Penumbra Occlusion Device for neurovascular vessel sacrifice: Feasibility and application.

PURPOSE: The purpose of this study is to describe the use of the Penumbra Occlusion Device (POD), which is a coil with an enhanced anchor segment, along with standard coils for carotid and vertebral artery sacrifice, and to assess its feasibility, safety, and efficacy. METHODS: This is a retrospective chart review of patients with vessel sacrifices who were treated using POD. For the procedure, a balloon test occlusion was performed prior to permanent arterial sacrifice. Following this, a POD was deployed followed by subsequent angiography to confirm occlusion. Secondary PODs or standard coils were deployed as necessary. RESULTS: A total of 5 internal carotid arteries and 5 vertebral arteries were treated in 10 patients. The mean vessel diameter of the vessel sacrificed was 4 mm (range 2.9-7.7 mm). The total mean number of coils required for vessel sacrifice was 7 (range 3-17). The mean number of PODs used for vessel sacrifice was 2.4 (range, 1-6). The mean number of additional standard coils used was 4.1 (range, 0-13). 9/10 (90%) parent arteries were successfully occluded. One patient had slow flow distal to the occluded segment. One (10%) of the patients had a delayed ischemic event. There were no immediate periprocedural complications including coil migrations or vessel dissections. 6/10 patients had follow-up imaging and no patients developed recanalization during the follow-up period. CONCLUSION: Parent vessel sacrifice using a combination of PODs and standard coils appear to be a feasible, safe and effective alternative to the traditional vessel sacrifice techniques.

Coated-Platelet Trends Predict Short-Term Clinical OutcomeAfter Subarachnoid Hemorrhage.

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high socio-economic burden. Prothrombotic states of early brain injury (EBI) and delayed cerebral ischemia (DCI) after aSAH determine morbidity and mortality. To understand how activated platelets might contribute to such prothrombotic states, we studied trends in coated-platelets during EBI and DCI periods. Serial blood samples from a prospective cohort of aSAH patients were collected and assayed for coated-platelet levels. Patient's coated-platelet level during post-hospital discharge follow-up served as an estimate of baseline. Occurrence of DCI, Montreal cognitive assessment (MOCA) score of < 26, and modified Rankin scale (mRS) of 3-6 were considered poor clinical outcomes. Non-linear regression analysis detected a transition between periods of rising and declining coated-platelet levels at day 4. Additional regression analyses of coated-platelet trends before day 4 showed differences among patients with modified Fisher 3-4 [4.2% per day (95% CI 2.4, 6.1) vs. - 0.8% per day (95% CI - 3.4, 1.8); p = 0.0023] and those developing DCI [4.6% per day (95% CI 2.8, 6.5) vs. - 1.9% per day (95% CI - 4.5, 0.5); p < 0.001]. Differences between peak coated-platelet levels and baseline levels were larger, on average for those with DCI [18.1 ± 9.6 vs. 10.6 ± 8.0; p = 0.03], MOCA < 26 [17.0 ± 7.8 vs. 10.7 ± 7.4; p = 0.05] and mRS 3-6 [24.8 ± 10.5 vs. 11.9 ± 7.6; p = 0.01]. Coated-platelet trends after aSAH predict DCI and short-term clinical outcomes. The degree of rise in coated-platelets is also associated with adverse clinical outcomes.

Status migrainosus as a potential stressor leading to takotsubo cardiomyopathy.

BACKGROUND: Takotsubo cardiomyopathy is a form of non-ischemic cardiomyopathy that may be acutely precipitated by stress. A number of neurologic conditions have been implicated in precipitating this disease such as subarachnoid hemorrhage, stroke, and seizures. Its association with status migrainosus, however, has never been described before. CASE: We report a case of a 25-year-old female presenting with status migrainosus followed by takotsubo cardiomyopathy. Supportive management was instituted in this patient and she made an excellent recovery. CONCLUSION: The intense pain associated with migraine may have acted as a stressor, thereby precipitating takotsubo cardiomyopathy. To our knowledge, this is the first reported case demonstrating a relationship between status migrainosus and takotsubo cardiomyopathy.

Zero on the NIHSS does not equal the absence of stroke.

STUDY OBJECTIVE: The National Institutes of Health Stroke Scale (NIHSS) measures deficits caused by a stroke, but not all stroke signs are captured on the NIHSS. We determine the symptoms and stroke localization of patients with brain infarction and an NIHSS score of 0. METHODS: We studied all patients who presented with acute neurologic symptoms to our stroke center from 2004 to 2008 and had persistent symptoms at the evaluation in the emergency department, an NIHSS score of 0, and an infarct on diffusion-weighted imaging. We characterized the symptoms, signs, lesion location, demographics, and stroke causes. RESULTS: Twenty patients met inclusion criteria. Symptoms frequently experienced were headache, vertigo, and nausea. The posterior circulation was commonly infarcted in this group. Truncal ataxia was the most common neurologic sign. CONCLUSION: Ischemic stroke may cause symptoms that are associated with no deficits on the NIHSS score.