Pediatric brain aneurysms: a review of 1458 brain MR angiograms.

PURPOSE: To evaluate clinical and imaging characteristics of pediatric brain aneurysms. MATERIALS AND METHODS: A retrospective review of 1458 MR angiograms of pediatric patients (≤18 years old) obtained between 2006 and 2021 was performed. A non-infundibular arterial luminal outpouching larger than 1mm in size was identified as an "Intracranial aneurysm." Patient demographics, clinical presentations, and predisposing risk factors, including family history and underlying medical conditions, were reviewed. MRA images were analyzed for aneurysm location, number, maximum diameter, and interval changes on follow-up. RESULTS: Forty-nine (3.3%) patients (30 females, 19 males) with 64 intracranial aneurysms were identified with an average age of 13.71 ± 3.67 years. Eleven (22.4%) patients had multiple aneurysms. An underlying systemic illness was observed in 81.6% (40/49) cases, with sickle cell disease as the most frequent (25/49, 51%) diagnosis. A first-degree family history of intracranial aneurysms was recognized in 36/1458 (2.5%) patients. However, no intracranial aneurysm was found in this group. While 02/49 (4%) patients presented with acute SAH, headache was the most common (16/49, 32.7%) symptom at presentation in unruptured cases. The majority (47/64, 73.4%) of the aneurysms were located in the anterior circulation, with the ICA ophthalmic segment being most frequently (24/47, 51%) involved. Most (54/64, 84.4%) aneurysms were smaller than 4mm in size at the time of diagnosis. At least one follow-up MRA was obtained in 72.3% (34/47) of the unruptured aneurysms cohort. There was no change in the aneurysm size and morphology in 31/34 (91.2 %) patients over an average imaging follow-up of 39.6 months. Three (6%) patients demonstrated an interval increase in the aneurysm size. SAH patients (n=2) and two unruptured aneurysm patients with an interval increase in size were successfully treated with endovascular techniques. CONCLUSION: Female predominance with a higher frequency of small and unruptured intracranial aneurysms was recognized in our cohort. A higher incidence of an underlying systemic illness, especially sickle cell disease, was also noted. Most intracranial aneurysms in children appear to remain stable. However, there seems to be the risk of an aneurysm size increase which warrants regular clinical and imaging follow-up.

Impact of magnetic resonance angiography parameters on stroke prevention therapy in pediatric patients with sickle cell anemia.

BACKGROUND: Degree of cerebrovascular stenosis in pediatric patients with sickle cell anemia (SCA) informs need for chronic transfusion therapy, which has significant risks. Flow artifact, intrinsic to magnetic resonance angiography (MRA), is dependent on technical parameters and can lead to overinterpretation of stenosis. The primary objective of this study was to document any change in stroke prevention therapy that could be attributed to the implementation of a standardized MRA scanning protocol for patients with SCA. METHODS: A standardized MRA scanning protocol with an echo time of less than 5 ms was implemented at Montefiore Medical Center (MMC), NY in May 2016. Retrospective chart review identified 21 pediatric patients with SCA, with an MRA head both pre- and post-May 2016. Arterial stenosis on MRA, machine parameters, and treatment plans were compared pre- and post-implementation. RESULTS: Ten of the 21 patients met inclusion criteria. Previously seen stenosis was re-classified to a lower degree in six of the 10 patients, leading to discontinuation of transfusions in five patients. No patients required escalation of therapy to chronic transfusions. CONCLUSION: Optimizing flow artifact by decreasing echo time to less than 5 ms can improve accurate interpretation of cerebrovascular disease, and ensure appropriate treatment plans are in place for stroke prevention. This is especially important for implementing "TCD With Transfusions Changing to Hydroxyurea (TWiTCH)" clinical trial results in the real-world setting.

Cement Augmentation of Two-Level Lumbar Corpectomy Cage After Malposition: A Novel Salvage Procedure Technical Note.

Intervertebral cage mispositioning is an uncommon complication of a posterior lumbar corpectomy. Most frequently, cages are placed obliquely, laterally, or protruding. However, there are few reports of implanted cages that fail to contact the adjacent vertebral endplate and thus no descriptions of successful revisions. The objective of this case report is to report a unique case of minimally invasive rescue vertebroplasty with cement augmentation following a lumbar corpectomy that resulted in graft-endplate noncontact in a medically complicated patient A 60-year-old male with a history of active intravenous (IV) drug use, untreated hepatitis C virus (HCV) infection, and chronic malnourishment presented with low back pain. He had a history of vertebral osteomyelitis managed with intravenous antibiotics, although he was noncompliant with infusions. The diagnosis of L2-L3 discitis-osteomyelitis with intradiscal abscess causing cord compression was made using inpatient lumbar imaging. The initial intervention was accomplished with L2 and L3 vertebral corpectomy with decompression and expandable cage placement as well as a T10-pelvis posterior fixation. Despite the resolution of presenting symptoms, routine postoperative radiographs identified noncontact between the inferior surface of the cage and the superior endplate of the L4 vertebral body. Salvage therapy was pursued via fluoroscopy-guided vertebroplasty with cement augmentation to correct cage malposition. Secondary surgical intervention was successful in bringing the intervertebral cage into contact with the adjacent vertebral body. Lower extremity strength improved, and back pain was resolved. The postoperative motor examination remained unchanged after the rescue procedure. Accurate intraoperative cage placement can be difficult in patients with poor bone quality, especially in the setting of ongoing infection and cachexia. For this reason, routine postoperative imaging is crucial to assessing graft complications. In patients who are poor candidates for revision surgery, we demonstrate that an interventional radiology-based approach may be successful in correcting cage mispositioning and preventing further changes during healing and fusion.

Successful Treatment of Pediatric Holo-Spinal Epidural Abscess With Percutaneous Drainage.

Spinal epidural abscess (SEA) is a rare and potentially devastating neurologic disease that is commonly treated with neurosurgical decompression and evacuation. We describe the case of an 11-month-old immunocompetent infant who presented with a large multiloculated methicillin-resistant Staphylococcus aureus abscess in the left lung apex with likely mediastinal involvement, extending into the epidural space from C7 down to L2 causing cord compression which was successfully treated with percutaneous placement of an epidural drainage catheter and antibiotic therapy. Although there are rare reports of percutaneous drainage of SEAs, to our knowledge, there are no reports of successful use of percutaneous indwelling catheters resulting in the complete resolution of an SEA. Holo-spinal epidural abscess in an infant is an extremely rare disease with limited literature available regarding the best practice for its treatment. Multiple considerations must be taken into account when weighing the different treatment options ranging from surgical decompression to conservative management with antibiotic therapy. We present a unique case of successful treatment with percutaneous epidural drain placement. This provides a reasonable alternative for management in children for whom surgical decompression carries multiple risks for complications both acutely and delayed.

Cost-effective analysis of mechanical thrombectomy (MT) in patients with poor baseline modified Rankin Score (mRS).

Mechanical thrombectomy (MT) has been established as a standard of care for patients with acute ischemic stroke for the past five years. However, the direct benefits of this treatment in patients with baseline disability remains unclear. This study aims to elucidate the cost impact of performing MT on patients with moderate-to-severe baseline disability to work towards an optimized system of care for acute ischemic stroke. We developed a Markov economic model with a life-time horizon analysis of costs associated with mechanical thrombectomy in patients grouped on baseline disability as defined by modified Rankin Score. Our clinical and economic data is based on an American payer perspective. Our results identified a marginal cost-effective ratio (mCER) of $18,835.00 per quality-adjusted life year (QALY) when mechanical thrombectomy is reserved as a treatment only for patients with no-to-minimal baseline disability as compared to those with any level of baseline disability. Our results provide a framework for these future studies and highlight key sectors that drive cost in the surgical treatment and life-long care of patients with acute ischemic stroke.

Social media usage for neurointerventionalists: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee.

The purpose of this publication is to provide a review of social media usage by neurointerventionalists. Using published literature and available local, regional, and national guidelines or laws, we reviewed data on social media usage as it pertains to neurointerventional surgery. Recommendations are provided based on the quality of information and conformity of medico-legal precedent and law. Social media is a growing entity as it is used both promotionally and educationally. Neurointerventionalists may post de-identified radiographic images with discussions, but should be conscientious and adhere to applicable laws and regulations, strict ethical codes, and institutional policies.

Sacroiliac joint injections with the guidance of three-dimensional cone beam computed tomography (3D-CBCT) and fluoroscopy fusion.

BACKGROUND: We describe our diagnostic sacroiliac joint (SIJ) injection technique under the guidance of three-dimensional cone beam computed tomography (3D-CBCT) fused with real-time fluoroscopy. METHODS: A retrospective review of 17 patients (mean age 55.4 (range 40-74) years) who received a total of 23 diagnostic SIJ injections between March 2016 and November 2017 were performed. Pre- and post-procedure pain scores were reviewed from the medical records and then these findings were correlated with which patients were and were not diagnosed with SIJ pain by clinical management. The final diagnosis of SIJ-related pain was made in cases with at least 50% symptomatic improvement following SIJ-specific pain treatments. RESULTS: Some 87% (n=20/23) of injections achieved more than 50% pain relief after the diagnostic SIJ injection. The final diagnosis of the target SIJ-related pain after follow-up and management was found in 90% (n=18/20) of cases. There were two cases with positive tests diagnosed as non-SIJ pain including one with the diagnosis of femuroacetabular impingement and one with pain related to loosening of knee hardware. The sensitivity, specificity, positive predictive value, and negative predicative value of diagnostic SIJ injections were 100%, 60%, 89%, and 100%, respectively, with a 40% false-positive rate. There were no procedure-related complications. CONCLUSION: 3D-CBCT fused with real-time fluoroscopy for SIJ injection is accurate and safe.

Predictors of mortality for patients with COVID-19 and large vessel occlusion.

BACKGROUND: This study evaluates the mortality risk of patients with emergent large vessel occlusion (ELVO) and COVID-19 during the pandemic. METHODS: We performed a retrospective cohort study of two cohorts of consecutive patients with ELVO admitted to a quaternary hospital from March 1 to April 17, 2020. We abstracted data from electronic health records on baseline, biomarker profiles, key time points, quality measures and radiographic data. RESULTS: Of 179 patients admitted with ischemic stroke, 36 had ELVO. Patients with COVID-19 and ELVO had a higher risk of mortality during the pandemic versus patients without COVID-19 (OR 16.63, p = 0.004). An age-based sub-analysis showed in-hospital mortality in 60% of COVID-19 positive patients between 61-70 years-old, 66.7% in between 51-60 years-old, 50% in between 41-50 years-old and 33.3% in between 31-40 years old. Patients that presented with pulmonary symptoms at time of stroke presentation had 71.4% mortality rate. 27.3% of COVID-19 patients presenting with ELVO had a good outcome at discharge (mRS 0-2). Patients with a history of cigarette smoking (p = 0.003), elevated d-dimer (p = 0.007), failure to recanalize (p = 0.007), and elevated ferritin levels (p = 0.006) had an increased risk of mortality. CONCLUSION: Patients with COVID-19 and ELVO had a significantly higher risk for mortality compared to COVID-19 negative patients with ELVO. A small percentage of COVID-19 ELVO patients had good outcomes. Age greater than 60 and pulmonary symptoms at presentation have higher risk for mortality. Other risk factors for mortality were a history of cigarette smoking, elevated, failure to recanalize, elevated d-dimer and ferritin levels.

WITHDRAWN: Neurological examination, rather than vascular risk factor assessment, serves to distinguish strokes from stroke mimics in a population with high prevalence of vascular risk factors.

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Transarterial and transvenous access for neurointerventional surgery: report of the SNIS Standards and Guidelines Committee.

The purpose of this publication is to provide a comprehensive review on the techniques and tools used for vascular access in neurointerventional procedures. Using published literature, we reviewed data on access methods, sites, tools, and techniques for neurointerventions. Recommendations are provided based on quality of data/levels of evidence and, where appropriate, expert consensus. While tools and techniques continue to be developed, current literature and experience supports certain principles regarding vascular access for neurointerventional procedures.

Risk of Ipsilateral Deep Vein Thrombosis After Use of AngioSeal Closure Device in Aneurysmal Subarachnoid Hemorrhage Patients.

BACKGROUND: Deep vein thrombosis (DVT) is a known complication in patients with aneurysmal subarachnoid hemorrhage (aSAH). This study investigated the association between use of the AngioSeal (St. Jude Medical, Minnetonka, MN) vascular closure device and the risk of ipsilateral and any DVT event after angiography in patients with aSAH. METHODS: We conducted a review of our institutional cerebral angiography database for the years 2005-2018 to identify all adult patients who underwent angiography for aSAH. We compared the incidence of DVT (occurring within 14 days) between aSAH patients who underwent manual compression versus the AngioSeal closure device. RESULTS: A total of 459 aSAH patients underwent angiography; 262 underwent manual compression (57.1%) and 197 received AngioSeal (42.9%). There was a 3.4% rate of ipsilateral DVT in the manual compression group and 7.6% in the AngioSeal closure device group (χ2 test, P = 0.04). Similarly, the rate of any DVT was 8.8% for manual compression and 16.8% for patients who received AngioSeal (χ2 test, P = 0.01). On multivariate analysis, AngioSeal remained a significant independent predictor of ipsilateral DVT (odds ratio 2.4, P = 0.04) and any DVT (odds ratio 2.3, P = 0.01). CONCLUSIONS: In aSAH patients undergoing cerebral angiographic procedures with access through the femoral artery, the use of AngioSeal closure device was found to be associated with a significantly increased risk of ipsilateral DVT within 14 days.

Percutaneous Interventional Management of Spinal Metastasis.

Spinal metastasis is usually associated with debilitating pain and results in deteriorating life quality. The role of percutaneous management of spinal metastasis has evolved from a diagnostic role to a significant part of therapeutic options in conjunction with conventional management techniques, including radiotherapy and open surgical options. Percutaneous vertebral augmentation (PVA) showed substantial pain reduction, vertebral stabilization, and improvement of quality of life. Minimally invasive local ablative procedures (MILAPs) demonstrated significant pain reduction, local tumor burden control, and improvement of quality of life. Though combined PVA and MILAP's synergistic role in pain reduction may need additional investigation, considering different actions on spine metastasis patients, combining both techniques might beneficial to selected patients. The role of percutaneous management will likely expand since its role in improving patient's quality of life with very minimal procedure-related risk and in conjunction with future technological advancement.

Brain Diffusion Imaging Findings May Predict Clinical Outcome after Cardiac Arrest.

BACKGROUND AND PURPOSE: We aim to correlate the patterns of brain diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) map in post cardiac arrest (PCA) patients with clinical outcomes. METHODS: Thirty-eight adult patients with PCA (mean age, 52.8 years; range 18-87 years) whose DWI obtained within 5 days of PCA were retrospectively reviewed. The visual DWI/ADC map categories include: Group 1: Normal; Group 2a: Mild [restricted diffusion (RD) < 1/3 cortical involvement (CI)]); Group 2b: Moderate (RD 1/3 > and < 2/3 CI); Group 2c: Severe (RD > 2/3 CI); and Group 3: Embolic (scattered, discrete foci of RD). Clinical outcomes were categorized according to cerebral performance categories (CPC) and modified Rankin scale (mRS). RESULTS: The most common DWI/ADC map pattern was Group 1 (28.9%, n = 11). The incidence of other DWI patterns such as Group 2a, 2b, 2c, and 3 were 21% (n = 8), 10.5% (n = 4), 21% (n = 8), and 18.4% (n = 7), respectively. Twenty-seven patients (71%) were CPC-5/mRS-6 and died or were category CPC-4/mRS-5, and 4 patients were CPC-1/mRS 0-1 (10.5%). Interobserver agreement for visual classification of DWI/ADC map patterns was excellent (kappa = .8795). There was moderate positive correlation between clinical outcomes and visual DWI classification (r = .461, P = .00358). The positive predictive value of this qualitative classification on DWI/ADC in predicting a poor clinical outcome (CPC-4/mRS-5 and CPC-5/mRS-6) was 81.4 % in the presence of restricted diffusion. CONCLUSION: Simple visual categorization system using DWI/ADC map may be helpful and practical in estimating the clinical outcome of PCA patients.

Gray matter atrophy in multiple sclerosis despite clinical and lesion stability during natalizumab treatment.

BACKGROUND: Brain volume loss is an important surrogate marker for assessing disability in MS; however, contribution of gray and white matter to the whole brain volume loss needs further examination in the context of specific MS treatment. OBJECTIVES: To examine whole and segmented gray, white, thalamic, and corpus callosum volume loss in stable patients receiving natalizumab for 2-5 years. METHODS: This was a retrospective study of 20 patients undergoing treatment with natalizumab for 24-68 months. Whole brain volume loss was determined with SIENA. Gray and white matter segmentation was done using FAST. Thalamic and corpus callosum volumes were determined using Freesurfer. T1 relaxation values of chronic hypointense lesions (black holes) were determined using a quantitative, in-house developed method to assess lesion evolution. RESULTS: Over a mean of 36.6 months, median percent brain volume change (PBVC) was -2.0% (IQR 0.99-2.99). There was decline in gray (p = 0.001) but not white matter (p = 0.6), and thalamic (p = 0.01) but not corpus callosum volume (p = 0.09). Gray matter loss correlated with PBVC (Spearman's r = 0.64, p = 0.003) but not white matter (Spearman's r = 0.42, p = 0.07). Age significantly influenced whole brain volume loss (p = 0.010, multivariate regression), but disease duration and baseline T2 lesion volume did not. There was no change in T1 relaxation values of lesions or T2 lesion volume over time. All patients remained clinically stable. CONCLUSIONS: These results demonstrate that brain volume loss in MS is primarily driven by gray matter changes and may be independent of clinically effective treatment.

Patients with cranial dural arteriovenous fistulas may benefit from expanded hypercoagulability and cancer screening.

OBJECTIVE: Cranial dural arteriovenous fistulas (DAVFs) have been associated with dural sinus occlusion, and previous reports have suggested the association of hypercoagulability with some cases. But the prevalence of a hypercoagulable state has not been systematically analyzed in conjunction with laboratory markers and clinical manifestations, including history of thromboembolism or systemic malignancy. The authors hypothesize that laboratory or clinical evidence of a hypercoagulable state, including cancer, is commonly identifiable in consecutively identified patients with DAVFs, with implications for clinical management. METHODS: The retrospective cohort study included all patients older than 17 years with cranial DAVFs diagnosed at University of Chicago Medicine during a 6-year period, whose medical records and imaging results were reviewed for objective laboratory or clinical evidence of a hypercoagulable state, including malignancy. Each case was analyzed for implications on clinical management. Data were analyzed in relation to a systematic review of the literature on this association. RESULTS: Fifteen (88%) of 17 cases of DAVFs had laboratory (n = 8) or clinical evidence of a hypercoagulable state (thromboembolism [n = 8] or cancer [n = 6]). This hypercoagulability or cancer impacted clinical care in all 15 cases. CONCLUSIONS: An underlying hypercoagulable state manifested by laboratory testing or clinically, including cancer, is staggeringly common. It is important to recognize this association, along with its impact on the management of the DAVFs and systemic diseases.

A Report of 2 Cases of Brainstem Hemorrhage After Suboccipital Craniectomy for Chiari Decompression.

BACKGROUND AND IMPORTANCE: Decompression surgery for Chiari malformation is known to have very low procedure-related complications. There has been no report of post-Chiari malformation decompression surgery development of brainstem hemorrhage. We report 2 post-Chiari decompression surgery brainstem hemorrhage cases with 2-yr follow-up. CLINICAL PRESENTATION: Two cases were reviewed in which patients underwent uncomplicated suboccipital craniectomy with expansive autologous pericranium duraplasty for Chiari decompression. Postoperatively, both patients awoke with hemibody sensory and motor deficits. Immediate postoperative magnetic resonance imaging revealed a small hemorrhage within the dorsal medulla in both cases. Follow-up imaging shows resolution along with near complete clinical recovery of deficits. CONCLUSION: These cases demonstrate a rare postdecompression surgery-related complication in Chiari malformation. We hypothesize that these hemorrhages may occur from the rapid drainage of cerebrospinal fluid resulting in a loss of positive pressure, allowing a low-pressure hemorrhage to occur. Given that these hemorrhages are of low pressure, recovery is excellent.