Wide-neck bifurcation aneurysms of the middle cerebral artery and basilar apex treated by endovascular techniques: a multicentre, core lab adjudicated study evaluating safety and durability of occlusion (BRANCH).

BACKGROUND AND PURPOSE: BRANCH (wide-neck bifurcation aneurysms of the middle cerebral artery and basilar apex treated by endovascular techniques) is a multicentre, retrospective study comparing core lab evaluation of angiographic outcomes with self-reported outcomes. MATERIALS AND METHODS: Consecutive patients were enrolled from 10 US centres, aged between 18 and 85 with unruptured wide-neck middle cerebral artery (MCA) or basilar apex aneurysms treated endovascularly. Patient demographics, aneurysm morphology, procedural information, mortality and morbidity data and core lab and self-reported modified Raymond Roy (RR) outcomes were obtained. RESULTS: 115 patients met inclusion criteria. Intervention-related mortality and significant morbidity rates were 1.7% (2/115) and 5.8% (6/103) respectively. Core lab adjudicated RR1 and 2 occlusion rates at follow-up were 30.6% and 32.4% respectively. The retreatment rate within the follow-up window was 10/115 (8.7%) and in stent stenosis at follow-up was 5/63 (7.9%). Self-reporting shows a statistically significant direction to angiographic RR one outcomes at follow-up compared with core lab evaluation, with OR 1.75 (95% CI 1.08 to 2.83). CONCLUSION: Endovascular treatment of wide-neck MCA and basilar apex aneurysms resulted in a core lab adjudicated RR1 occlusion rate of 30.6%. Self-reported results at follow-up favour better angiographic outcomes, with OR 1.75 (95% CI 1.08 to 2.83). These data demonstrate the need for novel endovascular devices specifically designed to treat complex intracranial aneurysms, as well as the importance of core lab adjudication in assessing outcomes in such a trial.

Feasibility, safety, and changes in systolic blood pressure associated with endovascular revascularization of symptomatic and chronically occluded cervical internal carotid artery using a newly suggested radiographic classification of chronically occluded cervical internal carotid artery: pilot study.

OBJECTIVEThe overall risk of ischemic stroke from a chronically occluded internal carotid artery (COICA) is around 5%-7% per year despite receiving the best available medical therapy. Here, authors propose a radiographic classification of COICA that can be used as a guide to determine the technical success and safety of endovascular recanalization for symptomatic COICA and to assess the changes in systemic blood pressure following successful revascularization.METHODSThe radiographic images of 100 consecutive subjects with COICA were analyzed. A new classification of COICA was proposed based on the morphology, location of occlusion, and presence or absence of reconstitution of the distal ICA. The classification was used to predict successful revascularization in 32 symptomatic COICAs in 31 patients, five of whom were female (5/31 [16.13%]). Patients were included in the study if they had a COICA with ischemic symptoms refractory to medical therapy. Carotid artery occlusion was defined as 100% cross-sectional occlusion of the vessel lumen as documented on CTA or MRA and confirmed by digital subtraction angiography.RESULTSFour types (A-D) of radiographic COICA were identified. Types A and B were more amenable to safe revascularization than types C and D. Recanalization was successful at a rate of 68.75% (22/32 COICAs; type A: 8/8; type B: 8/8; type C: 4/8; type D: 2/8). The perioperative complication rate was 18.75% (6/32; type A: 0/8 [0%]; type B: 1/8 [12.50%]; type C: 3/8 [37.50%], type D: 2/8 [25.00%]). None of these complications led to permanent morbidity or death. Twenty (64.52%) of 31 subjects had improvement in their symptoms at the 2-6 months' follow-up. A statistically significant decrease in systolic blood pressure (SBP) was noted in 17/21 (80.95%) patients who had successful revascularization, which persisted on follow-up (p = 0.0001). The remaining 10 subjects in whom revascularization failed had no significant changes in SBP (p = 0.73).CONCLUSIONSThe pilot study suggested that our proposed classification of COICA may be useful as an adjunctive guide to determine the technical feasibility and safety of revascularization for symptomatic COICA using endovascular techniques. Additionally, successful revascularization may lead to a significant decrease in SBP postprocedure. A Phase 2b trial in larger cohorts to assess the efficacy of endovascular revascularization using our COICA classification is warranted.

Piloting a Sex-Specific, Technology-Enhanced, Active Learning Intervention for Stroke Prevention in Women.

BACKGROUND: Recent studies reveal deficiencies in stroke awareness and knowledge of risk factors among women. Existing stroke education interventions may not address common and sex-specific risk factors in the population with the highest stroke-related rate of mortality. OBJECTIVE: This pilot study assessed the efficacy of a technology-enhanced, sex-specific educational program ("SISTERS") for women's knowledge of stroke. METHODS: This was an experimental pretest-posttest design. The sample consisted of 150 women (mean age, 55 years) with at least 1 stroke risk factor. Participants were randomized to either the intervention (n = 75) or control (n = 75) group. Data were collected at baseline and at a 2-week posttest. RESULTS: There was no statistically significant difference in mean knowledge score (P = .67), mean confidence score (P = .77), or mean accuracy score (P = .75) between the intervention and control groups at posttest. Regression analysis revealed that older age was associated with lower knowledge scores (P < .001) and lower confidence scores (P < .001). After controlling for age, the SISTERS program was associated with a statistically significant difference in knowledge (P < .001) and confidence (P < .001). CONCLUSIONS: Although no change occurred overall, after controlling for age, there was a statistically significant benefit. Older women may have less comfort with technology and require consideration for cognitive differences.

Clinical Reasoning: a woman with recurrent aphasia and visual field defects.

A 73-year-old woman with a history of hypertension and a recent stroke presented with recurrent nonsensical speech and visual problems. One month prior, she had been diagnosed with a stroke, after sudden-onset speech and visual difficulties that resolved after a few hours. Thirteen days before, she had had a second episode of similar symptoms. She was seen in our institution after a few hours of sudden-onset unintelligible speech. Her vital signs were within normal limits. She was not in distress, but appeared frustrated. Her general physical examination was unremarkable. She had no carotid, ophthalmic, or cranial bruits. Her neurologic examination was notable for fluent aphasia, with paraphasic errors and inability to name, read, or write. She also had right homonymous hemianopia, right-sided sensory loss, and generalized brisk deep tendon reflexes. The rest of her neurologic examination showed no abnormalities.

The diagnosis and management of brain arteriovenous malformations.

Although uncommon in the general population, cerebral arteriovenous malformations (AVMs) can pose a significant health risk if a rupture occurs. Advances in noninvasive imaging have led to an increase in the identification of unruptured AVMs, presenting new challenges in management, given their poorly understood natural history. Over the past decade, there have been significant developments in the management and treatment of intracranial AVMs. This article discusses the pathophysiology, natural history, clinical presentations, and current treatment options, including multimodal approaches, for these vascular malformations.

Retrievable stents, "stentrievers," for endovascular acute ischemic stroke therapy.

Endovascular therapy for acute ischemic stroke continues to evolve to improve both efficacy and safety. In the late 1990 s, intra-arterial chemical thrombolysis with prourokinase was shown to be effective in achieving partial recanalization and improving clinical outcome, in comparison with intra-arterial heparin administration. However, this was at the expense of an increase in the rate of symptomatic intracranial hemorrhage to 10%. To improve the rate of recanalization, expand the time window, and reduce the risk of symptomatic intracranial hemorrhage, mechanical thrombectomy was introduced, with initial approval of the Merci clot retriever, a corkscrew-like device, and then more recently with approval of the Penumbra thromboaspiration system. Both devices are associated with a high rate of recanalization (total, partial, and complete). However, time to recanalization was on average 45 minutes, with a low rate of complete clot resolution, given that the majority of patients achieved only partial recanalization. More recently, retrievable stents have shown promise in reducing the time to recanalization, and they achieve a higher rate of complete clot resolution with improved feasibility. The retrievable stent can be opened within the clot to engage it within the stent struts, and subsequently it is retrieved by pulling it under flow arrest. The retrievable stents provide a new tool in the armamentarium of devices that can be used to achieve safe and timely clot removal. This review provides the historical evolution of endovascular therapy to use of stentreivers.

Developing practice recommendations for endovascular revascularization for acute ischemic stroke.

Guidelines have been established for the management of acute ischemic stroke; however, specific recommendations for endovascular revascularization therapy are lacking. Burgeoning investigation of endovascular revascularization therapies for acute ischemic stroke, rapid device development, and a diverse training background of the providers performing the procedures underscore the need for practice recommendations. This review provides a concise summary of the Society of Vascular and Interventional Neurology endovascular acute ischemic stroke roundtable meeting. This document was developed to review current clinical efficacy of pharmacologic and mechanical revascularization therapy, selection criteria, periprocedure management, and endovascular time metrics and to highlight current practice patterns. It therefore provides an outline for the future development of multisociety guidelines and recommendations to improve patient selection, procedural management, and organizational strategies for revascularization therapies in acute ischemic stroke.

Outcome in patients with subarachnoid hemorrhage treated with antiepileptic drugs.

OBJECT: Prophylactic use of antiepileptic drugs (AEDs) in patients admitted with aneurysmal subarachnoid hemorrhage (SAH) is common practice; however, the impact of this treatment strategy on in-hospital complications and outcome has not been systematically studied. The goal in this study was twofold: first, to describe the prescribing pattern for AEDs in an international study population; and second, to delineate the impact of AEDs on in-hospital complications and outcome in patients with SAH. METHODS: The authors examined data collected in 3552 patients with SAH who were entered into four prospective, randomized, double-blind, placebo-controlled trials conducted in 162 neurosurgical centers and 21 countries between 1991 and 1997. The prevalence of AED use was assessed by study country and center. The impact of AEDs on in-hospital complications and outcome was evaluated using conditional logistic regressions comparing treated and untreated patients within the same study center. RESULTS: Antiepileptic drugs were used in 65.1% of patients and the prescribing pattern was mainly dependent on the treating physicians: the prevalence of AED use varied dramatically across study country and center (intraclass correlation coefficients 0.22 and 0.66, respectively [p < 0.001]). Other predictors included younger age, worse neurological grade, and lower systolic blood pressure on admission. After adjustment, patients treated with AEDs had odds ratios of 1.56 (95% confidence interval [CI] 1.16-2.10; p = 0.003) for worse outcome based on the Glasgow Outcome Scale; 1.87 (95% CI 1.43-2.44; p < 0.001) for cerebral vasospasm; 1.61 (95% CI 1.25-2.06; p < 0.001) for neurological deterioration; 1.33 (95% CI 1.01-1.74; p = 0.04) for cerebral infarction; and 1.36 (95% CI 1.03-1.80; p = 0.03) for elevated temperature during hospitalization. CONCLUSIONS: Prophylactic AED treatment in patients with aneurysmal SAH is common, follows an arbitrary prescribing pattern, and is associated with increased in-hospital complications and worse outcome.

Intraventricular hemorrhage from ruptured aneurysm: clinical characteristics, complications, and outcomes in a large, prospective, multicenter study population.

OBJECT: In this study the authors analyzed the relationship of intraventricular hemorrhage (IVH) to in-hospital complications and clinical outcome in a large population of patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS: Data from 3539 patients with aneurysmal SAH were evaluated, and these data were obtained from four prospective, randomized, double-blind, placebo-controlled trials of tirilazad that had been conducted between 1991 and 1997. Clinical characteristics, in-hospital complications, and outcome at 3 months post-SAH (Glasgow Outcome Scale score) were analyzed with regard to the presence or absence of IVH. RESULTS: Patients with SAH and IVH differ in demographic and admission characteristics from those with SAH but without IVH and are more likely to suffer in-hospital complications and a worse outcome at 3 months post-SAH. CONCLUSIONS: The presence of IVH in patients with SAH has an important predictive value with regard to these aspects.

Return of vision after transarterial coiling of a carotid cavernous sinus fistula: case report.

BACKGROUND: Carotid cavernous sinus fistulae are abnormal communications between the carotid circulation and cavernous sinus that may arise spontaneously or develop after craniocerebral trauma. They may present with a constellation of signs and symptoms characteristic of raised cavernous sinus pressure, including orbital or retro-orbital pain, pulsatile proptosis, chemosis, ocular or cranial bruit, deterioration of visual acuity, or ophthalmoplegia. Visual loss is likely the result of multiple insults to the visual system, including reversal of venous drainage from the fistula, arterial flow into the superior ophthalmic vein, increased intraocular venous pressure, venous stasis retinopathy, and eventually ischemic optic neuropathy [Brodsky MC, Hoyt WF, Halbach VV, et al. Recovery from total monocular blindness after balloon embolization of carotid-cavernous fistula. Am J Ophthalmol 1987;104:86-87; Sanders MD, Hoyt WF. Hypoxic ocular sequelae of carotid-cavernous fistulae: study of the causes of visual failure before and after neurosurgical treatment in a series of 25 cases. Br J Ophthalmol 1969;53:82-97]. CASE DESCRIPTION: With few exceptions, the literature is replete with evidence of persistent blindness despite successful treatment of the CCF [Albuquerque FC, Heinz GW, McDougall CG. Reversal of blindness after transvenous embolization of a carotid-cavernous fistula: case report. Neurosurgery 2003;52:233-237; Brodsky MC, Hoyt WF, Halbach VV, et al. Recovery from total monocular blindness after balloon embolization of carotid-cavernous fistula. Am J Ophthalmol 1987;104:86-87; Weinstein JM, Rufenacht DA, Partington CR, et al. Delayed visual loss due to trauma of the internal carotid artery. Arch Neurol. 1991;48:490-497]. Here, we report a patient who experienced recovery of vision after endovascular obliteration of the offending CCF. DISCUSSION: To our knowledge, this is the second reported case of recovery of visual function in a patient presenting with loss of light perception after treatment of a direct CCF.

Identification and treatment of cervical and oromandibular dystonia in acutely brain-injured patients.

INTRODUCTION: Primary cervical and oromandibular dystonia (CD and OMD, respectively) are well-recognized movement disorders, often treated with botulinum toxin (BTx). In contrast, dystonia related to acute brain injuries is not well delineated. Our objective was to define in neurocritically ill patients the clinical characteristics of CD and OMD and to investigate the safety of BTx. METHODS: All acutely brain-injured patients admitted to a neurocritical care unit over a 10-month period were prospectively screened for CD and OMD. Clinical characteristics, etiology of brain injury, and pattern of dystonia were analyzed. Patients with clinically significant CD and OMD were treated with BTx and followed for 12 weeks. RESULTS: Of 165 patients screened, 33 had new-onset CD or OMD. Of 21 patients enrolled, 14 had CD, 5 had OMD, and 2 had both. The pattern of brain injury included 13 cerebral hemorrhages, 6 ischemic strokes, 1 status epilepticus, and 1 unclear etiology. Improvement after BTx was seen in four of seven patients with CD and two of four with OMD; no adverse effects occurred. Spontaneous improvement was recorded in 7 of 11 nontreated patients with CD or OMD. CONCLUSIONS: Acute secondary CD or OMD, associated with a variety of causes, was identified in 20% of acutely brain-injured patients. The temporal profile of dystonia onset and resolution in these patients was variable. Treatment with BTx in the neurocritical care setting seems to be safe. Future, larger scale randomized studies should evaluate the effectiveness of BTx treatment in this patient population.

Early vasospasm on admission angiography in patients with aneurysmal subarachnoid hemorrhage is a predictor for in-hospital complications and poor outcome.

BACKGROUND AND PURPOSE: Early vasospasm (EVSP), defined here as arterial narrowing seen on diagnostic angiography within the first 48 hours of aneurysmal rupture, is a rarely reported and poorly defined phenomenon in patients with subarachnoid hemorrhage (SAH). The purpose of this study was to characterize EVSP in a large database of such patients. METHODS: We analyzed the relationship of EVSP to clinical characteristics, in-hospital complications, and outcome at 3 months among 3478 patients entered into 4 prospective, randomized, double-blind, placebo-controlled trials of tirilazad conducted in neurosurgical centers around the world between 1991 and 1997. RESULTS: Three hundred thirty-nine (10%) of 3478 patients had EVSP. EVSP was significantly more likely in patients with poor neurological grade on admission, history of SAH, intracerebral hematoma, larger aneurysm, thick SAH on cranial computed tomography, and intraventricular hemorrhage. EVSP was not associated with delayed cerebral vasospasm. After adjustment for differences in admission characteristics, EVSP was associated with cerebral infarction (adjusted odds ratios [OR]=1.51; 95% CI, 1.18 to 1.94; P=0.001), neurological worsening (OR=1.41; 95% CI, 1.10 to 1.81; P=0.007), and unfavorable outcome (OR=1.51; 95% CI, 1.15 to 2.00; P=0.003). In addition, there was a trend for patients with increasingly severe EVSP to have unfavorable outcome (OR=1.84 for mild and OR=2.66 for moderate/severe EVSP). CONCLUSIONS: EVSP was seen in 10% of SAH patients and was predictive of cerebral infarction and neurological worsening as well as unfavorable outcome at 3 months. EVSP was not associated with late vasospasm. EVSP may be as important as delayed vasospasm in predicting complications and long-term morbidity in SAH patients.