Mid-term safety and efficacy in small intracranial aneurysm coiling: results from TARGET® nano prospective independent core lab adjudicated multicenter registry.

Background: The primary objective is to evaluate the safety and effectiveness of Stryker second generation Target® Nano Coils in the treatment of ruptured and unruptured small (<7 mm) intracranial aneurysms. Methods: The TARGET Registry is a prospective, two-arm study with independent medical event monitoring and core-lab adjudication. This paper describes the second arm of the TARGET registry. Patients with de novo intracranial aneurysms were embolized with 2nd generation TARGET Nano coils in 12 US centers. The primary efficacy outcome was adequate aneurysm occlusion (RR occlusion grade I-II) on follow-up. Primary safety outcome was treatment-related morbidity and mortality. Secondary outcomes included aneurysm packing density immediately post-procedure, immediate adequate occlusion, aneurysm re-access rate, retreatment rate and clinical outcomes using modified ranking scale. A secondary analysis investigated the influence of using Nano-predominant coils (≥2/3 of total coil-length) vs. non-Nano-predominant coils (<2/3 of total length). Results: 150 patients with 155 aneurysms met the inclusion and exclusion criteria. (31%) patients with ruptured and (69%) with unruptured aneurysms were treated using TARGET coils. Median age was 58.8 (SD 12.7), 74.7% were females, and 80% were Caucasians. Mean follow-up was 5.23 (SD 2.27) months. Peri-procedural mortality was seen in 2.0% of patients. Good outcome at discharge (mRS 0-2) was seen in 81.3% of the cohort. The median packing density (SD) was 29.4% (14.9). Mid-term complete/near complete occlusion rate was seen in 96% of aneurysms and complete obliteration was seen in 75.2% of aneurysms. Patients treated predominantly with Nano coils had higher PD (32.6% vs. 26.1%, p < 0.001). There was no significant difference in clinical and angiographic outcomes. The mid-term mRS0-2 was achieved in 106/109 (97.2%) patients. All-cause mortality was 5/115 (4.3%). Conclusion: In the multicenter TARGET Registry, 75.8% of aneurysms achieved mid-term complete occlusion, and 96% achieved complete/near complete occlusion with excellent independent functional outcome.

Technique and impact on first pass effect primary results of the ASSIST global registry.

BACKGROUND: Patients treated with mechanical thrombectomy (MT) for acute ischemic strokes from large vessel occlusion (LVO) have better outcomes with effective reperfusion. However, it is unknown which technique leads to better technical and clinical success. We aimed to determine which technique yields the most effective first pass reperfusion during MT. METHODS: In a prospective, multicenter global registry we enrolled patients treated with operator preferred MT technique at 71 hospitals from January 2019 to January 2022. Three techniques were assessed: SR Classic with stent retriever (SR) and balloon guide catheter (BGC); SR Combination which employed SR with contact aspiration with or without BGC; and direct aspiration (DA) with or without BGC. The primary outcome was achieving an expanded Thrombolysis In Cerebral Infarction (eTICI) score of 2c or 3 on the first pass, with the primary technique as adjudicated by core lab. The primary clinical outcome measure was a 90-day modified Rankin Scale (mRS) score of 0-2. RESULTS: A total of 1492 patients were enrolled. Patients treated with SR Classic or SR Combination were more likely to achieve first pass eTICI 2c or 3 reperfusion (P=0.01). There was no significant difference in mRS 0-2 (P=0.46) or safety endpoints. CONCLUSIONS: The use of SR Classic or SR Combination was more likely to achieve first pass eTICI 2c or 3 reperfusion. There were no significant differences in clinical outcomes and safety endpoints.

Safety and outcomes of simultaneous vasospasm and endovascular aneurysm treatment (SVAT) in subarachnoid hemorrhage.

BACKGROUND: Simultaneous vasospasm and endovascular aneurysm treatment (SVAT) has been shown to be effective with good clinical outcomes in small series, but these studies have not examined predictive factors for clinical outcome after treatment. OBJECTIVE: To identify the safety and efficacy of SVAT in a large multicenter patient cohort and evaluate prognostic markers of clinical outcome following SVAT. METHODS: This study retrospectively enrolled 50 consecutive patients undergoing SVAT at 11 different centers. We analyzed Hunt and Hess and Fisher grades, aneurysm location, angiographic vasospasm grade, Glasgow Outcome Scale (GOS) at discharge, and 90-day modified Rankin Scale (mRS) scores. RESULTS: A total of 50 patients undergoing SVAT between the years 2003 and 2009 were identified. Patients presented, on average, 6.48±4.45 days after subarachnoid hemorrhage. Hunt and Hess and Fisher grades were 1 (n=7), 2 (n=12), 3 (n=14), 4 (n=15), 5 (n=2), and 3 and 4 (n=33), respectively. Aneurysm location was distributed as follows: anterior (n=32), posterior (n=16), anterior and posterior (n=2). Patients with good clinical condition (Hunt and Hess score 1-3) had significantly higher odds of surviving (OR=17.5, 95% CI 1.9 to 161.5), favorable GOS (OR=4.2, 95% CI 1.2 to 14.8), and favorable 90-day mRS (OR=4.2, 95% CI 1.2 to 14.8). CONCLUSIONS: SVAT is safe, with the majority of patients achieving good clinical outcome. Patients with lower Hunt and Hess grades have higher odds of surviving and favorable clinical prognosis.

The safety and efficacy of coiling multiple aneurysms in the same session.

OBJECTIVE: Multiple intracranial aneurysms are common. While sequential clipping of multiple aneurysms during a single open surgical procedure has been reported, the same is not true for endovascular coiling. We present our experience describing the safe coiling of multiple aneurysms in the same setting. METHODS: Retrospective review of our coiling log between 2006 and 2009 showed six cases in which multiple aneurysms were coiled in the same session. RESULTS: All patients were coiled using the same microcatheter. Distal aneurysms were coiled first. Good occlusion rates were achieved in all cases. There were no thromboembolic events or procedure-related rupture or mortality. CONCLUSION: In addition to safety and efficacy, cost savings are expected when coiling multiple aneurysms in the same procedure.

Safety and efficacy of intracranial stenting for acute ischemic stroke beyond 8 h of symptom onset.

OBJECTIVE: To report our experience with stent supported intracranial recanalization for acute ischemic stroke beyond 8 h of symptoms onset. Background Acute ischemic stroke (AIS) therapy is often limited to an 8 h window using mechanical means. However, recent reports have shown delayed recanalization beyond 8 h might be a viable option in a subset of patients. METHODS: A retrospective review was performed of our AIS database for patients who underwent stent supported intracranial recanalization beyond 8 h of symptom onset. Clinical and angiographic data were reviewed. Outcome was measured using modified Rankin Scale (mRS) scores at 30 and 90 days. RESULTS: 12 patients (11 men and one woman) underwent delayed stenting for AIS. Mean age was 49 years (range 37-73) and mean National Institutes of Health Stroke Scale was 17 (range 8-29, median 15). Mean time from stroke onset to intervention was 66.1 h (range 10-168 h, median 46 h). 10 patients presented with a Thrombolysis in Myocardial Infarction (TIMI) score of 0 and the remaining two had a TIMI of 1. Recanalized vessels included: left middle cerebral artery (n=6), basilar trunk (n=2), vertebrobasilar junction (n=3) and internal carotid artery (ICA)-T (n=1). Four patients had prior attempts of embolectomy/thrombolysis using mechanical and chemical means. Stents used included: six balloon mounted stents, five Wingspan and one Enterprise self-expanding intracranial stent. Recanalization, defined as a TIMI score of 2 or more, was achieved in 11 patients. Two patients (17%) had intracranial hemorrhage. Thirty day mRS of ≤3 was achieved in six patients (50%). Seven patients (58%) had a 90 day mRS of ≤2. CONCLUSION: Stent supported intracranial recanalization is a safe and feasible approach in a selective group of patients presenting with acute ischemic stroke beyond 8 h of symptom onset.

Stenting of acute and subacute intracranial vertebrobasilar arterial occlusive lesions.

BACKGROUND AND OBJECTIVE: The outcome of failed recanalization in patients with acutely symptomatic intracranial vertebrobasilar (VB) artery occlusive disease is poor. This paper reports the recanalization rate and safety of VB artery stenting in acutely symptomatic patients presenting >8 h after onset of symptoms. METHODS: A retrospective review of a prospectively maintained database of stent-supported endovascular treatment of intracranial circulation was carried out to identify patients with VB artery occlusive disease who were acutely revascularized >8 h after symptom onset. RESULTS: Of 12 patients (mean age 61 years), nine had acute stroke and three had recurrent transient ischemic attacks. The median time to intervention was 59 h (range 8-80). The median National Institute of Health Stroke Scale score was 11.5 (range 1-40). Angiography showed thrombolysis in myocardial infarction (TIMI) 0 flow in six patients and TIMI 1 flow in the other six. Stents were placed in the basilar artery in six and at the VB junction in the other six. Mechanical and/or intra-arterial thrombolysis was used in three patients before stenting. Nine patients had self-expanding stents and three had balloon-expandable stents. The recanalization rate was 100%. Procedure-related and 3-month mortality was zero. Two patients had asymptomatic intracranial hemorrhage. At 3-month follow-up a favorable outcome with a modified Rankin score ≤2 was achieved in eight. A follow-up angiogram in eight patients showed mild re-stenosis in three. CONCLUSION: Stent-supported VB artery revascularization can be a viable option with an acceptable safety profile in acute VB occlusion or unstable intracranial atherosclerotic arterial disease (ICAD) in carefully selected patients.

Clinical and angiographic outcome in patients with completely occluded intracranial aneurysms by endovascular coiling: our experience.

OBJECTIVE: There are limited data about the rate of recanalization following complete coil occlusion. Long term clinical and angiographic outcome of completely occluded intracranial aneurysms (IAs) by the endovascular approach are presented. METHODS: Over the course of 4 years, patients with IAs which were completely occluded by coiling at our institution were reviewed. Clinical and angiographic data were analyzed. The patients were clinically assessed using the Glasgow Outcome Scale (GOS). Follow-up angiographic findings were categorized as: stable aneurysm with no recanalization, recanalization with a neck remnant and recanalization with a body remnant. RESULTS: 83 aneurysms were identified in 74 patients (15 men and 59 women, average age 52.4 years) with complete occlusion post intervention. Treatment by coiling only was used in 73 aneurysms while stent assisted coiling was used in 10 cases. At the last angiographic follow-up (mean 16.3 months), 20 of the 83 aneurysms demonstrated various degrees of recanalization of which five had neck remnants and 15 had body remnants. The recanalization rate was significantly higher in large aneurysms (57%) compared with small aneurysms (14%). Clinically, 65 of the 74 patients showed good recovery (GOS score 5), eight had moderate disability (GOS score 4) and one was severely disabled (GOS score 3). CONCLUSION: Complete endovascular occlusion of IA is certainly effective in preventing aneurysmal bleeding. However, recanalization rate, despite being lower when compared with subtotal occlusion, remains an issue. Longer follow-up is required.

Endovascular management of a giant aneurysm through saphenous vein graft after extracranial-intracranial bypass: case report and literature review.

It is known that giant intracerebral aneurysms have a high rupture and mortality rate. Furthermore, their optimal treatment method is not straightforward. While traditionally they have been managed with surgical clipping, it is not always possible. A unique case is presented in which a patient with multiple intracranial aneurysms was treated using a multimodality approach. After an intracranial-extracranial bypass, the left internal carotid artery ophthalmic aneurysm continued to grow on follow-up angiogram. Thus it was decided to go ahead with coiling of the aneurysm. The coils were delivered through the saphenous vein graft. The patient tolerated the procedure well and there were no procedural complications.

Hangman's fracture: a historical and biomechanical perspective.

The execution technique of hanging, introduced by the Angle, Saxon, and Jute Germanic tribes during their invasions of the Roman Empire and Britain in the 5th century, has remained largely unchanged over time. The earliest form of a gallows was a tree on which prisoners were hanged. Despite the introduction of several modifications such as a trap door, the main mechanism of death remained asphyxiation. This created the opportunity for attempted revival after the execution, and indeed several well-known cases of survival following judicial hanging have been reported. It was not until the introduction of the standard drop by Dr. Samuel Haughton in 1866, and the so-called long drop by William Marwood in 1872 that hanging became a standard, humane means to achieve instantaneous death. Hangmen, however, fearing knot slippage, started substituting the subaural knot for the traditional submental knot. Subaural knots were not as effective, and cases of decapitation were recorded. Standardization of the long drop was further propagated by John Berry, an executioner who used mathematical calculations to estimate the correct drop length for each individual to be hanged. A British committee on capital sentences, led by Lord Aberdare, studied the execution method, and advocated for the submental knot. However, it was not until Frederic Wood-Jones published his seminal work in 1913 that cervical fractures were identified as the main mechanism of death following hanging in which the long drop and a submental knot were used. Schneider introduced the term "hangman's fracture" in 1965, and reported on the biomechanics and other similarities of the cervical fractures seen following judicial hangings and those caused by motor vehicle accidents.

Good outcome in HELLP syndrome with lobar cerebral hematomas.

BACKGROUND: HELLP syndrome is associated with high morbidity and mortality which is attributed most commonly to intracranial hemorrhage (ICH) and/or stroke. The presence of other complications further worsens the prognosis. METHODS: We present a rare case of HELLP syndrome which presented with ICH and further complicated by seizures, disseminated intravascular coagulation, and acute renal failure. RESULTS: Aggressive surgical and medical management of her ICH, HELLP syndrome and associated complications resulted in good functional recovery. Hypothermia seems to be a good adjunctive in treatment. CONCLUSION: ICH associated with HELLP syndrome when managed aggressively can have meaningful neurological recovery.

Safety of instrumentation in patients with spinal infection.

OBJECT: Treatment of spine infection remains a challenge for spine surgeons, with the most effective method still being a matter of debate. Most surgeons agree that in early stages of infection, antibiotic treatment should be pursued; under certain circumstances, however, surgery is recommended. The goals of surgery include radical debridement of the infective focus. In some cases, when surgery causes mechanical spinal instability, the question arises whether the risk of recurrent infection outweighs the benefits of spinal instrumentation and stabilization. The authors report their series of cases in which instrumentation was placed in actively infected sites and review the relevant literature. METHODS: The authors performed a retrospective analysis of all cases of spinal infection that were surgically treated with debridement and placement of instrumentation at their institution between 2000 and 2006. Patient presentation, risk factor, infective organism, surgical indication, level of involvement, type of procedure, and ultimate outcome were reviewed. Improved outcome was based on improvement of initial American Spinal Injury Association Impairment Score. RESULTS: Forty-seven patients (32 men, 15 women) were treated with instrumented surgery for spinal infection. Their average age at presentation was 54 years (range 37-78 years). Indications for placement of instrumentation included instability, pain after failure of conservative therapy, or both. Patients underwent surgery within an average of 12 days (range 1 day to 5 months) after their presentation to the authors' institution. The average length of hospital stay was 25 days (range 9-78 days). Follow-up averaged 22 months (range 1-80 months). Eight patients died; causes of death included sepsis (4 patients), cardiac arrest (2), and malignancy (2). Only 3 patients were lost to follow-up. Using American Spinal Injury Association scoring as the criterion, the patients' conditions improved in 34 cases and remained the same in 5. Complications included hematoma (2 cases), the need for hardware revision (1), and recurrent infection (2). Hardware replacement was required in 1 of the 2 patients with recurrent infection. CONCLUSIONS: Instrumentation of the spine is safe and has an important role in stabilization of the infected spine. Despite the presence of active infection, we believe that instrumentation after radical debridement will not increase the risk of recurrent infection. In fact, greater benefit can be achieved through spinal stabilization, which can even promote accelerated healing.

Supratentorial neurenteric cysts-A fascinating entity of uncertain embryopathogenesis.

The histopathological, immunologic, and ultrastructural findings of neurenteric cysts support an endodermal derivation. These developmental cystic lesions are generally located in the posterior mediastinum, abdomen, and pelvis and may also contain some mesodermal and neuroectodermal elements. In contrast, neurenteric cysts of the central nervous system are very infrequent and occur most commonly in the spinal canal. Intraspinal neurenteric cysts are usually encountered in the cervicothoracic region with an intradural, extramedullary location and are commonly associated with congenital defects of the overlying skin and/or vertebral bodies. Intracranial neurenteric cysts are very uncommon and typically located in the posterior fossa. Several hypotheses have been postulated to explain the origin of intracranial neurenteric cysts. However, the embryologic basis of these fascinating lesions remains incompletely understood. Supratentorial neurenteric cysts are distinctly rare often represent a diagnostic challenge on preoperative neuroimaging. In fact, only 22 cases of supratentorial neurenteric cysts have been reported in the literature including our own patient with a laterally based convexity extraaxial cyst presenting with seizures. In this report, we review the clinical, radiographic, and histological findings of supratentorial neurenteric cysts. We discuss the differential diagnoses and surgical considerations in the management of these intriguing lesions. We also provide an extensive review of normal human embryogenesis and discuss putative mechanisms of embryopathogenesis of supratentorial neurenteric cysts.

Synchronous meningioma and anaplastic large cell lymphoma.

Synchronous primary brain tumors are exceedingly rare. When they occur, most cases are associated with metastatic disease. To the best of our knowledge, we report the first case of an atypical meningioma infiltrated by a T-cell-primary central nervous system lymphoma (PCNSL), specifically anaplastic large cell lymphoma (ALCL). We present a novel, unifying, plausible mechanism for its origin based on theories in the current literature. A 65-year-old man with a history of near-total resection of atypical meningioma presented with a complaint of progressive headaches. Imaging revealed recurrent tumor. Left frontal-temporal craniotomy with near-total tumor resection followed by radiation was performed. Recurrent symptomatic tumor led to repeat left frontotemporal craniotomy with tumor resection and partial anterior temporal lobectomy. Part of the specimen showed predominantly fibrotic neoplasm composed of nests and whorls of meningothelial cells, highlighted by epithelial membrane antigen (EMA) staining. The remainder of the specimen consisted of densely cellular neoplasm centered in connective tissue, including areas involved by meningioma. This tumor was composed of moderately large lymphoid cells with large nuclei, prominent nucleoli, and amphophilic cytoplasm. These cells were strongly immunoreactive for CD3 and CD30 but remained unstained with EMA, anaplastic lymphoma kinase-1 (ALK-1), CD15 or cytotoxic associated antigen TIA-1. Smaller mature lymphocytes, chiefly T-cells, were intermixed. The morphologic and immunohistochemical features were considered typical of anaplastic large T-cell lymphoma. The pathogenesis of this association may have been due to radiation-mediated breakdown of the blood-brain barrier with subsequent T-cell infiltration and proliferation. We advocate aggressive resection and long-term surveillance for individuals with metastasis, especially higher-grade neoplasms that receive radiotherapy.

Peripheral ophthalmic artery aneurysm associated with multiple intracranial aneurysms: a case report.

Peripheral intraorbital ophthalmic artery aneurysms are rare. We here present a case of intraorbital ophthalmic artery aneurysm, associated with multiple anterior circulation aneurysms. The asymptomatic ophthalmic artery aneurysm was not treated. However, the symptomatic ones were embolized.

Pediatric spinal clear cell meningioma. Case report.

In this report the authors describe a unique case of spinal clear cell meningioma in a 13-year-old girl. Clear cell meningiomas (CCMs) are not uncommon. To the authors' knowledge, 14 cases of pediatric CCM occurring in the spinal canal have been reported. Factors lending resistance to meningioma initiation and invasion are analyzed. This 13-year-old girl presented with pain radiating down her left leg. Admission MR imaging showed an inhomogeneous enhancing intradural-extramedullary mass at the L4-5 level. Resection revealed a CCM, and radiotherapy was subsequently administered. Postoperatively there has been no recurrence in > 2 years. In this paper the authors report a case of CCM and provide a comprehensive literature review on this disease. Current recommendations for its management are still debatable, especially in the pediatric population, and the authors propose an algorithm for its treatment and surveillance.

Outcome of brain abscess by Clostridium perfringens.

OBJECTIVE: Despite the aggressive infection of soft tissue caused by Clostridium perfringens (gas gangrene-necrotizing fasciitis), a brain abscess with this bacteria treated by early surgical excision, debridement of necrotic tissue, and antibiotic coverage may be expected to have a good recovery. Long-term follow-up has not been well established in this group of patients. We report this case to show the outcome at 3 years post surgical and antibiotic treatment for C. perfringens brain abscess and stress the need for urgent intervention to achieve good outcome. We also present a literature review of Clostridial brain abscesses since the 1960s. CLINICAL PRESENTATION: A 53-year-old man was brought to the emergency room after having a witnessed seizure status postassault 3 days before admission. On presentation, he was febrile, disoriented, lethargic, and demonstrated right upper extremity weakness. A computed tomographic scan of the head showed a left frontoparietal depressed cranial fracture complicated with gas and intraparenchymal air fluid level cavity. INTERVENTION: Emergent surgery for debridement and excision of necrotic tissue was performed. Empiric intravenous antibiotic therapy was started and penicillin G was added for 6 weeks after C. perfringens was demonstrated. CONCLUSION: Despite the severe infection and effect of C. perfringens in soft tissues in the brain, it appears that emergent surgical debridement and antibiotic coverage will yield an excellent outcome for these patients.