Direct Carotid Puncture for Mechanical Thrombectomy in Acute Ischemic Stroke: Literature Review and a Single-Center Experience.

BACKGROUND: Endovascular thrombectomy (EVT) for acute ischemic stroke via direct carotid puncture (DCP) has been commonly reported as case reports and series in the literature. However, the reported procedural risk and therapeutic outcome associated with this approach were variable. In this study, we aim to establish the role and safety profile of this alternative access technique by describing our single-center experience and conducting a comprehensive review of the literature. METHODS: We conducted a retrospective review of consecutive patients at our center with large vessel occlusion (LVO) treated between 2018 and 2020 with DCP access. In addition, a literature review of studies published from 2012-2021 following PRISMA guidelines was conducted. RESULTS: During the 3-year period, 11 patients with LVO were treated with EVT using DCP technique in our local cohort. A total of 216 cases were found in the literature search. A combined total of 227 cases were reviewed separately and collectively. Combining the data, DCP access was successfully achieved in 93.3% of the cases; 76.6% achieved satisfactory recanalization (mTICI ≥2b). DCP-related complications were seen in 20.3% of cases. A total of 32.4% patients were functionally independent (mRS ≤2) upon follow-up. CONCLUSIONS: Results from the literature review and our experience illustrate DCP as a feasible approach for EVT. The role of DCP as a bailout is iterated despite a higher complication risk, which may be imperative in low-volume stroke centers. Further studies to evaluate the role of DCP as a primary vascular access technique for EVT in selected cases could be explored.

Invasive cerebral phaeohyphomycosis in a Chinese boy with CARD9 deficiency and showing unique radiological features, managed with surgical excision and antifungal treatment.

We report this rare case of cerebral phaeohyphomycosis in a previously healthy Chinese boy, who was found to have caspase recruitment domain family member 9 (CARD9) deficiency. Initial radiological features suggested a neoplastic cerebral lesion, while histopathological examination supplemented by internal transcribed sequencing (ITS) of cerebral tissue confirmed the diagnosis of phaeohyphomycosis. He was treated with intravenous (IV) liposomal amphotericin B and voriconazole, guided by plasma and cerebrospinal fluid (CSF) level monitoring at drug initiation. At the 1 year follow-up, the patient demonstrated near complete neurological and radiological recovery.

Endovascular Intervention for Early Postoperative Stenosis of Extracranial-Intracranial Bypass Graft: Case Report and Review of the Literature.

BACKGROUND: Bypass graft stenosis following extracranial-intracranial bypass surgery carries significant risks for morbidity and mortality. In case of graft failure, treatment options include surgical revision and endovascular intervention. Whereas endovascular intervention following coronary artery bypass is well established, the role of endovascular therapy in cerebral bypass conduits is rarely reported. We present a case of extracranial-intracranial bypass graft stenosis in the early postoperative period that was successfully treated by endovascular angioplasty and stenting. CASE DESCRIPTION: A middle-aged patient presented with a malignant skull base tumor with internal carotid artery invasion. Extracranial-intracranial bypass surgery was performed for flow preservation before tumor removal. Autologous radial artery was used as the bypass graft conduit. Symptomatic graft stenosis was encountered in the immediate postoperative period. Treatments in the form of intra-arterial vasodilator infusion and balloon angioplasty led to only minor flow improvement. The narrowing was eventually salvaged by endovascular stenting. Good clinical and radiologic outcomes were achieved at 6-month follow-up. CONCLUSIONS: Endovascular intervention is a feasible treatment option in management of graft stenosis after cerebral revascularization surgery. Our case adds evidence to the safety and role of endovascular intervention in early cerebral bypass conduit failure. In addition, endovascular stenting can be considered as a salvage option for cases that are refractory to angioplasty.

Optic neuropathy as the first sign of central nervous system relapse in acute myeloid leukaemia: MRI findings and its diagnostic challenge.

We describe the case of a 22-year-old man who presented with right eye visual impairment and oral mucositis. MRI revealed findings compatible with right optic neuritis. Herpes simplex virus 1 was detected in oral swab. He has a previous history of acute myeloid leukaemia (AML) and was in clinical remission. Initial investigations for possible relapse of AML with central nervous system (CNS) involvement were negative. Treatment for HSV-related optic neuritis was initiated but the patient's vision deteriorated. Repeat MRI revealed right optic nerve infarct, new left optic nerve abnormality and new leptomeningeal enhancement in the brain. Repeated cerebrospinal fluid analysis confirmed CNS relapse of AML. Despite prompt initiation of pulse steroid and high dose intrathecal cytarabine followed by cranial irradiation, the patient never regained his vision. We present a case of unexpected optic neuropathy as first and sole presentation of CNS relapse of AML.

Ultrasound-MRI Fusion for Targeted Biopsy of Myopathies.

OBJECTIVE. The purpose of this article is to describe the use of ultrasound-MRI fusion imaging to guide precise and targeted muscle biopsy in patients with suspected myopathies. CONCLUSION. Ultrasound-MRI fusion-guided muscle biopsy allows targeted sampling of tissues with active inflammatory changes and facilitates diagnosis of myopathies.

Long-Term Risk of In-Stent Restenosis and Stent Fracture for Extracranial Vertebral Artery Stenting.

PURPOSE: Stenting and angioplasty of the vertebral artery (VA) is used to treat symptomatic stenosis but the long-term outcomes and complications are unclear. This study evaluated the long-term clinical outcomes and procedure-related complications in patients who underwent extracranial VA stenting and angioplasty, in particular the risks of in-stent restenosis (ISR) and stent fracture. METHODS: This was a retrospective review of consecutive patients suffering from symptomatic extracranial VA stenosis who were treated with balloon-expandable bare metal stents. The clinical and angiographical outcomes were reviewed for procedural complications, recurrent stroke, ISR and stent fracture. RESULTS: In this study 22 patients (17 male, 5 female) with a mean age of 63.4 years (SD 9.1 years) were included. The median follow-up was 56 months (interquartile range IQR 51.8 months). There were no periprocedural complications. The cumulative ISR risk was 45% with 6 cases detected at 1 year and 3 cases detected at 3 years post operation. The cumulative stent fracture rate at 1 year, 3 years, 5 years and the entire follow-up period were 5%, 15%, 25%, and 30%, respectively. Posterior circulation stroke occurred in 1 patient (4.5%), and 3 patients died of non-cerebrovascular causes during follow-up. Of the patients 2 with ISR and stent fracture required additional treatment. CONCLUSION: The long-term ISR and stent fracture risks were high in extracranial VA stenosis treated with balloon-expandable bare metal stents. The risk of stent fracture increased over time during the follow-up period. Further studies should be conducted to clarify the long-term safety and efficacy of extracranial VA stenting.

Severity of intracranial carotid artery calcification in intracranial atherosclerosis-related occlusion treated with endovascular thrombectomy.

OBJECTIVES: Intracranial atherosclerosis related large vessel occlusions (ICAS-O) are challenging to diagnose and manage. The degree of intracranial carotid artery calcification may assist pre-thrombectomy diagnosis of ICAS and guide treatment strategy. The aim of the study is to determine if intracranial carotid calcification is associated with ICAS-O. PATIENTS AND METHODS: Consecutive large vessel occlusion patients who underwent thrombectomy from 2006 to 2017 were retrospectively studied. Patients were classified into ICAS-O if pre-existing atherosclerotic lesion was identified as the etiology for large vessel occlusion during the thrombectomy. The degree of intracranial carotid artery calcification (ICAC), technical and clinical outcomes of ICAS-O was compared with non-ICAS-O patients. RESULTS: In a retrospective cohort study of 64 thrombectomy patients, ICAS-O accounted for 14.1% of cases and was associated with higher degree of carotid calcification (mean Woodcock scale 2.8 vs 1.6, p = 0.044), need of stent-retreiver rescue (55.6% vs 5.5%, p = 0.001), and adjuvant stenting or angioplasty (33.3% vs 0%, p = 0.002) compared with non-ICAS-O. CONCLUSION: The severity of ICAC may be associated with ICAS-O as the underlying etiology amongst thrombectomy patients. Compared with large vessel occlusion of other causes, ICAS-O was associated with more failure of aspiration and a higher need of adjuvant stenting and angioplasty.

Antiplatelet Resumption after Antiplatelet-Related Intracerebral Hemorrhage: A Retrospective Hospital-Based Study.

BACKGROUND: Antiplatelet resumption in patients who developed intracerebral hemorrhage (ICH) while on antiplatelet therapy (antiplatelet-related ICH) represents an important medical dilemma. We aimed to study the long-term cardiovascular outcomes of antiplatelet-related ICH survivors, and the risk of recurrent ICH with antiplatelet resumption. METHODS: This was an observational study of 109 antiplatelet-related ICH survivors. The clinical end points were recurrent ICH, ischemic vascular events, and vascular death (fatal ICH or ischemic vascular events). Predictors of recurrent ICH and vascular death were derived using a multivariable Cox regression model. RESULTS: The median duration of follow-up was 3.5 years (interquartile range, 1.6-5.8 years). Ischemic vascular events were more common than recurrent ICHs (6.8 per 100 patient-years vs. 2.6 per 100 patient-years; P = 0.028). Antiplatelet use was not associated with an elevated risk of recurrent ICH (hazard ratio [HR], 1.11, 95% confidence interval [CI], 0.27-4.62). A mean follow-up systolic blood pressure of >140 mmHg increased the risk of both recurrent ICH (HR, 4.28; 95% CI, 1.01-18.11) and vascular death (HR, 11.14; 95% CI, 2.72-45.62). Cerebral amyloid angiopathy (CAA) was an independent predictor for recurrent ICH (HR, 24.34; 95% CI, 2.80-211.47). CONCLUSIONS: Antiplatelet resumption after antiplatelet-related ICH did not appear to carry a clinically significant risk of recurrent ICH, whereas inadequate blood pressure control and CAA contributed to a more robust risk. Antiplatelet resumption should be considered, especially in survivors with adequate blood pressure control and without CAA.

Orbital Ectopic Lymphoid Follicles with Germinal Centers in Aquaporin-4-IgG-Positive Neuromyelitis Optica Spectrum Disorders.

Neuromyelitis optica spectrum disorders (NMOSDs) are important autoimmune central nervous system (CNS) astrocytopathy causing acute myelitis, optic neuritis (ON), and encephalitis associated with significant morbidities and mortality. It is important to diagnose NMOSDs early as they are treatable. The majority of NMOSDs patients are seropositive for aquaporin-4 IgG (AQP4-IgG) autoantibodies, which target CNS aquaporin-4 (AQP4) expressed abundantly in astrocytic foot processes. We report the novel observation of orbital masses containing ectopic lymphoid follicles with germinal centres (GC) in two patients with AQP4-IgG-positive NMOSD. Both patients had severe extensive myelitis with symptomatic or asymptomatic ON, with the ectopic lymphoid structures detected on initial presentation. Histolopathological studies confirmed that the orbital masses contained reactive lymphoid follicles with GC containing B cells and plasma cells. Our observations support that AQP4-IgG positive NMOSDs patients have underlying AQP4 autoimmunity and suggest that ON (symptomatic or asymptomatic) may trigger formation of orbital ectopic GC contributing to development of high-affinity AQP4-specific memory B cells and plasma cells, which produce highly pathogenic AQP4-IgG.

Failure of Flow Diverter Treatment of Intracranial Aneurysms Related to the Fetal-type Posterior Communicating Artery.

PURPOSE: The pipeline embolization device (PED) is a flow diverter that has shown promise in the treatment of intracranial aneurysms. Close to one-fifth of aneurysms, however, fail to occlude after PED placement. This study aims to identify anatomical features and clinicopathologic factors that may predispose failed aneurysm occlusion with the PED. MATERIALS AND METHODS: We retrospectively reviewed all anterior circulation unruptured saccular aneurysms treated with the PED in a single-center. The primary outcome measure was angiographic occlusion. Anatomical features and potential predictors, including gender, aneurysm location, size, height, aspect ratio, neck width, prior treatment and the number of PED, were studied using binary logistic regression. RESULTS: 29 anterior circulation unruptured saccular aneurysms with a mean size of 6.99 mm treated with the PED in a single center were retrospectively studied. The overall occlusion rate was 79.3% after a mean follow-up of 9.2 months. Four aneurysms were related to the fetal-type posterior communicating artery (PComA), and all were refractory to flow diverter treatment. Female gender was significantly associated with a higher occlusion rate. We present the anatomical features and propose possible pathophysiological mechanisms of these PComA aneurysms that failed flow diverter treatment. CONCLUSION: A PComA aneurysm with persistent fetal-type circulation appears to be particularly refractory to flow diverter treatment, especially when the aneurysm incorporates a significant portion of the PComA. Our experience suggested that flow diverting stents alone may not be the ideal treatment for this subgroup of aneurysms, and alternative modalities should be considered. Female patients were found to have a significantly higher rate of treatment success.

Angioplasty and stenting for intracranial atherosclerotic stenosis: position statement of the Hong Kong Society of Interventional and Therapeutic Neuroradiology.

As a means of preventing secondary ischaemic stroke, angioplasty and stenting are considered potentially beneficial for patients with severe intracranial atherosclerotic stenosis. However, the role of stenting has been challenged since the publication of the first randomised controlled trial on Stenting versus Aggressive Medical Management for Preventing Recurrent stroke in Intracranial arterial Stenosis (SAMMPRIS). This indicated that aggressive medical management was superior to stenting using Wingspan to prevent recurrent stroke, because stenting has a high peri-procedural stroke and death rate. In this paper, we review the management of intracranial atherosclerosis, revisit the skepticism on stenting, and state our position on the topic in the form of recommendations. These are based on the prevalence of the disease in Hong Kong, the high risk of recurrent stroke despite medical therapy in the presence of haemodynamic intracranial stenosis without sufficient collaterals, an analysis of the weak points of SAMMPRIS, and results of clinical studies in Hong Kong.

Intracranial aneurysms: midterm outcome of pipeline embolization device--a prospective study in 143 patients with 178 aneurysms.

PURPOSE: To evaluate the midterm clinical and angiographic outcomes after pipeline embolization device (PED) placement for treatment of intracranial aneurysms. MATERIALS AND METHODS: This prospective nonrandomized multicenter study was approved by the review boards of all involved centers; informed consent was obtained. Patients (143 patients, 178 aneurysms) with unruptured saccular or fusiform aneurysms or recurrent aneurysms after previous treatment were included and observed angiographically for up to 18 months and clinically for up to 3 years. Study endpoints included complete aneurysm occlusion; neurologic complications within 30 days and up to 3 years; clinical outcome of cranial nerve palsy after PED placement; angiographic evidence of occlusion or stenosis of parent artery and that of occlusion of covered side branches at 6, 12, and 18 months; and clinical and computed tomographic evidence of perforator infarction. RESULTS: There were five (3.5%) cases of periprocedural death or major stroke (modified Rankin Scale [mRS] > 3) (95% confidence interval [CI]: 1.3%, 8.4%), including two posttreatment delayed ruptures, two intracerebral hemorrhages, and one thromboembolism. Five (3.5%) patients had minor neurologic complications within 30 days (mRS = 1) (95% CI: 1.3%, 8.4%), including transient ischemic attack (n = 2), small cerebral infarction (n = 2), and cranial nerve palsy (n = 1). Beyond 30 days, there was one fatal intracerebral hemorrhage and one transient ischemic attack. Ten of 13 patients (95% CI: 46%, 93.8%) completely recovered from symptoms of cranial nerve palsy within a median of 3.5 months. Angiographic results at 18 months revealed a complete aneurysm occlusion rate of 84% (49 of 58; 95% CI: 72.1%, 92.2%), with no cases of parent artery occlusion, parent artery stenosis (<50%) in three patients, and occlusion of a covered side branch in two cases (posterior communicating arteries). Perforator infarction did not occur. CONCLUSION: PED placement is a reasonably safe and effective treatment for intracranial aneurysms. The treatment is promising for aneurysms of unfavorable morphologic features, such as wide neck, large size, fusiform morphology, incorporation of side branches, and posttreatment recanalization, and should be considered a first choice for treating unruptured aneurysms and recurrent aneurysms after previous treatments. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12120422/-/DC1.

Brain involvement in neuromyelitis optica spectrum disorders.

BACKGROUND: Neuromyelitis optica spectrum disorders (NMOSDs) are severe inflammatory demyelinating disorders of the central nervous system. Brain involvement is increasingly recognized. OBJECTIVE: To study brain involvement in NMOSDs among Hong Kong Chinese patients. DESIGN: Retrospective study of patients with NMOSDs. SETTING: Tertiary medical center in Hong Kong. Patients  Thirty-four Hong Kong Chinese patients with NMOSDs of 2 years or longer were recruited. INTERVENTIONS: Brain and spinal cord magnetic resonance imaging was performed during NMOSD attacks and was repeated yearly for the first 3 years. MAIN OUTCOME MEASURES: We evaluated clinical features of NMOSDs associated with brain involvement and brain lesions on magnetic resonance imaging. RESULTS: Among 34 patients with NMOSDs of 2 years or longer, 20 (59%) had brain involvement. The mean age at onset among these 20 patients was 45.6 years (age range, 19-67 years); 18 were women. Eleven patients (32% of all the patients with NMOSDs) had clinical manifestation of brain involvement, 19 patients (56%) had brain abnormalities on magnetic resonance imaging consistent with inflammatory demyelination, and 2 patients (6%) fulfilled criteria for multiple sclerosis. Clinical manifestation of brain involvement included the following: trigeminal neuralgia; vomiting, vertigo, ataxia, dysphagia, and tetraparesis from lesions around the third and fourth ventricles and aqueduct; homonymous hemianopia, aphasia, hemiparesis, and cognitive impairment from extensive hemispheric white matter lesions; and ataxia, diplopia, hiccups, facial sensory loss, internuclear ophthalmoplegia, hemisensory loss, and hemiparesis from other lesions in the midbrain, pons, cerebellar peduncles, and medulla. Eight patients (24%) developed brainstem encephalitis clinically, and brainstem encephalitis was the initial clinical manifestation in 6 patients (18%). Brain abnormalities on magnetic resonance imaging were detected in brainstem in 15 patients (44%), hemispheric periventricular white matter in 7 patients (21%), deep white matter in 7 patients (21%), corpus callosum in 4 patients (12%), subcortical white matter in 3 patients (9%), thalamus in 2 patients (6%), hypothalamus in 1 patient (3%), basal ganglia in 1 patient (3%), internal capsule in 1 patient (3%), periaqueductal gray matter in 1 patient (3%), and around the third and fourth ventricles in 1 patient (3%); large confluent lesions were detected in 2 patients (6%). CONCLUSION: Brain involvement manifesting clinically as brainstem encephalitis is common among Hong Kong Chinese patients with NMOSDs.

Thalamo-perforating artery aneurysm in Moyamoya disease - case report.

A 31-year-old man with Moyamoya disease had received a right encephalo-duro-arterial synangiosis and later developed a rupture of the left thalamo-perforating artery aneurysm. Surgical strategies were discussed. Perfusion studies revealed increased haemodynamic stress on the left hemisphere which was likely the cause of the aneurysm.

Abnormal diffusion tensor in nonsymptomatic familial amyotrophic lateral sclerosis with a causative superoxide dismutase 1 mutation.

PURPOSE: To determine whether diffusion abnormalities can be observed in nonsymptomatic family members with a known causative Cu/Zn superoxide dismutase mutation (asymptomatic familial amyotrophic lateral sclerosis; AFALS(+SOD1)) in a family with autosomal dominant familial amyotrophic lateral sclerosis (ALS) using diffusion tensor imaging (DTI). MATERIALS AND METHODS: A total of eight AFALS(+SOD1) subjects (aged 17-43 years) were age-matched with 13 healthy controls (aged 19-45 years) without SOD1 mutations. DTI was carried out on a 1.5T scanner. The diffusion index maps derived were then normalized spatially for voxel-based analysis. region of interest (ROI)-based analysis was also carried out. RESULTS: Our voxel-based and ROI-based analysis showed that AFALS(+SOD1) subjects have decreased fractional anisotropy (FA) (0.5401 vs. 0.5168, P < 0.05) and increased tensor trace (TT) (2.5854 x 10(-3) mm(2)/second vs. 2.6226 x 10(-3) mm(2)/second, P < 0.04) at the posterior limb of the internal capsule compared to the control subjects. Increased radial diffusivity (E((2,3)/2)) was detected on both sides (right = 0.5710 x 10(-3) mm(2)/second vs. 0.5943 x 10(-3) mm(2)/second, P < 0.05; left = 0.5666 x 10(-3) mm(2)/second vs. 0.5872 x 10(-3) mm(2)/second, P < 0.05). No significant change in axial diffusivity (E(1)) was detected. CONCLUSION: Abnormal diffusivity was found at the posterior limb of the internal capsule in AFALS(+SOD1) subjects, hitherto unreported. Our results suggest that DTI may detect diffusion abnormalities in AFALS(+SOD1) subjects before symptoms develop.

Radiation ulcers of the neck should not be neglected: a case of vertebral artery blowout.

Radiotherapy for head and neck malignancies can result in late complications. Here, we report a patient with a rare vascular complication caused by radiation-induced ulcer of the head and neck region. The clinical presentation, its diagnosis, treatment and outcome are discussed.