Per-region interobserver agreement of Alberta Stroke Program Early CT Scores (ASPECTS).

BACKGROUND AND PURPOSE: The Alberta Stroke Program Early CT Score (ASPECTS) is a commonly used scoring system to select patients with stroke for endovascular treatment (EVT). However, the inter- and intra-reader variability is high. OBJECTIVE: To determine whether the inter- and intra-reader variability is different for various regions of the ASPECTS scoring system by evaluating the interobserver variability of ASPECTS between different readers in a per-region analysis. MATERIALS AND METHODS: All patients with acute ischemic stroke who proceeded to EVT in our institutions over a 4-year period were retrospectively identified from a prospectively maintained database. Images were reviewed by two experienced neuroradiologists, who recalculated the ASPECTS independently. We examined each region of the ASPECTS system to evaluate agreement between the raters in each area. RESULTS: 375 patients were included. The median total ASPECTS was 9 (IQR 8-9). The most common region showing ischemic change was the insula, with the M6 region being least commonly affected. Overall interobserver agreement for ASPECTS using Cohen's κ was 0.56 (95% CI 0.51 to 0.61). The region with the highest agreement was the insula (κ=0.56; 0.48 to 0.64). The region with the lowest agreement was M3 (κ=0.34; 0.12 to 0.56). Agreement was relatively good when ASPECTS were dichotomized into 0-5 versus 6-10 (κ=0.66; 0.49 to 0.84). CONCLUSIONS: Substantial interobserver variability is found when calculating ASPECTS. This variability is region dependent, and practitioners should take this into account when using ASPECTS for treatment decisions in patients with acute stroke.

Republished: Transradial approach in the treatment of a sacral dural arteriovenous fistula: a technical note.

Sacral dural arteriovenous fistulas (SDAVFs) are rare, constituting no more than 10% of all spinal dural fistulas. They are most commonly fed by the lateral sacral artery (LSA), a branch of the internal iliac artery (IIA). Catheterization of this vessel requires either a crossover at the aortic bifurcation in cases of right femoral access or retrograde catheterization from the ipsilateral common femoral artery. We present the case of a 79-year-old man with tethered cord syndrome and a symptomatic SDAVF fed by two feeders from the left LSA. Spinal diagnostic angiography was made exceptionally challenging by an aorto-bi-iliac endograft, and selective catheterization of the left IIA was not possible. The patient could not undergo surgery due to multiple comorbidities, therefore embolization was considered the best approach. The procedure was carried out through a transradial access (TRA) with Onyx and n-butyl cyanoacrylate. The SDAVF was successfully treated and the patient made a full neurological recovery.

Transradial approach in the treatment of a sacral dural arteriovenous fistula: a technical note.

Sacral dural arteriovenous fistulas (SDAVFs) are rare, constituting no more than 10% of all spinal dural fistulas. They are most commonly fed by the lateral sacral artery (LSA), a branch of the internal iliac artery (IIA). Catheterization of this vessel requires either a crossover at the aortic bifurcation in cases of right femoral access or retrograde catheterization from the ipsilateral common femoral artery. We present the case of a 79-year-old man with tethered cord syndrome and a symptomatic SDAVF fed by two feeders from the left LSA. Spinal diagnostic angiography was made exceptionally challenging by an aorto-bi-iliac endograft, and selective catheterization of the left IIA was not possible. The patient could not undergo surgery due to multiple comorbidities, therefore embolization was considered the best approach. The procedure was carried out through a transradial access (TRA) with Onyx and n-butyl cyanoacrylate. The SDAVF was successfully treated and the patient made a full neurological recovery.

Periprocedural safety and technical outcomes of the new Silk Vista Baby flow diverter for the treatment of intracranial aneurysms: results from a multicenter experience.

PURPOSE: The aim of our study was to assess the technical success and the safety of this new low-profile flow diverter Silk Vista Baby (SVB) by evaluating the intraprocedural and periprocedural complication rate. MATERIAL/METHODS: Clinical, procedural, and angiographic data were analyzed. RESULTS: 41 consecutive patients (28 women; age average 50.5 years) with 43 aneurysms were treated with SVB. Aneurysm sizes were classified by their maximum diameter, with an average size of 9.5 mm (range 2-30 mm). Thirty-four cases were unruptured. five aneurysms previously ruptured, had recurrence after the initial coiling. There were two ruptured cases. Aneurysms' locations were: M1 segment (five cases), M2 segment (three cases), M3 segment (one case), middle cerebral artery (MCA) bifurcation (six cases), carotid-T (two cases), anterior communicating artery/A1/A2 (11 cases), pericallosal artery (four cases), supraclinoid ICA (two cases), PCom (one case), V4 segment (three cases), PCA (three cases), SCA (one case), and PICA (one case). We had five intraprocedural complications which resolved without clinical consequences and three events postprocedural events. Initial occlusion rates were: eight aneurysms (18.6%) were completely occluded, five aneurysms (11.6%) showed near-complete occlusion, four cases (9.3%) showed incomplete filling, and 26 cases (60.4%) showed persisting filling. The mRS score at discharge from the hospital did not change from the admission mRS score. CONCLUSION: Our study demonstrated that the use of the new low-profile flow diverter, SVB device, for the treatment of intracranial aneurysms is feasible and technically safe.

Ruptured Duplicated Middle Cerebral Artery Aneurysm Successfully Treated by Coil Embolization with Balloon Remodeling.

A duplicated middle cerebral artery (dMCA) is a rare anatomical variant that can be associated with aneurysm formation and rupture. The dMCA arises from the terminal portion of the internal carotid artery, with the caudal trunk supplying the temporal lobe and the cranial trunk supplying the frontal lobe and the lenticulostriate perforators. Previous reported cases were all treated with open surgical clipping with or without cerebral revascularization to reconstruct the dMCA. We present a rare case of a young woman with a ruptured dMCA (subtype B) aneurysm. We have demonstrated the unique anatomical relationship among the dMCA, internal carotid artery, and the anterior choroidal artery. Understanding and preserving the dMCA anatomy is essential in such cases to prevent ischemic complications. This was achieved endovascularly by balloon remodeling and coil embolization of the aneurysm in this location.

Orbital Infarction Syndrome Following Mechanical Thrombectomy Secondary to Embolization in New Territory.

BACKGROUND: Orbital infarction syndrome (OIS) is a rare entity defined as ischemia of all intraorbital and intraoccular structures including the optic nerve, extraocular muscles, and orbital fat. This entity is rare due to rich anastomotic orbital vascularization from both the internal carotid artery and external carotid artery. We report a case of a patient who suffered emboli to previously nonaffected territories to the ophthalmic artery and external carotid artery, which resulted in orbital infarction syndrome, and describe techniques to avoid such complications. CASE DESCRIPTION: A 66-year-old male presented to our institution with an acute ischemic stroke secondary to occlusion of the internal carotid artery terminus and M1 segment. The vessel was revascularized after 1 pass using a stent retriever. Postoperative angiography demonstrated sluggish flow in the distal right ophthalmic artery, as well as occlusion of the distal external carotid artery. Twenty-four hours following the procedure, the patient was noted to have complete ophthalmoplegia of the right eye, proptosis, and conjunctival chemosis. Computed tomography angiography demonstrated persistent occlusion of the distal right ophthalmic artery and external carotid artery. The right optic nerve was swollen, as were all extraocular muscles. A final diagnosis of orbital infarction syndrome was made given the clinical presentation, imaging findings, and occlusion of all vascular supply to the orbit on both conventional angiography and 24-hour computed tomography angiography. CONCLUSIONS: OIS is a rare entity that has not been previously described as a complication of mechanical thrombectomy for acute ischemic stroke. OIS should be considered when patients present with blindness, orbital pain, and total ophthalmoplegia post thrombectomy.

MRI Vessel Wall Imaging and Treatment of an Aneurysm at the Atlanto-Axial Segment of an Aberrant Vertebral Artery / 신경중재치료의학

We report a case of unique location of an aneurysm at the atlanto-axial extradural segment of a unilateral aberrant vertebral artery. The MRI vessel wall imaging findings and possible mechanism of aneurysm formation were discussed. A 5 mm extracranial vertebral artery aneurysm located at the interlaminar space between C1 and C2 was diagnosed in a woman presenting with occipital headache. The index vertebral artery ran an aberrant course at the V3 segment, where it entered the dura between C1 and C2 instead of the usual atlanto-occipital space. MR vessel wall imaging showed homogenous wall enhancement of the aneurysm sac. We surmise the anomalous course of the vertebral artery subjected the V3 segment to repeated shearing force secondary to the atlanto-axial rotational neck movement. This led to vessel wall trauma and inflammation, and subsequent aneurysm formation. The aneurysm was successfully treated with endovascular coiling with resolution of symptoms.