Use of intracranial stent as rescue therapy after mechanical thrombectomy failure-9-year experience in a comprehensive stroke centre.

PURPOSE: There is no established rescue treatment in patients with mechanical thrombectomy (MT) failure. Our aim is to analyse whether the use of an intracranial stent improves prognosis in these patients. METHODS: Retrospective analysis of a prospective cohort of patients with ischemic stroke due to middle cerebral artery occlusion (MCA) or distal intracranial carotid artery (ICA) occlusion, from September 2009 to April 2019 in our comprehensive stroke care centre. Patients with MT failure were identified and dichotomized into two groups according to whether or not an intracranial stent was implanted. We analysed clinical outcomes in both groups. RESULTS: There was MT failure in 60 patients (14%) of the 433 with large vessel occlusion in distal ICA and proximal MCA. A stent was placed in 20 of them (33.3%). Compared to patients without rescue stenting, they showed better rates of independence at 3 months (mRS ≤ 2) 45% vs 2.5% (p < 0.001) and lower mortality 15% vs 50% (p = 0.009), maintaining statistical significance after multivariate analysis, without a significant increase of the rate of symptomatic intracranial haemorrhage (p = 0.209). CONCLUSION: Placement of an intracranial stent as rescue therapy after MT failure was associated with better clinical outcome without significant increase in haemorrhagic complications. We believe that this procedure should be appraised in these patients.

Radiation Doses in Patient Eye Lenses during Interventional Neuroradiology Procedures.

BACKGROUND AND PURPOSE: Eye lenses are among the most sensitive organs to x-ray radiation and may be considered at risk during neurointerventional radiology procedures. The threshold dose to produce eye lens opacities has been recently reduced to 500 mGy by the International Commission on Radiologic Protection. In this article, the authors investigated the radiation doses delivered to patients' eyes during interventional neuroradiology procedures at a university hospital. MATERIALS AND METHODS: Small optically stimulated luminescence dosimeters were located over patients' eyes during 5 diagnostic and 31 therapeutic procedures performed in a biplane x-ray system. Phantom measurements were also made to determine the level of radiation to the eye during imaging runs with conebeam CT. RESULTS: The left eye (located toward the lateral C-arm x-ray source) received a 4.5 times greater dose than the right one. The average dose during embolization in the left eye was 300 mGy, with a maximum of 2000 mGy in a single procedure. The patient who received this maximum eye dose needed 6 embolization procedures to treat his high-volume AVM. If one took into account those 6 embolizations, the eye dose could be 2-fold. Sixteen percent of the embolizations resulted in eye doses of >500 mGy. CONCLUSIONS: A relevant fraction of patients received eye doses exceeding the threshold of 500 mGy. A careful optimization of the procedures and follow-up of these patients to evaluate potential lens opacities should be considered.

Suboptimal interventional conditions for the occlusion of ruptured intracranial aneurysms do not increase periprocedural complications and poor clinical outcomes.

BACKGROUND AND OBJECTIVE: Occluding a ruptured intracranial aneurysm as early as possible may entail certain periprocedural conditions that compromise the outcome. The aim of the present study was to evaluate the effectiveness, safety, and clinical outcome of endovascular coiling procedures performed on an emergency basis under potentially suboptimal conditions, and to compare results with those from scheduled procedures under potentially optimal conditions. METHODS: Interventions performed on 66 SAH patients were retrospectively analysed by classifying them into two groups: under emergency (within three hours from diagnosis or during non-standard working hours) or scheduled conditions. A binary logistic regression analysis was also performed to identify characteristics associated with poor outcomes. RESULTS: No differences in effectiveness, periprocedural complications, or clinical outcomes were found between the two groups. Rebleeding was detected in 4.8 % of the emergency interventions and 2.2 % of the scheduled interventions. Multivariate analysis identified age and Hunt and Hess grade, but no conditions of treatment, as the factors associated to poor outcome. CONCLUSION: Suboptimal interventional conditions for occluding ruptured intracranial aneurysms, such as performing procedures outside of standard working hours or within three hours of diagnosis, do not result in increased periprocedural complications and poor clinical outcomes compared with scheduled procedures under potentially optimal conditions. These results suggest the need for treatment to be provided as soon as possible.

Brain radiation doses to patients in an interventional neuroradiology laboratory.

BACKGROUND AND PURPOSE: In 2011, the International Commission on Radiologic Protection established an absorbed-dose threshold to the brain of 0.5 Gy as likely to produce cerebrovascular disease. In this paper, the authors investigated the brain doses delivered to patients during clinical neuroradiology procedures in a university hospital. MATERIALS AND METHODS: The radiation dose delivered to the brain was investigated in 99 diagnostic and therapeutic interventional neuroradiology procedures. Brain doses were calculated in a mathematic model of an adult standard anthropomorphic phantom by using the technical and radiation dose data of an x-ray biplane system submitted to regular quality controls and calibration programs. RESULTS: For cerebral embolizations, brain doses resulted in a maximum value of 1.7 Gy, with an average value of 500 mGy. Median and third quartile resulted in 400 and 856 mGy, respectively. For cerebral angiography, the average dose in the brain was 100 mGy. CONCLUSIONS: This work supports the International Commission on Radiologic Protection recommendation on enhancing optimization when doses to the brain could be higher than 0.5 Gy. Radiation doses should be recorded for all patients and kept as low as reasonably achievable. For pediatric patients and young adults, an individual evaluation of brain doses could be appropriate.

Combined staged therapy of complex arteriovenous malformations: initial experience.

OBJECTIVES: Definitive treatment of complex supratentorial arteriovenous malformations (AVMs) has been classically assigned to ruptured or progressively symptomatic cases. The aim of this study is to report our initial experience in the treatment of complex AVMs by means of staged embolization with Onyx followed by microsurgery. MATERIAL AND METHODS: Thirteen consecutive patients with supratentorial Spetzler-Martin grades III, IV and V AVMs were treated between January 2009 and June 2010. Mean age at the beginning of the therapy was 34. All patients were symptomatic. Mean AVM size was 48 mm, and mean volume prior to embolization was 47 ml. RESULTS: Mean number of endovascular procedures was 3, and mean volumetric obliteration prior to surgery was 79.2%. Mean time between two embolizations was 24 days. One patient showed a non-disabling complication after endovascular procedures. Mean time between the last embolization and surgery was 42 days. Two patients showed disabling complications after surgery, and one patient showed a non-disabling complication. Follow-up angiography showed the complete removal of permeable AVM in all patients. According to the modified Rankin Scale, all patients were non-dependent concerning daily life activity at 6-month follow-up. One-year follow-up angiography has been performed in 11 patients so far showing an absence of permeable AVM in spite of the remainder intravascular Onyx. CONCLUSIONS: Staged preoperative embolization with Onyx followed by microsurgery has made possible 100% cure of complex AVMs with 0% mortality, 15.4% disabling complications and 15.4% non-disabling complications. Complete Onyx resection is not essential to achieve the cure of the patient.

Cytological changes induced by embolization in meningiomas.

OBJECTIVE: To describe cytological changes in meningiomas induced by embolization, which may be carried out a few days before surgery in order to soften the tumour and minimize intraoperative bleeding. Although histological changes have been described, we have found no description of such changes in the cytological literature. METHODS: We reviewed 22 cases of meningiomas with prior embolization in which cytological material was obtained during intraoperative consultation. In 13 of them recognizable cytological changes induced by embolization were present. On histology, these 13 tumours were grade I and showed intravascular embolic material. RESULTS: Cellular dissociation was prominent, with frequent single cells and small groups. Ischaemic cellular changes were a common finding and consisted of cell shrinkage, nuclear pyknosis and karyorrhexis. Confluent areas of necrosis were seen in one case. Additionally, numerous macrophages were present, many containing cellular debris, and neutrophils, giving a characteristic appearance of acute cellular ischaemia. Embolic material was seen cytologically in four cases as well-defined spherules surrounded by empty halos. Features of viable meningioma were recognized in all cases. CONCLUSION: Embolization of meningiomas induces cytological changes that mirror those seen on histology, but cellular dissociation with changes of ischaemia may result in a worrisome image. When faced with such changes the pathologist should consider the possibility of embolization, avoiding misdiagnosis of higher grade meningioma or metastatic carcinoma.

[Endovascular treatment for acute stroke: an open field to begin]. / Tratamiento endovascular del ictus agudo: un campo muy abierto que está por iniciar.

INTRODUCTION: The evidence that recanalization and reperfusion of the distal vascular bed in appropriately selected patients is crucial to achieve good functional outcome has triggered interest and research into endovascular treatment of acute ischemic stroke. DEVELOPMENT: Intravenous (iv) thrombolytic therapy is the treatment of choice in patients with acute ischemic stroke, however, it has certain limitations. Endovascular treatment is a promising alternative with theoretical advantages over iv therapy, such as an increased frequency of recanalization and longer therapeutic windows. Endovascular reperfusion strategies include intra-arterial fibrinolysis with drugs, or endovascular mechanical devices for thrombectomy or thrombus disruption, thromboaspiration, or thrombus entrapment in the vessel wall. The ideal of comprehensive treatment of acute stroke would provide specificity to treat an individual patient: with specific arterial occlusion and collaterals and a determined physiology of acute cerebral ischemia. With all this information, we would decide the best therapeutic strategy for the patient, and move from just a time-based approach to include a pathophysiology approach as well, and thus different patients could have different therapeutic windows. The endovascular treatment situation in Spain is heterogeneous and requires human and material resources to enable it to be implemented throughout the country. CONCLUSIONS: Endovascular treatment of stroke is a new therapeutic tool for achieving reperfusion safely in patients ineligible for Alteplase or who have failed reperfusion with an iv fibrinolytic.

Malformacion aneurismatica de la vena galeno / Vein of galen aneurysmatic malformation

Se estudiaron tres niñas y dos niños con malformación aneurismática de la vena de Galeno ( MAVG), tanto clínica como radiológicamente, durante 4 años. Dos tipos de angioarquitectura se encontraron y explican porque las macro fístulas del tipo coroidal que tenían tres pacientes se tuvieron que tratar con embolización agresiva por terapia endovascular, dado el gran compromiso neurológico. El cuarto caso se trataba de una MAVG de tipo mural en una niña asintomática que solamente presentaba macrocránea y en la que la familia no permitía ninguna intervención terapéutica. El quinto caso fue un hallazgo incidental en cirugía, ya que la resonancia y la angiografía fueron negativas para malformación vascular

Spontaneous intracranial hypotension: use of unenhanced MRI.

We report a case of spontaneous intracranial hypotension diagnosed with unenhanced cranial MRI, showing laminar subdural fluid and engorgement of the hypophysis and perisellar sinuses. Cerebrospinal fluid pressure was low. MRI was normal after resolution of symptoms. Prior reports emphasise the enhancing pachymeninges seen in this syndrome. We maintain that, when subdural collections and perisellar engorgement are detected on unenhanced MRI in the proper clinical setting, contrast enhancement may not be necessary for the diagnosis.

Cavernomas of the central nervous system: clinical and neuroimaging manifestations in 47 patients.

Forty seven cases of central nervous system cavernous angioma (21 males and 26 females) are described. The main clinical signs were epilepsy and brainstem syndromes. Digital subtraction intra-arterial angiography, when used, failed to reveal cavernoma. CT detected many of the lesions, but the most successful supplementary diagnostic procedure was MRI which produces highly characteristic images of cavernous angioma. The diagnosis of cavernous angioma was confirmed in the 18 cases in which the tumour was removed surgically.

[Images of magnetic resonance and computerized axial tomography in a case of subacute post-myocardial infarct heart rupture]. / Imágenes de resonancia magnética y tomografía axial computadorizada en un caso de rotura cardíaca subaguda postinfarto de miocardio.

In a patient with clinical and hemodynamic criteria of cardiac tamponade, during the acute phase of myocardial infarction, a two dimensional echocardiographic study showed pericardial effusion with an echo-dense mass in the pericardial space. Subacute ventricular free-wall rupture diagnosis was suspected. A cardiac computerized tomography (CT) and magnetic resonance (MR) study was made. CT showed an elevated density (32 HU) of pericardial effusion suggesting hemopericardium. RM imaging showed a very high and homogeneous signal in the pericardial space consistent with a methemoglobin phase clot. Anatomic confirmation was not possible.

[Cervicodorsal diastematomyelia in an adult]. / Diastematomielia cervicodorsal de presentación en un adulto.

A 44-year-old male had paraparesis which had began at age 20 years; a cleft spinal cord (diastematomyelia) was discovered at cervicodorsal level. The patient had nevus and hypertrichosis in the skin overlying the dysraphic spinal cord malformation. Both computer-assisted myelography and magnetic resonance scan showed the spinal cord segmentation and other associated disorders: bone spicula projecting between the 2 cordal halves, vertebral fusion defect and syringomyelic cavity. We emphasize the rarity of this abnormality in a so high spinal cord level and the onset of symptoms at adult age.

[Magnetic resonance in the evaluation of neurologic complications of cervical spondylosis]. / La resonancia magnética en la evaluación de las complicaciones neurológicas de la espondilosis cervical.

The evaluation of the neurological complications of cervical spondylosis frequently requires contrast myelography. Magnetic resonance (MR) scan would appear as a good alternative approach. We report the MR findings in 12 patients with symptoms and/or signs of spinal cord and radicular disease associated with cervical spondylosis, and we compare them with the conventional studies, including CT and CT assisted myelography. The MR image, weighted in T1, permitted to visualize the compressed spinal cord in the sagittal planes in 4 cases, with enhanced spinal cord signal in 2 of them. In a patient with herniated C5-C6 disk, the sagittal sections directly demonstrated the herniated material in the spinal canal, displacing and compressing the spinal cord. The sequences weighted in T2 demonstrated the degree of stenosis of the cervical canal caused by extradural compression. In these images, the diminished signal of the nucleus pulposus was correlated with degeneration of intervertebral disks. MR was more sensitive than the other studies to detect discal degeneration and herniation, stenosis of the spinal canal, compression of the subarachnoidal space and spinal cord injury.