Endovascular treatment of tandem extracranial/intracranial anterior circulation occlusions: preliminary single-center experience.

BACKGROUND AND PURPOSE: Acute ischemic stroke due to tandem occlusions of the extracranial internal carotid artery and intracranial arteries has a poor natural history. We aimed to evaluate our single-center experience with endovascular treatment of this unique stroke population. METHODS: Consecutive patients with tandem occlusions of the internal carotid artery origin and an intracranial artery (ie, internal carotid artery terminus, M1 middle cerebral artery, or M2 middle cerebral artery) were studied retrospectively. Treatment consisted of proximal revascularization with angioplasty and stenting followed by intracranial intervention. Endpoints were recanalization of both extracranial and intracranial vessels (Thrombolysis In Myocardial Ischemia ≥2), parenchymal hematoma, and good clinical outcome (modified Rankin Scale ≤2) at 3 months. RESULTS: We identified 77 patients with tandem occlusions. Recanalization occurred in 58 cases (75.3%) and parenchymal hematoma occurred in 8 cases (10.4%). Distal embolization occurred in 3 cases (3.9%). In 18 of 77 patients (23.4%), distal (ie, intracranial) recanalization was observed after proximal recanalization, obviating the need for distal intervention. Good clinical outcomes were achieved in 32 patients (41.6%). In multivariate analysis, Thrombolysis In Myocardial Ischemia ≥2 recanalization, baseline National Institutes of Health Stroke Scale score, baseline Alberta Stroke Programme Early CT score, and age were significantly associated with good outcome. CONCLUSIONS: Endovascular therapy of tandem occlusions using extracranial internal carotid artery revascularization as the first step is technically feasible, has a high recanalization rate, and results in an acceptable rate of good clinical outcome. Future randomized, prospective studies should clarify the role of this approach.

Role of endothelin-1 in human aneurysmal subarachnoid hemorrhage: associations with vasospasm and delayed cerebral ischemia.

BACKGROUND: Endothelin-1 (ET-1) is a potent vasoconstrictor implicated in the pathogenesis of vasospasm and delayed cerebral ischemia (DCI) in aneurysmal subarachnoid hemorrhage (aSAH) patients. The aim of this study was to investigate the relationship between cerebrospinal fluid (CSF) ET-1 levels and angiographic vasospasm and DCI. METHODS: Patients with aSAH were consented (n = 106). Cerebral vasospasm was determined by angiography. DCI was determined by transcranial Doppler (TCD) results and/or angiogram results with corresponding clinical deterioration. CSF ET-1 levels over 14 days after the initial insult was quantified by ELISA. ET-1 analysis included a group-based trajectory analysis and ET-1 exposure rate during 24, 48, and 72 h prior to, as well as 72 h post angiography, or clinical deterioration. RESULTS: Trajectory analysis revealed two distinct groups of subjects with 56% of patients in the low ET-1 trajectory group (mean at day 1 = 0.31 pg/ml; SE = 0.04; mean at day 14 = 0.41 pg/ml; SE = 0.15) and 44% of patients in the high ET-1 trajectory group (mean at day 1 = 0.65 pg/ml; SE = 0.08; mean at day 14 = 0.61 pg/ml; SE = 0.06). Furthermore, we observed that ET-1 exposure rate 72 h before angiography and clinical spasm was a significant predictor of both angiographic vasospasm and DCI, whereas, ET-1 exposure after angiography and clinical spasm was not associated with either angiographic vasospasm or DCI. CONCLUSION: Based on these results we conclude that ET-1 concentrations are elevated in a sub-group of patients and that the acute (72 h prior to angiography and clinical neurological deterioration), but not chronic, elevations in CSF ET-1 concentrations are indicative of the pathogenic alterations of vasospasm and DCI in aSAH patients.

Symptomatic delayed reocclusion after initial successful revascularization in acute ischemic stroke.

BACKGROUND: Endovascular stroke therapy is used for patients with ischemic stroke after failed intravenous thrombolysis or in patients not eligible for thrombolytics. With increasing experience, acute reocclusion has been described and likely worsens clinical outcomes. We assessed the rates and outcomes of delayed symptomatic reocclusion after endovascular therapy for acute ischemic stroke. METHODS: Patients with acute ischemic stroke undergoing endovascular procedures at out institutions from January 2008 to August 2008 were reviewed. In all, 107 consecutive acute stroke interventions were performed. Four patients (3.5%) experienced delayed symptomatic reocclusion detectable by the National Institutes of Health Stroke Scale (NIHSS). RESULTS: The 4 patients (age 45-79 years) had baseline NIHSS score ranging from 8 to 24. Three had right middle cerebral artery occlusions and one had a left middle cerebral artery occlusion. Successful recanalization (thrombolysis in myocardial infarction score 2-3) occurred in all cases after initial treatment. All patients improved postprocedure (NIHSS score 5-10). Clinical deterioration (NIHSS score 14-22) occurred 12 to 18 hours postprocedure. Successful recanalization was achieved in each patient, with improvement in NIHSS score (range 6-13) but not to a lower level compared with after the initial intervention. CONCLUSIONS: Delayed symptomatic reocclusion after initial endovascular stroke therapy can lead to sudden clinical deterioration and impact outcomes. The entity may be missed as many patients present with large clinical deficits at presentation thus requiring careful assessments of patients treated via endovascular methods.

Elevated cardiac troponin I and relationship to persistence of electrocardiographic and echocardiographic abnormalities after aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Cardiac injury persistence after aneurysmal subarachnoid hemorrhage (aSAH) is not well described. We hypothesized that post-aSAH cardiac injury, detected by elevated cardiac troponin I (cTnI), is related to aSAH severity and associated with electrocardiographic and structural echocardiographic abnormalities that are persistent. METHODS: Prospective longitudinal study was conducted of patients with aSAH with Fisher grade >or=2 and/or Hunt/Hess grade >or=3. Serum cTnI was collected on Days 1 to 5; cohort dichotomized into peak cTnI >or=0.3 ng/mL (elevated) or cTnI <0.3 ng/mL. Relationships among cTnI and aSAH severity, 12-lead electrocardiography early (or=7 days), Holter monitoring on Days 1 to 5, and transthoracic echocardiogram (left ventricular ejection fraction and regional wall motion abnormalities) early (Days 0 to 5) and late (Days 5 to 12) were evaluated. RESULTS: Of 204 subjects, 31% had cTnI >or=0.3 ng/mL. cTnI >or=0.3 ng/mL was incrementally related to aSAH severity by admission symptoms (Hunt/Hess P=0.001) and blood load (Fisher P=0.028). More patients with cTnI >or=0.3 ng/mL had prolonged QTc on early (63% versus 30%, P<0.0001) and late electrocardiography (24% versus 7%, P=0.024). On Holter monitoring, more patients with cTnI >or=0.3 ng/mL had ventricular tachycardia/fibrillation (22% versus 9%, P=0.018) but not atrial fibrillation/flutter (P=0.241). Cardiac troponin I >or=0.3 ng/mL was associated with both early ejection fraction <50% (44% versus 5%, P<0.0001) and regional wall motion abnormalities (44% versus 4%, P<0.0001). Regional wall motion abnormalities predominated in basal and midventricular segments and persisted to some degree in 73% of patients affected, whereas ejection fraction <50% persisted in 59% of patients affected. CONCLUSIONS: Cardiac injury is incrementally worse with increasing aSAH severity and associated with persistent QTc prolongation and ventricular arrhythmias. Regional wall motion abnormalities and depressed ejection fraction persist to some degree in the majority of those affected.

Minimal-access technique for distal catheter insertion during ventricular peritoneal shunt procedures: a review of 100 cases.

The authors report the safety and efficacy of using a percutaneous minimal-access insertion technique for distal shunt catheter placement in 100 cases. From June 2007 to March 2008, they attempted 100 minimal-access insertions of distal shunt catheters in 91 patients who required ventriculoperitoneal shunting. Using the minimal-access approach, they avoided utilizing laparoscopic assistance or a mini-laparotomy in 91% of the cases. There were no bowel injuries or misplaced distal catheters. Additional outcomes in terms of operative times, cases that required conversion to open or laparoscopically assisted implantation, and infection rates are presented. They conclude that intraperitoneal shunt catheter placement can be safely and effectively accomplished using a simplified percutaneous minimal-access insertion method that does not require direct laparoscopic visualization.

APOE genotype and functional outcome following aneurysmal subarachnoid hemorrhage.

Apolipoprotein E (apoE), the major apolipoprotein in the central nervous system, has been shown to influence neurologic disease progression and response to neurologic injury in a gene-specific manner. Presence of the APOE4 allele is associated with poorer response to traumatic brain injury and ischemic stroke, but the association between APOE genotype and outcome following aneurysmal subarachnoid hemorrhage (SAH) remains unclear. The purpose of this project was to investigate the association between APOE genotype and outcome after SAH. We also explored the association of APOE4 genotype and cerebral vasospasm (CV) presence in a subsample of our population with available angiographic data. A sample of 206 aneurysmal SAH participants had APOE genotyping performed, Glasgow outcome scores (GOS) and modified Rankin scores (MRS) collected at 3 and 6 months after aneurysm rupture. No significant association was found between the presence of the APOE4 genotype and functional outcomes controlling for age, race, size of hemorrhage (Fisher grade), and severity of injury (Hunt & Hess grade). However when controlling for CV and the covariates listed above, individuals with the APOE4 allele had worse functional outcomes at both time points. The presence of the APOE2 allele was not associated with functional outcomes even when considering presence of CV. There was no difference in mortality associated with APOE4 presence, APOE2 presence, or presence of CV. These findings suggest APOE4 allele is associated with poor outcome after aneurysmal SAH.

Treatment of extracranial carotid artery pseudoaneurysms with stent grafts: case series.

BACKGROUND AND PURPOSE: Extracranial carotid artery pseudoaneurysms are a rare entity with a poorly defined natural history. Treatment has been limited to open surgical repair and limited experience with endovascular repair. We review our experience with the use of stent grafts to treat this disease entity. METHOD: We retrospectively reviewed the interventional databases of two university hospitals (Michigan State University and University of Pittsburgh Medical Center) between 2004 and 2006 to identify patients with carotid pseudoaneurysms that were treated with stent grafts. A total of five patients were identified. RESULTS: Of the five patients treated, four presented with acute bleeding secondary to carcinomatous invasion of the carotid artery, while one presented with thromboembolic events. Four of the five were successfully occluded with stent grafts. The one patient in whom the bleeding could not be stopped with the stent graft expired due to cardiac arrest. There were no peri-procedural complications noted as a result of stent graft placement. CONCLUSIONS: Stent grafts can be utilized to treat pseudoaneurysms safely, but may not always stop active extravasation as an isolated therapy. Long-term data is required to determine the durability of the treatment.

Extensive brainstem ischemia on neuroimaging does not preclude meaningful recovery from locked-in syndrome: two cases of endovascularly managed basilar thrombosis.

We report 2 patients with angiographically demonstrated basilar artery thrombosis who received emergent intra-arterial thrombolysis with successful recanalization of the basilar artery. In the ensuing weeks after the procedure, both patients were in a locked-in state and had sustained large bilateral regions of pontine ischemia on brain imaging. Following aggressive supportive care and rehabilitation, outcomes obtained prospectively revealed that both patients made a remarkable recovery, becoming fully independent with Barthel scores of 20 and modified Rankin scores of 2.

Ethylenevinylalcohol copolymer (Onyx-18) used in endovascular treatment of vein of Galen malformation.

BACKGROUND: Vein of Galen malformations (VGM) are rare congenital arteriovenous fistulas that usually present with heart failure in the neonate. Endovascular treatment options in the past have utilized coils, balloons, and acrylics. CASE REPORT: We present, for the first time in the literature, a case of an infant with VGM treated initially with staged coil embolizations followed 1 year later by the transarterial and transvenous catheter based injection of Onyx-18 (ethylenevinylalcohol copolymer) in a single treatment session. The fistula was eliminated, and the infant's cardiopulmonary symptoms were improved.

Diagnostic Accuracy of Somatosensory Evoked Potential Monitoring in Evaluating Neurological Complications During Endovascular Aneurysm Treatment.

BACKGROUND: Somatosensory evoked potential (SSEP) monitoring is used extensively for early detection and prevention of neurological complications in patients undergoing many different neurosurgical procedures. However, the predictive ability of SSEP monitoring during endovascular treatment of cerebral aneurysms is not well detailed. OBJECTIVE: To evaluate the performance of intraoperative SSEP in the prediction postprocedural neurological deficits (PPNDs) after coil embolization of intracranial aneurysms. METHODS: This population-based cohort study included patients ≥18 years of age undergoing intracranial aneurysm embolization with concurrent SSEP monitoring between January 2006 and August 2012. The ability of SSEP to predict PPNDs was analyzed by multiple regression analyses and assessed by the area under the receiver operating characteristic curve. RESULTS: In a population of 888 patients, SSEP changes occurred in 8.6% (n = 77). Twenty-eight patients (3.1%) suffered PPNDs. A 50% to 99% loss in SSEP waveform was associated with a 20-fold increase in risk of PPND; a total loss of SSEP waveform, regardless of permanence, was associated with a greater than 200-fold risk of PPND. SSEPs displayed very good predictive ability for PPND, with an area under the receiver operating characteristic curve of 0.84 (95% CI 0.76-0.92). CONCLUSION: This study supports the predictive ability of SSEPs for the detection of PPNDs. The magnitude and persistence of SSEP changes is clearly associated with the development of PPNDs. The utility of SSEP monitoring in detecting ischemia may provide an opportunity for neurointerventionalists to respond to changes intraoperatively to mitigate the potential for PPNDs.

Safety, feasibility, and short-term follow-up of drug-eluting stent placement in the intracranial and extracranial circulation.

BACKGROUND AND PURPOSE: The use of bare metal stents to treat symptomatic intracranial stenosis may be associated with significant restenosis rates. The advent of drug-eluting stents (DESs) in the coronary circulation has resulted in a reduction of restenosis rates. We report our technical success rate and short-term restenosis rates after stenting with DESs in the intracranial and extracranial circulation. METHODS: This study was a retrospective review of the period between April 1, 2004, and April 15, 2006, of 59 patients with 62 symptomatic intracranial or extracranial atherosclerotic lesions at 2 medical centers (University of Pittsburgh and Borgess Medical Center). RESULTS: The mean age of our cohort was 61+/-12 years. The location of the 62 lesions was as follows: extracranial vertebral artery 31 (50%), intracranial vertebral artery or basilar artery 18 (29%), extracranial internal carotid artery (ICA) near the petrous bone 5 (8%), and intracranial ICA 8 (13%). There were 2 (3%) periprocedural complications: 1 non-flow-limiting dissection and 1 disabling stroke. Fifty vessels were available for follow-up angiography or computed tomography angiography at a median time of 4.0+/-2 months. A total of 2 of 36 extracranial stents (7%) and 1 of 26 intracranial stents (5%) were found to have restenosis > or = 50% at follow-up. CONCLUSIONS: This report demonstrates that DES delivery in the intracranial and extracranial circulation is technically feasible. A small percentage of patients developed short-term in-stent restenosis. Longer-term follow-up is required in the setting of a prospective study to determine the late restenosis rates for DESs in comparison with bare metal stents.

Multimodal reperfusion therapy for acute ischemic stroke: factors predicting vessel recanalization.

BACKGROUND AND PURPOSE: Endovascular therapies using mechanical and pharmacological modalities for large vessel occlusions in acute stroke are rapidly evolving. Our aim was to determine whether one modality is associated with higher recanalization rates. METHODS: We retrospectively reviewed 168 consecutive patients treated with intra-arterial (IA) therapy for acute ischemic stroke between May 1999 and November 15, 2005. Demographic, clinical, radiographic, angiographic, and procedural notes were reviewed. Recanalization was defined as achieving thrombolysis in myocardial infarction 2 or 3 flow after intervention. A logistic regression model was constructed to determine independent predictors of successful recanalization. RESULTS: A total of 168 patients were reviewed with a mean age of 64+/-13 years and mean National Institutes of Health Stroke Scale score of 17+/-4. Recanalization was achieved in 106 (63%) patients. Independent predictors of recanalization include: the combination of IA thrombolytics and glycoprotein IIb/IIIa inhibitors (odds ratio [OR], 2.9 [95% CI, 1.04 to 6.7]; P<0.048), intracranial stent placement with angioplasty (OR, 4.8 [95% CI, 1.8 to 10.0]; P<0.001), or extracranial stent placement with angioplasty (OR, 4.2 [95% CI, 1.4 to 9.8]; P<0.014). Lesions at the terminus of the internal carotid artery were recalcitrant to revascularization (OR, 0.34 [95% CI, 0.16 to 0.73]; P value 0.006). CONCLUSIONS: Intracranial or extracranial stenting or combination therapy with IA thrombolytics and glycoprotein IIb/IIIa inhibitors in the setting of multimodal therapy is associated with successful recanalization in patients treated with multimodal endovascular reperfusion therapy for acute ischemic stroke.

Magnesium infusion for vasospasm prophylaxis after subarachnoid hemorrhage.

OBJECT: Despite the application of current standard therapies, vasospasm continues to result in death or major disability in patients treated for ruptured aneurysms. The authors investigated the effectiveness of continous MgSO4 infusion for vasospasm prophylaxis. METHODS: Seventy-six adults (mean age 54.6 years; 71% women; 92% Caucasian) were included in this comparative matched-cohort study of patients with aneurysmal subarachnoid hemorrhage on the basis of computed tomography (CT) findings. Thirty-eight patients who received continuous MgSO4 infusion were matched for age, race, sex, treatment option, Fisher grade, and Hunt and Hess grade to 38 historical control individuals who did not receive MgSO4infusion. Twelve grams of MgSO4 in 500 ml normal saline was given intravenously daily for 12 days if the patient presented within 48 hours of aneurysm rupture. Vasospasm was diagnosed on the basis of digital substraction angiography, CT angiography, and transcranial Doppler ultrasonography, and evidence of neurological deterioration. Symptomatic vasospasm was present at a significantly lower frequency in patients who received MgSO4 infusion (18%) compared with patients who did not receive MgSO4 (42%) (p = 0.025). There was no significant difference in mortality rate at discharge (p = 0.328). A trend toward improved outcome as measured by the modifed Rankin Scale (p = 0.084), but not the Glasgow Outcome Scale (p = 1.0), was seen in the MgSO4 treated group. CONCLUSIONS: Analysis of the results suggests that MgSO4 infusion may have a role in cerebral vasospasm prophylaxis if therapy is initiated within 48 hours of aneurysm rupture.

Neuroform stent-assisted coil embolization of a ruptured A1 segment anterior cerebral artery aneurysm.

We report a case of a 71-year-old woman who presented with a ruptured wide-necked proximal anterior cerebral artery (ACA) aneurysm that was successfully embolized using Neuroform stent-assisted coiling.

Long-term outcomes of intradural cervical dorsal root rhizotomy for refractory occipital neuralgia.

OBJECT Occipital neuralgia (ON) causes chronic pain in the cutaneous distribution of the greater and lesser occipital nerves. The long-term efficacy of cervical dorsal root rhizotomy (CDR) in the management of ON has not been well described. The authors reviewed their 14-year experience with CDR to assess pain relief and functional outcomes in patients with medically refractory ON. METHODS A retrospective chart review of 75 ON patients who underwent cervical dorsal root rhizotomy, from 1998 to 2012, was performed. Fifty-five patients were included because they met the International Headache Society's (IHS) diagnostic criteria for ON, responded to CT-guided nerve blocks at the C-2 dorsal nerve root, and had at least one follow-up visit. Telephone interviews were additionally used to obtain data on patient satisfaction. RESULTS Forty-two patients (76%) were female, and the average age at surgery was 46 years (range 16-80). Average follow up was 67 months (range 5-150). Etiologies of ON included the following: idiopathic (44%), posttraumatic (27%), postsurgical (22%), post-cerebrovascular accident (4%), postherpetic (2%), and postviral (2%). At last follow-up, 35 patients (64%) reported full pain relief, 11 (20%) partial relief, and 7 (16%) no pain relief. The extent of pain relief after CDR was not significantly associated with ON etiology (p = 0.43). Of 37 patients whose satisfaction-related data were obtained, 25 (68%) reported willingness to undergo repeat surgery for similar pain relief, while 11 (30%) reported no such willingness; a single patient (2%) did not answer this question. Twenty-one individuals (57%) reported that their activity level/functional state improved after surgery, 5 (13%) reported a decline, and 11 (30%) reported no difference. The most common acute postoperative complications were infections in 9% (n = 5) and CSF leaks in 5% (n = 3); chronic complications included neck pain/stiffness in 16% (n = 9) and upper-extremity symptoms in 5% (n = 3) such as trapezius weakness, shoulder pain, and arm paresthesias. CONCLUSIONS Cervical dorsal root rhizotomy provides an efficacious means for pain relief in patients with medically refractory ON. In the appropriately selected patient, it may lead to optimal outcomes with a relatively low risk of complications.

Emergent stenting of extracranial internal carotid artery occlusion in acute stroke has a high revascularization rate.

BACKGROUND AND PURPOSE: Acute ischemic stroke attributable to extracranial internal carotid artery (ICA) occlusion is frequently associated with severe disability or death. In selected cases, revascularization with carotid artery stenting has been reported, but the safety, recanalization rate, and clinical outcomes in consecutive case series are not known. METHODS: We retrospectively reviewed all of the cases of ICA occlusions that underwent cerebral angiography with the intent to revascularize over a 38-month period. Two groups were identified: (1) patients who presented with an acute clinical presentation within 6 hours of symptom onset (n=15); and (2) patients who presented subacutely with neurologic fluctuations because of the ICA occlusion (n=10). RESULTS: Twenty-five patients with a mean age of 62+/-11 years and median National Institutes of Health Stroke Scale (NIHSS) of 14 were identified. Twenty-three of the 25 patients (92%) were successfully revascularized with carotid artery stenting. Patients in group 1 were younger and more likely to have a tandem occlusion and higher baseline NIHSS when compared with group 2. Patients in group 2 were more likely to show early clinical improvement defined as a reduction of their NIHSS by > or =4 points and a modified Rankin Score of < or =2 at 30-day follow-up. Two clinically insignificant adverse events were noted: 1 asymptomatic hemorrhage and 1 nonflow-limiting dissection. CONCLUSIONS: Endovascular treatment of acute ICA occlusion appears to have a high-recanalization rate and be relatively safe in our cohort of patients with acute ICA occlusion. Future prospective studies are necessary to determine which patients are most likely to benefit from this form of therapy.

Mental health, anxiety, and depression in patients with cerebral aneurysms.

OBJECT: Aneurysm disease and its treatment can have an adverse impact on mental health, yet the affects of cerebral aneurysms on general mental health, anxiety, and depression are poorly understood. METHODS: Patients with cerebral aneurysms who were seen at a neurosurgery clinic underwent a structured interview, completed the Hospital Anxiety and Depression Scale and the Medical Outcomes Study 12-item Short Form Health Survey (providing a mental component summary [MCS] score for general mental health), and were assigned functional status scores based on the Glasgow Outcome Scale (GOS), Rankin Scale, and Barthel Index. Rank-order methods were used to assess the relationship between mental health, aneurysm characteristics and history, and functional status. Data were collected in 166 patients (71% women) with a mean age of 53.7 years. Depression was present in 8% of the study population and an anxiety disorder in 17%. Patients with both an unsecured aneurysm and a history of subarachnoid hemorrhage (SAH) tended toward higher anxiety scores (p = 0.086). Higher depression scores were associated with a decreased functional status on the GOS (p = 0.015) and Rankin Scale (p = 0.010). The mean +/- standard deviation adjusted MCS score (37.9 +/- 7.1) was significantly less than that of the US population (p < 0.001). Lower MCS scores were associated with a decreased functional status on the GOS (p = 0.052), Rankin Scale (p < 0.001), and Barthel Index (p = 0.002). CONCLUSIONS: Patients with cerebral aneurysms have increased levels of anxiety and depression and poor general mental health. Those who have experienced an SAH and harbor an unsecured cerebral aneurysm demonstrate increased levels of anxiety. A lower functional status in patients with aneurysms is associated with depression and decreased general mental health.

The short form-12 and the measurement of health status in patients with cerebral aneurysms: performance, validity, and reliability.

OBJECT: Cerebral aneurysms can affect a patient's health status by rupture and stroke, impingement on neural structures, treatment side effects, or psychological stress. The authors assessed the performance, validity, and reliability of the Short Form-12 (SF-12), a self-administered written survey instrument, to assess health status in patients with cerebral aneurysms. METHODS: A cohort of 170 patients with cerebral aneurysms who were seen at a neurosurgery clinic underwent structured interviews including measurement of their health statuses (SF-12 physical component summary [PCS] and mental component summary [MCS]), functional status (Glasgow Outcome Scale score, modified Rankin Scale score, and Barthel Index), and mental health (Hospital Anxiety and Depression Scale score). The SF-12 scores were compared with US population norms by performing t-tests with unequal variances. The validity of the SF-12 was assessed by comparing the PCS and MCS scores with each patient's functional status and mental health scores by using rank-order methods. Inter-item reliability was assessed using the Cronbach alpha statistic. Patients with cerebral aneurysms had decreased health status PCS and MCS scores when compared with population norms (p < 0.001 for all). A history of subarachnoid hemorrhage (SAH) (p = 0.006) and previous surgical or endovascular treatment (p = 0.047) was associated with worse PCS scores. The validity of the SF-12 was supported by the relationship between the PCS and MCS scores and the patient's functional status and mental health (p < 0.001 for all). The reliability of the SF-12 was documented by the Cronbach alpha statistic (alpha = 0.76). CONCLUSIONS: Patients with cerebral aneurysms have a diminished physical and mental health status as measured using the SF-12. The presence of SAH and aneurysm treatment are associated with a worse physical health status. The SF-12 is a valid and reliable instrument for measuring health status in patients with cerebral aneurysms.

Endothelin-1 gene polymorphisms influence cerebrospinal fluid endothelin-1 levels following aneurysmal subarachnoid hemorrhage.

Aneurysmal subarachnoid hemorrhage is a type of stroke with high morbidity and mortality. Increased endothelin-1 (ET-1) levels have been associated with increased risk of cerebral vasospasm, which is associated with increased morbidity. The purpose of this study was to investigate the relationships between ET-1 genotypes and ET-1 protein levels in cerebrospinal fluid (CSF) measured 72 hr before angiographic vasospasm measurement in subjects at high risk of cerebral vasospasm. Specifically, this study evaluated the differences between variant positive and variant negative groups of nine different ET-1 single-nucleotide polymorphisms (SNPs) in relationship with the ET-1 protein exposure rate. The CSF ET-1 protein levels were quantified using enzyme-linked immunosorbent assay. One functional SNP and eight ET-1 tagging SNPs were selected because they represent genetic variability in the entire ET-1 gene. The variant negative group of SNP rs2070699 was associated with a significantly higher ET-1 exposure rate than the variant positive group (p = 0.004), while the variant positive group of the rs5370 group showed a trend toward association with a higher ET-1 exposure rate (p = 0.051). Other SNPs were not informative. This is the first study to show differences in ET-1 exposure rate 72 hr before angiography in relation to ET-1 genotypes. These exploratory findings need to be replicated in a larger study; if replicated, these differences in genotypes may be a way to inform clinicians of those patients at a higher risk of increased ET-1 protein levels, which may lead to a higher risk of angiographic vasospasm.

A rare case of a ruptured middle meningeal aneurysm causing intracerebral hematoma in a patient with moyamoya disease.

Moyamoya disease is infrequently associated with intracranial aneurysms arising from the circle of Willis vessels or from "peripheral" branches of choroidal and meningeal vessels. We present a rare case of a moyamoya-related aneurysm arising along the dural junction of multiple meningeal branches from the external carotid artery causing intracerebral hemorrhage. Endovascular coil embolization of the middle meningeal artery (MMA) and occipital artery (OA) led to delayed aneurysm obliteration without rehemorrhage.