 12% requiring intensive care unit (ICU) admission. There was a general trend for surgical/radiological intervention as the scores increased in severity. The four scoring systems were found to be statistically significant predictors of any intervention and of ICU admission with minimal statistical differences across the different scoring systems. CONCLUSION: Radiological CT scores for complicated diverticulitis are at best, moderate predictors of clinical and surgical outcomes and may serve to guide management with minimal statistical differences across different scores.

A Systematic Review of Neuropsychological Outcomes After Treatment of Intracranial Aneurysms.

BACKGROUND: Aneurysmal subarachnoid hemorrhage is a cause of profound morbidity and mortality. Its effects extend beyond functional neurological status to neurocognitive and psychological functioning. Endovascular treatment is becoming more prevalent after increasing evidence for its safety and efficacy; however, there is a relative paucity of evidence specific to neurocognitive status after treatment. OBJECTIVE: To assess and compare neuropsychological outcomes after the treatment of ruptured and unruptured intracranial aneurysms. METHODS: A systematic review of the literature was conducted searching for articles assessing the neuropsychological and cognitive outcomes after the treatment of ruptured and unruptured intracranial aneurysms. Inclusion criteria were English language, publication between January 2000 and October 2020, and discussion of neuropsychological outcomes in adequate detail. Outcomes were categorized into 8 domains: 5 Neurocognitive (Language, Executive Function, Complex Attention, Memory and Learning, and Perceptual motor function), Intelligence Quotient, Affect, and Quality of Life. RESULTS: Twenty-four articles were included comprising 2236 patients (924 surgical clipping, 1095 endovascular coiling, and 217 controls). These studies reported that most tests revealed no significant difference [n = 356/421 (84.56%)] between treatment modalities. More studies reported significantly superior test scores in the fields of language, executive function, and memory and learning after coiling [n = 53/421 tests (12.59%)] compared with clipping [n = 12/421 tests (2.85%)]. CONCLUSION: The current available data and published studies demonstrate a trend toward improved neurocognitive and psychological outcomes after endovascular treatment. Although these findings should be considered when deciding on the optimal treatment method for each patient, drawing definitive conclusions is difficult because of heterogeneity between patients and studies.

Clipping versus coiling: A critical re-examination of a decades old controversy.

BACKGROUND: Two major studies, The International Subarachnoid Aneurysm Trial and the Barrow Ruptured Aneurysm Trial, compare the long-term outcomes of clipping and coiling. Although these demonstrated coiling's initial benefits, rebleeding and retreatment rates as well as converging patient outcomes sparked controversy regarding its durability. This article will critically examine the available evidence for and against clipping and coiling of intracranial aneurysms. Critics of endovascular treatment state that the initial benefit seen with endovascular coiling decreases over the duration of follow-up and eventually functional outcomes of both treatment modalities are similar. Combined with the increased rate of retreatment and rebleeding, these trials reveal that coiling is not as durable and not as effective as a long-term treatment compared to clipping. Also, due to the cost of devices following endovascular treatment and prolonged hospitalization following clipping, the financial burden has been considered controversial. SUMMARY/KEY MESSAGES: Short-term outcomes reveal better morbidity and mortality outcomes following coiling. Despite the higher rates of retreatment and rebleeding with coiling, there was no significant change in functional outcomes following retreatment. Furthermore, examining more recent trials reveals a decreased rate of recurrence and rebleeding with improved technology and expertise. Functional outcomes deteriorate for both cohorts over time while recent results revealed improved long-term cognitive outcomes and levels of health-related quality of life after coiling in comparison to clipping. The expense of longer hospital stays following clipping must be balanced against the expense of endovascular devices in coiling.

STABILISE; treatment of aortic dissection, a single Centre experience.

PURPOSE: To outline the process of the STABILISE technique and its use; reporting patient outcomes and midterm follow up for complicated aortic dissection. MATERIALS AND METHODS: Single centre retrospective analysis from January 2011 to January 2021 using the STABILISE technique which utilises balloon assistance to facilitate intimal disruption and promote aortic relamination. RESULTS: Sixteen patients underwent endovascular aortic repair with the STABILISE technique for aortic dissection over the study period. Fourteen patients (14/16; 88%) had acute dissection. Two of 16 (12%) were chronic. The median age of the patient cohort was 61 years (range 32-80 years) and consisted of a male majority (n = 11; 69%). The median time from diagnosis to intervention was 5 days (1-115 days; IQR 1-17.3). More than half (56%) had surgical repair of a acute type A aortic dissection prior to radiological intervention. The procedure was technically successful with no procedural mortality. Two patients were lost to follow up and two died in the post-operative period. Twelve patients had ongoing follow up with an average number of 2.9 ± 1.6 scans performed. Follow up was available in thirteen patients (81%) with a median follow up period of 1097 days (IQR 707-1657). The rate of re-intervention (n = 2/16; 13%) requiring additional stenting was in line with published re-intervention data (15%). Follow up showed a reduction in false lumen size following treatment with total luminal dimensions remaining stable over the follow-up period. CONCLUSION: The STABILISE technique as a procedure for complicated aortic dissection, either acute or chronic, appears safe with stable mid-term aortic remodelling and patient outcomes. LEVEL OF EVIDENCE: Level 3, Retrospective cohort study.

Endovascular Treatment of Intracranial Aneurysms Using the Novel Low Profile Visualized Intraluminal Support EVO Stent: Multicenter Early Feasibility Experience.

PURPOSE: Low-profile, self-expandable stents have broadened therapeutic options available for definitive treatment of intracranial aneurysms. The novel Low-Profile Visualized Intraluminal Support (LVIS) EVO stent extends upon the success of its predecessor, the LVIS Jr stent, aiming to enable higher visibility and greater opening ability within a self-expandable and fully retrievable microstent system. In this study, we aim to report the early safety and feasibility experience with the LVIS EVO stent. MATERIALS AND METHODS: A multicenter, retrospective, observational study was conducted on patients who had intracranial aneurysms treated with the LVIS EVO stent across 3 Australian neurovascular centers between February 2020 and September 2020. Short-term technical and clinical outcomes were evaluated. RESULTS: A total of 22 LVIS EVO stents were successfully implanted to treat 15 aneurysms (3 ruptured, 12 unruptured) in 15 patients. Aneurysms ranged from 2 mm to 35 mm in dome height. The LVIS EVO stent was used for stent-assisted coiling in 11 patients and flow diversion in 4 patients. There were no device-related procedural complications. There were 2 cases of peri-procedural symptomatic thromboembolic complications and no procedure-related mortality. At early radiological follow up, 10 patients had complete occlusion, 4 patients had small neck remnants, and 1 patient who was managed with flow diversion had a residual aneurysm. CONCLUSION: Early experience with the LVIS EVO stent demonstrated safety and feasibility for stent-assisted coiling as well as flow diversion for intracranial aneurysms. In this heterogeneous cohort, including ruptured, complex, and large aneurysms, all cases were technically successful.

Radiological diagnosis of perinephric pathology: pictorial essay 2015.

The perinephric space, shaped as an inverted cone, sits between the anterior and posterior renal fasciae. It can play host to a variety of clinical conditions encountered daily in the reporting schedule for a radiologist. Lesions may be classified and diagnosed based on their imaging characteristics, location and distribution. A broad range of differential diagnoses can be attributed to pathology sitting within this space, often without clinical signs or symptoms. An understanding of commonly encountered conditions affecting the perinephric space, along with characteristic imaging findings, can illustrate and often narrow the likely diagnosis. The aim of this essay is to describe commonly encountered neoplastic and non-neoplastic entities involving the perinephric space and to describe their key imaging characteristics. TEACHING POINT: • Despite often a bulky disease, perinephric lymphoma does not produce obstruction or stenosis. • In primarily fatty masses, defects within the renal capsule likely represent angiomyolipoma. • Consider paraganglioma if biopsy is planned; biopsy may lead to catecholamine crisis.

Massive symptomatic right-sided Bochdalek hernia in an adult man.

A 22-year-old man presented to a rural hospital in Australia with right-sided pleuritic chest pain, right shoulder pain and dyspnoea. The patient had been receiving chronic asthma therapy without improvement. CT of the chest was performed after an abnormal X-ray, incidentally revealing one of the largest documented right-sided diaphragmatic hernias, with left lung compression due to mediastinal shift. The patient was definitively managed with thoracotomy alone. The contents of the hernia sac included colon and multiple loops of small bowel with a 10 cm neck. Definitive treatment was achieved with significant reduction in hernia size and formation of a neo-diaphragm with composite mesh. The postoperative period was complicated only by a wound infection. Two weeks after discharge the patient remained clinically well. Repeat chest X-ray showed no recurrence of the hernia. Congenital diaphragmatic hernias should be considered in patients with ongoing respiratory symptoms. Thoracotomy provides a safe approach.