Endovascular Treatment and Peri-interventional Management of Ruptured Cerebrovascular Lesions During Pregnancy : Case Series and Case-based Systematic Review.

PURPOSE: Hemorrhagic stroke, particularly occurring from ruptured cerebrovascular malformations, is responsible for 5-12% of all maternal deaths during pregnancy and the puerperium. Whether endovascular treatment is feasible and safe for both the mother and the fetus, is still a matter of debate. The main objective of this case series and systematic review was to share our multi-institutional experience and to assess the feasibility and safety of endovascular treatment during pregnancy, as well as the corresponding maternal and fetal outcomes based on currently available evidence. METHODS: We report a case series of 12 pregnant women presenting with hemorrhagic stroke from ruptured cerebrovascular arteriovenous malformations or aneurysms who underwent endovascular treatment prior to delivery. A systematic literature review of pregnant patients with endovascular treated cerebrovascular malformations, published between 1995 and 2022, was performed. Clinical patient information, detailed treatment strategies, maternal and fetal outcomes as well as information on the delivery were collected and assessed. RESULTS: In most patients the course was uneventful and an excellent outcome without significant neurological deficits (mRS ≤ 1) was achieved. Furthermore, the maternal outcome was not worse compared to the general population who underwent endovascular treatment of ruptured vascular brain lesions. Also, in most cases a healthy fetus was born. CONCLUSION: Endovascular treatment of ruptured cerebrovascular malformations during pregnancy is safe and feasible regarding both aspects, the maternal and fetal outcomes. Still, a stronger knowledge base is needed to correctly approach future cases of intracranial hemorrhage in the pregnant population.

Subdural evacuation port system and middle meningeal artery embolization for chronic subdural hematoma: a multicenter experience.

OBJECTIVE: Middle meningeal artery (MMA) embolization and the Subdural Evacuation Port System (SEPS) are minimally invasive treatment paradigms for chronic subdural hematoma (cSDH). Although SEPS offers acute decompression of local mass effect from a cSDH, MMA embolization has been shown to reduce the rate of cSDH recurrence. In combination, these procedures present a potentially safer strategy to a challenging pathology. The authors present a multi-institutional retrospective case series that assessed the safety, efficacy, and complications of SEPS and MMA embolization for cSDH. METHODS: A retrospective review was performed of patients who underwent SEPS placement and MMA embolization for cSDH between 2018 and 2021 at three institutions. RESULTS: One hundred patients with 136 cSDHs and a median age of 73 years underwent both SEPS placement and MMA embolization. Initial Glasgow Coma Scale scores were between 14 and 15 in 81% of patients and between 9 and 13 in 14%. The median initial midline shift (MLS) was 7 mm, with subdural hematoma (SDH) in the left hemisphere (lh) in 30% of patients, right hemisphere (rh) in 34%, and bilateral hemispheres in 36%. Follow-up was available for 86 patients: 93.4% demonstrated decreased MLS, and all patients with lhSDH and rhSDH demonstrated progressive decrease in SDH size. The overall complication rate was 4%, including 1 case of facial palsy and 3 cases of iatrogenic acute SDH. Two subjects (2%) required craniotomy for hematoma evacuation. The rate of good functional outcomes, with modified Rankin Scale (mRS) score < 2, was 89% on final follow-up and the overall mortality rate was 2%. A good mRS score on admission was associated with increased odds of functional improvement at follow-up (p < 0.001). CONCLUSIONS: SEPS placement with MMA embolization for cSDH can be done safely and effectively reduces cSDH size with minimal perioperative morbidity.

Giant Pediatric Dural Arteriovenous Fistula Management Using a Combined Operative Approach in a Hybrid Neuroendovascular Surgery Suite: Technical Nuances and Review of Literature.

BACKGROUND: Pediatric intracranial dural arteriovenous fistulas (dAVFs) are rare, complex entities usually presenting with macrocephaly from increased intracranial pressures at a young age. In the setting of a symptomatic intracranial dAVF that has undergone multiple endovascular treatments with subsequent recurrence or failed embolization attempts, the intracranial venous system can become inaccessible by traditional transvenous and transarterial routes. Direct puncture of the venous sinus for endovascular access after surgical exposure is a viable option. OBJECTIVE: To describe the technical nuances and available literature for direct puncture of the venous sinus for endovascular access in a pediatric patient with dAVF. METHODS: The clinical characteristics were reviewed and reported for a patient who underwent direct puncture of the venous sinus for endovascular access. In addition, a literature review was conducted for relevant literature pertaining to this technique and its associated indications, outcomes, and complications. RESULTS: Only 2 other reports of direct puncture of venous sinus for endovascular access after surgical exposure were found in the literature. Our patient achieved a favorable outcome with complete dAVF obliteration. CONCLUSION: Direct puncture of the venous sinus for endovascular access after surgical exposure for complex dAVFs that are inaccessible by transvenous or transarterial routes is a practical and safe approach to intracranial venous access that should be part of the vascular neurosurgeon's arsenal.

Association of Noncontrast Computed Tomography and Perfusion Modalities With Outcomes in Patients Undergoing Late-Window Stroke Thrombectomy.

Importance: There is substantial controversy with regards to the adequacy and use of noncontrast head computed tomography (NCCT) for late-window acute ischemic stroke in selecting candidates for mechanical thrombectomy. Objective: To assess clinical outcomes of patients with acute ischemic stroke presenting in the late window who underwent mechanical thrombectomy stratified by NCCT admission in comparison with selection by CT perfusion (CTP) and diffusion-weighted imaging (DWI). Design, Setting, and Participants: In this multicenter retrospective cohort study, prospectively maintained Stroke Thrombectomy and Aneurysm (STAR) database was used by selecting patients within the late window of acute ischemic stroke and emergent large vessel occlusion from 2013 to 2021. Patients were selected by NCCT, CTP, and DWI. Admission Alberta Stroke Program Early CT Score (ASPECTS) as well as confounding variables were adjusted. Follow-up duration was 90 days. Data were analyzed from November 2021 to March 2022. Exposures: Selection by NCCT, CTP, or DWI. Main Outcomes and Measures: Primary outcome was functional independence (modified Rankin scale 0-2) at 90 days. Results: Among 3356 patients, 733 underwent late-window mechanical thrombectomy. The median (IQR) age was 69 (58-80) years, 392 (53.5%) were female, and 449 (65.1%) were White. A total of 419 were selected with NCCT, 280 with CTP, and 34 with DWI. Mean (IQR) admission ASPECTS were comparable among groups (NCCT, 8 [7-9]; CTP, 8 [7-9]; DWI 8, [7-9]; P = .37). There was no difference in the 90-day rate of functional independence (aOR, 1.00; 95% CI, 0.59-1.71; P = .99) after adjusting for confounders. Symptomatic intracerebral hemorrhage (NCCT, 34 [8.6%]; CTP, 37 [13.5%]; DWI, 3 [9.1%]; P = .12) and mortality (NCCT, 78 [27.4%]; CTP, 38 [21.1%]; DWI, 7 [29.2%]; P = .29) were similar among groups. Conclusions and Relevance: In this cohort study, comparable outcomes were observed in patients in the late window irrespective of neuroimaging selection criteria. Admission NCCT scan may triage emergent large vessel occlusion in the late window.

Surgical management of Currarino syndrome in elderly patient with infected pre-sacral mass: Technical nuances and review of literature.

OBJECTIVE: Currarino Syndrome (CS) is a rare autosomal dominant genetic disorder that is defined by a triad of: presacral mass, anorectal malformations, and sacral bone dysplasia. Once discovered, these lesions are often surgically treated to avoid life threatening complications such as meningitis and malignant transformation of a sacral teratoma. As this syndrome is usually diagnosed in childhood, accurate diagnosis in adults presenting with this syndrome can be challenging and delay treatment. We present a case report with diagnostic and surgical management strategies of CS presenting in an elderly patient with accompanying review of literature. METHODS: We performed a literature review by searching PubMed, Ovid Embase, and Scopus electronic databases with the predetermined inclusion criteria of cases of CS in the adult population. RESULTS: A 70-year-old male with newly diagnosed CS and meningitis successfully underwent resection of his lesion as an interdisciplinary case between neurosurgery and colorectal surgery. At six-month follow up, the patient reports resolution of constipation and urinary symptoms, no longer has signs of infection, and remains neurologically full strength in his lower extremities. A review of literature revealed only 5 previously reported cases of CS presenting in the adult population with 3 of these cases requiring surgical intervention. CONCLUSION: Currarino Syndrome (CS) is an autosomal dominant genetic disorder characterized by a presacral mass, sacral bony deformities, and anorectal malformations. It is usually diagnosed in pediatric age group. In this article, we present a case of a 70-year-old male presenting with meningitis, encephalopathy, and gastrointestinal disturbances.

Impact of Increasing Aspiration Catheter Size and Refinement of Technique: Experience of Over 1000 Strokes Treated With ADAPT.

BACKGROUND: We present longitudinal data regarding the outcomes and evolution of mechanical thrombectomy (MT) using a direct aspiration first pass technique. OBJECTIVE: To evaluate the impact of increasing aspiration catheter size. METHODS: This is a planned analysis of a prospective cohort study that enrolled all patients who underwent a direct aspiration first pass technique MT in a comprehensive stroke center from January 2013 to December 2020. We did exploratory analysis of the characteristics and outcomes of patients who had intracranial internal carotid artery or M1 segment of middle cerebral artery occlusion based on the aspiration catheter bore size (small [041, 054, 058, and 060 inch] vs medium [0.064 and 0.068 inch] and medium vs large [0.071, 0.072, and 0.074 inch]). RESULTS: During the 8-year study period, a total of 1004 patients were included. Median age was 69 years, 49% were female patients, and 60.6% were White. Symptomatic hemorrhagic transformation was observed in 47 patients (4.7%), and 366 patients (36.5%) achieved the modified Rankin scale of 0 to 2 at 90 days after the stroke. For patients with intracranial internal carotid artery or M1 occlusion, medium-bore aspiration catheters were more likely to achieve successful recanalization after first aspiration attempt (63.9% vs 51.4%, P = .015) and had a faster groin-to-reperfusion time (16 vs 20 minutes, P = .001) when compared with small-bore catheters. However, these differences were not significant when comparing medium-bore with large-bore catheters. CONCLUSION: Medium-bore catheters had better performance measures compared with small-bore catheters. However, large-bore catheters did not show significantly better performance results that suggest a plateau effect.

Chronic subdural hematoma recurrence due to contralateral neovascularization following middle meningeal artery embolization.

INTRODUCTION: Chronic subdural hematoma (CSDH) is one of the most commonly encountered neurosurgical diseases. Middle meningeal artery embolization (MMAE) is a technique for the management of CSDH that has elicited promising results. Despite the encouraging results of MMAE, recurrence does occur. One uncommon mechanism for recurrence of CSDH is by means of neovascularization of the contralateral middle meningeal artery (MMA). We describe two cases of CSDH recurrence by means of contralateral middle meningeal artery neovascularization treated with contralateral MMAE. METHODS: We identified two cases of recurrent subdural hematoma secondary to neovascularization following treatment with contralateral MMAE. RESULTS: Two patients initially treated with MMAE were identified with CSDH recurrence secondary to contralateral MMA neovascularization. There was no traumatic or coagulopathic contribution to CSDH recurrence. In both cases, patients underwent contralateral MMAE. Both patients were neurologically intact with radiographic improvement of CSDH at follow up. CONCLUSIONS: Re-accumulation of SDH following MMAE by means of contralateral MMA neovascularization is a rare subtype of subdural hematoma (SDH) recurrence following MMAE. Within the context of re-accumulation of SDH following MMAE, catheter angiography is an important diagnostic investigation to elucidate the etiology of the recurrence. Furthermore, when angiography reveals neovascularization of the contralateral MMA, embolization of the contralateral MMA achieves good clinical and radiographic result.

Clinical outcomes for patients with lateral lumbar radiculopathy treated by percutaneous endoscopic transforaminal discectomy versus tubular microdiscectomy: A retrospective review.

BACKGROUND: Surgical management of lateral lumbar radiculopathy is evolving. TMD (Tubular microdiscectomy) and TELD (Transforaminal endoscopic lumbar discectomy) have emerged as viable MIS treatments. We aim to compare clinical outcomes of both techniques for the treatment of lateral lumbar radiculopathy in relation to pre-operative lumbar foraminal stenosis grade (LFS). METHODS: Retrospective observational cohort study of patients with back and leg pain from single level foraminal nerve root compression that underwent TMD or TELD. Data analyzed included pre- and post-operative VAS leg and back pain, MacNab clinical outcome scores, hospital length of stay, complication rates, and operative time. Outcomes were correlated with a pre-operative MRI grading system for LFS. RESULTS: 109 patients were enrolled (71 TELD and 38 TMD). Back and leg VAS pain scores improved in TELD and TMD (p < 0.0001). Patients with grade III stenosis showed significantly higher VAS scores (p < 0.01), and worse functional outcomes at latest follow-up compared with grade I/II LFS. Overall, there was no difference in outcome between procedure groups except that TMD VAS back pain scores were lower than TELD at last follow up (p < 0.05). Clinical outcome comparisons between procedures relating to LFS grade showed higher correlation of LFS to TELD (Spearman's rho (ρ)= 0.342 for TMD and 0.606 TELD). Regression analyses demonstrated correlation between higher-grade foraminal stenosis and poorer outcomes in TELD and TMD. CONCLUSIONS: Both TELD and TMD are viable for treating lateral lumbar radiculopathy. Higher-grade foraminal stenosis can be indicative of poorer outcomes regardless of procedure type, however, the severity of pre-operative LFS correlates with clinical outcomes in TELD more significantly than TMD.

Endovascular Management of Distal Anterior Cerebral Artery Aneurysms: A Multicenter Retrospective Review.

INTRODUCTION: Distal anterior cerebral artery aneurysms (DACAA) are a rare and difficult entity to manage. Endovascular treatment has evolved for safe and durable treatment of these lesions. The objective of this study is to report the safety, efficacy, and outcomes of endovascular treatment of DACAA. METHODS: A retrospective review of DACAA endovascularly treated at 5 different institutions was performed. Data included demographics, rupture status, radiographic features, endovascular technique, complication rates, and long-term angiographic and clinical outcomes. A primary endpoint was a good clinical outcome (modified Rankin scale 0-2). Secondary endpoints included complications and radiographic occlusion at follow-up. RESULTS: A total of 84 patients were reviewed. The mean age was 56, and 64 (71.4%) were female. Fifty-two (61.9%) aneurysms were ruptured. A good functional outcome was achieved in 59 patients (85.5%). Sixty (71.4%) aneurysms were treated with primary coiling, and the remaining 24 were treated with flow diversion. Adequate occlusion was achieved in 41 (95.3%) aneurysms treated with coiling, and 17 (89.5%) with flow diversion. There were total 11 (13%) complications. In the flow diversion category, there were 2, both related to femoral access. In the coiling category, there were 9: 5 thromboembolic, 3 ruptures, and 1 related to femoral access. CONCLUSION: Endovascular treatment, and in particular, flow diversion for DACAA, is safe, feasible, and associated with good long-term angiographic and clinical outcomes.

Neuroendovascular Management of Acute Ischemic Basilar Strokes: 2-Dimensional Operative Video.

Basilar artery occlusions (BAOs) are devastating ischemic strokes that account for 1% of all strokes with high morbidity and mortality; however, neuroendovascular techniques such as ADAPT have recently revolutionized the clinical outcomes of these patients.1-3 Common underlying pathology in patients with BAO include intracranial atherosclerotic disease (ICAD) as well as thromboembolic origin.4 Basilar artery ICAD in a setting of acute stroke portends a poor prognosis and post-thrombectomy residual critical flow limiting stenosis treatment options, including balloon angioplasty with or without stent placement.5-7 We present a video illustration of neuroendovascular technique and challenges encountered when managing this pathology. Image at 5:42 reprinted with permission from Alawieh et al, Lessons learned over more than 500 stroke thrombectomies using ADAPT with increasing aspiration catheter size, Neurosurgery, 86(1), 2020, pp. 61-70, with permission from the Congress of Neurological Surgeons.1.

Endovascular Treatment of Basilar Bifurcation Aneurysms With PulseRider-Assisted Coiling: 2-Dimensional Operative Video.

Wide-necked bifurcation aneurysms pose technical and anatomical challenges to endovascular treatment, which make the simpler assisted (balloon or single stent) coiling techniques less effective.1 Consequently, unique endovascular solutions to treat such aneurysms have been devised.2,3 One such device is PulseRider (Cerenovus, New Brunswick, New Jersey), which is designed to provide neck support for a coil mass while protecting the bifurcation.3 The device comprises a body or stem that is deployed in the parent artery and a saddle component that sits at the aneurysm neck to keep the coil mass away from the bifurcation. There are several technical nuances involved in successful use of the device during positioning, deployment, and detachment.3 We present a surgical video detailing the steps of PulseRider-assisted coiling of unruptured basilar bifurcation (or basilar apex) aneurysms. The first case highlights index treatment at diagnosis and the second showcases treatment of a recurrent basilar apex aneurysm. Both patients provided informed consent to the procedure. We also briefly discuss the rationale for treating basilar apex aneurysms.4,5.

Cystic angiomatosis skull lesion obliteration with neuroendovascular sclerotherapy as a unique treatment: case report.

Cystic angiomatosis is a rare bone condition with complex presentation and difficult treatment. Current management strategies have poorly tolerated side effects and a low likelihood of disease eradication. The control of calvarial lesions that are symptomatic usually involves surgical excision and subsequent cranioplasty. This paradigm can present with a risk of morbidity and mortality depending on the anatomy of the lesion. Here, the authors present a novel approach to a difficult-to-treat occipital calvarial lesion directly overlying the transverse sinus, performing a small, partial-thickness craniectomy and alcohol sclerotherapy in a combined neurosurgery-neuroendovascular approach. At 3 years after treatment, the authors noted a complete, encouraging radiographic and clinical outcome.

Anticoagulation and Spine Surgery.

STUDY DESIGN: Literature review. OBJECTIVE: Preoperative management of therapeutic anticoagulation in spine surgery is critical to minimize risk of thromboembolic events yet prevent postsurgical complications. Limited research is available, and most guidelines are based on drug half-lives. We aim to clarify current guidelines and available evidence for safe practice of spine surgery in this patient population. METHODS: A literature search in PubMed was done encompassing comprehensive search terms to locate published literature on anticoagulation and spine surgery. Predefined inclusion and exclusion criteria were applied and data extraction was performed. RESULTS: A total of 17 articles met the final inclusion criteria. Of these, 12 articles were retrospective chart reviews, 3 were prospective observational studies, and 2 were systematic reviews. Current practice suggests holding warfarin until international normalized ratio <1.4, anti-Xa drugs for 48 to 72 hours, 12 to 24 hours for low-molecular-weight heparin, and 4 to 24 hours for heparin, before surgery. Antiplatelet agents can be stopped for 1 to 3 days prior to operation (81-500 mg) but must be stopped for 1 week for doses >1 g/d. For Plavix, 5 to 7 days of discontinuation advised to prevent complications. CONCLUSIONS: This review provides an overview of main anticoagulation agents seen in preoperative setting for spine patients. Although data is mixed and no true randomized control trials are available, there is growing evidence suggesting the aforementioned guidelines are needed to optimize anticoagulation in setting of spine surgery. Further studies are needed to elucidate risk of complications while operating under therapeutic levels of anticoagulation for a variety of comorbid conditions.

Venous Thromboprophylaxis in Spine Surgery.

STUDY DESIGN: Review article. OBJECTIVE: A review of the literature on postoperative initiation of thrombophylactic agents following spine surgery. METHODS: A review of the literature and synthesis of the data to provide an update on venous thromboprophylaxis following spine surgery. RESULTS: Postoperative regimens of venous thromboprophylaxis measures following spine surgery remain a controversial issue. Recommendations regarding mechanical versus chemical prophylaxis vary greatly among institutions. CONCLUSION: Postoperative spine surgery initiation of thromboprophylaxis remains controversial regarding optimal timing and agent selection. The benefits of deep vein thrombosis/pulmonary embolism prophylaxis must be weighed against the possible postoperative complications associated with spine surgery.

Progressive Brown-Séquard syndrome: A rare manifestation of cervical disc herniation.

Brown-Séquard syndrome (BSS) is a rare syndrome and is often described in association with spinal cord injury resulting from hemisection of the spinal cord. BSS due to cervical disc herniation is rare with often delayed diagnosis. The importance of early recognition with imaging cannot be over-emphasized, as the prognosis is better when compared to traumatic and vascular etiologies of BSS. We report a rare case of BBS in an 86-year-old man secondary to cervical disc herniation who had dramatic improvement after surgical intervention. This case highlights the unusual presentation from a very common spinal pathology along with a review of the pertinent literature.

Blood Pressure Guideline Adherence in Patients with Ischemic and Hemorrhagic Stroke in the Neurointensive Care Unit Setting.

BACKGROUND AND PURPOSE: Patients with acute brain injuries require strict physiologic control to minimize morbidity and mortality. This study aimed to assess in-hospital compliance to strict physiologic parameters (BP, HR, ICP, SpO2) in these populations. METHODS: Patients with severe cerebrovascular events were admitted to the neurointensive care unit (NSICU) and were continuously monitored using the BedMasterEX (Excel Medical Electronics Inc, FL) system, which recorded hemodynamic data via an arterial catheter continuously in 5-s intervals. Furthermore, we investigated the impact of healthcare provider shift changes (6-8 a.m./p.m) and of day (6 a.m.-6 p.m.) versus night (6 p.m-6 a.m) shifts in hemodynamic control. RESULTS: Fifty patients admitted to the NSICU, 50 % male, mean age 59.7 ± 13.9 years with subarachnoid hemorrhage (23), ischemic stroke (8), subdural hematoma (4), intracerebral hemorrhage (3), intraventricular hemorrhage (2), and miscellaneous injuries (10) were enrolled. Data represented 2,337 total hours of continuous monitoring. Systolic BPs (SBP) were on average outside of recommended ranges 32.26 ± 30.46 % of the monitoring period. We subdivided adherence to ideal SBP range: optimal (≥99 % of time spent in NSICU within range) was achieved in 12 %, adequate (90 %) in 16 %, suboptimal (80 %) in 20 %, inadequate I (70 %) in 12 %, and inadequate II (<70 %) in 40 % of patients. Comparison of shift change %time and day versus night %time out of parameter yielded no statistically significant differences across SAH patients. CONCLUSION: Hemodynamic management of patients with cerebrovascular injuries, based on targeted thresholds in the NSICU, yielded optimal control of SBP in only 28 % of our patients (within parameters ≥90 % of time).