Standards of Practice in Acute Ischemic Stroke Intervention International Recommendations.

After five positive randomized controlled trials showed benefit of mechanical thrombectomy in the management of acute ischemic stroke with emergent large-vessel occlusion, a multi-society meeting was organized during the 17th Congress of the World Federation of Interventional and Therapeutic Neuroradiology in October 2017 in Budapest, Hungary. This multi-society meeting was dedicated to establish standards of practice in acute ischemic stroke intervention aiming for a consensus on the minimum requirements for centers providing such treatment. In an ideal situation, all patients would be treated at a center offering a full spectrum of neuroendovascular care (a level 1 center). However, for geographical reasons, some patients are unable to reach such a center in a reasonable period of time. With this in mind, the group paid special attention to define recommendations on the prerequisites of organizing stroke centers providing medical thrombectomy for acute ischemic stroke, but not for other neurovascular diseases (level 2 centers). Finally, some centers will have a stroke unit and offer intravenous thrombolysis, but not any endovascular stroke therapy (level 3 centers). Together, these level 1, 2, and 3 centers form a complete stroke system of care. The multi-society group provides recommendations and a framework for the development of medical thrombectomy services worldwide.

Standards of practice in acute ischemic stroke intervention: International recommendations.

This article was first published in JNIS. Cite this article as: Pierot L, Jayaraman MV, Szikora I, et al. Standards of practice in acute ischemic stroke intervention: international recommendations. Journal of NeuroInterventional Surgery. Published Online First: 28 August 2018. doi: 10.1136/neurintsurg-2018-014287.

Intraventricular Ganglioglioma Presenting with Spontaneous Hemorrhage.

Intraventricular gangliogliomas presenting with spontaneous hemorrhage are rare. Due to high density of important tracts lateral to the ventricular atrium, the intraparietal trans sulcal approach is a good option to remove lesions in this location. These tracts are displaced and sometimes destroyed by the presence of large masses. A 33-year-old male presented with a sudden headache and a generalized seizure. He had a left visual field hemianopia and left visual field neglect. Brain computer tomography and magnetic resonance imaging revealed a hemorrhagic tumor located in his right atrium. With the help of tractography an optimal corridor to the tumor through the intraparietal sulcus was planned. Gross total removal of a ganglioglioma was possible with recovery of visual impairment and control of epilepsy. The efficacy in using tractography as a planning tool for safe tumor removal is demonstrated with clinical, imagiological and histological data, and a surgical video.

Os gangliogliomas Intraventriculares com hemorragia espontânea são raros. Devido à densidade elevada de tractos importantes localizados lateralmente ao átrio ventricular, o sulco intraparietal é a via preferencial de acesso para remoção de lesões nesta localização. Um homem de 33 anos recorreu à urgência por cefaleia súbita e crise tónico-clónica generalizada. No exame neurológico, apresentava hemianopsia homónima esquerda e negligência visual esquerda. Realizou tomografia computorizada cranioencefálica e ressonância magnética que revelaram lesão ocupando espaço com hemorragia, localizada no átrio do ventrículo lateral direito. O estudo por tractografia permitiu estabelecer o corredor ideal de acesso ao tumor através do sulco intraparietal. A remoção total do ganglioglioma foi possível sem instalação de défices e com recuperação do défice visual e controle das crises epilépticas. A eficácia do uso da tractografia como ferramenta de planeamento para remoção segura de tumores é aqui apresentada com detalhes clínicos, neurorradiológicos, neuropatológicos e um vídeo cirúrgico.

[Endovascular thrombolysis for massive cerebral venous thrombosis in a teenager with nephrotic syndrome]. / Trombose venosa cerebral maciça submetida a trombólise endovascular num adolescente com síndrome nefrótica.

Cerebral venous thrombosis is a rare but potentially severe condition in children. We present the case of a teenager with corticodependent nephrotic syndrome diagnosed at five months of age and treated with cyclosporine A. In the context of recurrence of nephrotic syndrome he presented with headache, vomiting and severe intracranial hypertension. While the raised intracranial pressure and the status epilepticus were controlled, the brain imaging revealed venous thrombosis of all venous sinus, with absence of venous drainage. He was submitted to local thrombolysis with recombinant tissue plasminogen activator, with recanalization of the venous sinuses. The outcome was favourable, without neurological deficits. In this case, the early radiologic intervention was crucial, enabling a full neurological recovery, in a teenager whose initial prognosis was very poor.

[Endovascular management of post-traumatic head and neck arteriovenous fistulas]. / Terapêutica endovascular de fístulas arteriovenosas pós-traumáticas cranio-cervicais.

Endovascular treatment through the arterial or venous way is part of the management of diverse lesions in the head and neck, often as complementary of surgery, in highly vascularized tumors or single vascular lesions. Concerning the vascular pathology, the intra-arterial occlusive therapy can be used in some types of head and neck malformations, isolated or in association to surgery, to accomplish the complete removal of the "nidus" of the malformation, or for cosmetic purposes. Regarding the post traumatic arteriovenous fistulas, intra-arterial or intravenous embolization has been widely used and reported. The authors describe in this paper their experience with the endovascular management of carotid-cavernous post-traumatic fistulas, as well as with extracranial post traumatic a-v fistulas, related to the external carotid, vertebral and subclavian arterial branches. According to the location and type of the a-v shunt, several different strategies can be devised and diverse materials can be employed for embolization, like destacable microbaloons, cianocrilate, PVA particles and platin spirals. All the carotid-cavernous lesions were successfully occluded. In the extracranial lesions group, a successful result could not be obtained in one patient, who presented multiple a-v fistulas, and despite that he was clinically improved. In the present series of patients, only one case of cerebral thromboembolism was reported as a complication, with favourable outcome. Our overall results support the primary role played by the endovascular management in post-traumatic arteriovenous fistulas of the head and neck.