Current management of symptomatic intracranial stenosis.

Intracranial arterial stenosis (IAS) is the cause of about 10% of all ischemic strokes in the United States, but may account for about 40% of strokes in some populations. After a stroke or transient ischemic attack due to IAS, patients face a 12% annual risk of recurrent stroke on medical therapy, with most strokes occurring in the first year. Warfarin is no better than aspirin in preventing recurrent strokes but poses a higher risk of serious bleeding and death. Groups with the highest risk of recurrent stroke are those with high-grade (≥ 70%) stenosis, those with recent symptom onset, those with symptoms precipitated by hemodynamic maneuvers, and women. Endovascular treatment of IAS is a rapidly evolving therapeutic option. Antiplatelet agents are currently recommended as the primary treatment for symptomatic IAS, with endovascular therapy reserved for appropriate high-risk cases refractory to medical therapy.

Middle cerebral artery vasospasm: transcranial color-coded duplex sonography versus conventional nonimaging transcranial Doppler sonography.

OBJECTIVE: To prospectively compare accuracies of transcranial color-coded duplex sonography (TCCS) and transcranial Doppler sonography (TCD) in the diagnosis of middle cerebral artery (MCA) vasospasm. DESIGN: Prospective blinded head-to-head comparison TCD and TCCS methods using digital subtraction angiography (DSA) as the reference standard. SETTING: Department of Radiology in a tertiary university health center in a metropolitan area. PATIENTS: Eighty-one consecutive patients (mean age, 53.9 +/- 13.9 years; 48 women). The indication for DSA was subarachnoid hemorrhage in 71 patients (87.6%), stroke or transient ischemic attack in five patients (6.2%), and other reasons in five patients (6.2%). INTERVENTIONS: The MCA was graded as normal, narrowed <50%, and >50% using DSA. The accuracy of ultrasound methods was estimated by total area (Az) under receiver operator characteristic curve. To compare sensitivities of ultrasound methods, McNemar's test was used with mean velocity thresholds of 120 cm/sec for the detection of less advanced, and 200 cm/sec for the more advanced MCA narrowing. MEASUREMENTS AND MAIN RESULTS: Angiographic MCA narrowing 50% in 10 of 135 arteries. Accuracy of TCCS was insignificantly higher than that of TCD in the detection of 50% narrowing, total Az for mean velocity being 0.83 +/- 0.05, 0.77 +/- 0.05, and 0.95 +/- 0.02, 0.86 +/- 0.08, respectively. Sensitivity of TCCS at commonly used threshold of 120 cm/sec for less advanced MCA spasm was significantly better than that of TCD at similar specificity, 55% vs. 39%, p = 0.038, whereas at a threshold of 200 cm/sec used for more advanced spasm, sensitivities and specificities of both methods were not different. CONCLUSION: The accuracy of TCCS and TCD is similar, but TCCS is more sensitive than TCD in the detection of MCA spasm. Sensitivity of both techniques in the detection of mild and more advanced spasm using 120 cm/sec and 200 cm/sec thresholds, respectively, is poor; however, a larger sample is required to increase precision of our sensitivity estimates.

Neurovascular emergencies in the elderly.

Neurovascular diseases are major causes of disability and death in the elderly; many present as medical emergencies. With the continuing growth of the geriatric population, there has been increasing interest in the impact of aging on the cerebrovascular system. Recent advances in the clinical neurosciences have demonstrated that neurovascular emergencies in the elderly often are amenable to treatment; neuroimaging plays a critical role in diagnosis and neurointerventional techniques are becoming increasingly important therapeutic options. This article provides an overview of some of the common neurovascular disorders in the elderly that require urgent evaluation and treatment, with an emphasis on the expanding role for interventional neuroradiology in their management.

Suitability of temporal bone acoustic window: conventional TCD versus transcranial color-coded duplex sonography.

PURPOSE AND BACKGROUND: To determine whether the proportion of patients with suitable temporal bone acoustic windows is different for conventional transcranial Doppler sonography (TCD) and transcranial color-coded duplex sonography (TCCS), based on a head-to-head comparison in the same population of patients. SUBJECTS AND METHODS: Ninety patients, age 22-88 years (mean 57.1 +/- 11.7 years), 46 women and 44 men, 66 Caucasian, 19 African-American, and five Hispanic, underwent routine conventional TCD and the TCCS examination close in time to each other. Suitability of temporal bone acoustic window was defined by ability to insonate the middle and posterior and/or anterior cerebral arteries, while partial suitability was defined by ability to detect the posterior cerebral artery but not the middle cerebral artery. To compare proportions of suitable temporal bone windows for both sonographic methods, exact sign test by Liddell was used. RESULTS: Bilateral absence of temporal bone acoustic window was reported in six patients when studied with both conventional TCD and TCCS, whereas at least unilateral absence was reported in 10 patients. Partial, at least unilateral, suitability was reported in 11 patients with conventional TCD, and in 7 with TCCS. All differences in proportions were not significant (two-sided P>0.05). CONCLUSIONS: This study suggests that success rate of insonating the intracranial vessels through the temporal bone acoustic window is the same for conventional TCD and imaging TCCS.

De novo aneurysm formation and regression after brain arteriovenous malformation embolization: case report.

BACKGROUND: The formation of de novo aneurysms is a known complication of vessel occlusion (Wright RL, Sweet WH. Carotid or vertebral occlusion in the treatment of intracranial aneurysms: value of early and late readings of carotid and retinal pressures. Clin Neurosurg 1962:9;163-192). Aneurysms most commonly develop on newly formed primary collateral routes as a result of increased flow through these collaterals. Development of aneurysms is not commonly seen in vessels whose flow has been directly decreased by therapeutic or natural occlusion. CASE DESCRIPTION: A 53-year-old woman with an intracerebral hemorrhage underwent cerebral angiography which demonstrated a right parietal AVM. An enlarged right ACA gave rise to 3 direct feeding pedicles. Leptomeningeal collaterals from the right MCA as well as the right PCA also gave collateral supply to the AVM. The lesion had superficial drainage into the superior sagittal sinus and deep venous drainage into the right posterior pericallosal vein. No feeding artery aneurysms or intranidal aneurysms were present. Treatment plan included preoperative embolization followed by surgical resection. CONCLUSION: To our knowledge, this is the first reported case of a de novo aneurysm forming and regressing in an artery hemodynamically related to an embolized AVM. The short timescale of its development (6 weeks) is also noteworthy. The spontaneous regression suggests that at least some aneurysms forming in vessels after abrupt decrease in distal runoff may have a self-limited course. Such lesions may do best if not subjected to direct endovascular or surgical treatment.

Lumbar vertebral hemangioma presenting with the acute onset of neurological symptoms. Case report.

Vertebral hemangiomas are common entities that rarely present with neurological deficits. The authors report the unusual case of a large L-3 vertebral hemangioma with epidural extension in a 27-year-old woman who presented with hip flexor and quadriceps weakness, foot drop, and leg pain. The characteristics of the mass on magnetic resonance imaging suggested an aggressive, hypervascular lesion. The patient underwent embolization of the lesion followed by direct intralesional injection of ethanol. Significant resolution of clinical symptoms was observed immediately after the procedure and at her follow-up visits. Follow-up imaging studies obtained 9 months after the procedure also documented a considerable reduction in the size of the hemangioma with minimal loss of vertebral height and a mild kyphosis at the affected level. On repeated imaging studies obtained 21 months postoperatively, the size of the hemangioma and the degree of vertebral body compression were stable. As demonstrated in this case, patients with vertebral hemangiomas can present with acute nerve root compression and signs and symptoms similar to those of disc herniation. Vertebral hemangiomas can be treated effectively with interventional techniques such as embolization and ethanol injection.

Carotid artery diameter in men and women and the relation to body and neck size.

BACKGROUND AND PURPOSE: To explore relationships among gender, body size, neck size, and the diameters of the common carotid artery (CCA) and internal carotid artery (ICA). METHODS: Using multivariate regression, the best predictors of sonographic diameters of CCA and ICA were determined based on age, height, weight, body mass index, body surface area, neck circumference, neck length, and blood pressure. RESULTS: Measurements were obtained in 500 consecutive patients (age 52+/-15 years; 61% women). Mean diameters of ICA (4.66+/-0.78 mm) and CCA (6.10+/-0.80 mm) in women were significantly smaller than in men: 5.11+/-0.87 mm and 6.52+/-0.98 mm, respectively. Sex significantly influenced the diameters after controlling for body size, neck size, age, and blood pressure. CONCLUSIONS: Carotid arteries are smaller in women even after adjusting for body and neck size, age, and blood pressure.

Stroke associated with Barth syndrome.

Barth syndrome is an inherited disorder characterized by dilated cardiomyopathy, neutropenia, growth retardation, and skeletal myopathy. We describe a case of acute stroke owing to Barth syndrome that required intra-arterial thrombolysis. This case suggests that cardiovascular complications can be observed in patients with Barth syndrome. Stroke prevention measures, including the use of antithrombotic agents, might be warranted.

Otologic manifestations of petrous carotid aneurysms.

BACKGROUND AND PURPOSE: The petrous and cavernous segments of the extradural internal carotid artery take a complex course through the skull base before entering the subarachnoid space distal to the cavernous sinus. Despite the protection from trauma afforded by the anatomy, the petrous and carotid internal carotid artery (ICA) segments of the vessel remains subject to disease, the most important of which are aneurysms. Aneurysms affecting the petrous portion of the vessel are extremely uncommon, and presentation with otologic symptoms is unusual. These symptoms include hearing loss, tinnitus, and life threatening hemorrhage. This article emphasizes the need for a high level of suspicion for aneurysm as a potential cause for otologic symptoms. We report and discuss three cases of petrous carotid aneurysms with otologic manifestations to increase the awareness and aid in the diagnosis and treatment of this uncommon disorder. METHODS: The medical records and imaging studies of three patients presenting to our institution with aneurysms involving the petrous internal carotid artery were reviewed. One presented with progressive bilateral sensorineural hearing loss. The next patient presented with pulsatile tinnitus. The last patient presented to the emergency room unresponsive with severe epistaxis. RESULTS: All three patients had imaging studies revealing petrous carotid aneurysms. Each patient had symptoms related to the aneurysms ranging from hearing loss, tinnitus, and life-threatening hemorrhage. CONCLUSION: Petrous carotid aneurysms are rare, and presentation with otologic symptoms is unusual. Awareness of these lesions as a cause of otologic symptoms, however, is highly important. These cases also illustrate the usefulness of endovascular treatments for aneurysms of the petrous portion of the internal carotid artery, which are extremely difficult to treat by using an open surgical approach.

Normal reference intervals and ranges of side-to-side and day-to-day variability of ocular blood flow Doppler parameters.

The study presents normal reference intervals and ranges of "normal" side-to-side and day-to-day variability of ocular blood flow Doppler parameters. Peak-systolic (PSV), end-diastolic velocity (EDV) and impedance indices in the ophthalmic artery (OA), the central retinal artery (CRA) and the short posterior ciliary artery (SPCA) of both orbits were determined with color-coded duplex sonography in 140 healthy volunteers (range 18 to 83 y; 68 men and 72 women). Decreases in flow velocities and concomitant increases in impedance indices were found in all arteries with advancing age. The PSV and the EDV values for the OA, the CRA and the SPCA in the age group less than 40 yr-old were 40.6 +/- 8.9 and 11.2 +/- 3.7, 9.9 +/- 1.8 and 3.7 +/- 0.9, 13.8 +/- 2.6 and 5.7 +/- 1.5 cm/s (mean +/- SD), respectively. In the 40 to 60 yr-old age group, the values were 35 +/- 7.9 and 10.7 +/- 4.3, 9.7 +/- 2 and 3.5 +/- 0.8, 13.5 +/- 2.9 and 5.3 +/- 1.5 cm/s. In the age group over 60 yr-old, the values were 34 +/- 8 and 8.4 +/- 3.3, 9.3 +/- 2 and 3 +/- 0.9, 12.8 +/- 2.4 and 4.3 +/- 1.2 cm/s. In the youngest age group, the EDV in the CRA and the SPCA was higher in women, while in the OA the PSV and the EDV were higher in men. Ranges of side-to-side variability in the OA, the CRA and the SPCA, determined with repeatability coefficient for the PSV and the EDV, were 24, 5.4, 7.5 cm/s and 11, 2.5, 4.2 cm/s, respectively, whereas the values for day-to-day variability were 16.8, 4.3, 6.7 cm/s and 5.6, 1.7 and 3.9 cm/s. Ocular blood flow Doppler parameters range widely and are significantly age and sex dependent. Ranges of "normal" side-to-side and day-to-day variability of the parameters can help to determine abnormal flow pattern.

Successful treatment of cerebral vasospasm by use of transdermal nitroglycerin ointment (Nitropaste).

To our knowledge, the use of transdermal nitroglycerin ointment (Nitropaste) in the setting of intracranial vasospasm has not been described in the peer-reviewed literature. Five patients with intracranial vasospasm induced by subarachnoid hemorrhage were evaluated angiographically both before and after application of Nitropaste. All cases exhibited mild to moderate improvement in the degree of vasospasm. We conclude that Nitropaste is a simple noninvasive technique to reduce intracranial vasospasm.

Preliminary experience with endovascular reconstruction for the management of carotid blowout syndrome.

BACKGROUND AND PURPOSE: Permanent balloon occlusion (PBO) of the carotid artery has been previously shown to be an effective means to treat carotid blowout syndrome (CBS). However, despite the effectiveness of this endovascular technique, concern remains regarding its potential for producing delayed cerebral ischemic complications in 15% to 20% of patients. This significant limitation of carotid PBO led our group to evaluate an alternative management strategy, consisting of endovascular reconstruction of the carotid artery (ERCA) in patients thought to be at particularly high risk for carotid occlusion (ie, provocative balloon test occlusion, angiographic documented incomplete circle of Willis, or contralateral carotid artery occlusion). METHODS: We reviewed all cases of CBS referred to our service, in which ERCA was chosen as a management strategy for patients thought to be at high risk for PBO, based on previously defined criteria. RESULTS: Sixteen carotid blowout events occurred in 12 patients with CBS who were deemed to be at high risk for cerebral ischemic complications, which were managed with ERCA by using a variety of stent devices and techniques. Adjunctive embolization of carotid pseudoaneurysms was performed in five of these patients by using platinum coils or acrylic glue. Hemostasis was achieved in all cases, although one patient with traumatic CBS and three patients with aggressive head and neck cancer-related CBS, required retreatment with ERCA. Recurrent CBS rates were similar to those reported in other studies using PBO. Overall, no treatment-related strokes or deaths occurred. CONCLUSION: CBS managed with ERCA can be performed safely and with efficacy of outcomes at least equivalent to those previously reported in association with conventional carotid PBO, therefore representing an excellent alternative endovascular technique for patients who are at increased risk of stroke after PBO.

Peripheral aneurysms of the lateral posterior choroidal artery: clinical presentation and endovascular treatment: report of two cases.

OBJECTIVE AND IMPORTANCE: To describe the clinical presentation and endovascular management of peripheral aneurysms of the lateral posterior choroidal artery. Aneurysms in this location are exceptionally rare and optimal treatment may be difficult. CLINICAL PRESENTATION: Two patients with peripheral aneurysms of the distal portion of the lateral posterior choroidal artery presented with headaches from extensive intraventricular hemorrhage. INTERVENTION: Endovascular surgical therapy by use of superselective n-butylcyanoacrylate embolization of the aneurysm and adjacent distal parent artery was successful in both patients. CONCLUSION: Patients with peripheral aneurysms of the lateral posterior choroidal artery usually present with intraventricular hemorrhage. They may be difficult to treat by open surgical techniques owing to their intraventricular location and the frequent inability to preserve the parent artery by aneurysm clipping. Instead, it is typical that either proximal parent artery occlusion or aneurysm trapping must be used. An equivalent endovascular surgical technique may be an attractive alternative method of management.

Galenic dural arteriovenous fistula: unusual clinical presentation and successful endovascular therapy. Case report.

The authors report a case in which the clinical and neuroimaging findings were initially considered diagnostic of a brainstem glioma. Angiography revealed a deep venous system (galenic) dural arteriovenous fistula causing brainstem interstitial edema. Successful endovascular surgery resulted in complete clinical recovery of the patient and resolution of the structural abnormalities that had been observed on magnetic resonance images. The neuroimaging and therapeutic significance of this case are discussed.

Rapid cognitive decline following lumbar puncture in a patient with a dural arteriovenous fistula.

BACKGROUND: Dural arteriovenous fistulas (DAVFs) are frequently accompanied with raised intracranial pressure and clinical findings suggestive of pseudotumor cerebri. However, unlike pseudotumor cerebri, the clinical response to lumbar cerebrospinal fluid (CSF) removal can vary from beneficial to acute clinical deterioration leading to death. The criteria for the safe use of lumbar puncture (LP) in patients with a DAVF are not well established. METHODS: A 61-year-old man presented with visual difficulty. Magnetic resonance imaging (MRI) and angiography revealed a left transverse sinus DAVF. He underwent multiple embolizations of arterial feeders over 3 years. He was then noted to have cognitive deficits in short term memory, listening, and concentrating. Over several days after an LP he became increasingly lethargic but arousable. Within hours after a repeat LP there was a rapid deterioration in the patient's level of consciousness and he became unarousable. RESULTS: A brain MRI revealed extensive dilated cortical veins and left temporal lobe venous ischemia without tonsillar herniation. A cerebral angiogram showed an extensive left transverse sinus DAVF with an occluded lateral transverse sinus and increased retrograde venous drainage. Embolization of the arterial feeders in combination with trans-venous coil embolization of the left transverse sinus reversed the patient's neurologic decline. He was discharged neurologically intact except for his chronic visual acuity problems. CONCLUSION: We speculate that when a DAVF manifests retrograde venous flow sufficient to cause cognitive deficits, lumbar CSF drainage must be undertaken with extreme caution.

Use of a new double-lumen balloon catheter for single-catheter balloon-assisted coil embolization of intracranial aneurysms: technical note.

BACKGROUND: The prevalence of intracranial aneurysms is approximately 2% with an annual rupture rate of 0.7%. OBJECTIVE: We describe our initial feasibility experience using a new double-lumen balloon catheter for single-catheter balloon-assisted coil embolization of wide-neck intracranial aneurysms. METHODS: Two patients with large wide-neck intracranial aneurysms were referred for endovascular therapy. Endovascular treatment in the form of coil embolization alone was not feasible given the angioarchitecture of the aneurysms. Balloon-assisted coil embolization was planned. RESULTS: The patients underwent balloon-assisted coil embolization using the Ascent double-lumen balloon catheter (Micrus, San Jose, California). The balloon portion of the catheter was placed into the proximal neck of the aneurysm. The balloon was inflated and coil embolization performed through the inner lumen of the catheter. There were no procedural complications. CONCLUSION: Both aneurysms were successfully coiled by using the Ascent balloon occlusion catheter. The single-catheter balloon-assisted coil embolization technique can be performed safely and effectively with the Ascent double-lumen balloon catheter.

Onyx pulmonary artery embolization after treatment of a low-flow dural arteriovenous fistula: case report.

BACKGROUND AND IMPORTANCE: Endovascular management of dural arteriovenous fistulas (DAVFs) has become an accepted primary and often definitive therapy. We present the first documented case of Onyx pulmonary embolism after embolization of a low-flow DAVF. CLINICAL PRESENTATION: A 63-year-old man presented with subarachnoid hemorrhage secondary to a DAVF. Computed tomographic angiography, magnetic resonance imaging, and initial conventional angiogram were negative. A repeat angiogram demonstrated a DAVF, which was cured with Onyx embolization. A routine chest computed tomography after intervention revealed an asymptomatic Onyx embolization cast in a subsegmental pulmonary artery. CONCLUSION: Endovascular treatment options include transarterial embolization with microcoils, polyvinyl alcohol particles, n-butyl-2cyanoacrylate, and Onyx (ev3 Neurovascular, Irvine, California). Complications associated with the use of Onyx are low but include embolizate pulmonary embolism. Patients often remain asymptomatic, but for symptomatic patients, conservative treatment options usually result in resolution of symptoms.

Narrowing of the middle cerebral artery: artificial intelligence methods and comparison of transcranial color coded duplex sonography with conventional TCD.

The goal of the study was to compare performances of transcranial color-coded duplex sonography (TCCS) and transcranial Doppler sonography (TCD) in the diagnosis of the middle cerebral artery (MCA) narrowing in the same population of patients using statistical and nonstatistical intelligent models for data analysis. We prospectively collected data from 179 consecutive routine digital subtraction angiography (DSA) procedures performed in 111 patients (mean age 54.17+/-14.4 years; 59 women, 52 men) who underwent TCD and TCCS examinations simultaneously. Each patient was examined independently using both ultrasound techniques, 267 M1 segments of MCA were assessed and narrowings were classified as < or =50% and >50% lumen reduction. Diagnostic performance was estimated by two statistical and two artificial neural networks (ANN) classification methods. Separate models were constructed for the TCD and TCCS sonographic data, as well as for detection of "any narrowing" and "severe narrowing" of the MCA. Input for each classifier consisted of the peak-systolic, mean and end-diastolic velocities measured with each sonographic method; the output was MCA narrowing. Arterial narrowings less or equal 50% of lumen reduction were found in 55 and >50% narrowings in 26 out of 267 arteries, as indicated by DSA. In the category of "any narrowing" the rate of correct assignment by all models was 82% to 83% for TCCS and 79% to 81% for TCD. In the diagnosis of >50% narrowing the overall classification accuracy remained in the range of 89% to 90% for TCCS data and 90% to 91% for TCD data. For the diagnosis of any narrowing, the sensitivity of the TCCS was significantly higher than that of the TCD, while for diagnosis of >50% MCA narrowing, sensitivity of the TCCS was similar to sensitivity of the TCD. Our study showed that TCCS outperforms conventional TCD in detection of < or =50% MCA narrowing, whereas no significant difference in accuracy between both methods was found in the diagnosis of >50% MCA narrowing. (E-mail: jaroslaw.krejza@uphs.upenn.edu).

Intracranial vertebrobasilar artery dissection associated with postpartum angiopathy.

Background. Cervicocephalic arterial dissection (CCAD) is rare in the postpartum period. To our knowledge this is the first reported case of postpartum angiopathy (PPA) presenting with ischemic stroke due to intracranial arterial dissection. Case. A 41-year-old woman presented with blurred vision, headache, and generalized seizures 5 days after delivering twins. She was treated with magnesium for eclampsia. MRI identified multiple posterior circulation infarcts. Angiography identified a complex dissection extending from both intradural vertebral arteries, through the basilar artery, and into both posterior cerebral arteries. Multiple segments of arterial dilatation and narrowing consistent with PPA were present. Xenon enhanced CT (Xe-CT) showed reduced regional cerebral blood flow that is improved with elevation in blood pressure. Conclusion. Intracranial vertebrobasilar dissection causing stroke is a rare complication of pregnancy. Eclampsia and PPA may play a role in its pathogenesis. Blood pressure management may be tailored using quantitative blood flow studies, such as Xe-CT.

Obstructive hydrocephalus from venous sinus thrombosis.

BACKGROUND: Cerebral venous sinus thrombosis (CVST) is a rare form of stroke. Although increased intracranial pressure is a well-described complication of CVST, hydrocephalus has rarely been reported. CASE: We present the case of a 49-year-old woman who presented with one week of headache, vomiting, and progressive neurologic deterioration leading to coma. Head CT and MRI identified extensive CVST and accompanying hydrocephalus. She was treated with systemic anticoagulation as well as mechanical and pharmacologic endovascular thrombolysis. An external ventricular drain (EVD) was not inserted given the potential bleeding risk while anticoagulated. Subsequently, she made an excellent recovery and had a normal neurologic exam at long-term follow up. CONCLUSION: Hydrocephalus is a rare complication of cerebral venous sinus thrombosis. Treatment of hydrocephalus with an EVD may not be necessary if interventions are undertaken to urgently recanalize thrombosed venous sinuses.