Co-registration of Intravascular Ultrasound With Angiographic Imaging for Carotid Artery Disease.

BACKGROUND: Intravascular ultrasound (IVUS) provides endoluminal views and cross-sectional images of carotid arteries but lacks overview of vascular territory provided by angiography. Co-registration of IVUS with angiographic images may provide the potential to navigate both imaging modalities in a synchronous manner. The objective of this study is to evaluate the feasibility and accuracy of co-registering both imaging modalities in the carotid vasculature of the neck. METHODS: Fourteen patients with 15 cervical carotid artery lesions underwent angiography and subsequent treatment. In each case, an IVUS catheter was advanced to the target lesion and a reference angiography sequence was acquired. This was followed by an electrocardiography-triggered fluoroscopy sequence that was initiated upon IVUS catheter pullback. IVUS data collected during pullback were registered with fluoroscopy and evaluated for error and clinical usability. RESULTS: A total of 32 landmarks were identified that demonstrated reasonable agreement during IVUS-angiography co-registration. There was a mean registration error distance of 3.36 mm (SD 2.82 mm) between targets. The longitudinal extent and severity of the disease through the target segment could be easily evaluated after co-registration. CONCLUSION: Semiautomatic tracking and co-registration of angiography and IVUS is a new technology and has the potential to increase the use of IVUS in carotid disease and to proivde the opportunity to optimize procedural outcomes.

Importance of Driving and Potential Impact of Driving Cessation for Rural and Urban Older Adults.

PURPOSE: Analyses compared older drivers from urban, suburban, and rural areas on perceived importance of continuing to drive and potential impact that driving cessation would have on what they want and need to do. METHODS: The AAA LongROAD Study is a prospective study of driving behaviors, patterns, and outcomes of older adults. A cohort of 2,990 women and men 65-79 years of age was recruited during 2015-2017 from health systems or primary care practices near 5 study sites in different parts of the United States. Participants were classified as living in urban, surburban, or rural areas and were asked to rate the importance of driving and potential impact of driving cessation. Logistic regression models adjusted for sociodemographic and driving-related characteristics. FINDINGS: The percentages of older drivers rating driving as "completely important" were 76.9%, 79.0%, and 83.8% for urban, suburban, and rural drivers, respectively (P = .009). The rural drivers were also most likely to indicate driving cessation would have a high impact on what they want or need to do (P < .001). After adjustment for sociodemographic and driving-related characteristics, there was a 2-fold difference for rural versus urban older drivers in odds that driving cessation would have a high impact on what they need to do (OR = 2.03; 95% CI: 1.60-2.58). CONCLUSIONS: Older drivers from rural areas were more likely to rate driving as highly important and the prospect of driving cessation as very impactful. Strategies to enhance both the ability to drive safely and the accessibility of alternative sources of transportation may be especially important for older rural adults.

Surgical management of spontaneous cerebrospinal fistulas and encephaloceles of the temporal bone.

OBJECTIVES/HYPOTHESIS: To describe the presentation, surgical findings, and outcomes in patients with spontaneous temporal bone cerebrospinal fluid (CSF) fistulas and encephaloceles. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective chart review of patients treated for a spontaneous temporal bone CSF fistula and/or encephalocele over a 10-year period was performed. Data recorded included demographic information, presenting signs and symptoms, radiographic and laboratory studies, surgical approach, materials used for repair, surgical complications, and successful closure of the CSF fistula. RESULTS: Fifty patients were identified. Five patients underwent bilateral procedures, for a total of 55 surgical repairs. Thirty-seven of the patients were female, with a mean age of 57.2 years. Seventy percent of patients were obese, with a mean body mass index of 35.0 kg/m2 . The most common presentation was tympanostomy tube otorrhea (68%). Seven patients (14%) presented with meningitis. The middle fossa craniotomy approach was used in 87.3% of cases. Hydroxyapatite bone cement was used in 82.4% of cases. There were four surgical complications: seizure, mastoid infection, tympanic membrane retraction, and a delayed subdural hematoma. There were five persistent or recurrent CSF fistulas that underwent successful revision surgery. CONCLUSIONS: Spontaneous CSF fistulas are most common in obese females and should be suspected with a chronic middle ear effusion, persistent otorrhea after tympanostomy tube placement, or in patients with a history of meningitis. The middle fossa craniotomy approach with the use of hydroxyapatite bone cement has a high success rate with a low incidence of postoperative complications. LEVEL OF EVIDENCE: 4 Laryngoscope, 128:2170-2177, 2018.

Image-Guided Internal Fixation of an Oblique Sagittal Split Fracture of C1 Lateral Mass with Motion Preservation: A Technical Report.

A sagittal split fracture of the C1 lateral mass is an unstable subtype of C1 fractures and has a high propensity for developing late deformities and pain with nonoperative management. A primary internal fixation of this type of fracture has been recently described with good clinical outcomes and preservation of motion. We present a modified technique of primary internal fixation using an obliquely inserted C1 lag screw with imaging guidance. We successfully treated a 55-year-old woman with a unilateral C1 oblique sagittal split fracture who failed nonoperative management. Technical nuances are discussed with a review of pertinent literature.

Bilateral Thalamic Edema from Coexisting Choroid Plexus Arteriovenous Malformation and Sinus Thrombosis: Case Report.

Bilateral thalamic dysfunction secondary to venous congestion may result from either venous sinus thrombosis or high flow arteriovenous malformations or a combination of both. We present a case of bilateral thalamic edema resulting from concomitant choroid plexus arteriovenous malformation (AVM) and straight sinus thrombosis and describe our treatment approach. The patient presented with several weeks of progressive confusion and memory deficits. Magnetic resonance imaging and venography (MRI/ MRV) showed bilateral thalamic T2 hyperintensities and straight sinus thrombosis. Subsequent cerebral angiography revealed a choroid plexus AVM within the right lateral ventricle. The patient underwent surgical resection of the AVM resulting in postoperative resolution of bilateral thalamic edema on MRI and improvement of his confusion and memory deficits. This case demonstrates a rare example of reversible bilateral thalamic edema secondary to venous hypertension from both an AVM and sinus occlusion after appropriate treatment of the AVM.

Presence of the hyperintense acute reperfusion marker on MRI after mechanical thrombectomy for large vessel occlusion is associated with worse early neurological recovery.

BACKGROUND: Mechanical thrombectomy has become the accepted treatment for large vessel occlusion in acute ischemic stroke. Unfortunately, a large cohort of patients do not achieve functional independence with treatment, even though the results are more robust than with medical management. The hyperintense acute reperfusion marker (HARM) on MRI is an indication of the breakdown of the blood-brain barrier and reperfusion injury. OBJECTIVE: To examine the hypothesis that the presence of HARM on MRI correlates with worse neurological recovery after reperfusion therapy. METHODS: We retrospectively reviewed 35 consecutive patients who between February 24, 2016 and April 23, 2016 underwent MRI to determine the presence of HARM after thrombectomy for anterior circulation large vessel occlusion. Demographic, radiographic imaging, and outcome data were collected. Univariate and binary logistic regression models were performed to assess predictors for improvement of the National Institutes of Health Stroke Scale (NIHSS) score by ≥8 points at 24 hours. RESULTS: The 35 patients studied had an average age of 64±14 years of age with a median NIHSS score of 15 (IQR 9-20). Eighteen patients (51%) were found to have a HARM-positive MRI. In univariate analysis, patients with HARM were older, had lower reperfusion rates and more postprocedural hemorrhages. In binary logistic regression modeling, the absence of HARM was independently associated with a ≥8-point NIHSS score improvement at 24 hours (OR=7.14, 95% CI 1.22 to 41.67). CONCLUSIONS: This preliminary analysis shows that the presence of HARM may be linked to worse neurological recovery 24 hours after thrombectomy. Reperfusion injury may affect the number of patients achieving functional independence after treatment.

Bilateral Thalamic Edema from Coexisting Choroid Plexus Arteriovenous Malformation and Sinus Thrombosis: Case Report.

Bilateral thalamic dysfunction secondary to venous congestion may result from either venous sinus thrombosis or high flow arteriovenous malformations or a combination of both. We present a case of bilateral thalamic edema resulting from concomitant choroid plexus arteriovenous malformation (AVM) and straight sinus thrombosis and describe our treatment approach. The patient presented with several weeks of progressive confusion and memory deficits. Magnetic resonance imaging and venography (MRI/ MRV) showed bilateral thalamic T2 hyperintensities and straight sinus thrombosis. Subsequent cerebral angiography revealed a choroid plexus AVM within the right lateral ventricle. The patient underwent surgical resection of the AVM resulting in postoperative resolution of bilateral thalamic edema on MRI and improvement of his confusion and memory deficits. This case demonstrates a rare example of reversible bilateral thalamic edema secondary to venous hypertension from both an AVM and sinus occlusion after appropriate treatment of the AVM.

Progressive Deconstruction of a Distal Posterior Cerebral Artery Aneurysm Using Competitive Flow Diversion.

Progressive deconstruction is an endovascular technique for aneurysm treatment that utilizes flow diverting stents to promote progressive thrombosis by diverting blood flow away from the aneurysm's parent vessel. While the aneurysm thromboses, collateral blood vessels develop over time to avoid infarction that can often accompany acute parent vessel occlusion. We report a 37-year-old woman with a left distal posterior cerebral artery aneurysm that was successfully treated with this strategy. The concept and rationale of progressive deconstruction are discussed in detail.

Severe hemiparesis as a prehospital tool to triage stroke severity: a pilot study to assess diagnostic accuracy and treatment times.

INTRODUCTION: With the publication of the recent trials showing the tremendous benefits of mechanical thrombectomy, opportunities exist to refine prehospital processes to identify patients with larger stroke syndromes. MATERIALS AND METHODS: We retrospectively reviewed consecutive patients who were brought via scene flight from rural parts of the region to our institution, from December 1, 2014 to June 5, 2015, with severe hemiparesis or hemiplegia. We assessed the accuracy of the diagnosis of stroke and the number of patients requiring endovascular therapy. Moreover, we reviewed the times along the pathway of patients who were treated with endovascular therapy. RESULTS: 45 patients were brought via helicopter from the field to our institution. 27 (60%) patients were diagnosed with an ischemic stroke. Of these, 12 (26.7%) were treated with mechanical thrombectomy and 6 (13.3%) with intravenous tissue plasminogen activator alone. An additional three patients required embolization procedures for either a dural arteriovenous fistula or cerebral aneurysm. Thus a total of 15 (33%) patients received an endovascular procedure and 21/45 (46.7%) received an acute treatment. For patients treated with thrombectomy, the median time from first medical contact to groin puncture was 101 min, with 8 of the 12 patients (66.7%) being discharged to home. CONCLUSIONS: We have presented a pilot study showing that severe hemiparesis or hemiplegia may be a reasonable prehospital tool in recognizing patients requiring endovascular treatment. Patients being identified earlier may be treated faster and potentially improve outcomes. Further prospective controlled studies are required to assess the impact on outcomes and cost effectiveness using this methodology.

Use of flow-diverting stents as salvage treatment following failed stent-assisted embolization of intracranial aneurysms.

Flow-diverting stents, including the Pipeline embolization device (PED) and Silk, have been beneficial in the treatment of aneurysms previously unable to be approached via endovascular techniques. Recurrent aneurysms for which stent-assisted embolization has failed are a therapeutic challenge, given the existing intraluminal construct with continued blood flow into the aneurysm. We report our experience using flow-diverting stents in the repair of 25 aneurysms for which stent-assisted embolization had failed. Nineteen (76%) of these aneurysms at the 12-month follow-up showed improved Raymond class occlusion, with 38% being completely occluded, and all aneurysms demonstrated decreased filling. One patient developed a moderate permanent neurologic deficit. Appropriate stent sizing, proximal and distal construct coverage, and preventing flow diverter deployment between the previously deployed stent struts are important considerations to ensure wall apposition and prevention of endoleak. Flow diverters are shown to be a reasonable option for treating previously stented recurrent cerebral aneurysms.

Magnetic resonance imaging characteristics of typical and atypical/anaplastic meningiomas - Case series and literature review.

OBJECTIVE: The histologic grades of meningiomas have a significant impact on the risk of recurrence, prognosis, and the need for adjuvant treatment such as radiation therapy. The purpose of this study is to investigate the magnetic resonance imaging (MRI) characteristics of typical and atypical/anaplastic meningiomas. METHODS: The medical records of 32 consecutive patients who underwent meningioma resections between April 2004 and November 2006 were retrospectively reviewed. Preoperative MR studies were reviewed by board-certified neuroradiologists. Both univariate and multivariate analyses were used to analyze the MR characteristics of the typical and atypical/anaplastic meningiomas. A review of pertinent literature was also conducted. RESULTS: Thirty-two patients were identified during the study period. Histopathologic examination of the surgical specimens revealed 27 (84.4% - Group I) typical meningiomas and 5 (15.6% - Group 2) atypical/anaplastic meningiomas. The chi-square test showed that restricted diffusion was much more likely to be present in Group 2 (p < 0.01), and the choline-to-creatinine (Cho/Cr) ratio was significantly higher in Group 2 (8.8 vs. 5.1, p = 0.01). The multivariate analysis confirmed that the atypical/anaplastic group is much more likely to have restricted diffusion (p = 0.02) and higher Cho/Cr ratios (p = 0.03). CONCLUSION: Meningiomas with restricted diffusion and higher Cho/Cr ratio on MR spectroscopy are more likely to be atypical/anaplastic types. Preoperative MRI utilizing these sequences can provide important information which can be valuable to counsel patients regarding prognosis, risk of recurrence and the need for adjuvant radiation in addition to surgical resection.

"Contrast-less" stent-assisted coiling of an A1 aneurysm.

BACKGROUND: Iodine-based contrast medium used in diagnostic and therapeutic cerebrovascular imaging may cause renal toxicity, especially in patients with underlying renal impairment. Contrast dilution may impede efforts of the neurointerventionalist to treat intracranial vascular pathology. METHODS: A 36-year-old man with renal impairment presented with an unruptured A1 segment anterior cerebral artery aneurysm. Previously obtained magnetic resonance angiography was fused with intraoperative noncontrast computed tomography and live 2-dimensional fluoroscopic images. The aneurysm was successfully treated with stent-assisted coil embolization without the use of contrast. RESULTS: Neurointervention without contrast was feasible, and although the presented case is one example, the imaging fusion techniques used in this case can substantially decrease the exposure to contrast and subsequent risk of renal injury during intracranial procedures. CONCLUSIONS: Further development of and experience with this technique is needed to improve its safety and efficacy.

PKCδ regulates hepatic triglyceride accumulation and insulin signaling in Lepr(db/db) mice.

PKCδ has been linked to key pathophysiological features of non-alcoholic fatty liver disease (NAFLD). Yet, our knowledge of PKCδ's role in NAFLD development and progression in obese models is limited. PKCδ(-/-)/Lepr(db)(/)(db) mice were generated to evaluate key pathophysiological features of NAFLD in mice. Hepatic histology, oxidative stress, apoptosis, gene expression, insulin signaling, and serum parameters were analyzed in Lepr(db)(/)(db) and PKCδ(-/-)/Lepr(db)(/)(db) mice. The absence of PKCδ did not abrogate the development of obesity in Lepr(db)(/)(db) mice. In contrast, serum triglyceride levels and epididymal white adipose tissue weight normalized to body weight were reduced in PKCδ(-/-)/Lepr(db)(/)(db) mice compared Lepr(db)(/)(db) mice. Analysis of insulin signaling in mice revealed that hepatic Akt and GSK3ß phosphorylation were strongly stimulated by insulin in PKCδ(-/-)/Lepr(db)(/)(db) compared Lepr(db)(/)(db) mice. PKCδ may be involved in the development of obesity-associated NAFLD by regulating hepatic lipid metabolism and insulin signaling.

Y-stent-assisted coil embolization of cerebral aneurysms.

Y-stent-assisted coiling is a technique used by neuroendovascular surgeons to treat complex, wide-necked, bifurcation aneurysms in locations such as basilar tip and middle cerebral artery bifurcation. Several recent studies have demonstrated low complication rate and favorable clinical and angiographic outcomes. The Y-stent technique is illustrated here in detail and the intraoperative nuances are also discussed to minimize potential complications associated with technique. The video can be found here: http://youtu.be/77pEmqx_fyQ .

Endovascular transarterial embolization of cerebral arteriovenous malformation with ethylene-vinyl alcohol copolymer.

Cerebral arteriovenous malformations (AVMs) have an estimated 2-4% annual risk of hemorrhage. Treatment options for AVMs include microsurgical resection, stereotactic radiosurgery, and endovascular embolization. As endovascular technology and techniques continue to advance and mature, endovascular embolization is becoming an increasingly vital component of AVM treatment not only as a presurgical treatment to reduce microsurgical risks, but also as a stand-alone curative method in some cases. This case illustrates the successful and curative transarterial embolization of a right frontal AVM in a 17-year-old boy with ethylene-vinyl alcohol copolymer (Onyx). The video can be found here: http://youtu.be/L4hE1MvCZCY .

Manual Aspiration Technique to Retrieve a Prematurely Detached Coil during Cerebral Aneurysm Embolization.

Coil herniation, premature deployment, and fracture are procedure associated complications of endovascular aneurysm embolization that optimally necessitate coil retrieval when feasible. Several published techniques describe different strategies for managing coil complications including various snare retrieval devices, alligator retrieval devices, stent fixation, and open surgical resection of coils when distal blood flow is compromised. We report a novel technique employed to retrieve a prematurely detached coil during an aneurysm embolization using a syringe fixed to the microcatheter to carefully aspirate a loose coil with direct fluoroscopic visualization. This technique can only be utilized in the circumstance where the proximal end of the coil remains in the microcatheter. Conventional techniques of coil retrieval and stenting are discussed and compared to the rational for using the manual aspiration technique.

The "Spot Sign" secondary to a ruptured lenticulostriate artery aneurysm.

The "Spot Sign" is a well-recognized radiographic predictor for hematoma expansion in patients with intracerebral hemorrhages. Although the exact underlying pathophysiology is unknown, it is generally assumed to be the site of blood vessel rupture and contrast extravasation. We report a case of an 81-year-old man who presented with right basal ganglia hemorrhage and the "Spot Sign" on computed tomography angiography. Conventional angiography subsequently revealed a lenticulostriate artery aneurysm within the hematoma, which was treated with surgical clipping. This case demonstrates that rare entities such as lenticulostriate aneurysms must be kept in the differential diagnoses in order to optimize patient management and improve clinical outcome.

Lipid metabolism, oxidative stress and cell death are regulated by PKC delta in a dietary model of nonalcoholic steatohepatitis.

Steatosis, oxidative stress, and apoptosis underlie the development of nonalcoholic steatohepatitis (NASH). Protein kinase C delta (PKCδ) has been implicated in fatty liver disease and is activated in the methionine and choline-deficient (MCD) diet model of NASH, yet its pathophysiological importance towards steatohepatitis progression is uncertain. We therefore addressed the role of PKCδ in the development of steatosis, inflammation, oxidative stress, apoptosis, and fibrosis in an animal model of NASH. We fed PKCδ(-/-) mice and wildtype littermates a control or MCD diet. PKCδ(-/-) primary hepatocytes were used to evaluate the direct effects of fatty acids on hepatocyte lipid metabolism gene expression. A reduction in hepatic steatosis and triglyceride levels were observed between wildtype and PKCδ(-/-) mice fed the MCD diet. The hepatic expression of key regulators of ß-oxidation and plasma triglyceride metabolism was significantly reduced in PKCδ(-/-) mice and changes in serum triglyceride were blocked in PKCδ(-/-) mice. MCD diet-induced hepatic oxidative stress and hepatocyte apoptosis were reduced in PKCδ(-/-) mice. MCD diet-induced NADPH oxidase activity and p47(phox) membrane translocation were blunted and blocked, respectively, in PKCδ(-/-) mice. Expression of pro-apoptotic genes and caspase 3 and 9 cleavage in the liver of MCD diet fed PKCδ(-/-) mice were blunted and blocked, respectively. Surprisingly, no differences in MCD diet-induced fibrosis or pro-fibrotic gene expression were observed in 8 week MCD diet fed PKCδ(-/-) mice. Our results suggest that PKCδ plays a role in key pathological features of fatty liver disease but not ultimately in fibrosis in the MCD diet model of NASH.

Central skull base osteomyelitis: an emerging clinical entity.

OBJECTIVES/HYPOTHESIS: Skull base osteomyelitis (SBO) most commonly results as a complication of otitis externa in diabetic patients. Central or atypical presentations, unrelated to aural pathology, have been documented, though restricted to small patient series or case reports. The current study systematically analyzed the literature to construct the clinical profile of this rare entity. STUDY DESIGN: Systematic review of case series. METHODS: The MEDLINE database was searched for all published cases of central SBO. Four additional cases were included from the University of Texas Southwestern Medical Center. Statistical analysis was performed to identify trends affecting overall outcomes or differences in treatment. RESULTS: A total of 42 cases were included with mean age of 52 years and male:female ratio of 2.2:1. The most common presenting symptoms were headaches and cranial nerve palsies, including VI (31%), IX (29%), and X (29%). Staphylococcus aureus (21%) and Pseudomonas aeruginosa (19%) were the two most common causative pathogens. The mean duration of antimicrobial therapy was 21 weeks, with 55% requiring intravenous antibiotics for a mean duration of 6.9 weeks. Twenty of 42 patients (48%) received surgical biopsy for diagnosis, whereas 18 patients (43%) required adjunct surgical debridement. Women were more likely than men to require multiple courses of therapy (46% vs. 7%, P = .01). The overall mortality was 9.5%, with an additional 31% experiencing residual neurological dysfunction. CONCLUSIONS: Osteomyelitis of the central skull base poses significant challenges for timely and accurate diagnosis. Aggressive management with antimicrobials, coupled with surgical debridement in select cases, may avoid serious neurologic morbidity and mortality.

Progressive deconstruction: a novel aneurysm treatment using the pipeline embolization device for competitive flow diversion: case report.

BACKGROUND AND IMPORTANCE: A variety of deconstructive and reconstructive therapies have been used to treat intracranial aneurysms. The Pipeline embolization device (PED) has become a quite successful option to treat aneurysms, while reconstructing and remodeling the parent vessel. We report a case of off-label PED use, where a flow diverter was placed across the parent vessel of a giant intracranial aneurysm in a novel deconstructive strategy. CLINICAL PRESENTATION: A 40-year-old man with a giant, slow-flow aneurysm of the distal middle cerebral artery (MCA) was treated with the placement of a PED across the vessel containing the aneurysm after superselective test balloon occlusion of that vessel failed. PED was successfully deployed in a competing MCA branch across the origin of the MCA branch supplying the giant aneurysm. The patient continued dual-antiplatelet therapy for 5 months and aspirin monotherapy thereafter. Follow-up angiography, performed 6 months after treatment, demonstrated complete and asymptomatic thrombosis of the aneurysm and its parent MCA branch. A collateral pial and leptomeningeal network developed, reconstructing the distal branches of the occluded MCA branch. After 18 months, the patient remains neurologically intact. CONCLUSION: This appears to be the first description of progressive deconstruction for aneurysm treatment by using PED. Despite not tolerating acute vessel occlusion with superselective test balloon occlusion, the patient was asymptomatic following long-term occlusion with PED secondary to the growth of pial and leptomeningeal collateral networks.