A pilot randomised controlled trial of the management of systolic blood pressure during endovascular thrombectomy for acute ischaemic stroke.

It is unknown whether systolic blood pressure augmentation during endovascular thrombectomy improves clinical outcomes. This pilot randomised controlled trial aimed to assess the feasibility of differential systolic blood pressure targeting during endovascular thrombectomy procedures for anterior circulation ischaemic stroke. Fifty-one eligible patients fulfilling the national criteria for endovascular thrombectomy were randomly assigned to receive either standard or augmented systolic blood pressure management from the start of anaesthesia to recanalisation of the target vessel. Systolic blood pressure targets for the standard and augmented groups were 130-150 mmHg and 160-180 mmHg, respectively. The study achieved all feasibility targets, including a recruitment rate of 3.5 participants per week and median (IQR [range]) of mean systolic blood pressure separation between groups of 139 (135-143 [115-154]) vs. 167 (150-175 [113-188]) mmHg, p < 0.001. Data completeness was 99%. Independent functional recovery at 90 days (modified Rankin Scale 0, 1 or 2) was achieved in 30 (59%) patients, which is consistent with previously published data. There were no safety concerns with trial procedures. In conclusion, a large randomised controlled efficacy trial of standard vs. augmented systolic blood pressure management during endovascular thrombectomy is feasible.

Benign Enhancing Foramen Magnum Lesions: Clinical Report of a Newly Recognized Entity.

Intradural extramedullary foramen magnum enhancing lesions may be due to meningioma, nerve sheath tumor, aneurysm, or meningeal disease. In this clinical report of 14 patients, we describe a novel imaging finding within the foramen magnum that simulates disease. The lesion is hyperintense on 3D-FLAIR and enhances on 3D gradient-echo sequences but is not seen on 2D-TSE T2WI. It occurs at a characteristic location related to the posterior aspect of the intradural vertebral artery just distal to the dural penetration. Stability of this lesion was demonstrated in those patients who underwent follow-up imaging. Recognition of this apparently benign lesion may prevent unnecessary patient anxiety and repeat imaging.

Management strategy for treatment of vasospasm following transsphenoidal excision of craniopharyngioma.

We describe two cases of clinical and radiographic vasospasm after transsphenoidal resection of a craniopharyngioma. We review the literature on the association of vasospasm and craniopharyngioma and examine management options. Given the lack of evidence for the optimal management of these patients, treatment in concordance with protocols for vasospasm due to subarachnoid haemorrhage is recommended.

Spinal dural arteriovenous fistulas: clinical experience with endovascular treatment as a primary therapy at 2 academic referral centers.

BACKGROUND AND PURPOSE: Spinal dural arteriovenous fistulas are a rare entity that, if left untreated, can lead to considerable morbidity with progressive spinal cord symptoms. The aim of this study was to evaluate the clinical outcome of patients with spinal dural arteriovenous fistulas that were primarily treated with endovascular embolization. MATERIALS AND METHODS: A retrospective review was performed of all patients from 1997-2010 who underwent treatment at 2 academic referral centers for a spinal dural arteriovenous fistula. Follow-up was performed by clinical examination, and functional status was measured by use of the Aminoff-Logue Disability Scale, McCormick classification grading, and mRS scores. The nonparametric Wilcoxon signed rank test was used to compare pretreatment and posttreatment Aminoff-Logue Disability Scale gait and micturition scores, McCormick classification grading, and mRS scores. P values < .05 were considered significant. RESULTS: A total of 38 patients were included. Five patients (2 endovascular, 3 surgical) were lost to follow-up and therefore were excluded from the analysis, 29 patients were initially treated from an endovascular approach (9 Onyx, 20 cyanoacrylate), and 4 patients were treated from a standard surgical approach. Five patients in the endovascular group subsequently underwent surgery for various reasons. The clinical improvements in the Aminoff-Logue Disability Scale gait and micturition scores, McCormick classification grading, and the mRS scores were statistically significant (P < .05, Wilcoxon signed rank test). CONCLUSIONS: We conclude that endovascular treatment of spinal dural arteriovenous fistulas can result in good clinical outcomes. Surgery remains the treatment of choice when safe embolization of the proximal radicular draining vein cannot be obtained or because the shunting artery of the spinal dural arteriovenous fistula also supplies the anterior spinal, posterior spinal, or a radiculomedullary artery.

An evaluation of the capability of existing and novel serodiagnostic methods for porcine brucellosis to reduce false positive serological reactions.

Porcine brucellosis is a zoonotic disease of truly global significance because even in countries without the disease the occurrence of false positive serological reactions (FPSRs) creates significant problems. Statutory diagnostic testing is required in many disease free countries or regions and is often a prerequisite for the movement of live animals. Currently this testing is dependent almost entirely on serological assays and these may result in a significant number of FPSRs. The aim of this study was to examine existing and novel serodiagnostic assays to evaluate their diagnostic sensitivity and resilience to FPSRs. The existing assays evaluated were the RBT, smooth lipopolysaccharide (sLPS) indirect (i) ELISA, sLPS competitive (c) ELISA, and the FPA. The novel assays evaluated were the sLPS TR-FRET assay, a rough (r) LPS iELISA, a recombinant protein BP26 iELISA and a cytoplasmic protein extract (Brucellergene™) iELISA. Four populations of sera were evaluated: those from Brucella suis infected swine (n=34), randomly selected samples from non-infected swine (n=161), sera from non-infected swine within herds exhibiting FPSRs (n=132) and sera from swine experimentally infected with Yersinia enterocolitica O:9 (n=4). The results show that all the assays dependent on the sLPS O-polysaccharide (OPS) for their sensitivity (the RBT, sLPS ELISAs, FPA and the sLPS TR-FRET) had significantly reduced diagnostic specificity when applied to the FPSR population, the RBT being most affected. Of the two rapid homogeneous assays, the TR-FRET was diagnostically superior to the FPA in this study. Neither of the protein based iELISAs demonstrated sufficient diagnostic sensitivity to resolve the FPSRs. The rLPS iELISA showed no cross reaction with the FPSRs and had diagnostic sensitivity similar to that of the OPS based assays.

An arteriovenous malformation within the internal acoustic meatus and cerebellopontine angle cistern.

OBJECTIVES: We report a case of an arteriovenous malformation within the internal auditory meatus and cerebellopontine angle, and we discuss its imaging appearances and management. CASE REPORT: A 50-year-old man presented with a two-year history of vertigo. Magnetic resonance imaging and magnetic resonance angiography demonstrated a lesion consisting of multiple 'high flow' vessels within the left internal auditory meatus and cerebellopontine angle. Transarterial embolisation was performed, with obliteration of the arteriovenous malformation. CONCLUSION: Arteriovenous malformations of the internal auditory meatus and cerebellopontine angle are exceedingly rare. It is important that a pre-treatment diagnosis is made, as the management of arteriovenous malformation differs from that of other, more common lesions at this site.

Management and outcome of vein of Galen malformation.

OBJECTIVE: To describe our experience of treating children with vein of Galen aneurysmal malformation (VGM) in a single UK centre between 2003 and 2008. METHOD: Retrospective review of case notes and neuroimaging. RESULTS: 33 children were seen (26 neonates, seven infants), of whom 28 underwent endovascular treatment. Four were not offered treatment as they had evidence of severe diffuse brain injury at presentation; treatment was deferred in another who subsequently died. Seven children died (two of whom had endovascular treatment). Of the survivors (all treated), 13 (39%) are neurodevelopmentally intact, seven (21%) have mild neurodevelopmental impairment and the remaining six (18%) have significant neurological impairment. The authors were not able to identify clinical or radiological parameters which strongly predicted outcome. Of note, two children with initially low Bicêtre scores were neurologically intact after successful embolisation. CONCLUSION: The outlook for children with VGM is significantly better since the advent of endovascular treatment. Decisions about the appropriateness and timing of treatment should be taken by an experienced multidisciplinary team.

Subarachnoid hemorrhage with cerebral vein thrombosis and aneurysmal disease: a treatment conundrum. A case report.

SUMMARY: Coexisting cerebral vein thrombosis and aneurysmal disease in the setting of acute subarachnoid hemorrhage is rare. We present the case of a 62 year-old woman presenting to our institution with an episode of collapse with a transient loss of consciousness with a 24 hour history of occipital headache. Imaging demonstrated extensive basal cisternal, intraventricular and cortical subarachnoid hemorrhage. Digital subtraction angiography and magnetic resonance imaging confirmed the presence of an aneurysm in the proximity of the right posterior communicating artery as well as thrombosis of the right anastomotic vein of Labbe. The patient underwent endovascular coil embolization to exclude the aneurysm and post-treatment anticoagulation. Despite a SAH rebleed with reversal of the anticoagulation, the patient subsequently made an unremarkable recovery with no neurological deficit.

Improving the specificity of immunodiagnosis for porcine brucellosis.

This report describes the use of cell mediated immunity to improve specificity of current diagnosis for Brucella suis. Diagnosis is problematic due to cross reactions that lead to false positive serological reactions (FPSR) in the standard diagnostic tests. A common cause of this cross reactivity is infection with the organism Yersinia enterocolitica O:9. Gottingen mini-pigs were experimentally infected with B. suis biovar I field strain or Y. enterocolitica serotype O:9 biotype 3. Infection was followed for 70 days. During this time whole blood stimulation assays were set up using Brucella specific antigen. IFNgamma was measured in the supernatants (SN) from these assays by ELISA. Concurrent standard serological tests were carried out. The results indicate that the IFNgamma assay is specifically able to distinguish Y. enterocolitica O:9 infection from a B. suis infection in experimentally infected mini-pigs. These results represent an improvement in diagnostic specificity compared to currently used serological tests. Thus suggesting that in a surveillance setting this test could be applied as a confirmatory test in the face of FPSR.

The 2000 canine distemper epidemic in Caspian seals (Phoca caspica): pathology and analysis of contributory factors.

More than 10,000 Caspian seals (Phoca caspica) were reported dead in the Caspian Sea during spring and summer 2000. We performed necropsies and extensive laboratory analyses on 18 seals, as well as examination of the pattern of strandings and variation in weather in recent years, to identify the cause of mortality and potential contributory factors. The monthly stranding rate in 2000 was up to 2.8 times the historic mean. It was preceded by an unusually mild winter, as observed before in mass mortality events of pinnipeds. The primary diagnosis in 11 of 13 seals was canine distemper, characterized by broncho-interstitial pneumonia, lymphocytic necrosis and depletion in lymphoid organs, and the presence of typical intracytoplasmic inclusion bodies in multiple epithelia. Canine distemper virus infection was confirmed by phylogenetic analysis of reverse transcriptase-polymerase chain reaction products. Organochlorine and zinc concentrations in tissues of seals with canine distemper were comparable to those of Caspian seals in previous years. Concurrent bacterial infections that may have contributed to the mortality of the seals included Bordetella bronchiseptica (4/8 seals), Streptococcus phocae (3/8), Salmonella dublin (1/8), and S. choleraesuis (1/8). A newly identified bacterium, Corynebacterium caspium, was associated with balanoposthitis in one seal. Several infectious and parasitic organisms, including poxvirus, Atopobacter phocae, Eimeria- and Sarcocystis-like organisms, and Halarachne sp. were identified in Caspian seals for the first time.

Intravascular pressure measurements in feeding pedicles of brain arteriovenous malformations.

Pressure measurements in arterial feeders of arteriovenous malformations (AVMs) can be easily acquired during endovascular treatment procedures. In this study, mean arterial pressure values in arterial feeders (Pfed) of brain AVMs were determined using a pressure measuring system connected to a standard microcatheter. A total of 148 measurements were performed in 139 patients. Mean systemic arterial pressure values were subtracted for correction. The levels of correlation between the pressure values and various clinical parameters (i.e., AVM location, size, previous hemorrhage) and pathoanatomical features of the AVM (e.g., nidus structure, number of draining veins) were determined. Pfed values were 54.5 mmHg on average. Pfed was lower in more distally located AVMs, in larger lesions and in AVMs with multiple drainage veins. Pressure values were significantly higher in patients with previous hemorrhage and in smaller AVMs. Our results support the importance of hemodynamic parameters in determining the presentation of AVMs. More extensive studies using this simple technique may further elucidate these mechanisms and may result in improved criteria for patient selection and reduction of complications.

Harmonisation of European tests for serological diagnosis of Brucella infection in bovines.

The principal methods for the serological diagnosis of bovine brucellosis are the complement fixation test (CFT), serum agglutination test (SAT), Rose-Bengal test (RBT), indirect enzyme-linked immunosorbent assay (iELISA) and more recently the competitive ELISA (cELISA) and the fluorescent polarisation assay (FPA). Guidelines set by the World Organisation for Animal Health (OIE) describe methods and diagnostic thresholds for each of these tests. Many countries have adopted these methods for the purposes of eradication of brucellosis and have legislated for the use of these tests (the CFT and SAT in particular) for the prevention of the spread of the disease through international trade. Within the European Union (EU) each member state has a National Reference Laboratory which regulates the quality of brucellosis diagnosis and works to the recommendations set by the OIE. This article describes the results from the first three EU ring trials assessing the harmonisation of diagnostic tests between each member state. The general level of harmony for SAT, CFT, and iELISA was found to be good, but issues of standardisation of the RBT, cELISA and FPA remain. The cELISA and FPA in particular need further work to create European harmony. The ring trials also proved successful at providing specific evidence of poor performance in some areas. The decision on whether or not to take action on the basis of these results rested with the individual laboratories concerned. The increase in the number of participants in these trials over time reflected the enlargement of the EU and increased the need for quality assurance.

Syncope associated with pain as the presenting feature of neck malignancy: failure of cardiac pacemaker to prevent attacks in two cases.

Two patients are described in whom syncope was the presenting clinical feature of an undiagnosed neck malignancy. Both patients also had attacks associated with paroxysms of severe neck pain. Neither patient responded to cardiac pacing.

Reconstructive treatment of dural arteriovenous fistulas of the transverse and sigmoid sinus: transvenous angioplasty and stent deployment.

Various techniques for the endovascular treatment of dural arteriovenous fistulas (dAVFs) of the transverse and sigmoid sinus have recently evolved. Transvenous coil occlusion of the involved segment and transarterial embolization of the feeding arteries with liquid agents are the commonest treatments utilized. However, with respect to venous hypertension as the probable pathogenic cause of this disorder, a nonocclusive or remodeling technique might be preferable. We will present a series involving four patients, treated with transvenous angioplasty and stent deployment as a definitive treatment of dAVFs of the transverse and sigmoid sinus. This method was used as a primary treatment or as an adjunct to previous noncurative transarterial n-butyl cyanoacrylate and particle embolization. In three of the four cases, complete occlusion of the fistula was achieved with confirmation of occlusion seen on follow-up angiographical studies. In one case a negligible and nonsymptomatic remnant of the fistula fed by the tentorial artery was left untreated. From our experience, we conclude that transvenous stent deployment is an alternative to traditional concepts. Additionally, the pathological theory of dAVFs in this region located in venous pouches of the sinus wall is supported by the fact that they can be occluded by mechanical compression during angioplasty and subsequently maintained by a stent.

The Bryan cervical disc prosthesis as an alternative to arthrodesis in the treatment of cervical spondylosis: 46 consecutive cases.

We present data relating to the Bryan disc arthroplasty for the treatment of cervical spondylosis in 46 patients. Patients with either radiculopathy or myelopathy had a cervical discectomy followed by implantation of a cervical disc prosthesis. Patients were reviewed at six weeks, six months and one year and assessment included three outcome measures, a visual analogue scale (VAS), the short form 36 (SF-36) and the neck disability index (NDI). The results were categorised according to a modification of Odom's criteria. Radiological evaluation, by an independent radiologist, sought evidence of movement, stability and subsidence of the prosthesis.A highly significant difference was found for all three outcome measurements, comparing the pre-operative with the post-operative values: VAS (Z = 6.42, p < 0.0001), SF-36 (mental component) (Z = -5.02, p < 0.0001), SF-36 (physical component) (Z = -5.00, p < 0.0001) and NDI (Z = 7.03, p < 0.0001). The Bryan cervical disc prosthesis seems reliable and safe in the treatment of patients with cervical spondylosis.

Optic chiasm enhancement associated with giant aneurysm and yttrium treated pituitary adenoma.

A patient with a history of pituitary tumour treated with yttrium 29 years before presented with an asymmetrical chiasmal neuropathy. Magnetic resonance imaging showed a partially thrombosed giant aneurysm of the right internal carotid artery, with enhancement of the chiasm and right optic tract adjacent to the aneurysm. It was thought that, in addition to the effects of compression, a peri-aneurysmal inflammatory reaction had developed, causing breakdown of the blood-brain barrier and consequent inflammatory changes in the optic chiasm. High dose steroid treatment led to significant improvement in vision within two weeks. Steroids may have a role in the acute preservation of vision in similar cases, as well as in cases of deterioration following coiling or embolisation of aneurysms where thrombosis within the aneurysm has been induced.