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BACKGROUND: There is emerging interest in ophthalmic artery (OA) stenosis angioplasty for the treatment of age-related macular degeneration. Three-dimensional rotational angiography (3DRA) could be used during conventional angiography to determine the presence and severity of OA stenosis. In patients who had undergone 3DRA of the internal carotid artery, we aimed to assess the interrater agreement, prevalence, and risk factors for OA stenosis. METHODS: Consecutive patients from two centers who had undergone conventional angiography with 3DRA of the internal carotid arteries were enrolled in this study. 3DRAs were independently double read for the presence of OA stenosis, as defined as narrowing of the proximal OA of at least 50% when compared to the more distal "normal" OA. Interrater agreement for the evaluation of OA stenosis was assessed with the Cohen's kappa coefficient. Univariate and multivariable logistic regression were used to identify potential predictors of OA stenosis. RESULTS: Three hundred and two patients (97 men; mean ± SD 57.6 ± 13.4 years) were included in the analysis. Cohen's kappa coefficient (95% CI) was 0.877 (0.798-0.956). OA stenosis was present in 45 patients (14.9%). Multiple logistic regression demonstrated that female sex (odds ratio [OR] = 2.70, 95% confidence interval [CI] 1.18-6.09, p = 0.02) and smoking (OR = 2.11, 95% CI 1.10-4.06, p = 0.03) were significant risk factors for OA stenosis. Age, hypertension, diabetes, coronary artery disease, and subarachnoid hemorrhage were not associated with OA stenosis. CONCLUSION: The evaluation of OA stenosis on 3DRA had excellent interrater agreement. OA stenosis was common and was associated with smoking and female sex.
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The aim of this review is to provide an overview of the use of antiplatelet medication in neurointervention, with a focus on the clinical indications for antiplatelet use in both preventing and reducing platelet aggregation. This review will cover current antiplatelet medications, pharmacokinetics, and pharmacodynamics. We will provide an overview of different endovascular devices and discuss the antiplatelet regimes in neurointervention, highlighting gaps in evidence and scope for future studies.Two randomized controlled trials have evaluated antiplatelet use in the setting of acute large vessel occlusion stroke, with neither demonstrating benefit in their overall cohorts. Evidence on antiplatelet medication for both acute and elective stenting for acute stroke and treatment of cerebral aneurysms is currently based on large case series, and practice in neurointervention has increasingly utilized dual antiplatelet regimes with clopidogrel and second-line agents like prasugrel and ticagrelor. Clopidogrel function testing has an increasing role in neurointerventional procedures, particularly for high metal surface area stents such as the braided flow diverter type stents. Intravenous glycoprotein IIB/IIIA inhibitors have been utilized for both acute bridging and rescue therapy.Antiplatelet decision making is complex, and there are few randomized control trials to guide clinical practice. Comparative trials to guide decision making remain important in both the acute and elective settings. Standardised protocols incorporating platelet function testing may play a role in assisting decision making until more robust clinical evidence is available, particularly in the context of acute neurointerventional stenting for stroke and ruptured cerebral aneurysms.
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Aneurisma Intracraneal , Accidente Cerebrovascular , Humanos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Inhibidores de Agregación Plaquetaria/farmacología , Clopidogrel , Ticagrelor , Accidente Cerebrovascular/tratamiento farmacológico , Resultado del TratamientoRESUMEN
Blister aneurysms (BA) are high-risk cerebrovascular lesions accounting for 1% of intracranial aneurysms. The defective vessel wall and broad-based neck make this clinical entity difficult to treat, with high rates of re-rupture and mortality in patients presenting with acute subarachnoid haemorrhage. Blister aneurysms pose substantial challenges for both endovascular and microsurgical management. The objective of this study is to evaluate endovascular and microsurgical outcomes in intracranial blister aneurysm management across two tertiary hospitals. A review of two tertiary hospitals with a systematic imaging database search for term of "blister" in modalities from January 2010 to October 2022 was conducted. Operation reports were screened for the 5-year period since cerebral angiogram reports transitioned to surgical database. Identified reports were screened and reviewed for confirmed diagnosis by consultant neuroradiologist. A total of 21 cases of blister aneurysms managed at respective facilities were included. Sixteen cases (76%) were managed endovascularly. Four cases (19%) were managed surgically-2 with primary clipping, and 2 wrap and clipping. One case was managed conservatively (5%). Clinical outcomes were discharge disposition, aneurysm exclusion and post-operative complications. BAs have challenging considerations with high mortality and morbidity. Endovascular treatment offers a less invasive modality with lower rates of intraoperative rupture and morbidity. Mortality rates and patients discharged home were comparable. Commencement of dual anti-platelet therapy was safe in patients with flow diversion stents despite sub-arachnoid blood volume. Management of blister aneurysms is complex. Endovascular treatment shows promise for acute management but careful collaborative consideration of antithrombotic regime and requirement for further surgery should be considered.
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Aneurisma Roto , Embolización Terapéutica , Procedimientos Endovasculares , Aneurisma Intracraneal , Hemorragia Subaracnoidea , Humanos , Resultado del Tratamiento , Estudios Retrospectivos , Procedimientos Endovasculares/métodos , Aneurisma Intracraneal/complicaciones , Hemorragia Subaracnoidea/etiología , Embolización Terapéutica/métodos , Aneurisma Roto/complicaciones , Estudios Multicéntricos como AsuntoRESUMEN
We present a case of an adult with concurrent severe aortic coarctation, bilateral carotid artery stenosis, and anomalous right subclavian artery, posing the interventional dilemma of accepting potential cerebral hyperperfusion syndrome vs hypoperfusion ischemic injury. Transcatheter stenting of the aortic coarctation was successfully performed without any neurological deficits. (Level of Difficulty: Beginner.).
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BACKGROUND: The benefit of combined treatment with intravenous thrombolysis before endovascular thrombectomy in patients with acute ischaemic stroke caused by large vessel occlusion remains unclear. We hypothesised that the clinical outcomes of patients with stroke with large vessel occlusion treated with direct endovascular thrombectomy within 4·5 h would be non-inferior compared with the outcomes of those treated with standard bridging therapy (intravenous thrombolysis before endovascular thrombectomy). METHODS: DIRECT-SAFE was an international, multicentre, prospective, randomised, open-label, blinded-endpoint trial. Adult patients with stroke and large vessel occlusion in the intracranial internal carotid artery, middle cerebral artery (M1 or M2), or basilar artery, confirmed by non-contrast CT and vascular imaging, and who presented within 4·5 h of stroke onset were recruited from 25 acute-care hospitals in Australia, New Zealand, China, and Vietnam. Eligible patients were randomly assigned (1:1) via a web-based, computer-generated randomisation procedure stratified by site of baseline arterial occlusion and by geographic region to direct endovascular thrombectomy or bridging therapy. Patients assigned to bridging therapy received intravenous thrombolytic (alteplase or tenecteplase) as per standard care at each site; endovascular thrombectomy was also per standard of care, using the Trevo device (Stryker Neurovascular, Fremont, CA, USA) as first-line intervention. Personnel assessing outcomes were masked to group allocation; patients and treating physicians were not. The primary efficacy endpoint was functional independence defined as modified Rankin Scale score 0-2 or return to baseline at 90 days, with a non-inferiority margin of -0·1, analysed by intention to treat (including all randomly assigned and consenting patients) and per protocol. The intention-to-treat population was included in the safety analyses. The trial is registered with ClinicalTrials.gov, NCT03494920, and is closed to new participants. FINDINGS: Between June 2, 2018, and July 8, 2021, 295 patients were randomly assigned to direct endovascular thrombectomy (n=148) or bridging therapy (n=147). Functional independence occurred in 80 (55%) of 146 patients in the direct thrombectomy group and 89 (61%) of 147 patients in the bridging therapy group (intention-to-treat risk difference -0·051, two-sided 95% CI -0·160 to 0·059; per-protocol risk difference -0·062, two-sided 95% CI -0·173 to 0·049). Safety outcomes were similar between groups, with symptomatic intracerebral haemorrhage occurring in two (1%) of 146 patients in the direct group and one (1%) of 147 patients in the bridging group (adjusted odds ratio 1·70, 95% CI 0·22-13·04) and death in 22 (15%) of 146 patients in the direct group and 24 (16%) of 147 patients in the bridging group (adjusted odds ratio 0·92, 95% CI 0·46-1·84). INTERPRETATION: We did not show non-inferiority of direct endovascular thrombectomy compared with bridging therapy. The additional information from our study should inform guidelines to recommend bridging therapy as standard treatment. FUNDING: Australian National Health and Medical Research Council and Stryker USA.
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Isquemia Encefálica , Procedimientos Endovasculares , Accidente Cerebrovascular , Adulto , Australia , Isquemia Encefálica/tratamiento farmacológico , Procedimientos Endovasculares/métodos , Fibrinolíticos/efectos adversos , Humanos , Estudios Prospectivos , Accidente Cerebrovascular/tratamiento farmacológico , Accidente Cerebrovascular/cirugía , Trombectomía/métodos , Resultado del TratamientoRESUMEN
Superficial temporal artery (STA) to middle cerebral artery (MCA) bypass surgery for internal carotid artery (ICA) occlusive disease necessarily requires sufficient external carotid artery (ECA) blood flow. Surgical bypass is therefore precluded if there is common carotid artery (CCA) occlusion. Here we present two such cases: one patient had a CCA occlusion and the other had an ICA occlusion and ECA stenosis. Both had failed medical management, and were therefore treated with angioplasty and stenting of the ECA, followed by STA-MCA bypass. We describe the clinical and radiologic outcomes of these cases, and remark on the potential pitfalls associated with this novel approach.
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BACKGROUND: Posterior inferior cerebellar artery (PICA) aneurysms are uncommon and are typically found at the origin or proximal segments of the vessel. Giant aneurysms are uncommon and present unique treatment challenges. Giant distal PICA aneurysms are exceedingly rare and have traditionally been managed via open surgical approaches. METHODS: A total of 207 studies were assessed, identifying 26 cases of giant distal PICA aneurysms from 26 separate publications. One additional case is described followed by a review of presentation, anatomical characteristics, treatment and outcome. RESULTS: Presentation was due to local mass effect in 19 (70%), hydrocephalus in 4 (15%) and acute haemorrhage in 5 (19%). All reported cases were partially (86%) or completely (14%) thrombosed. The telovelotonsillar segment was involved in 18/24 (75%) cases. Two cases (7%) were associated with an arteriovenous malformation. Twenty-two (81%) were managed surgically and 5 (19%) managed endovascularly. Outcome was good in 22 (85%) and poor in one (4%). CONCLUSIONS: Giant distal PICA aneurysms can be managed effectively through a variety of open surgical and endovascular techniques.
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BACKGROUND: Endovascular procedures are standard of care for an increasing range of cerebrovascular diseases. Many endovascular devices contain plastic and are coated with a hydrophilic polymer which has been rarely described to embolize, resulting in distal granulomatous inflammatory lesions within the vascular territory. METHODS: We reviewed three cases of cerebral granulomatous reactions that occurred after endovascular intervention for internal carotid aneurysms. The patient procedure details, presentation, relevant investigations, and treatment course are described. We also provide a literature review on endovascular granulomatous reactions. RESULTS: These three cases represent the largest biopsy proven series of cerebral granulomatosis following endovascular intervention. We highlight the variable clinical presentation, with two of the three cases having an unusually delayed onset of up to 4 years following the intervention. We show the characteristic histological findings of granulomatous lesions with foreign body material consistent with a type IV reaction, radiological abnormalities of enhancing lesions within the vascular territory of the intervention, and the requirement of prolonged immunosuppression for maintenance of clinical remission, with two of the three patients requiring a corticosteroid sparing agent. In comparison with the available literature, in addition to hydrophilic gel polymer, we discuss that plastic from the lining of the envoy catheter may be a source of embolic material. We also discuss the recommendations of the Food and Drug Administration and the implementation of novel biomaterials for the prevention of these reactions in the future. CONCLUSIONS: There is a need for increased awareness of this severe complication of cerebral endovascular procedures and further longitudinal studies of its prevalence, optimal management and preventative measures.
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Aneurisma , Enfermedades de las Arterias Carótidas , Trastornos Cerebrovasculares , Procedimientos Endovasculares , Aneurisma Intracraneal , Procedimientos Endovasculares/efectos adversos , Humanos , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/cirugía , Polímeros/efectos adversos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
A 66-year-old woman had presented with a 3-month history of left trigeminal neuralgia. She had undergone successful microvascular decompression for right-sided trigeminal neuralgia 8 years previously. To optimize visualization, microvascular decompression for trigeminal neuralgia has been commonly associated with sacrifice of the superior petrosal vein during surgery. The absence of sufficient collaterals can result in most of the posterior fossa venous drainage relying solely on the contralateral superior petrosal vein, leading to subsequent vessel enlargement and a compressive effect on the trigeminal nerve and causing iatrogenic contralateral trigeminal neuralgia. We have provided preoperative and intraoperative images illustrating nicely the adapted postoperative change in venous outflow causing contralateral compression of the trigeminal nerve. Consecutive treatment effects should be carefully considered when offering and performing surgical microvascular decompression.
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Cirugía para Descompresión Microvascular/efectos adversos , Síndromes de Compresión Nerviosa/etiología , Complicaciones Posoperatorias/etiología , Neuralgia del Trigémino/etiología , Neuralgia del Trigémino/cirugía , Anciano , Venas Cerebrales/cirugía , Femenino , Humanos , Síndromes de Compresión Nerviosa/cirugía , Complicaciones Posoperatorias/cirugíaRESUMEN
A patient undergoes intracranial stent insertion for stent-assisted coiling of a basilar tip aneurysm and left middle cerebral artery aneurysm. A flow diverting stent is also placed across an anterior communicating artery aneurysm. Prior to the procedure, the patient takes dual antiplatelet medications, being aspirin and clopidogrel. Because of the concern regarding in-stent thrombus and thromboembolic complications related to intracranial stenting and the high rate of clopidogrel resistance, preoperative platelet function testing (PFT) was undertaken to ensure platelet inhibition. In this case, PFT was performed on a platelet function analyser which demonstrated platelet inhibition. Ten days following the procedure, the patient represented with thromboembolic stroke. Repeat PFT performed with whole blood impedance aggregometry and despite full medication compliance demonstrated clopidogrel resistance. Clopidogrel was then ceased and prasugrel commenced. This case demonstrates the importance of appropriate platelet inhibition in patients with intracranial stents and the controversy surrounding PFT.
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Aneurisma Intracraneal/tratamiento farmacológico , Stents/efectos adversos , Accidente Cerebrovascular/etiología , Tromboembolia/complicaciones , Anciano , Aspirina/uso terapéutico , Clopidogrel/uso terapéutico , Diagnóstico Diferencial , Resistencia a Medicamentos , Humanos , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/cirugía , Ataque Isquémico Transitorio/diagnóstico por imagen , Imagen por Resonancia Magnética/métodos , Masculino , Inhibidores de Agregación Plaquetaria/uso terapéutico , Pruebas de Función Plaquetaria/métodos , Clorhidrato de Prasugrel/uso terapéutico , Cuidados Preoperatorios/normas , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/tratamiento farmacológico , Resultado del Tratamiento , Privación de TratamientoRESUMEN
Bow Hunter's syndrome (BHS) is a rare cause of vertebrobasilar insufficiency and is reported to most commonly be caused by vertebral artery impingement on cervical vertebrae osteophytes. We report a case in a 56-year-old male patient who on investigation of recurrent posterior circulation ischaemic strokes was found to have BHS. The aetiology of the syndrome in this patient is due to a particularly unusual aberrancy in the path of the atlantoaxial portion of the culprit left vertebral artery. Aberrancy of the distal portion of the vertebral artery is in itself a rare entity, and there are few reports of it in relation to BHS. The patient in this case was successfully treated with endovascular sacrifice of the vertebral artery with no further dynamic occlusive symptoms.
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Angiografía por Resonancia Magnética/métodos , Arteria Vertebral/anomalías , Insuficiencia Vertebrobasilar/diagnóstico por imagen , Insuficiencia Vertebrobasilar/tratamiento farmacológico , Angiografía Cerebral/métodos , Tratamiento Conservador , Diagnóstico Diferencial , Mareo/diagnóstico , Mareo/etiología , Humanos , Masculino , Persona de Mediana Edad , Náusea/diagnóstico , Náusea/etiología , Medición de Riesgo , Síndrome , Arteria Vertebral/diagnóstico por imagen , Insuficiencia Vertebrobasilar/diagnóstico , Trastornos de la Visión/diagnóstico , Trastornos de la Visión/etiologíaRESUMEN
INTRODUCTION: Stroke caused by basilar artery occlusion (BAO) is a rare but potentially devastating neurological condition, with poor outcomes and high mortality rates, approaching 70-90%. Success of intravenous and intra-arterial thrombolysis in BAO is variable, leading to Endovascular Therapy (EVT) being utilized to a greater degree in this clinical setting. We investigate the use of EVT in BAO with regard to success of revascularization and patient mortality/outcome. METHODS: Retrospective patient data was collected from medical records and radiology information systems. RESULTS: Twenty-eight patients underwent EVT for BAO between 2010-17, with successful revascularization in 21/28 (75%) and an inpatient mortality rate of 39%. Successful revascularization correlated with lower mortality (P = 0.0001). Better revascularization and mortality rates occurred between 2013-17 (P = 0.007, 0.04). An average time to EVT of 16.8 hours was observed between 2010-17 but this did not correlate significantly with increased mortality. Basilar stenting correlated with lower revascularization, higher mortality and basilar artery reocclusion post EVT (P = 0.021, 0.022, 0.022). EVT times over 2 and 2.5 hours respectively associated with lower revascularization rates and higher mortality (P = 0.04, 0.022). Higher mortality was seen with intra-procedural complications and symptomatic intracranial haemorrhage, non-posterior circulation infarction and basilar artery reocclusion post EVT (P = 0.016, 0.03, 0.016, 0.016). Basilar atheroma correlated with intra-procedural complications and EVT times over 2 hours (P = 0.038, 0.004). CONCLUSION: Within the limitations of an underpowered study, we observed a benefit of EVT in acute BAO. With future multicentre trials, EVT will likely become the standard of care in acute BAO.
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Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/cirugía , Arteria Basilar , Procedimientos Endovasculares , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Arteriopatías Oclusivas/mortalidad , Australia , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Stents , Accidente Cerebrovascular/mortalidad , Resultado del TratamientoRESUMEN
BACKGROUND: Intravenous infusion of alteplase is used for thrombolysis before endovascular thrombectomy for ischemic stroke. Tenecteplase, which is more fibrin-specific and has longer activity than alteplase, is given as a bolus and may increase the incidence of vascular reperfusion. METHODS: We randomly assigned patients with ischemic stroke who had occlusion of the internal carotid, basilar, or middle cerebral artery and who were eligible to undergo thrombectomy to receive tenecteplase (at a dose of 0.25 mg per kilogram of body weight; maximum dose, 25 mg) or alteplase (at a dose of 0.9 mg per kilogram; maximum dose, 90 mg) within 4.5 hours after symptom onset. The primary outcome was reperfusion of greater than 50% of the involved ischemic territory or an absence of retrievable thrombus at the time of the initial angiographic assessment. Noninferiority of tenecteplase was tested, followed by superiority. Secondary outcomes included the modified Rankin scale score (on a scale from 0 [no neurologic deficit] to 6 [death]) at 90 days. Safety outcomes were death and symptomatic intracerebral hemorrhage. RESULTS: Of 202 patients enrolled, 101 were assigned to receive tenecteplase and 101 to receive alteplase. The primary outcome occurred in 22% of the patients treated with tenecteplase versus 10% of those treated with alteplase (incidence difference, 12 percentage points; 95% confidence interval [CI], 2 to 21; incidence ratio, 2.2; 95% CI, 1.1 to 4.4; P=0.002 for noninferiority; P=0.03 for superiority). Tenecteplase resulted in a better 90-day functional outcome than alteplase (median modified Rankin scale score, 2 vs. 3; common odds ratio, 1.7; 95% CI, 1.0 to 2.8; P=0.04). Symptomatic intracerebral hemorrhage occurred in 1% of the patients in each group. CONCLUSIONS: Tenecteplase before thrombectomy was associated with a higher incidence of reperfusion and better functional outcome than alteplase among patients with ischemic stroke treated within 4.5 hours after symptom onset. (Funded by the National Health and Medical Research Council of Australia and others; EXTEND-IA TNK ClinicalTrials.gov number, NCT02388061 .).
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Isquemia Encefálica/tratamiento farmacológico , Fibrinolíticos/uso terapéutico , Accidente Cerebrovascular/tratamiento farmacológico , Trombectomía , Activador de Tejido Plasminógeno/uso terapéutico , Anciano , Anciano de 80 o más Años , Hemorragia Cerebral/inducido químicamente , Terapia Combinada , Procedimientos Endovasculares , Femenino , Fibrinolíticos/efectos adversos , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Reperfusión/métodos , Índice de Severidad de la Enfermedad , Método Simple Ciego , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/cirugía , Tenecteplasa , Tiempo de Tratamiento , Activador de Tejido Plasminógeno/efectos adversosRESUMEN
BACKGROUND: Re-bleeding after management of a first haemorrhage following pancreatic surgery is an ever-present danger and often presents diagnostic and management dilemmas. METHODS: All cases of post-pancreatectomy haemorrhage (PPH) following pancreatoduodenectomy were identified from a tertiary referral, clinical database (April 2004-April 2013). Only those suffering a second re-bleeding episode were included in the final case notes review. RESULTS: A total of 301 patients underwent pancreatoduodenectomy during the study period (most common indication: pancreatic adenocarcinoma; 49.5%). Twenty-two (7.3%) patients suffered a PPH (five early). Of these cases, three suffered a re-bleeding event (one mortality). Endoscopy, interventional radiology and surgery were employed in each case. CONCLUSION: PPH presents major clinical challenges and is associated with significant morbidity and mortality. Early detection of the site and type of bleeding are critical and multimodal therapy is usually required. Interventional radiology techniques are making a major contribution to overall management.
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Adenocarcinoma/cirugía , Técnicas Hemostáticas , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/efectos adversos , Hemorragia Posoperatoria/terapia , Stents , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Hemorragia Posoperatoria/diagnóstico , Hemorragia Posoperatoria/etiología , Recurrencia , Estudios Retrospectivos , Adulto JovenRESUMEN
Background and hypothesis Intravenous thrombolysis with alteplase remains standard care prior to thrombectomy for eligible patients within 4.5 h of ischemic stroke onset. However, alteplase only succeeds in reperfusing large vessel arterial occlusion prior to thrombectomy in a minority of patients. We hypothesized that tenecteplase is non-inferior to alteplase in achieving reperfusion at initial angiogram, when administered within 4.5 h of ischemic stroke onset, in patients planned to undergo endovascular therapy. Study design EXTEND-IA TNK is an investigator-initiated, phase II, multicenter, prospective, randomized, open-label, blinded-endpoint non-inferiority study. Eligibility requires a diagnosis of ischemic stroke within 4.5 h of stroke onset, pre-stroke modified Rankin Scale≤3 (no upper age limit), large vessel occlusion (internal carotid, basilar, or middle cerebral artery) on multimodal computed tomography and absence of contraindications to intravenous thrombolysis. Patients are randomized to either IV alteplase (0.9 mg/kg, max 90 mg) or tenecteplase (0.25 mg/kg, max 25 mg) prior to thrombectomy. Study outcomes The primary outcome measure is reperfusion on the initial catheter angiogram, assessed as modified treatment in cerebral infarction 2 b/3 or the absence of retrievable thrombus. Secondary outcomes include modified Rankin Scale at day 90 and favorable clinical response (reduction in National Institutes of Health Stroke Scale by ≥8 points or reaching 0-1) at day 3. Safety outcomes are death and symptomatic intracerebral hemorrhage. Trial registration ClinicalTrials.gov NCT02388061.
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Procedimientos Endovasculares/métodos , Fibrinolíticos/uso terapéutico , Accidente Cerebrovascular/terapia , Trombectomía/métodos , Activador de Tejido Plasminógeno/uso terapéutico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Australia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Nueva Zelanda , Accidente Cerebrovascular/diagnóstico por imagen , Tomógrafos Computarizados por Rayos X , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Endovascular thrombectomy improves functional outcome in large vessel occlusion ischemic stroke. We examined disability, quality of life, survival and acute care costs in the EXTEND-IA trial, which used CT-perfusion imaging selection. METHODS: Large vessel ischemic stroke patients with favorable CT-perfusion were randomized to endovascular thrombectomy after alteplase versus alteplase-only. Clinical outcome was prospectively measured using 90-day modified Rankin scale (mRS). Individual patient expected survival and net difference in Disability/Quality-adjusted life years (DALY/QALY) up to 15 years from stroke were modeled using age, sex, 90-day mRS, and utility scores. Level of care within the first 90 days was prospectively measured and used to estimate procedure and inpatient care costs (US$ reference year 2014). RESULTS: There were 70 patients, 35 in each arm, mean age 69, median NIHSS 15 (IQR 12-19). The median (IQR) disability-weighted utility score at 90 days was 0.65 (0.00-0.91) in the alteplase-only versus 0.91 (0.65-1.00) in the endovascular group (p = 0.005). Modeled life expectancy was greater in the endovascular versus alteplase-only group (median 15.6 versus 11.2 years, p = 0.02). The endovascular thrombectomy group had fewer simulated DALYs lost over 15 years [median (IQR) 5.5 (3.2-8.7) versus 8.9 (4.7-13.8), p = 0.02] and more QALY gained [median (IQR) 9.3 (4.2-13.1) versus 4.9 (0.3-8.5), p = 0.03]. Endovascular patients spent less time in hospital [median (IQR) 5 (3-11) days versus 8 (5-14) days, p = 0.04] and rehabilitation [median (IQR) 0 (0-28) versus 27 (0-65) days, p = 0.03]. The estimated inpatient costs in the first 90 days were less in the thrombectomy group (average US$15,689 versus US$30,569, p = 0.008) offsetting the costs of interhospital transport and the thrombectomy procedure (average US$10,515). The average saving per patient treated with thrombectomy was US$4,365. CONCLUSION: Thrombectomy patients with large vessel occlusion and salvageable tissue on CT-perfusion had reduced length of stay and overall costs to 90 days. There was evidence of clinically relevant improvement in long-term survival and quality of life. CLINICAL TRIAL REGISTRATION: http://www.ClinicalTrials.gov NCT01492725 (registered 20/11/2011).
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We describe the case of a patient who presented with debilitating pulsatile tinnitus in association with two jugular bulb diverticula. The diverticula were treated with stenting of the jugular bulb and coil embolization of the diverticula over two procedures. This resulted in successful resolution of symptoms and at 10â months follow-up the patient is asymptomatic. The technique is discussed with regard to similar published cases and surrogate measures of safety taken from the literature pertaining to idiopathic intracranial hypertension.
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Divertículo/cirugía , Procedimientos Endovasculares/métodos , Venas Yugulares/cirugía , Acúfeno/cirugía , Divertículo/complicaciones , Divertículo/diagnóstico por imagen , Femenino , Humanos , Venas Yugulares/diagnóstico por imagen , Persona de Mediana Edad , Acúfeno/diagnóstico por imagen , Acúfeno/etiologíaRESUMEN
BACKGROUND: The recent literature pertaining to delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage has downplayed the role of angiographic vasospasm. However, it is our hypothesis that angiographic vasospasm has a significant pathophysiological role in this disease. We undertook an observational radiographic study of patients who presented in a delayed manner (>72â h from ictus) with evidence of severe angiographic vasospasm on initial angiography in order to describe an apparent association between vasospasm and infarct location. METHODS: This was a retrospective study of consecutive patients treated at our unit. Initial, subsequent, and follow-up cross-sectional imaging with CT or MRI was analyzed in conjunction with initial angiography. Sites of angiographic narrowing, angiographic hypoperfusion, and subsequent sites of infarction were assessed. RESULTS: Thirteen patients (6 women, 7 men) of mean age 49â years were assessed. Mean time to presentation was 6â days. All had severe angiographic vasospasm. Nine of the 13 patients suffered infarction; the infarcts in seven of the nine patients were large. There was correlation between sites of angiographic narrowing and infarction in all cases and eight of the nine cases showed angiographic hypoperfusion in a location corresponding to eventual infarct location. CONCLUSIONS: Severe angiographic vasospasm may be linked to infarction in patients who present late. These infarcts are mostly large despite maximal treatment. We question the notion that proximal vasospasm has a minor role in delayed ischemia.
Asunto(s)
Infarto Cerebral/etiología , Hemorragia Subaracnoidea/complicaciones , Vasoespasmo Intracraneal/complicaciones , Adulto , Anciano , Angiografía de Substracción Digital , Angiografía Cerebral , Infarto Cerebral/diagnóstico por imagen , Infarto Cerebral/cirugía , Circulación Cerebrovascular , Procedimientos Endovasculares , Femenino , Humanos , Angiografía por Resonancia Magnética , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Stents , Hemorragia Subaracnoidea/diagnóstico por imagen , Hemorragia Subaracnoidea/etiología , Tomografía Computarizada por Rayos X , Vasoespasmo Intracraneal/diagnóstico por imagen , Vasoespasmo Intracraneal/cirugíaRESUMEN
BACKGROUND: Surgical clipping and endovascular coiling yield similar functional outcomes for the treatment of saccular aneurysms of the anterior communicating (ACOM) artery. However, surgical treatment may be associated with greater rates of cognitive impairment due to injury of adjacent structures. We aimed to quantify the rates of injury (infarction/hemorrhage) for both clipping and coiling of ACOM aneurysms. METHODS: This was a retrospective dual-center radiological investigation of a consecutive series of patients with ruptured and unruptured ACOM aneurysms treated between January 2011 and October 2014. Post-treatment CT or MRI was assessed for new ischemic or hemorrhagic injury. Injury relating to the primary hemorrhage or vasospasm was differentiated. Univariate analysis using χ(2) tests and multivariate analysis using binary logistic regression was used. RESULTS: 66 patients treated with clipping were compared with 93 patients treated with coiling. 32/66 (48.5%) patients in the clipping group suffered treatment-related injury (31 ischemic, 1 hemorrhagic) compared with 4/93 (4.4%) patients in the coiling group (3 ischemic, 1 hemorrhagic) (p<0.0001). For patients with subarachnoid hemorrhage, the multivariate OR for infarction for clipping over coiling was 24.42 (95% CI 5.84 to 102.14), p<0.0001. The most common site of infarction was the basal forebrain (28/66 patients, 42.4%), with bilateral infarction in 4. There was injury of the septal/subcallosal region in 12/66 patients (18%). CONCLUSIONS: Clipping of ACOM aneurysms is associated with significantly higher rates of structural injury than coiling, and this may be a reason for superior cognitive outcomes in patients treated with coiling in previously published studies.