CT angiographic patterns predict carotid pseudo-occlusion in acute ischemic stroke.

Background: Identifying carotid pseudo-occlusion (PO) from true occlusion (TO) has implications in determining the candidacy and feasibility of successful endovascular thrombectomy (EVT) in acute ischemic stroke (AIS). Purpose: We reviewed the computed tomography angiographic (CTA) patterns differentiating a PO from a TO and analyzed the rate of successful recanalization after EVT. Materials and Methods: Patients with AIS and proximal internal carotid artery (ICA) occlusion who underwent EVT from 2014 to 2021 were identified. The patterns of carotid occlusion in CTA were classified into beak, dome, and flat patterns and correlated with microcatheter digital subtraction angiography (DSA) as PO and TO. The rates of successful recanalization in PO and TO were analyzed. Results: Of the 24 patients, 16 (66%) had ICA PO and eight (33%) had TO in DSA. A beak pattern of the proximal ICA on CTA was significantly higher among the PO group patients (87.5% vs. 25%, P = 0.005), and a flat pattern was significantly higher among the TO group patients (50% vs. 12%, P = 0.005). A gradual contrast decline of the proximal ICA on CTA images was seen only in PO group patients (85.7% vs. 0%, P = 0.05). There was no significant difference in the rate of successful recanalization between PO and TO group patients (81.25% vs. 62.5%, P = 0.362). Conclusion: Beak pattern and gradual contrast decline at the proximal ICA occlusion site in CTA are suggestive of carotid PO. Identification of PO in CTA can help in planning intervention strategies and prognostication.

Can Empirical Segmental Angioembolization of Splenic Artery Salvage Pancreatic Intraluminal Bleed?

Background Postpancreatectomy hemorrhage (PPH) and Hemosuccus Pancreaticus (HP) may present with slow but significant intraluminal bleed which may not be evident on imaging. We evaluated the efficacy of empirical segmental-angioembolization of splenic artery in intraluminal PPH and HP. Result This is a cross-sectional study done by analyzing all consecutive patients with PPH and HP who underwent empirical coil embolization of splenic artery. There were total of 137 pancreaticoduodenectomies (PD), 68 distal pancreatectomies (DP), 11 patients with median pancreatectomies (MP) and 134 admissions for acute pancreatitis and exacerbation of chronic pancreatitis during the study period. Eleven (5.1%) patients had PPH, of which two were managed surgically. Among nine patients, 4/9 (44.4%) with pseudoaneurysm on computed tomography angiography (CTA) were excluded. Among pancreatitis, 7 (5.2%) had HP, and 5/7 (71.4%) patients with pseudoaneurysm on CTA were excluded. Hence, seven patients, PPH-5 and HP-2, were included. Both HP patients were managed successfully with empirical segmental coil embolization of splenic artery. Among PPH, one patient required laparotomy for failed embolization. Overall, 6/7 (85.7%) had successful coil embolization. No reintervention, continued bleed, or blood transfusions were required postprocedure, and no splenic infarct or abscess was seen in any of the seven patients postembolization. The 72-hour rebleed rate was 1/7 (14.3%), which was managed surgically. Conclusion Empirical segmental coil embolization of splenic artery in intraluminal pancreatic bleed holds promise as a salvage life-saving procedure even when no blush or pseudoaneurysm is evident.

The Impact of Time to Reperfusion on Recanalization Rates and Outcome After Mechanical Thrombectomy: A Single Center Experience.

Background: Timely and effective recanalization to salvage the penumbra is the main determinant of outcome in acute ischemic strokes. Randomized controlled trials on late window mechanical thrombectomy (MT) have proved its safety and efficacy upto 24 h after stroke onset. We looked at the impact of time to reperfusion on vessel recanalization rates and short-term outcome in patients undergoing MT for large vessel occlusion. Methods: The clinical, imaging, and outcome of all patients undergoing MT upto 24 h from last seen normal was extracted from a prospectively maintained ischemic stroke database from January 2012 till September 2019. Results: There were 145 patients with a mean (SD) age of 58.2 (±14) years. Of them, 28 had wake up/unknown time of onset stroke and 9 presented beyond >360 min. There were 23 vertebrobasilar strokes. Median National Institute of Health Stroke scale score (NIHSS) at admission was 16.4 (Inter quartile range (IQR) 12-21). CT-Alberta Stroke program early CT score (CT-ASPECTS) was excellent (8-10) in 39 (31.6%) and fair (5-7) in 77 (63.6%) patients in anterior circulation strokes. About 25% underwent bridging therapy. Recanalization rates did not differ between those presenting early (<6 h) versus wake up strokes and late presenting patients (81.79% vs 71.9%). Symptomatic Intracerebral hemorrhage (ICH) occurred in 5%. At 3 months, excellent outcome (modified rankin scale <2) was observed in 28.9%. While Admission NIHSS remained strong predictor of poor outcome at 3 months, delay in presentation did not impact MT outcome (37.5% vs 45.79% and P = 0.460). Conclusions: The recanalization rates were similar in patients irrespective of the time to reperfusion from stroke onset. The functional outcome was not inferior in late presenters selected by advanced imaging.

Hypodensities within Hematoma is Time-Dependent and Predicts Outcome after Spontaneous Intracerebral Hemorrhage.

BACKGROUND: Non-contrast CT (NCCT) brain imaging biomarkers of hematoma expansion in intracerebral hemorrhage (ICH) has gained relevance in recent times. Though intra-hematoma hypodensities (IHH) can predict hematoma expansion and outcome, it is postulated to be time-dependent. AIM: To assess the differential prevalence of IHH in spontaneous ICH over time and assess its predictive valve in early hematoma expansion and functional outcome at 3 months. MATERIAL AND METHODS: Patients with ICH within 48 h of stroke onset were included. Baseline clinical and demographic data were collected. Baseline NCCT brain was analyzed for hematoma volume, characterization of IHH, with 24-hours follow-up NCCT hematoma volume calculated for identification of hematoma expansion. Poor functional outcome was defined as mRS ≥3. RESULTS: Around 92 subjects were included in the study. IHH was found in 40%. Prevalence of IHH was higher in those with baseline NCCT performed within 3 h of symptom onset compared to those beyond 3 h (71% vs 29%, P = 0.002). The hematoma expansion was more common in patients with IHH compared to those without (54% vs 29%; P = 0.02). Multivariate analysis revealed the presence of IHH (rather than pattern or number) to be strongly associated with poor functional outcome at 3 months (OR 3.86; 95% CI: 1.11-13.42, P = 0.03). CONCLUSION: There is a decreasing prevalence of IHH as the time from symptom onset to NCCT increases. Nevertheless, its presence is significantly associated with hematoma expansion and predicted poor short-term functional outcomes in spontaneous ICH.

Primary angiitis of the central nervous system: Clinical profiles and outcomes of 45 patients.

OBJECTIVE: To describe the clinical profile, treatment response and predictors of outcome in patients with primary angiitis of the central nervous system (PACNS) from a single tertiary care center. METHODOLOGY: Retrospective analysis of consecutive patients diagnosed with PACNS from January 2000 to December 2015. Outcome was defined as poor when the 6-month modified Rankin scale (mRS) was ≥3. RESULTS: The median age of the 45 patients included in this study was 36 (range 19-70) years at disease onset and 31 (68.9%) were males. The initial presentation was ischemic stroke in 15 (33.3%), hemorrhagic stroke in 4 (8.9%), headache in 11 (24.4%), seizures in 8 (17.8%) and cognitive dysfunction in 5 (11.1%) patients. Diagnosis was confirmed by a four vessel cerebral digital subtraction angiogram (DSA), biopsy and by both biopsy and DSA in 26 (57.8%), 15 (33.3%) and 4 (8.9%) patients, respectively. All patients received glucocorticoids and 14 patients received in addition either cyclophosphamide or azathioprine as their first treatment. The median duration of follow-up was 33.1 (0.7-356) months. A poor 6-month outcome was observed in 12 (26.7%) patients. Relapse occurred in 25 (55.6%) patients and 7 (15.6%) died. Predictors of a poor outcome consisted of cognitive dysfunction at diagnosis (80% vs 20%; P = 0.014) and NIHSS ≥5 (62.5% vs 37.5%; P <.0005). None of the patients with a normal EEG had a poor outcome (P = 0.046). Predictors of relapse were a higher NIHSS at admission (P =.032) and a normal DSA (P = 0.002). CONCLUSION: In this cohort, severe deficits and cognitive symptoms at onset and an abnormal EEG were associated with a poor 6-month outcome.

Dementia and Parkinsonism-a Rare Presentation of Intracranial Dural Arteriovenous Fistulae.

Intracranial dural arteriovenous fistulae (DAVF) are acquired fistulous communications between dural arterial branches and dural venous sinuses or cortical veins with the nidus located within the leaflets of the duramater. Dementia and Parkinsonism are amongst the rarest of clinical presentations in DAVFs and are important to diagnose early, being treatable with timely intervention. We present an interesting case of a patient who presented with rapidly progressive dementia and features of parkinsonism who was diagnosed to have extensive DAVF and made remarkable recovery after embolization of the fistulae.

A Case of Evolving Bilateral Sphenoidal Meningoencephaloceles: Case Report and Review of the Literature.

BACKGROUND: The evolution of sphenoid sinus meningoencephaloceles and cerebrospinal fluid (CSF) rhinorrhea is poorly understood. CASE DESCRIPTION: We present a case demonstrating the gradual evolution of encephaloceles from both the lateral walls of a previously normal sphenoid sinus in a patient with dural arteriovenous fistula; the CSF leak that developed after staged embolization of the dural arteriovenous fistula was managed by an endoscopic endonasal transpterygoid approach. CONCLUSIONS: We suggest that over a period of time, chronic elevation of intracranial pressure can result in gradual erosion of the lateral wall of the sphenoid with development of meningoencephaloceles and CSF leaks.

Skull Base Osseous Arteriovenous Fistula-A Rare Clinical Entity: Case Report and Literature Review.

PURPOSE: To describe a rare clinical entity of intraosseous skull base arteriovenous fistula managed with transvenous fistula embolization. CASE PRESENTATION: A 57-year-old woman presented with complaints of headache and episodic tinnitus with progressive left-sided visual deterioration. Cross-sectional imaging of the head revealed multiple vascular channels in the sphenoid bone and in bilateral masticator spaces. Catheter angiography showed the presence of a large osseous arteriovenous fistula epicentered in the body of sphenoid and left pterygoid plates with arterial feeders from bilateral external carotid arteries and venous drainage into bilateral cavernous sinuses and the pterygoid venous plexus. She was managed by transvenous coil and liquid embolic agent (Squid 18) embolization of the venous sac with significant reduction of shunt. In the postprocedure period, the patient developed paradoxical worsening of symptoms due to central retinal vein occlusion. CONCLUSIONS: Skull base osseous fistulae are uncommon clinical entities and fistulae centered within the sphenoid bone are very rare. The aim of this report was to highlight management issues associated with such a case and review the available literature on the subject.

Moyamoya disease: a comparison of long term outcome of conservative and surgical treatment in India.

BACKGROUND: Revascularization surgery (RS) is the therapy of choice in moyamoya disease (MMD). Due to rarity of disease and ethical concerns, randomized controlled trials about the treatment options are lacking. Very little information is available on the long-term outcome of conservatively treated moyamoya patients. AIM: We compared the long-term outcome of moyamoya patients treated conservatively to those who underwent RS. METHODS: Our study population included all patients with moyamoya disease/syndrome from 2002 to 2012. The demographic, clinical characteristic and imaging details were reviewed. The outcome was obtained prospectively. RESULTS: Of the 36 patients, 26 (72.2%) had MMD and 10 (27.8%) had moyamoya syndrome. The median age at onset of symptoms was 17.5 years (range, 10 months-55 years). Fifteen patients belonged to pediatric group and 21 were adults. All the pediatric patients had ischemic events at onset and 10 (47.6%) of the adults presented with hemorrhage. Twenty (55.6%) patients received conservative treatment and 16 (44.4%) underwent revascularization procedures. The median duration of follow-up was 28 months (range, 3-90 months). Three (18%) of the surgically treated patients had recurrent ischemic events on follow-up, but none of the conservatively treated patients had events. An excellent outcome (Modified Rankin Scale of ≤2) was seen in 12 (75%) surgically treated and 16 (94%) conservatively treated patients (p=0.17). CONCLUSION: Compared to East Asians, our patients had a lower stroke recurrence rate and good functional outcome even with conservative treatment. Future studies should focus on clinical and imaging predictors of progression to select moyamoya patients for RS.

Suction thrombectomy of thrombotic occlusion of the subclavian artery in a case of Takayasu's arteritis.

Takayasu's arteritis, also known as pulseless disease, is a chronic inflammatory arteritis affecting large vessels, predominantly the aorta and its main branches. Vessel inflammation leads to wall thickening, fibrosis, stenosis, and thrombus formation. Percutaneous removal of arterial thrombus with the use of several devices has been reported, with mixed results. We present a case of Takayasu's arteritis with thrombotic occlusion of the subclavian artery in which pulsed urokinase injection and suction thrombectomy were used to revascularize a threatened limb and to establish the sole arterial supply to the brain.

Bilateral cerebral venous angioma associated with varices: a case report and review of the literature.

A varix occurring with a cerebral venous angioma is a rare combination of cerebral vascular malformations. The most common vascular anomaly associated with a venous angioma is a cavernous angioma. We report a case of bilateral supratentorial venous angioma with 2 varices involving the angioma situated on the right frontotemporal region. Multiple subependymal veins were seen in the right supratentorial region, which joined to form multiple collector veins, which, in turn, unified into a tortuous channel in the region of the sylvian fissure and continued into venous varices.

Errata Corrige. Interv Neuroradiol 11: 241-246, 2005. Cerebral Arteriovenous Malformation Embolized through Persistent Primitive Hypoglossal Artery. A Case Report.

SUMMARY: Carotid-vertebral anastomoses are commonly detected as incidental findings. But sometimes these channels are important for the clinical condition of the patient. Here a case of right thalamo-capsular arteriovenous malformation is described where a persistent primitive hypoglossal artery was the only route for embolization of the arteriovenous malformation.