Long-term Outcomes of Carotid Artery Stenting for Radiation-Associated Stenosis.

BACKGROUND: In Taiwan, the prevalence of head and neck cancer is relatively high. Because radiation-associated carotid stenosis is a significant risk factor for stroke, carotid artery stenting (CAS), instead of carotid endarterectomy, is indicated in patients with radiation-associated carotid stenosis. We sought to evaluate the effect of neck radiotherapy (XRT) on the long-term outcome of patients undergoing CAS. METHODS: From March 2001 to November 2011, 147 CAS procedures were performed on 129 patients (n = 43 for XRT, n = 86 for non-XRT). Mean follow-up was 42.7 ± 20.5 months (median: 52 months; range: 1-60 months). Duplex velocity criterion for > 50% restenosis after CAS was defined as peak systolic velocity > 175 cm/s. Endpoints included 5-year freedom from mortality, ipsilateral recurrent stroke, and major adverse cardiovascular events (MACE). RESULTS: The mean age of XRT patients was significantly lesser than that of non-XRT patients (61 ± 8 vs. 71 ± 8, p < 0.001). There was significantly less coronary artery disease and other cardiovascular co-morbidities in XRT patients. No significant differences were noted in the composite 30-day ipsilateral stroke/myocardial infarction/mortality (XRT: 8.6% vs. non-XRT: 6%, p > 0.05) and 5-year freedom from mortality, ipsilateral recurrent stroke, and MACE (p > 0.05) between the two groups. Intra-stent carotid restenosis > 50% was significantly higher in the XRT group on follow-up. CONCLUSION: Long-term outcomes of CAS for radiation-associated stenosis were not altered by a history of neck XRT, except for asymptomatic carotid restenosis.

Intra-arterial thrombolytic therapy for acute intracranial large artery occlusive disease in patients selected by magnetic resonance image.

BACKGROUND AND PURPOSE: We reported an experience of intra-arterial thrombolysis (IAT) study triaged by emergent MRI. METHODS: Patients were recruited if vascular occlusions were identified by emergent MRA. Urokinase was infused hyperselectively within 6h after onset to a maximum dose of 900,000IU or recanalization achieved with mechanical thrombus disruption. Heparin infusion was discontinued after 2 hemorrhage in the first 7 patients. TIMI grade 2 and 3 recanalization was recognized as successful. Favorable outcomes were mRS 0-3 at 3months. RESULTS: Among 4225 ischemic stroke patients during the 29months study period, 52 patients met the inclusion criteria with 49 screened by MRA and 3 screened by CT, 30 patients were enrolled and 25 were treated. Three patients (10%) were unable for the MRI examination due to time or equipment limit. There were 5 ICA, 13 MCA, and 7 VBA occlusions. Among 27 patients screened from MRA, 25 patients had the same occluded vessels and 2 patients had compatible occluded vessels confirmed by cerebral angiography. The median NIHSS was 26 and median time from symptom onset to IAT was 283min. Successful recanalization was achieved in 68% (17/25). Intracerebral hemorrhage was recognized as symptomatic in 3 (12%) and asymptomatic in 8 (32%) at 3months. Mortality was 32%. 36% patients had a mRS of 0-3 at 3months. Patients with lower initial NIHSS score (20.9 vs. 28.4, P=0.02) and MCA occlusions (69.3%, 9/13, P<0.001) tend to have favorable outcomes. CONCLUSIONS: Though the incidence was low, IAT triage with emergent MRI appeared to be feasible. MRI screening might be incorporated in the future IAT studies. Mechanical thrombus disruption and heparin infusion in IAT might need further investigation in this area.

Comparison of carotid artery stenting performance between cardiologists and neuroradiologists: one medical center's experience.

PURPOSE: To report the experience of carotid artery angioplasty with stenting (CAS) by cardiologists (CV) and neuroradiologists (NR) in an area with less incidence of extracranial artery stenosis. METHODS: From 1999 to 2008, 210 patients with 231 stents were collected by claim records from the administrative office and reviewed by one independent neurologist. Outcome measures were peri-procedural adverse events (AE), restenosis and recurrent ipsilateral stroke (RS) rate, categorized into treatment groups by either CV or NR. RESULTS: The average age was 69.0 years and 82.9 % of the patients were men. 63.8% of the patients with 62.8% stents were treated by CV and the remaining 36.2% of patients with 37.2% stents were done by NR. Symptomatic CAS was evident in 70.1% of the CV cases and 83.0% in NR treated patients (P = 0.017). The peri-procedural AE rate was 31.6%; 35.9% in CV group and 24.4% in the NR group (P = 0.071). RS rate was 4.8% in 663.3 days; 4.1% in 920.8 days in the CV group and 5.8% in 354.2 days in the NR group (P = 0.865). The restenosis rate was 10.9% in 630.5 days; 5.4% in the CV group in 224.8 days and 20.6% in the NR group in 817.8 days (P = 0.007). CONCLUSIONS: The restenosis and recurrent stroke rates after carotid artery stenting in Taiwan appears to be consistent with other published and well organized trials. Measures to minimize peri-procedural AR rates are definitely warranted.

Effect of lipid-lowering therapy on the progression of intracranial arterial stenosis.

OBJECTIVES: Intracranial arterial stenosis (IAS) is a severe disease with a high recurrent stroke rate even under the best medical treatment. Statins have been demonstrated to prevent stroke and to slow or halt atherosclerosis progression. This study was performed to observe the effect of atorvastatin on the progression of IAS, explore the factors associated with atherosclerosis regression and the recurrent rate of stroke. METHODS: A hospital-base observation study enrolled 40 stroke patients with middle cerebral artery (MCA) or/and basilar artery (BA) stenosis. All participants had hyperlipidemia and were given atorvastatin 40 mg per day for at least six months. IAS was assessed by magnetic resonance angiogram (MRA) at the time of enrollment and then at least six months later. The primary outcome was the progression of IAS. All patients were also given antiplatelet agents for stroke prevention. RESULTS: At the end of the study, 23 (58 %), 15 (38 %) and 2 (4 %) patients had regressed, stationary and progressed IAS, respectively. Females were likely to have regressed IAS. The recurrent stroke rate was 18 %. Among the 54 stenotic vessels, 29 (54 %) vessels were assessed as improvement in stenosis. CONCLUSION: Compared with other studies, more regressed, stationary IAS and less progressed IAS were found in our study. Female gender was likely to have regressed IAS after statin treatment. Further clinical outcome trials are required to assess the effects of such therapy on morbidity and mortality in this particular group of patients.

Combination of olfactory course anterior cerebral artery and accessory middle cerebral artery (MCA) with occluded in situ MCA and related moyamoya phenomenon.

We describe a rare case of congenital persistence of a primitive olfactory anterior cerebral artery in association with an ipsilateral accessory middle cerebral artery. The normally and anatomically positioned, or in situ, middle cerebral artery was occluded. This, along with a well-developed anastomotic network of lenticulostriate artery domains and leptomeningeal collaterals suggested a moyamoya phenomenon. To our knowledge, ours is the first report of this anatomic variant and the altered conventional vascular territories of supply.

Transient contrast encephalopathy after carotid artery stenting mimicking diffuse subarachnoid hemorrhage: a case report.

Several types of brain injury incurred during carotid artery stenting (CAS), such as embolic injury, hemodynamic events, and hemorrhage. Rapid differential diagnosis is important for decision making, and may help to avoid subsequent complications. Here, we describe a case with severe triple vessel coronary artery disease, who underwent right coronary artery (RCA) stenting and ad hoc left CAS. Patient developed neurological deficit two hours after the procedure. Brain computed tomography (CT) revealed diffuse cortical enhancement similar to subarachnoid hemorrhage (SAH). Patient recovered dramatically with complete resolution of contrast enhancement after four days of conservative treatment, final diagnosis was a rare reported case of transient contrast encephalopathy.

Factors associated with brainstem congestive encephalopathy in dural arterio-venous fistulas.

OBJECTIVES: Cranial dural arterio-venous fistulas (DAVFs) are unique neuro-vascular entities that represent 10-15% of all intra-cranial arterio-venous lesions. This study describes the clinical characteristics and neuro-imaging findings of patients with posterior fossa DAVFs. METHODS: Twenty adult patients with posterior fossa DAVFs were enrolled in this 5-year retrospective study. The clinical details of seven patients with venous congestive encephalopathy are described, and patients with and those without brainstem encephalopathy were compared. RESULTS: Seven of 20 patients (35%) had brainstem venous congestive encephalopathy complicating the posterior fossa DAVFs. Patients with aggressive clinical symptomatology, aggressive Borden or Cognard classifications, and anterior venous draining patterns had higher risks of brainstem venous congestive encephalopathy. In terms of Glasgow outcome scale, one patient had moderate disabilities, five had severe disabilities, and one expired. CONCLUSIONS: Although most patients had good Glasgow coma scores with varying degrees of clinical symptoms on admission, those with brainstem venous congestive encephalopathy had poor outcomes despite full resolution of the cortical vein reflux.

Cerebellar hemorrhage and subsequent venous infarction followed by incomplete transvenous embolization of dural carotid cavernous fistulas: a rare complication: case report.

Endovascular therapy for dural carotid cavernous fistulas (CCFs) is generally accepted to be safe and effective. The authors report a rare complication of hemorrhage and subsequent venous infarcts of the pons and cerebellum after transvenous embolization. This 41-year-old man presented with a severe left frontal headache, congestion of the left conjunctiva, blurred vision, and photophobia. Cerebral angiography demonstrated a right dural CCF. The patient underwent transvenous embolization of the cavernous sinus but had the initial complication of cerebellar hemorrhage. One month later, he developed progressive dizziness, ataxia, and right-sided weakness. Magnetic resonance imaging revealed severe cerebellar and pontine edema. The cause was a residual fistula combined with delayed occlusion of the inferior petrosal sinus. The fistula was obliterated after repeated embolizations. The patient's symptoms gradually resolved, and there was no evidence of recurrence during the 4-year follow-up period. Incomplete transvenous embolization of a dural CCF can result in life-threatening vascular complications due to redistribution of shunt flow. Early recognition of redistributed drainage and preventive placement of coils at the origin of draining veins during the procedure could avert this rare complication.

Refractures in cemented vertebrae after percutaneous vertebroplasty: a retrospective analysis.

Percutaneous vertebroplasty is an efficient procedure to treat pain due to osteoporotic vertebral compression fractures. However, refracture of cemented vertebrae occurs occasionally after vertebroplasty. It is unclear whether such fractures are procedure-related or part of the natural course of osteoporosis. The effect of potentially important covariates on refracture risk in cemented vertebrae has not been evaluated previously. We retrospectively analyzed the incidence and possible causative mechanism of refracture in patients who had received only one vertebroplasty for a single level of vertebral compression fracture. We assessed the following covariates: age, sex, body weight, height, lumbar spine bone mineral density, treated vertebral level, pre-existing untreated vertebral compression fracture, and gas-containing vertebrae before treatment. Surgical variables, including surgical approach, cement injected, and anterior vertebral height restoration, were also analyzed. Anti-osteoporotic treatment after surgery was recorded. Multiple logistic regression analysis was used to determine the relative risk of refractures of cemented vertebrae. Over all, 98 patients were evaluated with a mean follow-up of 26.9 +/- 12.4 months (range, 7-55 months). We identified 62 refractures and the mean loss of anterior vertebral height was 13.3% (range 3.2-40.3%). The greater the anterior vertebral height obtained from vertebroplasty, the greater the risk of refracture occurring (P < 0.01). Gas-containing vertebrae were also prone to refracture after the procedure (P = 0.01). Anti-osteoporotic treatment was of borderline significance between refractured and non-refractured vertebrae (P = 0.07). Only restoration of anterior vertebral height was positively associated with refracture during the follow-ups (P < 0.01). In conclusion, refractures of cemented vertebrae after vertebroplasty occurred in 63% of osteoporotic patients. Significant anterior vertebral height restoration increases the risk of subsequent fracture in cemented vertebrae.

Rapid regrowth of a successfully coiled traumatic pericallosal aneurysm.

Regrowth of an intracranial aneurysm is a known complication of endovascular coiling. We report a patient with a traumatic pericallosal aneurysm which was initially treated successfully with endovascular coiling. Six-month follow-up angiography showed aneurysm regrowth with migration of the coils. To our knowledge, recurrence of a coiled pericallosal aneurysm of traumatic etiology has not been previously reported. Endovascular coiling may not be the best primary treatment for traumatic pericallosal artery aneurysms.

Multiple intracranial arterial stenoses in association with thyrotoxicosis: a case report.

A 26-year-old young man, had Graves' disease in hyperthyroid state, presented with frequent episodic transient left hemiparesis and mild slurred speech lasting for few minutes to 2 hours for one month. Infarction at posterior limb of right internal capsule was found on brain MRI. Angiography revealed multiple intracranial arteries stenoses around the circle of Willis. After treatment with propylthiouracil and aspirin, his thyroid function returned to normal and the patient remained free from stroke.

Severe acute respiratory syndrome: prognostic implications of chest radiographic findings in 52 patients.

PURPOSE: To retrospectively assess prognostic implications of radiographic findings in severe acute respiratory syndrome (SARS). MATERIALS AND METHODS: Radiographic findings were reviewed by two radiologists for 52 patients with SARS. On each radiograph, each lung was separated into upper, middle, and lower zones. A four-point scale was used to score extent of SARS-related lesions in each zone; points from all zones were added for a cumulative score. Patient sex, age, comorbidities, duration of developing lesions, lesion score for each radiograph, need for mechanical ventilation, and percentage of lung affected were compared between patients who died (n = 20) and survivors (n = 32). Continuous and categorical variables were analyzed with Mann-Whitney test and Fisher exact or chi(2) test, respectively. RESULTS: Survival and mortality groups showed no significant differences with respect to patient sex, duration of SARS-related lesions, development of lesion shifting, and acute respiratory distress syndrome. Patients who died were significantly older (mean +/- standard deviation, 56.9 years +/- 17.2 vs 40.4 years +/- 16.6; P =.002) and had higher frequency of comorbid lung illnesses (nine of 20 vs two of 32, P =.001), maximal lesion extent score of 7 or higher (20 of 20 vs five of 32, P <.001), involvement of four or more lung zones (17 of 20 vs four of 32, P <.001), bilateral lung involvement (19 of 20 vs 14 of 32, P <.001), need for mechanical ventilation (18 of 20 vs two of 32, P <.001), and higher percentage of affected areas (41.5% +/- 8.6 vs 16.4% +/- 10.0, P <.001) than those of survivors. CONCLUSION: On chest radiographs, maximal SARS-related lesion extent score of 7 or higher is a strong predictor of mortality, especially in patients with comorbid lung illnesses and involvement of four or more lung zones.

Trauma-induced ascending pharyngeal artery-internal jugular vein fistula: case report.

BACKGROUND: Ascending pharyngeal artery-internal jugular vein fistulas are rare. Only 2 spontaneous cases and one complicated neck surgery have been reported. We describe a trauma-induced case. CASE DESCRIPTION: A 31-year-old man presented left-sided tinnitus and a pulsating bruit for 5 months after head trauma. Cerebral angiography demonstrated a fistula between the left ascending pharyngeal artery and left internal jugular vein. Embolization of the fistula was performed using platinum fibrous microcoils. CONCLUSIONS: This case and a review of the literature illustrate the causes, manifestations, image studies, and treatment for a fistula between the ascending pharyngeal artery and internal jugular vein.

Development of intracranial complications following transoral stab wounds in children. Report of two cases.

Sharp penetrating trauma to the skull and brain is uncommon in children. The related pediatric literature consists mainly of cases involving penetrating stab wounds to the face or scalp resulting from assaults or accidents. Herein, we present two cases of perioral intracranial penetration. The first case was a 2-year-old boy who presented with septic complications and developed a brain abscess. The second case was a 2-year-old girl who presented with a subarachnoid hemorrhage and developed a traumatic pericallosal artery aneurysm. After craniotomy and clipping, both patients made a satisfactory recovery. A high index of suspicion, liberal use of neuroimaging and early operative intervention are important points in the successful management of such cases.