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BACKGROUND AND PURPOSE: Analysis of vessel wall contrast kinetics (ie, wash-in/washout) is a promising method for the diagnosis and risk-stratification of intracranial atherosclerotic disease plaque (ICAD-P) and the intracranial aneurysm walls (IA-W). We used black-blood MR imaging or MR vessel wall imaging to evaluate the temporal relationship of gadolinium contrast uptake kinetics in ICAD-Ps and IA-Ws compared with normal anatomic reference structures. MATERIALS AND METHODS: Patients with ICAD-Ps or IAs who underwent MR vessel wall imaging with precontrast, early postcontrast (5-15 minutes), and delayed postcontrast (20-30 minutes) 3D T1-weighted TSE sequences were retrospectively studied. ROIs of a standardized diameter (2 mm) were used to measure the signal intensities of the cavernous sinus, pituitary infundibulum, temporalis muscle, and choroid plexus. Point ROIs were used for ICAD-Ps and IA-Ws. All ROI signal intensities were normalized to white matter signal intensity obtained using ROIs of 10-mm diameter. Measurements were acquired on precontrast, early postcontrast, and delayed postcontrast 3D T1 TSE sequences for each patient. RESULTS: Ten patients with 17 symptomatic ICAD-Ps and 30 patients with 34 IA-Ws were included and demonstrated persisting contrast uptake (P < .001) of 7.21% and 10.54% beyond the early phase (5-15 minutes postcontrast) and in the delayed phase (20-30 minutes postcontrast) on postcontrast MR vessel wall imaging. However, normal anatomic reference structures including the pituitary infundibulum and cavernous sinus demonstrated a paradoxical contrast washout in the delayed phase. In both ICAD-Ps and IA-Ws, the greatest percentage of quantitative enhancement (>70%-90%) occurred in the early phase of postcontrast imaging, consistent with the rapid contrast uptake kinetics of neurovascular pathology. CONCLUSIONS: Using standard MR vessel wall imaging techniques, our results demonstrate the effects of gadolinium contrast uptake kinetics in ICAD-Ps and IA-Ws with extended accumulating enhancement into the delayed phase (> 15 minutes) as opposed to normal anatomic reference structures that conversely exhibit decreasing enhancement. Because these relative differences are used to assess qualitative patterns of ICAD-P and IA-W enhancement, our findings highlight the importance of standardizing acquisition time points and MR vessel wall imaging protocols to interpret pathologic enhancement for the risk stratification of cerebrovascular pathologies.
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Conventional imaging modalities, such as computed tomography angiography, MR angiography, transcranial Doppler ultrasonography, and digital subtraction angiography, are utilized in evaluating intraluminal or intravascular pathology of the intracranial vessels. Limitations of luminal imaging techniques can lead to inaccurate diagnosis, evaluation, and risk stratification, as many cerebrovascular pathologies contain an extrinsic vessel wall component. Furthermore, vessel wall imaging can provide information regarding extent, treatment response, and biopsy targets for vasculitis cases. Overall, while vessel wall imaging can provide robust data regarding intracranial pathologies, further prospective, multicenter studies are required to improve diagnostic application and accuracy.
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Aterosclerosis , Vasculitis , Humanos , Vasculitis/diagnóstico por imagen , Angiografía por Resonancia Magnética/métodos , Tomografía Computarizada por Rayos X , Angiografía de Substracción Digital , Imagen por Resonancia Magnética/métodosRESUMEN
Catheter Digital Subtraction Angiography (DSA) is markedly degraded by all voluntary, respiratory, or cardiac motion artifact that occurs during the exam acquisition. Prior efforts directed toward improving DSA images with machine learning have focused on extracting vessels from individual, isolated 2D angiographic frames. In this work, we introduce improved 2D + t deep learning models that leverage the rich temporal information in angiographic timeseries. A total of 516 cerebral angiograms were collected with 8784 individual series. We utilized feature-based computer vision algorithms to separate the database into "motionless" and "motion-degraded" subsets. Motion measured from the "motion degraded" category was then used to create a realistic, but synthetic, motion-augmented dataset suitable for training 2D U-Net, 3D U-Net, SegResNet, and UNETR models. Quantitative results on a hold-out test set demonstrate that the 3D U-Net outperforms competing 2D U-Net architectures, with substantially reduced motion artifacts when compared to DSA. In comparison to single-frame 2D U-Net, the 3D U-Net utilizing 16 input frames achieves a reduced RMSE (35.77 ± 15.02 vs 23.14 ± 9.56, p < 0.0001; mean ± std dev) and an improved Multi-Scale SSIM (0.86 ± 0.08 vs 0.93 ± 0.05, p < 0.0001). The 3D U-Net also performs favorably in comparison to alternative convolutional and transformer-based architectures (U-Net RMSE 23.20 ± 7.55 vs SegResNet 23.99 ± 7.81, p < 0.0001, and UNETR 25.42 ± 7.79, p < 0.0001, mean ± std dev). These results demonstrate that multi-frame temporal information can boost performance of motion-resistant Background Subtraction Deep Learning algorithms, and we have presented a neuroangiography domain-specific synthetic affine motion augmentation pipeline that can be utilized to generate suitable datasets for supervised training of 3D (2d + t) architectures.
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BACKGROUND: Arteriovenous malformations (AVMs) are the most common cause of intracranial hemorrhage in children, although they are rarer in neonates. Age, location, lesion architecture, and rupture status define treatment options. Sparse literature exists to guide the management of clinically symptomatic intraventricular AVM rupture in neonates. We highlight the case of a neonate with a ruptured intraventricular AVM to showcase considerations in treatment, discuss surgical technique, and help guide management. OBSERVATIONS: An 18-day-old female presented with lethargy in extremis and was found to have new intraventricular hemorrhage. Angiogram revealed a Spetzler-Martin grade 2 AVM with a right posterior choroidal feeder and deep venous drainage within the ventricle. Her age limited radiosurgical and endovascular interventions. She underwent an interhemispheric, transcollosal, intraventricular approach for complete AVM resection. Perioperative care was managed by a multidisciplinary team, successfully mitigating the patient's high risk of hemovascular collapse. LESSONS: Stereotactic radiosurgery, endovascular embolization, and microsurgery are options for AVM obliteration, and multimodal therapy must be tailored to the lesion and patient. Conservative management can also be considered. Each intervention carries risks and varying likelihoods of success. Balancing these outcomes is challenging without definitive, high-quality, evidence-based guidance. The best treatment maximizes the chance of AVM obliteration while minimizing morbidity.
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BACKGROUND: The introduction of carotid stenting (CAS) has led to numerous comparative trials with carotid endarterectomy (CEA). OBJECTIVE: The objective of the study was to review real-world volumes, outcomes, and complications following CEA versus CAS over an extended period to identify durable changes in practice. METHODS: Data were extracted from the National Inpatient Sample. Trends were assessed by annual percent change (APC), and adjusted risk ratios were calculated across the last 5 years of the study period. RESULTS: During 1997-2015, 199,330 symptomatic and 1,995,637 asymptomatic patients underwent carotid revascularization. In symptomatic patients, CEA declined (1997-2004; APC = -7.68%, P < 0.001) and CAS rose (1997-2008; APC = 15.48%, P < 0.001) during the first decade, subsequently becoming more muted. In asymptomatic patients, CEA decreased, whereas CAS initially increased (1997-2006; APC = 20.27%, P < 0.001) and then decreased (2007-2015; APC = -4.52%, P < 0.001). Routine discharge after symptomatic revascularization declined in CEA after 2003 and in CAS after 2006 (APC = -1.72% and -3.11%, respectively, P < 0.001 for both), corresponding to increasing patient comorbidity; similar trends were seen in asymptomatic patients. Death decreased after CEA (symptomatic and asymptomatic; APC = -4.85% and -3.53%, respectively, P < 0.001 for both) and CAS (asymptomatic only, APC = -2.53%, P = 0.04). CAS remained associated with a higher adjusted risk ratio for death, venous thromboembolism, and seizures in all patients and stroke and nonroutine discharge in symptomatic patients, during the last 5 years of the study period. CONCLUSIONS: Mortality has improved, but routine discharge has decreased following both CEA and CAS, congruent with increasing patient comorbidity. Trends in volumes, outcomes, and complication rates continue to favor CEA in real-world practice.
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Estenosis Carotídea , Endarterectomía Carotidea , Accidente Cerebrovascular , Estenosis Carotídea/complicaciones , Humanos , Pacientes Internos , Medición de Riesgo , Factores de Riesgo , Stents/efectos adversos , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/cirugía , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Individuals typically show a childhood nadir in adiposity termed the adiposity rebound (AR). The AR serves as an early predictor of obesity risk, with early rebounders often at increased risk; however, it is unclear why this phenomenon occurs, which could impede understandings of weight gain trajectories. The brain's energy requirements account for a lifetime peak of 66% of the body's resting metabolic expenditure during childhood, around the age of the AR, and relates inversely to weight gain, pointing to a potential energy trade-off between brain development and adiposity. However, no study has compared developmental trajectories of brain metabolism and adiposity in the same individuals, which would allow a preliminary test of a brain-AR link. METHODS: We used cubic splines and generalized additive models to compare age trajectories of previously collected MRI-based 4D flow measures of total cerebral blood flow (TCBF), a proxy for cerebral energy use, to the body mass index (BMI) in a cross-sectional sample of 82 healthy individuals (0-60 years). We restricted our AR analysis to pre-pubertal individuals (0-12 years, n = 42), predicting that peak TCBF would occur slightly after the BMI nadir, consistent with evidence that lowest BMI typically precedes the nadir in adiposity. RESULTS: TCBF and the BMI showed inverse trajectories throughout childhood, while the estimated age at peak TCBF (5.6 years) was close but slightly later than the estimated age of the BMI nadir (4.9 years). CONCLUSIONS: The timing of peak TCBF in this sample points to a likely concordance between peak brain energetics and the nadir in adiposity. Inverse age trajectories between TCBF and BMI support the hypothesis that brain metabolism is a potentially important influence on early life adiposity. These findings also suggest that experiences influencing the pattern of childhood brain energy use could be important predictors of body composition trajectories.
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Adiposidad , Obesidad , Adiposidad/fisiología , Índice de Masa Corporal , Encéfalo/diagnóstico por imagen , Circulación Cerebrovascular , Preescolar , Estudios Transversales , Humanos , Imagen por Resonancia Magnética , Factores de RiesgoRESUMEN
Spinal cord ischemia (SCI) is a rare entity with high mortality and morbidity which can arise from causes such as atherosclerosis, aortic dissection or aneurysm, thromboembolic events or systemic hypotension, and is a potential complication of spinal surgery. Published literature contains very few reports of SCI as a complication of intracranial interventions, highlighting the uncommon nature of SCI in these circumstances. We report the occurrence of anterior SCI in a 69-year-old patient following successful embolization of a cerebellar arteriovenous malformation (AVM), marked by upper extremity weakness, lower extremity paraplegia, loss of bladder and bowel control, and hypercapnic respiratory failure requiring mechanical ventilation. Magnetic resonance imaging (MRI) demonstrated upper cervical diffusion restriction and T2/STIR hyperintensity. Unusually, SCI occurred in this case without intraprocedural catheter wedging or obvious flow limitation, prolonged procedure time, hypercoagulable state, or general hypotension. We review previous cases in the literature as well as spinal cord vascular anatomy, and discuss the possible etiologies of this complication. Spinal cord ischemia could be a very rare complication of neuroendovascular procedures even in the absence of warning signs and should be carefully evaluated in patients with suspected neurologic symptoms after such procedures.
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Spinal dural arteriovenous fistula (SDAVF) is an elusive and underdiagnosed disease. Congestive myelopathy occurs from increased venous pressure transmitted by the fistula between a radiculomeningeal artery and the spinal venous plexus. While its cause remains unknown, associations between SDAVF and hyper-vascular states have been reported. We present the first documented case report of a de novo SDAVF diagnosis in a patient with active renal cell carcinoma (RCC) metastasis to the spinal epidural space and review the literature.
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OBJECTIVE: Cerebral aneurysms in the pediatric population are rare and optimal treatment strategies are not as well characterized as in adults. The Pipeline embolization device (PED) is an endoluminal flow diverter that is commonly used to treat aneurysms in adults, but experience with this device in children is limited. The authors sought to further characterize PED use and outcomes in this specific population by performing both a systematic review of patient-level data from studies reporting the use of the PED to treat pediatric aneurysms and a retrospective review of their experience. METHODS: A systematic review of the PubMed, Embase, and Scopus databases was performed to identify studies reporting the use of the PED in pediatric patients (age ≤ 18 years). Disaggregated data regarding demographics, aneurysm characteristics, treatment, and outcomes were collected. Retrospective data from the authors' two institutions were also included. RESULTS: Thirty studies comprising patient-level data on 43 pediatric patients with 47 aneurysms were identified. An additional 9 patients with 9 aneurysms were included from the authors' institutions for a total of 52 patients with 56 aneurysms. The mean patient age was 11.1 years. Presentations included aneurysm rupture (17.3%) and symptomatic mass effect (23.1%). Aneurysms were located in the anterior circulation in 55.4% of cases, and 73.2% were described as nonsaccular. Imaging follow-up was available for 89.3% with a mean follow-up of 13.3 months. Aneurysm occlusion was reported in 75%, with 1 case each (1.8%) demonstrating significant in-stent stenosis and parent vessel occlusion. Clinical follow-up was reported in 90.4% with a mean follow-up of 14.7 months. Good functional outcomes (modified Rankin Scale score of 0-1 or Glasgow Outcome Scale score of 5) were reported in 65.4% of the total population. Two major complications were reported, including 1 death. CONCLUSIONS: Despite substantial differences in aneurysm location and type between published pediatric and adult patient populations treated with the PED, the use of the PED in the pediatric population appears to be safe. While the short-term effectiveness is also similar to that of adults, additional studies are needed to further characterize the long-term outcomes and better define the use of this device in pediatric patients.
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Embolización Terapéutica/instrumentación , Embolización Terapéutica/métodos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/métodos , Aneurisma Intracraneal/terapia , Adolescente , Prótesis Vascular , Niño , Preescolar , Femenino , Humanos , Masculino , Estudios RetrospectivosRESUMEN
CONCLUSIONS: Direct percutaneous TCAA can be a feasible access for intracranial interventions in neonates with LBW and unavailable UA access.
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Senos Craneales , Embolización Terapéutica , Humanos , Recién NacidoRESUMEN
Background Following publication of trials demonstrating the efficacy of thrombectomy, societal guidelines were revised in 2015 to recommend this procedure for large-vessel stroke. Purpose To evaluate real-world thrombectomy rates, adverse events, outcomes, and readmissions across the United States in the 2 years after large-scale adoption of thrombectomy for acute stroke. Materials and Methods In this retrospective study, the authors queried the National Inpatient Sample and Nationwide Readmissions Database for patients undergoing thrombectomy between 2016 and 2017. Thrombectomy rates were compared by using the χ2 test. Adjusted risk ratios (aRRs) were obtained for factors affecting routine discharge, mortality, and readmission by using multivariable Poisson regression with clustering at the hospital level. Results There were 290 460 admissions (mean age, 70.5 years ± 14.2 [standard deviation]; 148 620 women) for internal carotid or middle cerebral artery stroke; 30 835 (10.6%) of these patients underwent thrombectomy. Thrombectomy rates were lower in patients aged 90 years or older (1815 of 24 090 patients, 7.5%), Black patients (4280 of 43 365 patients, 9.9%), patients with the lowest income (8520 of 85 905 patients, 9.9%), and those treated in West South Central division hospitals (2695 of 34 355 patients, 7.8%) (P < .001 for all). The inpatient mortality rate was 12.1% (3740 of 30 835 patients), and 19.1% of patients (5900 of 30 835) were discharged to home. In adjusted analyses, routine discharge was less likely in patients aged 90 years or older (aRR: 0.12; 95% CI: 0.09, 0.16; P < .001) and octogenarians (aRR: 0.37; 95% CI: 0.33, 0.41; P < .001). Patients aged 90 years or older (aRR: 1.78; 95% CI: 1.48, 2.14; P < .001), octogenarians (aRR: 1.76; 95% CI: 1.51, 2.06; P < .001), Asians and/or Pacific Islanders (aRR: 1.21; 95% CI: 1.06, 1.39; P = .005), and those treated in teaching (aRR: 1.20; 95% CI: 1.07, 1.34; P = .001) or West South Central division (aRR: 1.35; 95% CI: 1.14, 1.60; P < .001) hospitals had a higher risk of death. Following discharge, 18.9% of patients (3449 of 18 274) were readmitted within 90 days. Conclusion Rates and outcomes of thrombectomy are affected by demographic, socioeconomic, and hospital-related factors. Fewer than one-fifth of patients are discharged to home, nearly one-fifth are readmitted within 90 days, and mortality and outcomes may be less favorable than in published trials. © RSNA, 2021 Online supplemental material is available for this article.
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Procedimientos Endovasculares/métodos , Accidente Cerebrovascular Isquémico/cirugía , Readmisión del Paciente/estadística & datos numéricos , Trombectomía/métodos , Anciano , Anciano de 80 o más Años , Femenino , Mortalidad Hospitalaria , Humanos , Accidente Cerebrovascular Isquémico/mortalidad , Masculino , Evaluación de Procesos y Resultados en Atención de Salud , Selección de Paciente , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: The "weekend effect" has been shown to affect outcomes in acute ischemic stroke. We sought to compare metrics and outcomes of emergent stroke thrombectomy at three affiliated comprehensive stroke centers on weekdays versus nights/weekends for a three-year period beginning in 2015, when thrombectomy became common practice for large vessel occlusion acute ischemic stroke. METHODS: We performed a retrospective analysis of all stroke thrombectomy patients treated from 2015 to 2018 to compare standard thrombectomy metrics and outcomes in patients presenting during weekdays or nights/weekends. RESULTS: Two hundred-sixteen mechanical thrombectomy cases were evaluated, with 50.9% of patients presenting on weekdays and 49.1% presenting on nights/weekends. There were no statistical differences in baseline characteristics in demographics, stroke risk factors, or stroke severity, but patients presenting on nights/weekends had longer times from last known normal to presentation (130 versus 72.5 minutes, p=0.03). Door-to-groin times were delayed in patients presenting on nights/weekends compared to weekdays (median 104.5 versus 86 minutes, respectively; p=0.007) but groin-to-reperfusion times were similar (51.5 versus 48 minutes, respectively; p=0.4). Successful reperfusion was similar in both groups (90.6% nights/weekends versus 90% weekdays; p=1.0) as were the incidence of symptomatic intracerebral hemorrhage (10.4% nights/weekend versus 7.3% weekdays; p=0.48) and 90-day good functional outcomes based on the modified Rankin Scale did not differ between the two groups in a shift analysis (p=0.545). CONCLUSIONS: Despite delays in door-to-groin puncture times in acute ischemic stroke patients presenting on nights/weekends compared to weekdays, we did not identify significant differences in successful reperfusion or functional outcomes in this cohort. Further studies are warranted to continue to evaluate differences in stroke care on nights/weekends versus weekdays.
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Atención Posterior , Accidente Cerebrovascular Isquémico/terapia , Trombectomía , Tiempo de Tratamiento , Centros Médicos Académicos , Adulto , Anciano , Anciano de 80 o más Años , Chicago , Urgencias Médicas , Femenino , Hospitales Comunitarios , Humanos , Accidente Cerebrovascular Isquémico/diagnóstico , Accidente Cerebrovascular Isquémico/mortalidad , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Trombectomía/efectos adversos , Trombectomía/mortalidad , Terapia Trombolítica , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
CNS vascular malformation is an umbrella term that encompasses a wide variety of pathologies, with a wide range of therapeutic and diagnostic importance. This range spans lesions with a risk of devastating neurological compromise to lesions with a slow, static or benign course. Advances in neurovascular imaging along with increased utilization of these advances, have resulted in more frequent identification of these lesions. In this article, we provide an overview on definitions and classifications of CNS vascular malformations and outline the etiologic, diagnostic, prognostic, and therapeutic features for each entity. This review covers intracranial and spinal cord vascular malformations and discusses syndromes associated with CNS vascular malformations.
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Malformaciones Vasculares del Sistema Nervioso Central , Malformaciones Vasculares del Sistema Nervioso Central/complicaciones , Malformaciones Vasculares del Sistema Nervioso Central/diagnóstico , Malformaciones Vasculares del Sistema Nervioso Central/etiología , Malformaciones Vasculares del Sistema Nervioso Central/fisiopatología , Angiografía Cerebral , Angiografía por Tomografía Computarizada , Humanos , Imagen por Resonancia Magnética , MielografíaRESUMEN
BACKGROUND: Admission neutrophil-lymphocyte ratio (NLR) is significantly correlated to clinical outcomes in acute ischemic stroke (AIS). We investigated follow-up NLR and temporal changes in NLR after endovascular thrombectomy (EVT) with respect to successful revascularization, clinical outcomes, symptomatic intracranial hemorrhage (sICH) and mortality. METHODS: Retrospective analysis of EVT for anterior circulation emergent LVO was performed with both admission (NLR1) and 3-7 day follow-up NLR (NLR2) laboratory data. Patient demographics, National Institutes of Health Stroke Scale (NIHSS) presentations, reperfusion efficacy (modified Thrombolysis in Cerebral Infarction (mTICI) score), sICH, and clinical outcomes (modified Rankin Scale (mRS)) at 90 days were studied. Univariate analyses correlated NLR1, NLR2, and temporal change in NLR (NLR2-NLR1) with successful reperfusion (mTICI ≥2b), favorable outcomes (mRS ≤2), sICH, and mortality. Multivariable logistic regression model evaluated the independent effects of NLR2 on favorable outcomes. RESULTS: 142 AIS patients with median NIHSS 17 underwent EVT within 24 hours, and met NLR laboratory inclusion criteria. Lower follow-up NLR2 and less temporal change in NLR over 3-7 days, but not admission NLR1, inversely correlated with successful reperfusion (p<0.05) and favorable clinical outcomes (p<0.001). Higher follow-up NLR2 and greater temporal change in NLR was significantly associated with sICH and mortality (p≤0.05). In multivariable logistic regression, lower follow-up NLR2 remained a predictor of favorable outcomes (OR 0.785, p=0.001), independent of age or successful reperfusion. CONCLUSIONS: Follow-up NLR is a readily available and modifiable biomarker that correlates with the degree of reperfusion after mechanical stroke thrombectomy. Lower follow-up NLR2 at 3-7 days is associated with successful reperfusion and an independent predictor of favorable clinical outcomes, with reduced risk for sICH and mortality.
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Isquemia Encefálica/sangre , Linfocitos/metabolismo , Neutrófilos/metabolismo , Accidente Cerebrovascular/sangre , Trombectomía/métodos , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/cirugía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Reperfusión/métodos , Reperfusión/tendencias , Estudios Retrospectivos , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/cirugía , Trombectomía/tendencias , Resultado del TratamientoRESUMEN
Spinal pial arteriovenous fistulas (spAVFs) are believed to be congenital lesions, and the development of a de novo spAVF has not been previously described. A 49-year-old female with a childhood history of vascular malformation-induced right lower-extremity hypertrophy presented in 2004 with progressive pain in her right posterior thigh and outer foot. Workup revealed 3 separate type IV spAVFs, which were treated by combined embolization and resection, with final conventional angiography showing no residual spinal vascular lesion in 2005. Ten years later, the patient returned with new right lower-extremity weakness, perineal pain, and left plantar foot numbness. Repeat spinal angiography demonstrated 2 de novo intertwined conus medullaris spAVFs.
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Isquemia Encefálica/tratamiento farmacológico , Nimodipina/farmacología , Hemorragia Subaracnoidea , Vasodilatadores/farmacología , Vasoespasmo Intracraneal , Angiografía de Substracción Digital , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiología , Angiografía Cerebral , Fosa Craneal Posterior/patología , Humanos , Recién Nacido , Enfermedades del Recién Nacido , Imagen por Resonancia Magnética , Masculino , Nimodipina/administración & dosificación , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/diagnóstico , Ultrasonografía Doppler Transcraneal , Vasodilatadores/administración & dosificación , Vasoespasmo Intracraneal/complicaciones , Vasoespasmo Intracraneal/diagnóstico , Vasoespasmo Intracraneal/etiologíaRESUMEN
OBJECTIVE: Spinal cord infarction due to interruption of the spinal vascular supply during anterior thoracolumbar surgery is a rare but devastating complication. Here, the authors sought to summarize the data on this complication in terms of its incidence, risk factors, and operative considerations. They also sought to summarize the relevant spinal vascular anatomy. METHODS: They performed a systematic literature review of the PubMed, Scopus, and Embase databases to identify reports of spinal cord vascular injury related to anterior thoracolumbar spine procedures as well as operative adjuncts and considerations related to management of the segmental artery ligation during such anterior procedures. Titles and abstracts were screened, and studies meeting inclusion criteria were reviewed in full. RESULTS: Of 1200 articles identified on the initial screening, 16 met the inclusion criteria and consisted of 2 prospective cohort studies, 10 retrospective cohort studies, and 4 case reports. Four studies reported on the incidence of spinal cord ischemia with anterior thoracolumbar surgery, which ranged from 0% to 0.75%. Eight studies presented patient-level data for 13 cases of spinal cord ischemia after anterior thoracolumbar spine surgery. Proposed risk factors for vasculogenic spinal injury with anterior thoracolumbar surgery included hyperkyphosis, prior spinal deformity surgery, combined anterior-posterior procedures, left-sided approaches, operating on the concavity side of a scoliotic curve, and intra- or postoperative hypotension. In addition, eight studies analyzed operative considerations to reduce spinal cord ischemic complications in anterior thoracolumbar surgery, including intraoperative neuromonitoring and preoperative spinal angiography. CONCLUSIONS: While spinal cord infarction related to anterior thoracolumbar surgery is rare, it warrants proper consideration in the pre-, intra-, and postoperative periods. The spine surgeon must be aware of the relevant risk factors as well as the pre- and intraoperative adjuncts that can minimize these risks. Most importantly, an understanding of the relevant spinal vascular anatomy is critical to minimizing the risks associated with anterior thoracolumbar spine surgery.
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Vértebras Lumbares/irrigación sanguínea , Vértebras Lumbares/cirugía , Complicaciones Posoperatorias/etiología , Isquemia de la Médula Espinal/etiología , Vértebras Torácicas/irrigación sanguínea , Vértebras Torácicas/cirugía , Humanos , Infarto/diagnóstico por imagen , Infarto/etiología , Vértebras Lumbares/diagnóstico por imagen , Complicaciones Posoperatorias/diagnóstico por imagen , Estudios Retrospectivos , Isquemia de la Médula Espinal/diagnóstico por imagen , Enfermedades de la Columna Vertebral/diagnóstico por imagen , Enfermedades de la Columna Vertebral/cirugía , Vértebras Torácicas/diagnóstico por imagenRESUMEN
BACKGROUND: In-stent thrombosis is a potentially dangerous complication of flow diversion for cerebral aneurysms. The optimal management strategy for such thrombosis is not known. Here we present a case of acute ischemic stroke caused by occlusion of a Pipeline Embolization Device (PED) construct placed 18 months earlier for treatment of a fusiform middle cerebral artery aneurysm. This was successfully treated with mechanical thrombectomy with good neurologic outcome. CASE DESCRIPTION: A 40-year-old woman presented with acute onset of left-sided weakness and occlusion of the right middle cerebral artery harboring a PED construct. Intraarterial glycoprotein IIb/IIIa inhibitor was administered without success. Mechanical thrombectomy was then performed using a stent retriever and aspiration, and the patient was loaded with dual antiplatelet therapy. The patient showed initial neurologic improvement but several hours later demonstrated recurrent symptoms due to reocclusion of the PED construct. This was again treated with mechanical thrombectomy followed by an intravenous P2Y12 inhibitor infusion. She ultimately made an excellent neurologic recovery with persistent patency of the PED construct. CONCLUSIONS: Mechanical thrombectomy with a stent retriever and aspiration is a therapeutic option for treatment of delayed thrombosis of a flow-diverting stent.
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Isquemia Encefálica/etiología , Aneurisma Intracraneal/cirugía , Stents/efectos adversos , Accidente Cerebrovascular/etiología , Trombectomía/métodos , Trombosis/etiología , Adulto , Isquemia Encefálica/cirugía , Femenino , Humanos , Accidente Cerebrovascular/cirugía , Trombosis/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: Basilar perforator aneurysms are rare causes of subarachnoid hemorrhage and their natural history is poorly characterized. Although various treatment strategies have been reported, conservative management is an option that has been associated with a high likelihood of spontaneous resolution. CASE DESCRIPTION: Here we present 2 cases of subarachnoid hemorrhage, 1 diffuse and the other perimesencephalic, due to small ruptured basilar perforator artery aneurysms. These aneurysms were only identified after repeat angiography. Conservative management with serial imaging was pursued. Both patients did well clinically and repeat imaging demonstrated spontaneous resolution of the ruptured aneurysms. We also provide a literature review of ruptured basilar perforator aneurysms, showing a ~10% re-rupture rate within the early post-rupture period but otherwise a high rate of spontaneous resolution. CONCLUSIONS: Although basilar perforator aneurysms can re-rupture, there is also a high likelihood of spontaneous resolution. Given the challenges of treatment, conservative management is an option that can be considered.