Continuous infusion of low-dose unfractionated heparin after aneurysmal subarachnoid hemorrhage: a preliminary study of cognitive outcomes.

OBJECTIVECognitive dysfunction occurs in up to 70% of aneurysmal subarachnoid hemorrhage (aSAH) survivors. Low-dose intravenous heparin (LDIVH) infusion using the Maryland protocol was recently shown to reduce clinical vasospasm and vasospasm-related infarction. In this study, the Montreal Cognitive Assessment (MoCA) was used to evaluate cognitive changes in aSAH patients treated with the Maryland LDIVH protocol compared with controls.METHODSA retrospective analysis of all patients treated for aSAH between July 2009 and April 2014 was conducted. Beginning in 2012, aSAH patients were treated with LDIVH in the postprocedural period. The MoCA was administered to all aSAH survivors prospectively during routine follow-up visits, at least 3 months after aSAH, by trained staff blinded to treatment status. Mean MoCA scores were compared between groups, and regression analyses were performed for relevant factors.RESULTSNo significant differences in baseline characteristics were observed between groups. The mean MoCA score for the LDIVH group (n = 25) was 26.4 compared with 22.7 in controls (n = 22) (p = 0.013). Serious cognitive impairment (MoCA ≤ 20) was observed in 32% of controls compared with 0% in the LDIVH group (p = 0.008). Linear regression analysis demonstrated that only LDIVH was associated with a positive influence on MoCA scores (ß = 3.68, p =0.019), whereas anterior communicating artery aneurysms and fevers were negatively associated with MoCA scores. Multivariable linear regression analysis resulted in all 3 factors maintaining significance. There were no treatment complications.CONCLUSIONSThis preliminary study suggests that the Maryland LDIVH protocol may improve cognitive outcomes in aSAH patients. A randomized controlled trial is needed to determine the safety and potential benefit of unfractionated heparin in aSAH patients.

Flow diversion for the treatment of posterior inferior cerebellar artery aneurysms: a novel classification and strategies.

BACKGROUND: The pipeline embolization device (PED) is frequently used in the treatment of anterior circulation aneurysms, especially around the carotid siphon, with generally excellent results. However, treatment of posterior inferior cerebellar artery (PICA) aneurysms with flow diversion (FD) has not been specifically described or discussed. While there are reports of treating PICA aneurysms using placement of FD stents in the vertebral artery, there are no reports of treating these lesions by placement of flow diverting stents in the PICA vessel itself. Due to the unique anatomy and morphology of these aneurysms, it requires special attention. We assessed our multi-institutional experience treating these lesions, including the first reported cases of the PED placed within the PICA. METHODS: Institutional databases of neuroendovascular procedures were reviewed for cases of intracranial aneurysms treated with the PED. Patient and aneurysm data as well as angiographic imaging were reviewed for all cases of PICA aneurysms treated with the PED. PICA aneurysms were defined as aneurysms that involved the PICA. Vertebral aneurysms without disease in the PICA were excluded from the study. RESULTS: 10 PICA aneurysms were treated during the study period. These were classified based on their morphology and location into two main types and five total subtypes for consideration of treatment with flow diversion. All aneurysms were successfully treated, with 8/10 completely obliterated and 2 with a partial reduction in size. Three patients had the PED placed entirely in the PICA and no patient suffered from a medullary or cerebellar stroke. All PEDs were patent and all patients were independent at the last follow-up. CONCLUSIONS: The PED may be used successfully to treat select aneurysms of the PICA. We present the first described cases of successful PED treatment of PICA aneurysms with direct placement of the PED in the PICA vessel itself. The proposed classification system aids in that selection.

Clinical efficacy of 2-phase versus 4-phase computed tomography for localization in primary hyperparathyroidism.

BACKGROUND: Four-dimensional computed tomography is being used increasingly for localization of abnormal glands in primary hyperparathyroidism. We hypothesized that compared with traditional 4-phase imaging, 2-phase imaging would halve the radiation dose without compromising parathyroid localization and clinical outcomes. METHODS: A transition from 4-phase to 2-phase imaging was instituted between 2009 and 2010. A pre-post analysis was performed on patients undergoing operative treatment with a parathyroid protocol computed tomography, and relevant data were correlated with operative findings. Sensitivity, positive predictive value, technical success, and cure rates were calculated. The Fisher exact test or χ(2) test assessed the significance of 2-phase and 4-phase imaging and operative findings. RESULTS: Twenty-seven patients had traditional four-dimensional computed tomography and 35 had modified 2-phase computed tomography. Effective radiation doses were 6.8 mSy for 2-phase and 14 mSv for 4-phase. Four-phase computed tomography had a sensitivity and positive predictive value of 93% and 96%, respectively. Two-phase computed tomography had a comparable sensitivity and positive predictive value of 97% and 94%, respectively. Eight patients with discordant imaging had an average parathyroid weight of 240 g compared with 1,300 g for all patients. Technical surgical success (90% for 4-phase computed tomography versus 91% 2-phase computed tomography) and normocalcemia rates at 6 months (88% for both) did not differ between computed tomography protocols. Computed tomography correctly predicted multiglandular disease and localization for reoperations in 88% and 90% of cases, respectively, with no difference by computed tomography protocol. CONCLUSION: With regard to surgical outcomes and localization, 2-phase parathyroid computed tomography is equivalent to 4-phase for parathyroid localization, including small adenomas, reoperative cases, and multiglandular disease. Two-phase parathyroid computed tomography for operative planning should be considered to avoid unnecessary radiation exposure.

An overview of antithrombotics in ischemic stroke.

The use of antithrombotic medications is an important component of ischemic stroke treatment and prevention. This article reviews the evidence for best practices for antithrombotic use in stroke with focused discussion on the specific agents used to treat and prevent stroke.

Strategic and Technical Considerations for the Endovascular Embolization of Intracranial Meningiomas.

Endovascular embolization is a frequently used adjunct to operative resection of meningiomas. Embolization may decrease intraoperative blood loss, operative time, and surgical difficulty associated with resection. The specific clinical applications of this treatment have not been defined clearly. Procedural indications, preferred embolic agent, and latency until tumor resection all differ across operators. It is clear that strategic patient selection, comprehensive anatomic understanding, and sound operative technique are critical to the success of the embolization procedure. This article reviews the management and technical considerations associated with preoperative meningioma embolization.

Randomized controlled trial of vertebroplasty versus kyphoplasty in the treatment of vertebral compression fractures.

BACKGROUND: We present the results of a randomized controlled trial evaluating the efficacy of vertebroplasty versus kyphoplasty in treating vertebral body compression fractures. METHODS: Patients with vertebral body compression fractures were randomly assigned to treatment with kyphoplasty or vertebroplasty. Primary endpoints were pain (0-10 scale) and disability assessed using the Roland-Morris Disability Questionnaire (RMDQ). Outcomes were assessed at 3 days, 1 month, 6 months, and 1 year following the procedure. RESULTS: 115 subjects were enrolled in the trial with 59 (51.3%) randomly assigned to kyphoplasty and 56 (48.7%) assigned to vertebroplasty. Mean (SD) pain scores at baseline, 3 days, 30 days, and 1 year for kyphoplasty versus vertebroplasty were 7.4 (1.9) vs 7.9 (2.0), 4.1 (2.8) vs 3.7 (3.0), 3.4 (2.5) vs 3.6 (2.9), and 3.0 (2.8) vs 2.3 (2.6), respectively (p>0.05 at all time points). Mean (SD) RMDQ scores at baseline, 3 days, 30 days, 180 days, and 1 year were 17.3 (6.6) vs 16.3 (7.4), 11.8 (7.9) vs 10.9 (8.2), 8.6 (7.2) vs 8.8 (8.5), 7.9 (7.4) vs 7.3 (7.7), 7.5 (7.2) vs 6.7 (8.0), respectively (p>0.05 at all time points). For baseline to 12-month assessment in average pain and RMDQ scores, the standardized effect size between kyphoplasty and vertebroplasty was small at -0.36 (95% CI -1.02 to 0.31) and -0.04 (95% CI -1.68 to 1.60), respectively. CONCLUSIONS: Our study indicates that vertebroplasty and kyphoplasty appear to be equally effective in substantially reducing pain and disability in patients with vertebral body compression fractures. TRIAL REGISTRATION NUMBER: NCT00279877.

Single-center experience with a dual microcatheter technique for the endovascular treatment of wide-necked aneurysms.

OBJECT: The endovascular treatment of wide-necked aneurysms can be technically challenging due to distal coil migration or impingement of the parent vessel. In this paper, the authors illustrate an alternative method for the treatment of wide-necked intracranial aneurysms using a dual microcatheter technique. METHODS: The authors' first 100 consecutive patients who underwent coil embolization of a wide-necked aneurysm using a dual microcatheter technique are reported. With this technique, 2 microcatheters are used to introduce coils into the aneurysm. The coils are deployed either sequentially or concurrently to form a stable construct and prevent coil herniation or migration. Angiographic and clinical outcomes are reported. RESULTS: The technical success rate of the dual microcatheter technique is 91% with a morbidity and mortality of 1% and 2%, respectively. Clinical outcomes are excellent with 93% of patients demonstrating a modified Rankin Scale score of 0-2 at long-term follow-up regardless of their score at presentation. Retreatment rates are 18%. CONCLUSIONS: The dual microcatheter technique may be a safe and efficacious first line of treatment for widenecked aneurysms.

DynaCT imaging for intraprocedural evaluation of flow-diverting stent apposition during endovascular treatment of intracranial aneurysms.

The treatment of large, complex intracranial aneurysms is being increasingly performed using flow-diverting stents (FDS) such as the Pipeline Embolization Device (PED; ev3, Irvine, CA, USA). Malapposition of a FDS to the parent artery wall decreases the likelihood of aneurysm obliteration and increases the risk of both immediate and delayed complications. DynaCT scanning (Siemens Medical Solutions, Erlangen, Germany) is a novel imaging modality which uses a flat plane detector to generate CT images using the same C-arm employed for digital subtraction angiography. We present a 40-year-old woman with an unruptured, 11 mm cavernous internal carotid artery aneurysm who was treated with endovascular obliteration using a PED. Intraprocedural DynaCT scan performed after PED deployment demonstrated incomplete stent apposition to the parent vessel which could not be detected on digital subtraction angiography alone. Balloon angioplasty was performed to improve apposition of the stent to the vessel wall. There were no procedural or clinical complications. The aneurysm shrank in size at follow-up angiography 6 months after the procedure and will be monitored for progressive occlusion. While gross stent malapposition is readily evident after stent deployment, minor instances of malapposition may be undetectable by standard angiography. Therefore the use of DynaCT imaging may improve intraprocedural stent visualization and potentially avert long-term endovascular aneurysm treatment complications associated with inadequate stent apposition.

Persistent trigeminal artery: in situ thrombosis and associated perforating vessel infarction.

We report a patient with progressive brainstem infarction despite medical therapy. The patient was transferred to our institution for potential angioplasty of basilar stenosis. Imaging review demonstrated persistent trigeminal artery in situ thrombosis and associated perforating vessel infarction. Persistent trigeminal arteries are commonly associated with an atretic basilar artery and interventional treatment can result in significant morbidity and mortality.

Solitaire Flow Restoration thrombectomy for acute ischemic stroke: retrospective multicenter analysis of early postmarket experience after FDA approval.

BACKGROUND: The promising results of the Solitaire Flow Restoration (FR) With the Intention for Thrombectomy (SWIFT) trial recently led to Food and Drug Administration (FDA) approval of the Solitaire FR stent retriever device for recanalization of cerebral vessels in patients with acute ischemic stroke. OBJECTIVE: To report the early postmarket experience with this device since its FDA approval in the United States, which has not been previously described. METHODS: We conducted a retrospective analysis of consecutive acute ischemic strokes cases treated between March 2012 and July 2012 at 10 United States centers where the Solitaire FR was used as a single device or in conjunction with other intraarterial endovascular approaches. RESULTS: A total of 101 patients were identified (mean age, 64.7 years; mean admission National Institutes of Health Stroke Scale [NIHSS] score, 17.6). Intravenous thrombolysis was administered in 39% of cases; other endovascular techniques were utilized in conjunction with the Solitaire FR in 52%. Successful recanalization (Thrombolysis in Myocardial Infarction 2/3) was achieved in 88%. The rate of symptomatic intracranial hemorrhage within the first 24 hours was 15%. In-hospital mortality was 26%. At 30 days, 38% of patients had favorable functional outcome (modified Rankin scale score ≤2). Severity of NIHSS score on admission was a strong predictor of poor outcome. CONCLUSION: Our study shows that a variety of other endovascular approaches are used in conjunction with Solitaire FR in actual practice in the United States. Early postmarket results suggest that Solitaire FR is an effective tool for endovascular treatment of acute ischemic stroke.

Early postmarket results after treatment of intracranial aneurysms with the pipeline embolization device: a U.S. multicenter experience.

BACKGROUND: The pipeline embolization device (PED) is the latest technology available for intracranial aneurysm treatment. OBJECTIVE: To report early postmarket results with the PED. METHODS: This study was a prospective registry of patients treated with PEDs at 7 American neurosurgical centers subsequent to Food and Drug Administration approval of this device. Data collected included clinical presentation, aneurysm characteristics, treatment details, and periprocedural events. Follow-up data included degree of aneurysm occlusion and delayed (> 30 days after the procedure) complications. RESULTS: Sixty-two PED procedures were performed to treat 58 aneurysms in 56 patients. Thirty-seven of the aneurysms (64%) treated were located from the cavernous to the superior hypophyseal artery segment of the internal carotid artery; 22% were distal to that segment, and 14% were in the vertebrobasilar system. A total of 123 PEDs were deployed with an average of 2 implanted per aneurysm treated. Six devices were incompletely deployed; in these cases, rescue balloon angioplasty was required. Six periprocedural (during the procedure/within 30 days after the procedure) thromboembolic events occurred, of which 5 were in patients with vertebrobasilar aneurysms. There were 4 fatal postprocedural hemorrhages (from 2 giant basilar trunk and 2 large ophthalmic artery aneurysms). The major complication rate (permanent disability/death resulting from perioperative/delayed complication) was 8.5%. Among 19 patients with 3-month follow-up angiography, 68% (13 patients) had complete aneurysm occlusion. Two patients presented with delayed flow-limiting in-stent stenosis that was successfully treated with angioplasty. CONCLUSION: Unlike conventional coil embolization, aneurysm occlusion with PED is not immediate. Early complications include both thromboembolic and hemorrhagic events and appear to be significantly more frequent in association with treatment of vertebrobasilar aneurysms.

Telehealth stroke education for rural elderly Virginians.

OBJECTIVE: Stroke is a prevalent condition found in elderly, rural populations. However, stroke education, which can be effective in addressing the risks, is often difficult to provide in these remote regions. The objective of this study is to evaluate the effectiveness of delivering stroke education to elderly individuals through telehealth versus in-person stroke prevention education methods. MATERIALS AND METHODS: A quasi-experimental nonequivalent control group design was used in this study. A convenience sample of 11 elderly adults (36% men, 64% women) with a mean age of 70 was selected from an Appalachian Program for All Inclusive Care for the Elderly (day care) facility. Subjects completed preintervention surveys, received a 20-min group in-person or telehealth delivered education session, and then completed the postintervention surveys. RESULTS: Satisfaction with delivery method and post-education knowledge was equivalent between the two groups. Knowledge increased in both groups after the educational programs. Likelihood of reducing risk factors showed no differences pre-posttest. However, there were significant improvements in the pre-post likelihood scores of the telehealth group in contrast to the in-person group. CONCLUSIONS: This project provided a rural, high-risk population access to telehealth stroke education, thus enabling these individuals to receive education at a distance from experts in the field. The telehealth program was found to be equivalent to in-person stroke education in regards to satisfaction, knowledge, and likelihood of making changes to decrease vascular risk factors. The study demonstrated feasibility in providing effective stroke education through telehealth, thus suggesting an often overlooked route for providing patient education at a distance.

Symptomatic Wingspan stent stenosis and occlusion: stent-in-stent rescue.

The use of the Wingspan stent in severe intracranial stenosis is associated with a relatively high in-stent re-stenosis rate. Reported management strategies for re-stenosis have included angioplasty alone or angioplasty with placement of a second Wingspan stent. A case is presented in which thrombosis within a Wingspan stent was treated with a balloon expandable cobalt-chromium stent within the Wingspan stent. Subsequent follow-up imaging has shown persistent patency of the treated vessel, with no subsequent in-stent stenosis.

Imaging diagnosis of acute pulmonary embolism.

Pulmonary embolism represents a major public healthcare problem and it also imposes frequent clinical diagnostic issues. Despite the availability of the D-dimer tests, imaging remains the mainstay for its diagnosis. Computed tomography pulmonary angiography (CTPA) is now the most widely used diagnostic test and its utility has been well validated in a large number of trials. Nuclear medicine techniques, which are also well established, are now used significantly less frequently. Magnetic resonance pulmonary angiography is developing as an alternative to CTPA in patients who have contraindications to iodinated contrast media. Catheter pulmonary angiography remains the gold standard, although it is being used increasingly less frequently. In this article, we review the current knowledge on the imaging diagnosis of acute pulmonary embolism with special emphasis on the noninvasive techniques.

Soft tissue calcifications in the lower extremities of severely diabetic patients simulating venous stasis or collagen vascular disease.

The purpose of this work is to report soft tissue calcifications in severely diabetic patients that simulate venous stasis or scleroderma, without other stigmata of these diseases. Findings from lower extremity radiographs were reviewed on two patients with severe diabetes mellitus and abnormal soft tissue calcifications. Findings were correlated with clinical history, physical exam findings, and laboratory values. Both patients in this study demonstrate radiographic findings of lower extremity soft tissue calcifications similar to those seen in venous stasis or scleroderma. Clinical history, physical examination, and laboratory values support severe diabetes mellitus, with no evidence of these other disease entities. Patients with severe diabetes mellitus may exhibit soft tissue calcifications of their lower extremities that may simulate the changes of venous stasis or scleroderma. This association has not been previously described.

Surgical revascularization in the presence of a preserved primitive carotid-basilar communication.

Anomalous arteries that connect the anterior and posterior cranial arterial systems are unusual variants that can severely alter normal patterns of cerebral blood flow. Persistent trigeminal, hypoglossal, otic, and proatlantal arteries have been described. This report illustrates the technical aspects of carotid endarterectomy with an ipsilateral preserved primitive carotid-basilar communication. Identification of the internal carotid and hypoglossal arteries, maintenance of cerebral perfusion, arteriotomy closure, preoperative imaging, the use of shunts, and reconstruction strategy are discussed. Preoperative angiography and detailed, individualized surgical strategy should be used to ensure a successful endarterectomy in patients with preserved primitive carotid-basilar communications.

Lack of preoperative spinous process tenderness does not affect clinical success of percutaneous vertebroplasty.

PURPOSE: Some operators use the lack of point tenderness over compression fractures to exclude patients from undergoing percutaneous vertebroplasty procedures. The purpose of this study was to determine whether this lack of tenderness portends a poorer clinical outcome after vertebroplasty than is achieved in patients with such tenderness. MATERIALS AND METHODS: The authors conducted a retrospective review of consecutive percutaneous vertebroplasty procedures performed at their institution to define two populations. Group 1 included 90 patients with tenderness to palpation over the spinous process of the fractured vertebra, whereas group 2 included 10 patients without such tenderness. This second group presented with back pain and demonstrated tenderness distant from the fracture (n = 5), tenderness lateral to the fracture (n = 4), or no focal tenderness at all (n = 1). All were treated because of edema seen on magnetic resonance (MR) imaging and/or increased activity on bone scan. Clinical outcomes were assessed by quantitative measurements of pre- and postoperative levels of pain (11-point scale) and mobility (five-point scale). RESULTS: Pain improvement of three points or greater occurred in 77 of the 85 patients (91%) in group 1 who complied with follow-up and nine of nine such patients (100%) in group 2, with mean postoperative pain levels of 1.82 and 0.33 points, respectively (P =.14). Forty of 45 patients (89%) in group 1 with impaired preoperative mobility reported improvement postoperatively, as did two of three such patients (67%) in group 2. Mean levels of postoperative impaired mobility for groups 1 and 2 were 0.27 and 0.67 points, respectively (P =.27). CONCLUSION: Pain on palpation over the fractured vertebra is not a necessary requirement in selecting patients who will benefit from percutaneous vertebroplasty. Other factors, such as MR evidence of edema or increased uptake on bone scan, should be weighed considerably in the decision to treat a patient.

The therapeutic benefit of repeat percutaneous vertebroplasty at previously treated vertebral levels.

BACKGROUND AND PURPOSE: Recurrent pain after vertebroplasty is relatively common, usually representing a new fracture at a different vertebral level. In a small cohort described herein, clinical and imaging findings indicated that recurrent pain arose from abnormality of the previously treated level. Our purpose was to demonstrate that repeat percutaneous vertebroplasty performed within the same fractured vertebra can offer therapeutic benefit for patients with recurrent pain after initial treatment. METHODS: We conducted a retrospective review of consecutive vertebroplasty procedures performed at our institution to define a patient population that underwent repeat vertebroplasty for recurrent pain at previously treated vertebral levels. We identified six such patients over an 8-year period, and clinical outcomes were assessed through quantitative measurements of pre- and postoperative levels of pain and mobility. RESULTS: Initial vertebroplasty resulted in substantial improvement in pain in all six patients. Patients developed recurrent pain between 8 days and 167 days after initial vertebroplasty. After repeat vertebroplasty, five of the six patients reported a reduction of at least 3 points in their rating of pain, with a mean reduction of 6.5 points and a mean postoperative pain level of 3.5 points (11-point scale). Four of six patients reported impaired mobility before repeat vertebroplasty, and all four demonstrated a postoperative improvement in mobility. Mean increase in mobility was 1.50 points, and the mean postoperative mobility impairment was 0.25 points (5-point scale). CONCLUSION: The clinical outcomes of the patients within this case series suggest that repeat percutaneous vertebroplasty performed at previously treated vertebral levels for recurrent pain offer therapeutic benefit.

Relevance of antecedent venography in percutaneous vertebroplasty for the treatment of osteoporotic compression fractures.

BACKGROUND AND PURPOSE: Controversy exists regarding the utility of antecedent venography in percutaneous vertebroplasty. Our purpose was to determine whether antecedent venography improves clinical outcomes and/or decreases extravertebral cement extravasation in these procedures. METHODS: We retrospective reviewed outcomes of consecutive percutaneous vertebroplasty procedures performed at our institution to define two populations, each consisting of 24 patients treated at 42 vertebral levels. Group 1 included patients who underwent antecedent venography, and group 2 included patients treated without venography. Clinical outcomes were assessed with quantitative measurements of pain and mobility. Venograms and postprocedural radiographs were interpreted to evaluate the number of vertebrae with extravertebral cement extravasation, degree of extravasation at each level, and correlation between venography and vertebroplasty. RESULTS: Pain improved in 19 of 20 group 1 patients, compared with 21 of 22 group 2 patients; mean postoperative pain levels were 1.3 and 1.8, respectively (P =.50), on a scale of 0 (no pain) to 10 (worst pain). All 11 group 1 patients with impaired preoperative mobility reported postoperative improvement, as did all 12 group 2 patients; mean levels of postoperative impaired mobility for groups 1 and 2 were 0.35 and 0.27, respectively (P =.43). Twenty-two of 42 vertebrae treated in group 1 demonstrated extravasation, compared with 28 of 42 in group 2 (P =.266); amounts of extravasation did not differ. Among 22 levels of extravasation in group 1, venograms in 14 showed correlative extravasation. CONCLUSION: Antecedent venography does not significantly improve the effectiveness or safety of percutaneous vertebroplasty performed by qualified, experienced operators.