Periprocedural Outcomes of Carotid Artery Stenting in Elderly Patients.

BACKGROUND: Carotid artery stenting has emerged as an alternative to carotid endarterectomy especially in patients with high risk of carotid endarterectomy. Older age (≥80 years old) was recognized as one of the high risk factors of carotid endarterectomy. However, the association between older age and increased risk of adverse events for carotid artery stenting has been reported. The purpose of this study was to evaluate the association between age and periprocedural outcomes after carotid artery stenting. METHODS: A total of 126 symptomatic and asymptomatic cases of carotid artery stenosis were treated with tailored carotid artery stenting. The type of stents and embolic protection devices were chosen according to clinical and morphologic characteristics of the patients. Procedural, imaging, and clinical outcomes were retrospectively assessed and compared between the elderly patients group (≥80 years old) and the non-elderly patients group (<80 years old). RESULTS: Clinical and morphologic characteristics except for dyslipidemia were not significantly different between the 2 groups. Periprocedural neurologic complications were not significantly different between the 2 groups (P = .095). Minor stroke occurred more frequently in the elderly patients group (P = .021). However, the frequency of major stroke was not significantly different between the 2 groups (P = 1). Presence of new ischemic lesions on postprocedural examination was not significantly different between the 2 groups (P = .84). Myocardial infarction and death did not occur in either group. CONCLUSIONS: Carotid artery stenting can be performed safely in elderly patients, comparable with non-elderly patients.

Complications and Predictors of Hypotension Requiring Vasopressor after Carotid Artery Stenting.

A significant controversy exists regarding the clinical impact of hemodynamic depression on major adverse events after carotid artery stenting (CAS). The purpose of this study was to evaluate the incidence, predictors, and clinical significance of hypotension after CAS. A total of 118 cases of carotid artery stenosis were treated with CAS. Hypotension was defined as sustained systolic blood pressure <80 mmHg and requiring intravenous administration of vasopressor to maintain adequate systolic blood pressure after the procedure. Baseline characteristics, procedural characteristics, and periprocedural major adverse events were retrospectively compared between postprocedural hypotension group and non-hypotension group. Morphological and procedural characteristics were not significantly different between the two groups. Periprocedural major adverse events, presence of new ischemic lesions, and number of new ischemic lesions were not significantly different between the two groups (P = 1, P = 0.36, P = 0.68). Hypertension was an independent protective factor (P = 0.037), and use of proximal protection and the distance from carotid bifurcation to maximum stenotic lesion ≤ 10 mm were independent risk factors for developing hypotension after CAS (P = 0.034, P = 0.027). There was no significant relationship between hypotension after CAS and major adverse events in this study. Maintenance of periprocedural adequate cerebral perfusion is thought to be important to prevent ischemic complications due to hypotension after CAS, especially in these cases.

Duration of the horizontal decubitus position for prevention of cerebrospinal fluid leakage following transection of a tight filum terminale.

OBJECT: The untethering of a tethered spinal cord in patients with a tight filum terminale is a relatively simple procedure that can prevent or improve neurological symptoms. Postoperatively, patients are usually kept in the horizontal decubitus position to prevent a CSF leak. However, the optimal period for keeping patients flat has not been determined yet. The authors compared 2 cohorts with different periods of horizontal decubitus; one with 72 hours and the other with 8 days. METHODS: The authors retrospectively analyzed surgical results in 2 cohorts of pediatric patients who had tethered spinal cord with a tight filum terminale. One cohort was maintained flat for 8 days and the other cohort for 72 hours postoperatively. The patients' charts were reviewed for demographic data, clinical presentation, surgical therapy, and clinical course. RESULTS: Three hundred fifty-four patients underwent sectioning of a tight filum terminale. Of those, 238 were kept lying flat for 8 days postoperatively, and 116 were maintained flat for 72 hours. Magnetic resonance imaging was performed 1 to 2 weeks after the surgery. None of the patients in either cohort developed a CSF leak. Pseudomeningocele, which was confirmed by MRI, developed in 1 patient who had been kept flat for 8 days. The occurrence rates of a CSF leak and pseudomeningocele were not significantly different in either cohort. CONCLUSIONS: Keeping patients flat for longer than 72 hours did not change the rate of postoperative CSF leakage or pseudomeningocele. Seventy-two hours or less would be an appropriate period for maintaining patients flat after transection of a tight filum terminale.

Rare variant of persistent primitive hypoglossal artery, arising from the external carotid artery.

A 63-year-old man presented with an extremely rare variant of persistent primitive hypoglossal artery (PHA), which was found incidentally during examination for a contralateral asymptomatic internal carotid artery (ICA) stenosis. This anastomotic vessel arose from the external carotid artery, not the ICA, and joined the vertebrobasilar artery through the hypoglossal canal. Persistent PHA is rare and the reported incidence is 0.027-0.26%. Recognition of the existence of this variant vessel and preservation during neuroradiologic intervention or surgery is important to prevent possible ischemic complications.

[Two cases of spontaneous intracranial hypotension with bilateral chronic subdural hematomas].

Spontaneous intracranial hypotension (SIH) is characterized by postural headaches without obvious cause and is occasionally related to chronic subdural hematomas (CSHs). Brain sag due to decrease in cerebrospinal fluid, and growing CSHs may occur secondary to a decrease in intracranial pressure. Therapy for this condition differs from that for mere traumatic CSHs and is controversial. We report 2 cases of CSH related to SIH. One patient required drainage of the CSHs and an epidural self-blood patch. Furthermore, this patient had to undergo reoperation for drainage of the CSHs. The other patient was cured after the first time the CSHs were drained.