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BACKGROUND AND PURPOSE: The value of intravenous thrombolysis (IVT) in eligible tandem lesion patients undergoing endovascular treatment (EVT) is unknown. We investigated treatment effect heterogeneity of EVT + IVT versus EVT-only in tandem lesion patients. Additional analyses were performed for patients undergoing emergent internal carotid artery (ICA) stenting. METHODS: SWIFT DIRECT randomized IVT-eligible patients to either EVT + IVT or EVT-only. Primary outcome was 90-day functional independence (modified Rankin Scale score 0-2) after the index event. Secondary endpoints were reperfusion success, 24 h intracranial hemorrhage rate, and 90-day all-cause mortality. Interaction models were fitted for all predefined outcomes. RESULTS: Among 408 included patients, 63 (15.4%) had a tandem lesion and 33 (52.4%) received IVT. In patients with tandem lesions, 20 had undergone emergent ICA stenting (EVT + IVT: 9/33, 27.3%; EVT: 11/30, 36.7%). Tandem lesion did not show treatment effect modification of IVT on rates of functional independence (tandem lesion EVT + IVT vs. EVT: 63.6% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 65.6% vs. 58.2%; p for interaction = 0.77). IVT also did not increase the risk of intracranial hemorrhage among tandem lesion patients (tandem lesion EVT + IVT vs. EVT: 34.4% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 33.5% vs. 26.3%; p for interaction = 0.15). No heterogeneity was noted for other endpoints (p for interaction > 0.05). CONCLUSIONS: No treatment effect heterogeneity of EVT + IVT versus EVT-only was observed among tandem lesion patients. Administering IVT in patients with anticipated emergent ICA stenting seems safe, and the latter should not be a factor to consider when deciding to administer IVT before EVT.
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Procedimientos Endovasculares , Fibrinolíticos , Stents , Trombectomía , Activador de Tejido Plasminógeno , Humanos , Masculino , Femenino , Anciano , Persona de Mediana Edad , Fibrinolíticos/administración & dosificación , Activador de Tejido Plasminógeno/administración & dosificación , Activador de Tejido Plasminógeno/uso terapéutico , Trombectomía/métodos , Procedimientos Endovasculares/métodos , Estenosis Carotídea/cirugía , Anciano de 80 o más Años , Administración Intravenosa , Accidente Cerebrovascular Isquémico/cirugía , Accidente Cerebrovascular Isquémico/tratamiento farmacológico , Resultado del Tratamiento , Terapia Trombolítica/métodosRESUMEN
Spinal dural arteriovenous fistulas (SDAVF) are the most common vascular malformations affecting the spinal cord. It is infrequently encountered in clinical practice and is believed to be acquired, predominantly affecting middle-aged and elderly men with unknown etiology. It is usually misdiagnosed despite presenting with conventional clinical findings and radiological features. Insidious onset of myelopathic findings is seen in addition to pathognomonic findings of cord edema and intrathecal flow voids on MRI. We present a case of SDAVF that was missed by the treating orthopedic surgeon and underwent spinal decompression with subsequent persistence of myelopathic symptoms. Angiography is required to confirm the diagnosis location of the fistula. Treatment is with embolization using liquid embolic agents or surgical through ligation of the draining vein. Endovascular techniques are minimally invasive, safe, and effective. Knowledge of the characteristics and advantages/disadvantages of each agent helps in planning and appropriate selection of agents for the patient. We report successful embolization with improved clinical outcomes for the patient using precipitating hydrophobic injectable liquid (PHIL) embolic agent. The outcome and prognosis of SDAVF depend on the duration of symptoms, severity of neurological symptoms, and successful occlusion of the fistulous draining vein. Awareness of this rare condition amongst clinicians and radiologists, would enable an earlier diagnosis and avoid morbid outcomes of this treatable condition.
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OBJECTIVES: The optimal endovascular treatment for tandem occlusion in anterior circulation ischaemic stroke remains unknown. The aim of this study was to examine how the aetiology of carotid pathology, dissection versus atherothrombosis, affects clinical outcomes. MATERIALS AND METHODS: Data was obtained from prospectively collected registries from two stroke centres between April 2016 and December 2020. Tandem cases with complete cervical internal carotid artery (ICA) occlusion or near-total occlusion (≥90% stenosis) were included. Patients were divided into two groups based on carotid pathology: dissection versus atherothrombosis. RESULTS: A total of 134 patients were included: 36 were dissection and 98 were atherothrombosis. The dissection group had better clinical outcomes compared to the atherothrombosis group, although after adjusting for age and stroke risk factors differences were non-significant. In the non-stented cohort, the dissection patients achieved a better outcome (modified Rankin scale 0-2) than atherothrombotic patients (57% vs. 34%, p=0.04) at 90-days. CONCLUSION: Dissection-related tandem occlusions appear to have different clinical features from atherothrombotic tandem occlusions which suggests different management strategies are needed.
Asunto(s)
Arteriopatías Oclusivas , Isquemia Encefálica , Enfermedades de las Arterias Carótidas , Procedimientos Endovasculares , Accidente Cerebrovascular , Humanos , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/etiología , Isquemia Encefálica/complicaciones , Resultado del Tratamiento , Procedimientos Endovasculares/efectos adversos , Arteria Carótida Interna/diagnóstico por imagen , Arteriopatías Oclusivas/complicaciones , Trombectomía/efectos adversos , Enfermedades de las Arterias Carótidas/complicaciones , Estudios Retrospectivos , StentsRESUMEN
The WEB is an endovascular flow-disrupting device used in treating wide-necked intracranial aneurysms. Although the device is available in varying sizes, large aneurysms pose a challenge with the need for custom-made devices. We describe the use of coils as an adjunct to the WEB device in successfully treating large aneurysms in two patients, one with an acutely ruptured aneurysm. This novel technique of jailing a microcatheter, deploying the WEB and then coiling the aneurysm saves the need for intracranial stenting, thereby avoiding the need for antiplatelet therapy, which is of benefit in the setting of acute aneurysm rupture.
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Cateterismo Periférico/métodos , Embolización Terapéutica/métodos , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/terapia , Stents , Angiografía de Substracción Digital , Femenino , Arteria Femoral/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana EdadRESUMEN
A 69-year-old gentleman with metastatic esophageal adenocarcinoma presented with acute abdominal pain to the emergency medicine department and subsequently developed an acute left hemiplegia while in the resuscitation unit. An unenhanced computed tomography (CT) scan of the head showed right frontal cerebral gas emboli while an unenhanced CT scan of the abdomen and pelvis showed extensive portal venous gas and pneumatosis intestinalis, presumed secondary to bowel infarction.
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Embolia Aérea/etiología , Infarto/complicaciones , Intestino Delgado/irrigación sanguínea , Embolia Intracraneal/etiología , Complicaciones Posoperatorias/etiología , Abdomen Agudo , Adenocarcinoma/complicaciones , Adenocarcinoma/secundario , Adenocarcinoma/cirugía , Anciano , Embolia Aérea/diagnóstico por imagen , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/cirugía , Esofagectomía , Resultado Fatal , Lóbulo Frontal/irrigación sanguínea , Lóbulo Frontal/diagnóstico por imagen , Hemiplejía/etiología , Humanos , Ileostomía , Embolia Intracraneal/diagnóstico por imagen , Masculino , Venas Mesentéricas , Neoplasias Peritoneales/complicaciones , Neoplasias Peritoneales/secundario , Vena Porta , Complicaciones Posoperatorias/diagnóstico por imagen , RadiografíaRESUMEN
BACKGROUND: Liquid embolic agents are the preferred embolic material in endovascular treatment of pial and brain arteriovenous malformations and dural arteriovenous fistulas (DAVFs). There is little choice available in interventional neuroradiology practice other than two of the most commonly used liquid embolic agents-n-butyl cyanoacrylate and the Onyx liquid embolic system (ev3 Neurovascular, Irvine, California, USA). PHIL (Precipitating Hydrophobic Injectable Liquid) (Microvention, Inc California, USA) is a new liquid embolic agent, CE marked and available for clinical use in Europe. OBJECTIVE: To present our preliminary experience using PHIL in treating cranial and spinal DAVFs. METHODS: Between September 2014 and January 2015, eight patients, with five cranial DAVFs and three spinal DAVFs were treated with PHIL as the sole embolic agent used with intent to cure. Clinical presentation, location of DAVF, Borden type, fluoroscopic time, radiation dose, procedural time, injecting microcatheter used, volume of PHIL injected, complications, immediate angiographic data, premorbid and discharge modified Rankin Scale score, and any neurologic deficits were included in the analysis. RESULTS: Seven patients were successfully treated with complete angiographic exclusion of the fistula in a single sitting. Treatment failed in one patient where only suboptimal microcatheter positioning could be achieved and PHIL failed to penetrate the fistula's nidus. Venous penetration was achieved in all other patients except one with a small fistula, but with adequate fistula penetration by the embolic material. No other technical complication or neurologic deterioration occurred in any of the patients. CONCLUSIONS: PHIL liquid embolic agent appears to be an excellent alternative embolic material with certain advantages compared with other available liquid embolic agents. Further studies are required to fully evaluate its safety and efficacy.
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Fármacos Cardiovasculares/administración & dosificación , Malformaciones Vasculares del Sistema Nervioso Central/terapia , Dimetilsulfóxido/administración & dosificación , Embolización Terapéutica , Malformaciones Arteriovenosas Intracraneales/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Polímeros/administración & dosificaciónRESUMEN
The WEB is an endovascular flow-disrupting device used in treating wide-necked intracranial aneurysms. Although the device is available in varying sizes, large aneurysms pose a challenge with the need for custom-made devices. We describe the use of coils as an adjunct to the WEB device in successfully treating large aneurysms in two patients, one with an acutely ruptured aneurysm. This novel technique of jailing a microcatheter, deploying the WEB and then coiling the aneurysm saves the need for intracranial stenting, thereby avoiding the need for antiplatelet therapy, which is of benefit in the setting of acute aneurysm rupture.
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Embolización Terapéutica/instrumentación , Aneurisma Intracraneal/terapia , Microcirugia , Prótesis Vascular , Angiografía Cerebral , Embolización Terapéutica/métodos , Femenino , Humanos , Aneurisma Intracraneal/patología , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Resultado del TratamientoRESUMEN
Percutaneous vascular embolization is one of the major applications of interventional radiology. A wide variety of embolization agents are currently available for clinical use. The interventional radiologist needs to be up to date with the newer and different types of embolic agents available along with their biopharmaceutical characteristics, strengths, and weaknesses that have been reviewed. For the purpose of this review, we have classified embolization agents into mechanical occlusion devices, particulate agents, and liquid agents, with some degree of overlap between some of the agents.
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Angioplastia Coronaria con Balón , Embolización Terapéutica , Hemoptisis/terapia , Radiología Intervencionista , Soluciones Esclerosantes/uso terapéutico , Angioplastia Coronaria con Balón/métodos , Embolización Terapéutica/instrumentación , Embolización Terapéutica/tendencias , Femenino , Gelatina , Hemoptisis/diagnóstico por imagen , Humanos , Masculino , Microesferas , Polivinilos , Radiografía , Radiología Intervencionista/métodos , Adhesivos Tisulares/uso terapéuticoAsunto(s)
Cefaleas Primarias/diagnóstico por imagen , Cefaleas Primarias/etiología , Hemorragia Subaracnoidea/complicaciones , Angiografía de Substracción Digital , Humanos , Masculino , Persona de Mediana Edad , Hemorragia Subaracnoidea/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Trombosis de la Vena/complicaciones , Trombosis de la Vena/diagnóstico por imagenRESUMEN
Pelvic congestion syndrome (PCS) is an important cause of chronic pelvic pain in female patients. Chronic pelvic pain, defined as lower abdominal or pelvic pain for a duration of 6 months or more, causes significant morbidity and results in a large number of diagnostic laparoscopies. It is of utmost importance to identify treatable causes of chronic pelvic pain, one of which is PCS. The etiology, clinical features, investigations, and treatment options in PCS have been discussed in this paper.
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Diagnóstico por Imagen , Ovario/irrigación sanguínea , Dolor Pélvico/diagnóstico , Dolor Pélvico/etiología , Dolor Pélvico/terapia , Várices/complicaciones , Várices/diagnóstico , Várices/terapia , Enfermedad Crónica , Femenino , Humanos , Dimensión del Dolor , SíndromeRESUMEN
Hypercholesterolemia is an important and easily modifiable risk factor for peripheral arterial disease (PAD), but is frequently not adequately addressed by vascular interventionists. Patients with PAD often have extensive atherosclerotic disease elsewhere and have a 1-year mortality rate as high as 20%, mainly from cardiovascular events. This case discussion briefly addresses the evidence for treating hypercholesterolemia in this subgroup of patients. Statins not only lower cholesterol, but also are antiinflammatory, antiproliferative, and antithrombogenic, and improve endothelial function. Current guidelines are reviewed and an approach to initiation of statins and their management is discussed.
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Angioplastia de Balón , Arteriopatías Oclusivas/terapia , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Hipercolesterolemia/tratamiento farmacológico , Claudicación Intermitente/terapia , Angioplastia de Balón/instrumentación , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/etiología , Medicina Basada en la Evidencia , Humanos , Hipercolesterolemia/sangre , Hipercolesterolemia/complicaciones , Claudicación Intermitente/diagnóstico por imagen , Claudicación Intermitente/etiología , Lípidos/sangre , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Radiografía , Stents , Resultado del TratamientoRESUMEN
Thomas Willis is best known for the circle of Willis. The life story of this 17th- century medical genius, who remains an inspiration for all neuroscientists 300 years later, is summarized in this article. We outline his academic achievements, including his description of the famous basal arterial circle, and we attempt to obtain insight into his visionary thought process through this historical review.
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Círculo Arterial Cerebral , Neuroanatomía/historia , Neurociencias/historia , Médicos/historia , Historia del Siglo XVII , Retratos como AsuntoRESUMEN
The authors report a rare case of an aneurysm arising at fenestrated anterior cerebral artery. The embryogenesis of this anatomical variation is discussed along with the review of relevant literature. Management of such lesions depends upon the location and morphology of the aneurysms and intracranial vascular anatomy. The authors discuss various management options and highlight possible technical difficulties that can be encountered in the surgical management of this rare sub-group of aneurysms.
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Aneurisma Roto/cirugía , Arteria Cerebral Anterior/anomalías , Aneurisma Intracraneal/cirugía , Malformaciones Arteriovenosas Intracraneales/cirugía , Hemorragia Subaracnoidea/etiología , Aneurisma Roto/complicaciones , Aneurisma Roto/patología , Arteria Cerebral Anterior/cirugía , Humanos , Aneurisma Intracraneal/complicaciones , Aneurisma Intracraneal/patología , Malformaciones Arteriovenosas Intracraneales/complicaciones , Malformaciones Arteriovenosas Intracraneales/patología , Masculino , Persona de Mediana Edad , Enfermedades Raras/cirugía , Hemorragia Subaracnoidea/patología , Hemorragia Subaracnoidea/cirugía , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
We report two cases of broncho-pleural fistula resulting from trans-diaphragmatic migration of the distal catheter of a ventriculo-peritoneal shunt. Relevant literature on thoracic complications of a ventriculo-peritoneal shunt is reviewed. The clinical presentation, diagnosis and management of V-P shunt-related broncho-pleural fistulae are discussed.