Distinctive patterns of sequential platelet counts following blunt traumatic brain injury predict outcomes.

OBJECTIVE: To determine the role of platelet counts in the context of the decision to treat patients with non-compounded, non-surgically-treated blunt traumatic brain injury (NCNS-bTBI) with anticoagulants/antiaggregants. METHODS: A retrospective analysis of 141 anticoagulants/antiaggregants-naïve patients with NCNS-bTBI. Changes in PT-INR and prolonged aPTT were examined and correlated with Marshall and Rotterdam scores, clinical and neuroradiological outcomes. RESULTS: Three groups of platelet counts were identified. Group 1 (83% of patients) had normal platelet counts (150,000-450,000 platelets/mm3) from admission to discharge. Group 2 (13%) developed transient thrombocytopenia (<150,000 platelets/mm3) 2-3 days post-trauma. Group 3 (4%) developed extreme thrombocytosis > 1,000,000/mm3 platelets 6-9 days post-trauma. Neither acute coagulopathy of trauma nor progressive hemorrhagic insults followed NCNS-bTBI. Moreover, while patients with thrombocytosis/extreme thrombocytosis presented with a worse Glasgow coma score (GCS) on admission (8.8 ± 2.9 vs. 13 ± 2, p < 0.01) and had longer hospitalization (13.5 ± 10.4 vs. 4.5 ± 2.1 days), their improvement at discharge was the highest (delta GCS, 4 ± 2.8 vs. 1.2 ± 2.1, p = 0.05). Traumatic subarachnoid hemorrhage was associated with isolated thrombocytosis and 'best improvement.' No thromboembolic or hemorrhagic complications occurred. CONCLUSION: NCNS-bTBI, thrombocytosis was correlated with better outcomes and was not associated with an increased risk for developing thromboembolism or hemorrhage, precluding the immediate need for any additional antiaggregates.

Combined treatment approach to cerebral arteriovenous malformation in pediatric patients: stereotactic radiosurgery to partially Onyx-embolized AVM.

PURPOSE: Treatment of cerebral arteriovenous malformations (AVM)-the most common cause of stroke in the pediatric population-can be challenging due to the complexity of size, morphology, and location. There is a significant risk in comparison to AVM treatment among adults. Thus, AVM treatment in the pediatric population imposes unique challenges. Recent improvements include optimized catheter techniques and better embolization materials, such as Onyx, a non-adhesive liquid embolic agent used in the adult population. These improvements have increased the success rate of total and near-total obliteration of cerebral AVM. However, the use of Onyx causes significant distortion of the MR and CT images, which must be accounted for in any radiation treatment planning predicated on CT and MRI. These image distortions impact on the actual delivered dose to the nidus and behoove heterogeneity correction. Our group has previously shared a solution for heterogeneity correction in the adult population. The purpose of this study is to show our experience in this unique group of pediatric patients. METHODS: This is a retrospective review of pediatric patients, who were undergoing combined endovascular embolization followed by SRS. The cohort consists of 14 patients undergoing SRS treatment in our institute between November 2006 and December 2012 with a mean follow-up of 49.9 months. Within this cohort, we retrospectively reviewed 12 consecutive pediatric patients who underwent a combined endovascular and SRS approach with a mean follow-up of 52.1 months and two patients receiving SRS-only treatment were excluded. RESULTS: In our cohort of 14 patients, 7 (50%) were male, with a mean age of 17.3 years (12.0-22.9) at the time of radiosurgery treatment. Mean age of beginning the combined modality treatment was 15.3 years (8.4-20). The median time from diagnosis to SRS was 24.3 months (11.1-64.4 months) in the complete cohort and 25.6 months (11.1-64.4) in the multimodality group. The overall median follow-up period was 49.9 months (range 12.8-118.8 months) in the complete cohort and 52.1 months (range 12.8-118.8 months) in the multimodality group. Eleven (78.6%) patients had at least one episode of hemorrhage prior to treatment. Spezler-Martin grades at baseline ranged from 2 to 5 (mean 3.2). Fifty percent had grade IV and V. Patients underwent a median of 2 (range 1-5) embolization procedures. The radiosurgical treatment dose to the margin of the angiography-based nidus: median prescription dose of 21.49 Gy (14.39-27.51) with a median max dose of 27.77 Gy (18.93-32.52). The median treatment volume was 0.6 cm3 (0.1-7.3 cm3). The Onyx embolization reduced the nidus target volume by a median of 66.7% (12.0-92.7%). We confirmed 10/14 (71%) complete closures. In 2/14 (14.2%) additional patients, a significant flow reduction was noted. In 1/14 (7.1%) patients, no significant change was noted during the observation period and two (14.2%) patients were without follow-up information. In two patients, post-treatment edema was noted; however, none was clinically significant and resolved without additional intervention or treatment. CONCLUSIONS: This cohort comprises the largest combined Onyx-SRS pediatric experience in the literature. In conjunction with our adult group study, we show that the use of Onyx reduces the SRS treatment target volume significantly. Importantly, we implemented the heterogeneity correction to avoid increased radiation exposure to normal surrounding brain tissue. The combined approach appears to be safe provided that the above-mentioned corrections are implemented.

Impact of Onyx Embolization on Radiosurgical Management of Cerebral Arteriovenous Malformations: Treatment and Outcome.

BACKGROUND: Stereotactic radiosurgery (SRS) is a well-established treatment modality for cerebral arteriovenous malformations (AVMs). The main limiting factor in the radiosurgical treatment of AVMs is the volume of the nidus, with high-grade lesions often requiring combined treatment to reduce the SRS target volume. To overcome this limitation, we have been using a combined treatment approach consisting of endovascular embolization with Onyx followed by SRS. OBJECTIVE: To evaluate our clinical experience for safety and feasibility of this multimodality treatment approach. METHODS: This is a retrospective review of all adult patients with cerebral AVMs who received SRS treatment to their AVM after endovascular embolization with Onyx between June 2007 and June 2014. RESULTS: Thirty-five consecutive patients were identified. The mean follow-up period was 52.4 ± 22.6 months (range 18-97 months). We confirmed 18 (51.4%) complete nidus closures at a median time of 49.5 months (range 6.5-81 months) from SRS. High-resolution Magnetic resonance imaging/magnetic resonance angiography was performed routinely in all patients until closure of the nidus. Digital subtraction angiography was performed to confirm complete obliteration in 5 of the patients (28%); 13 patients are either planned for digital subtraction angiography or have refused it. In 6 patients (17%) a significant flow reduction was noted after a mean of 32 ± 16 months. No significant improvement was observed in 9 patients (26%) during the follow-up period. Two patients were lost to follow-up. CONCLUSIONS: The multimodality treatment of cerebral AVMs using embolization with Onyx followed by SRS is feasible and safe. The use of Onyx significantly reduced the SRS treatment target volume.

Electrophysiological monitoring during preoperative angiography to guide decisions regarding permanent occlusion of major radicular arteries in patients undergoing total en bloc spondylectomy.

OBJECTIVE Preoperative embolization is performed before spine tumor surgery when significant intraoperative hemorrhage is anticipated. Occlusion of radicular and segmental arteries may result in spinal ischemia. The goal of this study was to check whether neurophysiological monitoring during preoperative angiography in patients scheduled for total en bloc spondylectomy (TES) of spine tumors improves the safety of vessel occlusion. METHODS This was a case series study of patients who underwent tumor embolization under somatosensory evoked potential (SSEP) and motor evoked potential (MEP) monitoring in preparation for TES in treating spine tumors. The angiography findings, the embolized vessels, and the results are presented. RESULTS Five patients whose ages ranged from 33 to 75 years and who had thoracic spine tumors are reported. Four patients suffered from primary tumor and 1 patient had a metastatic tumor. Radicular arteries at the tumor level, 1 level above, and 1 level below were permanently occluded when SSEPs and MEPs were preserved during temporary occlusion. No complications were encountered during or after the angiography procedure and embolization. CONCLUSIONS Temporary occlusion with electrophysiological monitoring during preoperative angiography may improve the safety of permanent radicular artery occlusion, including the artery of Adamkiewicz in patients undergoing TES for the treatment of spine tumors.

Silk flow diverter in the treatment of complex intracranial aneurysms: a single-center experience with 60 patients.

BACKGROUND: Flow diverters are used to treat complex aneurysms that are not amenable to coiling. The aim of the present work was to retrospectively evaluate our experience with the Silk flow diverter. Technical nuances and complications are specifically discussed. METHODS: Retrospectively data was collected on patients treated with Silk between October 2008 and October 2013. RESULTS: Sixty patients harboring 67 aneurysms were treated using the Silk. Fifteen aneurysms were located in the posterior circulation and 52 in the anterior. A good angiographic result was achieved in 88 % (53/60) of the aneurysms available for imaging follow-up. There were ten treatment-related complications, 80 % were ischemic. Risk of complications increased with aneurysm size and in aneurysms of the posterior circulation. CONCLUSIONS: Silk flow diverters are a good treatment option for aneurysms of the anterior circulation. Additional stents may be required in specific cases due to the Silk's low radial resistance. Treatment of giant fusiform aneurysms of the posterior circulation with Silk flow diverters is associated with a high rate of severe complications.

Spinal Dural Arteriovenous Fistula: A Review.

Spinal dural arteriovenous fistula (SDAVF) is a rare disease, the etiology of which is not entirely clear. It is the most common vascular malformation of the spinal cord, comprising 60-80 % of the cases. The clinical presentation and imaging findings may be nonspecific and misleading, often mistaking it for other entities like demyelinating or degenerative diseases of the spine.This chapter describes the imaging findings, clinical signs, and symptoms of this disease and also the available treatment options according to the current literature.Angiography is still considered the gold standard for diagnosis; however, MRI/MRA is increasingly used as a screening tool. Modern endovascular techniques are becoming increasingly more effective in treating SDAVF offering a less invasive treatment option; however, they still lag behind surgical success rates which approach 100 %. The outcome of both treatment options is similar if complete obliteration of the fistula is obtained and depends mainly on the severity of neurological dysfunction before treatment.Heightened awareness by radiologists and clinicians to this rare entity is essential to make a timely diagnosis of this treatable disease. A multidisciplinary treatment approach is required in order to make appropriate treatment decisions.

Critical appraisal of endovascular treatment of brain arteriovenous malformation using Onyx in a series of 92 consecutive patients.

BACKGROUND: The introduction of Onyx has led us to adopt a new treatment approach for brain arteriovenous malformation (AVM), using endovascular embolization with Onyx as the first line treatment with a curative intent. The aim of the present report is to evaluate our results using this strategy, with special emphasis on angiographic characteristics affecting treatment risks and success rates. METHODS: From October 2006 to December 2009, 92 consecutive patients harboring brain AVM were treated with Onyx during 177 procedures. RESULTS: Endovascular treatments were completed in 68 out of 92 patients. Median number of procedures was two. Complete obliteration using embolization exclusively was achieved in 25 patients, resulting in a 37 % cure rate in patients who concluded treatments (25/68), and 27 % in the cohort. In Spetzler-Martin grades 1 & 2 AVMs, complete obliteration was achieved in 48 % of the cases. Complete obliteration rates were significantly higher in lesions with superficial big feeding arteries. There were 15 bleeding complications during 177 embolization sessions (8.4 % per procedure); seven cases resolved in less than 3 months. Permanent disability rate was 6.5 %; mortality rate was 2.2 %. Bleeding was related to the use of the microcatheter/guidewire in six cases and to the use of the embolization material in nine, the amount of Onyx injected was significantly higher in those nine cases. CONCLUSIONS: Embolization of brain AVM using Onyx and detachable tip microcatheters results in a relatively high rate of complete obliteration. Angioarchitecture of the lesion can predict treatment success. Higher amounts of Onyx injected per session increase the bleeding risk.

Multimodal treatment of hemorrhagic pituitary metastasis as first manifestation of renal cell carcinoma.

BACKGROUND: Metastatic tumors involving the pituitary gland are very rare, with only few cases reported so far in the literature. CASE DESCRIPTION: We report a case of a man who presented with an extremely vascular hemorrhagic pituitary metastasis as the first manifestation of renal cell carcinoma. The patient was successfully treated with staged procedures, including preoperative tumor vasculature embolization followed by transsphenoidal tumor resection. CONCLUSIONS: This is the first report describing multimodality treatment of a patient with pituitary metastasis of unknown origin requiring presurgical embolization before successful tumor removal.

Reversible freezing of gait caused by dural arteriovenous fistula and congestion of the globus pallidus.

BACKGROUND: Freezing of gait (FOG) is defined as an episodic inability to generate effective stepping in the absence of any known cause other than parkinsonism or high-level gait disorders. METHODS: We present a 59-year-old male with acute, progressive episodes of FOG. Imaging studies revealed a dural arteriovenous fistula (DAVF) associated with edema of the globus pallidus interna (GPi). Cerebral angiography confirmed the diagnosis of DAVF and demonstrated an occluded straight sinus and a retrograde blood flow of deep cerebral veins. RESULTS: After endovascular closure of the DAVF, a major improvement of FOG was observed concomitant with striking near resolution of GPi congestion. CONCLUSIONS: This reversal of the clinical course, correlated with changes in imaging studies, suggests a major role of the GPi in the pathology of FOG.

Treatment of intra-cranial aneurysms with the SILK flow diverter: 2 years' experience with 28 patients at a single center.

BACKGROUND: Flow diverters are recently developed stent-like endovascular devices developed to treat complex and non-coilable aneurysms. SILK is a type of flow diverter that has been used for nearly 3 years. Only sparse data about it are available. We would like to share our experience with this device. METHODS: Twenty-eight patients were treated with SILK from October 2008 to October 2010. Thirty-one treatment sessions were performed for 32 aneurysms using 31 SILKs. Twenty have been treated with SILK only and eight with SILK and adjuvant stents. Twenty-six (86%) patients performed cross-sectional imaging (MRA/CTA) for follow-up. Eighteen (64%) patients had follow-up brain angiography. RESULTS: In all patients the SILK could be deployed. No case of early or late aneurysmal rupture was noted. Five patients (17.8%) developed immediate clinical complications, which were permanent in three (10.7%). All the complications occurred in patients harboring aneurysms larger than 15 mm. In two other patients, occlusion of the SILK was noted with no clinical deficit. A complete or near-complete aneurysmal occlusion was found in brain angiography or cross-sectional imaging follow-up in 83.3% of the patients. CONCLUSIONS: SILK is a relatively simple device to use, with a low rate of technical and clinical complications and a high short-term aneurysmal occlusion rate. In aneurysms smaller than 15 mm, the results are excellent. Results are also encouraging in the larger aneurysms, taking into consideration their complexity. The device characteristics and mainly its drawbacks must be well known by the users.

Therapeutic and diagnostic implication of inadequate circle of willis in a patient with acute spontaneous bilateral internal carotid artery dissection: case report and review of the literature.

BACKGROUND AND PURPOSE: Emphasizing the therapeutic and diagnostic implications of concomitant inadequate collaterals from the circle of Willis in a rare case of spontaneous acute bilateral internal carotid artery dissection (BICAD) following 5 days of isolated rigorous cough (pertussis like). CASE DESCRIPTION: A 45-year-old male has been referred to our department with rapid neurological deterioration consisting of dysarthria and severe left hemiparesis following 5 days of isolated rigorous cough. CTA demonstrated BICAD, a tiny anterior communicating artery and no bilateral posterior communicating artery. The patient had no personal or familial risk factors. Infectious, traumatic, vascular and connective tissue diseases were ruled out. RESULTS: Neurological deterioration persisted despite immediate provision of continuous 'full-heparinization' with concomitant rigorous control of blood pressure. Endovascular treatment consisting of bilateral stenting was undertaken. Ten days later, the patient was discharged with mild hemiparesis and resuming normal activity after 3 months. CONCLUSIONS: BICAD with concomitant inadequate collaterals from the circle of Willis may predispose to hypoperfusion which might not respond to the usual conservative treatment prompting for flow reestablishment. Moreover, isolated rigorous cough can cause acute spontaneous BICAD even among patients without any risk factors.

Atypical postpartum stroke presenting as opalski syndrome: case report and review of the literature.

BACKGROUND AND PURPOSE: We present the first case of combined arterial (vertebral artery dissection) and venous [central sinus vein thrombosis (CSVT)] diseases presenting as Opalski syndrome in a female patient following induced delivery. CASE DESCRIPTION: A 32-year-old woman was admitted to our institute two weeks after induced delivery with intriguing neurological findings that were finally diagnosed as a combined venous-arterial disease. Although she was referred diagnosed with CSVT, her neurological findings indicated Wallenberg 'plus' syndrome with ipsilateral hemiparesis (Opalski syndrome), further confirmed by neuroimaging revealing arterial disease (vertebral artery dissection) combined with incidental acute CSVT. Coagulation, gynecological and cardiac problems were ruled out. Treatment consisted of continuous heparin with rigorous control of her blood pressure. Nine days later, the patient was discharged with prominent improvements. Most of the symptoms resolved following 3 months of rehabilitation. CONCLUSIONS: Atypical strokes (such as Opalski syndrome) might present in postpartum patients. This rare diagnosis should be suspected in patients with Wallenberg 'plus' syndrome, and neuroimaging studies for determining the presence of arterial disease and brain stem lesions should be performed. Concomitant CSVT is rare and might mislead. Fine diagnosis followed by immediate conservative treatment can be of great benefit.

Radiosurgical treatment planning of AVM following embolization with Onyx: possible dosage error in treatment planning can be averted.

Treatment of arteriovenous malformations (AVM) of the brain is challenging due to the size and location of the nidus-proper and its proximity to the cerebrovascular circulation. Recent advances in catheter techniques and new embolization materials such as Onyx (a liquid agent that is less adhesive and slowly polymerizing) have increased the probability of achieving obliteration. When planning radiosurgical cases following such embolization, however, one must be cognizant of the distortions introduced by this novel substance on imaging studies. A sample of Onyx was irradiated to define the attenuation per mm thickness. The difference in attenuation compared to water was determined. Dose calculations were performed using 3 methods of inhomogeneity corrections. Homogeneous calculations were compared to "standard" heterogeneity corrections and to "modified" heterogeneity corrections by assigning individual electron densities to the normal brain and the Onyx. The difference between the attenuation of water in comparison to the Onyx was approximately 3% for beam energy of 6 MV. Best calculation results were achieved when using the modified inhomogeneity corrections which were based on the actual attenuation of the Onyx. The use of Onyx caused significant image artifact on MR and especially CT. As such, a correction must be manually introduced into the planning system to account for this potential error. Otherwise, dose calculation may be unreliable and could have dire consequences for patients receiving high doses of radiotherapy.

Chiasmal cavernoma: a rare cause of acute visual loss improved by prompt surgery.

We report a 16-year-old healthy boy who presented with sudden loss of vision in both eyes, accompanied by a mild headache. Magnetic resonance imaging showed a chiasmal apoplexy. An urgent craniotomy revealed a cavernous malformation of the chiasm, which was evacuated. There was a subsequent dramatic improvement in bilateral visual acuity and visual field defects. This case report emphasizes the importance of rapid diagnosis and surgery of an anterior visual pathway cavernous malformation.

Endovascular embolization of a hemorrhagic jugular bulb diverticulum.

A jugular bulb diverticulum (JBD) is considered to be a rare venous anomaly. In exceptional cases it extends into the middle ear cavity with no bony covering, and slight oozing to massive bleeding might be encountered during routine middle ear surgical procedures. We report a case of massive bleeding from a dehiscent jugular bulb diverticulum that appeared during myringotomy and was successfully managed by endovascular embolization. This report emphasizes the value of interventional neuroradiology in otosurgical cases in which preoperative control of blood vessels or vascular malformations is crucial to avoid severe complications.

Anophthalmia-plus syndrome: a clinical report and review of the literature.

We describe a term male infant of healthy non-consanguineous parents, born with congenital malformations, including bilateral cleft palate and lip, mild microphthalmia with iris coloboma and glaucoma of the right eye, and blepharophimosis with severe microphthalmia of the left eye. Spine radiograph and MRI showed first sacral hemivertebra with spina bifida, and agenesis of the 2nd, 3rd, 4th, and 5th sacral vertebrae and coccyx. Spine MRI showed caudal tethering of spinal cord at L(3) level, filum terminalis lipoma and a syringomyelia. Brain ultrasound and MRI showed hypoplasia of corpus callosum with mild dilatation of the lateral ventricles. Orbital MRI showed bilateral microphthalmia-distorted small left eyeball with posteriorly located lens, and a split vitreous body in the right eye, suggestive of primary hyperplastic vitreous. The karyotype was normal. Summary of the findings in nine cases (our case and eight published cases) support the notion that anophthalmia-plus syndrome (APS) is a distinct syndrome. Gene locus of APS is yet to be identified.

Brain computed tomography angiographic scans as the sole diagnostic examination for excluding aneurysms in patients with perimesencephalic subarachnoid hemorrhage.

OBJECTIVE: In an era in which new computed tomographic scanners approach 100% sensitivity for finding intracranial aneurysms in patients with a perimesencephalic subarachnoid hemorrhage (SAH) pattern, digital subtraction angiography (DSA) is still considered the gold standard. Our purpose was to investigate whether or not computed tomography angiographic (CTA) scanning can be used as the sole diagnostic tool in this setting, and thus replace DSA. METHODS: Two hundred fifty patients with atraumatic SAH presented to our institute between November 2001 and November 2005. We performed a retrospective search for those patients who had a negative brain CTA scan for aneurysms. Of these, those with a computed tomographic scan showing perimesencephalic SAH at admission were selected, and only those who had DSA performed were included. RESULTS: We found 30 patients with negative brain CTA scans that matched the perimesencephalic SAH pattern and had DSA performed. The mean time for performing a brain CTA scan was 3.8 +/- 4.4 days, and for DSA 11 +/- 12 days, after the initiation of symptomatology. The interval between CTA and DSA was 5.9 +/- 15 days. There were two patients in whom CTA was considered negative but still suspicious for having an aneurysm; DSA was negative for both. CONCLUSION: Brain CTA scanning alone is a good and conclusive diagnostic tool to rule out aneurysms in patients presenting with the classic perimesencephalic SAH pattern and thus can replace DSA and its corresponding risks. The latter can be reserved for those patients in whom CTA is doubtful.

Evolution of oculomotor nerve paresis after endovascular coiling of posterior communicating artery aneurysms: a neuro-ophthalmological perspective.

OBJECTIVE: Guglielmi detachable coil treatment is becoming an accepted alternative to microsurgical clipping for select intracerebral aneurysms. Resolution of oculomotor nerve paresis (ONP) after endovascular packing was claimed to be complete in two prior series, with three and six cases. We describe the evolution of ONP after Guglielmi detachable coil treatment of posterior communicating artery aneurysms, and we search for endovascular and patient factors correlated with the degree of functional nerve recovery. METHODS: Twelve cases of ONP attributable to posterior communicating artery aneurysms were treated with Guglielmi detachable coils between 1999 and 2002. Eleven patients were available for follow-up monitoring. The degree of ONP was recorded at admission, at discharge, after 3 months, and at yearly intervals thereafter. The size of the aneurysm, the duration of ONP before coiling, the degree of coiling, age, and the presence of other microvascular risk factors were correlated with the degree of nerve recovery. RESULTS: Complete resolution of ONP did not occur in any of the 11 cases in this series. However, residual oculomotor nerve deficits did not cause diplopia with primary gaze for 10 of 11 patients. Clinically significant ptosis did not persist for any of the patients. The pupil remained minimally affected in all cases. CONCLUSION: Although mass effect remains after endovascular packing, oculomotor nerve dysfunction improves comparably to the recovery observed after surgical clipping. Contrary to previous reports, typical residual oculomotor nerve deficits persist. Older age and the presence of microvascular risk factors seem to be detrimental to ONP recovery.